Every finding on record at Meadowbrook Nursing Center

Based on observation, record review, and interview, the facility failed to ensure adequate supervision to prevent an elopement for 1 (#1) of 3 sampled residents reviewed for elopement.The administrator identified 28 residents who resided in the facility.Findings:On 04/15/26 at 12:07 p.m., Res #1 was observed in their room sitting on the side of their bed. Res #1 was observed to be clean and dressed appropriately.On 04/16/26 at 10:45 a.m., Res #1 was observed resting in bed with their eyes closed.On 04/16/26 at 2:00 p.m., Res #1 was observed in their room sitting on the side of their bed looking through papers.An undated policy titled Missing Resident, read in part, It is the intent of the facility to be aware of its resident's usual habits and locations as reasonably practicable. This is with the intent of not invading privacy but to identify a possible missing resident.An undated face sheet showed Res #1 admitted to the facility with diagnoses which included congestive heart failure and hypertension.An elopement assessment, dated 02/12/26, showed Res #1 was not at risk for elopement.A significant change assessment, dated 02/13/26, showed Res #1 had a brief interview for mental status score of 13 which indicated the resident was cognitively intact for daily decision making. The assessment showed Res #1 was ambulatory with the use of a walker.An initial incident report, dated 04/04/26, showed the nurse was at the nurse's station charting when they were informed Res #1 was out of the building and walking towards the highway. The report showed Res #1 walked onto the highway and stood in front of a semi-truck that had stopped and asked the driver to take them home. The report showed staff were eventually able to get Res #1 back to the facility safely without any injuries. The report showed Res #1 was placed on one-on-one supervision and referrals were made to a geriatric-psychiatric facility for review. The report showed the administrator, DON, and physician were notified. The report showed Res #1's family member was notified of the elopement on 04/04/26 at 9:50 p.m.A typed statement from Res #1, dated 04/06/26, showed Res #1 was angry because their family member would not answer their questions and hung up on them. The statement showed Res #1 walked slowly down the hallway while waiting for the nurse to leave. The statement showed Res #1 saw the nurse was no longer at the desk and hurried to the door and entered the code. The statement showed Res #1 went out the door and continued down the road toward the highway. The statement showed Res#1 moved slowly toward the edge of the road until a passing truck stopped and they asked the driver to take them home. The statement showed nurses and other staff arrived and returned Res #1 to the facility. The note showed Res #1 asked the staff to type their statement.A final incident report, dated 04/09/26, showed the following measures were implemented:a. On 04/04/26, Res #1 was placed on one-on-one supervision; exit door codes were changed; a psychiatric hospital referral was made at Res #1's request; and Res #1's family member was notified of the elopement.b. On 04/05/26, Res #1's care plan was updated to address elopement.c. On 04/06/26, new assessments for elopement, pain, and skin were completed for Res #1; elopement observations were completed on all residents; a medication review was ordered; the ombudsman was notified and asked to assist with concerns regarding Res #1's home and bank account involving a family member; social services completed questionnaires regarding elopement risk and desire to leave the facility; and signage was posted on exit doors reminding staff and visitors to remain alert, as the residents may resemble visitors. d. On 04/06/26, Res #1 was admitted to a geriatric psychiatric facility.e. To prevent reoccurrence, the facility will update elopement/wandering observations quarterly and as needed; maintain an updated elopement log at the nurse's station for at-risk residents; ensure exit door codes remain current; and post alerts on front doors to notify staff and visitors upon exit.A Quality Assurance and Performance Improvement meeting agenda, dated 04/10/26, showed elopement/accidents were addressed in the meeting.A nurse note, dated 04/14/26, showed Res #1 returned from the geriatric psychiatric facility.On 04/15/26 at 12:07 p.m., Res #1 stated they had just returned from the hospital. Res #1 stated I needed that. Res #1 stated the day they left the facility; they were having a bad day and had just wanted to go home to check on their house because their family member hung up on them when they called. Res #1 stated I did not walk out in front of that truck until it had stopped.On 04/15/26 at 2:45 p.m., the corporate nurse consultant stated the resident should have never been able to leave the building unattended.

On 03/11/26, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent accident hazards related to smoking. On 03/02/26, Resident #26 was smoking in their room while wearing oxygen. The oxygen combusted which caused a facial burn, singed beard, and mustache hair. On 03/11/26 at 2:56 p.m., the Oklahoma State Department of Health verified the existence of an IJ situation. On 03/11/26 at 3:05 p.m., the administrator was notified of the IJ situation. An IJ template was provided to the administrator. On 03/12/26 at 10:47 a.m., an acceptable POR (plan of removal) was received. The POR read in part, Plan of Removal for lJ Amended 3/12/2026 at 0950 [9:50 a.m.]1. Notify MedicaI Director2. Notify resident # 26 hospice provider of lJ and coordination of care3. New Smoking Assessment for all smokers4. Review/revise smoking policy with resident and resident council with agreement and approval for revision of checking for any smoking material at the end of each smoke break. Update smoking policy to include observation of smoking residents to distinguish and dispose of smoking material ie: cig butts and return lighter at end of smoking times. With a check list to ensure each resident has complied. Staff supervising smoke break(s) will keep the smoking materials container in their passion[sic], with only one lighter available, and will give each resident only one cigarette at a time. All smoking materials brought in by friends/family are to be checked in at nurse's station.5. Post reviewed/revised smoking policy with resident council approval at nurses' station, by exit leading to smoking area.6. Have smoking residents sign revised smoking policy for acknowledging policy7. Administrator to In-Service Staff on revised smoking policy8. Regional supervisor to ln-Service Administrator/DON on ODHS [sic] form 283 and completing with adequate supervision of residents and follow-up for accident and incidents related to smoking and charting for interventions and follow up care.9. Up-date care plan for resident # 26.10. Review all smoking residents care plan and revise as needed for adequate supervision/intervention for possible accidents/injury if occurrence happens.11. Move resident # 26 to room closer to nurse's station.12. Educate resident # 26 on hazards of smoking in room and the potential to harm self and other resident due to combustion with oxygen and possible injuries and sign education sheet and upload to resident EHR under resident documents.13. All ODHS [sic] for 283 will be sent to a Regional Supervisor for review for completeness and adequate intervention to prevent reoccurrence and follow-up,14. QAPI for lJ started and monitored for the above intervention for removal of lJ with monitoring implementation. The IJ was lifted, effective 03/12/26 at 10:15 a.m., when all components of the POR were verified. Observation of the room change for Resident #26 was made. Observation of placement of new smoking policy was made to ensure posted in listed areas. Care plans and assessments of smokers were reviewed to ensure updates were completed. The smoking policy was reviewed to ensure it had been updated. Interviews with residents who smoke were conducted to ensure education had been provided. Multiple staff from all shifts were interviewed to verify in-service was completed. The deficient practice remained at an isolated level with actual harm. Based on observation, record review, and interview, the facility failed to provide supervision to prevent accident hazards for 1 (#26) who smoked while wearing oxygen which resulted in facial burns, of 5 sampled residents reviewed who smoked. Regional Nurse #2 identified 5 residents in the facility who smoked. Findings: 1. On 03/10/26 at 8:53 a.m., Resident #26 was observed in the dining room with singed mustache hair above their lip and a wound approximately one inch wide by two inches long to the left of their upper lip. An undated, Smoking policy, read in part, Residents will not be allowed to have cigarettes or paraphernalia's [sic] such as: matches or lighters in their possession or in their rooms. These items will be kept secured at the nurses' station and will be distributed at designated smoking times if applicable.No smoking is permitted in resident rooms or hallways. A care plan, reviewed/revised 02/24/25, showed Resident #26 had a concern for decreased oxygen levels due to a diagnosis of COPD and smoking. The interventions showed to perform smoking assessments quarterly according to facility policy, monitor when smoking to assure resident's safety, and provide smoking policy and rules regarding cigarette and lighter being kept at the desk. An admission assessment, dated 05/14/25, showed Resident #26 had a BIMS of 15, which indicated they were cognitively intact and smoked. A Smoking Assessment, dated 11/12/25, showed Resident #26 had demonstrated ability to safely smoke cigarettes with minimal supervision. A Smoking Assessment, dated 02/12/26, showed Resident #26 was observed to hide a cigarette in their pocket to smoke later. The assessment showed Resident #26 had demonstrated ability to safely smoke cigarettes with minimal supervision. A nurse progress note, dated 02/12/26, showed Resident #26 was observed by the CMA to put a cigarette in their jacket pocket to smoke later. The staff obtained the cigarette and educated the resident on the dangers of smoking while wearing oxygen. A quarterly assessment, dated 02/12/26, showed Resident #26 had a BIMS of 15 and was cognitively intact for daily decision making. The assessment showed diagnoses which included lung cancer of the right lower lobe, anxiety, depression, paranoid schizophrenia, COPD, and respiratory failure. A nurse progress note, dated 03/03/26, showed Resident #26 had smoked in their room the night before while wearing oxygen and the resident's face had been burned. On 03/10/26 at 8:53 a.m., Resident #26 stated they burned themself while smoking and wearing oxygen. They stated the staff have treated the burn with Silvadene (wound ointment) and it had helped. On 03/11/26 at 12:28 p.m., CNA #1 stated residents had set times for smoking, and they were posted all over the building. They stated residents required staff with them at all times while smoking. CNA #1 stated residents were not allowed to keep cigarettes and lighters on them and when staff entered their rooms, they were to use sight and smell to determine if a resident had been smoking in their room. They stated they were to report to the nurse if there were signs of smoking. On 03/11/26 at 12:34 p.m., CMA #1 stated residents could smoke in designated areas and must be evaluated for safe smoking. They stated the smoking hours were posted. CMA #1 stated cigarette butts must be put in the receptacle, and someone must supervise residents while they smoked. CMA #1 stated they had observed cigarette ash around the toilet of Resident #26 in the past and thought they had reported it to a charge nurse. On 03/11/26 at 12:48 p.m., the DON stated residents were able to sign themselves out and go smoke out front at the end of the sidewalk. They stated in the past housekeeping had found ashes on the toilet seat of Resident #26. The DON stated since the incident on 03/02/26, the facility did not allow residents to have smoking materials in their possession; staff provided direct supervision and lit their cigarettes for them. They stated staff supervised residents while they smoked. The DON stated they completed smoking assessments quarterly. The DON stated they could not be sure they obtained all the lighters from Resident #26 and stated, I can't legally go through their stuff. On 03/11/26 at 1:03 p.m., the administrator stated residents had regular smoke times and the CMA would hold the lighter and light the resident's cigarettes. The administrator stated in the past housekeeping had reported ashes on the toilet seat of Resident #26. They stated the last time this was reported was a couple months ago. They stated they asked Resident #26 if they had been smoking in their room and the resident stated they had smoked in their room but would not do it anymore. The administrator stated they had confiscated the smoking materials from Resident #26. The administrator stated on 03/03/26, the day after the incident, the maintenance director had found a lighter under the bed of Resident #26. The administrator stated it had been reported to them Resident #26 had been smoking in their room six times from 01/02/26 to 03/03/26. They stated there was no guarantee residents did not have lighters or cigarettes in their room.

Based on observation, interview, and record review, the facility failed to ensure nurse staffing was posted.The administrator identified 34 residents who resided in the facility. Findings: On 03/12/26 at 1:30 p.m., nurse staffing information was not observed posted in the facility. On 03/13/26 at 9:28 a.m., a dry erase board was observed by the nurse's station that contained the date, staff name with titles, census, and how many residents were in the hospital. An undated policy titled, Staffing Requirement Policy, read in part, Daily staffing reports will be posted for residents and visitors to view. On 03/13/26 at 9:28 a.m., LPN #2 stated they posted nurse staffing information on the dry erase board by the nurse's station. On 03/13/26 at 9:41 a.m., the DON stated nurse staffing information was documented on the dry erase board for visitors and residents. They stated they had a book at the nurse's station for daily assignments for the staff but those were not available for visitors and residents. On 03/13/26 at 9:51 a.m., the administrator stated they posted nurse staffing information in the past, but the ball has been dropped on that.

Based on observation, record review, and interview, the facility failed to have effective administration who utilized its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility administration failed to:a. report allegations of abuse to OSDH,b. investigate allegations of abuse,c. develop/implement comprehensive care plans, d. review and revise care plans, ande. provide supervision to prevent accident hazards related to smoking. The administrator identified 34 residents who resided at the facility.Findings: a. Based on record review and interview, the facility failed to ensure allegations of abuse were reported to OSDH for 1 (#4) of 1 sampled residents who were reviewed for abuse. On 03/12/26 at 3:56 p.m., the administrator stated they had not reported the allegations of abuse made by Resident #4 on 02/22/26 or 02/28/26 to OSDH because the abuse had not occurred per a skin assessment and the police officer's investigation. b. Based on record review and interview, the facility failed to ensure allegations of abuse were investigated for 1 (#4) of 1 sampled residents who were reviewed for abuse. On 03/12/26 at 3:56 p.m., the administrator stated the DON, MDS coordinator, or themself would investigate allegations of abuse. The administrator stated they had not investigated the allegation made on 02/28/26 because the police had unsubstantiated the allegation. The administrator stated they had not investigated the allegation on 02/22/26 because they had asked the shower aide on 02/23/26 to check for bruises during the shower and no bruising was observed. They stated when they asked Resident #4 they had denied being abused. The administrator stated, Then what is there to investigate? The administrator stated they had never had to conduct an abuse investigation and had not documented the conversation with Resident #4. c. Based on observation, record review, and interview, the facility failed to ensure comprehensive care plans were completed for 2 (#4 and #20) of 12 sampled residents reviewed for care plans. On 03/16/26 at 1:05 p.m., the DON stated they were responsible to oversee the MDS coordinator to ensure comprehensive care plans had been developed. The DON stated the MDS coordinator was on vacation. They reviewed the care plan for Resident #4 and stated the resident had smoked since admission and they did not know why a care plan for smoking had not been developed. On 03/16/26 at 1:11 p.m., the DON stated the smoking care plan was implemented and added to the care plan for Resident #20 on 03/12/26. They stated care plans were reviewed and updated quarterly, and care plan meetings were supposed to be quarterly as well. On 03/17/26 at 10:52 a.m., Regional Nurse #2 stated the smoking care plan was probably implemented on 03/12/26 and should not have been dated 12/15/25. They stated they did not know why the care plan did not include smoking on the original care plan. d. Based on record review and interview, the facility failed to ensure care plans were updated quarterly for 5 (#4, 28, 1, 37, and #26) of 12 sampled residents whose care plans were reviewed. On 03/16/26 at 1:23 p.m., the DON stated care plans were to be updated quarterly. On 03/16/26 at 1:49 p.m., the DON stated they had reviewed the care plan for Resident #26. They stated care plans had not been reviewed/revised quarterly and as needed. On 03/16/26 at 1:05 p.m., the DON stated they were responsible to oversee the MDS coordinator to ensure care plans had been reviewed/revised quarterly and as needed. The DON stated the MDS coordinator was on vacation. They stated they did not know why the care plan had not been revised. On 03/16/26 at 1:07 p.m., the DON stated Resident #28 had received hospice services for less than one year. The DON stated they did not know why the care plan for Resident #28 had not been reviewed/revised since 01/31/25 to include hospice services. On 03/16/26 at 1:49 p.m., the DON reviewed the care plan for Resident #1 and stated they did not know why the care plan had not been revised to reflect the resident's current status. They stated the care plan should have been revised to exclude fluid restriction that was currently reflected on the care plan and include nutrition/weight loss and the interventions they had in place. They stated they did not know why the care plan had not been updated. e. Based on observation, record review, and interview, the facility failed to provide supervision to prevent accident hazards for 1 (#26) of 5 sampled residents reviewed for smoking. On 03/11/26 at 1:03 p.m., the administrator stated residents had regular smoke times and the CMA would hold the lighter and light the resident's cigarettes. The administrator stated in the past housekeeping had reported ashes on the toilet seat of Resident #26. They stated the last time this was reported was a couple months ago. They stated they asked Resident #26 if they had been smoking in their room and the resident stated they had smoked in their room but would not do it anymore. The administrator stated they had confiscated the smoking materials from Resident #26. The administrator stated on 03/03/26, the day after the incident, the maintenance director had found a lighter under the bed of Resident #26. The administrator stated it had been reported to them Resident #26 had been smoking in their room six times from 01/02/26 to 03/03/26. They stated there was no guarantee residents did not have lighters or cigarettes in their room. On 03/17/26 at 1:28 p.m., regional nurse #1 with Regional Nurse #2 present, stated the regional nurses, regional administrator, and Chief Operating Officer were involved with the governing body. They stated they provided training and offered any support the facility administration would allow to be provided. Regional Nurse #1 stated there were a lot of personalities in the building, when some support was provided, they did not want to listen. They stated they knew coming in to this there would be systemic failures. Regional Nurse #1 stated there was a strong personality in the building and they tried to take control over things. They stated the system failure was every time help was offered, it was refused.

Based on observation, record review, and interview, the facility failed to maintain an effective Quality Assessment and Performance Improvement (QAPI), as evidenced by failure to demonstrate systematic identification, reporting, investigation, analysis, and prevention of adverse events and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility had systematic problems with identification of abuse allegations, reporting abuse allegations to OSDH, development of comprehensive care plans/revision of care plans, and adequate supervision to prevent accident hazards related to smoking.The administrator identified 34 residents who resided in the facility.Findings: Please refer to CMS form 2567 with exit date 03/17/26, F609, F610, F656, F657, and F689 for evidence details. A policy titled Quality Assessment and Assurance Program dated 06/27/13, read in part, 4. Each department or services will submit to the Quality Assessment and Assurance Committee a quarterly report of its own monitoring systems. 5. Reports will be evaluated to determine problems, plan solutions, implement actions, and ensure follow-up as well as consistent monitoring of results over a specified time frame. On 03/17/26 at 11:51 a.m., the administrator stated the QAPI committee met at least quarterly. They stated they completed a process improvement project (PIP) annually with the most recent regarding urinary catheters. They stated during QAPI meetings, they reviewed what the facility had concerns with, and the head of that department would monitor to ensure goals had been met. On 03/17/26 at 1:49 p.m., the administrator stated system failures identified during the survey, including accident hazards regarding smoking, failure to report and investigate abuse allegations, and comprehensive care plan development/revision had not been identified by the QAPI committee because things had been hectic.

Based on record review and interview, the facility failed to ensure residents and/or resident representatives had been informed of medication changes for 3 (#4, 15, and #37) of 5 sampled residents who were reviewed for unnecessary medications. LPN #1 identified 34 residents who received medications in the facility.Findings: 1. A policy titled, Notification of Changes Policy, read in part, It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative . A physician order, dated 12/17/25, showed Resident #4 was ordered clozapine (an antipsychotic medication) 50mg at bedtime. Nurse progress notes, dated 12/17/25 through 12/22/25, did not show the resident had been made aware of the new medication order or the risks/benefits of the change in their medication treatment regimen. A quarterly assessment, dated 01/16/26, showed Resident #4 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, received antipsychotic medications, and had a diagnosis of schizophrenia. A physician order, dated 01/28/26, showed Resident #4 was ordered haloperidol (an antipsychotic medication) 5mg twice daily. Nurse progress notes, dated 01/28/26 through 01/31/26, did not show the resident had been informed of the new medication order or the risks/benefits of the change in their medication treatment regimen. On 03/11/26 at 11:52 a.m., Resident #4 stated they received medication for mental health diagnoses and they were adjusted at times. They stated they were not sure they were notified of the haloperidol or clozapine orders but could tell when they needed an adjustment to their medication regimen. On 03/13/26 at 11:48 a.m., LPN #2 stated the charge nurse who received the physician order for a new medication was responsible to notify the resident and/or resident representative of the change to the medication regimen. They stated they did not discuss the risks/benefits of the treatment but did discuss possible side effects of the new medication. They stated they documented the notification in the progress notes. On 03/13/26 at 11:50 a.m., the DON stated the charge nurses were to document in the progress notes when they had notified the resident and/or resident representatives of changes to the medication regimen, but it was not a common practice. They stated they had discussed the risks/benefits a couple of times with residents but had not discussed them with Resident #4 or with their representative. Findings: 2.A physician order, dated 09/21/25, showed to administer Rexulti (antipsychotic) 3 mg daily. A physician order, dated 09/21/25, showed to administer tramadol (opioid analgesic) 50 mg TID. An admission assessment, dated 09/28/25, showed Resident #15 had a BIMS of 15 which indicated they were cognitively intact for daily decision making. The assessment showed diagnoses which included depression and schizoaffective disorder. The assessment showed Resident #15 took antipsychotic, antianxiety, antidepressant, and opioid medications during the seven-day look back period. The assessment showed an indication was provided for each medication. A physician order, dated 10/21/25, showed to administer trazodone (antidepressant) 50 mg at bedtime. A care plan, revised 01/06/26, showed a category of mood state with increased risk for behaviors, loneliness, sleep disturbance, depression, anxiety and schizoaffective bipolar type with a potential to be physically aggressive. The care plan showed an approach to administer medication as ordered and to monitor for side effects and effectiveness. A physician order, dated 01/28/26, showed to administer buspirone (anti-anxiety) 7.5 mg TID. Review of progress notes, dated 09/15/25 to 03/12/26, did not show the resident or representative had been notified of the risks and benefits of medications. On 03/17/26 at 11:05 a.m., the DON stated information regarding risk and benefit of medications were provided to the resident/representative before the medication was given and was provided by the physician. The stated it was documented in the physician's progress note. 3. A significant change assessment, dated 01/12/26, showed a BIMS of 08, which indicated Resident #37 was moderately impaired in cognition for daily decision making. The assessment showed diagnoses which included emphysema, heart failure, hypertension, and depression. A care plan, revised 01/31/25, showed concern for mood state with medications. A physician order, dated 03/09/26, showed to administer Lantus (insulin) Solostar 15 units daily. A physician order, dated 03/09/26, showed to administer Lantus Solostar 5 units daily. A physician order, dated 03/09/26, showed to administer Levofloxacin (antibiotic) 750 mg on 03/10/26 and 03/12/26 for bacterial pneumonia. Review of progress notes dated 03/09/26 did not show the facility had discussed with the resident or representative the benefits and side effects of medications. On 03/13/26 at 11:50 a.m., the DON stated the charge nurses were to document in the progress notes when they had notified the resident and/or resident representatives of changes to the medication regimen, but it was not a common practice. They stated they had discussed the risks/benefits a couple of times with residents but had not discussed them with Resident #37 or with their representatives as applicable.

Based on record review and interview, the facility failed to provide residents assistance to develop an advance directive for 1 (#15) of 3 sampled residents reviewed for advance directives. The administrator identified 34 residents who resided at the facility.Findings: An Advance Directive Policy and Record form, dated 09/21/25, for Resident #15 read in part, Documents were not received, Facility informed of Document. The form showed a POA was in place, with initials from the responsible party for Resident #15. An admission assessment, dated 09/28/25, showed Resident #15 had a BIMS of 15 which indicated they were cognitively intact for daily decision making. The assessment showed diagnoses which included dementia. On 03/13/26 at 3:30 p.m., the DON stated the business office manager typically went through the admission packet with all new admissions. The DON stated the resident was not offered/declined/accepted assistance to formulate an advance directive.

Based on observation, record review, and interview, the facility failed to ensure comprehensive care plans were completed for 2 (#4 and #20) of 12 sampled residents reviewed for care plans. The administrator identified 34 residents who resided at the facility. Findings: 1. On 03/09/26 at 3:35 p.m., Resident #20 stated they required someone to stay with them when they smoked. They stated they could not push their wheelchair because it was a transport chair. An admission assessment, dated 12/08/25, showed Resident #20 was a smoker. A care plan, dated 12/13/25, saved on 03/11/26 by the surveyor, showed no concern for smoking for Resident #20. A care plan, revised 12/15/25, saved on 03/12/26 by the surveyor, showed a concern for smoking with interventions. A Quarterly Smoking Assessment, dated 03/10/26, showed Resident #20 was safe for smoking with minimal supervision. A Quarterly Smoking Assessment, dated 03/11/26, showed Resident #20 was safe for smoking with minimal supervision. No other smoking assessments were located in the clinical record. On 03/16/26 at 1:11 p.m., the DON stated the smoking care plan was implemented and added to the care plan for Resident #20 on 03/12/26. They stated care plans were reviewed and updated quarterly, and care plan meetings were supposed to be quarterly as well. On 03/17/26 at 10:52 a.m., Regional Nurse #2 stated the smoking care plan was probably implemented on 03/12/26 and should not have been dated 12/15/25. They stated they did not know why the care plan did not include smoking on the original care plan. 2. On 03/09/26 at 1:06 p.m., Resident #4 was observed to be outside smoking with other residents and staff. A policy titled Smoking and Vaping Policy, showed Resident #4 had signed the smoking policy on 10/24/24. The care plan, revised 01/31/25, did not show the resident smoked. A Quarterly Smoking assessment dated [DATE], showed Resident #4 was able to smoke with minimal supervision. On 03/16/26 at 1:05 p.m., the DON stated they were responsible to oversee the MDS coordinator to ensure comprehensive care plans had been developed. The DON stated the MDS coordinator was on vacation. They reviewed the care plan for Resident #4 and stated the resident had smoked since admission and they did not know why a care plan for smoking had not been developed.

Based on record review and interview, the facility failed to ensure care plans were updated quarterly for 5 (#4, 28, 1, 37, and #26) of 12 sampled residents whose care plans were reviewed.The administrator identified 34 residents who resided at the facility. Findings: 1.A Care Planning-Interdisciplinary Team policy, revised 09/2013, read in part, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.The interdisciplinary team must review and update the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. A care plan for Resident #4 showed it was last reviewed/revised on 01/31/25. A quarterly assessment, dated 01/16/26, showed Resident #4 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and had diagnoses which included schizophrenia. On 03/16/26 at 1:05 p.m., the DON stated they were responsible to oversee the MDS coordinator to ensure care plans had been reviewed/revised quarterly and as needed. The DON stated the MDS coordinator was on vacation. They stated they did not know why the care plan had not been revised. 2. A physician order, dated 08/07/25, showed Resident #28 was admitted to hospice services for senile degeneration of the brain. A care plan showed it was last reviewed/revised on 01/31/25 and did not show a concern regarding hospice services. A quarterly assessment, dated 02/10/26, showed Resident #28 had a BIMS score of four, which indicated the resident was severely impaired in cognition for daily decision making, and a had chronic disease or condition that may result in a life expectancy of less than six months. On 03/16/26 at 1:07 p.m., the DON stated Resident #28 had received hospice services for less than one year. The DON stated they did not know why the care plan for Resident #28 had not been reviewed/revised since 01/31/25 to include hospice services. 3. A care plan for Resident #1 showed it was last reviewed/revised on 10/14/25. The care plan did not show a concern regarding nutrition. A dietician note, dated 10/10/25, showed Resident #1 had poor meal intake, a weight loss of 9.5% in six months, received a supplement, and the dietician would consult with the physician to determine if the resident was a candidate for an appetite stimulant. A dietician note, dated 12/10/25, showed Resident #1 had a weight loss of 5% in 1 month, to offer high calorie snacks twice daily, and periactin (an antihistimine medication used for appetite). A quarterly assessment, dated 01/11/26, showed Resident #1 had a BIMS score of nine which indicated the resident was moderately impaired in cognition for daily decision making, and had experienced a weight loss. On 03/16/26 at 1:49 p.m., the DON reviewed the care plan for Resident #1 and stated they did not know why the care plan had not been revised to reflect the resident's current status. They stated the care plan should have been revised to exclude fluid restriction that was currently reflected on the care plan and include nutrition/weight loss and the interventions they had in place. They stated they did not know why the care plan had not been updated. 4. An annual assessment, dated 10/23/25, showed Resident #37 had a BIMS of 15 and was cognitively intact for daily decision making. The assessment showed diagnoses which included emphysema and COPD. A care plan for Resident #37, reviewed/revised on 01/31/25 did not show a concern for hospice services. A physician's order, dated 03/09/26, showed Resident #37 was admitted to Hospice services with a diagnosis of COPD. On 03/16/26 at 1:23 p.m., the DON stated care plans were to be updated quarterly. 5. A care plan for Resident #26 showed it was last reviewed/revised on 02/24/25. A re-admission assessment, dated 05/14/25, showed Resident #26 had hospice services. The assessment showed Resident #26 had a prognosis of less than six months. A nurse progress note, dated 02/12/26, showed Resident #26 was observed by a CMA to put a cigarette in their pocket and the charge nurse had to obtain it. This was not included in the care plan. A nurse progress note, dated 03/03/26, showed Resident #26 had lit a cigarette in their room while wearing oxygen and it ignited. This was not included in the care plan. On 03/10/26 at 8:53 a.m., Resident #26 stated they burned themself while smoking and wearing oxygen. They stated the staff had treated the burn with Silvadene (ointment for burns) and it had helped. On 03/16/26 at 1:23 p.m., the DON stated care plans were to be updated quarterly. On 03/16/26 at 1:49 p.m., the DON stated they had reviewed the care plan for Resident #26. They stated care plans had not been reviewed/revised quarterly and as needed.

Based on record review and interview, the facility failed to ensure staff competencies were completed for 4 (CNA#2, 3, 4, and CNA #5) of 4 employee files reviewed who were hired in the past 4 months.The administrator identified 11 CNAs who were hired in the past 4 months.Findings:An undated policy titled New Hire Process, read in part, All other functions turned over to the DON or other department head for scheduling and training .Employees are subject to TB test, employee physical, competencies, and three [3] days of training on the floor at the DON's discretion and schedule.The employee file for CNA #3 showed they were hired on 11/22/25. The employee file did not show a staff competency had been completed.The employee file for CNA #4 showed they were hired on 01/28/26. The employee file did not show a staff competency had been completed.The employee file for CNA #5 showed they were hired on 01/08/26. The employee file did not show a staff competency had been completed.The employee file for CNA #2 showed they were hired on 02/05/26. The employee file did not show a staff competency had been completed.On 03/13/26 at 9:39 a.m., the DON stated newly hired CNAs were trained by another CNA. They stated they were to document the check off of the CNAs competencies on a form. The DON stated they had not documented staff competencies due to the staff turnover they recently had. The DON stated, It slipped through the cracks.

Based on observation, record review, and interview, the facility failed to ensure performance reviews were completed every 12 months for 1 (CMA #1) of 1 employee file reviewed who had been employed by the facility for 12 months or more.The administrator identified 34 residents who resided in the facility.Findings: On 03/11/26 at 9:41 a.m., CMA #1 was observed to administer Resident #1 zinc 50mg by mouth. A physician order, dated 03/03/26, showed an order for Resident #1 for zinc 30mg every day. The employee file for CMA #1 showed they were hired on 11/19/24. The employee file did not show a performance review had been completed since they were hired. On 03/13/26 at 9:39 a.m., the DON stated they did not have a system in place to ensure CNA/CMAs had performance reviews completed at least every 12 months. The DON confirmed they could not locate documentation to show CMA #1 had a performance review since being hired.

Based on observation and interview, the facility failed to:a. ensure medications were secured for 1 (nurse treatment cart) of 3 medication/treatment carts observed for secured medications;b. ensure medications were dated when opened and not expired for 1 (nurse treatment cart) of 3 medication/treatment carts observed for medication storage; andc. ensure discontinued narcotics were stored in a separately locked, permanently affixed compartment for 1 (DON medication/treatment cart) of 3 medication/treatment carts observed for medication storage.RN #1 identified three medication/treatment carts in the facility and one medication/treatment cart for discontinued narcotic storage.Findings:1.On 03/09/26 at 11:16 a.m., the nurse treatment cart was observed to be unlocked and unattended by the nurse's station. On 03/09/26 at 11:18 a.m., RN #1 was observed to lock the nurse treatment cart.On 03/13/26 at 1:13 p.m., the nurse treatment cart was observed to be unlocked and unattended at the nurse's station. On 03/13/26 at 1:16 p.m., the administrator was observed to walk by the nurse treatment cart. On 03/13/26 at 1:20 p.m., a visitor was observed to walk by the unlocked and unattended nurse treatment cart. On 03/13/26 at 1:21 p.m., LPN #2 was observed to approach the nurse treatment cart and open the top drawer. On 03/09/26 at 11:16 a.m., RN #1 stated the nurse treatment cart was to be kept locked because it contained medications. On 03/13/26 at 1:21 p.m., LPN #2 stated they thought they had locked the nurse treatment cart before leaving it unattended. On 03/16/26 at 1:21 p.m., the DON stated medication/treatment carts were to be kept locked when unattended. 2. On 03/16/26 at 1:31 p.m., the nurse treatment cart was observed to contain the following:a. one bottle of glucometer check strips that were opened and not dated;b. one albuterol inhaler with an expiration date of 10/31/25 for Resident #40;c. one bottle of nystatin powder with an expiration date of 04/04/25 for Resident #11;d. one bottle of nystatin powder with an expiration date of 08/18/25 for Resident #8;e. one lantus insulin pen for Resident #4 was opened and not dated;f. one lantus insulin pen for Resident #27 was opened and not dated;g. one lantus insulin pen and one novolog insulin pen were opened and not dated for Resident #22;h. one novolog insulin pen opened and not dated for Resident #40;i. one lantus insulin pen and one lispro insulin pen were opened and not dated for Resident #11;j. one lantus insulin pen opened and not dated for Resident #3; andk. one lantus insulin pen and one novolog insulin pen opened and not dated for Resident #5. On 03/16/26 at 1:31 p.m., RN #1 stated they did not know how often the nurse treatment cart was monitored for expired medications. On 03/16/26 at 1:32 p.m., LPN #2 stated the pharmacist monitored the nurse treatment cart monthly for expired medications. On 03/16/26 at 1:39 p.m., RN #1 stated they did not know how long the insulin pens listed above had been opened since they were not dated. On 03/16/26 at 1:45 p.m., the DON stated the nurses were to date insulin pens when they were opened and placed on the nurse treatment cart for use. They stated LPN #1 was responsible to monitor the nurse treatment cart to ensure opened medications were labeled and medications were not expired. The DON stated they did not monitor to ensure LPN #1 had audited the nurse medication cart to ensure opened medications were dated and expired medications had been removed. 3. On 03/16/26 at 2:32 p.m., the discontinued narcotics were observed in the DON's office. The discontinued narcotics were observed to be kept in a drawer in a locked medication/treatment cart. On 03/16/26 at 2:33 p.m., the DON stated the discontinued narcotics were behind two locks, their office door and the lock on the medication/treatment cart. The DON stated they did not have a key to the locked compartment inside the medication/treatment cart, so it was not able to be locked. They stated the medication/treatment cart, which stored the discontinued narcotics, was not permanently affixed.

Based on observation and interview, the facility failed to ensure eggs, served over easy, were pasteurized for 1 (breakfast meal) of 2 meals observed and failed to ensure left over foods were labeled and dated in the refrigerator for 1 of 1 refrigerators in the kitchen. The dietary manager identified 8 residents who ate eggs over easy and 34 residents who ate food from the kitchen. Findings: On 03/09/26 at 11:29 a.m., the cold storage refrigerator was observed to have sliced cheese in an unlabeled open zip close bag that was dated 02/26/26. An undated, unlabeled clear plastic container with a lid was observed in the refrigerator. The container was observed to have an unknown liquid. Two flats of unpasteurized eggs were observed in the refrigerator. No other eggs were observed. On 03/10/26 at 8:26 a.m., three residents in the dining room were observed to eat eggs over easy. No policy for storage of food or the use of pasteurized/unpasteurized eggs was provided by the end of the survey. On 03/09/26 at 11:30 a.m., the DM stated the cheese should have been zipped closed. They stated the clear plastic container was the lunch of an employee. The DM stated staff had a separate refrigerator for their food. They stated the unpasteurized eggs were used for scrambled, over easy, and fried eggs every morning. The DM stated they used the eggs that morning for over easy eggs and fried eggs. They stated they did not know if the eggs were pasteurized or not. On 03/17/26 at 12:04 p.m., the administrator stated they were not aware the eggs ordered from the supplier were not pasteurized. They stated they assumed the supplier would provide what was required for a nursing facility. The administrator stated their representative should have known they required pasteurized eggs.

