Every finding on record at NHC Healthcare, Smithville

Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASRR) to include an active mental health condition present upon admission for 1 resident (Resident #74) of 7 residents reviewed for PASRR. The findings include: Review of the facility's policy titled, PRE-ADMISSION SCREENING AND RESIDENT REVIEW (PASRR), revised 11/2016, revealed .all centers to screen patients before admission to determine if they have Mental Illness, Intellectual or Developmental Disability or related condition .It must be determined whether this individual requires the level of services provided by a health care center or whether they need specialized treatment .Center should refer any patient for a Level II resident review upon a significant change in status/condition such as newly evident or possible serious mental disorder . Review of the medical record revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, and Psychotic Disorder with Delusions. Review of a Physician's Order for Resident #74 dated 1/6/2025, revealed .Rexulti [anti-psychotic medication] 0.5 mg [milligram] po [by mouth] daily for Psychotic Disorder with Delusions . Review of the Notice of PASRR Level I Screen Outcome for Resident #74 dated 1/6/2025, revealed .No PASRR Level II Required .DIAGNOSIS .Anxiety Disorder .Dementia/Neurocognitive Disorder . Further review revealed Psychotic Disorder with Delusions was not included as an active mental health diagnosis. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #74 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident had active diagnoses of Dementia, Anxiety, and Psychotic Disorder. Review of the comprehensive care plan for Resident #74 dated 1/17/2025, revealed .Psychiatric conditions .at risk for complications r/t [related to] Psychotic Disorder with Delusions . During an interview on 2/25/2025 at 2:02 PM, the Assistant Director of Nursing (ADON) stated she was responsible for resubmitting the PASRRs at the facility. The ADON confirmed the mental health condition of Psychotic Disorder with Delusions was active upon admission and was not included as a diagnosis on the PASRR dated 1/6/2025. The ADON stated a new PASRR for Resident #74 should have been resubmitted after admission to include the diagnosis of Psychotic Disorder with Delusions.

Based on facility policy review, medical record review, and interviews, the facility failed to ensure the medical record was accurate for 1 resident (Resident #37) of 25 residents reviewed for accurate medical records. The findings include: Review of the facility's policy titled, Introduction to Documentation For Inpatient Medical Records, dated 11/2023, revealed .It is the responsibility of each health care center to establish and maintain comprehensive records which accurately reflect all aspects of the organization .Professional Standards of Documentation .Observations .assessments/evaluations .are accurately recorded . Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including Hypertensive Heart Disease with Heart Failure, Neoplasm of Respiratory System, Major Depression, Peripheral Vascular Disease, and Malnutrition. Review of a comprehensive care plan for Resident #37 dated 2/12/2024, revealed .Nutrition .At risk for malnutrition .Pt [patient] at risk for wt [weight] fluctuations r/t [related to] CHF [congestive heart failure] .Hx [history] of wt fluctuations w/ [with] significant wt loss [2/2025] w/ decreased intakes and refusal of meals .Obtain weights as ordered and observe for significant change . Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #37 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Review of the medical record for Resident #37 revealed the resident weighed 170.9 pounds (lbs.) on 1/27/2025; 221 lbs. on 1/30/2025; 159.4 lbs. on 2/6/2025; 158.8 on 2/24/2025. During an interview on 2/26/2025 at 2:00 PM, the Registered Dietician (RD) stated she felt the documented weight of 221 lbs. on 1/30/2025 for Resident #37 was inaccurate. The RD stated the resident's weights had consistently been in the 170's until the end of January and the resident's weight was currently stable. During an interview on 2/26/2025 at 2:30 PM, the Restorative Nurse stated she felt the documented weight of 221 lbs. on 1/30/2025 for Resident #37 was inaccurate. During a telephone interview on 2/26/2025 at 3:05 PM, Licensed Practical Nurse (LPN) A stated the electronic documentation system gave a pop-up warning if the weight was out of range and the staff had the capability to look at previous weights for comparison. LPN A stated if Resident #37's weight was flagged as out of range, she would have requested a reweigh. LPN A stated .sounds like the one [Resident #37's weight on1/30/2025] was incorrect .there are multiple weights documented, so I could have documented someone else's weight . During an interview on 2/26/2025 at 3:40 PM, Family Nurse Practitioner (FNP) stated the weight of 221 lbs. on 1/30/2025 for Resident #37 was .an inaccurate weight .no way .[weight gain] would not even happen with fluid overload . During an interview on 2/26/2025 at 3:53 PM, the Assistant Director of Nursing (ADON) stated her expectation was the staff would accurately enter documentation in the medical record and confirmed Resident #37's recorded weight for 1/30/2025 was inaccurate. During a telephone interview on 2/27/2025 at 9:15 AM, Certified Nursing Assistant (CNA) B stated he recalled obtaining a weight of 221 lbs. for Resident #37. CNA B stated he entered Resident #37's weight in the computer, then reported the resident's weight to the day shift and night shift nurse. CNA B stated the nurses looked at Resident #37's previous weights and stated the weight was .off quite a bit . CNA B stated he reweighed Resident #37, but could not recall the re-weight value, but it was close to his baseline (150's to 170's). CNA B stated the weight was amended in the electronic documentation system to reflect the new weight. CNA B stated .it [new weight] .must not have taken [saved in the electronic documentation system] .

