Every finding on record at Miller's Merry Manor

Based on observation, record review and interview, the facility failed to update a resident's Care Plan timely related to activities for 1 of 2 residents reviewed for activities. (Resident 8) Finding includes: During an observation on 6/23/2025 at 9:38 A.M., Resident 8 was seated in front of the nurses station, alone and talking to herself. During an observation on 6/24/2025 at 10:40 A.M., Resident 8 was alone in her room, seated in her wheel chair and was talking to herself. A record review was completed on 6/26/2025 at 10:00 A.M., Resident 8's diagnoses included but were not limited to: dementia, hearing loss of both ears, dysphagia, major depressive disorder and contrature of the right hand. A Significant Change Minimum Data Set (MDS) dated , 1/3/2025, indicated Resident 8 was unable to complete a cognitive assessment, had moderate difficulty hearing, was able to understand others sometimes and was able to make herself understood to others sometimes. Resident 8's preferences were listed as: somewhat important to do favorite activities, somewhat important to have books, newspapers and magazines, somewhat important to be around animals, somewhat important to go outside and somewhat important to do things with groups of people. The MDS indicated Resident 8 was the primary respondent to the preferences section. A current Care Plan initiated on 10/4/2019, indicated Resident 8 was considered cognitively impaired. The goal of the Care Plan was for Resident 8 to express contentment with her activity level. All of the Care Plan interventions had been initiated on 10/4/2018. Interventions included, but were not limited to: provide resident with in room activities, Resident 8's favorite activities included being around family and staff, seeing animals and going outside when the weather allowed. The May 2025 Group Activity Report indicated Resident 8 had gone to a group activities on May 4, 28 and 29, 2025. The May PRN (as needed) Activity Report indicated Resident 8 had a one to one activity longer than 5 minutes on May 1, 3, 7, 14, 15, 16, 18, 22, 28, 29 and 30, 2025. The June 2025 Group Activity Report indicated Resident 8 had gone to a group activity on June 4, 11, 23 and 25, 2025. The June PRN Activity Report indicated Resident 8 had a one to one activity longer than 5 minutes on June 3, 4, 16, 18, 19, 20 and 21, 2025. Resident 8's record lacked the documentation she had refused an activity or had any difficulties during an activity. During an interview on 6/26/2025 at 1:15 P.M., the Activities Assistant (AA) 5 indicated he had not invited Resident 8 to many group activities, but he did visit with her as much as possible. AA 5 indicated the resident was not able to hear and no longer accepted newspapers, magazines or books. AA 5 indicated when he did visit Resident 8, it was for only one to five minutes at a time because the resident did not participate in the visit. AA 5 indicated the amount of time he had spent with Resident 8 was not enough time and he was not able to provide the resident with any stimulating materials because Resident 8 no longer accepted the materials he had tried to provide. AA 5 indicated the Activities Director had been out on medical leave and the Activities Director had been the employee providing stimulation activities for residents with dementia. During an interview on 6/26/2025 at 1:29 P.M., the Director of Nursing (DON) indicated she believed Resident 8 had received more activities than what was being charted. She indicated Resident 8 had not been taken to group activities because the resident was hard of hearing and had been disruptive during group activities in the past. The DON indicated the Care Plan's interventions for Resident 8's activities were no longer appropriate. On 6/26/2025 at 1:39 P.M., the DON provided a policy dated, 10/3/2023, and titled, Activity Care Plan. The DON indicated the policy was the one currently used by the facility. The policy indicated, .Activity care plan goals will be developed to aid the resident in pursuing meaningful leisure activities and enhancing functional, mental and spiritual well-being . 2. Procedure: .B, Care plans should also be initiated as activity needs change; such as isolation, loss of function, cognitive decline 3.1-35(d)(2)(B)

Based on observation, interview and record review, the facility failed to provide an ongoing resident centered activities program for 2 of 2 residents reviewed for activities. (Residents 36 and 8) Findings include: 1. A record review completed on 6/24/2025 at 2:30 P.M. indicated Resident 36's diagnoses included, but were not limited to, dementia, generalized anxiety disorder and cognitive communication deficit. An Annual Minimum Data Set (MDS) assessment, dated 5/6/2025, indicated Resident 36's cognition was severely impaired and activity preferences included listening to music, attending religious activities and doing things with groups of people. She had no functional deficits and used a wheelchair. A current Care Plan initiated on 5/24/2024, indicated Resident 36 was still capable of making decisions about activity involvement. During interviews, the family indicated the resident enjoys music, going outside, animals, family visits, and that religion was important to her. Activity documentation indicated in the month of April 2025 the resident had attended the following group activities: -refreshment time twice. -religious group three times. -sensory group three times. -educational/reading group twice. -exercise group once. In the month of May 2025 the resident attended the following group activities: -sensory group twice -religious group once Thus far in June 2025 the resident had attended the following activities: -a pet visit on 6/4/2024. -on 6/23/2025 Bingo, educational/reading group and religious groups. -on 6/24/2025 education/reading group, res council, sensory group, religious group and a movie. -on 6/25/2025 Bingo, educational/reading group, religious group, refreshments and exercise. There were daily 1:1 visits documented that lasted 1-5 minutes on 23 out of 30 days with a second 1:1 visit the same day that lasted 1-5 minutes on 1 out of 30 days in April 2025. There were daily 1:1 visits documented that lasted 1-5 minutes on 23 out of 31 days and a second 1:1 visit the same day that lasted 1-5 minutes on 3 out of 31 days in May 2025. There were daily 1:1 visits that lasted 1-5 minutes for 24 out of 25 days and a second 1:1 visit the same day that lasted 1-5 minutes on 6/5/2025. Two 1:1 visits lasted 11-15 minutes on 6/24 and 6/25/2025. During an observation on 6/26/2025 at 1:09 P.M., Resident 36 was sitting in her wheelchair in a common area near the nurses station holding a stuffed animal. No other activity or stimulation was occurring. During an interview on 6/26/2025 at 1:09 P.M., the Activity Assistant indicated the first thing he did in the mornings was go to the dining room to greet everyone and let them know what was going on that day. He then went room to room to greet the other residents and let them know what was going on that day. Resident 36 sometimes fell sleep during activities and indicated he did try to include her but may not have documented all the time spent with her. During an interview on 6/26/2025 at 1:17 P.M., the DON indicated the resident had been included in many groups and activity documentation should have been more accurate to reflect actual time spent. 2. During an observation on 6/23/2025 at 9:38 A.M., Resident 8 was seated in front of the nurse's station, alone and was talking to herself. During an observation on 6/24/2025 at 10:40 A.M., Resident 8 was alone in her room, seated in her wheel chair and she was talking to herself. A record review was completed on 6/26/2025 at 10:00 A.M., Resident 8's diagnoses included but were not limited to: dementia, hearing loss of both ears, dysphagia, major depressive disorder and contrature of the right hand. A Significant Change Minimum Data Set (MDS) dated , 1/3/2025, indicated Resident 8 was unable to complete a cognitive assessment, had moderate difficulty hearing, was able to understand others sometimes and was able to make herself understood to others sometimes. Resident 8's preferences were listed as: somewhat important to do favorite activities, somewhat important to have books, newspapers and magazines, somewhat important to be around animals, somewhat important to go outside and somewhat important to do things with groups of people. The MDS indicated Resident 8 was the primary respondent to the preferences section. A current Care Plan initiated on 10/4/2019, indicated Resident 8 was considered cognitively impaired. The goal of the Care Plan was for Resident 8 to express contentment with her activity level. All of the Care Plan interventions had been initiated on 10/4/2018. Interventions included, but were not limited to: provide resident with in room activities, Resident 8's favorite activities included being around family and staff, seeing animals and going outside when the weather allowed. The May 2025 Group Activity Report indicated Resident 8 had gone to a group activities on May 4, 28 and 29, 2025. The May PRN (as needed) Activity Report indicated Resident 8 had a one to one activity longer than 5 minutes on May 1, 3, 7, 14, 15, 16, 18, 22, 28, 29 and 30, 2025. The June 2025 Group Activity Report indicated Resident 8 had gone to a group activity on June 4, 11, 23 and 25, 2025. The June PRN Activity Report indicated Resident 8 had a one to one activity longer than 5 minutes on June 3, 4, 16, 18, 19, 20 and 21, 2025. Resident 8's record lacked the documentation she had refused an activity or had any difficulties during an activity. During an interview on 6/26/2025 at 1:15 P.M., the Activities Assistant (AA) 5 indicated he had not invited Resident 8 to many group activities, but he did visit with her as much as possible. AA 5 indicated the resident was not able to hear and no longer accepted newspapers, magazines or books. AA 5 indicated when he did visit Resident 8, it was for only one to five minutes at a time because the resident did not participate in the visit. AA 5 indicated the amount of time he had spent with Resident 8 was not enough time and he was not able to provide the resident with any stimulating materials because Resident 8 no longer accepted the materials he had tried to provide. AA 5 indicated the Activities Director had been out on medical leave and the Activities Director had been the employee providing stimulation activities for residents with dementia. During an interview on 6/26/2025 at 1:29 P.M., the Director of Nursing (DON) indicated she believed Resident 8 had received more activities than what was being charted. She indicated Resident 8 had not been taken to group activities because the resident was hard of hearing and had been disruptive during group activities in the past. The DON indicated the Care Plan's interventions for Resident 8's activities were no longer appropriate. A policy for providing activities was requested, but one was not provided. 3.1-33(a)

Based on interview and record review, the facility failed to complete a post dialysis assessment for 1 of 1 residents reviewed for dialysis. (Resident 17) Finding includes A record review completed on 6/25/2025, for Resident 17, indicated diagnoses of: type 2 diabetes mellitus, end-stage renal disease and dependence on renal dialysis. A Quarterly Minimum Data Set (MDS) assessment, dated 6/13/2025, indicated Resident 17's cognition was intact and she received dialysis. A Physician Order, dated 1/16/2025, indicated Resident 17 received hemo-dialysis three times a week on Tuesdays, Thursdays and Saturdays. A current Care Plan, initiated on 6/13/2024 indicated Resident 17 received dialysis three times a week due to end stage renal failure. Staff was to assess the bruit and thrill (A bruit was a whooshing sound that could be heard with a stethoscope over the access site, while a thrill was a vibration that could be felt by touch.) at the fistula site in her left arm. The clinical record indicated post-dialysis assessments were missing for 5/27/2025, 6/14/2025 and 6/19/2025. During an interview on 6/25/2025 at 1:05 P.M., RN 2 indicated when a resident returned from dialysis she checked the resident over and completed the Nursing-Outpatient/ER Services Return Assessment form in the computer. During an interview on 6/25/2025 at 1:32 P.M., the DON indicated the Nursing-Outpatient/ER Services Return Assessment should have been completed on 5/27/2025, 6/14/2025 and 6/19/2025. On 6/25/2025 at 1:30 P.M., a current policy dated 10/3/2019, and titled, Dialysis Policy and Procedure and Communication form, was provided by the DON. The policy indicated, .Upon return of the resident to the facility after clinic visit, the licensed nurse will complete the Assessment Procedure form Nursing-Outpatient/ER Services Return Assessment 3.1-37(a)

Based on observation, interview and record review, the facility failed to follow infection control standards regarding glove usage and isolation procedures for 2 of 3 residents. (Residents 20 & 7) Findings include: 1. During an observation of Resident 20's catheter care on 6/25/2025 at 10:03 A.M., CNA 3 cleaned the resident's catheter and genitals but did not change her gloves before she helped the resident roll onto her side for wound care. CNA 3 also helped remove the resident's brief, repositioned the resident's clothing and straightened the resident's blankets before she removed her contaminated gloves. During an interview on 6/25/2025 at 10:22 A.M., CNA 3 indicated she had not changed her gloves after washing the resident's catheter. She indicated she should have changed her gloves before she dried the resident's catheter and genital area. During an interview on 6/25/2025 at 2:10 P.M., the Director of Nursing indicated the facility did not have a policy with on all the steps of providing catheter care but the facility followed the standard of care when providing catheter care. 2. On 6/23/2025 at 10:06 A.M., staff was observed transferring Resident 7, who had an indwelling urinary catheter and was on Enhanced Barrier Precautions (EBP), without donning gowns. During an interview on 6/23/2025 at 10:16 A.M., CNA 3 indicated she should have looked for the sign that indicated Resident 7 was on EBP before giving care. A record review completed on 6/26/2025 at 9:33 A.M. indicated Resident 7's diagnoses included, but were not limited to, urinary retention. Physician Orders for Resident 7 included, but were not limited to, on 12/30/2024, on 12/30/2024 Enhanced Barrier Precautions for Foley catheter. On 6/24/2025 at 10:59 A.M. a policy dated, 3/5/2024 and titled, Enhanced Precautions for novel and targeted MDRO's, was provided by the DON. The policy indicated, .Residents with wounds or indwelling devices and residents infected or colonized with a multi drug resistant organism will be cared for by staff using a gown and gloves during high contact resident care 3.1-18(j)(l)

Based on observation, interview, and record review the facility failed to ensure a resident was assisted with personal hygiene for 1 of 2 records reviewed for Activities of Daily Living (ADL) (Resident 2) Finding includes: During an observation and interview on 8/14/2024 at 10:21A.M., Resident 2 indicated the facility staff help sometimes with shaving. During an observation and interview on 8/15/2024 at 9:47 A.M., Resident 2 indicated he used to shave himself and he liked to shave every 2 days, that as he did in the past. During an observation on 8/16/2024 at 9:07 A.M., the Resident 2 was unshaven. During an observation and interview on 8/19/2024 at 9:07 A.M., Resident 2 was unshaven and he indicated no one had offered to shave him. He indicated he would have shaved himself, but they took his razors away from him. A record review was completed for Resident 2, on 8/15/2024 at 4:03 P.M. Diagnoses included, but not limited to: hemiplegia, unspecified affecting right dominant side, aphasia, wrist drop, right wrist and seizures. A current Care Plan, initiated 2/16/2024, indicated Resident 2 needed assist with Activities of Daily Living (ADL'S). Intervention included but were limited to: dated 4/5/2024, assist with shaving with a straight razor and not to leave the razors in his room. During an interview on 8/16/2024 at 9:52 A.M., CNA 2 indicated when she provided A.M. care, she washed their face and peri area, brushed teeth and hair, then dressed them. She had them wash their hands in the morning and after using the toilet. During an interview on 8/16/2024 at 9:57 A.M., CNA 3 indicated when she provided A.M., care she got them dressed, toileted and brushed their teeth uses mouthwash and make sure they had everything for the day. During an interview on 8/16/2024 at 10:04 A.M., CNA 4 indicated when he provided A.M., care he knocked on the door introduced himself and asked if they would ready to get up. He will ask them what they would like to wear, then assisted with washing, dressing, transferring, brushing teeth and see to determine if their need a shave, and took them to the dining room. During an interview on 8/16/2024 A.M., the Interim DON (IDON) indicated she would expect with A.M. care, the Residents would be washed: arm pits, under breast, peri area, and buttock. Then teeth brushed or dentures washed, provide glasses, deodorant, lotion and assisted to the bathroom. On 8/19/2024 at 10:45 A.M., the IDON provided a policy titled, Morning Care, dated 3/13/2012, and indicated the policy was the one currently used by the facility. The policy indicated .Purpose: To cleanse and refresh resident, while stimulating circulation and providing comfort and preparing resident for the day. Procedure: 8. Remind or assist male residents to shave . 3.1-38(3)(D)

