Every finding on record at Onyx Care of Winnfield

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections. The facility failed to ensure the following:Resident room and living space were maintained in a clean and sanitary manner,Droplet precautions signage was posted for Resident #1,Shower rooms were maintained in a clean and sanitary manner,Proper staff training of chemicals used for cleaning and disinfection of environment,Proper staff training of handling soiled linen and waste,Necessary staff had access to chemicals used for cleaning and disinfection of environment, andImplement Enhanced Barrier Precautions for Resident #76.This deficient practice had the potential to affect all residents who reside in the facility. The total resident census was 71.Findings:Record review of an undated facility policy on 01/14/2026 at 2:02 p.m. titled Droplet Precautions read in part. Contact Precautions are a transmission based precaution that will be utilized to reduce the risk of droplet transmission of infectious agents. Equipment: Door sign that reads Droplet Precautions or Visitors Must See Nurse Before Entering Observation on 01/12/2026 at 8:40 a.m. of Room B revealed heavily soiled floor with a large amount of debris, overall the room was unkempt with trash on tables and overfilling the trashcan. Interview on 01/12/2026 at 9:00 a.m. with S21HK revealed Room B was in need of cleaning. S21HK stated the facility was short staffed for housekeeping as there was normally 4 or 5 housekeepers during the day, but only 2 scheduled for today, 01/12/2026. Observation on 01/12/2026 at 10:30 a.m. revealed Resident Room E with heavily soiled floors that had black buildup throughout. There was multiple personal items and popcorn spilt onto the floor. There was a soiled adult brief lying on bed. Interview on 01/12/2026 at 10:32 a.m. with S19LPN revealed there was 1 COVID/FLU positive resident on Hall X, which was Resident #1. Observation of Resident #1's room door, Room D, revealed no droplet precaution signage. Interview with S19LPN at time of observation revealed the signage was placed on the wrong resident door. Droplet precaution signage was observed on Room F's door, which was an empty room. S19LPN removed the droplet precaution signage from Room F, and placed on Resident #1's door. Observation on 01/12/2026 at 10:34 a.m. revealed Resident Room C revealed a heavily soiled floor with milk spilt onto floor near bed, and a soiled adult brief beneath the bed. Observation on 01/12/2026 at 10:50 a.m. revealed S21HK gathered soiled linen and waste from Room D. S21HK was observed asking Hall X staff where she needed to place the soiled linen and waste. Interview with S21HK at time of observation revealed she stated she did not know where to store or how to transport soiled linen and waste as she had not been fully trained yet. Observation on 01/12/2026 at 10:53 a.m. of Room G shower room with S22CNA revealed the shower room did not have cleaning products in shower rooms to clean between each resident use. S22CNA stated staff had to go to find a house keeper and get a product to clean. S22CNA stated she did not know the name of the cleaning product and did not know the dwell time. S22CNA stated there is normally a house keeper on Hall X, but today there is not. S22CNA stated she would have to get with S18HouseKeepingSupervisor to get cleaning product to clean Room G. Interview on 01/12/2026 at 10:58 a.m. with S18HouseKeepingSupervisor revealed she became housekeeping supervisor last month. S18HouseKeepingSupervisor confirmed she had not had training on the cleaning products used at the facility and did not know the dwell times of the products, but should. S18HouseKeepingSupervisor confirmed S21HK and all housekeeping staff should be trained and should know the process of handling soiled linen/waste. Observation on 01/12/2026 at 11:00 a.m. of Room G shower room with S18HousKeepingSupervisor