Based on facility policy review, facility investigation review, medical record review, observation, and interview the facility failed to provide an environment free from abuse for 5 of 9 sampled residents (Resident #1, Resident #2, Resident #6, Resident #7 and Resident #8) reviewed for abuse. On [DATE] Resident #2, a vulnerable, severely cognitively impaired, ambulatory female resident wandered into Resident #1's room. Resident #1, an alert male resident with a Brief Interview for Mental Status (BIMS) score of 15 and an extensive psychiatric history, willfully hit Resident #2 multiple times on her head and back. On [DATE] Resident #7, a vulnerable, severely cognitively impaired, female resident in a wheelchair, bumped into Resident #1's wheelchair in the dining room. Resident #1 was verbally abusive and called Resident #7 derogatory names. The facility's failure to recognize and intervene with Resident #1's continued physical and verbally abusive behaviors toward residents placed Resident #2 and Resident #7 in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The facility failed to prevent an incident physical abuse when Resident #6 and Resident #8 were involved in a resident-to-resident altercation on [DATE] which did not rise to an IJ level. The facility failed to report the resident-to-resident altercation that occurred between Resident #6 and Resident #8 on [DATE] to the appropriate agencies. The Administrator was notified of the IJ on [DATE] at 6:38 PM in the Conference room. The facility was cited at F-600 at a scope and severity of K, which constitutes Substandard Quality of Care. The Immediate Jeopardy began [DATE], continued through [DATE], and was removed on [DATE]. A partial extended survey was conducted on [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-600 was received on [DATE]. The corrective actions were validated onsite by the surveyors on [DATE] through observation, review of records, audit review, education review, and staff interviews. The facility's noncompliance at F-600 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Abuse, Neglect, Misappropriation of Property and Exploitation, dated [DATE], revealed .Abuse, Neglect .will not be tolerated by anyone, including staff, patients .The patient has the right to be free from abuse, neglect .Abuse: the willful infliction of injury .intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes verbal abuse .physical abuse, and mental abuse .Willful .means the individual must have acted deliberately .Verbal Abuse: the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents .or within their hearing distance regardless of their .ability to comprehend .Physical Abuse: includes hitting, slapping, pinching and kicking .PREVENTION POLICY .The center will provide supervision and support services designed to reduce the likelihood of abuse behaviors .All supervisory partners who receive reports of and/or identify inappropriate behaviors will take immediate steps to correct such behaviors .Patients with needs and behaviors that might lead to conflict with partners or other patients will be identified by the Care Planning team, with interventions and follow through designed to minimize the risk of conflict .The Interventions designed to meet the needs of such patients will include .identification of patients whose personal histories render them at risk for abusing other patients or partners .Assessment of appropriate intervention strategies to prevent occurrences .Monitoring the patient for any changes that would trigger abusive behavior .Dementia management program as needed .Any patient event that is reported to any partner by patient, family .any person will be considered an allegation of either abuse, neglect .Any allegation (or) indication of possible willful infliction .Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect .must report the event immediately, but not later than 2 hours after forming the suspicion if the events that cause the suspicion involve abuse .it is the policy of this facility that abuse allegations (abuse, neglect .mistreatment .) are reported per Federal and State Law .The investigation is conducted immediately .When it is identified that an alleged incident may have occurred .As soon as any partner has knowledge and reports an alleged event .When there is a question as to whether to conduct an investigation, it is best to do so .The results of all investigations will be completed within five working days of the incident .all necessary corrective actions will be taken .Any individual found to be in danger of injury will be removed from the source of the suspected abusive behavior including but not limited to room or staffing changes .to protect the patient (s) from the alleged perpetrator .Increased supervision of the alleged victim and patients . Review of the undated facility policy titled, PATIENT RIGHTS, revealed, .the patient/resident's right to live in an environment which is individualized for them .Your sense of well being and your safety during your stay here are of the utmost importance to us .your care is planed with a group of professionals holding your well-being as their primary concern .Your plan of care will include an assessment of your strengths and needs. The ultimate goal is to assist you to achieve and/or maintain the highest level of functioning . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Delusional Disorders, Schizoaffective Disorder, bipolar type, Hallucinations, Anxiety Disorder, and Major Depressive Disorder. Review of the care plan for Resident #1 revealed, .Start Date XXX[DATE] Problem: At risk for alteration in behaviors .Pt [patient] has delusions, hallucinations, talks to himself, verbal and physical behaviors toward others, short tempered, easily annoyed, impatient .Approach: Remove patient from triggering situations when possible; respect personal space and rights Start date XXX[DATE] . Review of the Physician Progress Notes dated [DATE] for Resident #1 revealed schizoaffective disorder .does not tolerate dosage [medication dosage] decrease. Review of the Progress Notes dated [DATE] for Resident #1 revealed, .PT [Patient] IS ALERT WITH HALLUCINATIONS NOTED . Review of the Nurse Practitioner (NP) Progress Note dated [DATE] for Resident #1 revealed, .Patient is delusional - reports his mother is coming to get him to take him home for extended work they need to do with children . Review of the Nurse Practitioner Progress Note dated [DATE] for Resident #1 revealed, .Patient is found sitting up in his wheelchair .Delusional .Reports 'I am now the governor and I have served 15 terms' . Review of the Progress Notes dated [DATE] for Resident #1 revealed, .A patient entered [Named Resident #1]'s room and was attempting to sit in his electric wheelchair. [Named Resident #1] was afraid the patient was going to get hurt so he yelled for patent to leave his room and [Named Resident #1] struck the patent with his hand on the head and back . Review of the facility investigation revealed on [DATE] at 6:00 PM, Resident #2 wandered into Resident #1's room. Resident #1 yelled at Resident #2 to get out of his room and while she was at his bedside, he struck the resident with his open hand on the head and back. A nurse aide heard the commotion and immediately intervened. The victim Resident #2 was removed from the room and provided increased observation. The nurse performed a skin assessment on both residents with no injuries noted. A stop sign was placed on Resident #1's room to intervene wandering behavior. The facility investigation revealed the staff were trained on abuse policy and procedures. The staff should be with Resident #2 during mealtimes. A Velcro stop sign was affixed to Resident #1's doorway. The Quality Assurance Performance Improvement (QAPI) will oversee question and answers regarding abuse policy and procedures. The staff will monitor patients for behaviors that may increase their risk for physical abuse. The QAPI committee will confirm compliance with Stop Sign usage. Both residents will continue to be seen by Psych services. Review of the PSYCHOTHERAPY PROGRESS NOTE dated [DATE] for Resident #1 revealed, .Pt .was able to discuss incident yesterday of increased agitation/low frustration tolerance leading to an incident with another resident who came into his room, trying to use his electric w/c [wheelchair] .(pt. Experiencing grandiose baseline delusions) leading to broader issues with interpersonal skills (impulsivity/agitation) .Pt will reduce inappropriate behaviors by 50 % [percent] during review period, substituting with more appropriate patterns of interaction . Review of the Progress Notes dated [DATE] for Resident #1 revealed, .NO ABNORMAL BEHAVIORS. NO YELLING OR CRUSING [cursing] NOTED . Review of the Progress Notes dated [DATE] for Resident #1 revealed, .PT IS ALERT WITH DELUSIONAL BEHAVIORS NOTED AT TIMES . Review of the Progress Notes dated [DATE] for Resident #1 revealed, .Patient takes meds for schizoaffective bipolar type Still with delusions/hallucinations . Review of the Progress Notes dated [DATE] for Resident #1 revealed, .PT IS ALERT WITH DAILY DELUSIONS (HE OWNS MULTIPLE SPORT CARS, HOUSES, OR HE IS KIN TO FAMOUS PEOPLE .) ALL AT BASELINE . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #1 experienced delusions and other behaviors not directed toward others. Review of the PSYCHIATRIC PERIODIC EVALUATION dated [DATE] for Resident #1 revealed, .New/Ongoing Target sx's [symptoms] .Pressured Speech, Impulsive Action, Compulsivity . Review of the PSYCHIATRIC PERIODIC EVALUATION dated [DATE] for Resident #1 revealed, .Pt [patient] has a persistent, chronic mental illness that requires ongoing therapeutic intervention to prevent exacerbation of presenting behaviors/psychological symptoms and to sustain baseline stability and overall well-being . Review of the care plan for Resident #1 revealed, .Problem: At risk for alteration in behaviors .Pt [patient] has delusions, hallucinations, talks to himself, verbal and physical behaviors toward others, short tempered, easily annoyed, impatient .Approach: Remove patient from triggering situations when possible; respect personal space and rights Start date .Approach: When Pt is upset by hallucinations or delusions, attempt to redirect by talking one-on-one in a calm tone about something they enjoy .Start Date [DATE] . Review of the Progress Note dated [DATE] for Resident #1 revealed, .PT WAS SITTING IN DINING ROOM FOR BREAKFAST WHEN A DEMENTED PT ROLLED IN AND BUMPED HIS WHEELCHAIR. PT BECAME AGGRESSIVE CURSING AND YELLING IN DINING ROOM AS LOUD AS HE COULD. NURSE INTERVENED AND REMOVED DEMENTIA PT. PT YELLED AND SCREAMED AT NURSE AND WAS NAME CALLING. PT NOW IN ROOM EATING BREAKFAST . Review of the Behavior Analysis Report (CareAssist only) note dated [DATE] for Resident #1 revealed, .Pt was in the dining room for breakfast another pt [Resident #7] accidentally bumped the back of his [Resident #1's] chair with hers. [Resident #7's wheelchair] and [Named Resident #1] started yelling and screaming at pt.[Named Resident #7] Nurse went in to redirect pt [Resident #7] and he [Resident #1] started cursing nurse calling her a whore he was asked to leaving [leave] the dining room. pt is currently in his room . Review of the Quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 which indicated intact cognitive abilities. Continued review of the MDS revealed Resident #1 experienced delusions. Observation in the dining room on [DATE] at 10:20 AM, revealed Resident #1 was in the dining room in an electric wheelchair. Observation in the resident's room on [DATE] at 9:00 AM, revealed Resident #1 was in his room sitting in his wheelchair. No stop sign was present over the doorway of Resident #1's room. Observation in resident's room on [DATE] at 8:20 AM, revealed Resident #1 was in the bed and no stop sign was present over the doorway of his room. During an interview on [DATE] at 1:35 PM, Resident #1 was asked to explain what happened when Resident #2 came into his room. Resident #1 stated, .She went to my wheelchair (electric wheelchair) she turned it on .I told her to go back .I turned on the call light .she wouldn't listen, I don't want to have an accident .scared the wheelchair would have run her over .I patted her on the head .they yelled at me for doing that .I mean the jaws of life would have had to come in here and pull that wheelchair off of her .She didn't say anything to me just headed straight to the wheelchair .She backed off and staff was coming in .I don't remember the social worker coming and talking to me .She came in my room one time nude as a chicken .staff got her out of the room that night . Resident #1 was asked if the Administrator or the Director of Nursing (DON) came to talk with him related to the altercation. Resident #1 replied, No, I got a scholarship to work at [NAME] to work as a manager .They want me to take the job and sell them Hybrids that are coming out . 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, Aphasia, Cognitive Communication Deficit, Manic episode, Dementia, Anxiety, and Depression and expired at the facility on [DATE]. Review of the Progress Notes dated [DATE] revealed for Resident #2, .Wanders and will intrude in other Pts' [Patient's] rooms . Review of the Progress Notes dated [DATE] revealed for Resident #2 , .Pt wanders and will intrude in other pt's personal space and rooms . Review of the Progress Notes dated [DATE], for Resident #2 revealed, .Pt wanders and will intrude in other patient's personal space and rooms . Review of the Progress Notes dated [DATE] for Resident #2 revealed, .AMBULATES AD LIB [as much and as often as desired] GAIT SEMI STEADY WITH STAFF ASSISTANCE. W/C [wheelchair] MAIN MODE OF TRANSPORTAION. ABLE TO PROPEL SELF IN HALLWAYS .PT TENDS TO WANDER AT TIMES INTO OTHERS ROOMS . Review of the Nurse Practitioner Progress Note dated [DATE] for Resident #2 revealed, .Patient continues to be up daily with assistance of staff and wheelchair. Patient is able to ambulate short distances with assistance of staff . Review of the Progress Note dated [DATE] for Resident #2 revealed, .PT COMBATIVE WITH CARE AND SHOWER THIS SHIFT. PT ROAMS WHEN UP IN WHEELCHAIR AND ENTERS OTHER ROOMS . Review of the Progress Note dated [DATE] for Resident #2 revealed, .Pt frequently roams when up in W/C and will enter other patients' rooms . Review of the annual MDS assessment dated [DATE] revealed Resident #2 had a staff assessment for mental status which indicated poor short term and long-term memory. Continued review of the MDS revealed no mood or behavior symptoms were present over the last 7 days. Review of the Progress Note dated [DATE] for Resident #2 revealed, .Alert: [Named Resident #2] entered a patients room [Named Resident #1's room] and was attempting to sit in the patients wheelchair. The other patient was afraid that [Named Resident #2] was going to get hurt. The other patient [Named Resident #1] yelled for [Named Resident #2] to get out of the room and struck [Named Resident #2] with his hand on her head and back. Two nurses completed a skin assessment with no new skin issues noted . Review of the PSYCHIATRIC EVALUATION dated [DATE] for Resident #2 revealed, .Staff report cognition loss .Mood is worse with adls [activities of daily living] Patient has associated symptom of confusion .Safety concerns - Staff education regarding communication and re-direction in dementia patients . Review of the edited care plan dated [DATE] for Resident #2 revealed, .At risk for alteration in behaviors r/t [related to] disrobing, cursing at others, wandering, combativeness, and refusal of meds .Assist and encourage Pt to stay in high traffic areas when up in W/C as Pt allows Created :[DATE] .When Pt becomes annoyed with care/interactions .Provide safe environment and attempt care/interactions later when possible. Created: [DATE] .Redirect me when needed I will wander in my W/C. Offer me a snack or drink if I become agitated when redirected. I do not know my personal boundaries .Created: [DATE] .Encourage patient to be up for meals and in dining room to discourage wandering during meal times Created:[DATE] . The facility staff failed to redirect, prevent, or provide a safe environment for Resident #2 on [DATE] prior to her being struck by Resident #1 after wandering into his room. Review of the 5-day MDS assessment dated [DATE] revealed Resident #2 had a staff assessment for mental status which indicated poor short term and long-term memory. Continued review of the MDS revealed no mood or behavior symptoms were present over the last 7 days. 3. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Vascular Dementia, unspecified severity, with mood disturbance and Depression. Review of the care plan for Resident #7 revealed, .Problem Start Date: [DATE] Behavioral Symptoms .Approach Start Date XXX[DATE] .promote safety XXX[DATE] Encourage and assist Pt with staying in high traffic areas when up in W/C as Pt allows .Offer and assist Pt to lay down in bed when wandering in W/C as Pt allows . Review of the Quarterly MDS dated [DATE] revealed Resident #7 had a BIMS score of 6 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #7 experienced delusions, physical behaviors directed toward others, and wandered ,d+[DATE] days over the last 7 day look back period. Review of the nurse Progress Notes for [DATE] for Resident #7 revealed no details related to the verbally abusive interaction that occurred on [DATE] with Resident #1. Review of the Progress Note dated [DATE] for Resident #7 revealed, .Spoke with NP .and reviewed previous verbal abusive interaction that occurred on [DATE] involving patients [Resident #1 was verbally abusive toward Resident #7] . Review of the revised care plan for Resident #7 dated [DATE] revealed, .Behavioral Symptoms .At risk for alteration in behaviors refusal of plan of care .Pt has impulsive behaviors with decreased safety awareness, false beliefs/misperceptions, physical behavior towards staff, and wandering Edited XXX[DATE] .Approach Start Date XXX[DATE] Patient may attract negative attention from other patients due to their poor understanding of personal space and spatial boundaries. Redirect as needed .When Pt is wandering, assess for unmet physical needs, psychological distress, and environmental factors. Distract Pt by introducing enjoyed activities .Educate and encourage patient to comply with plan of care . Resident #7 with a BIMS score of 6 does not have the ability to understand the need to comply with the plan of care. Review of the NP progress note dated [DATE] for Resident #7 revealed, .Per staff, patient remains at her baseline. She is pleasantly confused. She is able to propel herself in her wheel chair. She is easily redirected. No acute needs are reported by staff to this provider today .No distress. No needs identified . No mention of Resident #7's involvement in a verbal altercation with Resident #1. Observation in the resident's room on [DATE] at 2:45 PM, revealed staff assisted Resident #7 to bed. Observation in the dining room on [DATE] at 12:30 PM, revealed Resident #7 was in her wheelchair rolling to different residents introducing herself. During an interview on [DATE] at 3:50 PM, Licensed Practical Nurse (LPN) G stated, .I was here the night [Named Resident #2] went into [Named Resident #1]'s room. It was close to supper, [Named Resident #2] liked to wander, and she would get gone before you could get to her .I heard some yelling .[Named Resident #1] told me he hit her .the Administrator was still here, I told him .She was in her wheelchair but she could walk .Her room was straight across from his .they were on the same hall .Nobody seen her get up from her wheelchair that night .It wasn't the first time she had been in his room .he would yell at her and we would remove her .we tried to keep her in a wheelchair close to us .she would wheel throughout the facility .the staff knew she wandered .[Named Resident #1] said he hit her on the back, I looked at her skin I didn't see any redness .Certified Nursing Assistants (CNAs) were putting people to bed .we put a stop sign on [Named Resident #1]'s door to prevent her from going in his room . LPN G was asked if Resident #1 had ever been abusive toward any other residents. LPN G stated, .One time [Named Resident #7] was in the dining room and she bumped into his [Resident #1]wheelchair .He started cursing, I went in the dining room, he cursed me . LPN G was asked if Resident #1 was verbally abusive toward Resident #7. LPN G stated, .Yes I would say that would be verbal abuse, but I don't think I reported it .I did mention it to the NP today [[DATE]] .I was concerned about his outburst .[Named Resident #1] is delusional thinking he is married to the queen .will say he was in the military but he wasn't .He first tried to deny he hit [Named Resident #2] . During an interview on [DATE] at 4:30 PM, CNA H stated, .[Named Resident #1] has rage of fits screaming at other residents .he would scream at his previous roommate [Named Resident #5] .he will scream he would shoot them if he had a gun .[Named Resident #2] would go in everybody's room . CNA H stated, .[Named Resident #1] has been aggressive toward [Named Resident #7] .she wanders and often looking for her children .he will instantly become aggressive toward her .I feel like he could be physical or verbally aggressive toward any resident . During an interview on [DATE] at 4:45 PM, CNA I stated, .[Named Resident #1] will yell at his roommate if he gets in his way .he has a loud tone of voice .don't want anybody getting close to him .the roommate that he had before would yell some in the night .[Named Resident #1] would yell at him to be quiet . During an interview on [DATE] at 8:00 AM, CNA J stated, .[Named Resident #1] he yells and screams mostly at other residents .He got after [Named Resident #7] in the dining room one day because she tried to talk to him .He called her .[derogatory names] .[Named Resident #7] just moved and said 'why don't you want to talk to me' .we try to keep the patients away from him .he doesn't like anyone getting close to him .he did yell at his roommate [Named Resident #5] . During an interview on [DATE] at 8:20 AM, CNA L was asked why Resident #1 did not have the stop sign over his door. CNA L, stated, .After Resident #2 passed away I think they took it down . CNA L was asked if the facility still had residents that wander that could go into his room and potentially get hit like Resident #2. CNA L stated, .yea, [Named Resident #7] wanders .He [Resident #1] gets agitated with his roommate's stuff don't want nothing near him .constantly wanting his roommates stuff moved .[Named Resident #7] agitates him . During an interview on [DATE] AT 8:25 AM, the Social Service Director (SSD), stated, .I never knew [Named Resident #1] was aggressive. I wasn't aware of the interaction he [Resident #1] had with [Named Resident #7] on [DATE]. I am just now reading this in the notes. I have not done a follow up with either resident because I was not aware of the incident. The staff should have notified the Abuse Coordinator. Verbal abuse is cursing, yelling, demeaning language toward another resident. I would have observed [Named Resident #7] demeanor toward [Named Resident #1] to see if she would shy away from him or would she continue with her normal behavior. [Named Resident #7] is a very social person, so I would watch for any changes in her behavior. We have other residents that could wander in [Named Resident #1]'s room . During an interview on [DATE] at 8:55 AM, the DON stated, .I was aware that [Name Resident #7] bumped into [Named Resident #1]'s wheelchair in the dining room and [Named LPN G] intervened. I wasn't aware that he called the other resident any derogatory names. I thought he just called the nurse names. As far as I know [Named Resident #1] got along with his roommates . During an interview on [DATE] at 10:45 AM, Registered Nurse (RN) R stated, .I used these [the Quality Assurance and Performance Improvement monitoring tool] sheets for education not monitoring of the wandering resident [Resident #2]. I just mainly done teaching on what to do for a wandering resident .redirect them out of the patient's room . During an interview on [DATE] at 2:50 PM, Resident #1 stated, .I know [Named Resident #7] she is a busy body .comes around pushed me and poked me in the dining room .It upsets me I don't want to be touched .I had to leave the room .I had to get out of there, she will keep on until she provokes me to a fight .she won't back down .she just keeps on poking at me .she makes me sick .she has wandered in my room twice .they took down my stop sign off my door since the little woman passed away [Resident #2] .Named Resident #7] won't listen just keeps on trying to talk . During an interview on [DATE] at 4:31 PM, CNA W stated, .I heard a man yell, 'get out, get out' .I looked down the hall and seen [Named Resident #2]'s wheelchair sitting outside the room .[Named Resident #1] was laying in the bed .She had went to sit in his electric wheelchair .he was hitting her [Resident #2] on her back .he was raring back hitting her multiple times .I didn't know what else to do but scream stop, stop until I could get over to her .he instantly started apologizing .I got her in her wheelchair and took her to the nurse .[Named Resident #1] had his palm straight to her hitting her in the back and head ,d+[DATE] times .I mean having at it .I don't remember his call light being on . During an interview on [DATE] at 12:50 PM, the DON stated, .I would expect staff to redirect a wandering resident .try to find out the reason for wandering .does the resident need something .hungry .and stay with the resident to verify the resident's safety . The DON was asked if the facility performed any monitoring of Resident #2 after the physical altercation with Resident #1. The DON stated, .we trained our staff on how to protect the patients, going over the abuse policy .wandering patients what do you do .patient safety .the QAPI follow up training I would consider that follow up on [Named Resident #2] . 4. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease, Renal Dialysis, Muscle Wasting and Atrophy, Heart Failure, Long-Term Use of Anticoagulants, and Malignant Neoplasm of Stomach. Review of the Admission MDS dated [DATE], revealed Resident #6 had a BIMS score of 13, which indicated intact cognition. Review of Registered Nurse (RN) U's Progress Note for Resident #6, dated [DATE] at 10:25 AM, revealed .Alert: I was in patient room giving him medicine and roommate [Resident #8] pushed his own bedside table that accidentally bumped this patients bedside table through the curtain. Patients bedside table bumped patients top of right knee. Patient was not bleeding at the time. Patient then came to nurses station and stated his knee was bleeding. This nurse cleaned and applied a dressing to top of right knee. MD and family notified . Review of a Physician's Order, for Resident #6, dated [DATE] revealed, .abrasion to top of right knee .Special Instructions: abrasion to top of right knee clean with normal saline and pat dry. Apply polymem [a dressing that manages drainage] oval every shift until healed .Every Shift .Day, Night . Review of the NP progress note dated [DATE] at 7:45 PM, for Resident #6, revealed, .Today staff report that the patient did sustain a small abrased area just above his right knee. Staff state that the patient reported that his knee was injured on his bedside table. Patient is found sitting on the side of his bed in his room .When asked what happened to his knee he states 'the curtain was pulled and my roommate pushed his bedside table into my bedside table and my bedside table hit my knee.' Patient did show provider how he sits on the side of his bed with his feet on the lower part of his table and pointed out the area of his table that hit his knee. Provider asked if this hurt and patient stated 'it did a little at the time but not now.' . 5. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses which included Type 2 Diabetes Mellitus, Hypertensive Heart Disease, Chronic Obstructive Pulmonary Disease, and Long-Term Use of Anticoagulants. During an interview on [DATE] at 11:45 AM, Resident #6 stated, .Just an hour ago my roommate cursing people throwing a fit and he shoved his tray table toward me and caused my leg to start bleeding .he shoved the nurse [RN U] that was in here too because she told him don't push me .he [Resident #8] yells and hollers and he knows I will get up . The observation revealed blood on the floor and bloody gauze laying on the overbed table. Resident #6 raised up his pants leg on his right leg to show the surveyor where the nurse just bandaged his leg due to the injury he sustained when Resident #8 became angry and pushed his tray table into Resident #6's tray table. During the interview with Resident #6, Resident #8 yelled for the nurse 3 different times. During an interview on [DATE] at 12:30 PM, RN U stated, .[Named Licensed Practical Nurse V] reported to me he [Resident #6] had an old skin tear that reopened . During an interview on [DATE] at 3:25 PM, LPN V stated, .[Named RN U] done [did] all the treatments today .[Named Resident #6]'s roommate [Resident #8] pushed the overbed table toward him and caused a skin tear .the table has now been moved to the other side of [Named Resident #8]'s bed . During an interview on [DATE] at 5:20 PM, RN U was asked about her nurse note on Resident #6. RN U stated, .I was in the room when it happened .[Named Resident #8] pushed his overbed table .water picture hit the floor .the table hit [Named Resident #6] on his knee .[Named Resident #8] was flying off with the 'F' word it aggravated him, he wanted ice in his water .I lied to you earlier .I didn't report it .I applied pressure he [Resident #6] has poor skin he is a dialysis patient . During an interview on [DATE] at 4:00 PM, the SSD was asked if she was notified of the incident between Resident #6 and Resident #8. The SSD stated, .We talked to RN U about it .[ [TRUNCATED]

