Every finding on record at Oakhaven Nursing Center

Based on review of the facility policy, record review, and interviews, the facility failed to ensure that the advance directive information kept in the electronic health record (EHR) and hard chart reflected the same advance directive decision for Resident (R)48. This has the potential to allow the facility to not be able to carry out the resident's correct advance directive decision. Findings Include: Review of facility's policy titled, Advance Directive with a revision date of 01/24 revealed, Each resident shall be deemed a Full Code until we have the appropriate DNR documents signed by the resident or responsible party and physician. Review of R48's Facesheet revealed, R48 was admitted into the facility on [DATE] with diagnoses including but not limited to, congestive heart failure, hemiplegia, cerebral ischemic attack, hypertension, depression, edema, anemia, and muscle weakness. Review of R48's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/12/24 revealed, a Brief Interview for Mental Status (BIMS) score of 15, indicating resident is cognitively intact. Further review of the MDS revealed, R48 needs partial assistance from another person to complete any activity. Review of a document titled, Use of Resuscitation Procedures dated 06/07/24 revealed a request that if R48 has a sudden failure of vital function, that no emergency medical measure be used to restore this function. Review of an Emergency Medical Services Do Not Resuscitate Order dated 06/07/24 revealed the document contained R48's and physician signatures. During review of R48's medical record on 10/01/24 at 4:05 PM revealed a discrepancy with the advance directive. The hard chart had an advance directive of Do Not Resuscitate (DNR) and the EHR had a full code status. During an interview on 10/03/24 at 8:44 AM with Certified Nursing Assistant (CNA)1 revealed, the social worker put the advance directives in the charts and if the advance directives are in the wrong place, the unit secretary will put it in the right place. The unit secretary does packets to send residents out. If there are discrepancies in the EHR and hard chart, the unit secretary will let the unit manager know or the appropriate department. During an interview on 10/03/24 at 8:52 AM with the Unit Manager (UM) revealed, whenever a resident comes in, they are automatically a full code. They are asked and if they desire to become a DNR, they can once the order is signed by a physician. The unit manager writes the telephone order for the physician to sign. The social worker sends a ghost buster and order to the physician for a signature. For discrepancies, they look to make sure the physician has signed the order and if not they are still a full code. In case of an emergency the UM stated, she would go to the chart first and look at face sheet, then have a second person to check other source. During an interview on 10/03/24 at approximately 2:57 PM with the Director of Nursing (DON) revealed, The advance directives are handled by social services. Social services rounds to see if any changes need to be made and carried out.

Based on record review, observations, and staff interviews, the facility failed to provide activities of daily living (ADL) care for 2 of 2 sampled residents reviewed for ADL care (Residents #28 and #49). The findings included: 1. Resident #28 had [DIAGNOSES REDACTED]. Resident #28's current care plan, last updated 10/15/19, documented the resident had a problem with ADLs. The goals documented the resident would be clean, dry, and odor free. Interventions included assist with turning and repositioning approximately every hour and as needed. A quarterly Minimum Data Set (MDS), dated [DATE], documented the resident's cognition was severely impaired. The resident was totally dependent on staff for locomotion, and toilet use. The resident was always incontinent of bowel and bladder. On 12/06/19 at 9:29 AM, Resident #28 was observed up in his geri-chair at the nurses' station near the activity room. On 12/06/19 from 9:29 AM to 11:01 AM the resident was observed continuously up in his geri-chair at the nurses' station. The resident's eyes were closed on and off. Twice he yelled out he needed to go to the bathroom before closing his eyes again. There were staff at the nurses' station and nearby in the hall but they did not check on the resident or provide any care when he yelled out. At 11:01 AM, a nurse passed by and stated, He's asleep. She did not stop to check on or reposition the resident. On 12/06/19 at 11:04 AM, the resident again began to yell out and say he needed to go to the bathroom. Registered Nurse (RN) #56, heard the resident, stopped, looked down then left. No one checked on the resident and did not provide any care. On 12/06/19 at 11:04 AM to 11:47 AM the resident remained up in the geri-chair at the nurses' station without any care being provided. He again called out twice he needed to go the bathroom, and no one stopped to take him or provide care. The unit manager and two certified nurse aides (CNAs) were at the nurses' station while he yelled that he needed to go the bathroom. From 11:47 AM to 12:12 PM the resident remained up with no care being provided. At 12:12 PM, a CNA took the resident to his room and then left the room. She did not provide any care to the resident when she took him to the room. From 12:12 PM to 1:14 PM the resident remained in his room without any care being provided. At 1:14 PM, CNA #39 was observed providing the resident his meal tray. She sat down and assisted him with his meal. CNA #39 stated she only provided meal assistance and was not responsible for providing any care to the resident. She stated she probably would help change him after the meal if she was asked by CNA #50. At 1:21 PM, CNA #39 brought the resident out of his room and placed him at the nurses' station. No care was provided prior to bringing him out of his room after the meal. From 1:21 PM to 1:48 PM the resident remained out in the hall with no care being provided. At 1:48 PM RN #56 and licensed practical nurse (LPN) #77 took the resident to his room and placed a splint on his hand. They then returned him to the hallway without providing any care to the resident. At 1:56 PM, LPN #77 stated the resident was incontinent and when he says he had to go to the bathroom he needs to be changed. She stated the resident should be changed, repositioned, and checked at least every two hours or more often if needed. On 12/06/19 at 2:02 PM, CNA #50 and CNA #39 were observed taking the resident to his room to provide care. The resident was observed up without care being provided for four hours and thirty-two minutes. On 12/06/19 at 2:05 PM, CNA #50 stated she was the one working with the resident and she had not provided care since early in the morning when she first started her shift. She stated the resident will yell if he had to have a bowel movement. She stated he was last changed when she got him up for breakfast around 8:00 AM. She then stated he should have been checked and changed at least every two hours. She stated the resident had a bowel movement and was wet when she changed him. 2. Resident #49 had [DIAGNOSES REDACTED]. An annual MDS, dated [DATE], documented the resident's cognition was severely impaired. The resident was totally dependent on one staff for bed mobility, transfers, dressing, eating, and toilet use. Resident #49's current care plan, last updated 11/11/19, documented the resident required total assistance with all ADL's related to severe cognitive impairment. Interventions included the resident required total assistance with dressing, personal hygiene, oral care and bathing. The care plan also documented the resident was incontinent of bowel and bladder and was unaware of toileting needs. The interventions included to check for incontinent episodes and provide care as needed at least every two hours. On 12/06/19 at 9:29 AM, Resident #49 was observed up in her Broda chair (a wheelchair that can be tilted back in a reclining position) at the nurses' station near the activity room. On 12/06/19 from 9:29 AM to 10:39 AM the resident remained at the nurses' station in her chair. Staff was observed passing by her and not checking her, repositioning her or taking her to the room to provide care. On 12/06/19 at 10:39 AM a CNA took the resident into the activity room where a Bible study was going on. The CNA did not take the resident to her room to provide any care or reposition her in the chair. On 12/06/19 from 10:39 AM to 11:34 AM, the resident remained in the activity room for the Bible study. No staff came in and checked on the resident or provided any care or repositioning. On 12/06/19 at 11:34 AM, the Life Enrichment Director took the resident from the activity room and placed her outside in the hall on hall D. The resident remained there until 11:39 AM when she was transported down to the main dining room for the noon meal. No care was provided to the resident prior to her going to the dining room. On 12/06/19 from 11:39 AM to 1:52 PM the resident remained in the dining room. No staff was observed providing any care to the resident during this time. At 1:52 PM, the resident was observed being taken from the dining room to her room to be laid down for care. The resident was observed up in her chair for four hours and twenty-three minutes without any care or being repositioned. On 12/06/19 at 1:42 PM CNA #30 stated the resident was incontinent and required total assistance with all care. She stated she was the aide working on the hall responsible for her care and she last provided care early in the morning when she first arrived at 7:00 AM. She stated the resident was to have care every two hours. She then stated she was going to change the resident, but she was in an activity then taken to the dining room for her meal. She then stated she did not want to interrupt the activity and her meal to provide the care. At 1:56 PM, LPN #77 stated the resident was incontinent and was not able to make her needs known. She stated the resident should be checked and changed at least every two hours. She then stated the resident was totally dependent on staff for all care.

AMENDED 11/7/18 Based on observation, interview, record review, and review of the facility's Falls Management policy, the facility failed to provide supervision and/or assistance devices needed to prevent accidents for one of four residents reviewed for falls, (Resident (R) 78), out of 20 sampled residents. Accidents were not thoroughly investigated, resulting in a failure to identify potential contributing factors. Care plan interventions to prevent falls were not implemented for R78, who sustained multiple falls. Findings include: Review of R78's Face Sheet revealed she was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS), an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period of 01/26/18, indicated under Section C: Cognitive Patterns, the R78's Brief Interview for Mental Status (BIMS) score was 15 of 15, which indicated the resident had intact cognition. Section E: Behavior, indicated the resident did not reject care. Section G: Functional Status, indicated the resident required limited assistance with bed mobility, transfers, ambulation, and dressing, and extensive assistance with toilet use. Section H: Bladder and Bowel, indicated R78 exhibited occasional incontinence of urine. Review of the resident's comprehensive care plan revealed the staff developed a problem related to falls as of 01/19/18. Per the care plan, the resident is at risk for falls related to weakness of core and legs, pain in knees, decreased activity tolerance. Interventions to prevent the goal of no major injury from falls included: Transfer with 1 person assist. Ensure that she is wearing appropriate footwear when walking. Uses rollator. Be sure call light is within reach and encourage her to use it for assistance. Review of R78's fall history, as documented in Resident Incident Report forms, included: a. 04/10/18 at 9:44 PM: Called to Room Per CNA (Certified Nursing Assistant). Resident observed sitting on floor with pants halfway down and blanket on floor with her foot on top of it. Resident stated, I was going to the bathroom and fell on my butt. Review of facility records revealed no evidence that a thorough investigation was conducted in response to this fall. In addition to the Resident Incident Report, the only other evidence of investigation provided by the facility was a three-sentence Incident Investigation form which stated, Root/cause analysis: Noted sitting on floor. Stated she was going to (the) bathroom and fell on her butt. A 3-day bowel and bladder (B & B) patterning assessment to be completed. Review of this information revealed that it failed to thoroughly describe and evaluate all possible contributing factors. For example, the investigation records failed to address the resident's footwear at the time of the fall and identify if the care plan intervention of appropriate footwear had been in place. There was no mention of the resident's call light as to whether it had been in place per the care plan, was used by the resident, and if so, if staff had responded in a timely manner to the resident's need for assistance with toileting. Review of R78's comprehensive care plan revealed that in response to this fall on 04/10/18, the resident's care plan was updated with the new approach of, 3-day B&B patterning assessment. Review of R78's electronic health record (EHR) and the hard copy record, revealed that the B&B patterning assessment was completed. b. 06/07/18 at 4:40 AM: Per the Resident Incident Report, staff were, called to room per resident. Resident observed sitting on buttocks on (the) floor on the right side of the bed. Bed was in (the) lowest position. Resident stated, I was going to the bathroom and slid down on my butt. Review of facility records revealed no evidence that a thorough investigation was conducted in response to this fall. In addition to the Resident Incident Report, the only other evidence of investigation provided by the facility was a two-sentence Incident Investigation form, which stated, Root/cause analysis: Noted sitting on buttocks on right side of bed. To have low bed with mat at bedside. Review of this information revealed that it failed to thoroughly describe and evaluate all possible contributing factors. For example, the investigation records again failed to address the resident's footwear at the time of the fall and determine if the care plan intervention of appropriate footwear had been in place. There was no mention of the resident's call light as to whether it had been in place per the care plan, was used by the resident, and if so, if staff had responded in a timely manner. c. 06/26/18 at 9:00 PM: Per the Resident Incident Report staff was standing at medication cart preparing meds for resident when I heard resident yell out, 'Oh.' When I went into resident's room, resident noted lying on left side on floor in front of the closets.Resident stated, 'I was going to the bathroom and the walker slipped away from me.' Resident then asked to go to the bathroom, as resident stood up with assist, she complaint (sic) of left hip pain when trying to walk. Review of an Accident/Incident Reporting Form - Bureau of Health Facilities Licensing form revealed the facility made a report of this accident to the State Survey Agency (SSA). Per this form, after the fall, the resident was transferred to the hospital, where x-rays showed that the resident had non-displaced fractures of the inferior and superior pubic rami (pelvic) on the L (left) side. Further review of the report to the SSA revealed, Intervention was placed for her to wear non-skid socks or shoes when she starts to ambulate. Review of the investigation records provided by the facility revealed no evidence that a thorough investigation was conducted in response to the fall. Review of the Incident Investigation form revealed, Root cause analysis: Noted lying on left side on floor. Stated going to bathroom and walker slipped away from her. Non-skid socks to be worn when not wearing shoes. Review of the investigation revealed the facility failed to thoroughly assess and address all possible contributing factors. For example, the new intervention was for the resident to have non-skid sock when not wearing shoes. There was no evidence to indicate the facility investigated why this intervention, which had been in place since admission on 01/19/18, was now considered a new intervention. The investigation failed to document what type (if any) footwear the resident was wearing at the time of the fall or assess why (if none was present) the care plan had not been followed. After the resident's fall with fracture on 06/26/18, a significant change assessment MDS, dated [DATE], revealed the resident had experienced declines in cognition and bladder continence, required extensive assistance with bed mobility, transfers, ambulation, and locomotion in a wheelchair, and had developed a Stage II pressure ulcer to the sacrum. A new comprehensive care plan, dated 07/30/18, was developed which showed the resident continued to be at risk for falls and fracture. Review of this care plan revealed the previously identified intervention of 6/7/18 - low bed with mat at bedside was not carried forward to the new care plan, although there was no information to justify why this intervention was no longer necessary. The care plan did continue the interventions of, To wear non-skid socks when not wearing shoes as tolerated and for call light availability. d. 07/28/18 at 1:16 PM: The resident sustained [REDACTED]. Resident stated that she was tryin (sic) to get to the bathroom and slid and (sic) to the ground. Review of the Incident Investigation form revealed Root/Cause Analysis: Noted sitting on floor with back to bed. Stated attempting to go to bathroom. Staff to offer toileting every hour while awake. Review of the investigation records revealed no evidence that the facility thoroughly described the incident and assessed possible contributing factors such as use of footwear or call light availability in accordance with the care plan. e. 08/12/18 at 7:30 AM: The resident was noted on floor in room beside bed per the Resident Incident Report. Per the Incident Investigation the Root/Cause Analysis: Noted on floor in room beside bed. To be placed on frequent checks. There was no evidence of a thorough investigation to determine the possible root causes of the resident's fall. Review of these two investigation records, as well as a Post -Fall Investigation form provided by the facility, revealed no evidence as to whether previously identified care plan interventions, such as appropriate footwear and call light availability, were in use at the time of the fall. f. 08/31/18 at 4:21 PM: The resident was found sitting in floor at foot of bed per the Resident Incident Report. Per the Incident Investigation the Root/Cause Analysis: Noted sitting on floor at foot of bed. A room change provided moving resident closer to nurse's (sic) station. There was no evidence of a thorough investigation to determine the possible root causes of the resident's fall. Review of the investigation records provided no evidence as to whether previously identified care plan interventions, such as appropriate footwear, call light availability, and fall mats were in place at the time of the fall. Observations throughout the survey revealed that previously identified care plan interventions to prevent falls were not consistently implemented. Observation on 09/10/18 at 9:00 AM during the initial tour of the facility, revealed the resident was in bed on her back, complaining of pain due to a spot on my rectum. During this observation, the resident was noted to have a fall mat on the floor next to the left side of her bed. However, there was no fall mat on the right side of the bed. Additional observations of the resident in bed on 09/10/18 at 11:45 AM and 3:50 PM, and on 09/11/18 at 7:35 AM and 5:00 PM, revealed that although there was a fall mat on the floor next to the left side of bed, there was none on the right side of the bed. In addition, observation on 09/11/18 at 5:13 PM revealed that while the resident was in bed, she was noted to be barefoot and not wearing non-skid socks or shoes. During an interview on 09/11/18 at 5:13 PM, Licensed Practical Nurse (LPN) 78 verified that the resident was not wearing anything on her feet. He stated the resident should have been wearing socks while in bed. During this interview, LPN78 stated that the resident (who requires extensive assistance with dressing) will sometimes take off her socks. However, observation at this time revealed there were no socks present in the bed or on the floor nearby to indicate they had been provided by staff and then removed by the resident. Interview on 09/11/18 at 4:45 PM with the Director of Nursing (DON) revealed that she had provided all the facility's investigative information for each fall since the resident's admission. She confirmed the information provided did not constitute a thorough investigation of each fall, as she was unable to answer specific questions about the circumstances of each fall, based on the facility's investigation reports. Further interview with the DON revealed that the facility had identified a problem with staff not completing a thorough investigation after each fall. She provided an Immediate Post - Fall Investigation form and stated that staff should be completing this form after every fall; however, the facility was having problems getting staff to complete these forms so that they could accurately determine root causes. Review of the form revealed it required staff to document multiple factors, including resident and staff interviews, observations of the environment, and a review of medication changes and then determine the Why of the problem. Further interview with the DON revealed that although this process had been in place since at least (MONTH) (YEAR), there were no Immediate Post-Fall Investigation forms for either of the two falls the resident sustained [REDACTED]. Further interview with the DON revealed that prior to the 06/26/18 fall with fracture, the resident was ambulatory. The DON stated that the 06/26/18 fracture occurred when the resident got up out of bed to go to the bathroom and fell . The DON stated at the time of that fall, the resident was not wearing footwear, and as a result, the need for non-skid socks was added to the care plan. When informed that the intervention of appropriate footwear had already been in place since 01/19/18, the DON stated, I don't know why she did not have footwear on. The DON responded, Oh definitely when asked if the resident should have had footwear on at the time of the fall. Further interview with the DON on 09/11/18 at 4:45 PM revealed the DON did not know, based on the investigation records, if R78 had a low bed and a fall mat in place (as per the resident's care plan) at the time of her fall with fracture on 06/26/18. Review of the Medication and Treatment Administration Records revealed that the low bed and mat were in place. After a review of the record, the DON confirmed that the previous intervention of a low bed with fall mat was not carried forward to the new comprehensive care plan when it was revised after the 07/17/18 significant change assessment. She stated it should be on the current care plan, as it was an intervention that was still needed. The DON stated it would make sense to have mats on both sides of the bed, as the resident could fall from either side. The DON stated that prior to the last fall (08/31/18), the resident was in a different room, and only needed one mat due to the placement of her bed against a wall. She stated that R78 was moved closer to the nursing station after her last fall and it appeared staff failed to identify that she now needed a mat for both sides of the bed, due to the placement of her bed in the new room. Interview on 09/11/18 at 5:21 PM with the MDS Coordinator revealed that the care plan intervention for the low bed with fall mat just got missed when the care plan was revised on 07/30/18. She stated that the low bed with fall mat was still a current intervention and should have been included on the new care plan initiated after the significant change assessment. Review of the facility policy titled, Falls Management, revised 02/2017, revealed that it included the following steps: . 4. Staff will implement care approaches per the resident's individual care plan . 8. The following measures will be implemented as indicated post a Fall: Assess and provide care to the resident. Evaluate the fall for new contributing or underlying causes and the resident for any change in condition. Visual inspection of resident and environment and communication with resident and staff. 9. The resident's care plan will be modified and updated as indicated. 10. Nursing staff will identify and implement interventions to try to reduce the risk and minimize consequences of falls.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to use appropriate infection control precautions during the performance of ostomy care for one of two residents observed for dressing changes, (Resident (R) 31), and during the performance of blood sugar testing for one of one resident observed for blood sugar monitoring, (R2). Findings include: 1. Observation on 09/10/18 at 10:35 AM, revealed Licensed Practical Nurse (LPN)59 prepared to change the dressing to R31's stoma site. LPN59 put a pair of uncovered scissors into the right pocket of her scrub-top. After removing the old dressing and cleaning the stoma, LPN59 removed her gloves, but did not sanitize her hands before donning new gloves. LPN59 then dried the area around the stoma with a dry towel and removed her gloves. The LPN did not sanitize her hands before donning new gloves. LPN59 then pulled the scissors from her scrub-top pocket and used the potentially contaminated scissors to cut a new dressing, which she placed around the stoma site. The LPN put the scissors back into the pocket of her scrub-top and removed her gloves. The LPN failed to sanitize her hands. LPN59 then picked up a new pair of gloves from the supply box; however, LPN59 decided not to don the new pair of gloves and then put the potentially contaminated gloves back into the supply box. LPN59 then washed her hands and left the room. During an interview on 09/10/18 at 11:02 AM, LPN59 stated that another nurse (the wound nurse) had cleaned the scissors before giving them to LPN59 to use for the dressing change. LPN59 stated she did put the scissors into the pocket of her scrub-top pocket, and probably should not have done so. LPN59 stated she should have washed her hands after cleaning of the resident's stoma area and before going on to apply the new stoma dressing and bag, and in between the dirty to clean tasks. During an interview on 09/10/18 at 11:49 AM, the wound nurse stated the staff use Sani-cloth Germicidal Disposable wipes to clean their scissors before putting the scissors back into the treatment cart. The scissors were stored in a plastic bag. During an interview on 09/11/18 at 9:20 AM, Corporate Nurse 2 stated, We don't have a policy specific to putting gloves in pockets. We have an infection control policy. A review of the facility's undated policy titled, (Facility name) Infection Prevention and Control, indicated the policy instructed the staff as flows: Procedure: 1. Disposable gloves will be worn by all employees when caring for all patients if there is actual or anticipated contact with blood, bloody body fluid, secretions, mucous membranes or non-intact skin . 3. Hands will be washed with soap and water or cleaned with the instant antiseptic gel after removing gloves. A review of the facility's policy titled, Dressing change (Clean Technique), last updated 08/2016, instructed the staff as follows: . Procedure: 5. Prepare equipment and supplies. Clean scissors with (a) Super Sani-Wipe . 2. Clean the scissors with (a) Super Sani-Wipe and place on a clean corner of your setup, if you need to use scissors again during the procedure. 2. Observation on 09/11/18 at 7:25 AM, revealed LPN78 prepared to perform a blood glucose monitoring test on R2. LPN78 placed a clean pair of gloves into his pants pockets prior to entering the resident's room. After sanitizing his hands, LPN78 reached into his pocket and pulled out the pair of gloves and donned them. LPN78 then performed the resident's blood glucose test while wearing the potentially contaminated gloves. During an interview on 09/11/18 at 7:34 AM, LPN78 stated, (I) probably should get them (gloves) straight out of the box and put them on. (I) probably shouldn't have put them in my pocket. Review of the facility's policy titled, Glucometer (Finger-stick Procedure), last updated 06/2007, instructed staff to wash their hands and apply gloves, and how to prepare the equipment and supplies, but it did not address the transportation of supplies.