revealed there was no cleaning products available in the shower room for sanitizing between resident uses. S18HouseKeepingSupervisor confirmed Hall X was in need of cleaning related to the heavily soiled floors in resident's rooms. S18HouseKeepingSupervisor stated this was due to not having a housekeeper on Hall X today, but she would get the rooms and floors cleaned. Interview on 01/12/2026 at 11:18 a.m. with S23HK revealed the facility had recently switched products used for cleaning and she had not yet been trained on the new medline cleaning products. Interview on 01/13/2026 at 10:45 a.m. with S20HK revealed she had not yet been trained on the new medline cleaning products that were located in their house keeping closets for use. Observation on 01/14/2026 at 10:07 a.m. of Hall Y shower room with S20HK revealed there was a strong urine odor with observation of the trash can overflowing with soiled adult briefs. There was a large puddle of a yellow liquid substance on the shower room floor near the trash can. S20HK stated she had not yet been able to clean the room. S20HK revealed the CNA's do not clean between uses as the CNA's come and get a housekeeper to clean the area. Interview on 01/14/2026 at 10:10 a.m. with S16CNA on Hall Y revealed CNA staff did not have access to cleaning products, so they call for housekeeping to clean shower room between resident uses. Observation on 01/14/2026 at 10:34 a.m. of Room G, Hall X's shower room, with S24CNA revealed a strong urine odor with resident's personal clothing on floor and not contained within a bag. Soiled linen observed not contained on the shower room floor. Interview with S24CNA at time of observation revealed CNA staff was to remove soiled linen from shower room after use and housekeeping was to come and sanitize the room, but had not. Interview on 01/14/2026 at 10:48 a.m. with S18HouseKeepingSupervisor confirmed shower rooms should not have soiled linen uncontained on the floor. Observation on 01/14/2026 at 10:59 a.m. of Room G, Hall X's shower room, with S18HouseKeepingSupervisor confirmed the shower room was in need of cleaning and removal of resident's personal clothing as the clothing needed to be contained. Observation on 01/14/2026 at 11:04 a.m. of Hall Z shower room with S18HouseKeepingSupervisor revealed the whirlpool had a small amount of feces near the drain area. S18HouseKeepingSupervisor confirmed the whirlpool was in need of cleaning. 7. Review of Resident #76's EMR revealed an admission date of 08/21/2025 with diagnoses including End-Stage Renal Disease, Severe Sepsis, Recurrent Enterocolitis due to Clostridium Difficile, Diabetes, Dysphagia, Heart Failure, Acute Embolism and Thrombosis, and Hypotension of Hemodialysis. Review of Resident #76's Quarterly MDS with ARD of 11/27/2025 revealed a BIMS score of 15, which indicated intact cognition. Resident #76 required substantial/maximal assistance with toileting, bathing, dressing, personal hygiene, turning, position changes, and transfers. Review of Resident #76's Provider's Orders revealed, in part. Change peg tube dressing daily, dated 01/11/2026; Daily wound care to left 2nd toe, left elbow, left great toe, left inner thigh, left knee, left posterior thigh, right elbow, right heel, right inner lower leg, posterior right lower leg, and sacrum, dated 01/09/2026; Treatment nurse to remove bandage from dialysis fistula to left upper arm the following morning after dialysis days every Tuesday, Thursday, and Saturday, dated 09/24/2025; and Enhanced Barrier Precautions, dated 01/12/2026. Observation of Resident #76's wound care on 01/13/2026 at 9:20 a.m. revealed S5RN failed to don a gown while assisting with wound care by turning, repositioning, and holding Resident #76. Interview with S5RN on 01/13/2026 at 10:02 a.m. revealed Resident #76 was on EBP. S5RN confirmed she did not wear a gown while performing direct care to Resident #76, but should have.

