Every finding on record at Nick's Health Care Center

Based on interview and record review, the facility failed to protect one resident (Resident #2) from physical abuse when Resident #1 punched Resident #2 in the face to the extent hospitalization was required. The facility census was 66.The Administrator was notified on 10/20/2025 at 5:05 PM of the past noncompliance which began on 10/20/2025. The facility administration immediately separated and protected the residents from further abuse by Resident #1. Residents #1 and #2 were sent to separate hospitals for medical assessment and treatment, staff updated regarding each resident's plan of care, and all residents were interviewed and provided updated abuse and neglect information. All staff were In-serviced on the abuse and neglect policy and procedure by 10/23/25. The noncompliance was corrected on 10/23/2025. Review of the facility's Abuse and Neglect Policy dated 6/12/24., showed:- The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences;- Alleged violation is defined as a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse;- Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse;- Physical Abuse is defined as purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking;- Protection of Residents: Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. The accused residents shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents;- The facility will identify, correct, and intervene in situations where abuse is likely to occur;- The facility will identify patterns, behaviors, and trends of behaviors that could result in harm to others;- The facility will protect all residents from harm;- The Administrator will complete an administrative investigation and notify the appropriate agencies no later than 24 hours after discovery of the incident;- The Administrator will follow up with appropriate agencies, during business hours, to confirm the report was received. 1. Review of Resident #1's Discharge MDS (Minimum Data Set), a federally mandated assessment tool completed by facility staff, dated 10/20/25., showed:- Mild cognitive impairment;- Diagnoses included: schizophrenia (a mental health condition characterized by a distorted perception of reality, leading to symptoms like hallucinations, delusions, disorganized thinking, and a loss of motivation), antisocial personality disorder (a mental health condition characterized by persistent disregard of the rights of other people, failure to comply with laws and social customs, and irresponsible and reckless behavior), anxiety, depression, intermittent explosive disorder (a mental health condition characterized by repeated, sudden bouts of impulsive, aggressive, violent behavior or angry verbal outbursts), and heart disease;- Independent with ambulation and all mobility.Review of the resident's care plan, dated 10/21/25, showed:- The resident had the potential to be physically or verbally aggressive related to diagnoses;- The resident was at risk for delusions (fixed false beliefs that can't be reasoned with), hallucinations (hearing, seeing, feeling, smelling things that are not there), or irritability;- The resident was at risk for cursing, hollering, moving around in or frequently getting up and down from the chair, nervousness, pacing on the unit, or restlessness;- The resident required nursing staff to be aware of body stance and facial expressions when approached; - The resident would be provided the lowest restrictive environment while maintaining protective oversight.Review of the resident's nursing progress notes for the month of October 2025 showed:- On 10/20/25 at 3:50 A.M., Resident #1 came to staff and reported he/she had stabbed Resident #2. Resident #1 was calm and cooperative and placed on immediate one on one with facility staff for protective oversight of all residents and staff. Appropriate personnel were notified;- On 10/20/25 at 5:57 A.M., Chlorpromazine (antipsychotic medication) 50 milligrams (mg) administered to the resident for related to increased delusions and voiced hallucinations per psychiatric physician order. The resident reported to staff they are telling me to harm others, and I am being attacked. The resident remained on one on one with facility staff until taken out of the facility by Emergency Medical Services (EMS);- On 10/20/25 at 4:00 A.M., Neurologic Focused Evaluation showed the resident had some confusion and had voiced having auditory hallucinations and delusions;- On 10/20/25 at 4:24 A.M., Psychosocial Post-Incident Impact Note showed the resident was the aggressor in an incident;- On 10/20/25 at 6:44 A.M., The resident was sent to hospital per psychiatric provider order. 2. Review of Resident #2's Quarterly MDS, dated [DATE], showed;- Cognition Intact;- Diagnoses: Parkinson's disease (a progressive neurological disorder that affects movement, balance, and coordination, osteomyelitis (a bone infection that occurs when bacteria or other microorganisms invade and damage the bone tissue), Human Immunodeficiency Virus (HIV) (a virus that attacks the body's immune system), and anxiety;- Required substantial assistance from staff for activities of daily living (ADL's) to include showering, toileting, and transfers.Review of the resident's care plan, dated 10/9/25, showed:- The resident had an ADL self-care performance deficit related to a left leg above the knee amputation;- Resident would have the lowest restrictive environment while maintaining protective oversight.Review of the resident's nursing progress notes for the month of October 2025, showed:- On 10/20/25 at 3:50 A.M., the resident's call light was on and upon staff entering the room, the resident was lying in bed with lacerations to both sides of the face and with a moderate amount of blood. The resident stated that an old person had come into his/her room and started punching him/her in the face. An immediate assessment was done and the Administrator, the Director of Nursing (DON), and emergency services were notified. The resident was transferred to the hospital for evaluation and treatment to the facial wounds.- On 10/20/25 at 4:00 A.M., Skin check assessment documentation completed and showed two new wounds classified as lacerations below both eyes had been acquired in the facility;- On 10/20/25 at 3:59 P.M., Psychosocial Post-Incident Impact Note showed the resident said he/she felt safe and had always got along with the Resident #1;- On 10/20/25 at 8:30 P.M., New orders placed by provider for Cefdinir oral antibiotic 300mg twice a day for 10 days and Clindamycin topical antibiotic three times a day for 10 days for treatment to facial wounds;- On 10/21/25 at 11:07 P.M., nursing documentation to continue all antibiotics and closure strips on face were still in place;- On 10/22/25 at 1:39 P.M., nursing documentation to continue antibiotic for facial trauma;- On 10/23/25 at 5:40 A.M., nursing documentation to resident's wounds on face are clean and the closure-strips are intact. Light bruising noted to left and right cheeks under both eyes.Review of the resident's hospital records, dated 10/20/25, showed:- The resident was seen and treated at a local hospital emergency department for facial fracture, reported assault, and multiple open wound to the face;- The resident received a Tetanus Diphtheria Acellar Pertussis (TDAP) Vaccine (vaccine that protects against three serious bacterial infections) and the orders had been given for Cefdinir and Clindamycin antibiotics.Review of the facility's self-report, dated 10/20/25 at 5:57 A.M., showed:- Resident #1 had gone to nursing staff and let them know he/she had stabbed someone and Resident #2 was found to have wounds to his/her cheek;- Resident #1 was placed on one-on-one observation and staff went into conjoined room and found Resident #2 with blood on his/her face and wound to cheek;- Notifications were made, Resident #2 was sent to the emergency room for treatment, and Resident #1 was interviewed by the Sheriff's deputies and sent to the hospital for psychiatric evaluation.During an interview on 11/4/25 at 8:50 A.M., Resident #2 said:- He/She felt safe at the facility, as long as the facility didn't let Resident #1 come back;- On 10/20/25 at around 4:00 A.M., Resident #1 had entered his/her room and started assaulting him/her by hitting him in the face which caused cuts to his face. It made me scared because I can't defend myself anymore.During an interview on 11/4/25 at 11:50 A.M., the Administrator said:- He had been notified of the incident on 10/20/25 by Licensed Practical Nurse (LPN) A;- After the incident the facility did everything, reached out to all the guardians, providers, Sheriff, and both residents were sent out to the hospital;--It is undetermined at this time if resident #1 will be allowed to return;- He believed Resident #1 had a pen in his/her hand when hitting Resident #2 in the face;- LPN A provided cares and sent Resident #2 out via EMS for treatment and evaluation of face. Resident #1 was put on one-to-one supervision until he/she was picked up by EMS and taken for psychiatric evaluation.During an interview on 11/4/25 at 12:56 P.M., Resident #2 said:- He/She hadn't seen any item in Resident #1's hand because he/she only saw a blur as Resident #1 was hitting his/her face;- He/She tried to fight back but he/she is getting weaker with age;- He/She had never had any problems with Resident #1 before. During an interview on 11/4/25 at 1:04 P.M. the Director of Nursing (DON) said:- When she arrived at the facility, Resident #1 was with staff and LPN A was caring for Resident #2;- EMS arrived and began talking with and caring for Resident #2 and police arrived and began getting statements;- She notified the physicians and responsible parties, and Resident #1 was given Chlorpromazine per provider order in effort to calm the resident's behaviors;- Resident #1 had always had delusions but had never had an incident before and this was out of character. She had never seen Resident #1 be upset with anybody and the facility had no reason to exceed the least restrictive supervision for Resident #1;- Resident #2 had completed the ordered antibiotics for the infection prevention for his/her wounds and was doing well.During an interview on 11/6/25 at 8:45 A.M., LPN A said:- Both residents had been getting along with no issues prior to this incident;- Resident #1 had gone to the nurse's station and said he/she had stabbed Resident #2;- He/She had nursing staff begin one on one supervision with Resident #1 and he/she went to Resident #2's room where he/she found the resident with a bloody face and saying he/she had been punched in the face;- He/She immediately notified EMS, assessed and cared for Resident #2 and notified the DON;- EMS assessed Resident #2 then transported via ambulance to a nearby hospital for evaluation and treatment;- Another EMS arrived and transported Resident #1 to a different hospital for psychiatric evaluation and treatment. Intake 2660057

Based on observation, interview and record review, the facility failed to provide sanitary conditions when the facility failed to address a fly problem in the kitchen/dining area and failed to address walls, flooring, and doors that were in need of repair. The facility census was 69. Review of the facility's Dietary Equipment, Infection Control and Sanitation policy, revised 2/2/24, showed the Dietary Manager is responsible for assembling, organizing and maintaining the needs for the operating and cleanliness of the kitchen and all dietary equipment. Review of the facility's Pest Control Program policy, dated 5/14/24, showed it was the policy of the facility to maintain an effective pest control program that eradicates common household pests such as flies. 1.Observation on 10/1/25 at 11:45 A.M., showed:-flies in the kitchen that landed on the peaches that were in bowls and on the salads being prepped; -dead flies on the floor;-the wall behind the cook stove had a section of the corner of the wall pushed in with missing dry wall. 2. Observation on 10/1/25 at 11:15 A.M., showed the kitchen flooring at the serving line peeling away from the floor. The flooring had separated from the concrete and had caked on debris lodged between the peeling laminate flooring and concrete creating a space for food build up and inability to clean the floor of the debris. 3. Observation on 10/2/25 at 12:15 P.M., showed the kitchen's back delivery door was lopsided in the frame causing a 1.5 - 2 inch gap of open visual space allowing flies and insects into the kitchen. Observation showed flies in the kitchen in clusters on all surfaces and on food being prepped and served. Additionally, a fly sticky strip was hanging in the kitchen bathroom with the door open and showed it to be covered in dead flies. Dead flies were also on the floors by all prep areas in the kitchen. During an interview on 10/1/25 at 11:55 A.M., the Dietary Manager said he/she was aware the wall behind the stove was falling in about a week ago, but had not yet reported it to maintenance to be repaired. During an interview on 10/2/25 at 11:45 A.M., [NAME] A said the flies were always a problem in the kitchen and he/she was always swatting them off food and cooking/prep food areas. The fly problem had just always been a problem at the facility even with fly traps and exterminators help. During an interview on 10/2/25 at 1:30 P.M., the Dietary Manager said she knew the flooring had been steadily coming up in pieces by the serving table line area and it was hard to keep the floors clean. She additionally had not thought to report the floor issues to maintenance. She said the exit door to the back of the kitchen did not fit correctly and that was the main reason the flies were so bad in the kitchen and dining room area. The door problem had been reported to maintenance some time ago, but was not sure when that was. She had not issued a new work order to request to have the door issue resolved. During an interview on 10/2/25 at 1:45 P.M., Resident #27 said the flies while trying to eat were ridiculous and they are annoying. Resident #27's table mate, Resident #34 said he/she did not like the flies landing on his/her food or touching his/her face when he/she was trying to eat. During an interview on 10/2/25 at 2:10 P.M., the Maintenance Director said he had just started 2 weeks ago and was unaware of the kitchen floor, back door, or the wall behind the stove. He admitted there was a fly problem in the facility, especially the kitchen and dining room area. He was not sure what the facility's plan was for managing the fly problem, but agreed it was a problem in the kitchen. During an interview on 10/3/25 at 11:25 A.M., the Administrator said he was aware of the fly problem in the facility and the issue was worse in the summer months. He was aware the kitchen door leading outside to the dumpster area did not sit level in the frame of the door, which caused an opening that allowed flies to enter into the kitchen area and then into the rest of the building. The residents have the right to live in a home without flies landing on them and their food continually. He was unaware of the wall crumbling behind the cook stove or the flooring peeling up from the floor in the kitchen by the serving table.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program when residents were observed with flies on them during meals, cares, and activities. The facility census was 69.Review of the facility's Pest Control Program policy, dated 5/14/24, showed it is the policy of the facility to maintain an effective pest control program that eradicates common household pests such as flies. The facility was unable to provide documentation of the last pest control services in the facility. Observation on 9/30/25 at 10:05 A.M., showed flies in the main entrance of the facility flying around residents. Observation on 9/30/25 at 12:45 P.M., showed flies landing on residents' food during the noon meal, flies on the tables where residents were eating, and flies being swatted away by residents while they ate. Observation on 10/1/25 at 9:30 A.M., showed flies in groups of clusters (more than one) on residents dining tables, landing on the residents face and hands. Observations of the kitchen on 10/1/25 at 10:45 A.M. and 10/2/25 at 11:30 A.M., showed the staff bathroom door open with a sticky fly strip hanging from the ceiling completely coated with dead flies and flies flying around the sticky fly strip. Observation of the kitchen on 10/2/25 at 12:25 P.M., showed Resident #27 and #34 in the dining room drinking beverages as noon meal trays were being passed by staff. The residents were swatting away flies while trying to drink and eat. Observation on 10/3/25 at 10:10 A.M., showed Resident #34 and #27 sat in the facility hallways with flies landing on them. Multiple flies were seen landing on doors, walls, handrails, and staff and residents swatting the flies away from their face. During an interview on 9/30/25 at 11:45 A.M., Resident #31 said the flies were always bothering him/her during meals and in his/her room. He/she wished something could be done about all the flies. During an interview on 10/2/25 at 12:30 P.M., Resident #47 said The flies drive me crazy, especially when I am trying to eat! I hate the flies. During an interview on 10/1/25 at 12:13 P.M., the Housekeeping Services Manager said the facility used to have a pest control company that came monthly, but was not sure when they last were out to the building. She said the flies are a problem, but did not know how to manage the fly problem. She was not sure where to find the information regarding pest control. During an interview on 10/3/25 at 11:25 A.M., the Administrator said he/she was aware of the fly problem in the facility. Pest control comes monthly, but was unsure when the company last provided service for flies. The issue is just worse in the summer months. The residents have the right to live in a home without flies landing on them and their food continually.

Based on observation and interview, the facility failed to ensure laundry services were provided in a manner to ensure a safe/clean/ comfortable homelike environment, when laundry services did not return clean clothes to one Resident (Resident # 49) causing the resident to wear a hospital gown in the dining room. Additionally, failure to keep the dirty laundry caught up resulted in a strong urine odor outside the hall of the laundry room. The facility census was 69. The facility was unable to provide a policy regarding duties of the laundry.1.Observation on 9/30/25 at 10:45 A.M., showed the laundry room located outside the hallway of the dining room and a strong odor of urine on the hallway prior to entry of the dining room. Upon entry into the laundry room there were three large barrels overflowing the top, full of dirty linen and clothing. Both washing machines were full of clothes and clean clothes were stacked three feet high waiting to be folded. No laundry staff were in the laundry room. Observation on 9/30/25 at 2:45 P.M., showed a strong odor of urine on the hallway prior to entry of the laundry room. Large barrels overflowing the top, full of dirty linen and clothing. Both washing machines were full of clothes and clean clothes were stacked three feet high still waiting to be folded. One laundry staff was working in the laundry training a new employee. Observation on 10/1/25 at 10:15 A.M., showed a strong urine odor outside the hall of the laundry room. Inside the laundry there were large barrels full of soiled wet linen and clothes. The folding area had large amounts of resident's clothing waiting to be folded, hung, and sorted. One laundry person was working in the laundry. Review of Resident #49's Quarterly Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 5/2/25, showed: -Cognition was intact;-Diagnoses: schizoaffective disorder, Chronic Obstructive Pulmonary Disease, and diabetes;-Independent with activities of daily living.Observation on 09/30/25 at 9:10 A.M., showed the resident in the main dining room wearing a hospital gown with some dark colored short pants.Observation on 9/30/25 at 1:05 P.M., showed the resident in the dining room for lunch in a hospital gown and brown pants.During an interview on 09/30/25 at 9:15 A.M., Licensed Practical Nurse (LPN) D said the resident did not have any of his/her own personal clothing that was clean to wear. The resident instead had to wear a facility gown until his/her clothes were cleaned. LPN D said the facility failed to maintain clean laundry for most residents due to a lack of help in the laundry room. During an interview on 9/30/25 at 9:25 A.M., the resident said he/she hated wearing hospital gowns and would prefer to wear his/her own clothes instead of a hospital gown. The resident said that this happened often and he/she did not want to come out of his/her room without his/her own clothes on. During a group interview on 10/1/25 at 10:00 A.M., the resident's voiced concerns regarding the delay of laundry being returned to them. During an interview on 10/1/25 at 9:35 A.M., the housekeeping manager said she was aware of the amount of laundry backed up in the laundry and the strong smell of urine. She said staffing the laundry had been hard and currently laundry was staffed only Monday-Friday from 7:00 A.M.-3:30 P.M. or with whoever could help with laundry. She said, we all do multiple roles in this building. She was aware that resident's needed their clean clothes and should have them returned within a couple of days. She planned to work in laundry today to help get laundry delivered to the residents. During an interview on 10/3/25 at 11:45 A.M., the Administrator said he was aware of the laundry services issues regarding large amounts of laundry and was actively hiring for laundry staff and that other departments were helping when they could start and sort laundry.

Based on interview and record review, the facility failed to use the correct advanced beneficiary notice of non-coverage form to notify three of three sampled residents (Residents #2, #34, and #36) of changes in coverage to items and services covered by Medicare and/or by the Medicaid State plan. The facility census was 69.Review of the facility's Medicare Advance Beneficiary and Medicare Notice, policy last revised 11/05/24, showed residents are informed in advance when changes occur to their bills. CMS (Center for Medicare/Medicaid Services) form 10055 will be provided to the resident prior to discharging from Medicare part A.1.Review of Resident #34's order summary report showed the resident was admitted to Medicare part A on 4/02/25 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), acute respiratory failure, muscle weakness, and Type II diabetes and discharged from Med A on 05/07/25.2. Review of Resident #36's order summary report showed the resident was admitted to Medicare part A on 7/07/25, for skilled nursing and/or rehabilitation care and was discharged from Med A on 07/13/25. 3. Review of Resident #2's order summary report showed the resident was admitted to Medicare part A on 8/22/25, with a diagnosis of COPD, tremors, and stroke and was discharged from Med A on 08/28/25.Review of the facility's ABN Form, (the advanced beneficiary notice of non-coverage), showed the facility used an outdated form, titled CMS-R-131. The form did not include the date that Medicare part A coverage would be ending for Resident #34, Resident #36, and Resident #2. Review of the residents' medical records showed, the facility did not have the current CMS-10055 ABN form for all three residents (Resident #2, #34, and #36). During an interview on 10/03/25 at 9:30 A.M., the Social Service Director said she was unaware that she was using the incorrect CMS form to notify residents about the discontinuance of Medicare part A benefits and should be using CMS 10055 form.During an interview on 10/03/25 at 9:40 A.M., the Administrator said he was unaware the facility was not utilizing the correct ABN form.

