Every finding on record at Oak Lane Wellness & Rehabilitative Center

Based on observation, interview, and policy review, the facility failed to store food in accordance with professional standards for food service safety by failing to ensure that cut produce stored in the refrigerator was protected from contamination and that refrigerated produce was labeled and dated. A total of 74 residents consumed meals from the kitchen.Findings:On 07/13/2026, a review of the facility's policy titled, Food Receiving and Storage, with a review date of 05/25/2026, revealed, in part; 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date).On 07/13/2026 at 8:30 a.m., during a kitchen tour with S3DSC, observation of the walk-in cooler revealed a bin containing six whole green bell peppers that were not labeled with a received date or use by date. The same bin contained one cut half head of romaine lettuce in its original bag. The cut surface of the lettuce was exposed, the bag was not fully closed and the lettuce was not labeled with a received date or use by date. S3DSC confirmed that the cut romaine lettuce should have been protected by being fully covered and both the cut lettuce and the whole green bell peppers should have been labeled with received and use by dates and was not.

Based on interviews, the facility failed to ensure the residents rights to receive their mail on Saturday. This deficient practice has the potential to affect the census of 74 residents that reside in the facility. Findings:On 07/14/2026 at 9:30 a.m., a resident council meeting was conducted with Residents #7, #15, #21, #28 and #63 who each confirmed they did not receive any mail on Saturdays. On 07/14/2026 at 9:40 a.m., an interview with S7HR confirmed the residents get their mail on weekdays Monday through Friday. She stated the mail was delivered to the facility on Saturday, however, the residents received the mail on Monday morning after the facility's office staff sorted through the mail. On 07/15/2026 at 1:34 p.m., an interview with S6ADM confirmed the residents should be receiving their mail on Saturday.

Based on observations, interviews, and record review, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. This was evidenced by staff failing to perform hand hygiene after removing gloves. This deficient practice had the potential to affect 74 residents who resided in the facility.Findings: On 07/14/2026, a review of the facility's policy titled Handwashing/ Hand Hygiene with a reviewed date of 05/25/2026, read in part: This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub.or, alternatively, soap.and water for the following situations.m. after removing gloves. On 07/13/2026 at 10:45 a.m., an observation was made of S5CNA wearing gloves while providing care to Resident #39. After completing care, S5CNA removed her gloves and left Resident #39's room. She did not perform hand hygiene. S5CNA then walked down the hallway and entered Resident #72's room. On 07/13/2026 at 10:48 a.m., an interview was conducted with S5CNA. S5CNA confirmed that she had not performed hand hygiene after removing her gloves in Resident #39's room, and before entering Resident #72's room, and stated she should have. On 07/13/2026 at 1:30 p.m., an interview was conducted with S2ADON/IP. She confirmed that staff should perform hand hygiene after removing gloves.

Based on record review and interviews, the facility failed to ensure residents and/or residents' RP (Responsible Party) were informed of the risks, benefits, and side effects of psychotropic/antipsychotic medications for 1 (Resident #3) of 5 residents reviewed for unnecessary medications. Findings:A review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring with a last review date of 05/25/2026, read in part, Policy Statement: 3.The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. Management: 4.The resident and family/representatives will be informed of the resident's condition as well as the potential risks and benefits as well as proposed interventions/medications. A review of Resident #3's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia, unspecified severity with other behavioral disturbance, bipolar disorder, unspecified, depression, unspecified, and anxiety disorder, unspecified. A review of Resident #3's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/22/2026 in Section C - Cognitive, revealed he had a BIMS (Brief Interview for Mental Status) of 12, indicating he was moderately, cognitively impaired. A review of Resident #3's current physician order summary report revealed the following psychotropic medication (prescription drugs that alter brain chemicals to affect mood, thoughts, behavior, or perception) orders:Clonazepam oral tablet 0.5 mg (milligram) give 1 tablet by mouth two times a day for restlessness/agitation related to anxiety disorder, unspecified. Order date 07/11/2026Depakote Sprinkles oral capsule delayed release sprinkle 125 mg give 2 capsules by mouth three times a day related to bipolar disorder, unspecified. Order date 04/29/2026Escitalopram oxalate oral tablet 5 mg give 1 tablet by mouth one time a day for isolation related to depression, unspecified. Order date 12/10/2025 Rexulti oral tablet 2 mg give 1 tablet by mouth one time a day for restlessness/agitation related to unspecified dementia, unspecified severity, with other behavioral disturbance; bipolar disorder, unspecified. Order date 04/15/2026Seroquel oral tablet 50 mg give 1 tablet by mouth at bedtime for target behavior: agitation related to unspecified dementia, unspecified severity, with other behavioral disturbance; bipolar disorder, unspecified; anxiety disorder, unspecified. Order date 06/08/2026Trazodone HCL (hydrochloride) oral tablet 50 mg give 1 tablet by mouth at bedtime for insomnia related to depression, unspecified, give 1/2 tablet. Order date 06/29/2026Further Review of Resident #3's electronic medication record failed to reveal documentation that Resident #3 or his RP had been informed in advance of the risks, benefits, and possible alternatives of treatments. On 07/14/2026 at 12:20 p.m., an interview with Resident #3 was conducted. He was unable to state which medications he took and was unaware that he took any mood or behavior altering medications. On 07/15/2026 at 12:35 p.m., an interview and review of Resident #3's physician order summary was conducted with S4DON and S6ADON. Both confirmed that Resident #3 received the above psychotropic medications and that neither he nor his RP had been informed of the risks, benefits, or alternate treatments prior to administration of these medications and should have.

Based on observations, interviews, and record review, the facility failed to implement physician orders to address weight loss by failing to offer a dietary supplement that was ordered for 1 (Resident #8) out of 2 residents investigated for nutrition.Findings:Review of Resident #8's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type two diabetes mellitus, anorexia, and unspecified protein-calorie malnutrition.A review of Resident #8's Weights and Vitals Summary revealed a weight of 147 pounds on 02/09/2026 and a weight of 141 pounds on 03/13/2026. This was a 4.08% weight loss in 30 days. A review of Resident #8's clinical record revealed a telephone order dated 02/11/2026, which read, Add Glucerna (oral snack/meal replacement) to meals as supplement secondary to low intake.A review of Resident #8's care plan revealed an intervention dated 02/11/2026 which read: add Glucerna to meals as supplement related to low intake as ordered.A review or Resident #8's MAR (Medication Administration Record) did not reveal an order for Glucerna.On 07/13/2026 at 11:30 a.m., an observation was made of Resident #8's lunch. The resident's lunch tray did not have Glucerna dietary supplement on it.On 07/15/2026 at 1:30 p.m., an interview was conducted with S4DON. She stated that dietary did not provide residents with Glucerna on their meal trays. She stated that nurses provided this supplement during medication pass. On 07/15/2026 at 2:50 p.m., an interview and a record review was conducted with S7LPN who was assigned to Resident #8. She confirmed the order for Glucerna was not on the MAR for Resident #8. She also confirmed that she had not offered a Glucerna supplement with each meal to resident #8 as ordered by the physician from 02/11/2026 to present. On 07/15/2026 at 3:50 p.m., an interview and review of Resident #8's dietary card was conducted with S3DSC. She confirmed that the dietary card for Resident #8 did not have instructions for Glucerna. She also confirmed that he had not received it on his meal trays for breakfast, lunch, or dinner. S3DSC stated that dietary did not provide Glucerna to residents on their meal trays. On 07/15/2026 at 3:00 p.m., an interview and record review was conducted with S6ADON/IP. She confirmed that the physician's telephone order for a house supplement for Resident #8 should have been entered on the MAR so nursing staff would be prompted to provide it the resident. S6ADON/IP stated there was no way to confirm the order was implemented since it was not documented on the MAR. She further stated that the nurse taking the telephone order should have recorded it on the MAR so nurses would be notified to offer it during medication pass. S6ADON/IP confirmed that Resident #8 should have been offered Glucerna with meals by the nurse and was not.

Based on observations, record review, and interview, the facility failed to ensure residents received the appropriate amount of oxygen as ordered by the physician for 1 (#2) of 3 residents review for respiratory care Findings:Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnosis not limited to chronic obstructive pulmonary disease, cognitive communication deficit, shortness of breath, severe dementia, insomnia, anxiety disorder, and aphasia.Record review of Resident #2's Quarterly MDS (Minimum Data Set) dated 05/21/2026 BIMS (Brief Interview for Mental Status) score was 10 indicating she had moderate cognitive impairment.Record review of Resident #2's active physician order summary dated 07/15/2026 read in part, Oxygen 2 liters per NC (nasal cannula) for SOB (shortness of breath) every shift for related to COPD (chronic obstructive pulmonary disorder).On 07/13/2026 at 1:40 p.m., observed Resident #2 sitting up in her wheelchair in therapy wearing a nasal cannula with the oxygen concentrator set at 3 liters. On 07/13/2026 at 4:15 p.m., observed Resident #2 sitting up in her wheelchair in her room wearing a nasal cannula with the oxygen concentrator set at 3 liters. On 07/14/2026 at 10:30 a.m., observed Resident #2 sitting up in her wheelchair in her room wearing a nasal cannula with the oxygen concentrator set at 3 liters. On 07/14/2026 at 1:28 p.m., observed Resident #2 lying in her bed wearing a nasal cannula with the oxygen concentrator set at 3 liters. On 07/14/2026 at 1:33 p.m., an interview with S9CNA revealed she cares for Resident #2. S9CNA stated Resident #2 has to wear continuous oxygen with a nasal cannula. S9CNA stated the oxygen concentrator should be set at 2 liters. On 07/14/2026 at 1:34 p.m., S7LPN confirmed she was Resident #2's nurse. S7LPN stated the resident has chronic obstructive pulmonary disease and has to wear continuous oxygen per nasal cannula set at 2 liters as ordered by the physician. She confirmed Resident #2's oxygen was on 3 liters and should have been on 2 liters. On 07/15/2026 at 2:13 p.m., S4DON reviewed Resident #2's physician orders and care plan and confirmed Resident #2 should be on continuous oxygen per nasal cannula at 2 liters as ordered by the physician.

Based on record review and interview, the facility failed to ensure the resident's plan of care was implemented as ordered through five consecutive months by failing to follow physician orders for completing wound care and monitor swelling for 1 (Resident #2) out of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.Findings:Review of Resident #2's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease and dementia.Review of Resident #2's November 2025 physician's order and TAR (Treatment Administration Order) revealed the following order dated 11/07/2025: Skin tear to R (right) forearm. Clean with NS (normal saline), apply TAO (triple antibiotic ointment), cover with a dry dressing daily until healed. The TAR failed to reveal evidence that treatment for the skin tear to the right forearm was administered for the resident for November 2025.Review of Resident #2's December 2025 physician's order and TAR revealed the following in part:Order dated 12/06/2025: Clean skin tear to right elbow with NS, then apply TAO, and a covered dressing q day until healed. The TAR failed to include nurses' initials or evidence that the treatment was administered on the dates of 12/08/2025 and 12/31/2025.Order dated 12/11/2025: Cleanse laceration to mid forehead with normal saline and apply triple antibiotic QD (every day), cover with dressing until resolved. The TAR failed to include nurses' initials or evidence that the treatment was administered for the resident on the date of 12/31/2025.Order dated 12/12/2025: Bacitracin External Ointment 500 unit/gram, apply to forehead topically two times per day for wound to forehead. Cleanse forehead with NS, apply Bacitracin and cover with dry dressing until healed. The TAR failed to include nurses' initials or evidence that the treatment was administered for the resident on the dates of 12/23/2025 HS (at bedtime), 12/29/2025 HS, and 12/31/2025 AM (morning).Review of Resident #2's January 2026 physician's orders and TAR revealed the following order dated 01/01/2026: Cleanse skin tear to webbing of left hand outer middle finger and ringer finger with normal saline and apply triple antibiotic ointment, cover with dressing QD until healed. The TAR failed to include nurses' initials or evidence that the treatment was administered for the resident on the date of 01/08/2026.Review of Resident #2's February 2026 physician's orders and TAR revealed the following order dated 02/26/2026: Cleanse skin tears to right outer pinky finger with normal saline and apply triple antibiotic QD with cover dressing until resolved. The TAR failed to include nurses' initials or evidence that the treatment was administered for the resident on the date of 02/27/2026.Review of Resident #2's March 2026 physician's orders and TAR revealed the following orders dated 03/10/2026:Cleanse skin tear to right outer eye with normal saline and apply triple antibiotic ointment with cover dressing QD. The TAR failed to include nurses' initials or evidence that the treatments were administered for the resident on the dates of 03/19/2026 and 03/22/2026.Cleanse skin tear to right outer hand with normal saline and apply triple antibiotic ointment with cover dressing QD until healed. The TAR failed to include nurses' initials or evidence that the treatments were administered for the resident on the dates of 03/19/2026, 03/22/2026 and 03/24/2026.Monitor swelling to right knee q shift three times a day. The TAR failed to include nurses' initials or evidence that monitoring of the swelling was done for the resident on the dates of 03/19/2026 AM, 03/19/2026 MID (midday), 03/22/2026 AM, and 03/22/2026 MID.On 03/25/2026 at 9:00 a.m., an interview and record review was conducted with S1DON who was responsible for nursing services in the facility. She reviewed Resident #2's November 2025 TAR and confirmed there was no evidence the nurses administered the treatment of resident's skin tear to right forearm. S1DON stated the order may be on Resident #2's MAR (Medication Administration Record) for November 2025, MAR was reviewed, and she confirmed there was no evidence the nurses administered the treatment of resident's skin tear to right forearm. S1DON stated she would further check Resident #2's electronic health record. S1DON also reviewed Resident #2's December 2025, January, February and March 2026 TAR, and confirmed that the TARs failed to include nurses' initials or evidence that the treatments were administered for the above dates. S1DON confirmed the resident's treatments and monitoring were not done as ordered in December 2025, January 2026, February 2026 and March 2026.On 03/25/2026 at 10:00 a.m., another interview was conducted with S1DON who confirmed there was no documented evidence that treatments were administered as ordered for Resident #2's skin tear to right forearm for the month of November 2025.

Based on record review and interview, the facility failed to develop and/or implement a comprehensive person-centered plan of care and/or physician's orders for 1 (Resident #38) out of 29 sampled residents. This deficient practice was evidenced when the facility failed to implement standing orders for constipation for Resident #38. Findings: Review of Resident #38's admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Alzheimer's disease, Diabetes Mellitus and Cerebral Infarction. Review of Resident #38's Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C, revealed Resident #38's Brief Interview for Mental Status (BIMS) score was 12, indicating her cognition was moderately impaired. Further review of the assessment, under Section H revealed Resident #38's bowel continence was always incontinent. Review of Resident #38's Care Plan revealed in part, risk for inadequate bowel pattern. Interventions included in part, administer medication as ordered, monitor effectiveness/adverse reactions and observe for signs and symptoms of . constipation . On 06/25/2025 at 8:40 a.m., an interview was conducted with Resident #38. She stated she had a history of constipation and her last bowel movement was four days ago. On 06/25/2025 at 9:15 a.m., an interview was conducted with S20LPN (Licensed Practical Nurse). S20LPN stated Resident #38 has standing physician's orders to give Resident #38 milk of magnesia or bisacodyl (laxatives), if the resident did not have a bowel movement in three days. Review of a facility document titled Routine Standing Orders 2025 revealed in part, constipation, if no BM (bowel movement) in 3 days: milk of magnesia 30 cc (cubic centimeters) at bedtime prn (as needed) or bisacodyl 3 tablets po (by mouth) at bedtime prn. Further review revealed in part, if no results in 24 hours then give bisacodyl 10 mg (milligram) suppository x 1, if still no BM after 24 hours, check for impaction and notify MD (Medical Doctor). On 06/25/2025 at 12:24 p.m., a review was conducted of Resident #38's electronic medial record which revealed a report titled, Follow-up question report dated 06/01/2025 - 06/25/2025. The report revealed Resident #38 did not have a bowel movement on 06/18/2025, 06/19/2025, 06/20/2025, 06/21/2025, 06/22/2025, and 06/23/2025. On 06/25/2025 at 1:32 p.m., a review of Resident #38's June 2025 MAR (Medication Administration Record) was conducted. No milk of magnesia or bisacodyl was administered to Resident #38 in June 2025. On 06/25/2025 at 1:48 p.m., an interview and record review was conducted with S2DON (Director of Nursing). S2DON confirmed that Resident #38 did not have a bowel movement from 06/18/2025 to 06/23/2025. S2DON reviewed Resident #38's June 2025 MAR and confirmed the resident did not receive milk of magnesia or bisacodyl for constipation and should have.

Based on observations and interviews, the facility failed to maintain professional standards for food service safety by failing to: 1. Discard food items that were past the used by date, 2. Label and date opened food items stored in the walk in cooler, 3. Label and date an opened food item in the area where food is prepared 4. Label and date an opened food item in the pantry, 5. Remove a dented can from the dry storage area, 6. Ensure kitchen staff wear proper hair restraints. The facility's census was 69. Findings: A review of the facility's policy titled Food Receiving and Storage with a last review date of 08/07/2024 read in part, Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use bydate). A review of the facility's policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices with a last review date of 08/07/2024 read in part, Policy Statement: Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. On 06/23/2025 at 8:55 a.m., an initial tour of the kitchen was made with S5DSC (Dining Service Coordinator). The following were identified: 1. In the reach in cooler, there were (19) 8 ounce containers of chocolate milk with a used by date of 06/19/2025 and (1) 48 ounce cream cheese opened with no label or date opened. 2. In the kitchen, near the sink where food was prepared, there was a container of browning seasoning sauce opened with no label or date opened. 3. In the walk in cooler, there was (1) container of minced garlic and (1) container of chicken base with no label or date opened. 4. In the pantry there was (1) 50 ounce can of chicken noodle soup dented and (1) 18 ounce container of ground cinnamon with no label or date opened. 5. S7DC (Dietary Cook) with exposed facial hair. On 06/23/2025 at 09:15 a.m., an interview was conducted with S5DSC and she confirmed that all items with a past used by date should have been discarded, there should have been no dented cans in the pantry and all opened food items should have been labeled with a date when the item was opened. On 06/23/2025 at 10:34 a.m., a second observation was made of S7DC cleaning the stove with exposed facial hair. At this time an interview with S5DSC was conducted. She confirmed that S7DC's facial should have been covered.

Based on observation and interviews, the facility failed to promote and facilitate residents' self- determination through support of the residents' choice about aspects of his or her life in the facility that were significant to the resident for 1 (#59) out of 29 sampled residents. The facility failed to provide a diet according to Resident #59's food preferences. Findings: A review of Resident #59's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Cerebral Infarction, Dementia, and Vitamin Deficiency. A review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident has a BIMS (Brief Interview for Mental Status) score of 06, indicating the resident's cognition was severely impaired. On 06/23/2025 at 11:18 a.m., an observation was conducted of Resident #59 consuming lunch. He did not eat the mixed vegetables or beans that were on his lunch tray. An interview was conducted with Resident #59 at this time, and he stated he does not like beans and mixed vegetables. He said he told the facility of his dislikes already. A review of Resident #59's meal ticket on his lunch tray dated 06/23/2025 read in part, Dislikes: Mixed Vegetables/Beans . On 06/23/2025 at 11:25 a.m., an observation and interview were conducted with S10CNA (Certified Nursing Assistant). S10CNA confirmed Resident #59's meal ticket stated that he has a dislike of mixed vegetables and beans. An observation was conducted with S10CNA of the resident's lunch tray and she confirmed that he did not eat his mixed vegetables and beans. She stated this should not have been on his lunch tray, and a substitute should have been on his plate instead. On 06/23/2025 at 11:29 a.m., an observation and interview were conducted with S6DC (Dietary Cook). S6DC reviewed Resident #59's meal ticket and lunch plate. She confirmed the resident has a dislike of mixed vegetables and beans. She confirmed mixed vegetables and beans should not have been on the resident's lunch plate, and they should have put a substitute on his plate such as salad or cucumbers. She further stated she should have clarified, with the resident what type of beans he wanted and she had not done this. On 06/24/2025 at 3:34 p.m., an interview was conducted with S5DSC (Dining Service Coordinator). She confirmed that the resident's likes and dislikes on their meal ticket should be honored, and if there are any dislikes on the meal ticket that is on the menu, it should be substituted with a resident's preferences.

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #66) out of 29 sampled residents. Findings: Review of Resident #66's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to unspecified combined systolic (congestive) and diastolic (congestive) heart failure. Further review revealed Resident #66 was discharged on 04/25/2025. Review of Resident #66's Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed a code of 2 in section A0310 - Type of Assessment, which indicated unplanned discharge. Review of Resident #66's care plan revealed a focus area initiated on 01/28/2025 for D/C (discharge) planning - active plans to return to the community. A review of progress notes revealed on 04/24/2025 at 10:59 a.m. S12LPN (Licensed practical Nurse) wrote: New order per (by) Dr. (doctor) .for patient to be discharged home with home health services on 04/25/2025. An interview and record review of Resident #66's Discharge MDS assessment dated [DATE] was conducted with S21MDS on 06/24/2025 at 11:38 a.m. S21MDS confirmed the resident's discharge MDS assessment was coded as an unplanned discharge and stated it should have been coded as a planned discharge.