Based on facility policy review, medical record review, www.wunderground.com, Electrical Company invoice, observation and interview, the facility failed to provide adequate supervision to prevent an accident for 2 (Resident #5 and Resident #10) of 6 sampled residents reviewed for accidents. The facility failed to ensure adequate supervision to prevent an exit seeking, wandering, cognitively impaired resident (Resident #10) with a Brief Interview for Mental Status (BIMS) score of 9, assessed to be an elopement risk, from leaving a safe environment and exiting the facility to an unsafe environment. Resident #10 (wearing a wander guard bracelet) exited a double door connected to the door alarm/wander guard system that malfunctioned on [DATE] at an unknown time until [DATE] at 2:00 AM. No alarm was activated when Resident #10 exited through the double doors. Resident #10 walked approximately 618 feet down a sidewalk, an embankment, and into a street to a house in the nearby community. Resident #10 knocked on the door and stated, I am trying to find my house. A member of the house (a previous male employee) recognized Resident #10 and drove her back to the facility at approximately 2:15 AM. The staff were unaware Resident #10 was missing from the facility. Resident #10 reported to the nurse when she returned that she fell down the hill. Resident #10 had dirt on the back of her clothes. Resident #10 reported to the Nurse Practitioner (NP) on [DATE] that she bit her tongue when she fell , and a small laceration to right side of her tongue was noted. The facility also failed to provide supervision to ensure an environment free of accidents for Resident #5, a vulnerable high fall risk resident, receiving blood thinner. On [DATE] at 2:05 PM, Resident #5 had a witnessed fall which resulted in a head injury. The Conservator was notified of the fall via email. At 5:00 PM Resident #5's blood pressure had decreased to ,d+[DATE]. Licensed Practical Nurse (LPN) A (Hospice nurse) noted Resident #5 was pale in color, with slurred speech, an abrasion/ raised area to forehead, weak grip, shallow breathing, was tense and moaning, hypotensive with an irregular heart rate, and Resident #5 stated he was cold. On [DATE] and [DATE] staff noted in a nursing note: Resident #5 had blood in his mouth and was combative with care and restless. Resident #5 expired in the facility on [DATE], 3 days after the fall. The facility's failure to provide adequate supervision for vulnerable residents resulted in Resident #10's elopement and Resident #5's accident which placed the residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident) with actual harm. The Administrator was notified of the Immediate Jeopardy (IJ) for F-689 on [DATE] at 4:33 PM related to Resident #10 in the conference room. The Administrator and the Senior [NAME] President were notified of the IJ on [DATE] at 6:33 PM related to Resident #5 in the conference room. The facility was cited at F-689 at a scope at severity of J, which is Substandard Quality of Care. The Immediate Jeopardy began [DATE], continued through [DATE], and was removed on [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-689 was received on [DATE]. The corrective actions were validated onsite by the surveyors on [DATE] through observation, review of records, audit review, education review, and staff interviews. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled, Incident and Accident Process, dated ,d+[DATE] revealed, .An incident or accident is defined as 'any occurrence that is outside the norms or any happening that is not consistent with the routine operation of the center or care of a particular patient .All patient incidents should be documented in the EHR [electronic health record] .When any incident results in injury, as defined below, and/or there is evidence of negligence, they must be reported to clinical risk management .Significant injury including: Fracture or dislocation of bones or joints, Closed head injury with altered consciousness, and Subdural hematoma .Any condition requiring medical treatment outside the center that is inconsistent with the routine management of the patient's preexisting condition(s) .The DON [Director of Nursing] should review all incidents for accuracy and complete documentation .is data complete and thorough and paints a picture of what happened .Was the care plan updated to reflect the incident .Is additional investigation needed to determine the exact events of the incident .What can be done to avoid similar incidents recurring on this or any patient in the center . Review of the undated facility policy titled, MISSING PATIENT PROCEDURE, revealed, .In the event a patient is discovered missing from the building, the following policies and procedures shall govern the situation .Person discovering that a patient may be potentially missing or not accounted for shall report the situation to their immediate supervisor .If the patient has not lawfully left the center, an immediate search of the building shall take place (corridor by corridor) at the direction of the charge nurse. Every patient's room bathroom, closet, or storage area will be thoroughly searched .Concurrent with the internal search, an external search of the grounds and adjacent areas shall be scanned for a wandering patient .including street and side street proximal to the center the charge nurse shall delegate this task .The Administrator and Director of Nurses shall be notified of situation immediately as well .When a missing patient has been found, an incident report and detailed description of the search shall be completed and forwarded to the DON and Administrator .All staff should be alert as to the whereabouts of all patients at all times to the extent possible and should be familiar with these procedures . 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease with late onset, Dementia without Behavioral Disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the care plan for Resident #10 revealed, .Problem Start Date XXX[DATE] Elopement: At risk for complications r/t [related to] impaired cognition due to dementia, wanders .Goal Target Date XXX[DATE] Will have elopement risk minimized through next 120 days or next review. Will remain in safe confines of center unless supervised by staff/representative .Approach Start Date XXX[DATE] apply and maintain wanderguard as need for accidental or self removing .Approach Start Date XXX[DATE] check wanderguard placement & function as ordered. Replace one month prior to expiration date .Approach Start Date XXX[DATE] Redirect and reassure patient during episodes of exit-seeking . The care plan for Resident #10 revealed at risk for elopement since [DATE]. Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt [patient] noted to pace hallways this night when asked what she was doing she stated she didn't know and felt like walking .when oriented to time of night pt stated maybe i [I] should sleep . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Frequently requires redirection by staff. Occasionally delusional . Review of the Elopement Risk dated [DATE] for Resident #10 revealed, .Has patient exhibited wandering or exit seeking behavior in the last 90 days .No .Is patient cognitively impaired with poor decision making skills .Yes .Does patient have indications of dementia or a diagnosis of dementia .Yes .Elopement Risk Score: 0.0 . The progress notes revealed Resident #10 was pacing the halls and expressed she did not know why, which placed this resident to be at risk for an elopement. Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt wandering in hallway earlier looking for daughter going room to room redirected returned to her room and 10 mins. [minutes] later doing same thing .easily redirected but doesn't last long. since med d'c 'd [discontinued] pt is more alert but some paranoia noted along with wandering in the evening and night .will monitor . Review of the Elopement Risk dated [DATE] for Resident #10 revealed, .Has patient exhibited wandering or exit seeking behavior in the last 90 days .No .Is patient cognitively impaired with poor decision making skills .Yes .Does patient have indications of dementia or a diagnoses of dementia .Yes .Elopement Risk Score: 0.0 . The progress notes revealed Resident #10 was wandering the halls and searching for family which placed the resident to be at risk for an elopement. Review of the Progress Notes dated [DATE] for Resident #10 revealed, .NP, notified of Pt's increased paranoia and not sleeping at night. New order noted for Trazadone [antidepressant] 25mg [milligram] PO [by mouth] q [every] HS.[hour of sleep] Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt wanders halls looking for daughter or trying to figure out 'what i am supposed to do' redirected multiple times by staff . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt wandering in hallway off and on during the night looking for family .redirected and then 30 mins. later same thing .will monitor . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt in hallways last night looking around then would go into room a few mins later looking around again .off and on all night .when asked what are you looking for stated 'i dont know' would go back to room and lay down .will monitor . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt up at night looking up and down hallways .then will dart back in room .when asked if pt needs something stated 'i'm [stated I'm] just looking .will monitor . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt paranoid and packing clothes up unable to redirect .will monitor . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Staff report behaviors such as packing to leave and wondering [wandering] -state . Review of the Elopement Risk dated [DATE] for Resident #10 revealed, .Has patient exhibited wandering or exit seeking behavior in the last 90 days .Yes .Is patient cognitively impaired with poor decision making skills .Yes .Does patient have indications of dementia or a diagnosis of dementia .Yes .Elopement Risk Score: 1.0 Level: The patient is at risk for elopement. Proceed with appropriate safety intervention . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Episodes of wandering up et [and] down halls looking for family . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had Brief Interview for Mental Status (BIMS) score of 9 which indicated moderately impaired cognition. Continued review of the MDS revealed Resident #10 wandered ,d+[DATE] days over the last 7 days. Continued review of the MDS revealed Resident #10 required supervision with locomotion on unit and no setup or physical help from staff for locomotion off unit. Continued review of the MDS revealed Resident #10 was able to walk 10 feet - 150 feet independently. Review of the care plan for Resident #10 revealed, .Problem Start Date XXX[DATE] .Behavioral Symptoms .At risk for altercation in behaviors r/t refusal of plan of care .Pt has wandering, delusions, and hallucinations .Approach Start Date XXX[DATE] .promote safety .Remind patient that words and actions have impact; redirect as needed .Remove patient from triggering situations when possible; respect personal space and rights . The behavior care plan for Resident #10 revealed she wandered and was delusional which placed the resident at risk for elopement. Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Pt had walked to other unit .was frantically and repeatedly asking for . her ex husband [named Ex-husband] . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .wanders throughout building looking for family members .will continue to monitor . Review of the Order History for Resident #10 revealed XXX[DATE] .Wanderguard: check for placement and skin integrity under band nightly .Wanderguard .expiration date Jun [June] 2023; check skin for placement, skin integrity, and functionality daily . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Pt is noted with increased confusion and pacing . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Continues to wander in hallway and requires some redirection . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt wanders halls looking for family members or locations . Review of the Elopement Risk dated [DATE] for Resident #10 revealed, .Has patient exhibited wandering or exit seeking behavior in the last 90 days .No .Is patient cognitively impaired with poor decision making skills .Yes .Does patient have indications of dementia or a diagnoses of dementia .Yes .Elopement Risk Score: 0.0 . The progress notes revealed Resident #10 was wandering the halls and searching for family which placed the resident to be at risk for an elopement. Review of the Progress Notes dated [DATE] for Resident #10 revealed, .increased confusion/paranoia noted this week .pacing and looking for husband or family .rummaging/hoarding items primarily on bed .refuses to allow staff to remove items . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Staff state that patient continues with occasional behaviors (packing to leave and wandering) . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Pt noted in room packing stating that she is going home that the Md [medical doctor] okayed it . Review of the Elopement Risk dated [DATE] for Resident #10 revealed, .Has patient exhibited wandering or exit seeking behavior in the last 90 days .No .Is patient cognitively impaired with poor decision making skills .Yes .Does patient have indications of dementia or a diagnosis of dementia .Yes .Elopement Risk Score: 0.0 . The progress notes revealed Resident #10 was wandering the halls, searching for family, and packing to leave which placed the resident to be at risk for an elopement. Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt exited building .walked to near by house .was returned to facility by member of the community .pt reports falling on hill outside door .no injury or pain noted .NP and daughter .notified .pt resting in bed at this time .will continue to monitor . Review of the POST FALL REPORT dated [DATE] revealed, .pt stated fell while outside on the hill . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .PT SEEN BY NP .THIS AM .PT REPORTED TO HAVE BITTEN HER TONGUE WHEN SHE fell .NP ORDERED WARM SALT WATER WRINSES [rinses] FOR THIS .PT CALM, NOT EXIT SEEKING .WILL CONT [CONTINUE] TO MONITOR . Review of the NP Progress Notes dated [DATE] for Resident #10 revealed, .Patient is seen today for follow up after exiting the facility early this morning and a self reported fall upon her return. Per staff, the patient did have dirt on the back of her clothes consistent with a fall as she had reported .Patient's daughter and daughter-in-law did arrive and the patient did report to them that her tongue was sore. Patient states that she thinks she bit it. No other injuries noted. Family is concerned about insomnia and requests that the patients night time sleep medicine 'trazadone' be increased . Review of the Order History dated [DATE] - [DATE] for Resident #10 revealed .Wanderguard: check for placement and skin integrity under band nightly .Wanderguard .expiration date Jun [June] 2023; check skin for placement, skin integrity, and functionality daily . Review of an invoice from Electrical Company revealed, the Senior [NAME] President (SVP) called the company on [DATE] at 6:10 AM and stated need electrical work at exit door on South end exit today. Continued review of the invoice revealed Electrical Company OO arrived at the facility on [DATE] and relocated exit light and power to exit panel and lock to an unswitched circuit. Review of the www.wunderground.com [weather underground] website the weather on [DATE] was a low of 67 degrees, high of 79 degrees, with 1.35 inches of rain for the day. During an interview on [DATE] at 4:20 PM the Director of Nursing (DON) stated, .we have an investigation on [Named Resident #10] exiting the building . Observation in the dining room on [DATE] at 10:57 AM, revealed Resident #10 was sitting at a table playing bingo. After the activity she followed staff out of the activity and goes straight to her bed to lay down and cover up. During an interview on [DATE] at 8:00 AM, the Administrator stated, .we were unable to determine what time she left .I don't know which house exactly she went to, but I have an address and phone number of the previous employee that brought her back to the building . During an interview on [DATE] at 9:05 AM, Family Member (FM) X stated, .They called me in the middle of the night said she [Resident #10] got out the door because the electricity went out or something .She wandered to a house in the neighborhood .I understood she either knocked on the door or rung the doorbell .that is the only time I knew she ever got out of the building .She went down an embankment .she said she fell .might have got some minor scratches .I went and looked where she walked out you could see in the mud where she slipped .I am so glad she didn't wander where them 2 bull dogs were chained up .a gentleman from the house she walked to brought her back .I know by 3:16 AM she was back in the building .The staff didn't even realize she was gone .she went out the double door close to her room .I don't have any idea the last time the staff had seen her .I was told the alarm didn ' t sound it wasn't working or something .I went down to the facility and the alarm was not working on the door .The facility said they would get the door fixed immediately but I couldn't understand why that was the only safety device they had in place to monitor the residents . During a telephone interview on [DATE] at 12:15 PM, Licensed Practical Nurse (LPN) Z stated, .I was working the night [Named Resident #10] left the building .I was not aware she was missing .She knocked on a door of a house near by .a CNA that use to work here was living there and he recognized her and brought her back to the facility .She had gotten up a couple of times .wandering a few times that night .I am not sure what time she left the building .I usually give her medicines between 7:00 PM - 9:00 PM .we were aware she was missing when the building got the phone call .We turned the light switch off to help the residents rest and that disengaged the door. She was more confused when she came back .mud and grass on her bottom .she said she slide down the hill . She didn't have any injuries .I contacted the person on call but I can't remember who that was .I spoke to the [Named Administrator] as well .I know the doors are checked by the maintenance department .they had someone to come out and repair the wiring to the door .we did a check for all the residents being in the building after she exited the building . During a telephone interview on [DATE] at 12:19 PM, LPN AA stated, .I was working that night when [Named Resident #10] got out of the building .the phone at the facility rang and someone asked if we had a resident missing .and then the doorbell rang and a gentleman had brought [Named Resident #10] back .We didn't know she was missing .She was a little scared and confused .she had some mud on her bottom and leg .[Named Resident #10] knocked on the neighbors door and said something about work she had to do in the basement .I am not sure how he got her back to the facility . During a telephone interview on [DATE] at 12:23 PM, CNA BB, stated, .[Named Resident #10] was having a hard time sleeping that night .[[DATE] the night Resident #10 eloped from the facility]kept wanting her son, wanting to leave to catch the bus .She went to sleep I thought .later I thought I heard a door closing .I thought the sound came from the vending machine .then an employee that use to work here brought her back to the building .she had walked to his family's house down the road .She had mud on her clothes, it had rained that day .we didn't see no visible injuries .I think that light switch was connected to the door and when we turned the lights off the door wasn't working .I usually do a round to check on everybody at 10:30 PM, 12:00 AM, or 1:00 AM .I don't remember what time it was I performed a check on her . During an interview on [DATE] at 1:50 PM, LPN Q stated, .If we had a missing wander guard or a missing resident, we would immediately do a head count . During an interview on [DATE] at 2:10 PM, the Administrator stated, .the door shorted out when the light switch was turned to the off position .we had an electrician come out to fix the door the next day .Initially the staff did not know she was gone .the staff said they heard a sound like a door slamming .two of the CNAs started checking the unit and that is when they realized [Named Resident #10] was missing . During an observation and interview on [DATE] at 4:15 PM, the Administrator and this Surveyor walked off the potential footage Resident #10 walked when she exited the facility on [DATE]. Resident #10 exited the 200 hall double doors, walked along a sidewalk, potentially walked down an embankment into the road. Resident #10 continued to walk to the fifth house to the right and knocked on the door. The potential footage walked was approximately 618 feet. The Administrator was asked if an interview was obtained from the former employee who brought Resident #10 back to facility, and he replied, No. During a telephone interview on [DATE] at 4:15 PM, Former Employee EE stated, .[Named Resident #10] walked to our house and knocked on the door around 2:00 AM .She was really confused and said she was trying to find her house, she was needing to go home .I had taken care of her before when I worked at the facility as a nurse aide .I helped to calm her down and got her into my car .in the meantime my family was calling the facility to make sure they had a missing resident .an employee came to the door to get her .They didn't know she was missing .She had one of those ankle bracelets on but [Named LPN Z] said it must have been broken . During a telephone interview on [DATE] at 4:34 PM, CNA GG stated, .[Named Resident #10] did get out of the building .I don't remember the time or if we knew really what time she left .she knocked on a neighbors door .I don't know if we knew she was gone or not .she would walk around the building independently . During an interview on [DATE] at 12:00 PM, the DON stated, .I would expect if a resident exited the building the nurse would do a full body assessment .chart the last time the resident was observed in the building .the alarm on the door did not sound when [Named Resident #10] went out the side door .I know the light switched contributed to her exiting the building .I did not interview [Named Former Employee EE] .I would expect my staff to know a resident was missing . Record review revealed there was no documentation for the last time Resident #10 was observed in the facility. ________________________________________ 3. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnosis which included Alzheimer's disease, Dementia, and Long Term Use of Anticoagulants. Review of the Quarterly MDS dated [DATE] revealed Resident #5 had a BIMS score of 4 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #5 required extensive assist with bed mobility, transfer, locomotion on unit and off unit, and dressing. Further review of the MDS revealed Resident #5 received an anticoagulant (blood thinner) over the last 7 days. Review of fall event dated [DATE] revealed Resident #5 had a witnessed fall in the hallway while leaning over in his wheelchair. Resident #5 sustained an abrasion noted to his forehead with the witnessed fall. Review of the neuro check sheet revealed the frequency to be performed was every 30 minutes times (x) 4, every 1 hour x 4, every 4 hours x 4, and every 8 hours x 6. Review of the neuro checks for [DATE] - [DATE] revealed missing documentation on [DATE] at 3:00 PM for the neuro check. Review of the Medication Administration Record (MAR) from [DATE] to [DATE] revealed Resident #5 received Eliquis (blood thinner) 2.5 mg by mouth twice a day. Review of the Progress note dated [DATE] for Resident #5 revealed, .PT WAS WITNESSED LEANING OVER IN WHEELCHAIR AND fell TO THE FLOOR. PT NOTED TO HAVE AN ABRASION NOTED TO FOREHEAD. [Named Conservator B] MADE AWARE, [Named NP C] AWARE . The progress note does not reveal if Conservator B was made aware of the risk of a fall with head injury while receiving a blood thinner for Resident #5. Review of the Physician Progress Notes dated [DATE] for Resident #5 revealed, .Routine visit for patient [with] progressive dementia, Afib [Atrial Fibrillation] .per Nursing fell last week bending over reaching for glasses Abrasion to R [right] forehead . Review of the care plan for falls for Resident #5 revealed .Problem Start Date [DATE] .At risk for falls r/t [related to] Hx [history] of falls, Alzheimer's and Dementia with decreased safety awareness, Delusional disorder .Goal .Patient will have fall risks minimized through 120 days or next review XXX[DATE] Encourage me to ask for assistance when picking items up off the floor XXX[DATE] Encourage me to ask for assistance when wanting to leave the dining room XXX[DATE] I will go from my low bed to mats and crawl in the floor in my room at times. I will do this instead of using my call light for assistance XXX[DATE] place bed control out of reach so that I do not adjust my bed to unsafe level XXX[DATE] Encourage patient to use non-skid footwear during transfers/ambulation .Encourage to use call light for needed assistance . The care plan interventions to prevent falls were not appropriate for Resident #5. Resident #5 had a BIMS score of 4 with the inability to remember to ask for assist or the ability to put non-skid footwear on prior to transfers and no ambulation occurred over the last 7 days of the MDS look back period. Review of the 5-day MDS assessment dated [DATE] for Resident #5 revealed a BIMS score of 4 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #5 required substantial/maximal assistance with sit to stand, chair/bed to chair transfer, and walking 10 feet was not attempted. Further review of the MDS revealed Resident #5 received an anticoagulant over the last 7 days. Review of the MAR dated [DATE]-[DATE] revealed an order for Eliquis 2.5 mg by mouth twice a day administered from [DATE]-[DATE]. Review of Hospice D's Visit Note Report dated [DATE], revealed Resident #5 was admitted to hospice with primary diagnoses of Cerebral Atherosclerosis and secondary diagnoses of Dementia. Review of the Visit Note Report revealed Resident #5 was confused, able to verbalize his name, self-propels in wheelchair short distances, and 3 or more falls in past 3 months. Review of Hospice D's Visit Note Report dated [DATE], revealed Resident #5 was being changed by CNA; the Hospice nurse assisted with Resident #5 transferring from bed to the wheelchair. Resident #5 stood, and nurse pivoted patient to the chair. Continued review of the Visit Note Report revealed Resident #5's vital signs were within normal limits (blood pressure (b/p) ,d+[DATE], Pulse (P) 88, Respirations (R) 16, Temperature (T) 97.2). Review of the Hospice D's Visit Note Report dated [DATE] for Resident #5 revealed, .CHAPLAIN HOSPICE EVALUATION .Narrative .ESCORTED PATIENT TO DINING AREA HE EVENTUALLY RESPONDED. HE WAS ABLE TO ANSWER SOME QUESTIONS. PATIENT STATED HE WAS A CHRISTIAN. HE STATED HE WAS FROM [NAME]. HE SMILED AND SEEMED PROUD THAT HE WAS A FIREFIGHTER .THIS CHAPLAIN OFFERED PRAYER AND PATIENT SAID SURE .PATIENT DID STATE HE WAS MARRIED AND HAD 2 CHILDREN. HIS FAMILY DOES NOT SEEM TO BE ENVOLVED [involved] IN HIS CARE XXX[DATE] 01:33 PM . Review of the Progress Notes dated [DATE] for Resident #5 revealed, .2:05PM .PT [patient] WAS LEANING FORWARD IN WHEELCHAIR REACHING TO THE FLOOR AND fell OUT OF CHAIR HITTING HEAD ON FLOOR CREATING AN ABRASION. [Named Conservator B] AWARE AND NP .[Named NP C] AND HOSPICE AWARE WITH NO NEW ORDERES [orders] AT THIS TIME . The facility's progress notes did not reflect Conservator B was made aware of Resident #5's routine administration of a blood thinner and the risks of a fall with a head injury. Review of the care plan for falls for Resident #5 revealed .At risk for falls r/t [related to] Hx [history] of falls, Alzheimer's and Dementia with decreased safety awareness, Delusional disorder .Goal .Patient will have fall risks minimized through 120 days or next review XXX[DATE] Encourage me to ask for assistance when picking items up off the floor XXX[DATE] Encourage patient to use non-skid footwear during transfers/ambulation .Encourage to use call light for needed assistance . The circumstance of Resident #5's fall on this date ([DATE]) was identical to the fall on [DATE] with a post fall care plan intervention not being appropriate to prevent further falls. Review of the neuro checks dated [DATE] for Resident #5 revealed: a. 1:30 PM B/P ,d+[DATE], P 114; b. 2:00 PM B/P ,d+[DATE], P 66; c. 2:30 PM ,d+[DATE], P 55; d. 3:00 PM ,d+[DATE], P 67; e. 4:00 PM ,d+[DATE], P 66; f. 5:00 PM ,d+[DATE], P 76; g. 6:00 PM ,d+[DATE], P 50; h. 7:00 PM ,d+[DATE], P 43; i. 11:00 PM ,d+[DATE], P 70. Review of the Progress Notes dated [DATE] for Resident #5 revealed, .6:50PM .PT NOTED TO HAVE A DECLINE THIS AFTERNOON HOSPICE HERE TO EVAL PT WITH NEW ORDERS. CONSERVATOR AWARE OF DECLINE . Review of Hospice D's Visit Note Report dated [DATE] for Resident #5 revealed, .Vital Signs .Pulse 98 .Blood Pressure ,d+[DATE] .PT HAD FALL HYPOTENSIVE [NAME] [DECLINE] NOTED IN STATUS AND SLURRED SPEECH .MOANING TENSE .TYLENOL FOR PAIN ADDED ROXANOL [Narcotic given for severe pain] .RESPIRATORY STATUS .SHALLOW SHORTNESS OF BREATH .HEART RATE FINDINGS IRREGULAR TACHYCARDIA .PALE .ABRASION FOREHEAD .FALL REPORT ABRASION AREA TO FOREHEAD HYPOTENSIVE .HOSPICE NURSE IN FACILITY FOR VISIT FOR OTHER RESIDENTS. FACILITY NURSE ASKED NURSE TO VISIT WITH PT DUE TO RECENT FALL DECLINE THROUGHTOUT DAY. NURSE ENTERED