Based on interview and record review, the facility failed to honor one resident's (Resident #27) right to make choices about aspects of his/her life in the facility that were significant to the resident, when the facility failed to honor and follow through on the resident's request to transfer to a different Long Term Care (LTC) facility that would allow the resident to live closer to his/her family member. The facility census was 69.Review of the facility's Resident Rights Policy, revised 9/21/25, showed all residents have a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. The facility must protect and promote the right of each resident.Review of Resident #27's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 7/19/25., showed the resident's cognition was intact and was independent in activities of daily living (ADLs).Review the resident's admission Record showed:-The resident was independent with ADLs. -Diagnoses included: Insulin dependent diabetic, kidney disease, cervical cancer, and heart disease.-Had resided in the facility for the past three years.Review of the resident's undated care plan showed the resident was alert and oriented and cognition was intact. The resident had the ability to understand and make all needs known.During an interview on 10/1/25 at 10:15 A.M., the resident said he/she had been trying for months to get moved to a different facility in a nearby town where his/her son lived. The resident wanted to be closer to his/her child who was special needs and resided in a group home and said that moving to the new facility would allow him/her the ability to visit his/her child more often. The resident said that no one had followed up regarding the request and that he/she had reached out to social services and administrative staff in the front office. The resident said this had been emotionally stressful and my rights have been violated! Review of the nursing and social service progress notes, from June 2025 through October 2025, showed no documentation regarding the resident's wish to discharge to another LTC facility, no follow up regarding the request, or communication to the resident regarding the progress of the request to move.Review of the social service notes showed there was documentation in the resident's record regarding when the original referral was sent to the neighboring facility that the resident wished to be transferred to in May of 2025.Review of the resident's undated care plan showed no documentation to support the resident's wishes to discharge from the facility and move to a facility closer to the resident's child. During an interview on 10/1/25 at 11:45 A.M., the Social Services Director (SSD) said she had sent the initial admission referral to the neighboring facility in May of 2025. The SSD was unable to locate or provide documentation regarding the resident's request, the referral, the follow up, or the timeline of the admission referral request. The SSD said the Administrator had been in contact with the admissions department at the neighboring facility and that additional nursing notes had been sent, but was unable to speak to the progress of the referral. The SSD had not called the facility to inquire about the referral. The SSD said the referral should have been followed up on, documented, and communicated with the resident. She was unsure what the holdup was on the referral the resident had requested and could not provide documentation to support the referral being worked on or that it had been communicated with the resident.During an interview on 10/2/25 at 2:15 P.M., the Administrator said he was aware of the resident's request to move to another facility to be closer to his/her child. The Administrator was unable to provide documentation from the time of the original referral to the date of this interview. The Administrator had one text message to the neighboring facility's admission person regarding the initial referral status and response was to send nursing notes to the facility to review. The Administrator had no further documentation to support the facility was actively working the referral to assist the resident with the move closer to his/her child.During an interview on 10/3/25 at 9:05 A.M., the admissions nurse at neighboring facility said she had told the referring facility to send updated nursing progress notes more than once and that the referral was no good after 30 days and would require a new referral be sent to the requested facility for admission consideration. The neighboring facility was still waiting on an updated referral to be sent and once it was received the resident would be placed on a waiting list for a LTC bed. The initial referral was sent 4 months ago.During an interview on 10/3/25 at 11:25 A.M., the Administrator and Director of Nursing said the resident's referral for admission to another facility should be followed through, documented in the clinical record, and communicated with the resident and additionally that every resident had the right to self-determination.Intake 2626895 & 2619608

Based on interview and record review, the facility failed to protect one Resident's (Resident #1) right to be free from abuse when Resident#2, hit Resident #1 in the face causing bodily injury to Resident #1. The deficient practice affected one out of five sampled residents. The facility census was 67. Review of the facility provided policy titled, Abuse and Neglect, dated 6/12/24 showed: -Abuse is the willful infliction of injury; -Purposefully beating, striking, wounding or injuring any resident; -The facility will identify and correct, by providing interventions, in which abuse, neglect, or misappropriation are more likely to occur; -The facility desires to prevent abuse, neglect and theft by establishing a resident sensitive and resident secure environment; -As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict; -Assess the environment for circumstances which may make abuse, neglect or misappropriation of resident items more likely to occur; -Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. 1. Review of Resident #1's Quarterly Minimum Data Set (MDS: a federally mandated assessment tool) completed by facility staff, dated 1/14/25 showed: -Brief Interview of Mental Status (BIMS) of 1 indicated significant cognitive deficits; -Behaviors not directed at others such as rummaging, scratching,and pacing, one to three of seven days; -Rejection of care, one to three of seven days. Review of the resident's Comprehensive Care Plan dated 1/14/25 showed: -He/She had a behavior problem of going through peers belongings and taking things that do not belong to him/her; -Staff were to ensure protective oversight, anticipate and meet the resident's needs, provide positive interactions, monitor behaviors and provide a program of activities. Review of Resident #2 Quarterly MDS dated [DATE] showed: -BIMS of 9 indicated moderate cognitive loss; -No behaviors; -Diagnoses of Major Depressive Disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), Traumatic Brain Injury (an injury to the brain caused by an outside physical force, such as a blow, bump, fall, or car accident), anxiety, crushing injury to the head, pain and insomnia. During an interview on 2/4/25 at 1:02 P.M. Resident #2 said: -He/She had told Resident #1 to stay out of his/her things multiple times; -He/She could not take Resident #1 going through his/her things any more and hit Resident #1 in the face; -He/She reported to staff immediately after he/she hit Resident #1; -He/She should not have hit Resident #1 and he/she was sorry. Review of Resident #1's progress notes showed on 1/31/25 at 10:49 A.M. the resident was observed on the floor, lying on his/her back. Resident #2 was asked to leave the room for safety. Resident #1 had blood on his/her face, an abrasion to his/her right hand and verbalized he/she had been hit in the face. The resident's Nurse Practitioner was notified and the resident was sent to the hospital for evaluation. Review of Resident #1 Electronic Medical Record showed: -He/She was admitted to an area hospital on 1/31/25; -His/Her Radiology report dated 1/31/25 of the right shoulder: Indication of shoulder pain after trauma, and limited range of motion (ROM: the normal movement range of a joint). Impression was a non-displaced fracture of the junction of the humeral head and neck. (a bone break at the top of the upper arm bone,where the fracture fragments have not moved out of position). -His/Her Radiology report dated 1/31/25 for computed topography (CT scan) of the head: Indication of head injury. Impression was a right nasal bone fracture; -Hospital records dated 1/31/25 showed he/she was involved in an altercation with his/her roommate and was struck in the face. Observation on 2/4/25 at 11:45 A.M. showed Resident #1: -Right eye orbit (area surrounding the eye and eyelids) was purple/green/yellow in color from the bridge of the nose to the right temple into the top of the cheek; -Right arm was in sling, held at a 90 degree angle across his/her body. During an interview on 2/4/25 at 11:45 A.M. Resident #1 said he/she did not remember what happened to cause the bruise and arm sling. During an interview on 2/4/25 at 12:47 P.M. the Social Service Director said: -After the incident he/she walked with Resident #2. Resident #2 reported Resident #1 would not get out of his/her things and had struck out at Resident #2; -Resident #2 did not tell him/her Resident #1 was going through his/her things, prior to this event; During an interview on 2/14/25 at 12:48 P.M. Licensed Practical Nurse (LPN) A said: -He/She was the Charge Nurse on 1/31/25 when Resident #2 reported he/she had struck Resident #1; -Resident #1, was found sitting on the floor, had a bloody nose and complained of shoulder pain; -Resident #1 was immediately sent to a local hospital for evaluation; -He/She has had education at least yearly on abuse; -Abuse is reported immediately to the Administrator and/or Director of Nursing; -He/She immediately texted the Administrator and Director of Nursing after the incident, as they were not in the facility. During an interview on 2/14/25 at 1:47 P.M. Certified Medication Technician said: -He/She had abuse training at the time of hire, on line training about every 3 months and in person training about 2 weeks ago; -Any abuse should be reported to the Administrator immediately. During an interview on 2/4/25 at 2:45 P.M. the Administrator said: -Staff texted notification to him and the DON immediately after the event occurred. -Resident #2 had no previous outbursts or aggressive behaviors; -The residents were moved apart 1/31/25; -The incident between Resident #1 and #2 was intentional and therefore was abuse. MO248880

Based on interviews and record review, the facility failed to protect the resident's right to be free from abuse by Resident #1, when Resident #1 struck Resident #2 in the face resulting in a bloody lip. The facility census was 64. Review of the facility's Abuse and Neglect policy, dated 6/12/24, showed: - It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility; - Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations; - Physical Abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment, or management. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Physical abuse also includes corporal punishment, which is physical punishment used as a means to correct or control behavior; - As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis; Review of Resident #1's Quarterly Minimum Data Set, a federally mandated assessment completed by staff, dated 12/10/24, showed: - Resident was admitted on [DATE]; - Resident has the diagnoses of hypertension (high blood pressure), Alzheimer's Disease (progressive brain disorder), dementia (decline in cognitive abilities), seizure disorder, depression, bipolar (extreme mood swings), schizophrenia (chronic mental disorder characterized by persistent disruptions in thinking, perception, emotions, and behavior), post traumatic stress disorder (mental health condition that can develop after experiencing or witnessing a traumatic event), and asthma; - Resident scored 9 on the BIMS (Brief Interview for Mental Status). This score indicates moderate cognitive impairment. Review of the resident's comprehensive care plan, dated 6/20/24 showed: - Resident does not harm self or others 1/16/25; - Resident has impaired thought processes due to head injury and needs redirection often; - Resident has potential to be verbally/physical aggressive with regards to mental/emotional illness. Resident will verbally lash out at other residents when he/she is in a bad mood or feels disappointed; - Resident was physically aggressive with roommate on 1/26/25. Staff are to intervene when resident becomes agitated and guide away from source of distress; - Staff directed, when resident becomes agitated to intervene before agitation escalates and guide away from source of distress; Review of Resident #2's Quarterly MDS, dated [DATE], showed: - Resident was admitted on [DATE]; - Resident has the diagnoses of hypertension (high blood pressure), cerebral palsy (this affects movement, muscle tone, and coordination), quadriplegia (paralysis of all four limbs), psychotic disorder (a mental health condition characterized by a loss of touch with reality), post traumatic stress disorder (mental health condition that can develop after experiencing or witnessing a traumatic event), and asthma; - Resident scored 12 on the BIMS. This score indicates moderate cognitive impairment. Review of the resident's comprehensive care plan, dated 2/9/24 showed: - Resident became verbally aggressive towards his/her roommate resulting in a physical altercation 1/16/25; - Resident has the potential to be verbally aggressive towards staff and peers due to ineffective coping skills, mental/emotional illness and poor impulse control; Review of the facility investigation, dated 1/16/25 showed: - Resident #2 reported to staff at the nurse's station that resident #1 had hit them. Resident was noted to have a small amount of blood and saliva on upper lip. - Resident #1 stated he/she was trying to get to the bathroom and resident #2 was in wheelchair and blocking their path; - Resident #2 would not move so resident #1 stuck him/her in the face; - Both residents were separated, and physical assessments completed; - Resident #2 was noted to have a small area on upper lip which had been bleeding but had now stopped; - Resident #1 had a small abrasion on their left hand treated. Neither resident reports any pain; - Resident #2 relocated to another room on unit opposite end of resident #1's room; - Resident #2 family member guardian notified; - Facility indicated that this event was not a result of abuse; During an interview on 1/24/25 at 11:15 A.M., the Director of Nursing (DON) and Administrator said: - Resident #2 sustained a minor bloody lip which staff attended to as well as to the abrasion on resident #1's hand; - Staff re-education, separation and monitoring of residents was ongoing and that the incident could not have been prevented by staff; - Resident #2 is very challenging to re-direct. MO248118

Based on observation, interview, and document review, the facility failed to ensure the roast beef served for lunch on 10/09/2024 was not tough for 5 (Residents #4, #34, #37, #49, #58) of 5 residents who attended the resident council meeting. Findings included: The facility planned menu for the lunch meal on 10/09/2024 consisted of roast beef, mashed potatoes and gray, mixed vegetables, and a mud cake. A test tray received on 10/09/2024 at 12:30 PM consisted of roast beef, mashed potatoes, and mixed vegetables. The surveyor noted the roast beef was seasoned, but was tough and hard to cut. During the resident council meeting on 10/09/2024 at 1:58 PM, five residents stated the meat served for lunch on 10/09/2024 was tough. During an interview on 10/09/2024 at 3:39 PM, the Dietary Supervisor (DS) said residents complained that the roast beef served on 10/09/2024 was tough. The DS stated she tasted the roast beef and acknowledged it was tough. During an interview on 10/10/2024 at 12:27 PM, the Director of Nursing (DON) stated she expected the dietary staff to have food that looked good and that the residents could eat. The DON stated she expected the food to not be tough. MO243029

Based on observation, interview, record review, and facility policy review, the facility failed to maintain an effective pest control for the prevention and control of flies in the facility. The deficient practice had the potential to affect all 69 resident who currently resided in the facility. Findings included: A facility policy titled, Pest Control Program Policy, revised on 05/14/2024, indicated, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. During an observation on 10/07/2024 at 9:24 AM, flies were noted in the residents' rooms and at the nurses' station. Staff were observed swatting at the flies. During an interview on 10/07/2024 1:35 PM, Resident #13 stated the flies were bad in the building and added when they tried to lie down the flies crawled on them and that really was a bother. Resident #13 stated as far as they knew the facility has done nothing to try to control the flies or get rid of the flies. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/11/2024, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. During a concurrent observation and interview on 10/08/2024 at 3:14 PM, Licensed Practical Nurse (LPN) #1 was seen using a fly swatter to swat flies at the nurses' station. Three dead flies were observed on the floor. LPN #1 said flies had been a problem at the facility. LPN #1 stated pest control visited the facility, but the flies were still everywhere. During a telephone interview on 10/08/2024 at 5:51 PM, the pest control representative confirmed the facility had a contract with the company to perform routine pest control for general services internally and externally. The pest control representative stated the facility received the basic fly insect service monthly, but the pest control company could offer other services if the facility requested. During an interview on 10/09/2024 at 9:52 AM, Housekeeper #5 said the flies had gotten worse. During an interview on 10/09/2024 at 10:32 AM, Certified Nurse Aide #2 said she thought the flies were really bad. During an interview on 10/09/2024 at 11:53 AM, the Maintenance Assistant stated the facility had monthly pest control and he did not think the facility had a problem with flies. During the resident council meeting on 10/09/2024 at 1:58 PM, five residents in attendance stated the flies had been bad for at least a month. During an interview on 10/10/2024 at 12:27 PM, the Director of Nursing said she had residents who had complained to her about the flies. During an interview on 10/10/2024 at 4:51 PM, the Administrator said he expected the maintenance department to keep the facility free of pests and rodents. During a telephone interview on 10/11/2024 at 8:18 AM, the Maintenance Director stated pest control came to the facility on ce a month. Per the Maintenance Director, the pest control did not do anything for the flies except place fly traps on the walls. The Maintenance Director stated he had been in healthcare a long time and had never seen so many flies. Per the Maintenance Director, he had not discussed any additional services with the pest control to get rid of the flies in the facility. MO243029

Based on observation, interview, and facility policy review, the facility failed to ensure expired food items were discarded after their expiration and use-by-date, items stored in the walk-in refrigerator were sealed from potential contamination, and food items were not stored on the floor of the walk-in freezer. These deficient practices had the potential to affect all residents who received food from the kitchen. Findings included: A facility policy titled, Dietary - Receiving and Storing Food and Supplies, with a revision date of [DATE], indicated, III. Food Storage Food items will be stored, thawed, and prepared in accordance with good sanitary practice. All foods shall be stored away from the walls and off the floor. During an observation of the dry good storage on [DATE] beginning at 9:53 AM with the Dietary Supervisor (DS), the surveyor noted two packs of bread with an expiration date of [DATE], one gallon bottle of hot sauce with an expiration date of [DATE], and an unsealed five-pound box of pancake mix. During an observation on [DATE] beginning at 10:12 AM with the DS, the surveyor noted tuna salad with a use-by-date of [DATE], shredded cheese with a use-by-date of [DATE], and a five-pound bag of brown iceberg lettuce in the walk-in refrigerator. During an observation on [DATE] at 10:18 AM with the DS, the surveyor noted five boxes of tater tots on the floor of the walk-in freezer. In an interview on [DATE] at 11:12 AM, the DS stated the kitchen staff were aware and had been trained to discard expired food items, to not store items on the floor, and to make sure all items stored were sealed. In an interview on [DATE] at 12:05 PM, the Director of Nursing (DON) stated she expected the kitchen staff to serve food items that were fresh and safe to eat. The DON stated food items should be thrown away after their expiration date. In an interview on [DATE] at 4:06 PM, the Administrator stated he expected the kitchen staff to ensure residents were served foods that were fresh and safe to eat.

Based on interview, record review, and facility policy review, the facility failed to timely report allegations of abuse to the state agency for 2 (Resident #19 and Resident #21) of 2 sampled residents reviewed for abuse. Findings included: A facility policy titled, Abuse and Neglect Policy, with a revision date of 06/12/2024 indicated, c. Refer to State Operations Manual (SOM) for reporting and utilize the Abuse-Neglect Reporting Decision Tree to assess the particular incident. Best practice is to include the SOM and Decision Tree with the investigation. Should the incident be a reportable event, notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming the suspicion. Should the event not be reportable continue and complete the investigation with all supporting information and place file with all investigations. 1. An Admission Record revealed the facility admitted Resident #19 on 07/23/2018. According to the Admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder, bipolar disorder, attention-deficit hyperactivity disorder, and mild intellectual disabilities. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/13/2024, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. During an interview on 10/07/2024 at 1:58 PM, Resident #19 reported to a surveyor that Certified Medication Technician #6 told them about three weeks ago to come and take their expletive word medications. On 10/07/2024 at 2:23 PM, the surveyor reported Resident #19's allegation to the Administrator. In an interview on 10/09/2024 at 3:40 PM, the Administrator acknowledged he did not report the allegation to the state agency as he felt since the survey team was onsite that he did not need to. In an interview on 10/10/2024 at 4:42 PM, the Director of Nursing stated allegations of abuse should be reported immediately, but not later than two hours after being notified of the allegation. 22445 2. An Admission Record revealed the facility admitted Resident #21 on 05/03/2024. According to the Admission Record, the resident had a medical history that included diagnoses of antisocial personality disorder, intermittent explosive disorder, paranoid schizophrenia, and unspecified anxiety disorder. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/2024, revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. During an interview on 10/07/2024 at 11:01 AM, Resident #21 stated they had not reported to anyone that Resident #18 cursed at them and made them feel bad. On 10/07/2024 at 11:20 AM, surveyor reported Resident #21's allegation of verbal abuse to the Administrator. In an interview on 10/10/2024 at 3:27 PM, the Administrator stated on 10/07/2024 was the first time he heard about an allegation of verbal abuse toward Resident #21 from another resident. The Administrator stated he did not immediately report the allegation to the state agency because previously, with state surveyors, any allegation received would have been an in-person report. The Administrator stated he reported the allegation of verbal abuse to the state agency on 10/09/2024. MO243359

Based on interview, record review, and facility policy review, the facility failed ensure care plan meetings were conducted for 2 (Resident #15 and Resident #56) of 19 sampled residents. Findings included: A facility policy titled, Comprehensive Care Plans, last revised 06/26/2024, revealed 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment. 1. An Admission Record revealed the facility admitted Resident #15 on 08/13/2018. According to the Admission Record, the resident had a medical history that included diagnoses of spinal stenosis, low back pain, anxiety disorder, somatization disorder, and age-related physical debility. An annual MDS, with an Assessment Reference Date (ARD) of 09/04/2024, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. During an interview on 10/10/2024 at 12:27 PM, the Director of Nursing (DON) said she expected care plan meetings to be documented. The DON stated from January 2024 to April 2024, the facility did not conduct care plan meeting as required. During an interview on 10/10/2024 at 3:14 PM, the MDS Coordinator stated the only evidence of care plan meetings for 2024 the facility had for Resident #15 was a meeting in July 2024. The MDS Coordinator stated care plan meetings should be done quarterly. During an interview on 10/10/2024 at 4:51 PM, the Administrator said he expected care plan meetings to be done as required. 51749 2. An Admission Record revealed the facility admitted Resident #56 on 08/10/2022. According to the Admission Record, the resident had a medical history that included diagnoses of adjustment disorder, major depressive disorder, and chronic pain. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/24/2024, revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #56's comprehensive care plan revealed the resident's care plan was last revised 12/20/2023. There was no evidence the resident's care plan review was conducted by the staff once the quarterly MDS with an ARD of 09/24/2024 was completed. In an interview on 10/10/2024 at 8:53 AM, the MDS Coordinator acknowledged Resident #56's care plan conference was missed. In an interview on 10/10/2024 at 9:08 AM, the Director of Nursing (DON) stated a resident's care plan should be reviewed quarterly. The DON stated she was aware that there was no documented evidence of care plan meetings for Resident #56. In an interview on 10/10/2024 at 9:19 AM, the Administrator stated the MDS Coordinator or the social services staff conducted the care plan meeting on a quarterly basis or as needed. MO243029

Based on observation, interview, and facility policy review, the facility failed to ensure the nurse staffing data was posted daily for 3 of 5 days of the survey. Findings included: A facility policy entitled, Nurse Staffing Posting Information Policy, last revised on 06/26/2024, specified Purpose: It is the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time. Policy: 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name b. The current date c. Facility's current resident census d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides 2. The facility will post the Nurse Staffing Sheet at the beginning of each shift. During an observation of the facility on 10/07/2024 at 10:23 AM, the posted nurse staffing sheet could not be found. During an observation of the facility on 10/08/2024 at 8:40 AM, the posted nurse staffing sheet could not be found. During an observation of the facility on 10/09/2024 at 10:04 AM, the posted nurse staffing was dated 10/08/2024. During an interview on 10/09/2024 at 12:05 PM, the medical records (MR) staff person stated she was responsible for posting the nurse staffing sheet on a daily basis. The MR staff person stated she did not post the nurse staffing sheet for 10/07/2024 and posted the wrong sheet for 10/08/2024. During an interview on 10/10/2024 at 10:33 AM, the Director of Nursing stated she expected for the MR staff and/or social services to post the nurse staffing data daily. During an interview on 10/10/2024 at 11:48 AM, the Administrator stated the MR staff were responsible for posting the nurse staffing data and it was hit or miss if it got posted daily as it should be.