Based on record review and interview, the facility failed to ensure allegations of abuse were reported to OSDH for 1 (#4) of 1 sampled residents who were reviewed for abuse.The administrator identified 34 residents who resided at the facility. Findings:The undated policy titled Abuse Prohibition Procedure, read in part, PURPOSE: To assure that any or all suspected abuse is reported, investigated and that the residents of this facility are kept in a safe environment at all times .If any person(s) see or suspects abuse to a resident or group of residents or Finds any unexplained injury this should be reported immediately to the charge nurse, DON, or Administrator.The Administrator or designees will immediately initiate an investigation And notify the OSDH.A quarterly assessment, dated 01/16/26, showed Resident #4 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of schizophrenia. A progress note, dated 02/22/26 at 11:42 p.m., read in part, Resident telling other residents during smoke break today that [they had] been getting beaten and has bruises on [their] arms and back. The progress note was signed by LPN #3.A progress note, dated 02/28/26 at 4:56 p.m., read in part, Resident called 911 from resident phone in living area. Police officer showed up stating resident called stating staff were beating [them] with whips and chains. Full body assessment completed with this nurse and police officer, no bruising noted to body. The progress note was signed by LPN #4. On 03/12/26 at 2:31 p.m., LPN #4 stated Resident #4 had called the police department and reported to them staff were beating them with whips and chains. They stated when the police officer arrived, they had observed the resident and had not identified any marks on the resident's body. They stated after the police officer left the facility they had notified the DON of the allegation of abuse. On 03/12/26 at 3:19 p.m., LPN #3 stated after Resident #4 had made an allegation of abuse on 02/22/26 they had notified the administrator and the DON of the allegation. On 03/12/26 at 3:28 p.m., the DON stated allegations of abuse were immediately investigated by the MDS coordinator, the administrator, or themself. The DON stated they were not sure they had been notified of the allegation of abuse on 02/22/26. The DON stated they had been made aware of the allegation of abuse on 02/28/26. The DON stated they had investigated the allegation but had not reported it to OSDH since the police had looked into it and had not substantiated the allegation. On 03/12/26 at 3:56 p.m., the administrator stated they had not reported the allegations of abuse made by Resident #4 on 02/22/26 or 02/28/26 to OSDH, because the abuse had not occurred per a skin assessment, and the police officer's investigation.

Based on record review and interview, the facility failed to ensure allegations of abuse were investigated for 1 (#4) of 1 sampled residents who were reviewed for abuse.The administrator identified 34 residents who resided in the facility.Findings:An untitled and undated policy, read in part, Purpose: To assure that any or all suspected abuse is reported, investigated and that the residents of this facility are kept in a safe environment at all times.The Administrator or designees will immediately initiate an investigation and notify the OSDH.A quarterly assessment, dated 01/16/26, showed Resident #4 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of schizophrenia. A progress note, dated 02/22/26 at 11:42 p.m., read in part, Resident telling other residents during smoke break today that [they had] been getting beaten and has bruises on [their] arms and back. The progress note was signed by LPN #3.A progress note, dated 02/28/26 at 4:56 p.m., read in part, Resident called 911 from resident phone in living area. Police officer showed up stating resident called stating staff were beating [them] with whips and chains. Full body assessment completed with this nurse and police officer, no bruising noted to body. The progress note was signed by LPN #4. On 03/12/26 at 2:31 p.m., LPN #4 stated Resident #4 had called the police department and reported to them staff were beating them with whips and chains. They stated when the police officer arrived, they had observed the resident and had not identified any marks on the resident's body. They stated after the police officer left the facility they had notified the DON of the allegation of abuse. On 03/12/26 at 3:19 p.m., LPN #3 stated after Resident #4 had made an allegation of abuse on 02/22/26 they had notified the administrator and the DON of the allegation. On 03/12/26 at 3:28 p.m., the DON stated allegations of abuse were immediately investigated by the MDS coordinator, the administrator, or themself. The DON stated they had not investigated the allegations of abuse for Resident #4 but would look to see if the MDS coordinator or the administrator had completed an investigation. On 03/12/26 at 3:53 p.m., the DON stated they had no evidence the allegation of abuse for Resident #4 on 02/22/26 or 02/28/26 had been investigated. On 03/12/26 at 3:56 p.m., the administrator stated the DON, MDS coordinator, or themself would investigate allegations of abuse. The administrator stated they had not investigated the allegation made on 02/28/26 because the police had unsubstantiated the allegation. The administrator stated they had not investigated the allegation on 02/22/26 because they had asked the shower aide on 02/23/26 to check for bruises during the shower and no bruising was observed. They stated when they asked Resident #4 they had denied being abused. The administrator stated, Then what is there to investigate? The administrator stated they had never had to conduct an abuse investigation and had not documented the conversation with Resident #4.

Based on record review and interview, the facility failed to ensure the clinical record contained documentation for a discharge for 1 (#36) of 1 sampled residents who were reviewed for discharge.Regional nurse #2 identified 13 residents who had discharged from the facility in the past 3 months. Findings: A discharge return-not anticipated assessment, dated 12/29/25, showed Resident #36 was admitted to the facility on [DATE], and discharged from the facility to home on [DATE]. Review of the clinical record, dated 12/23/25 through 12/29/25, did not show the reason for the discharge, the status of the resident upon discharge, a physician order for discharge, or what resources were required/provided upon discharge. On 03/16/26 at 9:37 a.m., LPN #2 stated Resident #36 had returned to their apartment upon discharge from the facility with hospice services and left with medication and personal belongings. On 03/16/26 at 9:39 a.m., the DON stated the physician had provided an order that Resident #36 could be discharged to home. On 03/16/26 at 9:46 a.m., the DON stated they had reviewed the clinical record but it had not shown a physician order for discharge, documentation of the resident's status upon discharge, or what resources were required/provided upon discharge. On 03/16/26 at 10:22 a.m., the administrator stated Resident #36 had discharged from the facility to return to their apartment as a planned discharge and that the resident had improved. They stated at times the resident discussed staying at the facility long term but had decided to discharge back to their apartment. The administrator stated the resident left with their personal belongings and medications with instructions. The administrator stated they did not know why the information had not been documented in the clinical record for the discharge of Resident #36. On 03/16/26 at 10:36 a.m., family member #1 for Resident #36 stated the resident had decided to return to their apartment and left with medications and hospice services.

Based on record review and interview, the facility failed to ensure a discharge summary was completed and the State Ombudsman office was notified of discharge for 1 (#36) of 1 sampled resident reviewed for discharge.Regional nurse #2 identified 13 residents who had been discharged in the past 3 months. Findings: A discharge return-not anticipated assessment, dated 12/29/25, showed Resident #36 was admitted to the facility on [DATE] and discharged from the facility to home on [DATE]. Review of the clinical record, dated 12/23/25 through 12/29/25, did not show a discharge summary had been completed or the State Ombudsman office had been notified of the discharge for Resident #36. On 03/16/26 at 9:37 a.m., LPN #2 stated Resident #36 had returned to their apartment upon discharge from the facility with hospice services and left with medication and personal belongings. On 03/16/26 at 9:39 a.m., the DON stated discharge summaries were completed by the MDS coordinator and placed in the clinical record under the 'observations' section. On 03/16/26 at 9:46 a.m., the DON stated they had reviewed the clinical record but it had not shown a discharge summary. On 03/16/26 at 10:22 a.m., the administrator stated they were responsible to notify the State Ombudsman of discharges. They stated they had not notified the State Ombudsman office for Resident #36. They stated they only notified them if the discharge was involuntary.

Based on record review and interview, the facility failed to ensure pre and post dialysis assessments were completed for 1 (#10) of 1 sampled residents who were reviewed for dialysis.Regional nurse #2 identified two residents who received dialysis at the facility.Findings: An admission assessment, dated 12/15/25, showed Resident #10 had a BIMS score of 11, which indicated the resident was moderately impaired in cognition for daily decision making, and received dialysis. A physician order, dated 02/20/26, showed Resident #10 received dialysis weekly on Monday, Wednesday, and Friday. A care plan, dated 03/05/26, showed Resident #10 had a diagnosis of end stage renal disease and received dialysis. Dialysis Communication forms and progress notes, dated 03/02/26 through 03/13/26, did not show nurses had conducted a pre or post dialysis assessment on 03/02/26 or 03/09/26. On 03/13/26 at 4:32 p.m., LPN #2 stated pre and post dialysis assessments were documented on Dialysis Communication forms or in the progress notes. On 03/16/26 at 1:17 p.m., the DON stated they could not locate documentation Resident #10 had received a pre or post dialysis assessment on 03/02/26 or 03/09/26. The DON stated they did not know why the assessments had not been completed and did not know what monitoring was in place to ensure pre and post dialysis assessments were completed.

Based on observation, interview, and record review, the facility failed to ensure assessments were conducted for bedrails for 1 (#1) of 1 sampled residents who were reviewed for bedrails.CNA #1 identified six residents who had bedrails.Findings: On 03/10/26 at 8:44 a.m., Resident #1 was observed in bed. An enabler style bedrail was observed on the right side of the bed, in the up position. A physician order, dated 12/22/25, showed Resident #10 may use an enabler style bedrail to assist with positioning. A care plan, revised 12/27/25, read in part, 12/22/2025-Transfer bar evaluation with demonstration completed for safety of repositioning while in bed and transferring in and out of bed safely. Review of the observation section and the progress notes, dated 12/25/25 through 03/13/26, did not show the resident had been assessed for safety with the use of the bedrail. On 03/10/26 at 8:44 a.m., Resident #1 stated they used the enabler style bedrail to assist them in getting out of bed. On 03/13/26 at 3:33 p.m., the DON stated residents with bedrails were to be assessed when bedrails were ordered and then quarterly. The DON stated they were not aware Resident #1 had a bedrail. On 03/13/26 at 3:38 p.m., the DON stated they did not have any documentation the resident had been assessed for safety for use of the bedrail.

Based on record review and interview, the facility failed to ensure TB testing, Flu, and Pneumonia immunizations were performed annually for 2 (#16 and #26) of 5 sampled residents reviewed for immunizations. The administrator identified 34 residents resided at the facility.Findings: 1. An admission assessment, dated 09/28/25, showed Resident #15 had a BIMS of 15 which indicated they were cognitively intact for daily decision making. The assessment showed diagnoses which included dementia. The assessment showed Resident #15 admitted to the facility 09/21/25. Review of the immunization record for Resident #16 showed they had not received their TB test on admission or their flu and pneumonia vaccinations annually. 2. A quarterly assessment, dated 02/12/26, showed Resident #26 had a BIMS of 15 and was cognitively intact for daily decision making. The assessment showed diagnoses which included lung cancer of the right lower lobe. The assessment showed Resident #26 re-admitted to the facility on [DATE]. Review of the immunization record for Resident #26 showed they had not received their TB test upon admission to the facility. On 03/16/26 at 3:55 p.m., the DON was provided a list of residents for TB tests and vaccinations. They stated it should be in the electronic health record. On 03/16/26 at 4:22 p.m., the DON stated the TB and vaccination documentation were in the administration office. On 03/17/26 at 11:07 a.m., the DON stated TB tests were to be completed on admission. Immunization and TB tests documentation for Residents #15 and #26 were not provided by the end of the survey.

Based on observation, record review, and interview, the facility failed to ensure residents did not experience resident to resident abuse for two (#10 and #16) of two residents sampled for abuse. The facility failed to ensure: a. Res #80 did not assault and injure Res #10 and #16. b. Res #10 was assessed for psychosocial harm and interventions were put in place to mitigate the harm after the assault by Res #80. c. a follow up of Res #16 possible brain bleeding caused by the assault by Res #80 was conducted. d. they instituted new interventions to protect the staff, the resident, or other residents when the facility the facility knew or should have known Res #80 was capable of aggressive behaviors towards others and had continued behaviors. The Resident Census and Conditions of Residents form documented 28 residents resided in the facility. Findings: A facility policy, titled Abuse - Reportable Events, revised on 01/2018, read in parts, .It is the responsibility of all facility staff to prohibit resident abuse, neglect, exploitation, and misappropriation of resident's property in any form; and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse, neglect and/or exploitation caused by another person .6. Protection .c. If another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the home's primary concern .7 .c. After investigation, administration will analyze the occurrence to determine what changes, if any, are needed to the policies and procedures to prevent further occurrences . 1. An incident report, titled Incident Report Form, dated 04/12/23 at 12:45 a.m., included a nurse note which documented Res #80 was observed lying in bed and was on 15 minute visual checks for history of climbing out windows. The note documented at 12:50 a.m., a loud noise was heard and Res #80 was banging on the door of Res #16 and a CNA had shut the door of Res #16 to protect them as Res #16 was defenseless. The note documented Res #80 had pulled Res #16 off their bed and on to the floor. The note documented at 12:55 a.m., 911 was notified and the police, fire, and an ambulance had arrived. The note documented Res #80 had poured mouthwash on the police officers and was yelling at them to get out of Res #80's home. The note documented Res #10 came out of their room with multiple skin tears to their arms and stated Res #80 had grabbed their arms and forced them out of their bed. The note documented first aide was provided to Res #10 and the police sat with Res #80 while placement at a hospital with the appropriate psychiatric services were found and transport could be arranged. A police report titled, Incident/Offence Report, dated 04/12/23 at 12:49 a.m., documented a offence of simple assault when a resident became combative to staff members and other residents. The report documented at the time of arrival of the author of the report, Res #80 was sitting at the nursing station and appeared calm. The report documented the nursing staff reported to them Res #80 had pulled Res #10 out of their bed and in the process had injured Res #10's arm. The report documented the officer could see what looked like a piece of missing skin from Res #10's arm. The report documented a witness statement of CNA #1 who had heard Res #16 yelling and went to check on them. The report documented when the CNA entered the room they found Res #16 on the floor and then Res #80 had gone to Res #10's room and assaulted them. The report documented the CNA took Res #10 to Res #16's room to get away from Res #80 and closed the door. The report documented the CNA stated Res #80 was pounding on the door, spraying Lysol at them, and striking them. 2. Res #10 had diagnoses which included anxiety disorder, schizoaffective disorder, insomnia, and recurrent depressive disorder. An annual assessment, dated 09/06/22, documented Res #10 was intact in cognition and required supervision and set up with ADLs. A nurse note, dated 04/12/23 at 5:05 a.m., documented the resident had been in an altercation with another resident. The note documented this resident defended theirself and received multiple skin tears on bilateral arms. A nurse note, dated 04/12/23 at 1:47 p.m., documented after the altercation with the other resident there was now bruising to bilateral lower arms. The note documented the resident had two bruises on the right arm measuring 12.0 x 3.0 cm and another one measuring 2.0 x 3.0 cm. The note documented the resident's left arm had a 20.0 x 3.0 cm injury which was not defined and a 3.0 x 2.0 cm skin tear to the posterior antecubital area with treatment in place. The note documented the resident complained of mild pain and soreness in the shoulder and neck area. Interventions, dated 04/12/23, were added to the resident's care plan for falls and documented an intervention/approach to monitor skin tears for signs and symptoms of infection and for bruising on bilateral upper extremities to treat as ordered by the physician. The care plan entry documented to frequently check the resident through the night to ensure their safety. A progress note from a mental health provider, dated 05/06/23, documented a chief complaint of Establish care for depression. The note documented the resident did not like it in the nursing home. The note documented the resident stated their anxiety was under control with medications and they denied mood swings, new or worsening depression, or night terrors. A progress note from a mental health provider, dated 06/02/23, documented chief complaint of Follow up Schizoaffective. The note documented the resident had anxiety and was worried about their health and was able to sleep with medications. A progress note, dated 06/26/23 at 2:44 p.m., documented the resident was seen by their physician and had complained of anxiety, pain in their feet, and daily headaches. The note documented the physician ordered depakote twice daily for the headaches and increased the resident's dose of trazodone to 75 mg at night. On 07/31/23 at 11:49 a.m., Res #10 was observed in their room lying on their bed. The resident stated they remembered the incident when they was assaulted by Res #80 very well and had not felt safe living in the facility since. The resident stated their fear was getting better but they were very frightened for a long time. The resident recalled the incident when Res #80 entered her room, pulled them up from their bed, and was scratching their arms causing them to bleed. When asked what the facility had done to help them feel safe the resident stated they were told Res #80 would not be returning to the facility. The resident was asked if they went to the hospital after the incident and they stated they had not but wished they had because their neck had bothered them since then. The resident stated they had told the doctor about their neck pain but they did not do anything about it. On 07/31/23 at 12:07 p.m., the administrator was asked if they had conducted an in-service on what to do with this type of resident to resident abuse. The administrator stated they would have to check the in-service book. The administrator was asked if the facility had checked to ensure the residents felt safe after the incident. The administrator stated Res #10 had expressed they did not feel safe at the facility and anytime the door bell rang Res #10 would become frightened and express worry that Res #80 was returning to hurt them. The administrator was asked if the facility had put anything in place to help Res #10 with their anxiety regarding Res #80 and the administrator stated they kept reassuring the resident that Res #80 would not be returning. The administrator asked if the facility had looked into mental health counseling for the resident to help them process and deal with the feelings, and stated not to their knowledge. The administrator was asked if the care plan had been updated to include interventions to help the resident feel safe. The administrator stated not to their knowledge. On 07/31/23 at 12:25 p.m., the administrator and RN #1 provided two copies of mental health notes for Res #10 dated after the incident. The administrator and RN #1 were asked if they had made the mental health professional aware of the event and Res #10's fearfulness. RN #1 stated they were unaware if the mental health professional had been made aware as they were a new service for the facility. RN #1 stated the Res #10 seemed better in June of this year than they were in May after the event when they had been very fearful. The administrator stated they looked though the in-service book and a post incident in-service was not conducted. The administrator stated they had spoken with staff during the stand up meeting on the morning of the incident only and had no documentation on what was discussed. On 07/31/23 at 1:25 p.m., the mental health professional was interviewed by phone and stated they had seen the resident in May and June as part of the resident's regular psychiatric health care. The mental health professional stated they always asked about abuse when starting care for a new client and if it was not documented in their notes it was because the resident had denied abuse occurred. The mental health professional was asked if the facility had told them the resident had been experiencing fearfulness related to an assault which had occurred in April of 2023. The mental health professional stated they had not been notified and it could take several months for a resident to open up about what they were dealing with since this was a new service provider to the facility and only saw clients at the facility starting in May. The mental health provider stated another service had been providing mental health services at the facility before April. 3. Res #16 had diagnoses which included symptomatic epilepsy, traumatic brain injury, schizoaffective disorders, and chromosomal abnormality. An annual assessment, dated 03/12/23, documented the resident was severely impaired in cognition, required extensive to total assistance with most ADLs, had upper extremity impairment on one side and lower extremity impairment on both sides. A nurse note, dated 04/12/23 at 1:15 a.m., documented the resident had been possibly injured in a fall and was sent to the hospital for evaluation and treatment. A nurse note, dated 04/12/23 at 4:40 a.m., documented a nurse from the hospital had contacted the facility for further information on Res #16. The nurse stated the resident had a brain bleed and was being held for observation for six hours and then a new CT would be done. A nurse note, dated 04/12/23 at 10:10 a.m., documented the facility called the hospital and spoke with the ER nurse, who at that time, told the facility it was not a brain bleed but was it was possible bruising and a non emergent MRI would be needed to be set up as an outpatient. A nurse note, dated 04/12/23 12:18, documented the resident had returned to the facility and the CT scans at the hospital had indicated an impression of a small left frontal hyperdensity which may have reflected a small parenchymal bleed. The note documented a follow up was recommended in two weeks. A quarterly assessment, dated 06/17/23, documented the resident was severely impaired in cognition, required extensive to total assistance with most ADLs, had upper extremity impairment on one side and lower extremity impairment on both sides. On 07/26/23 at 3:50 p.m., the administrator stated Res #80 was on every 15 minute observation and when the CNA had last checked on her she was in bed with her eyes closed. The administrator stated the CNA heard a noise and Res #80 had pulled Res #16 out of their bed and onto the floor. The administrator stated the nurse and the CNAs were immediately in the room removing Res #80 from the room and Res #16 was sent to the hospital. The administrator stated Res #16 returned later that day and neuro checks were done on the resident. The administrator was asked if they had any indication the resident may have been physically aggressive before they were admitted to the facility. The administrator stated the family had stated Res #80 had ''sundowners'' but there was no mention of physical aggression at that time. On 07/31/23 at 11:52 a.m., Res #16 was observed sitting in a geri-chair in the dining room positioned to look out the window. The resident was observed to be clean, dressed, and not in obvious distress. The resident was unable to be interviewed. The resident's hard chart and EHR were reviewed and no documentation of the follow up from the hospital visit on 04/12/23 were located. On 07/31/23 at 4:15 p.m., MDS coordinator #1 provided documentation from the physician they had ordered extended neuro checks on the resident and if anything changed the physician would consider further imaging. The MDS coordinator stated they thought the physician may not have followed up as the resident had a history of a previous traumatic brain injury and their condition. 4. Res #80 was admitted on [DATE] and had diagnoses which included dementia with behavioral disturbance. A base line care plan, dated 04/03/23, documented the resident was exit seeking and to redirect to room when wandering into others rooms. An admission assessment was not available. A nurse note, dated 04/03/23 at 9:35 p.m., documented Res #80 was wandering the facility and was exit seeking. The note documented the resident was entering other resident rooms and turning the lights on and had to be redirected but continued to pace the halls. A nurse note, dated 04/04/23 at 10:30 p.m., documented the resident was wandering up and down the halls and entering other resident rooms. The note documented the resident refused to go to their room and continued entering other resident rooms and going through their belongings. The note documented the resident stated, This is my house and they are in my rooms and I can go where I want. The note documented the staff continued to try to redirect the resident and the resident slapped a CNA's arm when the CNA placed their hand over a light switch to prevent Res #80 from turning on the light. The note documented the staff continued to walk with the resident as they paced the halls to attempt to redirect them when they tried to enter other resident room. The note documented Res #80 was paying no attention to redirection attempts. A nurse note, dated 04/04/23 at 11:04 p.m., documented the nurse was called to the end of the hall as Res #80 was attempting to climb out of the window. The note documented documented Res #80 punched the nurse in the jaw on the lower side of their face when they attempted to close the window and told the resident they could get cut by glass if they tried to break through the glass. The note documented the resident then returned to their room and sat in a recliner. The note documented the administrator was notified of the incident. A nurse note, dated 04/05/23 at 2:36 p.m., documented Res #80 was attempting to open a window in the front office and climb out and attempted to swing at the BOM. A nurse note, dated 04/05/23 at 3:11 p.m., documented the resident was in another resident's room and was swinging at staff for trying to close the window. The note documented Res #80 also was swinging at therapy personal for assisting the nursing staff. The note documented the physician was contacted and the resident was sent to ER for evaluation and treatment at a geri-psych unit. A nurse note, dated 04/05/23 at 10:16 p.m., documented the resident was brought back to the facility as the hospital did not think the resident needed a psychiatric evaluation and had contacted APS and obtained a police escort to return the resident to the facility. The note documented the family were notified that no acts of aggression towards staff or other residents would be tolerated and the resident would be referred out for geri-psych the next day for an appropriate evaluation. A nurse note, dated 04/07/23 at 5:50 a.m., documented Res #80 was constantly having to be redirected to not go in other resident rooms. A nurse note, dated 04/08/23 at 7:12 p.m., documented a woman called the facility to notify the nursing staff Res #80 was crawling out of the bedroom window. The note documented the nursing staff found the resident walking towards the highway. The note documented the staff returned the resident to the facility and placed the resident on 15 minute visual checks. A nurse note, dated 04/09/23 at 3:58 p.m., documented the resident had been placed in isolation due to a positive COVID-19 test and was non-compliant. A nurse note, dated 04/11/23 at 9:18 p.m., documented the resident was positive for COVID-19 and was up and ambulating around the facility. A nurse note, dated 04/12/23 at 2:30 a.m., documented 15 minute visual check completed at 12:45 a.m. The note documented around 12:50 a.m., Res #80 was in the room of Res #10, grabbing and clawing at the resident. The note documented Res #80 yelled at Res #10 to get out of bed and out of their house. The note documented Res #10 went to the bathroom to clean blood off of their arms and Res #80 went to Res #16's room and pulled defenseless resident on to the floor. The note documented a CNA responded by protecting Res #16 from Res #80s screaming and angry rage. The note documented 911 was notified and police, fire, and ambulance responded quickly. The note documented Res #80 responded by swinging at staff and throwing mouthwash on the officers. The note documented the EMTs were reluctant to transport Res #80. The note documented the ambulance left with Res #80 to a geri-psych unit at a hospital. A discharge summary, dated 04/13/23, documented the residents provisional diagnosis was dementia with behavioral disturbance and the final diagnosis was dementia with severe behavioral disturbance. On 07/31/23 at 9:18 a.m., the DON stated they had Res #80 on 15 minute checks and a CNA had just walked by. The DON stated they heard yelling and the resident was attacking two other residents as well as the staff members. The DON called EMS, the police, and contacted the physician right after EMS was called to get the resident to a place they could receive help. On 07/31/23 at 5:00 p.m., the administrator, RN #1, and the MDS coordinator, were in the administrator's office and were asked if they had any knowledge Res #80 could possibly become aggressive. The MDS coordinator stated the facility had been actively seeking placement in an geri-psych facility since the resident returned from the hospital after striking a staff member on 04/05/23 and the resident was placed on every 15 minute checks due to the elopement attempts. RN #1 confirmed every 15 minute checks had not worked to prevent exit seeking behavior and the resident should have been placed on one-on-one supervision. The MDS coordinator stated it would be hard to say if one on one supervision until placement in a geri-psych facility would have prevented the resident from attempting to hurt others but it might have made it much less likely.

Based on observation, interview, and record review, it was determined the facility failed to: ~ provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for two (#1 and #6) of eight sampled residents who had experienced falls. Resident #1 experienced six falls in two months, with one of the six falls resulting in actual harm when the resident sustained [REDACTED]. The facility identified five residents who were at high risk for falls. ~ provide thickened water in a resident's room for one (#6) of one resident who had a physician's orders [REDACTED]. The facility identified one resident who received thickened liquids. ~ ensure three bottles of alcohol, two bottles of wound cleanser, and one bottle of iodine solution were in a locked area, unaccessible to residents; and the medical supply closet was locked and did not create an accident hazard for residents. The resident census and condition report identified four residents who independently ambulated throughout the facility. Findings: An undated facility policy, titled Fall Prevention, documented, "...To provide a safe environment for the residents of our facility...On admission, each resident will be evaluated using the fall assessment tool. If the resident receives a score of 10 or greater, the Fall Protocol will be initiated...Reassess every day for change in fall risk and adjust interventions accordingly... If the resident: -is confused, disoriented, combative, or has unpredictable behavior... -has no regard for personal safety... -is unable to comprehend/recall instructions... -has a history of falls... has unsteady gait/moderate to severe physical impairment... -has bladder or bowel urgency/incontinence... -is receiving multiple medications... Then the following interventions will be added to the protocol: ...The bed rail evaluation form will be used to assess need and appropriate use of a bedside rail(s)...Use bedside rails while in bed for safety..." 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission evaluation/interim care plan, dated 03/28/14, documented the resident required supervision for bed mobility, transfers, and toileting. The evaluation documented the resident required assistance with walking/locomotion. A fall risk screen completed with the evaluation documented the resident's score was 14. The evaluation documented a score of 10 or higher indicated the resident was at risk for falls. A fall risk assessment, dated 03/28/14, documented the resident's score was 10. The assessment documented, "...total score of 10 or above represents HIGH RISK." There was no signature/title/date by who completed the assessment. An admission assessment, dated 04/10/14, documented the resident had a BIMS score of 3. This score indicated the resident was severely impaired for daily decision making. The assessment documented the resident required limited assistance with one person assistance for transfers, toileting, and required no assistance with walking in her room. The assessment documented the resident was not steady moving from seated to standing position, walking, and moving on and off toilet. The assessment documented the resident had no falls prior to admission. A care plan, dated 04/15/14, documented, "Problem: Falls...is at risk for falling due to previous fall resulting in hip fracture. Goal: will remain free from falls for the next 90 days. Approach: have light available in her room at night...keep bed in lowest position with brakes locked." An incident report, dated 05/22/14 at 3:10 p.m., documented, "Res. attempting to transfer self from w/c ...slid down to floor landing on bottom in front of dresser. Denies pain or discomfort. (No) bruising noted...Safety precautions to prevent recurrence: educated to use call light & lock w/c brakes before transfers..." The fall care plan, updated 05/22/14, documented, "...had a fall in her room...educate her on call light and to use it for assit (sic)...Lock w/c brakes before transfers." An incident report, dated 05/31/14 at 11:15 p.m., documented, "Resident's roommate was asking for help, stated her neighbor had fallen, Res found sitting in the floor beside her bed. States "I slid off the bed." c/o pain...red area to R hip and lower R side of back...Safety precautions to prevent recurrence: mobile x-ray to x-ray R hip. encouraged resident to use call light for assistance to the bathroom. Follow up: No visible injuries noted. Does not report any pain or discomfort at time of follow-up..." The fall care plan, updated on 05/31/14, documented, "Problem: had another fall in her room. Approach: She had mobil (sic) xray to rule our fracture. Instructed her again to not be getting up by herself, and use call light for assitance (sic)." An incident report, dated 06/21/14 at 5:50 a.m., documented, "resident on floor by her bed. Resident states she was getting (up) to the bathroom...slid to her bottom, hitting her back...bottom...states back and bottom are sore. Safety precautions to prevent recurrence: told resident to wear non-slip shoes when walking...ask for help. Follow up: Had another fall 6/23..." The fall care plan, updated 06/21/14, documented, "Problem: slid to floor while getting up to BR. Approach: Staff to ensure she is wearing non-slip shoes/socks when walking and to always ask for help when needing to go to the bathroom." An incident report, dated 06/23/14 at 9:40 a.m., documented, "Resident slipped and fell coming out of the bathroom, room was very cluttered, aides assisted to clean room to limit further fall risks...No visible injury or s/s pain...Safety precautions to prevent recurrence: ensure room remains clutter free and proper foot wear is in place. Follow up: resident placed on 72 (hour) charting room remains free of clutter..." The fall care plan, updated 06/23/14, documented, "Problem: slipped and fell coming out of BR. Approach: CNAs cleaned room of clutter and will monitor to ensure it stays clutter-free." An incident report, dated 07/01/14 at 7:05 p.m., documented, "Res. found on floor near closet in room. Lying on left side. c/o pain in L hip. Assisted to bed. Called mobile xray for L hip xray...red area on L hip noted...Safety precautions to prevent recurrence: monitor for assist to BR. Follow up: Xray results negative..." The fall care plan, updated 07/01/14, documented, "Problem: fall in room. Approach: Staff is to offer to assist her to bathroom before meals and at bedtime." An incident report, dated 07/06/14, documented, "...Resident was up going to the bathroom...fell on floor and hit L hip. Assisted to bed v/s taken. Dr...called. Pt educated not to get up (without) calling nurse...also educated pt on fall prevention...also instructed to use call light...portable xray called for hip xray." The fall care plan, updated 07/06/14, documented, "Problem: fall in her room Fall score 13. Approach: Fall mat placed on floor, Oxygen tubing changed to shorter tube, and her staff will ensure that her room remains free of clutter." An initial state reportable incident report, dated 07/06/14, documented, "...Resident stated that she was on her way to bathroom when she fell and hit her Left hip. Denies slipping or tripping on anything. States that she was just walking and fell . Resident sent to ER with a fracture..." A final state reportable incident report, dated 07/06/14, documented, "...Portable x-ray obtained. Resident sent to ER with a fracture...has a [DIAGNOSES REDACTED]. O2 tubing replaced with standard length tubing. De-cluttered room and provided a fall mat. Hip protectors ordered. Frequent toileting implemented..." A fall investigation report, dated 07/07/14, by the RN consultant, documented at the time of the fall the resident needed to use the bathroom, was wearing shoes, and was going to the bathroom. The report documented, "Interventions pre-fall: -Blank." There were no post fall interventions documented on the report. The RN consultant documented, "Resident states she did not slip or trip on anything. Stated she just fell on her way to the B.R." The resident was readmitted to the facility on [DATE]. A quarterly assessment, dated 07/18/14, documented the resident had a BIMS of 3. This score indicated the resident was severely impaired for daily decision making. The assessment documented the resident required limited assistance with ADLs, did not ambulate, was frequently incontinent, was not on a toileting program, and had a [DIAGNOSES REDACTED]. The fall care plan had not been updated to address the resident had fractured her hip. No new interventions had been added to the care plan to prevent future falls. A fall care plan, updated 08/25/14, documented, "...Care plan reviewed...Continue with current care plan and interventions." The fall care plan did not address that the resident had sustained a hip fracture. No interventions were put in place to prevent future falls. On 08/25/14 at 10:30 a.m., the resident was observed in her room, fall mat was at bedside, and call light within reach. The resident was alert and responsive to questions. The resident was asked if she received assistance with toileting and transfers. The resident stated, "Sometimes." The resident was asked about her recent fall and hip fracture. The resident stated she had broken both hips since she had been admitted to long term care. She stated she had recently broke a hip at this facility. On 08/28/14 at 11:25 a.m., the DON was asked if bowel and bladder assessments had been done on the resident. She stated, "No." She was asked if the resident was on a toileting schedule. She stated, "No." She was asked how they monitored the resident for assistance to the bathroom. She stated, "I will have to look." The plan and the schedule to monitor the resident was not provided. The DON was informed of the numerous falls that had occurred and the last fall on 07/06/14, which had resulted in a hip fracture. She was asked if the root cause of the falls had been determined. The DON stated the root cause had not been determined. 2. Resident #6 had [DIAGNOSES REDACTED]. A fall risk assessment, dated 01/08/14, documented the resident had experienced three or more falls in the past three months. The assessment documented a score of 18. This score indicated the resident was at high risk for falls. An incident report, dated 01/13/14, documented, "...resident was walking to the bathroom in his room & lost his balance & landed on the floor...(no) injury noted...Safety precautions to prevent recurrence: ...encourage/remind resident to use call light & wait for assistance..." An incident report, dated 01/19/14, documented, "...Residents alarm going off - Resident found laying in floor by nurses station - states "I slipped out of my chair" wheelchair was sitting in Lobby away from Resident...c/o back and hips hurting...Safety precautions to prevent recurrence: ...Staff to offer Resident glass of water when sitting in Lobby...sent to ER for Eval and treat..." An incident report, dated 01/20/14, documented, "...resident was transferring from couch into his chair & went down on his rear...(no) injury noted...Safety precautions to prevent recurrence: ...resident reminded to leave alarm intact & to ask for assistance..." An incident report, dated 01/20/14, documented, "...resident was transferring hisself (sic) from scoot chair to potty chair & fell alarm intact & working...(no) injury noted...Safety precautions to prevent recurrence: ...remind resident to use call light & ask for assistance..." A follow up to the incident, dated 01/21/14, documented, "...Check c hospice to see if chair can be lowered in back or a cushion provided to hinder resident from getting up (without) assistance..." An incident report, dated 01/24/15 (14), documented, "...Maintenance saw res in w/c in hall but when he looked over saw res going to floor holding side rails in hall & sat on floor...states bottom sore...Safety precautions to prevent recurrence: ...After further investigation noted cushion on scoot chair coming...sliding - straps not long enough to wrap around (with) velcro in w/c..." A follow up to the incident, dated 01/28/15 (14), documented, "...OT/PT ordered for strengthening..." An incident report, dated 02/02/14, documented, "...Pt stated I stood up to get TV control & sat down on floor my legs got weak...no injury...Safety precautions to prevent recurrence: Instructed resident to not get up (without) asking for assistance..." A follow up to the incident, dated 02/03/14, documented, "...continues to get up (without) assistance...w/c pad will not stay in chair, straps too short..." An incident report, dated 02/04/14, documented, "...Res found on floor in room - states he was going to turn off TV & fell on bottom...(no) injuries does say bottom is sore...Safety precautions to prevent recurrence: ...talked c DON & QA RN - about...TV..." A fall care plan, updated 02/04/14, documented, "...Remind...to ask for assistance with transfer...non-skid socks, slippers, or shoes...provide...with safety device/appliance: ...A scoot chair with a lower seat has been implemented to decrease the risk of falls...fall star program...fall prevention program...call light..." The fall care plan did not address a fall intervention related to the resident's attempts at toileting, the falls regarding the television being turned off or the access to the remote control, no documentation physical therapy and occupational therapy were started, and what the falling star program/fall prevention program consisted of regarding the prevention of falls. A follow up to the incident, dated 02/06/14, documented, "...will be moving...to different area of room or another room to be able to arrange furniture and television in such a way to prevent falls..." An incident report, dated 02/06/14, documented, "...resident found in front lobby in the floor c TV remote in his hand states he was trying to change the channel...alarm did not sound...(no) injury...Safety precautions to prevent recurrence: ...resident reminded to ask for assistance c transfers & getting stuff...ensure chair alarm is in working order...lower back of scoot chair..." A fall risk assessment, dated 02/06/14, documented the resident had experienced three or more falls in the past three months. The assessment documented a score of 18. This score indicated the resident was at high risk for falls. The fall care plan, updated 02/06/14, documented, "...Ensure his chair alarm is in working order... ...02/11/2014...Scoot chair has been lowered to lowest position...Keep...remote control and personal items and frequently used items within reach...fall mat at Bedside...Bed and chair alarms in place..." An incident report, dated 02/14/14, documented, "...Resident had gotten out of bed to use restroom, when attempting to get up from toilet fell on bottom...states only bottom hurts (no) injuries...Safety precautions to prevent recurrence: ...Reminded resident to use the call light & not to attempt walking (without) help from CNAs..." A follow up to the incident, dated 02/16/14, documented, "...discuss delivery of a low bed..." An incident report, dated 02/16/15 (14), documented, "...Residents bed alarm going off - resident found laying in floor in the bathroom - States "I needed to go to the bathroom"...(no) redness or bruising noted...or injury...Safety precautions to prevent recurrence: ...Assisted resident to chair, c chair alarm in place...Low bed requested..." The fall care plan, updated 02/16/14, documented, "...low bed... ...02/21/2014...Therapies to write a restorative plan... ...03/01/2014...has been moved to the other side of room so TV plug in cannot be reached by him..." The fall care plan did not address a fall intervention related to the resident's attempts at toileting and falling and no documentation physical therapy and occupational therapy were started. An incident report, dated 04/09/14, documented, "...Resident scooted out of bed & on the floor to the door. Bed alarm malfunctioned. Resident stated he was hungry, so we provided a snack...(no) c/o pain or hitting anything @ all...Safety precautions to prevent recurrence: ...Advised resident in using his call light & put a new bed alarm in place..." An incident report, dated 04/11/14, documented, "...res found sitting on floor in room in doorway facing hallway...Res said he got (up) to (change) his TV & needed remote - remote was in bed (with) him...states bottom a little sore...Safety precautions to prevent recurrence: ...Provide remote in resident's hand when put to bed..." An incident report, dated 04/12/14, documented, "...Resident was attempting to ambulate (without) assistance...Resident fell on bottom...Bruise starting to appear on top of bottom...Safety precautions to prevent recurrence: ...Educated resident on call light & provided a snack..." An incident report, dated 04/22/14, documented, "...res had parked w/c to door & got (up) & walked toward bed & fell - on R side...c/o hips sore BL - & back soreness...had alarm still stuck to him & did not go off...Safety precautions to prevent recurrence: ...(Blank)..." The resident had experienced four falls during the month of April. There was no documentation to indicate physical therapy and occupational therapy were started, and the fall care plan had not been updated with new interventions for the prevention of further falls. An incident report, dated 05/07/14, documented, "...Resident was in front lobby & tried to transfer self from couch to chair when he said chair "scooted" out from underneath him & he slid down then laid down...(no) marks or injuries noted...Safety precautions to prevent recurrence: ...Resident was re-iterated to over waiting for help to transfer..." An annual assessment, dated 05/07/14, documented the resident had a BIMS score of 8. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident had not exhibited any behaviors, required extensive assistance with transfers, was not steady with moving from a seated to a standing position, not steady with walking, not steady with moving on and off the toilet, not steady with surface-to-surface transfers (transfer between bed and chair or wheelchair), was always incontinent of urine, was always incontinent of bowels, was not on a toileting program, had a [DIAGNOSES REDACTED]. days. A nurse's note, dated 05/09/14, documented, "...Attempts to get out of bed on own x2..." A fall care plan, dated 05/12/14, documented, "...Problem: ...has had an increase in falling R/T to impaired mobility...has had frequent falls for 1/13/14 through 2/16/14...has been sliding self off his low bed...Approach: ...Instructed again to not be getting self up from his chair without assitance (sic) from staff...Ensure safety alarm is connected properly to chair...Educated on call light use...new bed alarm...low bed...fall mat...keep...remote control and personal items and frequently used items within reach...Scoot chair...to lowest position...fall star program...fall prevention program...non-skid socks..." The fall care plan did not address a fall intervention related to the resident's attempts at toileting and falling, no documentation physical therapy and occupational therapy were started, and there were no new interventions addressed for the prevention of further falls. A nurse's note, dated 05/20/14, documented, "...Several attempts to ambulate alone...res ret'd to chair..." An incident report, dated 06/06/14, documented, "...resident was found on floor of room stated he got (up) from w/c to go to bed landed on bottom...c/o of soreness...(no) injury...Safety precautions to prevent recurrence: ...resident reminded to ask for assistance c transfers..." An incident report, dated 06/11/14, documented, "...Res (up) in geri chair in living room & attempted to transfer self to couch & slid to floor...(no) injuries...Safety precautions to prevent recurrence: ...Asked staff to leave res. in bed until ready for him to go to dining room for meal..." The fall care plan, dated 06/11/14, documented, "...When...through with meals offer to toilet and assist him to bed or to sit on couch in lobby..." The care plan did not address new fall interventions when the resident was in the lobby area or his room and falling, no documentation physical therapy and occupational therapy were started, and there were no new interventions for the prevention of further falls. An incident report, dated 06/21/14, documented, "...Res found sitting on bottom in B/R between w/c & toilet...hit butt...states her was going to B/R...fell ...Res had left DR after eating to toilet self...Did not ask...c/o soreness to bottom...stated BL arms sore...had red area to bottom...Safety precautions to prevent recurrence: ...reminded res to only transfer c help-told CNAs to monitor & keep in D/R till they are able to leave & (assist) him..." The fall care plan, updated 06/21/14, documented, "...Staff is to leave (resident) in dining room after eating to moniter (sic) him until they (staff) are able to take him to bathroom..." An incident report, dated 07/11/14, documented, "...resident stated he was going to bathroom was found on floor of bathroom door laying on left side states his back & butt hurt able to move all extremities...red areas indicated...Safety precautions to prevent recurrence: ...discussed c hospice getting mattress c bolsters..." A fall risk assessment, dated 07/11/14, documented the resident had experienced one to two falls in the past three months. The assessment documented a score of 19. This score indicated the resident was at high risk for falls. The resident's clinical record revealed the resident had experienced nine falls in the past three months. A fall investigation record, dated 07/11/14, documented the resident needed to use the bathroom and fell going to the bathroom. The investigation record documented, "...Interventions in Place Pre-Fall: ...Toileting program...Chair Alarm...Fall Prevention Program...Increased Monitoring...Low Bed...Bed Alarm...Comments: ...states he was going to the bathroom & fell ...ordering new alarms for bed & chair & mattress c bolsters..." The fall investigation record did not address the resident had fallen six times going to the bathroom without assistance, or how the staff were to increase the monitoring. There was no documentation to indicate physical therapy and occupational therapy were started, and there were no new interventions for the prevention of further falls. The fall care plan, updated 07/11/14, documented, "...Staff to take to bathroom before laying him down..." An incident report, dated 07/17/14, documented, "...resident was found on floor in front lobby between a wicker love seat & his scoot chair...states he was trying to get in his w/c...c/o back pain red area noted to R back...Safety precautions to prevent recurrence: ...new alarm put in scoot chair..." A fall risk assessment, dated 07/17/14, documented the resident had experienced three or more falls in the past three months. The assessment documented a score of 22. This score indicated the resident was at high risk for falls. A fall investigation record, dated 07/17/14, documented the resident wanted to get in his wheelchair and fell . The investigation record documented, "...Interventions in Place Pre-Fall: ...Chair Alarm...scoot chair...Comments: ...Chair alarm turned on but did not sound when resident stood up..." The investigation record did not address if the alarm was attached to the wicker chair the resident was sitting in at the time of the recorded fall and there was no documentation physical therapy and occupational therapy were started. The investigation record did not address any new interventions for the prevention of further falls. A nurse's note, dated 07/18/14, documented, "...continue to remind Res. not to stand unassisted. Forgets & stands unassisted x2..." A nurse's note, dated 07/19/14, documented, "...Resident found face first on fall matt (sic) in room...went to room after hearing bed alarm going off...Resident states he hit his forehead...Told resident to ask for help going to bathroom...call light within reach..." An occupational therapy evaluation note, dated 07/30/14, documented, "...Reason for Referral: ...resident who exhibits decline and falls...fall risk with non-compliance to call likght (sic) reported...Prior Therapy Services: none this year...Pt. displays significant deficit in UE function, sit & stand balance, muscle strength and tolerance..." A quarterly assessment, dated 08/07/14, documented the resident had a BIMS score of 4. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had not exhibited any behaviors, required extensive assistance with transfers, was not steady with moving from a seated to a standing position, not steady with walking, not steady with moving on and off the toilet, not steady with surface-to-surface transfers (transfer between bed and chair or wheelchair), was always incontinent of urine, was frequently incontinent of bowels, was not on a toileting program, had a [DIAGNOSES REDACTED]. days. A physical therapy assessment progress note, dated 08/08/14, documented, "...has had a fair response to treatment, and has made little progress. Pt. has refused to participate in any strengthening exercises, and transfer training has been limited by pt. tolerance..." A physical therapy note, dated 08/11/14, documented, "...Pt. became agitated when asked to start therapy session and refused to participate in therapy today..." The fall care plan, updated 08/12/14, documented, "...falls have decreased slightly...Numerous Interventions have been added to his care plan...Staff responds quickly to his alarm and follow care plan interventions...has a Scoot chair...has PT OT ordered but is not compliant...Continue with care plan..." A physical therapy note, dated 08/13/14, documented, "...Pt. became agitated when asked to start therapy session and refused to participate in therapy today..." A physical therapy note, dated 08/15/14, documented, "...Pt. became agitated when asked to start therapy session and refused to participate in therapy today. Pt. will discharge from PT on 08/15/14 due to refusal to participate in POC..." An occupational therapy note, dated 08/18/14, documented the resident had been discharged from occupational therapy. On 08/25/14 at 4:00 p.m., the resident was observed in his room. When a CMA entered the resident's room to offer his medication the resident asked her to fix the television for him. The resident was not observed with his remote control to the television. On 08/28/14 at 9:16 a.m. the DON was asked about the fall risk assessments. She stated, "We have a book with those. July and August we have started attaching a fall risk assessment to the incident report. She was asked about the bowel and bladder assessments. She stated, "The bowel and bladder assessments are done on admission." The DON was informed of the resident's 21 falls since January 2014 and during seven of those falls the resident had attempted to go to the bathroom, unassisted, and had fallen. The DON stated, "We added it to the care plan to toilet after meals and at bedtime. He has a urinal and we make frequent rounds on him." The DON was asked for the resident's bowel and bladder assessment and his toileting program. She stated, "I have not done one. I don't know if we have a bowel and bladder book." No assessment was provided. At 4:28 p.m., the DON and the care plan coordinator were informed of the resident's falls since January 2014 and why new interventions had not been addressed on the care plan. They were asked if the resident used his call light. The DON stated, "No he doesn't use the call light." The care plan coordinator stated, "Not very often. Very seldom." They were asked if the resident could ambulate. The DON stated, "He can stand, unsteady." They were asked if he could get out of the low chair unassisted. The care plan coordinator stated, "Yes." They were asked why there were no new interventions to address the residents continued attempts to transfer unassisted, attempts to "fix" his television, and continued attempts to go to the bathroom unassisted. The DON stated, "We have tried many interventions." The DON and the care plan coordinator were asked what the falling star program and the fall prevention program consisted of to prevent the resident from falling. The DON stated, "We aren't doing it." 3. Resident #6 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A nurse's note, dated 07/11/14, documented, "...resident diet (changed) to Nectar thick liquids...will cont to monitor..." A quarterly assessment, dated 08/07/14, documented the resident had a BIMS score of 4. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident did not have signs and symptoms of a possible swallowing disorder and required a mechanically altered diet which required a change in the texture of foods or liquids. On 08/28/14 at 1:26 p.m., the resident was observed in his bed. A small glass of thickened water and a small glass of thin water with a straw were observed on the resident's night stand. At 1:49 p.m., LPN #1 was asked if the resident could have water in his room. The LPN stated, "Yes. We provide it if he asks for it." The LPN was asked if the resident was to receive thin water. She stated, "Not suppose to. He is allowed thickened water." CNA #1 was asked if t