Based on observations, interviews, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living (ADLs) receives services to maintain personal hygiene for 1 (#16) of 1 (#16) residents investigated for ADL care. The sample size was 29. Findings: Resident #16 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cerebral infarction and unspecified dementia, unspecified severity and encounter for palliative care. Review of Resident #16's Significant Change Minimum Data Set (MDS) assessment revealed a code of 1 in section GG0115 A. Upper extremity, indicating the resident had impairment on one side. Further review revealed a code of 03 in section GG0130. Self-Care I. Personal hygiene indicating the following .Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Review of Resident #16's care plan revealed a focus area initiated on 01/24/2025 for mobility and self-care needs with an intervention to check fingernails daily and clean as needed. On 06/24/2025 at 9:27 a.m., an observation was made of Resident #16 in her room. The resident was lying in bed and a dried, brown, stool colored substance coated her right hand, fingers, and underneath her fingernails. During an observation and interview with S11CNA (Certified Nursing Assistant) on 06/24/2025 at 9:30 a.m., she stated that she was responsible for Resident #16's care. S11CNA confirmed the resident's right hand, fingers, and nails were coated with brown, stool colored substance and stated she must have placed her hand in her diaper. When asked, S11CNA stated that she started her shift a 6:00 a.m. but had not checked on the resident because she had to go to the dining room to assist other residents. On 06/24/2025 at 9:55 a.m., an interview was conducted with S13CNA. She stated that she fed the resident at around 7:30 a.m. but did not check her hands or her incontinent brief. When asked what she did, S13CNA stated she put the head of the bed up and fed her. During an interview with S3ADONIP (Assistant Director of Nursing/Infection Preventionist) on 06/25/2025 at 9:08 a.m., she stated that the last round for the night shift was 4:30 a.m. to 5:30 a.m., and at 6:00 a.m. when the new shift started, the CNA from each shift should have rounded together to check each resident to make sure they were clean and dry. S3ADONIP further stated that breakfast started at 7:00 a.m., and checking the residents should have been completed before breakfast. On 06/25/2025 at 10:37 a.m., an Interview was conducted S14CNAS (Certified Nursing Assistant Supervisor). She stated CNAs were supposed to check on all their residents as soon as they started their shift. S14CNAS further stated that breakfast did not start until 7:00 a.m. She stated she spoke to the CNAs after she became aware of the incident and one of them told her she didn't see it. S14CNAS stated, I don't know how she didn't see that.

Based on observations and interviews the facility failed to properly store respiratory equipment for 2 (Resident #16 and Resident #22) out of 3 residents (Resident #16, Resident #22 and Resident # 63) investigated for respiratory care. Findings: Resident #22: Review of Resident #22's electronic medical record revealed that she was admitted on [DATE] with a diagnosis of obstructive sleep apnea. Review of the resident's June 2025 physician orders revealed an order to change replacement cushion (mask) on CPAP machine every month on the 22nd. On 06/23/2025 at 09:15 a.m., an observation was made of Resident #22's CPAP mask in a plastic storage bag dated 05/13/2025. On 06/23/2025 at 2:35 p.m., an interview and observation was conducted with S2DON (Director of Nursing). S2DON stated the plastic storage bags for the CPAP mask should be changed once a month when they change the CPAP mask. She confirmed the plastic bag with the resident's CPAP mask was dated 05/13/2025. She stated that the plastic storage bag should have been changed when the resident's CPAP mask was changed. Review of the facility's policy CPAP/BiPAP (Continuous Positive Airway Pressure/ Bilevel Positive Airway Pressure) Support with a revised date of 08/27/2024 read in part, . General Guidelines for Cleaning .9. Infection control--keep cpap mask in clean dry bag and change out monthly when changing out mask . Resident #16: Resident #16 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to hypertensive heart disease with heart failure. Review of physician's orders revealed an order written on 02/26/2025 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliter) (Ipratropium-Albuterol)1 vial inhale orally four times a day related to heart failure, unspecified. During an observation of Resident #16's room on 06/24/2025 at 9:27 a.m., Resident #16 was in bed and her oxygen nebulizer mask was connected to her breathing treatment machine which was on the seat of a chair in the room and not stored in a bag. The chair was not within reach of the resident. During an observation and interview with S11CNA (Certified Nursing Assistant) on 06/24/2025 at 9:30 a.m., she confirmed the resident's oxygen nebulizer mask on the chair was not stored in a bag. An observation and interview was conducted with S12LPN (Licensed Practical Nurse) on 06/24/2025 at 9:42 a.m. He confirmed Resident #16's nebulizer mask should have been stored in a bag. S12LPN stated the resident was unable to place the mask on the chair because it was outside of her reach. On 06/25/2025, a review of the facility's policy titled Departmental (Respiratory Therapy) - Prevention of Infection, with a last reviewed date of 08/07/2024, read in part .Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: .7. Store the circuit in plastic bag, marked with date and resident's name, between uses.

Resident #50 Review of Resident #50's electronic medical record revealed he was admitted to the facility on 09/12//2022 with the following diagnoses in part, but not limited to, Type 2 Diabetes mellitus, cerebral infarction and chronic obstructive pulmonary disease. On 06/23/2025 at 10:20 a.m., a medication administration observation was conducted with S15LPN (Licensed Practical Nurse). After S15LPN drew up Resident #50's insulin injection, she proceeded to the resident's room and administered his injection without donning gloves prior to giving the injection. On 06/23/2025 at 10:30 a.m., an interview was conducted with S15LPN. S15LPN confirmed she did not wear gloves when she administered Resident #50's injection. She stated that she should have worn gloves to give the injection. Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 2 (Resident #31 and Resident #50) out of 29 sampled residents. The deficient practice was evidenced when the facility failed to ensure staff: 1. Wore proper PPE (Personal Protective Equipment) while providing care for Resident #31 who was on EBP (Enhanced Barrier Precautions) and 2. Wore gloves prior to and while administering an insulin injection to Resident #50. Findings: Review of the facility's policy titled, Enhanced Barrier Precautions' with a last reviewed date of 08/07/2024 read in part, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .Examples of high-contact resident care activities requiring the use of gown and gloves for EBP include .bathing/showering .EBPs are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with the following .ESBL (extended-spectrum beta-lactamase) producing enterobacterales . Review of Resident #31's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, cerebral infarction, Hemiplegia and Hemiparesis following Cerebral Infarction, and Urinary Tract Infection. Review of Resident #31's Care Plan Report revealed EBP precautions - MDRO ESBL with interventions that included in part, EBP precautions must wear gloves and gown for high contact interactions. Review of Resident #31's Urinalysis Culture dated 06/07/2025 revealed in part, organisms identified: Escherichia coli ESBL. On 06/25/2025 at 9:35 a.m., an observation was made of a sign posted on Resident #31's room door indicating he required EBP and staff should wear a gown as a part of their PPE. On 06/25/2025 at 9:40 a.m., an observation was made of S19CNA (Certified Nursing Assistant) not wearing a gown while providing a bed bath for Resident #31. An interview was conducted with S19CNA, who stated she was aware that Resident #31 was on EBP and confirmed she failed to wear a gown while providing resident care. On 06/25/2025 at 10:25 a.m., an interview was conducted with S3ADON/IP (Assistant Director of Nursing/Infection Preventionist). She confirmed a gown and gloves must be donned (worn) when providing high contact activities such as bed baths if a resident required EBP.

Based on record reviews, observations, and interviews, the facility staff failed to recognize and properly respond to a resident who was demonstrating exit seeking behaviors or recognize the Wanderguard alarm to prevent elopement for 1 (Resident #1) of 5 residents investigated for elopement (Resident #1, #4, #5, #6 and #7). This deficient practice resulted in an Immediate Jeopardy on 03/22/2025 at 10:40 a.m. when Resident #1, a moderately cognitively impaired resident, eloped from the facility located in a residential area. On the morning of 03/22/2025, prior to his elopement, Resident #1 asked staff members for the code to the facility's door alarm and expressed that he wanted to go home before exiting the facility undetected by staff. Staff failed to recognize the residents exit seeking behavior and the sound of the wanderguard as he went out of the door. On 03/22/2025 at 10:50 a.m., the facility received a phone call from Resident #1's responsible party that Resident #1 was at his home. Resident #1 walked approximately 0.2 miles from the facility to his home. He was returned to the facility by facility staff 03/22/2025 at 11:12 a.m. and placed into the monitored unit. S1ADM (Administrator) was notified of the Immediate Jeopardy on 03/31/2025 at 5:51 p.m. The deficient practice had the likelihood to cause more than minimal harm to 5 residents identified by the facility as an elopement risk. Findings: Review of Resident #1's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's disease and dementia with other behavioral disturbance. Review of Resident #1's Admission MDS (Minimum Data Set) with an ARD (Assessment Review Date) of 02/28/2025 revealed he had a BIMS (Brief Interview for Mental Status) of 09, indicating his cognition was moderately impaired. Behavioral section of the MDS revealed Resident #1 had no wandering behaviors at the time of the assessment. Further review of his functional abilities section revealed Resident #1 did not use any assistive devices and could walk independently 150 feet. Review of Resident #1's care plan read in part: Focus: Risk for elopement related to impairment cognition and safety awareness secondary to Dementia. Goal: No wandering behaviors; date initiated 02/21/2025. Resident's safety will be maintained initiated 02/21/2025. Interventions read in part: Wander Guard (elopement alarm bracelet) device applied due to risk elopement related to impaired cognition and safety awareness. Monitor every shift for proper placement and functioning of device initiated 02/21/2025. Review of Resident #1's current physician orders revealed an order dated 02/25/2025 for Wander guard applied due to risk of elopement related to impaired cognition and safety awareness. Review of Resident #1's elopement assessment dated [DATE] revealed Resident #1 was negative for elopement risk. However, there was a statement documented that read Wander guard device applied to right wrist due to risk of elopement related to impaired cognition and safety awareness secondary to dementia. Monitor q (every) shift for proper placement and functioning of device. Review of Resident #1's incident report completed on 03/22/2025 at 10:50 a.m. by S4ALPN (Agency Licensed Practical Nurse) read in part, this nurse was made aware by the facility staff that Resident #1's responsible party called to advise that Resident #1 had left the facility and was currently at his residence. Facility transportation went and picked up Resident #1 at that location. At approximately 11:15 a.m., this nurse asked resident what happened and Resident #1 stated I left and will not leave again for a few more months. Review of witness statement completed by S8FS (Facility Staff) on 03/22/2025 read in part, the last time I saw him was at 10:30 a.m. Resident #1 came to the desk and asked me to let him out the building. Review of witness statement completed by S5CNA (Certified Nursing Assistant) on 03/22/2025 read in part .Resident #1 came and asked me and S6CNA to let him out because he was ready to go home, so we sent him to the nurse's station to talk to the nurse at the end of the hall and that was the last time I saw him. A little while later after about 10:40 a.m., we started bringing residents to the dining room and then we sat behind the nurse's station. The door alarm started going off, but we did not know where it was coming from. I checked the door and looked outside and then I put the code in to disarm the alarm but I didn't see anyone outside. Review of witness statement completed by S6CNA on 03/22/2025 read in part I was working with S5CNA and we had just finished rounding and went to get something out of our bags when Resident #1 approached and asked if we would let him out because he wanted to go home. We told him we wouldn't and that he would have to ask the nurse at the end of the hall. After that, we went and sat behind the nurse's station. Resident #1 came up to the nurse's station again and asked if we could put in the code to the door and we told him that we didn't know the code and that he had to ask the nurse. After that Resident #1 went down the hall toward the nurse station. On 03/31/2025 at 12:02 p.m., an interview was conducted with S5CNA. She confirmed that she was present and responsible for Resident #1 on 03/22/2025 when he eloped. She stated that Resident #1 followed her in the lounge and asked her to open the door because he was ready to go home. She then told him to go ask the nurse and watched him until he approached the nurse. She stated that Resident #1 had been asking to go home all day, but she thought nothing of it. S5CNA reported that when the alarm went off, she just thought the door had been left opened too long and did not know which door was alarming. She stated that when she went to Hall W's front exit door, she looked outside from the door and did not see anyone so she disarmed the alarm. S5CNA confirmed that she did not know how to identify where an alarm was coming from when it sounded or what should be done when an alarm sounded. On 03/31/2025 at 12:28 p.m., an interview was conducted with S6CNA. She stated that she was also caring for Resident #1 the day he eloped. She stated that when she went by the lounge room to get a drink, Resident #1 asked her for the code to get out because he was ready to go home. She stated that she knew that he was an elopement risk and had a Wander guard bracelet, but did not think that would have left the building. S6CNA said that she told him to go and ask the nurse for the code. She stated that later, when the alarm went off, she did not know what it was or where it was coming from. S6CNA stated that eventually S5CNA went to the exit door and canceled the alarm. On 03/31/2025 at 1:27 p.m., a review of the facility's video surveillance dated 03/22/2025 and interview was conducted with S1ADM (Administrator). Prior to the review of the video, S1ADM advised that the time on the video surveillance had not been set to daylight savings time, therefore, timing would be one hour later than the time stamps on the video. Review of the surveillance revealed that on 03/22/2025 at 09:40 a.m., Resident #1 walked out to the facility following a visitor. There is no audio on the video, however, S1ADM stated that this was when the alarm when off. On 03/22/2025 at 09:41 a.m., a staff member's head poked out from the nurse's station. At 09:42 a.m., S5CNA came from the nurse's station, walked toward Hall W's front exit door, peered through the door's glass from inside of the facility, and reset the alarm and returned back to the nurse's station. At this time, S1ADM confirmed that the two CNA's working with Resident #1, S5CNA and S6CNA, did not know where the alarm sound came from. He stated that the two CNA's had just started working about 2 weeks prior to the incident. He also stated the CNA's could have gotten to Resident #1 quicker had they known where the alarm was coming from. A review of the Elopement Policy with S1ADM was conducted and revealed nothing about alarms, how to respond to an alarm or how to recognize exit seeking behaviors. He stated that he would have to look for a policy on alarms. S1ADM stated that on 03/22/2025, after the incident of elopement, he began an in-service with all staff on the elopement policy, how to identify where an alarm is coming from and how to respond when an alarm activated. Review of the facility's policy with a review date of 08/2024 titled Elopements read in part, Policy Interpretation and Implementation: 1. Staff shall promptly report an resident who tries to leave the premises .2. If an employee observes a resident leaving the premises .3. If an employee discovers that a resident is missing from the facility .4. When the resident returns to the facility . A request for the facility's policy on alarms/Wander guard was requested on 03/31/2025 at 1:27 p.m., but not provided until a second request was made for a policy and presented approximately 1.5 hours before the notification of Immediate Jeopardy. Review of the facility's policy with a review date of 8/2024 titled Door Guardian WanderguardSystem read in part Policy Statement: The Wanderguard would be used for residents at risk for elopement. Procedure: 5. The Wanderguard notification systems are located at each nurse's station. (Secure Care box located on the wall with door labels and lights). 6. If the notification system starts sounding, locate the alarming door by looking for the light next to the door label that is alerting. Go to the door, look for any residents that may have set off the alarm, once you have determined that no residents are missing, reset the alarm. The Immediate Jeopardy was removed on 04/01/2025 at 1:37 p.m. after it was verified through observations, interviews, and record reviews that the provider implemented an acceptable Plan of Removal prior to the survey exit. The facility implemented the following actions to correct the deficient practice: The facility initiated in-service with staff on 03/22/2025 regarding door alarms within the facility and the Elopement Policy. Staff were educated on how to respond to an activated door alarm. On 03/31/2025, an additional in-service on the Door Guardian, Wander Guard Policy to all staff on duty was conducted. Pictures of the alarming modules located at the nurse's stations were presented to staff for visual recognition. Education continued on 04/01/2025 to all staff as they came for their assigned shifts. The facility continued to educate on 04/01/2025 to all on coming staff members on the policies and procedures for dealing with elopements, residents with elopement risk, alarming doors and how to react and respond accordingly to an alarm. The administrator and/or designee will evaluate new hires and agency staff prior to beginning their shifts on policies and procedures for dealing with elopements, resident with elopement risk, alarming doors and how to react and respond accordingly to an alarm. The charge nurse will evaluate any agency staff to ensure full understanding prior to beginning their shifts. The administrator and/or designee will provide additional monthly education on elopements, elopement risk residents, exit seeking behavior, alarms within the facility and how to properly respond to alarms within the facility to staff for the next 6 months. The DON (Director of Nursing) and/or designee will conduct random weekly audits of staff's knowledge on the policies and procedures on elopements, residents with elopement risk, alarming doors and how to react and respond accordingly for 8 weeks. The Policy on Elopement was revised to include attempted elopements and exit seeking behaviors and how to deal with exit seeking behaviors.

Based on interview and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 resident (#2) out of 7 (#1,#2, #3, #4, #5, #6, #7) sampled residents. Findings: Review of the facility's policy titled Prevention of Pressure Ulcer/Injuries, with a last reviewed date of August 2024, read in part: 1. Evaluate, report, and document potential changes in the skin with weekly skin assessments. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including; type 2 diabetes, pressure ulcer of sacral region, and unstageable pressure induced deep tissue damage of other site. Review of Resident #2's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed section M in part: Resident has a pressure ulcer/injury, at risk for developing pressure ulcers. Review of Resident #2's care plan initiated on 12/12/2024 revealed an intervention to conduct body audit per schedule. Further review of Resident #2's medical record failed to reveal weekly body audits for 12/11/2024 through 12/24/2024. Review of Resident #2's wound assessments revealed a facility acquired, unstageable wound was identified to the resident's sacrum on 12/24/24. On 04/02/2025 at 10:20 a.m., an interview was conducted with S7TN (Treatment Nurse). She stated she completed skin assessments and body audits on all residents weekly. She further stated that these were head to toe assessments, and she assessed the residents' backsides as well. S7TN also stated that weekly skin impairment assessments were conducted on residents who had current skin impairments. A review of Resident #2's weekly skin impairment assessment for the week of 12/17/2024 did not include an assessment of the resident's buttocks and the assessment was for the resident's yeast infection rash. S7TN was asked to provide documented evidence that a body audit was conducted on Resident #2 between his admission assessment on 12/11/2024 and the identification of the unstageable wound to his sacrum on 12/24/2024 and could not provide any documented evidence.

Based on record review and interview, the facility failed to implement its antibiotic stewardship policy to timely evaluate culture and sensitivity results in order to determine appropriate antibiotic usage by failing to: 1. Obtain culture report and sensitivity data in a timely manner in order to initiate possible treatment for Residents #43 and #77 and; 2. Notify the physician of culture report and sensitivity data in order to ensure Resident #380 was prescribed the appropriate antibiotic, out of 6 (Residents #34, #43, #54, #65, #70, #77, and #380) residents reviewed for infection control tracking and trending during the Infection Control facility task. The facility's census was 77. This deficient practice resulted in actual harm when Resident #43's final urine culture and sensitivity final report dated 04/26/24 showed that the bacteria, Klebsiella pneumoniae, was present in the resident's urine. The facility failed to have the final culture and sensitivity report resulted on 4/26/2024 in the resident's record from a urinalysis specimen collected on 04/23/2024. The facility was not aware of the results and therefore not able to report the results to the resident's physician for possible treatment with antibiotics. On 04/30/2024, Resident #43 complained of weakness and dizziness and her blood pressure was 80/40 (low). The resident was subsequently sent to the emergency room the same day (04/30/2024) where a urine culture was ordered and showed Klebsiella pneumonia as previously identified in the culture that the facility collected on 4/23/2024. The resident was discharged from the emergency roiagnom on [DATE] with a prescription for antibiotic therapy. A review of the facility's policy titled, Antibiotic Stewardship read in part: 11. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. 1. Resident #43: A review of resident #43's medical record revealed a urine specimen was collected for urinalysis on 04/23/2024. No final microbiology report was present in resident #43's medical record on 05/20/2024. Review of the final microbiology report that was obtained for this resident during the survey on 05/20/2024 indicated that on 04/26/2024, Klebsiella pneumoniae was present in the urine collected on 04/23/2024. No documentation was found that the physician had been notified of the final microbiology results or that Resident #43's infection had an antibiotic ordered for treatment. Review of S11LPN's nurse's notes dated 04/30/2024 at 8:00 a.m. revealed that Resident #43 had complaints of weakness and dizziness with a low blood pressure of 80/40. She was transferred to the emergency room . Review of S11LPN's nurse's notes dated 04/30/2024 at 12:45 p.m. revealed that the resident returned from the emergency with a diagnosis of Urinary Tract Infection and a new order for the antibiotic, Cipro. Review of Resident #43's emergency room visit notes on 04/30/2024 revealed that the resident had a diagnosis of UTI (Urinary Tract Infection) and discharged with an order for Ciprofloxacin (antibiotic). Resident #77: A review of resident #77's medical record revealed a Urine Culture and Sensitivity was collected on 04/30/2024. The final microbiology report issued on 05/03/2024 revealed that Enteroccocus faecalis was present in the resident's urine. Review of S12LPN's nurse's dated 05/05/2024 at 5:15 p.m. revealed that the physician was notified with no new orders at that time related to the resident being in the hospital. On 05/21/2024 at 01:10 p.m., an interview was conducted with S3ADON (Infection Preventionist.) S3ADON stated that the floor nurses were responsible for obtaining the culture results. She stated that the QA (Quality Assurance) Nurse or herself also attempts to call the lab for the results, but it may not be the day the results were issued. This would depend on which days her or the QA nurse worked. She stated that the facility has had difficulty with the laboratory sending final culture reports. She stated that someone at the facility usually has to call the lab and request the results. She confirmed that Resident #43's final urine (C&S) results from the urine sample collected on 04/23/2024, was not present in Resident #43's medical record. She also confirmed that there was no documentation the physician had been notified of the results and that no treatment was initiated for the urinary tract infection. She stated that final microbiology results should have been obtained by the facility, the physician should have been notified, and that an appropriate treatment should have been initiated for Resident #43's infection. She also confirmed that Resident #77's C & S final report on 05/03/2024 for the urine collected on 04/30/2024, was not reported to the physician until 05/05/2024 which was 2 days after the results were available. 2. Review of Resident #380's physician orders revealed an order date 04/10/2024 for Macrobid (brand name for Nitrofurantoin) 100mg capsule, give one capsule by mouth twice daily for seven days. A review of resident #380's medical record revealed a Urine Culture and Sensitivity was collected on 04/10/2024. The final microbiology report issued on 04/12/2024 revealed that Klebsiella pneumoniae ESBL (Extended Spectrum Beta-Lactamase) was present in the urine and that the organism was resistant to Nitrofurantoin (Macrobid). There was no documentation in the resident's record that the culture and sensitivity report was reported to the physician or that a change in treatment was initiated due to the bacteria being resistant to the antibiotic the resident had been prescribed for the treatment of the urinary tract infection. On 04/18/2024, Resident #380 was discharged to her home. On 05/21/2024 at 01:10 p.m., a continued interview with S3ADON (Infection Preventionist) confirmed that Resident #380's culture and sensitivity report of the urine, collected on 04/10/2024, was resulted on 04/12/2024. She confirmed the organism identified on the report was resistant to the antibiotic (Macrobid) ordered on 04/10/2024 for the resident's Urinary Tract Infection. She verified that that no documentation was present regarding the physician being notified of these results or that the treatment for the resident's urinary tract infection was changed. She verified that the physician should have been notified in a timelier manner of Resident #380's final microbiology results and that the treatment should have been changed to an appropriate antibiotic based on those results