Based on observation, interview, and record review, the facility failed to ensure environmental hazards were removed from the resident's room after a suicide attempt for 1 of 2 residents reviewed for accidents/hazards. (Resident 5) The immediate jeopardy began on June 6, 2023 when Resident 5 wrapped a bed remote cord around his neck and the facility failed to remove the hazard from his room. The administrator and regional nurse consultant were notified of the immediate jeopardy on July 26, 2023 at 4:50 P.M. The immediate jeopardy was removed on July 27, 2023, but noncompliance remained at the lower scope and severity level of no actual harm, with potential for more than minimal harm that is not immediate jeopardy. Finding includes: A record review for Resident 5 was completed on 7/26/2023 at 9:02 A.M. Diagnoses included, but were not limited to: Friedreich's Ataxia (disease which causes progressive nervous system damage), anxiety disorder, psychotic disorder with delusions due to known physiological condition, major depressive disorder, single episode, moderate, rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement and paraplegia unspecified. During an observation, on 7/26/2023 at 10:47 A.M., the resident's bed was in a high position from the floor. During an observation on 7/26/2023 at 3:34 P.M., the bed remote cord was not fastened to the bed rail with a zip tie, only the call light was. The resident had full access to the bed remote cord hanging from the assist/bed rail. The bed was also not in a low position, but up high. A Progress Note, dated 6/6/2023 at 4:24 P.M., indicated .CNA came by nurse's station stating that resident had attempted to strangle himself with his bed cord. CNA went and got Social Services. Nurse went in and spoke with resident. Resident was tearful. Nurse asked Resident if he was trying to harm himself and he became even more tearful while shaking his head yes. Social Worker came in to speak with Resident. A Progress Note, dated 6/6/2023 at 5:13 P.M., indicated .Late Entry: SS [Social Service] visited with [Resident 5] today due to reports of increased behaviors. [Resident 5] presented very emotional and became tearful several times during conversation. SS talked with him about putting cord around his neck. He expressed he was not trying to kill self. he just needed help from staff and he was frustrated. SS explained to [Resident] that when he does things like that he runs the risk of being sent to inpatient psyche stay. He expressed he did not want he wants. SS discussed alternate ways to get staff assistance. SS allowed him time to express his feelings and offered comfort and reassurance. SS offered him time to reminisce about when he was younger and mutual friends he has with SS. At the end of conversation he expressed he was doing better. he was no longer tearful and was smiling and laughing at times. SS will update psyche services and have them visit with him on next visit to the facility A Progress Note, dated 6/7/2023 at 2:22 P.M., indicated the resident was sent to the hospital to be evaluated for right lower quadrant pain. A Psychiatry Progress Note, dated 6/8/2023 from 7:30 A.M. to 7:55 A.M., indicated Symptom Description and Subjective Report; Patient is seen today for follow up assessment of mood and behavior and medications. Patient has been more irritable and made a gesture to harm himself .Objective Content: Alert and pleasant. Appears in no distress or discomfort. Resting in his bed. Engages in conversation easily. Able to make some needs known. Staff also will anticipate his needs. He had been more irritable and staff states he put the call light cord around his neck. Patient readily admits to doing so but states he was frustrated. He denies current suicidal ideations or intent to harm himself. Patient state he was in pain and didn't feel well. He was recently seen in ER [emergency room ] and diagnoses with a UTI [Urinary Tract Infection]. He is receiving[sic] an antibiotic. Staff also report he didn't have his scheduled pain medication due to an insurance issue. Plan: Patient diagnosed with UTI and was not receiving his usual pain medication which likely contributed to his mood issues A Licensed Clinical Psychologist Progress Note, dated 6/8/2023 from 11:22 A.M. to 11:47 A.M., indicated Patient was seen in follow-up for symptoms of depression and anxiety. Staff report that patient has been wrapping his call light around in neck in a gesture to hurt himself. Patient has a UTI, and has had increased pain because insurance issues have limited the pain medications that can be used. Staff are working to resolve this issue. Patient presents as very angry, tearful and expressed a desire to end his life. He calmed down and became more rational as we talked, and more calm at the end of the session. Staff were consulted about patient's labile mood, and about ways to manage his impulsive behavior .Objective Content: Patient and I talked about the fact that he was sent to the ER a couple of days ago because of pain and a UTI and they were not helpful. At first, patient was unable to think rationally about the fact that staff are working to manage his pain, and having a UTI will contribute to him feeling bad in general. He was able to calm down, and acknowledge he is more depressed but not planning to kill himself. Upon consultation, staff indicated they plan to lower patient's bed to the floor so he cannot injure himself by throwing himself out of bed, and securing his call light and bed control so he cannot hurt himself with the cords, in case he becomes upset again and tries to get impulsively A Progress Note, dated 6/8/2023 at 1:20 P.M., indicated Resident 5 arrived back to the facility with antibiotics for the treatment of a urinary tract infection. A Care Plan, dated 6/15/2023, indicated .I display irrational thoughts and ideas related to dx [diagnosis] of psychosis r/t [related to] [NAME] [sic] Ataxia as evidenced by digging in my ears thinking my hearing aides are wedged in my ears, thinking someone is remotely messing with my computer and convinced I can have an apartment and take care of self. Leading to potential for self-harm. Resulting in use of antipsychotic medication. Interventions: Allow [Resident 5] to express his thoughts and feelings and assist in helping him understand the reality of situations. Maintain a calm, consistent environment and attend to his basic needs. Provide support with skills to de-escalate, cope and manage stress. Make sure environment is clear of clutter or self-harm objects. A Care Plan, created 1/10/2016, revised on 1/18/2023 and 6/15/2023, indicated . I have altered mood related to dx of anxiety as evidenced by yelling/screaming/cursing at staff, clenching my fist, repetitive yelling out for specific people and refuses to talk when it is not what I want to hear and I attempt to wrap call cord around my neck for staff attention. Resulting in use of anxiolytic medication. Interventions: Approach in call manner and provide comfort /assurance during times of illness. Encourage use of two staff to reposition when in bed to reduce random movements by [Resident 5], Zip tie call cord to half side rail on bed with enough length at end for him to have call cord to half rail on bed with enough lengths at end for him to have call cord in lap to prevent him from attempting to wrap call cord around his neck. Medication as ordered. Notify physician as needed. Monitor quarterly for Medication GDR for psychoactive medication. Allow time to express feelings and provide validation and comfort as needed. SS to visit PRN. Document mood and behavior #1: I have altered mood related to dx of anxiety as evidence by yelling/screaming/cursing/ at staff, clenching my fist, repetitive yelling out for specific people and refused to talk when it is not what I want to hear and I attempt to wrap call cord around my neck for staff attention. Interventions: 1. Allow [Resident 5] time to express his feelings and provide validation and comfort, if unable to understand then get another staff member to assist. 2. Offer a sip of a drink to clear throat and make sure all basic needs are met, encourage use of two when repositioning to reduce random movements by [Resident 5]. 3. Make sure [Resident name] is aware that you are here to help him and he can trust you, maintain a calm consistent responses, change caregivers if needed. 4. Make sure [Resident 5] is safe and inform him that you will return when he has time to calm down and he is ready to have a conversation. During an interview, on 7/26/2023 at 3:07 P.M., CNA 2 indicated she was working on 6/6/2023 but was not assigned to Resident 5's room. She indicated in the past she had observed the resident wrap a cord around his neck. She indicated she had rehired 10 months ago, and he had only done this a few times in the past 10 months but a few years ago when she worked here, he often displayed that behavior. She indicated he would use the call light and/ or bed remote cord. During an interview, on 7/26/2023 at 3:10 P.M., CNA 3 indicated via a phone interview she heard [Resident 5] yell and saw the bed remote cord was around his neck he would not let go, he said, Let me die I don't want to do this anymore! He was hysterically crying. He was pulling the remote cord and there were purple indents on his neck. He was lying flat on his back in bed and the cord was wrapped around the neck at least 2 times maybe 3 but definitely 2. That is the first time she had ever seen this happen. The nurse went in there to see if he was ok. She went to tell the Administrator who directed her to Director of Nursing and then told her to get the Social Worker. Afterwards if he put on the call light, we answered timely. He was not put on 1 on 1's or sent out. At 7/26/2023 at 3:28 P.M. the CNA called back she forgot to mention she was in the room during the Social Workers interview, and she stated multiple times to the resident, Don't make me send you out I don't want to have to do that! During an interview, on 7/26/2023 at 3:35 P.M., the Social Service Director indicated she believed the agency nurse contacted her about the cord around his neck. She went down to talk to him; he was very emotional and talked about why he was upset. She discussed ramifications when he puts a call light around his neck, let him express himself and reminisced which got him laughing, talking, and smiling. She did not call the doctor or psych (psychiatry) following the occurrence, but was going to schedule him on their next facility visit. She indicated the policy was to remove any harmful items, place on 1 on 1- or 15 minute checks and notify the doctor and psych. She did not remove the cord form the room, maintenance was to resecure it after she was done talking to the resident. During an interview, on 7/26/2023 at 3:49 P.M., the Director of Nursing (DON) indicated the Social Service (SS) informed her or the agency nurse. They said the resident wrapped the call light cord around his neck, so SS went down to talk to him. The DON had talked to him earlier to discuss his medications and what they were for. He was okay then. There was no problem with any of his medications. She went down and saw him after the event and he was in bed with his head of bed up watching TV. She did not see any discoloration around his neck. The call light cord was secured with zip tie so he could reach it but not pull it up. This was not the first time he did this. She was not sure how the zip tie got undone. The Maintenance Director refastened it. She did not have an investigation on this incident, and an unplanned occurrence was not filled out, but she would need to check the chart. He was okay after SS talked to him. The policy was to remove all objects that could cause harm and notify the physician and family. It should have been in the Progress Notes. During an interview, on 7/26/2023 at 3:53 P.M., the Maintenance Director indicated he had reattached the call cord to the assist/bed rails a couple times. He thought he did go last month after morning meeting at the request of the team, but did not recall any specific staff member asking him. The resident was calm and asked him to leave enough cord to go from the wall over his shoulder. I told him I couldn't do that, but then he asked if I could attach it to both the bed rail and the assist rail so it couldn't be moved. I asked him, Don't you want it to be able to reach your lap? and he said, No and indicated he would rather have it attached to the assist rail. He did not know how the zip tie got untied. He also did not indicate it was an emergency but usually when asked, he promptly responded to any request to check things out. He received a text from the DON on 6/6/2023 at 10:51 A.M., asking him to rezip the call cord in Resident 5's room. The text indicated he wrapped the cord around his neck. On 7/26/2023 at 4:10 P.M., the DON indicated that there was no unplanned occurrence or any documentation in the Progress Notes that the physician or family was notified. During an interview, on 7/26/2023 at 4:21 P.M., the Administrator indicated he could not recall who contacted him. He acknowledged the SS went to the resident's room and the resident indicated that he had no attempt to self-harm. They tell you whether that is their intentions. He had a BIMS [Brief Interview for Mental Status] of 15 (cognitively intact) so he had no plan. He indicated management does investigations and he had sent the SS. On 7/26/2023 at 4:09 P.M., the Director of Nursing provided a policy titled, Suicide Precautions, dated 6/12/2020, and indicated the policy was the one currently used by the facility. The policy indicated .2. Procedure A. When residents verbalize the intent or demonstrate an attempt at suicide, the following procedures are recommended. I. ACTUAL: a. If the resident demonstrates an actual suicide attempt, emergency admit to acute care or inpatient psychiatric care will be requested. b. A designated staff person will be assigned to observe the resident at the bedside until relocation/transfer can be completed The immediate jeopardy that began on June 6, 2023 was removed on July 27, 2023 when the facility secured all environmental hazards within Resident 5's room and ensured all staff were inserviced regarding responding to suicide attempts and removing all potential environmental hazards. The non-compliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility will need to inservice any new or agency staff ongoing. The facility will continue to monitor Resident 5 as well as all residents who are at risk for self harm. 3.1-45(a)

Based on observation, record review and interview, the facility failed to ensure the physician was notified timely of significant changes in condition for 3 of 13 residents reviewed. (Residents 2, 5 and 38) Findings include: 1. The clinical record for Resident 38 was reviewed on 7/25/2023 at 2:19 P.M. Resident 38 was admitted to the facility with diagnoses including, but not limited to: osteomyelitis of the vertebra, sacral and sacrococcygeal region, gout, idiopathic peripheral autonomic neuropathy, stage 4 pressure ulcer of the sacral region, chronic kidney disease stage 3B, glaucoma, age related osteoporosis, hypothyroidism, hypertension, cognitive communication deficit, hypokalemia, hyperlipidemia and abnormality of albumin. The Admission MDS (Minimum Data Set) assessment, completed on 6/13/2023, indicated the resident was mildly cognitively impaired, had little pleasure, felt down, had little energy, trouble sleeping and poor appetite for the past 7 - 13 days. It was somewhat important to her to have snacks in between meals, had not transferred out of bed for the assessment period, was totally dependent on staff for dressing, bed mobility, toileting, personal hygiene and bathing needs and required limited assistance from one staff for eating needs. The assessment indicated the resident had exhibited no swallowing or chewing issues, weighed 200 pounds and had not experienced any recent weight changes. The resident was admitted with 1 stage 4 pressure ulcer. The current Care Plan related to nutritional needs, initiated on 6/6/2023, included an intervention to notify the physician and resident representative of significant weight loss. The Nutritional Assessment, completed by the RD (Registered Dietician) on 6/15/2023, indicated the resident had above normal BMI (Body Mass Index), had no weight trend identified yet, was on a NAS (No Added Sugar) diet with double eggs, vitamin and iron supplements and Proheal supplement. The weight record for Resident 38 indicated the following: On 6/6/2023 200 pounds. On 6/21/2023 179.4 pounds. On 7/5/2023 169.8 pounds. On 7/10/2023 154.6 pounds. On 7/12/2023 157.6 pounds. On 7/17/2023 154.9 pounds. On 7/24/2023 149.1 pounds. A Weight and Wound Meeting Progress Notes indicated a meeting had been held on 7/5/2023. The note acknowledged the weights on specific dates, indicated the resident had been admitted with edema, had an urinary tract infection and restated the resident's diet orders and supplements, which were put in place when she was admitted . The note did not indicated the percent of weight loss the resident had experienced since her admission, one month prior. The resident had lost 30.2 pounds, equivalent to 8.49 percent, denoting a significant weight loss. There was no documentation the physician was notified of the significant weight loss for Resident 38. A Weight and Wound Meeting Progress Note, completed on 7/13/2023, indicated a meeting had been held on 7/12/2023. The note documented the dates and weights of the resident since admission. The July 10 weight was 154.6 pounds, a weight loss of another 15.2 pounds since the 7/5/2023 meeting was held. The percent of weight loss since admission was now 23 percent. The note indicated a 4 ounce health shake at lunch was added to her diet, but there was no documentation the physician was notified of the significant, continued weight loss. There was no documentation of Physician notification of the significant weight loss until a late entry dated 7/20/2023 indicated the MD was notified of the continued weight loss and the daughter was being asked to set up a care plan meeting. During an interview with the Registered Dietician (RD), conducted 7/27/2023 at 10:00 A.M., she indicated the RD responsible for the facility was on vacation. She indicated there were interventions implemented on admission to address the resident's nutritional needs, the resident's diet was changed from no added sugar to regular on 7/5/2023 to allow more alternative choices and calories. Health shakes were added on 7/13/2023. The RD indicated the Wound and Weight Progress Notes could have been more specific regarding the percent of weight loss and should have reflected any Physician notification and interventions. During an interview with the Regional Nurse Consultant, on 7/28/2023 at 10:39 A.M., she indicated the physician would have documented weight loss notification but there was no documentation of the significant weight loss until 7/20/2023. 44111 2. A record review for Resident 5 was completed on 7/26/2023 at 9:02 A.M. Diagnoses included, but were not limited to: Friedreich's Ataxia (disease which causes progressive nervous system damage), anxiety disorder, psychotic disorder with delusions due to known physiological condition, major depressive disorder, single episode, moderate, rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement and paraplegia unspecified. A Progress Note, dated 6/6/2023 at 4:24 P.M., indicated .CNA came by nurse's station stating that resident had attempted to strangle himself with his bed cord. CNA went and got Social Services. Nurse went in and spoke with resident. Resident was tearful. Nurse asked Resident if he was trying to harm himself and he became even more tearful while shaking his head yes. Social Worker came in to speak with Resident. A Care Plan, created 1/10/2016, revised on 1/18/2023 and 6/15/2023, indicated . I have altered mood related to dx. [diagnosis] of anxiety as evidenced by yelling/screaming/cursing at staff, clenching my fist, repetitive yelling out for specific people and refuses to talk when it is not what I want to hear and I attempt to wrap call cord around my neck for staff attention. Resulting in use of anxiolytic medication. Interventions: Approach in call manner and provide comfort /assurance during times of illness. Encourage use of two staff to reposition when in bed to reduce random movements by [Resident 5], Zip tie call cord to half side rail on bed with enough length at end for him to have call cord to half rail on bed with enough lengths at end for him to have call cord in lap to prevent him from attempting to wrap call cord around his neck. Medication as ordered. Notify physician as needed During an interview, on 7/26/2023 at 4:10 P.M., the Director of Nursing indicated that there was no unplanned occurrence completed or any documentation in the progress notes that the physician or family were notified about Resident 5 placing a cord around his neck. During an interview, on 7/27/2023 at 1:31 P.M., the Medical Director indicated that she was not notified of the incident that occurred on 6/6/2023 involving the resident placing a cord around his neck. During an interview, on 7/27/2023 at 2:31 P.M., RN 5 indicated she did not notify the physician or family that the resident wrapped a cord around his neck. 48054 3. A record review for resident 2 was completed on 07/27/23 at 11:48 A.M. Diagnoses included, but were not limited to: type 2 diabetes, end Stage Renal Disease, dependence on renal dialysis and atrial fibrillation. A Quarterly MDS (Minimum Data Set) assessment, dated 7/14/2023, indicated Resident 2 had moderately impaired cognition. Resident 2's medication regimen, included but was not limited to: Baqsimi (Glucagon) inhalation powder as needed, Humalog insulin 4 units with breakfast and lunch, Lantus insulin 12 units once daily and Lantus insulin 8 units at bedtime. A Physician's Order, dated 11/18/2022, indicated the resident was to receive Insulin Lispro Solution 100 UNIT/ML (milliliter) inject 4 unit subcutaneously two times a day for diabetes mellitus. There were parameters to notify the MD (Medical Doctor) if the resident's blood sugar was less than 70 or greater than 400. In addition, there were instructions to follow the blood sugar flowchart if the resident exhibited signs and/or symptoms of low blood sugar. The instructions also indicated the event was to documented in the Nursing Progress Notes. A review of the current Care Plan regarding blood sugar levels, indicated the following: .I have Diabetes and the potential for having hyper/hypoglycemia as seen by: Interventions included: no signs and symptoms of high or low blood sugar levels, blood sugar less than 70 or greater than 200 requires an assessment documented on the blood sugar tracking form. Follow specific physician orders if symptoms present, blood sugar less than 70- give 4 oz juice and retest in 15-20 minutes, communicate blood sugar readings to (physician's name), give medications as ordered, notify MD (Medical Doctor) of blood sugar readings outside the ordered parameters, monitor and document food and fluid intake on point of care. Offer replacements for food uneaten if resident eats less than 50%, monitor blood sugar as ordered, monitor labs as ordered, monitor meal intake, serve diet as ordered A review of the blood sugar log for Resident 2 indicated blood sugar readings were out of range on the following days: 5/7/23 blood sugar was 67. 5/11/23 blood sugar was 63. 5/23/23 blood sugar was 63. 5/27/23 blood sugar was 60. 6/5/23 blood sugar was 70. 6/12/23 blood sugar was 69. 6/13/23 blood sugar was 64. 6/15/23 blood sugar was 68. 6/20/23 blood sugar was 60. 6/24/23 blood sugar was 69. A notification to the doctor was made on 6/13/2023 for a blood sugar of 64 and a notification was written on 7/3/2023 for a blood sugar of 59, indicating the resident had no signs and symptoms of low blood sugar and 4 Units of Humalog was held. These notifications were found in the paper chart, no other documentation was found in the electronic medical record. No other progress notes were found to indicate communication or notification of other blood sugar readings or interventions were provided to the Medical Doctor. During an interview, on 7/31/2023 at 11:10 A.M., RN 5 indicated the Physician had discontinued the resident's Lispro and the Lantus insulin did not have any documented notifications. Staff were to notify the doctor if the resident's blood sugar was less than 70 or above 200. RN 5 indicated Resident 2 had been having some blood sugars that were all over the place. RN 5 looked in the chart and indicated the highest blood sugar reading was 300, and the lowest reading was 56. She indicated the doctor should have been notified if the resident's blood sugar was less than 70. RN 5 indicated the doctor was made aware of Resident 2's blood sugar readings via a facsimile and presented documentation of the communication, dated 7/3/2023. During an interview, on 7/31/2023 at 11:32 A.M., the DON (Director of Nursing) indicated if a resident had an abnormal blood sugar reading, the nursing staff would call the doctor and document the communication in the resident's progress notes. If a note was documented in the MAR (medication administration record), a note would then populate in the nursing progress notes. On 7/31/2023 at 11:40 A.M., a current policy was provided by the DON (Director of Nursing), titled Physician and Family Notification of Condition Changes. The policy had a start date of 11/30/2016 with no revision date. The policy included the following: .the purpose is to keep physician and family appraised of all condition changes either by telephone or fax cover sheet. Telephone notification is required for all emergencies, all condition changes, critical laboratory results, abnormal radiology or diagnostic test that require immediate response. Notify the physician of any change in condition that may or may not warrant a change in treatment plan. Document the information reported to the physician in the nurse's notes. Be thorough and explicit. Document the response from the physician in the nurse's notes. If faxing, document information in black ink on a fax form which includes a confidentiality statement. Include all information required for physician to make decisions. If immediate physician response is required, do not fax. Thoroughly document information to be reported in the nurse's note. Be thorough and explicit, including that the physician was faxed, date and time. Document in nurse's note when the physician responds to the fax. Notify the resident and responsible party of any change in condition that may or may not warrant a change in treatment plan, including critical lab values, abnormal radiology or diagnostic testing results 3.1-5(a)(2)(3)