Based on observation, interview, and record review, the facility failed to assure effective ongoing pain management for one of two residents (Resident (R) 185) reviewed for pain, out of a sample selection of 20 residents. The facility failed to take action when the resident continued to experience ongoing pain after the discontinuation of a PRN (as needed) pain medication. Findings include: During an interview on [DATE] at 4:05 PM, R185 stated she was a new admission to the facility and was currently receiving therapy services. R185 stated she had been having issues with pain in her back and left leg since she was admitted to the facility. The resident stated she had different orders for pain medication but was still having pain. During the interview as she discussed her pain, the resident was observed to continuously rub her lower back, hip and along the outside of her upper left leg. Review of the resident's Face Sheet revealed she was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Per the resident's admission Minimum Data Set (MDS), an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period, of [DATE], the resident's [DIAGNOSES REDACTED]. The MDS specified under Section C: Cognitive Patterns, R185 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated the resident had no cognitive impairment. Section H: Health Conditions, indicated in the five days prior to being interviewed for the assessment, the resident experienced pain, which limited her day-to-day activities. Review of the resident's Baseline Care Plan revealed the problem of Pain was marked. The care plan noted interventions that included observing for signs and symptoms of pain, as well as Medication as ordered, Monitor for effectiveness, and Report to MD if resident has no reduction or relief of pain PRN. The Baseline Care Plan noted the resident received three medications for pain: [MEDICATION NAME] (opioid pain reliever), [MEDICATION NAME] (muscle relaxer), and [MEDICATION NAME] (nerve pain medication). Review of the resident's [DATE] admission Physician Orders revealed they included: [MEDICATION NAME] HCL ([MEDICATION NAME]) 10 milligrams (mg) Take 1 tablet by mouth every 6 hours as needed for pain x (times) 7 days. The Physician's Orders sheet showed a stop date of this medication of [DATE]. [MEDICATION NAME] ([MEDICATION NAME]) 5 mg, one tablet three times daily (no stop date). [MEDICATION NAME] 800 mg, one tablet three times daily (no stop date). In addition, admission orders [REDACTED]. Use pain scale 0 = no pain to 10 = worst pain .Medicate if in pain. There was no stop date to this order. Review of the resident's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Per this MAR, the resident received [MEDICATION NAME] on: [DATE] at 4:15 PM for a pain level of 5; [DATE] at 1:14 PM for a pain level of 6; [DATE] at 10:54 AM for a pain level of 8; [DATE] at 9:06 AM for a pain level of 8; and [DATE] at 7:55 PM for a pain level of 8. Review of the physician's orders revealed no further orders for any PRN pain medications after the admission order for PRN [MEDICATION NAME] expired on [DATE]. Review of the resident's Notes tab in the electronic health record revealed the resident continued to experience pain after the order for PRN [MEDICATION NAME] was discontinued on [DATE]. These notes included: [DATE] 2:46 PM - Therapy note - Resident reports LB (lower back) discomfort. [DATE] 1:37 PM - Therapy note - Patient requires rest break due to c/o (complaint of) LBP (lower back pain). Patient requests pain medication, consulted with nsg (nursing) who followed up with patient. [DATE] 2:41 PM - LPN (Licensed Practical Nurse) note - Resident c/o pain ,[DATE] to mid-abdomen. PRN pain pill given as ordered and noted to be effective. [DATE] 5:17 PM - LPN note - Resident c/o pain ,[DATE] to lower back. PRN pain pill given as ordered and noted to be effective. [DATE] 12:27 PM - Therapy note - Increased tenderness left lumbar paraspinals noted today. C/O LBP during ambulation, requiring rest breaks between bouts for pain relief. Although the nursing notes on both [DATE] and [DATE] stated the resident received a PRN pain pill due to complaints of pain at a level of ,[DATE] (severe pain), a review of the physician's orders revealed no evidence that the physician was contacted to obtain a new order for PRN pain medication. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview on [DATE] at 9:36 AM with LPN40 revealed that she was aware the resident had ongoing issues with pain. She stated, I know she had surgery on her back, and has pain. I've given her a pain pill before. Interview on [DATE] at 9:41 AM with the Director of Nursing (DON) revealed the resident was monitored each shift for pain. She reviewed the resident's record and stated, I'm not seeing that she has had pain meds ordered since [DATE], although she had required a daily PRN every day prior to the stop date of the [MEDICATION NAME]. After a review of the record, the DON confirmed that the resident was still experiencing pain after the PRN [MEDICATION NAME] was discontinued. The DON stated that after the admission order for the PRN pain medication ended, the physician should have been notified that the resident was still complaining of pain. She stated the facility should have contacted the physician for new orders and did not know why this did not occur. Further interview with the DON confirmed that although nursing staff documented they gave PRN pain medication on [DATE] and [DATE], there was no order for any PRN pain medications. After reviewing the record, the DON stated that although she could see where the resident received her routine [MEDICATION NAME] and [MEDICATION NAME], a review of the MAR indicated [REDACTED]. Interview with Corporate Nurse 2 on [DATE] at 9:50 AM revealed that after surveyor intervention, she went and interviewed the nurse who documented that he gave PRN pain medication on [DATE] and [DATE]. Corporate Nurse 2 stated the LPN told her that he was so used to writing PRN, that's what he put in the nursing note; however, what he actually administered was the resident's regularly scheduled [MEDICATION NAME] and [MEDICATION NAME]. Interview with LPN78 on [DATE] at 10:00 AM confirmed the resident did not have orders for PRN pain medications on the days he had documented that he had given them ([DATE], [DATE]) and what he had actually administered was the resident's routine medications. Review of the facility policy titled, Pain Management, dated ,[DATE], revealed: Resident pain will be identified and addressed with pharmacological and/or non-pharmacological interventions with the goal of pain control to promote comfort and quality of life .Nursing will monitor the effectiveness of the interventions and notify the MD as needed.

Based on observation, interview, record review, and review of the facility's Gastrostomy/PEG Tube Medication Administration policy, the facility failed to ensure the staff flushed the resident's [DEVICE] after medication administration for one of one resident, (Resident (R) 5), reviewed for administration of medication via a [DEVICE]. Findings include: Observation on 09/11/18 at 8:20 AM revealed Licensed Practical Nurse (LPN)78 retrieved, crushed, and mixed several medications in a 5-ounce (oz) plastic disposable cup with 30 cubic centimeters (cc) of water for administration to R5 via the resident's [DEVICE] (gastrostomy tube- a flexible tube placed in the stomach through surgically-created opening in the abdominal wall and stomach). LPN78 first checked for residual gastric volume, and then flushed the [DEVICE] with 30 cc of water. LPN78 then poured the medication mixture from the 5-oz cup into a 60-cc syringe and gravity-fed the medications through the [DEVICE]. After the medication-water mixture had infused, a significant amount of residual medication was left in the bottom of the 5-oz cup. LPN78 used 30 ccs of water, which had been set aside for the final flush of the [DEVICE], to remix the medications in the 5-oz cup. LPN78 then infused the remainder of the medications from the 5-oz cup into the [DEVICE]. Upon the delivery of the medication-water mixture, LPN78 did not conduct a final flush of R5's [DEVICE]. During an interview on 09/11/18 at 8:45 AM, LPN78 stated, I was told you could use the last flush water to clean out the med (medication) cup. Normally, I would re-hook the feeding tube and the water (for automatic flushes), but I'm going to change them out. A review of R5's eMAR (electronic medication administration record) indicated an order, dated 11/28/17, that read, [MEDICATION NAME] 1.5 (a liquid nutritional solution) at 42ml/hr (hour) with 27 ml/hr water flushes continuously via gastrostomy tube. The order failed to include instructions for flushes before and after medication administration. During an interview on 09/11/18 at 10:17 AM, the DON stated the resident's monthly Physician Recap for (MONTH) (YEAR), showed 27 milliliters (ml) per hour of continuous flush with water, but did not address flushing the [DEVICE] before or after the administration of medications. Review of the facility's policy titled, Gastrostomy/PEG tube Medication Administration, last updated on 01/2013, indicated the policy instructed the staff as follows: . Procedure: 16. After medication administration is completed, provide a 30-cc flush as ordered.