Based on facility policy review, medical record review, observations, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 17 residents sampled (Resident #5 and Resident #7) that resulted in actual harm for Resident #5. The findings include: Review of the policy titled, Documentation Guidelines, dated 6/2023 revealed, .The center will ensure an interdisciplinary and comprehensive approach to the development of the patient's care plan of care. Patient's goals for care and preferences will be determined and used to develop their plan of care .Full care plan within 7 days of completion .of a clinical MDS assessment .Problems are patient conditions, needs, or weakness which currently do, or potentially could, prevent the patient from achieving or maintaining the highest practicable level of weel-being .Care Plan Approaches are specific, individualized steps partners and patients will take together to assist the patient to achieve the goal .Approaches serve as instructions of patient care an provide for continuity of care by all partners . Review of the facility policy titled, Incident and Accident Process, dated 1/2024 revealed, .An incident or accident is defined as any occurrence that is outside the norms or any happening that is not consistent with the routine operation of the center or care of a particular patient .When any incident results in injury, as defined below, and/or there is evidence of negligence, they must be reported to clinical risk management .Significant injury including: Fracture or dislocation of bones or joints, Closed head injury with altered consciousness, and Subdural hematoma .Any condition requiring medical treatment outside the center that is inconsistent with the routine management of the patient's preexisting condition(s) .The DON [Director of Nursing] should review all incidents for accuracy and complete documentation .is data complete and thorough and paints a picture of what happened .Was the care plan updated to reflect the incident .Is additional investigation needed to determine the exact events of the incident .What can be done to avoid similar incidents recurring on this or any patient in the center . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnosis which included Alzheimer's disease, Dementia, and Long-term use of anticoagulants. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #5 required extensive assist with bed mobility, transfer, locomotion on unit and off unit, and dressing. Further review of the MDS revealed Resident #5 received an anticoagulant (blood thinner) over the last 7 days. Review of fall event dated 11/18/2023 revealed Resident #5 had a witnessed fall in the hallway while leaning over in wheelchair. Resident #5 sustained an abrasion noted to his forehead with the witnessed fall. Review of the Medication Administration Record (MAR) from 11/1/2023 to 11/30/2023 revealed Resident #5 received Eliquis (blood thinner) 2.5 mg (milligram) by mouth twice a day. Review of the Progress note dated 11/18/2023 for Resident #5 revealed, .PT WAS WITNESSED LEANING OVER IN WHEELCHAIR AND fell TO THE FLOOR. PT NOTED TO HAVE AN ABRASION NOTED TO FOREHEAD. [Named Conservator B] MADE AWARE, [Named Nurse Practitioner (NP) C] AWARE . Review of the Physician Progress Notes dated 11/24/2023 for Resident #5 revealed, .Routine visit for patient [with] progressive dementia .per Nursing fell last week bending over reaching for glasses Abrasion to R [right] forehead . Review of the care plan for falls for Resident #5 revealed .Problem Start Date 6/18/2019 .At risk for falls r/t [related to] Hx [history] of falls, Alzheimer's and Dementia with decreased safety awareness, Delusional disorder .Goal .Patient will have fall risks minimized through 120 days or next review .11/18/2023 Encourage me to ask for assistance when picking items up off the floor .8/19/2023 Encourage me to ask for assistance when wanting to leave the dining room .4/16/2023 I will go from my low bed to mats and crawl in the floor in my room at times. I will do this instead of using my call light for assistance .8/4/2022 place bed control out of reach so that I do not adjust my bed to unsafe level .6/18/2019 Encourage patient to use non-skid footwear during transfers/ambulation .Encourage to use call light for needed assistance . The care plan interventions to prevent falls were not appropriate for Resident #5. Resident #5 had a BIMS score of 4 with the inability to remember to ask for assistance or any ability to put non-skid footwear on prior to transfers and no ambulation occurred over the last 7 days of the MDS look back period. Review of the 5-day MDS assessment dated [DATE] for Resident #5 revealed a BIMS score of 4 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #5 required substantial/maximal assistance with sit to stand, chair/bed to chair transfer, and walking 10 feet was not attempted. Further review of the MDS revealed Resident #5 received an anticoagulant over the last 7 days. Review of the MAR dated 1/1/2024-1/31/2024 revealed an order for Eliquis 2.5 mg by mouth twice a day administered from 1/1/2024-1/23/2024. Review of the Progress Notes dated 1/23/2024 for Resident #5 revealed, .2:05PM .PT [patient] WAS LEANING FOWARD IN WHEELCHAIR REACHING TO THE FLOOR AND fell OUT OF CHAIR HITTING HEAD ON FLOOR CREATING AN ABRASION. [Named Conservator B] AWARE AND NP .[Named NP C] AND HOSPICE AWARE WITH NO NEW ORDERES [orders] AT THIS TIME . The circumstance of Resident #5's fall on this date (1/23/2024) was identical to the fall on 11/18/2023, with a post care plan intervention, which was not appropriate to prevent further falls due to Resident 5's impaired cognitive status. Review of the neuro checks dated 1/23/2024 for Resident #5 revealed: 1:30 PM B/P 124/60, P 114; 2:00 PM B/P 102/87, P 66; 2:30 PM 105/60, P 55; 3:00 PM 130/55, P 67; 4:00 PM 107/89, P 66; 5:00 PM 90/62, P 76; 6:00 PM 98/40, P 50; 7:00 PM 90/46, P 43; 11:00 PM 90/52, P 70. Review of the Progress Notes dated 1/23/2024 for Resident #5 revealed, .6:50PM .PT NOTED TO HAVE A DECLINE THIS AFTERNOON HOSPICE HERE TO EVAL . Review of the Hospice D's Visit Note Report dated 1/23/2024 for Resident #5 revealed, .Vital Signs .Pulse 98 .Blood Pressure 88/52 .PT HAD FALL HYPOTENSIVE [NAME] [DECLINE] NOTED IN STATUS AND SLURRED SPEECH .MOANING TENSE .TYLENOL FOR PAIN ADDED ROXANOL [Narcotic given for severe pain] .RESPIRATORY STATUS .SHALLOW SHORTNESS OF BREATH .HEART RATE FINDINGS IRREGULAR TACHYCARDIA .PALE .ABRASION FOREHEAD .FALL REPORT ABRASION AREA TO FOREHEAD HYPOTENSIVE .HOSPICE NURSE IN FACILITY FOR VISIT FOR OTHER RESIDENTS. FACILITY NURSE ASKED NURSE TO VISIT WITH PT DUE TO RECENT FALL DECLINE THROUGHTOUT DAY. NURSE ENTERED ROOM .INCREASED PALE IN COLOR AND SLURRED SPEECH NOTED WITH WORDS. ABRASION NOTED TK [TO] FOREHEAD RISED AREA .HAND GRIPS WEAK .PT TENSE AND MOANING WITH TOUCH BREATHING SHALLOW HYPOTENSIVE IRREGULAR .HEART RATE .NEW ORDER PER MD [MEDICAL DOCTOR] .ROXANOL 0.5ML [MILLILITERS] BY MOUTH OR UNDER TONGUE EVERY 2 HOURS AS NEEDED FOR PAIN RESTLESSNESS AND OR AIR HUNGER .PT DAID [SAID] HE WAS COLD .NEW ORDERS REPORTED TO NURSE AND CONSERVATOR MADE AWARE BY FACILITY NURSE HOSPICE NURSE BESIDE NURSE .VISIT TIME .7:00PM . Review of the Nurse Practitioner (NP) C's progress note dated 1/24/2024 for Resident #5 revealed, .He was admitted to hospice services on 1/19/24. Staff did notify ths [this] provider, by way of phone, yesterday evening that the patient had fell forward out of his wheelchair and hit his head on the floor. The nurse reported that the patient was now having what she believed were neurological changes. She stated that he appeared more drowsy and confused .New orders were given to discontinue patient's Eliquis at this time due to possibility of bleeding .Today staff report that the patient continues to be more confused than his baseline. He is reported to have increased agitation and also hypotension .Patient is found in his room .drowsy and with nonsensical speech . Review of the Progress Notes dated 1/24/2024 for Resident #5 revealed, .1:01PM .ALERT .PT RESTING IN BED AT THIS TIME.ABRASION CONTS [continues] OT [to] FOREHEAD.PT COMBATIVE THIS AM DURING CARE. SMALL AMOUNT OF BLOOD NOTED TO MOUTH, CLEANSED WITH TOOTHETTES . Review of the Progress Notes dated 1/25/2024 for Resident #5 revealed, .2:54AM .ALERT .Patient with abrasion noted .Patient noted to be rambling/mumbling with this nurse not able to understand patient .Patient with blood noted to mouth from recent fall .Patient has continued to attempt to get out of bed without assistance with staff providing education to patient to not get up without assistance . Resident #5 with a BIMS score of 4 was unable to comprehend any type of education on safety. Review of Hospice D's Visit Note Report for Resident #5 dated 1/25/2024 revealed, .Pulse 110 .Blood Pressure 86/53 .OCCASIONAL MOAN OR GROAN .FRIGHTENED .KNEES PULLED UP .UNABLE TO SPEAK .HE IS DISORIENTED .UNABLE TO BE REDIRECTED .COMBATIVE WITH ANY ACTIVITY .DAZED LOOK ON HIS FACE. HE IS HYPOTENSIVE AND TACHCARDIC .7:02 AM . Review of the Progress Notes dated 1/25/2024 for Resident #5 revealed, .10:27AM .ALERT .Pt confused with combativeness .Pt reaching for things not present in the room. Abrasion to forehead remains . Review of the Progress Notes dated 1/25/2024 for Resident #5 revealed, .11:55AM .Spoke with NP this am regarding patients decline. Patient has been combative with staff when attempting to provide .care .Hospice made aware of patients decline and will be out to make a visit this shift . Review of the Progress Notes dated 1/26/2024 for Resident #5 revealed, .12:43AM .Patient .mumbling with this nurse unable to understand what patient is saying. Patient continues with abrasion to forehead .Patient combative with staff this shift .Patient has continued to attempt to get out of bed without assistance with staff . Review of the Progress Notes dated 1/26/2024 for Resident #5 revealed, .11:32AM .ALERT .Pt unable to swallow anything PO [by mouth] at this time. Abrasion remains to forehead .Neurochecks completed from recent fall. R/T [related to] pt decline, Roxanol administered for pain per order . Review of the Progress Note dated 1/26/2024 for Resident #5 revealed, .2:48PM .patient unable to take PO meds due to decline in conditions. meds discontinued per NP and hospice . Review of the Progress Note dated 1/26/2024 for Resident #5 revealed, .10:11PM .This nurse was notified that pt was unresponsive. Went in to [into] pt's room to assess. Pt seen lying on bed unresponsive, no spontaneous movements and no response to verbal and painful stimuli noted. Pupils were fixed dilated, non reactive to light and accommodation. Carotid pulse not palpated. No heart and lung sounds auscultated. No noted rise and fall of abdomen. Pt pronounced dead at 9:57pm [PM] . During an interview on 4/10/2023 at 2:13 PM, the DON was asked if the care plan intervention for Resident #5's fall was an appropriate intervention for a resident with a BIMS score of 4. The DON stated, .No, I thought we went back and fixed the care plans for the residents with poor cognition .he can't remember to ask for assistance and to use non skid socks would not be appropriate .I thought we changed the word encourage to the word remind . During an interview on 3/19/2024 at 12:28 PM, Registered Nurse (RN) R stated, .with any fall you perform a head to toe assessment .if a resident hits their head we would start neuro checks .Call MD immediately with any changes RN R was asked if the facility would treat a hospice resident that had a fall any different. RN R stated, .we still treat a hospice patient the same notify hospice, call doctor, family and update them with any changes .just because the resident is on hospice doesn't mean they can't go to the hospital if that is what the family wants to do . RN R stated, .when a fall happens you put in an event in the computer system .it asks if the resident takes anticoagulants .you should call the MD to see if they want to continue the blood thinner .a resident could have a fracture, subdural hematoma .watch their blood pressure to see if it is dropping .heart rate going up .changes in their cognition .could be signs of a bleed . During an interview on 3/20/2023 at 3:06 PM, LPN G stated, .I talked to [Named Conservator B] after his fall .I think I told her he hit his head, I don't remember if I told her he was taking a blood thinner .I think I talked to her about his decline in his blood pressure .I told the NP about his changes . During a telephone interview on 4/5/2024 at 7:55 AM, Conservator B called this surveyor back and stated, .I knew [Named Resident #5] had been declining and was placed on hospice but I have no record that I was told he was taking a blood thinner when he fell and hit his head .I even asked my boss to see if she recalled anything being said about blood being found in his mouth .just because a resident is on hospice it doesn't mean they shouldn't be sent out for treatment .I just recently sent a hospice patient out of a facility due to a head injury .I had a doctor tell me that if the blood pressure can be more stabilized it helps with the patients comfort. I was notified by email about the fall .I have no records of any phone call related to the fall .I wish I would have been told about blood in his mouth .I did receive a call on the day he passed away . Conservator B provided the email dated 1/23/2024 at 2:15 PM from LPN G which revealed, .Hey, just wanted to let you know that [Named Resident #5] fell out of wheelchair and got an abrasion to forehead During an interview on 4/8/2024 at 11:48 AM, Hospice LPN HH stated, .I was at the facility visiting other hospice residents on 1/23/2024 and [Named LPN HH] wanted me to see [Named Resident #5] because he was hypotensive after his fall .he was restless .I heard [Named LPN HH] call the conservator and made her aware of .his overall decline .I think it was between 6:00 PM and 7:00 PM when I saw him .I know the NP was notified related to him being on Eliquis and his blood pressure being lower . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnosis which included Vascular Dementia, unspecified severity. Review of the care plan for Resident #7 revealed, .Start Date: 11/09/2023 .Behavioral Symptoms .At risk for alteration in behaviors refusal of plan of care .Pt has impulsive behaviors with decreased safety awareness, false beliefs/misperceptions, physical behavior towards staff, and wandering .Approach Start Date .3/19/2024 Patient may attract negative attention from other patients due to their poor understanding of personal space and spatial boundaries. Redirect as needed .When Pt is wandering, assess for unmet physical needs, psychological distress, and environmental factors. Distract Pt by introducing enjoyed activities .Educate and encourage patient to comply with plan of care . Resident #7 with a BIMS score of 6 does not have the ability to understand the need to comply with the plan of care. Review of the Quarterly MDS dated [DATE] revealed Resident #7 had a BIMS score of 6 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #7 experienced delusions, physical behaviors directed toward others, and wandered 4-6 days over the last 7 day look back period. Review of the NP progress note dated 3/18/2024 for Resident #7 revealed, .Per staff, patient remains at her baseline. She is pleasantly confused . Observation in the resident's room on 3/19/2024 at 2:45 PM, revealed Resident #7 being assisted to bed. Observation in the dining room on 3/20/2024 at 12:30 PM, revealed Resident #7 was in her wheelchair rolling to different residents introducing herself.