Based on observation, record review and interview, the facility failed to ensure a baseline care plan was completed and a summary was shared with the resident and/or her representative for 1 of 1 new residents reviewed for baseline care plans. (Resident 38) Finding includes: The clinical record for Resident 38 was reviewed on 7/25/2023 at 2:19 P.M. Resident 38 was admitted to the facility on [DATE] with diagnoses included, but not limited to: osteomyelitis of the vertebra, sacral and sacrococcygeal region, gout, idiopathic peripheral autonomic neuropathy, stage 4 pressure ulcer of the sacral region, chronic kidney disease stage 3B, glaucoma, age related osteoporosis, hypothyroidism, hypertension, cognitive communication deficit, hypokalemia, hyperlipidemia and abnormality of albumin. The Admission MDS assessment, completed on 6/13/2023, indicated the resident was mildly cognitively impaired, had little pleasure, felt down, had little energy, trouble sleeping and poor appetite for the past 7 - 13 days. It was somewhat important to her to have snacks in between meals, had not transferred out of bed for the assessment period, was totally dependent on staff for dressing, bed mobility, toileting, personal hygiene and bathing needs and required limited assistance from one staff for eating needs. The assessment indicated the resident had exhibited no swallowing or chewing issues, weighed 200 pounds and had not experienced any recent weight changes. The resident was admitted with 1 stage 4 pressure ulcer. During an interview with Resident 38's representative, conducted on 7/24/2023 at 2:09 P.M., she indicated she had not been given any care plan documentation, had not received any invitation to a care plan meeting, nor had she participated in any care plan meeting since the resident had been admitted to the facility on [DATE]. During an interview with the Social Service Director, on 7/26/2023 at 1:47 P.M., she indicated there had been no initial care plan meeting or baseline care plan meeting set up for Resident 38. She indicated the department managers had signed a form on 6/7/2023 for a New Admission Management Introduction and Review meeting but there had not been a care plan meeting conducted. The Admissions staff member was responsible for setting up the initial care plan meetings, but there had been a vacancy for that position and the care plan meetings for Resident 38 had been missed. The current facility policy, titled, Care Plan Development and Review, provided by the Director of Nursing on 7/28/2023 at 9:00 A.M., included the following: .2. CARE PLAN DEVELOPMENT: A. An interdisciplinary team, in conjunction with the resident, physician and representative will develop a comprehensive care plan for each resident .4. CARE PLAN CONFERENCE: A. Care plan conferences with all disciplines will be held with resident and representative, at their convenience within seven days of admission, 21 days of admission, quarterly, and as needed .B. VII. If representative is not present for the seven day care conference, a call will be made to them by the care plan coordinator or director of nursing to discuss the care plan .5. COMMUNICATION TO STAFF, RESIDENTS AND RESPONSIBLE PARTY: .C. Residents and their representative will be given a summary of their baseline care plan by a member of the care plan team via printing: resident dashboard for that resident. The resident and/or resident representative will sign and date a copy of the summary to be placed in the medical record as evidence it has been received by the resident or representative

Based on observation, record review and interviews, the facility failed to ensure a care plan meeting was conducted after an admission assessment was completed for 1 of 13 residents reviewed. (Resident 38) The facility also failed to ensure a care plan was revised and updated regarding safety measures for 1 of 3 residents reviewed for accidents. (Resident 5) Findings include: 1. The clinical record for Resident 38 was reviewed on 7/25/2023 at 2:19 P.M. Resident 38 was admitted to the facility on [DATE] with diagnoses included, but not limited to: osteomyelitis of the vertebra, sacral and sacrococcygeal region, gout, idiopathic peripheral autonomic neuropathy, stage 4 pressure ulcer of the sacral region, chronic kidney disease stage 3B, glaucoma, age related osteoporosis, hypothyroidism, hypertension, cognitive communication deficit, hypokalemia, hyperlipidemia and abnormality of albumin. The Admission MDS Assessment, completed on 6/13/2023 indicated the resident was mildly cognitively impaired, had little pleasure, felt down, had little energy, trouble sleeping and poor appetite for the past 7 - 13 days. It it was somewhat important to her to have snacks inbetween meals, had not transferred out of bed for the assessment period, was totally dependent on staff for dressing, bed mobility, toileting, personal hygiene and bathing needs and required limited assistance from one staff for eating needs. The assessment indicated the resident had exhibited no swallowing or chewing issues, weighed 200 pounds and had not experienced any recent weight changes. The resident was admitted with 1 stage 4 pressure ulcer. During an interview with Resident 38's representative, conducted on 7/24/2023 at 2:06 P.M., she indicated she had not yet been invited to a care plan meeting. There were no nursing notes or documentation in the clinical record regarding any scheduling of a care plan meeting. During an interview with the Social Service Director, on 7/26/2023 at 1:47 P.M., she indicated there had been no initial care plan meeting or baseline care plan meeting set up for Resident 38. She indicated the department managers had signed a form, on 6/7/2023, for a New Admission Management Introduction and Review meeting but there had not been a care plan meeting conducted. She indicated the Admissions staff member was responsible for setting up the initial care plan meetings but there had been a vacancy for that position and the care plan meetings for Resident 38 had been missed. The current facility policy, titled, Care Plan Development and Review, provided by the Director of Nursing on 7/28/2023 at 9:00 A.M., included the following: .2. CARE PLAN DEVELOPMENT: A. An interdisciplinary team, in conjunction with the resident, physician and representative will develop a comprehensive care plan for each resident .D. The resident's comprehensive care plan is developed within seven (7) days of the completion of the comprehensive assessment or within twenty-one (21) days after the resident's admission .4. CARE PLAN CONFERENCE: A. Care plan conferences with all disciplines will be held with resident and representative, at their convenience within seven days of admission, 21 days of admission, quarterly, and as needed .B. VII. If representative is not present for the seven day care conference, as call will be made to them by the care plan coordinator or director of nursing to discuss the care plan .5. COMMUNICATION TO STAFF, RESIDENTS AND RESPONSIBLE PARTY: .C. Residents and their representative will be given a summary of their baseline care plan by a member of the care plan team via printing: resident dashboard for that resident. The resident and/or resident representative will sign and date a copy of the summary to be placed in the medical record as evidence it has been received by the resident or representative 44111 2. A record review for Resident 5 was completed on 7/26/23 at 9:02 A.M. Diagnoses included, but were not limited to: Friedreich's Ataxia (disease which causes progressive nervous system damage), anxiety disorder, psychotic disorder with delusions due to know physiological condition, major depressive disorder, single episode, moderate, rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement and paraplegia unspecified. During an observation, on 7/26/2023 at 10:47 A.M., Resident 5's bed was in a high position from the floor. During an observation, on 7/27/2023 at 9:52 A.M., the resident's bed was not in the lowest position. During an observation, on 7/28/2023 at 9:53 A.M., the resident's bed was not in the lowest position. A Care Plan, dated 12/10/2015, indicated .Fall Risk characterized by risk factors: Use of narcotics, antidepressant, anti-anxiety, back pain, Dx [diagnosis] of Fredrechs [sic] Ataxia. Limitations to all extremities. When up in w/c [wheelchair] will take off arm rests and slide self down w/c. Resident chooses to not get out of bed for therapy to eval [evaluate] for w/c seating. Interventions, dated 6/30/2023, included bed in lowest position when receiving suppository for BM [bowel movement], bed in lowest position. On 7/14/2023, bolsters to mattress for tactile boundaries was added. During an interview, on 7/28/2023 at 9:55 A.M., the Director of Nursing (DON) indicated that a low bed is when it is lowered as far as it will go down. The interventions that were put in place after his fall were to put the bed in low position when receiving a suppository for BM and bolsters to the mattress. The other intervention of bed in lowest position was put in by the floor nurse and the care plan should have been revised. On 7/28/2023 at 12:37 P.M., the Director of Nursing provided a policy titled, Care Plan Development and Review, dated 1/24/2020, and indicated the policy was the one currently used by the facility. The policy indicated .3. CARE PLAN REVISION: A. Care plans will be revised daily and PRN as changes in the resident's condition dictate. Changes include but are not limited to changes in Physician orders, diet changes, therapy changes, behavior changes, ADL changes, skin changes etc . 4. CARE PLAN CONFERENCE: A. Care plans conferences with all disciplines will be held with resident and representative, at their convenience within seven days of admission, 21 days of admission, quarterly, and as needed. B. The initial (7 day) care plan conference will be held within seven days of admission with the resident, representative, available department heads, and care plan coordinator (designee). The Admission Director will set the time and date of the 7-day care conference during the time of the admission process 3.1-35(2)(B)(e)

Based on observation, record review, and interview, the facility failed to ensure the medication regimen was adequately monitored for 1 of 5 residents reviewed for unnecessary medications. (Resident 21) Finding includes: The record for Resident 21, reviewed on 7/26/2023 at 9:01 A.M., indicated the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to: Alzheimer's disease late onset, chronic systolic congestive heart failure, localization related symptomatic epilepsy and epileptic syndromes, hypertensive heart and chronic kidney disease and hypothyroidism. The current Physician Orders for medications, included an order for Levothyroxine Sodium tablet 125 mcg (microgram), one table by mouth one time a day for low thyroid hormone. The current Physician Orders for laboratory testing indicated the resident was to have a TSH (Thyroid Stimulating Hormone) level test (a test utilized to determine correct effectiveness of thyroid medication), along with other testing, completed on 8/3/2023. The testing order indicated it was to be completed every 365 days. A previous Physician's Order, initiated on 1/19/2022 and discontinued on 4/28/2023, indicated a TSH level and other routine testing was to have been completed in March. The most recent TSH level for Resident 21, provided by the Medical Records staff on 7/31/2023 at 12:00 P.M., indicated the TSH level had not been completed since 10/14/2021. During an interview with the Regional Nurse Consultant, on 7/31/2023 at 12:15 P.M., she indicated she could not locate a more recent TSH level test and there should have been one completed in the past year. She indicated there was no specific policy regarding TSH level testing, but the physician had ordered the test and it was not completed. The test was now scheduled to be drawn on 8/3/2023. 3.1-48(a)(3)

Based on record review and interview, the facility failed to ensure laboratory culture results were received before initiating an antibiotic for 3 of 4 residents reviewed for antibiotic stewardship. (Residents 5, 30, and 32) Findings include: 1. During a record review, completed on 7/28/2023 at 9:00 A.M., Resident 5 returned from the ER (emergency room ) with an order for cephalexin 500 mg (milligrams) every 8 hours for 5 days for a UTI (urinary tract infection). A C&S (culture and sensitivity) report could not be found in the record. 2. During a record review, completed on 7/28/2023 at 9:20 A.M., Resident 30 was noted to have a fall on 4/18/2023 and her urine had a foul odor. A C&S was done on 4/18/2023 and the physician ordered Macrobid 100 mg twice a day for 7 days on the same day. The results from the C&S were not received until 4/21/2023. 3. During a record review, completed on 7/28/2023 at 9:43 A.M., Resident 32 was sent to the ER and returned with an order for cephalexin 500 mg 3 times a day for 7 days. A C&S could not be found in the record. During an interview, on 7/28/2023 at 10:32 A.M., the IP (Infection Preventionist) nurse indicated in 2 of the cases, the residents returned from the hospital with the orders for the antibiotics, and in the 3rd case the physician gave the order by telephone. The facility used the McGreer Criteria for the use of antibiotics, and when a resident returned from the hospital with orders for an antibiotic, they would try to call the physician to clarify the order so as to follow the criteria, but sometimes they did not catch it in time. During an interview, on 7/28/2023 at 2:46 P.M., the DON (Director of Nursing) indicated the normal process was to wait until the C&S was returned before starting the antibiotic, and when the resident returned from the ER with an antibiotic order, they should have notified the attending physician for further instructions, but they did not in these cases. A current policy titled, Antibiotic Stewardship and dated 9/2/2019, provided on 7/24/2023 at the entrance conference, included, but was not limited to: .The facility's Infection Control Program has defined standards outlining specific clinical criteria for identification of infections, action plans to administer when infections occur and a surveillance program that aggressively monitors and implements procedures to treat and prevent future outbreaks. One of these procedures includes judicial and appropriate use of antimicrobial agents. Collaboratively, with the Medical Director, Resident's Attending Physicians, the Consultant Pharmacist and the Administration of each facility, every effort will be made to prevent the misuse or overuse of antimicrobials A copy of the McGreer Criteria was attached to the policy.