Based on interview, record review, and facility policy review, the facility failed to develop and implement comprehensive care plans for 2 (Resident #57 and Resident #66) of 19 residents whose care plans were reviewed. Specifically, the facility failed to ensure Resident #57's comprehensive care plan addressed a diagnosis of type two diabetes mellitus and failed to develop a comprehensive care plan for Resident #66. Findings included: A facility policy titled, Comprehensive Care Plans, revised on 06/26/2024, indicated, PURPOSE: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy specified, 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS [Minimum Data Set] assessment. 1. An Admission Record revealed the facility admitted Resident #57 on 04/08/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of type two diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/15/2024, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. According to the MDS, the resident had an active diagnosis to include type two diabetes mellitus and received an insulin injection during one of seven days of the assessment look-back period. Resident #57's comprehensive care plan, last revised on 10/07/2024, did not include a problem area with measurable goals and interventions related to the resident's diagnosis of type two diabetes mellitus. The MDS Coordinator was interviewed on 10/10/2024 at 12:11 PM. The MDS Coordinator stated the purpose of a care plan was to enable staff to provide the best care for residents, which was why care plans needed to be individualized. The MDS Coordinator said a resident's diagnosis of diabetes was typically addressed in their care plan and explained it would be important to care plan diabetes so that staff would know the resident's treatment and the resident's signs and symptoms of hyperglycemia (high blood glucose level) or hypoglycemia (low glucose level). The MDS Coordinator reviewed Resident #57's comprehensive care plan and confirmed diabetes was not addressed. The MDS Coordinator stated this was due to an oversight. The Director of Nursing (DON) was interviewed on 10/10/2024 at 12:31 PM. The DON stated she expected Resident #57's diagnosis of type two diabetes mellitus to be included on their care plan to direct staff to monitor for any changes in the resident. The Administrator was interviewed on 10/10/2024 at 3:34 PM. He stated he expected Resident #57's diagnosis of diabetes to be care planned. 51749 2. An Admission Record revealed the facility admitted Resident #66 on 08/13/2024. According to the Admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease, hypertension and mixed hyperlipidemia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/26/2024, revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #66's medical record reviewed no evidence to indicate a comprehensive care plan had been developed for the resident. During a concurrent record review and interview on 10/09/2024 at 10:49 AM, the MDS Coordinator stated Resident #66 did not have a comprehensive care plan. During a follow-up interview on 10/10/2024 at 8:53 AM, the MDS Coordinator a resident's comprehensive care plan should be developed within 21 days of admission. During an interview on 10/10/2024 at 9:08 AM, the Director of Nursing (DON) stated the MDS Coordinator was ultimately responsible for the completion of a resident's comprehensive care plan. The DON stated a resident's comprehensive care plan should be developed within seven days of the MDS ARD. During an interview on 10/10/2024 at 9:19 AM, the Administrator stated the MDS Coordinator completed care plans and it did not meet his expectation for Resident #66 to not have a comprehensive care plan.

Based on interview, record review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) was completed when 1 (Resident #54) of 1 sampled resident reviewed for PASARR received a new mental illness diagnosis. Findings included: The facility PASARR policy, last revised 07/09/2021, revealed, The purpose of this policy is to utilize the [PASARR] assessments to develop a plan of care that shows continuity from previous history of behaviors and placement. An Admission Record revealed the facility admitted Resident #54 on 01/30/2024. According to the Admission Record, the resident had a medical history that included diagnoses of major depressive disorder, and anxiety disorder. Per the Admission Record, the resident received a diagnosis of post-traumatic stress disorder and impulse disorder on 04/16/2024. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/07/2024, revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had active diagnoses to include anxiety disorder, depression, psychotic disorder, impulse disorder, post-traumatic stress disorder. Resident #54's care plan, included a problem statement initiated 02/09/2024, that indicated the resident had a potential for a behavioral problem related to major depressive disorder, unspecified psychosis, anxiety disorder, adjustment disorder, mild cognitive impairment, and insomnia. Resident #54's medical record revealed no evidence to indicate a PASARR was completed after the resident obtained new mental illness diagnoses on 04/16/2024. During an interview on 10/09/2024 at 4:12 PM, the MDS Coordinator stated a new PASARR for Resident #54 should have been completed with the resident got a new mental health diagnosis. During an interview on 10/10/2024 at 12:27 PM, the Director of Nursing said she thought Resident #54's mental illness diagnosis was a previous diagnosis, but that a PASARR should have been completed.

Based on observation, interview, record review, and facility policy review, the facility failed to remove dead bugs and cobwebs in 1 (main dining room) of 2 dining rooms in the facility. Findings included: An undated facility policy titled, Environmental Cleaning: Policy and Procedure, revealed Purpose To maintain a clean environment for patients and minimize the risk of patient and healthcare personnel exposure to potentially infectious microorganisms. During an interview on 10/07/2024 at 10:40 AM, Resident #18 stated the dining room was always dirty and they were unsure how the facility stayed opened. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/27/2024, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. During an observation of the dining room on 10/07/2024 at 12:08 PM, cobwebs and dead bugs were seen in the dining room windowsill. During an observation of the dining room on 10/08/2024 at 12:10 PM, cobwebs and dead bugs were seen in the dining room windowsill. Certified Nursing Aide (CNA) #2 was interviewed on 10/09/2024 at 11:07 AM. CNA #2 stated housekeeping services were not available daily and was only offered three to four days per week. Housekeeper (HK) #3 was interviewed on 10/10/2024 at 8:24 AM. HK #3 stated she was not responsible for cleaning the dining room and added that was the responsibility of the dietary department. The Dietary Supervisor (DS) was interviewed on 10/10/2024 at 8:42 AM. The DS confirmed the dietary staff was responsible for cleaning the dining room The DS stated she was unsure who was responsible for cleaning the window blinds, walls, windows, or cleaning cobwebs. The DS observed the windows and windowsills and confirmed dead bugs and cobwebs were in the windows and confirmed the condition of the windows and windowsills did not promote a homelike, sanitary environment. The Director of Nursing (DON) was interviewed on 10/10/2024 at 12:43 PM. The DON stated she expected the building to be clean, adding she would not expect to go into the dining room and see dead bugs and cobwebs in the windows and on the windowsills. The Housekeeping Supervisor was interviewed on 10/10/2024 at 2:30 PM and stated the staff in the dietary department was responsible for cleaning the dining room. The Housekeeping Supervisor stated cleaning the dining room included cleaning the windows, windowsills, and blinds. The Administrator was interviewed on 10/11/2024 at 8:38 AM and acknowledged he observed cobwebs and dead bugs in the windows in the lobby. He stated he heard about the cobwebs and dead bugs in the dining room windows and stated he would not expect the residents to eat or live in an environment that was dirty and had cobwebs and dead bugs in the windows.

Based on record review and interview, the facility failed to implement their water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia). The facility also failed to ensure facility staff were informed on the facility's Water Management Plan and on safe water temperatures to maintain for the hot water. The facility census was 56. Review of the CMS Quality Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed: - Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella (a [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. - The facility should develop and implement a water management program that considers the American Society of Heating Refrigerating and Air Conditioning Engineers (ASHRAE) industry standard and the Center for Disease Control and Prevention (CDC) toolkit. 1. Review of the facility's policy dated 6/6/18, titled Infection Control Identifying and Investigating Legionnaires' Disease showed the following: - Section L- Facilities must have water management plans and documentation that, at a minimum, ensure each facility: - See Water Management Program Section N; - Conducts a facility risk assessment to identify where Legionnaires' Disease and other opportunistic waterborne pathogens could grow and spread in the facility water system' o Implements a water management program (Section N) that considers the ASHRAE industry standard and the CDC toolkit includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections and environmental testing for pathogens; o Specific testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained; and; o Conduct an environmental facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. - Section N- Environmental Water Management Program for Legionnaires' Disease o This section covered how a sample of the water system would be collected, tested and emergency remediation if Legionella was identified in the water system. It did not include how often the system was to be tested ; - Section O Other Preventative Measures: o This section addressed ice machines and showed ice machines would be cleaned and disinfected according to manufacturers' inspections. - There was no record of any assessments, flow diagrams to show how water was distributed in the facility, and no additional control measures being established. During an interview on 3/30/23 at 2:19 P.M., the Infection Preventionist/Director of Nursing said she had been in the position since the fall of 2022. There had not been any meetings to discuss the water program in that timeframe and she did not had a lot of knowledge of Legionella. During an interview on 3/30/23 at 2:30 P.M. the Maintenance Director said he: - Took samples for Legionella testing annually, and checked water temperatures in random resident rooms daily; - He checked the water temperature in locations per day, binder kept in his office. He maintained the water between 105 degrees Fahrenheit (F) and 120F. - Did not flush or monitoring for stagnant water; - Had not been part of any meeting for the water management plan; - Had not seen a flow diagram; - Knew Legionella grew in stagnant water, and caused a lung infection; - There had not been any cases of Legionnaires in the two years he had worked at the facility. During an interview on 3/30/23 at 2:55 P.M., the Environmental Services Manager said: - She did not know anything about a water management program, or Legionella. During an interview on 3/30/23 at 3:01 P.M., the Administrator said: - He could not find any assessments or flow diagram but he knew he had one because it was cited at the last survey. The facility tested for Legionella annually. - The Maintenance Director was in charge of the water management program; - They had not had an Interdisciplinary Team meeting about the water management program that he was sure it had been discussed with staff. 44395

Based on observations, interviews, and record review, the facility failed to assure residents have the right to file grievances in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievances, the right to obtain a written decision regarding his or her grievance. This had the ability to affect all residents. The facility census was 66. Review of the facility grievance policy titled,, Grievance Policy -Residents, dated 9/17/21, showed: -Facility wants to hear and address any concern of a resident. A resident or their legal representative can bring concerns to a staff member, the resident concern group, or call the compliance hotline. Additionally each resident has the right to use the formal grievance process. The formal grievance process as outlined in this policy. -The social services director shall serve as the grievance officer and may be reached at the facility address and phone number. If the facility does not have a social service director, the administrator shall appoint someone to serve as a grievance officer. -A resident, his/her legal representative, or family/friend may voice their grievance orally to the grievance officer or in writing. Written grievances can be given to any employee who will take them to the grievance officer. A form will be provided to residents to assist them in documenting their grievance, but use of the form is not required. -Grievances may be filed anonymously. If a resident requests to be anonymous, the grievance officer shall respect that request and will not disclose the resident's name to anyone else. However if the grievance is a reportable event under any rule or regulation, the facility is unable to honor the request to be anonymous. -Grievance officer shall track all grievances received. This should include the name of the resident (if not anonymous), date of grievance, manner received, investigation and resolution. The Grievance Investigation Form can be used for this purpose. -The grievance officer shall endeavor to complete an investigation as soon as reasonable and within 7-14 days. The grievance officer or their designee may interview any resident or employee necessary to complete the investigation. The grievance office shall inform the Administrator of the result of their investigation. The administrator should determine if coordination with the interdisciplinary team or the care plan team is necessary. A response to individual making the grievance shall be provided as soon as possible but no later than thirty days after the grievance is made. -If requested by the resident or legal representative or family/friend, the response to the grievance shall be put in writing. Any written response shall include the date the grievance was received, a summary statement of the resident's grievance, a summary of the pertinent finding or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not, any corrective action taken or to be taken by the facility, and the date the written decision was issued. -All documentation of grievances shall be maintained for three years from the date of grievance decision 1. During an interview on 3/27/23 at 12:55 P.M., Resident #217 said: -He/she has been in the facility for five weeks -The Director of Nursing (DON) refused to come talk to him/her about not receiving medications at the time he/she wanted them. The DON is never on the unit. He/she has requested to talk to the DON and the Administrator will come instead. Neither the DON or Administrator will follow up with him/her During an interview on 3/27/23 at 3:54 P.M., Resident #20 said: -He/she was unsure how to complete grievances or who to go to for that -When he/she does complain about something, no one ever comes back and tells you what they found -He/she cannot request money from his/her guardian, staff has to request the money. Sometimes he/she asks staff to make the request for them and they still do not do it or follow up on requests. During an interview on 3/27/23 at 4:00 P.M., Resident #48 said: -The facility staff never tells the residents anything -He/she can complain over and over and nothing ever gets done Observation on 3/28/23 showed -No grievance forms were posted in the facility for residents or community members to access -No grievance box for anonymous complaints to be received -Compliance number was posted on the bulletin board in the front entry hallway only The social services director vacated his/her position during survey and was unable to be interviewed During an interview on 3/28/23 at 1:30 P.M., the Administrator said: -He has not had any grievances for the last 90 days During an interview on 3/30/23 at 10:56 A.M., Certified Nursing Assistant (CNA) A said: -He/she would go to the charge nurse first if a resident had a complaint -If a resident complained about missing clothes, he/she would go to the housekeeping supervisor as he/she keeps inventory of everything -Would report any other issues to front management During an interview on 3/30/23 at 11:00 A.M. the Activities Assistant said: -If he/she received a complaint, he/she would take it to the Administrator or DON, but it would depend on what it was -Was unsure if there is a way for residents to make anonymous complaints -Staff have grievance forms available at the desk During an interview on 3/30/23 at 11:05 A.M., the Housekeeper said -If he/she received resident complaints it was usually about clothes not being dry or clothes coming up missing -He/she never sees written complaints During an interview on 3/30/23 at 11:16 A.M., Licensed Practical Nurse (LPN) A said: -Department heads address complaints after their meetings by going to address staff that are in the building -He/she stated they don't let staff know what resident made a complaint but provided staff members advice on resolving the issue -He/she follows up with resident complaints by going back to residents to see if an issue has gotten better or is the same During an interview on 3/30/23 at 12:24 P.M., the Administrator said: -For the grievance process the residents should go through the social worker -The social worker should do an investigation and look into it -Residents can make anonymous complaints via the compliance hotline that goes to corporate management office and compliance officer -The facility receives from corporate what they deem is appropriate and the facility fixes what they can -Number is not available to the public, someone wanting to make an anonymous report would have to ask for the compliance telephone number. He/she does not know that the number is listed anywhere else -He/she believes someone wanting to make an anonymous complaint could call the corporate management office and ask for the number

Based on observation, record review, and interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for all residents of the facility, when the staff did not keep rooms clean, floors throughout the building clean and in good repair, doors and walls in all the hallways and in resident rooms scuffed with missing paint, and an overall un-cleanliness about the building which affected all of the facility's residence halls, and all common areas of the facility. The facility census was 66. Review of the facility deep cleaning and daily cleaning policy dated 2/26/21, showed: - It is the purpose of this policy to ensure rooms are clean. 1. Observation on 3/27/23 at 10:45 A.M., showed: - On the 100 hall, room [ROOM NUMBER] missing baseboards in the entire resident room exposing sheetrock and old paint. - room [ROOM NUMBER] has large patched areas on the wall that have not been painted. - The 100 hall has missing and scuffed paint around door frames and doors to the residents' room. - The sitting area at the top of the 100 hall had dirty furniture and was dusty. Observation on 3/28/23 at 8:05 A.M., showed: - The dining room fixtures, tables, and windows were dusty, without decor, and plain tables. - The dining room doorways missing paint. - The dining room floor, dull, with wax build up and debris. Observation on 3/29/23 at 7:25 A.M., showed: - The following resident rooms with multiple white colored patched areas on the walls from repairs that need painted: Rooms #106, #108, #107, #109, #111, #112, #117, #118. - room [ROOM NUMBER] has a large area inside the resident's room, in front of the closet, where the floor tile was broken in multiple places. Observation on 3/30/23 at 10:22 A.M., showed: - The men's shower room on the 100 hall had a sewer septic smell. - This shower room was without a hook or bench for residents to place their clean clothes on while showering. - Clean clothing observed lying on the floor during showers. During an interview on 3/27/23 at 9:11 A.M., Resident # 58 said: - He/she felt that the facility needed better cleaning and updating. - He/she felt that the building was depressing. During an interview on 3/28/23 at 1:11P.M., Resident # 61 said: - He/she did not know who fixed the floors. - The floor looks broken in his/her room. During an interview on 3/29/23 at 9:20 A.M., Resident # 15 said: - This place needed some decorations. During an interview on 3/30/23 at 7:33 A.M., Licensed Practical Nurse (LPN) A said: - room [ROOM NUMBER] has had missing baseboards for at least two months. - There were several resident rooms that needed to be painted. - The resident rooms and sitting areas were dated. During an interview on 3/30/23 at 8:22 A.M., Certified Medication Technician (CMT) A said: - room [ROOM NUMBER] has had missing baseboards for as long as he/she could remember. - There were many rooms that needed wall patches painted. - The resident rooms are not as clean as they used to be. - He/she has not seen the housekeeper for this hall today. During an interview on 3/30/23 at 2:20 P.M., the Maintenance staff said: - He was aware of the baseboard needing to be replaced in the resident rooms, and the painting that was needed. - He was waiting on supplies to repair flooring and paint walls. During an interview on 3/30/23 at 2:45 P.M., the Administrator said: - He expected projects to be completed timely or as soon as possible. - He was aware of baseboards needing to be replaced in resident rooms and that painting in the facility needed to be completed. - He was aware the facility was waiting on supplies for baseboards. - It was his expectation that the facility and resident rooms were kept clean, free from dirt, cobb-webbs, debris, and have a home like appearance and feel.