Based on interview and record review, it was determined the facility failed to notify the physician of a head injury and a change in condition for one (#7) of one sampled resident who received a head injury during a resident to resident altercation. The resident complained of a headache after the injury and continued to complain of a headache. The resident expired eight days following the incident. This had the potential to affect 37 of 37 residents who resided in the facility. Findings: Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented, "Problem: Behavioral Symptoms ...has socially inappropriate/disruptive behavioral symptoms as evidenced by: Yelling...kicking other residents, resistive in approach to room mates. Goal: Resident will not harm self or others secondary to socially inappropriate/disruptive behavior within the next 90 days. Current behavior pattern: Yelling, kicking other residents, resistive in his approach to room mates. Approach: ...Assess whether the behavior endangers the resident and/or others. Intervene if necessary...Avoid over-stimulation noise, crowding, other physically aggressive residents...Maintain a calm approach...convey an attitude of acceptance..." A quarterly assessment, dated [DATE], documented the resident had a BIMS score of 13. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident had not exhibited any behaviors, ambulated with limited assistance, used a walker and wheelchair for mobility, and received an antidepressant medication on seven of the last seven days. An incident report, dated [DATE], documented, "...BP ,[DATE]...Resi got into altercation with another male resident. ...said that he (resident #5) had hit him twice - once on the forehead + once on the chin. - he said he then kicked him back, they were immediately separated...Injury: redness c sm bump on forehead...physician notified... send to hosp for eval geri psych...son notified..." The care plan, updated [DATE], documented, "Problem: He got into an altercation with another resident. Approach: He was removed from other resident. Checked for injuries, notified family, Dr., D.O.N., and APS and was counseled by administrator. Placed on monitoring. A follow up report by the DON, dated [DATE], documented, "Not sent to geri- psych per administrators decision. No [MEDICATION NAME] injuries noted, neuros WNL. 1:1 complete, random checks done to check residents whereabouts to prevent resident to resident interaction." There was no documentation to indicate random checks had been initiated. A nurse's note, dated [DATE] at 11:10 a.m., documented, "res in D/R heard yell + saw another res + him - (resident #7) had came to him to confront him (per (resident #7) (after)) about - (resident #5) walking in his room last night + told him that all the rooms were his - When he confronted him (unable to read) to (resident #7) He picked (up) the D/R chair + hit him. Noted cut to eyebrow (R) - bleeding cleaned c NS + applied dsg...Does c/o being sore + c/o HA..." An incident report, dated [DATE], documented, "Res in DR - wheeled over to another res - (per (resident #7) report) + saw him there. He said he confronted him re- previously last night going into his room. + other res ( resident #5) picked up a chair + hit him in the head - cut to R eyebrow. bleeding - not too deep - c/o headache + sore to area - neuros initiated...physician notified fax...son notified...Educate...that he cannot confront other residents about their behavior...to let staff know so they can monitor more closely..." An OSDH incident report form, dated [DATE], documented, "(Resident #5) was sitting in the dining room waiting for mealtime. (Resident #7) rolled up to him in his wheelchair and confronted (resident #5) about 'coming into his room'. (Resident #5) became agitated when confronted and picked up his chair and hit (resident #7) in the head with it. (Resident #7) received a cut to his right brow, cleansed with NS and bandaged. Neuros initiated..." A nurse's note at 3:15 p.m., documented, "Called Hospice talked to nurse...re: incident...need for some kind of counseling or psych eval - DT confrontation had recently taken off some psych meds res was confronting other res + I had spoken to him about always letting us know if there is an issue + let us take care of it. (Resident #7) states he did not tell anyone about it last night or today. But decided to confront him by himself - also states he would tell us next time - but feels he had the right - told him that that could cause agitation behavior + to leave it up to us to deal c it + not take care of it on his own. LPN at hospice will look into getting some kind of counseling services started + ask Dr about resuming prev - dc'd psych meds if needed." The care plan, updated [DATE], documented, "Problem: confronted male resident...hit in head. Approach: Removed from other resident, taken to his room and assessed. Instructed him to let staff take care of issues with other residents. Hospice was notified for need of counseling or psych eval." A nurse's note, dated [DATE] at 3:00 a.m., documented, "VS 98 - ,[DATE] - 59 - 18 98%. In bed resting c/o H/A (headache). Prn pain med given & res. stated relief 1 (hour) later. Neuro (checks) WNL." A nurse's note, dated [DATE], documented, "C/O Headache...neck pain. [MEDICATION NAME] given per prn orders. S further c/o...neuros cont - WNL." A MAR, dated ,[DATE], documented the resident received [MEDICATION NAME] ,[DATE]mg prn for pain seven times and [MEDICATION NAME] 50mg four times from [DATE] through [DATE]. There was no documentation to show the physician was notified the resident had sustained a head injury or of the headaches the resident experienced following the head injury. A nurse's note, dated [DATE], documented, "CNA's called this nurse to residents room resident was unresponsive but moaning tried sternal rub (no) response. (Check) FSBS 182 BP ,[DATE] P 89 O2 49% RA hospice called + O2 put on via NC hospice nurse (name deleted) here resident moved to room...for privacy." A nurse's note, dated [DATE] at 11:02 a.m., documented, "resident passed away..." On [DATE] at 2:00 p.m., RN #1 was asked what had occurred when residents' #7 and #5 had an altercation in the dining room on [DATE]. She stated she was the charge nurse and resident #7 told her that he had confronted resident #5 after the altercation had occurred. She stated, "We were trying to get people into the dining room and I don't know if anyone saw that or not." The RN was asked if she had notified the resident's physician regarding his head injury. She stated she had sent a fax of the incident report to inform the physician of what had occurred. She was asked if she had heard back from the physician or attempted to notify him further. She stated, "No, I don't think I did. I didn't further follow up with doctor just fax to let him know there was an incident." She was asked why she did not notify the physician. She stated, "I felt like he was ok so I didn't." She stated she had done neuro checks on the resident and they were within normal limits. She stated she had notified the resident's son and told him what had happened. On [DATE] at 3:35 p.m., the primary care physician was asked if he was notified that resident #7 had sustained a head injury on [DATE] and had several headaches after the altercation occurred. He stated he had been out of town and was not sure if any of his colleagues had been notified. He stated generally they contact the doctor on call for the group. He was asked if the facility should have notified him or another physician that the resident had sustained a head injury and had experienced headaches after the injury. He stated, "I believe someone should have been told." He was asked if he was aware the resident had expired on [DATE]. He stated he was still out of town then but had received the resident's death certificate. The physician stated he was unaware of a fax sent by the facility on [DATE] due to he was out of town and had not received the information. On [DATE] at 2:00 p.m., the DON was asked if the resident's physician should had been notified regarding the head injury and headaches that followed. She stated, "Yes, considering it was a head injury we should have talked to the doctor or made sure the fax was addressed." She was asked if the nurses should have notified the physician when the resident continued to have headaches after the injury had occurred. She stated, "Yes, they should have put that together and notified him." She was asked who would be responsible to follow up on the nurses to ensure they notified the physician. She stated, "I should be the one that followed up." She was asked if she had. She stated, "I don't recall that I did."

Based on interview and record review, it was determined the facility failed to assess, monitor, and intervene for one (#7) of six sampled residents who were involved in resident to resident altercations. The resident received a head injury during an altercation and complained of a headache after the injury and continued to complain of a headache for six days after the incident. The resident expired eight days following the incident. This had the potential to affect 37 of 37 residents who resided in the facility. Findings: Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented, "Problem: Behavioral Symptoms ...has socially inappropriate/disruptive behavioral symptoms as evidenced by: Yelling...kicking other residents, resistive in approach to room mates. Goal: Resident will not harm self or others secondary to socially inappropriate/disruptive behavior within the next 90 days. Current behavior pattern: Yelling, kicking other residents, resistive in his approach to room mates. Approach: ...Assess whether the behavior endangers the resident and/or others. Intervene if necessary...Avoid over-stimulation noise, crowding, other physically aggressive residents...Maintain a calm approach...convey an attitude of acceptance..." A quarterly assessment, dated [DATE], documented the resident had a BIMS score of 13. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident had not exhibited any behaviors, ambulated with limited assistance, used a walker and wheelchair for mobility, and received an antidepressant medication on seven of the last seven days. An incident report, dated [DATE], documented, "...BP ,[DATE]...Resi got into altercation with another male resident. ...said that he (resident #5) had hit him twice - once on the forehead + once on the chin. - he said he then kicked him back, they were immediately separated...Injury: redness c sm bump on forehead...physician notified... send to hosp for eval geri psych...son notified..." The care plan, updated [DATE], documented, "Problem: He got into an altercation with another resident. Approach: He was removed from other resident. Checked for injuries, notified family, Dr., D.O.N., and APS and was counseled by administrator. Placed on monitoring." The care plan did not include any specific interventions regarding how the resident was to be monitored. No specific interventions were put in place to prevent future resident to resident altercations. A follow up report by the DON, dated [DATE], documented, "Not sent to geri- psych per administrators decision. No [MEDICATION NAME] injuries noted, neuros WNL. 1:1 complete, random checks done to check residents whereabouts to prevent resident to resident interaction." There was no documentation to indicate random checks had been initiated. A nurse's note, dated [DATE] at 11:10 a.m., documented, "res in D/R heard yell + saw another res + him - (resident #7) had came to him to confront him (per (resident #7) (after)) about - (resident #5) walking in his room last night + told him that all the rooms were his - When he confronted him (unable to read) to (resident #7) He picked (up) the D/R chair + hit him. Noted cut to eyebrow (R) - bleeding cleaned c NS + applied dsg...Does c/o being sore + c/o HA..." An incident report, dated [DATE], documented, "Res in DR - wheeled over to another res - (per (resident #7) report) + saw him there. He said he confronted him re- previously last night going into his room. + other res (resident #5) picked up chair + hit him in the head - cut to R brow. bleeding - not too deep - c/o headache + sore to area - neuros initiated...Educate...that he cannot confront other residents about their behavior...to let staff know so they can monitor more closely..." The form documented the physician was notified by fax and that the son was notified. An OSDH incident report form, dated [DATE], documented, "(Resident #5) was sitting in the dining room waiting for mealtime. (Resident #7) rolled up to him in his wheelchair and confronted (resident #5) about 'coming into his room'. (Resident #5) became agitated when confronted and picked up his chair and hit (resident #7) in the head with it. (Resident #7) received a cut to his right brow, cleansed with NS and bandaged. Neuros initiated..." A nurse's note at 3:15 p.m., documented, "Called Hospice talked to nurse...re: incident...need for some kind of counseling or psych eval - DT confrontation...had recently taken off some psych meds res was confronting other res + I had spoken to him about always letting us know if there is an issue + let us take care of it. (Resident #7) states he did not tell anyone about it last night or today. But decided to confront him by himself - also states he would tell us next time - but feels he had the right - told him that that could cause agitation behavior + to leave it up to us to deal c it + not take care of it on his own. LPN at hospice will look into getting some kind of counseling services started + ask Dr about resuming prev - dc'd psych meds if needed." The care plan, updated [DATE], documented, "Problem: confronted male resident...hit in head. Approach: Removed from other resident, taken to his room and assessed. Instructed him to let staff take care of issues with other residents. Hospice was notified for need of counseling or psych eval." A nurse's note, dated [DATE] at 3:00 a.m., documented, "VS 98 - ,[DATE] - 59 - 18 98%. In bed resting c/o H/A (headache). Prn pain med given & res. stated relief 1 (hour) later. Neuro (checks) WNL." A nurse's note, dated [DATE], documented, "C/O Headache...neck pain. [MEDICATION NAME] given per prn orders. S further c/o...neuros cont - WNL." A MAR, dated ,[DATE], documented the resident received [MEDICATION NAME] ,[DATE]mg prn for pain seven times and [MEDICATION NAME] 50mg four times from [DATE] through [DATE]. There was no documentation to show the physician was notified the resident had sustained a head injury or of the headaches the resident experienced following the head injury. A nurse's note, dated [DATE], documented, "CNA's called this nurse to residents room resident was unresponsive but moaning tried sternal rub (no) response. (Check) FSBS 182 BP ,[DATE] P 89 O2 49% RA hospice called + O2 put on via NC hospice nurse (name deleted) here resident moved to room...for privacy." A nurse's note, dated [DATE] at 11:02 a.m., documented, "resident passed away..." On [DATE] at 2:00 p.m., RN #1 was asked what had occurred when residents' #7 and #5 had an altercation in the dining room on [DATE]. She stated she was the charge nurse and resident #7 told her that he had confronted resident #5 after the altercation had occurred. She stated, "We were trying to get people into the dining room and I don't know if anyone saw that or not." The RN was asked if she had notified the resident's physician regarding his head injury. She stated she had sent a fax of the incident report to inform the physician of what had occurred. She was asked if she had heard back from the physician or attempted to notify him further. She stated, "No, I don't think I did. I didn't further follow up with doctor just fax to let him know there was an incident." She was asked why she did not notify the physician. She stated, "I felt like he was ok so I didn't." She stated she had done neuro checks on the resident and they were within normal limits. She stated she had notified the resident's son and told him what had happened. At 3:35 p.m., the primary care physician was asked if he was notified that resident #7 had sustained a head injury on [DATE] and had several headaches after the altercation occurred. He stated he had been out of town and was not sure if any of his colleagues had been notified. He stated generally they contact the doctor on call for the group. He was asked if the facility should have notified him or another physician that the resident had sustained a head injury and had experienced headaches after the injury. He stated, "I believe someone should have been told." He was asked if he was aware the resident had expired on [DATE]. He stated he was still out of town then but had received the resident's death certificate. The physician stated he was unaware of a fax sent by the facility on [DATE] due to he was out of town and had not received the information. On [DATE] at 2:00 p.m., the DON was asked if the resident's physician should had been notified regarding the head injury and headaches that followed. She stated, "Yes, considering it was a head injury we should have talked to the doctor or made sure the fax was addressed." She was asked if the nurses should have notified the physician when the resident continued to have headaches after the injury had occurred. She stated, "Yes, they should have put that together and notified him." She was asked who would be responsible to follow up on the nurses to ensure they notified the physician. She stated, "I should be the one that followed up." She was asked if she had. She stated, "I don't recall that I did."