Based on in record review and interviews, the facility failed to ensure ongoing communication and collaboration with the dialysis facility by failing to ensure dialysis communication forms were filled out completely for 1 (#66) resident sampled for dialysis. The deficient practice had the potential to affect 1 dialysis resident that resided in the facility. Findings: On 05/22/2024 at 2:27 p.m., a request was made for a facility policy for dialysis communication. No policy was provided by the time of survey completion and exit. A review of Resident #66's EMR (Electronic Medical Record) revealed an admitted [DATE] with diagnoses that included End Stage Renal Disease, Essential Hypertension, and Type 2 Diabetes Mellitus. A review of Resident #66's Physician's Orders from May 2024 revealed an order with a start date of 01/26/2024 that read; Hemodialysis at dialysis center on Tuesday, Thursday, Saturday. Send communication form on all visits. A review of Resident #66's dialysis communication forms revealed a total of 39 sheets with date ranges from 02/01/2024 through 05/18/2024 that contained incomplete documentation. Missing information included: blood pressure, pulse, respirations, temperature, date, time, medications administered, time of last meal, diet, fluid restriction, fluid restriction amount, significant alerts, and facility nurse name and signature. On 05/22/2024 at 11:49 a.m., a concurrent record review and interview was conducted with S6LPN (Licensed Practical Nurse). She confirmed that the nurses are to fill out the dialysis communication form completely prior to the resident leaving for dialysis treatment. S6LPN viewed Resident #66's dialysis communication forms and confirmed 39 communication forms were incomplete. On 05/22/2024 at 2:22 p.m., a concurrent record review and interview was conducted with S3ADON (Assistant Director of Nurses). S3ADON confirmed the nurses are to fill out the dialysis communication form completely prior to the resident leaving for dialysis treatment. S3ADON viewed resident #66's dialysis communication forms and confirmed that 39 forms were incomplete.

Based on observations, record reviews, and interviews, the facility failed to ensure recipes for pureed, chopped, and bite sized meals were used during meal preparation. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for 1 (#26) resident who received pureed meals, 6 residents ( #16, #19, #29, #32, #49 and #65) who received mechanical chopped meals, and 13 residents (#2, #4, #5, #7, #23, #28, #30, #42, #46, #58, #68, #69, and #71) who received bite sized meals. Findings: On 05/20/2024, a review of the facility's policy and procedure titled, Therapeutic Diets, with a reviewed date of 08/02/2023 revealed in part: .7. Residents on therapeutic diets will not receive extra or reduced portions or modifications that are not part of the diet, unless approved by the Attending Physician in conjunction with the Clinical Dietitian . Review of the facility's dinner menu for pureed, mechanical chopped and bite sized meals on 05/20/2024 revealed hamburger steak with gravy. Review of the facility's week 3 day 2 recipe for Hamburger Steak with Onion Gravy 3 oz (ounce) revealed: 15 servings of Ground Beef Patty (4 oz) = 15 each Salt= 1 teaspoon Spice pepper black= 1 teaspoon Season patties. Place patties on pan Yellow onions, sliced= 2 3/4 cup Brown gravy (mix)= 2 oz Chop onions. Place in pan. Smother meat in gravy and onions. Cover pan. Bake. Notes: 1. For ground or chopped menu items, grind or chop food to appropriate consistency. 2. Soft and Bite Sized: All food pieces must be less than or equal to 15 MM (Millimeters) x 15 MM in size. Note: 4 oz portion should yield 3 oz actual meat/protein. Review of the pureed recipe for Hamburger steak with onion gravy revealed: 1. Prepare according to regular recipe Stock beef/soup base conversion= 1/4 cup and 2 tablespoon Food thickener bulk= 2 and 1/4 teaspoon 2. Prepare slurry. 3. Process until smooth adding 1 oz slurry per portion. On 05/20/2024 at 1:36 p.m., S9KS (Kitchen Staff) was observed preparing pureed hamburger steak with onion gravy for one resident who received pureed meals. She added two whole cooked hamburger patties in the food processor and added an unmeasured amount of beef broth and stated usually just eyeball it when asked how much liquid was required. S9KS then blended the mixture, added an unmeasured amount of beef broth, blended the mixture, then added thickener straight from the container by sprinkling an unmeasured amount to the mixture, blended it, and then sprinkled more thickener to the mixture and blended it again. S8DM (Dietary Manager) was present during the preparation and had observed the finished texture. S8DM approved the texture. There was no recipe used. On 05/20/2024 at 1:48 p.m., S9KS was observed preparing the chopped hamburger steak by adding nine cooked hamburger patties with cooked onions in the food processor. S9KS then poured an unmeasured amount of beef broth into the food processor and blended the mixture to a chopped consistency. S9KS then added then blended mixture to a metal dish. S8DM was then observed adding an unmeasured amount of beef broth to the blended mixture and stirred the mixture. On 05/20/2024 at 1:51 p.m., S9KS was observed placing five cooked hamburger patties with cooked onions in the food processor. S9KS then blended the mixture, added an unmeasured amount of beef broth, blended the mixture again, and then added the mixture to a metal dish. On 05/20/2024 at 1:53 p.m., S9KS was observed placing 4 four cooked hamburger patties in the food processor, added unmeasured amount of beef broth, blended and added to a metal dish and stored for dinner meal. On 05/20/2024 at 1:55 p.m., an observation was conducted of S9KS was preparing the bite sized meats. Fourteen cooked hamburger patties were used by cutting each patty into eight pieces. She stated she knew one large baking sheet fitted 15-17 patties which was enough for the residents who received bite sized and mechanical chopped meats. S9KS denied use of following recipes, she stated the kitchen did have the recipes but the S8DM had instructed her to not follow the recipes because we put our own spin on it and eyeball how much to use. On 05/20/2024 at 2:05 p.m., S8DM showed the surveyor the kitchen's binder of recipes for pureed, mechanical chopped and bite sized diets. S8DM confirmed the kitchen staff did not use the recipes.

Based on observation and interview, the facility failed to provide a homelike environment for 1 (#50) out of 3 (#44, #48, and #50) residents investigated for environment out of a total sample of 55 residents. Findings: Resident #50 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Hypertension, Heart Failure, and Hyperlipidemia. Review of Resident #50's Quarterly MDS (Minimum Data Set) dated 02/21/2024 revealed the Brief Interview for Mental Status (BIMS) of 15, suggesting his cognition was intact. Under Section GG: Functional Abilities and Goals revealed the resident utilized a wheelchair as his mobility device. On 05/20/2024 at 8:47 a.m., an observation was made of Resident #50's bathroom. There were multiple areas of paint scraped off of the wall on the left side of the toilet. Further observation revealed there were multiple areas of paint scraped off the wall near the shower. On 05/22/2024 at 8:43 a.m., a second observation was made of the resident's bathroom. The multiple areas of paint scraped off the wall on the left side of the toilet and shower were still present. Further observation of Resident #50's room revealed a sharp piece of metal trim sticking out approximately halfway off of the doorway trim. On 05/22/2024 at 8:55 a.m., an interview and observation of the resident's bathroom was conducted with S4MS (Maintenance Supervisor). He confirmed the findings of the multiple areas of paint scraped off of the wall on the left side of the toilet and near the shower wall. He also confirmed the sharp piece of metal sticking out of the doorway trim. S4MS stated it was unacceptable and should not be like that and the sharp piece of metal sticking out of the doorway trim had the potential to harm a resident. On 05/22/2024 at 9:05 a.m., an interview and observation of the resident's bathroom was conducted with S2DON (Director of Nursing). S2DON confirmed the findings of the multiple areas of paint scraped off the wall on the left side of the toilet and shower. She also confirmed the sharp piece of metal sticking out of the doorway trim. She confirmed it was unacceptable and had the potential to hurt Resident #50 who wheels himself in his room.

Based on observation, record review and interview the facility failed to ensure that cognitively impaired residents at risk for falls receives adequate supervision and assistance to prevent accidents by initiating new interventions to prevent falls for 2 (#4, #5) of 5 (#1, #2, #3, #4, #5) residents. This failed practice resulted in an actual harm for resident #4 when the resident fell and sustained an eye laceration, subdural hematoma, and left hip fracture on 1/10/15. The facility was aware of resident #4 ' s history of removing and disconnecting the bed/chair and bed pad alarms. This failed practice has continued in the facility knowing that Resident #5 can disable his chair alarm and fell on [DATE], 1/14/15 and 1/15/15 with facility staff continuing to replace the Chair/bed alarms. Findings: 1. Resident #4. Resident #4 is a [AGE] year old female admitted to the facility's dementia unit on 12/16/14 and discharged on [DATE]. Her [DIAGNOSES REDACTED]. A review of Resident #4's Minimum (MDS) data set [DATE] under Section C Cognitive Patterns revealed a Brief Interview Mental Status score of 4 which indicates severely impaired. A continued review under Section G Functional status revealed that Resident #4 required no physical help from staff for locomtion on and off the unit, one person physical assist for bed mobility and walking in room, and two+ persons physical assist for transfer and walk in corridor. Further review revealed she was coded as not steady but able to stabilize without staff assistance for the tasks of moving from seated to standing position, walking, turning around, moving on and off toilet and surface-to-surface transfer. A review of Resident #4's Assessment Risk for Falls dated 12/16/14 revealed a score of 3. Continued review of the fall assessment revealed 00-06 Resident is low risk. A review of Resident #4's care plan revealed that she was care planned to be at risk for falls/injury on 12/16/14 with a fall in resident's room on 12/22/14 and a fall in hallway on 1/10/15. Interventions included check resident every 2 hours, have call bell in reach and answer call in a timely manner, allow assistive devices as needed (walker, wheelchair), PT/OT evaluation and treament as indicated, keep hall/room free from clutter, keep areas lit as desires, avoid bumping skin, apply falling star with each new fall and with a fall in last 6 months. On 12/22/14 an intervention of bed pad alarm applied to resident's bed was added and on 1/10/15 the interventions of ensure bed alarm is attached and out of resident's reach, ensure alarm is in proper working condition, offer alternative activities when she appears restless at night (reading, conversation, TV, etc) and notify MD of excessive restlessness. A review of Resident #4's Resident Incident Report dated 12/22/14 at 1:45 am revealed: Narrative of incident and description of injuries: "Summoned to resident's room per CNA. CNA reports resident sitting on floor in bedroom door way." A review of Post-Incident Actions for Resident #4 dated 12/22/14 revealed: Immediate Post-Incident Action: Bed Alarm A review of Incident Investigation for Resident #4 dated 12/22/14 revealed: Narrative of investigation: "Upon investigation and speaking with resident and staff resident transferred from bed alone attempting to walk when she made it to the doorway of her room when she lost balance causing her to fall. Resident reported that she was going home. Intervention : bed alarm applied to bed." A review of the Resident Incident Report for Resident #4 prepared by S8LPN dated 1/10/15 at 11:00 pm revealed: Narrative of incident and description of injuries: " Was summoned to Alzheimer ' s unit per CNA. Resident noted on the floor in hallway. Resident was assessed. Deep laceration noted above left eyebrow. Pressure was applied, cleaned with normal saline and applied gauze. Resident also complaining of left hip pain. Resident removed alarm, got out of the bed without assistance, ambulated to hallway and fell on the floor, hitting the left side of head. Resident was then brought to her room and put in bed. " A Review of post incident actions dated 1/10/2015 revealed: Make sure alarm is attached when lying in bed.......... A review of incident investigation dated 1/10/15 and signed by S2ADON revealed: Narrative of investigation: " Upon investigation and speaking with staff, CNA on duty reports that she was in the alz (Alzheimer ' s) day room when she heard a loud noise. Upon exiting the dayroom and entering the hallway resident was noted laying on the floor with just a pajama top on right outside her room door. CNA reports she called out for help in which the nurse arrives to assess resident. Resident found with laceration above left eye brow and c/o left hip pain. CNA reports that she just left residents room a few minutes ago from assisting her to bed. Reports bed pad alarm was in place and functioning. After incident occurred staff re-entered room to assess bed pad alarm and found it disconnected...... Intervention: Ensure bed alarm is attached...." A review of Bed Sensor Pad user instructions under section titled Warning revealed: The UMP and Micro-Tech fall monitors and pressure pads can be defeated by a cognitively aware person, a person with only a few moments of lucidity or an uncooperative person. Properly assess each individual before the UMP or Micro-Tech fall monitors are used A review of UMP Model Monitor user guide under section titled Warnings revealed: ? The UMP fall monitor will not stop a person from leaving a bed, chair, wheelchair or room. It is intended only to alert a caregiver that a person may need assistance. Other interventions may still be required for some people. ? The UMP fall monitor and UMP pressure pads can be defeated by a cognitively aware person, a person with only a few moments of lucidity or an uncooperative person. Properly assess each individual before the UMP fall monitor is used. During an interview on 1/22/15 at 12:10 pm, S7CNA stated that she was assigned to Resident #4 during the night shift on 1/10/15. She reported that she received report from the off going nurse and noted that Resident #4 was in bed and sleeping when she began making her rounds. While she was walking down the hall to get a blood pressure cuff she heard Resident #4's bed alarm going off. S7CNA explained that the resident is confused so she showed her that is was night time so she would know that it was time to sleep. She then went to finish vital signs on other residents and then heard the alarm again and upon responding to the alarm she found Resident #4 in her recliner. She then put Resident #4 back in the bed and then went to the nurse ' s station. Shortly after that, she heard a noise and went to check it out at which time found Resident #4 on the floor. S7CNA explained that Resident #4 must have undone her bed alarm and she was on the floor. She stated that Resident #4 ' s bed alarm went off several times the night (1/10/15) because she was moving around not because she was pulling it off that night. She acknowledged that she had seen Resident #4 disconnect the alarm on at least 3 other occasions before 1/10/15 and that she had reported it verbally to oncoming shifts but had not documented it. A phone interview was conducted on 1/21/15 at 11:00 am with S8LPN. She stated that Resident #4 had set off the bed alarm a few times when she came on the night of 1/10/15 and that she had checked that the alarm was functioning at the beginning of her shift. Additionally, she stated the resident must have unplugged the alarm the night she fell . She acknowleged that Resident #4 had unplugged the alarm on other occasions before the 1/10/15 fall but that she had not reported it to anyone or documented that the resident was unplugging the alarm. 2. Resident #5. On 1/22/15 at 10:25 am, the resident was observed sitting down in his wheelchair in the activity room listening to gospel music. The resident was observed to have a chair alarm attached to the upper back of his wheelchair. Review of the resident ' s MDS (minimum data set) dated 10/28/14 revealed documentation that the resident ' s BIMS (brief interview for mental status) score was a 4 for being severely impaired. Also, the MDS dated [DATE] revealed that the resident required extensive assistance with 2 plus person assist for bed mobility, transfers, walking in the room and walking in the corridors. Review of the resident ' s Incident Report dated 11/13/14 at 9:50 pm revealed, " Summoned to res rm by CNA and find res on the floor on his buttocks next to his bed. Assess res for injuries and help aide put res in the bed. Ask res what happen. Res stated he was going to the restroom and he fell down. Res alarm was in place but res knows how to take alarm off. ........". Review of the resident ' s Incident Investigation dated 11/13/14 at 9:50 pm revealed, " Upon investigation and speaking with staff resident attempted to transfer from bed to bathroom alone without assistance. Resident alarms were noted in place but pad alarm turned and clip alarm laying on pillow. Resident reports that he takes it off so it don ' t make that loud noise ... ... " Review of the resident ' s Incident/Accident note dated 1/14/15 at 7:00 pm revealed, " Summoned to res rm by ward clerk and find res on the floor in fetal position. Ask res what happen. Res stated he was trying to get up and he fell . Res stated he did hit his head. Neuro checks initiated as a precaution ... ..... " There was no documentation that a chair or bed alarm was in use during the time of the fall. Review of the resident ' s Incident/Accident note dated 1/15/15 at 8:45 pm revealed, " Nurse coming back up hallway with med cart and CNA called nurse to room. Upon approaching room nurse and CNA found resident on floor on side of bed in front of recliner with bed/chair alarm in hand in resident ' s room. Nurse asked resident where he was going. Resident stated ' I was going home ' ." On 1/22/15 at 10:30 am, S5CNA (certified nursing assistant) stated that the resident does have falls and that his falls usually occur when he has removed the chair alarm. S5CNA stated that she attaches the chair alarm in the back of the resident ' s wheelchair where he cannot reach it. On 1/22/15 at 11:05 am, S3LPN (licences practical nurse) stated that the resident has had falls. S3LPN stated that a bed and chair alarm is used to monitor the resident when he is getting up out of his bed or wheelchair without assistance. S3LPN stated that the resident was capable of removing the alarms to where when he would get up the alarm was not in place to alert the staff when he was getting up without assistance. S3LPN confirmed that she did not document if the bed/chair alarm was in place and if the alarm was going off for the resident's fall that occurred on 1/14/15. On 1/22/15 at 11:15 am, S2ADON (assistant director of nurses) stated that the resident was able to remove the bed/chair alarm. Also, S2ADON confirmed that the resident did have falls that occurred when the resident had removed the bed/chair alarm. S2ADON confirmed that the bed/chair alarm was still in use as an intervention to prevent the resident from getting up without assistance. On 1/22/15 at 11:20 am, S1DON (director of nurses) stated that the resident was able to remove the bed/chair alarm. Also, S1DON confirmed that the resident did have falls that occurred when the resident had removed the bed/chair alarm. S1DON confirmed that the bed/chair alarm was still in use as an intervention to prevent the resident from getting up without assistance. On 1/22/15 at 11:35 am, S4LPN stated that the fall that occurred on 1/15/15 the resident was found on the floor. S4LPN stated that the resident ' s bed/chair alarm was removed and was in the resident ' s hand when he was found on the floor on 1/15/15.