Based on observation and interview, the facility failed to ensure reasonable accommodation of needs by failing to ensure a properly-fitting helmet was provided for 1 (Resident #25) of 42 sampled residents. Resident #25 Review of Resident #25's medical record revealed an admit date of 01/23/2025 with diagnoses that included: Nontraumatic Subarachnoid Hemorrhage, Generalized Anxiety Disorder, Diffuse Traumatic Brain Injury, Schizoaffective Disorder and Hypertension Review of Resident #25's Review of Resident #25's Care plan with review date of 02/04/2026 read in part.Resident #25 is at risk for injuries/falls. Ensure a protective helmet is worn when out of bed. Encourage use due to poor memory. Review of Resident #25's Quarterly MDS with ARD of 10/13/2025 revealed a BIMS of 06, indicating severe cognitive impairment. An observation on 01/12/2026 at 10:08 a.m. Resident #25 is observed sitting up in a chair in his room without a helmet. Resident #25's helmet is observed in a bag at the foot of the bed. Resident #25 stated that he does not really wear it anymore. An observation 01/14/26 at 9:05 a.m. Resident #25 is observed sitting up in chair near nurse station without helmet on. Residen#25 stated that he was not offered to wear his helmet today and during the interview a staff member brought Resident #25 his helmet and put it on his head. Resident #25's helmet appeared too big. Resident #25 then stated it's too big and comes down and goes over my eyes Resident #25 stated this is one of the reasons he does not wear the helmet. An observation on 01/14/2026 at 11:53 a.m. Resident #25 is observed sitting in dining area without a helmet on. An observation/interview on 01/14/2026 at 1:30 p.m. S2DON stated that she implemented the helmet for Resident #25's a few months ago as a fall intervention. At this time Resident #25 notified S2DON that the reason he does not wear his helmet often because it falls down in front of his eyes and because he does not always need it. S2 DON observed Resident #25 with the helmet on and confirmed that the helmet did not fit properly. S2 DON stated when she implemented the helmet as a fall intervention, she notified staff that resident is to wear a helmet when out of bed. S2DON stated that she did not fit Resident #25 for the helmet, but only told staff that he now required a helmet while out of bed. An observation on 01/14/2026 at 3:30 p.m. Resident #25 is sitting up in a chair near the nurse's station with different helmet that straps near the chin. Resident #25 stated the helmet fits nice and he had no issues wearing it.

Number of residents sampled:Number of residents cited:Review of facility policy titled, Notification of Change in a Resident's Status with a revision date of 11/2017 revealed in part. The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the resident representative will be notified of a change in the resident's condition, per standards of practice and Federal and/or State Regulations. Responsibility: All Nursing Personnel. Guideline for notification of physician/ responsible party (not all inclusive). d. Any accident or incident (per Federal and State regulation).Review of Resident #52's electronic health record revealed an admission date of 12/23/2024, with diagnoses that included, in part. Schizoaffective Disorder, Bipolar Type, Bipolar Disorder, Current Episode Mixed severe with Psychotic features, Recurrent Major Depressive Disorder, Unspecified Dementia with other Behavioral Disturbance, and Type 2 Diabetes Mellitus.Review of Resident #52's Annual MDS with an ARD of 12/11/2025 revealed Resident #52 had a BIMS score of 6, indicating severe cognitive impairment.Review of the facility incident report revealed the facility reported an incident on 12/31/2025 at 11:00 a.m. for an injury of unknown origin related to discoloration/bruising to Resident #52's face. Review of facility progress note dated 12/31/2025 at 12:20 a.m. created by S12LPN read in part. Resident is noted with dark purple bruising to the area between the eyes. Resident denies fall and no complaint of pain to area. ED made aware of above events and findings.Further review of facility progress notes revealed no documentation that reflected Resident #52's resident representative or physician was notified upon the discovery of new facial discoloration/bruising of unknown origin.In an interview on 01/14/2026 at 07:30 a.m., S12LPN revealed that during her 12/30/2025 7 p.m.-7 a.m. shift, she observed new discoloration/bruising to Resident #52's face when she arrived at the resident's room to collect a urine analysis. S12LPN reported that after observing Resident #52's new facial discoloration, she notified the executive director via telephone of the findings. S12LPN confirmed she did not notify Resident #52's physician/nurse practitioner or representative of a change in resident status, and should have.In an interview on 01/14/2026 at 10:50 a.m., S2DON revealed she was unsure if Resident #52's resident representative and physician were notified upon discovery of Resident #52's change in condition of new facial bruising on 12/31/2025. S2DON revealed that if the physician had been notified, the call would have gone through the facility's on-call program.In an interview on 01/14/2026 at 02:03 p.m., S2DON revealed she called the facility on-call group and was notified that no calls had been received from the facility for the night shift on 12/30/2025-12/31/2025.In an interview on 01/14/2026 at 02:40 p.m., S1ADM stated that a new-onset discoloration/bruising to a resident's face of unknown origin is considered a change in resident status. S1Admin confirmed that the administration, resident representative, and resident physician were not notified of Resident #52's change of status of facial discoloration/bruising upon discovery, and should have been.