Based on record review, observation and interview, the facility failed to prevent the development of an unstageable pressure area, failed to assess a residents skin weekly, and failed to initiate a pressure ulcer treatment timely for 2 of 3 residents reviewed for pressure ulcers. (Residents 11 & 31) Findings included: 1. During an observation, on 6/1/2022 at 9:05 A.M., Resident 11 was observed in bed lying on her back. On 6/1/2022 at 9:15 A.M., along with LPN 6, Resident 11's buttocks were observed. Resident 11's coccyx area had an open area approximately the size of a quarter, with exposed red tissue with no dressing to the area. A clinical record review was completed on 6/2/2022 at 10:14 A.M. Resident 11's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) assessment, dated 2/21/2022, indicated Resident 11 required extensive assist of 2 staff for bed mobility and toilet use, extensive assist of 1 staff for transfers, total assist of 1 staff for dressing and limited assist for eating. A current care plan, dated 8/21/2020, indicated the resident had Bowel and Bladder incontinence with potential for skin breakdown related to Dementia and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Ability to sit on toilet or assist with toileting varies. Interventions included, but were not limited to: Toilet as able upon rising, before/after meals, at bed time and PRN (as needed) during the night with prompt peri-care, turn and reposition every 2-3 hours and prn, and weekly skin assessment. A current care plan, dated 1/9/2022, indicated the resident was at risk for skin breakdown. Had incontinence, history of pressure ulcer, dementia and Alzheimer's disease. Interventions included, but were not limited to: monitor skin daily during care, provide air loss mattress, provide pressure reduction device to chair, remind or assist to turn at least every 2 hours, serve supplements as ordered and skin assessments at least weekly by nurse. A Nurses' Note, dated 4/6/2022 at 7:15 P.M., indicated Resident 11 had a reddened non blanchable area to her coccyx. A preventative dressing was applied. On call Nursing supervisor notified of area. The April Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] A Nursing-Weekly Assessment, dated 4/7/2022, indicated Resident 11's skin was assessed and no new skin issues were noted during this assessment. A Nurses' Note, dated 4/10/2022 indicated a Weight and wound meeting was held on 4/8/2022. The resident has had a weight loss. April 4-118.2. Was on a mechanical soft diet with super cereal, super potatoes at lunch, and magic cup at dinner. Average food intakes are as follows 50% or less for most meals. Average fluid intakes are as follows 821 ml (milliliter) per day. Will continue to monitor through weight and wound. The note lacked any documentation of the red area to the coccyx. The clinical record lacked a Nursing-Weekly Assessment for 4/14/2022. A Nurses' Note, dated 4/15/2022 at 12:21 P.M., indicated a Weight and wound meeting was held on 4/14/2022. The resident has had a weight loss. April 11-111.2 April 4-118.2. Is on a mechanical soft diet with super cereal, super potatoes at lunch, and magic cup at dinner. Moved to an assist table for hopefully better intakes. Average food intakes are as follows declines to 50% or less for most meals. Average fluid intakes are as follows 770 ml per day. Will continue to monitor through weight and wound. The note lacked any documentation of the red area to the coccyx. A Nurses' Note, dated 4/25/2022 at 2:08 P.M., indicated a Weight and wound meeting was held on 4/21/2022. The resident has had a weight loss. April 18-112.6, April 11-111.2, and April 4-118.2. Was on a mechanical soft diet with super cereal, super potatoes at lunch, and magic cup at dinner. Moved to an assist table for hopefully better intakes. Average food intakes are as follows declines to 50% or less for most meals. Average fluid intakes are as follows 770 ml per day. Will continue to monitor through weight and wound. The note lacked any documentation of the red area to the coccyx. A Nurses' Note, dated 4/29/2022 indicated a Weight and wound meeting was held on 4/28/2022. The resident has had a weight loss. April 25-113.8, April 18-112.6, April 11-111.2 April 4-118. Was on a mechanical soft diet with super cereal, super potatoes at lunch, and magic cup at dinner. Moved to an assist table for hopefully better intakes. Average food intakes are as follows declines to 50% or less for most meals. Average fluid intakes are as follows 1027 ml per day. Will continue to monitor through weight and wound. The note lacked any documentation of the red area to the coccyx. The clinical record lacked completed Nursing-Weekly Assessments from 4/18/2022 to 5/4/2022. A New Skin Alteration Assessment, dated 5/19/2022 at 2:53 P.M., indicated a new wound: gluteal cleft 0.7cm (centimeters) x 0.8cm covered with yellow slough (dead tissue). A Nurses' Note, dated 5/19/2022 at 2:56 P.M., indicated: Pressure injury: Unstageable; Current status: New-inhouse; Original date: 5/19/2022; In-house developed; Location: Gluteal cleft; PUSH score: 4; Length:0.7; Width: 0.8; Treatment: Offload in bed between meals and Duoderm dot Q (every) 3 days. A current care plan, dated 5/25/2022, indicated Resident 11 had developed an actual pressure injury. Interventions included, but were not limited to: Nurse to measure/assess weekly & notify family & physician as needed. Skin assessment weekly by nurse. A Nursing-Weekly Assessment, dated 5/26/2022, indicated Resident 11's skin was assessed and no new skin issues were noted during this assessment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Rinse, then pat dry. Apply skin prep to good skin around wound then cover wound with Duoderm Dot. On Tuesday and Friday every day shift and PRN (as needed). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the April and the May treatment sheets indicated no treatment had been in place for the area. A NP (Nurse Practitioner) progress note, dated 5/31/2022, indicated Resident 11's skin was not addressed in the note. During an observation, on 6/02/2022 at 2:05 P.M.,CNA 1 was observed to provide incontinence care to the resident due to loose stools. A piece of duoderm was observed on the open area to the residents left gluteal cleft area, but not fully attached to the wound with the edges rolled up. CNA 1 indicated the resident was turned every 2 hours. During an interview on 6/06/2022 at 10:07 A.M., the wound nurse indicated the resident does off load between meals and did not like to turn and reposition. Resident 11 was now eating in the dinning room and started to eat better. The wound nurse indicated the resident had been on the air mattress for awhile now and the Skin Assessments had not been done timely. She indicated the treatment was usually done for 2 weeks and was using the duodern to take off the slough and that there were no new interventions added when the red area occurred. 2. A clinical record review was completed, on 6/2/2022 at 10:29 A.M., for Resident 31. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) assessment, on 4/14/22 indicated Resident 31 needed extensive assistance with one staff member for bed mobility. Resident 31 had a stage 2 pressure ulcer, was at risk for pressure ulcers, and receives hospice services. A Nursing Assessment, on 1/20/2022, entitled New Skin Alteration Assessment indicated the left buttock had a 2 cm round, open, and moist area with pinpoint area to left buttock. The right buttock has three pinpoint areas with the same description. A Care Plan, on 1/20/2022 indicated, I have a stage 2 pressure injury on the inner aspect of my left buttock. On 1/26/2022, an intervention to the care plan was added and indicated, Apply treatment as ordered. Confer with hospice as needed. On 1/24/2022, a Nursing Assessment titled, Pressure Injury Assessment with Braden Scale was completed by the Wound Nurse. The assessment indicated an in-house developed pressure ulcers as described above. The Stage 2 pressure ulcer measured 1.9 cm x 1 cm x <0.1 cm. The most recent notification to the attending physician was on 1/24/2022. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover with [MEDICATION(S)] dressing. every day shift every 5 day(s) for Wounds AND as needed for loss of dressing integrity. There was not a treatment ordered for the left buttock. During an interview, on 6/6/2022 at 10:56 A.M., the Wound Nurse indicated a pressure ulcer treatment should begin immediately after the pressure ulcer was noted and the physician should be notified for a new order. The Wound Nurse indicated she did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated this was considered a delay in treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/7/2022 at 12:00 P.M., the DON provided a policy titled, Wound (Pressure Injury) & Non-Wound Assessment & Documentation. The policy indicated, .All wounds .will be managed by the facility wound nurse(s) .Assessment findings will be documented on the Pressure Injury assessment and non-pressure injury assessment located in the EMR [Electronic Medical Record]. Each week or more often if needed, the wound assessment will be completed to include: location, stage, current status, measurement, description, pain associated, PUSH score [a tool that monitors three parameters: surface area of the wound, wound exudate and type of wound tissue] and current treatment. On 6/6/2022 at 10:18 A.M., the Infection Preventionist provided the policy titled, Skin Management Program, dated 8/14/2014, and indicated the policy was the one currently use by the facility. The policy indicated . I. A comprehensive head to toe assessment (inspection) will be completed by a licensed nurse upon admission/return, and at least weekly thereafter.H. Documentation: I. Routine daily and/or weekly skin assessments will be documented in the EMR on respective assessment (daily or weekly). II . In addition the wound nurse will follow up on all non-pressure wounds weekly and prn and document in the EMR on the Wound-non pressure assessment. III. Physician will make note of wound progress/regress and unavoidability if applicable at routine visits. Wound nurse will keep physician up to date with progress/regress as needed. IV. Non-wound skin alterations will be assessed and monitored by the licensed staff nurse On 6/6/2022 at 10:18 A.M., the Infection Preventionsit provided the policy titled, Pressure Injury Treatment, dated 1/16/2020, and indicated the policy was the one currently use by the facility. The policy indicated .3. Re-evaluate the pressure injury, the plan of care and the individual if the pressure injury does not show progress towards healing with in 2 weeks. General Treatment Recommendations: 1. [MEDICATION(S)] dressings: (duoderm)- Use for clean stage 2 in body areas where they will not roll or melt 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to revise and individualize the care plans for 4 out of 23 residents charts reviewed for care plans. (Resident 3, 44, 49 and 253) Findings include: 1. A clinical record review was completed, on 6/2/22 at 1:29 P.M., and indicated Resident 44's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician Order, dated 1/26/2022, indicated Resident 44's right leg, mid calf circumference measurement every month, for [CONDITION(S)] monitoring. During an interview, on 6/6/22 at 10:08 A.M., the Director of Nursing indicated that they are measuring her leg weekly, and the intervention is not on the care plan and it should have been. 2. A clinical record review, was completed on 6/3/2022 at 9:27 A.M., and indicated the Resident 49's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated the resident was admitted on [DATE]. During an observation, on 6/1/2022 at 11:49 A.M., resident had a low bed with a fall mat next to it, ½ rails positioned in the middle of the bed and bandages on bilateral forearms, bump on right forehead with discoloration. The Care Plan, dated 4/25/2022, indicated interventions of call light within reach, monitor for changes in gait/positioning and notify MD of changes in condition. During an interview, on 6/2/22 at 10:00 A.M., the Director of Nursing indicated Resident 49 had fallen seven times and the fall care plan was not updated after each fall and should have been. 3. During an interview with alert and oriented, Resident 3, conducted on 5/31/2022 at 2:24 P.M., he indicated he had fallen out of his wheelchair because it was not equipped with a chest strap or seat belt. The clinical record review for Resident 3 was initiated on 6/1/2022 at 3:05 P.M. Resident 3 was admitted with diagnoses, including but not limited to: Friedriech's Ataxia, [CONDITION(S)], chronic pain, neuromuscular dysfunction of the bladder, urine retention, anxiety disorder, abnormal posture, muscle weakness, dysphasia, major depressive disorder, and constipation., Review of an Initial Occurrence Assessment, completed on 1/18/2022, indicated Resident 3 was found on the floor beside his bed. The documentation indicated the resident had attempted to roll himself over in bed and rolled out of the bed. Review of an Initial Occurrence Assessment, completed on 1/31/2022, indicated the resident had been up in his wheelchair in his room and when the staff went into his room to assist him back into his bed, he had slid himself down in the chair and the mechanical lift sling could not be positioned correctly so the resident was lowered to the floor. Review of an Initial Occurrence Assessment, completed on 4/21/22 at 9:15 A.M., indicated Resident 3 was being assisted with care while in his bed and when he was rolled over his legs slid out of the bed and he landed on the floor on his bottom. The form indicated the resident would be monitored. Review of the current health care plan related to falls indicated all of the interventions were initiated prior to January 2022. During an interview with the MDS nurse, conducted on 6/6/2022 at 2:50 P.M., she indicated she did not see any updated interventions on Resident 3's care plans related to any of his falls in 2022. 4. During initial observations, on 5/31/2022 at 10:31 A.M., multiple bruises were observed to Resident 253's bilateral arms. Resident 253 indicated the bruising was from intravenous therapy and laboratory draws from being hospitalized from 5/9/2022 through 5/11/2022. Resident 253 also indicated she was on a blood thinner. Resident 253 indicated she was on antibiotic therapy for a venous lump in her right forearm. A clinical record review was completed, on 6/2/2022 at 2:39 P.M., for Resident 253. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order, on 5/18/2022 indicated to give [MEDICATION(S)] tablet 3 MG one tablet by mouth in the evening for [CONDITION(S)]. On 5/26/22 an ultrasound was performed of the right forearm for localized swelling, mass and lump of the right forearm. The results indicated a heterogenous soft tissue swelling with cystic components and mild vascularity seen subcutaneously in the right forearm at the area of interest, with a possibly abscess formation/neoplastic lesion. A Physician's Note, on 5/27/2022, indicated Resident 253 was requested to be seen after she was found to have a mass and ecchymosis (bruising) to her right forearm. Resident 253 did not have decreased range of motion, but the area was tender to palpation. There was no trauma to be reported. Resident 253 was not sure if she had intravenous therapy in the identified location. Resident 253 felt the area was enlarging since she first identified the mass. The Physician identified the right forearm to have yellowed ecchymosis, with no warmth and a mobile mass measuring seven centimeters by four centimeters. A Nurse's Note, on 5/27/2022 at 4:57 P.M., indicated, [Physician's Name] in facility today for routine rounds. Res[resident] seen for acute problem visit for mass in right forearm with bruising. Res assessed, ultrasound report reviewed, CBC reviewed, medications and chart reviewed, progress note written. New orders received to schedule resident for MRI of right forearm. Start [MEDICATION(S)] 875/125mg by mouth BID [twice daily] for 10 days. Start probiotic daily for 14 days. Continue to monitor area for s/s of infection or changes. Resident updated and in agreement with plan. During an interview, on 6/07/2022 at 8:45 A.M., the MDS Coordinator indicated the floor nurse was responsible for completing a care plan if an acute issue arises. On 6/07/2022 at 9:12 A.M., the Unit Manager indicated a care plan should have been completed for the abscess formation and the use of an antibiotic. On 4/7/2022 at 12:00 P.M., the DON provided the policy titled, [CONDITION(S)] Medication Use. The policy indicated, .Purpose: To ensure that medication regimen helps promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being .Ongoing monitoring will be in place to assess the risks vs [versus] benefits of continued medication use and [CONDITION(S)] medications will not be used as a restraint .Side Effect Monitoring: Monitoring daily on Med Admin Record [MAR] .PRN [as needed] [CONDITION(S)] medications: [MEDICAL RECORD OR PHYSICIAN ORDER] A policy titled, Care Plan Development & Review was provided by the DON. The policy indicated, .3. Care Plan Revision: A. Care plans will be revised daily and PRN as changes in the resident's condition dictate. Changes include, but are not limited to changes in Physician orders Review of the facility policy and procedure, titled, Care Plan Development and Review indicated care plans were to be revised daily and as needed regarding changes in the resident's condition. In addition, the comprehensive care plan was to reflect treatment goals and identified risks. 3.1-35(d)(2)(B)

Based on record review and interview, the facility failed to ensure a Notice of Medicare Non-Coverage letter was signed timely for 1 of 3 residents reviewed for Medicare Coverage. (Resident 255) Finding includes: On 6/3/2022 at 11:51 A.M., the Business Office manager provided the Medicare SNF Beneficiary Protection Notification Review, which was completed by the facility and the Notice of Medicare Non-Coverage documents for Resident 255. Resident 255's Medicare Beneficiary Notification documents were reviewed on 6/3/2022 at 11:23 A.M. Resident 255 was identified by the facility to have remained in the facility after being discharged from Medicare Skilled Services. The SNF Beneficiary Protection Notification Review document indicated Resident 255's Medicare Part A Skilled Services Episode Start Date was 12/16/2021, and the Last Covered Day of Part A Services was on 12/28/2021. The document also indicated the facility initiated the discharge from Medicare Part A Services when the benefit days were not exhausted. The document indicated a SNF ABN (Skilled Nurse Facility Advance Beneficiary Notice of Non-Coverage) form had been provided to Resident 255's Representative. The document indicated the facility provided a NOMNC (Notice of Medicare Non-Coverage) form to Resident 255's Representative. The NOMNC form had been signed by Resident 255's Representative on 12/31/2021. The form indicated the current Skilled Nursing Services would end on 12/28/2021. During an interview, on 6/6/2022 at 9:27 A.M., the Business Office Manager (BOM) indicated the POA (power of attorney) for Resident 255 lived out of state, and it took her a few days to get here to sign the form. The BOM indicated she had not sent the POA a copy of the NOMNC to sign, or documented it in the residents chart that she had spoken to the POA and indicated the forms were not signed 2 days prior to the last covered day and should have been. On 6/6/2022 at 9:31 A.M., the BOM provided a policy titled, Noncovered Letters, dated 5/25/2006, and indicated the policy was the one currently used by the facility. The policy indicated .1. Noncovered letters are to be issued to a resident when: e. Medicare services are going to be noncovered. 2. These letters are important because they determine when the beneficiary becomes liable .b. Letter II SNF Determination on Continued Stay-Medicare covered services are going to be noncovered. This letter must always be dated and mailed, or signed by the responsible party, no sooner and no later than the day before (24 hours) the noncovered days 3.1-12 (f)(1)(2)

Based on observation, record review and interview, the facility failed to ensure a comprehensive care plan was initiated for 3 of 23 residents reviewed for care planning. (Resident 2, 11 and 44) Findings include: 1. During an interview, with alert and oriented Resident 2, on 5/31/2022 at 11:15 A.M., he indicated he had been in the hospital three times since he was admitted in January. He indicated two of the three times were for low hemoglobin, once as low as 5mg/dl (milligram per deciliter) . He indicated when this occurred he initially felt very short of breath even though his oxygen level was normal. The clinical record for Resident 2 was reviewed on 6/2/2022 at 10:13 A.M. Resident 2 was admitted with diagnoses, including but not limited to: status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Progress notes for Resident 2, dated 4/8/2022, indicated the resident had complained of shortness of breath and was placed on 1 liter of oxygen for comfort. Subsequent notes, dated 4/11/2022 at 4:44 P.M. indicated the laboratory blood test results were received and the resident's hemoglobin level was noted to be at a critically low level of 5.7 g/dL [grams per deciliter (11.1 - 15.9 normal range)]. The resident was sent to the emergency room for evaluation and treatment. Nursing notes, on 5/2/2022 ,indicated laboratory test results were received for Resident 2. His Hemoglobin was slightly low at 7.4 g/dL and his hematocrit was low at 23.6 % ( normal range 34-46%). The physician was notified of the test results and an iron panel was ordered for the next laboratory day. A Nursing note, dated 5/4/2022 indicated the iron panel laboratory test was obtained from Resident 2. A subsequent nursing note, dated 5/6/2022 indicated the resident's iron panel test results were received and the physician was notified of the resident's low iron level of 24 ug/dL (micrograms per deciliter) (normal range 38 - 169 ug/dL). The physician gave orders for [MEDICATION(S)] sulfate (an iron supplement tablet) and Vitamin C for [CONDITION(S)] and orders to repeat the CBC and iron panel test in 4 weeks. A Nursing note, completed on 5/9/2022, indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The test was obtained and subsequent notes indicated the resident was again sent to the acute care facility due to a low hemoglobin level, 6.8 g/dL and a low RBC (Red Blood Cell) count of 2.89 xl0E6/uL (unit of measurement) (Normal range 4.24 - 5.6) Review of the most recent Minimum Data Set (MDS) assessment indicated it had been completed on 5/23/2022 due to a significant change in the resident's status. Review of the current health care plans for Resident 2 indicated there was no plan to address the resident's recent low hemoglobin levels and need for blood [CONDITION(S)] and there was also no plan to address the resident's new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, conducted on 6/6/2022 at 2:49 P.M., with the Minimum Data Set (MDS) nurse, she indicated she had initiated a new care plan for contractures for Resident 2, but had not initiated any care plans to address the resident's acute bleeding issues or new [CONDITION(S)] diagnosis. 2. A clinical record review was completed on 6/2/2022 at 10:14 A.M. Resident 11's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse's Note, dated 4/6/2022 at 7:15 P.M., indicated an aide notified a nurse that Resident 11 had redness to her coccyx. Area to coccyx was red and non blanchable, skin was intact. Preventative dressing placed. A Nurses Note, dated 5/19/2022 at 2:56 P.M., indicated: Pressure injury: Unstageable; Current status: New-inhouse; Original date: 5/19/2022; In-house developed; Location: Gluteal cleft; PUSH score: 4; Length:0.7cm (centimeter); Width: 0.8 cm; Treatment: Offload in bed between meals and Duoderm dot Q (every) 3 days. A new skin alteration assessment, dated 5/19/2022, indicated a new wound to the gluteal cleft 0.7cm x 0.8 cm covered with yellow slough (dead tissue). A current care plan, dated 1/9/2020, indicated Resident 11 was at risk for skin breakdown due to Incontinence and history of pressure ulcer. Resident 11's clinical record lacked a current comprehensive care plan for the unstageable pressure area that was noted on 5/19/2022. A care plan for Resident 11's unstageable pressure area was initiated on 5/25/2022, 7 days after the area was observed. During an interview, on 6/2/2022 at 11:28 A.M., the Unit Manager indicated the wound nurse updates the wound care plans. 3. A clinical record review was completed, on 6/2/22 at 1:29 P.M. Resident 44's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) assessment, dated 4/28/22, indicated Resident 44 had severely impaired cognition, and that she is always incontinent of bowel and bladder and needs extensive assist of two staff for toileting and transfers. During an interview, on 6/3/2022 at 8:56 AM, the MDS Nurse indicated she does not have an incontinent of bowel and bladder care plan and should have had one. On 6/2/2022 at 10:19 A.M., the Director of Nursing provided a policy titled, Care Plan Development and Review, dated 1/24/2020, and indicated the policy was the one currently used by the facility. The policy indicated .To assure that a comprehensive care plan for each resident includes measurable, objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment process. To assure that the care plan is communicated effectively to the staff and responsible party 3.1-35(a)

Based on record review and interview, the facility failed to complete a discharge summary or provide post discharge resident instructions for 1 of 1 closed records reviewed. (Resident 51) Finding includes: A closed clinical record review was completed on, 6/1/2022 at 3:43 P.M. Resident 51 was admitted on [DATE] and discharged on [DATE]. A Physicians' Order, dated 3/16/2022, indicated to discharge the resident home on 3/20/2022 with all personal belongings and medications on hand. Resident to have Home Health Care Services, evaluate and treat with PT/OT (physical /occupational) therapy upon discharge. A Pre-Discharge Planning Assessment, dated 3/16/2022 indicated: IDT (interdisciplinary team) met with Resident 51's son and granddaughter to discuss the NOMNC (Notice of Medicare Non-Coverage) issued by the residents insurance. Appeal process was reviewed. Occupational therapy states that the resident still has trouble with managing pants during the toileting process and they recommend a wheelchair at home and possible a toilet riser and shower bench. Physical Therapy recommended a wheelchair as well. The resident could still benefit from some work with the walker. Recommended someone to help with light housekeeping and no driving until cleared by MD and recommended that he does not sleep on the floor. Reviewed home health and what they would do for the resident and reviewed compression hose instead of wrapping legs. Discussed medicaid- benefits of applying and community based and facility based. Reviewed cost of private and semi private rooms. Family expressed understanding of all topics discussed. They will discuss more in private and most likely will be filing an appeal. A Nurses' Note, dated 3/17/2022 at 4:20 P.M., indicated Social Service staff received notice from insurance that the resident did not win the appeal. Social service staff spoke with Resident 51's son and informed him of the news and that the last covered day would be 3/17/2022. The son stated that he would be taking his father home tonight (3/17/2022). Social Service informed nursing and made a referral to Indiana Home Care for PT/OT services and updated Resident 51's son. Nursing to call medications into the pharmacy. During an interview, on 6/2/2022 at 2:38 P.M., Medical Records staff indicated the nurses would fill out a discharge plan of care form when a resident leaves. A Post Discharge Plan of Care form, dated 3/17/2022, indicated I give permission to send all discharge information to my community physician to ensure continuity of care. There were no initials documented on the form indicating yes or no. Discharge Passport: (resident/representative to initial each item or mark as N/A (none applicable). I have received a passport binder that includes the following information: Medication list with directions and diagnosis. Discharge/Transfer/Bedhold notice. Educational materials regarding diagnosis. Personal property inventory sheet. Final summary of functional status and discharge plan of care. Do Not Resuscitate state form and/or POST form (if applicable). Community care and support services information sheet available if needed. There form had no initials and or N/A for each of the above items. Medication/Treatments: (resident/representative to initial each item or mark as N/A. I understand the medications on hand in the facility will be sent home with me. I understand a 30 days supply of medications were called into (blank) Pharmacy. I understand the prescriptions were sent home in passport and I am to take to pharmacy. I have treatment supplies for 3 days (if applicable). The form had no initials and or N/A for each of the above items. Equipment: (resident/representative to initial each item or mark as N/A. The following equipment is needed at home (blank). I understand the equipment will be delivered by: (blank) on (blank). I have all of the equipment needed on hand at home or have access to it. The form had no initials and or N/A for each of the above items. Home Services: (resident/representative to initial each item or mark as N/A. I decline any home services at this time. I agree to the following Home Health Agency listed below to follow me at home. There was a check mark to indicate the resident agreed to be followed by a home health care agency. The form was signed by Resident 51's representative and an RN (registered nurse) and dated 3/17/2022. During an interview, on 6/2/2022 at 2:51 P.M., the Director of Nursing indicated the Post Discharge Plan of Care form, should have been checked off and should have been in the binder they sent home with the resident. She indicated the facility does not make copies of what the resident takes home in the binder. On 6/2/2022 at 3:40 P.M., the Director of Nursing provided the policy titled, Voluntary Home/other facility Discharge, with a start date of 11/12/2019, and indicated the policy was the one currently used by the facility. The policy indicated .To plan and prepare resident for discharge from the facility and to ensure continuity of care between facility and home . II. Nursing-Discharge Plan of Care, Summary and Recap of stay located in PCC will be completed prior to discharge to home or other facility. Follow the list in the assessment for printing attachments to add to the passport. III. Teaching tools will be printed from the intranet and added to the passport as applicable. The carbon copy Discharge Instruction form in the passport will be completed by nursing prior to resident leaving. Resident/Representative will sign and the yellow copy will be kept in the facility 3.1-36(a) 3.1-36(a)(1) 3.1-36(a)(2) 3.1-36(a)(3) 3.1-36(b)