Based on record review and interview the facility failed to provide sufficient fluid intake to maintain proper hydration and health for 1 (# 54) of 4 (#53,#54,#89,#144) residents reviewed for hydration out 4 residents who triggered for Hydration in the QCLI Results. The facility failed to: 1. follow the Registered Dietitian's recommendation to ensure Resident #54 received at leasr 2550 cc of fluids per day; 2. identify new interventions to ensure Resident #54 received the recommended amount of fluids every day after returning from the hospital with a [DIAGNOSES REDACTED]. 3. have a system of clinical monitoring and supervision to ensure Resident #54 was receiving his recommended daily fluid requriements; 4. identify new interventions and implement clinical monitoring to ensure resident #54 received the recommended amount of fliuds every day after returning from the hospital with a [DIAGNOSES REDACTED]. 5. have a system in place to ensure staff identified new care plan interventions to ensure Resident #54 received the recommended amount of fluid every day. An Immediate Jeopardy situation began on 1/24/13 when this Resident (#54), returned from the hospital with a [DIAGNOSES REDACTED]. The Immediate Jeopardy ended on 2/18/13 when the resident was discharged from the facility. Scope and severity remains at level 2. Findings: Resident #54: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified the resident as moderately impaired with his vision and was scored as a 0 out of a possible 15 for a BIMS indicating the resident's mental status was severely impaired. The MDS further scored the resident as a "2" under section C1300 indicating the resident had inattention difficulties identifying the resident to be easily distracted, out of touch or having difficulty following what was said. The assessment did not indicate the resident refused care. The resident's admission contracture risk assessment dated [DATE] scored the resident as a "2" under upper extremities which indicated the resident had very limited use of his upper extremities. A review of Nurse's notes in November 2012 identified on 11/11/12 the resident required maximum care for ADL ' s. Documentation on 11/13/12, 11/17/12, 11/18/12 and 11/19/12 read " fed per staff. " During an interview with S12CNA at 5:00 p.m. on 2/19/13 she stated the resident needed someone to help him get a cup to his mouth. During an interview with S11 CNA on 2/20/13 at 9:40 a.m. she stated resident #54 could not hold a cup. She stated he would spill it all over himself because he shook. During an interview with S13LPN on 2/20/13 at 3:15 p.m. she stated resident #54 could not do anything for himself and that is how he had always been. She stated he could not hold a cup because he would have dropped it. She stated his hands shook. She further stated resident #54 was not on any fluid restrictions. During an interview with S14CNA on 2/20/13 at 4:30 p.m. she stated the resident could not do anything for himself. She stated the resident had a squirt bottle but he could not pick up the bottle without staff assistance. The Medical Nutrition Therapy assessment dated [DATE] signed by S33RD identified resident #54 required a minimum of 2550 ccs of fluids daily. The monthly intake and output flow sheets for 11/26/12 - 2/17/13 were reviewed. From 11/26/12 - 1/16/13 the resident received an average of 1758 ccs /day which was 792 ccs/day less than the RD recommendations. The resident was hospitalized from [DATE] - 1/24/13 with a [DIAGNOSES REDACTED]. The resident was again hosptalized on [DATE] with a [DIAGNOSES REDACTED].The resident returned to the facility on [DATE], continued to receive less than the recommended 2550 ccs of fluid until he was discharged from the facility on 2/18/13. Further review of resident #54's Nurse's Notes indicated the resident was sent to the hospital on [DATE] at 3:50 p.m. The notes further read at 7:00 p.m. - resident admitted with [DIAGNOSES REDACTED]. A review of the hospital physician documentation dated 1/16/13 at 22:39 read: [DIAGNOSES REDACTED]. The Nurse's Notes dated 2/7/13 at 10:45 a.m. indicated resident #54 was difficult to arouse and was sent to the emergency room at 10:55 a.m. The notes read at 2:30 p.m. the resident was admitted to the hospital with [REDACTED]. The hospital history and physical dated 2/8/13 was reviewed. It read: "he has not been eating or drinking well at the nursing home. He comes in extremely dehydrated. " The lab chemistries dated 2/8/13 had critical labs of Sodium at 160 (normal 136-145), Chloride at 121 (normal 98 - 107), Creatinine at 3.8 (normal 0.6 - 1.3). The BUN was also elevated at 106 (normal 7 - 18), and Potassium 5.5 (normal 3.5 - 5.1). These labs are used as indicators of hydration status. The resident's Care Plan was reviewed. The care plan did not indicate a problem of the resident refusing care. The care plan included a self-care deficit upon admission on page 15 but did not address which ADL's the resident required assistance. On page 3 it identified a risk for dehydration on admission. Interventions included encourage adequate fluid intake, I &O record, observe for s/s of fluid excess or depletion and report significant findings. The care plan did not identify the 2550 cc fluid recommendations of the RD. Upon return from the hospital on [DATE] with a [DIAGNOSES REDACTED]. There were no interventions added to the care plan until 2/11/13 following the resident's 2nd return from the hospital with a [DIAGNOSES REDACTED]. During an interview with S1DON on 2/21/13 at 2:40 p.m. she confirmed resident #54 required at least 2550 ccs of fluid daily according to the RD's assessment and recommendations dated 11/26/12. S1 reviewed the intake and output flow sheets and further confirmed the resident had not received at least 2550 ccs of fluid on any of the days the resident was in the facility between 11/26/12 and 2/17/12 except on 12/2/12. S1 was asked to identify where in the care plan new interventions were put in place to assure resident #54 was getting adequate fluid intake to prevent further episodes of dehydration following either hospitalization for dehydration. She verified the Care Plan read to continue to encourage fluids which was put in place when the resident was identified as at risk for dehydration at admission. She confirmed the care plan did not address any new interventions related to the resident ' s [DIAGNOSES REDACTED].

A. Based on observation, record review and interview, the facility failed to maintain a safe environment for residents identified as being at risk due to unsafe smoking. resident (#87). The facility failed to do a complete and accurate assessment of the cigarette burn, failed to identify this resident as needing constant supervision, and failed to provide the supervision this resident needed when smoking. This deficient practice has the potential to effect 9 (#25, #27, #58, #63, #68, #76, #86, #87, #113) residents who were identified by the facility as being smokers. Record review and interview also identified resident #76 as having an inaccurate smoking assessment. Findings: 1. Resident #87: During an observation and interview on 2-19-13 at 9:35 a.m., a round sore that looked like a cigarette burn that was the size of a pencil eraser was observed on this resident's right finger located next to the little finger. During an interview with this resident ,who was in her bedroom, she stated the area was from a cigarette burn and had happened about a month ago. She was asked if staff went with her to smoke and she stated, "no, not now". During another observation on 2-19-13 at 11:50 a.m., the resident was sitting on the patio located by the dining room. She was smoking a cigarette and the only person with her was another resident, #66, who was also smoking. A record review revealed a smoking assessment dated [DATE]. This resident was assessed as being unable to demonstrate safe technique for putting out matches, lighters or disposing of ash. She was also assessed as being unable to remain alert during the course of smoking. Under the portion of the assessment, IDT Determination, the determination was that this resident was an unsafe smoker and that she required frequent supervision every 30 minutes to 1 hour. A review of another smoking assessment dated [DATE], 10 days earlier, showed the resident was assessed as being unable to demonstrate safe technique for putting out matches, lighters or disposing of ash. She was also assessed as being unable to remain alert during the course of smoking. The assessment had not changed from 2-8-13 until 2-18-13 when the resident was reassessed, however on 2-8-13, the resident was determined to be an unsafe smoker with constant supervision (every 30 minutes to an hour). Further review showed smoking assessments dated 12-7-12, 11-13-12,8-9-12, 5-25-12. The smoking assessments for these dates showed the resident was assessed as being unable to demonstrate safe technique for putting out matches, lighters or disposing of ash. She was also assessed as being unable to remain alert during the course of smoking and the degree of supervision was determined to be frequent. Review of an assessment dated 5-11-12 showed this resident was assessed as being a safe smoker with no supervision required. All of the smoking assessments from 5-25-12 through 2-18-13 were signed as being done by S5SSD. During an interview on 2-19-13 at 4:25 p.m. with S1DON, she stated this resident use to be safe but had been getting some burns. She was asked for incident reports in regards to the burns and provided one incident report dated 9-27-12 in which a CNA summoned a nurse to see an area on her upper abdomen that the resident stated was from a burn that occurred 2 weeks prior to this incident report dated 9-27-12.. During an interview on 2-19-13 at 4:17 p.m., with S5SSD, she was asked why the supervision had changed from constant on 2-8-13 to frequent on 2-18-13 even though the resident had been assessed as having the same unsafe factors and she stated that S1DON told her that this resident wanted to try smoking without constant supervision. She was asked what had changed from the last assessment to this assessment to make this resident safer and she did not provide an answer. During an interview 2-19-13 at 4:25 p.m. with S1DON, she was asked who does actual observations for safe smoking. She did not provide an answer but stated this resident had been getting some burns. She stated she was changed from constant supervision to frequent supervision because she had not had any burns recently. She was asked if she was aware this resident had a cigarette burn on her at this time and she stated, no. At this time, S1DON and S5SSD were asked who did assessments. S5SSD said that she was the designated person to do the smoking assessments, however, she did it with input from others. She stated that part of the assessment could be based on the resident's BIMS score. She was again asked how she determined this resident was safer to smoke with frequent supervision rather than constant supervision as she was assessed as needing on 2-8-13 and she stated the resident was safer now because she had less burns. Policies were requested from S1 DON . A review of skin assessments dated 2-5-12 and 2-17-13 did not show a burn on the resident's finger. A review of the current Treatment Record did not show a treatment for [REDACTED]. A review of the Wound/Skin Management Documentation Record for this resident from November, 2013 until present did not show that an area had been identified as a cigarette burn on any of the fingers of the right hand and a review of the Weekly Skin Reports for January and February, 2013 did not show a cigarette burn had been identified. A review of nurses ' notes did not show the cigarette burn had been identified. A review of the incident log did not reveal any incidents in regards to this resident having a cigarette burn other than the burn on 9-27-12 documented on an incident report and provided by the facility. A review of the current MDS dated [DATE] showed this resident had a BIMS score of 15, indicating that the resident was able to answer all of the cognition question correctly. A review of the policy provided by S1DON did not show the policy contained any documentation as to when residents were to be assessed for smoking and did not have any information as to what called for the appropriate supervision if the resident was deemed an unsafe smoker. S1DON confirmed during an interview on 2-20-13 at 9:35 a.m. that the only policy the facility had on smoking was The Smokers Agreement. During an interview on 2-19-13 at 3:55 p.m. with S5SSD, a request was made for a list of smokers who reside in the facility. On 2-19-13 at 4:10 p.m., S5SSD provided a list of smokers, safe/unsafe. The list had 5 unsafe smokers. During an interview at this time, S1DON stated no other residents have had burns or accidents with cigarettes. During an interview on 2-20-13 at 8:25 a.m. with S22LPN/ Tx Nurse, she was asked what skin conditions this resident had at this time and she stated the resident had the following: Buttock area - stage II pressure sore - right leg - trauma area where resident hit it on table - venous ulcers right proximal LE- She also stated the resident had a cigarette burn to her 2nd right finger. She stated the resident had had the burn for 2-3 weeks and that she was treating it with Bactroban. During an interview on 2-20-13 at 7:40 a.m. with S22LPN/ TX Nurse, she provided the current TARS and treatment notes. She reviewed the TARS and notes and was unable to find where the burn to the finger located next to the small finger was documented as having a cigarette burn. She stated she had been putting Bactroban on it. A review of physician's orders [REDACTED]. During an interview on 2-20-13 at 8:50 a.m. with S1DON, she was asked what frequent and constant meant for supervision of smokers. She stated she would have to check for more policies, however, she failed to provide more policies.. A review of the careplan showed a problem in which this resident was at risk for injury/falls asleep while smoking. The goal was for this resident to be able to safely smoke and the approach was to assess as safe or unsafe smoker and for the smoker to follow the smokers agreement. The careplan called for the resident to have constant observation that had been changed on 2-18-13 to frequent, however, showed nothing explaining why frequent supervision was more appropriate than constant supervision. A review of SSD notes showed that on 5-24-12, S5SSD noticed the resident was outside, holding a cigarette in her hand, the cigarette was lit and the resident was asleep. A safe smoking assessment was done on 5-25-12 and showed the smoker to be unsafe. The assessment called for the resident to have frequent supervision (every 30 minutes), even though S5SSD had observed the resident with a lit cigarette in her hand while she was asleep. An SSD note dated 5-28-12 showed that the resident was made aware that she had to be monitored and encouraged to wear a safety apron while smoking. The documentation showed that the resident refused and that the safety apron would continued to be offered. SSD notes on 12-7-12 documented that the resident was left unattended smoking outside through the night. This resident smokes frequently and staff made attempts to monitor but not consistently as recommended. Notes on 2-18-13 documented that the resident continued to be deemed an unsafe smoker but level of supervision would be frequent (every 30 minutes). Resident has exhibited a level of improved compliance with smoking not requiring constant supervision, however, the assessment on 2-18-13 assessed the resident as unable to demonstrate safe technique for putting out matches, lighters or disposing of ash. She was also assessed as being unable to remain alert during the course of smoking. 2. Resident #76: The Smoking assessments of 12/19/12, 9/19/12 and 6/19/12 had resident #76 checked as an unsafe smoker. The degree of supervision was checked as occasional on the assessments of 9/19/12 and 12/19/12. There was no degree of supervision checked on the assessment of 6/19/12. The assessment further read if the resident is determined to be an unsafe smoker and the resident is required to wear a protective smoking apron and/or direct observation by caregivers. None of the assessments reviewed indicated whether or not the resident required a smoking apron/vest when smoking. The resident was currently in the hospital, and was not present in the facility during the survey. The surveyor accompanied S2RN, QA into resident #76 ' s room on 2/20/13 at 9:15 a.m. and visualized the resident's clothing. Five shirts and three pairs of pants were identified with cigarette burn holes. The holes were identified by S2RN as cigarette burns and confirmed the clothing belonged to resident #76 as the resident's name was in the clothing. The resident's Care Plan was reviewed. Unsafe smoker was checked as a problem and dated 2/15/12. It read: " If deemed an unsafe smoker, the resident is required to wear a protective smoking vest/apron and/or direct observation by care givers. It read further - direct observation while smoking - occasional. It was marked out that resident is to wear an apron and had NA written next to this area. The document titled smokers agreement identified as the facility's smoking policy by S1DON was reviewed and read nurses will ensure that the smoking apron is worn by all unsafe smokers who need to wear one ... During an interview with S19LPN on 2/20/13 at 9:30 a.m. she stated she thought the resident wore a smoker's apron and was not sure if he needed someone with him all the time while smoking. She stated this information would be identified in the CNAs care plan binder. During an interview with S11CNA on 2/20/13 at 9:40 a.m. she directed the surveyor to the CNA care Plan binder and confirmed the care plan for resident #76 indicated he was an unsafe smoker and the area for wearing an apron was marked through reading that he did not need a smoking apron. She stated she thought he wore an apron. B. Based on interview and record review the facility failed to assure 1 (#54) out of 7 (#27,#31,#54,#76,#87,#123,#126) residents reviewed for accidents was free from accident hazards. Resident #54 suffered actual harm when he required total assistance with feeding, was left unsupervised in his room drinking hot coffee and sustained a third degree burn to his left inner thigh due to spilling hot coffee causing a scald. Resident #54: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an incident reporting form dated 11/20/12 read resident #54 had " wasted " his hot coffee on his left inner thigh. The report further read: " CNA should remain c resident when drinking hot liquid. " The resident's admission contracture risk assessment dated [DATE] scored the resident as a " 2 " under upper extremities which indicated the resident had very limited use of his upper extremities. The resident ' s admission nutritional risk assessment dated [DATE] scored the resident as a " 2 " for meals assistance needed which indicated the resident required " total assist " for meals. The admission MDS dated [DATE] identified the resident as moderately impaired with his vision and was scored as a 0 out of a possible 15 for a BIMS indicating the resident's mental status was severely impaired. The MDS further scored the resident as a " 2 " under section C1300A. indicating the resident had inattention difficulties identifying the resident to be easily distracted, out of touch or having difficulty following what was said. The Personal Care Record documenting CNA care read on 11/20/12 the resident was coded a 1/4 which indicated he ate in the dining room and required assistance. The CNA Care Plan dated 11/9/12 read under eating : (feeder) - Yes; requires assistance of 1 person. The resident's comprehensive Care Plan identified the resident as at risk for falls and injury upon admission on page 8. The interventions included fall prevention but did not address other potential accident hazards for the resident. The care plan included a self-care deficit upon admission on page 15 but did not address which ADL's the resident required assistance. The care plan identified the left inner thigh/burn and blistering on page 4. The approaches did not indicate any interventions to prevent further burn accidents with the resident. A review of Nurse's notes in November 2012 identified on 11/11/12 the resident required maximum care for ADL's. Documentation on 11/13/12, 11/17/12, 11/18/12 and 11/19/12 read " fed per staff. " The note dated 11/20/12 at 7:00 a.m. read Summons to Resident's room per CNA. Resident wasted his coffee (hot) on his lt. inner thigh. Redness noted to inner leg. The notes read at 11:15 am - left inner thigh was blistering from coffee he spilled on self this am. During an interview with S12CNA at 5:00 p.m. on 2/19/13 she stated the resident needed someone to help him get a cup to his mouth. She stated he spilled a lot from his cup because his hands shook. During an interview with S11 CNA on 2/20/13 at 9:40 a.m. she stated resident #54 had to be fed by the restorative aid in the dining room or if he ate in his room he had to be fed by staff. She stated he could not hold a cup or a fork. She stated he would try but he would spill it all over himself because he shook. During an interview with S13LPN on 2/20/13 at 3:15 p.m. she stated he could not do anything for himself and that is how he had always been. She stated he was fed by staff in the dining room and he could not hold a cup because he would have dropped it. She stated his hands shook. During an interview with S14CNA on 2/20/13 at 4:30 p.m. she stated the resident could not do anything for himself, needed to be fed, and never could feed himself since being admitted . S14 stated he could not hold a cup because he would spill it or drop it on himself. During an interview with S2RN, QA on 2/21/13 at 11:00 a.m. she stated any staff member should remain in room with resident when the resident was drinking a hot substance. S2 confirmed the CNA was not in the room with the resident at the time of the accident and further stated the CNA should have been in the room. An interview was conducted with S15, Dietary Manager on 2/21/13 at 1:20 p.m. She stated since admission resident #54 ate in the dining room and was not able to feed himself. She confirmed the resident could not hold a cup without assistance. She stated he shook a lot and when he tried to bring a cup or fork to his mouth he would not get it to his mouth and spilled it on himself. The resident's care plan was reviewed with S1DON on 2/21/13 at 2:45 p.m. An interview was conducted at this time with S1. She confirmed resident #54 was coded as requiring total assistance for meals according to the nutritional risk assessment done on 11/9/12. When S1 was asked to locate in the resident ' s care plan interventions put in place to protect the resident from further burns after the resident spilled hot coffee on himself she stated there were none in the Care Plan.