Based on observation, record review, and interview, it was determined the facility failed to provide supervision and prevention from resident to resident altercations and mistreatment for [REDACTED].#3, #5, #6, and #7) of five residents with aggressive and/or abusive behaviors; and failed to supervise and protect two (#1 and #4) of two residents who left the facility property unsupervised. Resident #1 was missing from the facility for approximately four hours on [DATE] and one hour on [DATE]. Resident #7 sustained a head injury during an altercation when another resident picked up a dining room chair and hit him over the head. Three residents were identified as wanderers. The facility identified five residents who left the facility property unsupervised, and five residents with aggressive and/or abusive behaviors. This had the potential to affect all 37 residents who resided in the facility. Findings: A facility policy, titled Abuse Prohibition Procedure, documented, "...Mistreatment: is defined as actions by a demented resident that constitute inappropriate behavior and/or may be a threat to other residents (resident to resident) or themselves... Facility will ensure preventive measures on wandering residents not to be abused by other residents and/or mistreatment. Preventive measure will be removing resident from harm's way immediately. A licensed nurse will assess and treat any injuries to the wandering resident. Depending on the injury, if any, resident may be sent to the hospital for further treatment... For the protection of the wandering resident, resident will be placed on a Q15 minute check for the first 72 hours. The Interdisciplinary Team will determine the longevity to monitor the wandering resident and prepare a care plan that establishes the protection of wandering residents from aggressive/abusive residents..." A facility policy, titled Missing Person Procedure-Elopement, documented, "...A missing person is identified as a person who cannot be located after one minute of searching...After the resident is found: a. Assess for injuries, changes in condition...b. Complete an incident report...c. Follow procedures outlined in QI procedures...d. Take steps to assure the elopement is prevented in the future..." A facility policy, titled Wandering or Missing Resident, documented, "...The facility will provide supervision to promote a safe environment for residents as (sic) risk for injury due to wandering or elopement behaviors... Wandering exhibited by residents who are cognitively impaired can put the resident at risk for harm...Whenever a resident leaves facility property, unaccompanied by staff or family members, without notifying the facility staff, an elopement has occurred...Residents who 'elope' from the facility may or may not be cognitively impaired... If a resident repeatedly wanders off the unit, the Resident Care Plan should reflect a monitoring schedule to ensure resident safety..." 1. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated [DATE], documented, "Problem: Behavioral Symptoms...has socially inappropriate/disruptive behavioral symptoms as evidenced by: Yelling...kicking other residents, resistive in approach to room mates. Goal: Resident will not harm self or others secondary to socially inappropriate/disruptive behavior within the next 90 days. Current behavior pattern: Yelling, kicking other residents, resistive in his approach to room mates. Approach...Assess whether the behavior endangers the resident and/or others. Intervene if necessary...Avoid over-stimulation noise, crowding, other physically aggressive residents...Maintain a calm approach...convey an attitude of acceptance..." A quarterly assessment, dated [DATE], documented the resident had a BIMS score of 13. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident had not exhibited any behaviors, ambulated with limited assistance, used a walker and wheelchair for mobility, and received an antidepressant medication on seven of the last seven days. An incident report, dated [DATE], documented, "...BP ,[DATE]...Resi got into altercation with another male resident....said that he (resident #5) had hit him twice - once on the forehead + once on the chin. - he said he then kicked him back, they were immediately separated...Injury: redness c sm bump on forehead...physician notified...send to hosp for eval geri psych...son notified..." The care plan, updated [DATE], documented, "Problem: He got into an altercation with another resident. Approach: He was removed from other resident. Checked for injuries, notified family, Dr., D.O.N., and APS and was counseled by administrator. Placed on monitoring." The care plan did not include any specific interventions regarding how the resident was to be monitored. No specific interventions were put in place to prevent future resident to resident altercations. A follow up report by the DON, dated [DATE], documented, "Not sent to geri- psych per administrators decision. No lasting injuries noted, neuros WNL. 1:1 complete, random checks done to check residents whereabouts to prevent resident to resident interaction." There was no documentation to indicate random checks had been initiated. A nurse's note, dated [DATE] at 11:10 a.m., documented, "res in D/R heard yell + saw another res + him - (resident #7) had came to him to confront him (per (resident #7) (after)) about - (resident #5) walking in his room last night + told him that all the rooms were his - When he confronted him (unable to read) to (resident #7) He picked (up) the D/R chair + hit him. Noted cut to eyebrow (R) - bleeding cleaned c NS + applied dsg...Does c/o being sore + c/o HA..." An incident report, dated [DATE], documented, "Res in DR - wheeled over to another res - (per (resident #7) report) + saw him there. He said he confronted him re- previously last night going into his room. + other res (resident #5) picked up a chair + hit him in the head - cut to R eyebrow. bleeding - not too deep - c/o headache + sore to area - neuros initiated...physician notified fax...son notified...Educate...that he cannot confront other residents about their behavior...to let staff know so they can monitor more closely..." There were no specific inteventions put in place to prevent future resident to resident altercations. An OSDH incident report form, dated [DATE], documented, "(Resident #5) was sitting in the dining room waiting for mealtime. (Resident #7) rolled up to him in his wheelchair and confronted (resident #5) about 'coming into his room'. (Resident #5) became agitated when confronted and picked up his chair and hit (resident #7) in the head with it. (Resident #7) received a cut to his right brow, cleansed with NS and bandaged. Neuros initiated..." A nurse's note at 3:15 p.m. documented, "Called Hospice talked to nurse...re: incident...need for some kind of counseling or psych eval - DT confrontation had recently taken off some psych meds res was confronting other res + I had spoken to him about always letting us know if there is an issue + let us take care of it. (Resident #7) states he did not tell anyone about it last night or today. But decided to confront him by himself - also states he would tell us next time - but feels he had the right - told him that that could cause agitation behavior + to leave it up to us to deal c it + not take care of it on his own. LPN at hospice will look into getting some kind of counseling services started + ask Dr about resuming prev - dc'd psych meds if needed." The care plan, updated [DATE], documented, "Problem: confronted male resident...hit in head. Approach: Removed from other resident, taken to his room and assessed. Instructed him to let staff take care of issues with other residents. Hospice was notified for need of counseling or psych eval." The care plan did not address any specific interventions to prevent future resident to resident altercations. A nurse's note, dated [DATE] at 3:00 a.m., documented, "VS 98 - ,[DATE] - 59 - 18 98%. In bed resting c/o H/A (headache). Prn pain med given & res. stated relief 1 (hour) later. Neuro (checks) WNL." A nurse's note, dated [DATE], documented, "C/O Headache...neck pain. Norco given per prn orders. S further c/o...neuros cont - WNL." A MAR, dated ,[DATE], documented the resident received Norco ,[DATE]mg prn for pain seven times and tramadol 50mg four times from [DATE] through [DATE]. There was no documentation to show that the physician was notified that the resident had sustained a head injury or of the headaches the resident experienced following the head injury. A nurse's note, dated [DATE], documented, "CNA's called this nurse to residents room resident was unresponsive but moaning tried sternal rub (no) response. (Check) FSBS 182 BP ,[DATE] P 89 O2 49% RA hospice called + O2 put on via NC hospice nurse (name deleted) here resident moved to room...for privacy." A nurse's note, dated [DATE] at 11:02 a.m., documented, "resident passed away..." On [DATE] at 2:00 p.m., RN #1 was asked what had occurred when residents' #7 and #5 had an altercation in the dining room on [DATE]. She stated she was the charge nurse and resident #7 told her that he had confronted resident #5 after the altercation had occurred. She stated, "We were trying to get people into the dining room and I don't know if anyone saw that or not." The RN was asked if she had notified the resident's physician regarding his head injury. She stated she had sent a fax of the incident report to inform the physician of what had occurred. She was asked if she had heard back from the physician or attempted to notify him further. She stated, "No, I don't think I did. I didn't further follow up with doctor just fax to let him know there was an incident." She was asked why she did not notify the physician. She stated, "I felt like he was ok so I didn't." She stated she had done neuro checks on the resident and they were within normal limits. She stated she had notified the resident's son and told him what had happened. She was asked if there were any staff monitoring the dining room when the altercation occurred. She stated, "Not at that time, we were all doing things." The RN was asked if any interventions were put in place at that time to prevent resident to resident altercations. She stated, "No, not specifically." The RN was asked if resident #5 had been involved in an altercation earlier that day with another resident. She stated yes and that he was put on one to one monitoring after the altercation. She was asked who was assigned to monitor him. She stated, "CNA #4." She was asked if the CNA was monitoring the resident at the time of the altercation. She stated, "She was helping us get people in the dining room." She was asked if she should have been with the resident. She stated, "Yes, and I told her after that we had to be one on one on top of him and cannot look away." The RN was asked if any other interventions had been put in place to prevent resident to resident altercations. She stated, "No, not that I'm aware of." At 3:35 p.m., the primary care physician was asked if he was notified that resident #7 had sustained a head injury on [DATE] and had several headaches after the altercation occurred. He stated he had been out of town and was not sure if any of his colleagues had been notified. He stated generally they contact the doctor on call for the group. He was asked if the facility should have notified him or another physician that the resident had sustained a head injury and had experienced headaches after the injury. He stated, "I believe someone should have been told." He was asked if he was aware the resident had expired on [DATE]. He stated he was still out of town then but had received the resident's death certificate. The physician stated he was unaware of a fax sent by the facility on [DATE] due to he was out of town and had not received the information. On [DATE] at 11:00 a.m., CNA #4 was asked if she had been monitoring resident #5 when the altercation had occurred between him and resident #7. She stated she was doing fifteen minute checks but was not with the resident constantly. She was shown the monitoring sheet and stated she had completed it from 7:30 a.m. on [DATE] because she was told to do so by the charge nurse. She stated she didn't actually start the checks until after the second altercation occurred after 11:00 a.m. She stated, "I wrote down his whereabouts, but was not sitting with him one on one." She was asked why she had not monitored the resident after the first altercation had occurred between him and another resident at 7:30 a.m. She stated, "The charge nurse didn't assign me to do that." At 2:00 p.m., the DON was asked if any staff were monitoring the dining room. She stated, "We try to but we are all doing things." She was asked if there had been any interventions put in place to prevent resident to resident altercations in the dining room. She stated, "None, but I can see where we need to." The DON was asked if the resident's physician should had been notified regarding the head injury and headaches that followed. She stated, "Yes, considering it was a head injury we should have talked to the doctor or made sure the fax was addressed." She was asked who would be responsible to follow up on the nurses to ensure they notified the physician. She stated, "I should be the one that followed up." She was asked if she had. She stated, "I don't recall that I did." The DON was asked if they were supervising the residents to prevent resident to resident altercations. She stated, "No we are not." She was asked if the care plan should have been updated to include appropriate interventions to prevent future resident to resident altercations. She stated, "Yes." 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated [DATE], documented the resident had a BIMS score of 4. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had behavioral symptoms not directed toward others, had not wandered, ambulated independently, and received an antipsychotic and antidepressant medication on seven of the last seven days. A care plan, dated [DATE], documented, "Problem...is at risk for other residents not accepting him to be in their space, or groups. He has become combative with other residents. Goal...will not exhibit signs of isolation, and will feel safe and secure in this facility. Approach...Assess for mood and behavior problems...Intervene as quickly as possible if you see another resident getting upset with him...Moniter (sic) him, and provide assitance (sic) when he is looking for his rm, D.R. etc...Provide 1:1 activities..." An incident report, dated [DATE], documented, "resi got into altercation c another male resi. he hit other resi on forehead...chin...other res (#7) then kicked him on his shin. they were immediately seperated (sic)...no injury...send to geri psych for eval... " The care plan, updated [DATE], documented, "Problem: He had an altercation with another male resident. Approach: Removed from other resident...was coulseled (sic) by Administrator. He was placed on monitering (sic)." A follow up report by the DON, dated [DATE], documented, "No injuries sustained, remains separated from other resident...1:1 completed, randomly check on whereabouts @ this time." There was no documentation to indicate the interventions had been done. A nurse's note, dated [DATE], documented, "resident called a female resident a (derogatory term) + raised his hand like he was gonna slap her they were in the dining room waiting for lunch...behavior eval...spoke c residents brother about transporting...resident left facility with his brother..." The care plan, updated [DATE], documented, "Problem: called fenale (sic) resident a (derogatory term) and raised his hand to her. Approach: He was removed from the resident. And was sent to...geripsych unit..." There were no new interventions added to keep the residents safe and prevent future resident to resident altercations in the dining room and resident rooms. A nurse's note, dated [DATE], documented, "CNA...reported to me that the resident went into another resident's room telling him that this was his...room...his bathroom...that he needed to get out or he was gonna hurt him. He was in the resident's face, yelling @ him. She removed resident from the room telling him that wasn't his room." The care plan, updated [DATE], documented, "Problem: He yelled at a another resident while he was in his room. Approach: CNA removed him from other resident's room." There were no new interventions addressed to supervise the resident to prevent him from entering other resident rooms or supervise him in the dining room to prevent future resident to resident altercations. An incident report, dated [DATE] at 7:30 a.m., documented, " Res got in confrontation c another resident...told him to...shut up...he hit @ her (mostly pushed @ her) He was agitated, said 'She shouldn't have told me to shut up'...(no) injuries to other res - (no) c/o pain...1:1 for now q 15 minute checks - keep separated from other resident..." An incident report, dated [DATE] at 11:10 a.m., documented, "Res in DR sitting, another res came up to him...he picked up chair and hit him with it after resident confronted him (about) going into his room last night...No injuries on (resident #5)...physician notified...may send to ER for eval... admit to psych...res sent to ER for eval..." A wandering monitoring sheet, dated [DATE], documented the resident was monitored every 15 minutes from 7:30 a.m. through 1:00 p.m. The care plan, updated [DATE], documented, "Problem: 2 incidents. Swung at female resident. Hit another resident on head. Approach: Seperated (sic) residents and he was removed from the area. And placed on 1:1 monitering (sic)...Seperated (sic) residents, continue 1:1..." A follow up report by the DON, dated [DATE], regarding the incident on [DATE] at 7:30 a.m., documented, "Monitored every 15 minutes per protocol. Other resident and this resident kept apart. No injuries resulted from this incident." There was no documentation to indicate any new interventions were implemented to prevent resident to resident altercations or to prevent the resident from wandering into other resident rooms or be monitored in the dining room. A follow up report by the DON, dated [DATE], regarding the incident on [DATE] at 11:10 a.m., documented, "Unable to follow-up - in hospital" There was no documentation any new interventions were implemented to prevent resident to resident altercations or to prevent the resident from wandering into other resident rooms or be monitored in the dining room. On [DATE] at 11:00 a.m., CNA #4 was asked if she had been monitoring resident #5 when the altercation had occurred between him and resident #7. She stated she was doing fifteen minute checks but was not with the resident constantly. She was shown the monitoring sheet and stated she had completed it from 7:30 a.m. on [DATE] because she was told to do so by the charge nurse. She stated she didn't actually start the checks until after the second altercation occurred after 11:00 a.m. She stated, "I wrote down his whereabouts, but was not sitting with him one on one." She was asked why she had not monitored the resident after the first altercation had occurred between him and another resident at 7:30 a.m. She stated, "The charge nurse didn't assign me to do that." At 2:00 p.m., the DON was asked if any staff were monitoring the dining room. She stated, "We try to but we are all doing things." The DON was asked if there had been any interventions put in place to prevent resident to resident altercations in the dining room. She stated, "None, but I can see where we need to." She was asked if they supervised the residents to prevent resident to resident altercations. She stated, "No we are not." She was asked if the care plan should have been updated to include appropriate interventions to supervise the resident and prevent future resident to resident altercations. She stated, "Yes." 3. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Monthly physician's orders [REDACTED]. A care plan, dated [DATE], documented, "Problem: ...is at risk for elopement from the facility...has no regard for his safety when leaving facility grounds. He may leave facility after letting the nurse know, and signing himself in and out...Goal: ...will only go outside after signing self in and out, and following facility rules for the next 90 days. Approach: Allow...the freedom to roam within the facility and outside after following protocol...can go outside after letting nurse know and signing self in and out...will have a smart alarm device on to alert staff when leaving facility...Inservice all staff on new interventions, and care plan..." The care plan, updated [DATE], documented, "Problem: Resident has new Dr. She has allowed him to have 1 beer a day...Goal: ...will not leave facility to buy his beer and will be content to have just 1 per day...Approach: Notify his Dr. if his behavior changes or his beer intake becomes a problem...Provide him with his daily beer as ordered." A nurse's note, dated [DATE], documented, "Resident went OOF w/sister. Upon return the resident's sister was trying to give me things to check in when I noticed a small brown bag & accepted it from his sister. Inside was a bottle of vodka...I took it to the DON..." A nurse's note by the DON, dated [DATE], documented, "(resident, name deleted) and his sister returned from an outing together and checked in at the nurses' station. He returned c a six pack of beer..XXX,[DATE] pint of vodka...These items were conviscated (sic) immediately and put in DON's office. Afterwards, had a conversation with (resident's) sister about (resident) ability to talk others, especially her, to get what he wants no matter what his orders are...She stated it might be best for her to...no longer take him out of the facility...when she visits." An incident report, dated [DATE], documented, "...Resident left the facility refusing to sign out. He stated he had somewhere to go. I asked that he not leave & he said "oh well." Resident returned unharmed..." Safety precautions to prevent recurrence: (blank)..."follow up...No injuries sustained from this incident...has resumed signing out when he leaves the facility to go outside for his walk or to water the plants..." There were no interventions addressed to monitor/supervise the resident when he leaves the facility property. The care plan, updated [DATE], documented, "...left facility without signing himself out, staff was aware he left and staff went and got him..." There were no new interventions addressed to keep the resident safe and prevent future unsupervised elopements off facility property. A quarterly assessment, dated [DATE], documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident had additional [DIAGNOSES REDACTED]. A physician's orders [REDACTED]...1 12oz (3.5 pt) beer daily p supper prn..." An updated care plan, dated [DATE], documented, "...will have beer in facility for him so he does not have to go to store and buy." A physician's orders [REDACTED]." On [DATE] at 9:05 a.m., the resident was observed outside walking alone." No staff were observed to be near or watching the resident. He was asked if staff were to walk with him. He stated, "No, I sign out." At 10:30 a.m., the resident was asked if he had a wander guard bracelet on. He stated, "Not anymore, I used to, but they took it off a few days ago. He was asked why it had been removed. He stated, "I guess I don't need it anymore." He was asked what the process was for him to go outside. He stated, "I sign out and go outside." He was asked if staff go with him. He stated, "No." He was asked if he signed back in when he came inside. He stated, "Not always, sometimes I forget." A nurse's note, dated [DATE], documented, "resident seen walking down the road CNA (#5) went after him to see where he was going I had followed her out I came back in to see if anyone could go get him since he was already to the corner ask admin + office manger if either one of them could go get him they came outside + were talking admin said we can't be going after him everytime he takes off...office manager went after him in company car..." On [DATE], at 10:40 a.m., the resident was asked if he had left the facility recently. He stated, "Yeah, I went to my sister's place on Tuesday, the 3rd of June." He stated his sister's friend picked him up and let him out at the courthouse in the next town. He stated he walked to the facility he used to live at. He stated, "I wanted to see some people, my friends there." He stated the administrator there had called the administrator at this facility and he came and got him, took him to eat, and then to his sister's. He stated his sister's friend brought him back to the facility at 4:30 or 5:00 p.m. that day. At 2:05 p.m., LPN #2 was asked if she was the charge nurse on [DATE]. She stated, "Yes." She was asked if the resident had left the facility that day. She stated, "Yes, he told me the day before he was going with his sister." She stated his sister called and said she couldn't come get him because of the rain. She stated that the next day, [DATE], the resident's sister had called around 8:00 a.m. and stated she would be there to get him in 30 minutes. She stated, "I honestly don't know who came and got him, I was down the hall attending to another resident when he left." She was asked if anyone had signed out that he was leaving with them or if he had signed himself out. She stated, "I don't know, I think she (resident's sister) is supposed to now, but he also signs himself out. She was asked if she knew his whereabouts when he signed out and went outside. She stated, "Honestly, half the time, no." She was asked if there was enough staff to watch him when he goes outside. She stated no and that she would watch him out the window when she had time. She stated, "He is allowed to go outside, but cannot leave the property unsupervised. The administrator said he was allowed to leave as long as he's not getting beer." She was asked if she knew where the resident was after he had left the facility. She stated she was told the administrator had went and got him in the next town and took him to his sister's who was going to bring him back later that day and she had told the next shift he would be back around supper time. The LPN was asked why there was no documentation in the nurses' notes regarding he was out of the facility. She stated, "I don't know." She was asked if there should have been some documentation regarding the resident had left the facility and his whereabouts were unknown. She stated, "Yes." She was asked if she had completed an incident report regarding what had occurred. She stated, "No." At 3:55 p.m., the DON was asked if there had been any other reports that the resident had left the facility property unsupervised. She stated on [DATE] that she had heard the resident left the facility and was found at another nursing facility that he had resided in before he transferred to this facility. She stated the facility he was found at was in the next town. She was asked what had occurred. She stated she was notified by the administrator that (administrator #2) had called and said the resident was there. She stated that a.m. the resident had told them he was going to a friend's house that day, but she did not ask who was going to sign him out. She was asked if anyone had signed him out. She stated, "No one came in and signed him out, I found that out after the fact." She was asked if any other staff had seen him leave the facility. She stated, "It doesn't sound like it, I have no witnesses that seen him leave. I don't know how he left." She was asked when they had discovered the resident was gone. She stated, "When the administrator called me and we looked at the (sign out) book. She was asked what they did then. She stated, "Panicked." She stated, "I left it in the administrator's hands, he picked him up and talked to the sister and said only sister could sign him out." The DON was asked if they had found out what had occurred regarding the resident leaving the facility and how he had come to be at another nursing home in another town. She stated, "I don't know, in the morning meeting we talked about removing the wander guard because the administrator said no one paid attention to it, it would just go off and no one followed up on it." She was asked what systems were in place to keep the resident safe and prevent him leaving the facility unsupervised. She stated, "In my opinion, nothing." She was asked if the resident should be supervised when going outside. She stated, "Yes and I believe he shouldn't go out with his sister either, she's not reliable." The DON was asked if there were any other instances where he left facility property and no one knew where he was. She stated, "Yes, he went down and bought a 24 ounce beer." She was asked if he drank the beer. She stated, "Yes, as fast as he could out in front of the facility." The DON was asked why the incident on [DATE] was not documented in the nurses' notes or on an incident report. She stated it should have been documented in the nurses' notes. She was asked why the care plan had not been updated. She stated if it wasn't documented the care plan coordinator would not be aware it had occurred. She was asked if there were incident reports for the times the resident left the facility. She stated no because the resident had been able to sign himself out and come and go and they had not considered them to be incidents. She stated, "He has the right to sign himself out." She stated the plan that was put in place was to take the wander guard off and let him come and go as he wanted. She stated she felt like they were taking away the plans in place and having even less responsible plans and had expressed her concerns. At 4:32 p.m., the administrator was asked if the resident had left the faciity on [DATE]. He stated yes, that the resident had signed himself out and left with a friend who took him to visit at another nursing facility in another town because his sister couldn't pick him up. He stated the administrator of that facility called him and he went and picked up the resident. He stated, "He wanted lunch." He stated he took him to lunch and explained to him that we need to make sure he is safe. He stated he took

Based on observation, interview, and record review, it was determined the facility failed to: ~ provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for two (#1 and #6) of eight sampled residents who had experienced falls. Resident #1 experienced six falls in two months, with one of the six falls resulting in actual harm when the resident sustained [REDACTED]. The facility identified five residents who were at high risk for falls. ~ provide thickened water in a resident's room for one (#6) of one resident who had a physician's orders [REDACTED]. The facility identified one resident who received thickened liquids. ~ ensure three bottles of alcohol, two bottles of wound cleanser, and one bottle of iodine solution were in a locked area, unaccessible to residents; and the medical supply closet was locked and did not create an accident hazard for residents. The resident census and condition report identified four residents who independently ambulated throughout the facility. Findings: An undated facility policy, titled Fall Prevention, documented, "...To provide a safe environment for the residents of our facility...On admission, each resident will be evaluated using the fall assessment tool. If the resident receives a score of 10 or greater, the Fall Protocol will be initiated...Reassess every day for change in fall risk and adjust interventions accordingly... If the resident: -is confused, disoriented, combative, or has unpredictable behavior... -has no regard for personal safety... -is unable to comprehend/recall instructions... -has a history of falls... has unsteady gait/moderate to severe physical impairment... -has bladder or bowel urgency/incontinence... -is receiving multiple medications... Then the following interventions will be added to the protocol: ...The bed rail evaluation form will be used to assess need and appropriate use of a bedside rail(s)...Use bedside rails while in bed for safety..." 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission evaluation/interim care plan, dated 03/28/14, documented the resident required supervision for bed mobility, transfers, and toileting. The evaluation documented the resident required assistance with walking/locomotion. A fall risk screen completed with the evaluation documented the resident's score was 14. The evaluation documented a score of 10 or higher indicated the resident was at risk for falls. A fall risk assessment, dated 03/28/14, documented the resident's score was 10. The assessment documented, "...total score of 10 or above represents HIGH RISK." There was no signature/title/date by who completed the assessment. An admission assessment, dated 04/10/14, documented the resident had a BIMS score of 3. This score indicated the resident was severely impaired for daily decision making. The assessment documented the resident required limited assistance with one person assistance for transfers, toileting, and required no assistance with walking in her room. The assessment documented the resident was not steady moving from seated to standing position, walking, and moving on and off toilet. The assessment documented the resident had no falls prior to admission. A care plan, dated 04/15/14, documented, "Problem: Falls...is at risk for falling due to previous fall resulting in hip fracture. Goal: will remain free from falls for the next 90 days. Approach: have light available in her room at night...keep bed in lowest position with brakes locked." An incident report, dated 05/22/14 at 3:10 p.m., documented, "Res. attempting to transfer self from w/c ...slid down to floor landing on bottom in front of dresser. Denies pain or discomfort. (No) bruising noted...Safety precautions to prevent recurrence: educated to use call light & lock w/c brakes before transfers..." The fall care plan, updated 05/22/14, documented, "...had a fall in her room...educate her on call light and to use it for assit (sic)...Lock w/c brakes before transfers." An incident report, dated 05/31/14 at 11:15 p.m., documented, "Resident's roommate was asking for help, stated her neighbor had fallen, Res found sitting in the floor beside her bed. States "I slid off the bed." c/o pain...red area to R hip and lower R side of back...Safety precautions to prevent recurrence: mobile x-ray to x-ray R hip. encouraged resident to use call light for assistance to the bathroom. Follow up: No visible injuries noted. Does not report any pain or discomfort at time of follow-up..." The fall care plan, updated on 05/31/14, documented, "Problem: had another fall in her room. Approach: She had mobil (sic) xray to rule our fracture. Instructed her again to not be getting up by herself, and use call light for assitance (sic)." An incident report, dated 06/21/14 at 5:50 a.m., documented, "resident on floor by her bed. Resident states she was getting (up) to the bathroom...slid to her bottom, hitting her back...bottom...states back and bottom are sore. Safety precautions to prevent recurrence: told resident to wear non-slip shoes when walking...ask for help. Follow up: Had another fall 6/23..." The fall care plan, updated 06/21/14, documented, "Problem: slid to floor while getting up to BR. Approach: Staff to ensure she is wearing non-slip shoes/socks when walking and to always ask for help when needing to go to the bathroom." An incident report, dated 06/23/14 at 9:40 a.m., documented, "Resident slipped and fell coming out of the bathroom, room was very cluttered, aides assisted to clean room to limit further fall risks...No visible injury or s/s pain...Safety precautions to prevent recurrence: ensure room remains clutter free and proper foot wear is in place. Follow up: resident placed on 72 (hour) charting room remains free of clutter..." The fall care plan, updated 06/23/14, documented, "Problem: slipped and fell coming out of BR. Approach: CNAs cleaned room of clutter and will monitor to ensure it stays clutter-free." An incident report, dated 07/01/14 at 7:05 p.m., documented, "Res. found on floor near closet in room. Lying on left side. c/o pain in L hip. Assisted to bed. Called mobile xray for L hip xray...red area on L hip noted...Safety precautions to prevent recurrence: monitor for assist to BR. Follow up: Xray results negative..." The fall care plan, updated 07/01/14, documented, "Problem: fall in room. Approach: Staff is to offer to assist her to bathroom before meals and at bedtime." An incident report, dated 07/06/14, documented, "...Resident was up going to the bathroom...fell on floor and hit L hip. Assisted to bed v/s taken. Dr...called. Pt educated not to get up (without) calling nurse...also educated pt on fall prevention...also instructed to use call light...portable xray called for hip xray." The fall care plan, updated 07/06/14, documented, "Problem: fall in her room Fall score 13. Approach: Fall mat placed on floor, Oxygen tubing changed to shorter tube, and her staff will ensure that her room remains free of clutter." An initial state reportable incident report, dated 07/06/14, documented, "...Resident stated that she was on her way to bathroom when she fell and hit her Left hip. Denies slipping or tripping on anything. States that she was just walking and fell . Resident sent to ER with a fracture..." A final state reportable incident report, dated 07/06/14, documented, "...Portable x-ray obtained. Resident sent to ER with a fracture...has a [DIAGNOSES REDACTED]. O2 tubing replaced with standard length tubing. De-cluttered room and provided a fall mat. Hip protectors ordered. Frequent toileting implemented..." A fall investigation report, dated 07/07/14, by the RN consultant, documented at the time of the fall the resident needed to use the bathroom, was wearing shoes, and was going to the bathroom. The report documented, "Interventions pre-fall: -Blank." There were no post fall interventions documented on the report. The RN consultant documented, "Resident states she did not slip or trip on anything. Stated she just fell on her way to the B.R." The resident was readmitted to the facility on [DATE]. A quarterly assessment, dated 07/18/14, documented the resident had a BIMS of 3. This score indicated the resident was severely impaired for daily decision making. The assessment documented the resident required limited assistance with ADLs, did not ambulate, was frequently incontinent, was not on a toileting program, and had a [DIAGNOSES REDACTED]. The fall care plan had not been updated to address the resident had fractured her hip. No new interventions had been added to the care plan to prevent future falls. A fall care plan, updated 08/25/14, documented, "...Care plan reviewed...Continue with current care plan and interventions." The fall care plan did not address that the resident had sustained a hip fracture. No interventions were put in place to prevent future falls. On 08/25/14 at 10:30 a.m., the resident was observed in her room, fall mat was at bedside, and call light within reach. The resident was alert and responsive to questions. The resident was asked if she received assistance with toileting and transfers. The resident stated, "Sometimes." The resident was asked about her recent fall and hip fracture. The resident stated she had broken both hips since she had been admitted to long term care. She stated she had recently broke a hip at this facility. On 08/28/14 at 11:25 a.m., the DON was asked if bowel and bladder assessments had been done on the resident. She stated, "No." She was asked if the resident was on a toileting schedule. She stated, "No." She was asked how they monitored the resident for assistance to the bathroom. She stated, "I will have to look." The plan and the schedule to monitor the resident was not provided. The DON was informed of the numerous falls that had occurred and the last fall on 07/06/14, which had resulted in a hip fracture. She was asked if the root cause of the falls had been determined. The DON stated the root cause had not been determined. 2. Resident #6 had [DIAGNOSES REDACTED]. A fall risk assessment, dated 01/08/14, documented the resident had experienced three or more falls in the past three months. The assessment documented a score of 18. This score indicated the resident was at high risk for falls. An incident report, dated 01/13/14, documented, "...resident was walking to the bathroom in his room & lost his balance & landed on the floor...(no) injury noted...Safety precautions to prevent recurrence: ...encourage/remind resident to use call light & wait for assistance..." An incident report, dated 01/19/14, documented, "...Residents alarm going off - Resident found laying in floor by nurses station - states "I slipped out of my chair" wheelchair was sitting in Lobby away from Resident...c/o back and hips hurting...Safety precautions to prevent recurrence: ...Staff to offer Resident glass of water when sitting in Lobby...sent to ER for Eval and treat..." An incident report, dated 01/20/14, documented, "...resident was transferring from couch into his chair & went down on his rear...(no) injury noted...Safety precautions to prevent recurrence: ...resident reminded to leave alarm intact & to ask for assistance..." An incident report, dated 01/20/14, documented, "...resident was transferring hisself (sic) from scoot chair to potty chair & fell alarm intact & working...(no) injury noted...Safety precautions to prevent recurrence: ...remind resident to use call light & ask for assistance..." A follow up to the incident, dated 01/21/14, documented, "...Check c hospice to see if chair can be lowered in back or a cushion provided to hinder resident from getting up (without) assistance..." An incident report, dated 01/24/15 (14), documented, "...Maintenance saw res in w/c in hall but when he looked over saw res going to floor holding side rails in hall & sat on floor...states bottom sore...Safety precautions to prevent recurrence: ...After further investigation noted cushion on scoot chair coming...sliding - straps not long enough to wrap around (with) velcro in w/c..." A follow up to the incident, dated 01/28/15 (14), documented, "...OT/PT ordered for strengthening..." An incident report, dated 02/02/14, documented, "...Pt stated I stood up to get TV control & sat down on floor my legs got weak...no injury...Safety precautions to prevent recurrence: Instructed resident to not get up (without) asking for assistance..." A follow up to the incident, dated 02/03/14, documented, "...continues to get up (without) assistance...w/c pad will not stay in chair, straps too short..." An incident report, dated 02/04/14, documented, "...Res found on floor in room - states he was going to turn off TV & fell on bottom...(no) injuries does say bottom is sore...Safety precautions to prevent recurrence: ...talked c DON & QA RN - about...TV..." A fall care plan, updated 02/04/14, documented, "...Remind...to ask for assistance with transfer...non-skid socks, slippers, or shoes...provide...with safety device/appliance: ...A scoot chair with a lower seat has been implemented to decrease the risk of falls...fall star program...fall prevention program...call light..." The fall care plan did not address a fall intervention related to the resident's attempts at toileting, the falls regarding the television being turned off or the access to the remote control, no documentation physical therapy and occupational therapy were started, and what the falling star program/fall prevention program consisted of regarding the prevention of falls. A follow up to the incident, dated 02/06/14, documented, "...will be moving...to different area of room or another room to be able to arrange furniture and television in such a way to prevent falls..." An incident report, dated 02/06/14, documented, "...resident found in front lobby in the floor c TV remote in his hand states he was trying to change the channel...alarm did not sound...(no) injury...Safety precautions to prevent recurrence: ...resident reminded to ask for assistance c transfers & getting stuff...ensure chair alarm is in working order...lower back of scoot chair..." A fall risk assessment, dated 02/06/14, documented the resident had experienced three or more falls in the past three months. The assessment documented a score of 18. This score indicated the resident was at high risk for falls. The fall care plan, updated 02/06/14, documented, "...Ensure his chair alarm is in working order... ...02/11/2014...Scoot chair has been lowered to lowest position...Keep...remote control and personal items and frequently used items within reach...fall mat at Bedside...Bed and chair alarms in place..." An incident report, dated 02/14/14, documented, "...Resident had gotten out of bed to use restroom, when attempting to get up from toilet fell on bottom...states only bottom hurts (no) injuries...Safety precautions to prevent recurrence: ...Reminded resident to use the call light & not to attempt walking (without) help from CNAs..." A follow up to the incident, dated 02/16/14, documented, "...discuss delivery of a low bed..." An incident report, dated 02/16/15 (14), documented, "...Residents bed alarm going off - resident found laying in floor in the bathroom - States "I needed to go to the bathroom"...(no) redness or bruising noted...or injury...Safety precautions to prevent recurrence: ...Assisted resident to chair, c chair alarm in place...Low bed requested..." The fall care plan, updated 02/16/14, documented, "...low bed... ...02/21/2014...Therapies to write a restorative plan... ...03/01/2014...has been moved to the other side of room so TV plug in cannot be reached by him..." The fall care plan did not address a fall intervention related to the resident's attempts at toileting and falling and no documentation physical therapy and occupational therapy were started. An incident report, dated 04/09/14, documented, "...Resident scooted out of bed & on the floor to the door. Bed alarm malfunctioned. Resident stated he was hungry, so we provided a snack...(no) c/o pain or hitting anything @ all...Safety precautions to prevent recurrence: ...Advised resident in using his call light & put a new bed alarm in place..." An incident report, dated 04/11/14, documented, "...res found sitting on floor in room in doorway facing hallway...Res said he got (up) to (change) his TV & needed remote - remote was in bed (with) him...states bottom a little sore...Safety precautions to prevent recurrence: ...Provide remote in resident's hand when put to bed..." An incident report, dated 04/12/14, documented, "...Resident was attempting to ambulate (without) assistance...Resident fell on bottom...Bruise starting to appear on top of bottom...Safety precautions to prevent recurrence: ...Educated resident on call light & provided a snack..." An incident report, dated 04/22/14, documented, "...res had parked w/c to door & got (up) & walked toward bed & fell - on R side...c/o hips sore BL - & back soreness...had alarm still stuck to him & did not go off...Safety precautions to prevent recurrence: ...(Blank)..." The resident had experienced four falls during the month of April. There was no documentation to indicate physical therapy and occupational therapy were started, and the fall care plan had not been updated with new interventions for the prevention of further falls. An incident report, dated 05/07/14, documented, "...Resident was in front lobby & tried to transfer self from couch to chair when he said chair "scooted" out from underneath him & he slid down then laid down...(no) marks or injuries noted...Safety precautions to prevent recurrence: ...Resident was re-iterated to over waiting for help to transfer..." An annual assessment, dated 05/07/14, documented the resident had a BIMS score of 8. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident had not exhibited any behaviors, required extensive assistance with transfers, was not steady with moving from a seated to a standing position, not steady with walking, not steady with moving on and off the toilet, not steady with surface-to-surface transfers (transfer between bed and chair or wheelchair), was always incontinent of urine, was always incontinent of bowels, was not on a toileting program, had a [DIAGNOSES REDACTED]. days. A nurse's note, dated 05/09/14, documented, "...Attempts to get out of bed on own x2..." A fall care plan, dated 05/12/14, documented, "...Problem: ...has had an increase in falling R/T to impaired mobility...has had frequent falls for 1/13/14 through 2/16/14...has been sliding self off his low bed...Approach: ...Instructed again to not be getting self up from his chair without assitance (sic) from staff...Ensure safety alarm is connected properly to chair...Educated on call light use...new bed alarm...low bed...fall mat...keep...remote control and personal items and frequently used items within reach...Scoot chair...to lowest position...fall star program...fall prevention program...non-skid socks..." The fall care plan did not address a fall intervention related to the resident's attempts at toileting and falling, no documentation physical therapy and occupational therapy were started, and there were no new interventions addressed for the prevention of further falls. A nurse's note, dated 05/20/14, documented, "...Several attempts to ambulate alone...res ret'd to chair..." An incident report, dated 06/06/14, documented, "...resident was found on floor of room stated he got (up) from w/c to go to bed landed on bottom...c/o of soreness...(no) injury...Safety precautions to prevent recurrence: ...resident reminded to ask for assistance c transfers..." An incident report, dated 06/11/14, documented, "...Res (up) in geri chair in living room & attempted to transfer self to couch & slid to floor...(no) injuries...Safety precautions to prevent recurrence: ...Asked staff to leave res. in bed until ready for him to go to dining room for meal..." The fall care plan, dated 06/11/14, documented, "...When...through with meals offer to toilet and assist him to bed or to sit on couch in lobby..." The care plan did not address new fall interventions when the resident was in the lobby area or his room and falling, no documentation physical therapy and occupational therapy were started, and there were no new interventions for the prevention of further falls. An incident report, dated 06/21/14, documented, "...Res found sitting on bottom in B/R between w/c & toilet...hit butt...states her was going to B/R...fell ...Res had left DR after eating to toilet self...Did not ask...c/o soreness to bottom...stated BL arms sore...had red area to bottom...Safety precautions to prevent recurrence: ...reminded res to only transfer c help-told CNAs to monitor & keep in D/R till they are able to leave & (assist) him..." The fall care plan, updated 06/21/14, documented, "...Staff is to leave (resident) in dining room after eating to moniter (sic) him until they (staff) are able to take him to bathroom..." An incident report, dated 07/11/14, documented, "...resident stated he was going to bathroom was found on floor of bathroom door laying on left side states his back & butt hurt able to move all extremities...red areas indicated...Safety precautions to prevent recurrence: ...discussed c hospice getting mattress c bolsters..." A fall risk assessment, dated 07/11/14, documented the resident had experienced one to two falls in the past three months. The assessment documented a score of 19. This score indicated the resident was at high risk for falls. The resident's clinical record revealed the resident had experienced nine falls in the past three months. A fall investigation record, dated 07/11/14, documented the resident needed to use the bathroom and fell going to the bathroom. The investigation record documented, "...Interventions in Place Pre-Fall: ...Toileting program...Chair Alarm...Fall Prevention Program...Increased Monitoring...Low Bed...Bed Alarm...Comments: ...states he was going to the bathroom & fell ...ordering new alarms for bed & chair & mattress c bolsters..." The fall investigation record did not address the resident had fallen six times going to the bathroom without assistance, or how the staff were to increase the monitoring. There was no documentation to indicate physical therapy and occupational therapy were started, and there were no new interventions for the prevention of further falls. The fall care plan, updated 07/11/14, documented, "...Staff to take to bathroom before laying him down..." An incident report, dated 07/17/14, documented, "...resident was found on floor in front lobby between a wicker love seat & his scoot chair...states he was trying to get in his w/c...c/o back pain red area noted to R back...Safety precautions to prevent recurrence: ...new alarm put in scoot chair..." A fall risk assessment, dated 07/17/14, documented the resident had experienced three or more falls in the past three months. The assessment documented a score of 22. This score indicated the resident was at high risk for falls. A fall investigation record, dated 07/17/14, documented the resident wanted to get in his wheelchair and fell . The investigation record documented, "...Interventions in Place Pre-Fall: ...Chair Alarm...scoot chair...Comments: ...Chair alarm turned on but did not sound when resident stood up..." The investigation record did not address if the alarm was attached to the wicker chair the resident was sitting in at the time of the recorded fall and there was no documentation physical therapy and occupational therapy were started. The investigation record did not address any new interventions for the prevention of further falls. A nurse's note, dated 07/18/14, documented, "...continue to remind Res. not to stand unassisted. Forgets & stands unassisted x2..." A nurse's note, dated 07/19/14, documented, "...Resident found face first on fall matt (sic) in room...went to room after hearing bed alarm going off...Resident states he hit his forehead...Told resident to ask for help going to bathroom...call light within reach..." An occupational therapy evaluation note, dated 07/30/14, documented, "...Reason for Referral: ...resident who exhibits decline and falls...fall risk with non-compliance to call likght (sic) reported...Prior Therapy Services: none this year...Pt. displays significant deficit in UE function, sit & stand balance, muscle strength and tolerance..." A quarterly assessment, dated 08/07/14, documented the resident had a BIMS score of 4. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had not exhibited any behaviors, required extensive assistance with transfers, was not steady with moving from a seated to a standing position, not steady with walking, not steady with moving on and off the toilet, not steady with surface-to-surface transfers (transfer between bed and chair or wheelchair), was always incontinent of urine, was frequently incontinent of bowels, was not on a toileting program, had a [DIAGNOSES REDACTED]. days. A physical therapy assessment progress note, dated 08/08/14, documented, "...has had a fair response to treatment, and has made little progress. Pt. has refused to participate in any strengthening exercises, and transfer training has been limited by pt. tolerance..." A physical therapy note, dated 08/11/14, documented, "...Pt. became agitated when asked to start therapy session and refused to participate in therapy today..." The fall care plan, updated 08/12/14, documented, "...falls have decreased slightly...Numerous Interventions have been added to his care plan...Staff responds quickly to his alarm and follow care plan interventions...has a Scoot chair...has PT OT ordered but is not compliant...Continue with care plan..." A physical therapy note, dated 08/13/14, documented, "...Pt. became agitated when asked to start therapy session and refused to participate in therapy today..." A physical therapy note, dated 08/15/14, documented, "...Pt. became agitated when asked to start therapy session and refused to participate in therapy today. Pt. will discharge from PT on 08/15/14 due to refusal to participate in POC..." An occupational therapy note, dated 08/18/14, documented the resident had been discharged from occupational therapy. On 08/25/14 at 4:00 p.m., the resident was observed in his room. When a CMA entered the resident's room to offer his medication the resident asked her to fix the television for him. The resident was not observed with his remote control to the television. On 08/28/14 at 9:16 a.m. the DON was asked about the fall risk assessments. She stated, "We have a book with those. July and August we have started attaching a fall risk assessment to the incident report. She was asked about the bowel and bladder assessments. She stated, "The bowel and bladder assessments are done on admission." The DON was informed of the resident's 21 falls since January 2014 and during seven of those falls the resident had attempted to go to the bathroom, unassisted, and had fallen. The DON stated, "We added it to the care plan to toilet after meals and at bedtime. He has a urinal and we make frequent rounds on him." The DON was asked for the resident's bowel and bladder assessment and his toileting program. She stated, "I have not done one. I don't know if we have a bowel and bladder book." No assessment was provided. At 4:28 p.m., the DON and the care plan coordinator were informed of the resident's falls since January 2014 and why new interventions had not been addressed on the care plan. They were asked if the resident used his call light. The DON stated, "No he doesn't use the call light." The care plan coordinator stated, "Not very often. Very seldom." They were asked if the resident could ambulate. The DON stated, "He can stand, unsteady." They were asked if he could get out of the low chair unassisted. The care plan coordinator stated, "Yes." They were asked why there were no new interventions to address the residents continued attempts to transfer unassisted, attempts to "fix" his television, and continued attempts to go to the bathroom unassisted. The DON stated, "We have tried many interventions." The DON and the care plan coordinator were asked what the falling star program and the fall prevention program consisted of to prevent the resident from falling. The DON stated, "We aren't doing it." 3. Resident #6 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A nurse's note, dated 07/11/14, documented, "...resident diet (changed) to Nectar thick liquids...will cont to monitor..." A quarterly assessment, dated 08/07/14, documented the resident had a BIMS score of 4. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident did not have signs and symptoms of a possible swallowing disorder and required a mechanically altered diet which required a change in the texture of foods or liquids. On 08/28/14 at 1:26 p.m., the resident was observed in his bed. A small glass of thickened water and a small glass of thin water with a straw were observed on the resident's night stand. At 1:49 p.m., LPN #1 was asked if the resident could have water in his room. The LPN stated, "Yes. We provide it if he asks for it." The LPN was asked if the resident was to receive thin water. She stated, "Not suppose to. He is allowed thickened water." CNA #1 was asked if

Based on observation, record review, and interview, it was determined the facility failed to ensure one (#6) of nine sampled residents who were reviewed for behaviors received care and services to assist the resident in reaching and maintaining the highest level of mental and psychcosocial functioning. The facility's roster/sample matrix identified 16 residents with behaviors. Findings: Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 12/07/14, documented the resident had a BIMS score of 14. This score indicated the resident was cognitively intact. The assessment documented the resident had a mood severity score of 14, exhibited verbal behavioral symptoms directed toward others four to six days but less than daily and other behavioral symptoms not directed toward others one to three days. A behavioral symptoms care plan, dated 01/21/14, documented, "Problem: ...experiences crying, tearfulness, anger and irritation R/T not getting her way...Goal: ...will respond to others without crying, yelling or throwing fit and express her needs appropriately...Approach: ...allow to have control over situations, if possible...encourage to verbalize feelings, concerns and fears by signing or writing them down rather than yelling, crying or throwing a fit. Clarify misconceptions...Establish a trusting relationship...Support and praise appropriate behaviors..." A psychosocial well-being care plan, dated 01/21/14, documented, "Problem: ...expresses irritation/frustration/anger and throws fits if she does not get her way by yelling, hitting at you or throwing things...Goal: ...will demonstrate less episodes of irritation/frustration/anger and yelling and accept the reality of her situation of LTC during the next 90 days...Approach: allow to make decisions, to set realistic goals, and to participate in her own self care...assess for characteristics that may impede ability to interact with others (e.g., cognitive, communication, vision, mobility deficits, etc)...convey an attitude of acceptance but establish boundaries for her that are appropriate..." On 01/24/14 through 01/29/14 the resident had experienced anywhere from 12 to 50 episodes daily of yelling, screaming, and throwing things with no documentation for how the staff redirected and assessed her needs and no outcomes to address if the resident's behaviors were redirected. The resident was sent to the hospital on [DATE] for threatening to shoot staff members. She returned to the facility on [DATE]. From 02/07/14 through 02/09/14 the resident had experienced anywhere from four to eight episodes daily of yelling, screaming, and hitting with no documentation of interventions or outcomes to address how the resident was redirected and if the interventions were effective. The resident was sent to the hospital on [DATE] for shortness of breath, dizziness, and chest pain but did not address the behaviors. The resident returned on the same date. From 02/10/14 through 02/12/14 the resident had experienced anywhere from 10-16 episodes daily of yelling and screaming with no documentation of interventions or outcomes to address how the resident was redirected and if the interventions were effective. The resident was sent to the hospital on [DATE] for a psychiatric crisis and returned to the facility on [DATE]. From 02/14/14 through 02/18/14 the resident had experienced anywhere from 0-8 episodes daily of yelling, screaming, and hitting self with a pop bottle with no interventions and no outcomes to address how the resident was redirected and if the interventions were effective. On 02/18/14 at 9:07 a.m., the resident was observed in the hall by the nurse's station yelling and upset. At 9:15 a.m., the DON was asked why the resident was screaming at her. She stated, "She wanted to smoke." She was asked what she did to redirect the resident. She stated, "I told her this morning she was scaring the residents with her yelling and she needed to calm down." She was asked if the resident had calmed down. She stated, "For a little bit. About 15 minutes." The DON was asked if the resident had been screaming an yelling all weekend. She stated, "She was calm on Saturday with a few outbursts but nothing that couldn't be redirected. Sunday a few more and became more frequent." She was asked to describe the episodes. She stated, "She was yelling and getting louder more frequently and harder to redirect. She started hitting her wheelchair on Monday morning and hit her head with a pop bottle." At 9:30 a.m., the resident was sitting at the nurses' station yelling "I want out. I don't like it here. I want to go home." She also began to hit the arms of her wheelchair. At 10:32 a.m., the resident was in her room with call light on and yelling, "Help me. Help me." At 3:20 p.m., the resident was observed sitting in the smoke room with LPN. Another female resident entered the smoke room and the resident began yelling at the second resident and stated, "I want to get out of here now." At 4:23 p.m., the DON was asked what the plan was to protect other residents from the resident's outbursts. She stated, "When I'm gone I don't know what they do. When I'm here I try to spend time with her." She was asked what interventions were put in place. She stated, "They didn't write anything down for the behaviors or the interventions." On 02/19/14 at 1:55 p.m., the resident was asked how she had adjusted to the facility. She stated, "I want to move. I don't want to stay here. I need my medicine to calm down." At 3:18 p.m., the DON was asked what she had done to help the resident adjust to the facility. She stated, "I've spent time with her one on one, reassure her we care about her, and I've asked her what we could do to make it better." She was asked if she had documented anything. She stated, "Oh, I didn't document it."