Based on record review and interview, the facility failed to ensure the SNF ABN Form CMS-10055 (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form CMS-10055) was provided to the resident and/or the resident's responsible party prior to the discontinuation of Medicare Part A services for 1 (Resident #31) of 1 resident reviewed for Beneficiary Notification who required the notification.Review of Resident #31's SNF Beneficiary Notification Review revealed Resident #31 was discharged from Medicare Part A services when benefit days were not exhausted. Further review revealed a SNF ABN Form CMS-10055 was not provided to the resident or their RP prior to discharge from the service.Interview with S9MDS on 01/14/2026 at 1:30 p.m. confirmed Resident #31 remained in the facility after being discharged from skilled services with benefit day remaining. S9MDS confirmed she did not send the SNF ABN Form CMS-10055 to Resident #31 or their RP, but should have.

Based on observation and interview, the facility failed to ensure the privacy and confidentiality of medical records for 3 (Resident #23, Resident #45, and Resident #66) of 42 sampled residents.Resident #23 On 01/12/2026 at 9:20 a.m., observation of the facility outside dumpster area with S10Dietary revealed 3 medication blister packs on the ground with patient labels still fully intact. 1 of the 3 blister packs observed had Resident #23's name present and was labeled as Divalproex 125 milligram (mg) capsule. Resident #45 On 01/12/2026 at 9:20 a.m., observation of the facility outside dumpster area with S10Dietary revealed 3 empty medication blister packs on the ground with patient labels still fully intact. 2 of the 3 medication blister packs observed had Resident #45's name present and labeled as medications Naltrexone 50mg Tablet and Amlodipine 10mg tablet. On 01/12/2026 at 09:22 a.m. S10 Dietary confirmed empty medication blister packs with Resident #23's and Resident #45's patient information present on them were lying outside the dumpster area and should not have been. On 01/12/2026 at 09:24 a.m. S10Dietary accompanied the surveyor to S2DON office with 3 empty medication blister packs that revealed the patient information for Residents #23 and #45, to discuss the above findings. At this time, S2DON confirmed empty medication pill packs with Resident #23 and Resident #45 patient information present on them, were lying outside of the dumpster area and should not have been. Resident #66 Observation of Hall W on 01/13/2026 at 12:32 p.m. revealed Cart A was unattended, with the EMR screen open and Resident #66's PHI visible. The surveyor remained with Cart A until S3LPN approached Cart A Interview with S3LPN on 01/13/2026 at 12:34 p.m. revealed she was using Cart A to provide medications to residents on Hall W. S3LPN confirmed the computer screen displaying Resident #66's PHI was visible while she was away from Cart A, but should not have been.

Based on observations and interviews, the facility failed to maintain a clean and homelike environment for 1 (#76) out of 3 residents sampled for environment. Observation of Resident #76's room on 01/12/2026 at 9:51 a.m. revealed the privacy curtain was visibly soiled with multiple black and brownish-orange stains.Observation of Resident #76's room on 01/12/2026 at 4:01 p.m. revealed the privacy curtain was visibly soiled with multiple black and brownish-orange stains.Interview with S15RN on 01/13/2026 at 9:12 a.m. revealed the facility did not have a general housekeeping policy.Observation of Resident #76's room on 01/13/2026 at 10:00 a.m. accompanied by S1ADM confirmed the privacy curtain was visibly soiled with multiple black and brownish-orange stains. S1ADM revealed she was unaware of the facility's policy regarding soiled privacy curtains.Interview with S6HK on 01/13/2026 at 10:30 a.m. revealed privacy curtains were removed if visibly soiled, and replaced with a clean privacy curtain.Interview with S15RN on 01/13/2026 at 11:46 a.m. revealed the facility did not have a policy regarding cleaning of privacy curtains.Observation of Resident #76's room on 01/13/2026 at 3:34 p.m. accompanied by S3LPN confirmed the privacy curtain was visibly soiled, but should not have been.