Based on observation, interview, and record review, the facility failed to assure that one (Resident (R) 1) of three residents reviewed for range of motion (ROM) out of a sample of 20 residents, received services in accordance with her plan of care to prevent further decline in ROM. Findings include: Observations on 09/10/18 at 9:30 AM, 11:27 AM, 12:02 PM, 1:01 PM, 4:56 PM, and 09/11/18 at 11:45 AM revealed R1 had limitations in range of motion on both sides of the body and sat in a motorized wheelchair which she operated by using her thumb to push a switch. The resident's hands were contracted, with the fingers of both hands in bent positions, affecting her ability to use them in a normal fashion. Interview with R1 on 09/10/18 at 1:01 PM revealed she was waiting for staff to feed her lunch, saying, I need help because she could not feed herself. Review of R1's Face Sheet revealed she was a long-term resident with [DIAGNOSES REDACTED]. Review of OT (Occupational Therapy) - Therapy Progress and Discharge Summary records revealed the resident last received skilled therapy services in (YEAR). At that time, the resident received therapy services for range of motion issues in the upper extremities (shoulder and elbow). Review of Restorative Nursing forms revealed the resident was placed on a restorative nursing program on 12/01/16 for passive range of motion (PROM) to both lower extremities three times per week to maintain flexibility and ROM. A Restorative Nursing communication form, dated 04/18/17, also revealed the resident was to receive ROM to both upper extremities five times per week. Review of the resident's Care Plan revealed that it included a problem for, ADLs (Activities of Daily Living), with a target (completion) date of 11/01/18. Per the care plan, the resident is unable to perform ADLs r/t (related to) (the) effects of [MEDICAL CONDITION]. She is at risk for decreased flexibility and ROM in BLE (bilateral lower extremities) d/t (due to) (the) effects of [MEDICAL CONDITION]. Approaches to meet the goal of maintaining flexibility and ROM included, RNP (Restorative Nursing Program) 3x/week for PROM to BLE to maintain flexibility and ROM. The care plan also listed an intervention for the RNP to provide range of motion for the bilateral upper extremities; however, this intervention had a line drawn through it, indicating that it was no longer current. Review of Departmental Notes by Registered Nursing (RN) staff on 08/14/18 and 09/03/18 revealed notes stating, RNP continues 3x wk (week) for PROM to bilateral lower extremities to maintain flexibility and ROM. However, review of the Restorative CNA (certified nursing assistant) Roster revealed R1 did not receive ROM three times per week on a consistent basis as directed in her care plan. For example: Week of 08/12/18 - did not receive one of three ROM sessions. Week of 08/19/18 - did not receive one of three ROM sessions. Week of 08/26/18 - did not receive two of three ROM sessions. Week of 09/02/18 - did not receive one of three ROM sessions. During an interview on 09/11/18 at 12:50 PM, CNA51 stated she was the restorative aide routinely assigned to R1. She stated she provided PROM to R1's lower extremities and used a little weight when providing ROM for her arms. CNA51 stated she worked Monday - Friday; however, she could get pulled for other stuff and was not able to provide restorative services when that occurred. CNA51 stated on any day that ROM was provided, it was documented, and If she's (R1) not getting (PROM) three times a week, it's because I'm pulled to the floor (to perform routine nurse aide duties). During an interview on 09/11/18 at 12:53 PM, the Director of Nursing (DON) stated if the resident's care plan called for ROM three times per week, she (R1) should be receiving those services. The DON stated there were two restorative CNAs. However, if one of the two restorative aides were off work or pulled away from restorative services due to other staffing needs, the remaining restorative aide would have up to 40 residents and can't get them all done. Further interview with the DON revealed the restorative staff, normally doesn't get pulled more than once per week and confirmed this could explain why R1 was consistently not receiving all three days of ROM as care planned.

Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure a clean and comfortable environment free of the growth of a black substance in one of four shower rooms. Findings include: Observation of shower room D on 09/10/18 at 10:34 AM with the Environmental Director (ED), revealed a black substance along the base of the wall where the wall met the floor that measured approximately 18 inches in length and 0.25 inches in width. This wall contained the shower head and shower controls. The black substance was also observed at the base of the left (as facing the controls) sidewall where it met the floor and measured approximately 12 inches in length and 0.25 inches in width. The ED was able to scrape off the substance with his pocketknife. The black substance was also observed in the corner of the walls along the caulk/grout line. This area measured approximately 8 inches in length and 0.25 inches in width. Observation of the soap dispenser that was attached to the wall revealed more of the black substance behind the soap dispenser. During an interview at this same time, the ED confirmed the presence of the black substance at the base of the two walls and behind the soap dispenser on the wall. Continued observation revealed when the soap dispenser was opened, additional amounts of the black substance were found inside the dispenser. The ED scraped off the substance with his pocketknife. The ED closed the shower room for use until it could be cleaned. During an interview on 09/10/18 at 10:42 AM, Housekeeper (HSKP) 12 confirmed the black substance located at the base of the walls and behind the soap dispenser attached to the wall. At 11:20 AM, HSKP12 stated the old soap dispenser had been removed, the area cleaned with bleach, and a new dispenser mounted was on the wall. HSPK12 also stated, I never thought to look behind the soap dispenser. During an interview on 09/10/18 at 4:42 PM, with the Administrator and the ED, the Administrator and the ED both stated the shower rooms were to be cleaned daily. They both confirmed there was no documentation to show the cleaning has been completed, and that confirmation is provided by general oversight by staff. Review of the facility's policy titled, Environmental Services Guidelines dated 07/2017, indicated for the routine cleaning of horizontal surfaces, the policy directed the staff as follows: Horizontal surfaces such as tabletops, window ledges, beside stands, counters, sinks, tubs, shower floors, toilet seats, floors etc. will be cleaned daily with an acceptable disinfectant/germicide. This procedure will vary with the item being cleaned. For cleaning of other surfaces, the policy directed the staff as follows: Doorknobs, handrails, bath rails, sink handles, etc. will all be cleaned at least once daily and as needed.

Based on observation, interview and record review it was determined the facility failed to ensure a resident who self-administered medication was assessed as safe to do so. Failure to assess Resident #92's ability to self-administer, obtain physician's orders [REDACTED]. Findings include: RESIDENT #92 Observation of the resident's bedside table on 04/24/17 at 8:16 a.m. revealed three bottles of eye drops, an unlabeled orange prescription bottle with a lotion like substance, and two bottles of nasal spray with the labels marked out in black ink. In an interview at that time, Resident #92 stated the lotion was his magic cream, the nasal spray bottles contain Listerine that he sprays in his face (to kill germs), and the eye drops are different over the counter treatments. He explained he asked family members to bring these items to him as he previously used them at home and wanted to continue to do so. He stated he used each of the substances whenever, on no schedule and did not notify staff or record the administration. He stated staff had not asked him about the items on the over the bed table, that were visible. Review of the resident's record on 04/26/17 at 8:12 a.m. revealed Resident #92 admitted in 01/2017. Review of physician's orders [REDACTED]. In an interview on 04/26/17 at 8:43 a.m., Registered Nurse 87 stated if a resident wanted to self administer medication, the nurse would contact the physician to determine if it was safe. Nursing staff would then educate the resident about the administration of the medication and have the resident demonstrate their ability to do so safely. Registered Nurse 87 stated she had not had any resident request self-administration since she started as Unit Manager ten months earlier. When the multiple medications at Resident #92's bedside were described, along with his admission of self-administration, Registered Nurse 87 stated she was not aware of the medications at the resident's bedside. She stated staff should have identified the medications / treatments, assessed the resident's ability to self-administer and gotten physician's orders [REDACTED].

Based on record review and interview the facility failed to ensure Resident #75 received physician ordered medication prior to [MEDICAL TREATMENT] for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. Resident #75 did not receive [MEDICATION NAME] Mag DR on [MEDICAL TREATMENT] days. The Findings Included: The facility admitted Resident #56 with a [DIAGNOSES REDACTED]. Review of the Physicians Orders and the Medication Administration Record [REDACTED]. On further investigation, it was noted that the medication was not given on Tuesdays, Thursdays, or Saturdays. The dates omitted were as follows: 06/23/2016, 06/25/2016, 06/28/2016, 07/02/2016, 07/05/2016, 07/07/2016, 07/09/2016, and 07/12/2016. Review of the nursing documentation for these dates revealed .was not administered-Resident not available. When asked about the omitted doses on the MAR indicated [REDACTED].

Based on observation, interview and review of the facility policy titled, Meal Service, the facility failed to distribute and serve food under sanitary conditions for 1 of 2 Units. Certified Nursing Assistant (CNA)#1, was entering rooms and setting up trays without cleansing hands. The findings included: An observation on 7/11/2017 at approximately 12:17 PM of the lunch meal service on the C Hall revealed CNA staff delivering trays to resident rooms without cleansing hands prior to setting up the meal trays. Further observation on 7/14/2016 at approximately 12:30 PM of the lunch meal service on the C Hall revealed CNA #1 distributing meal trays. He/she was entering rooms with the lunch trays, pulling the cord to a light fixtures, handling oxygen tubing, and the bed control apparatus. He/she then proceeded to remove the straw from the paper cover and insert it into the tea. Then CNA #1 removed the eating utensils from the paper wrap, open the food items. He/she was not observed cleansing his/her hands after handling the light fixture cord, the oxygen tubing and the bed control apparatus. During an interview on 7/14/2016 at approximately 12:32 PM with CNA #1, he/she confirmed that after delivering the tray to the resident, he/she did pull the cord to the over bed light and turn on the light. CNA #1 confirmed that he/she did remove the oxygen tubing from a residents nostrils and raised the head of the bed using the bed control apparatus, and proceeded to set up the meal tray without first cleansing his/her hands. Review on 7/14/2016 at approximately 1:00 PM of the facility policy titled, Meal Service, revealed under Procedure, reads under number 2, Hand hygiene is performed per staff as indicated.

Based on record review, interviews, and review of the facility policy titled, Behavior Management, the facility failed to review and revise the Plan of Care for Resident #80 to include rejection of care for 1 of 1 resident reviewed for Behavior and Emotional Status. The findings included: The facility admitted Resident #80 with [DIAGNOSES REDACTED]. Review on 7/12/2016 at approximately 12:39 PM of the MDS (minimum Data Set) assessments, for Resident #80, dated 1/19/2016 and 2/3/2016 revealed Section E- Behavior, E0800 - Rejection of Care: Presence and frequency coded as (2). Behavior of this type occurred 4 to 6 days, but less than daily. Further review on 7/12/2016 at approximately 12:39 PM of the MDS assessments dated 3/4/2016 and 3/31/2016, for Resident #80, revealed Section E - Behavior, E0800, Rejection of Care, coded as a (3), Behavior of this type occurred daily. Review on 7/12/2016 at approximately 12:39 PM of the MS assessment dated [DATE] revealed Section E, Behavior, E0800, Rejection of Care coded as a (1), Behavior of this type occurred 1 to 3 days. No documentation could be found in the medical record as to what care Resident #80 was rejecting. Review 7/12/2016 at approximately 3:42 PM of the Plan of Care for Resident did indicate that Resident #80 was non compliant with turning and repositioning and he/she was encouraged to do so. Also, included on the plan of care was that, at times Resident #80 would choose not to take a protein supplement. During an interview on 7/13/2016 at approximately 8:40 AM with Licensed Practical Nurse (LPN) #1, Care Plan Coordinator, stated, at times the resident would choose not to take the protein supplement. He/she went on to say, since the resident chose not to take the protein supplement as ordered 1 time daily, it is now ordered and being offered, 2 times daily. This surveyor asked how he/she received the information that the resident was rejecting care and she went on to say, the Certified Nursing Assistants (CNAs) will let him/her know, but confirmed that no documentation could be found in the medical record as to what care was being rejected. An interview on 7/13/2016 at approximately 9:44 AM with Registered Nurse (RN) #1 confirmed, that Resident #80 is non compliant at times with turning and repositioning, but he/she is encouraged to do so. No problem of resident rejecting care was found on the plan of care nor were there interventions in place to ensure Resident #80 was receiving the appropriate care and services to meet his/her needs related to the rejection of care. During an interview on 7/14/2016 at approximately 9:15 AM with RN #2, he/she stated,there are no behavior monitoring sheets for Resident #80 since he/she is not receiving any medications for behaviors that would warrant monitoring. Review on 7/14/2016 at approximately 9:15 AM of the facility policy titled, Behavior Monitoring, revealed under Policy, reads, :It is the policy of this facility to observe and assess resident behavior and implement interventions to address behavior issues. The Purpose, reads, To implement interventions to address behavior issues to promote the quality of life, safety and well being of all residents. Under Procedure, reads, The interdisciplinary team will collaborate on residents exhibiting behaviors and implement interventions to address these behaviors.

Based on record review, interviews and review ot the facility policy titled, Behavior Management, the facility failed to ensure the appropriate treatment and services were provided for Resident #80 to ensure interventions were in place for rejection of care for 1 of 1 resident reviewed for Behavioral and Emotional Status. The findings included: The facility admitted Resident #80 with [DIAGNOSES REDACTED]. Review on 7/12/2016 at approximately 12:39 PM of the MDS (minimum Data Set) assessments, for Resident #80, dated 1/19/2016 and 2/3/2016 revealed Section E- Behavior, E0800 - Rejection of Care: Presence and frequency coded as (2). Behavior of this type occurred 4 to 6 days, but less than daily. Further review on 7/12/2016 at approximately 12:39 PM of the MDS assessments dated 3/4/2016 and 3/31/2016, for Resident #80, revealed Section E - Behavior, E0800, Rejection of Care, coded as a (3), Behavior of this type occurred daily. Review on 7/12/2016 at approximately 12:39 PM of the MS assessment dated [DATE] revealed Section E, Behavior, E0800, Rejection of Care coded as a (1), Behavior of this type occurred 1 to 3 days. No documentation could be found in the medical record as to what care Resident #80 was rejecting. During an interview on 7/13/2016 at approximately 8:40 AM with Licensed Practical Nurse (LPN) #1, Care Plan Coordinator, stated, at times the resident would choose not to take the protein supplement. He/she went on to say, since the resident chose not to take the protein supplement as ordered 1 time daily, it is now ordered and being offered, 2 times daily. This surveyor asked how he/she received the information that the resident was rejecting care and she went on to say, the Certified Nursing Assistants (CNAs) will let him/her know, but confirmed that no documentation could be found in the medical record as to what care was being rejected. An interview on 7/13/2016 at approximately 9:44 AM with Registered Nurse (RN) #1 confirmed, that Resident #80 is non compliant at times with turning and repositioning, but he/she is encouraged to do so. No problem of resident rejecting care was found on the plan or care nor were there interventions in place to ensure Resident #80 was receiving the appropriate care and services to meet his/her needs related to the rejection of care. During an interview on 7/14/2016 at approximately 9:15 AM with RN #2, he/she stated,there are no behavior monitoring sheets for Resident #80 since he/she is not receiving any medications for behaviors that would warrant monitoring. Review on 7/14/2016 at approximately 9:15 AM of the facility policy titled, Behavior Monitoring, revealed under Policy, reads, :It is the policy of this facility to observe and assess resident behavior and implement interventions to address behavior issues. The Purpose, reads, To implement interventions to address behavior issues to promote the quality of life, safety and well being of all residents. Under Procedure, reads, The interdisciplinary team will collaborate on residents exhibiting behaviors and implement interventions to address these behaviors.

Based on observation, interview and review of the facility policy entitled, "Storage of Drugs," the facility failed to follow a procedure to ensure medications were properly stored in 1 of 4 medication carts. A discontinued narcotic was stored with current medication for administration in the medication cart. In addition, based on observations and interviews, the facility failed to safely store medication on 1 of 2 units. A prescription external medication was observed stored in an unsecured area in a resident room, accessible to residents. The findings included: Observation of the A Hall medication cart on the East Wing on 3/12/2015 at approximately 11:50 AM revealed 67 discontinued Hydrocodone 10/325 milligram tablets stored on the medication cart. The last administration date of the Hydrocodone was 2/27/2015. During an interview on 3/12/2015 at approximately 11:50 AM, Registered Nurse #1, the Unit Manager of the A Hall East Wing, verified the findings and stated, "The discontinued medications are given to the Director of Nursing and are locked up until destroyed." The facility policy entitled "Storage of Drugs" states: "All drugs in the medication cart shall be stored under the following conditions: ... 7. Discontinued drugs shall be returned to the provider pharmacy for destruction. Any Schedule II, III, IV or V drugs will be given to the D.O.N. (Director of Nursing), to remain locked up for disposal by proper personnel at a later date." Observation on 3/9/2015 at approximately 12:16 PM revealed a liquid prescription medication, Dakin's Solution, which contains the active ingredient Sodium Hypochlorite, in a resident's room on the bedside table. The label clearly stated, "Do Not Take Internally - For External Use Only." It was brought to the attention of the Administrator and was removed from the resident's room. An observation on 3/12/2015 at approximately 9:15 AM revealed the same bottle of Dakin's Solution, unsecured in the resident's room in a clear plastic box. During an interview on 3/12/2015 at approximately 10:00 AM, Registered Nurse #2, Unit Manager of the West Hall, verified the findings and the bottle of Dakin's Solution was once again removed from the resident's bedside table. On 3/12/2015 at approximately 10:20 AM, the Administrator provided a list of 20 residents who were cognitively impaired and self-mobile throughout the facility and who could have accessed the unsecured solution.