On 01/14/14, an Immediate Jeopardy (IJ) situation was determined to exist regarding administration's failure to ensure the facility was administered in a manner to prevent Immediate Jeopardy situations related to the facility's failure to prevent resident to resident altercations and to prevent mistreatment of [REDACTED]. Administration also failed to ensure their quality assessment and assurance program was effective to ensure measures were implemented to prevent the resident to resident altercations and mistreatment. At 5:23 p.m., The Oklahoma State Department of Health (OSDH) was called and verified the existence of the Immediate Jeopardy situation. At 5:32 p.m., the administrator, the DON, the ADON, and the QA nurse, were informed of the Immediate Jeopardy situation. They were informed that a plan of removal would be required. At 6:10 p.m., an acceptable plan of removal was received from the administrator. The plan documented: "January 14, 2014. 5:40 pm Plan of removal regarding lack of Supervision and prevention of accidents; Quality Assurance, Administration: 1. Facility will and shall provide personal supervision by a C.N.A. and or hospitality aide to ensure the safety of wandering resident as well as all other residents within the facility. 2. At 5:56pm, a hospitality aide was assigned to (name deleted). Hospitality aide shall be with resident 24 hours a day to include weekends. 3. At 6:30pm, Hospitality aide shall document every 15 minutes and q 15 min x 72 hours nurse will visually monitor resident and aides where abouts and initial the cna. Hospitality aide will remain at residents' (sic) side during the tour of their duty. 4. Person assigned shall document every 15 minute (sic) in progress note and the Charge Nurse shall visually observe residents whereabouts and activities. The Charge Nurse shall initial the progress note of the resident for the first 72 hours and upon every downgrade according to the IDCP Team. 5. After review of every 15 minute checks x 72 hrs. icdt will review incidents and then evaluate possibilities of downgrading to 30 minute checks x72 hours. 6. Progress notes shall be reviewed and ICDP Team shall review q 72 hours to monitor and to ensure ongoing compliance as well as to determine if charge nurse checks can be downgrade (sic) or need to remain the same or increase. 7. Q.A. team will meet q 72 hours to review and determine if any modifications in the supervision plan can be made. 8. At 6:30pm, facility In-serviced staff in regards to the proper documentation of the whereabouts of wandering resident and any potential residents that may arise during this occurrence. 9. At 8:00pm, QA meeting conducted with Department heads, Charge Nurse, and C.N.A. with regards to wandering resident and maintain compliance to proper documentation. 10. At 8:10pm, nursing staff were in-serviced regarding incident reports and witness statements to be taken and given to DON. 11. At 8:15pm, department heads were in-service (sic) regarding incident report, state reportable, given to department heads and how to conduct thorough investigations and witness statements. 12. At 8:15pm, residents were in-serviced regarding Resident to Resident abuse to include verbal, sexual, physical, or mental abuse, corporal punishment an involuntary seclusion. 13. Administrator was in-serviced at regarding (sic) monitoring and evaluation of proper documentation, the Q.A. process as well as Incident Report investigation and process." The IJ was removed on 01/15/14 at 2:10 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a widespread level with a potential for more than minimal harm. Based on observation, record review, and interview, it was determined the facility was not being administered effectively to prevent Immediate Jeopardy situations related to the facility's failure to provide supervision and protection to prevent resident to resident altercations and mistreatment of [REDACTED]. This had the likelihood to affect all 41 residents who resided in the facility. Findings: 1. Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent resident to resident altercations and mistreatment by two (#1 and #2) of three sampled residents with aggressive and/or abusive behaviors. The facility failed to protect resident #1 and #3 from mistreatment by cognitively impaired residents when they were hit in the face or pushed in the hallway. This resulted in an Immediate Jeopardy situation. Refer to F-323. 2. Based on observation, record review, and interviews, it was determined the facility failed to have an effective quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies, which would in turn ensure the nursing staff provided nursing and related services to enable residents to achieve and maintain their highest practicable well-being. The facility's quality assessment and assurance committee failed to ensure measures were provided to supervise and prevent resident to resident altercations and mistreatment by two (#1 and #2) of three sampled residents with aggressive and/or abusive behaviors; and failed to protect residents #1 and #3 from mistreatment by cognitively impaired residents. This resulted in an Immediate Jeopardy situation. Refer to F-520. 3. On 01/16/14 at 5:06 p.m., the QA nurse was asked what systems were in place to ensure the facility was operated effectively to protect the residents from abuse, including resident to resident altercations and fearfulness. She stated, "I can't think of anything." 4. On 01/17/14 at 11:17 a.m., the administrator was asked what systems were in place to ensure the facility was administered effectively to protect the residents from resident to resident altercations and wandering residents. The administrator stated, "Staff were filling out the forms. I personally would check on the residents. I would call on the weekend. I had meetings with (QA nurse and DON)." The administrator was asked if she had been aware these interventions were not working. She stated, "(Resident #6) had improved. (Resident #1) had the aides with him doing the walking. He set in chair in the lobby or go to his room. Lotion or snacks. He did all right. I would make sure someone was with him. I thought they were working. He did all right on the 15 minute and 30 minute checks he would be aggitated."

On 01/14/14, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to have an effective quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies. The facility's quality assessment and assurance committee failed to ensure measures were provided to supervise and prevent resident to resident altercations and failed to protect residents from mistreatment by cognitively impaired residents with aggressive and/or abusive behaviors. At 5:23 p.m., The Oklahoma State Department of Health (OSDH) was called and verified the existence of the Immediate Jeopardy situation. At 5:32 p.m., the administrator, the DON, the ADON, and the QA nurse, were informed of the Immediate Jeopardy situation They were informed that a plan of removal would be required. At 6:10 p.m., an acceptable plan of removal was received from the administrator. The plan documented: "January 14, 2014. 5:40 pm Plan of removal regarding lack of Supervision and prevention of accidents; Quality Assurance, Administration: 1. Facility will and shall provide personal supervision by a C.N.A. and or hospitality aide to ensure the safety of wandering resident as well as all other residents within the facility. 2. At 5:56pm, a hospitality aide was assigned to (name deleted). Hospitality aide shall be with resident 24 hours a day to include weekends. 3. At 6:30pm, Hospitality aide shall document every 15 minutes and q 15 min x 72 hours nurse will visually monitor resident and aides where abouts and initial the cna. Hospitality aide will remain at residents' (sic) side during the tour of their duty. 4. Person assigned shall document every 15 minute (sic) in progress note and the Charge Nurse shall visually observe residents whereabouts and activities. The Charge Nurse shall initial the progress note of the resident for the first 72 hours and upon every downgrade according to the IDCP Team. 5. After review of every 15 minute checks x 72 hrs. icdt will review incidents and then evaluate possibilities of downgrading to 30 minute checks x72 hours. 6. Progress notes shall be reviewed and ICDP Team shall review q 72 hours to monitor and to ensure ongoing compliance as well as to determine if charge nurse checks can be downgrade (sic) or need to remain the same or increase. 7. Q.A. team will meet q 72 hours to review and determine if any modifications in the supervision plan can be made. 8. At 6:30pm, facility In-serviced staff in regards to the proper documentation of the whereabouts of wandering resident and any potential residents that may arise during this occurrence. 9. At 8:00pm, QA meeting conducted with Department heads, Charge Nurse, and C.N.A. with regards to wandering resident and maintain compliance to proper documentation. 10. At 8:10pm, nursing staff were in-serviced regarding incident reports and witness statements to be taken and given to DON. 11. At 8:15pm, department heads were in-service (sic) regarding incident report, state reportable, given to department heads and how to conduct thorough investigations and witness statements. 12. At 8:15pm, residents were in-serviced regarding Resident to Resident abuse to include verbal, sexual, physical, or mental abuse, corporal punishment an involuntary seclusion. 13. Administrator was in-serviced at regarding (sic) monitoring and evaluation of proper documentation, the Q.A. process as well as Incident Report investigation and process." The IJ was removed on 01/15/14 at 2:10 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a widespread level with a potential for more than minimal harm. Based on observation, record review, and interviews, it was determined the facility failed to have an effective quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies, which would in turn ensure the nursing staff provided nursing and related services to enable residents to achieve and maintain their highest practicable well-being. The facility's quality assessment and assurance committee failed to ensure measures were provided to supervise and prevent resident to resident altercations and mistreatment by two (#1 and #2) of three sampled residents with aggressive and/or abusive behaviors; and failed to protect residents #1 and #3 from mistreatment by cognitively impaired residents. This had the likelihood to affect all 41 residents who resided in the facility. Findings: A facility policy, dated 06/27/13, titled Quality Assessment and Assurance Program documented, "Policy: To implement and maintain an ongoing program designed to monitor and evaluate the quality of resident care, pursue methods to improve quality care and to resolve identified problems...Each department or services will submit to the Quality Assessment and Assurance Committee a quarterly report of its own monitoring systems... Reports will be evaluated to determine problems, plan solutions, implement actions, and ensure follow-up as well as consistent monitoring of results over a specified time frame..." 1. Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent resident to resident altercations and mistreatment by two (#1 and #2) of three sampled residents with aggressive and/or abusive behaviors. The facility failed to protect resident #1 and #3 from mistreatment by cognitively impaired residents when they were hit in the face or pushed in the hallway. This had the likelihood to affect all 41 residents who resided in the facility. This resulted in an Immediate Jeopardy situation. Refer to F-323. 2. On 01/16/14 at 4:37 a.m., the QA nurse was asked if the facility had an established QA committee. She stated, "Yes." She was asked how often the facility had QA meetings. She stated, "We meet monthly and quarterly." The QA nurse was asked how many residents had been identified that wandered throughout the facility. She stated, "I identified two." The QA nurse was asked what systems were in place to identify residents who wander and are at risk for resident to resident altercations. She stated, "Admission assessment and behavior sheets to track behaviors." The DON and the QA nurse were asked if the problem with wandering residents had been addressed in the QA committee meeting. The QA nurse stated, "I discussed it with (medical director) over the telephone, maybe the week of the 20th (December)." The DON stated, "I spoke with him yesterday on the phone to let him know you (survey team) were here and had three IJs." They were asked if the problem regarding resident to resident altercations had been addressed in the QA committee. The QA nurse stated, "I don't remember a formal discussion." The DON stated, "We discussed it in a stand up." The QA nursed stated, "I didn't remember that we discussed it." The QA nurse was asked what systems were in place to ensure the residents were protected. She stated, "Had increased staff for more supervision and checks periodically, staff to visually observe whereabouts, and keep stop signs up." The QA nurse was asked what systems were in place to identify issues that are addressed in the QA. She stated, "Behavior sheets and the CNAs to report and address." 3. On 01/17/14 at 11:24 a.m., the administrator was asked if the QA was effective. She stated, "My perception, we were talking more about those focused residents and teach staff to be more aware of their surroundings. Brought more awareness to the staff."

On 01/14/14, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to provide supervision to prevent resident to resident altercations and protect residents from mistreatment by cognitively impaired residents with aggressive and abusive behaviors. At 5:23 p.m., the Oklahoma State Department of Health (OSDH) was called and verified the existence of the Immediate Jeopardy situation. At 5:32 p.m., the administrator, the DON, the ADON, and the QA nurse were informed of the Immediate Jeopardy situation regarding the aggressive and abusive behaviors of resident #1, toward resident #3, when the resident had wandered into the other resident's room and resident #2 mistreatment toward the wandering resident #1. They were informed that a plan of removal would be required. They were also informed that this placed the facility in an extended survey. At 6:10 p.m., an acceptable plan of removal was received from the administrator. The plan documented: "January 14, 2014. 5:40 pm Plan of removal regarding lack of Supervision and prevention of accidents; Quality Assurance, Administration: 1. Facility will and shall provide personal supervision by a C.N.A. and or hospitality aide to ensure the safety of wandering resident as well as all other residents within the facility. 2. At 5:56pm, a hospitality aide was assigned to (name deleted). Hospitality aide shall be with resident 24 hours a day to include weekends. 3. At 6:30pm, Hospitality aide shall document every 15 minutes and q 15 min x 72 hours nurse will visually monitor resident and aides where abouts and initial the cna. Hospitality aide will remain at residents' (sic) side during the tour of their duty. 4. Person assigned shall document every 15 minute (sic) in progress note and the Charge Nurse shall visually observe residents whereabouts and activities. The Charge Nurse shall initial the progress note of the resident for the first 72 hours and upon every downgrade according to the IDCP Team. 5. After review of every 15 minute checks x 72 hrs. icdt will review incidents and then evaluate possibilities of downgrading to 30 minute checks x72 hours. 6. Progress notes shall be reviewed and ICDP Team shall review q 72 hours to monitor and to ensure ongoing compliance as well as to determine if charge nurse checks can be downgrade (sic) or need to remain the same or increase. 7. Q.A. team will meet q 72 hours to review and determine if any modifications in the supervision plan can be made. 8. At 6:30pm, facility In-serviced staff in regards to the proper documentation of the whereabouts of wandering resident and any potential residents that may arise during this occurrence. 9. At 8:00pm, QA meeting conducted with Department heads, Charge Nurse, and C.N.A. with regards to wandering resident and maintain compliance to proper documentation. 10. At 8:10pm, nursing staff were in-serviced regarding incident reports and witness statements to be taken and given to DON. 11. At 8:15pm, department heads were in-service (sic) regarding incident report, state reportable, given to department heads and how to conduct thorough investigations and witness statements. 12. At 8:15pm, residents were in-serviced regarding Resident to Resident abuse to include verbal, sexual, physical, or mental abuse, corporal punishment an involuntary seclusion. 13. Administrator was in-serviced at regarding (sic) monitoring and evaluation of proper documentation, the Q.A. process as well as Incident Report investigation and process." The IJ was removed on 01/15/14 at 2:10 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern of actual harm. Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent resident to resident altercations and mistreatment by two (#1 and #2) of three sampled residents with aggressive and/or abusive behaviors. The facility failed to protect resident #1 and #3 from mistreatment by cognitively impaired residents when they were hit in the face or pushed in the hallway. This had the likelihood to affect all 41 residents who resided in the facility. Findings: A facility policy, titled Wandering, Unsafe Resident, documented, "The staff will identify residents who are at risk for harm because of unsafe wandering...staff will assess at-risk individuals for potentially correctible (sic)risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. Staff will institute a detailed monitoring plan, as indicated for residents who have a high risk of elopement or other unsafe behavior." A facility policy, titled resident to resident abuse, documented, "Facility staff will immediately intervene to halt abusive behavior and initiate appropriate actions to ensure the safety of all residents...provide one on one immediate supervision until problem behavior alleviated..." 1. Resident #1 had [DIAGNOSES REDACTED]. A care plan, dated 01/18/13, documented, "Resident is a threat to self and/or others; combativeness toward staff during care activities R/T chronic confusion secondar (sic) to dementia. The goal was documented as, "Resident will not harm self and/or others secondary to disruptive behavior. Current disruptive behavior pattern: combativeness during care activities toward staff." Approaches included: Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents)...." An update to this care plan, dated 05/07/13, documented, "Resident has started pinching other residents and staff and must be reminded often of boundaries Easily redirected when removed from situation..." A quarterly assessment, dated 10/14/13, documented the resident had short and long term memory problems; was severely impaired with cognitive skills for daily decision making; had physical behaviors directed toward others; other behavior symptoms not directed toward others; wandered daily; had received antipsychotic, antianxiety, and antidepressant medications during the last seven days; and ambulated independently. A care plan for cognitive loss/dementia, dated 12/02/13, documented, "(Resident) experiences wandering, moves with no rational purpose, seemingly oblivious to needs or safety." The goal was documented as, "(Resident) will wander safely within specified boundaries." Approaches included: "Remove (resident) from other resident's rooms and unsafe situations. Provide visual deterrents. Specify: stop signs, across doors to prevent entering resident rooms." An activity care plan, dated 12/17/13, documented, "Problem: Patient is exhibiting a decline in activity/therapy and requires evaluation and treatment in preventing and alleviating boredom. Goal: This patient will remain stimulated with no decline in physical, emotional, or psychosocial well-being daily. Approaches: ...will remain on Q 15 minutes checks for the 1st week with ongoing staff supervision...After the 2nd week...will be downgraded to Q 30 minute checks with ongoing staff supervision...Social/activities coordinator will ensure to discover through direct inquiry and family/staff input likes and dislikes and individualize current plan of care according to those likes and dislikes presently and prior history of vocation/recreational enrichments daily and as needed..." An activity progress note, dated 12/19/13, documented the resident was resting in a chair and being changed. There was no documentation to indicate an activity was provided to the resident. An activity progress note, dated 12/20/13, documented the resident tried to do an activity but became combative on two occasions. The activity care plan was not updated to address the resident had been combative. No new interventions were added to address what activities the resident liked/disliked or his preferences regarding his vocation. No new activities were developed or implemented for the resident. A care plan, dated 12/20/13, documented, "...Psychotropic Drug Use (Resident) is at risk for side effects related to use of psychotropic medications for current [DIAGNOSES REDACTED]. Approaches included: "...(Resident) will be evaluated at (geriatric psychiatric facility) for appropriate [DIAGNOSES REDACTED]. (Resident's) behaviors will be monitored every shift and documented on the behavior flow sheet..." A wandering resident monitor sheet, dated 12/24/13, documented, "...Check (sic) are every 30 minutes via administrator..." A nurse's note, dated 12/31/13 at 7:45 p.m., documented, "res (sic) wandered into another res room - another res female stated she was lying in her bed (and) he pushed @ her (and) then - used his fist (and) hit her in the jaw - CNA the (sic) went in (sic) removed him (and) he was hitting @ her - have been doing sp (sic) checks on him @ least q 30 min - (and) redirecting prn - res seems to be getting (increased) aggravated c all the extra attention/redirection - will cont to monitor res to help prevent further issues (and) will call Dr..." An incident report for resident #3, dated 12/31/13, documented, "...No bruising to L jaw...says Res (resident #1) pushed @ her (and) hit her c fist in L jaw. Said @ 1st he didn't hit her very hard - then said he did, (and) stated he pushed @ her c both hands 1st before he hit her in the jaw. CNA stated he pushed @ her as well..." The area of the incident report to document safety precautions to prevent reoccurrence was left blank. A nurse's note, dated 12/31/13 at 8:45 p.m., documented, "spoke (sic) c Dr. (name deleted) stated she would like him admitted to psych hosp if one available - opening. Dr. (name deleted) also stated...can start Back (sic) on Zyprexa (and) Celexa that was Dc'd earlier in month as recommended by Pharmacy..." A nurse's note, dated 12/31/13 at 10:15 p.m., documented, "spoke (sic) c (name deleted) at (hospital deleted) may be able to admit him in the am..." An update to the behavior care plan, dated 12/31/13, documented, "Problem: (Increased) behaviors - aggression towards others...Goal: Improved mood and behavior...Intervention: Admit to psych hospital for behaviors when bed available...Restart Celexa (and) Zyprexa at previous order dose..." A nurse's note, dated 01/01/14 at 4:00 p.m., documented, "resident (sic) (up) ambulating, wandering around most of shift...spoke with wife this am regarding last night's behaviors..." A nurse's note at 9:30 p.m., documented, "res (sic) amb ad lib this shift. redirected (sic) per staff q need..." A physician's telephone order, dated 01/02/14, documented, "resident (sic) sent to (hospital, name deleted) for eval (and) tx..." An update to the behavior care plan, dated 01/02/14, documented, "admitted to (name deleted, hospital)." An undated final state reportable incident report documented, "...(resident #3) reported that (resident #1) came into her room while she was in bed and pushed at her, then hit her in the jaw with his fist. CNA took him out of her room...(resident #1) has become increasingly agitated while 1:1 supervision is provided. Redirection from staff seems to be aggravating him...remained on 1:1 supervision following incident and was advanced to q 30 minute observation within 24 hours from time of incident until able to arrange evaluation and treatment at (hospital, name deleted) as soon as bed available...was admitted on [DATE]nd. No evidence of injury, redness, swelling or bruising noted to (resident #3) at this time..." A nurse's note, dated 01/09/14, documented, "resident (sic) returned from (name deleted) (up) ambulating ad lib..." The care plan was not updated to address the resident's return to the facility and no interventions were put in place to prevent the resident from entering other residents' rooms. No interventions were put in place to keep the resident and other residents' safe from future resident to resident altercations. A behavioral summary for resident #2, dated 01/12/14, documented, "Resident (resident #1) was just walking by resident (resident #2) (and) she (resident #2) pushed him out of the way...staff intervention:...verbal intervention..." The care plan was not updated to address the resident to resident altercation that occurred on 01/12/14 and no interventions were put in place to keep the resident and other residents' safe from resident to resident altercations. A behavior monitoring sheet for January 2014 documented the resident had behavioral symptoms of delusions and pacing. Aggression towards others was added as a behavior on 01/03/14. The sheet documented the resident had five episodes of pacing on 01/01/14, six on 01/10/14, four on 01/11/14 and two on 01/12/14. An untimed nurse's note, dated 01/13/14, documented, "resident (up) wandering this afternoon for short period of time..." The next nurse's note was dated 01/13/14 at 10:30 p.m. The note documented, "...Res Amb (sic) ad lib in halls..." On 01/14/14 from 9:40 a.m. through 10:50 a.m., the resident was observed to be in his room, in his bed, asleep. During this time no staff were observed to check on the resident. A wandering resident monitor sheet, dated 01/14/14, documented the resident was in the lobby at 10:00 a.m. At 10:11 a.m., CNA #2 was asked if staff were supervising resident #1. She stated, "For a little bit we all were. For about a week after you guys left." (The previous survey was completed on 12/17/14.) She stated someone on the day shift was assigned to have activities for him but he had been roaming everywhere. She was asked if staff were monitoring his whereabouts. She stated, "No. He does his routine roaming up and down the hall." She stated no one was assigned to him today and they were no longer monitoring him. She was asked if any of the residents were afraid of him. She stated, "Yes." At 10:48 a.m., CNA #5 was asked if anyone was assigned to monitor resident #1. She stated, "They tell us just to keep an eye on him." She stated he still wandered and was sent out because of something that occurred with another resident. At 10:55 a.m., the resident was observed to leave his room alone and attempt to enter another resident's room. A staff person that was in the room stopped the resident and turned him out of the room and lead him down the hall to his room. She assisted the resident to sit down on his bed and left the room. At 10:57 a.m., CMA #2 was asked if any staff were assigned to monitor resident #1. She stated, "Just whoever is on the hall, no one specifically." She was asked if the resident was wandering in and out of resident rooms. She stated, "Yes. Everyone knows to get him if they see him." She stated yesterday, 01/13/14, he was in another resident's room. At 1:47 p.m., a family member was asked if he was aware of resident #1 wandering. He stated, "Yes." He stated he was at the facility last night, 01/13/14, and he heard a resident scream at the end of the hall. He stated he observed two CNAs leave the dining room and go down the hall and remove resident #1 from another resident's room. He stated he then saw the two CNAs leave the resident's room and they came back up the hall. He stated the resident had also came into his mother's room and she was afraid of him. He stated, "This is a continuous thing." At 2:15 p.m., LPN #1 was asked how they were monitoring the resident. She stated, "30 minute checks, activities door, if they can get him to sit down and to do it." She stated since his return on 01/09/14, they had been doing 30 minute checks and kept a flow sheet by the time clock in the hallway to document where the resident was every 30 minutes. She was asked if the resident wandered freely. She stated "Yes." She stated he still wandered and did take down the stop signs. At 2:45 p.m., the resident was observed in his room, in his bed, asleep. The resident was observed to remain in his bed asleep until 4:25 p.m. He then wandered out of his room unattended by staff and began wandering in the hallway. At 3:28 p.m., the QA nurse was asked what interventions had been put in place to protect the residents after resident #1 had a physical altercation with resident #6 on 12/31/13. She stated, "We had the continual checks. They had done the checks and then five minutes after he would wander down the hall. We asked for an evaluation, I believe he was sent out." She was asked if the DON and the administrator had asked her what interventions needed to be put in place. She stated, "No." She was asked if the 30 minute checks were working. She stated, "At that moment they weren't working well." At 3:56 p.m., CNA #4 was observed to document the resident's whereabouts incorrectly for the time period of 3:00 p.m. through 4:00 p.m. The wandering resident monitor sheet, dated 01/14/14, documented the resident was in the lobby at 3:00 p.m., 3:15 p.m., 3:30 p.m., 3:45 p.m., and 4:00 p.m. The care plan was not updated with new interventions to address the resident's wandering and resident to resident altercations. No new interventions were added to the care plan after the resident's return on 01/09/14 and the resident continued to wander unsupervised throughout the facility. At 4:30 p.m., resident #1 was observed wandering, unattended, in the hallway from his room on the west end of the facility, past all of the resident rooms on the west hall, past the nurses' station, past the dining room, past the offices, and past several staff to the east end of the facility. He wandered the entire length of the facility and was going into another resident's room when staff stopped him and guided him back to his room and left him there. At 5:00 p.m., CNA #6 was asked about the activity/wandering of resident #1. She stated, "Usually one of us monitors, we just know who takes over. We document 30 minute checks." She stated no one designates who watches the resident and they all try to monitor him. She stated, "We are busy, but not too busy to stop what we are doing to help him." At 5:14 p.m., resident #7 was asked if there were any residents that wandered into her room. She stated, "Yes." She stated that residents' #1 and #6 wandered. She stated. "Both came in last night." She stated she was not afraid of resident #6, but was afraid of resident #1. She stated she told the staff they needed to lock them up and that it doesn't do any good to tell resident #1 no. She was asked if the stop sign banner across the door kept him from entering her room. She stated, "No. He just pulls it down or comes under it." She stated she had came in and found him in her bed before." At 5:15 p.m., Resident #9 was asked if resident #1 had wandered into her room on 01/13/14. She stated, "Yes." She stated she had yelled for someone to come and get him out of her room. She stated the resident stood in her room until the CNAs came and assisted him out. She was asked if she was afraid of the resident. She stated, "Yes." On 01/17/14 at 11:55 a.m., the care plan coordinator was asked why the resident's care plan was not updated to address the resident's continued wandering and the resident to resident altercations that occurred on 12/31/12 and 01/12/14. She stated, "I didn't do it." She was asked if the care plan should have been updated when the resident returned to the facility on [DATE]. She stated, "Yes, it should have been." 2. Resident #3 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/18/13, documented the resident had a BIMS score of 13. This score indicated the resident was cognitively intact. The assessment also documented the resident had not exhibited any behaviors. A nurse's note, dated 12/31/13, documented, "res (sic) state (sic) she was lying in her bed - (and) another male res walked into her room, pushed @ her then took his fist (and) hit her in the jaw. @ (sic) first stated he didn't hit her hard then 5 min later stated he did - No bruising or redness noted @ the x redirected res (male) out of her room per CNA..." An incident report, dated 12/31/13, documented, "...No bruising to L jaw...says Res (resident #1) pushed @ her (and) hit her c fist in L jaw. Said @ 1st he didn't hit her very hard - then said he did, (and) stated he pushed @ her c both hands 1st before he hit her in the jaw. CNA stated he pushed @ her as well..." The area of the incident report to document safety precautions to prevent reoccurrence was left blank. An undated final state reportable incident report documented, "...(resident #3) reported that (resident #1) came into her room while she was in bed and pushed at her, then hit her in the jaw with his fist. CNA took him out of her room...(resident #1) has become increasingly agitated while 1:1 supervision is provided. Redirection from staff seems to be aggravating him...remained on 1:1 supervision following incident and was advanced to q 30 minute observation within 24 hours from time of incident until able to arrange evaluation and treatment at (hospital, name deleted) as soon as bed available...was admitted on [DATE]nd. No evidence of injury, redness, swelling or bruising noted to (resident #3) at this time..." The resident's care plan was not updated to include the resident to resident altercation had occurred and no interventions were developed to protect the resident from future resident to resident altercations. A social service note, dated 01/10/14, documented, "...Res is concerned that (resident #1) has returned from (name deleted). Res is extremely upset and crying. Res stated that is (sic) (resident #1) stays she is not staying here, due to fear of him coming back in her room and having a repeat of previous incadent (sic)...I tried to explain to her that the doctor was the one that made that choice. Res became more upset..." On 01/14/14 at 10:08 a.m., resident #3 was observed to be in her room and asked about the altercation with resident #1. She stated, "He came in, scared me, hit me in the jaw." She stated, "I was shaking, so scared." She was asked if she had reported her fear to anyone. She stated the nurse was aware and had watched her all night. The care plan was not updated to address the resident's fear. No new interventions were put in place to protect the resident or prevent future resident to resident altercations from occurring. On 01/15/14 at 3:45 p.m., the administrator, the DON, and the QA nurse were asked what had been done regarding the resident's fear of resident #1 and how they had addressed the situation. The administrator stated, "We were going to talk to her again on Friday (01/17/14) and I have asked her when I saw her and she is not fearful. She was asked if she documented the conversation. She stated, "I would just ask her in passing, I didn't write anything down." They were asked if the care plan had been updated to address the resident's safety concerns regarding her fear and future resident to resident altercations. The DON and QA nurse stated, "No." The QA nurse stated, "We didn't document anything, we just talked to her in passing." 3. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/04/13, documented the resident had a BIMS score of 12. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident rejected care one to three of the last seven days. No other behaviors were documented. A behavior care plan, updated on 11/12/13, documented, "Problem: ...sometimes a threat to herself and/or others R/T hitting out at others when startled while asleep in her wheelchair...no patience with other residents and yells at them or swings at them...Goal: ...will not harm self and/or others secondary to socially inappropriate and/or disruptive behavior by having less episodes...Approach: ...remove (name deleted) from other residents' rooms and any other unsafe situations to prevent altercations...set expectations and limits..." A behavior monitoring record, dated December 2013, documented the resident had pushed another resident on 12/28/13 and on 12/30/13. No interventions and no outcomes were documented for 12/28/13 and she was told to stop pushing on 12/30/13. The behavior care plan was not updated to include the two episodes of pushing residents or interventions to prevent future episodes. No incident reports were found for the resident to resident altercations on 12/28/13 and 12/30/13. A behavior monitoring record, dated January 2014, documented no episodes of pushing other residents. A nurse's note, dated 01/12/14, documented, "Saw resident push another resident away when resident was just walking past her. Instructed resident that it was not right for her to being (sic) pushing other residents out of the way." A behavioral summary, dated 01/12/14, documented, "Resident (name deleted-Resident #1) was just walking by resident (name deleted-Resident #2) & she pushed him out of the way." The behavior care plan was not updated to include the episode of pushing the resident or interventions to prevent future episodes. No incident report was found for the resident to resident altercation on 01/12/14. On 01/17/14 at 12:00 p.m., the care plan coordinator was asked if she knew the name of the other resident that was pushed on 12/28/13. She stated, "I don't." She was asked if the altercation was updated on the care plan. She stated, "No." The care plan coordinator was asked if the altercation should have been updated on the care plan with new interventions to prevent future episodes. She stated, "Yes." She was asked if she knew the name of the other resident that was pushed on 12/30/13. She stated, "No." She was asked if the altercation was updated on the care plan. She stated, "No." The care plan coordinator was asked if the altercation should have been updated on the care plan with new interventions to prevent future episodes. She stated, "Yes." She was asked why the incident documented in the nurse's notes and behavioral summary on 01/12/14 was not documented on the behavior monitoring sheet. She stated, "I don't know." She was asked if the altercation was updated on the care plan. She stated, "No." The care plan coordinator was asked if the altercation should have been updated on the care plan with new interventions to prevent future episodes. She stated, "Yes." She was asked if there were incident reports for the resident to resident altercations on 12/28/13, 12/30/13, and 01/12/14. She stated, "If they are not in the incident book. There isn't any." She was asked how the facility was protecting other residents from her behaviors. She stated, "Other than monitoring and counseling her after she does it, we're not."