Based on observation, interview and record review the facility failed to assure staff followed the Plans of Care by failing to: 1. Provide sufficient fluids to 1 (#54) resident out of 4 (#53, #54, #89, #144) residents reviewed for hydration and Plan of Care. Resident #54 sustained actual harm when he did not receive the amount of fluids recommended by the RD, and was hospitalized on 2 separate occasions for dehydration; 2. Provide finger nail care for a resident who was unable to carry out activities of daily living to maintain grooming, and personal hygiene for 1 (# 11) resident out of 3 (#1, #11, #119) residents looked at for Activities of Daily Living out of 8 residents who triggered for this care area on the QCLI Results; 3. Hang a catheter bag to gravity for 1 (#23) resident out of 2 (#1, #23) residents looked at for catheter use and, failed to assure 1 (#23) resident received eye exams as needed out of 3 (#23, #60, #84) residents looked at for lack of corrective action for vision problems out of 30 residents who triggered in the QCLI Results for this problem; and 4. Check the shunt on 1 (#148) resident who required [MEDICAL TREATMENT] out of 2 residents who required [MEDICAL TREATMENT], according to a list provided by the facility. This deficient practice has the potential to affect a total of 118 residents residing in the facility. Findings: 1. Resident #54: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident #54's Nurse's notes indicated the resident was sent to the hospital on [DATE] at 3:50 p.m. The notes further read at 7:00 p.m. - resident admitted with [DIAGNOSES REDACTED]. A review of the hospital physician documentation dated 1/16/13 at 22:39 read: [DIAGNOSES REDACTED]. A review of the Nurse's notes dated 2/7/13 at 10:45 a.m. indicated resident #54 was difficult to arouse and was sent to the emergency room at 10:55 a.m. The notes read at 2:30 p.m. the resident was admitted to the hospital with [REDACTED]. The hospital history and physical dated 2/8/13 was reviewed. It read: "he has not been eating or drinking well at the nursing home. He comes in extremely dehydrated. " The lab chemistries dated 2/8/13 had critical labs of Sodium at 160 (normal 136-145), Chloride at 121 (normal 98 - 107), Creatinine at 3.8 (normal 0.6 - 1.3). The BUN was also elevated at 106 (normal 7 - 18), and Potassium 5.5 (normal 3.5 - 5.1). These labs are used as indicators of hydration status. The Medical Nutrition Therapy assessment dated [DATE] signed by S33RD identified resident #54 required a minimum of 2550 ccs of fluids daily. The monthly intake and output flow sheets for 11/26/12 - 2/17/13 were reviewed. From 11/26/12 - 1/16/13 the resident received an average of 1758 ccs /day which was 792 ccs/day less than the RD recommendations. The resident was hospitalized from [DATE] - 1/24/13 with a [DIAGNOSES REDACTED]. The resident was again hosptalized on [DATE] with a [DIAGNOSES REDACTED].The resident returned to the facilty on 2/11/13, continued to receive less than the recommended 2550 ccs of fluid until he was discharged from the facility on 2/18/13. During an interview with S1DON on 2/21/13 at 2:40 p.m. she confirmed resident #54 required at least 2550 ccs of fluid daily according to the RD ' s assessment and recommendations dated 11/26/12. S1 reviewed the intake and output flow sheets and further confirmed the resident had not received at least 2550 ccs of fluid on any of the days the resident was in the facility between 11/26/12 and 2/17/12 except on 12/2/12. 2. Resident #11 is a [AGE] year old resident who was admitted to the nursing home on 8/30/05. The resident has [DIAGNOSES REDACTED]. On 02/19/2013 at 9:07 a.m., during an interview with the resident, it was noted that her fingernails needed to be cut. The resident stated that she had to call the nurse to do her nails even though she is not a diabetic. She stated that this was her choice. Review of the physician's orders [REDACTED]. The Care Plan was reviewed on 2/21/13 and a problem dated 9/27/2005 read [MEDICAL CONDITION]/Independent with most ADL's; may need assistance /supervision with walking, locomotion, dressing, personal hygiene, toileting, and bathing. Approaches included "Keep nails clean and trimmed/encourage compliance". Personal Care Records, used by the CNA's to document care, for the months of November 2012, December 2012, January 2013, and February 2013 were reviewed, and revealed fingernail care requiring Total Help was initialed on everyday of the week for all three shifts. The Treatment Records for November 2012 through February 2013 were reviewed, and documentation for Nail Care Q 2 weeks/CNA Monitor Compliance was reviewed. On the November document there was documentation on the 8th, on December document there was documentation on the 1st and 2nd, and on January 2013 there was documentation on the 19th. No documentation was present on the February record, through the 21st. The resident was interviewed on 2/21/13 and she stated that she had her own nail clippers and had been doing her own nail care, until she applied nail polish for the first time, at which time, she could no longer cut her own nails, as they were too hard. Resident #11 added that limitations of motion in her right hand made it too hard to do her own nail care, and since then, the nurse, and only the nurse, cut her nails. On 2/21/13 at 2:35 PM S 34 CNA Whirlpool Aide stated that she was the whirlpool aide, and if the resident's nails needed to be cut, she would cut them. The Whirlpool Aide added that she reported that to the CNA's on the floor. The S22 Treatment Nurse was interviewed on 2/21/13 at 2:40 p.m. She stated that she was the Treatment Nurse, and she documented that the CNA's were compliant with nail care, that the CNA's did the nail care for the resident. S22 Treatment Nurse added, that at times a nurse may do the nail care. If there was no documentation that the CNA's had done the nail care, then she may not have gotten the info from the CNA's. 3. Resident #23: During an interview on 2-18-13 at 12:05 p.m. S35, she was questioned if this resident had an indwelling Foley catheter, and she stated, "yes". During an observation on 2-21-13 at 9:00 a.m., this resident was seated in her geri chair in the activity room. The catheter tubing could be seen running along the side of the resident and then under the blanket, covering the resident whose feet were on the footrest. During an observation on 2-21-13 at 9:30 a.m., the resident was still in the activity room in her geri-chair, foot rest up and Foley catheter tubing running along the side of the resident and under the blanket, which covered the lower portion of the resident. During another observation on 2-21-13 at 10:00 a.m., the resident was still in the geri-chair with the catheter tubing in the same position. A review of the careplan showed to keep the catheter bag below the level of the bladder. A review of the current physician's orders [REDACTED]. During an interview on 2-21-13 at 9:35 a.m. with S26CNA, she stated she had to do everything for the resident. She stated the only thing the resident could do was hold a glass and drink sometimes. She stated she emptied the Foley bag at each shift. During an interview and observation of the resident on 2-21-13 at 10:00 with staff #S13LPN, she stated the Foley catheter was supposed to be hung to gravity. She proceeded to remove the Foley bag which was in between the resident's leg and hung it on the lower right side of the chair. Resident #23: During an interview on 2-21-13 at 9:35 a.m. with staff #S26CNA, she stated this resident doesn't wear eyeglasses. A review of the careplan showed a problem impaired vision, does wear eyeglasses. The goal was to maintain current visual status. The approaches were to keep room well lit during daytime hours, keep call light within reach at all times, monitor for decline in visual status and report to MD and to provide transport to eye exams as needed. During interview on 2-21-13 at 11:05 a.m. with S13LPN, she stated she did not recall this resident wearing glasses. She looked in the resident's room in the drawers and did not find glasses. During an interview on 2-21-13 at 12:20 p.m. with S6SSD Assistant, she stated she does not assess residents for vision. During an interview on 2-21-13 at 1:25 p.m. with staff #S30MDS, she stated she had spoken to the family, and the family stated they took the eyeglasses because the resident had an eye exam, and the doctor said she needed new glasses, adding that the resident's insurance would not pay for the glasses. She stated the resident's last exam was 2007, 6 years ago. A record review showed this resident had [DIAGNOSES REDACTED]. 4. Resident #148: A review of the careplan showed [MEDICAL TREATMENT] shunt site to the left arm. The shunt was to be checked every shift. During an interview on 2-20-13 at 3:00 p.m. with staff #S19LPN, she stated this was her first day working with the resident. She stated when the resident got back from [MEDICAL TREATMENT], she was going to check the shunt and do vital signs. A record review revealed this resident was admitted to the facility on [DATE]. A review of the current MARS for January and February, 2013 did not show a space for checking the shunt. During an interview on 2-20-13 with S23LPN, she stated that documentation for checking the shunt was documented on the TAR. A review of the February TAR did not show that the shunt was being assessed on each shift. This was confirmed by S23LPN. A review of the nurses' notes for February, 2013 showed the shunt was assessed on 2-20-13, not on any other days. A review of the [MEDICAL TREATMENT] communication records show the resident went to [MEDICAL TREATMENT] on 2-18-13, 2-15-13, 2-13-13, 2-11-13, 2-8-13, 2-6-13 and 2-4-13. Surveyor: Dixon, Caroline

Based on record review, observation and interview, the Administration failed to ensure the facility was managed in a manner that uses resources effectively and efficiently by failing to: 1. maintain a safe environment for resident for 1 (Resident #87) out of 9(#25, #27, #58, #63, #68, #76, #86, #87) residents identified as being at risk due to unsafe smoking by failing to: 1. ensure residents identified as unsafe smokers were supervised during smoking to pervent burn injuries; 2. have a system to ensure accurate assessments of residents' ability to smoke unsupervised; 3. ensureaccurate skin assessments were conducted to identify cigarette burn injuries. and 2. provide sufficient fluid intake to maintain proper hydration and health for 1 (# 54) of 4 (#53,#54,#89,#144) residents reviewed for hydration out 4 residents who triggered for Hydration in the QCLI Results. The facility failed to: 1.ensure staff identified and implemented new interventions to ensure Resident #54 received the recommended amount of fluids per day to prevent dehydration after returning from the hospital with a [DIAGNOSES REDACTED]. 2. have a system of clinical monitoring and supervision to ensure Resident #54 was receiving his recommended daily fluid requriements; Findings: 1. Resident #87: During an observation and interview on 2-19-13 at 9:35 a.m., a round sore that looked like a cigarette burn and was the size of a pencil eraser was observed on this resident's right finger located next to the little finger. During an interview with this resident ,who was in her bedroom, she stated the area was from a cigarette burn and had happened about a month ago. She was asked if staff went with her to smoke and she stated, "no, not now". During another observation on 2-19-13 at 11:50 a.m., the resident was sitting on the patio located by the dining room. She was smoking a cigarette and the only person with her was another resident, #66, who was also smoking. A record review revealed a smoking assessment dated [DATE]. This resident was assessed as being unable to demonstrate safe technique for putting out matches, lighters or disposing of ash. She was also assessed as being unable to remain alert during the course of smoking. Under the portion of the assessment, IDT Determination, the determination was that this resident was an unsafe smoker and that she required frequent supervision every 30 minutes to 1 hour. A review of another smoking assessment dated [DATE], 10 days earlier, showed the resident was assessed as being unable to demonstrate safe technique for putting out matches, lighters or disposing of ash. She was also assessed as being unable to remain alert during the course of smoking. The assessment had not changed from 2-8-13 until 2-18-13 when the resident was reassessed, however on 2-8-13, the resident was determined to be an unsafe smoker with constant supervision (every 30 minutes to an hour). Further review showed smoking assessments dated 12-7-12, 11-13-12,8-9-12, 5-25-12. The smoking assessments for these dates showed the resident was assessed as being unable to demonstrate safe technique for putting out matches, lighters or disposing of ash. She was also assessed as being unable to remain alert during the course of smoking and the degree of supervision was determined to be frequent. Review of an assessment dated 5-11-12 showed this resident was assessed as being a safe smoker with no supervision required. All of the smoking assessments from 5-25-12 through 2-18-13 were signed as being done by staff #S5SSD. During an interview on 2-19-13 at 4:25 p.m. with staff #S1DON, she stated this resident use to be safe but had been getting some burns. She was asked for incident reports in regards to [MEDICAL CONDITION] provided one incident report dated 9-27-12 in which a CNA summoned a nurse to see an area on her upper abdomen that the resident stated was from a burn that occurred 2 weeks prior to this incident report dated 9-27-12.. During an interview on 2-19-13 at 4:17 p.m., with staff #S5SSD, she was asked why the supervision had changed from constant on 2-8-13 to frequent on 2-18-13 even though the resident had been assessed as having the same unsafe factors and she stated that staff #S1DON told her that this resident wanted to try smoking without constant supervision. She was asked what had changed from the last assessment to this assessment to make this resident safer and she did not provide an answer. During an interview 2-19-13 at 4:25 p.m. with staff #S1DON, she was asked who does actual observations for safe smoking. She did not provide an answer but stated this resident had been getting some burns. She stated she was changed from constant supervision to frequent supervision because she had not had [MEDICAL CONDITION]. She was asked if she was aware this resident had a cigarette burn on her at this time and she stated, no. At this time, staff #S1DON and staff #S5 SSD were asked who did assessments. Staff #S5SSD said that she was the designated person to do the smoking assessments, however, she did it with input from others. She stated that part of the assessment could be based on the resident ' s BIMS score. She was again asked how she determined this resident was safer to smoke with frequent supervision rather than constant supervision as she was assessed as needing on 2-8-13 and she stated the resident was safer now because she had less burns. Policies were requested from staff #S1 DON . A review of skin assessments dated 2-5-12 and 2-17-13 did not show a burn on the resident ' s finger. A review of the current Treatment Record did not show a treatment for [REDACTED]. A review of the Wound/Skin Management Documentation Record for this resident from November, 2013 until present did not show that an area had been identified as a cigarette burn on any of the fingers of the right hand and a review of the Weekly Skin Reports for January and February, 2013 did not show a cigarette burn had been identified. A review of nurses ' notes did not show the cigarette burn had been identified. A review of the incident log did not reveal any incidents in regards to this resident having a cigarette burn other than the burn on 9-27-12 documented on an incident report and provided by the facility. A review of the current MDS dated [DATE] showed this resident had a BIMS score of 15, indicating that the resident was able to answer all of the cognition question correctly. A review of the policy provided by staff #S1DON did not show the policy contained any documentation as to when residents were to be assessed for smoking and did not have any information as to what called for the appropriate supervision if the resident was deemed an unsafe smoker. Staff #S1DON confirmed during an interview on 2-20-13 at 9:35 a.m. that the only policy the facility had on smoking was The Smokers Agreement. During an interview on 2-19-13 at 3:55 p.m. with staff #S5SSD, a request was made for a list of smokers who reside in the facility. On 2-19-13 at 4:10 p.m., staff #S5SSD provided a list of smokers, safe/unsafe. The list had 5 unsafe smokers. During an interview at this time, staff #S1DON stated no other residents have [MEDICAL CONDITION] accidents with cigarettes. During an interview on 2-20-13 at 8:25 a.m. with staff #S22LPN/ Tx Nurse, she was asked what skin conditions this resident had at this time and she stated the resident had the following: Buttock area - stage II pressure sore - right leg - trauma area where resident hit it on table - venous ulcers right proximal LE- She also stated the resident had a cigarette burn to her 2nd right finger. She stated the resident had had the burn for 2-3 weeks and that she was treating it with [MEDICATION NAME]. During an interview on 2-20-13 at 7:40 a.m. with staff #S22LPN/ TX Nurse, she provided the current TARS and treatment notes. She reviewed the TARS and notes and was unable to find where the burn to the finger located next to the small finger was documented as having a cigarette burn. She stated she had been putting [MEDICATION NAME] on it. A review of physician's order [REDACTED]. During an interview on 2-20-13 at 8:50 a.m. with staff #S1DON, she was asked what frequent and constant meant for supervision of smokers. She stated she would have to check for more policies, however, she failed to provide more policies.. A review of the careplan showed a problem in which this resident was at risk for injury/falls asleep while smoking. The goal was for this resident to be able to safely smoke and the approach was to assess as safe or unsafe smoker and for the smoker to follow the smokers agreement. The careplan called for the resident to have constant observation that had been changed on 2-18-13 to frequent, however, showed nothing explaining why frequent supervision was more appropriate than constant supervision. A review of SSD notes showed that on 5-24-13, staff #S5SSD noticed the resident was outside, holding a cigarette in her hand, the cigarette was lit and the resident was asleep. A safe smoking assessment was done on 5-25-12 and showed the smoker to be unsafe. The assessment called for the resident to have frequent supervision (every 30 minutes) even though staff #S5SSD had observed the resident with a lit cigarette in her hand while she was asleep. An SSD note dated 5-28-12 showed that the resident was made aware that she had to be monitored and encouraged to wear a safety apron while smoking. The documentation showed that the resident refused and that the safety apron would continued to be offered. SSD notes on 12-7-12 documented that the resident was left unattended smoking outside through the night. This resident smokes frequently and staff made attempts to monitor but not consistently as recommended. Notes on 2-18-13 documented that the resident continued to be deemed an unsafe smoker but level of supervision would be frequent every 30 minutes. Resident has exhibited a level of improved compliance with smoking not requiring constant supervision, however, the assessment on 2-18-13 assessed the resident as unable to demonstrate safe technique for putting out matches, lighters or disposing of ash. She was also assessed as being unable to remain alert during the course of smoking. 2. Resident #54: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified the resident as moderately impaired with his vision and was scored as a 0 out of a possible 15 for a BIMS indicating the resident's mental status was severely impaired. The MDS further scored the resident as a "2" under section C1300 indicating the resident had inattention difficulties identifying the resident to be easily distracted, out of touch or having difficulty following what was said. The assessment did not indicate the resident refused care. The resident's admission contracture risk assessment dated [DATE] scored the resident as a "2" under upper extremities which indicated the resident had very limited use of his upper extremities. A review of Nurse's notes in November 2012 identified on 11/11/12 the resident required maximum care for ADL ' s. Documentation on 11/13/12, 11/17/12, 11/18/12 and 11/19/12 read " fed per staff. " During an interview with S12CNA at 5:00 p.m. on 2/19/13 she stated the resident needed someone to help him get a cup to his mouth. During an interview with S11 CNA on 2/20/13 at 9:40 a.m. she stated resident #54 could not hold a cup. She stated he would spill it all over himself because he shook. During an interview with S13LPN on 2/20/13 at 3:15 p.m. she stated resident #54 could not do anything for himself and that is how he had always been. She stated he could not hold a cup because he would have dropped it. She stated his hands shook. She further stated resident #54 was not on any fluid restrictions. During an interview with S14CNA on 2/20/13 at 4:30 p.m. she stated the resident could not do anything for himself. She stated the resident had a squirt bottle but he could not pick up the bottle without staff assistance. The Medical Nutrition Therapy assessment dated [DATE] signed by S33RD identified resident #54 required a minimum of 2550 ccs of fluids daily. The monthly intake and output flow sheets for 11/26/12 - 2/17/13 were reviewed. From 11/26/12 - 1/16/13 the resident received an average of 1758 ccs /day which was 792 ccs/day less than the RD recommendations. The resident was hospitalized from [DATE] - 1/24/13 with a [DIAGNOSES REDACTED]. The resident was again hosptalized on [DATE] with a [DIAGNOSES REDACTED].The resident returned to the facilty on 2/11/13, continued to receive less than the recommended 2550 ccs of fluid until he was discharged from the facility on 2/18/13. Further review of resident #54's Nurse's Notes indicated the resident was sent to the hospital on [DATE] at 3:50 p.m. The notes further read at 7:00 p.m. - resident admitted with [DIAGNOSES REDACTED]. A review of the hospital physician documentation dated 1/16/13 at 22:39 read: [DIAGNOSES REDACTED]. The Nurse's Notes dated 2/7/13 at 10:45 a.m. indicated resident #54 was difficult to arouse and was sent to the emergency room at 10:55 a.m. The notes read at 2:30 p.m. the resident was admitted to the hospital with [REDACTED]. The hospital history and physical dated 2/8/13 was reviewed. It read: "he has not been eating or drinking well at the nursing home. He comes in extremely dehydrated. " The lab chemistries dated 2/8/13 had critical labs of Sodium at 160 (normal 136-145), Chloride at 121 (normal 98 - 107), Creatinine at 3.8 (normal 0.6 - 1.3). The BUN was also elevated at 106 (normal 7 - 18), and Potassium 5.5 (normal 3.5 - 5.1). These labs are used as indicators of hydration status. The resident's Care Plan was reviewed. The care plan did not indicate a problem of the resident refusing care. The care plan included a self-care deficit upon admission on page 15 but did not address which ADL's the resident required assistance. On page 3 it identified a risk for dehydration on admission. Interventions included encourage adequate fluid intake, I &O record, observe for s/s of fluid excess or depletion and report significant findings. The care plan did not identify the 2550 cc fluid recommendations of the RD. Upon return from the hospital on [DATE] with a [DIAGNOSES REDACTED]. There were no interventions added to the care plan until 2/11/13 following the resident's 2nd return from the hospital with a [DIAGNOSES REDACTED]. During an interview with S1DON on 2/21/13 at 2:40 p.m. she confirmed resident #54 required at least 2550 ccs of fluid daily according to the RD's assessment and recommendations dated 11/26/12. S1 reviewed the intake and output flow sheets and further confirmed the resident had not received at least 2550 ccs of fluid on any of the days the resident was in the facility between 11/26/12 and 2/17/12 except on 12/2/12. S1 was asked to identify where in the care plan new interventions were put in place to assure resident #54 was getting adequate fluid intake to prevent further episodes of dehydration following either hospitalization for dehydration. She verified the Care Plan read to continue to encourage fluids which was put in place when the resident was identified as at risk for dehydration at admission. She confirmed the care plan did not address any new interventions related to the resident ' s [DIAGNOSES REDACTED].