On the days of the Complaint and Extended Survey, based on record reviews, observations and interviews, the facility failed to provide social services to maintain the physical, mental and psychosocial well-being of 4 of 6 residents with behaviors, and/or psychosocial needs. The Social Service Director failed to adequately assess, monitor and evaluate Residents A, #2, #5, and #11 related to resident to resident abuse. The findings included: Cross refers to F-319 Psychosocial Needs as it relates to the failure of the facility to provide interventions to promote psychosocial well being for four of six residents identified with psychosocial issues. Three residents, Resident A, #2, and #11, had physical or verbal altercations with Resident #5. Resident #5 shared a room at sometime during his admission to the facility with each of the residents. Cross refers to F-323 Accident Hazards/supervision/devices, Residents A, #2, and #11 were allegedly involved in a resident to resident altercation with Resident #5 due to the failure of the facility to ensure that each resident receives adequate supervision and assistance to prevent harm (4 of 6 residents reviewed). The residents were not placed in an environment to promote their safety. All three residents and/or families expressed fear of Resident #5. Review of the Departmental Notes dated 1/5/14 at 12:30 PM for Resident #2 documented that when the nurse was called to Resident #2's room he alleged that his roommate (Resident #5) hit him and attempted to put the sheet down his throat. Documentation indicated that the Social Worker saw the resident the next day (1/6/14) at 4:44 PM and apologized for the incident. At 4:13 PM on 1/7/14 the family and resident was notified of a roommate change. Following the incident on 1/5/14 Resident #5 was transferred to the emergency room for evaluation and returned to the facility at 6:10 PM the same day. Resident #5 was not moved out of the room with Resident #2 until 1/7/14 at approximately 4:29 PM. After 1/6/14 there was no documented Social Work follow up with Resident #2 regarding this incident. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 1/27/14 included a problem for "Anxiety R/T (related to) fear D/T (due to) hx (history of aggressive resident contact". Interventions included to "provide reassurance that he is safe. On 2/6/14 an intervention was added, "Room change to increase feelings of security." Resident #5 admitted to the facility with [DIAGNOSES REDACTED]. Review of the resident's Departmental Notes (nurse's notes and social work notes) from 9/13/13 through 3/13/14 documented the incident on 1/5/14 with his roommate, Resident #2. On 1/6/14 at 4:48 PM the Social Worker (SW) note indicated she talked with Resident #5 regarding the incident with Resident #2. "SW asked what happened when he hit his roommate and tried to put a sheet in his mouth. ... (resident) stated that it happened two nights ago. He said that his roommate called him an SOB and he didn't hit him hard. He also said he laid the sheet on top of his mouth. SW discussed that hitting another resident was inappropriate and unacceptable behavior. Resident changed the subject and would not discuss the matter any more. 1/7/14 4:29 PM social service notes stated, "Resident and RP (responsible party), notified of the room change." On 1/7/14, Resident #5 was moved to another room. Review of Resident #5's Departmental Nurse's Note from 1/11/14 through 2/26/14 documented behaviors on 1/11/2014 at 2:00 AM of curing and walking toward staff member with hands balled up. Social Work notes indicated she met with the resident on 1/13/14 around 1:30 PM regarding his behavior the evening prior. "SW continued to redirect the resident but he kept changing the subject..." From 1/16/14 through 1/21/14 documentation included the resident trying to remove his gastrostomy tube and fears of being poisoned. He continued to display agitated and combative behaviors; he pulled out his gastrostomy tube on 1/17/14. On 1/21/14 he expressed a fear that lions were after him. Continued review of the Departmental Notes indicated that Resident #5 was sent out to the emergency roiagnom on 1/22/2014 at 4:36 PM as a result of an incident when a CNA reported to the nurse that Resident (#5) lunged at his roommate (Resident #11) attempting to attack him. Resident (#5) stated, 'My roommate had a knife with holes in it and said he was going to stab me where it hurts.' Res has been noted with paranoia and stated the same story about his previous roommate..." On 2/5/2014 1:19 PM Resident was readmitted to the facility with [DIAGNOSES REDACTED].#11 on 1/22/14 Resident #5 became Resident A's roommate. The Departmental Notes following the readmission revealed no Social Work notes. On 2/8/14 nursing documented the resident asking about his brother's death. The Departmental Notes on 2/25/14 at 8:20 AM stated, "CNA reported that she went to resident's room to check on him this morning and resident had the bed pushed against the door, CNA had to force the door open to get in and noted that resident (#5) was standing over his roommate (Resident A) with no clothes on staring at his roommate... Resident was immediately placed on 1:1 supervision. 1:1 supervision was not in place when this incident occurred, the facility staff documented that the resident pushed a bed against the door and the staff forced the door open. Res was noted this morning telling staff that 'all the black men in here are trying to rape him.' Res is hearing voices of multiple people say that 'we going to get him, we going to rape him ' MD made aware of resident hallucinations and behaviors, awaiting new orders..." The first documented Social Work note following the residents readmission on 2/5/14 was on 2/26/2014 at 2:26 PM, SW spoke with resident regarding his paranoid and delusional thoughts. SW asked him to tell her what was going on with him. SW also asked resident about him saying people wanted to rape him. Resident did not comprehend SW and he was not lucid. Resident #5 was transported to a psychiatric hospital at 1:23 PM, on 2/26/14. Review of Resident #5's care plan revealed a care plan originally dated 9/10/13 for Mood and Behavior. The care plan was updated on 1/5/14 Physical behavior towards others. Interventions included to remind resident it is not appropriate to have physical behavior towards others, educated resident to inform staff when upset with another resident, psych evaluation as indicated, and 1:1 Supervision as indicated. The care plan was updated again on 1/21/14 for Delusions and seeing "lions eating hogs " believes staff is trying to poison him, and again on 2/25/14 with delusions, hallucinations and undressing self. Review of Resident #11 current medical record revealed no documentation related to an incident on 1/22/14 at 4:36 PM when a CNA reported to the nurse that Resident (#5) lunged at his roommate Resident #11attempting to attack him. Resident #11 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #11 with a BIMS (brief interview of mental status) of 15 indicating no cognitive impairment. Review of the Social Services notes for 1/22/2014 at 4:15 PM revealed that the resident is self-responsible and was made aware of his room change. In an interview with the surveyor on 3/14/14 at 9:00 AM Resident #11 was asked if he had ever had a room change? He responded he had four room changes since admission. He stated in January he was in the room with a man for about 5 minutes. "I was in the room first and on 1:1 observation with a CNA. Then 10 minutes later, Resident (#5) was brought to the room for 5 minutes. He (Resident #5) had a reputation for attacking people. One time I saw him grabbing at the Social Workers' breasts. I saw him grabbing at other nurse's breast area. He made sexual and physical statements out loud at the nurse's desk when I was sitting there. I was in the room and he shouted at me and lunged at me. He shouted, 'He is coming at me with a knife.' No contact was made because the CNA intervened between me and him. The CNA grabbed him and told him he could not be in the room with me. She told him that he cannot stay in here and he was taken out of the room immediately. I was afraid and scared. I did not want him in my room to begin with and I told the Social Worker. The Social Worker laughed at me and said 'Yes, he will be your roommate.' The Social Worker told me he was moving in my room. I was upset to begin with that I was getting him as a roommate before the incident happened during his 5-minute stay in my room." Review of Resident A's current medical record revealed no documentation of an incident that occurred on 2/25/14 at 8:20 AM when a CNA reported that she went to the resident's room to check on him and the resident had the bed pushed against the door, the CNA had to force the door open to get in and noted that resident (#5) was standing over his roommate (Resident A) with no clothes on staring at his roommate. Resident A admitted to the facility with [DIAGNOSES REDACTED]. Resident A had a BIMS Score (Brief Interview for Mental Status) of 15 on the most current assessment. The resident had no memory problem and was able to make decisions regarding his daily care. The surveyor on 3/14/14 interviewed the resident at approximately 11:10 AM. The resident stated that he had changed rooms because he had a problem with a roommate. The roommate was wandering all night, sleeping all day. The resident stated that he had a roommate who had threatened to kill him. Calling him "a snake". The resident stated he was kind of afraid of the resident after the incident but kinda not. He stated he could keep an eye on the roommate, "but you have to sleep " The resident stated he was worried the resident would be his roommate on his return to the unit. Resident stated the incident occurred a couple of weeks ago and no one had come to talk to him about the incident. Review of Resident A's Departmental Notes (including Nurses and Social Services Notes) from 1/1/2014 through 3/13/2014 revealed no social services notes. In an interviewed with the surveyor on 3/13/14 at approximately 10:30 AM the Social Services Director (SSD) stated that Resident #5 was sent out for a psych evaluation on 1/22/14 and returned on 2/5/14 or 2/6/14. The SSD confirmed that Resident #2's family wanted a room change because Resident #5 went into the room and frightened them. She stated that they did not want their family member on the same hall with Resident #5. The Social Service Director stated that Resident #5 had been placed on 1:1 on 1/6/14 and was sent out that day. (Record review revealed that Resident #5 was sent out on 1/5/14 and returned the same day.) She added that on 1/7/14 Resident #5 changed rooms and remained on 1:1. The SSD stated the resident went out on 1/22/14 for psych evaluation and they (hospital) sent him to a psychiatric hospital. Per the SSD when Resident #5 returned they deemed the resident to be safe to self and others and the resident's physician increased his Risperdol dose. She stated that the resident left the faciity on [DATE] and was discharged to another psychiatric hospital on [DATE]. The SSD stated that anytime the resident exhibited behaviors he was sent out. During the interview she denied any knowledge of the facility behavior monitoring documentation. The ED (Executive Director (Administrator) was interviewed by the surveyor on 3/13/14 at approximately 11:25 AM. She stated that any resident on a psych med received behavior monitoring. Nursing was responsible for the monitoring. "Nursing does sheets. I don't know if Social Services knows. SS notified in the morning meetings and as needed." The ED stated the Social Worker was responsible for the psychosocial needs of the residents. The behavior monitoring sheets were requested for resident #5. Behavior and Mood sheets were provided. January 5, 2014 there was no documentation. Explanation was resident was in hospital. On 1/16/14 Wandering and resisting care was checked for the night shift. 1/17/14 at 3:25 resident was documented to be not available. No other behaviors were noted in January. February 11, 2014 wandering was checked for the night shift. Socially Inappropriate behavior was checked for 2/17/14 at 7:15. 2/25/14 wandering was checked at 6:56. There were no behaviors documented for physical or verbal abusive behaviors. The Administrator, Director of Nursing, and a Corporate Representative were present on 3/14/14 at 11:30 AM when advised that Immediate Jeopardy had been identified after consulting with the State Agency. The facility submitted an Allegation of Compliance (AOC), which was reviewed and approved on 3/19/14. The AOC included the following: "...1. Resident #5 was sent to a psychiatric facility on 2/27/14. On 3/14/14 at 9:30 am, the Administrator notified the psychiatric facility that Resident #5 would not be accepted back to the facility. On 3/14/14, the Social service Director met with Resident #11 to discuss his voiced fear on 3/14/14 related to resident to resident abuse incident on 1/22/13 and to assure him that Resident #5 was not returning to the facility. Resident #11 has been seeing a licensed professional counselor on an outpatient basis since 10/31/13. On 3/17/14 Resident #11's care plan was reviewed and updated per Nurse Assessment Coordinator and Social Service Director regarding voiced fear related to resident to resident abuse. Resident #11 (he is his own responsible party) was notified on 3/17/14 for input on the care plan and updates to the Psychosocial Care plan per Social Service Director. Additional interventions to Resident #11's psychosocial care plan to address expressed fear include: *Reinforcement that life is not over and there is much good he can do in life per Nursing and Social Services *Provide opportunities to read, study and interact with others per Activities *Continue to provide laptop computer with internet, encourage journaling on internet, encourage positive influences. Try to exercise positive thinking, keep positive outlets or expression of emotional needs per Activities, Social Services and Nursing *Engage in active communication in politics and world events per Activities and Nursing On 3/14/14, Resident A was identified as having a psychosocial problem related to fear of another resident. On 3/14/14, Resident A was interviewed per the Social Service Director related to his fear related to incident on 2/05/14. On 3/17/14 Social Service Director and Nurse Assessment Coordinator developed the psychosocial care plan problem to include the following interventions: *Observe for signs of anxiety related to fear, inquire about anxious feelings, encourage to verbalize feelings and concerns, provide assurance that he will be kept safe from harm per Social Services and Nursing staff *Discuss feelings of fear per Social Service Director On 3/17/14, the Social Service Director met with Resident #2 to assure him that Resident #5 was not returning to the facility. On 3/17/14, the Care plan for Resident #2 was reviewed and updated per Social Service Director and Nurse Assessment Coordinator. Resident #2's responsible party was notified of updates to the Psychosocial Care plan goal per the Nurse Assessment Coordinator and the Social Service Director on 3/17/14 to the following goal: *Resident will verbalize he feels safe without fear or anxiety with goal met on 3/17/14 Resident to Resident Abuse policy and Behavior Management policies were reviewed and updated per Administrator, DON, and CCO on 3/17/14. The updates include Social Service Director assessment, monitoring, and evaluation of resident behaviors and interventions related to resident to resident abuse. The Administrator educated the Social Service Director on revised policies and procedures for Behavior Management and Resident to Resident Abuse on 3/17/14 and Social Service Director verbalized understanding of new policies and procedures... 2. To identify any resident with fear related to resident to resident abuse, all interviewable residents were interviewed by the Social Service Director on 3/17/14. (1) resident was identified and care plan was updated on 3/17/14 per Nurse Assessment Coordinator and Social Service Director. On 3/18/14, all resident's nurse's notes and social service notes since 1/1/14 were reviewed by RN Unit Managers using a behavior audit tool and (1) resident was identified with behaviors that may affect other residents. The behaviors were previously addressed and care planned on 3/14/14 for the (1) resident per Nurse Assessment Coordinator and Social Service Director. On 3/18/14 the nurse's notes and social service notes of residents who are not interviewable were reviewed back to 1/1/14 per RN Unit Managers to identify any evidence of change in their behavior that may indicate fear of resident to resident abuse and no such behavior changes were identified. All resident's care plans were reviewed on 3/17/14 by the Nurse Assessment Coordinator to identify other residents with aggressive behaviors who could elicit fear to ensure appropriate interventions are care planned and to determine if residents have psychosocial Care plans to address individual needs... 3. The Director of Nursing and RN Unit Managers provided one on one education utilizing the Behavior Management policy/procedure and a Help Guide explaining Behavior recognition and management including but not limited to how to handle and report behaviors. Education was initiated on 3/14/14 through 3/17/14 and will be ongoing with new hires in orientation and annually for staff. Staff will not be allowed to report to work until one on one behavior education is provided. Effective 3/14/14, the CNA's were educated to report any resident behaviors to nurse and nurses were educated to document any behaviors in the nurse's notes. RN Unit Managers and RN Supervisors were educated per the DON on additional responsibility of reviewing all resident nurse's notes and social service notes, completing the daily behavior monitoring tool which identifies resident behaviors, interventions MD/Responsible Party notification, and DON, Administrator, and Social service notification for resident to resident abuse immediately. The completed behavior monitoring audit tool will be forwarded to the DON and the Social Service Director daily effective 3/14/14. The DON, Social Services Director, and RN supervisor on the weekends will initiate interventions as needed and provide oversight of the implementation of those interventions effective 3/14/14. The Social Service Director will review and maintain a copy of the behavior audit tools in a notebook in her office effective 3/14/14. The Social Service Director was educated on the Behavior monitoring audit tool and the updated policy and procedure for Behavior Monitoring on 3/17/14 per the Administrator and verbalized understanding. The Social Service Director will assess resident behaviors identified per Behavior Monitoring Tool and provide follow-up monitoring and evaluation of behaviors and additional interventions as indicated effective 3/14/14. Resident behaviors will be addressed and appropriate interventions will be developed in the Daily Stand-Up Meeting (Monday-Friday) per RN Unit Managers/Nurse Assessment Coordinator, DON, Administrator, Social Service Director, Rehab and Activities Director effective 3/18/14. Effective 3/15/14, the weekend RN Supervisor will address behaviors identified per behavior monitoring tool, utilizing the care plan and additional interventions as deemed appropriate to include notification of the Social Service Director, DON and/or Administrator of resident to resident abuse or the potential for resident to resident abuse. Effective 3/14/14, the Nurse Assessment Coordinator and Social Service Director will review the psychosocial plans of care on a monthly basis for 3 months and then quarterly per MDS/Care Plan schedule to ensure residents have appropriate individualized interventions. On 3/18/14, the Administrator, DON and CCO reviewed the Resident to Resident Abuse and Behavior Management policies and updated the Social Services Director job description including assessment, monitoring and evaluation of resident behaviors and interventions related to resident to resident abuse. Compliance completed 3/18/14" Observations, interviews, and review of policies revealed the allegation of compliance developed by the facility on 3/14/14 had been implemented and were in practice removing the immediacy. Facility nursing staff had been educated and was knowledgeable of the policy. The Administrator was informed of this on 3/19/2014. The Immediate Jeopardy and Substandard Quality of Care at, F-250 was lowered to a "D" as of 3/18/14.