On 12/13/13, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to provide supervision and protection to prevent resident to resident altercations and mistreatment of [REDACTED].#3 and #12) residents with aggressive and abusive behaviors. At 3:49 p.m., The Oklahoma State Department of Health (OSDH) was called and verified the existence of the Immediate Jeopardy situation. At 3:54 p.m., the administrator, the DON, and the ADON, were informed of the Immediate Jeopardy regarding the aggressive and abusive behaviors of resident #3 and #12 toward the wandering residents #1 and #9 and that a plan of removal would be required. They were also informed that this placed the facility in an extended survey. At 6:45 p.m., an acceptable plan of removal was received from the administrator. The plan documented: "December 13, 2013, 6:30 pm Plan of removal regarding lack of Supervision and prevention of accidents and staffing: 1. First and second shift will have two additional staff member which will be from the nursing staff department to include L.P.Ns, C.N.As, C.M.As', and/or hospitality aide to ensure the safety of wandering residents...in the prevention of being harmed by others (sic) residents. 2. As of 5:00 pm., one-on-one staff was with wandering residents in the prevention of being harmed and for their own safety. Visual continual monitoring with wandering residents until all staff are in-serviced from December 13, 2013 to December 16, 2013. 3. To ensure wandering residents safety and well-being, additional staff has been added as of December 13, 2013 in the prevention to protect the wandering resident and will continue with the additional staff. Inservice shall be completed as of December 16, 2013 by 11:00 a.m. 4. In-service commenced on December 13, 2013 at 6:30 pm, for second shift 3:00 pm to 11:00 pm. Prior to commencement of third shift, 11:00 pm to 7:00 pm, staff shall be in-serviced and on December 14, 2013, prior to shift, staff shall be inserviced. All shifts must document their time of commencement of inservice. Inservice shall be presented by the Administrator...and/or...DON. 5. All other residents who want to maintain their privacy and do not want wandering resident to enter their rooms, will be offered a stop sign guard or asked if they prefer their door closed. 6. To ensure the residents protection and safety, a scheduled monitoring sheet of 15 minute checks will be documented of the residents' whereabouts, time, and who is monitoring the resident with signature. Staff shall monitor until Monday, December 16, 2013 until noon and additional plans shall be implemented. 7. Attached is a list of employees who are presently out of town and until they (sic) in-serviced, they cannot return to work. Employees that were out of town came back on December 14 and 16 were in-serviced prior to returning to work or scheduled work. 8. Identified residents will receive PT/OT/SLP services as ordered to ensure optimal physical and cognitive functioning at least 3 times per week. 9. The identified residents will be provided group counseling services at a minimum two times per week from...to retain/improve cognitive functioning..." The IJ was removed on 12/17/13 at 11:45 p.m. when all components of the plan of removal had been completed. The deficient practice remained at a pattern level of actual harm. Based on observation, interview, and record review, it was determined the facility failed to provide supervision and protection to prevent resident to resident altercations and mistreatment of [REDACTED].#3 and #12 with aggressive and abusive behaviors, and other residents in the facility when the residents who wandered throughout the facility were pushed, hit, yelled at, and had their pants pulled down. The facility identified four residents who were at risk for wandering. Findings: A facility abuse prohibition procedure documented, "...Mistreatment: is defined as actions by a demented resident that constitute inappropriate behavior and/or may be a threat to other residents or themselves..." The abuse prohibition procedure failed to address resident to resident mistreatment, preventative measures to ensure wandering residents would not be abused and/or mistreated, and protection of wandering residents from aggressive/abusive residents. A facility policy titled resident to resident abuse failed to address wandering residents, preventative measures to ensure wandering residents would not be abused and/or mistreated, and protection of wandering residents from aggressive/abusive residents. 1. Resident #1 had [DIAGNOSES REDACTED]. A behavior care plan, dated 01/18/13, documented, "Problem: Resident is a threat to self and/or others; combativeness toward staff during care activities R/T chronic confusion secondar (sic) to dementia...Goal: Resident will not harm self and/or others secondary to disruptive behavior...Current disruptive behavior pattern: combativeness during care activities toward staff...Approach: Avoid over-stimulation (...noise, crowding, other physically aggressive residents)..." The care plan did not address the resident wandering into other residents' rooms, wandering up and down the hallway, other residents becoming aggressive with the resident, and interventions attempted or implemented to prevent wandering into other residents' rooms. The care plan did not address interventions attempted or implemented to protect the resident from being mistreated by other residents. An activity care plan, dated 01/18/13, documented, "Problem: Activities...Goal: ...will feel comfortable c 1:1 interactions c staff...Approach: ...provide 1:1 ...if upsets him leave alone & approach later...Turn on TV in lobby for him to watch..." The activity care plan did not address what the individualized one on one activities were to include for the resident. A social service note, dated 05/10/13, documented, "Res. cont. to be up and walking the facility - upset & combative at times...Res. always eating a sandwich or cookies between meals - he wanders into others rooms & takes naps - When found - he is re-directed to his room...No chgs at this time..." A quarterly assessment, dated 07/14/13, documented the resident had a short/long term memory problem, was severely impaired with cognitive skills for daily decision making, had trouble concentrating on things, short-tempered and easily annoyed, other behavioral symptoms not directed toward others, wandering daily, and had received an antipsychotic, antianxiety, and antidepressant medication during the past seven days. The behavior care plan, updated 07/14/13, documented, "...No change. Goal met cont c care plan..." An incident report, dated 08/14/13, documented, "...res wandered into another res room & she was shooing him out c a magazine...he then grabbed her on the arm...other res denies injury just upset that he did that...redirected out of room/hall...Safety precautions to prevent recurrence...(blank)...Follow Up: 8/16/13...Stop sign ordered...these hinder this resident from entering rooms..." An incident report, dated 08/23/13, documented, "...res wandered into another res. room. She yelled at him & was pushing him out & he pushed her down...Safety precautions to prevent recurrence: watch res & redirect out of others rooms...Follow Up: 8/27/13 Recent redirection (sic) of Zyprexa from 10mg to 5mg. Have requested increase back to previous dose. Stop signs put across doors of residents' rooms that are irritated by residents wandering behavior and these hinder him from going in rooms..." A state reportable incident report, dated 08/23/13, revealed additional information not documented on the facility incident report. The state report documented, "...confused - will retaliate if confronted..." A nurse's note, dated 08/30/13, documented, "...res amb ad lib...go in to other room (sic) x2...redirected..." An activity note, dated 09/12/13, documented, "Res. still wanders the facility, takes naps in various places - watches activities but does not participate..." An incident report, dated 10/12/13, documented, "...Unknown injury - found - 3x1cm - red abrasion on R side of forehead & a red area on L side forehead...Safety precautions to prevent recurrence: Monitor res while (up) ambulating in hallways..." A quarterly assessment, dated 10/14/13, documented the resident had a short/long term memory problem, was severely impaired with cognitive skills for daily decision making, had trouble concentrating on things, was short-tempered and easily annoyed, had physical behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, wandered daily, and had received an antipsychotic, antianxiety, and antidepressant medication during the past seven days. The behavior care plan, updated 10/14/13, documented, "...Cont's to have behaviors to staff while providing care...Approaches still current...Goal mostly met Cont c care plan..." The care plan did not address the incidents that had occurred on 08/14/13 and on 08/23/13 when the resident wandered into other residents' rooms. The care plan did not address the resident being mistreated by other residents, the resident would retaliate when confronted, and the increase in the antipsychotic medication, Zyprexa. The care plan did not address interventions attempted or implemented to protect the resident from being mistreated by other residents or nonpharmacological interventions to prevent the resident from wandering into other residents' rooms. A social service note, dated 11/09/13, documented, "...cont to wander throughout the facility...no rec. or chgs at this time..." An activity note, dated 11/09/13, documented, "...Res. cont to wander throughout facility - We cont to offered (sic) activities to res. but res. just stares at you & keeps on walking or is constantly napping at various places in facility...No chgs at this time..." A witness statement signed by the activity director, dated 11/15/13, documented, "asking residents if they wanted to come & play Bingo - going room to room - ...saw (resident #1) ...come out of (name deleted) room - he misjudged the distance...bumped his head on door frame...I called for ...chg nurse...she walked (resident) down the hallway toward his room - I went on to the dining room to begin residents (sic) Bingo session..." There was no documentation to address the resident was taken to activities or any interventions implemented to keep the resident from entering other residents' rooms. A nurses' note, dated 11/21/13, documented, "...resident (up) wandering around facility..." An incident report, dated 11/26/13, documented, "...Resident fell on to his G. Maximus getting out of another residents (sic) bed...no injury visible...Safety precautions to prevent recurrence: (blank)...Follow Up: Resident unable to verbally communicate...watch for residents (sic) in beds that aren't his own and to help- resident to his own bed @ night, non slip socks in use and pictures of resident & his family are clearly visible on residents (sic) bedroom door to help orrientate (sic) resident to proper room..." An incident report, dated 11/27/13, documented, "...Went into resi's rm. She pushed & yelled at him & she said he hit her on chest...Safety precautions to prevent recurrence: Monitor him for goin (sic) into others rm & be sure stop signs are up on doors..." A nurse's note, dated 11/27/13, documented, "2230 (10:30 p.m.) ...res had new incident...(acc. to another res) tried to sit in her lap & slid (down) to floor - lying on L side - (no) injury... 2250 (10:50 p.m.) ...Res. amb in halls Ad Lib. Wandering into other res rooms, if door open..." There was no documentation to indicate interventions were implemented to address the resident wandering into other residents' rooms. The behavior care plan, updated 12/02/13, documented, "Problem: ...experiences wandering, moves with no rational purpose, seemingly oblivious to needs or safety...Goal: ...will wander safely within specified boundaries...Approach: ...Remove...from other resident's rooms and unsafe situations..." The care plan did not address the incidents that had occurred on 11/15/13, 11/26/13, and two incidents on 11/27/13 when the resident wandered into other residents' rooms and an altercation was exhibited. The care plan did not address the resident being mistreated by other residents and that he would retaliate when confronted. The care plan did not address interventions attempted or implemented to protect the resident from being mistreated by other residents, did not address what the specified boundaries were to be, and nonpharmacological interventions to prevent the resident from wandering into other residents' rooms. On 12/10/13 at 10:30 a.m., a group meeting was conducted for the residents. Six alert residents were in attendance. The residents stated that a man wandered into their rooms at night and would get in their beds. The residents stated they had not reported this to anyone because they were afraid. The residents were asked what they would do when a resident wandered into their room. The residents stated they would shut the door on him or scream. The resident was observed on 12/11/13 at 1:55 p.m., ambulating in the hallway. Resident #3 was observed ambulating in the hallway with her walker. When resident #1 began to pass her (resident #3) in the hallway, resident #3 yelled for the resident to "get out of the way." When resident #1 passed by resident #3 she (resident #3) was observed to make a fist and punch resident #1 in the arm. Resident #1 spun around and the ADON came out of her office and grabbed the resident to keep him from falling. The ADON walked with resident #1 to the lobby and then returned to her office. Resident #1 ambulated in the hallway and entered another resident's room and sat in the other resident's recliner. Staff were observed as they were up and down the hallway and did not remove resident #1 from the other resident's room. An incident report, dated 12/11/13, documented, "...was walking in the hallway a female resident yelled @ him and said get away from me. Female resident...pushed (resident) as he walked down the hall...Safety precautions to prevent recurrence: (blank)..." A nurses' note, dated 12/12/13, documented. "On 12-11-13...resi was amb in hallway walked by female resi & she began yelling at him to "get out of here" - 'get away from me" - She then pushed him away . Staff intervened & he was removed from this situation & redirected to other end of hall..." On 12/12/13 at 3:00 p.m., the DON was asked if Zyprexa should have been increased for wandering. She stated, "No." The care plan coordinator was asked if the resident had a care plan for Zyprexa. She stated, "I don't think there is one. There should have been one." The DON was asked if they were keeping the wandering residents safe from other residents. She stated, "We are failing." At 4:12 p.m., the activity director was asked if she had planned, scheduled, individualized activities for the resident. She stated, "No. I didn't know anything about that." On 12/13/13 at 9:52 a.m., the DON was asked if they were protecting the residents who wander from other residents hitting and pushing them. She stated, "Majoritively yes, but yes it does occur." The DON was asked how they were protecting the resident from other residents. She stated, "Visually supervised." She was asked who visually supervised the wandering residents. She stated, "Everyone in the building. They aren't watching him like they should." The DON was asked how they were protecting other residents from the residents who wander in their rooms. She stated, "The residents have stop signs on their doors. Visual supervision but, clearly there is a problem with that." The DON was asked if there was enough staff on duty to provide that type of visual supervision. She stated, "No we do not." On 12/16/13 at 5:08 p.m., the administrator was asked why the abuse policy and procedure did not address how the residents would be protected during a resident to resident altercation and how wandering residents would be protected from mistreatment by other residents. The administrator reviewed the abuse policy. She stated, "That's all I have. I didn't see anything on the protection. We keep the residents separated or apart. In terms of protection we don't." At 5:23 p.m., the care plan coordinator was asked why wandering had not been addressed on the care plan. She stated, "I don't have an answer." She was asked if any interventions had been attempted for residents who wander into other residents' rooms. She stated, "We have put the stop signs up on the residents' rooms he frequently goes to. Not every door. We redirect." She was asked where the resident was redirected. She stated, "In the hallway." The DON was asked if they had attempted nonpharmacological interventions. She stated, "Not really. Not at all." On 12/17/13 at 11:07 a.m., CNA #4 was asked if she had seen any resident hit another resident. She stated, "I have seen them do it to (resident #1 and resident #9)." The CNA was asked what she had done to protect the resident. She stated, "I saw another resident swat at him (resident #1). I went and got the resident (#1). I told (resident #12) not to do that. The resident said, "Well, keep him out of my room." CNA #4 was asked how she kept the wandering residents out of other residents' rooms. She stated, "I try to monitor as I'm working and keep them out of their rooms." She was asked if there was enough staff for her to monitor the residents, keep them out of other residents' rooms, and complete her assigned tasks. She stated, "I'm trying my best, but I can't get to everyone." At 11:15 a.m., CNA #8 was asked if she was aware of any resident to resident altercations. She stated, "Yes (resident #12 and resident #9). She was asked what had occurred. She stated, "They (residents) were in the hall and (resident #12) hit (resident #9) and tried to knock her down. The CNA stated she had separated the residents and escorted (resident #9) to the lobby. She was asked if she had reported the resident to resident altercation. She stated, "Yes, I told the nurse (LPN #1) and she said OK I will chart it." LPN #1 was asked what she would do if a resident to resident altercation occurred. She stated, "I try to keep them separated." The LPN was asked if she had received training regarding abuse. She stated, "I honestly couldn't answer because during the inservice I'm on the floor." 2. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/18/13, documented the resident had a BIMS score of three. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had disorganized thinking and inattention, physical and verbal behaviors, and other behavior symptoms not directed toward others. The assessment also documented the resident wandered daily, was independent in ambulation, had [DIAGNOSES REDACTED]. A care plan, dated 04/18/13, documented, "Problem: Communication...socially inappropriate/disruptive behavior symptoms as evidenced by going into other residents room...Goal: ...will not harm self or others secondary to socially inappropriate/disruptive behavior next 90 days...Approach: Avoid over-stimulation...as not to escalate behavior (...noise, crowding, other physically aggressive residents)...Remove (resident) from other residents' rooms and unsafe situations..." A quarterly assessment, dated 09/18/13, documented the resident had a BIMS score of one. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment also documented the resident wandered daily, was independent in ambulation, had [DIAGNOSES REDACTED]. An update to the care plan, dated 09/18/13, documented, "...behaviors (decreased) - goal met. Cont c care plan." A nurse's note, dated 09/21/13, documented, "resident was found in storage room sitting down...no apparent injuries noted...cont to amb in hall c no c/o." A care plan meeting note, dated 09/26/13, documented, "...Other issues/problems: Cont's to wander in hallways + other rms. Staff redirects as needed." A nurse's note, dated 10/10/13, documented, "CNA saw another resident hit this resident twice c her w/c (no) S/S pain or discomfort noted. (No) injury noted @ this time resident continues to ambulate around facility ad lib..." The care plan was not updated to address the incident had occurred and no new interventions were put in place to prevent future incidents. An incident report, dated 10/10/13, documented, "Place: East hallway...resident was hit twice by another residents w/c that the other resident was walking behind + pushing..." The section of the incident report to add safety precautions/interventions was left blank. A nurse's note, dated 10/24/13, documented, "res noted by CNA to wander in another res room. CNA went to get her + other res tried to hit her c her w/c then hit her in face c a newspaper + shoo her out...No injuries noted p c/o from res - redirected out of room." The care plan was not updated to address the incident had occurred and no new interventions were put in place to prevent future incidents. A nurse's note, dated 10/26/13, documented, "Res (up) ambulating @ lib (sic)..." A nurse's note, dated 11/01/13, documented, "Resident (up) ambulating around facility..." A nurse's note, dated 11/02/13, documented, "(Up) ambulating in hall all day..." A nurse's note for resident #12, dated 11/28/13, documented, "resident has pulled down another residents pants @ least twice as the other resident walked passed (sic) her + then laughed @ her residents were separated each time. Will cont to monitor..." The resident that had her pants pulled down was identified by the author of the note, as (resident #9). There was no documentation found regarding the incident in the clinical record of resident #9. On 12/13/13 at 9:50 a.m., resident #9 was observed to walk up and down the east and west hall of the facility. She was observed to enter the therapy room and PTA #1 was observed to turn her around and guided her out of the room and closed the door. She then walked from the west end of the building toward the nurses' station and went into the dining room. The administrator was standing near the entrance to the dining room and turned the resident around and guided her toward the lobby and stated, "This way (name deleted), they are going to sweep and mop in here and I don't want you to fall." The resident ambulated from the dining room to resident room #17, another residents' room, and entered the room. She went to the resident's bathroom and stood by the door and then went to a bedside commode that had pillows laid on top of it and spoke softly as she adjusted the pillows back and forth. Staff were observed to walk up and down the hall and did not notice the resident was in another resident's room for approximately eight to ten minutes. At 10:05 a.m., CNA #5 was observed to enter the room and stated, "(name deleted) you are going to get hurt in there. Come on and I'll find you a place to sit." She guided the resident out of the room and took her to the lobby and assisted her to sit down on the sofa. The resident stayed seated. The CNA did not offer her a magazine or any activity. On 12/13/13 at 2:30 p.m., the DON and care plan coordinator were asked what interventions had been put in place to address the resident's wandering and protect the resident from other residents who did not want her to enter their room. They stated they try to monitor her and residents' used the Velcro stop signs across their door, and also shut their door. They were asked if the interventions were working. They stated, "No. She does walk alone in the hallways and all the staff try to monitor her and keep her from entering other residents' rooms." 3. Resident #3 had [DIAGNOSES REDACTED]. A nurse's note for resident #3, dated 05/15/13, documented, "...Resident has become mad and mean with her roommate, stating she loves Elvis more than Jesus, points at you and says, 'you are going down there,' referring going to 'hell' and states, 'down there c the devil'..." A nurse's note, dated 05/16/13, documented, "...cursing, threatening roommate. pushed recliner against roommate to (the) point (other) resident unable to get w/c out. Yelled at this nurse, 'get out of here.'...con't to yell and curse, harassing other resident, telling her she was going to hell and she was going to fail (sic) if she didn't turn off the TV. Resident was still going on cursing and so forth over after 45 min blaming everyone for her not getting to sleep...Resident pushed roomate's (sic) recliner again her again, yelling at nurse for moving it back. 'That's on my side of the room. She is nothing but a fat B!!!h'...Res agitated this AM. Yelling at roomate (sic) and staff. Upset about roommate. States, 'this is a den of hell!'...CNA stated she was afraid she would run her walker into other res so go between them and (resident #3) hit at her..." A nurse's note, dated 05/30/13, documented, "...yelling and making threatening gestures to peers..." The nurses' monthly summary, dated 06/22/13, documented, "...Resident tends towards aggressive behavior towards staff and other residents. Refuses medication quite often. Alert but confused..." A nurse's note, dated 07/17/13, documented, "...Resident attempted to hit both nurse and aide and was hollering..." A nurse's note, dated 08/20/13, documented, "...Was yelling and upset...another res at her table -- difficult to re-direct. Upset and complaining about other residents being 'smart-alichs' (sic)..." A nurse's note, dated 08/21/13, documented, "...resident hollering at another resident. Staff talked to resident and explained that she coundn't be yelling at other people. Resident told staff to 'shut up'..." A nurse's note, dated 08/23/13, documented, "...res (up) amb c walker to and from D/R...Yells at other res at X's. States 'get out of my way!'..." A care plan, dated 09/04/13, documented: "Cognitive Loss/Dementia (Resident) has impaired decision making skills and short and long term memory problems R/T BIM score of 3 out of 15 and secondary to dementia... Goal...(Resident) will have positive experiences in daily routine without overly demanding tasks and without becoming overly stressed or agitated during the next 90 days. Approach...Avoid an overly protective attitude toward (resident) and allow her freedom to roam... Calm (resident) and separate her from areas of stimulation if signs of distress develop during the decision-making process (feeling overwhelmed, fatigue, agitation, restlessness, withdrawal)... Determine if decisions made by (resident) endanger herself or others. Intervene if necessary... Set expectations and limits for (resident). Do not permit (resident) to lash out verbally toward staff or other residents..." An activity progress note, dated 09/13/13, documented, "...res con't to come to Bingo. Still insist that only she sits at her table alone, w/ exception of her daughter or guest during activities..." An activity progress note, dated 10/14/13, documented "...history of being rude, hateful, bossy, to any roommates she has had..." The nurses' monthly summary, dated 10/17/13, documented, "...tends to berate others at X's..." A nurse's note, dated 11/10/13, documented, "...Res (up) to Bfast. Fed self. Yelling at others. At X's calling people 'smart alechs' (sic)..." An incident report, dated 11/10/13, documented, "...(Roommate) and (resident #3) are roommates in room...(Resident #3) was found sitting in the floor on (roommate's) side of the room @ 0910 (9:10 a.m.) this morning... (Resident #3) said (roommate) had pushed her down... (Roommate) denies pushing (resident #3) down, (roommate) said she she (sic) shoved her, but did not knock her down. (Resident #3) yelled at her and (roommate) retreated to her side of the room, (resident #3) followed (roommate) continuing to yell at her and (roommate) states she shoved (resident #3)..." A quarterly assessment, dated 11/23/13, documented the resident had a BIMS score of 3, which indicated the resident had severe cognitive impairment. Resident #1 was observed on 12/11/13 at 1:55 p.m., ambulating in the hallway. Resident #3 was observed ambulating in the hallway with her walker. When resident #1 began to pass her (resident #3) in the hallway, resident #3 yelled for resident #1 to "get out of the way." When resident #1 passed by resident #3, she was observed to make a fist and punch the resident in the arm. Resident #1 spun around and the ADON came out of her office and grabbed the resident to keep him from falling. The ADON walked with resident #1 to the lobby and then returned to her office. Resident #3 continued to ambulate to her room. An incident report, dated 12/11/13, documented, "...was walking in the hallway a female resident yelled @ him and said get away from me. Female resident...pushed (resident) as he walked down the hall...Safety precautions to prevent recurrence: (blank)..." A nurse's note, dated 12/12/13, documented. "On 12-11-13...resi was amb in hallway walked by female resi & she began yelling at him to "get out of here" - 'get away from me" - She then pushed him away. Staff intervened & he was removed from this situation & redirected to other end of hall..." 4. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 08/04/13, documented the resident had a BIMS score of nine. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident had not exhibited any behaviors, had [DIAGNOSES REDACTED]. A behavioral care plan, dated 08/20/13, documented, "Problem: ...is sometimes a threat to herself and/or others when startled while asleep on her wheelchair...does at times also have no patience with other residents and yells at them or swings at them. Goal: ...will not harm self and/or others secondary to socially inappropriate and/or disruptive behavior by having less episodes of hitting at others when startled during sleep during the next 90 days. Approach: Assess...whether the behavior endangers herself and /or others. Intervene if necessary...Remove (name deleted) from other resident's rooms and any other unsafe situations to prevent altercations...Set expectations and limits...let her know that her behavior is unacceptable..." A nurse's note, dated 10/10/13, documented, "CNA saw this resident hitting another resident (resident #9) c her w/c (sic) resident was ambulating while pushing her w/c (sic) CNA saw her hit her twice c w/c (sic) residents were separated + other resident (resident #9) cont to ambulate down the hall (sic)" A

On 12/13/13, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to have sufficient nursing staff to supervise, protect, and prevent, mistreatment for two wandering residents (#1 and #9) who were identified at high risk for wandering; and to supervise two (#3 and #12) residents with aggressive and abusive behaviors. At 3:49 p.m., The Oklahoma State Department of Health (OSDH) was called and verified the existence of the Immediate Jeopardy situation. At 3:54 p.m., the administrator, the DON, and the ADON, were informed of the Immediate Jeopardy regarding the failure to have nursing staff to supervise, protect, and prevent, mistreatment of wandering residents #1 and #9 and that a plan of removal would be required. At 6:45 p.m., an acceptable plan of removal was received from the administrator. The plan documented: "December 13, 2013, 6:30 pm Plan of removal regarding lack of Supervision and prevention of accidents and staffing: 1. First and second shift will have two additional staff member which will be from the nursing staff department to include L.P.Ns, C.N.As, C.M.As', and/or hospitality aide to ensure the safety of wandering residents...in the prevention of being harmed by others (sic) residents. 2. As of 5:00 pm., one-on-one staff was with wandering residents in the prevention of being harmed and for their own safety. Visual continual monitoring with wandering residents until all staff are in-serviced from December 13, 2013 to December 16, 2013. 3. To ensure wandering residents safety and well-being, additional staff has been added as of December 13, 2013 in the prevention to protect the wandering resident and will continue with the additional staff. Inservice shall be completed as of December 16, 2013 by 11:00 a.m. 4. In-service commenced on December 13, 2013 at 6:30 pm, for second shift 3:00 pm to 11:00 pm. Prior to commencement of third shift, 11:00 pm to 7:00 pm, staff shall be in-serviced and on December 14, 2013, prior to shift, staff shall be inserviced. All shifts must document their time of commencement of inservice. Inservice shall be presented by the Administrator...and/or...DON. 5. All other residents who want to maintain their privacy and do not want wandering resident to enter their rooms, will be offered a stop sign guard or asked if they prefer their door closed. 6. To ensure the residents protection and safety, a scheduled monitoring sheet of 15 minute checks will be documented of the residents' whereabouts, time, and who is monitoring the resident with signature. Staff shall monitor until Monday, December 16, 2013 until noon and additional plans shall be implemented. 7. Attached is a list of employees who are presently out of town and until they (sic) in-serviced, they cannot return to work. Employees that were out of town came back on December 14 and 16 were in-serviced prior to returning to work or scheduled work. 8. Identified residents will receive PT/OT/SLP services as ordered to ensure optimal physical and cognitive functioning at least 3 times per week. 9. The identified residents will be provided group counseling services at a minimum two times per week from...to retain/improve cognitive functioning..." The IJ was removed on 12/17/13 at 11:45 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern level of actual harm. Based on observation, record review, and interview, it was determined the facility failed to: ~ have sufficient nursing staff to supervise, protect, and prevent, mistreatment for two wandering residents (#1 and #9) who were identified at high risk for wandering; and two (#3 and #12) residents with aggressive and abusive behaviors. The facility identified four residents who were at risk for wandering. ~ have sufficient nursing staff to provide resident care for seven (#1, 2, 3, 6, 8, 13 and #16) of ten residents who required assistance with showers and oral care; and failed to have sufficient staff to answer call lights to ensure the residents received care and assistance in a timeframe to meet the residents' needs. This had the potential to affect 42 of 42 residents who resided in the facility. Findings: A facility staffing policy documented, "...Policy: The facility shall provide 24-hour nursing service, seven days a week to meet the needs of the residents admitted to the facility..." 1. Resident #1 had [DIAGNOSES REDACTED]. A behavior care plan, dated 01/18/13, documented, "Problem: Resident is a threat to self and/or others; combativeness toward staff during care activities R/T chronic confusion secondar (sic) to dementia...Goal: Resident will not harm self and/or others secondary to disruptive behavior...Current disruptive behavior pattern: combativeness during care activities toward staff...Approach: Avoid over-stimulation (...noise, crowding, other physically aggressive residents)..." The care plan did not address the resident wandering into other residents' rooms, wandering up and down the hallway, other residents becoming aggressive with the resident, and interventions attempted or implemented to prevent wandering into other residents' rooms. The care plan did not address interventions attempted or implemented to protect the resident from being mistreated by other residents. An activity care plan, dated 01/18/13, documented, "Problem: Activities...Goal: ...will feel comfortable c 1:1 interactions c staff...Approach: ...provide 1:1 ...if upsets him leave alone & approach later...Turn on TV in lobby for him to watch..." The activity care plan did not address what the individualized one on one activities were to include for the resident. A social service note, dated 05/10/13, documented, "Res. cont. to be up and walking the facility - upset & combative at times...Res. always eating a sandwich or cookies between meals - he wanders into others rooms & takes naps - When found - he is re-directed to his room...No chgs at this time..." A quarterly assessment, dated 07/14/13, documented the resident had a short/long term memory problem, was severely impaired with cognitive skills for daily decision making, had trouble concentrating on things, was short-tempered and easily annoyed, other behavioral symptoms not directed toward others, wandered daily, and had received an antipsychotic, antianxiety, and antidepressant medication during the past seven days. The behavior care plan, updated 07/14/13, documented, "...No change. Goal met cont c care plan..." An incident report, dated 08/14/13, documented, "...res wandered into another res room & she was shooing him out c a magazine...he then grabbed her on the arm...other res denies injury just upset that he did that...redirected out of room/hall...Safety precautions to prevent recurrence...(blank)...Follow Up: 8/16/13...Stop sign ordered...these hinder this resident from entering rooms..." An incident report, dated 08/23/13, documented, "...res wandered into another res. room. She yelled at him & was pushing him out & he pushed her down...Safety precautions to prevent recurrence: watch res & redirect out of others rooms...Follow Up: 8/27/13 Recent redirection (sic) of [MEDICATION NAME] from 10mg to 5mg. Have requested increase back to previous dose. Stop signs put across doors of residents' rooms that are irritated by residents wandering behavior and these hinder him from going in rooms..." A state reportable incident report, dated 08/23/13, revealed additional information not documented on the facility incident report. The state report documented, "...confused - will retaliate if confronted..." A nurse's note, dated 08/30/13, documented, "...res amb ad lib...go in to other room (sic) x2...redirected..." An activity note, dated 09/12/13, documented, "Res. still wanders the facility, takes naps in various places - watches activities but does not participate..." An incident report, dated 10/12/13, documented, "...Unknown injury - found - 3x1cm - red abrasion on R side of forehead & a red area on L side forehead...Safety precautions to prevent recurrence: Monitor res while (up) ambulating in hallways... A quarterly assessment, dated 10/14/13, documented the resident had a short/long term memory problem, was severely impaired with cognitive skills for daily decision making, had trouble concentrating on things, short-tempered and easily annoyed, had physical behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, wandering daily, and had received an antipsychotic, antianxiety, and antidepressant medication during the past seven days. The behavior care plan, updated 10/14/13, documented, "...Cont's to have behaviors to staff while providing care...Approaches still current...Goal mostly met Cont c care plan..." The care plan did not address the incidents that had occurred on 08/14/13 and on 08/23/13 when the resident wandered into other residents' rooms. The care plan did not address the resident being mistreated by other residents, the resident would retaliate when confronted, and the increase in the antipsychotic medication, [MEDICATION NAME]. The care plan did not address interventions attempted or implemented to protect the resident from being mistreated by other residents or nonpharmacological interventions to prevent the resident from wandering into other residents' rooms. A social service note, dated 11/09/13, documented, "...cont to wander throughout the facility...no rec. or chgs at this time..." An activity note, dated 11/09/13, documented, "...Res. cont to wander throughout facility - We cont to offered (sic) activities to res. but res. just stares at you & keeps on walking or is constantly napping at various places in facility...No chgs at this time..." A witness statement signed by the activity director, dated 11/15/13, documented, "asking residents if they wanted to come & play Bingo - going room to room - ...saw (resident #1) ...come out of (name deleted) room - he misjudged the distance...bumped his head on door frame...I called for ...chg nurse...she walked (resident) down the hallway toward his room - I went on to the dining room to begin residents (sic) Bingo session..." There was no documentation to address the resident was taken to activities or any interventions implemented to keep the resident from entering other residents' rooms. A nurses' note, dated 11/21/13, documented, "...resident (up) wandering around facility..." An incident report, dated 11/26/13, documented, "...Resident fell on to his G. Maximus getting out of another residents (sic) bed...no injury visible...Safety precautions to prevent recurrence: (blank)...Follow Up: Resident unable to verbally communicate...watch for residents (sic) in beds that aren't his own and to help- resident to his own bed @ night, non slip socks in use and pictures of resident & his family are clearly visible on residents (sic) bedroom door to help orrientate (sic) resident to proper room..." An incident report, dated 11/27/13, documented, "...Went into resi's rm. She pushed & yelled at him & she said he hit her on chest...Safety precautions to prevent recurrence: Monitor him for goin (sic) into others rm & be sure stop signs are up on doors..." A nurse's note, dated 11/27/13, documented, "2230 (10:30 p.m.) ...res had new incident...(acc. to another res) tried to sit in her lap & slid (down) to floor - lying on L side - (no) injury... 2250 (10:50 p.m.) ...Res. amb in halls Ad Lib. Wandering into other res rooms, if door open..." There was no documentation to indicate interventions were implemented to address the resident wandering into other residents' rooms. The behavior care plan, updated 12/02/13, documented, "Problem: ...experiences wandering, moves with no rational purpose, seemingly oblivious to needs or safety...Goal: ...will wander safely within specified boundaries...Approach: ...Remove...from other resident's rooms and unsafe situations..." The care plan did not address the incidents that had occurred on 11/15/13, 11/26/13, and two incidents on 11/27/13 when the resident wandered into other residents' rooms. The care plan did not address the resident being mistreated by other residents and that he would retaliate when confronted. The care plan did not address interventions attempted or implemented to protect the resident from being mistreated by other residents, did not address what the specified boundaries were to be, and nonpharmacological interventions to prevent the resident from wandering into other residents' rooms. On 12/10/13 at 10:30 a.m., a group meeting was conducted for the residents. Six alert residents were in attendance. The residents stated that a man wandered into their rooms at night and would get in their beds. The residents stated they had not reported this to anyone because they were afraid. The residents were asked what they would do when a resident wandered into their room. The residents stated they would shut the door on him or scream. On 12/11/13 resident #1 was observed at 1:55 p.m., ambulating in the hallway. Resident #3 was observed ambulating in the hallway with her walker. When resident #1 began to pass her (resident #3) in the hallway, resident #3 yelled for resident #1 to "get out of the way." When resident #1 passed by resident #3 she (resident #3) was observed to make a fist and punch resident #1 in the arm. Resident #1 spun around and the ADON came out of her office and grabbed the resident to keep him from falling. The ADON walked with resident #1 to the lobby and then returned to her office. Resident #1 ambulated in the hallway and entered another resident's room and sat in the other resident's recliner. Staff were observed as they were up and down the hallway and did not remove resident #1 from the other resident's room. On 12/12/13 at 12:12 p.m., the resident was observed in another resident's room. Staff were observed up and down the hallway but did not remove the resident from the other resident's room. On 12/13/13 at 9:52 a.m., the DON was asked if they were protecting the residents who wander from other residents hitting and pushing them. She stated, "Majoritively yes, but yes it does occur." The DON was asked how they were protecting the resident from other residents. She stated, "Visually supervised." She was asked who visually supervised the wandering residents. She stated, "Everyone in the building. They aren't watching him like they should." The DON was asked how they were protecting the other residents from the residents who wander in their rooms. She stated, "The residents have stop signs on their doors. Visual supervision but, clearly there is a problem with that." The DON was asked if there was enough staff on duty to provide that type of visual supervision. She stated, "No we do not." At 11:15 a.m., CNA #5 was asked to identify the residents she was to visually monitor for supervision. She did not identify resident #1 or resident #9. She was asked what type of supervision she was monitoring. She stated, "Falls, incontinence, total care." At 11:15 a.m., CNA #2 was asked to identify the residents she was to visually monitor for supervision. She did not identify resident #1 or resident #9. She was asked what type of supervision she was monitoring. She stated, "For falling residents on the falling star program." On 12/17/13 at 11:07 a.m., CNA #4 was asked if she had seen any resident hit another resident. She stated, "I have seen them do it to (resident #1 and resident #9)." The CNA was asked what she had done to protect the resident. She stated, "I saw another resident swat at him (resident #1). I went and got the resident (#1). I told (resident #12) not to do that. The resident said, "Well, keep him out of my room." CNA #4 was asked how she kept the wandering residents out of other residents' rooms. She stated, "I try to monitor as I'm working and keep them out of their rooms." She was asked if there was enough staff for her to monitor the residents, keep them out of other residents' rooms, and complete her assigned tasks. She stated, "I'm trying my best, but I can't get to everyone." 2. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/18/13, documented the resident had a BIMS score of three. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had disorganized thinking and inattention, physical and verbal behaviors, and other behavior symptoms not directed toward others. The assessment also documented the resident wandered daily, was independent in ambulation, had [DIAGNOSES REDACTED]. A care plan, dated 04/18/13, documented, "Problem: Communication...socially inappropriate/disruptive behavior symptoms as evidenced by going into other residents room...Goal: ...will not harm self or others secondary to socially inappropriate/disruptive behavior next 90 days...Approach: Avoid over-stimulation...as not to escalate behavior (...noise, crowding, other physically aggressive residents)...Remove (resident) from other residents' rooms and unsafe situations..." A quarterly assessment, dated 09/18/13, documented the resident had a BIMS score of one. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment also documented the resident wandered daily, was independent in ambulation, had [DIAGNOSES REDACTED]. An update to the care plan, dated 09/18/13, documented, "...behaviors (decreased) - goal met. Cont c care plan." A nurse's note, dated 09/21/13, documented, "resident was found in storage room sitting down...no apparent injuries noted...cont to amb in hall c no c/o." A care plan meeting note, dated 09/26/13, documented, "...Other issues/problems: Cont's to wander in hallways + other rms. Staff redirects as needed." A nurse's note, dated 10/10/13, documented, "CNA saw another resident hit this resident twice c her w/c (no) S/S pain or discomfort noted. (No) injury noted @ this time resident continues to ambulate around facility ad lib..." The care plan was not updated to address the incident had occurred and no new interventions were put in place to prevent future incidents. An incident report, dated 10/10/13, documented, "Place: East hallway...resident was hit twice by another residents w/c that the other resident was walking behind + pushing..." The section of the incident report to add safety precautions/interventions was left blank. A nurse's note, dated 10/24/13, documented, "res noted by CNA to wander in another res room. CNA went to get her + other res tried to hit her c her w/c then hit her in face c a newspaper + shoo her out...No injuries noted p c/o from res - redirected out of room." The care plan was not updated to address the incident had occurred and no new interventions were put in place to prevent future incidents. A nurse's note, dated 10/26/13, documented, "Res (up) ambulating @ lib (sic)..." A nurse's note, dated 11/01/13, documented, "Resident (up) ambulating around facility..." A nurse's note, dated 11/02/13, documented, "(Up) ambulating in hall all day..." A nurse's note for resident #12, dated 11/28/13, documented, "resident has pulled down another residents pants @ least twice as the other resident walked passed (sic) her + then laughed @ her residents were separated each time. Will cont to monitor..." The resident that had her pants pulled down was identified by the author of the note, as (resident #9). There was no documentation found regarding the incident in the clinical record of resident #9. On 12/13/13 at 9:50 a.m., resident #9 was observed to walk up and down the east and west hall of the facility. She was observed to enter the therapy room and PTA #1 was observed to turn her around and guided her out of the room and closed the door. She then walked from the west end of the building toward the nurses' station and went into the dining room. The administrator was standing near the entrance to the dining room and turned the resident around and guided her toward the lobby and stated, "This way (name deleted), they are going to sweep and mop in here and I don't want you to fall." The resident ambulated from the dining room to resident room [ROOM NUMBER], another residents' room, and entered the room. She went to the resident's bathroom and stood by the door and then went to a bedside commode that had pillows laid on top of it and spoke softly as she adjusted the pillows back and forth. Staff were observed to walk up and down the hall and did not notice the resident was in another resident's room for approximately eight to ten minutes. At 10:05 a.m., CNA #5 was observed to enter the room and stated, "(name deleted) you are going to get hurt in there. Come on and I'll find you a place to sit." She guided the resident out of the room and took her to the lobby and assisted her to sit down on the sofa. The resident stayed seated. The CNA did not offer her a magazine or any activity. On 12/13/13 at 2:30 p.m., the DON and care plan coordinator were asked what interventions had been put in place to address the resident's wandering and protect the resident from other residents who did not want her to enter their room. They stated they try to monitor her and residents' used the Velcro stop signs across their door, and also shut their door. They were asked if the interventions were working. They stated, "No. She does walk alone in the hallways and all the staff try to monitor her and keep her from entering other residents' rooms." 3. Resident #3 had [DIAGNOSES REDACTED]. A nurse's note for resident #3, dated 05/15/13, documented, "...Resident has become mad and mean with her roommate, stating she loves Elvis more than Jesus, points at you and says, 'you are going down there,' referring going to 'hell' and states, 'down there c the devil'..." A nurse's note, dated 05/16/13, documented, "...cursing, threatening roommate. pushed recliner against roommate to (the) point (other) resident unable to get w/c out. Yelled at this nurse, 'get out of here.'...con't to yell and curse, harassing other resident, telling her she was going to hell and she was going to fail (sic) if she didn't turn off the TV. Resident was still going on cursing and so forth over after 45 min blaming everyone for her not getting to sleep...Resident pushed roommate's (sic) recliner again her again, yelling at nurse for moving it back. 'That's on my side of the room. She is nothing but a fat B!!!h'...Res agitated this AM. Yelling at roommate (sic) and staff. Upset about roommate. States, 'this is a den of hell!'...CNA stated she was afraid she would run her walker into other res so go between them and (resident #3) hit at her..." A nurse's note, dated 05/30/13, documented, "...yelling and making threatening gestures to peers..." The nurses' monthly summary, dated 06/22/13, documented, "...Resident tends towards aggressive behavior towards staff and other residents. Refuses medication quite often. Alert but confused..." A nurse's note, dated 07/17/13, documented, "...Resident attempted to hit both nurse and aide and was hollering..." A nurse's note, dated 08/20/13, documented, "...Was yelling and upset...another res at her table -- difficult to re-direct. Upset and complaining about other residents being 'smart-alichs' (sic)..." A nurse's note, dated 08/21/13, documented, "...resident hollering at another resident. Staff talked to resident and explained that she couldn't be yelling at other people. Resident told staff to 'shut up'..." A nurse's note, dated 08/23/13, documented, "...res (up) amb c walker to and from D/R...Yells at other res at X's. States 'get out of my way!'..." A care plan, dated 09/04/13, documented: "Cognitive Loss/Dementia (Resident) has impaired decision making skills and short and long term memory problems R/T BIM score of 3 out of 15 and secondary to dementia... Goal...(Resident) will have positive experiences in daily routine without overly demanding tasks and without becoming overly stressed or agitated during the next 90 days. Approach...Avoid an overly protective attitude toward (resident) and allow her freedom to roam... Calm (resident) and separate her from areas of stimulation if signs of distress develop during the decision-making process (feeling overwhelmed, fatigue, agitation, restlessness, withdrawal)... Determine if decisions made by (resident) endanger herself or others. Intervene if necessary... Set expectations and limits for (resident). Do not permit (resident) to lash out verbally toward staff or other residents..." An activity progress note, dated 09/13/13, documented, "...res con't to come to Bingo. Still insist that only she sits at her table alone, w/ exception of her daughter or guest during activities..." An activity progress note, dated 10/14/13, documented "...history of being rude, hateful, bossy, to any roommates she has had..." The nurses' monthly summary, dated 10/17/13, documented, "...tends to berate others at X's..." A nurse's note, dated 11/10/13, documented, "...Res (up) to Bfast. Fed self. Yelling at others. At X's calling people 'smart alechs' (sic)..." An incident report, dated 11/10/13, documented, "...(Roommate) and (resident #3) are roommates in room...(Resident #3) was found sitting in the floor on (roommate's) side of the room @ 0910 (9:10 a.m.) this morning... (Resident #3) said (roommate) had pushed her down... (Roommate) denies pushing (resident #3) down, (roommate) said she she (sic) shoved her, but did not knock her down. (Resident #3) yelled at her and (roommate) retreated to her side of the room, (resident #3) followed (roommate) continuing to yell at her and (roommate) states she shoved (resident #3)..." A quarterly assessment, dated 11/23/13, documented the resident had a BIMS score of 3, which indicated the resident had severe cognitive impairment. Resident #1 was observed on 12/11/13 at 1:55 p.m., ambulating in the hallway. Resident #3 was observed ambulating in the hallway with her walker. When resident #1 began to pass her (resident #3) in the hallway, resident #3 yelled for resident #1 to "get out of the way." When resident #1 passed by resident #3, she (resident #3) was observed to make a fist and punch resident #1 in the arm. Resident #1 spun around and the ADON came out of her office and grabbed the resident to keep him from falling. The ADON walked with resident #1 to the lobby and then returned to her office. Resident #3 continued to ambulate to her room. An incident report, dated 12/11/13, documented, "...was walking in the hallway a female resident yelled @ him and said get away from me. Female resident...pushed (resident) as he walked down the hall...Safety precautions to prevent recurrence: (blank)..." A nurse's note, dated 12/12/13, documented. "On 12-11-13...resi was amb in hallway walked by female resi & she began yelling at him to "get out of here" - 'get away from me" - She then pushed him away. Staff intervened & he was removed from this situation & redirected to other end of hall..." 4. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 08/04/13, documented the resident had a BIMS score of nine. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident had not exhibited any behaviors, had [DIAGNOSES REDACTED]. A behavioral care plan, dated 08/20/13, documented, "Problem: ...is sometimes a threat to herself and/or others when startled while asleep on her wheelchair...does at times also have no patience with other residents and yells at them or swings at them. Goal: ...will not harm self and/or others secondary to socially inappropriate and/or disruptive behavior by having less episodes of hitting at others when startled during sleep during the next 90 days. Approach: Assess...whether the behavior endangers herself and /or others. Intervene if necessary...Remove (name deleted) from other resident's rooms and any other unsafe situations to prevent altercations...Set expectations and limits...let her know that her behavior is unacceptable..." A nurse's note, dated 10/10/13, documented, "CNA saw this resident hitting another resident (resident #9) c her w/c (sic) resident was ambulating while pushing her w/c (sic) CNA saw her hit her twice c w/c (sic) residents were separated + other resident (resident #9) cont to ambulate down the hall (sic)" A nurse's note, dated 10/14/13, documented, "res in lobby during church service another res walked by + res stuck her foot out as if to trip her according to CNA. res denies this p I spoke c her." A fax to the physician, dated 10/14/13, documented, "...res. (sic) noted per CNA to attempt to stick out her leg + trip another res. res (sec) denies it..." A nurse's note, dated 10/21/13, documented, "res acted as if she was going to kick another res as he went by. did (sic) not kick but acted like it + was laughing. I spoke with her to not do that res stopped." A nurse's note, dated 10/24/13, documented, "res noted to shove her w/c into a wandering res that wandered into her room. She also hit @ her c a newspaper. (No) injuries noted to other res. (resident #12) diff to understand how this is wrong - thinks she has the right: Dx: Dementia." A nurse's note on 10/25/13, documented, "...was in hall making fun + teasing other residents." A quarterly assessment, dated 11/04/13, documented the resident had a BIMS score of 12. This score indicated the resident had moderately impaired cognitive skills for daily decision making. The assessment documented the resident had not exhibited any behaviors, had [DIAGNOSES REDACTED]. An update to the behavioral care plan, dated 11/12/13, documented, "Occas. episodes cont. especially when she is sleeping and awakened. Staff reapproaches later + is monitored for others safety. Goal met cont. c care plan." The care plan did not address the resident had attempted to physically hit or trip other residents, or that the resident did not understand why it was not appropriate behavior to hit, trip, kick, tease, and laugh at other residents. There were no new interventions put in place to prevent future occurrences. A nurse's note, dated 11/27/13, documented, "...male resident wandered into her rm - she said she yelled at him to get out + shoved him he then hit her on the chest. Male res removed from hallway. She was (checked) for injury + none was noted at this time - reminded her to keep stop sign up on her door to prevent him from entering her room..." A nurse's note on 11/28/13, documented, "resident has pulled down another residents pants @ least twice as the other resident walked passed (sic) her + then laughed @ her residents were separated each time. Will cont to monitor." The resident was observed at random times during the survey. She was not observed to hit, shove, remo