Based observation, interviews, and record review, the facility staff failed to assess and monitor one resident (Resident 1). The facility staff failed to assess and monitor the resident when he/she complained of leg pain and after he/she developed wounds on both his/her legs. The resident's leg wounds worsened and he/she was admitted to the hospital with a diagnosis of Necrotizing Fasciitis,(a serious bacterial infection that destroys tissue under the skin) and sepsis (an infection in the bloodstream). The resident died in the hospital. The facility census was 65. Review of the pain monitoring policy dated [DATE] showed: - Resident's will be assessed for pain quarterly and as needed to address the presence of pain, the frequency of pain, acceptable pain level, and effectiveness of the current pain management plan of care. - The primary care physician (PCP) will be updated as needed regarding the effectiveness of the pain management and provide further interventions as needed. - The pain management interventions will be care planned and updated as needed. Review of the skin integrity assessment policy dated [DATE] showed: - All resident's skin will be assessed weekly for skin integrity concerns. - Any skin integrity concerns will be reported to the director of nursing (DON) or designee and the physician for treatment orders if needed. - Residents will also have a skin assessment completed by the Certified Nurse Assistant (CNA) or designee on the residents' shower day. - The CNA will complete a skin assessment shower sheet and report any skin integrity concerns to the charge nurse. Review of the wound management policy dated [DATE] showed: - The Resident Care Coordinator (RCC), facility wound nurse, or designee will monitor all abnormal skin conditions weekly, and communicate wound changes to the physician, responsible party and interdisciplinary team (IDT). - The RCC, or designee will notify the physician when new skin integrity issues are found. Review of the special wound investigation policy dated [DATE] showed: - Weekly wound assessment will be completed by the nurses providing wound care and reviewed by the DON. - Comprehensive wound assessment is to include the following: wound location, wound measurements, wound pain, drainage, odor, appearance of the wound, and current treatment. 1. Review of Resident #1 admission Minimum Data Set (MDS) a federally mandated assessment completed by the facility staff dated [DATE] showed: - Admit to the facility on [DATE] - Brief Interview for Mental Status score of 11, indicating minimal cognitive deficit. - End stage renal disease (ESRD, the kidneys are not functioning properly to remove toxins from the blood stream) and diabetes mellitus (DM) type 2 (a condition that affects the way the body processes blood sugar). - Independent with bed mobility, walking, dressing, eating, and toilet use. - Pain in the last 5 days. - Skin is without wounds. Review of the skin care plan dated [DATE] showed: - Wound management to both lower extremities and feet. - Encourage him/her to elevate legs. - Evaluate the ulcer characteristics. - Monitor ulcer for signs of infection. - Notify the PCP if there are no signs of improvement on the current wound treatment. - Provide wound care per the treatment order. The facility staff did not provide a pain care plan. Review of the physician order sheet (POS) dated ,d+[DATE] showed: - An order dated [DATE] Assess pain every shift. - An order dated [DATE] Clean bilateral (both) lower extremities with wound cleanser, cover areas to both feet and legs with petroleum gauze, wrap with kerlix (dry gauze), daily and as needed if the dressing becomes soiled. - An order dated [DATE] Tylenol tablet (a medication that helps relieve mild pain and fever), 325 MG per tablet, give two tablets by mouth every eight hours as needed for pain, not to exceed two grams in 24 hours. Review of skin assessments showed: - [DATE] his/her skin is intact. - [DATE] his/her skin not intact, he/she with open blisters that are pinkish-red in color - The facility staff did not measure or describe the affected area. - The facility staff did not document any further skin assessments. Review of the medical record showed: - License Practical Nurse (LPN) B documented on a nurses' note dated [DATE], edema was noted in both legs that were leaking clear fluid and had scattered fluid filled blisters. - LPN B did not document notifying the physician. - LPN A documented in a nurses' note dated [DATE] at 3:04 P.M. that Resident #1 complained of bilateral leg pain. - LPN A documented that he/she encouraged him/her to elevate both legs as much as possible. Dressing to his/her legs were intact. Review of the November medication administration record (MAR) showed that the facility staff did not give him/her Tylenol during the month of November. Review of the resident's medical record included the following: - LPN C documented in a nurses' note dated [DATE] at 5:08 A.M. that the resident has been up most of the night with complaints of leg pain and moans continuously. - LPN C encouraged the resident to elevate his/her legs and rest. No fluid leaking was seen from the lower extremities and his/her legs remain wrapped. - Review of the December MAR showed that LPN C did not administer Tylenol. - LPN A documented in a nurses' note dated [DATE] at 8:49 A.M. that he/she contacted the family to notify them of the condition of his/her feet and contacted the Nurse Practitioner (NP) and obtained an order for him/her to be seen at the wound clinic. - LPN A documented in a nurses' note [DATE] at 10:47 A.M. that an appointment to be seen at the wound clinic was on [DATE] after dialysis (a process where blood is mechanically filtered to remove toxins from the body). - LPN D documented in a nurses' note on [DATE] at 3:30 A.M. the wounds on both of his/her legs have moved upward, with the wounds to the right leg worsening with discoloration. - The right foot was turning black on the back side of the foot, heel and part of the ankle. - The left foot had some dark discoloration. - The dressing was reapplied, passed on to the oncoming nurse during report, and placed this new information on the communication board in the computer. - LPN D did not document notification of the PCP. - LPN A documented on [DATE] at 6:26 A.M. that he/she called the after-hours physician and obtained an order to send the resident to the emergency room . - He/she was to go to the emergency room after dialysis is finished. Review of Hospital A records dated [DATE] at 10:55 A.M. showed: - The resident arrived to the emergency room with a wound to the left foot and black discoloration to the right foot. - Superficial (on the surface) ulcers with eschar (dead tissue) in the wound bed on both feet, - No drainage or evidence of cellulitis (inflammation of tissue) seen. - Pedal pulses (pulses felt in the foot) was not able to be felt. - Blood pressure ,d+[DATE], pulse 84 beats per minute, respirations 14 breaths per minute, temperature 97.6 degrees Fahrenheit. - The final impression was that he/she has chronic bilateral extremities wounds, and possible peripheral vascular disease (a disease of the veins that affects blood flow to the extremities). - He/she was sent back to the facility with an order to see a podiatrist and to have a Doppler ultrasound (test to see how the blood flow was in the lower extremities). Review of the nurses' notes dated [DATE] LPN A documented: - 5:03 P.M. He/she returned to the facility from the emergency room . - New order for Doppler ultrasound to be done and consultation with a vein doctor. - DON was notified that the appointments needed to be scheduled. - The family was with him/her at the emergency room and aware of the new orders. Review of nurses' note dated [DATE] at 9:00 A.M. LPN A documented: - The family is concerned about his/her increased confusion and requests that he/she be sent to a different emergency room . - The wound dressing to his/her right root became saturated with drainage and was changed before breakfast. - The wound dressing to his/her right foot became saturated with drainage after breakfast and was changed. - The right foot is black in color and the drainage smells bad. - He/she is moaning in pain and unable to stand up on either foot. - LPN A sent the resident to Hospital B by ambulance. Review of Hospital B's medical records showed: - He/she arrived [DATE] at 10:12 A.M. at the hospital with wounds to both legs from the knees down to the feet. - The right lower extremity was black from the knee to the foot and with blistering and oozing drainage. - Increased pain and swelling to the right leg. - [DATE] at 10:46 A.M. an X-ray (picture of the bone) showed that he/she had a moderate amount of gas in the soft tissue that indicated an infection. - A wound culture (a test to see what type of infection is growing in a wound) on [DATE] showed growth of Group B streptococcus (an bacteria that is a common and causes infections). - He/she was admitted to the hospital for necrotizing fasciitis and sepsis. - He/she was sent to the operating room for immediate debridement (surgical removal of dead tissue from a wound). - The family chose to make him/her comfortable rather that pursue surgery and the surgery was canceled. - He/she was placed on the palliative floor (made comfortable) on [DATE]. - He/she died on [DATE] at 1:10 A.M. During an interview on [DATE] at 10:09 A.M. the NP said: - He/she would expect weekly skin assessments to be done for a resident that is receiving dialysis. - He/she only saw him/her one time. - The facility staff did not notify the PCP of the worsening wounds prior to [DATE]. During an interview on [DATE] at 1:26 P.M. LPN A said: - The nurses do the skin assessments weekly and with each dressing change. - The DON is responsible for measuring and describing the wounds. - The nurses document for pain every shift. - The nurses are supposed to contact the physician immediately if the resident is moaning. During an interview on [DATE] at 12:44 P.M. the interim DON said: - He/she expects the nurses to assess wounds weekly. - The wound assessment includes measurements and description of the wound. - He/she expects the nurses to notify the PCP immediately once a wound has been identified. - He/she expects the nurse to contact the PCP immediately if the resident is moaning in pain and complete a pain assessment. During an interview on [DATE] at 2:03 P.M. the administrator said: - He/she expects the nurses to complete skin assessments weekly. - He/she expects the DON to measure and describe wounds weekly and the assessment should be documented in the electronic medical record. - He/she expects the nurses to complete a pain assessment every shift and to call the PCP if a resident is moaning in pain. - He/she expects the nurses to follow the PCP orders. During an interview on [DATE] at 4:10 P.M. the PCP said: - The first notification of the wounds was on [DATE], facility staff called and spoke with the NP. - The facility staff told the NP that they had been wrapping his/her legs because they were draining fluid, now his/her legs were draining more and bleeding. - Referral to the wound clinic was made at that time. - He/she expects the facility staff to notify him/her when the resident has a condition change. - The facility staff should have notified him/her when the resident had developed the wounds on his/her legs and when the resident had increased pain. MO195216

Based on interviews, observations and record review, the facility failed to provide adequate supervision, care planning and staff training to prevent ongoing verbal conflicts between residents from escalating into physical altercation in which one resident received a fractured arm and another resident suffered emotional stress as a result of how the facility reacted after the incident. The facility only staffed one certified nurse aide (CNA) to work on the behavior unit and the licensed nurse assigned as charge nurse over all facility residents had not received any training associated with the facility's behavior unit. This affected two of four sampled residents (Resident #4 and #15) and had the potential to affect all residents who resided on the behavior unit. The facility census was 35. The facility did not provide a behavior policy. 1. Review of Resident #4's current care plan, dated 7/1/14, with target date of 10/01/14, showed: - Problem: Resident has a history of verbal/physical abuse towards staff. - Goal: Resident will demonstrate methods of releasing anger; on going through next review. - Approach: Allow resident to verbalize/ventilate feelings. One on one with staff as needed. Encourage resident to participate in all individual and group therapies offered. Encourage resident to attend and participate in classes offered. Assess for contributing factor leading to behavior. Evaluate behavior documentation for success or failure of interventions and update care plan as needed. Staff to notify physician of new or worsening behaviors. Psychiatric evaluation per order as needed. Assess homicidal, suicidal, elopement ideation as needed. C.A.L.M. (Community Support, Acceptance, Lifestyle Changes and Meaning) technique (which includes training on how to take down a resident) as needed when resident becomes a threat to self or others. Review of the resident's psychological services progress report, dated 10/17/14, showed resident addressed relationship skills with peers. Plan to continue supportive psychotherapy to relief of distressing symptoms. Summary: Resident frustration for being under guardianship. Explored peer interaction skills for improving interactions and avoiding conflict. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/14/14, showed: - A BIMS (basic interview for mental status) score of 15 (a score of 13-15 indicated cognitively intake for decision making). - Verbal behavioral symptoms directed toward others (threatening, screaming, cursing); - [DIAGNOSES REDACTED]. - [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS, a federally mandated assessment instrument completed by facility staff, dated 1/14/15 showed: - No changes to his/her BIMS score or diagnoses; - No behaviors symptoms. Review of the resident's psychological services progress notes, dated 12/19/14, showed: - Treatment goals: to stabilize depressed mood and to reduce conflict relations. - Addressed relationship skills with peers/self and maintaining a positive attitude. - Plan to continue supportive psychotherapy for relief of distressing symptoms. - Summary: Supported resident as he/she shared interactions and contact with family member and continued addressing coping skills. 2. Review of Resident #15's care plan, dated 2/11/14, with approach (target/goal) dates of 8/11/14, showed: - Uses [MEDICAL CONDITION] medications due to diagnoses. Resident to show no signs or symptoms of side effects through 8/11/14; facility to notify physician for any adverse effects or need to adjust medications. - Resident at risk for elopement. Resident not to leave facility unattended for next 90 days, target date 8/11/14. - Resident requires supervision with razors, sharp objects (eating utensils) and products containing alcohol. Staff will provide supervision with these objects for the next 90 days with target date of 8/11/14. Staff will monitor use of all sharp objects and products containing alcohol. Review of the nurses' notes, dated 8/12/14, showed staff documented the following: - Charge nurse went to the unit and upon entering, heard Resident #15 in the phone room yelling. - Resident exited the phone room and entered the lobby, yelling and cursing. - Licensed Practical Nurse (LPN) told the resident his/her behavior was inappropriate for the lobby and he/she needed to go to his/her room. - Resident responded by cursing and stating "your not my boss." - The resident said he/she wanted out of the unit and the nurse would either send him/her out or he/she could leave in a coffin. - Interim director of nursing (DON) attempted to give resident a shot. - At this point resident appeared to be out of control. - Police called for assistance. - Resident then stood up and walked quickly to the intern DON and placed both of his/her hands around the interim DON's throat. - The LPN and three others staff members lowered the resident to the floor. - Police arrived and the resident tried to kick the police officer. - Police office held the resident, allowing the interim DON to administer a PRN injection. - After 10 minutes, the resident calmed down and apologized to staff for his/her behavior. - Resident on 15 minute watch. Review of the resident's psychological service progress notes, dated 10/17/14, showed: - Treatment goals: stabilization of depressed mood, reduced incidence of assaultive or inappropriate behaviors; stabilization of anxious/irritable mood and reduction in conflictual relations. - Patient address: coping skills and relationship skills with peers/staff. - No plan marked. - Summary: Explored mood, peer interactions, frustration tolerance and anger. Processed triggers and anger control. Resident acknowledged peers aggravate resident at times and he/she struggles to control anger outbursts. Review of the resident's annual MDS, dated [DATE], showed: - A BIMS score of 15. - Other verbal behavioral symptoms not directed toward others. - Behaviors have no impact others. - [DIAGNOSES REDACTED]. - History of [MEDICAL CONDITION]/[MEDICAL CONDITION] (a [MEDICAL CONDITION] is the medical term for a stroke. A stroke is when blood flow to a part of your brain is stopped either by a blockage or a rupture.) 3. During an interview on 2/11/15, at 2:45 P.M., the administrator said first time he heard about the recliner/chair was when the resident, who originally had the chair, moved out a few weeks ago. When social service confirmed resident was moving, the facility decided who would get the chair. Social service talked to the residents who wanted the chair and explained who got the chair. Maintenance was to move the chair when they had time to Resident #15's room. During an interview on 2/11/15, at 11:00 A.M., the social service designee said: - This disagreement between Resident #4 and Resident #15 started when another resident moved out and both residents asked for the chair. - The administrator checked and found Resident #15 asked first and he/she got the chair. - He/she and the administrator told Resident #15 he/she would get the chair as soon as maintenance had time to move the chair to his/her room. - We told Resident #4 he/she would receive the next chair but Resident #15 had asked first and got this chair. - Resident #4 got mad. He/she explained why Resident #15 got the chair and she thought Resident #4 understood and was okay with the decision. Review of a CNA note written in a legal pad (the CNAs kept notes on what happened on the unit on a legal pad. They used the legal pad notes as a type of communication for each other to give other CNAs an idea of what happened on the unit during the last shift or over the last few days with the residents), dated 2/1/15, showed Resident #4 and Resident #15 "fighting," numerous profanities, argument over phone time. He/she told both residents to go to their rooms, but both refused. During an interview on 2/10/15, at 1:05 P.M., Resident #4 said Resident #15 always yelled at him/her and other residents. They had words three days before the incident in which he/she was injured, and several other times. Most of their issues were over the phone. Review of Resident #4's behavior charting, dated 2/3/15, at 4:30 (staff did not indicate A.M. or P.M. on the chart), showed staff wrote resident screaming in another resident's face. Interventions: Removal from situation or area and verbal counseling session with staff. Review of Resident #15's behavior charting, dated 2/3/15, at 4:30 staff did not indicate A.M. or P.M. on the chart), showed: - Resident was playing the activity when he/she noticed two other residents dragging a chair up the hall. - Resident went to the room to see what other residents were doing and immediately started yelling at the other two residents "all in their faces." - CNA F wrote he/she told the resident to break it up and next thing he/she knew Resident #15 shoved Resident #4 full force and Resident #4 hit the railing, then the floor. - CNA F paged for the nurse to come from the nursing home side of the building to the unit. - Resident #15 went to his/her room as instructed and continued screaming and hitting things. Review of the nurse's note for Resident #4, dated 2/3/14, at 5:00 P.M., showed: - RN C called to unit by certified nurse aide (CNA); - Upon entry, Resident #4 was visualized lying on floor face down with complaint of left shoulder pain. - Resident stated another resident pushed him/her down and he/she bumped his/her left shoulder on the wall then fell down. - Vitals taken. - Assisted resident to sitting position, - Resident refused to do range of motion stating shoulder is "out of place." - Offered to get order to transport by ambulance to the emergency room (ER). - Resident refused starting he/she wanted to go smoke. - Resident stated he/she would get X-ray at the facility. - Resident assisted to feet by this RN and two CNAs with a gait belt. - Resident continued to guard left arm. Review of the nurses' notes for Resident #15, dated 2/3/15, at 5:00 P.M., showed Registered Nurse (RN) C wrote: - Called to unit by CNA. - CNA said Resident #15 pushed another resident down. - Resident #15 instructed to go to his/her room to allow RN C to assess the downed resident. - Resident screaming stating