Based on observation , record review and interview, the facility failed to ensure care was provided for dependent residents for shaving needs (Resident 3) and bathing/showering needs (Resident 37). Findings include: 1. During an interview with alert and oriented Resident 3, conducted on 5/31/22 at 2:33 P.M., he was noted to have a short beard. Resident 3 indicated he preferred to be shaved but was not offered facial shaving very often. He indicated he could not shave himself and required staff assistance to perform the task. On 6/1/2022 from 9:00 A.M. through 3:00 P.M., Resident 3 was observed to remain in his bed and had not been assisted to shave. On 6/2/2022 at 9:00 A.M., Resident 3 was noted to have been shaved. The resident had dry skin flakes noted on his shirt collar. When the shaving was mentioned, Resident 3 stated Finally. During an interview, on 6/2/202 at 9:55 A.M., with CNA 8, he indicated male residents, who could speak, would tell staff their preference regarding shaving and if they needed assistance, staff would help them. He indicated Resident 3 preferred to be shaved. On 6/3/2022 at 9:50 A.M., Resident 3 was observed in his bed and his face had not been shaved. On 6/6/22 at 10:36 A.M. Resident 3 was observed in his room awake in bed. He had not been shaved and was noted to have a few days stubble on his face. He confirmed he had not been shaved since last week. During an interview with 6/6/22 at 10:36 AM, with CNA 2, she indicated Resident 3 was to be shaved on his shower days and in between if he asked. When asked if he (Resident 3) preferred to be shaved she indicated Yes, he doesn't grow out his beard very often. During an interview with the Social Service Director, conducted on 6/6/2022 at 1:30 P.M., she indicated she did not complete the portion of the initial assessments that focused on hygiene preferences but she did not think it was the facility policy to only offer shaving to dependent residents on their shower days. Review of the most recent Minimum Data Set assessment, completed on 2/8/2022, indicated Resident 3 was totally dependent on staff for personal hygiene and bathing needs. The current care plan addressing Activity of Daily Living needs indicated the resident required total staff assistance for all dressing, bathing and personal hygiene. (needs) There were no specific instructions regarding shaving preferences on the care plan. 2. During an initial observation on 5/31/2022 at 11:15 A.M., Resident 37 was observed to have greasy looking hair and long facial stubble. On 6/1/2022 at 9:32 A.M., 6/2/2022 at 8:52 A.M., and 6/3/2022 at 8:45 A.M., Resident 37 was observed having greasy hair and long facial stubble. On 6/7/2022 at 8:50 A.M., Resident 37 was observed with slightly greasy hair and minimal facial stubble. A clinical record review was completed on 6/2/2022 at 2:12 P.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS assessment, dated 4/20/2022, indicated Resident 37 was cognitively intact. Resident 37 was dependent for bathing with the assistance of one staff member. A Significant Change MDS assessment, dated 1/28/2022, indicated Resident 37 felt it was somewhat important to choose between a tub bath, shower, bed bath, or sponge bath. On 7/8/2015, a Care Plan indicated it was important to Resident 37 to choose a shower and shave daily. An intervention on 7/8/2015, indicated Resident 37's preference for bathing was a shower twice weekly with no preference as to the time of day, and on 7/31/2015 to provide shaver every morning and the shaver is kept in the medication care. A Care Plan on 7/20/2015 indicated Resident 37 needed extensive to total assistance for bathing and personal hygiene. The goal on 7/20/2015 was, I will have my needs met/anticipated as evident by clean, well-groomed appearance. An intervention on 7/20/2015 indicated Resident 37 would receive a shower and shampoo twice weekly. On 10/29/2015, an intervention indicated Resident 37's razor was in the medication cart. A review of the ADL (Activities of Daily Living) documentation indicated Resident 37 received a shower on 5/7/2022, 5/10/2022, 5/17/2022, 5/21/2022, 6/3/2022 and 6/4/2022. On 6/6/2022 at 2:45 P.M., shower sheets were reviewed from 5/1/2022 through 6/5/2022. Shower sheets indicated the following: 5/3/22 showered, but not shaved 5/7/22 showered and shaved 5/10/22 showered, but not shaved 5/14/22 showered and shaved 5/17/22 showered, but not shaved 5/21/22 showered and shaved 6/3/22 showered 6/4/22 showered, refused shave During an interview on 6/3/2022 at 12:59 P.M., Resident 37 indicated he received a shower a couple of days ago. He indicated he likes to be shaved daily and he has never had a beard before. On 6/6/2022 at 2:59 P.M., QMA 3 indicated Resident 37 received his showers on Tuesday and Saturday evenings. She indicated he refused his showers frequently. She indicated a shower sheet should be completed when a shower is refused. On 6/7/2022 at 8:50 A.M., Resident 37 indicated he has not refused his showers. On 6/7/2022 at 12:00 P.M., the DON provided the policy titled, Bath Shower. The policy indicated, .Purpose: to cleanse and refresh the residents skin A policy for resident preferences was requested but not provided prior to exiting the survey. Review of a policy and procedure, provided on 6/6/2022 at 3:00 P.M. by the Medical Record staff, titled, Morning Care indicated the following Purpose: To cleanse and refresh resident, while stimulating circulation and providing comfort and preparing resident for the day: .Procedures: .7. Remind or assist male residents to shave This Federal tag relates to Complaint IN 560. 3-1.38(a)(3)(A) 3.1-38(a)(3)(B) 3.1-38(a)(3)(D)

Based on interview and record review, the facility failed to reassess the resident and his falls, determine the root cause of fall, and revise the care plan interventions, for a resident who fell , sustaining a hematoma to forehead and skin tears to bilateral hands, for 2 out of 3 charts reviewed for falls. (Resident 3 & 49) 1. A clinical record review was completed, on 6/3/2022 at 9:27 A.M., and indicated the Resident 49's diagnoses included but were not limited to: Alzheimer's, dementia without behavioral disturbances, [CONDITION(S)], and hypertension. During an observation, on 6/1/2022 at 11:49 A.M., resident had a low bed with a fall mat next to it, ½ rails positioned in the middle of the bed and bandages on bilateral forearms, bump on right forehead with discoloration. A Nurse's Note, dated 5/6/2022, indicated resident 49 was observed on the floor lying on his right side in the common area in front of recliner sustaining a hematoma to the right forehead and skin teat to right thumb and first finger. The Care Plan, dated 4/25/2022, indicated interventions of call light within reach, monitor for changes in gait/positioning and notify MD of changes in condition. During an interview on 6/2/2022 at 10:00 A.M., the Director of Nursing indicated that Resident 49 had a total of 7 falls with the following dates of 4/25/2022, 4/26/2022, 4/29/2022, 5/5/2022, 5/6/2022, 5/7/2022, and 5/14/2022. The process after a fall they fill out a facility post occurrence form with each fall and update the care plan and she is the one responsible for doing it. She indicated she did not fill out the facility occurrence and update the care plan and should have had. 2. During an interview with alert and oriented, Resident 3, conducted on 5/31/2022 at 2:24 P.M., he indicated he had fallen out of his wheelchair because it was not equipped with a chest strap or seat belt. Resident 3 was noted to have upper extremity contractures to both hands and spastic movement to his arms. He observed to be unable to obtain a drink for himself or position himself in bed. The clinical record review, for Resident 3 was initiated on 6/1/2022 at 3:05 P.M. Resident 3 was admitted with diagnoses, including but not limited to: Friedriech Ataxia, [CONDITION(S)], chronic pain, neuromuscular dysfunction of the bladder, urine retention, anxiety disorder, abnormal posture, muscle weakness, dysphasia, major depressive disorder, and constipation., Review of an Initial Occurrence Assessment, on 1/18/2022 indicated Resident 3 was found on the floor beside his bed. The documentation indicated the resident had attempted to roll himself over in bed and rolled out of the bed. The portion of the assessment form to indicate the root cause, any new interventions or any IDT (interdisciplinary team) recommendations was left blank. Review of an Initial Occurrence Assessment, on 1/31/2022, indicated the resident had been up in his wheelchair in his room and when the staff went into his room to assist him back into his bed, he had slid himself down in the chair and the mechanical lift sling was not under the resident and could not be positioned correctly, so the resident was lowered to the floor. The portion of the assessment form to indicate the root cause, any new interventions or any IDT (interdisciplinary team) recommendations was left blank. Review of an Initial Occurrence Assessment, completed on 4/21/22 at 9:15 A.M., indicated Resident 3 was being assisted with care ,while in his bed, and when he was rolled over his legs slid out of the bed and he landed on the floor on his bottom. The form indicated the resident would be monitored. The portion of the form to indicate any root cause, any new intervention or any IDT recommendations was left blank. Review of the current health care plan related to falls indicated all of the interventions were initiated prior to January 2022 and there were no new interventions implemented after the falls on 01/18/2022, 01/31/2022 and 04/18/2022. During an interview with the MDS nurse, conducted on 06/06/2022 at 2:50 P.M., she indicated she did not see any updated interventions on Resident 3's care plans related to falls. Review of the facility policy and procedure, titled, Fall Management, provided by the Director of Nursing on 06/07/2022 at 11:45 A.M., included the following instructions: .B. Immediately post fall - an intervention must be put into place to prevent reoccurrence, if no intervention cab be determined to be appropriate at this time, the resident should be placed on 15 minutes checks and each check documented on the 15 minute checklist until the IDT can review the fall circumstances and complete the post fall investigation to determine root cause and determine an appropriate fall prevention intervention/s. C. The intervention immediately implemented must be documented on the Occurrence Assessment of the fall, communicated to staff and added to the Health care plan . 3.1-45(a)

Based on observation, record review and interview, the facility failed to ensure a resident maintained appropriate Foley catheter positioning for 1 of 3 residents reviewed for indwelling urinary catheters. (Resident 252) Finding includes: During an initial observation, on 5/31/2022 at 10:52 A.M., Resident 252 was observed with his Foley catheter urinary drainage bag attached to the armrest of his wheelchair with no dignity bag covering the drainage bag. The drainage bag was placed above bladder level. On 6/1/2022 at 9:09 A.M., Resident 252 was observed in the therapy gym on an exercise machine. The Foley catheter drainage bag was on the floor next to the exercise equipment. A dignity bag was not around the drainage bag. On 6/3/2022 at 12:51 P.M., the Foley catheter drainage bag was attached to the top of Resident 252 rollator as he was sitting in his recliner. The drainage bag was placed above the bladder level. Urine was observed pooling in the tubing. A clinical record review was completed, on 6/2/2022 at 1:49 P.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS (Minimum Data Set) assessment, on 5/24/22 indicated Resident 252 had an indwelling catheter. A Nurse's Note, on 5/31/2022 at 10:49 A.M., indicated Resident 252 returned from urology appointment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan, on 5/18/2022, indicated I require the use of a catheter due to urinary retention related to obstructive [CONDITION(S)]. Catheter is to remain in place until seen by urologist. An intervention on 5/18/2022, indicated to maintain the urinary drainage bag below bladder level to facilitate flow of urine. During an interview, on 6/3/2022 at 12:55 P.M., CNA 4 indicated the Foley drainage bag should be inside a dignity bag and the drainage bag should be below bladder level. CNA 4 came into Resident 252's room and stated, No, no, it can't be like that. CAN 4 moved the Foley catheter drainage bag to below bladder level. On 6/7/2022 at 12:00 P.M., the DON provided a policy titled, Foley Catheter Care & Maintenance and indicated it was the one currently being used by the facility. The policy indicated, .A. Purpose: 1. To reduce the likelihood of infection and to maintain a closed drainage system for all anchored catheters and not break the closed system unnecessarily .E. Placement of Catheter Tubing Procedure: 1. When in the wheelchair or bed: a. Position tubing with no tension b. Place in a catheter cover bag underneath wheelchair o r on the side of the bed c. Ensure bag and tubing is not touching floor

Based on observation, record review and interview, the facility failed to ensure that there was signage on the back of the door with oxygen in use, dates on the oxygen/nebulizer/[CONDITION(S)] tubing, humidifier, [CONDITION(S)]/nebulizer not stored in a bag and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 22 & 33) Findings include: 1. A clinical record review was completed, on 6/1/2022 at 3:07 P.M., and indicated the Resident 22's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated that resident 22 was admitted on [DATE]. During an observation, on 5/31/2022 at 11:00 A.M., the [CONDITION(S)] (Continuous Positive Airway Pressure) mask and tubing were lying on top of the nightstand uncovered. During an observation on 6/1/2022 at 10:06 A.M., the [CONDITION(S)] was lying on the bed without a covering and no date is on tubing/equipment. During the record review, on 6/1/2022 at 3:07 P.M., there was no order noted for the use of the [CONDITION(S)] nor for the cleaning of. During an interview, on 6/1/2022 at 3:36 P.M., the Director of Nursing indicated the [CONDITION(S)] should be in a bag with a date and there should have been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. A clinical record review was completed, on 6/1/2022 at 2:59 P.M., and indicated the Resident 33's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation, on 5/31/22 at 11:00 A.M., there was no date on the oxygen/nebulizer tubing, humidifier bottle, nebulizer was sitting on top of the machine uncovered. During an observation, on 6/01/2022 at 9:01 A.M., there was no date on the oxygen/nebulizer tubing, humidifier bottle, nebulizer was sitting on top of the machine uncovered and no signage on the back of the door. A Physician Order, dated 10/20/2020, indicated O2: change oxygen tubing and humidifier and clean concentrator filter weekly as needed. A record review, on 6/1/2022 at 3:25 P.M., of the (TAR) Treatment Administration Record, dated May 2022, indicated the tubing, humidifier and concentrator filter were not changed the month of May, no documentation on the treatment record. A Physician Order, dated 10/8/2020, indicated O2: No smoking magnets in place on inside and outside of door every shift. During an interview, on 6/1/2022 at 3:38 P.M., the Director of Nursing indicated that the signage should be on the back of the door for oxygen in use, nebulizer tubing should be dated and placed in a bag, and the humidifier water bottle/oxygen tubing should be dated and changed weekly. On 6/2/2022 at 8:35 A.M., the Director of Nursing provided a policy titled, O2-Nasal Cannula, dated 8/1/2013, and indicated the policy was the one currently used by the facility. The policy indicated .AFTERCARE OF EQUIPMENT: 1. Dispose of humidifier when empty or at least weekly.3. Cannulas and tubing should be stored in a plastic bag when not in use and changed weekly at a minimum. 4. Tubing and cannula changes should be documented on the treatment record On 6/1/2022 at 3:35 P.M., a policy was requested for the [CONDITION(S)] and one was not provided prior to the exit of the survey. 3. A clinical record review, was completed on 6/1/2022 at 3:07 P.M., and indicated the Resident 22's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated he was admitted on [DATE]. During an observation on 5/31/2022 at 11:00 A.M. and 6/1/2022 at 10:06 A.M., a [CONDITION(S)] (Continuous Positive Airway Pressure) machine was on the resident's nightstand. During an interview, on 6/1/2022 at 10:06 A.M., Resident 22 indicated that he brought his [CONDITION(S)] from home they fill it with water every day and he recently had it serviced, and the filters replaced. During the record review on 6/1/2022 at 3:07 P.M., there was no Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] A Care Plan, dated 5/12/2022, titled: I am at risk for altered sleep/respiratory function r/t Obstructive Sleep Apnea, with an intervention apply [CONDITION(S)]/[CONDITION(S)] as ordered. I am at risk for altered sleep/respiratory During an interview, on 6/1/2022 at 3:31 P.M., the Director of Nursing indicated that she does not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/1/2022 at 3:35 P.M., the policy was requested, and one was not provided prior to the exit of the survey. On 6/6/2022 at 10:18 A.M., the Infection Preventionist provided the policy titled, Skin Management Program, dated 8/14/2014, and indicated the policy was the one currently use by the facility. The policy indicated . I. A comprehensive head to toe assessment (inspection) will be completed by a licensed nurse upon admission/return, and at least weekly thereafter.H. Documentation: I. Routine daily and/or weekly skin assessments will be documented in the EMR on respective assessment (daily or weekly). II . In addition the wound nurse will follow up on all non-pressure wounds weekly and prn and document in the EMR on the Wound-non pressure assessment. III. Physician will make note of wound progress/regress and unavoidability if applicable at routine visits. Wound nurse will keep physician up to date with progress/regress as needed. IV. Non-wound skin alterations will be assessed and monitored by the licensed staff nurse 3.1-37(a) 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to provide preventative measures, including skin care and assessment, prior to the development of a pressure ulcer for a resident with a fractured right tibia and leg immobilizer which resulted in an unstageable pressure ulcer and increased pain. This affected one of three residents reviewed for pressure ulcers. (Resident #55) Finding includes: On 9-15-2014 at 1:18 P.M., Resident #55 was observed sitting in her wheelchair with her right leg in an immobilizer (a device for keeping a limb immobile). The resident's right leg was resting on a wooden board that extended from the wheelchair seat to the foot rest. During an interview at this time, Resident #55 indicated, . I have pain in my right leg.it started about a week ago.I think I am sitting in my wheelchair too much but there is not enough staff to help get me into the recliner. On 9-15-2014 at 2:20 P.M., Resident #55's record was reviewed. Resident #55 was admitted on [DATE]. [DIAGNOSES REDACTED]. The physician orders [REDACTED].#55 had been ordered [MEDICATION NAME] 5/325 mg (milligrams) 1 tablet PO (per oral) Q4H (every 4 hours) PRN (as needed) for moderate to severe pain. The MDS (Minimum Data Set-an assessment tool), dated 8-31-2014, indicated Resident #55 had a BIMS (Brief Interview for Mental Status) of 13/15, indicating cognitively intact. An Occurrence Initial Assessment, dated 9-5-2014 at 8 P.M., .Resident has sustained a 3cm x 3cm (centimeter) abrasion to right posterior calf draining scant amount of blood from the leg brace she wears to RLE (right lower extremity). Resident states she has some discomfort to the area. Applied [MEDICATION NAME] (a non-stick bandage) and ABD (gauze dressing) for support. On 9-7-2014, Resident #55's physician orders [REDACTED]. The pressure ulcer assessment, completed by the Wound Nurse, indicated a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough) pressure ulcer had developed on 9-9-2014, to the back of Resident #55's right calf. On 9-15-2014 at 2:45 P.M., during an observation with the DON (Director of Nursing), Resident #55's right calf showed a pressure ulcer which was irregular in shape, with greenish black tissue to the center of the ulceration. The surrounding tissue was pink and blood was noted on the dressing removed at that time. Swelling was noted to Resident #55's right knee and lower leg. During an interview at this time, the DON indicated, .that looks worse; I would call this an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the ulcer bed) wound at this time. During an interview on 9-15-2014 at 3:10 P.M., LPN #4 indicated, .I did the dressing change on Friday (9-12-2014).I didn't measure it.I don't document the assessment, I just sign it off on the TAR (Treatment Administration Record). During an interview on 9-15-2014 at 3:36 P.M., the Wound Nurse indicated, .I was told about the wound on the morning of 9-9-2014.the night nurse told me about it.it was found on 9-5-2014 and being documented as an abrasion but when I looked at it on 9-9-2014 it was a Stage II pressure ulcer. During an interview on 9-17-2014 at 9:51 A.M., Resident #55 indicated, .I told them that I had pain to my leg and they took off the immobilizer and found the sore.they do not take my immobilizer off every day. On 9-17-2014 at 1:22 P.M., Resident #55's care plan was reviewed. The care plan indicated, .Wound: Actual skin breakdown. Location: right posterior calf d/t (due to) use of immobilizer.Date initiated: 9/11/2014.Goals.Show reduction in size/stage of pressure ulcer.Have no drainage from pressure ulcer.Interventions.Nursing to assess area every shift (Date initiated: 9/15/2014).Monitor dressing site every shift for soiling and displacement (Date initiated: 9/16/2014).Therapy working with resident for positioning of immobilizer (Date initiated: 9/16/2014).Leg to be floated to avoid pressure to Right posterior calf (Date initiated: 9/16/2014).nursing staff in-serviced on proper placement of immobilizer (Date initiated: 9/16/2014).Provide with pressure reducing device to chair (Date initiated: 9/16/2014). During an interview on 9-19-2014 at 10:47 A.M., the DON indicated, .I requested that therapy do an in-service to show the staff how to remove the immobilizer and move her broken leg. There is no documentation to indicate this was done. The Pressure Ulcer Treatment policy was received on 9-16-2014 at 8:51 A.M. from the DON. The policy indicated .K. Continue to turn and reposition the resident regardless of the support system in place. Inspect the skin for additional damage each time turned. During an interview at this time, the DON indicated, .we (the facility) do not have a policy related to immobilizer's. 3.1-40(a)(1)