Based on interviews and review of clinical records, incident reports and facility policies, it was determined the facility failed to implement their abuse policy to identify and/or address the aggressive and abusive behavior of resident #3 and #12; to protect two (#1 and #9) of two sampled wandering residents from being mistreated by resident #3, resident #12, and other residents in the facility when the residents who wander throughout the facility were pushed, hit, yelled at, and had their pants pulled down; and failed to address in their abuse policy how the facility would protect residents who wander from resident to resident mistreatment. The facility identified four residents who wander. This had the potential to affect 42 of 42 residents who resided in the facility. Findings: An allegation of abuse and/or mistreatment facility policy documented, "...has a no tolerance policy for abuse and/or mistreatment of [REDACTED]. Procedure: All suspicions of abuse and/or mistreatment will be immediately reported to the Administrator, including...physical abuse...verbal abuse...mental abuse...patterns and trends...recognizing high risk residents, recognizing high risk situations, signs of staff burnout and stress...remove any immediate threat to the resident to prevent further potential abuse...document protective measures taken..." A facility abuse prohibition procedure documented, "...Mistreatment: is defined as actions by a demented resident that constitute inappropriate behavior and/or may be a threat to other residents or themselves..." The abuse prohibition procedure and the resident to resident abuse policy failed to address resident to resident mistreatment, preventative measures to ensure wandering residents would not be abused and/or mistreated, and protection of wandering residents from aggressive/abusive residents. 1. Resident #1 had [DIAGNOSES REDACTED]. A behavior care plan, dated 01/18/13, documented, "Problem: Resident is a threat to self and/or others; combativeness toward staff during care activities R/T chronic confusion secondar (sic) to dementia...Goal: Resident will not harm self and/or others secondary to disruptive behavior...Current disruptive behavior pattern: combativeness during care activities toward staff...Approach: Avoid over-stimulation (...noise, crowding, other physically aggressive residents)..." The care plan did not address the resident wandering into other residents' rooms, wandering up and down the hallway, other residents becoming aggressive with the resident, and interventions attempted or implemented to prevent wandering into other residents' rooms. The care plan did not address interventions attempted or implemented to protect the resident from being mistreated by other residents. An activity care plan, dated 01/18/13, documented, "Problem: Activities...Goal: ...will feel comfortable c 1:1 interactions c staff...Approach: ...provide 1:1 ...if upsets him leave alone & approach later...Turn on TV in lobby for him to watch..." The activity care plan did not address what the individualized one on one activities were to include for the resident. A social service note, dated 05/10/13, documented, "Res. cont. to be up and walking the facility - upset & combative at times...Res. always eating a sandwich or cookies between meals - he wanders into others rooms & takes naps - When found - he is re-directed to his room...No chgs at this time..." A quarterly assessment, dated 07/14/13, documented the resident had a short/long term memory problem, was severely impaired with cognitive skills for daily decision making, had trouble concentrating on things, was short-tempered and easily annoyed, other behavioral symptoms not directed toward others, wandering daily, and had received an antipsychotic, antianxiety, and antidepressant medication during the past seven days. The behavior care plan, updated 07/14/13, documented, "...No change. Goal met cont c care plan..." An incident report, dated 08/14/13, documented, "...res wandered into another res room & she was shooing him out c a magazine...he then grabbed her on the arm...other res denies injury just upset that he did that...redirected out of room/hall...Safety precautions to prevent recurrence...(blank)...Follow Up: 8/16/13...Stop sign ordered...these hinder this resident from entering rooms..." An incident report, dated 08/23/13, documented, "...res wandered into another res. room. She yelled at him & was pushing him out & he pushed her down...Safety precautions to prevent recurrence: watch res & redirect out of others rooms...Follow Up: 8/27/13 Recent redirection (sic) of [MEDICATION NAME] from 10mg to 5mg. Have requested increase back to previous dose. Stop signs put across doors of residents' rooms that are irritated by residents wandering behavior and these hinder him from going in rooms..." A state reportable incident report, dated 08/23/13, revealed additional information not documented on the facility incident report. The state report documented, "...confused - will retaliate if confronted..." A nurse's note, dated 08/30/13, documented, "...res amb ad lib...go in to other room (sic) x2...redirected..." An activity note, dated 09/12/13, documented, "Res. still wanders the facility, takes naps in various places - watches activities but does not participate..." An incident report, dated 10/12/13, documented, "...Unknown injury - found - 3x1cm - red abrasion on R side of forehead & a red area on L side forehead...Safety precautions to prevent recurrence: Monitor res while (up) ambulating in hallways... A quarterly assessment, dated 10/14/13, documented the resident had a short/long term memory problem, was severely impaired with cognitive skills for daily decision making, had trouble concentrating on things, short-tempered and easily annoyed, had physical behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, wandering daily, and had received an antipsychotic, antianxiety, and antidepressant medication during the past seven days. The behavior care plan, updated 10/14/13, documented, "...Cont's to have behaviors to staff while providing care...Approaches still current...Goal mostly met Cont c care plan..." The care plan did not address the incidents that had occurred on 08/14/13 and on 08/23/13 when the resident wandered into other residents' rooms. The care plan did not address the resident being mistreated by other residents, that the resident would retaliate when confronted, and the increase in the antipsychotic medication, [MEDICATION NAME]. The care plan did not address interventions attempted or implemented to protect the resident from being mistreated by other residents or nonpharmacological interventions to prevent the resident from wandering into other residents' rooms. A social service note, dated 11/09/13, documented, "...cont to wander throughout the facility...no rec. or chgs at this time..." An activity note, dated 11//09/13, documented, "...Res. cont to wander throughout facility - We cont to offered (sic) activities to res. but res. just stares at you & keeps on walking or is constantly napping at various places in facility...No chgs at this time..." A witness statement signed by the activity director, dated 11/15/13, documented, "asking residents if they wanted to come & play Bingo - going room to room - ...saw (resident #1) ...come out of (name deleted) room - he misjudged the distance...bumped his head on door frame...I called for ...chg nurse...she walked (resident) down the hallway toward his room - I went on to the dining room to begin residents (sic) Bingo session..." There was no documentation to address the resident was taken to activities or any interventions implemented to keep the resident from entering other residents' rooms. A nurses' note, dated 11/21/13, documented, "...resident (up) wandering around facility..." An incident report, dated 11/26/13, documented, "...Resident fell on to his G. Maximus getting out of another residents (sic) bed...no injury visible...Safety precautions to prevent recurrence: (blank)...Follow Up: Resident unable to verbally communicate...watch for residents (sic) in beds that aren't his own and to help- resident to his own bed @ night, non slip socks in use and pictures of resident & his family are clearly visible on residents (sic) bedroom door to help orrientate (sic) resident to proper room..." An incident report, dated 11/27/13, documented, "...Went into resi's rm. She pushed & yelled at him & she said he hit her on chest...Safety precautions to prevent recurrence: Monitor him for goin (sic) into others rm & be sure stop signs are up on doors..." A nurse's note, dated 11/27/13, documented, "2230 (10:30 p.m.) ...res had new incident...(acc. to another res) tried to sit in her lap & slid (down) to floor - lying on L side - (no) injury... 2250 (10:50 p.m.) ...Res. amb in halls Ad Lib. Wandering into other res rooms, if door open..." There was no documentation to indicate interventions were implemented to address the resident wandering into other residents' rooms. The behavior care plan, updated 12/02/13, documented, "Problem: ...experiences wandering, moves with no rational purpose, seemingly oblivious to needs or safety...Goal: ...will wander safely within specified boundaries...Approach: ...Remove...from other resident's rooms and unsafe situations..." The care plan did not address the incidents that had occurred on 11/15/13, 11/26/13, and two incidents on 11/27/13 when the resident wandered into other residents' rooms. The care plan did not address the resident being mistreated by other residents and that he would retaliate when confronted. The care plan did not address interventions attempted or implemented to protect the resident from being mistreated by other residents, did not address what the specified boundaries were to be, and nonpharmacological interventions to prevent the resident from wandering into other residents' rooms. On 12/10/13 at 10:30 a.m., a group meeting was conducted for the residents. Six alert residents were in attendance. The residents stated that a man wandered into their rooms at night and would get in their beds. The residents stated they had not reported this to anyone because they were afraid. The residents were asked what they would do when a resident wandered into their room. The residents stated they would shut the door on him or scream. The resident was observed on 12/11/13 at 1:55 p.m., ambulating in the hallway. Resident #3 was observed ambulating in the hallway with her walker. When resident #1 began to pass her (resident #3) in the hallway, resident #3 yelled for the resident to "get out of the way." When resident #1 passed by resident #3, she (resident #3) was observed to make a fist and punch resident #1 in the arm. Resident #1 spun around and the ADON came out of her office and grabbed the resident to keep him from falling. The ADON walked with resident #1 to the lobby and then returned to her office. Resident #1 ambulated in the hallway and entered another resident's room and sat in the other resident's recliner. Staff were observed as they were up and down the hallway and did not remove resident #1 from the other resident's room. An incident report, dated 12/11/13, documented, "...was walking in the hallway a female resident yelled @ him and said get away from me. Female resident...pushed (resident) as he walked down the hall...Safety precautions to prevent recurrence: (blank)..." A nurse's note, dated 12/12/13, documented. "On 12-11-13...resi was amb in hallway walked by female resi & she began yelling at him to "get out of here" - 'get away from me" - She then pushed him away . Staff intervened & he was removed from this situation & redirected to other end of hall..." On 12/12/13 at 3:00 p.m., the DON was asked if [MEDICATION NAME] should have been increased for wandering. She stated, "No." The care plan coordinator was asked if the resident had a care plan for [MEDICATION NAME]. She stated, "I don't think there is one. There should have been one." The DON was asked if they were keeping the wandering residents safe from other residents. She stated, "We are failing." At 4:12 p.m., the activity director was asked if she had planned, scheduled, individualized activities for the resident. She stated, "No. I didn't know anything about that." On 12/13/13 at 9:52 a.m., the DON was asked if they were protecting the residents who wander from other residents hitting and pushing them. She stated, "Majoritively yes, but yes it does occur." The DON was asked how they were protecting the resident from other residents. She stated, "Visually supervised." She was asked who visually supervised the wandering residents. She stated, "Everyone in the building. They aren't watching him like they should." The DON was asked how they were protecting the other residents from the residents who wander in their rooms. She stated, "The residents have stop signs on their doors. Visual supervision but, clearly there is a problem with that." The DON was asked if there was enough staff on duty to provide that type of visual supervision. She stated, "No we do not." On 12/16/13 at 5:08 p.m., the administrator was asked why the abuse policy and procedure did not address how the residents would be protected during a resident to resident altercation and how wandering residents would be protected from mistreatment by other residents. The administrator reviewed the abuse policy. She stated, "That's all I have. I didn't see anything on the protection. We keep the residents separated or apart. In terms of protection we don't." At 5:23 p.m., the care plan coordinator was asked why wandering had not been addressed on the care plan. She stated, "I don't have an answer." She was asked if any interventions had been attempted for residents who wander into other residents' rooms. She stated, "We have put the stop signs up on the residents' rooms he frequently goes to. Not every door. We redirect." She was asked where the resident was redirected. She stated, "In the hallway." The DON was asked if they had attempted nonpharmacological interventions. She stated, "Not really. Not at all." On 12/17/13 at 11:07 a.m., CNA #4 was asked if she had seen any resident hit another resident. She stated, "I have seen them do it to (resident #1 and resident #9)." The CNA was asked what she had done to protect the resident. She stated, "I saw another resident swat at him (resident #1). I went and got the resident (#1). I told (resident #12) not to do that. The resident said, "Well, keep him out of my room." CNA #4 was asked how she kept the wandering residents out of other residents' rooms. She stated, "I try to monitor as I'm working and keep them out of their rooms." She was asked if there was enough staff for her to monitor the residents, keep them out of other residents' rooms, and complete her assigned tasks. She stated, "I'm trying my best, but I can't get to everyone." At 11:15 a.m., CNA #8 was asked if she was aware of any resident to resident altercations. She stated, "Yes (resident #12 and resident #9). She was asked what had occurred. She stated, "They (residents) were in the hall and (resident #12) hit (resident #9) and tried to knock her down. The CNA stated she had separated the residents and escorted (resident #9) to the lobby. She was asked if she had reported the resident to resident altercation. She stated, "Yes, I told the nurse (LPN #1) and she said OK I will chart it." LPN #1 was asked what she would do if a resident to resident altercation occurred. She stated, "I try to keep them separated." The LPN was asked if she had received training regarding abuse. She stated, "I honestly couldn't answer because during the inservice I'm on the floor." 2. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/18/13, documented the resident had a BIMS score of three. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had disorganized thinking and inattention, physical and verbal behaviors, and other behavior symptoms not directed toward others. The assessment also documented the resident wandered daily, was independent in ambulation, had [DIAGNOSES REDACTED]. A care plan, dated 04/18/13, documented, "Problem: Communication...socially inappropriate/disruptive behavior symptoms as evidenced by going into other residents room...Goal: ...will not harm self or others secondary to socially inappropriate/disruptive behavior next 90 days...Approach: Avoid over-stimulation...as not to escalate behavior (...noise, crowding, other physically aggressive residents)...Remove (resident) from other residents' rooms and unsafe situations..." A quarterly assessment, dated 09/18/13, documented the resident had a BIMS score of one. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment also documented the resident wandered daily, was independent in ambulation, had [DIAGNOSES REDACTED]. An update to the care plan, dated 09/18/13, documented, "...behaviors (decreased) - goal met. Cont c care plan." A nurse's note, dated 09/21/13, documented, "resident was found in storage room sitting down...no apparent injuries noted...cont to amb in hall c no c/o." A care plan meeting note, dated 09/26/13, documented, "...Other issues/problems: Cont's to wander in hallways + other rms. Staff redirects as needed." A nurse's note, dated 10/10/13, documented, "CNA saw another resident hit this resident twice c her w/c (no) S/S pain or discomfort noted. (No) injury noted @ this time resident continues to ambulate around facility ad lib..." The care plan was not updated to address the incident had occurred and no new interventions were put in place to prevent future incidents. An incident report, dated 10/10/13, documented, "Place: East hallway...resident was hit twice by another residents w/c that the other resident was walking behind + pushing..." The section of the incident report to add safety precautions/interventions was left blank. A nurse's note, dated 10/24/13, documented, "res noted by CNA to wander in another res room. CNA went to get her + other res tried to hit her c her w/c then hit her in face c a newspaper + shoo her out...No injuries noted p c/o from res - redirected out of room." The care plan was not updated to address the incident had occurred and no new interventions were put in place to prevent future incidents. A nurse's note, dated 10/26/13, documented, "Res (up) ambulating @ lib (sic)..." A nurse's note, dated 11/01/13, documented, "Resident (up) ambulating around facility..." A nurse's note, dated 11/02/13, documented, "(Up) ambulating in hall all day..." A nurse's note for resident #12, dated 11/28/13, documented, "resident has pulled down another residents pants @ least twice as the other resident walked passed (sic) her + then laughed @ her residents were separated each time. Will cont to monitor..." The resident that had her pants pulled down was identified by the author of the note, as (resident #9). There was no documentation found regarding the incident in the clinical record of resident #9. On 12/13/13 at 9:50 a.m., resident #9 was observed to walk up and down the east and west hall of the facility. She was observed to enter the therapy room and PTA #1 was observed to turn her around and guided her out of the room and closed the door. She then walked from the west end of the building toward the nurses' station and went into the dining room. The administrator was standing near the entrance to the dining room and turned the resident around and guided her toward the lobby and stated, "This way (name deleted), they are going to sweep and mop in here and I don't want you to fall." The resident ambulated from the dining room to resident room [ROOM NUMBER], another residents' room, and entered the room. She went to the resident's bathroom and stood by the door and then went to a bedside commode that had pillows laid on top of it and spoke softly as she adjusted the pillows back and forth. Staff were observed to walk up and down the hall and did not notice the resident was in another resident's room for approximately eight to ten minutes. At 10:05 a.m., CNA #5 was observed to enter the room and stated, "(name deleted) you are going to get hurt in there. Come on and I'll find you a place to sit." She guided the resident out of the room and took her to the lobby and assisted her to sit down on the sofa. The resident stayed seated. The CNA did not offer her a magazine or any activity. On 12/13/13 at 2:30 p.m., the DON and care plan coordinator were asked what interventions had been put in place to address the resident's wandering and protect the resident from other residents who did not want her to enter their room. They stated they try to monitor her and residents' used the Velcro stop signs across their door, and also shut their door. They were asked if the interventions were working. They stated, "No. She does walk alone in the hallways and all the staff try to monitor her and keep her from entering other residents' rooms." 3. Resident #3 had [DIAGNOSES REDACTED]. A nurse's note for resident #3, dated 05/15/13, documented, "...Resident has become mad and mean with her roommate, stating she loves Elvis more than Jesus, points at you and says, 'you are going down there,' referring going to 'hell' and states, 'down there c the devil'..." A nurse's note, dated 05/16/13, documented, "...cursing, threatening roommate. pushed recliner against roommate to (the) point (other) resident unable to get w/c out. Yelled at this nurse, 'get out of here.'...con't to yell and curse, harassing other resident, telling her she was going to hell and she was going to fail (sic) if she didn't turn off the TV. Resident was still going on cursing and so forth over after 45 min blaming everyone for her not getting to sleep...Resident pushed roomate's (sic) recliner again her again, yelling at nurse for moving it back. 'That's on my side of the room. She is nothing but a fat B!!!h'...Res agitated this AM. Yelling at roomate (sic) and staff. Upset about roommate. States, 'this is a den of hell!'...CNA stated she was afraid she would run her walker into other res so go between them and (resident #3) hit at her..." A nurse's note, dated 05/30/13, documented, "...yelling and making threatening gestures to peers..." The nurses' monthly summary, dated 06/22/13, documented, "...Resident tends towards aggressive behavior towards staff and other residents. Refuses medication quite often. Alert but confused..." A nurse's note, dated 07/17/13, documented, "...Resident attempted to hit both nurse and aide and was hollering..." A nurse's note, dated 08/20/13, documented, "...Was yelling and upset...another res at her table -- difficult to re-direct. Upset and complaining about other residents being 'smart-alichs' (sic)..." A nurse's note, dated 08/21/13, documented, "...resident hollering at another resident. Staff talked to resident and explained that she coundn't be yelling at other people. Resident told staff to 'shut up'..." A nurse's note, dated 08/23/13, documented, "...res (up) amb c walker to and from D/R...Yells at other res at X's. States 'get out of my way!'..." A care plan, dated 09/04/13, documented: "Cognitive Loss/Dementia (Resident) has impaired decision making skills and short and long term memory problems R/T BIM score of 3 out of 15 and secondary to dementia... Goal...(Resident) will have positive experiences in daily routine without overly demanding tasks and without becoming overly stressed or agitated during the next 90 days. Approach...Avoid an overly protective attitude toward (resident) and allow her freedom to roam... Calm (resident) and separate her from areas of stimulation if signs of distress develop during the decision-making process (feeling overwhelmed, fatigue, agitation, restlessness, withdrawal)... Determine if decisions made by (resident) endanger herself or others. Intervene if necessary... Set expectations and limits for (resident). Do not permit (resident) to lash out verbally toward staff or other residents..." An activity progress note, dated 09/13/13, documented, "...res con't to come to Bingo. Still insist that only she sits at her table alone, w/ exception of her daughter or guest during activities..." An activity progress note, dated 10/14/13, documented "...history of being rude, hateful, bossy, to any roommates she has had..." The nurses' monthly summary, dated 10/17/13, documented, "...tends to berate others at X's..." A nurse's note, dated 11/10/13, documented, "...Res (up) to Bfast. Fed self. Yelling at others. At X's calling people 'smart alechs' (sic)..." An incident report, dated 11/10/13, documented, "...(Roommate) and (resident #3) are roommates in room...(Resident #3) was found sitting in the floor on (roommate's) side of the room @ 0910 (9:10 a.m.) this morning... (Resident #3) said (roommate) had pushed her down... (Roommate) denies pushing (resident #3) down, (roommate) said she she (sic) shoved her, but did not knock her down. (Resident #3) yelled at her and (roommate) retreated to her side of the room, (resident #3) followed (roommate) continuing to yell at her and (roommate) states she shoved (resident #3)..." A quarterly assessment, dated 11/23/13, documented the resident had a BIMS score of 3, which indicated the resident had severe cognitive impairment. Resident #1 was observed on 12/11/13 at 1:55 p.m., ambulating in the hallway. Resident #3 was observed ambulating in the hallway with her walker. When resident #1 began to pass her (resident #3) in the hallway, resident #3 yelled for resident #1 to "get out of the way." When resident #1 passed by resident #3, she was observed to make a fist and punch the resident in the arm. Resident #1 spun around and the ADON came out of her office and grabbed the resident to keep him from falling. The ADON walked with resident #1 to the lobby and then returned to her office. Resident #3 continued to ambulate to her room. An incident report, dated 12/11/13, documented, "...was walking in the hallway a female resident yelled @ him and said get away from me. Female resident...pushed (resident) as he walked down the hall...Safety precautions to prevent recurrence: (blank)..." A nurse's note, dated 12/12/13, documented. "On 12-11-13...resi was amb in hallway walked by female resi & she began yelling at him to "get out of here" - 'get away from me" - She then pushed him away. Staff intervened & he was removed from this situation & redirected to other end of hall..." 4. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 08/04/13, documented the resident had a BIMS score of nine. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident had not exhibited any behaviors, had [DIAGNOSES REDACTED]. A behavioral care plan, dated 08/20/13, documented, "Problem: ...is sometimes a threat to herself and/or others when startled while asleep on her wheelchair...does at times also have no patience with other residents and yells at them or swings at them. Goal: ...will not harm self and/or others secondary to socially inappropriate and/or disruptive behavior by having less episodes of hitting at others when startled during sleep during the next 90 days. Approach: Assess...whether the behavior endangers herself and /or others. Intervene if necessary...Remove (name deleted) from other resident's rooms and any other unsafe situations to prevent altercations...Set expectations and limits...let her know that her behavior is unacceptable..." A nurse's note, dated 10/10/13, documented, "CNA saw this resident hitting another resident (resident #9) c her w/c (sic) resident was ambulating while pushing her w/c (sic) CNA saw her hit her twice c w/c (sic) residents were separated + other resident (resident #9) cont to ambulate down the hall (sic)" A nurse's note, dated 10/14/13, documented, "res in lobby during church service another res walked by + res stuck her foot out as if to trip her according to CNA. res denies this p I spoke c her." A fax to the physician, dated 10/14/13, documented, "...res. (sic) noted per CNA to attempt to stick out her leg + trip another res. res (sec) denies it..." A nurse's note, dated 10/21/13, documented, "res acted as if she was going to kick another res as he went by. did (sic) not kick but acted like it + was laughing. I spoke with her to not do that res stopped." A nurse's note, dated 10/24/13, documented, "res noted to shove her w/c into a wandering res that wandered into her room. She also hit @ her c a newspaper. (No) injuries noted to other res. (resident #12) diff to understand how this is wrong - thinks she has the right: Dx: Dementia." A nurse's note on 10/25/13, documented, "...was in hall making fun + teasing other residents." A quarterly assessment, dated 11/04/13, documented the resident had a BIMS score of 12. This score indicated the resident had moderately impaired cognitive skills for daily decision making. The assessment documented the resident had not exhibited any behaviors, had [DIAGNOSES REDACTED]. Alzheimer's dementia and anxiety disorder, and had not received an antipsychotic medication in the last seven days. An update to the behavioral care plan, dated 11/12/13, documented, "Occas. episodes cont. especially when she is sleeping and awakened. Staff reapproaches later + is monitored for others safety. Goal met cont. c care plan." The care plan did not address the resident had attempted to physically hit or trip other residents, or that the resident did not understand why it was not appropriate behavior to hit, trip, kick, tease, and laugh at other residents. There were no new interventions put in place to prevent future occurrences. A nurse's note, dated 11/27/13, documented, "...male resident wandered into her rm - she said she yelled at him to get out + shoved him he then hit her on the chest. Male res removed from hallway. She was (checked) for injury + none was noted at this time - reminded her to keep stop sign up on her door to prevent him from entering her room..." A nurse's note on 11/28/13, documented, "resident has pulled down another residents pants @ least twice as the other resident walked passed (sic) her + then laughed @ her residents were separated each time. Will cont to monitor." The resident was observed at random times during the survey. She was not observed to hit, shove, remove the pants of, tease, make fun of, or laugh at any resident. On 12/13/13 at 12:00 p.m., LPN #1 was asked what had occurred between resident #12 and resident #9. She stated the CNA had reported to her that resident #12 had pulled down the pants of resident #9 at least tw

Based on observation, record review, and interviews, it was determined the facility failed to have an effective quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies, which would in turn ensure the nursing staff provided nursing and related services to enable residents to achieve and maintain their highest practicable well-being. The facility failed to identify and implement a plan of action to correct systems failures related to: a. implementation of their abuse policy to ensure identification of aggressive and abusive behavior of resident #3 and #12 directed toward two (#1 and #9) of two sampled residents who wandered throughout the facility; b. protection from aggressive and abusive behavior of resident #3 and #12 for two (#1 and #9) of two sampled residents who wandered throughout the facility; and c. addressing in their abuse policy how the facility would protect residents who wander from resident to resident mistreatment. d. the provision of sufficient nursing staff to supervise, protect, and prevent mistreatment for two wandering residents (#1 and #9) who were identified at high risk for wandering. e. the provision of sufficient nursing staff to provide resident care for seven (#1, 2, 3, 6, 8, 13 and #16) of ten residents who required assistance with showers and oral care; and failed to have sufficient staff to answer call lights to ensure the residents received care and assistance in a timeframe to meet the residents' needs. f. the provision of supervision and protection from resident to resident altercations for two (#1 and #9) of two sampled residents who wandered, from two (#3 and #12) residents with aggressive and abuse behaviors. This resulted in actual harm to the two residents who were pushed, hit, yelled at, and had their pants pulled down. Four residents were identified as at risk for wandering. Findings: A facility policy, dated 06/27/13, titled Quality Assessment and Assurance Program documented, "Policy: To implement and maintain an ongoing program designed to monitor and evaluate the quality of resident care, pursue methods to improve quality care and to resolve identified problems...Each department or services will submit to the Quality Assessment and Assurance Committee a quarterly report of its own monitoring systems... Reports will be evaluated to determine problems, plan solutions, implement actions, and ensure follow-up as well as consistent monitoring of results over a specified time frame..." 1. Based on observation, interview, and record review, it was determined the facility failed to provide supervision and protection to prevent resident to resident altercations and mistreatment of two (#1 and #9) residents who wandered by residents #3 and #12 with aggressive and abusive behaviors, and other residents in the facility when the residents who wandered throughout the facility were pushed, hit, yelled at, and had their pants pulled down. This resulted in an Immediate Jeopardy situation. The facility identified four residents who were at risk for wandering. Refer to F-323. 2. Based on observation, record review, and interview, it was determined the facility failed to: ~ have sufficient nursing staff to supervise, protect, and prevent, mistreatment for two wandering residents (#1 and #9) who were identified at high risk for wandering; and two (#3 and #12) residents with aggressive and abusive behaviors. The facility identified four residents who were at risk for wandering. ~ have sufficient nursing staff to provide resident care for seven (#1, 2, 3, 6, 8, 13 and #16) of ten residents who required assistance with showers and oral care; and failed to have sufficient staff to answer call lights to ensure the residents received care and assistance in a timeframe to meet the residents' needs. This had the potential to affect 42 of 42 residents who resided in the facility. This resulted in an Immediate Jeopardy situation when two (#1 and #9) of two residents who wandered throughout the facility were pushed, hit, yelled at, and had their pants pulled down and there were not enough staff to ensure they were protected. Refer to F-353. 3. Based on interviews and review of clinical records, incident reports and facility policies, it was determined the facility failed to implement their abuse policy to identify and/or address the aggressive and abusive behavior of resident #3 and #12; to protect two (#1 and #9) of two sampled wandering residents from being mistreated by resident #3, resident #12, and other residents in the facility when the residents who wandered throughout the facility were pushed, hit, yelled at, and had their pants pulled down; and failed to address in their abuse policy how the facility would protect residents who wander from resident to resident mistreatment. This resulted in substandard care when residents were being mistreated by other residents and the abuse policy had not been implemented or revised to address protection of residents during resident to resident altercation. The facility identified four residents who wander. This had the potential to affect 42 of 42 residents who resided in the facility. Refer to F-226. 4. On 12/10/13 at 10:02 a.m., the administrator, the DON, and the ADON were asked how often their QA (Quality Assurance) committee met. The administrator stated, "Monthly." On 12/16/13 at 11:52 a.m., the DON was asked how many residents wander in and out of other residents' rooms. She stated, "Four that I can think of." She was asked for a list of residents identified who wander in and out of other residents' rooms. The DON was asked what systems were in place to identify residents who wander and are at risk for resident to resident altercations. She stated, "Behavior monitoring system and assessment on admission." She was asked if the resident had been in the facility a long time and developed behaviors did they complete an assessment. She stated, "That's a good question. I have not developed a system for that." The DON was informed there were no behavior monitoring forms completed in the behavior monitoring book. She stated, "They are ineffective. They need to be revamped." She was asked when they had addressed the problem with wandering residents in the QA meeting. She stated, "We have not addressed it since I have been here, as a team. We have got to get aggressive and address this." The DON was asked if the problem regarding staffing to meet the needs of the residents had been addressed in the QA meetings. She stated, "No." The DON was asked what systems were in place to ensure residents' needs were met by staffing. She stated, "It's been a daily fire fight. The aides were exhausted and calling in. I changed the staffing. We do need more. There is not enough staff. We have not talked about it in QA." She stated, "They have gone by the matrix." She was asked if the facility used the staffing ratio established in the state regulations. She stated, "Yes that is the system." She was asked if their systems were working. She stated, "No."