Based on record review, observation and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well - being by neglecting to ensure 1 resident (#3), out of 5 sampled residents (#1, #2, #3,#4, and #5) would not be mentally and psychosocially harmed by Resident #2. This deficient practice has the potential to affect a total of 122 residents residing in the facility. An Immediate Jeopardy Situation began on 10/17/12 at 6:10 a.m., when Resident #3 became fearful and scared of Resident #2 when Resident #2 hit Resident #3 on the head. Resident #2 made verbal threats to Resident #3, and hit her on the head on two occasions. Resident #3 was afraid to go in her room to sleep, afraid that Resident #2 would go in her room and harm her again. Resident #2 also made verbal threats to Resident #3, and also told her "You are the Devil". Resident #3 also showed fear and did not want to stay at the nursing home following an outing with a family member, because she was afraid Resident #2 would hurt her again. The facility was aware of the incidents, and fears of Resident #2, and failed to protect from further physical harm, and provide the necessary services to maintain the resident ' s mental, physical and psychosocial wellbeing. The Immediate Jeopardy Situation ended when Resident #2 was sent out of the nursing home on 1/9/13 and the facility notified at 9:45 a.m. that Resident #2 was being admitted to a psych hospital related to hitting another resident on 1/7/13. Findings: Resident #3: Resident #3 is a [AGE] year old female admitted to the facility on [DATE] from her home with a [DIAGNOSES REDACTED]. She resides on the Dementia/Alzheimer's unit, and record review indicated her BIMS score at "9". Review of Resident #3's record revealed a nurse's note dated 9/20/12 indicated Resident #3 had tapped the nurse on the shoulder laughing and joking. Resident #2 got the wrong idea and started yelling at Resident #3 to hit him. The note indicated Resident #3 was frightened. On 10/17/12 at 0610 a nurses's note indicated Resident #3 had been hit in the head by Resident #2 because she "was sitting in his chair". Further record review indicated on 10/25/12 Resident #3 stated she was afraid of Resident #2. The nurse told Resident #3 she would let S1DON know, and they would notify Social Services in the morning. On 11/5/12 at 0700 the nurse was summoned to the Alzheimer's unit and told by the CNAs on duty that Resident #3 had been struck in the head by Resident #2. This was the second time in thirty days Resident #2 had struck resident #3. When questioned, Resident #2 stated he struck her because Resident #3 was sitting in his chair. The nurse ' s note also indicated Resident #3 was in distress and very upset. Following this incident, at 0900 on 11/5/12, Resident #3 complained of neck pain, and an order for [REDACTED]. On 11/22/12 at 10:35 a.m. the resident went out on pass with her family and returned at 6:15 p.m. The note indicated the resident was tearful and stating she was afraid to come back to the nursing home because "that guy might hit her again". The nurse reassured the resident of her safety, but the resident had to be redirected twice to go to her room. Resident #3's Social History and Initial assessment dated [DATE], and completed by S3SSD, indicated the resident ' s family had been concerned about her adjusting to nursing home placement, but the resident was no longer safe to remain at home due to the progression of her symptoms. On 9/25/12 another assessment was completed, including a BIMS and Resident Mood Interview. The resident was alert and aware. SSD notes dated 9/28/12 indicated the resident had been made aware that her roommate would be discharged to home on the next day. The last SSD note was dated 10/28/12, and indicated the resident was made aware she would be receiving a new roommate the next day. A Social Services Documentation Record dated 12/24/12 indicated a BIMS and Resident Mood Interview had been conducted. The Resident was alert and aware, understood and able to understand others. Resident #3 was able to repeat three words, and oriented to month only. There were no signs of [MEDICAL CONDITION] ... no signs/symptoms of behaviors during mood interview. The resident did admit to signs and symptoms of feeling down. There was no further documentation of Social Services involvement or actions taken with regards to care of the resident. There was no documentation of the resident being scared of Resident #2, nor the incidents which occurred. Resident #2: Resident #2 was a [AGE] year old male admitted on [DATE] to the nursing home from a psych facility. According to a Social History and Initial Assessment, the resident was placed on the Alzheimer's unit to provide supervision and redirection as needed for behavior symptoms. He was able to sign documents, read and use the phone, ambulate with minimal assistance. According to the Social History, there were no plans to return to the community. The resident was to receive therapy services and psychiatric care to manage symptoms related to psychiatric diagnosis. The resident ' s family was hopeful that he would do well in order to remain at the facility. [DIAGNOSES REDACTED]. On 9/21/12 a BIMS and Resident Mood Interview were conducted. Resident #2 was alert and aware, with his BIMS noted to be "13". The resident was understood and able to understand others. He was oriented to year, month, and day of the week. His recall ability was good, and he had not exhibited any signs/symptoms of [MEDICAL CONDITION]. He admitted to mood symptoms such as feeling down and feeling tired. On 10/1/12 a Social Service Documentation Record indicated another BIMS and Resident Interview had been conducted. Resident #2 was understood and could understand others, and was able to repeat three words on the first attempt. He was oriented to the year, month, and day of the week. Resident #2 had exhibited signs/symptoms of [MEDICAL CONDITION] such as keeping eyes close continuously. The resident also admitted to mood symptoms such as feeling down and feeling tired. Review of Resident #2's record revealed on 9/20/12 the resident got the wrong idea when another resident (#3) tapped the nurse on the shoulder, and started yelling at her to hit him. The resident was redirected and calmed down immediately. On 10/17/12 the nurse was summoned to unit and made aware that Resident #2 had hit Resident #3 in the head, telling Resident #3 that she was in his chair. On 10/17/12 the facility received a call from a psych day program nurse stating that Resident #2 had slapped another woman, indicating he told her she was sitting in his chair. On 11/5/12 0700 the nurse was summoned to unit. Resident #3 had been struck by resident #2, which was the second incident within the last thirty days in which the Resident #3 had been struck in the head by Resident #2. When questioned why, Resident #2 stated she was sitting in his chair. On 11/5/12 at 8:30 a.m. Resident #2 was admitted to a psych hospital and returned for readmission to the nursing home on 11/19/12. On 1/7/13 at 9:30 a.m. called to PHP to inform them that Resident #2 had threatened another resident at the facility (no documentation of which resident was noted or known). On 1/8/13 at 8:30 p.m. witnesses heard a scream coming from Resident #2's room, and upon entering they asked what happened. Resident #2 stated he hit the other resident (roommate is Resident #4). When asked why, Resident #2 stated " just look at him ". The Residents were separated and kept apart. The MD was notified and instructed nursing home staff to keep Resident #2 in a locked room. Resident #2's family member was notified, and the family member took the resident home for the night, and brought him back to the facility on [DATE]. When the resident returned to the facility, the staff questioned the resident about what had happened the night before. Resident #2 stated the other resident moved around to much, and made that bell (bed alarm) go off, and that made him nervous and he could not sleep. On 1/9/13 Resident #2 was admitted to a psych facility for inpatient care. The resident was refused readmission to the nursing home on 1/23/13. During an interview with S1DON on 1/25/13 at 10:30 a.m., she stated Resident #2 had hit Resident #3 and Resident #4, indicating this would have been discussed in the morning meetings, and Social Services would have been also made aware of the incidents, at that time. During an interview on 1/25/13 at 1:45 p.m. Resident #3 stated she had been afraid of Resident #2 since the first day he had been admitted to the facility. She indicated he had hit her on her head more than one time, and she was afraid to go to sleep at night. When questioned, Resident #3 stated she was afraid to go in her room to go to sleep at night, because he might go in and hurt her again. At that point the resident grabbed the side armrests of the chair she was sitting in, and having a frightened look on her face stated "he ' s not here is he, I don't want him around me, he scares me", while rising off of the seat of the chair, as if to get up and leave. She stated again that she was scared of Resident #2, that he would hit her again, and she did not like him. Resident #3 stated he had told her she was sitting in his chair and had hit her on the head, stating it was not in his chair, it was just a chair for anyone to sit in. At this time, the resident was still gripping the armrest of the chair with a terrified look on her face, had to be reassured the resident was not in the unit, nor was he in the facility. After reassuring Resident #3 that she was safe, and Resident #2 was not in the building, she calmed down and sat back down in the chair. She stated Resident #2 had threatened to hit her, and called her names. During an interview with Resident #3's family member on 1/25/13 at 2:30 p.m. she stated the following, Resident #3 had not liked Resident #2 since admission. She was scared of him because he would cursed her, threaten to hit her. The family member also verbalized Resident #3 did not want to go out of her room, and she was scared that Resident #2 would come into her room in the middle of the night and hurt her. On one occasion, when the nurse was in hallway giving meds, and she was in Resident #3's room, her mom went into the hallway and she heard loud talking. When she went into the hallway, Resident #2 was threatening to hit Resident #3. A couple of weeks later the family member was notified by Resident #3 ' s husband that Resident #2 had hit Resident #3 because she was sitting in his chair. Resident #2 came back from being hospitalized , and the facility said he was good, he had medication changes. Resident #3 continued to be afraid of him. The family member said after being out on pass, Resident #3 would cry because she did not want to go back to the facility because she was afraid of Resident #2. There were times that Resident #3 would not want the family member to leave the facility because she was so scared of Resident #2. The family member would have to get the staff to help calm the resident down so she could leave the facility. The facility was aware from day one of Resident #3's fear of Resident #2. The family member indicated residents husband had numerous conversations with S2Previous Administrator, S1DON and the charge nurse concerning her mom ' s fear of Resident #2. During an interview with Resident #3's husband on 1/25/13 at 4:15 p.m., he stated that he had spoken with facility staff about Resident #3's fear of Resident #2, on numerous occasions. When Resident #3 sat in Resident #2 ' s place and he hit her, S1DON said she would check into it, and that Resident #2 would be transferred out. When he came back to visit Resident #3, the facility said Resident #2 had been discharged . Resident #3's husband indicated his wife was afraid of Resident #2. Resident #3 did not want to go out into the hallway, and verbalized Resident #2 would look in the room and tell her "You are the Devil". He stated the nurses were aware of the incident. Resident #3's husband also indicated he had questioned the nurses if Resident #2 had become violent, and they just told him Resident #2 had problems with others, stating he had also hit Resident #1. Resident #2 also told Resident #3 that he would get her. The resident's husband also verbalized Resident #3 had been afraid that Resident #2 would go in her room at night and hurt her.

Based on record review, interview and observation the facility failed to prohibit mistreatment and neglect of 2 (#3, #1) of 5 sampled residents (#1, #2, #3, #4, and #5), out of a total of 8 residents who resided on the locked unit of the facility. An Immediate Jeopardy Situation began on 10/17/12 at 6:10 a.m., when Resident #3 became fearful and scared of Resident #2 after being hit by Resident #2 on the head. Resident #2 made verbal threats to Resident #3, told her that "You are the Devil" and hit her on the head on two separate occasions. Resident #3 was afraid to go in her room to sleep, afraid that Resident #2 would go in her room and harm her again. Resident #3 also showed fear and did not want to stay at the nursing home following an outing with a family member, because she was afraid Resident #2 would hurt her again. The facility was aware of the incidents, and fears of Resident #2, and failed to protect from further physical harm, and provide the necessary services to maintain the resident's mental, physical and psychosocial wellbeing. The Immediate Jeopardy Situation ended when Resident #2 was sent out of the nursing home on 1/9/13 and the facility notified at 9:45 a.m. that Resident #2 was being admitted to a psych hospital for evaluation and treatment, following evaluation related to the resident hitting another resident on 1/8/13. The facility staff failed to take necessary steps to provide Resident #3 services for Resident to cope with her fear of Resident #3, and protect her from further harm from him. Findings: Resident #3: Resident #3 is a [AGE] year old female admitted to the facility on [DATE] from her home with a [DIAGNOSES REDACTED]. She resided on the Dementia/Alzheimer ' s unit, and record review indicated her BIMS score at "9". Review of Resident #3's record revealed a nurse's note dated 9/20/12 indicated Resident #3 had tapped the nurse on the shoulder laughing and joking. Resident #2 got the wrong idea and started yelling at Resident #3 to hit him. The note indicated Resident #3 was frightened. On 10/17/12 at 0610 a nurse's note indicated Resident #3 had been hit in the head by Resident #2 because she "was sitting in his chair". Further record review indicated on 10/25/12 Resident #3 stated she was afraid of Resident #2. The nurse told Resident #3 she would let S1DON know, and they would notify Social Services in the morning. On 11/5/12 at 0700 the nurse was summoned to the Alzheimer's unit and told by the CNAs on duty that Resident #3 had been struck in the head by Resident #2. This was the second time in thirty days that Resident #2 had struck Resident #3. When questioned, Resident #2 stated he struck her because Resident #3 was sitting in his chair. The nurse s note also indicated Resident #3 was in distress and very upset. Following this incident, at 0900 on 11/5/12, Resident #3 complained of neck pain, and an order for [REDACTED]. On 11/22/12 at 10:35 a.m. Resident #3 went out on pass with her family and returned at 6:15 p.m. The note indicated the resident was tearful and stated she was afraid to come back to the nursing home because that guy might hit her again. The nurse reassured the resident of her safety, but the resident had to be redirected twice to go to her room. Resident #3's Social History and Initial assessment dated [DATE], and completed by S3SSD, indicated the resident ' s family had been concerned about her adjusting to nursing home placement, but the resident was no longer safe to remain at home due to the progression of her symptoms. On 9/25/12 another assessment was completed, including a BIMS and Resident Mood Interview. The resident was alert and aware. SSD notes dated 9/28/12 indicated the resident had been made aware that her roommate would be discharged to home on the next day. The last SSD note was dated 10/28/12, and indicated the resident was made aware she would be receiving a new roommate the next day. A Social Services Documentation Record dated 12/24/12 indicated a BIMS and Resident Mood Interview had been conducted. The Resident was alert and aware, understood and able to understand others. Resident #3 was able to repeat three works, and orientated to month only. There were no signs of [MEDICAL CONDITION] ... no signs/symptoms of behaviors during mood interview. The resident did admit to signs and symptoms of feeling down. There were no further documentation of Social Services involvement or actions taken with regards to care of the resident. There was no note documentation of the resident being scared of Resident #2, nor the incidents which occurred. Resident #2: Resident #2 was a [AGE] year old male admitted on [DATE] to the nursing home from a psych facility. According to a Social History and Initial Assessment, the resident was placed on the Alzheimer's unit to provide supervision and redirection as needed for behavior symptoms. He was able to sign documents, read and use the phone, ambulated with minimal assistance. According to the Social History, there were no plans to return to the community. The resident was to receive therapy services and psychiatric care to manage symptoms related to psychiatric diagnosis. The resident's family was hopeful that he would do well in order to remain at the facility. [DIAGNOSES REDACTED]. On 9/21/12 a BIMS and Resident Mood Interview were conducted. Resident #2 was alert and aware, with his BIMS noted to be "13". The resident was understood and able to understand others. He was orientated to year, month, and day of the week. His recall ability was good, and he had not exhibited any signs/symptoms of [MEDICAL CONDITION]. He admitted to mood symptoms such as feeling down and feeling tired. On 10/1/12 a Social Service Documentation Record indicated another BIMS and Resident Interview had been conducted. Resident #2 was understood and could understand others, and was able to repeat three words on the first attempt. He was orientated to the year, month, and day of the week. Resident #2 had exhibited signs/symptoms of [MEDICAL CONDITION] such as keeping eyes close continuously. The resident also admitted to mood symptoms such as feeling down and feeling tired. Review of Resident #2's record revealed on 9/20/12 Resident #2 got the wrong idea when Resident #3 tapped the nurse on the shoulder. Resident #2 started yelling at Resident #3 to hit him. The Resident #2 was redirected and calmed down immediately. On 10/17/12 the nurse was summoned to unit and made aware that Resident #2 had hit Resident #3 on the head, telling her that she was in his chair. On 10/17/12 the facility received a call a psychiatric day program nurse stating that Resident #2 had slapped another woman, indicating he told her she was sitting in his chair. On 11/5/12 at 0700 the nurse was summoned to unit. Resident #3 had been struck by resident #2, which was the second incident within the last thirty days that the same resident (#3) had been struck in the head by Resident #2. When questioned why, Resident #2 stated she was sitting in his chair. On 11/5/12 at 8:30 a.m. Resident #2 was admitted to a psych hospital and returned for readmission to the nursing home on 11/19/12. On 1/7/13 at 9:30 a.m. a staff nurse called PHP to inform them that Resident #2 had threatened another resident at the facility (no documentation of which resident was noted or known). On 1/8/13 at 8:30 p.m. witnesses heard a scream coming from Resident #2's room, and upon entering they asked what happened. Resident #2 stated he hit the other resident (roommate is Resident #4). When asked why, Resident #2 stated "just look at him". The Residents were separated and kept apart. The MD was notified and instructed nursing home staff to keep Resident #2 in a locked room. Resident #2's family member was notified, and the family member took the resident home for the night, and brought him back to the facility on [DATE]. When the resident returned to the facility, the staff questioned the resident about what had happened the night before. Resident #2 stated the other resident moved around to much, and made that bell (bed alarm) go off, and that made him nervous and he could not sleep. On 1/9/13 Resident #2 was admitted to a psych facility for inpatient care. The resident was refused readmission to the nursing home on 1/23/13. During an interview with S1DON on 1/25/13 at 10:30 a.m., she stated Resident #2 had hit Resident #3, and Resident #4. S1 added that these incidents would have been discussed in the morning meeting, and Social Services would have been made aware of, at that time. During an interview on 1/25/13 at 1:45 p.m. Resident #3 stated she had been afraid of Resident #2 since the first day he had been admitted to the facility. She indicated he had hit her on her head more than one time, and she was afraid to go to sleep at night. When questioned, Resident #3 stated she was afraid to go in her room to go to sleep at night, because he might go in and hurt her again. At that point the resident grabbed the side armrests of the chair she was sitting in, and having a frightened look on her face stated "he's not here is he, I don't want him around me, he scares me", while rising off of the seat of the chair, as if to get up and leave. She stated again that she was scared of Resident #2, that he would hit her again, and she did not like him. Resident #3 stated he had told her she was sitting in his chair and had hit her on the head, stating it was not in his chair, it was just a chair for anyone to sit in. At this time, the resident was still gripping the armrest of the chair with a terrified look on her face, had to be reassured the resident was not in the unit, nor was he in the facility. After reassuring Resident #3 that she was safe, and Resident #2 was not in the building, she calmed down and sat back down in the chair. She stated Resident #2 had threatened to hit her, and called her names. During an interview with Resident #3's family member on 1/25/13 at 2:30 p.m. she stated the following: Resident #3 had not liked Resident #2 since admission. She was scared of him because he would cursed her, threaten to hit her. The family member also verbalized Resident #3 did not want to go out of her room, and she was scared that Resident #2 would come into her room in the middle of the night and hurt her. On one occasion, when the nurse was in hallway giving meds, and she was in Resident #3's room, her mom went into the hallway and she heard loud talking. When she went into the hallway, Resident #2 was threatening to hit Resident #3. A couple of weeks later the family member was notified by Resident #3 ' s husband that Resident #2 had hit Resident #3 because she was sitting in his chair. Resident #2 came back from being hospitalized , and the facility said he was good, he had medication changes. Resident #3 continued to be afraid of him. The family member said after being out on pass, Resident #3 would cry because she did not want to go back to the facility because she was afraid of Resident #2. There were times that Resident #3 would not want the family member to leave the facility because she was so scared of Resident #2. The family member would have to get the staff to help calm the resident down so she could leave the facility. The facility was aware from day one of Resident #3's fear of Resident #2. The family member also stated the residents husband had numerous conversations with S2Previous Administrator, S1DON and the charge nurse concerning Resident #3's fear of Resident #2. During an interview with Resident #3's husband on 1/25/13 at 4:15 p.m., he stated that he had spoken with facility staff about Resident #3's fear of Resident #2, on numerous occasions. When Resident #3 sat in Resident #2's place and he hit her, S1DON said she would check into it, and that Resident #2 would be transferred out. When he came back to visit Resident #3, the facility said Resident #2 had been discharged . Resident #3's husband indicated his wife was afraid of resident #2. Resident #3 did not want to go out into the hallway, verbalizing that Resident #2 had looked into her room and told her "You are the Devil". Resident #3's husband stated the nurses were aware of the incident. Resident #3's husband also indicated he had questioned the nurses if Resident #2 had become violent, and they just told him Resident #2 had problems with others, stating he had also hit Resident #1. Resident #2 also told Resident #3 that he would get her. The resident's husband also verbalized Resident #3 had been afraid that Resident #2 would go in her room at night and hurt her.