Based on record review and interview, the facility failed to conduct yearly performance evaluations for 2 of 6 Certified Nurse Assistant (CNA MM and CNA NN) personnel files reviewed. The findings include: 1. Review of the job description titled, Job Descriptions, Nurse, Director of Nursing, dated 10/12/2021 revealed, .Demonstrated leadership and supervisory skills in the areas of nursing administration, nursing practice .Is responsible for maintaining clinical competency as evidenced by application of integrated nursing knowledge and skill, leadership, and communications skills .Monitors to see that there is accurate and adequate documentation in the medical record including electronic health record .Plan and encourages participation in in-service and continuing education for all levels of nursing personnel (including CNA training program .) .Promotes and delegate accountability for maintaining an effective performance appraisal system for nursing . Review of the job description titled, Job Descriptions, Certified Nurse Assistant, dated 11/3/2021 revealed, .Ability to meet performance requirements .Attend in-service programs, as assigned, to learn procedures and develop skills and meet state requirements . 2. Review of CNA MM's personnel file, on 4/10/2024 at 1:15 PM, revealed CNA MM's date of hire was 6/16/2020. Continued review of CNA MM's employee filed revealed no performance evaluation completed over the last year. Review of CNA NN's personnel file, on 4/10/2024 at 1:25 PM, revealed CNA NN's date of hire was 12/7/2021. Continued review of CNA NN's employee file revealed no performance evaluation completed over the last year. During an interview on 4/4/2024 at 1:32 PM, the DON stated, We started the performance evaluations back last year some time . During an interview on 4/10/2024 at 4:20 PM, the Accounts Payable QQ stated, .At some point last year, we started doing performance evaluations to get back on track. After COVID we had postponed this. The DON felt we needed to do them to help them improve and let them know what they were doing good, wanted to connect with the partners . During an interview on 4/10/2024 at 5:00 PM, the Administrator stated, .During COVID 2020-2021, we suspended performance evals for a lot of reasons .the PIE (performance improvement evaluation) was not done due to pandemic regardless annual review middle of 2023 we started tracking that and adding to our annual plan .

Based on facility policy review, job description review, employee file review, medical record review, observation, and interview, the facility failed to provide competent and proficient nursing staff to assure residents' safety and attain or maintain the highest practicable physical wellbeing for 3 of 17 (Resident #5, Resident #7 and Resident #6) sampled residents reviewed. The facility failed to have a person-centered appropriate intervention in place to prevent a second fall for Resident #5 on 1/23/2024, which resulted in a head injury. The nurse failed to provide pertinent details related to a fall with a head injury for Resident #5 who was on long term use of an anticoagulant (blood thinner). Resident #1 and Resident #7 were involved in a resident-to-resident altercation on 3/9/2024 which resulted in verbal abuse with Resident #7. Resident #6 and Resident #8 were involved in a resident-to-resident altercation on 3/19/2024 which resulted in physical harm for Resident #6. The Director of Nursing (DON) failed to perform yearly licensed nurse performance evaluations for 3 of 5 licensed nurse files reviewed. The findings include: 1. Review of the job description titled, Job Descriptions, Nurse, Director of Nursing, dated 10/12/2021 revealed, .Demonstrated leadership and supervisory skills in the areas of nursing administration, nursing practice .Is responsible for maintaining clinical competency as evidenced by application of integrated nursing knowledge and skill, leadership, and communications skills .Monitors to see that there is accurate and adequate documentation in the medical record including electronic health record .Plan and encourages participation in in-service and continuing education for all levels of nursing personnel (including CNA training program .) .Promotes and delegate accountability for maintaining an effective performance appraisal system for nursing . Review of the job description titled, Job Descriptions, Registered Nurse, dated 11/2/2021 revealed, .Ability to meet performance requirements .Is responsible for maintaining clinical competency as evidenced by application of integrated nursing knowledge and skills, leadership, and communication skills .Utilizes the nursing process in assessment, planning and implementing care .Integrates current standards of practice as well as local, state, and federal regulations related to nursing services in the care of patients .Assures the personal dignity and physical safety of each patient . Review of the job description titled, Job Descriptions, Licensed Practical Nurse, dated 11/2/2021 revealed, .Ability to meet performance requirements .Is responsible for maintaining clinical competency as evidenced by application of integrated nursing knowledge and skills, leadership, and communication skills .Integrates current standards of practice as well as local, state, and federal regulations related to nursing services in the care of patients .Maintains open and ongoing communication with patients and families, providing opportunity and encouragement to participate in decision making .Assure the personal dignity and physical safety of each patient . Review of the job description titled, Job Descriptions, Certified Nurse Assistant, dated 11/3/2021 revealed, .Ability to meet performance requirements .Attend in-service programs, as assigned, to learn procedures and develop skills and meet state requirements . Review of the facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 2/1/2023 revealed, .Abuse, Neglect .will not be tolerated by anyone, including staff, patients .The patient has the right to be free from abuse, neglect .Abuse: the willful infliction of injury .intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain, physical, mental, and psychosocial well-being .It includes verbal abuse .physical abuse, and mental abuse .Willful .means the individual must have acted deliberately .Verbal Abuse: the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents .or within their hearing distance regardless of their .ability to comprehend .Physical Abuse: includes hitting, slapping, pinching and kicking .Neglect: the failure of the facility, its employees .to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress .PREVENTION POLICY .The center will provide supervision and support services designed to reduce the likelihood of abuse behaviors .All supervisory partners who receive reports of and/or identify inappropriate behaviors will take immediate steps to correct such behaviors .Patients with needs and behaviors that might lead to conflict with partners or other patients will be identified .Monitoring the patient for any changes that would trigger abusive behavior .Dementia management program as needed .any person will be considered an allegation of either abuse, neglect .Any allegation (or) indication of possible willful infliction .Any complaint of deprivation by an individual caregiver of goods and services necessary to attain or maintain physical, mental, and psychological well being .Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect .must report the event immediately, but not later than 2 hours after forming the suspicion if the events that cause the suspicion involve abuse .it is the policy of this facility that abuse allegations (abuse, neglect .mistreatment .) are reported per Federal and State Law .The investigation is conducted immediately .When it is identified that an alleged incident may have occurred .As soon as any partner has knowledge and reports an alleged event .When there is a question as to whether to conduct an investigation, it is best to do so .The results of all investigations will be completed within five working days of the incident .Any individual found to be in danger of injury will be removed from the source of the suspected abusive behavior including but not limited to room or staffing changes .to protect the patient (s) from the alleged perpetrator .Increased supervision of the alleged victim and patients . Review of the facility policy titled, .Incident and Accident Process ., dated 1/2024 revealed, .An incident or accident is defined as any occurrence that is outside the norms or any happening that is not consistent with the routine operation of the center or care of a particular patient .All patient incidents should be documented in the EHR [electronic health record] .When any incident results in injury, as defined below, and/or there is evidence of negligence, they must be reported to clinical risk management .Significant injury including: Fracture or dislocation of bones or joints, Closed head injury with altered consciousness, and Subdural hematoma .Any condition requiring medical treatment outside the center that is inconsistent with the routine management of the patient's preexisting condition(s) .The DON [Director of Nursing] should review all incidents for accuracy and complete documentation .is data complete and thorough and paints a picture of what happened .Was the care plan updated to reflect the incident .Is additional investigation needed to determine the exact events of the incident .What can be done to avoid similar incidents recurring on this or any patient in the center . 2. Review of LPN G's personnel file, on 4/10/2024 at 1:15 PM, revealed LPN G's date of hire was 6/2/2005. LPN G's personnel file revealed her last performance evaluation was completed on 4/9/2018. Review of RN U's personnel file, on 4/10/2024 at 1:25 PM, revealed RN U's date of hire was 12/1/2013. RN U's personnel file revealed her last performance evaluation was completed on 4/19/2018. Review of LPN JJ's personnel file, on 4/10/2024 at 4:10 PM, revealed LPN JJ's date of hire was 4/15/1993. LPN JJ's personnel file revealed her last performance evaluation was completed on 4/18/2018. During an interview on 4/10/2024 at 4:20 PM, Accounts Payable QQ stated, .At some point last year, we started doing performance evaluations to get back on track. After COVID we had postponed this. The DON felt we needed to do them to help them improve and let them know what they were doing good, wanted to connect with the partners . During an interview on 4/10/2024 at 5:00 PM, the Administrator stated, .During COVID 2020-2021, we suspended performance evals for a lot of reasons .the PIE (performance improvement evaluation) was not done due to pandemic regardless annual review middle of 2023 we started tracking that and adding to our annual plan . 3. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnosis which included Alzheimer's disease, Dementia, and Long-Term Use of Anticoagulants. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #5 required extensive assist with bed mobility, transfer, locomotion on unit and off unit, and dressing. Further review of the MDS revealed Resident #5 received an anticoagulant (blood thinner) over the last 7 days. Review of the Medication Administration Record (MAR) from 11/1/2023 to 11/30/2023 revealed Resident #5 received Eliquis (blood thinner) 2.5 milligram (mg) by mouth twice a day. Review of the Physician Progress Notes dated 11/24/2023 for Resident #5 revealed, .Routine visit for patient [with] progressive dementia .per Nursing fell last week bending over reaching for glasses Abrasion to R [right] forehead . Review of the care plan for falls for Resident #5 revealed, .Problem Start Date 6/18/2019 .At risk for falls r/t [related to] Hx [history] of falls, Alzheimer ' s and Dementia with decreased safety awareness, Delusional disorder .Goal .Patient will have fall risks minimized through 120 days or next review .11/18/2023 Encourage me to ask for assistance when picking items up off the floor .8/19/2023 Encourage me to ask for assistance when wanting to leave the dining room .6/18/2019 Encourage patient to use non-skid footwear during transfers/ambulation .Encourage to use call light for needed assistance . The care plan interventions to prevent falls were not appropriate for Resident #5. Resident #5 had a BIMS score of 4 with the inability to recall asking for assistance or any ability to put non-skid footwear on prior to transfers and no ambulation occurred over the last 7 days of the MDS look back period. Review of the MAR dated 1/1/2024-1/31/2024 revealed an order for Eliquis 2.5 mg by mouth twice a day administered from 1/1/2024-1/23/2024. Review of the Progress Notes dated 1/23/2024 for Resident #5 revealed, .2:05PM .PT [patient] WAS LEANING FOWARD IN WHEELCHAIR REACHING TO THE FLOOR AND fell OUT OF CHAIR HITTING HEAD ON FLOOR CREATING AN ABRASION. [Named Conservator B] AWARE AND NP .[Named NP C] AND HOSPICE AWARE WITH NO NEW ORDERES [orders] AT THIS TIME . The circumstance of Resident #5's fall on this date (1/23/2024) was identical to fall on 11/18/2023 with a post care plan intervention not being appropriate to prevent further falls. Review of the medical record dated 1/23/2024-1/25/2024 for Resident #5, revealed resident became hypotensive after his fall, had neurologic changes, became combative, increase symptoms of pain, blood in his mouth two different times, and slurred speech. Review of the Hospice D's Visit Note Report dated 1/23/2024 for Resident #5 revealed, .Vital Signs .Pulse 98 .Blood Pressure 88/52 .PT HAD FALL HYPOTENSIVE [NAME] [DECLINE] NOTED IN STATUS AND SLURRED SPEECH .MOANING TENSE .TYLENOL FOR PAIN ADDED ROXANOL [Narcotic given for severe pain] .RESPIRATORY STATUS .SHALLOW SHORTNESS OF BREATH .HEART RATE FINDINGS IRREGULAR TACHYCARDIA .PALE .ABRASION FOREHEAD .FALL REPORT ABRASION AREA TO FOREHEAD HYPOTENSIVE .HOSPICE NURSE IN FACILITY FOR VISIT FOR OTHER RESIDENTS. FACILITY NURSE ASKED NURSE TO VISIT WITH PT DUE TO RECENT FALL DECLINE THROUGHTOUT [throughout] DAY. NURSE ENTERED ROOM .INCREASED PALE IN COLOR AND SLURRED SPEECH NOTED WITH WORDS. ABRASION NOTED TK [TO] FOREHEAD RISED [raised] AREA .HAND GRIPS WEAK .PT TENSE AND MOANING WITH TOUCH BREATHING SHALLOW HYPOTENSIVE IRREGULAR .HEART RATE .NEW ORDER PER MD [MEDICAL DOCTOR] .ROXANOL 0.5ML [milliliters] BY MOUTH OR UNDER TONGUE EVERY 2 HOURS AS NEEDED FOR PAIN RESTLESSNESS AND OR AIR HUNGER .PT DAID [said] HE WAS COLD .7:00PM . Review of the Progress Notes dated 1/25/2024 for Resident #5 revealed, .2:54AM .ALERT .Patient with abrasion noted .Patient noted to be rambling/mumbling with this nurse not able to understand patient .Patient with blood noted to mouth from recent fall .Patient has continued to attempt to get out of bed without assistance with staff providing education to patient to not get up without assistance . Resident #5 with a BIMS score of 4 was unable to comprehend any type of education on safety. Review of Hospice D's Visit Note Report for Resident #5 dated 1/25/2024 revealed, .Pulse 110 .Blood Pressure 86/53 .OCCASIONAL MOAN OR GROAN .FRIGHTENED .KNEES PULLED UP .UNABLE TO SPEAK .HE IS DISORIENTED .UNABLE TO BE REDIRECTED .COMBATIVE WITH ANY ACTIVITY .DAZED LOOK ON HIS FACE. HE IS HYPOTENSIVE AND TACHCARDIC .7:02 AM . Review of the Progress Notes dated 1/25/2024 for Resident #5 revealed, .10:27AM .ALERT .Pt confused with combativeness .Pt reaching for things not present in the room. Abrasion to forehead remains . Review of the Progress Notes dated 1/26/2024 for Resident #5 revealed, .12:43AM .Patient .mumbling with this nurse unable to understand what patient is saying. Patient continues with abrasion to forehead .Patient combative with staff this shift .Patient has continued to attempt to get out of bed without assistance with staff . Review of the Progress Notes dated 1/26/2024 for Resident #5 revealed, .11:32AM .ALERT .Pt unable to swallow anything PO [by mouth] at this time. Abrasion remains to forehead . Review of the Progress Note dated 1/26/2024 for Resident #5 revealed, .10:11PM .This nurse was notified that pt was unresponsive. Went in to [into] pt's room to assess. Pt seen lying on bed unresponsive, no spontaneous movements and no response to verbal and painful stimuli noted. Pupils were fixed dilated, non reactive to light and accommodation. Carotid pulse not palpated. No heart and lung sounds auscultated. No noted rise and fall of abdomen. Pt pronounced dead at 9:57pm . During an interview on 3/19/2024 at 12:28 PM, Registered Nurse (RN) R stated, .with any fall you perform a head to toe assessment .if a resident hits their head we would start neuro checks .Call MD immediately with any changes RN R was asked if the facility would treat a hospice resident that had a fall any different. RN R stated, .we still treat a hospice patient the same notify hospice, call doctor, family and update them with any changes .just because the resident is on hospice doesn ' t mean they can ' t go to the hospital if that is what the family wants to do . RN R stated, .when a fall happens you put in an event in the computer system .it asks if the resident takes anticoagulants .you should call the MD to see if they want to continue the blood thinner .a resident could have a fracture, subdural hematoma .watch their blood pressure to see if it is dropping .heart rate going up .changes in their cognition .could be signs of a bleed . During an interview on 3/20/2023 at 3:06 PM, LPN G stated, .I talked to [Named Conservator B] after his fall .I think I told her he hit his head, I don't remember if I told her he was taking a blood thinner .I think I talked to her about his decline in his blood pressure . During a telephone interview on 4/5/2024 at 7:55 AM, Conservator called this surveyor back and stated, .I knew [Named Resident #5] had been declining and was placed on hospice but I have no record that I was told he was taking a blood thinner when he fell and hit his head .I even asked my boss to see if she recalled anything being said about blood being found in his mouth .just because a resident is on hospice it doesn't mean they shouldn't be sent out for treatment .I just recently sent a hospice patient out of a facility due to a head injury .I had a doctor tell me that if the blood pressure can be more stabilized it helps with the patients comfort. I was notified by email about the fall .I have no records of any phone call related to the fall .I wish I would have been told about blood in his mouth .I did receive a call on the day he passed away . The Conservator provided the email dated 1/23/2024 at 2:15 PM from LPN G which revealed, .Hey, just wanted to let you know that [Named Resident #5] fell out of wheelchair and got an abrasion to forehead During an interview on 4/8/2024 at 11:48 AM, Hospice LPN HH stated, .I was at the facility visiting other hospice residents on 1/23/2024 and [Named LPN HH] wanted me to see [Named Resident #5] because he was hypotensive after his fall .he was restless .I heard [Named LPN HH] call the conservator and made her aware of .his overall decline .I never heard the facility nurse say to [Conservator B] that Resident #5 was taking a blood thinner and there could be a potential for a bleed due to the head injury . During an interview on 4/10/2023 at 2:13 PM, the DON was asked if the care plan intervention for Resident #5's fall was an appropriate intervention for a resident with a BIMS score of 4. The DON stated, .No, I thought we went back and fixed the care plans for the residents with poor cognition .he can't remember to ask for assistance and to use non skid socks would not be appropriate .I thought we changed the word encourage to the word remind . Staff failed to implement appropriate care plan interventions for Resident #5, who had severe cognitive impairment and failed to notify the conservator of risks of a fall with a head injury for a resident taking blood thinners. 4. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Delusional Disorders, Schizoaffective Disorder-Bipolar type, Hallucinations, Anxiety Disorder, and Major Depressive Disorder. Review of the Annual MDS (MDS) assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #1 experienced delusions and other behaviors not directed toward others. Review of the Progress Note dated 3/9/2024 for Resident #1 revealed, .PT WAS SITTING IN DINING ROOM FOR BREAKFAST WHEN A DEMENTED PT ROLLED IN AND BUMPED HIS WHEELCHAIR. PT BECAME AGGRESSIVE CURSING AND YELLING IN DINING ROOM AS LOUD AS HE COULD. NURSE INTERVENED AND REMOVED DEMENTIA PT. PT YELLED AND SCREAMED AT NURSE AND WAS NAME CALLING . Review of the Behavior Analysis Report (CareAssist only) note dated 3/9/2024 for Resident #1 revealed, .Pt was in the dining room for breakfast another pt accidently bumped the back of his chair with hers. [Resident #7] and [Named Resident #1] started yelling and screaming at pt . Observation in the dining room on 3/18/2023 at 10:20 AM, Resident #1 was in an electric wheelchair. 5. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnosis which included Vascular Dementia with Mood Disturbance and Depression. Review of the care plan for Resident #7 revealed, .Approach Start Date .3/19/2024 Patient may attract negative attention from other patients due to their poor understanding of personal space and spatial boundaries. Redirect as needed .When Pt is wandering, assess for unmet physical needs, psychological distress, and environmental factors. Distract Pt by introducing enjoyed activities .Educate and encourage patient to comply with plan of care . Resident #7 with a BIMS score of 6 does not have the ability to understand the need to comply with the plan of care. Review of the Quarterly MDS dated [DATE] revealed Resident #7 had a BIMS score of 6 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #7 experienced delusions, physical behaviors directed toward others, and wandered 4-6 days over the last 7 day look back period. Review of the nurse Progress Notes for 3/9/2024 for Resident #7 revealed no details related to the verbally abusive interaction with Resident #1. Review of LPN G's Progress Note dated 3/18/2024 for Resident #7 revealed, .Spoke with NP .and reviewed previous verbal abusive interaction that occurred on 3/9/24 involving patients [Resident #1 was verbally abusive toward Resident #7] . Review of the Nurse Practitioner (NP) progress note dated 3/18/2024 for Resident #7 revealed, .Per staff, patient remains at her baseline. She is pleasantly confused . The NP note does not mention Resident #7's involvement in a verbal altercation with Resident #1. Observation in the resident's room on 3/19/2024 at 2:45 PM, revealed Resident #7 being assisted to bed. Observation in the dining room on 3/20/2024 at 12:30 PM, revealed Resident #7 was in her wheelchair rolling to different residents introducing herself. During an interview on 3/18/2024 at 3:50 PM, Licensed Practical Nurse (LPN) G stated, .One time [Named Resident #7] was in the dining room and she bumped into his [Resident #1]'s wheelchair .He started cursing, I went in the dining room, he cursed me . LPN G was asked if Resident #1 was verbally abusive toward Resident #7. LPN G stated, .Yes I would say that would be verbal abuse, but I don't think I reported it .I did mention it to the NP today [3/18/2024] .I was concerned about his outburst .[Named Resident #1] is delusional thinking he is married to the queen .will say he was in the military but he wasn't .He first tried to deny he hit [Named Resident #1] . The interview revealed LPN G failed to report a resident-to-resident altercation involving verbal abuse. During an interview on 3/18/2024 at 4:30 PM, Certified Nursing Assistant (CNA) H stated, .[Named Resident #1] has been aggressive toward [Named Resident #7] .she wanders and often looking for her children .he will instantly become aggressive toward her .I feel like he could be physical or verbally aggressive toward any resident . During an interview on 3/19/2024 at 8:00 AM, CNA J stated, .He got after [Named Resident #7] in the dining room one day because she tried to talk to him .He called her .[derogatory names] .[Named Resident #7] just moved and said 'why don't you want to talk to me' .we try to keep the patients away from him .he doesn't like anyone getting close to him . During an interview on 3/19/2024 AT 8:25 AM, the Social Service Director (SSD), stated, .I never knew [Named Resident #1] was aggressive. I wasn't aware of the interaction he had with [Named Resident #7] on 3/9/2024. I am just now reading this in the notes. I have not done a follow up with either resident because I was not aware of the incident. The staff should have notified the Abuse Coordinator. Verbal abuse is cursing, yelling, demeaning language toward another resident. I would have observed [Named Resident #7] demeanor toward [Named Resident #1] to see if she would shy away from him or would she continue with her normal behavior. [Named Resident #7] is a very social person, so I would watch for any changes in her behavior . During an interview on 3/19/2024 at 8:55 AM, the Director of Nursing (DON) stated, .I was aware that [Name Resident #7] bumped into [Named Resident #1]'s wheelchair in the dining room and [Named LPN G] intervened. I wasn't aware that he called the other resident any derogatory names. I thought he just called the nurse names . During an interview on 3/19/2024 at 2:50 PM, Resident #1 stated, .I know [Named Resident #7] she is a busy body .comes around pushed me and poked me in the dining room .It upsets me I don't want to be touched .I had to leave the room .I had to get out of there, she will keep on until she provokes me to a fight .she makes me sick .[Named Resident #7] won't listen just keeps on trying to talk . 6. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease, Renal Dialysis, Muscle Wasting and Atrophy, Heart Failure, Long-Term Use of Anticoagulants, and Malignant Neoplasm of Stomach. Review of the Admission MDS dated [DATE], revealed Resident #6 had a BIMS score of 13, which indicated intact cognition. Review of a Physician's Order, for Resident #6, dated 3/19/2024 revealed, .abrasion to top of right knee .Special Instructions: abrasion to top of right knee clean with normal saline and pat dry. Apply polymem [a dressing that manages drainage] oval every shift until healed .Every Shift .Day, Night . Review of Registered Nurse (RN) U's Progress Note for Resident #6, dated 3/19/2024 at 10:25 AM, revealed, .Alert: I was in patient room giving him medicine and roommate [Resident #8] pushed his own bedside table that accidentally bumped this patients [patient's] bedside table through the curtain. Patients bedside table bumped patients top of right knee. Patient was not bleeding at the time. Patient then came to nurses station and stated his knee was bleeding. This nurse cleaned and applied a dressing to top of right knee. MD and family notified . Review of the NP progress note dated 3/19/2024 at 7:45 PM, for Resident #6, revealed, .Today staff report that the patient did sustain a small abrased area just above his right knee. Staff state that the patient reported that his knee was injured on his bedside table. Patient is found sitting on the side of his bed in his room .When asked what happened to his knee he states 'the curtain was pulled and my roommate pushed his bedside table into my bedside table and my bedside table hit my knee.' Patient did show provider how he sits on the side of his bed with his feet on the lower part of his table and pointed out the area of his table that hit his knee. Provider asked if this hurt and patient stated 'it did a little at the time but not now. ' . 7. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses which included Type 2 Diabetes Mellitus, Hypertensive Heart Disease, and Chronic Obstructive Pulmonary Disease. Review of the Admission Annual MDS assessment dated [DATE] revealed Resident #8 had poor short term and long term memory. Continued review of the MDS revealed Resident #8 was short tempered and easily annoyed. Further review of the MDS revealed Resident #8 had verbal outbursts, behaviors toward others, and his behaviors affecting his environment. During an observation and interview on 3/19/2024 at 11:45 AM, Resident #6 stated, .Just an hour ago my roommate cursing people throwing a fit and he shoved his tray table toward me and caused my leg to start bleeding .he shoved the nurse that was in here too because she told him don't push me .he [Resident #8] yells and hollers and he knows I will get up . The observation revealed blood on the floor and bloody gauze laying on the overbed table. Resident #6 raised up his pants leg on his right leg to show the surveyor where the nurse just bandaged his leg due to the injury. During an interview on 3/19/2023 at 12:30 PM, RN U stated, .an LPN reported to me he [Resident #6] had an old skin tear that reopened . During an interview on 3/19/2024 at 3:25 PM, LPN V stated, .[Named RN U] done all the treatments today .[Named Resident #6]'s roommate pushed the overbed table toward him and caused a skin tear . During an interview on 3/20/2024 at 4:00 PM, SSD was asked if she was notified of the incident between Resident #6 and Resident #8. SSD stated, .We talked to RN U about it .[Named Resident #8] got upset because he wanted his pain medicine .I went down to talk to him [Named Resident #6] because I heard something about the incident .we [DON, Administrator, and department heads] were discussing it last night .I let them know I went down to check on [named Resident #6] .I don't know why I didn't do a progress note . The SSD was asked if Resident #6 continues to be at risk being in the room with Resident #8. The SSD stated, .I don't really think so .he can take precautions if he feels he needs to .he isn't at risk because he is alert and oriented . During an interview on 3/19/2024 at 5:20 PM, RN U was asked about her nurse note on Resident #6. RN U stated, .I was in the room when it happened .[Named Resident #8] pushed his overbed table .water picture hit the floor .the table hit [Named Resident #6] on his knee .[Named Resident #8] was flying off with the 'F' word it aggravated him, he wanted ice .I lied to you earlier .I didn't report it . The interview revealed RN U previously informed the surveyor the injury for Resident #8 was an old skin tear. RN U stated she did not report the incident between Resident #6 and Resident #8. During an interview on 4/4/2024 at 1:32 PM, the DON stated, We started the performance evaluations back last year some time .I am observing the nurses daily . During an interview on 4/10/2024 at 5:00 PM, the Administrator stated, .Abuse should be reported immediately .reported to state agency within 2 hours .complete an investigation and send up our findings within 5 days .