On the days of the Complaint and Extended Survey, based on record reviews, observation and interviews the facility failed to provide interventions to promote psychosocial well being for four of six residents identified with psychosocial issues. Three residents, Resident A, #2, and #11, had physical or verbal altercations with resident #5. Resident #5 shared a room at sometime during his admission to the facility with each of the listed residents. The findings included: Cross refers to F-250 Social Services as it relates to the failure of the facility to provide social services to maintain the physical, mental and psychosocial well-being of 4 of 6 residents with behaviors, and/or psychosocial needs. The Social Service Director failed to adequately assess, monitor and evaluate Residents A, #2, #5, and #11 related to resident to resident abuse. Cross refers to F-323 Accident Hazards/supervision/devices, Residents A, #2, and #11 were allegedly involved in a resident to resident altercation with Resident #5 due to the failure of the facility to ensure that each resident receives adequate supervision and assistance to prevent harm (4 of 6 residents reviewed). The residents were not placed in an environment to promote their safety. All three residents and/or families expressed fear of Resident #5. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 1/27/14 included a problem for "Anxiety R/T (related to) fear D/T (due to) hx (history of aggressive resident contact". Interventions included to "provide reassurance that he is safe. On 2/6/14 an intervention was added, "Room change to increase feelings of security." Review of Resident #2's Departmental Notes, which included Nurse's Notes and Social Services Notes revealed a Nurse's Note on 1/5/14 at 2:34 PM. "12:30 PM Nurse called into room. Resident stated that roommate (Resident #5) hit him and attempted to put sheet down his throat. Roommate immediately removed from room and separated from resident..." 1/6/14 4:44 PM Social Services Notes stated, "SW (Social Worker) met with ____(Resident #2) in his room regarding the altercation on Sunday 1/5/14. SW apologized for that happening to him. He said that he was scared when it happened. SW told him they were working on solving the situation.". 1/7/14 4:13 PM Social Service note stated, "Resident and (family member) made aware of roommate change..." 2/6/14 11:17 AM Social Service note stated "Resident (#2) and family requested a room change. Resident and family notified that resident will be moved..." Review of the Resident Incident Report dated 1/5/14 recorded an incident that occurred on "1/5/14... Resident (#2) stated that roommate (#5) hit him and tried to stuff sheet down his throat... Immediate Post-Incident Action: "Roommate separated from resident. Roommate (sic) placed on 1:1 immediately." Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the resident's Departmental Notes (nurse's notes and social work notes) from 9/13/13 through 3/13/14 revealed on 1/5/14 at 1:40 PM, the Nurse was called to resident's room and made aware by Resident #2 that his roommate (Resident #5) attempted to stuff a sheet down his throat and hit him in the face. "resident's immediately separated. Resident (#5) stated that he did not hit the roommate but did put a sheet over roommates mouth to stop cursing him. Resident placed at nurse's station for supervision. Supervisor and Physician made aware" Orders were received on 1/5/14 to send the resident to the hospital for a psych evaluation. At 6:15 PM on 1/5/14 the resident returned from the hospital. On 1/6/14 at 4:48 PM the Social Worker (SW) note indicated she talked with Resident #5 regarding the incident with Resident #2. "SW asked what happened when he hit his roommate and tried to put a sheet in his mouth. ...(resident) stated that it happened two nights ago. He said that his roommate called him an SOB and he didn't hit him hard. He also said he laid the sheet on top of his mouth. SW discussed that hitting another resident was inappropriate and unacceptable behavior. Resident changed the subject and would not discuss the matter any more." 1/7/14 4:29 PM social service stated, "Resident and RP (responsible party), notified of the room change." Resident #5 remained in the same room with Resident #2 for 2 nights following the incident on 1/5/14. On 1/7/14, Resident #5 was moved to another room. Review of Resident #5's Departmental Nurse's Note from 1/11/14 through 2/26/14 documented the following behaviors: 1/11/2014 2:00 AM, "Resident up out of bed cursing at CNA (Certified Nursing Assistant), caring for other resident in room c/o that she was disturbing him and that so and so radio. Resident roommate responded yes when asked if he was watching his television. Resident out of bed and threw linen on floor and proceeded down hallway to other side of facility, when asked where he was going, he started cursing and walking toward staff member with hands balled up, then turned around and went down B hall, called nurse on other side to inform that resident was upset and to let him walk around and maybe calm down and to make sure he does not disturb any other residents. There was no evidence Resident #5 was on 1:1 supervision at this time. 1/13/2014 2:29 AM, "Resident remains on sofa near nurses station, refuses to go to room and to let staff change soiled clothing, removes wet jeans and brief and throws on floor beside sofa, after several attempts able to ambulate with resident down to room..." Social Services Notes (SS) 1/14/14 1:35 PM: "SW met with resident on 1/13/14 around 1:30 pm regarding his behavior the evening prior. SW continued to redirect the resident but he kept changing the subject..." 1/16/2014 1:39 PM, "Resident up at present saying that the DR. (doctor) has to remove this thing out of my stomach or it will choke me (gastrostomy tube)." 1/16/2014 2:07 PM, "SW and OT (Occupational Therapy) spoke with resident in SW's office. He was paranoid stating someone was poisoning his food. He said he thinks it is the girl who has blonde hair. Both professionals told him that he was mistaken and that no one had poisoned his food. He was continuously paranoid during their conversation with him. He also said, 'they may as well get a gun and shoot me.' When asked why he stated because they were talking about poisoning him. Resident became extremely agitated and got up out of his wheelchair... SW phoned to let Dr. know about his paranoia increasing... Dr. had already seen him and increased resident's medication." 1/17/2014 1:14 AM, "...Has been attempting to pull GT (gastrostomy tube) out..." 3:27 AM "Resident has pulled G Tube out with bulb fully inflated. Small amount of blood noted at site... Resident combative". 1/21/2014 10:40 AM "Res. came to nurses station stating, 'there is a lion after me, he already ate all the pigs we had.' Reassured resident that he was safe here and there was no lion here." 1/22/2014 4:17 PM Social Service noted, Resident and RP was made aware of the room change. 1/22/2014 7:15 PM, "Res out to hospital ER (emergency room ) at 4:36 PM." (see late entry below for 1/22/14 at 4:10 PM) 1/23/2014 8:02 AM "Res out toER on [DATE] at 4:36 PM for Psychological evaluation." 1/23/2014 2:39 PM, "Late Entry 1/22/14 at 4:10 pm. Called to resident's room, CNA reported that resident (#5) lunged at his roommate (Resident #11) attempting to attack him. Resident was removed from room immediately, Resident (#5) stated, 'My roommate had a knife with holes in it and said he was going to stab me where it hurts.' Res has been noted with paranoia and stated the same story about his previous roommate. MD made aware. New orders noted." 1/27/2014 11:42 Social Service noted, Late Entry: "SW notified son that resident had been sent from the psych unit to a psych hospital." 2/5/2014 1:19 PM Resident was readmitted to the facility with [DIAGNOSES REDACTED].#11, Resident #5 became Resident A's room mate.) 2/25/2014 10:51 AM, Late Entry 2/25/14 at 8:20 am. CNA reported that she went to resident's room to check on him this morning and resident had the bed pushed against the door, CNA had to force the door open to get in and noted that resident (#5) was standing over his roommate (Resident A) with no clothes on staring at his roommate... Resident was immediately placed on 1:1 supervision. "Res was noted this morning telling staff that 'all the black men in here are trying to rape him.' Res is hearing voices of multiple people say that 'we going to get him, we going to rape him' MD made aware of resident hallucinations and behaviors, awaiting new orders." 1:1 supervision was apparently not in place during this incident, the facility staff documented that the resident pushed a bed against the door and the staff forced the door open. 2/26/2014 at 2:26 PM, "SW spoke with resident regarding his paranoid and delusional thoughts. SW asked him to tell her what was going on with him. SW also asked resident about him saying people wanted to rape him. Resident did not comprehend SW and he was not lucid." Resident #5 was transported to a psychiatric hospital at 1:23 PM, on 2/26/14. Review of the resident's care plan revealed a care plan originally dated 9/10/13 for Mood and Behavior. The care plan was updated on 1/5/14 Physical behavior towards others. Interventions included to remind resident it is not appropriate to have physical behavior towards others, educated resident to inform staff when upset with another resident, psych evaluation as indicated, and 1:1 Supervision as indicated. The care plan was updated again on 1/21/14 for Delusions and seeing "lions eating hogs" believes staff is trying to poison him , and again on 2/25/14 with delusions, hallucinations and undressing self. Review of the Physician's Progress Notes revealed on 1/9/14 the MD documented resident with "...psych disorder reviewed ER visit watch behaviors closely." 1/16/14, "Pt (patient) at times delusional, chest cl(ear), pt angry and uncooperative... Trys to pull his PEG out I will increase [MEDICATION NAME] and start [MEDICATION NAME] for his own protection." 1/21/14 "Pt persists with paranoid ideation 'We are trying to poison him seeing lions in room and ate all his hogs'. Increase [MEDICATION NAME] may need to increase [MEDICATION NAME] again he is not sedated." 2/19/14 "Yells out often... on [MEDICATION NAME]." 2/20/14 "He is having paranoid delusions. Thinks people are trying to kill him and God talks to him from the phone and walls. Will increase meds as he has acted out before if he becomes over sedated will decrease antipsychotics." Resident #11 entered the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #11 with a BIMS (brief interview of mental status) of 15 indicating no cognitive impairment. Review of the Social Services notes for 1/22/2014 at 4:15 PM revealed that the resident is self-responsible and was made aware of his room change. In an interview with the surveyor on 3/14/14 at 9:00 AM Resident #11 was asked if he had ever had a room change? He responded he had four room changes since admission. In January he stated he was in the room with a man for about 5 minutes. "I was in the room first and on 1:1 observation with a CNA. Then 10 minutes later, Resident (#5) was brought to the room for 5 minutes. He (Resident #5) had a reputation for attacking people. One time I saw him grabbing at the Social Workers' breasts. I saw him grabbing at other nurses breast area. He made sexual and physical statements out loud at the nurses desk when I was sitting there." I was in the room and he shouted at me and lunged at me. He shouted, 'He is coming at me with a knife.' No contact was made because the CNA intervened between me and him. The CNA grabbed him and told him he could not be in the room with me. She told him that he cannot stay in here and he was taken out of the room immediately. I was afraid and scared. I did not want him in my room to begin with and I told the Social Worker. The Social Worker laughed at me and said 'Yes, he will be your room mate.' The Social Worker told me he was moving in my room. I was upset to begin with that I was getting him as a roommate before the incident happened during his 5-minute stay in my room. I was on 1:1 with a CNA because I was having thoughts of depression..." Resident #11 stated that he had heard Resident #5 make statements about his brother saying, "My brother was shot and came back to life. Someone threatened to stab me in the heart the boy who paints." Resident#11 stated, "I did not go near him because I was afraid of him. Review of Resident #11's Departmental Notes from July 2013 through 3/14/14 revealed no notes regarding an incident between Resident #5 and Resident #11 on 1/22/14. Resident A was admitted to the facility with [DIAGNOSES REDACTED]. The surveyor on 3/14/14 interviewed the resident at approximately 11:10 AM. The resident stated that he had a roommate who was standing beside his (Resident A) bed with his hands balled into fists saying he had to "kill the snake." The resident stated that he didn't need to put his call light on because the staff heard the roommate and responded right away and the roommate was placed in another room and was gone the next day. The resident stated he was kind of afraid of the resident after the incident but kinda not. He stated he could keep an eye on the roommate, "but you have to sleep" The resident stated he was worried the resident would be his roommate on his return to the unit. Resident stated the incident occurred a couple of weeks ago and no one had come to talk to him about the incident. He stated that he did not know who the social worker was. Review of Resident A's Departmental Notes (including Nurses and Social Services Notes) from 1/1/2014 through 3/13/2014 revealed no social services notes. There was no documentation of the 2/25/14 incident with Resident #5 in the Nurse's Notes. Resident A had a BIMS Score (Brief Interview for Mental Status) of 15 on the most current assessment. The resident had no memory problem and was able to make decisions regarding his daily care. The Director of Nursing (DON) was interviewed on 3/14/14 at approximately 3:05 PM regarding the 2/25/14 incident. The DON stated there was no incident report. "No one aware of incident." The DON stated that the "CNA reported the resident (A) was on side asleep". Although the DON stated no one was aware of the incident a review of the Nurse's Notes documented a late entry on 2/25/2014 at 10:51 AM that stated on 2/25/14 at 8:20 AM, "CNA reported that she went to resident's room to check on him this morning and resident had the bed pushed against the door, CNA had to force the door open to get in and noted that resident (#5) was standing over his roommate (Resident A) with no clothes on staring at his roommate... MD made aware of resident hallucinations and behaviors, awaiting new orders. The Nurse's Note does not indicated that 1:1 supervision was in place during this incident, the facility staff documented that the resident pushed a bed against the door and the staff forced the door open. Further documentation on 2/26/2014 at 2:26 PM indicated the Social Worker (SW) spoke with the resident regarding his paranoid and delusional thoughts. SW asked him to tell her what was going on with him. The Resident #5 was transported to a psychiatric hospital at 1:23 PM, on 2/26/14. On 3/14/14 the surveyor requested from the Director of Nurses a copy of the 1:1 documentation for Resident #5. At 12:10 PM the DON gave the surveyor a list of sitters for the whole building. The surveyor again asked for Resident #5's 1:1 information, the DON provided a sitters log with Resident #5's name and dates for 1/5 through 1/26/14; no 1:1 log for February 2014 was provided. The behavior monitoring sheets were requested for Resident #5. The Behavior and Mood Sheets were provided. Review of the Behavior Mood Sheets revealed no documentation for the incident on January 5, 2014. The explanation was that the resident was in the hospital. On the Behavior and Mood Sheets for 1/16/14 wandering and resisting care was checked for the night shift; 1/17/14 at 3:25 resident was documented to be not available. No other behaviors were noted on the January 2014 sheets. On the February 11, 2014, sheet, wandering was checked for the night shift; socially inappropriate behavior was checked for 2/17/14 at 7:15; 2/25/14 wandering was checked at 6:56. No physically or verbally abusive behaviors were documented on the sheets. In an interviewed with the surveyor on 3/13/14 at approximately 10:30 AM the Social Services Director (SSD) stated that Resident #5 was sent out for a psych evaluation on 1/22/14 and returned on 2/5/14 or 2/6/14. The SSD confirmed that Resident #2's family wanted a room change because Resident #5 went into the room and frightened them. She stated that they did not want their family member on the same hall with Resident #5. The Social Service Director stated that Resident #5 had been placed on 1:1 on 1/6/14 and was sent out that day. (Record review revealed that Resident #5 was sent out on 1/5/14 and returned the same day.) She added that on 1/7/14 Resident #5 changed rooms and remained on 1:1. The SSD stated the resident went out on 1/22/14 for psych evaluation and they (hospital) sent him to a psychiatric hospital. Per the SSD when Resident #5 returned they deemed the resident to be safe to self and others and the resident's physician increased his [MEDICATION NAME] dose. She stated that the resident left the faciity on [DATE] and was discharged to another psychiatric hospital on [DATE]. The SSD stated that anytime the resident exhibited behaviors he was sent out. During the interview she denied any knowledge of the facility behavior monitoring documentation. In an interview with the surveyor on 3/13/14 at approximately 11:25 AM the ED (Executive Director (Administrator) stated that any resident on a psych med received behavior monitoring and that nursing was responsible for the monitoring. "Nursing does sheets. I don't know if Social Services knows. Social Service notified in the morning meetings and as needed." The ED stated the Social Worker was responsible for the psychosocial needs of the residents. The Administrator, Director of Nursing, and a Corporate Representative were present on 3/14/14 at 11:30 AM when advised that Immediate Jeopardy had been identified after consulting with the State Agency. The facility submitted an Allegation of Compliance (AOC), which was reviewed and approved on 3/19/14. The AOC included the following: "...1. Resident #5 was sent to a psychiatric facility on 2/27/14. On 3/14/14 at 9:30 am, the Administrator notified the psychiatric facility that Resident #5 would not be accepted back to the facility. On 3/14/14, the Social service Director met with Resident #11 to discuss his voiced fear on 3/14/14 related to resident to resident abuse incident on 1/22/13 and to assure him that Resident #5 was not returning to the facility. Resident #11 has been seeing a licensed professional counselor on an outpatient basis since 10/31/13. On 3/17/14 Resident #11's care plan was reviewed and updated per Nurse Assessment Coordinator and Social Service Director regarding voiced fear related to resident to resident abuse. Resident #11 (he is his own responsible party) was notified on 3/17/14 for input on the care plan and updates to the Psychosocial Care plan per Social Service Director. Additional interventions to Resident #11's psychosocial care plan to address expressed fear include: *Reinforcement that life is not over and there is much good he can do in life per Nursing and Social Services *Provide opportunities to read, study and interact with others per Activities *Continue to provide laptop computer with internet, encourage journaling on internet, encourage positive influences. Try to exercise positive thinking, keep positive outlets or expression of emotional needs per Activities, Social Services and Nursing *Engage in active communication in politics and world events per Activities and Nursing On 3/14/14, Resident A was identified as having a psychosocial problem related to fear of another resident. On 3/14/14, Resident A was interviewed per the Social Service Director related to his fear related to incident on 2/05/14. On 3/17/14 Social Service Director and Nurse Assessment Coordinator developed the psychosocial care plan problem to include the following interventions: *Observe for signs of anxiety related to fear, inquire about anxious feelings, encourage to verbalize feelings and concerns, provide assurance that he will be kept safe from harm per Social Services and Nursing staff *Discuss feelings of fear per Social Service Director On 3/17/14, the Social Service Director met with Resident #2 to assure him that Resident #5 was not returning to the facility. On 3/17/14, the Care plan for Resident #2 was reviewed and updated per Social Service Director and Nurse Assessment Coordinator. Resident #2's responsible party was notified of updates to the Psychosocial Care plan goal per the Nurse Assessment Coordinator and the Social Service Director on 3/17/14 to the following goal: *Resident will verbalize he feels safe without fear or anxiety with goal met on 3/17/14 Resident to Resident Abuse policy and Behavior Management policies were reviewed and updated per Administrator, DON, and CCO on 3/17/14. The updates include Social Service Director assessment, monitoring, and evaluation of resident behaviors and interventions related to resident to resident abuse. The Administrator educated the Social Service Director on revised policies and procedures for Behavior Management and Resident to Resident Abuse on 3/17/14 and Social Service Director verbalized understanding of new policies and procedures... 2. To identify any resident with fear related to resident to resident abuse, all interviewable residents were interviewed by the Social Service Director on 3/17/14. (1) resident was identified and care plan was updated on 3/17/14 per Nurse Assessment Coordinator and Social Service Director. On 3/18/14, all resident's nurse's notes and social service notes since 1/1/14 were reviewed by RN Unit Managers using a behavior audit tool and (1) resident was identified with behaviors that may affect other residents. The behaviors were previously addressed and care planned on 3/14/14 for the (1) resident per Nurse Assessment Coordinator and Social Service Director. On 3/18/14 the nurse's notes and social service notes of residents who are not interviewable were reviewed back to 1/1/14 per RN Unit Managers to identify any evidence of change in their behavior that may indicate fear of resident to resident abuse and no such behavior changes were identified. All resident's care plans were reviewed on 3/17/14 by the Nurse Assessment Coordinator to identify other residents with aggressive behaviors who could elicit fear to ensure appropriate interventions are care planned and to determine if residents have psychosocial Care plans to address individual needs... 3. The Director of Nursing and RN Unit Managers provided one on one education utilizing the Behavior Management policy/procedure and a Help Guide explaining Behavior recognition and management including but not limited to how to handle and report behaviors. Education was initiated on 3/14/14 through 3/17/14 and will be ongoing with new hires in orientation and annually for staff. Staff will not be allowed to report to work until one on one behavior education is provided. Effective 3/14/14, the CNA's were educated to report any resident behaviors to nurse and nurses were educated to document any behaviors in the nurse's notes. RN Unit Managers and RN Supervisors were educated per the DON on additional responsibility of reviewing all resident nurse's notes and social service notes, completing the daily behavior monitoring tool which identifies resident behaviors, interventions MD/Responsible Party notification, and DON, Administrator, and Social service notification for resident to resident abuse immediately. The completed behavior monitoring audit tool will be forwarded to the DON and the Social Service Director daily effective 3/14/14. The DON, Social Services Director, and RN supervisor on the weekends will initiate interventions as needed and provide oversight of the implementation of those interventions effective 3/14/14. The Social Service Director will review and maintain a copy of the behavior audit tools in a notebook in her office effective 3/14/14. The Social Service Director was educated on the Behavior monitoring audit tool and the updated policy and procedure for Behavior Monitoring on 3/17/14 per the Administrator and verbalized understanding. The Social Service Director will assess resident behaviors identified per Behavior Monitoring Tool and provide follow-up monitoring and evaluation of behaviors and additional interventions as indicated effective 3/14/14. Resident behaviors will be addressed and appropriate interventions will be developed in the Daily Stand-Up Meeting (Monday-Friday) per RN Unit Managers/Nurse Assessment Coordinator, DON, Administrator, Social Service Director, Rehab and Activities Director effective 3/18/14. Effective 3/15/14, the weekend RN Supervisor will address behaviors identified per behavior monitoring tool, utilizing the care plan and additional interventions as deemed appropriate to include notification of the Social Service Director, DON and/or Administrator of resident to resident abuse or the potential for resident to resident abuse. Effective 3/14/14, the Nurse Assessment Coordinator and Social Service Director will review the psychosocial plans of care on a monthly basis for 3 months and then quarterly per MDS/Care Plan schedule to ensure residents have appropriate individualized interventions. On 3/18/14, the Administrator, DON and CCO reviewed the Resident to Resident Abuse and Behavior Management policies and updated the Social Services Director job description including assessment, monitoring and evaluation of resident behaviors and interventions related to resident to resident abuse. Compliance completed 3/18/14" Observations, interviews, and review of policies revealed the allegation of compliance developed by the facility on 3/14/14 had been implemented and were in practice removing the immediacy. Facility nursing staff had been educated and was knowledgeable of the policy. The Administrator was informed of this on 3/19/2014. The Immediate Jeopardy and Substandard Quality of Care at, F-319 was lowered to a scope and severity of "D" as of 3/18/14.