not his/her fault and not fair he/she was in trouble. - Assured resident he/she was not in trouble, but he/she needed the residents to be separated. - Resident went into room and began hitting wall and door, and continued to scream. - PRN (as needed) [MEDICATION NAME] (medication used to treat anxiety disorders or anxiety associated with depression) given to prevent resident from harming self. Review of Resident #4's X-ray report, dated 2/3/14, showed an acute humeral neck and greater tuberosity fractures (bone located on the arm at the point of the shoulder), with mild displacement, moderate soft tissue swelling of proximal arm (closest to shoulder), moderate [MEDICAL CONDITION] ([MEDICAL CONDITION] is a condition of fragile bone with an increased susceptibility to fracture) demonstrated and moderate [MEDICAL CONDITION] (a joint disease caused by cartilage loss in a joint. Pain and stiffness are symptoms). Review of behavior charting for Resident #15, dated 2/4/14, (should be dated 2/4/15) showed staff wrote: - Resident stated to nurse he/she did not know what he/she would do when Resident #4 returned from the hospital. - He/she stated he/she might want to choke the resident. - Charge nurse talked to the resident and gave as needed medication and requested the resident stay in his/her room. During an interview on 2/10/15, at 1:35 A.M., Resident #15 said: - He/she did not want to be in trouble and started crying. - The administrator told him/her not to talk about the incident. - CNA E told him/her it would be okay to talk about the incident with this surveyor. - He/she said Resident #4 was also told to stop talking about the incident, but he/she kept telling the other residents he/she will hurt them and making him/her out to be a bad person. - Now no one wanted to be his/her friend. - Resident #15 became visibly upset and started crying again. - After he/she calmed down, Resident #15 said he/she did not know if he/she could control his/her temper when he/she had to listen to Resident #4 mouth him/her all the time. - Resident #4 threatened to have him/her arrested. - He/she tried to talk to staff when he/she got upset but with only one staff on the unit they did not always have time for him/her to talk to them. - Resident #4 tried to steal the recliner that the administrator and social services designee promised him/her. - They told him/her he/she got the recliner. - It made him/her mad when they stole the recliner. - They knew it his/her recliner. - He/she yelled at Resident #4 for taking his/her chair. - Resident #4 shook his/her fist in his/her face, told him/her it was none of his/her business because he/she needed the chair worse and pushed him/her first. - Now he/she was the bad person for pushing his/her back. - He/she did not mean to hurt Resident #15, just to get him/her away from him/her and the chair. - He/she tried to control his/her temper, but it was very difficult. - The counselor said he/she needed to work on controlling his/her anger, but it was hard. - He/she would like to talk to the counselor or psychiatrist more often, but they were not here very often. - He/she did not want to be sent to another facility, but was not sure he/she could control his/her temper if Resident #4 did not shut up. - Resident #4 has called him/her names for months. During an interview on 2/10/15, at 1:05 P.M., and 2:20 P.M., Resident #4 said: - He/she was afraid of Resident #15 because he/she pushed him/her and broke his/her arm up by the shoulder. - He/she was afraid Resident #15 would hurt him/her again. - Resident #15 had hurt other people including staff. - He/she was afraid of the administrator because he threatened to send him/her to a "worse place" if he/she did not stop talking about the incident when Resident #15 pushed him/her into the wall and broke his/her arm up by the shoulder. - The incident happened with he/she and Resident #2, a friend, went to a former resident's room and started to move a recliner to his/her room. - He/she wanted to try out the recliner because he/she had back and leg pain. - He/she was going to ask for the recliner. - Resident #15 "wants everything". -Resident #15 was setting at the table; he/she got up and ran toward him/her. - He/she told Resident #15 "to get out of my face." - Resident #15 pushed him/her then went into his/her room and started hitting his/herself. - Resident #15 pushed him/her in the back full force, making him/her hit the wall then hit the floor. - Resident #4 said he/she was supposed to have a recliner because he/she had back and leg pain. - Other people took things from unused rooms; he/she did not know why administrative staff said it was his/her fault. - He/she needed the recliner. During an interview on 2/10/15, at 2:40 P.M., Resident #2 said - He/she helped his/her friend, Resident #4, move a chair toward his/her room from a former resident's room when the incident happened. - Resident #15 ran toward them screaming, wanting to know what they were doing. - Resident # 15 said we were not getting that chair. - Resident #4 made a fist and shook it in Resident #15's face and told him/her to shut up. - Resident #15 told Resident #4 to go ahead and hit him/her. - Resident #4 made fist again and told him/her to shut up, but he/she did not hit Resident #15. - Resident #15 shoved Resident #4 in the back and into the handrail. - Resident #4 hit his/her arm on the handrail and wall, and hit the floor sliding on his/her stomach. During an interview on 2/10/15, at 2:50 P.M., CNA F said: - He/she worked the unit the evening the incident happened on 2/3/15. - He/she was at the table with Resident #15 and another resident playing a game. - He/she saw Resident #4 and Resident #2 moving a chair down the corridor. - Resident #15 got up and started yelling, running toward the chair. - Resident #4 and Resident #15 were in each other's faces. - He/she told them to break it up and go to their rooms. - He/she turned around to listen to another resident and when he/she turned back he/she saw Resident #15 shove Resident #4 in the chest with his/her open hands. - Resident #4 hit the wall then the floor. - The residents were facing each other when the incident happened. - Staff had told him/her about other physical altercations on the unit, but this was the first physical assault he/she had witnessed. - He/she called over to the skilled side of the building for help. - He/she did not see Resident #4 shake his/her fist at Resident #15. - He/she did not see Resident #4 hit Resident #15 first. - He/she had looked away to answer another resident who was yelling. - He/she was the only staff on the unit. - He/she called for help, and CNA B came to help him/her. - RN C came and helped assess the resident. - Resident #4 pushed people with his/her mouth, made out like he/she was innocent, but he/she had to do something bad to make Resident #15 react like he/she did. - Resident #4 wanted him/her to do a police report on the accident, but he/she did not do a police report since both residents had guardians. - The charge nurse was responsible to contact the guardians about the incident. During an interview on 2/10/15, at 3:35 P.M., CNA B said: - CNA F called him/her to the unit on 2/3/15. - When he/she came through the locked door, one of the residents told him/her Resident #4 was on the floor. - He/she made sure there was no blood and called the nurse for assistance. - RN C came over to assess the resident on the floor. - Resident #4 said he/she did not do anything and the other resident pushed him/her. - He/she then went to Resident #15's room to get him/her calmed down. - He/she did not see the incident but knew the residents well. - Resident #15 said Resident #4 hit him/her first. - Resident #15 has never lied to him/her, but Resident #4 lied all the time. - Resident #4 would go up to Resident #15 and give him/her the finger and told him/her in a vulgar way what to do with it. - Resident #4 did this just to upset Resident #15 and get him/her going. - Staff told residents, who had verbal conflicts, to stop and then sent them to their rooms, but they did not always do what staff said. - If conflicts got really bad, staff called the nurse. - Have had a resident who left a couple of weeks ago; he/she had lots of behaviors and staff had no control. - He/she was really scared! It got so bad at times he/she went home shaking and in tears. During an interview on 2/12/15, at 12:05 P.M., RN C said: - He/she worked as the charge nurse the evening of 2/3/15. - The CNA, who worked on the unit, called him/her over to the unit because of an altercation between two residents. - He/she did not know what to do. - The facility had not trained him/her on how to deal with situations on the unit. - He/she had no knowledge of the unit's residents or their specific behaviors. - His/her only exposure to the unit's residents was when he/she passed the controlled medications. - The facility now had care plans for the residents on the unit, but he/she had not seen the care plan including care plans for behaviors prior to this incident. - When he/she entered the unit, he/she had to rely on CNA B to know how to handle the residents and their behaviors so he/she could deal with the injured resident. - Prior to the incident, the charge nurses' only assigned one CNA to work on the unit. - The only time another staff worked on the unit was when they did a specific task, like pass medications. - He/she was scheduled to attend C.A.L.M. training later this month. He/she would feel much better going into the unit after he/she received some training on how to deal with the residents and their behaviors. During an interview on 2/11/15, at 11:40 A.M., Resident #17 said he/she witnessed the incident, but did not want everyone to know he/she saw what happened. He/she did not want the residents involved to be mad at him/her. He/she watched as Resident #2 and Resident #4 moved one of their chairs down the hall and came back down the hall with the recliner. Resident #15 ran up to Resident #2 and Resident #4 and asked what they were doing with his/her chair. Resident #15 said the administrator said it was his/her chair. Resident #4 made a fist, shook it at Resident #15 and told Resident #15 to mind his/her own business. Resident #15 screamed at Resident #4 to go ahead and hit him/her. Resident #4 and Resident #15 were facing each other and Resident #2 was behind the chair. He/she could not see if Resident #4 hit Resident #15 first, but Resident #4 had his/her fists up. He/she did not see the actual push, but saw Resident #4 go flying down the hall and hit the wall. CNA F joined the group outside his/her room, but had his/her back to the incident talking to Resident #14 at the activity table. Residents #4, #15 and #14 were all yelling. CNA F told Resident #15 to go to his/her room and went for help. Resident #15 continued yelling from his/her room. Residents #4, #15 and #14 are always into a verbal altercation. During an interview on 2/11/15, at 1:10 P.M., Resident #7 said he/she heard all the yelling and carrying on but, he/she did not see the altercation. He/she was not sure what it was all about but the next day Resident #4 had an injured shoulder. He/she was smart enough to keep out of their way. Resident #4 did not push his/her buttons, but he/she felt uneasy about the mix of extreme behaviors the residents of the unit exhibits. During an interview on 2/11/15, at 3:35 P.M., CNA B said: - Resident #4 and Resident #15 had a verbal fight over the same chair a week before the physical altercation. - Resident #4 had a big mouth and would not "shut up," every day he/she said something that got several of the other residents all worked up. - He/she caused verbal conflicts all the time, he/she liked to "egg on" Resident #15. - Resident #4 called Resident #15 names; always calling him/her a "fat cow" because he/she got a reaction out of Resident #15. - Resident #15 went off like a snap of the finger. - This was not the first time Resident #4's mouth caused "blows;" it was an everyday occurrence. - Resident #4 mouthed off to another resident a couple of months ago and was hit three times on the head. During an interview on 2/10/15, at 2:50 P.M., CNA F said: - Resident #4 and Resident #15 get into a verbal altercation on a regular basis. - Resident #4 called Resident #15 "a fat cow" often. - The altercations between the two had always been verbal before this incident. - He/she would tell them to break it up and go to their rooms. - Resident #4 pushes people with his/her mouth then, when they react, he/she made out like he/she was all innocent. During an interview on 2/11/15, at 1:10 P.M., Resident #7 said Resident #4 pushed Resident #15's buttons daily. During an interview on 2/10/15, at 2:40 P.M., Resident #2 said Resident # 15 verbally fought with other residents, using "nasty" words, cussing at other residents all the time. Resident #15 had not been physical with other residents in his/her fighting, but all the verbal fighting and screaming was really hard on all the other residents' nerves. During an interview on 2/11/15, at 11:00 A.M., the social service designee said she did not know of any other altercations between Resident #4 and Resident #15, but they bickered all the time. They verbally fought over markers, the phone, etc. Resident #4 stirred up stuff, and talked about people to make them mad. During an interview on 2/11/15, at 11:35 A.M., Resident #17 said Resident #4 and Resident #15 had words daily. They yelled and screamed at each other and called each other names and used a lot of profanity. During an interview on 2/10/15, at 3:00 P.M., the administrator said it was a big problem when a resident was out of control. There were a limited number of mental health facilities, and if they sent a resident to the ER because of behaviors, they would just send them right back. Staff gave Resident #15 medication that de-stressed the situation and Resident #4 received the needed medical care for the injury. Resident #15's physician was aware of the situation and gave no new orders. During an interview on 2/11/15, at 11:00 A.M., the social service designee said: - On 2/5/15, he/she, the quality assurance (QA) nurse and the administrator had a meeting with Resident #4, Resident #2 and Resident #15. - Resident #4 said he/she needed the chair worse than Resident #15. - Resident #4 played like he/she had not been told the chair was promised to Resident #15. - We talked this out and said they needed to let it go and stop talking about the incident. - Resident #4 continued to bring up the incident talking to the new residents and others, which upset Resident #15. - He/she talked to Resident #4 and told him/her they did not need to be best friends, but needed to learn to get along. - He/she told Resident #4 to stop reminding everyone of the incident. - He/she agreed. - He/she also talked to Resident #15, who said he/she could not help getting upset with what Resident #4 says about him/her. - Both wanted the other one to move and both want to stay. - They needed to learn to get along. - No one told them in the meeting they would be sent to a "bad place" if they did not get along. - We discussed that other locked units could be worse than here. - Resident #4 tried to play the new residents against Resident #15. - He/she felt Resident #4 was a pot stirrer. - Staff redirected the residents when they caught them talking or doing things inappropriate. - Staff had C.A.L.M. training for protection, but felt this was probably not good training on mental health issues. - Things happened differently daily on the unit. - The facility had an in-service about six months ago from a psychologist on behaviors. - The trainer discussed how to approach residents and how to deescalate a situation. - We have had several staff changes since this training. During an interview on 2/11/15, at 11:39 A.M., Resident #15 said, "Am I in trouble?" Resident #4 was telling everyone he/she was dangerous, he/she was getting him/her sent out and that he/she should go to jail for hurting him/her. He/she pushed him/her first, why should he/she be in trouble? He/she did not want to go to jail or be sent out. The resident cried as he/she spoke. CNA E talked to the resident, trying to calm him/her down and reminding him/her not to listen to Resident # 4. During an interview on 2/11/15, at 1:50 P.M., the QA nurse said staff met with the residents involved in the altercation. Resident #4 said over and over Resident #15 hit him/her. We told them we were not going to rehash the incident, but we needed to deal with the issues. They told them they all lived here and needed to get along. If they did not like each other, stay away from each other. Resident #4 did most of the talking. They told them if they had an issue to ask to talk to the administrator or social services. They told them they investigated incident and were going to move forward. They found they were both at fault. During an interview on 2/11/15, at 2:45 P.M., the administrator said he had a meeting with the residents, social services and QA nurse on 2/5/15. He told them if they continued to have these behaviors he would talk to their guardians. He told them they may be moved to stricter facility. He explained charges could be pressed. They could not move either one to the skilled side. If they have to separate them, their new facility might be stricter. We tell staff when residents have behaviors, they are to identify, separate them and tell them to stop. When something like this incident happened, the CNAs on the unit should stop the behavior; tell the nurse, him and social services. The CNAs usually told them about behaviors on the unit. The first time he heard about the reclining chair was when the resident who had the chair moved out. When social service confirmed resident was moving, we decided who would get the chair. Social service talked to the residents who wanted the chair and explained who getting the chair. During an interview on 2/10/15, at 1:05 P.M., and 2:20 P.M., Resident #4 said he/she was afraid of Resident #15 because he/she pushed him/her, broke his/her arm up by the shoulder and was afraid he/she would hurt him/her again. Resident #15 had hurt other people, including staff. He/she was afraid of the administrator because he threatened to send him/her to a "worse place" if he/she did not stop talking about the incident when Resident #15 pushed him/her into the wall and broke his/her arm up by the shoulder. Everyone was upset that Resident #15 did not get sent out for hurting him/her. Resident #15 caused him/her a great deal of pain. He/she had staff make a police report. He/she discussed filing charges. The administrator and social service met with him/her, Resident #15 and Resident #2 and told us we would be sent to a "worse place" if keep talking about the incident. During an interview on 2/10/15, at 2:40 P.M., Resident #2 said he/she, Residents #4 and #15 had a meeting with the administrator and social services. The administrator said if we don't stop talking about the incident we would be sent to St. Louis to another locked unit, but it was worse than here. He/she had family close; he/she did not want to be moved. He/she did not think they were stealing the chair; no one was using the chair. He/she thought he/she was helping a friend. He/she was concerned Resident #15 would go off on him/her next. Resident #15 said things like "you are not my friend" and that concerned him/her. He/she would not want to be hit by Resident #15 because he/she was big and strong. He/she felt uneasy because Resident #15 was still at the facility and got by with hurting another resident. During an interview on 2/10/15, at 1:20 P.M. and 2/11/15 at 1:45 P.M., CNA E said the CNAs who worked on the unit kept notes on what happened during their shift for each other. Only the nurses could do legal charting. The residents' files were kept on the skilled side of the building. They had no care plans or individual knowledge of the residents other than what they learn from working with them on the unit or from the notes they share with each other. The facility admits new residents but the nurses' provide no information to the CNA's who work with the residents on their behaviors or how to approach the residents. The CNA assigned to the unit worked alone most of the time and really needed to have more information on the residents and how best to deal with their behaviors. The unit CNAs needed more training on how to deal with the resident's behaviors. The unit's CNAs were told to call the nurse for help, but sometimes the nurse came when called paged but not always. Even when the change nurse did come they were new and had no knowledge or training on how to handle the situations on the unit. Things happened quickly, some residents would be fine one minute and not the next. All staff that came onto the unit needed more training on how to deal with the residents' behaviors on the unit. During an interview on 2/11/15, at 1:50 P.M., the QA nurse said they were working on the developing and updating the resident care plans. The facility had a large turnover of staff and was working to hire and properly train their staff. During an interview on 2/11/15, at 2:55 P.M., the corporate director of operations said staff should have other orientation on how to work on the unit. If the CNAs who worked on the unit did not know what to do in a given situation they needed to go to the charge nurse. There should be two staff on the unit and one of those two people should be able to get the nurse when needed. There was not supposed to have b