Based on record review and interview, the facility failed to identify verbal aggression and threats between residents as verbal abuse, thoroughly investigate the verbal abuse and report the abuse to the appropriate state agencies for 1 of 4 residents (Resident # 5) reviewed for abuse in a sample of 13. This practice of not identifying verbal altercations between residents as abuse and the need for reporting had the potential to affect all residents in the facility. The immediate jeopardy began on 2/13/11 when the facility failed to recognize the verbal aggression, threats, and use of intimidation by Resident # 5 toward Resident # 45 as abuse and failed to report the abuse to the appropriate authorities. The Administrator, Director of Nursing, and Corporate Administrator were notified of the immediate jeopardy at 10:43 A.M. on 7/8/11. The immediate jeopardy was removed on 7/12/11, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. The clinical record for Resident # 5, reviewed on 7/5/11 at 3:50 P.M., indicated [DIAGNOSES REDACTED]. During initial tour of the facility on 7/5/11 at 10:05 A.M., RN # 1 indicated Resident # 5 was alert and oriented and he was in a private room due to behaviors. Review of the Progress Notes indicated, "...2/12/11 11:50 (A.M.)...Staff overheard resident yell "move you idiot" in angry tone....2/13/11 19:53 (7:53 P.M.)...This resident has been very angry with res (resident) (Name) (# 45). Resident states "I dont (sic) have to be nice to that thief." Resident (Name) (# 45) has been affected by the statement. This nurse asked (Name) (# 5) if he tried to do anything to the other resident d/t (due to) peer accusing resident of trying to run him over. Resident got angry with this nurse. So this resident (sic) towards his room and wouldn't (sic) allow peer to go to his room....2/14/11 19:41 (7:41 P.M.) Resident was sitting at nurses station in middle of hallway when resident from (Room #) (# 45) came and asked for a pillow case. Mr. (Name) (# 5) told this resident to "shut the F... up....sorry but the guy is an idiot"....2/15/11 22:19 (10:19 P.M.) Has been sitting outside of doorway waiting for resident in (Room #) (# 45) to come out of room and tells him he is an "idiot". Yelled at staff this evening as they were taking care of roommate and told them to "get the f... out of here!" Staff stated they needed to help roommate get into bed. He stated "I don't care get the h... out of here!" Has been purposely sitting in middle of hallway knowing that roommate in (Room #) (# 45) is scared of him and when he tries to go by he yells at him and calls him an idiot.... 2/16/11 16:35 (4:35 P.M.) Resident witnessed by this nurse verbally harassing resident in (Room #) (# 45). Resident making remarks such as "he is a pain in the a.., and he is an idiot. I am going to lay him out if he comes by my room."...2/16/11 16:42 (4:42 P.M.) Res sitting in w/c in hall by nsg (nursing) station when another male res walked near him, stopped and asked "how are you today?" Res replied gruffly "Get away from me!" This nurse told res "(Name), why are you being so rude to him, he was being nice to you." (Name) replied gruffly again "I don't like him that's why, he's a thief." Other res replied "that's not so." Res then replied "Yes you are!"....2/17/11 21:40 (9:41 P.M.) This nurse witnessed this resident coming towards resident (Name) (# 45) in a threatening way with facial frown and glaring at him. (Name) (# 45) turned away to avoid confrontation. Later in evening this resident was going down 300 hallway following (Name) (# 45)....3/4/11 20:37 (8:37 P.M.) CNA (Name) observed this resident attempting to hit fell ow resident (Name) (# 45). (Name) (# 45) was going to his room when looked at (Name) (# 5) and said "Dont (sic) let him come to my room and wake me up in the middle of the night." Then (Name) (# 5) came toward (Name) (# 45) in attempt to hit (Name) (# 45)....4/26/11 14:11 (2:11 P.M.) This morning a resident was coughing in the MDR at breakfast and this resident told peer to shut up....4/27/11 14:20 (2:20 P.M.) This am this resident voiced that he would like to shoot another resident....5/22/11 10:01 (A.M.) Housekeeping staff person working in hall, witnessed resident returning to room after being in MDR for breakfast meal, propelling w/c in 200 hall, came upon a female resident ambulating with a front wheeled walker and in a loud gruff tone stated "get moving." "I know you're old but geez, get out of my f...ing way!"... Interview with the Director of Nursing (DON) and Administrator on 7/7/11 at 10:00 A.M., the DON indicated the verbal issues with Resident # 5 have not been investigated or reported because that's who he is, when you have this many people, not everyone will get along. A facility policy titled "Abuse Prohibition, Reporting, and Investigation", dated 8/23/10, indicated, "...Abuse-Physical, sexual, verbal and/or mental (known or alleged) abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish....This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, pain and/or mental anguish. Physical Abuse-includes, but not limited to, hitting, slapping, pinching and corporal punishment. Resident to resident abuse that results in injury. Resident to resident abuse without injury...Verbal Abuse-is defined as the use of oral, written and/or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident;...belittling residents....Mental Abuse-includes, but not limited to, humiliation, harassment,...Violations of the aforementioned will be reported to the Long Term Care Division of the Indiana State Department of Health and other officials in accordance with state law through established procedures...The Administrator, or designees, shall initiate and direct the investigation immediately, and within 5 days a report of this investigation must be forwarded to the Long Term Care Division of the Indiana State Department of Health....Residents will be protected from abuse through the provisions of this policy..." The immediate jeopardy that began on 2/13/11 was removed on 7/12/11 when through observations, and interviews, it was determined that the facility had implemented the plan of action to remove the immediacy of the problem, but the noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to continue inservicing staff on recognizing verbal altercations between residents as abuse and how to report the abuse. 3.1-28(c)

Based on record review and interview, the facility failed to recognize verbal altercations, intimidation and threats between residents as abuse, failed to thoroughly investigate the verbal altercations and report to the appropriate state agencies in accordance with facility policies and procedures. This practice actually affected for 1 of 4 residents (Resident # 5) reviewed for abuse in a sample of 13 had the potential to affect all residents in the facility. The immediate jeopardy began on 2/13/11 when the facility failed to recognize the verbal aggression, threats, and use of intimidation by Resident # 5 toward Resident # 45 as abuse and failed to report the abuse to the appropriate authorities according to their policies. The Administrator, Director of Nursing, and Corporate Administrator were notified of the immediate jeopardy at 10:43 A.M. on 7/8/11. The immediate jeopardy was removed on 7/12/11, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. The clinical record for Resident # 5, reviewed on 7/5/11 at 3:50 P.M., indicated [DIAGNOSES REDACTED]. During initial tour of the facility on 7/5/11 at 10:05 A.M., RN # 1 indicated Resident # 5 was alert and oriented and he was in a private room due to behaviors. Review of the Progress Notes indicated, "...2/12/11 11:50 (A.M.)...Staff overheard resident yell "move you idiot" in angry tone....2/13/11 19:53 (7:53 P.M.)...This resident has been very angry with res (resident) (Name) (# 45). Resident states "I dont (sic) have to be nice to that thief." Resident (Name) (# 45) has been affected by the statement. This nurse asked (Name) (# 5) if he tried to do anything to the other resident d/t (due to) peer accusing resident of trying to run him over. Resident got angry with this nurse. So this resident (sic) towards his room and wouldn't (sic) allow peer to go to his room....2/14/11 19:41 (7:41 P.M.) Resident was sitting at nurses station in middle of hallway when resident from (Room #) (# 45) came and asked for a pillow case. Mr. (Name) (# 5) told this resident to "shut the F... up....sorry but the guy is an idiot"....2/15/11 22:19 (10:19 P.M.) Has been sitting outside of doorway waiting for resident in (Room #) (# 45) to come out of room and tells him he is an "idiot". Yelled at staff this evening as they were taking care of roommate and told them to "get the f... out of here!" Staff stated they needed to help roommate get into bed. He stated "I don't care get the h... out of here!" Has been purposely sitting in middle of hallway knowing that roommate in (Room #) (# 45) is scared of him and when he tries to go by he yells at him and calls him an idiot.... 2/16/11 16:35 (4:35 P.M.) Resident witnessed by this nurse verbally harassing resident in (Room #) (# 45). Resident making remarks such as "he is a pain in the a.., and he is an idiot. I am going to lay him out if he comes by my room."...2/16/11 16:42 (4:42 P.M.) Res sitting in w/c in hall by nsg (nursing) station when another male res walked near him, stopped and asked "how are you today?" Res replied gruffly "Get away from me!" This nurse told res "(Name), why are you being so rude to him, he was being nice to you." (Name) replied gruffly again "I don't like him that's why, he's a thief." Other res replied "that's not so." Res then replied "Yes you are!"....2/17/11 21:40 (9:41 P.M.) This nurse witnessed this resident coming towards resident (Name) (# 45) in a threatening way with facial frown and glaring at him. (Name) (# 45) turned away to avoid confrontation. Later in evening this resident was going down 300 hallway following (Name) (# 45)....3/4/11 20:37 (8:37 P.M.) CNA (Name) observed this resident attempting to hit fell ow resident (Name) (# 45). (Name) (# 45) was going to his room when looked at (Name) (# 5) and said "Dont (sic) let him come to my room and wake me up in the middle of the night." Then (Name) (# 5) came toward (Name) (# 45) in attempt to hit (Name) (# 45)....4/26/11 14:11 (2:11 P.M.) This morning a resident was coughing in the MDR at breakfast and this resident told peer to shut up....4/27/11 14:20 (2:20 P.M.) This am this resident voiced that he would like to shoot another resident....5/22/11 10:01 (A.M.) Housekeeping staff person working in hall, witnessed resident returning to room after being in MDR for breakfast meal, propelling w/c in 200 hall, came upon a female resident ambulating with a front wheeled walker and in a loud gruff tone stated "get moving." "I know you're old but geez, get out of my f...ing way!"... Interview with the Director of Nursing (DON) and Administrator on 7/7/11 at 10:00 A.M., the DON indicated the verbal issues with Resident # 5 have not been investigated or reported because that's who he is, when you have this many people, not everyone will get along. A facility policy titled "Abuse Prohibition, Reporting, and Investigation", dated 8/23/10, indicated, "... It is the policy of Miller's Health Systems that all residents have the right to be free from verbal, sexual, physical and mental abuse,.... ...Abuse-Physical, sexual, verbal and/or mental (known or alleged) abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish....This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, pain and/or mental anguish. Physical Abuse-includes, but not limited to, hitting, slapping, pinching and corporal punishment. Resident to resident abuse that results in injury. Resident to resident abuse without injury...Verbal Abuse-is defined as the use of oral, written and/or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident;...belittling residents....Mental Abuse-includes, but not limited to, humiliation, harassment,...Violations of the aforementioned will be reported to the Long Term Care Division of the Indiana State Department of Health and other officials in accordance with state law through established procedures...The Administrator, or designees, shall initiate and direct the investigation immediately, and within 5 days a report of this investigation must be forwarded to the Long Term Care Division of the Indiana State Department of Health....Residents will be protected from abuse through the provisions of this policy..." The immediate jeopardy that began on 2/13/11 was removed on 7/12/11 when through observations, and interviews, it was determined that the facility had implemented the plan of action to remove the immediacy of the problem, but the noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to continue inservicing staff on recognizing verbal altercations between residents as abuse and how to report the abuse. 3.1-28(a)