Based on record review, observation and interview, the facility failed to ensure each resident receives adequate supervision to prevent accidents by failing to ensure 1 sampled resident (#3), out of 5 sampled residents (#1 - #5) was free from being hit in the head on more than one occasion, and threatened by another resident (#2). This deficient practice has the potential to effect a total of 122 residents residing in the facility. An Immediate Jeopardy Situation began on 10/17/12 at 6:10 a.m., when Resident #3 became fearful and scared of Resident #2 when Resident #2 hit Resident #3 on the head. Resident #2 made verbal threats to Resident #3, and hit her on the head on two occasions. Resident #3 was afraid to go in her room to sleep, afraid that Resident #2 would go in her room and harm her again. Resident #2 also made verbal threats to Resident #3, and also told her "You are the Devil". Resident #3 also showed fear and did not want to stay at the nursing home following an outing with a family member, because she was afraid Resident #2 would hurt her again. The facility was aware of the incidents, and fears of Resident #2, and failed to protect from further physical harm, and provide the necessary services to maintain the resident ' s mental, physical and psychosocial wellbeing. The Immediate Jeopardy Situation ended when Resident #2 was sent out of the nursing home on 1/9/13 and the facility notified at 9:45 a.m. that Resident #2 was being admitted to a psych hospital related to hitting another resident on 1/7/13. Findings: Resident #3: Resident #3 is a [AGE] year old female admitted to the facility on [DATE] from her home with a [DIAGNOSES REDACTED]. She resided on the Dementia/Alzheimer's unit, and record review indicated her BIMS score at "9". Review of Resident #3's record revealed a nurse's note dated 9/20/12 indicated Resident #3 had tapped the nurse on the shoulder laughing and joking. Resident #2 got the wrong idea and started yelling at Resident #3 to hit him. The note indicated Resident #3 was frightened. On 10/17/12 at 0610 a nurse's note indicated Resident #3 had been hit in the head by Resident #2 because she "was sitting in his chair". Further record review indicated on 10/25/12 Resident #3 stated she was afraid of Resident #2. The nurse told Resident #3 she would let S1DON know, and they would notify Social Services in the morning. On 11/5/12 at 0700 the nurse was summoned to the Alzheimer's unit and told by the CNAs on duty that Resident #3 had been struck in the head by Resident #2. This was the second time in thirty days that Resident #2 had struck Resident #3 in the head. When questioned, Resident #2 stated he struck her because Resident #3 was sitting in his chair. The nurse's note also indicated Resident #3 was in distress and very upset. Following this incident, at 0900 on 11/5/12, Resident #3 complained of neck pain, and an order for [REDACTED]. On 11/6/12 the results of the neck x-ray were noted to be within normal limits. On 11/22/12 at 10:35 a.m. Resident #3 went out on pass with her family and returned at 6:15 p.m. The note indicated the resident was tearful and stating she was afraid to come back to the nursing home because that guy might hit her again. The nurse reassured the resident of her safety, but the resident had to be redirected twice to go to her room. Resident #3's Social History and Initial assessment dated [DATE], and completed by S3SSD, indicated the resident ' s family had been concerned about her adjusting to nursing home placement, but the resident was no longer safe to remain at home due to the progression of her symptoms. On 9/25/12 another assessment was completed, including a BIMS and Resident Mood Interview. The resident was alert and aware. SSD notes dated 9/28/12 indicated the resident had been made aware that her roommate would be discharged to home on the next day. The last SSD note was dated 10/28/12, and indicated the resident was made aware she would be receiving a new roommate the next day. A Social Services Documentation Record dated 12/24/12 indicated a BIMS and Resident Mood Interview had been conducted. The Resident was alert and aware, understood and able to understand others. Resident #3 was able to repeat three works, and orientated to month only. There were no signs of delirium ... no signs/symptoms of behaviors during mood interview. The resident did admit to signs and symptoms of feeling down. There were no further documentation of Social Services involvement or actions taken with regards to care of the resident. There was no note documentation of the resident being scared of Resident #2, nor the incidents which occurred. Resident #2: Resident #2 was a [AGE] year old male admitted to the facility on [DATE] to from a psychiatric hospital. According to a Social History and Initial Assessment, the resident was placed on the Alzheimer's unit to provide supervision and redirection as needed for behavior symptoms. He was able to sign documents, read and use the phone, ambulated with minimal assistance. According to the Social History, there were no plans to return to the community. The resident was to receive therapy services and psychiatric care to manage symptoms related to psychiatric diagnosis. The resident's family was hopeful that he would do well in order to remain at the facility. [DIAGNOSES REDACTED]. On 9/21/12 a BIMS and Resident Mood Interview were conducted. Resident #2 was alert and aware, with his BIMS noted to be "13". The resident was understood and able to understand others. He was orientated to year, month, and day of the week. His recall ability was good, and he had not exhibited any signs/symptoms of delirium. He admitted to mood symptoms such as feeling down and feeling tired. On 10/1/12 a Social Service Documentation Record indicated another BIMS and Resident Interview had been conducted. Resident #2 was understood and could understand others, and was able to repeat three words on the first attempt. He was orientated to the year, month, and day of the week. Resident #2 had exhibited signs/symptoms of delirium such as keeping eyes close continuously. The resident also admitted to mood symptoms such as feeling down and feeling tired. Review of Resident #2's record revealed on 9/20/12 Resident #2 got the wrong idea when Resident #3 tapped the nurse on the shoulder. Resident #2 started yelling at Resident #3 to hit him. The resident was redirected and calmed down immediately. On 10/17/12 the nurse was summoned to unit and made aware that the resident had hit another resident (Resident #3) in the head, telling her that she was in his chair. On 10/17/12 the facility received a call from a psych day program nurse stating that Resident #2 had slapped a woman indicating he told her she was sitting in his chair. On 11/5/12 at 0700 the nurse was summoned to unit. Resident #3 had been struck by resident #2, which was the second incident within last the last thirty days in which Resident #3 had been struck in the head by Resident #2. When questioned why, Resident #2 stated she was sitting in his chair. On 11/5/12 at 8:30 a.m. Resident #2 was admitted to a psych hospital and returned for readmission to the nursing home on 11/19/12. On 1/7/13 at 9:30 a.m. called to PHP to inform them that Resident #2 had threatened another resident at the facility (no documentation of which resident was noted or known). On 1/8/13 at 8:30 p.m. witnesses heard a scream coming from Resident #2's room, and upon entering they asked what happened. Resident #2 stated he hit the other resident (roommate is Resident #4). When asked why, Resident #2 stated "just look at him". The Residents were separated and kept apart. The MD was notified and instructed nursing home staff to keep Resident #2 in a locked room. Resident #2's family member was notified, and the family member took the resident home for the night, and brought him back to the facility on [DATE]. When the resident returned to the facility, the staff questioned the resident about what had happened the night before. Resident #2 stated the other resident moved around to much, and made that bell (bed alarm) go off, and that made him nervous and he could not sleep. On 1/9/13 Resident #2 was admitted to a psych facility for inpatient care related to Resident #2 hitting another resident at the facility on 1/8/13. The resident was refused readmission to the nursing home on 1/23/13. During an interview with S1DON on 1/25/13 at 10:30 a.m., she stated Resident #2 had hit Resident #3 and Resident #4, indicating this would have been discussed in the morning meetings, as well as Social Services being made aware of the incidents. During an interview on 1/25/13 at 1:45 p.m. Resident #3 stated she had been afraid of Resident #2 since the first day he had been admitted to the facility. She indicated he had hit her on her head more than one time, and she was afraid to go to sleep at night. When questioned, Resident #3 stated she was afraid to go in her room to go to sleep at night, because he might go in and hurt her again. At that point the resident grabbed the side armrests of the chair she was sitting in, and having a frightened look on her face stated "he ' s not here is he, I don't want him around me, he scares me", while rising off of the seat of the chair, as if to get up and leave. She stated again that she was scared of Resident #2, that he would hit her again, and she did not like him. Resident #3 stated he had told her she was sitting in his chair and had hit her on the head, stating it was not in his chair, it was just a chair for anyone to sit in. At this time, the resident was still gripping the armrest of the chair with a terrified look on her face, had to be reassured the resident was not in the unit, nor was he in the facility. After reassuring Resident #3 that she was safe, and Resident #2 was not in the building, she calmed down and sat back down in the chair. She stated Resident #2 had threatened to hit her, and called her names. During an interview with Resident #3's family member on 1/25/13 at 2:30 p.m. she stated the following: Resident #3 had not liked Resident #2 since admission. She was scared of him because he would cursed her, threaten to hit her. The family member also verbalized Resident #3 did not want to go out of her room, and she was scared that Resident #2 would come into her room in the middle of the night and hurt her. On one occasion, when the nurse was in hallway giving meds, and she was in Resident #3's room, her mom went into the hallway and she heard loud talking. When she went into the hallway, Resident #2 was threatening to hit Resident #3. A couple of weeks later the family member was notified by Resident #3 ' s husband that Resident #2 had hit Resident #3 because she was sitting in his chair. Resident #2 came back from being hospitalized , and the facility said he was good, he had medication changes. Resident #3 continued to be afraid of him. The family member said after being out on pass, Resident #3 would cry because she did not want to go back to the facility because she was afraid of Resident #2. There were times that Resident #3 would not want the family member to leave the facility because she was so scared of Resident #2. The family member would have to get the staff to help calm the resident down so she could leave the facility. The facility was aware from day one of Resident #3's fear of Resident #2. The family member stated the resident's husband had numerous conversations with S2Previous Administrator, S1DON and the charge nurse concerning Resident #3's fear of Resident #2. During an interview with Resident #3's husband on 1/25/13 at 4:15 p.m., he stated that he had spoken with facility staff about Resident #3's fear of Resident #2, on numerous occasions. When Resident #3 sat in Resident #2 ' s place and he hit her, S1DON said she would check into it, and that Resident #2 would be transferred out. When he came back to visit Resident #3, the facility said Resident #2 had been discharged . Resident #3's husband indicated his wife was afraid of resident #2. She did not want to go out in the hallway, and verbalized Resident #2 had looked in Resident #3's room and told her "You are the Devil" . He stated the nurses were aware of the incident. Resident #3's husband also indicated he had questioned the nurses if Resident #2 had become violent, and they just told him Resident #2 had problems with others, stating he had also hit Resident #1. Resident #2 also told Resident #3 that he would get her. The resident's husband also verbalized Resident #3 had been afraid that Resident #2 would go in her room at night and hurt her. During an interview on 1/24/13 at 11:20 a.m. S6CNA verbalized there were only 2 CNAs on the unit, along with the nurse. During an interview on 1/24/13 at 11:30 a.m. S4CNA also stated there were 2 CNAs on the unit at all times, ant the nurse did go out of the unit to give meds. She added when one of the CNAs goes on break, the nurse would come and take her place. There was no evidence that increased supervision had been implemented to protect Resident #3 from Resident #2.

A. Based on observation, record review and interview, the facility failed to maintain a safe environment for residents identified as being at risk due to unsafe smoking. An Immediate Jeopardy situation began on 1-15-13 when this resident (#87), who had been deemed an unsafe smoker due to her inability to demonstrate safe technique for putting out matches, lighter or disposing of ash, had no supervision when smoking and burned herself with a cigarette. The facility failed to do a complete and accurate assessment of the cigarette burn, failed to identify this resident as needing constant supervision, and failed to provide the supervision this resident needed when smoking. The Immediate Jeopardy Situation ended on 2-21-13 at 1:30 p.m., when the facility provided an acceptable plan of removal which included reassessment of smokers, supervision of unsafe smokers and inservices to all staff. This deficient practice has the potential to effect 9 (#25, #27, #58, #63, #68, #76, #86, #87, #113) residents who were identified by the facility as being smokers. Record review and interview also identified resident #76 as having an inaccurate smoking assessment. Findings: 1. Resident #87: During an observation and interview on 2-19-13 at 9:35 a.m., a round sore that looked like a cigarette burn that was the size of a pencil eraser was observed on this resident's right finger located next to the little finger. During an interview with this resident ,who was in her bedroom, she stated the area was from a cigarette burn and had happened about a month ago. She was asked if staff went with her to smoke and she stated, "no, not now". During another observation on 2-19-13 at 11:50 a.m., the resident was sitting on the patio located by the dining room. She was smoking a cigarette and the only person with her was another resident, #66, who was also smoking. A record review revealed a smoking assessment dated [DATE]. This resident was assessed as being unable to demonstrate safe technique for putting out matches, lighters or disposing of ash. She was also assessed as being unable to remain alert during the course of smoking. Under the portion of the assessment, IDT Determination, the determination was that this resident was an unsafe smoker and that she required frequent supervision every 30 minutes to 1 hour. A review of another smoking assessment dated [DATE], 10 days earlier, showed the resident was assessed as being unable to demonstrate safe technique for putting out matches, lighters or disposing of ash. She was also assessed as being unable to remain alert during the course of smoking. The assessment had not changed from 2-8-13 until 2-18-13 when the resident was reassessed, however on 2-8-13, the resident was determined to be an unsafe smoker with constant supervision (every 30 minutes to an hour). Further review showed smoking assessments dated 12-7-12, 11-13-12,8-9-12, 5-25-12. The smoking assessments for these dates showed the resident was assessed as being unable to demonstrate safe technique for putting out matches, lighters or disposing of ash. She was also assessed as being unable to remain alert during the course of smoking and the degree of supervision was determined to be frequent. Review of an assessment dated 5-11-12 showed this resident was assessed as being a safe smoker with no supervision required. All of the smoking assessments from 5-25-12 through 2-18-13 were signed as being done by S5SSD. During an interview on 2-19-13 at 4:25 p.m. with S1DON, she stated this resident use to be safe but had been getting some burns. She was asked for incident reports in regards to the burns and provided one incident report dated 9-27-12 in which a CNA summoned a nurse to see an area on her upper abdomen that the resident stated was from a burn that occurred 2 weeks prior to this incident report dated 9-27-12.. During an interview on 2-19-13 at 4:17 p.m., with S5SSD, she was asked why the supervision had changed from constant on 2-8-13 to frequent on 2-18-13 even though the resident had been assessed as having the same unsafe factors and she stated that S1DON told her that this resident wanted to try smoking without constant supervision. She was asked what had changed from the last assessment to this assessment to make this resident safer and she did not provide an answer. During an interview 2-19-13 at 4:25 p.m. with S1DON, she was asked who does actual observations for safe smoking. She did not provide an answer but stated this resident had been getting some burns. She stated she was changed from constant supervision to frequent supervision because she had not had any burns recently. She was asked if she was aware this resident had a cigarette burn on her at this time and she stated, no. At this time, S1DON and S5SSD were asked who did assessments. S5SSD said that she was the designated person to do the smoking assessments, however, she did it with input from others. She stated that part of the assessment could be based on the resident's BIMS score. She was again asked how she determined this resident was safer to smoke with frequent supervision rather than constant supervision as she was assessed as needing on 2-8-13 and she stated the resident was safer now because she had less burns. Policies were requested from S1 DON . A review of skin assessments dated 2-5-12 and 2-17-13 did not show a burn on the resident's finger. A review of the current Treatment Record did not show a treatment for [REDACTED]. A review of the Wound/Skin Management Documentation Record for this resident from November, 2013 until present did not show that an area had been identified as a cigarette burn on any of the fingers of the right hand and a review of the Weekly Skin Reports for January and February, 2013 did not show a cigarette burn had been identified. A review of nurses ' notes did not show the cigarette burn had been identified. A review of the incident log did not reveal any incidents in regards to this resident having a cigarette burn other than the burn on 9-27-12 documented on an incident report and provided by the facility. A review of the current MDS dated [DATE] showed this resident had a BIMS score of 15, indicating that the resident was able to answer all of the cognition question correctly. A review of the policy provided by S1DON did not show the policy contained any documentation as to when residents were to be assessed for smoking and did not have any information as to what called for the appropriate supervision if the resident was deemed an unsafe smoker. S1DON confirmed during an interview on 2-20-13 at 9:35 a.m. that the only policy the facility had on smoking was The Smokers Agreement. During an interview on 2-19-13 at 3:55 p.m. with S5SSD, a request was made for a list of smokers who reside in the facility. On 2-19-13 at 4:10 p.m., S5SSD provided a list of smokers, safe/unsafe. The list had 5 unsafe smokers. During an interview at this time, S1DON stated no other residents have had burns or accidents with cigarettes. During an interview on 2-20-13 at 8:25 a.m. with S22LPN/ Tx Nurse, she was asked what skin conditions this resident had at this time and she stated the resident had the following: Buttock area - stage II pressure sore - right leg - trauma area where resident hit it on table - venous ulcers right proximal LE- She also stated the resident had a cigarette burn to her 2nd right finger. She stated the resident had had the burn for 2-3 weeks and that she was treating it with Bactroban. During an interview on 2-20-13 at 7:40 a.m. with S22LPN/ TX Nurse, she provided the current TARS and treatment notes. She reviewed the TARS and notes and was unable to find where the burn to the finger located next to the small finger was documented as having a cigarette burn. She stated she had been putting Bactroban on it. A review of physician's orders [REDACTED]. During an interview on 2-20-13 at 8:50 a.m. with S1DON, she was asked what frequent and constant meant for supervision of smokers. She stated she would have to check for more policies, however, she failed to provide more policies.. A review of the careplan showed a problem in which this resident was at risk for injury/falls asleep while smoking. The goal was for this resident to be able to safely smoke and the approach was to assess as safe or unsafe smoker and for the smoker to follow the smokers agreement. The careplan called for the resident to have constant observation that had been changed on 2-18-13 to frequent, however, showed nothing explaining why frequent supervision was more appropriate than constant supervision. A review of SSD notes showed that on 5-24-13, S5SSD noticed the resident was outside, holding a cigarette in her hand, the cigarette was lit and the resident was asleep. A safe smoking assessment was done on 5-25-12 and showed the smoker to be unsafe. The assessment called for the resident to have frequent supervision (every 30 minutes), even though S5SSD had observed the resident with a lit cigarette in her hand while she was asleep. An SSD note dated 5-28-12 showed that the resident was made aware that she had to be monitored and encouraged to wear a safety apron while smoking. The documentation showed that the resident refused and that the safety apron would continued to be offered. SSD notes on 12-7-12 documented that the resident was left unattended smoking outside through the night. This resident smokes frequently and staff made attempts to monitor but not consistently as recommended. Notes on 2-18-13 documented that the resident continued to be deemed an unsafe smoker but level of supervision would be frequent (every 30 minutes). Resident has exhibited a level of improved compliance with smoking not requiring constant supervision, however, the assessment on 2-18-13 assessed the resident as unable to demonstrate safe technique for putting out matches, lighters or disposing of ash. She was also assessed as being unable to remain alert during the course of smoking. 2. Resident #76: The Smoking assessments of 12/19/12, 9/19/12 and 6/19/12 had resident #76 checked as an unsafe smoker. The degree of supervision was checked as occasional on the assessments of 9/19/12 and 12/19/12. There was no degree of supervision checked on the assessment of 6/19/12. The assessment further read if the resident is determined to be an unsafe smoker and the resident is required to wear a protective smoking apron and/or direct observation by caregivers. None of the assessments reviewed indicated whether or not the resident required a smoking apron/vest when smoking. The resident was currently in the hospital, and was not present in the facility during the survey. The surveyor accompanied S2RN, QA into resident #76 ' s room on 2/20/13 at 9:15 a.m. and visualized the resident's clothing. Five shirts and three pairs of pants were identified with cigarette burn holes. The holes were identified by S2RN as cigarette burns and confirmed the clothing belonged to resident #76 as the resident's name was in the clothing. The resident's Care Plan was reviewed. Unsafe smoker was checked as a problem and dated 2/15/12. It read: " If deemed an unsafe smoker, the resident is required to wear a protective smoking vest/apron and/or direct observation by care givers. It read further - direct observation while smoking - occasional. It was marked out that resident is to wear an apron and had NA written next to this area. The document titled smokers agreement identified as the facility's smoking policy by S1DON was reviewed and read nurses will ensure that the smoking apron is worn by all unsafe smokers who need to wear one ... During an interview with S19LPN on 2/20/13 at 9:30 a.m. she stated she thought the resident wore a smoker's apron and was not sure if he needed someone with him all the time while smoking. She stated this information would be identified in the CNAs care plan binder. During an interview with S11CNA on 2/20/13 at 9:40 a.m. she directed the surveyor to the CNA care Plan binder and confirmed the care plan for resident #76 indicated he was an unsafe smoker and the area for wearing an apron was marked through reading that he did not need a smoking apron. She stated she thought he wore an apron. B. Based on interview and record review the facility failed to assure 1 (#54) out of 7 (#27,#31,#54,#76,#87,#123,#126) residents reviewed for accidents was free from accident hazards. Resident #54 suffered actual harm when he required total assistance with feeding, was left unsupervised in his room drinking hot coffee and sustained a third degree burn to his left inner thigh. Resident #54: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an incident reporting form dated 11/20/12 read resident #54 had " wasted " his hot coffee on his left inner thigh. The report further read: " CNA should remain c resident when drinking hot liquid. " The resident's admission contracture risk assessment dated [DATE] scored the resident as a " 2 " under upper extremities which indicated the resident had very limited use of his upper extremities. The resident ' s admission nutritional risk assessment dated [DATE] scored the resident as a " 2 " for meals assistance needed which indicated the resident required " total assist " for meals. The admission MDS dated [DATE] identified the resident as moderately impaired with his vision and was scored as a 0 out of a possible 15 for a BIMS indicating the resident's mental status was severely impaired. The MDS further scored the resident as a " 2 " under section C1300A. indicating the resident had inattention difficulties identifying the resident to be easily distracted, out of touch or having difficulty following what was said. The Personal Care Record documenting CNA care read on 11/20/12 the resident was coded a 1/4 which indicated he ate in the dining room and required assistance. The CNA Care Plan dated 11/9/12 read under eating : (feeder) - Yes; requires assistance of 1 person. The resident's comprehensive Care Plan identified the resident as at risk for falls and injury upon admission on page 8. The interventions included fall prevention but did not address other potential accident hazards for the resident. The care plan included a self-care deficit upon admission on page 15 but did not address which ADL's the resident required assistance. The care plan identified the left inner thigh/burn and blistering on page 4. The approaches did not indicate any interventions to prevent further burn accidents with the resident. A review of Nurse's notes in November 2012 identified on 11/11/12 the resident required maximum care for ADL's. Documentation on 11/13/12, 11/17/12, 11/18/12 and 11/19/12 read " fed per staff. " The note dated 11/20/12 at 7:00 a.m. read Summons to Resident's room per CNA. Resident wasted his coffee (hot) on his lt. inner thigh. Redness noted to inner leg. The notes read at 11:15 am - left inner thigh was blistering from coffee he spilled on self this am. During an interview with S12CNA at 5:00 p.m. on 2/19/13 she stated the resident needed someone to help him get a cup to his mouth. She stated he spilled a lot from his cup because his hands shook. During an interview with S11 CNA on 2/20/13 at 9:40 a.m. she stated resident #54 had to be fed by the restorative aid in the dining room or if he ate in his room he had to be fed by staff. She stated he could not hold a cup or a fork. She stated he would try but he would spill it all over himself because he shook. During an interview with S13LPN on 2/20/13 at 3:15 p.m. she stated he could not do anything for himself and that is how he had always been. She stated he was fed by staff in the dining room and he could not hold a cup because he would have dropped it. She stated his hands shook. During an interview with S14CNA on 2/20/13 at 4:30 p.m. she stated the resident could not do anything for himself, needed to be fed, and never could feed himself since being admitted . S14 stated he could not hold a cup because he would spill it or drop it on himself. During an interview with S2RN, QA on 2/21/13 at 11:00 a.m. she stated any staff member should remain in room with resident when the resident was drinking a hot substance. S2 confirmed the CNA was not in the room with the resident at the time of the accident and further stated the CNA should have been in the room. An interview was conducted with S15, Dietary Manager on 2/21/13 at 1:20 p.m. She stated since admission resident #54 ate in the dining room and was not able to feed himself. She confirmed the resident could not hold a cup without assistance. She stated he shook a lot and when he tried to bring a cup or fork to his mouth he would not get it to his mouth and spilled it on himself. The resident's care plan was reviewed with S1DON on 2/21/13 at 2:45 p.m. An interview was conducted at this time with S1. She confirmed resident #54 was coded as requiring total assistance for meals according to the nutritional risk assessment done on 11/9/12. When S1 was asked to locate in the resident ' s care plan interventions put in place to protect the resident from further burns after the resident spilled hot coffee on himself she stated there were none in the Care Plan.