On 04/17/12, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide supervision to prevent falls, and to identify and implement interventions to prevent falls for resident #7. The resident had 15 falls within 4 1/2 months, resulting in seven injuries which included a hip fracture and a head laceration that required four sutures. At 2:41 p.m., OSDH verified the existence of the IJ related to the facility's failure to supervise residents to prevent accidents. At 2:47 p.m., the administrator, and DON were informed of the IJ related to the facility's failure to prevent accidents for resident #7 resulting in seven injuries which included a hip fracture and a head injury with a laceration which required four sutures. Facility Plan of Removal for Immediate Jeopardy At 5:19 p.m., the facility submitted an acceptable plan of removal. The plan of removal documented, "...Do assessment on resident 4:30 p.m. and on her environment, 4:30 p.m.. Care Plan problem, goal, and update interventions, after assessment of Resident, by 7:00 p.m.. Instruct staff to toilet resident at least every hour and when resident indicates that she needs to use the bathroom, and document on the toileting schedule sheet, starting at 6:00 p.m.. Place staff one on one with resident, at 3:30 p.m. to 9:00 p.m. today. Document staff with resident and record any change of staff for bathroom breaks, etc. Do inservice to educate all staff on fall prevention with current staff in building at 5:00 p.m., and other staff as they come to building, to be completed by 10:30 p.m.. Each employee will sign in and record time of arrival. The original sign in sheet will be given to surveyors. Content of inservice will be given to surveyors. New staff orientation will include fall prevention education. Remove closet door to provide easier access to closet from resident's wheelchair. Lower hanger rod in closet to enhance access from wheelchair height. Remove items from top shelf, to a place in room where she can reach these items. Place toilet riser on toilet. Changes in environment to be completed by 6:00 p.m..." On 04/18/12 at 10:47 a.m., a plan of removal addendum was accepted. The plan of removal addendum documented, "...When the environment assessment was done on 4/17/12, it was noticed that the floor in front of the toilet was uneven and posed a tripping hazard. On 4/18/12 repairs on the floor were started and should be finished by 4:00 p.m. on 4/18/12..." Staff were interviewed on 04/18/12, in regard to their knowledge of the in-service, to ensure their understanding of fall prevention. They answered with understanding of the four Ps of fall prevention which included, po intake, possessions within reach, pathways clear, and potty residents. The resident was re-assessed related to risk for falls and the resident's care plan was updated with new interventions to prevent falls. The IJ was removed effective 04/18/12 at 4:06 p.m., when the last employee in-service was completed and the repairs of the resident's bathroom was observed to be completed. The deficient practice remained at a level of actual harm at a pattern that was not an immediate jeopardy. Based on observation, interview and record review, it was determined the facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for two (#4 and #7) of eight sampled residents who had experienced falls which resulted in harm. A. Resident #7 had experienced 15 falls in four months with seven falls resulting in an immediate jeopardy situation of an actual harm of a fractured hip and a head laceration that required four sutures. B. Resident #4 had experienced 6 falls in five months with four falls resulting in actual harm of two hematomas to the back of the head and hip pain. The resident census and condition identified 18 residents who needed assistance with transfers and 10 resident who were dependent on staff for transfers. Findings: Facility Policies & Procedures A Fall prevention policy documented, "...identify residents at risk for falls and to implement a fall prevention approach to reduce the risk of falls and possible injury. The Fall Prevention Approach is incorporated with the facility's Quality Improvement and Safety committees. Every resident will be evaluated for falls upon admission and subsequently thereafter when the resident's condition changes or at least quarterly. The care plan will state the goals, interventions and approaches for every resident who is identified as being at risk for falls. Staff will be trained to be alert to risk and hazards for falls in the environment. The falls prevention approaches will be evaluated by the Quality Improvement Committee to determine the effectiveness of the approaches. With the recommendations of the committee, changes will be implemented to reduce falls risk in the facility. Procedure: Within three days of admission, the resident will be assessed for risk of falls. Either nursing staff or therapy staff may complete the falls assessment... Based on the results of the falls assessment, the interdisciplinary team will determine the best approach to implement for fall prevention, adjust the care plan, inform the family and resident and implement comprehensive fall prevention management approach. Direct Care Providers will be instructed regarding approaches and goals for the management of the resident falls risk. Any resident experiencing a pattern of falls (2 or more during a 30-day period) or an injury from a fall will be referred for a falls assessment to be completed by the nurse or therapist. If a resident experiences a fall, nurses will complete an incident report and document the fall in the resident record, as well as the 24-hour report. Daily entries regarding the status of the resident's condition will occur each shift for 72 hours following the incident..." A policy, titled Falls prevention, documented, "Falls are a major concern for risk in the long-term-care setting...They occur frequently in the older population and can have severe consequences. Falls create a complex clinical picture; the interacting effects of age-related changes, illnesses and disease processes...A well-designed and implemented Falls Program should include: Fall control program: reduce fall potential, provides safety for the residents and employees, maintains focus on care..." 1. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A fall care plan, dated 09/06/11, documented, "...Problem: risk for falls...Goals:...will be free from falls x 90 days...Interventions: 1. Administer all medications as ordered. 2. Monitor gait and notify PCP for possible therapy if decline present. 3. Notify PCP and DON of any falls, if they occur, utilizing the incident report form..." An incident report, dated 11/02/11 at 7:30 a.m., documented, "...res found sitting on floor in front of w/c roommate said she was walking back from B/R and went to sit in w/c & slid to floor...no injuries...suggested safety precautions to prevent recurrence: remind res to not get up s (A) (assist)..." An incident report, dated 11/22/11 at 3:45 p.m., documented, "...res was outside trying to get into van. fell , hit knees on pavement...bilateral knees red, no opened areas. Res states knees hurt...suggested safety precautions to prevent recurrence: (blank)..." An incident report, dated 11/29/11 at 6:05 p.m., documented, "...Res was trying to get a soft drink out of her refrigerator. She lost her balance and sat down on the floor...Red on her bottom. No open areas...suggested safety precautions to prevent recurrence: (blank)..." An incident report, dated 12/04/11 at 4:30 p.m., documented, "...Res was on the ground outside...no injuries...suggested safety precautions to prevent recurrence: Reminded res she is not to go outside by herself..." A quarterly assessment, dated 12/09/11, documented the resident had a severe impairment of cognition, was able to transfer with supervision, and needed limited assistance with ambulation, dressing, and bathing. The resident was continent of bladder and bowel. The resident had two falls since admission or prior assessment with injury. A fall care plan, updated, 12/09/11, documented, "...Goal partially met. cont care..." The fall care plan failed to address the falls on 11/02/11, 11/22/11, 11/29/11 and 12/04/11. A resident fall tracking log, dated 12/28/11 at 11:10 p.m., documented, "...Each time a resident experiences a fall, enter the date and time of the fall at the top of the column. In that same column check all the items listed that may have contributed to that fall. Be sure to include items listed on the reverse. Summarize findings, make any conclusions drawn on related plans on the reverse, sign and date all entries." The staff had checked cognitive deficit, a loss or decrease in ADL's, antianxiety medication and antidepression medication. The reverse side of the fall tracking log was blank. It did not summarize the findings of the fall on 12/28/11, and included no interventions. An incident report, dated 01/22/12 at 8:00 a.m., documented, "...Res got up on her own and was getting into her closet and fell . She hit her head and fell on her R hip. Res c/o hip pain...suggested safety precautions to prevent recurrence: Reminded Res to use call light to help c her needs..." The fall was not addressed on the resident's care plan and no new interventions were put in place to prevent future falls. A hospital admission record, dated 01/22/12, documented, "...fell earlier today, injuring her right hip...brought to the ER, where x-rays revealed a right intertrochanteric hip fracture..." A hospital discharge record, dated 01/26/12, documented the resident returned to the nursing home on 01/26/12. A physician's orders [REDACTED]. Release during care..." A nurse's note, dated 01/31/12 at 4:35 a.m., documented, "...found sitting in the floor (sic) in front of recliner. She was sitting on buttocks c both legs straight out in front of her, leaning back on her hands. Res had not used her call light. She stated, 'I needed to go to the bathroom'...transported to the hospital..." An incident report, dated 01/31/12 at 4:35 a.m., documented, "...Resident fell on her buttocks in her room. Resident did not use call light. Res needed to go to the bathroom. Resident was found sitting in floor c legs straight in front of her...Res c/o R hip pain...physician's orders [REDACTED]. The fall was not addressed on the resident's care plan and no new interventions were put in place to prevent future falls. An incident report, dated 01/31/12 at 4:00 p.m., documented, "...resident found on floor next to mat near bed. Sitting on floor c/o pain in R hip. Denies hitting her head...suggested safety precautions to prevent recurrence: check on resident more often...Follow Up: Ensure call light in reach, remind resident to not attempt to get up independently..." The fall was not addressed on the resident's care plan and no new interventions were documented and put in place to prevent future falls. A fall risk assessment, dated 02/01/12, documented the resident had a score of 18. A total score of 10 or above represents high risk for falls. The resident's fall care plan, dated 02/06/12, documented a problem, "...Risk for falls related to history of falls and unsteady with transfers." The goal was, "Will have no serious injury from falls X 90 days." Interventions included, "...Assist with transfers...assist to the toilet q 2 hours and as needed...physical therapy as ordered...ensure that lap buddy is in place while in her wheelchair..." A significant change assessment, dated 02/20/12 documented the resident had a severe impairment of cognition, needed extensive assistance with transfers, did not ambulate, and needed extensive assistance with dressing and bathing. The resident was continent of bowel and frequently incontinent of urine. The resident had one fall since admission or prior assessment with injury. An incident report, dated 03/07/12 at 2:10 p.m., documented, "...Res on floor in B/R on L side. Had lap buddy off - CNAs state lap buddy was on a few min. before...Initially c/o L shoulder hurting. No injury noted - then said R hip hurt...suggested safety precautions to prevent recurrence: (blank)..." The fall was not addressed on the resident's care plan and no new interventions were put in place to prevent future falls. An incident report, dated 03/11/12 at 4:10 p.m., documented, "...Res was found on floor next to bed. Denies hitting her head...Stated 'My old hip still hurts'...suggested safety precautions to prevent recurrence: (blank)..." The fall was not addressed on the resident's care plan and no new interventions were put in place to prevent future falls. An untimed nurse's note, dated 03/14/12, documented, "...resident had removed lap buddy and roommate informed her that resident had walked to the bathroom where CNA (name deleted) found her. Resident has had numerous falls. The most recent fall resulted in a hip fracture. At that time we had obtained order from PCP and signed consent from family for lap buddy while in wheelchair. Resident continually removes the lap buddy. Placed a call to family regarding possible use of pelvic restraint and faxed order request to PCP. Daughter stated she would need to speak to other family. Daughter called and stated the other family does not want pelvic restraint used, 'don't want her tied down..." The fall was not addressed on the resident's care plan and no new interventions were put in place to prevent future falls. A nurse's note, dated 03/22/12 at 12:45 p.m., documented, "...res on floor on bottom in B/R...res denies pain or injury..." An incident report, dated 03/22/12 at 12:45 p.m., documented, "...res found sitting on bathroom next to w/c...denies pain or injury...suggested safety precautions to prevent recurrence: cont to remind res to not get up by herself...follow up:...will continue to monitor and utilize lap buddy..." The fall was not addressed on the resident's care plan and no new interventions were put in place to prevent future falls. A nurse's note, dated 04/13/12 at 2:00 p.m., documented, "...Res slid out of W/C perpelling (sic) self down the hall. c/o R elbow hurting no redness or swelling noted..." The fall was not addressed on the resident's care plan and no new interventions were put in place to prevent future falls. A nurse's note, dated 04/15/12 at 7:30 a.m., documented, "...Res roommate (sic) informed CNA that her roommate (sic) was on the floor. Res tried to ambulate to her bathroom on her own and fell on the floor. She hit the back of her head. She has a laceration to the back of her head and is c/o R elbow pain...pupils are sluggish bilat to react to light...res sent to hospital..." At 12:45 p.m., a nurse's note documented, "...Resident will be returning...4 sutures..." An incident report, dated 04/15/12, documented, "...incident type...(blank)...incident location was the resident's room..." No interventions to prevent further falls were documented. The fall was not addressed on the resident's care plan and no new interventions were put in place to prevent future falls. On 04/16/12 at 1:45 p.m., the DON was asked if the resident used her call light for assistance. She stated, "Not at this point, because she doesn't remember." When asked if the resident was assessed to determine if she could use the call light when she needed assistance, she stated, "No." She was asked why the resident had been told to use her call light. She stated, "I don't know." She was asked if she documented on the care plan that the resident did not use her call light. She stated, "No." She was asked if other interventions had been tried before the lap buddy. She stated, "I spoke with the resident's family about a possible chair alarm, but I didn't think she would realize it was even alarming. I don't remember how it all came about and why we chose to use the lap buddy and not the alarm." She was asked if the care plan had been updated with each fall with interventions. She stated, "I did not care plan each time she fell . We just continued to try to do the same thing." She was asked if the lap buddy was keeping the resident safe from falling. She stated, "When she takes the lap buddy off she continues to fall, so I guess it's not." She was asked if the resident continually taking off the lap buddy was addressed on the prerestraint assessment or the care plan. She stated, "No." She was asked if she should have re-assessed the lap buddy related to preventing the resident from falling. She stated, "I should have re-assessed." At 4:27 p.m., the DON was asked if the recent change in condition assessment was related to the resident's falls and a decline in her ADLs. She stated, "Yes, I believe it was." She was asked why she did not address the falls on the care plan and implement new interventions. She stated, "I just failed to do it." She was asked if the interventions of a lap buddy and call light were keeping the resident safe. She stated, "What we are doing now is not working." 2. Resident #4 had [DIAGNOSES REDACTED]. An incident report, dated 09/12/11, documented, "resi in G/C in rm got (up) by self & fell landing on her back...questionable raised area back head 2 hematomas (up) R back elbow...knot back of R buttock...Suggested Safety Precautions to Prevent Recurrence: (Blank)..." A quarterly assessment, dated 09/16/11, documented a BIMS score of 7. This score indicated the resident was severely impaired in cognitive skills for daily decision making. The assessment documented the resident utilized a chair to prevent rising as a physical restraint, the resident had experienced one fall with no injury, one fall with injury, one fall with a major injury, and required extensive assistance with transfers. An incident report, dated 09/16/11, documented, "...Found on floor c feet toward bed...redness on cocyx (sic) area only...Suggested Safety Precautions to Prevent Recurrence: (Blank)..." A fall care plan, dated 09/16/11, documented, "Falls - recent falls - hip fx...cont c bed & chair alarm...cont care plan..." The fall care plan did not address the fall with injury on 09/12/11, or if the resident was to be on fall precautions and what the fall precautions were. There were no new interventions addressed for the prevention of further falls. A restraint care plan, dated 09/16/11, documented, "...Problem: Geri chair in use for positioning of L hip...Goal: L hip Fx will heal...Intervention: Use G/C while (up) OOB...chair alarm in place...monitor for safety..." The restraint care plan did not address the fall with injury on 09/12/11, when the resident attempted to climb out of the geriatric chair, or if a least restrictive device was attempted. There were no new interventions addressed for the prevention of further falls. An incident report, dated 10/15/11, documented, "Res was found on the floor in Dinning (sic) room...(no) injury noted...Suggested Safety Precautions to Prevent Recurrence: (Blank)..." The fall care plan did not address how the fall had occurred on 10/15/11, or if the resident was to be on fall precautions and what the fall precautions were. There were no interventions addressed for the prevention of further falls. An incident report, dated 10/19/11, documented, "Aide found res. on floor...res c/o L hip hurting...Suggested Safety Precautions to Prevent Recurrence: Reminded resident to ask an aide for help & to stay in gerichair..." The fall care plan did not address how the fall had occurred on 10/19/11, if the resident had climbed out of the geriatric chair, or if the resident was to be on fall precautions and what the fall precautions were. There were no interventions addressed for the prevention of further falls. The restraint care plan did not address the fall on 10/19/11, or if a less restrictive device was attempted. There were no interventions addressed for the prevention of further falls. A social service note, dated 10/20/11, documented, "...continues to try and get out of her geri chair..." An incident report, dated 10/28/11, documented, "Res found in floor She was sitting in floor behind geri chair 1cm skin tear to R elbow noted...Suggested Safety Precautions to Prevent Recurrence: Reminded res about asking for help before getting up...Follow up: No further C/O Pelvic restraint ordered..." The fall care plan did not address the fall on 10/28/11, in which an injury was sustained when the resident attempted to climb out of the geriatric chair. There were no interventions addressed for the prevention of further falls except to order a pelvic restraint. The restraint care plan did not address the fall on 10/28/11 in which an injury was sustained when the resident attempted to climb out of the geriatric chair, or if a less restrictive device was attempted. The only intervention addressed for the prevention of further falls related to the resident climbing out of the geriatric chair was to place the resident in a pelvic restraint. A physician's orders [REDACTED]. Dx: Dementia..." A physical restraint elimination assessment, dated 11/17/11, documented the resident's score was an 18. This score indicated the resident was a priority candidate for the elimination of the physical restraint. A physical restraint assessment, dated 11/17/11, documented, "...Diagnosis: [REDACTED].? yes...no falls since restraint initiated...res does not ask for assist unable to use call light...continue restraint..." A social service note, dated 11/21/11, documented, "...has tried to get out of her geri chair, so placing her in a wheelchair has helped solve this problem..." A physical restraint elimination assessment, dated 12/06/11, documented the resident's score was a 16. This score indicated the resident was a priority candidate for the elimination of the physical restraint. An annual assessment, dated 12/15/11, documented a BIMS score of 8. This score indicated the resident was moderately impaired in cognitive skills for daily decision making, a trunk physical restraint, the resident had experienced one fall with no injury, one fall with injury, and required extensive assistance with transfers. A fall care plan, dated 12/15/11, documented, "Problem: Risk for injury r/t hx of falls...Goal: Res will remain free from injury r/t falls x 90 days...Approaches: Utilize pelvic restraint while up in chair as a reminder for res to ask for assistance...Utilize low bed c mat while res is in bed...Pelvic restraint will be released q 2 (hours) x 15 min & prn...Remind resident to use call light for assistance...Ensure needs are promptly met..." The fall care plan did not address the falls the resident had sustained in September and October. The resident experienced two falls with injuries and three falls with no injuries sustained. The care plan did not address if the resident was to be on fall precautions and what the fall precautions were. The only new intervention was the use of a pelvic restraint. The restraint care plan did not address the falls on 09/12/11, 10/19/11, and 10/28/11, when the resident attempted to climb out of the geriatric chair, or if a less restrictive device was attempted. The restraint care plan did not address the use of a pelvic restraint, that the resident was a priority candidate for the elimination of the physical restraint, and new interventions for the prevention of further falls. A physician's orders [REDACTED]. A physical restraint assessment, dated 01/03/12, documented, "Diagnosis: [REDACTED].? yes...Resident has pelvic restraint while in wc and low bed...does not ask for assist and unable to use call light Continue c restraint..." A physical restraint elimination assessment, dated 01/19/12, documented the resident's score was an 18. This score indicated the resident was a priority candidate for the elimination of the physical restraint. A restraint care plan, dated 01/25/12, documented, "Pelvic restraint in use while (up) in w/c...Goal: Will be free of falls x 90 days...Intervention: pelvic restraint while (up) in w/c..." The restraint care plan did not address the resident would not ask for assistance, the resident's non use of the call light, and the discontinued use of the bed alarm. The care plan did not address the resident was a priority candidate for the elimination of the physical restraint and what alternatives would be attempted for further reduction and future elimination of the physical restraint. A nurse's note, dated 01/31/12, documented, "Res found on floor near mat, next to bed...c/o pain in R hip..." An incident report, dated 01/31/12, documented the interventions would be to check on the resident more often and place the call light within reach. A physical restraint assessment, dated 02/12/12, documented, "Diagnosis: [REDACTED]. A physical restraint assessment, dated 03/02/12, documented, "Diagnosis: [REDACTED].? Yes...Resident does not remember to request assist for transfers; does not use call light for assist..." A quarterly assessment, dated 03/16/12, documented a BIMS score of 7. This score indicated the resident was severely impaired in cognitive skills for daily decision making. The assessment documented the resident used a trunk restraint, had experienced one fall with injury, and required extensive assistance with transfers. The fall care plan, updated 03/16/12, documented, "resident 1 fall since assessment...she is on low bed c mat at B S...continue c pelvic restraint while (up)...Assist c all transfers...Goal met...continue c care plan..." The fall care plan did not address the discontinued use of the bed alarm, the fall that had occurred on 01/31/12, and interventions for the prevention of further falls. The restraint care plan, updated 03/16/12, documented, "Problem: continues pelvic restraint while (up) has not had a fall from w/c while (up) c restraint in use...Goal partially met - See Falls...continue c care plan..." On 04/16/12 at 12:10 p.m., the resident was observed in the dining room with the pelvic restraint in place. The restraint remained in place throughout the meal. On 04/17/12 at 9:05 a.m., the resident was observed in the front lobby in the wheelchair. The pelvic restraint was in place. On 04/18/12 at 11:38 a.m., the resident was observed in the wheelchair. The resident was in the dining room and the pelvic restraint was in place. CNA #2 was asked why the resident was in the pelvic restraint. She stated, "She is a high fall risk." She was asked if the resident could ambulate. She stated, "Yes. I walk her from her chair to the bed." On 04/19/12 at 2:19 p.m., the DON and ADON were asked why the resident was in a pelvic restraint. The ADON stated, "Multiple falls. Family wanted the restraint." The DON and ADON were asked why the resident went from a geriatric chair to a pelvic restraint. The ADON stated, "She tried to climb out of the geri-chair." They were asked if any other alternatives attempted to prevent falls had been tried. The ADON stated, "Not that I'm aware of." They were asked if the pelvic restraint was the appropriate intervention for the resident. The ADON stated, "Probably not." The DON was asked if the resident asked for help. She stated, "Yes." She was asked if the resident used her call light. She stated, "Not always." The DON and ADON were asked what alternatives had been attempted from the geriatric chair to the pelvic restraint. The DON stated, "We haven't." At 2:48 p.m., the DON was asked when the care plans were updated. She stated, "Significant change and quarterly." The DON was asked if the falls should have been care planned. She stated, "Yes." The DON was asked if falls were discussed during the staffs' morning meetings. She stated, "No."

Based on observation, interview, and record review, it was determined the facility failed to prevent severe weight loss for one (#4) of one sampled resident with weight loss. This resulted in actual harm for resident #4, who had a severe weight loss of 17.3% in six months, 12.6% in 3 months, and 9.8% in 1 month. Three residents were identified by the facility with weight loss within the last 180 days. Findings: An undated facility policy titled Significant Weight Change documented, "Policy: To ensure best possible care for the residents by intervening anytime the (sic) is a significant weight change..." Resident #4 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/16/11, documented a BIMS score of 7. This score indicated the resident was severely impaired in cognitive skills for daily decision making. The assessment documented the resident weighed 102 pounds, had no weight loss, and required one person physical assist with limited assistance while eating. The facility's weight records documented the following 2011 weights: September - 105 pounds, October - 100 pounds, November - 102.3 pounds, and December - 97 pounds. A nutritional care plan, dated 09/16/11, documented, "Nutrition - Cardiac diet c supplement...wt: 102# (down) 5# in last 30 days...Requires intermitten (sic) supervision...Goal partially met...cont care plan..." The dietary notes, dated 09/30/11, documented, "...eats in DR...self feeded (sic)/w asst...appt (sic) fair - good supplement/w meals wt 105..." An RD note, dated 10/18/11, documented, "Weight 100. Wt (down) 9% x 6 months...HS TID c meals. Meal intake fair. Rec: (change) diet to Regular, consider use of an appetite stimulant..." There were no new dietary interventions documented that were implemented regarding the five pound weight loss from September through October 2011. The nutritional care plan had not been updated to address the resident's five pound weight loss or new interventions for the prevention of further weight loss. An RD note, dated 11/15/11, documented, "Weight 102.3 Wt (change) not significant...Cardiac diet, house supplement TID c meals...Response (not) found to previous rec. No new recs..." The dietitian did not address any new interventions for the prevention of further weight loss. A fax to the physician, dated 12/12/11, documented, "...Current Weight: 97...Amount of weight change: -5.18% x 30 days...-7.62 x 90 days...Current supplements: House supplements TID c meals...Average meal Acceptance: 65%...Method of Feeding: Assist...Doctor: Continue to encourage p.o. intake..." A nutritional assessment, dated 12/13/11, documented, "...Diet order: Cardiac...house supp TID...WT: 97 lb...underweight...50% meal intake...Recommend appetite stimulant [MEDICATION NAME] wt (down) 5% x 1 month. Nsg has already faxed noted (sic) to PCP..." There were no dietary interventions documented that were implemented regarding the eight pound severe weight loss of 12.6% in three months. An annual assessment, dated 12/15/11, documented a BIMS score of 8. This score indicated the resident was moderately impaired in cognitive skills for daily decision making. The assessment documented the resident weighed 97 pounds, had a weight loss of 5% or more in the last month or 10% or more in the last 6 months, and required one person physical assist with supervision while eating. A nutritional care plan, dated 12/15/11, documented, "Problem: Readiness for enhanced nutrition...Goal: Res will tolerate current diet c no wt loss x 90 days...Approaches: ...Monitor amount of food eaten q meal...house supplement TID c meals...notify PCP of any significant changes in weight..." The care plan failed to address the resident's weight loss of 5.3 lbs documented in the dietary notes from 11/15/11 through 12/13/11, the resident's need to be seated at the feeder table and assisted by the staff, how the staff were to monitor meal intake, and what intervention to implement when the resident's meal intake was 25-50%. A physician's orders [REDACTED]. The facility's weight record documented the following 2012 weights: January - 95.5 pounds, February - 95 pounds, March - 92 pounds, and April - 93 pounds. An RD note, dated 01/10/12, documented, "Weight 95.5. Wt (down) 10% x 6 months...Avg meal intake 55%...Diet Cardiac House supplement TID c [MEDICATION NAME] started 12/17 per MAR...Will follow c current intervention to monitor wt and intake..." An RD note, dated 02/17/12, documented, "Weight 95. Wt stable x 1 month. Reported meal intake 25-50%. Cardiac diet, house supp TID c meals Receives [MEDICATION NAME] 400 mg daily...No new recs @ this time..." There were no dietary interventions documented that were implemented regarding the 7.3 pound severe weight loss of 9.4% in three months, the intervention for the resident's meal intake of 25-50%, and the resident's continued weight loss. The nutritional care plan had not been updated to address the resident's severe weight loss of 9.4% in three months, how the staff were to monitor meal intake, what intervention to implement when the resident's meal intake was 25-50%, and the physician's orders [REDACTED]. A nurses' monthly summary, dated 02/28/12, documented, "...Eating: Independently...Eats in DR assisted as needed...Appetite: Usually eats 75% to 100%..." An RD note, dated 03/08/12, documented, "Weight 92. Wt (down) 3# x 1 month. Reflects sig wt loss of 12% x 6 months. Cardiac diet, house supp TID c meals. Eating 25-50%. Receives [MEDICATION NAME] 400 mg/day...Suggest (increase) [MEDICATION NAME] to 800 mg/day..." A quarterly assessment, dated 03/16/12, documented a BIMS score of 7. This score indicated the resident was severely impaired in cognitive skills for daily decision making. The assessment documented the resident had a poor appetite nearly every day for the past 12-14 days, weighed 92 pounds, had a weight loss of 5% or more in the last month or 10% or more in the last 6 months, and required one person physical assist with limited assistance while eating. The nutritional care plan, updated 03/16/12, documented, "No diet change...wt this assessment 92#...Dr. notified of (decreased) cont [MEDICATION NAME] 400 mg qd. She is at feeder table & assist when need. Goal partially met. Continue c care plan..." The nutritional care plan did not address the resident's severe weight loss of 13 pounds (17.3%) in six months, how the staff were to monitor meal intake, what intervention to implement when the resident's meal intake was 25-50%, and new interventions for the prevention of further weight loss. A nurses' monthly summary, dated 03/22/12, documented, "...Eating: Independently...Eats in DR assist/encourage as needed...Appetite: Usually eats 75% to 100%..." A nurses' monthly summary, dated 04/08/12, documented, "...Eating: Independently...Eats in DR c assist and encouragement as needed...Appetite: Usually eats 75% to 100%..." An RD note, dated 04/13/12, documented, "Wt 93 wt (up) x 1 mo...Cardiac diet house supp TID c meals...reported meal intake 25 -50%...Pt. receives [MEDICATION NAME] 400 mg daily. Suggestion to (increase) [MEDICATION NAME] to 800 mg/day declined by physician. No new recommendations." The only dietary intervention documented and implemented regarding the resident's continued severe weight loss of 13 pounds in six months was in December 2011 when the resident received [MEDICATION NAME] 400mg daily. On 04/16/12 during the lunch meal the resident was observed seated at the feeder table in the dining room. The resident received her meal at 12:30 p.m. The resident began to feed herself by taking a bite of her meat and two bites of mashed potatoes. No staff assisted or encouraged the resident to eat. At approximately, 12:45 p.m., CNA #4 was seated next to the resident, the resident continued to feed herself. The aide did not assist the resident or encourage the resident with her meal. The resident was removed from the dining room at 1:00 p.m. The resident drank approximately 75% of her supplement, ate no bread with butter, a few bites of the pears, a bite of the vegetables, and approximately 50% of the mashed potatoes. At 12:50 p.m., CNA #4 was asked about assisting and encouraging the resident to eat. She stated, "We encourage her and let her feed herself for a while and then toward the end of the meal we sit next to her and assist her." On 04/17/12 at 5:30 p.m., the resident was observed during the evening meal. The resident was seated at a regular dining room table in the dining room. There were no staff assisting the resident with her meal. The resident was not eating, she was just sitting at the table looking around. CMA #2 walked by and stated, "We give them lots of snacks. Sometimes they just don't want to eat." The aide did not speak to the resident, encourage the resident to eat any of the meal, or seat the resident at the feeder table as indicated in the resident's care plan. On 04/18/12 at 5:09 p.m., during the evening meal the resident was observed in the dining room seated at a regular dining table. The resident received her meal at 5:15 p.m. The resident began to eat a chip and tore a piece of bread from her sandwich. No staff assisted the resident. The resident attempted to eat a peach slice, but the peach fell on the floor. The resident did not eat any of her peaches. The resident ate a few more bites of her chips. At 5:38 p.m., the resident took a few drinks of her supplement. No staff assisted or encouraged the resident to eat. At 5:40 p.m., the dietary manager walked by and stated, "Are you going to eat?" Then she walked away. At 5:42 p.m., CNA #1 asked the resident, "Are you eating? You need help? Are you full?" The CNA gave the resident one bite of soup. The CNA asked, "You don't want it?" At 5:44 p.m., the CNA walked away. At 5:47 p.m., the resident was not eating and was just sitting at the table looking around. At 5:48 p.m., CNA #1 asked, "Are you through?" She stirred the supplement and handed it to the resident. The CNA stated, "Finish this and you can go." The resident drank the remaining portion of the supplement, with the CNA's encouragement. No other staff assisted or encouraged the resident to eat her meal. The resident was removed from the dining room at 5:50 p.m. She ate a bite of bread, a bite of meat, a bite of lettuce, a few chips, and drank all of her supplement. On 04/19/12 at 9:05 a.m., during the breakfast meal the resident was observed in the dining room seated at the feeder table. The resident had not eaten her biscuits/gravy and had not drank her supplement. There was some of the cereal left in the bowl and the resident was trying to drink out of the cereal bowl. Then the resident poured the cereal into her plate of food. Staff were observed at the feeder table helping another resident. No staff were observed assisting or encouraging the resident to eat. The aide asked, "Are you done?" The resident shook her head yes. At 9:14 a.m., the resident was taken to her room. On 04/19/12 at 1:55 p.m., the DON and ADON were asked why the resident had experienced a severe weight loss of 17.3% in six months, 12.6% in 3 months, and 9.8% in 1 month. The DON stated, "She was independent. We moved her to the feeder table with assistance." The DON and ADON were informed of the meal observations. They were asked if the resident had received assistance with her meals. The DON stated, "No." The DON and ADON were informed of the documentation regarding the interventions for weight loss from September 2011 through March 2012. The only new intervention was for [MEDICATION NAME] 400 mg daily for an appetite stimulant. They were asked why no recommendations or interventions had been implemented. The DON stated, "I can think of things we can do, finger foods may help and feeder table with encouragement." She was asked if there should have been more interventions. She stated, "Yes." They were asked if the weight loss should have been addressed on the care plan. The DON and the ADON stated, "Yes, it should have been more specific." They were asked if the weight loss had been addressed in their morning meetings. She stated, "We haven't." The administrator was asked if the weight loss had been addressed in the QA meeting. She stated, "We didn't address it in QA." She was asked if the weight loss should have been addressed in the QA. She stated, "Yes and we will."

Based on observation, record review, and interviews, it was determined the facility failed to have an effective quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies. The facility failed to identify and implement a plan of action to correct systems failures related to: a. supervision and implementation of measures to prevent falls for two (#4 and #7) of 2 sampled residents with falls. b. prevention of severe weight loss for one (#4) of one sampled resident who had experienced a severe weight loss; and This had the potential to affect 43 of 43 residents who resided in the facility. Findings: 1. The facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for two (#4 and #7) of eight sampled residents who had experienced falls which resulted in harm. Refer to F-323. 2. The facility failed to prevent severe weight loss for one (#4) of one sampled resident with weight loss. This resulted in actual harm for resident #4, who had a severe weight loss of 17.3% in six months, 12.6% in 3 months, and 9.8% in 1 month. Three residents were identified by the facility with weight loss within the last 180 days. Findings: Refer to F-325. On 04/19/12 at 1:55 p.m., the DON and ADON were asked why the resident had experienced a severe weight loss of 17.3% in six months, 12.6% in 3 months, and 9.8% in 1 month. The administrator was asked if the weight loss and falls had been addressed in the QA meetings. She stated, "We didn't address it in QA." She was asked if the weight loss should have been addressed in the QA. She stated, "Yes and we will." The administrator and DON were asked how often they had their QA meetings. The administrator stated, "Quarterly, but we will be having them monthly." They were asked if their QA committee was effective. The administrator stated, "No."