On the days of the Complaint and Extended Survey, based on record reviews, observations and interviews, Residents A, #2, and #11 were allegedly involved in a resident to resident altercation with Resident #5 due to the failure of the facility to ensure that each resident receives adequate supervision and assistance to prevent harm (4 of 6 residents reviewed). The residents were not placed in an environment to promote their safety. All three residents and/or families expressed fear of Resident #5. The findings included: Cross refers to F-250 Social Services as it relates to the failure of the facility to provide social services to maintain the physical, mental and psychosocial well-being of 4 of 6 residents with behaviors, and/or psychosocial needs. The Social Service Director failed to adequately assess, monitor and evaluate Residents A, #2, #5, and #11 related to resident to resident abuse. Cross refers to F-319 Psychosocial Needs as it relates to the failure of the facility to provide interventions to promote psychosocial well being for four of six residents identified with psychosocial issues. Three residents, Resident A, #2, and #11, had physical or verbal altercations with Resident #5. Resident #5 shared a room at sometime during his admission to the facility with each of the residents. Review of the Departmental Notes dated 1/5/14 at 12:30 PM for Resident #2 documented that when the nurse was called to Resident #2's room he alleged that his roommate (Resident #5) hit him and attempted to put the sheet down his throat. Documentation indicated that the Social Worker saw the resident the next day (1/6/14) at 4:44 PM and apologized for the incident. At 4:13 PM on 1/7/14 the family and resident was notified of a roommate change. Resident #5 was not moved out of the room with Resident #2 until 1/7/14 at approximately 4:29 PM. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 1/27/14 included an identified problem with anxiety related to his fear due to a history of aggressive resident contact. Interventions included providing reassurance that he would be safe. On 2/6/14 an intervention was added for a room change to increase his feelings of security. Resident #5 admitted to the facility with [DIAGNOSES REDACTED]. Review of the resident's Departmental Notes (nurse's notes and social work notes) from 9/13/13 through 3/13/14 documented the incident on 1/5/14 with his roommate, Resident #2. On 1/6/14 at 4:48 PM the Social Worker (SW) note indicated she talked with Resident #5 regarding the incident with Resident #2. "SW asked what happened when he hit his roommate and tried to put a sheet in his mouth. ... (resident) stated that it happened two nights ago. He said that his roommate called him an SOB and he didn't hit him hard. He also said he laid the sheet on top of his mouth. SW discussed that hitting another resident was inappropriate and unacceptable behavior. Resident changed the subject and would not discuss the matter any more. On 1/7/14 4:29 PM social service notes stated, "Resident and RP (responsible party), notified of the room change." On 1/7/14, Resident #5 was moved to another room. Review of Resident #5's Departmental Nurse's Note from 1/11/14 through 2/26/14 documented behaviors on 1/11/2014 at 2:00 AM of cursing and walking toward staff member with hands balled up. From 1/16/14 through 1/21/14 documentation included the resident trying to remove his gastrostomy tube and fears of being poisoned. He continued to display agitated and combative behaviors; he pulled out his gastrostomy tube on 1/17/14. On 1/21/14 he expressed a fear that lions were after him. Continued review of the Departmental Notes indicated that Resident #5 was sent out to the emergency roiagnom on 1/22/2014 at 4:36 PM as a result of an incident when a CNA reported to the nurse that Resident (#5) lunged at his roommate (Resident #11) attempting to attack him. Resident (#5) stated, 'My roommate had a knife with holes in it and said he was going to stab me where it hurts.' Res has been noted with paranoia and stated the same story about his previous roommate..." On 2/5/2014 1:19 PM Resident was readmitted to the facility with [DIAGNOSES REDACTED].#11 on 1/22/14 Resident #5 became Resident A's roommate. The Departmental Notes on 2/25/14 at 8:20 AM stated, "CNA reported that she went to resident's room to check on him this morning and resident had the bed pushed against the door, CNA had to force the door open to get in and noted that resident (#5) was standing over his roommate (Resident A) with no clothes on staring at his roommate..." Resident was immediately placed on 1:1 supervision. 1:1 supervision was not in place when this incident occurred, the facility staff documented that the resident pushed a bed against the door and the staff forced the door open. The 2/25/14 notes further stated that the resident was noted this morning telling staff that 'all the black men in here are trying to rape him.' The physician was notified due to the resident hearing voices of multiple people say that 'we going to get him, we going to rape him '. Resident #5 was transported to a psychiatric hospital at 1:23 PM, on 2/26/14. Review of Resident #5's care plan revealed a care plan originally dated 9/10/13 for Mood and Behavior. The care plan was updated on 1/5/14 Physical behavior towards others. Interventions included to remind the resident it is not appropriate to have physical behavior towards others, educated resident to inform staff when upset with another resident, psych evaluation as indicated, and 1:1 Supervision as indicated. The care plan was updated again on 1/21/14 for Delusions and seeing "lions eating hogs " believes staff is trying to poison him, and again on 2/25/14 with delusions, hallucinations and undressing self. Review of Resident #11 current medical record revealed no documentation related to an incident on 1/22/14 at 4:36 PM when a CNA reported to the nurse that Resident (#5) lunged at his roommate Resident #11 attempting to attack him. Resident #11 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #11 with a BIMS (brief interview of mental status) of 15 indicating no cognitive impairment. Review of the Social Services notes for 1/22/2014 at 4:15 PM revealed that the resident is self-responsible and was made aware of his room change. In an interview with the surveyor on 3/14/14 at 9:00 AM Resident #11 was asked if he had ever had a room change? He responded he had four room changes since admission. He stated in January he was in the room with a man for about 5 minutes. "I was in the room first and on 1:1 observation with a CNA. Then 10 minutes later, Resident (#5) was brought to the room for 5 minutes. He (Resident #5) had a reputation for attacking people. One time I saw him grabbing at the Social Workers' breasts. I saw him grabbing at other nurse's breast area. He made sexual and physical statements out loud at the nurse's desk when I was sitting there. I was in the room and he shouted at me and lunged at me. He shouted, 'He is coming at me with a knife.' No contact was made because the CNA intervened between me and him. The CNA grabbed him and told him he could not be in the room with me. She told him that he cannot stay in here and he was taken out of the room immediately. I was afraid and scared. I did not want him in my room to begin with and I told the Social Worker. The Social Worker laughed at me and said 'Yes, he will be your roommate.' The Social Worker told me he was moving in my room. I was upset to begin with that I was getting him as a roommate before the incident happened during his 5-minute stay in my room." Review of Resident A's current medical record revealed no documentation of an incident that occurred on 2/25/14 at 8:20 AM when a CNA reported that she went to the resident's room to check on him and the resident had the bed pushed against the door, the CNA had to force the door open to get in and noted that resident (#5) was standing over his roommate (Resident A) with no clothes on staring at his roommate. Resident A admitted to the facility with [DIAGNOSES REDACTED]. Resident A had a BIMS Score (Brief Interview for Mental Status) of 15 on the most current assessment. The resident had no memory problem and was able to make decisions regarding his daily care. The surveyor on 3/14/14 interviewed the resident at approximately 11:10 AM. The resident stated that he had changed rooms because he had a problem with a roommate. The roommate was wandering all night, sleeping all day. The resident stated that he had a roommate who had threatened to kill him. Calling him "a snake". The resident stated he was kind of afraid of the resident after the incident but kinda not. He stated he could keep an eye on the roommate, "but you have to sleep " The resident stated he was worried the resident would be his roommate on his return to the unit. Resident stated the incident occurred a couple of weeks ago and no one had come to talk to him about the incident. In an interview with the surveyor on 3/13/14 at approximately 10:30 AM the Social Services Director (SSD) stated that Resident #5 was sent out for a psych evaluation on 1/22/14 and returned on 2/5/14 or 2/6/14. The SSD confirmed that Resident #2's family wanted a room change because Resident #5 went into the room and frightened them. She stated that they did not want their family member on the same hall with Resident #5. The Social Service Director stated that Resident #5 had been placed on 1:1 on 1/6/14 and was sent out that day. (Record review revealed that Resident #5 was sent out on 1/5/14 and returned the same day.) She added that on 1/7/14 Resident #5 changed rooms and remained on 1:1. The SSD stated the resident went out on 1/22/14 for psych evaluation and they (hospital) sent him to a psychiatric hospital. Per the SSD when Resident #5 returned they deemed the resident to be safe to self and others and the resident's physician increased his Risperdol dose. She stated that the resident left the faciity on [DATE] and was discharged to another psychiatric hospital on [DATE]. The Director of Nursing (DON) was interviewed on 3/14/14 at approximately 3:05 PM regarding the 2/25/14 incident. The DON stated there was no incident report. "No one aware of incident." The DON stated that the "CNA reported the resident (A) was on side asleep". Although the DON stated no one was aware of the incident a review of the Nurse's Notes documented a late entry on 2/25/2014 at 10:51 AM that stated on 2/25/14 at 8:20 AM, "CNA reported that she went to resident's room to check on him this morning and resident had the bed pushed against the door, CNA had to force the door open to get in and noted that resident (#5) was standing over his roommate (Resident A) with no clothes on staring at his roommate... MD made aware of resident hallucinations and behaviors, awaiting new orders. The Nurse's Note does not indicate that 1:1 supervision was in place during this incident, the facility staff documented that the resident pushed a bed against the door and the staff forced the door open. On 3/14/14 the surveyor requested from the Director of Nurses a copy of the 1:1 documentation for Resident #5. At 12:10 PM the DON gave the surveyor a list of sitters for the whole building. The surveyor again asked for Resident #5's 1:1 information, the DON provided a sitters log with Resident #5's name and dates for 1/5 through 1/26/14; no 1:1 log for February 2014 was provided. The Administrator, Director of Nursing, and a Corporate Representative were present on 3/14/14 at 11:30 AM when advised that Immediate Jeopardy had been identified after consulting with the State Agency. The facility submitted an Allegation of Compliance (AOC), which was reviewed and approved on 3/19/14. The AOC included the following: "...1. Resident #5 was sent to a psychiatric facility on 2/27/14. On 3/14/14 at 9:30 am, the Administrator notified the psychiatric facility that Resident #5 would not be accepted back to the facility. On 3/14/14, the Social service Director met with Resident #11 to discuss his voiced fear on 3/14/14 related to resident to resident abuse incident on 1/22/13 and to assure him that Resident #5 was not returning to the facility. Resident #11 has been seeing a licensed professional counselor on an outpatient basis since 10/31/13. On 3/17/14 Resident #11's care plan was reviewed and updated per Nurse Assessment Coordinator and Social Service Director regarding voiced fear related to resident to resident abuse. Resident #11 (he is his own responsible party) was notified on 3/17/14 for input on the care plan and updates to the Psychosocial Care plan per Social Service Director. Additional interventions to Resident #11's psychosocial care plan to address expressed fear include: *Reinforcement that life is not over and there is much good he can do in life per Nursing and Social Services *Provide opportunities to read, study and interact with others per Activities *Continue to provide laptop computer with internet, encourage journaling on internet, encourage positive influences. Try to exercise positive thinking, keep positive outlets or expression of emotional needs per Activities, Social Services and Nursing *Engage in active communication in politics and world events per Activities and Nursing On 3/14/14, Resident A was identified as having a psychosocial problem related to fear of another resident. On 3/14/14, Resident A was interviewed per the Social Service Director related to his fear related to incident on 2/05/14. On 3/17/14 Social Service Director and Nurse Assessment Coordinator developed the psychosocial care plan problem to include the following interventions: *Observe for signs of anxiety related to fear, inquire about anxious feelings, encourage to verbalize feelings and concerns, provide assurance that he will be kept safe from harm per Social Services and Nursing staff *Discuss feelings of fear per Social Service Director On 3/17/14, the Social Service Director met with Resident #2 to assure him that Resident #5 was not returning to the facility. On 3/17/14, the Care plan for Resident #2 was reviewed and updated per Social Service Director and Nurse Assessment Coordinator. Resident #2's responsible party was notified of updates to the Psychosocial Care plan goal per the Nurse Assessment Coordinator and the Social Service Director on 3/17/14 to the following goal: *Resident will verbalize he feels safe without fear or anxiety with goal met on 3/17/14 Resident to Resident Abuse policy and Behavior Management policies were reviewed and updated per Administrator, DON, and CCO on 3/17/14. The updates include Social Service Director assessment, monitoring, and evaluation of resident behaviors and interventions related to resident to resident abuse. The Administrator educated the Social Service Director on revised policies and procedures for Behavior Management and Resident to Resident Abuse on 3/17/14 and Social Service Director verbalized understanding of new policies and procedures... 2. To identify any resident with fear related to resident to resident abuse, all interviewable residents were interviewed by the Social Service Director on 3/17/14. (1) resident was identified and care plan was updated on 3/17/14 per Nurse Assessment Coordinator and Social Service Director. On 3/18/14, all resident's nurse's notes and social service notes since 1/1/14 were reviewed by RN Unit Managers using a behavior audit tool and (1) resident was identified with behaviors that may affect other residents. The behaviors were previously addressed and care planned on 3/14/14 for the (1) resident per Nurse Assessment Coordinator and Social Service Director. On 3/18/14 the nurse's notes and social service notes of residents who are not interviewable were reviewed back to 1/1/14 per RN Unit Managers to identify any evidence of change in their behavior that may indicate fear of resident to resident abuse and no such behavior changes were identified. All resident's care plans were reviewed on 3/17/14 by the Nurse Assessment Coordinator to identify other residents with aggressive behaviors who could elicit fear to ensure appropriate interventions are care planned and to determine if residents have psychosocial Care plans to address individual needs... 3. The Director of Nursing and RN Unit Managers provided one on one education utilizing the Behavior Management policy/procedure and a Help Guide explaining Behavior recognition and management including but not limited to how to handle and report behaviors. Education was initiated on 3/14/14 through 3/17/14 and will be ongoing with new hires in orientation and annually for staff. Staff will not be allowed to report to work until one on one behavior education is provided. Effective 3/14/14, the CNA's were educated to report any resident behaviors to nurse and nurses were educated to document any behaviors in the nurse's notes. RN Unit Managers and RN Supervisors were educated per the DON on additional responsibility of reviewing all resident nurse's notes and social service notes, completing the daily behavior monitoring tool which identifies resident behaviors, interventions MD/Responsible Party notification, and DON, Administrator, and Social service notification for resident to resident abuse immediately. The completed behavior monitoring audit tool will be forwarded to the DON and the Social Service Director daily effective 3/14/14. The DON, Social Services Director, and RN supervisor on the weekends will initiate interventions as needed and provide oversight of the implementation of those interventions effective 3/14/14. The Social Service Director will review and maintain a copy of the behavior audit tools in a notebook in her office effective 3/14/14. The Social Service Director was educated on the Behavior monitoring audit tool and the updated policy and procedure for Behavior Monitoring on 3/17/14 per the Administrator and verbalized understanding. The Social Service Director will assess resident behaviors identified per Behavior Monitoring Tool and provide follow-up monitoring and evaluation of behaviors and additional interventions as indicated effective 3/14/14. Resident behaviors will be addressed and appropriate interventions will be developed in the Daily Stand-Up Meeting (Monday-Friday) per RN Unit Managers/Nurse Assessment Coordinator, DON, Administrator, Social Service Director, Rehab and Activities Director effective 3/18/14. Effective 3/15/14, the weekend RN Supervisor will address behaviors identified per behavior monitoring tool, utilizing the care plan and additional interventions as deemed appropriate to include notification of the Social Service Director, DON and/or Administrator of resident to resident abuse or the potential for resident to resident abuse. Effective 3/14/14, the Nurse Assessment Coordinator and Social Service Director will review the psychosocial plans of care on a monthly basis for 3 months and then quarterly per MDS/Care Plan schedule to ensure residents have appropriate individualized interventions. On 3/18/14, the Administrator, DON and CCO reviewed the Resident to Resident Abuse and Behavior Management policies and updated the Social Services Director job description including assessment, monitoring and evaluation of resident behaviors and interventions related to resident to resident abuse. Compliance completed 3/18/14" Observations, interviews, and review of policies revealed the Allegation of Compliance developed by the facility on 3/14/14 had been implemented and was in practice removing the immediacy. Facility nursing staff had been educated and was knowledgeable of the policy. The Administrator was informed of this on 3/19/2014. The Immediate Jeopardy and Substandard Quality of Care at, F-323 was lowered to a "D" as of 3/18/14.