Based on facility policy review, Facility Reported Investigation (FRI) review, medical record review, and interview, the facility failed to report allegations of abuse within 2 hours for 4 of 9 (Resident #1, Resident #7, Resident #6, and Resident #8) sampled residents reviewed for abuse. The facility failed to report the 5-day investigation of abuse for 2 of 9 (Resident #3 and Resident #4) residents reviewed for abuse. The findings include: 1. Review of the facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 2/1/2023 revealed, .Abuse, Neglect, Misappropriation of Patient Property .will not be tolerated by anyone, including staff, patients .The patient has the right to be free from abuse, neglect, misappropriation of patient property .Abuse: the willful infliction of injury .intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes verbal abuse .physical abuse, and mental abuse .Willful .means the individual must have acted deliberately .Verbal Abuse .use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents .or within their hearing distance regardless of their .ability to comprehend .Physical Abuse: includes hitting, slapping, pinching and kicking .TRAINING POLICY .The center will train all partners, through orientation and ongoing in-services, on the prevention, identification, investigation and reporting of abuse, neglect, misappropriation of patient property .Any patient event that is reported to any partner by patient, family .any person will be considered an allegation of either abuse, neglect, misappropriation of patient property .Any allegation (or) indication of possible willful infliction .Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property .must report the event immediately, but not later than 2 hours after forming the suspicion if the events that cause the suspicion involve abuse .it is the policy of this facility that abuse allegations (abuse, neglect .mistreatment .misappropriation of resident property) are reported per Federal and State Law .The investigation is conducted immediately .When it is identified that an alleged incident may have occurred .As soon as any partner has knowledge and reports an alleged event .When there is a question as to whether to conduct an investigation, it is best to do so .The results of all investigations will completed within five working days of the incident . Review of the undated facility policy titled, PATIENT RIGHTS, revealed, .the patient/resident's right to live in an environment which is individualized for them .Your sense of well being and your safety during your stay her are of the utmost importance to us .your care is planed with a group of professionals holding your well-being as their primary concern .Your plan of care will include an assessment of your strengths and needs. The ultimate goal is to assist you to achieve and/or maintain the highest level of functioning . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Delusional Disorders, Schizoaffective Disorder-Bipolar type, Hallucinations, Anxiety Disorder, and Major Depressive Disorder. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #1 experienced delusions and other behaviors not directed toward others. Review of the PSYCHIATRIC PERIODIC EVALUATION dated 1/23/2024 for Resident #1 revealed, .New/Ongoing Target sx's [symptoms] .Pressured Speech, Impulsive Action, Compulsivity . Review of the PSYCHIATRIC PERIODIC EVALUATION dated 2/6/2024 for Resident #1 revealed, .Pt [patient] has a persistent, chronic mental illness that requires ongoing therapeutic intervention to prevent exacerbation of presenting behaviors/psychological symptoms and to sustain baseline stability and overall well-being . Review of the Progress Note dated 3/9/2024 for Resident #1 revealed, .PT [patient] WAS SITTING IN DINING ROOM FOR BREAKFAST WHEN A DEMENTED PT [Resident #7] ROLLED IN AND BUMPED HIS WHEELCHAIR. PT BECAME AGGRESSIVE CURSING AND YELLING IN DINING ROOM AS LOUD AS HE COULD. NURSE INTERVENED AND REMOVED DEMENTIA PT. PT YELLED AND SCREAMED AT NURSE AND WAS NAME CALLING. PT NOW IN ROOM EATING BREAKFAST . Review of the Behavior Analysis Report (CareAssist only) note dated 3/9/2024 for Resident #1 revealed, .Pt was in the dining room for breakfast another pt [Resident #7] accidently bumped the back of his [Resident #1's] chair with hers. [Resident #7's wheelchair] and [Named Resident #1] started yelling and screaming at pt.[Named Resident #7] Nurse went in to redirect pt [Resident #7] and he [Resident #1] started cursing nurse calling her a whore he was asked to leaving [leave] the dining room. pt is currently in his room . Review of the Quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 which indicated intact cognitive abilities. Continued review of the MDS revealed Resident #1 experienced delusions. Observation in the dining room on 3/18/2023 at 10:20 AM, revealed Resident #1 was in an electric wheelchair. Observation in the resident's room on 3/19/2024 at 9:00 AM, revealed Resident #1 was sitting in his wheelchair. Observation in the resident's room on 3/20/2024 at 8:20 AM, revealed Resident #1 was in the bed. 3. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnosis which included Vascular Dementia with Mood Disturbance and Depression. Review of the Quarterly MDS dated [DATE] revealed Resident #7 had a BIMS score of 6 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #7 experienced delusions, physical behaviors directed toward others, and wandered 4-6 days over the last 7 day look back period. Review of the nurse Progress Notes for 3/9/2024 for Resident #7 revealed no details related to the verbal abusive interaction. Review of the Progress Note dated 3/18/2024 for Resident #7 revealed, .Spoke with NP .and reviewed previous verbal abusive interaction that occurred on 3/9/24 involving patients [Resident #1 was verbally abusive toward Resident #7] . Review of the NP progress note dated 3/18/2024 for Resident #7 revealed, .Per staff, patient remains at her baseline. She is pleasantly confused. She is able to propel herself in her wheelchair. She is easily redirected. No acute needs are reported by staff to this provider today .No distress. No needs identified . No mention of Resident #7's involvement in a verbal altercation with Resident #1. Observation in the resident's room on 3/19/2024 at 2:45 PM, revealed Resident #7 being assisted to bed. Observation in the resident's room on 3/20/2024 at 12:30 PM, revealed Resident #7 was in her wheelchair rolling to different residents introducing herself. During an interview on 3/18/2024 at 3:50 PM, Licensed Practical Nurse [LPN] G was asked if Resident #1 had ever been abusive toward any other residents. LPN G stated, .One time [Named Resident #7] was in the dining room, and she bumped into his wheelchair .He started cursing, I went in the dining room, he cursed me . LPN G was asked if Resident #1 was verbally abusive toward Resident #7. LPN G stated, .Yes I would say that would be verbal abuse, but I don't think I reported it .I did mention it to the NP today (3/18/2024) .I was concerned about his outburst . During an interview on 3/18/2024 at 4:30 PM, Certified Nursing Assistant (CNA) H stated, .[Named Resident #1] has rage of fits screaming at other residents . CNA H stated, .[Named Resident #1] has been aggressive toward [Named Resident #7] .she wanders and often looking for her children .he will instantly become aggressive toward her .I feel like he could be physical or verbally aggressive toward any resident . During an interview on 3/18/2024 at 4:45 PM, CNA I stated, .[Named Resident #1] will yell at his roommate if he gets in his way .he has a loud tone of voice .don't want anybody getting close to him . During an interview on 3/19/2024 at 8:00 AM, CNA J stated, .[Named Resident #1] he yells and screams mostly at other residents .He got after [Named Resident #7] in the dining room one day because she tried to talk to him .He called her .[derogatory names] . During an interview on 3/19/2024 at 8:20 AM, CNA L stated, .[Named Resident #7] wanders .He gets agitated with his roommate's stuff don't want nothing near him .constantly wanting his roommates stuff moved .[Named Resident #7] agitates him . During an interview on 3/19/2024 AT 8:25 AM, the Social Service Director (SSD), stated, .I wasn't aware of the interaction he [Resident #1] had with [Named Resident #7] on 3/9/2024. I am just now reading this in the notes. I have not done a follow up with either resident because I was not aware of the incident. The staff should have notified the Abuse Coordinator. Verbal abuse is cursing, yelling, demeaning language toward another resident . During an interview on 3/19/2024 at 8:55 AM, the Director of Nursing (DON) stated, .I was aware that [Name Resident #7] bumped into [Named Resident #1]'s wheelchair in the dining room and [Named LPN G] intervened. I wasn't aware that he called the other resident any derogatory names. I thought he just called the nurse names. As far as I know [Named Resident #1] got along with his roommates . During an interview on 3/19/2024 at 2:50 PM, Resident #1 stated, .I know [Named Resident #7] she is a busy body .comes around pushed me and pocked me in the dining room .It upsets me I don't want to be touched .I had to leave the room .I had to get out of there, she will keep on until she provokes me to a fight .she won't back down .she just keeps on poking at me .she makes me sick .she has wandered in my room twice .they took down my stop sign off my door .[Named Resident #7] won't listen just keeps on trying to talk . 4. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease, Renal Dialysis, Muscle Wasting and Atrophy, Heart Failure, Long-Term Use of Anticoagulants, and Malignant Neoplasm of Stomach. Review of the Admission MDS dated [DATE], revealed Resident #6 had a BIMS score of 13, which indicated intact cognition. Review of Registered Nurse (RN) U's Progress Note for Resident #6, dated 3/19/2024 at 10:25 AM, revealed .Alert: I was in patient room giving him medicine and roommate [Resident #8] pushed his own bedside table that accidentally bumped this patients bedside table through the curtain. Patients bedside table bumped patients top of right knee. Patient was not bleeding at the time. Patient then came to nurses [nurses's] station and stated his knee was bleeding. This nurse cleaned and applied a dressing to top of right knee. MD and family notified . Review of the NP progress note dated 3/19/2024 at 7:45 PM, for Resident #6, revealed, .Today staff report that the patient did sustain a small abrased area just above his right knee. Staff state that the patient reported that his knee was injured on his bedside table. Patient is found sitting on the side of his bed in his room .When asked what happened to his knee he states 'the curtain was pulled and my roommate pushed his bedside table into my bedside table and my bedside table hit my knee.' Patient did show provider how he sits on the side of his bed with his feet on the lower part of his table and pointed out the area of his table that hit his knee. Provider asked if this hurt and patient stated 'it did a little at the time but not now . 5. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses which included Type 2 Diabetes Mellitus, Hypertensive Heart Disease, Chronic Obstructive Pulmonary Disease, and Long-Term Use of Anticoagulants. Review of the Admission MDS assessment dated [DATE], revealed Resident #8 had a staff assessment for mental status which indicated poor short term and long-term memory. Continued review of the MDS revealed Resident #8 was short tempered and easily annoyed. Further review of the MDS revealed Resident #8 had verbal outbursts, behaviors toward others, and his behaviors affecting his environment. During an observation and interview in the resident's room on 3/19/2024 at 11:45 AM, Resident #6 stated, .Just an hour ago my roommate cursing people throwing a fit and he shoved his tray table toward me and caused my leg to start bleeding .he shoved the nurse that was in here to because she told him don't push me .he [Resident #8] yells and hollers and he knows I will get up . The observation revealed blood on the floor and bloody gauze lying on the overbed table. Resident #6 raised up his pants leg on his right leg to show the surveyor where the nurse just bandaged his leg due to the injury. During an interview on 3/19/2023 at 12:30 PM, RN U stated, .an LPN reported to me he [Resident #6] had an old skin tear that reopened . During an interview on 3/19/2024 at 3:25 PM, LPN V stated, .[Named RN U] done [did] all the treatments today .[Named Resident #6] s roommate pushed the overbed table toward him and caused a skin tear .the table has now been moved to the other side of [Named Resident #8]'s bed . During an interview on 3/19/2024 at 5:20 PM, RN U was asked about her nurse note on Resident #6. RN U stated, .I was in the room when it happened .[Named Resident #8] pushed his overbed table .water picture hit the floor .the table hit [Named Resident #6] on his knee .[Named Resident #8] was flying off with the 'F' word it aggravated him he wanted ice .I lied to you earlier .I didn't report it .I applied pressure he has poor skin he is a dialysis patient . During an interview on 3/20/2024 at 4:00 PM, SSD was asked if she was notified of the incident between Resident #6 and Resident #8. SSD stated, .We talked to RN U about it .[Named Resident #8] got upset because he wanted his pain medicine .I went down to talk to him [Named Resident #6] because I heard something about the incident .we [DON, Administrator, and department heads] were discussing it last night .I let them know I went down to check on [named Resident #6] .I don't know why I didn't do a progress note . The SSD was asked if Resident #6 continues to be at risk for potential abuse since he continues to be in the room with Resident #8. The SSD stated, .I don't really think so .he can take precautions if he feels he needs to .he isn't at risk because he is alert and oriented . During an interview on 4/11/2024 at 12:08 PM, the Administrator stated, .abuse should be reported immediately .reported to the state agency within 2 hours and the completed investigation should be sent up within 5 days . _______________________________________________ 6. Review of facility investigation #20230313103123 revealed, on 3/13/2023 at 9:30 AM, Resident #4 reported to staff that his roommate (Resident #3) hit him in the side of his head when he (Resident #4) was coming out of the bathroom. Hospice LPN (Licensed Practical Nurse) HH made sure both residents were separated and interviewed both residents. Resident #4 also reported the allegation that Resident #3 had hit him to Hospice LPN HH, Resident #4 stated he tried to hit him back. Resident #3 stated to Hospice LPN HH that he had hit Resident #4 for trying to .run me over . The incident was reported to the state agency on 3/13/2023 at 10:31 AM. Skin assessments performed on both Residents #3 and #4 on 3/13/2023, with no redness or bruises noted. No visible signs of physical abuse. Residents ' representatives, Adult Protective Services, and Police Department were notified of the incident on 3/13/2023. There were no witnesses to the abuse allegation. The facility determined the contact between Resident #3 and Resident #4 could not be verified. Both Residents were referred to Psychiatric Services and the Residents were separated to rooms on 2 separate halls. The final investigation was not uploaded to the state agency system until 2/1/2024. Review of the intake information revealed no additional information was sent to the state agency as of 3/21/2023. 7. Review of the medical record revealed Resident #3 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included Paroxysmal Atrial Fibrillation, History of falling, adjustment disorder with mixed disturbance of emotions and conduct, Unspecified Dementia, and Restlessness and agitation. Review of the Quarterly MDS dated [DATE] for Resident #3 revealed a BIMS score of 5 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #3 no behaviors over the last 7 days. Continued review of the MDS revealed Resident #3 required extensive assistance related to bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Further review revealed Resident #3 received an anticoagulant over the last 7 days. Review of the Progress Note dated 3/13/2023 for Resident #3 revealed, .Alleged allegation with roommate. Family and appropriate agency notified . Review of the weekly skin observation dated 3/13/2023 for Resident #3 revealed no injuries related to alleged allegation with his roommate. During an interview on 4/2/2024 at 9:00 AM, Resident #3 stated, .I don't know how they are treating me .yea .yea . Resident #3 could not give any clear answers about his stay at the facility just nodded yes to all questions. 8. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnosis which included Hemipleagia and Hemiparesis following Cerebral Infarction, Aphasia, Adjustment disorder with mixed anxiety and depressed mood, and mild cognitive impairment. Review of the Admission MDS dated [DATE] for Resident #4 revealed 3/17/2023 for Resident #4 revealed a BIMS score of 12 which indicated moderate impaired cognition. Continued review of the MDS revealed Resident #4 had physical and other behaviors toward others. Continued review of the MDS revealed Resident #4 required extensive assistance related to bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Review of the Progress Note dated 3/13/2023 for Resident #4 revealed, .PT [patient] WAS EXITING HIS ROOM AND VOICED THAT HIS ROOMATE HIT AT HIM AFTER HE WAS ROLLING BACKWARDS INTO ROOM AFTER USING THE BATHROOM, PT SAID HE SAID IM [I'm] SORRY AND TRIED TO MOVE AND THE ROOMATE HIT AT HIM AT HIS RIGHT SIDE HEAD. NO BRUSING REDNESS OR CHANGE NOTED IN SKIN. FAMILY MADE AWARE. PT REMOVED AND OUT OF ROOM AT NURSES STATION WITH STAFF . Review of the weekly skin observation dated 3/13/2023 for Resident #4 revealed no injuries related to alleged allegation with his roommate. Review of the Progress Note dated 3/14/2023 for Resident #4 revealed, .Pt resting in bed at this time. No bruising noted to right side of face or c/o [complaints of] pain. Adjusting to room change this shift . Review of the Progress Note dated 3/15/2023 for Resident #4 revealed, .No bruising noted to rt [right] side of face. Adjusting to room change this shift . Review of the Progress Notes from 3/26/2023 to 4/19/2023 revealed Resident #4 had increased inappropriate behaviors toward staff. Review of the Progress Notes dated 4/19/2023 for Resident #4 revealed, .Patient with noted increased inappropriate behaviors toward staff .Redirection and medication changes made with no affects. MD [Medical Doctor] notified and ordered for psych stay. Worked on placement to admit for psyc eval. Transfers patient via EMS [Emergency Management Services] to .Hospital for psych eval . Resident #4 did not return to the facility. During an interview on 3/19/2024 at 11:39 AM, Health Information Management T stated, .I was going down hall and [Named Resident #4] asked if I was a nurse .he said he had a disagreement with his roommate .[Named Resident #3] hit me .I hit him back .Nurse .went to check on them .the Administrator asked me to write out a statement . During an interview on 4/11/2024 at 12:08 PM, the Administrator stated, .abuse should be reported immediately .reported to the state agency within 2 hours and the completed investigation should be sent up within 5 days .we were going through our files just making sure all reportable investigations had been submitted and that is why the date is 2/1/2024 its the day we printed it .