Based on observations, interviews, and record reviews, the facility failed to assure staff put measures in place to prevent accidents or injury when staff did the following: - Failed to follow the fall precaution policy and procedure program and the manufacturer's instructions to reduce the possibility of accidents and injury for one sampled resident (Resident #2) and one of five extended sample residents (Resident #13); - Failed to implement measures to prevent accidents for one extended sampled resident (Residents #14) when the resident carried a serrated table knife and wandered throughout the facility and into a closed area of the facility without staff supervision; - Failed to follow the facility's mechanical lift and transfer policies to prevent the possibility of accidents and injury for two of nine sampled residents (Residents #3 and #6) and one additional resident (Resident #16); - And failed to attach footrests to wheelchairs prior to wheeling one of five extended sampled residents (Resident #13) and three additional residents (Residents #16, #17 and #18) in their wheelchairs to and from the dining room at meals. The facility census was 25. 1. Review of the facility's undated Fall Precaution Program, showed the objective of the program directed staff to identify residents at risk of falls and provide for additional precautions to reduce risk, and utilize the following procedure: - A resident will be placed on the Fall Precaution Program when any of the following conditions exist: Fall Risk Assessment score is 10 or above; the resident is identified through the use of the Resident Assessment Protocol (RAP) for falls as requiring care planning interventions to prevent falls; or the resident had a fall and the fall committee recommends he/she be placed on Fall Precautions. - A Fall Risk Assessment is to be completed: at the time of admission to the facility; upon readmission following a hospitalization ; or when a falls occurs and the resident is not already on the Fall Precaution Program. - Ongoing fall assessments will be done in conjunction with the Fall RAP when triggered. Fall status will be evaluated at the time of all care plan reviews for all residents. - Residents on Fall Precautions will have a Falling Leaf placed outside their door, in front of their chart, and in their care plan. - All staff is to know that the presence of a Falling Leaf indicates the resident is at risk for falls: the resident is to be under increased observation, particularly by nurse aides, but all the facility staff is be alert to the need to assist the resident; the resident has a care plan with interventions specific to his/her individual risk factors; the resident is to be assisted immediately if there are signs he/she might fall, i.e. trying to climb out of bed, asking to go to the bathroom, etc, or evidence of other unmet needs; if assistive devices are to be used, to be sure they are in place, i.e. walkers, canes, personal alarms, etc.; and be certain any safety devices are in place, i.e. wheelchair anti-tipping devices, seatbelts, specialty cushions, etc. - All incidents are to be immediately investigated by the charge nurse for possible cause(s) and/or contributing factors, and corrective measures to prevent further falls implemented to the extent possible. - All falls and incidents are to be logged by the director of nursing (DON), or designee, for review at the weekly Risk Management Committee meeting at the direction of the Quality Assurance (QA) Committee for its' further review. - The Risk Management Committee shall be coordinated by the DON. The DON, or designee, will keep a record of which residents are on Fall Precautions and will assure that care plans are updated accordingly and interventions are followed by staff. 2. Review of the undated manufacturer's Owner's Manual supplied for the low air-loss mattress used by the facility for Resident #2, showed: - Indications for use: The mattress provides flotation therapy or alternating pressure (to different areas of the body) to prevent constant pressure to pressure point areas and is indicated to prevent pressure ulcers; - General Warnings: Failure to comply with all directions and warnings may result in injury or death; this product is not suitable for all individuals and other devices may be required; adequate training for use and precautions by staff; - Important Warnings: This product is designed to assist in the prevention and treatment of [REDACTED]. This may include, but is not limited to bed rails for repositioning and fall prevention; - Check to make sure the control unit is plugged into a live electrical socket and the unit is turned on. 3. Review of Resident #2's Fall Risk Assessment, dated [DATE], showed: - Alert and oriented to person, place, and time; - No falls in the last three months; - Chair bound, assist with elimination; - Poor vision with or without glasses; - Not able to stand or walk; - Took three to four medications currently and within the last seven days: Narcotics (pain medications), psychotropic medications (medications that affect mood and behavior), diabetic medications, sedatives/hypnotics (sleeping medications), blood pressure medications or diuretics (removes excess fluid from the body); - One to two disease processes: Stroke and seizures; - Total score of 12 which indicated the resident was a high risk for falls. Review of a significant change MDS dated [DATE], showed: - A Brief Interview for Mental Status score of six which indicated cognition severely impaired, not able to make daily decisions. Review of the care plan, dated [DATE], showed: - Problem: Stage II (a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater) PU on the tailbone due to limited ability to reposition self due to a stroke and hemiparesis (paralysis on one side), and incontinence of bladder and bowel; - Approach: Assist of two staff for bed mobility, turning, and repositioning every two hours; - Problem: At risk for falls due to hemiparesis and medications; - Approach: Two staff needed to assist with the mechanical lift for transfers with sling and remove sling after transfer; - Remind to use the call light and keep within reach of the resident instead of yelling out. - Did not address the use of bed alarm. Review of the nurses' notes, dated [DATE], showed staff found the resident (on the floor) on the bedside fall mat. The resident did not complain of pain. RN B notified the DON, the physician, and Family Member (FM) A. RN B documented a silver-dollar sized bruise to the resident's left hip; no other injuries noted. Review of the resident's care plan showed staff did not update the care plan to include interventions to prevent falls after the fall on [DATE]. Record review showed staff did not provide a facility Fall Investigation Report for the resident's fall on [DATE], when requested by the survey team. Review of a quarterly MDS, dated [DATE], showed: - A BIMS score of six which indicated cognition severely impaired, not able to make daily decisions. Review of a Fall Investigation Report, dated [DATE], showed: - At 3:30 P.M., the resident rolled out of bed onto a fall mat (a foam pad placed on the floor to cushion a fall) beside his/her low bed and no staff witnessed the fall; - The bed alarm did not sound; - No side rails were in place; - The resident sustained [REDACTED]. - The investigation showed pain and bruising to the head; - A bruise, skin tear, abrasion, or laceration (cut) to the left hip; - Narrative: Staff found the resident face down on the bedside fall mat. The resident yelled for help. An unidentified CNA called the charge nurse for help with the resident. The resident complained of head pain in the center of the forehead. Staff found a three inch abrasion on the resident's head when he/she hit the corner of the wall and bruising to the corner of the left eye. The resident was oriented to person only. Review of a nurses' note, dated [DATE], showed: - Blood pressure (B/P) ,[DATE] (normal ,[DATE]), pulse (P) 78, oxygen saturation (Sp O2, the amount of oxygen in the blood stream) 77% (normal is greater than 93%). - Oxygen placed on the resident at three liters/minute to increase the SpO2 to 94%; - The bruising noted around the left eye extended up toward the eyebrow; - Bruising to the left hip; - Staff notified the DON, the Adm, the ambulance, and FM A; - The ambulance transported the resident to the hospital for evaluation. Review of Physician B's admission history and physical, dated [DATE], showed: - The resident fell out of bed during the night at the nursing facility and sustained a hematoma (an abnormal collection of blood under the skin) over his/her left temple area with a superficial laceration to the scalp; - The resident had dementia, did not open his/her eyes, and did not answer questions well; - He/she was confused and oriented to self only; - Weakness of the lower extremities and cannot move his/her left arm; - Assessment and Plan: Closed head injury, but stable; - History of irregular heart beat and stroke with left-sided weakness; - Taking Coumadin (a blood thinning medication); - Seizure disorder, continue Depakote (a psychotropic medication used to control seizures); - Diabetes mellitus, continue Amaryl (used to treat blood sugar levels); - [DIAGNOSES REDACTED], continue Synthroid (used to treat thyroid disease); - Depression and anxiety, continue Zoloft (an antidepressant). Review of the care plan, updated [DATE], showed: - Problem: Fall from bed; - Goal: Will not fall from bed through the next review (no target date recorded). Review of the care plan, updated [DATE], showed: - Interventions: Candy cane bedrail (a small, candy cane shaped bed rail to assist the resident to move in bed); - Bed against the wall; - Scoop mattress (an overlay with raised sides to place over a foam mattress to prevent the resident from rolling out of bed); - High/low bed (a bed that can be raised to administer care or lowered closer to the floor, usually about 18 inches from the floor, for residents at risk for rolling out of bed, falls, or to get out of bed unassisted). - Staff did not care plan the use of a bed alarm. Review of the Side Rail Assessment sheet, dated [DATE], showed: - Scoop mattress with bumpers, high-low bed, floor mat on one side of bed, bed against main wall of room, brakes on bed locked, support bar on side of bed with floor mat; - Side rails are not indicated at this time; - Frequent monitoring; - Put resident to bed when fatigued; - Remind to use the call light. Review of a nurses' note, dated [DATE], showed: - The resident readmitted to the facility after hospitalization ; - Laceration to top left side of scalp which measured 4 centimeters (cm) x 0.4 cm which was closed; - Bruise above the left eye. During an interview on [DATE], at 5:30 P.M., the acting DON said: - Staff placed placed a low air loss mattress (a mattress with baffles that are filled with air by way of a pump. The baffles have alternating air pressure to help reduce the formation of PU), on the resident's bed after the [DATE] fall, not a scoop mattress. During an interview on [DATE], at 10:30 A.M., CNA A said: - He/she worked the evening the resident rolled out of bed on [DATE]; - The resident had an air-mattress, without wings, on the bed at the time of the fall; - He/she hit his/her head on the wall and RN B sent him/her to the hospital; - A fall mat was beside the bed, but he/she hit the wall; - He/she rolled a lot in bed, especially if he/she was agitated. During an interview on [DATE], at 2:30 P.M., RN B said: - Staff called him/her to the resident's room and saw the resident lying on the floor by the bed near the wall; - He/she cannot get out of bed by him/herself, he/she rolled off the air mattress and out of bed onto the floor; - He/she suffered a bruise to the left eye and a cut to the top of the head when he/she hit the corner of the wall by the bathroom; - He/she notified the physician, the DON, FM A, and called the ambulance to transport the resident to the hospital for evaluation; - The hospital admitted the resident at that time with a closed head injury; - He/she did not have a side rail on the bed at the time of the fall; - Staff placed a small side rail on the bed after the fall and changed the mattress to a different air mattress with wings; - He/she did not know of any other interventions put into place after the fall. Review of the quarterly MDS, dated [DATE], showed: - A BIMS score of 3, which indicated severely impaired decision making skills; - Extensive assist of two or more staff for bed mobility and transfers; - Fall within the last two to six months; - [DIAGNOSES REDACTED]. Review of the facility's Fall Investigation Report, dated [DATE], at 5:00 A.M. showed: - Licensed Practical Nurse (LPN) A documented the resident's bed was against the wall by an electrical outlet (plug in); - Staff did not witness the fall; - No injury; - Resident found by roommate; roommate yelled down the hall for help; CNAs found the resident's air mattress deflated and the resident lying on the floor between the bed and the wall; - Staff found the bed unplugged from the electrical outlet; - Cause of fall: Raising and lowering of bed may have loosened the electrical plug and deflated the mattress; CNAs to check the plug before they leave the resident's room. - Root cause: Staff documented the bed low air mattress was unplugged from the wall. - Staff did not document if the wheels of the bed were locked. Review of a nurses' note, dated [DATE], at 5:30 A.M.,. showed: - Resident's roommate yelled down the hall for help; - LPN A entered the resident's room and found the resident lying on the floor between the bed and the wall on his/her right side; - The resident's low air-loss mattress deflated; - Right eye swollen and red indentations on right shoulder, right knee, and left knee; - Denied pain; assisted to wheelchair by staff and the mechanical lift; - Staff notified the Adm, the DON, FM A, and the physician; - Alert and oriented, neurological checks within normal limits. Review of the care plan, updated on [DATE], showed: - Problem: Fall from bed with no injuries; - Goal: No falls through next review period (no target date given); - Interventions: Staff will check low air-loss mattress and make sure the mattress is plugged in and working; - Staff discontinued the candy cane rail and the bed against the wall. - Staff did not document other interventions for fall prevention. During an interview on [DATE], at 5:30 P.M., FM B said: - The resident fell out of bed three times since October, 2011; - One fall ended in admission to the hospital with a head injury; - Staff left an air mattress on his/her bed until the last fall a few weeks ago; - Staff removed the air mattress after the last fall. During interviews on [DATE], at 5:40 A.M., and [DATE], at 5:00 A.M., LPN A said: - Resident #2 rolled out of bed recently when the air mattress deflated; - The mattress' electrical cord became dislodged from the electrical plug when the CNAs raised and lowered the bed for cares; - His/her bed was against the wall and he/she lay on the floor between the bed and the wall; - The resident did not have any injuries at the time of the fall except a scrape to his/her left knee when he/she assessed the resident; - A few days after the fall, the abrasion to the left knee opened up and staff applied steri-strips (adhesive strips used to close a laceration) to the laceration; - Staff assisted the resident off the floor with a mechanical lift (a device used to transfer dependent residents); - His/her vital signs and neurological checks remained within normal limits; - CNAs performed room checks every two hours on residents during the night shift; - Staff did not know the resident lay on the floor until the roommate yelled for help; - He/she did not know how long the resident lay on the floor before the roommate yelled out for help; - The facility in-serviced staff on keeping the low air loss mattress and bed plugged into the electrical outlet to prevent deflation of the air mattress; - Staff changed the air mattress to the current foam, pressure reducing mattress after the fall and moved the bed away from the wall; - He/she did not know about the fall on [DATE]. During an interview on [DATE], at 5:45 A.M., CNA H said: - He/she worked the night the resident rolled out of bed, but did not remember the time or day the fall happened; - The roommate called out and staff found the resident on the floor between the bed and the wall; - The air mattress was deflated; - Staff told him/her it was the CPR (Cardio Pulmonary Resuscitation) plug (a plug that can be pulled to inflate the mattress to a firm surface to assist with CPR), that became unplugged; - He/she and another CNA provided care to the resident earlier in the shift and the mattress was inflated, but when they went back the air mattress was deflated and the resident lay on the floor; - The fall happened sometime between bed checks which staff performed every two hours on all residents during the night; - Staff used the mechanical lift to get the resident off the floor; - Staff changed the air mattress to the current foam mattress with wings (an overlay with raised edges that covers the foam mattress to reduce the risk of falls); - The facility in-serviced staff on the air mattress and how to keep the mattress from deflating; - A fall mat lay beside the bed when he/she rolled out of bed; - He/she did not know about the fall on [DATE]; he/she only worked at the facility for one month. During an interview on [DATE], at 10:30 A.M., CNA A said: - He/she did not remember the date of Resident #2's fall out of bed, but it was early morning; - He/she rolled out of bed because the air mattress deflated; - It took six staff to get him/her off the floor because the mechanical lift did not go all the way to the floor and it was difficult to use the lift; - Staff changed the low air-loss mattress out to a foam pressure reducing mattress after the fall; - The low air-loss mattress did have wings, but the resident rolled a lot in bed at times, especially if he/she was agitated; - He/she did not suffer any injuries with that fall. During an interview on [DATE], at 1:00 P.M., the Adm said she only knew about two falls the resident had since October, 2011. The resident rolled out of bed on [DATE], and [DATE]. She did not remember if the resident was admitted to the hospital in October, 2011 and did not know why FM A said there was a third fall. She did not have an investigation for a third fall. During an interview on [DATE], at 1:55 P.M., the acting DON said: - She only knew about two falls out of bed the resident sustained [REDACTED]. - That Hi-Low bed did not sit as low to the floor as the current Hi-low bed to help prevent him/her from rolling out of bed; - He/she already had a fall mat on the floor; - He/she hit his/her head during the fall; - Staff sent the resident to the hospital and he/she was admitted for a closed head injury; - After the fall on [DATE], staff changed his/her bed to the current Hi-Low bed which sat even closer to the floor to prevent falls and placed the bed against the wall on one side; staff placed a fall mat on the floor by the bed on the side away from the wall; and removed the candy cane side rail; - The bed bumped the plug and the dislodged the plug; - The air mattress deflated and caused the resident to roll out of bed; - The air mattress did not deflate right away; it took a while to deflate; - Staff should make sure the bed remained plugged in after each time they provided care; - She expected staff to perform room checks every two hours on all residents during the night. 6. Review of Resident #13's significant change MDS, dated [DATE], showed: - Re-entered facility on [DATE], from an acute hospital; - Extensive assistance of one staff for transfer and ambulation; - One fall with major injury since admission or prior assessment, whichever was most recent. Review of the resident's care plan, updated on [DATE], showed: - Assist of one staff for transfers; - Remind resident to use call light, location of call light, and how it works; - Remind resident to use wheelchair; - Body alarm on at all times; - Pad alarm in recliner and bed. - Low bed with floor mat. Review of the resident's quarterly MDS, dated [DATE], showed: - Extensive assistance of one staff for transfer and ambulation; - One fall with injury but not major injury since admission or prior assessment, whichever was most recent. - Pad alarm in wheelchair and when in bed. Review of the resident's care plan, updated on [DATE], showed: - The resident fell in his/her room while attempting to transfer without assistance. Staff did not hear the alarm, because it did not sound very loud. - Remind staff to check alarms sounds and make sure the alarm was turned on. Review of the resident's quarterly MDS, dated [DATE], showed: - Extensive assistance of one staff for transfer and ambulation; - No falls since admission or prior assessment, whichever was most recent. - The MDS did not show the resident's [DATE], fall, which was since the last assessment. During an interview on [DATE], at 10:30 A.M., the acting DON said: - She worked as a charge nurse on [DATE], when the resident fell . - Staff found the resident on the floor in his/her room. - The resident said a male resident entered his/her room and bothered the roommate. - The resident fell out of the wheelchair and bumped his/her head when he/she tried to get a male resident to leave the room. - Staff assessed the resident and he/she was not injured. Review of the resident's fall investigation report, dated [DATE], at 7:00 P.M., showed: - Unwitnessed fall; - The resident was in a wheelchair; - No wheelchair alarm; - Staff found resident on floor in his/her room. Resident told staff another resident entered his/her room and harassed the roommate. The resident fell out of the wheelchair when he/she attempted to encourage the intruder to leave. The resident hit his/her head in the fall, but did not know if his/her head hit the floor, wheelchair or closet. The resident later said his/her head hurt and staff administered pain medication. Review of the resident's quarterly MDS, dated [DATE], showed: - Extensive assistance of one staff for transfer and ambulation; - No falls since admission or prior assessment, whichever was most recent. - The MDS did not show the resident's fall on [DATE], which was since the last assessment. Review of the resident's fall risk assessment, date [DATE], showed: - Staff assessed the resident as a 16 for fall risk; - A total score of 10 of above represented a high risk for falls. Review of the resident's fall investigation report, dated [DATE], at 7:30 P.M., showed: - Unwitnessed fall; - The resident was in a wheelchair and unplugged the wheelchair alarm; - Staff found resident on floor in his/her room. Resident told staff "I was trying to move my roommate." The resident fell and hit the right side his/her head, right shoulder, right hip, and right knee. The resident was alert and oriented to person, place, time, and event. The resident complained of pain and staff administered Tylenol. During an interview on [DATE], at 9:15 A.M., RN A and RN D said: - About 50% to 60% of the time, the resident accurately described the details of a fall. - The resident did not accurately recall the dates of the falls. - The facility tried several different types of wheelchair alarms, and at times, the resident removed the alarms or unplugged the alarms. - On every shift, the charge nurse checked to assure the resident had the alarm on. Review of the resident's fall investigation report, dated [DATE], at 4:30 P.M., showed: - Unwitnessed fall; - The resident was in a wheelchair; - Staff found the resident on day room floor. The resident told staff he/she tried to pick up a puzzle piece off the floor and fell . "I was trying to pick up a puzzle piece and slipped out of my chair." The resident lacerated the second finger on the right hand during the fall. Staff cleaned and covered the laceration with a steri-strip (an adhesive strip used to pull the sides of a laceration together). The resident did not complain of pain. After the fall, staff found the resident's body alarm (an alarm with a clip attached to a magnet by a cord, the clip attaches to the resident's clothes and alarms when the magnet was pulled loose) in the shower room and attached the alarm to the resident. Review of the resident's annual MDS, dated [DATE], showed: - BIMS score of 4 (a score of ,[DATE] showed the resident's cognitive ability for daily decision-making was severely impaired); - No behaviors; - Assist of one staff for transfers; - Did not ambulate; - Not steady, but able to stabilize without human assistance when moving from seated to standing position; - Not steady, only able to stabilize with human assistance when transferring between bed and chair; - Walker and wheelchair for mobility; - No falls since admission or prior assessment whichever is most recent; - Hospice; - [DIAGNOSES REDACTED]. - The MDS did not show the resident's falls on [DATE], and the [DATE], which happened since the last assessment. Observation on [DATE], at 5:30 P.M., showed: - The resident sat on a pad alarm (a pressure sensitive device that alarmed when the pressure was removed) in a wheelchair. - No alarm on the bed and no fall mats in the room. - The resident's recliner held numerous boxes and clothes. Review of the resident's treatment administration record (TAR), dated [DATE], to [DATE], showed: - Check body alarm/chair alarm pad every shift. - Staff initialed each of the three shifts from [DATE], through [DATE], to show they checked the alarm. During an interview and observation on [DATE], at 4:45 P.M., the resident and RN B did and said: - The resident sat in a wheelchair on a pad alarm in the open day area. - The day area attached to the nurses' station and was completely visible from the nurses' station. - The resident worked on a jigsaw puzzle at the table in the day area. - RN D sat in a chair at the nurses' station. - The resident stood up from the wheelchair, walked around the table, and no alarm sounded. He/she moved several puzzle pieces then picked up a puzzle piece. - No staff intervened. - After about 45 seconds, the surveyor told RN D the resident was out of the wheelchair. - RN D walked to the resident, sat the resident in the wheelchair, and returned to the nurses' station. - The surveyor told RN D the pad alarm did not sound when the resident stood from the chair. - RN D said the facility tried several different types of chair alarms and the resident took the alarms off, turned them off, or hid the alarms. RN D did not return to the wheelchair to check the pad alarm. - The resident's pad alarm switch was in the on position. Observation on [DATE], at 5:30 A.M., showed: - The resident lay in bed. - The height of the resident's bed hit above the surveyor's knee height with no mats on the floor. - No alarm on the bed or attached to the bed. Review of the resident's TAR, dated [DATE] to [DATE], showed: - Check body alarm/chair alarm pad every shift. - Staff initialed each of the three shifts from [DATE], through [DATE], to show they checked the alarm. Observation on [DATE], at 8:55 A.M., showed: - The resident sat in a wheelchair in the day area. - The resident's pad alarm switch was in the one position. - Steri-strips covered two bleeding lacerations. The resident had a 1.0 centimeter (cm) laceration on the left side of his/her head and a 0.5 cm laceration on the left temple area. During an interview on [DATE], at 9:00 A.M., RN C said: - Staff got the resident up at 7:00 A.M., this morning. - Staff went to the closet to get the resident's clothes. - The resident stood and staff caught him/her and "broke the fall." During an interview on [DATE], at 9:10 A.M., NA C said: - Today the facility staffed only three NA on the day shift and no CNA. - The facility did not allow an NA to transfer residents with the mechanical lift without a CNA so they were getting the one person transfers up for breakfast. - About 7:30 A.M. this morning, he/she walked down the hall and saw the resident sitting on the side of his/her bed. - He/she dressed the resident, left him/her sitting on the side of the bed, and walked to the roommate's trash can to get a plastic bag for the soiled linen. - He/she heard a crash and saw the resident on the floor. - The resident hit his/her head on the nightstand. NA C ran and caught the resident's head before it hit the floor. - "I did not break the resident's fall." He/she said the resident fell on the floor and hit his/her head on the nightstand before he/she got to the resident. - Staff got RN C, who assessed the resident. - He/she said no alarm sounded and found no alarm on the resident's bed. Review of the nurses' note, dated [DATE], showed: - At 7:30 A.M., RN C documented: NA in room assisting resident with activities of daily living (ADL, any activity done on a daily basis in one's life). The NA went to get clothing from the drawer and heard movement. When the NA turned, the resident was standing, then fell and hit his/her head on the bedside table. The resident had a 0.5 cm laceration on the left temple and a 1.0 cm long laceration on the side of his/her head. Notified Physician; - At 2:00 P.M., RN C documented: Intervention to prevent future falls, re-enforce to the resident that he/she needed to ask for assistance before standing. - At 4:10 P.M., RN B documented: The lacerations on the resident's left temple and left scalp appears to need stitches. Guardian and physician notified. Orders received to transport resident to the hospital emergency room (ER) for evaluation. Staff transported in facility van and Administrator accompanied resident. - At 6:20 P.M., RN B documented the resident returned to facility by van accompanied by Administrator. ER staff closed the head laceration with two staples and gave resident a tetanus booster injection. Orders to monitor resident for head injury and remove staples in five days. During an interview and observation on [DATE], at 9:00 A.M., showed; - The resident sat in a shower chair. - The switch on the pad alarm in the resident's wheelchair remained in the on position. - The alarm did not sound, even though the switch remained on and the resident no longer sat on the pad. - Two staples closed the laceration on the resident's head and dried blood covered the temple laceration. - The resident touched the stapled area of his/her head and said "my head hurts." - CNA G said staff told him/her the resident fell yesterday, but no staff told him/her how the resident fell . - CNA G washed the resident's hair and said the resident had a bump on his/her head. Observation on [DATE], at 10:15 A.M., showed: - The resident sat in the wheelchair on the pad alarm. The pad alarm switch sat in the on position. - Dark blue-black bruising spread from the resident's left temple, under the eye, and to the nose. The resident had a 1.0 cm raw scraped area on the bridge of his/her nose. - The resident touched his/her head and said it hurt. - The resident said he/she fell and hit his/her head on the table. Review of the resident's pad alarm, on [DATE], showed: - Warning - Read the instructions on this pad carefully. Failure to do so could result in injury or death. - This pad is designed and approved for use with UMP and Micro-Tech brand alarm monitors. - Stanley chair sensor pad 45 day use model; - This product was warranted for up to 45-days from recorded "in-use date," in accordance with manufacturer's standard limited warranty. If product fails to function properly at any time, stop use immediately and replace with new Sensor pad. - Staff marked the Sensor pad alarm with the in-use date of [DATE], (132 days earlier). During an interview on [DATE], at 10:30 A.M., the acting DON and Adm said: - The resident was confus