A. Based on observation, interview, and record review, the facility failed to ensure a resident was protected from numerous occasions of verbal abuse by Resident # 5 along with threats of physical harm to Resident # 45 and acts of intimidation leaving Resident # 45 expressing fear of Resident # 5 for 1 of 4 residents reviewed for abuse in a sample of 13. The immediate jeopardy began on [DATE] when the facility failed to properly supervise an alert and oriented resident from verbally abusing, threatening physical harm, and using intimidation toward a severely demented resident. The Administrator, Director of Nursing, and Corporate Administrator were notified of the immediate jeopardy at 10:43 A.M. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. B. Based on record review and interview, the facility failed to ensure a resident (Resident # 39) was protected from verbal abuse from a staff member for 1 of 4 residents reviewed for abuse in a sample of 13. Findings include: A.1. The clinical record for Resident # 5, reviewed on [DATE] at 3:50 P.M., indicated [DIAGNOSES REDACTED]. During initial tour of the facility on [DATE] at 10:05 A.M., RN # 1 indicated Resident # 5 was alert and oriented and he was in a private room due to behaviors. Review of the Progress Notes indicated, "..XXX[DATE] 11:50 (A.M.)...Staff overheard resident yell "move you idiot" in angry tone. Staff responded to area of call to witness resident propelling his w/c (wheelchair) on left side of hall with therapy staff next to him and peer walking on right side of hall toward him...XXX[DATE] 19:53 (7:53 P.M.)...This resident has been very angry with res (resident) (Name) (# 45). Resident states "I dont (sic) have to be nice to that thief." Resident (Name) (# 45) has been affected by the statement. This nurse asked (Name) (# 5) if he tried to do anything to the other resident d/t (due to) peer accusing resident of trying to run him over. Resident got angry with this nurse. So this resident (sic) towards his room and wouldn't (sic) allow peer to go to his room. Resident sent peer back towards the nurses station. Nurses intervened and help (sic) resident (Name) (# 45) back to his room. Will continue to do 15 minute checks on resident until end of this shift...XXX[DATE] 10:44 (A.M.)...Social Services and this nurse approached resident to speak with him about his mood and verbalization toward peer. Informed resident that it is unacceptable for alert resident such as himself to speak harshly or redirect another peer and that appropriate action would be to seek staff to intervene with peer. Resident voiced understanding and stated he would call staff as needed...XXX[DATE] 19:41 (7:41 P.M.) Resident was sitting at nurses station in middle of hallway when resident from (Room #) (# 45) came and asked for a pillow case. Mr. (Name) (# 5) told this resident to "shut the F... up". Was told do not talk to other residents like that it is rude and Mr. (Name) (# 5) said "sorry but the guy is an idiot". Was told if he had nothing nice to say then maybe it would be a good time for him to go back to his room and watch tv and he said "no I promise I will be good"...XXX[DATE] 22:19 (10:19 P.M.) Has been sitting outside of doorway waiting for resident in (Room #) (# 45) to come out of room and tells him he is an "idiot". Yelled at staff this evening as they were taking care of roommate and told them to "get the f... out of here!" Staff stated they needed to help roommate get into bed. He stated "I don't care get the h... out of here!" Has been purposely sitting in middle of hallway knowing that roommate in (Room #) (# 45) is scared of him and when he tries to go by he yells at him and calls him an idiot. (Name) (# 5) was asked to go to his room or down another hall and to watch his language in speaking to other residents and staff. He stated he was sorry and would not do it again and then did it repeatedly throughout night...XXX[DATE] 15:35 (3:35 P.M.) Dr. (Name) informed of res' (residents) behavior's. New order received to increase [MEDICATION NAME] (medication used for depression) from 10 mg (milligrams) daily to 20 mg po (orally) daily. Dr. also stated to use the [MEDICATION NAME] (medication used for anxiety) prn (as needed) if agitation. Sister (Name) notified of new orders and stated "I know he has to have something and maybe this will help."..XXX[DATE] 21:40 (9:41 P.M.) This nurse witnessed this resident coming towards resident (Name) (# 45) in a threatening way with facial frown and glaring at him. (Name) (# 45) turned away to avoid confrontation. Later in evening this resident was going down 300 hallway following (Name) (# 45). He was redirected and PRN [MEDICATION NAME] given per order. No further problems...XXX[DATE] 20:37 (8:37 P.M.) CNA (Name) observed this resident attempting to hit fell ow resident (Name) (# 45). (Name) (# 45) was going to his room when looked at (Name) (# 5) and said "Dont (sic) let him come to my room and wake me up in the middle of the night." Then (Name) (# 5) came toward (Name) (# 45) in attempt to hit (Name) (# 45). (Name) (CNA) intervened and separated the two and redirected (Name) (# 5) to his room. (Name) (# 5) then stated, "(Name) (# 45) is calling me a homosexual." (Name) went to his room...XXX[DATE] 4:24 (A.M.) Resident remained in bed on this shift. No behaviors noted at this time. Will continue to monitor. [DATE] 10:44 (A.M.)...Health Care Plan meeting note...Social Service talked about what resident to resident abuse is, and what happens if abuse accures (sic). Explained how some of the residents here do not know what they are doing, and they have rights, and are not to be yelled at ever. Informed him to get staff, and they will handle all situations. Voiced he understood...XXX[DATE] 8:10 (A.M.) Resident in MDR...After he finished breakfast he propelled himself with w/c to nurses med cart...At that time an ambulatory male resident was walking towards the med cart from the opposite direction. (Name) (# 5) became loud and told the other male to "Move", when the other resident did not move (Name) (# 5) attempted to roll his w/c faster towards him. Two staff members were needed to hold his w/c back in order for him to be prevented from reaching the other resident. As this was happening (Name) (# 5) stated, "Come on old man I'm not afraid of you, bring it" The other male resident then struck (Name) (# 5) in the left cheek. The two residents were separated, however (Name) (# 5) turned around 3 more times yelling "I'll get you, you son of a b...." Staff verbally attempted to deescalate (Name) (# 5) however he continued yelling for approximately 3 more minutes at which time (Name) (# 5) let staff assist him to his room....When asked if he was all right (Name) (# 5) stated, "Of course I'm fine that old man can't hurt me."..XXX[DATE] 9:20 (A.M.)...Physician order...(Lab work) ordered for increased agitation, verbal outbursts to staff and peers. 15 minute safety checks started...XXX[DATE] 10:28 (A.M.)...We then talked about going to (Hospital), and explained to him it is now (Name). Explained they are the experts in Psych med and anger management. After talking with him for awhile, he agreed to go...XXX[DATE] 13:50 (1:50 P.M.) (Name) from (Hospital) called and said (Name) (# 5) did not met (sic) criteria for in-house admission...XXX[DATE] 11:30 (A.M.)...Talked to (Name) (# 5) about services available from (Hospital) and he agreed for psych services...XXX[DATE] 13:17 (1:17 P.M.) Patient voiced agreement to having referral to (Hospital) related to [MEDICAL CONDITION] and anxiety. Physician order [REDACTED]. Mood pleasant this day and up to meals via w/c...XXX[DATE] 18:06 (6:06 P.M.) (Name) from psych services in for follow up. New Order for [MEDICATION NAME] (medication used for depression) 1 mg (milligram) po (orally) every AM (morning)...XXX[DATE] 14:20 (2:20 P.M.) This am this resident voiced that he would like to shoot another resident. When this nurse redirected him resident stopped behavior. No further behaviors noted for the rest of the day on ,[DATE] shift...XXX[DATE] 17:19 (5:19 P.M.) Dr. (Name) informed of new order per psych services for [MEDICATION NAME] as adjunctive therapy for depression...XXX[DATE] 11:22 (A.M.) Visited (Name) in his room....Asked how things were going for him. He said ok. We talked a little about him having psych services now. He said, "What ever" (sic) Was calm and did not talk in angry tone. Told him if he ever needed to talk. We would be glad to talk with him...XXX[DATE] 13:26 (1:26 P.M.) Dr. (Name) in for routine exam....Discussed mood and episode of verbal agitation with patient in joking and stating "not a big deal". Staff has noted that patient has spent more time outside of room often joking with staff in sarcastic manner then laughing..XXX[DATE] 9:12 (A.M.) Health Care Plan meeting note...New [DIAGNOSES REDACTED]. Can become agitation. Is receiving psych. services, due to verbal aggression...XXX[DATE] 10:28 (A.M.) Resident was in hallway near nurses station and couple of staff members asked him to please go to his room and pull up his pants. Staff offered to assist him with him refusing. His pants were half way on and his hips were exposed. Resident states all of the staff member can go to hell. Informed Social Services of resident behavior and, (Name) spoke with him...XXX[DATE] 15:42 (3:42 P.M.) Dr. (Name) in for psych services follow up....order noted for increase in [MEDICATION NAME] to 2.5 mg/day." Review of the "Facility-Behavior and [MEDICAL CONDITION] Monthly Review" indicated, "..XXX[DATE][MEDICATION NAME] 20 mg daily for depression increased from 10 mg on [DATE], it had been started [DATE]. [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg q (every) 4 hr (hours) as needed agitation. Behaviors being monitored: Verbal Agitation. Frequency of behavioral issues...Verbal agitation 1 episoded (sic) in November to 1 episode in December to 1 in January. Evaluation of interventions/changes to care plan. He moved to 200 hall as his skilled time ended and continues to need therapy. He has displayed anger since move. Doctor reviewed him and increased his [MEDICATION NAME] with recent visit. He continues to get angry at times and his is unrealistic thinking he will be able to get prostesis (sic) and start walking without using stump shrinker or therapy. Started medications related to not wanting to participate and make effort in his recovery. Has showed small improvements. Mood has been a little better and a little more cooperative...XXX[DATE][MEDICATION NAME] 20 mg daily for depression increased from 10 mg on [DATE], it had been started [DATE]. [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg q 4 hr as needed for agitation....Verbal Agitation....Verbal agitation 1 episoded (sic) in November to 1 episode in December to 1 in January to 35 in February...XXX[DATE][MEDICATION NAME] 20 mg daily for depression increased from 10 mg on [DATE], it had been started [DATE]. [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg q 4 hr as needed for agitation. [MEDICATION NAME] 1 mg daily for adjunctive therapy for depression started [DATE]....Verbal agitation...10 in March. Verbally aggressive 5 episodes in March. Verbally innappropriate (sic) 5 episodes in April. Aggressive behavior 6 episodes in April....Wording on behavior log was changed. Will refine the wording for him. His behaviors are usually verbal agitation however often he is sarcastic and this is difficult for different staff to evaluate her (sic) statement. He agreed for psych monitoring and ability (sic) was started with [DATE] visit. He continues to get angry at times..." The "Social Service Assessment", dated [DATE] and [DATE] respectively, indicated, "...interview completed [DATE]...(Name) mood varies over the course of the day. He is very short-tempered, and will yell at peers if they are in his way. This has improved some with the addition of [MEDICATION NAME]. Is behavior tracked for aggressive behavior towards peers or staff, and verbally inappropriate. Is monitored by psych services for medication management....interview completed [DATE]...Recently his yelling at staff has increased. (Name #5) does not like to pull his pants up....He wears them very low, and at times his thighs, and buttocks can be seen. Explained to (Name #5) how this is inappropriate. Voices he understands, but does not always comply. When staff remind him, he becomes verbally aggressive. Is followed by Psych services and has a [DIAGNOSES REDACTED]. and [MEDICATION NAME] 1 mg. Has PRN [MEDICATION NAME] 0.5 mg. for agitation." A care plan, initiated [DATE], revised [DATE], indicated, "...Feeling of depression and agitation. Reseived (sic) new order for [MEDICATION NAME] on ,[DATE] for [DIAGNOSES REDACTED]. Increase in [MEDICATION NAME] dose [DATE] per Dr. (Name)...Resident will have no s/s (signs/symptoms) of mood decline, aggressive behavior or be verbally inappropriate towards staff....Interventions...Give medication as per physician orders. Date initiated [DATE]...Monitor mental status/mood state changes as needed..XXX[DATE]...Observe and report any changes in mental status..XXX[DATE]...Offer activities of which resident has shown interest..XXX[DATE]...psych services as order per physician relted (sic) to noted episodes of difficulty tolerating other, adjustment disorder..XXX[DATE]...Offer 1:1 with reassurances. Redirect as needed and remind res is inappropriate if shows aggression towards staff, or is verbally inappropriate..XXX[DATE]..." Review of a "(Name) Center Initial NP (new patient) Psychiatric Visit", dated [DATE], indicated, " (age) male assessed for [MEDICAL CONDITION] medication needs. diagnosed with [REDACTED]. Antagonizing an elderly resident with dementia....c/o (complaints of) feeling irritated by the behavior of residents that "aren't right in the head", realizes he doesn't handle these feelings as well as he should...oriented to situation....[MEDICAL CONDITION] Disorder with depressed [MEDICATION NAME] 1 mg for adjunctive tx (treatment) for depressive sx's (symptoms) - increased irritation & anger...Cont. (continue) [MEDICATION NAME] 20 mg po qd (once daily)..." A "Psychiatric Progress Note", dated [DATE], indicated, "...The staff was noting that he agitates other people on purpose and that he seems to be fairly comfortable (sic) the staff, but he is given to rather unkind disparagement of the older residents. Of course, then most of them are older and many are demented. The N.P. (Nurse Practitioner) began to treat him with [MEDICATION NAME] and then added a supplement of 1 mg of [MEDICATION NAME], all which seems to have modified somewhat his aggressive behavior. About that, "oh I do get into it once and awhile", as though this had been a lifetime experience of his....There is still a bit of depression, but based on what I was told he is better on that score than he had been. There are no impulses for self harm....There are no evidence of any psychotic or delusional thinking. His treatment of [REDACTED].[MEDICAL CONDITION] Disorder...Adjustment Disorder with Depressed Mood...treatment plan: [REDACTED]." Review of a History of Room Locations provided by the facility and clinical record review indicated Resident # 5 was admitted to the facility on [DATE] to the 100 unit to a room with no roommate, the resident was re-admitted to the facility on [DATE] following a hospital stay to a room with no roommate on the 100 hall. On [DATE], Resident # 5 was moved to the 200 hall in a room with a roommate and across the hall from Resident # 45. On [DATE], Resident # 45 was moved to a room on the 300 hall. On [DATE], Resident # 5 was moved from the semi private room to a private room. Review of the February 2011, MAR (Medication Administration Record) lacked documentation of any PRN [MEDICATION NAME] given. A facility form titled "Resident Control Medication Record Sheet", undated, indicated, Resident # 5 received PRN [MEDICATION NAME] on [DATE] 8:00 P.M. - one tablet; [DATE] 8:00 P.M. - one tablet; [DATE] 8:00 P.M. - one tablet. Review of an Indiana State Department of Health reportable, indicated, "...incident [DATE]...Verbal altercation followed by Resident (Name) (#45) hitting Resident (Name) (# 5) on L (left cheek)...." Observations of Resident # 5 include: [DATE] 12:20 P.M. Resident eating lunch in Main Dining Room. [DATE] 1:20 P.M. Resident sitting in wheelchair directly in front of North entrance. Staff members had to ask Resident # 5 to move twice before he eventually agreed to move to let a visitor out the door. [DATE] 1:44 P.M. Resident # 5 in 300 hall TV lounge which is located on the opposite end of the hall from his room. Resident # 45's room is located approximately 20 feet from the 300 hall TV lounge. During interview with the DON (Director of Nursing) on [DATE] at 5:40 P.M., she indicated that "(name of Resident # 5) is just (name of Resident # 5)." He can be very gruff at times. She further indicated the addition of the [MEDICATION NAME] has greatly improved Resident # 5's mood and behaviors. We now see more joking and less meanness as previously noted. Interview with the DON on [DATE] at 2:50 P.M., she indicated she was not aware of the statement recorded in the [DATE] nursing notes of Resident # 5's comment made about wanting to shoot another resident. Social Service Director during interview on [DATE] at 3:20 P.M., indicated she doesn't remember hearing about Resident # 5 threatening to shoot another resident. She stated she was unsure how to interpret the information in the chart. She further indicated Resident # 5 was very much upsetting Resident # 45 and that is why Resident # 45 was moved across the building. Interview with the DON and Administrator on [DATE] at 10:00 A.M., they indicated Resident # 5's remarks were mostly verbal with no harm. They further stated the residents were moved and Resident # 5 was moved to a private room due to his intolerance. The DON further indicated she feels Resident # 5's language is appropriate for his age group because he is a younger resident. She also indicated the verbal issues with Resident # 5 have not been reported because that's who he is, when you have this many people, not everyone will get along. She indicated when Resident # 5 was waiting in the hall outside Resident # 45's room that this was resolved because staff separated them. She further indicated a nurse would probably not document short term 15 minute checks and she is unsure if these were put in place for safety reasons or to reassure Resident # 45. During interview with Social Service Director on [DATE] at 10:51 A.M., she indicated they attempted to seek inpatient treatment for [REDACTED].# 5 was appropriate for inpatient admission. She further indicated when Resident # 5 was found waiting in the hall for Resident # 45, the staff would attempt to move Resident # 5 to his room. She further indicated Resident # 45 tried to stay away from Resident # 5. On [DATE] at 1:20 P.M., LPN # 3 indicated she was present when Resident # 5 made the comment that he wanted to shoot another resident and that the statement was directed toward Resident # 45. She does not remember whether Resident # 45 was within hearing distance or not. She stated Resident # 5 was upset about being called a thief. She further indicated that Resident # 5 chased Resident # 45 down the hall and Resident # 45 acted afraid of Resident # 5. She feels that Resident # 5 would hit someone. She indicated she took the shooting statement very seriously and she reported it to the ADON (Assistant Director of Nursing). Interview with the ADON on [DATE] at 1:44 P.M., she indicated the shooting incident was not reported to her. She further indicated if it had been reported to her, she would have taken it seriously and involved the Administrator, DON, and Social Services. She also indicated that she would consider Resident # 5's outbursts and harsh words verbal abuse. During interview on [DATE] at 2:05 P.M., Resident # 5 indicated he did not like being in the facility and he has had issues with the staff and other residents. He further indicated there are times when residents have made him mad, he felt this was normal. Resident # 5 became agitated very quickly when questioned how he felt about staff and residents. On [DATE] at 2:25 P.M., Resident # 5's family member indicated Resident # 5 has been very grouchy lately. She further indicated he seemed to have a problem with Resident # 45 and he yells at this resident because he walks around the entire facility looking for his deceased wife. She also indicated Resident # 5 went down to the 300 hall TV lounge a couple times by himself since being moved into his last room and also when family comes they take him down there. The 300 hall TV lounge is located approximately 20 feet from Resident # 45's room. Interview on [DATE] at 9:22 A.M., with the Social Service Director, she indicated Resident # 5 was not willing to sign up for psychiatric services in February so the Medical Doctor started him on medications. She further indicated if the nurses initiate 15 minute checks on a resident, these would be reported during morning meetings. She indicated it is hard to monitor mobile, confused residents. During interview on [DATE] at 12:00 P.M., the Administrator indicated that Resident # 5 had not caused any physical harm to anyone ever. The DON on [DATE] at 12:00 P.M., indicated the nursing notes related to some incidents probably didn't say everything they should have but she is sure if a nurse witnessed any altercations between residents, they would have taken care of it even if it was not charted that way. Interview on [DATE] at 1:15 P.M., RN # 4 indicated Resident # 5 and Resident # 45's rooms were across from each other in the beginning so the nurses would just separate Resident # 45 from Resident # 5's vicinity. She further indicated if Resident # 5 saw Resident # 45 in the hallway, he would probably pick on him. She indicated she witnessed Resident # 45 "side step" around Resident # 5 in the hallway to avoid getting close. She stated if Resident # 5 was waiting in the hallway outside of Resident # 45's room, she would take her med cart into the hall and stand close. She further indicated when Resident # 5 was waiting outside of Resident # 45's room, he was redirected, but continued to do this throughout the night for a couple more times. RN # 4 indicated she feels Resident # 5 is an angry man and becomes angry very easily. She indicated he's very gruff and could have flown off the hook easily especially when he first came because he was more hot tempered. She also indicated for a little while Resident # 5 would seek Resident # 45 out. After Resident # 5 and Resident # 45 were moved to different halls, it helped with the behaviors of Resident # 5 a lot. On [DATE] at 2:35 P.M., RN # 1 indicated the [DATE] at 4:35 P.M., episode where Resident # 5 talks gruffly involved Resident # 45. She further indicated the staff just tried to keep Resident # 5 and Resident # 45 away from each other. During interview with the DON on [DATE] at 2:46 P.M., she indicated she could not recall which resident was involved in the [DATE] with Resident # 5. A facility policy titled "Abuse Prohibition, Reporting, and Investigation," dated [DATE], indicated, "...It is the policy of Miller's Health Systems that all residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion....has policies and procedures in place that ensures that all alleged violations...neglect or abuse...are reported immediately to the Administrator of the facility and to other officials in accordance with State law through established procedures.... Abuse...verbal...(known or alleged) abuse is defined as the willful infliction of injury...intimidation...mental anguish....This presumes that instances of abuse of all residents...Verbal Abuse is defined as the use of oral...gestured language that willfully includes disparaging and derogatory terms to residents...regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include...threats of harm, saying things to frighten a resident...Resident to Resident...verbal threats of harm...It is the responsibility of every employee of Miller's Health Systems to not only report abuse situations, but also suspicion of abuse and unusual observations and circumstances, to their immediate supervisor....All reports of alleged abuse/abuse and all unusual occurrences, must be reported to the Administrator immediately, and to the resident's representative...as soon as feasibly possible, but no later than within 24 hours of the reporting or discovery of the incident....Residents will be protected from abuse through the provisions of this policy, the procedure...." A.2. The clinical record for Resident #45 was reviewed on [DATE] at 11:10 a.m. Resident #45 was admitted to facility on [DATE]. Resident #45 was discharged home with family and then re-admitted [DATE]. Resident #45's [DIAGNOSES REDACTED]. A "Progress Note" under "General Note," dated [DATE] at 7:48 p.m., stated, "This resident came up to nurses station and stated to this nurse "That man is trying to strike me" as resident is pointing to res (Name) Resident #5. Asked this resident what happened and resident states that man tried to run me over. will (sic) continue doing checks on this resident every 15 minutes to make sure he is safe til (sic) end of this shift." A late entry "Progress Note" under "General Note" dated [DATE] at 10:15 a.m., entered on [DATE] at 10:19 a.m,. by the Social Service Director, stated, "Spoke with (Name) Resident #45 several times while he was sitting in administrative lounge this week. He indicates frustration with another resident (Resident #5) that has move (sic) onto the 200 hall. He indicated he tries to stay away from him. Nursing has indicated he does not ambulate on the 200 hall as much as he did prior weeks...." A "Progress Note" under "General Note," dated [DATE] at 4:53 p.m., stated, "(Name) Resident #45 was standing in hall by nsg (nursing) station, walked over towards another male res (Resident #5) who was in his w/c (wheelchair), stopped and asked "how are you today?" Res replied gruffly "Get away from me!" This nurse told the other res "Why are you being so rude to him, he was being nice to you." Other res replied gruffly again "I don't like him that's why, he's a thief." (Name) Resident #45 res (sic) replied "that's not so." Res then replied "Yes you are!" This nurse reassured (Name) Resident #45 saying "we know it's not true, (sic) as (Name) Resident #45 was becoming visibly upset." (sic) (Name) Resident #45 told this nurse, "I find my hands wanting to make a fist when I hear something like that." Reassured that staff knows this is not true and to try to disregard when spoken to in that manner. Other res moved to a different area away from (Name) Resident #45, who calmed easily with 1:1." A "Progress Note" under "General Note," dated [DATE] at 9:28 a.m., stated, "Called (Name) Resident #45's son and put a message on his answering machine about the need for room change. Requested he call facility." On the "Census List" provided on [DATE] at 10:00 a.m., it was indicated that Resident #45 moved rooms onto a different hall on [DATE]. A "Progress Note" under "Behavior Note," dated [DATE] at 8:10 a.m., stated, "Resident ate breakfast in MDR (Main Dining Room) this am, after breakfast resident was ambulating back and forth from MDR to front lobby. While ambulating back towards MDR he was standing next to a med (medication) cart when another male resident in a w/c (wheelchair) approached him and told him to "Move". (Name) Resident #45 stated "No I'm not moving, (Resident #5) I'm not going anywhere" The other male resident attempted to roll up to (Name) Resident #45, however 2 staff members intervened and held his w/c back. The other male resident continued to yell, "Come on old man, I'm not afraid of you, bring it" At that time (Name) Resident #45 took his right had (sic) and struck the other resident in (sic) his left cheek" (sic) The two residents were immediately separated. Resident had no s/s (signs and/or symptoms) of injury to his right hand and quickly deescalated once the other resident was out of sight. Within 10 minutes of the above resident was sleeping on a couch in the front lobby." A "Progress Note" under "General Note," dated [DATE] at 7:48 p.m., stated, "...Has spent a lot of time at the end of 300 hall sitting on the couch and reading. The form "Assessment for New Behaviors 7 Day Observation Check List," dated [DATE], stated, "...Part II...What activity(s) most often precipitates the behavioral symptoms? antagonizing statement by peer...Yes...Feels threatened by other residents? Yes...." The immediate jeopardy that began on [DATE] was removed on [DATE] when through observations, and interviews, it was determined that the facility had implemented the plan of action to remove the immediacy of the problem, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to continue to inservice staff on how to recognize verbal abuse and protect residents from being abused and needed to monitor or re-assess residents for verbal aggression towards other residents. B. 1. During an interview with the Administrator on [DATE] at 9:00 a.m., he indicated an abuse incident involving a staff member abusing a resident had been reported to ISDH (Indiana State Department of Health). The Administrator indicated the staff member had been terminated following the investigation. He further indicated the staff member was identified as LPN # 5, the resident was identified as Resident # 39. Review of an Abuse Investigation report on [DATE] at 11:00 a.m., indicated the date of the incident was [DATE] at 7:30 - 8:00 p.m. The incident form indicated the following: "Description of Allegation: Rec'd (received) call approx (approximately) 9:15 P (p.m.) from ADON (Assistant Director of Nursing) informing me that LPN # 6 had called her at approx 8 -8:30 P "just got done talking to her" with report that (LPN # 5) was witnessed yelling at resident "swore" put her hands on her when she was standing...Investigation of nurses action- nurse off until compl