Based on facility policy review, Facility Reported Investigation review, medical record review, observation, and interview, the facility's Quality Assurance Performance Improvement (QAPI) committee failed to monitor implemented plans of action for a resident-to-resident abuse. The findings include: Review of the facility policy titled, QAPI [Quality Assurance Performance Improvement] Plan 2024-2025 NHC HealthCare Center, revealed, .Quality Assurance Performance Improvement is the basis for all care delivered in this center. QAPI is what we do every day as we deliver care to our patients. All departments and all services are included covered by the QAPI Plan. Clinical care will be monitored by reviewing clinical outcome monitors on a consistent basis as well as monitoring the CMS quality measures .The main focus of QAPI will be safety and high quality in all clinical interventions while emphasizing autonomy and choice in daily life for all patients .QAPI is the responsibility of every partner during their everyday work. Ultimately the Administrator and Director of Nursing are accountable for the success or failure of the program .Root Cause Analysis will be used to determine the underlying causes of issues .The 5 Why Method of root cause analysis will be used to determine root causes of problems . Review of the facility investigation revealed on 7/26/2023 at 6:00 PM, Resident #2 wandered into Resident #1's room. Resident #1 yelled at Resident #2 to get out of his room and while she was at his bedside, he struck the resident with his open hand on the head and back. A nurse aide heard the commotion and immediately intervened. The victim Resident #2 was removed from the room and provided increased observation. A stop sign was placed on Resident #1's room to intervene wandering behavior. The facility investigation revealed the staff were trained on abuse policy and procedures. A Velcro stop sign was affixed to Resident #1's doorway. The Quality Assurance Performance Improvement (QAPI) will oversee question and answers regarding abuse policy and procedures. The staff will monitor patients for behaviors that may increase their risk for physical abuse. The QAPI committee will confirm compliance with Stop Sign usage. Both residents will continue to be seen by Psych [psychiatric] services. Review of the facility event recovery form revealed, .Event .[Named Resident #2] entered into [Named Resident #1's] room and was touching his electric wheelchair. [Named Resident #1] hit [Named Resident #2] .7/26/23 [7/26/2023] QA [Quality Assurance] nurse, Director of Nursing [DON] .started in-servicing on patient protection .Beginning the week of 7/31/2023 DON .QA Nurse will monitor compliance by interviewing 10 partners of what we do if we suspect abuse and on the types of abuse every month x [times] 3 .interviewing 5 partners on each shift weekly x 4 as to what would you do if you see a patient entering another patient's room and then continuing monthly x 2 .The monitor and in-service training will be continued as determined by the Administrator and Director of Nursing . Review of the Performance Improvement Plan (PIP) dated 8/3/2023 revealed the study title was, .What do you do if you suspect abuse . The (PIP) revealed only 9 employee names. During an interview on 3/19/2024 at 10:50 AM, Certified Nursing Assistant (CNA) S was asked to review the sheets related to the PIP dated 8/3/2023 related to the incident between Resident #1 and Resident #2. CNA S stated, .that is not my signature .I don't remember this training .It looks like someone just wrote my name down . CNA S signed her name, and it was not her signature on the PIP. Review of the PIP dated 8/9/2023 revealed the study title was, .What would you do if you see a patient entering in another patient's room . During an interview on 3/19/2023 at 10:28 AM, Licensed Practical Nurse (LPN) Q reviewed the sheet related to the PIP dated 8/9/2024 and stated, .That's not my signature on the education. I don't know what the education was about on this note .Usually when we have some type of training or in-service we sign the sheet, not have someone write our name down . LPN Q signed her name, and it was not her signature on the PIP. Review of the PIP dated 8/25/2023 revealed the study was, .Partners will be able to name the types of abuse . The form had 1-10 with Y beside the number. No employee names or signatures were on the form. Review of the PIP dated 9/26/2023 revealed the study title was, .What would you do if you seen [saw] a pt [patient] entering another pts [patient's] room . No employee names or signatures were on the form. Review of the PIP dated 9/26/2023 revealed the study title was, .Stop sign will remain in place to doorway . The form revealed no patient name. Review of the PIP dated 9/26/2023 revealed the study was, .What would you do if you suspect abuse . No employee names or signatures were on the form. Review of the PIP dated 10/26/2023 revealed the study title was, .redirect patient out of room .20 partners .y [yes] . No employee names or signatures were on the form. Review of the PIP dated 10/26/2023 revealed the study was, .What would you do if you seen a pt entering another pts room . No employee names or signatures were on the form. Review of the PIP dated 10/26/2023 revealed the study was, .Remove the patient from harm or stay with them .report immediately .20 partners .y (yes) . No employee names or signatures were on the form. Review of the PIP dated 11/27/2023 revealed the study title was, .What would you do if you see a patient entering in another patient's room . The form had number 1-10 with Y (yes) beside the number. No employee names or signatures were on the form. Review of the PIP dated 11/27/2023 revealed the study was, .Able to identify types of abuse .Able to identify what they would do if suspect abuse . The form had number 1-10 with the word employee noted. No employee names or signatures were on the form. During an interview on 3/19/2023 at 10:45 AM, Registered Nurse R (the employee that performed the PIP education) stated, .I used these sheets for education not monitoring of the wandering resident. I just mainly done [did] teaching on what to do for a wandering resident .redirect them out of the patient's room . During an interview on 4/4/2024 at 12:30 PM the DON was asked to provide the documentation for increased observation for Resident #2 which the facility investigation dated 7/26/2023 noted would be completed. The DON stated, .I think the education on how to protect the patients and going over the policy for wandering residents covered increased observations . During an interview on 4/10/2024 at 12:08 PM, the Administrator reviewed the PIP documentation on education and was asked how he could verify and hold staff accountable without any staff signatures. The Administrator stated, .I think we done it that way due to HIPAA [Health Insurance Portability Accountability Act] .try not to have identifiable information related to residents or staff . The Administrator was unable to answer this surveyor's question of how the facility would verify and hold staff accountable for the education provided without staff signatures.

Based on facility policy, medical record review, observations and interviews, the facility failed to protect 2 of 5 sampled residents(Resident #'s 2, and #5) reviewed for abuse. The findings include: Review of the facility's policy titled Patient Protection and Response /Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation dated 8/1/2001 and revised 12/11/2017, revealed, .exploitation .will not be tolerated .mental abuse includes, but is not limited to .using photographs or recordings in any manner that would demean or humiliate regardless of consent or cognitive status . Review of the facility's booklet titled Resident's Rights revised on 11/2017, revealed, .goal is to assist you to achieve and/or maintain the highest level of functioning possible .right to accept or refuse .privacy so that you may maintain a dignified existence .shall respect a patient's rights to the use and quiet enjoyment of his or her personal space . Review of the facility's undated policy titled Cell Phones revealed, .absolutely no personal cell phone usage in Patient Care areas .if you see any staff taking a photograph or videotaping in a Patient Care area, intervene and report immediately .staff may not take digital or still photos or record audio or video footage with cellular phones or personal electronic devices .while on company premises . Review of the Facility Reported Incident (FRI) # 9 revealed the incident was reported within the required time frame to the State, the Ombudsman, Adult Protective Services and the local police department the facility investigated the incident, substantiated the abuse and terminated the employee. All families and residents were appropriately notified of the potential HIPAA privacy breach. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change in Status Minimum Data Set (MDS) dated [DATE], revealed Resident #2 had a BIMS score of 9, which indicated moderate cognitive impairment. Resident requires extensive assistance of one to two persons physical assist with personal hygiene and bathing. Review of the Care Plan revealed, Resident #2 was care planned for Activities of Daily Living (ADL)s, refuses assistance from staff at times. Interventions and revisions were appropriately implemented. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change in Status MDS assessment dated [DATE], revealed Resident #5 had a BIMS score of 99, which indicated severe cognitive impairment. Resident required extensive assistance of one person physical assist with personal hygiene and bathing. Review of the Care Plan revealed, Resident #5 was care planned for assistance with personal care and behavioral symptoms, resists care and refuses meds at time. Interventions and revisions appropriately implemented. Review of the Employee File for the Temporary Nurses Aide (TNA) #1 revealed a hire date of 8/3/2021 and a termination date of 2/14/2022. The employee completed TNA training and received a certificate of Completion on 7/23/2021. Appropriate reference checks and background checks were completed, including the Abuse Registry. Further review of 2 other CNA employee files revealed proper reference and background checks were completed, including the Abuse Registry. During an interview on 3/1/2022 at 11:01 AM, Resident #5 was not able to answer any questions related to the allegations of abuse due to cognitive impairment. Observation and interview on 3/1/2022 at 11:12 AM, revealed Resident #2 in bed awake, dressed in personal clothing. During interview Resident #2 stated, I do not remember a time when anyone used their cell phone in my room. During an interview on 3/1/2022 at 11:51 AM, the Director of Social Services confirmed that she was made aware of the abuse allegations and she had conducted interviews for FRI # 9, with all residents with a BIMS score of 8 or above. She asked questions related to the investigation and only documented concerns. There were no concerns voiced related to abuse from any of the residents interviewed. During continued interview she appropriately answered the abuse questions for employees. During an interview on 3/1/2022 at 12:19 PM, the Administrator stated, I was made aware of an allegation of abuse on 2/14/2022 at approximately 11:35 AM. An employee [named, CNA] #3 made a facetime (video) call to a friend during work and the friend recorded the facetime call. The friend texted the video to me and I confirmed the identity of [named,Residents] #2 and #5. He stated during the video, CNA #3 made demeaning gestures with her hands towards Resident #5 and pulled a cover over Resident #2's face. He stated, CNA #3 was terminated on 2/14/2022 and did not return to the facility. It is unknown if CNA #3 or the friend shared the video with anyone else or posted the video to social media.

Based on the facility policy review, medical record review, observation, and interview, the facility failed to evaluate and implement an appropriate positioning device for 1 resident (#24) of 2 residents reviewed for positioning and mobility of 33 sampled residents. The findings include: Review of the facility's Repositioning Policy, revised 5/30/14, revealed .Assessment for Appropriate Repositioning .Assess residents who sit or recline in a chair .Does the resident need intervention to maintain postural alignment .When a resident is up in a chair .supporting of feet . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a care plan dated 10/9/17 and updated 8/27/18 revealed the resident utilized a .(specialized wheelchair) . (a wheelchair that tilts, rocks and reclines) for mobility. Continued review revealed the resident required assistance with all activities of daily living (ADL). Medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderate cognitive impairment. Continued review revealed the resident required extensive assistance of 2 staff for bed mobility, dressing, toileting and hygiene, and total dependence of 2 staff with transfers. Further review revealed the resident was on pain management and utilized a wheelchair for mobility with extensive 1 staff assistance. Observation of Resident #24 on 10/29/18 at 11:05 AM, 12:19 PM, and 2:05 PM, on the 100 hall activity room, revealed Resident #24 was sitting in a specialized wheelchair in a reclined position without a foot pedal on the right side of the wheelchair. Continued observation revealed the bilateral lower extremities (BLE) dangled freely from the wheelchair. Further observation revealed the foot pedal that was in place on the left side of the specialized wheelchair was extended further than the foot and did not allow the foot to rest on the pedal. Observation of Resident #24 on 10/30/18 at 8:00 AM, 8:47 AM, 9:05 AM, 1:20 PM, and 3:30 PM, on the 100 hall activity room, revealed Resident #24 was sitting in a specialized wheelchair in a reclined position. Continued observation revealed there was no support for the BLE which allowed the BLE to dangle freely from the wheelchair. Observation of Resident #24 and interview with Licensed Practical Nurse (LPN) #1 on 10/31/18 at 8:45 AM, on the 100 hall, revealed .we lost one of her foot pedals . Interview with Resident #24 on 10/31/18 at 11:45 AM, on the 100 hall activity room, revealed the resident preferred her lower legs elevated. Interview with the Director of Nursing (DON) on 10/31/18 at 11:55 AM, in the resident's room, confirmed the resident did not have a foot pedal on the right side of the wheelchair or BLE support. Further interview confirmed the specialized wheelchair needed foot rests, support or cushions to elevate the BLEto aid in the resident's positioning and comfort.