On the days of the Complaint and Extended Survey based on record review, observations and interviews, the facility Administration failed to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility failed to put adequate interventions in place to promote well being for four of six residents identified with psychosocial issues. Three residents, Resident A, #2, and #11, had physical or verbal altercations with resident #5. Resident #5 shared a room at sometime during his admission to the facility with each of the residents. The residents were not placed in an environment to promote their safety. All three residents and/or families expressed fear of Resident #5. The Social Service Director failed to assess, monitor and evaluate the four residents (A, #2, #5, #11) sampled related to psychosocial needs. The findings included: Cross refers to F-250 Social Services as it relates to the failure of the facility to provide social services to maintain the physical, mental and psychosocial well-being of 4 of 6 residents with behaviors, and/or psychosocial needs. The Social Service Director failed to adequately assess, monitor and evaluate Residents A, #2, #5, and #11 related to resident to resident abuse. Cross refers to F-319 Psychosocial Needs as it relates to the failure of the facility to provide interventions to promote psychosocial well being for four of six residents identified with psychosocial issues. Three residents, Resident A, #2, and #11, had physical or verbal altercations with resident #5. Resident #5 shared a room at sometime during his admission to the facility with each of the residents. The residents were not placed in an environment to promote their safety. All three residents and/or family members expressed fear of Resident #5. Cross refers to F-323 Accidents Hazards/supervision, Residents A, #2, and #11 were allegedly involved in a resident to resident altercation with Resident #5 due to the failure of the facility to ensure that each resident receives adequate supervision and assistance to prevent harm (4 of 6 residents reviewed). The residents were not placed in an environment to promote their safety. All three residents and/or families expressed fear of Resident #5. In an interview with the surveyor on 3/13/14 at approximately 10:30 AM the Social Services Director (SSD) stated that Resident #5 was sent out for a psych evaluation on 1/22/14 and returned on 2/5/14 or 2/6/14. The SSD confirmed that Resident #2's family wanted a room change because Resident #5 went into the room and frightened them. She stated that they did not want their family member on the same hall with Resident #5. The Social Service Director stated that Resident #5 had been placed on 1:1 on 1/6/14 and was sent out that day. (Record review revealed that Resident #5 was sent out on 1/5/14 and returned the same day.) She added that on 1/7/14 Resident #5 changed rooms and remained on 1:1. The SSD stated the resident went out on 1/22/14 for psych evaluation and they (hospital) sent him to a psychiatric hospital. Per the SSD when Resident #5 returned they deemed the resident to be safe to self and others and the resident's physician increased his [MEDICATION NAME] dose. She stated that the resident left the faciity on [DATE] and was discharged to another psychiatric hospital on [DATE]. The SSD stated that anytime the resident exhibited behaviors he was sent out. During the interview she denied any knowledge of the facility behavior monitoring documentation. The ED (Executive Director (Administrator) was interviewed by the surveyor on 3/13/14 at approximately 11:25 AM. She stated that any resident on a psych med received behavior monitoring. Nursing was responsible for the monitoring. "Nursing does sheets. I don't know if Social Services knows. Social Services notified in the morning meetings and as needed." Morning meeting attendance included the Executive Director, Director of Nursing and the Social Worker. The ED stated the Social Worker was responsible for the psychosocial needs of the residents. The Administrator, Director of Nursing, and a Corporate Representative were present on 3/14/14 at 11:30 AM when advised that Immediate Jeopardy had been identified after consulting with the State Agency. The facility submitted an Allegation of Compliance (AOC), which was reviewed and approved on 3/19/14. The AOC included the following: "...1. Resident #5 was sent to a psychiatric facility on 2/27/14. On 3/14/14 at 9:30 am, the Administrator notified the psychiatric facility that Resident #5 would not be accepted back to the facility. On 3/14/14, the Social service Director met with Resident #11 to discuss his voiced fear on 3/14/14 related to resident to resident abuse incident on 1/22/13 and to assure him that Resident #5 was not returning to the facility. Resident #11 has been seeing a licensed professional counselor on an outpatient basis since 10/31/13. On 3/17/14 Resident #11's care plan was reviewed and updated per Nurse Assessment Coordinator and Social Service Director regarding voiced fear related to resident to resident abuse. Resident #11 (he is his own responsible party) was notified on 3/17/14 for input on the care plan and updates to the Psychosocial Care plan per Social Service Director. Additional interventions to Resident #11's psychosocial care plan to address expressed fear include: *Reinforcement that life is not over and there is much good he can do in life per Nursing and Social Services *Provide opportunities to read, study and interact with others per Activities *Continue to provide laptop computer with internet, encourage journaling on internet, encourage positive influences. Try to exercise positive thinking, keep positive outlets or expression of emotional needs per Activities, Social Services and Nursing *Engage in active communication in politics and world events per Activities and Nursing On 3/14/14, Resident A was identified as having a psychosocial problem related to fear of another resident. On 3/14/14, Resident A was interviewed per the Social Service Director related to his fear related to incident on 2/05/14. On 3/17/14 Social Service Director and Nurse Assessment Coordinator developed the psychosocial care plan problem to include the following interventions: *Observe for signs of anxiety related to fear, inquire about anxious feelings, encourage to verbalize feelings and concerns, provide assurance that he will be kept safe from harm per Social Services and Nursing staff *Discuss feelings of fear per Social Service Director On 3/17/14, the Social Service Director met with Resident #2 to assure him that Resident #5 was not returning to the facility. On 3/17/14, the Care plan for Resident #2 was reviewed and updated per Social Service Director and Nurse Assessment Coordinator. Resident #2's responsible party was notified of updates to the Psychosocial Care plan goal per the Nurse Assessment Coordinator and the Social Service Director on 3/17/14 to the following goal: *Resident will verbalize he feels safe without fear or anxiety with goal met on 3/17/14 Resident to Resident Abuse policy and Behavior Management policies were reviewed and updated per Administrator, DON, and CCO on 3/17/14. The updates include Social Service Director assessment, monitoring, and evaluation of resident behaviors and interventions related to resident to resident abuse. The Administrator educated the Social Service Director on revised policies and procedures for Behavior Management and Resident to Resident Abuse on 3/17/14 and Social Service Director verbalized understanding of new policies and procedures... 2. To identify any resident with fear related to resident to resident abuse, all interviewable residents were interviewed by the Social Service Director on 3/17/14. (1) resident was identified and care plan was updated on 3/17/14 per Nurse Assessment Coordinator and Social Service Director. On 3/18/14, all resident's nurse's notes and social service notes since 1/1/14 were reviewed by RN Unit Managers using a behavior audit tool and (1) resident was identified with behaviors that may affect other residents. The behaviors were previously addressed and care planned on 3/14/14 for the (1) resident per Nurse Assessment Coordinator and Social Service Director. On 3/18/14 the nurse's notes and social service notes of residents who are not interviewable were reviewed back to 1/1/14 per RN Unit Managers to identify any evidence of change in their behavior that may indicate fear of resident to resident abuse and no such behavior changes were identified. All resident's care plans were reviewed on 3/17/14 by the Nurse Assessment Coordinator to identify other residents with aggressive behaviors who could elicit fear to ensure appropriate interventions are care planned and to determine if residents have psychosocial Care plans to address individual needs... 3. The Director of Nursing and RN Unit Managers provided one on one education utilizing the Behavior Management policy/procedure and a Help Guide explaining Behavior recognition and management including but not limited to how to handle and report behaviors. Education was initiated on 3/14/14 through 3/17/14 and will be ongoing with new hires in orientation and annually for staff. Staff will not be allowed to report to work until one on one behavior education is provided. Effective 3/14/14, the CNA's were educated to report any resident behaviors to nurse and nurses were educated to document any behaviors in the nurse's notes. RN Unit Managers and RN Supervisors were educated per the DON on additional responsibility of reviewing all resident nurse's notes and social service notes, completing the daily behavior monitoring tool, which identifies resident behaviors, interventions MD/Responsible Party notification, and DON, Administrator, and Social service notification for resident to resident abuse immediately. The completed behavior monitoring audit tool will be forwarded to the DON and the Social Service Director daily effective 3/14/14. The DON, Social Services Director, and RN supervisor on the weekends will initiate interventions as needed and provide oversight of the implementation of those interventions effective 3/14/14. The Social Service Director will review and maintain a copy of the behavior audit tools in a notebook in her office effective 3/14/14. The Social Service Director was educated on the Behavior monitoring audit tool and the updated policy and procedure for Behavior Monitoring on 3/17/14 per the Administrator and verbalized understanding. The Social Service Director will assess resident behaviors identified per Behavior Monitoring Tool and provide follow-up monitoring and evaluation of behaviors and additional interventions as indicated effective 3/14/14. Resident behaviors will be addressed and appropriate interventions will be developed in the Daily Stand-Up Meeting (Monday-Friday) per RN Unit Managers/Nurse Assessment Coordinator, DON, Administrator, Social Service Director, Rehab and Activities Director effective 3/18/14. Effective 3/15/14, the weekend RN Supervisor will address behaviors identified per behavior monitoring tool, utilizing the care plan and additional interventions as deemed appropriate to include notification of the Social Service Director, DON and/or Administrator of resident to resident abuse or the potential for resident to resident abuse. Effective 3/14/14, the Nurse Assessment Coordinator and Social Service Director will review the psychosocial plans of care on a monthly basis for 3 months and then quarterly per MDS/Care Plan schedule to ensure residents have appropriate individualized interventions. On 3/18/14, the Administrator, DON and CCO reviewed the Resident to Resident Abuse and Behavior Management policies and updated the Social Services Director job description including assessment, monitoring and evaluation of resident behaviors and interventions related to resident to resident abuse. Compliance completed 3/18/14" Observations, interviews, and review of policies revealed the allegation of compliance developed by the facility on 3/14/14 had been implemented and were in practice removing the immediacy. Facility nursing staff had been educated and was knowledgeable of the policy. The Administrator was informed of this on 3/19/2014. The Immediate Jeopardy at, F-490 was lowered to a scope and severity of "D" as of 3/18/14.