Based on obervation, record review and interview, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of 2 residents (#3, and #1) by failing to: 1. Intervene and provide necessary social services for Resident #3. This lack of Social Services caused actual harm when the resident was struck in the head on two separate occasions by Resident #2, which caused the resident mental and psychosocial harm as evidenced by extreme fear, not wanting to go to sleep at night, being tearful, and scared, and not wanting a family member to leave her at the nursing home for fear that Resident #2 would harm her again; 2. Intervene and provide necessary Social Services for Resident #2 following his behaviors towards Residents #3, #1 which caused mental, and psychosocial harm to Resident #3; and 3. Initiate an appropriate Discharge for Resident #2 following discharge from a psych hospital which resulted in the resident not being allowed back to the nursing home out of a total of 5 sampled residents (#1, #2, #3, #4, and #5). At that time, there were a total of 9 residents on the Alzheimer's unit. Findings: 1. Resident #3 is a [AGE] year old female admitted to the facility on [DATE] from her home with a [DIAGNOSES REDACTED]. Resident #3 resided on the Dementia/Alzheimer's unit, and record review indicated her BIMS score at "9". Review of Resident #3's record revealed a nurse's note dated 9/20/12 indicated Resident #3 had tapped the nurse on the shoulder laughing and joking, when Resident #2 got the wrong idea and started yelling at Resident #3 to hit him. The note indicated Resident #3 was frightened. On 10/17/12 at 0610 a nurse's note indicated Resident #3 had been hit in the head by Resident #2 because she "was sitting in his chair". Further record review indicated on 10/25/12 Resident #3 stated she was afraid of Resident #2. The nurse told Resident #3 she would let S1DON know, and they would notify Social Services in the morning. On 11/5/12 at 0700 the nurse was summoned to the Alzheimer's unit and told by the CNAs on duty that Resident #3 had been struck in the head by Resident #2. This was the second time in thirty days that Resident #2 had struck resident #3. When questioned, Resident #2 stated he struck her because Resident #3 was sitting in his chair. The nurse's note also indicated Resident #3 was in distress and very upset. Following this incident, at 0900 on 11/5/12, Resident #3 complained of neck pain, and an order for [REDACTED]. On 11/6/12 the results of the neck x-ray were noted to be within normal limits. On 11/22/12 at 10:35 a.m. Resident #2 went out on pass with her family and returned at 6:15 p.m. The note indicated the resident was tearful and stating she was afraid to come back to the nursing home because that guy might hit her again. The nurse reassured the resident of her safety, but the resident had to be redirected twice to go to her room. Resident #3's Social History and Initial assessment dated [DATE], and completed by S3SSD, indicated the resident's family had been concerned about her adjusting to nursing home placement, but the resident was no longer safe to remain at home due to the progression of her symptoms. On 9/25/12 another assessment was completed, including a BIMS and Resident Mood Interview. The resident was alert and aware. SSD notes dated 9/28/12 indicated the resident had been made aware that her roommate would be discharged to home on the next day. The last SSD note was dated 10/28/12, and indicated the resident was made aware she would be receiving a new roommate the next day. A Social Services Documentation Record dated 12/24/12 indicated a BIMS and Resident Mood Interview had been conducted. The Resident was alert and aware, understood and able to understand others. Resident #3 was able to repeat three works, and orientated to month only. There were no signs of delirium ... no signs/symptoms of behaviors during mood interview. The resident did admit to signs and symptoms of feeling down. There were no further documentation of Social Services involvement or actions taken with regards to care of the resident. There was no note documentation of the resident being scared of Resident #2, nor the incidents which occurred. During an interview on 1/25/13 at 1:45 p.m. Resident #3 stated she had been afraid of Resident #2 since the first day he had been admitted to the facility. She indicated he had hit her on her head more than one time, and she was afraid to go to sleep at night. When questioned, Resident #3 stated she was afraid to go in her room to go to sleep at night, because he might go in and hurt her again. At that point the resident grabbed the sides armrests of the chair she was sitting in, and having a frightened look on her face stated "he's not here, is he, I don't want him around me, he scares me", while rising off of the seat of the chair, as if to get up and leave. She stated again that she was scared of Resident #2, that he would hit her again, and she did not like him. Resident #3 stated he had told her she was sitting in his chair and had hit her on the head, stating it was not in his chair, it was just a chair for anyone to sit in. At this time, the resident was still gripping the armrest of the chair with a terrified look on her face, had to be reassured the resident was not in the unit, nor was he in the facility. After reassuring Resident #3 that she was safe, and Resident #2 was not in the building, she calmed down and sat back down in the chair. She stated Resident #2 had threatened to hit her, and called her names. During an interview with Resident #3's family member on 1/25/13 at 2:30 p.m. she stated the following Resident #3 had not liked Resident #2 since admission. She was scared of him because he would cursed her, threaten to hit her. The family member also verbalized Resident #3 did not want to go out of her room, and she was scared that Resident #2 would come into her room in the middle of the night and hurt her. On one occasion, when the nurse was in hallway giving meds, and she was in Resident #3's room, her mom went into the hallway and she heard loud talking. When she went into the hallway, Resident #2 was threatening to hit her Resident #3. A couple of weeks later the family member was notified by Resident #3 ' s husband that Resident #2 had hit Resident #3 because she was sitting in his chair. Resident #2 came back from being hospitalized , and the facility said he was good, he had medication changes. Resident #3 continued to be afraid of him. The family member said after being out on pass, Resident #3 would cry because she did not want to go back to the facility because she was afraid of Resident #2. There were times that Resident #3 would not want the family member to leave the facility because she was so scared of Resident #2. The family member would have to get the staff to help calm the resident down so she could leave the facility. The facility was aware from day one of Resident #3's fear of Resident #2. The resident's family member indicated the resident's husband had numerous conversations with S2Previous Administrator, S1DON and the charge nurse concerning Resident #3's fear of Resident #2. During an interview with Resident #3's husband on 1/25/13 at 4:15 p.m., he stated that he had spoken with facility staff about Resident #3's fear of Resident #2, on numerous occasions. When Resident #3 sat in Resident #2's place and he hit her, S1DON said she would check into it, and that Resident #2 would be transferred out. When he came back to visit Resident #3, the facility said Resident #2 had been discharged . Resident #3's husband indicated his wife was afraid of resident #2. She did not want to go out in the hallway, and verbalized Resident #2 and the resident would look in the room and told her " You are the Devil " . He stated the nurses were aware of the incident. Resident #3's husband also indicated he had questioned the nurses if Resident #2 had become violent, and they just told him Resident #2 had problems with others, stating he had also hit Resident #1. Resident #2 also told Resident #3 that he would get her. The resident's husband also verbalized Resident #3 had been afraid that Resident #2 would go in her room at night and hurt her. During an interview with S1DON on 1/25/13 at 10:30 a.m., she stated Resident #2 had hit Resident #3 and Resident #4, indicating this would have been discussed in the morning meetings, and Social Services would have been made aware of at that time. During an interview on 1/25/13 at 10:40 a.m., when questioned about how she had helped, or become involved with Resident #3's fear of Resident #2, and his harm to her, she verbalized the nurses and doctor were dealing with the situation. 2. Resident #2 was a [AGE] year old male admitted on [DATE] to the nursing home from a psych facility. According to a Social History and Initial Assessment, the resident was placed on the Alzheimer ' s unit to provide supervision and redirection as needed for behavior symptoms. He was able to sign documents, read and use the phone, ambulated with minimal assistance. According to the Social History, there were no plans to return to the community. The resident was to receive therapy services and psychiatric care to manage symptoms related to psychiatric diagnosis. The resident's family was hopeful that he would do well in order to remain at the facility. [DIAGNOSES REDACTED]. On 9/21/12 a BIMS and Resident Mood Interview were conducted. Resident #2 was alert and aware, with his BIMS noted to be "13". The resident was understood and able to understand others. He was orientated to year, month, and day of the week. His recall ability was good, and he had not exhibited any signs/symptoms of delirium. He admitted to mood symptoms such as feeling down and feeling tired. On 10/1/12 a Social Service Documentation Record indicated another BIMS and Resident Interview had been conducted. Resident #2 was understood and could understand others, and was able to repeat three words on the first attempt. He was orientated to the year, month, and day of the week. Resident #2 had exhibited signs/symptoms of delirium such as keeping eyes close continuously. The resident also admitted to mood symptoms such as feeling down and feeling tired. Review of Resident #2's record revealed on 9/20/12 the resident got the wrong idea when another resident (#3) tapped the nurse on the shoulder, and started yelling at her to hit him. The resident was redirected and calmed down immediately. On 10/17/12 the nurse was summoned to unit and made aware that the resident had hit another resident (Resident #3) in the head, telling her that she was in his chair. On 10/17/12 at 2 p.m., the facility received a call from a nurse at the psych day program nurse stating that the resident had slapped another woman indicating he told her she was sitting in his chair. On 11/5/12 0700 the nurse was summoned to unit. Resident #3 had been struck by resident #2, which was the second incident within last the last thirty days in which the same resident (#3) had been struck in the head by the other resident (#2). When questioned why, Resident #2 stated she was sitting in his chair. On 11/5/12: at 8:30 a.m. Resident #2 was admitted to a psych hospital and returned for readmission to the nursing home on 11/19/12. On 1/7/13 9:30 a.m. called to PHP to inform them that Resident #2 had threatened another resident at the facility (no documentation of which resident was noted or known). On 1/8/13 at 8:30 p.m. witnesses heard a scream coming from Resident #2's, and upon entering they asked what happened. Resident #2 stated he hit the other resident (roommate is Resident #4). When asked why, Resident #2 stated " just look at him ". The Residents were separated and kept apart. The MD was notified and instructed nursing home staff to keep Resident #2 in a locked room. Resident #2's family member was notified, and the family member took the resident home for the night, and brought him back to the facility on [DATE]. When the resident returned to the facility, the staff questioned the resident about what had happened the night before. Resident #2 stated the other resident moved around to much, and made that bell (bed alarm) go off, and that made him nervous and he could not sleep. On 1/9/13 Resident #2 was admitted to a psych facility for inpatient care. The resident was refused readmission to the nursing home on 1/23/13. During an interview with S1DON on 1/25/13 at 10:30 a.m., she stated Resident #2 had hit Resident #3 and Resident #4, indicating this would also been discussed in the morning meetings, and is also where Social Services is made aware. On 1/25/13 at 10:35 a.m., S3SSD verbalized she was unsure if she had charted on Resident #2 concerning his behaviors, adding she was not always involved when a resident would hit other residents. S3 again added that she was not always involved in situations dealing with residents, that other administrative staff would be involved, not herself. S3 also verified she had not provided Social Services for Resident #2, #3, nor #4 related to Resident #2's behavior. This included measures to help Resident #3's mental and psychosocial anguish because of Resident #2's actions towards her. 3. During an interview with S1 DON on 1/25/13 at 10:15 a.m. she stated the Resident #2 was not coming back to the facility because there were no beds available for a male, and the family wanted the resident in the general population, and not on the unit. When questioned, she verified the facility had plans to admit another male resident to the facility that day (1/25/13). S1 further stated when it was time for the resident #2 to return to the facility, there were no beds available for a male resident. According to a Census List presented at that time, there were beds available for male residents in 3 rooms. S1DON indicated the 1st room was had a private paying male resident, therefore they could not put another resident in the room; a male resident residing in the second room was in a Geri Chair, and Resident #2 would not be an appropriate roommate with him, and the third room available, was on the unit. A transmittal sheet from the nursing home to Dr. ___ indicated the family had requested the resident be removed from the Alzheimer ' s unit upon return to the facility. The Doctors reply was "1/23/13 Resident d ' cd from nursing home". There was no documentation regarding the issues with the other beds available for a male, nor any other documentation regarding communication with the family regarding the discharge of the resident. During an interview on 1/25/13 at 10:40 a.m., when questioned about the involuntary discharge of Resident #2, S3SSD stated when had been involved in the conversation, but did not have a direct role, adding she though he had received orders to go off the unit. S3 indicated nor had she done anything to help Resident #2, or the family, to find other placement, as the hospital was doing this. Resident #2 had been denied readmission to the nursing home, and was involuntarily discharged on [DATE].

Based on record review, observation and interview, the Administration failed to ensure the facility was managed in a manner that uses resources effectively and efficiently by failing to ensure staff supervised residents on the locked unit, specifically Resident #3, to maintain her highest mental, physical and social wellbeing, and to prevent neglect , which allowed Resident #3 to be hit by Resident #2 twice on the head within a thirty day period. This caused Resident #3 to become fearful of Resident #2, being afraid to sleep in her room at night for fear Resident #2 would harm her again, and not wanting family to leave her at the facility, because Resident #2 may harm her again. There were a total of 5 sampled residents (#1-5), all of which resided on the locked unit. This failure of the Administrative responsibility has the potential to affect a total of 122 residents residing at the facility. An Immediate Jeopardy Situation began on 10/17/12 at 6:10 a.m., when Resident #3 became fearful and scared of Resident #2. Resident #2 made verbal threats to Resident #3, and hit her on the head on two separate occasions. Resident #3 was afraid to go in her room to sleep, afraid that Resident #2 would go in her room and harm her again. Resident #2 also commented to Resident #3, telling her "You are the Devil". Resident #3 also showed fear and did not want to stay at the nursing home following an outing with a family member, because she was afraid Resident #2 would hurt her again. The facility was aware of the incidents, and fears of Resident #2, and failed to protect from further physical harm, and provide the necessary services to maintain the resident's highest mental, physical and psychosocial wellbeing. The Immediate Jeopardy ended when Resident #2 was sent out of the nursing home on 1/9/13 and the facility notified at 9:45 a.m. that Resident #2 was being admitted to a psych hospital following an incident on 1/8/13 when Resident #2 hit another resident. The Administration failed to take necessary steps to provide Resident #3 with services to protect her from Resident #2, as well as help her with her fear of the resident. Findings: Resident #3: Resident #3 is a [AGE] year old female admitted to the facility on [DATE] from her home with a [DIAGNOSES REDACTED]. She resides on the Dementia/Alzheimer ' s unit, and record review indicated her BIMS score at "9". Review of Resident #3's record revealed a nurse's note dated 9/20/12 indicated Resident #3 had tapped the nurse on the shoulder laughing and joking. Resident #2 got the wrong idea and started yelling at Resident #3 to hit him. The note indicated Resident #3 was frightened. On 10/17/12 at 0610 a nurse's note indicated Resident #3 had been hit in the head by Resident #2 because she "was sitting in his chair". Further record review indicated on 10/25/12 Resident #3 stated she was afraid of Resident #2. The nurse told Resident #3 she would let S1DON know, and they would notify Social Services in the morning. On 11/5/12 at 0700 the nurse was summoned to the Alzheimer's unit and told by the CNAs on duty that Resident #3 had been struck in the head by Resident #2. This was the second time in thirty days that Resident #2 had struck Resident #3. When questioned, Resident #2 stated he struck her because Resident #3 was sitting in his chair. The nurse's note also indicated Resident #3 was in distress and very upset. Following this incident, at 0900 on 11/5/12, Resident #3 complained of neck pain, and an order for [REDACTED]. On 11/22/12 at 10:35 a.m. the resident went out on pass with her family and returned at 6:15 p.m. The note indicated the resident was tearful and stating she was afraid to come back to the nursing home because that guy might hit her again. The nurse reassured the resident of her safety, but the resident had to be redirected twice to go to her room. Resident #3's Social History and Initial assessment dated [DATE], and completed by S3SSD, indicated the resident ' s family had been concerned about her adjusting to nursing home placement, but the resident was no longer safe to remain at home due to the progression of her symptoms. On 9/25/12 another assessment was completed, including a BIMS and Resident Mood Interview. The resident was alert and aware. SSD notes dated 9/28/12 indicated the resident had been made aware that her roommate would be discharged to home on the next day. The last SSD note was dated 10/28/12, and indicated the resident was made aware she would be receiving a new roommate the next day. A Social Services Documentation Record dated 12/24/12 indicated a BIMS and Resident Mood Interview had been conducted. The Resident was alert and aware, understood and able to understand others. Resident #3 was able to repeat three works, and orientated to month only. There were no signs of [MEDICAL CONDITION] ... no signs/symptoms of behaviors during mood interview. The resident did admit to signs and symptoms of feeling down. There were no further documentation of Social Services involvement or actions taken with regards to care of the resident. There was no note documentation of the resident being scared of Resident #2, nor the incidents which occurred. Resident #2: Resident #2 was a [AGE] year old male admitted to the facility on [DATE] to from a psychiatric hospital. According to a Social History and Initial Assessment, the resident was placed on the Alzheimer's unit to provide supervision and redirection as needed for behavior symptoms. He was able to sign documents, read and use the phone, ambulated with minimal assistance. According to the Social History, there were no plans to return to the community. The resident was to receive therapy services and psychiatric care to manage symptoms related to psychiatric diagnosis. The resident's family was hopeful that he would do well in order to remain at the facility. [DIAGNOSES REDACTED]. On 9/21/12 a BIMS and Resident Mood Interview were conducted. Resident #2 was alert and aware, with his BIMS noted to be "13". The resident was understood and able to understand others. He was orientated to year, month, and day of the week. His recall ability was good, and he had not exhibited any signs/symptoms of [MEDICAL CONDITION]. He admitted to mood symptoms such as feeling down and feeling tired. On 10/1/12 a Social Service Documentation Record indicated another BIMS and Resident Interview had been conducted. Resident #2 was understood and could understand others, and was able to repeat three words on the first attempt. He was orientated to the year, month, and day of the week. Resident #2 had exhibited signs/symptoms of [MEDICAL CONDITION] such as keeping eyes close continuously. The resident also admitted to mood symptoms such as feeling down and feeling tired. Review of Resident #2's record revealed on 9/20/12 Resident #2 got the wrong idea when Resident #3 tapped the nurse on the shoulder. Resident #2 started yelling at Resident #3 to hit him. The resident was redirected and calmed down immediately. On 10/17/12 the nurse was summoned to unit and made aware that the resident had hit another resident (Resident #3) in the head, telling her that she was in his chair. On 10/17/12 the facility received a call from a psych day program nurse stating that Resdent #2 had slapped a woman indicating he told her she was sitting in his chair. On 11/5/12 at 0700 the nurse was summoned to unit. Resident #3 had been struck by resident #2, which was the second incident within last the last thirty days in which Resident #3 had been struck in the head by Residetn #2. When questioned why, Resident #2 stated she was sitting in his chair. On 11/5/12 at 8:30 a.m. Resident #2 was admitted to a psych hospital and returned for readmission to the nursing home on 11/19/12. On 1/7/13 at 9:30 a.m. called to PHP to inform them that Resident #2 had threatened another resident at the facility (no documentation of which resident was noted or known). On 1/8/13 at 8:30 p.m. witnesses heard a scream coming from Resident #2's room, and upon entering they asked what happened. Resident #2 stated he hit the other resident (roommate is Resident #4). When asked why, Resident #2 stated "just look at him". The Residents were separated and kept apart. The MD was notified and instructed nursing home staff to keep Resident #2 in a locked room. Resident #2's family member was notified, and the family member took the resident home for the night, and brought him back to the facility on [DATE]. When the resident returned to the facility, the staff questioned the resident about what had happened the night before. Resident #2 stated the other resident moved around to much, and made that bell (bed alarm) go off, and that made him nervous and he could not sleep. On 1/9/13 Resident #2 was admitted to a psych facility for inpatient care related the inicdent on 1/8/13 when he hit another resident. Resident #2 was refused readmission to the nursing home on 1/23/13. During an interview with S1DON on 1/25/13 at 10:30 a.m., she stated Resident #2 had hit Resident #3 and Resident #4, indicating this would have been discussed in the morning meetings, and Social Services made aware of the incidents at that time. During an interview on 1/25/13 at 1:45 p.m. Resident #3 stated she had been afraid of Resident #2 since the first day he had been admitted to the facility. She indicated he had hit her on her head more than one time, and she was afraid to go to sleep at night. When questioned, Resident #3 stated she was afraid to go in her room to go to sleep at night, because he might go in and hurt her again. At that point the resident grabbed the side armrests of the chair she was sitting in, and having a frightened look on her face stated "he ' s not here is he, I don't want him around me, he scares me", while rising off of the seat of the chair, as if to get up and leave. She stated again that she was scared of Resident #2, that he would hit her again, and she did not like him. Resident #3 stated he had told her she was sitting in his chair and had hit her on the head, stating it was not in his chair, it was just a chair for anyone to sit in. At this time, the resident was still gripping the armrest of the chair with a terrified look on her face, had to be reassured the resident was not in the unit, nor was he in the facility. After reassuring Resident #3 that she was safe, and Resident #2 was not in the building, she calmed down and sat back down in the chair. She stated Resident #2 had threatened to hit her, and called her names. Resident #3 also verbalized that Resident #2 had also hit Resident #1. During an interview with Resident #3's family member on 1/25/13 at 2:30 p.m., she stated the following: Resident #3 had not liked Resident #2 since admission. She was scared of him because he would cursed her, threaten to hit her. The family member also verbalized Resident #3 did not want to go out of her room, and she was scared that Resident #2 would come into her room in the middle of the night and hurt her. On one occasion, when the nurse was in hallway giving meds, and she was in Resident #3's room, her mom went into the hallway and she heard loud talking. When she went into the hallway, Resident #2 was threatening to hit Resident #3. A couple of weeks later the family member was notified by Resident #3 ' s husband that Resident #2 had hit Resident #3 because she was sitting in his chair. Resident #2 came back from being hospitalized , and the facility said he was good, he had medication changes. Resident #3 continued to be afraid of him. The family member said after being out on pass, Resident #3 would cry because she did not want to go back to the facility because she was afraid of Resident #2. There were times that Resident #3 would not want the family member to leave the facility because she was so scared of Resident #2. The family member would have to get the staff to help calm the resident down so she could leave the facility. The facility was aware from day one of Resident #3's fear of Resident #2. The family member stated Resident's husband had numerous conversations with S2Previous Administrator, S1DON and the charge nurse concerning Resident #3's fear of Resident #2. During an interview with Resident #3's husband on 1/25/13 at 4:15 p.m., he stated that he had spoken with facility staff about Resident #3's fear of Resident #2, on numerous occasions. When Resident #3 sat in Resident #2's place and he hit her, S1DON said she would check into it, and that Resident #2 would be transferred out. When he came back to visit Resident #3, the facility said Resident #2 had been discharged . Resident #3's husband indicated his wife was afraid of resident #2. She did not want to go out in the hallway, and verbalized Resident #2 had looked in Resident #3's room and told her "You are the Devil" . He stated the nurses were aware of the incident. Resident #3's husband also indicated he had questioned the nurses if Resident #2 had become violent, and they just told him Resident #2 had problems with others, stating he had also hit Resident #1. Resident #2 also told Resident #3 that he would get her. The resident's husband also verbalized Resident #3 had been afraid that Resident #2 would go in her room at night and hurt her. During an interview on 1/24/13 at 11:20 a.m. S6CNA verbalized there were only 2 CNAs on the unit, along with the nurse. During an interview on 1/24/13 at 11:30 a.m. S4CNA also stated there are 2 CNAs on the unit at all times, the nurse goes out to give meds on the other side of the unit. She added when one of the CNAs goes on break, the nurse would come and take her place. There was no evidence that increased supervision had been implemented to protect Resident #3 from Resident #2.