Based on facility policy review, facility documentation, observation, and interview, the facility failed to properly store steam table pans in 9 of 12 pans observed, failed to properly store frozen food items in 1 of 1 walk in freezers, failed to properly store frozen food items, failed to properly labed food in 1 of 1 refrigerators, failed to properly store dry stock items, failed to ensure kitchen equipment was clean and maintained in a sanitary manner in 1 of 2 kitchen observations made, and failed to properly store potable water in 1 of 1 observations made, affecting 29 of 29 residents. The findings included: Review of the facility policy Safety & Sanitation Best Practice Guidelines .Manual Ware Washing dated 1/2011 revealed .Air-dry all items. Make sure all items are completely dry before stacking to prevent wet-nesting . Review of the facility policy Safety & Sanitation Best Practice Guidelines .Refrigerator and Freezer Storage dated 1/2011revealed .Foods will be stored in their original container or a NFS (National Food Safety) approved container or wrapped tightly in moisture-proof film, foil, etc. Clearly labeled with the contents and the use by date . Review of the facility policy Safety & Sanitation Best Practice Guidelines .Dry Storage dated 1/2011 revealed .If opened, packages should be closed securely to protect product . Review of the facility protocol Equipment Cleaning Schedule dated 1/2011 revealed .Can Opener clean and sanitize after each use . Review of the facility policy Safety & Sanitation Best Practice Guidelines dated .Deep Fryer dated 1/2011 revealed .After each use clean outside surfaces . Review of the facility documentation, Emergency Liquid Sources, not dated, revealed .bottled water stored in the building .mechanical room .196 gallons (potable/hygiene) . Observation with the Dietary Manager on 10/2/16 at 9:15 AM, in the dish room, revealed 9 of 12 four inch steam table pans observed were stored wet. Observation with the Dietary Manager on 10/2/16 at 9:20 AM, of a walk-in freezer in the kitchen, revealed the following were available for resident consumption: a). One 10 pound box of frozen pancakes approximately ¾ full not sealed and open to air b). Two 1 gallon bags each approximately ½ full of frozen pancakes with no label or use by date Observation with the Dietary Manager on 10/2/16 at 9:25 AM, of a reach in refrigerator in the kitchen, revealed the following food/beverage items with no label or use by date were available for resident consumption: a). 2 flavored coffee creamers open approximately 3/4 full b). 5 various condiment containers approximately 3/4 full Observation with the Dietary Manager on 10/2/16 at 9:35 AM, in the dry stock room, revealed the following items open to air, with no label or use by date, and available for resident consumption: a). one 5 pound bag of crispy rice cereal approximately ¾ full b). 2 sleeves of assorted crackers each approximately 3/4 full Observation with the Dietary Manager on 10/2/16 at 9:40 AM in the kitchen, revealed the following: a). a manual can opener with dried food debris on the blade b). a deep fryer with dried food debris and thick grease build up on the top and outside Interview with the Dietary Manager on 10/2/16 at 9:45 AM, in the kitchen, confirmed the facility failed to properly store opened packages of frozen foods and dry stock items to maintain food quality and prevent cross contamination. Further interview confirmed the facility failed to ensure kitchen equipment was clean and maintained in a sanitary manner, and failed to properly air dry and store steam table pans. Observation on 10/3/16 at 12:45 PM, in the mechanical room, revealed 32 cases of potable water (each case contained 24 twenty ounce bottles) stored on the floor in the mechanical room. Further observation revealed 33 transporting crates with 4 gallons of water in each create stored on the floor in the mechanical room. Interview with the Maintenance Supervisor on 10/3/16 at 12:50 PM, in the mechanical room, confirmed the water was stored on the floor of the mechanical room. Further interview confirmed .we have a building outside where the water could be stored better .

Based on observation and interview, the facility failed to post accurate nurse staffing information in 1 of 3 observations. The findings included: Observation on 10/2/16, at 9:32 AM, in the main entrance foyer, revealed the staffing information posted did not accurately reflect the nursing staff on duty for the current day. Observation of the posted staffing revealed the staffing information posted was the staff scheduled for 9/29/16, and had not been updated to reflect current nursing staff in the facility on 10/2/16. Interview with Licensed Practical Nurse #1, on 10/2/16 at 9:35 AM, in the main entrance lobby, confirmed the staffing information did not reflect the current nursing staff present; and confirmed the facility failed to post accurate staffing.

Based on medical record review, review of the facility Post Falls Nursing Assessments and interview, the facility failed to maintain a safe environment to prevent accidents by not ensuring the wheels had been locked on a bed, resulting in a fall with a laceration and a fracture for one resident, #55, of four residents reviewed for falls, from a sample of thirty-two residents reviewed in stage II. This failure resulted in harm to resident #55. The findings included: Resident #55 was admitted to the facility from the hospital December 20, 2013, with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set (MDS), dated [DATE], revealed the resident had short and long term memory impairment, severe cognitive impairment for daily decision making, required extensive assistance with all activities of daily living, had unsteady balance, and required the physical assistance of one person with most activities of daily living. Medical record review of the quarterly MDS, dated [DATE], revealed the resident had short and long term memory impairment, severe cognitive impairment for daily decision making, required extensive assistance with all activities of daily living, had unsteady balance, and required the physical assistance of one person with most activities of daily living. Medical record review of the resident's Care Plan, dated April 25, 2014, revealed the resident was assessed to be at risk for falls and planned interventions included: "...Be alert to increased confusion or change in level of consciousness...Make sure staff aware of the risk for falls...Assess for environmental hazards...Provide assistance with transfers and ambulation as needed x I person..." Facility record review of the facility Post Falls Nursing Assessment, dated May 1, 2014, revealed, "Date and time of incident: 5/01/2014 2:50 p.m...CNA (Certified Nursing Assistant) heard pt (patient) yelling for help. CNA found pt on the floor...sitting on buttocks in upright position. Right index finger was bleeding. ..Pt stated did not hit...head. C/O (complained of) pain to whole left hand. Left index finger laceration noted and end of finger dangling. Pt stated...was walking around bed and lost...balance, grab for bed, bed rolled away...and ...fell on the floor hitting the left hand on the bed end and then hitting it on the metal wheel of the bed. The bed wheels were not locked..." Continued review of the Post Falls Nursing Assessment revealed "Description of Injury: Site 1. Laceration to left index finger, middle and ring finger swelling and bruising noted...First Aide Treatment...cleanse left index finger with NS (normal saline) loosely applied gauze dres (dressing)... Vital signs post fall...ROM (range of motion assessment for each extremity)...(all extremities assessed) WNL (within normal limits). Physician...notified and orders received to send resident sent to ER (emergency room ) for X-ray to left hand, eval and tx (evaluation and treatment)." Medical record review of the hospital radiology report dated May 1, 2014, at 3:39 p.m., " Procedure: XR (x-ray) hand 3 vws (views) left, Diagnosis: [REDACTED]. Interview with the Director of Nursing, in the conference room, on July 22, 2014, at 9:30 a.m., confirmed the bed wheels had not been locked, the resident sustained [REDACTED].#55 had been harmed by the facility's failure to ensure the bed wheels were locked. Complaint #

Based on facility policy review, observation, and interview, the facility failed to maintain cold food at or below 41 degrees Fahrenheit on the resident tray line in three of three dining rooms. The findings included: Review of the facility policy, Safety & Sanitation Best Practice Guidelines, dated January 2011, revealed "Cold food should be held at 41 degrees or lower throughout the serving process." Observation and interview with dietary staff #1 on July 14, 2014, at 11:35 a.m., in the ICF (lntermediate Care Facility) resident dining room, revealed the tray line was in process with dietary staff #1 obtaining food temperatures. Further observation revealed a rack positioned in the dining area with seven plates of salads with chicken strips. Further observation revealed the temperature of the chicken strips was 71 degrees Fahrenheit (F). Further observation revealed salads with chicken strips had not been served to residents. Further observation of the milk stored in the reach-in refrigerator revealed the temperature was 44.8 degrees F. Interview with dietary staff #1 revealed the staff member "thought the temperature was ok for a salad (with chicken strips)". Further interview with dietary staff #1 revealed the milk was stocked into the reach-in refrigerator just prior to the lunch service. Observation and interview with dietary staff #2 on July 14, 2014, at 11:47 a.m., in the Reflections resident dining room, revealed dietary staff #2 had served the lunch meal to one of three tables with residents. Further observation revealed two plates of salad with chicken strips on the counter. Further observation revealed the chicken strip temperature was 79.9 degrees F. Further observation revealed milk stored in the reach-in refrigerator was 45 degrees F. Interview with dietary staff #2 revealed one plate of salad with chicken strips had been served to a resident eating in their room. Further interview revealed dietary staff #2 was "not sure if (salad with chicken strips) temperature was ok." Interview with dietary staff #2 revealed the milk had been stocked in the reach-in refrigerator just prior to the meal service. Observation and interview with dietary staff #3 and Certified Nurse Aide (CNA) #1, on July 14, 2014, at 12:02 p.m., in the Skilled resident dining room, revealed dietary staff #2 serving the food. Further observation revealed three residents eating salads with chicken strips. Further observation revealed two salads with chicken strips on a rack stored next to the reach-in refrigerator. Further observation revealed the chicken strip temperature was 73.9 degrees F. Further observation revealed the milk in the reach-in refrigerator was 47.3 degrees F. Interview with dietary staff #3 revealed the salad with chicken strips "needs to be thrown out and made fresh." Further interview revealed the milk had been stocked into the reach-in refrigerator just prior to the meal service. Interview with CNA #1 confirmed three residents had consumed the salad with chicken strips.

Based on medical record review, observation, review of the Pest Control Agreement and interview, the facility failed to maintain effective pest control for one resident (#9) of thirty-two sampled residents. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum Data Set, dated dated dated [DATE], revealed the resident had a Stage 4 pressure ulcer. Medical record review of a physician's orders [REDACTED]. Observation of resident #9 on July 16, 2014, at 7:57 a.m., in the resident's room, revealed a fly on the top sheet of the resident in the bed. Observation of the resident's wound care and [DEVICE] change on July 16, 2014, at 2:45 p.m., in the resident's room, with the Unit Manager, revealed four flies in the room. Observation on July 16, 2014, at 3:35 p.m., in the resident's room, revealed two flies on the floor mat on the right side of the resident's roommate's bed; one fly on the foot of the resident's bed, which moved and landed on the resident's blanket near the stomach area; and one fly on the outside top frame of the resident's bathroom door. Review of the facility's Pest Control Agreement, revealed the pest control agreement "...does not include...flying insects..." Interview with the Unit Manager on July 16, 2014, at 3:39 p.m., in the resident's room, confirmed the presence of the four flies in the resident's room, and the facility failed to maintain effective pest control for resident #9.

Based on medical record review, observation and interview, the facility failed to maintain complete medical records for nutritional supplement intake for two residents (#52, #134) of thirty-two residents reviewed. The findings included: Resident #52 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set, dated dated dated [DATE], revealed resident #52 required supervision and set-up assistance with eating, and was cognitively intact. Medical record review of the physician orders [REDACTED]. Medical record review of a Dietary Progress Note dated July 3, 2014, revealed a recommendation for Ensure (nutritional supplement) with meals "...as (resident) can drink better than eat at this time..." Observation on July 16, 2014, at 7:54 a.m., revealed an eight ounce can of Ensure on the breakfast tray. Review of the facility intake documentation revealed no documentation of nutritional supplement intake. Interview with the Director of Nursing on July 16, 2014, at 2:35 p.m., in the training class room, confirmed the facility failed to document the nutritional supplement intake. Resident # 134 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician orders [REDACTED]. Further review revealed no order for nutritional supplements. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed resident #134 required extensive assistance with one person physical assistance for eating. Medical record review of the Initial Care Plan, dated February 3, 2014, updated on July 10, 2014, revealed the "...Resident is at risk of alternation in nutritional status/ weight loss...with Approaches including...Supplements as ordered: 1 - 2 (cans) Ensure with...meals (added May 19, 2014)... " Review of the facility document, July 2014 ICF Meal Sheet, revealed resident #134 was listed for "...Ensure x 2 (times two (cans))..." supplements at breakfast, lunch and supper. Further review revealed no documentation of the nutritional supplement intake on July 5 and 6, 2014, at supper, July 12, 2014, at lunch, and July 14, 2014, at supper. Interview with the Director of Nursing in the training classroom on July 17, 2014, at 7:55 a.m., confirmed "...they are not documenting (nutritional supplement intake) correctly on these sheets. We have a problem with that..."

Based on observation, and interview, the facility dietary department failed to ensure thermometers were in refrigeration units, failed to maintain equipment in a sanitary manner, failed to store food in a sanitary manner, and failed to maintain a clean and sanitary environment. The findings included: Observation of the facility dietary department revealed, and interview with the Dietary Manager present during the observations confirmed, on July 15, 2013, beginning at 10:30 a.m., the following: 1.) The milk chest refrigerator did not have an interior thermometer and had ice build-up on the interior walls; 2.) The walk-in freezer had opened containers or bags of hamburger patties, okra, pancakes, and potato rounds; 3.) The meal preparation reach-in refrigerator did not have an interior thermometer; 4.) The large mixer motor had food debris present; 5.) The small mixer motor had brown debris present; 6.) The drawer on the preparation table contained 2 spatulas with white debris; 7.) The small mixer bowl was on the clean side of the three compartment sink drainage area in contact with the drainage water; 8.) The large strainer, stored on the clean pan storage rack, had a white substance present; 9.) A 1/8 size steam table pan, stored on the clean pan storage rack, had food debris and two areas with blackened debris present; and 10.) The Dietary Manager lifted the lids of two trash cans, and without washing or sanitizing the hands, handled clean pans. Observation of the facility dietary department revealed, and interview with the Dietary Manager present during the observations confirmed, on July 15, 2013, beginning at 4:20 p.m., the following: 1.) The walk-in refrigerator box, labeled "Lemons", had a layer of mold on the lid; 2.) The dry goods store room lower shelf containing nutritional supplements had a cob web with debris hanging onto the web; 3.) The flour and cornmeal storage bin lids had dried debris present; 4.) Six sheet pans on the clean pan storage rack, had undersides covered with a heavy accumulation of blackened debris; 5.) The can opener base had a heavy black sticky accumulation of debris; 6.) The plastic covered meat slicer had an accumulation of dried debris on the blade; 7.) The Fruit/Vegetable reach-in refrigerator contained a frozen bag of blackened mixed lettuce; 8.) The grill spill pan had a foil lining and under the foil was a heavy accumulation of blackened debris.

Based on observation and interview, the facility dietary department failed to maintain equipment in a safe operating manner. The findings included: Observation of the facility dietary department revealed, and interview with the Dietary Manager present during the observation confirmed, on July 15, 2013, at 10:30 a.m., the large mixer bowl interior was rusted. Observation of the facility dietary department revealed, and interview with the Dietary Manager present during the observation confirmed, on July 15, 2013, at 4:20 p.m., the walk-in refrigerator had six of six shelving storage units with rusted surfaces and a variety of food items were stored on the shelving units.

Based on medical record review, observation, and interview, the facility failed to develop a care plan for four resident's (#97, #85, #29, #28) of fifty-one residents reviewed. The findings included: Resident #97 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the Care Plan dated June 19, 2013, revealed "...I have a hx (history) of fx (fracture) ankle..." Observation on July 16, 2013, in the 300 dining room, revealed the resident sitting in a wheelchair with a boot on the right foot. Interview with the Minimum Data Set (MDS) Nurse #1 on July 17, 2013, at 1:46 p.m., in the MDS Office, confirmed the facility failed to develop a care plan with goals and approaches for the fractured right ankle. Resident #85 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Review of Indicators of Physical Restraints dated June 6, 2013, revealed "...patient uses SR (side rails) while in bed..." Medical record review of the Care Plan dated June 14, 2013, revealed no care plan for the side rails. Interview with the Assistant Director of Nursing (ADON) #1 on July 16, 2013, at 4:28 p.m., in the 300 chart room, confirmed the facility failed to develop a care plan with goals and approaches for the side rails. Resident #29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on July 17, 2013, at 8:45 a.m., in the resident's room, revealed the resident was asleep in the bed with a clip alarm connected to the gown on the left shoulder, and a pressure alarm connected to the left side rails. Medical record review of the nursing care plan dated July 8, 2013, revealed no care plan for the clip and pressure alarm in bed. Interview with Licensed Practical Nurse (LPN) #5 on July 17, 2013, at 9:30 a.m., in the resident's room, confirmed a clip alarm and a pressure alarm in place. Interview on July 17, 2013, at 9:50 a.m., in the Assistant Director of Nursing #1 (ADON) office confirmed the clip alarm and the bed alarm were not addressed on the nursing care plan and were to be used only when the resident was up in a chair. Resident #28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation and interview on July 17, 2013, at 9:00 a.m., in the 200 hallway revealed the resident sitting up in the wheel chair and had a large bruise on the right hand and several bruises on the right arm, the resident commented that "bruise easy got these at the hospital" Medical record review of the current care plan dated July 10, 2013, revealed no approaches for bruising which can be a side effect of anticoagulation medications the resident routinely takes. Interview on July 17, 2013, at 3:20 p.m., in the classroom with the DON, confirmed the resident's care plan failed to include bruising.