On the days of the Complaint and Extended Survey, based on record review, observations and interviews. The facility failed to review and revise care plans to accurately depict the resident's condition for 1 of four residents with pressure sores. Resident #1's care plan did not include all interventions that were in place to treat pressures sore. The findings included: Cross refer to F314 Pressure Sores as it relates to the failure of the facility to prevent the development of pressure sores for 1 of 4 residents sampled for pressure sores. Approximately 10 days following readmission to the facility with a [MEDICAL CONDITION] that limited his/her mobility Resident #1 developed pressure sores on his/her feet and heels. Documentation also revealed that his/her physician on 2/10/14 and the wound clinic on 3/6/14 noted Resident #1 with a left lateral wound that was not documented as treated by the facility until 3/10/14. Resident #1 was admitted by the facility with [DIAGNOSES REDACTED]. The resident was readmitted following a Right Hip Displaced Femoral Neck Fracture. Review of the medical record revealed the resident returned from the hospital with a small circular excoriated area noted between buttocks, a linear intact blister on right buttocks and a surgical incision on the right lateral thigh. The Nurse's Notes on readmission stated the resident had a trapeze on bed, pressure reducing mattress and TED (antiembolic hose) hose. Resident #1 was documented as non-weight bearing and as requiring two persons assistance. On 12/26/14 at 7:11 AM, "Floor nurse called to room by frantic family members after being told by CNA (Certified Nursing Assistant) that resident had a bed sore. Assessed skin and concluded that top layer of skin possibly wiped off." A treatment was provided to area. 3:04 PM, "Wound nurse and grandson present Stage II to sacrum 2.5 cm (centimeters) x 4 cm. 100% [MEDICATION NAME] tissue present. Nurse's notes continued to speak to wound on sacrum and blister area. On 12/30/13 the resident was documented as receiving extensive assistance with bed mobility and turned every two hours; checked for continence every hour. The resident required extensive assistance with transfers and eating; total assistance with locomotion, dressing and toileting. On 12/31/13 the Wound Nurse documented Pressure Ulcer on sacrum and on a trial low air loss mattress. The Nurse's Notes of 1/3/2014 at 1:31 PM stated, "Res. has pressure area noted to sacrum. Dressing clean dry and intact. Res has pressure reducing mattress, heels are off loaded, heel medix (boots) are in use". On 1/9/14 at 3:51 PM the nurse documented, "Dressing to Stage II on sacrum dry and intact. DTI (Deep Tissue Injury) to bilateral heels, off loading heels. Res. on Air mattress." Review of the resident's Comprehensive Care Plan dated 1/9/14 revealed a problem for "Risk for Skin breakdown r/t (related to) incontinence and decreased mobility as deemed unavoidable per MD. Added to the problem was Surgical incision with staples right hip. Open Blister on right buttock (stage II pressure ulcer) on admission from hospital. DTI (Deep Tissue Injury) right and left heels. On 1/10/14 Dry skin was added to the care plan. 2/26/14 Drainage from wound on left heel had been added and on 3/10/14 DTI of left top of foot lateral foot was added". The care plan did not include the changes in the resident's wounds to show the development of eschar of the right and left heel. The wounds on the lateral left foot had been addressed by the physician on 2/10/14 as a DTI, by the wound clinic on 2/26/14 as eschar and [MEDICAL CONDITION] with orders for antibiotics, which was not addressed on the care plan. During the days of the survey, the resident was observed to have a foot cradle, a wedge cushion and a heel offloading cushion, which were not addressed in the care plan. During wound care observation on 3/12/14 at approximately 11/15 AM, the resident was observed with the heel offloading cushion under his legs with both feet resting on the mattress. He was wearing his boots. The Wound Care Nurse stated that the resident frequently moved his feet and would rub the edge of the cushion with his heels. The care plan did not address the resident frequently moving his feet. The surveyor on 3/13/14 interviewed the Minimum Data Set (MDS) Coordinator a Licensed Practical Nurse. The MDS Coordinator stated she reviewed the residents chart , nurse's notes, physician orders [REDACTED]. She stated, "Sometimes I look at the resident." When asked by the surveyor about the wedge cushion, foot cradle and heel offloading cushion for Resident #1, the MDS Nurse stated, "I wasn't aware that (resident) had a cushion, foot cradle or heel float cushion. I haven't seen him in the bed". The surveyor asked the MDS Nurse if she ever went into the resident's room to look for equipment. She denied. Certified Nursing Assistant (CNA) #1 was interviewed by the surveyor on 3/13/14 at 11:45 AM. The CNA stated the special equipment that residents needed which included special cushions or boots were documented in the Kiosk. The surveyor on 3/13/14 interviewed CNA # 2 at 11:50 AM. The CNA stated that information regarding resident's special equipment included heel offloader was in the Kiosk. The surveyor on 3/13/14 interviewed CNA #3 at 12:00 PM. The CNA stated the Kiosk contained the information regarding resident care. Information included special instructions like heel medix boots, foot cushions and how often to turn the resident.

On the days of the Complaint and Extended Survey, based on record review, observations and interviews, the facility failed to prevent the development of pressure sores for 1 of 4 residents sampled for pressure sores. Approximately 10 days following readmission to the facility with a [MEDICAL CONDITION] that limited his/her mobility Resident #1 developed pressure sores on his/her feet and heels. Documentation also revealed that his/her physician on 2/10/14 and the wound clinic on 3/6/14 noted Resident #1 with a left lateral wound that was not documented as treated by the facility until 3/10/14. The findings included: Resident #1 was readmitted to the facility after a hospital stay for a [MEDICAL CONDITION]. Upon return from the hospital the resident was non-weight bearing and had limited mobility. No interventions were put in place for the potential for skin breakdown on the resident's heels. Ten days after readmission wounds were observed on his/her heels at which time the facility then put in place the use of Helix Boots, an air mattress and to treat the heels with skin prep. The resident developed a pressure ulcer on his/her left lateral foot the resident's physician progress notes [REDACTED]. The resident was referred to the wound care clinic on 2/26/14 and documented the left lateral wound and other right and left heel wounds. The left lateral foot wound was not documented or treated by the nursing staff until after the wound was draining and had developed eschar on 3/10/14. Resident #1 was admitted by the facility with [DIAGNOSES REDACTED]. The resident was readmitted on [DATE] following a Right Hip Displaced Femoral Neck Fracture. Review of the medical record revealed the resident returned from the hospital with a small circular excoriated area between the buttocks, a linear intact blister on right buttocks and a surgical incision on the right lateral thigh. The Nurse's Notes on readmission stated that the resident had a trapeze on the bed, a pressure reducing mattress and TED (antiembolic hose) hose in place. The resident was documented as non-weight bearing requiring two persons assistance. A Braden Assessment was conducted on 12/20/14 to assess the resident's risk for pressure sores. The resident scored a 16. The coding stated "17 or less represents high risk". Review of the resident's nurse's notes dated 12/26/14 at 7:11 AM stated, "Floor nurse called to room by frantic family members after being told by CNA (Certified Nursing Assistant) that resident had a bed sore. Assessed skin and concluded that top layer of skin possibly wiped off." A treatment was provided to area. 3:04 PM, "Wound nurse and grandson present Stage II to sacrum 2.5 cm (centimeters) x 4 cm. 100% [MEDICATION NAME] tissue present. Nurse's notes continued to speak to wound on sacrum and blister area. 12/30/13 the resident was documented to receive extensive assistance with bed mobility and turned every two hours and checked for continence every hour. "Resident requires extensive assistance with transfers and eating and total assistance with locomotion, dressing and toileting". 12/31/13 the Wound Nurse documented a Pressure Ulcer on the resident's sacrum and that the resident was on a trial low air loss mattress. 1/3/2014 at 1:31 PM a nurse's note stated, "Res(ident) has pressure area noted to sacrum. Dressing clean dry and intact. Res has pressure reducing mattress, heels are off loaded, heel medix (boots) are in use. 1/9/14 at 3:51 PM the nurse documented, "Dressing to Stage II on sacrum dry and intact. DTI (Deep Tissue Injury) to bilateral heels, off loading heels. Res. on Air mattress." The 1/9/14 note was the first documentation of any issues with the resident's heels. Review of the Resident's Wound Assessment Reports from 12/20/13 through 3/11/14 revealed on the following: 12/30/13 "...Assessment Occasion, New Wound Unstageable due to suspected deep tissue injury. 5.00 cm (centimeters) x 7.00 cm. Under the notes section stated, "DTI noted to be maroon in color. heel medix on as tolerated". Under treatments, "12/30/13 Heel Medix Boots on as tolerated". 12/30/13 Skin prep DTI to right heel twice a day". 12/31/13 a second Wound Assessment Report for the left heel was completed. The wound was identified as a new wound, unstageable due to suspected deep tissue injury. The area measured 7:00 cm x 8.00 cm. The DTI was described as maroon in color. Heel Medix Boots and skin prep was added on 12/30/13. 3/10/14 the Wound Assessment Report stated New Wound, Left top of foot, Left Lateral Foot that measured 2.00 x 2.00 cm. The wound was described as a suspected deep tissue injury. Under the Notes section it stated, "[MEDICAL CONDITION] drainage noted coming from wound edge. Surrounding tissue shows slight maceration r/t (related to) drainage. Eschar noted to be black and leathery." The wound was documented as a suspected deep tissue injury initially discovered with eschar and drainage by the nursing staff. Review of the Wound Healing Progress Report dated 12/20/13 through 3/11/14 revealed the wounds on the right and left heel were documented as unstageable due to suspected DTI weekly through 3/11/14, not until 3/10/14 was the left lateral foot wound noted. The resident was initially seen in the Wound Clinic on 2/26/2014. The Wound Clinic report under Physical Examination, the physician documented, "...Wound #1 is on the right heel. This was in the form of an eschar, which was leathery... It measured 8 cm in length x 9.5 cm in width x 0 cm in depth. On the left heel there was a wound, which measured 4 x 4.5 cm, again as eschar. There was a little drainage on the bandage and this is starting to loosen up and I anticipate will need [MEDICATION NAME] soon. On the left lateral foot , there again was an eschar, which measured 2.5 x 2.5. Under the section "Impressions" 1. "...pressure ulcer and the right heel, left heel and lateral foot, which are really unstageable because of the thick eschar that is on top of them. I suspect these are full thickness, but we are not sure as to the depth of which they penetrate at this point but I would suspect it is going to be at least a Stage III. But at this time are unstageable." On 3/6/14 the physician at the wound center described the wounds as: "Number 1 is to the right heel. This is a large eschar measuring 5.7 cm in length x 8.5 cm in width. It is starting to loosen on the periphery. We have been treating this with just [MEDICATION NAME] to keep it more or less dry... Wound on the left heel is another eschar measuring 4 X 4.5. Again it is starting to loosen, but no drainage or eschar S/he has another eschar on his/her lateral foot, which is 2.5 x 2.5 and the left distal lateral foot which is 0.8 x 0.4 x 0.1". Review of the Treatment Administration Records from December 20, 2013 through March 14, 2014 revealed treatment was initiated to the left and right heels on 12/30/13. Treatment was initiated to the left lateral foot wound on 3/10/14. Review of the physician progress notes [REDACTED]. Also 2 D.T.I. and Stage II on sacrum". The progress note dated 2/10/14 stated, "No new problem. Working on decubitus that pt developed at (hospital) when s/he was there for his/her hip fx in Dec (December). 1 cm sacral decubitus Stage II, large DTI to both heels and several 2 smaller areas to L (left) lat (lateral) foot." The surveyor on 3/14/2014 observed wound care. The wound on the sacrum was noted to be clean, healing with no drainage. Observation of the right and left heels revealed black leathery eschar pulling away from the edges of the wound. The left lateral foot was noted as black eschar with dark, bloody drainage. In an interview with the surveyor on 3/13/14 at approximately 9:15 AM the Wound Nurse, certified in wound care stated that the resident's were assessed, measured and documented weekly; the Registered Nurse staged the wounds. S/he added that to promote healing the facility routinely used Prostat, Prostat AWC and vitamin C. The Wound Nurse stated that if there was a change in the wound the Registered Nurse (RN) Unit Manager or Director of Nurses (DON) would be notified. S/he stated that the doctor "sees the residents but not every time" and that the Registered Dietician is notified by referrals and has access to the Wound Assessment Manager (in the computer). S/he also stated that there is a turn log at the nurse's station that the nurses check every 2 hours. "_____ (Resident #1) had no skin issues when sent out to hospital. The Deep Tissue Injuries were identified on 12/30/14. The CNA came and notified me. The Helix boots wee started on 12/30/13 at 2:00 PM... There is a wound meeting weekly with the Dietary Manager, MDS Nurse, RN , Director of Nurses and the Wound Nurse." In an interview with the surveyor on 3/13/2014 at approximately 2:47 PM The Medical Director (MD) stated the wounds were looked at by the physician about every other visit, most were going to the wound clinic. "Not sure what the protocols are. Every wound is different." The MD stated that the wound nurse had been doing wound care about a year.