Based on observations, interviews, and record reviews, showed: - The facility failed to assure staff followed the Patient Education for Nephrostomy Tubes (a sterile tube surgically inserted into the kidney to drain urine) policy and provide nephrostomy tube care in a way to prevent infection for a resident with a history of urosepsis (an infection in the blood stream from a severe UTI), and failed to identify symptoms of a urinary tract infection [MEDICAL CONDITION] and failed to inform the physician to obtain treatment for [REDACTED].#1); - Failed to provide indwelling catheter (a sterile tube inserted into the bladder to drain urine) care in a manner to prevent a UTI, failed to identify the resident's UTI symptoms and notify the physician in a timely manner, failed to inform the physician of the results resident's culture and sensitivity (C&S, a test to identity the type and amount of bacteria in the urine and medications effective in treating the infection) in a timely manner which resulted in a five day delay in starting the appropriate antibiotic, and failed to secure the indwelling catheter to prevent injury for one sampled resident (Resident #5). - Failed to assure staff followed the Incontinence Care policy and provide care in a way to prevent UTI for one sampled resident (Resident #3). - Failed to assure staff provided indwelling catheter care in a manner to prevent infection for one sampled resident (Resident #6). - The facility census was 25. 1. Review of the facility's undated Patient Education for Nephrostomy Tubes showed: - Prior to insertion of the tube into the kidney, an ultrasound (a special picture made by using sound waves) is performed to guide the physician in placing the tube; - A medication will be injected into the skin of the back to numb the area; - A small cut will be made in the skin and a needle will be inserted into the kidney; - A special dye will be injected through the needle to make the kidney visible on x-ray and an x-ray will be taken to confirm the position of the needle; - A guide wire will be used to help place the catheter, more dye will be injected and another x-ray will be performed to make sure the tube is in the correct place; - The tube can be secured firmly by forming a loop inside the kidney and the tube can be attached to the skin by stitches and/or tape can be used for more support. - The drainage bag should be changed every seven days or sooner if it becomes dirty, foul smelling, or punctured; - Wash hands, swab the end of the drainage tubing attached to the nephrostomy tube, disconnect the old drainage bag, swab the end of the tube, connect a new bag, and secure the drainage bag to the calf of the leg, the thigh, or waste with tape or straps; - To maintain the nephrostomy drainage system in good working order, keep the drainage bag below the level of the kidneys to prevent urine from backing up into the kidneys. Review of Resident #1's Care Assessment Area Summary (CAAS), used by the facility to develop a care plan for a resident, dated 11/4/11 showed: - Urinary incontinence and indwelling catheter; - Incontinent of bladder and bowel related to [DIAGNOSES REDACTED]. Review of the care plan, dated 2/8/12, showed: - Problem: At risk for infection related to placement of bilateral (both sides) nephrostomy tubes; - Goal: Will remain free of infection through the next review, 5/9/12; - Approach: Care will be taken when performing cares not to displace the nephrostomy tubes or dressings; - Drainage bags will be changed, as needed; - Dressings around the nephrostomy tubes will be changed two times weekly; - Nephrostomy tube sites will be monitored frequently for redness, swelling, warmth, pain, or signs of infection; - Scheduled appointments will be made to have the nephrostomy tubes changed by the physician. Review of a physician's orders [REDACTED]. - Change the nephrostomy tube dressing two times weekly, and as needed; - Change nephrostomy drainage bags (bags attached to the tube to collect urine) as needed. Review of the treatment administration record (TAR), dated 2/15/12 through 3/14/12, showed: - Staff initialed they changed the nephrostomy dressings on 3/9/12; - Staff did not initial the dressings as changed on 3/13/12, as scheduled. Review of the quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff, dated 2/24/12, showed: - Brief Interview for Mental Status (BIMS) score of eight which indicated moderately impaired decision making, needed supervision; - Staff did not toilet the resident; - Catheter; - [DIAGNOSES REDACTED]. Review of nurses' notes, dated 3/9/12 and 3/13/12, showed: - 3/9/12: Dressings to the right and left nephrostomy tubes changed at 10:00 P.M. - 3/13/12: Staff did not record they changed the dressings to the nephrostomy tubes on any shift. Observation on 3/11/12, from 6:30 P.M. until 7:00 P.M., showed: - The resident sat at the nurse's desk in a wheelchair. - Urine filled one of his/her two nephrostomy drainage bags and the bag hung from the nephrostomy tube and laid on the floor beneath the wheel chair. During an interview and observation on 3/12/12, at 10:40 A.M., Registered Nurse (RN) A did and said the following: - RN A turned the resident to his/her right side and provided pressure ulcer (PU) care to the left heel and lower buttocks. - The dressings to the bilateral nephrostomy sites remained intact. - RN A said staff changed the nephrostomy dressings two times per week, and as needed. He/she needed to check to see when they needed to be changed. Observation on 3/12/12, at 10:40 A.M., the Corporate Quality Assurance Nurse (CQAN) did the following: - Assisted RN A with the PU dressing changes; - Urine filled the nephrostomy drainage bags that lay on the mattress beside the resident; - The CQAN lifted the urine filled right nephrostomy drainage bag above the level of the resident's kidney and; the left nephrostomy drainage bag rested above the resident's right arm higher than the level of the kidney and lay on the mattress. During an interview and observation on 3/12/12, at 11:15 A.M., Certified Nurse Aide (CNA) B did and said the following: - Turned the resident to his/her right side and the resident lay on the right nephrostomy drainage bag which was full of urine and completed incontinent care; - Raised both nephrostomy drainage bags above the level of the kidneys when he/she turned the resident from side to side to perform incontinent care; - Emptied the right nephrostomy drainage bag into a measuring container, touched the emptying port to the side of the measuring container, and did not clean the port with alcohol; - Emptied the left drainage bag and did not clean the port with alcohol; - Emptied the measuring container, dropped the container in the toilet, rinsed the toilet with water and placed the container in a black trash bag in the bathroom for reuse; - Washed his/her hands, used a perineal wipe and cleansed the port of each drainage bag. - The resident asked for the call light, felt for the call light, picked up the nephrostomy drainage bag, and placed the drainage port in his/her mouth; - CNA B told the resident not to put the port in his/her mouth and the resident said he/she thought it was the call light; - CNA B did not clean the port and told RN A the resident put the port in his/her mouth; - CNA B said the drainage bags usually lay on the bed by the resident, on the resident's stomach when in bed, on the seat of the wheelchair, or on the resident's lap when up in the wheelchair; - The bags could be placed in a privacy bag on the side of the chair but they did not have bags to fit the drainage bags; - He/she sometimes placed them in the waistband of the resident's pants to secure them. Review of nurses notes dated 3/9/12 through 3/14/12 showed staff did not document the resident had any signs or symptoms of confusion, increased temperature, or signs and symptoms of UTI. Observation on 3/13/12, at 11:40 A.M., showed the following: - CNA A wheeled the resident down the hall towards the dining room; - The left nephrostomy drainage bag and catheter hung over the side of the wheelchair, over the arm of the wheelchair, and the bag dragged on the floor for approximately 10 feet; - CNA A saw the bag dragging on the floor, picked up the bag and placed the bag on the resident's lap; During an interview on 3/13/12, at 1:00 P.M., CNA A said he/she did not clean the resident's drainage bag or tell the charge nurse after the bag dragged on the floor at lunch. Review of a nurse's note dated 3/15/12 showed RN A documented scant amount of blood, red in color, observed on the resident's pad in the morning and afternoon; no complaints voiced; possible trauma from pulling on the nephrostomy tubes; will continue to monitor. During an interview on 3/15/12, at 10:00 A.M., and 11:15 A.M., RN A said: - 10:00 A.M.: He/she did not change the nephrostomy drainage bag on 3/12/12, after the resident put the port into his/her mouth; - He/she thought the CNA meant the resident put the bag in his/her mouth not the port; - 11:00 A.M.: He/she thought staff changed the nephrostomy dressings on 3/13/12; - He/she reported to the oncoming evening nurse no one changed the dressings on the day shift; - He/she checked the old TAR, dated 2/15/12 through 3/14/12, and no staff documented they changed the dressings since 3/9/12; - He/she checked the new TAR, dated 3/15/12 through 4/14/12, and no staff documented they changed the dressings. Observation on 3/15/12, at 1:15 P.M., showed the bilateral nephrostomy dressings with frayed edges, loose tape, and exposed tube insertion sites during incontinent care. Review of nurses' notes dated 3/16/12 showed LPN A did not document the resident had any signs or symptoms of confusion, increased temperature, or signs and symptoms of infection/UTI/Urosepsis. Review of a nurses' note, dated 3/17/12, at 4:15 P.M., showed: - Nurse's Aide (NA, an employee that had not had nurse aide training for certification) reported the right nephrostomy catheter came out; - RN B notified Physician A, the Administrator (Adm), the acting Director of Nursing (DON), the Durable Power of Attorney (DPOA, the person assigned to make medical and/or financial decisions for a resident); - Physician A gave the order to send the resident to the hospital for evaluation; - The ambulance transported the resident to the hospital at 4:55 P.M. - RN B did not document the resident had any signs or symptoms of confusion, increased temperature, or signs and symptoms of infection/UTI/Urosepsis. During an interview on 3/17/12, at 8:00 P.M., NA B said: - He/she entered the resident's room to administer care and the right nephrostomy tube and drainage bag lay on the floor beside the resident's bed; - Urine filled the drainage bag; - He/she picked up the bag, placed it on the resident's bed, and summoned the charge nurse; - He/she did not pull out the nephrostomy tube during cares; it lay already on the floor when he/she entered the room; - Day shift should have emptied the catheter drainage bag before they left at 2:00 P.M.; - He/she did not see the drainage bag earlier in the shift; - No one in-serviced him/her on care of the nephrostomy tube and drainage bag, he/she just followed the CNA and watched how they cared for the residents. Review of the hospital emergency room and admission record, from 3/17/12, showed the following: - The emergency room physician documented he/she spoke with the facility an the facility said they sent the resident to the hospital because the resident accidently pulled out his/her right nephrostomy tube; - Bloody drainage noted at the right nephrostomy site; - The emergency room physician admitted the resident to the hospital with a [DIAGNOSES REDACTED]. Review of the hospital emergency room triage sheets dated 3/17/12 showed: - The resident was sent to the hospital after his/her right nephrostomy tube was pulled out. - Current symptom: Nephrostomy tube pulled out of right flank (kidney area of back). - New order: Administered [MEDICATION NAME] (an antibiotic to treat infection) intravenously (IV) piggy back (along with a bag of IV fluid), 1 gram (gm) in 50 milliliters (ml) of [MEDICATION NAME] (sugar) and water over 30 minutes. - Physical exam: Back, right nephrostomy site with bloody drainage. - Vital sign record: Temperature 99.6 (low grade fever), heart rate 89 (normal 72-88), blood pressure 153/85 (normal 120/80), respirations 18 (normal 18-22). - Urinalysis (a lab test on the urine to assess for infection): White Blood Cells- greater than 50 (should be 0), bacteria 3+- (should be 0), clarity- cloudy, blood- 1+ (should be negative), protein 1+ (indicative of infection), leukocyte esterase 3+ (should be 0). - Recommendation from the consulting physician- Admit to the hospital. Review of the hospital history and physical examination [REDACTED] - The resident's nephrostomy tube dislodged, on 3/17/12; - He/she was scheduled to have the nephrostomy tubes replaced however, the right-sided tube became dislodged yesterday. - History of urosepsis (an infection in the blood stream from a severe UTI) without the nephrostomy tubes and infac,has developed fever and become quiet confused this morning; - Impression and plan: Altered mental status secondary to urosepsis, end-stage MS, replacement of the right nephrostomy tube, will administer [MEDICATION NAME] and [MEDICATION NAME] (antibiotics to treat urosepsis); -Overall the resident's prognosis is poor. Review of the hospital consultation, dated 3/18/12, by Physician D, showed: - History of urosepsis in October, 2011; - Impending urosepsis; - Bilateral [MEDICAL CONDITION] obstruction (blockage in the tube leading from the kidney to the bladder which drains urine from the kidney into the bladder); - Traumatic dislodgement of the right nephrostomy tube; - UTI highly possible; - Strongly urge emergent replacement of the right nephrostomy tube and possible [MEDICAL CONDITION] stent (artificial tube placed into the blocked ureter and kidney to assist with draining of urine from the kidney). Review of the diagnostic imaging report (x-ray) dated 3/18/12 showed: - Placement of a 10 French (size, diameter of the nephrostomy tube) [MEDICAL CONDITION] tube. - The distal ureter (tube that enters into the kidney and drains urine from the kidney) was dilated (enlarged, expanded) with a 5 millimeter (mm) x 4 centimeter (cm) balloon (when filled with sterile water, holds the tube in place inside the kidney). - Successful right percutaneous nephrostomy (surgical procedure to place the nephrostomy tube) [MEDICAL CONDITION] dilatation (expansion of the ureter to pass the tube into the kidney) an placement of the [MEDICAL CONDITION] tube. Review of an operative note, dated 3/18/12, showed the right nephrostomy tube placed under conscious sedation (a combination of medications to help one relax and control pain during a medical procedure). Review of an operative note, dated 3/19/12, showed the left nephrostomy tube placed under conscious sedation. The tube was due to be changed. During an interview on 3/19/12, at 10:00 A.M., the acting DON, who also worked as the MDS coordinator, said: - Surgeons placed the nephrostomy tubes in each of the resident's kidneys late 2011; - The resident's nephrostomy tube pulled out on 3/17/12, but she did not know how; - Staff notified the physician and sent the resident to the hospital, where he/she was admitted ; - Staff should monitor the drainage bag for the amount of urinary drainage and empty as necessary; - Each shift should empty the drainage bags before leaving; - Hospice provided an abdominal binder (an elastic wrap that goes around the back and across the abdomen and is secured with two strips of fabric that stick together for fastening) to hold the drainage bags against the resident's body to secure the bags and prevent pulling the catheters out of the kidneys; - She did not know if staff used the abdominal binder; - She did not know where to find the abdominal binder; - Usually the drainage bags lay on the bed, the resident ' s lap, or in the wheelchair beside the resident when he/she sat in the wheelchair; - Staff did not routinely secure the bags to protect them from being pulled out; - Staff did not try any other method of securing the drainage bags; - She expected staff to be careful with the nephrostomy tubes and drainage bags and not pull the tubes out of the kidneys; - Staff should change the dressings to both nephrostomy sites twice a week and as needed; - The facility did not have a policy to instruct staff to clean the drainage port of the drainage bags; she did not recall this as a necessary step in the care of a urinary drainage bag; - Staff should keep the bag and tubing off the floor; - The bag should not be raised above the level of the kidneys; - She did not know why staff did not change the dressing on 3/13/12 as ordered; - She did not know if staff were in-serviced on the care and use of the nephrostomy catheters, she would have to check to see; - No one in-serviced her on the care and use of nephrostomy tubes; - She knew the nephrostomy tubes were pulled out several different times since they were first placed into the resident's kidneys. During an interview on 3/19/12, at 11:30 A.M., RN A said: - Staff used abdominal binders to secure the nephrostomy drainage bags for a while, but the resident did not like to wear it; - Never tried anything else to secure the bags as far as he/she knew, they just laid them on the bed, the resident's lap, or in the wheelchair. During an interview on 3/19/12, at 11:35 A.M., NA C said: - The resident wore an abdominal binder when he/she first started working at the facility in January, 2012; - He/she did not know what happened to it or why staff did not use it on the resident. During an interview at the exit conference on 3/19/12, at 5:30 P.M., showed: - The CQAN asked what the facility could do differently to secure the nephrostomy tubes as she did not feel they were long enough to drag on the floor. - The Adm admitted the nephrostomy tubes were long and could drag on the floor. Review of hospital discharge instruction sheet, dated 3/20/12, showed: - Discharge back to the nursing facility, 3/20/12; - Nephrostomy tubes to be changed every three months; - Change dressings to the nephrostomy sites as needed; - Hospice to follow. 2. Review of the facility's Incontinence Care Policy, dated April, 2006, showed: - Purpose: To keep the skin clean, dry, free of irritation and odor; to identify skin problems as soon as possible so treatment could be started; to prevent skin breakdown; and to prevent infection; - Guidelines: Wash all soiled skin areas and dry very well, especially between skin folds; apply protective skin lubricant and thoroughly rub into skin; inspect skin and report all irritation areas to the charge nurse; change or replace line as necessary. Review of Resident #3's quarterly MDS, dated [DATE], showed: - Short- and long-term memory problems; - Moderately impaired decision making, supervision needed; - Toileting program; - Extensive assistance of two or more staff for toileting and transfers; - Always incontinent of bowel and bladder; Review of the care plan, updated 5/25/11, showed: - Problem: Required assistance with activities of daily living (toileting, bathing, hygiene, etc) related to history of right [MEDICAL CONDITION]; - Goals: Directed staff to provide adequate cleanliness and good appearance daily, and as needed, through next review date (no date given); - Directed staff to assist with bathing body parts the resident cannot do; - Directed staff that the resident was able to tell staff when he/she needed to use the bathroom. - Directed staff to assist the resident to the toilet with the assistance of one staff, with the use of a gait belt, and bathroom grab bars. Problem: Repeated "help me, help me", "I need to pee" frequently even though "I am okay" and wear briefs because of incontinence. - Goal: Staff will care for the resident appropriately through next review. - Approach: Assess the residents needs/desires, reassure resident he/she is okay, and assist the resident with his/her needs/desires. Observation on 3/11/12, at 5:00 P.M., 6:50 P.M., 7:10 P.M., and 7:30 P.M. showed the following: - At 5:00 P.M., the resident wheeled him/herself around the nurses' station and said "Help me, help me; I've got to pee;" "Somebody help me, where do I go?" - At 6:50 P.M., Certified Medication Technician (CMT) A and NA A wheeled the resident to his/her room and the resident said "Where can I go pee; help me; would somebody give me a drink; help me;" - The resident started to wheel him/herself out of his/her room into the hallway; - CMT A said he/she did this all the time, always said he/she needed to pee, always said "help me," this is just what he/she did; he/she will be back in his/her room in 10-15 minutes and will continue to say "help me, help me, I have to pee." - At 7:10 P.M., the CQAN wheeled the resident to his/her room and said the resident needed to use the rest room; - At 7:10 P.M., the administrator said the resident repetitively and continually said "help me, help me, I need to go to bathroom;" the administrator wheeled the resident out of his/her room and said he/she went in and out of his/her room frequently; - At 7:30 P.M., CNA C and NA A wheeled the resident to his/her room to provide incontinent care; - Both washed their hands and assisted the resident to his/her bed with a gait belt; - The resident said "Help me. I have to pee, bad." - Urine soaked the back of the resident's slacks and the resident said "I have to pee, bad." - CNA C and NA A removed the resident's slacks and brief; urine saturated the brief; - CNA C and NA A turned the resident to his/her right side and fecal material and urine covered the incontinent pad and sheet; - CNA C said the resident was "really wet; he/she dribbled constantly;" - CNA C used a wash cloth and perineal wash and wiped the rectal area from front to back, removed a moderate amount of fecal material with the wash cloth, used a second wash cloth with perineal wash and removed a small amount of fecal material, removed his/her gloves, did not wash his/her hands, and said "He/she is going again." - CNA C gloved and used a clean wash cloth with perineal wash, cleaned the resident's rectal area of a moderate amount of soft fecal material, shook the fecal material from the wash cloth, folded the wash cloth and wiped the soiled cloth front to back four times, until no more fecal material appeared; - CNA C removed soiled gloves, washed his/her hands, applied clean gloves, and applied Calazyme cream (a moisture barrier) to the rectal area and applied a brief. - CNA C or NA A did not wash the front perineal area or open the labia (folds of skin that cover the vagina and urinary opening), washed their hands and left the resident's room. Observation on 3/14/12, at 8:30 A.M., 1:05 P.M., and 1:35 P.M., showed: - At 8:30 A.M.: The resident wheeled around the nurse's station and said "Help me, help me." - The surveyor asked the resident what he/she needed and the resident responded "It's what I don't need!" - At 1:05 P.M.: The resident sat at the nurses' station in his/her wheelchair and said "Help me, help me." - At 1:35 P.M.: The beautician wheeled the resident to the beauty shop to wash his/her hair and the resident continued to say "Help me, I don't want to have my hair washed, I have to pee bad." - The resident continued to yell out in the beauty shop "Help me, help me, I've got to pee" until 2:15 P.M., and no staff assisted the resident. Observation on 3/14/12, from 2:15 P.M. until 2:50 P.M., showed: - The resident said "Help me" and an unidentified CNA asked the resident "what do you want?' - The resident said "My butt hurts, bad!" - The Activities Director said he/she wanted to do the resident's fingernails, but he/she needed to use the "potty" first; - The resident said "I don't know where I want to go, somebody help me, whatever is wrong with me, help me!" - The resident said to RN C and CMT A that he/she needed "pee bad," and the resident spilled a cup of water on his/her shirt; - RN C and CMT A took the resident to the main shower room to change his/her shirt and the resident said "I don't want to go in there, but it will have to be okay, I have to pee bad, hurry up!" - RN B then told the resident staff would take him/her to pee in a minute; he/she needed to wait until staff could help him/her; - The resident said "I don't think I will bother to have my nails done;" - At 2:27 P.M., CNAs stood at the end of the 100 hallway with the mechanical lift and talked with the administrator, the CQAN, and the Acting DON while the resident continued to wait to be toileted; - At 2:31 P.M., RN C assisted the resident to eat ice cream and the resident continued to say "Help me!" - At 2:45 P.M., RN B said staff check and change residents every two hours; staff did not lay the resident down since he/she got up for lunch; he/she " did not know what to for him/her, he/she was fixated on going to the bathroom;" - At 2:50 P.M., CNA C and NA C put the resident to bed and performed incontinent care; - CNA C and NA C washed hands and applied gloves; - CNA C removed the resident's brief and a moderate amount of formed fecal material rested between the buttocks at the rectal area; - CNA C used one wash cloth with perineal wash and cleansed the rectal area of fecal material, used a second cloth and perineal wash and wiped the rectal area front to back and removed a smear of fecal material, folded the cloth and wiped the rectal area again, front to back, no fecal material was noted; - CNA C and NA C turned the resident to his/her back and CNA C changed his/her gloves, washed his/her hands, applied clean gloves, and cleaned the resident's front perineal area front to back, opened the labia and there was no fecal material on the cloth; - CNA C asked the resident if he/she felt better laying down and the resident said "I guess so." During an interview on 3/14/12, at 3:00 P.M., CNA C said: - Complete incontinent care included washing front to back in the front perineal area, opening the labia and cleaning inside the labia, and washing front to back in the rectal area; - He/she did not clean the resident properly on the evening of 3/11/12 and he/she should have; but he/she did it correctly today; - Staff did not put the resident on the toilet, because he/she could not sit on the seat for long periods; he/she would lean to one side and could fall. During an interview on 3/15/12, at 2:10 P.M., the acting DON said: - She expected staff to toilet the resident before and after each meal, at bedtime, and when staff got him/her up in the morning; - He/she should be checked and changed before any activity; - She did not know why the resident yelled out "Help me, I have to pee" all the time, he/she said this repeatedly on a daily basis. - It would be hard to say if the resident might have a UTI; - Staff should clean the perineal area from front to back and wash the front and back perineal areas with each incontinent care given; - Staff should wash hands or use gel after cleaning a soiled area and apply clean gloves as necessary, before they go on to other tasks. Observation on 3/17/12, at 6:15 P.M., showed the resident wheeled him/herself up and down the hall and said "Help me, I need to pee." During an observation and interview on 3/17/12, from 7:10 P.M. until 7:35 P.M., showed: - CNA C, NA B, and the Adm wheeled the resident into his/her room; the resident continued to say "Help me, help me, where can I go pee;" - CNA C and NA B put the resident to bed and removed his/her brief; - The resident sat in a moderate amount of fecal material while in the wheelchair; - CNA C cleaned the fecal material from the resident; - The Adm said she talked with a family member who cared for the resident and they told her the resident yelled out all the time when he/she lived at home; the family member did not know what to do for him/her and finally admitted him/her to the facility. The resident sat in fecal material while up in the wheelchair; - After staff completed incontinent care, the resident continued to yell out "I have to pee, bad!" During an interview on 3/19/12, at 10:45 A.M., the CQAN said: - The resident says the same thing all the time, "Help me, I have to pee!" - If you ask him/her what he/she needed, he/she did not know: - She did not know what to do for the resident. - The resident needed to have symptoms before a urinalysis (UA- a test used to analyze the contents of urine and aid in diagnosing disease and infection) could be performed and the resident did not have symptoms; Review of a UA and culture and sensitivity (C&S, a lab test to determine the bacteria that cause an infection and the antibiotics that will treat the infection adequately), dated 3/19/12, showed: - The facility collected a urine sample on 3/19/12, at 11:30 P.M., and sent to the laboratory for examination on 3/20/12, at 12:58 P.M. - On 3/27/12, the final urine report showed: - Blood 1+ (should be negative, could be indicative of kidney involvement); - Leukocyte Esterase (screening to show white blood cells in the urine which may indicate infection, should be negative) 3+; - Triple [MEDICATION NAME] Crystals (white sediment in urine usually indicative of infection, none should be seen); - Red blood cells 5-10(none should be seen, indicative of infection); - White blood cells greater than 150 (none should be seen, indicative of infection); - The urine culture showed the colony count was greater than 100/000 CFU/ml (colony forming units per milliliter of urine), indicative of infection; - The culture grew Proteus Mirabilis and was sensitive to a number of antibiotics. Review of the Medical-Dictionary website, showed: - Proteus mirabilis usually found in fecal material; - A leading cause of urinary tract infections. 3. Review of the facility's policy and procedure for indwelling catheter care, dated April 2006, showed: - Purpose: To prevent infection; - Equipment: Basin of warm water and soap, towel and washcloth, gloves, measuring device, catheter care kit, antiseptic ointment, as ordered. - Position resident in semi-Fowler's position (a reclined sitting position) on bedpan, if tolerated. Alternate position is a Lateral Sims (positioned on the side with the knees pulled upward) facing away from you. - Put on gloves and wash perineum well with soap and warm water, taking care to wash from the front to back. - Note: Do not contaminate area with fecal material. If resident has had an involuntary bowel movement, clean this area first. Wash your hands and obtain clean equipment before continuing. - Cleanse area well at catheter insertion, taking care not to pull on catheter or advance further into urethra (the tube that connects the bladder to the outside of the body). - Rinse well with warm water and pat dry gently with clean towel; - Apply antiseptic ointment at catheter insertion site as ordered by physician; - Empty, clean and store bedpan or measuring device properly; - Position resident comfortably with call light within reach. - The policy did not direct staff to clean the spout of the bedside drainage bag (BDB, a bag connected to the catheter to hold the urine) if the spout came in contact with other objects. - The policy did not direct staff to secure the catheter to prevent pulling. 4. Review of Resident #5's current care plan, dated 8/12/11, and last updated on 9/26/11, showed: - Problem: Resident may experience bladder incontinence, related to diuretics. - Goal: Resident will maintain current level of bladder continence.- Approaches: Do not put a pad or incontinent brief on the resident; keep call light in reach, provide assistance with toileting when the resident requests; Review of the resident's UA report, dated 12/29/11, showed: - Cloudy (normal - clear); - Leukocytes 3 plus (normal - negative); - White blood cells (WBC) 100-150 (normal - none); - Bacteria 4+ (normal - none); - [MEDICATION NAME] positive (normal - negative). Review of Physician F's order, dated 1/4/12, showed: -[MEDICATION NAME](an antibiotic) 500 milligrams (mg) twice a day for seven days to tr