Based on observations, interviews, and record review, the facility failed to ensure a resident (Resident # 5) with verbal and physical behaviors was supervised close enough to ensure other residents were not threatened by this resident and failed to ensure a resident (Resident # 45) a safe environment free of hazards by not ensuring a wanderguard alarm was on each door in the facility to protect exit seeking residents. This action resulted in Resident #45 eloping from the building through a dining room door and wandering through a field, in extreme heat, before staff became aware of the elopement. Resident #45 then wandered to a busy street and attempted to cross. This deficient practice effected 2 of 2 residents reviewed for supervision in a sample of 13. The immediate jeopardy began on 2/13/11 when the facility failed to properly supervise an alert and oriented resident from verbally abusing, threatening physical harm, and using intimidation toward a severely demented resident. The Administrator, Director of Nursing, and Corporate Administrator were notified of the immediate jeopardy at 10:43 A.M. on 7/8/11. The immediate jeopardy was removed on 7/12/11, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. The clinical record for Resident # 5, reviewed on 7/5/11 at 3:50 P.M., indicated [DIAGNOSES REDACTED]. During initial tour of the facility on 7/5/11 at 10:05 A.M., RN # 1 indicated Resident # 5 was alert and oriented and he was in a private room due to behaviors. Review of the Progress Notes indicated, "...2/13/11 19:53 (7:53 P.M.)...This resident has been very angry with res (resident) (Name) (# 45). Resident states "I dont (sic) have to be nice to that thief." Resident (Name) (# 45) has been affected by the statement. This nurse asked (Name) (# 5) if he tried to do anything to the other resident d/t (due to) peer accusing resident of trying to run him over. Resident got angry with this nurse. So this resident (sic) towards his room and wouldn't (sic) allow peer to go to his room. Resident sent peer back towards the nurses station. Nurses intervened and help (sic) resident (Name) (# 45) back to his room. Will continue to do 15 minute checks on resident until end of this shift....2/14/11 19:41 (7:41 P.M.) Resident was sitting at nurses station in middle of hallway when resident from (Room #) (# 45) came and asked for a pillow case. Mr. (Name) (# 5) told this resident to "shut the F... up". Was told do not talk to other residents like that it is rude and Mr. (Name) (# 5) said "sorry but the guy is an idiot". Was told if he had nothing nice to say then maybe it would be a good time for him to go back to his room and watch tv and he said "no I promise I will be good"....2/15/11 22:19 (10:19 P.M.) Has been sitting outside of doorway waiting for resident in (Room #) (# 45) to come out of room and tells him he is an "idiot". Yelled at staff this evening as they were taking care of roommate and told them to "get the f... out of here!" Staff stated they needed to help roommate get into bed. He stated "I don't care get the h... out of here!" Has been purposely sitting in middle of hallway knowing that roommate in (Room #) (# 45) is scared of him and when he tries to go by he yells at him and calls him an idiot. (Name) (# 5) was asked to go to his room or down another hall and to watch his language in speaking to other residents and staff. He stated he was sorry and would not do it again and then did it repeatedly throughout night....2/16/11 16:35 (4:35 P.M.) Resident witnessed by this nurse verbally harassing resident in (Room #) (# 45). Resident making remarks such as "he is a pain in the a.., and he is an idiot. I am going to lay him out if he comes by my room. PRN Ativan given per orders. No further problems."...2/16/11 16:42 (4:42 P.M.) Res sitting in w/c in hall by nsg (nursing) station when another male res walked near him, stopped and asked "how are you today?" Res replied gruffly "Get away from me!" This nurse told res "(Name), why are you being so rude to him, he was being nice to you." (Name) replied gruffly again "I don't like him that's why, he's a thief." Other res replied "that's not so." Res then replied "Yes you are!"...2/16/11 20:37 (8:37 P.M.)...Later that evening at bed time residents from (Room #) (# 45) and (Room #) and (Name) (# 5) were arguing in hallway and nurse from that hall asked them all to go to their rooms and left her med cart in the hall to monitor them and they are all sleeping at this time with call light in reach....2/17/11 21:40 (9:41 P.M.) This nurse witnessed this resident coming towards resident (Name) (# 45) in a threatening way with facial frown and glaring at him. (Name) (# 45) turned away to avoid confrontation. Later in evening this resident was going down 300 hallway following (Name) (# 45). He was redirected and PRN Ativan given per order. No further problems....3/4/11 20:37 (8:37 P.M.) CNA (Name) observed this resident attempting to hit fell ow resident (Name) (# 45). (Name) (# 45) was going to his room when looked at (Name) (# 5) and said "Dont (sic) let him come to my room and wake me up in the middle of the night." Then (Name) (# 5) came toward (Name) (# 45) in attempt to hit (Name) (# 45). (Name) (CNA) intervened and separated the two and redirected (Name) (# 5) to his room. (Name) (# 5) then stated, "(Name) (# 45) is calling me a homosexual." (Name) went to his room....4/22/11 8:10 (A.M.) Resident in MDR...After he finished breakfast he propelled himself with w/c to nurses med cart...At that time an ambulatory male resident was walking towards the med cart from the opposite direction. (Name) (# 5) became loud and told the other male to "Move", when the other resident did not move (Name) (# 5) attempted to roll his w/c faster towards him. Two staff members were needed to hold his w/c back in order for him to be prevented from reaching the other resident. As this was happening (Name) (# 5) stated, "Come on old man I'm not afraid of you, bring it" The other male resident then struck (Name) (# 5) in the left cheek. The two residents were separated, however (Name) (# 5) turned around 3 more times yelling "I'll get you you son of a b...." Staff verbally attempted to deescalate (Name) (# 5) however he continued yelling for approximately 3 more minutes at which time (Name) (# 5) let staff assist him to his room....When asked if he was all right (Name) (# 5) stated, "Of course I'm fine that old man can't hurt me."...4/27/11 14:20 (2:20 P.M.) This a.m. this resident voiced that he would like to shoot another resident. When this nurse redirected him resident stopped behavior. No further behaviors noted for the rest of the day on 7-3 shift...." Review of the "Facility-Behavior and Psychotropic Monthly Review" indicated, "...2/21/11...Lexapro 20 mg daily for depression increased from 10 mg on 2/16/11, it had been started 11/3/10. Ativan (Lorazepam) 0.5 mg q (every) 4 hr (hours) as needed agitation. Behaviors being monitored: Verbal Agitation. Frequency of behavioral issues...Verbal agitation 1 episoded (sic) in November to 1 episode in December to 1 in January. Evaluation of interventions/changes to care plan. He moved to 200 hall as his skilled time ended and continues to need therapy. He has displayed anger since move. Doctor reviewed him and increased his Lexapro with recent visit. He continues to get angry at times and his is unrealistic thinking he will be able to get prostesis (sic) and start walking without using stump shrinker or therapy. Started medications related to not wanting to participate and make effort in his recovery. Has showed small improvements. Mood has been a little better and a little more cooperative....4/11/11...Lexapro 20 mg daily for depression increased from 10 mg on 2/16/11, it had been started 11/3/10. Ativan (Lorazepam) 0.5 mg q 4 hr as needed for agitation....Verbal Agitation....Verbal agitation 1 episoded (sic) in November to 1 episode in December to 1 in January to 35 in February....5/9/11...Lexapro 20 mg daily for depression increased from 10 mg on 2/16/11, it had been started 11/3/10. Ativan (Lorazepam) 0.5 mg q 4 hr as needed for agitation. Abilify 1 mg daily for adjunctive therapy for depression started 4/26/11....Verbal agitation...10 in March. Verbally aggressive 5 episodes in March. Verbally innappropriate (sic) 5 episodes in April. Aggressive behavior 6 episodes in April....Wording on behavior log was changed. Will refine the wording for him. His behaviors are usually verbal agitation however often he is sarcastic and this is difficult for different staff to evaluate her statement. He agreed for psych monitoring and ability (sic) was started with 4/26/11 visit. He continues to get angry at times..." The "Social Service Assessment," dated 5/13/11 and 6/3/11, respectively, indicated, "...interview completed 5/6/11...(Name) mood varies over the course of the day. He is very short-tempered, and will yell at peers if they are in his way. This has improved some with the addition of abilify. Is behavior tracked for aggressive behavior towards peers or staff, and verbally inappropriate. Is monitored by psych services for medication management....interview completed 6/3/11...Recently his yelling at staff has increased. (Name) does not like to pull his pants up....He wears them very low, and at times his thighs, and buttocks can be seen. Explained to (Name) how this is inappropriate. Voices he understands, but does not always comply. When staff remind him, he becomes verbally aggressive. Is followed by Psych services and has a [DIAGNOSES REDACTED]. and abilify 1 mg. Has PRN ativan 0.5 mg. for agitation." A care plan, initiated 11/9/2010, revised 6/29/11, indicated, "...Feeling of depression and agitation. Reseived (sic) new order for Lexapro on 11/3 for [DIAGNOSES REDACTED]. Increase in abilify dose 6/29/11 per Dr. (Name)...Resident will have no s/s (signs/symptoms) of mood decline, aggressive behavior or be verbally inappropriate towards staff....Interventions...Give medication as per physician orders. Date initiated 11/9/10...Monitor mental status/mood state changes as needed...11/9/10...Observe and report any changes in mental status...11/9/10...Offer activities of which resident has shown interest...11/9/10...psych services as order per physician relted (sic) to noted episodes of difficulty tolerating other, adjustment disorder...5/4/11...Offer 1:1 with reassurances. Redirect as needed and remind res is inappropriate if shows aggression towards staff, or is verbally inappropriate...6/28/11..." A "Psychiatric Progress Note", dated 6/29/11, indicated, "...The staff was noting that he agitates other people on purpose and that he seems to be fairly comfortable (sic) the staff, but he is given to rather unkind disparagement of the older residents. Of course, then most of them are older and many are demented....About that, "oh I do get into it once and awhile", as though this had been a lifetime experience of his....His treatment of [REDACTED]." Observations of Resident # 5 include: 7/5/11 12:20 P.M. Resident eating lunch in Main Dining Room. 7/7/11 1:20 P.M. Resident sitting in wheelchair directly in front of North entrance. Staff members had to ask Resident # 5 to move twice before he eventually agreed to move to let a visitor out the door. 7/7/11 1:44 P.M. Resident # 5 in 300 hall TV lounge which is located on the opposite end of the hall from his room. Resident # 45's room is located approximately 20 feet from the 300 hall TV lounge. Interview with the DON and Administrator on 7/7/11 at 10:00 A.M., she indicated a nurse would probably not document short term 15 minute checks and she is unsure if these were put in place for safety reasons or to reassure Resident # 45. During interview with Social Service Director on 7/7/11 at 10:51 A.M., she indicated when Resident # 5 was found waiting in the hall for Resident # 45, the staff would attempt to move Resident # 5 to his room. She further indicated Resident # 45 tried to stay away from Resident # 5. On 7/7/11 at 2:25 P.M., Resident # 5's family member indicated Resident # 5 went down to the 300 hall TV lounge a couple times by himself since being moved into his last room and also when family comes they take him down there. The 300 hall TV lounge is located approximately 20 feet from Resident # 45's room. Interview on 7/8/11 at 9:22 A.M. with the Social Service Director, she indicated if the nurses initiate 15 minute checks on a resident, these would be reported during morning meetings. She indicated it is hard to monitor mobile, confused residents. On 7/8/11 at 1:15 P.M., RN # 4 indicated for a little while Resident # 5 would seek Resident # 45 out. After Resident # 5 and Resident # 45 were moved to different halls, it helped with the behaviors of Resident # 5 a lot. During interview on 7/11/11 at 2:35 P.M., RN # 1 indicated the staff just tried to keep Resident # 5 and Resident # 45 away from each other. Interview on 7/12/11 at 2:00 P.M., the DON indicated there is not a specific supervision policy. She further indicated that supervision is just a standard of practice and they had multiple supervision policies although none of them seemed to address general direct care supervision. 2. The clinical record for Resident #45 was reviewed on 7/7/11 at 11:10 a.m. Resident #45 was admitted to facility on 1/12/11. Resident #45's [DIAGNOSES REDACTED]. A "Behavior Note," dated 6/7/11 at 6:15 p.m., stated, "This nurse (RN #25) walked to back kitchen doorway and noticed this resident (#45) was outside in the middle of the field behind the facility and was walking away from building. Did not see how he exited facility. Called for help and attempted to talk resident (#45) into coming back to facility. Started cussing at me and became combative and scratched me so I stayed with resident while he walked and maintained safety. Resident unaware of safety hazard as he did not stop at street. (Name) RN #4 arrived. Resident continued to be combative. Shoved kitchen staff member as he tried to keep him from going into street. Police arrived and talked to resident...." A "Behavior Note," dated 6/7/11 at 7:50 p.m., stated, "7:50 p.m. This nurse (RN #2) entered building as police were leaving...Attempted to have resident drink ice water however he pushed this writers hand away...Resident's face was flushed and he was warm and moist to touch. Assisted him to remove his hat and his flannel shirt. Temp (temperature) axillary (under arm) 99.2. Placed cool wash cloth on the back of his neck and encouraged him to drink ice water...Wanderguard on and functioning." A "Behavior Note," dated 6/7/11 at 10:12 p.m., by RN #25, stated, "At approximately 6:15 pm...Arrived outside to find him with staff on Chapman drive (sic). As staff was trying to keep in the area called 911 and supervisor...As we waited for police, resident was trying to cross road and becoming combative at Timothy and Chapman drive (sic)...police arrived approximately 10 min (minutes) later...3 police officers tried to get him to get into the car but he refused and yelled at them not to touch him...Still combative and not letting anyone touch him. 3 police officers help this nurse get him back to the building which involved walking through the field which was the only way he would go...It took us 30 minutes...He was becoming very tired and unsteady and when anyone touched him to prevent him from falling he would become combative. When we arrived at the building he refused to come in and sat on the lawn furniture. The police were able to convince him to come in...Wander guard checked and working...." The investigation provided by the DON (Director of Nursing) on 7/7/11 at 1:30 p.m., stated, "Elopement of resident (Room #) Resident #45 (on) 6/7/11...Wanderguard bracelet in place and remained functional...Assessment completed of patient condition per nursing with temperature elevated...remove layer of clothing (normally dresses in several layers)...Statements requested from staff in facility to help in investigation of exit. One statement noted that barrel alarm was not turned on when she exited laundry room to assist...6/8/11...determination that door to south side of building by MDR (main dining room) was exit route. Patient had been accompanied to MDR at 5:50 pm, approx (approximately), and was witnessed due south of facility in less than 30 minutes...Per staff statements noted door sticks and another statement noted barrel alarm not activated...6/8/11-4pm-Recheck of door function with notation that door closes with stiffness when in sunlight but that barrel key alarm continues to function accurately when door opened...6/17/11...information received that nursing assistant had opened door to go outside for break prior to supper hour...." A care plan stated, "Focus-Potential for elopement...initiated 2/1/11...Goals-Will not leave facility unattended...initiated 2/1/11...Wanderguard sensor bracelet applied...initiated 2/1/11...Redirect when asking to go home or at an exit door...initiated 2/1/11...." During an interview with the DON on 7/7/11 at 1:40 p.m. she stated, "that door probably wasn't pulled as snuggly as it should have been. Didn't have a wanderguard on it at the time of elopement. Out that door is the designated smoking area for the staff and for trash removal." On 7/8/11 at 10:45 a.m., Resident #45 was observed checking the door in the MDR, no staff was present or redirected. Then Resident #45 went to the main entrance door, he checked to see if it was locked, no staff visible for approximately 3 minutes, no staff addressed exit seeking or offered redirection. In a policy entitled Elopement/Missing Resident Procedure" with "Policy Start Date: 2006-05-31" and expires 7/8/2011, stated, "...13. Specific individualized interventions will be initiated immediately based upon the resident needs i.e. safety checks, wanderguard, 1:1 assignment etc..." The immediate jeopardy that began on 2/13/11 was removed on 7/12/11 when through observations, and interviews, it was determined that the facility had implemented the plan of action to remove the immediacy of the problem, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to continue to inservice staff on how to recognize verbal abuse and protect residents from being abused and needed to monitor or re-assess residents for verbal aggression towards other residents. 3.1-45(a)(1) 3.1-45(a)(2)