Based on observation, interview and record review, the facility failed to assure staff immediately and appropriately responded to one of one sampled resident's (Resident #1's) need for resuscitation measures. The facility had determined the resident wished to be resuscitated. However, when staff found the resident without a pulse and not breathing, that staff person did not begin cardiopulmonary resuscitation (CPR), but got the nurse. The nurse delayed beginning CPR and did not follow facility policy for giving CPR. The nurse did not direct staff to call 911 and stopped resuscitation after about 10 minutes without contacting the physician. The resident expired. The facility identified seven current residents who chose to be resuscitated. The facility census was 31. 1. Review of the facility policy, dated April, 2006 entitled "Cardiopulmonary Resuscitation (CPR)," showed: - Providing CPR was a basic responsibility of the licensed nurse and any person in the facility who was CPR certified. - The purpose was to ventilate (provide for air exchange) and establish circulation for a resident with absence of respirations (spontaneous breathing) and pulse (heartbeat). Equipment included: - [MEDICAL CONDITION] board or hard surface (necessary for effective chest compressions). - Sphygmomanometer (blood pressure cuff) and stethoscope (required equipment for taking a blood pressure). - Airway (curved plastic device sometimes used to hold a person's tongue forward and maintain an open airway during resuscitation attempts). - Oxygen (increases benefit of ventilations, requires a regulator attached and tubing for administration). - Suction machine (used to help remove liquids obstructing the airway/requires set up of collection canister, tubing and suction catheter). - Disposable CPR mask (used to provide a barrier between the person administering mouth-to-mouth ventilations and the person receiving resuscitation). Guidelines in the policy included the caution, "Specific guidelines for CPR are revised frequently; verify protocol with the American Heart Association and/or the American Red Cross in your area." Other specific guidelines included the following: - Determine unresponsiveness. Call out for help. - Delegate a specific individual to check resident care plan for CPR or no CPR orders; have that individual call paramedics, attending physician and administrative personnel per facility guidelines and report back to you as soon as possible. - Position resident on back. - Open airway. - Determine breathlessness. - If breathless, perform rescue breathing, by mouth-to-mouth or mouth-to-CPR mask . - Determine pulselessness. Palpate the carotid pulse (side of neck, pulse more easily felt there because large artery is close to surface). - If resident is pulseless, make sure resident is on a hard surface; backboard ([MEDICAL CONDITION] board) or floor. - Perform chest compressions. - Continue a cycle of 15 chest compressions (given at a rate of 80 - 100/minute), then two rescue breaths and evaluate the resident periodically. - Once CPR is started do not discontinue until qualified help arrives (paramedics) or a physician pronounces the resident dead and gives orders to discontinue CPR. 2. Review of Resident #1's admission physician's orders dated [DATE] showed "code status: full." Review of the resident's admission Social Service Progress Notes dated [DATE], showed: - The resident was alert and oriented to time/date, place and person. - He/she came to the facility for rehabilitation to return home. - He/she needed some assist with activities of daily living due to a broken arm. - He/she was a "full code" (resident desired resuscitation measures if his/her heartbeat/breathing stopped). During an interview on [DATE] at 2:20 P.M., Certified Nurse Aide (CNA) A said: - He/she had current CPR certification. - He/she was working on the resident's hall from the evening of [DATE] until the morning of [DATE]. That night was the first night he/she worked on that hall. - He/she checked on the resident every two hours that night. - At 2:00 A.M. the resident was snoring. - At about 4:00 A.M., the resident was lying on his/her side facing the doorway and did not look right, his/her face was ashen (very pale), eyes partially open and "jaw ajar." - He/she left the resident's room and went to get the charge nurse, Registered Nurse (RN) A. - Both he/she and RN A checked the resident for a pulse, neither felt a pulse, both thought the resident felt warm. - He/she could not remember if the resident was on an air mattress (inflated with air/used for pressure relief). - RN A left the room and went back to the nurses' station. - He/she also left the room and followed RN A to the nurses' station. - He/she asked RN A if he/she should move the resident's roommate to a different room. RN A said yes. - He/she spent the next few minutes awakening the roommate and assisting him/her up and to a different room. - When he/she finished, RN A said the resident was "gone" (expired) and told him/her to clean the resident. - During this time, RN A did not direct him/her to get any supplies, assist with CPR, call 911 or call the physician. - He/she could not think of anything he/she could have done differently. - He/she had no previous experience with a "code" and no previous training (other than CPR certification) regarding his/her responsibilities in that situation. During an interview on [DATE] at 10:45 A.M., Nurse Aide (NA) A said: - He/she began work in the facility on [DATE] and [DATE] was the first night he/she had worked on a hall without another CNA with him/her. This was also the first night shift he/she had worked in the facility. - He/she had three or four days of orientation, but no one had discussed what his/her responsibilities were when a resident required resuscitation. - His/her CPR certification had expired in 2008. - He/she knew where they stored oxygen tanks in the facility and knew how to attach the regulators because of previous work experience. He/she knew where staff kept the key to the oxygen storage room. - He/she assumed oxygen masks were in a different store room. That room was locked and the charge nurse kept the key to that room. CNAs and NAs were not allowed to get oxygen and supplies from the store room. - He/she did not know where staff kept a suction machine for emergency use. - He/she did not know where they kept CPR masks at that time. - He/she had asked about the dot system during orientation and knew that a green dot by the resident's name outside the door to the room meant do CPR, a red dot meant the resident was DNR (do not resuscitate), but said on that night, that was the farthest thing from his/her mind. - The resident went on a smoke break around 9:00 P.M. and seemed fine at that time. - The charge nurse had assigned him/her to the other hall in the facility that night. - He/she had checked on all of her residents and they were okay. He/she went to the other hall to see if CNA A needed help. - CNA A asked him/her and the charge nurse if the resident always slept with his/her eyes open. - The charge nurse got in a wheelchair and went down the hall. - The charge nurse wheeled down the hall and into the resident's room and looked at the resident. The charge nurse tried to awaken the resident, but the resident did not respond. - He/she observed for signs of the resident breathing, but saw none. CNA A tried to feel a pulse, but did not feel one. - RN A didn't say anything and wheeled back to the nurses' station. - He/she asked CNA A what they should do. CNA A said he/she didn't know and would go ask RN A. - He/she left to go answer a resident's call light. - When he/she returned to the resident's room, CNA A was washing the resident's body. - He/she was not aware anyone provided CPR for the resident. During interviews on [DATE] at 6:03 P.M. and [DATE] at 10:25 A.M., RN A said: - He/she had worked in the facility for two years at night. - He/she had been certified in CPR, but knew his/her certification had expired. - He/she knew there was a CPR mask at the nurses' station. - He/she did not know if the facility had a cart of emergency equipment for use in resuscitative efforts. - On the night shift on [DATE], he/she, CNA A and nurse aide (NA) A were the only staff in the facility. - CNA A had checked the resident at 2:00 A.M. and he/she was fine. - At about 4:10 A.M., CNA A got him/her because the resident was unresponsive. - He/she went to the resident's room and saw that the resident was ashen and checked for a pulse at the resident's wrist and ankle and did not feel a pulse and did not observe any breathing attempts. He/she thought the resident felt warm. The resident was not "mottled" (bluish/purple discoloration that occurs with decreased blood supply; this can be a sign of approaching death) and he/she did not know how long the resident had been without a pulse or breathing. - He/she had to look at the resident's chart to determine if the resident was a "full code." - He/she did not know about the dot system (used by the facility to indicate whether the resident was to be a full code or was to be DNR (do not resuscitate) outside the resident's door. - He/she left the room and went to the nurses' station and got a stethoscope and came back to the bedside and listened for a heartbeat. He/she did not hear a heartbeat. - He/she turned the resident on his/her back and started "CPR." - He/she did chest compressions, but did not provide ventilations (breathing). - He/she learned to do both ventilations and chest compressions in his/her CPR training, but thought he/she had heard recently, maybe on TV, that it was not recommended to give ventilations. - He/she did not remember if the resident was on an air mattress. If the resident was on an air mattress, he/she did not deflate it. - He/she did not call 911 or the resident's physician and did not direct CNA A or NA A to call 911 or the physician. - He/she planned to wait for the day shift to call the physician. - He/she stopped giving chest compressions after about 10 minutes. He/she stopped because the resident had not responded to anything and had no breathing or pulse. He/she felt there was no point in continuing. - He/she did not remember CPR guidelines for when to stop CPR. - No one had ever discussed with him/her what to do when you find someone "already gone." He/she had no further training on CPR, since he/she was certified (to provide CPR) in ,[DATE]. He/she had not been in a situation like this before. During an interview on [DATE] at 2:00 P.M., Director of Nurses (DON) A (who was DON at the facility for approximately six months before [DATE]) said: - RN A left a message on her phone at about 4:30 A.M. that staff had found the resident dead. - She went to work at about 7:15 A.M. that morning and interviewed the three staff members who worked the previous night shift. - RN A told her at about 4:00 A.M. CNA A said the resident was acting funny. He/she went to check on the resident. The resident's eyes were half open and he/she did not respond. When DON A asked RN A what he/she did, RN A said, "I didn't do anything." - RN A told her she didn't know the resident was a full code and did not check for a red or green dot outside the door of the resident's room. - There was a green dot by the resident's name outside the door. - RN A told her he/she did not call 911. - RN A said he/she did chest compressions for awhile, but did not deflate the air mattress and did not provide ventilations. He/she stopped compressions after 10 to 15 minutes. He/she could not give a reason why he/she stopped compressions. - She reviewed the dot system of identifying which residents required resuscitation and which residents didn't with RN A. - She discussed the need to begin CPR immediately. - She told RN A he/she could not do effective chest compressions without deflating the resident's air mattress and reviewed the CPR policy with him/her and explained that included providing ventilations. - She told RN A that legally he/she was required to continue CPR until someone qualified (such as paramedics) took over or physician said to stop. - He/she told RN A that he/she should have had the aides call 911 and the physician. - He/she had not discussed with staff what they should do in this situation, but she felt the standard of practice was that once staff begin to provide CPR, they should continue until the resident's physician discontinues the process or the paramedics arrive and take over. - The facility did not have emergency equipment in one central location. - The facility did not have a crash cart, but were slowly trying to acquire equipment. At present the facility had four Ambu bags (used by healthcare providers trained in CPR to provide ventilations) and a suction machine (these items were kept in the supply room). The facility kept a simple CPR mask (used to prevent direct contact with mouth-to-mouth ventilations) at the nurses' station. The facility kept a [MEDICAL CONDITION] board at the 200 hall medication room (opposite hall from where this resident resided). - They were trying to get all needed supplies, but their corporation had rejected some requests due to cost. - She assured all licensed nurses on her staff were able to respond appropriately to a resident in need of resuscitation by requiring a copy of their current CPR certification. This included newly hired staff as well as current staff. All licensed nurses had current CPR certification at that time. - The corporation who owned the facility required all their licensed nurses to have CPR training. - They showed new nurses where staff kept the emergency equipment during orientation. - She felt the facility neglected the resident because the nurse on duty did not do what he/she should have done. - This resident was a perfect example of a resident who should be resuscitated. He/she was getting stronger every day and was full of life and always laughing. He/she and his/her family expected him/her to go home. His/her family had prepared his/her home, cleaned and made a "welcome home" sign. - He/she had in-serviced licensed nursing staff on the following - the dot system to identify residents who were to be a "full code", the red (do not resuscitate) or green (full code) sheets by each resident's Medication Administration Record, [REDACTED]. We also discussed having an aide call 911 and bring supplies. - He/she did not inservice aides and other staff regarding their responsibilities if they happened upon a resident not breathing or pulseless. He/she thought the administrator was going to do that. - She said the facility's aides knew where oxygen and a suction machine were located in the facility, although they would have to get the key to the supply room from the nurse. She did not think the aides would have known where staff kept the CPR mask, but RN A should have told them. - She said CNA A, who first discovered the resident was unresponsive, should have checked for a pulse and stepped into the hallway and called for the nurse. - While waiting for the nurse to get there, the aide could have opened the airway. - Because CNA A had CPR certification, he/she should have followed the facility's CPR policy and did not know why CNA A did not do that. - The nurse should have taken over CPR from CNA A and directed him/her or NA A to call 911. He/she should have directed one of the aides to bring a CPR mask to use to provide ventilations. During an interview on [DATE] at 2:05 P.M., RN B, the facility's corporate Quality Assurance (QA) nurse said: - After this resident's death, she instructed DON A to inservice all nurses on CPR/resuscitation procedures. - DON A said she did that, but they cannot find a copy of the inservice. During an interview on [DATE] at 2:06 P.M., DON B (charge nurse in the facility during the time of the resident's death and has since taken over the position of DON) said the only inservice she attended that day covered medication administration, not staff responsibilities when a resident needs resuscitation. Review of a Mini In-Service DON A provided on [DATE], showed six nurses (including DON B) and one CNA attended the in-service. Topics DON A documented she covered included "Administration of [MEDICATION NAME] (heart medication)," "Calling 911" and "CPR." Specific information DON A documented that she covered included: - "Anytime that a resident is a full code and is found unresponsive or unconscious - you are required to call 911 and begin CPR until relieved or told to stop by a physician." - "Mouth breather (CPR mask) is located at both nurse's stations. Make sure that you place a back board ([MEDICAL CONDITION] board) under the resident and/or deflate the air mattress in order to effectively do CPR." Observation and interview on [DATE] at 1:20 P.M. with RN B showed: - Twenty-six oxygen cannisters stored in the oxygen supply room. The regulators required to use the oxygen cannisters were also in that room, however none were attached and ready to use. The key to this room was outside and near the top of the door. - In a second supply room (opened after obtaining the key from the charge nurse) staff kept boxes of oxygen masks, cannulas (for nasal administration), and extra tubing. Staff stored a suction machine (not set up and ready to use) on the top shelf of room. - RN B didn't know if the facility had a [MEDICAL CONDITION] board or where it was. - There was no one place or cart where staff kept all emergency supplies. During an interview on [DATE] at 1:30 P.M., Licensed Practical Nurse (LPN) A said: - He/she did not know if the facility had a [MEDICAL CONDITION] board. - Staff had no central location for emergency supplies. During an interview on [DATE] at 10:06 A.M., RN B said she had not been able to find a [MEDICAL CONDITION] board and the facility had ordered one. During an interview on [DATE] at 4:50 P.M., Physician A, the medical director for the corporation who owned the facility said: - The facility's corporate policy said that licensed nurses could perform CPR and the policy did not require current CPR certification. - The newest information for healthcare providers is that it is not necessary to provide ventilations to a resident who is pulseless and not breathing. - He was not in total agreement that ventilations were not necessary, but said that legally, compressions were all that was required. During an interview on [DATE] at 2:20 P.M., Physician B, the resident's physician said: - He/she was sure the facility notified him/her of the resident's admission to the facility, but he/she did not know the resident at all. - He/she could not say what staff should or should not have done when they found the resident pulseless and not breathing, because he/she did not know the resident and his/her family. During an interview on [DATE] at 9:40 A.M., Emergency Medical Technician/Paramedic (EMTP) A, who is currently certified as a CPR instructor for the American Heart Association (AHA) and Red Cross and is a affiliate faculty member for the AHA said: - The current recommendation for healthcare providers is to provide ventilations as well as chest compressions for the pulseless, nonbreathing person. - The "no ventilation" technique is taught only to the lay public and those who have no CPR mask available. - Healthcare providers should use an Ambu bag with valve and mask (device which provides more effective and controlled ventilations than mouth to mouth or mouth to CPR mask) connected to 15 liters/minute of oxygen to provide ventilations. Healthcare providers are trained to use this in the CPR for Healthcare Providers certification course. NOTE: At the time of the survey, the violation was determined to be at an imminent danger class I level. Prior to the onsite visit, the facility's new DON had inserviced licensed staff (including the nurse involved in this SOD) regarding the facility's CPR policy and procedure and had reviewed staff responsibilities particularly with regard to making the decision to begin CPR, calling 911 and not stopping CPR until a paramedic takes over. The DON also reviewed the fact that a physician was the only person to call the time of death for a full code resident. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility verified that all licensed nurses had been trained and were competant to provide CPR per facility policy. The facility had acquired and stocked an emergency cart with all supplies they determined might be needed in an emergency situation with the exception of a [MEDICAL CONDITION] board (which had been ordered). The facility had placed the cart in a central location on the one hall open in the facility and were in the process of inservicing licensed nursing staff about the cart and the need for daily checks of the cart to assure readiness. The facility planned to provide quarterly medical emergency response drills and annual CPR inservicing. At the time of the exit, the severity of the deficiency was lowered from a J level to a D. The facility had not completed quarterly medical emergency response drills and had not acquired a [MEDICAL CONDITION] board for their emergency cart. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violation(s). A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. MO