Based on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good personal hygiene for 2 ( #57 and #58) of 3 (#6, #57, and #58) residents reviewed for ADL care. The facility failed to ensure:Resident #57 was provided nail care and was shaved; and Resident #58 was provided a bath on scheduled bath days. Findings:Review of the facility's policy dated 10/2009 titled Fingernails/Toenails Care read in part.Policy: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. 3. Nail care includes daily cleanings and regular trimming. Review of the facility's policy dated 08/2011 titled Shaving- Male and Female read in part.Policy: Residents will be free of facial hair- both male and female. If the resident is alert and oriented and request not to be shaved, this will be noted in the care plan. Resident #57 Review of Resident #57's medical record revealed an admit date of 09/30/2025 with diagnoses that included: Vascular Dementia, Major Depressive Disorder, Hypothyroidism, Anxiety Disorder, , Depression, Cognitive Communication Deficit, and Mild Cognitive Impairment. Review of Resident #57's admission MDS with ARD of revealed a BIMS of 4, indicating severe cognition impairment. Resident #57's required supervision/touch assistance with personal hygiene. Review of Resident #57's Care plan with a review date of 01/11/2026 read in part .Resident #57 is at risk for decline in ADL's requiring 1 person assist with oral hygiene, toileting, personal hygiene, bathing, dressing and bathing. An observation on 01/12/2026 at 10:26 a.m. Resident #57 was observed with long facial hair and long, dirty, and jagged fingernail. An observation on 01/13/2026 at 9:13 a.m. Resident #57 continues with long, dirty, jagged nail and long facial hair. Resident responded Yes when asked if he would like for his face to be shaved and nails to be cleaned and cut. An interview on 01/13/2026 at 9:25 a.m. S13LPN confirmed that resident nails and hair on face are long and should have been cut. S13LPN denies that Resident #57 refuses care. An observation on 01/14/2026 at 10:00 a.m. Resident #57 is observed sitting up in room and continues with long facial hair and long, dirty, and jagged fingernails. An interview on 01/14/2026 at 11:16 a.m. S14CNA denies that Resident #57 refuses care. S14CNA stated that she assisted with Resident #57's bath on 01/11/2026, but there were no access to razors in the building to shave anyone. Resident #58 Review of Resident #58's Electronic Health Record revealed the Resident was admitted to the facility on [DATE]. Resident #58 had diagnoses that included in part. Generalized Muscle Weakness, Personal History of Pulmonary Embolism, Unspecified Sequelae of Cerebral Infarction, and Dysphagia. Review of Resident #58's admission MDS with an ARD date of 01/28/2026 revealed in part . Resident# 58 had BIMS of 06 indicating severe cognitive impairment and required substantial/maximal assistance from staff for personal hygiene, toileting, and bathing. Resident #58 had no behaviors or rejection of care Review of Resident #58's Care Plan with a target completion date of 02/04/2026 revealed in part. At risk for decline in ADL's (Activities of Daily Living). Interventions included: Incontinence care every 2 hours, and as needed, Needs 1 person assist with grooming, hygiene, bathing. Interview with Resident #58's RP (Responsible Party) on 01/12/2026 at 9:42 a.m. revealed he had concerns of staff not bathing Resident #58 on her scheduled days, and that Resident #58 had not been bathed and remained in the same clothes for 1 week. Observation of Resident #58 at time of interview revealed she was seated up on the side of bed with her bottom jogging pants removed, the pants were on the side of bed and wet. Resident #58 was observed with an adult brief and towel between her legs and she stated she was soaking wet. Resident #58 stated she had been calling since early morning for help getting cleaned up. Resident #58's sweat shirt appeared heavily soiled. Review of the facility Bath Schedule for Resident #58 revealed she was scheduled to receive a bath on Monday's, Wednesday's and Friday's, and as needed during the day. Review of Resident #58's ADL (bath) documentation for previous 30 days revealed Resident #58 had 7 baths in the last 30 days, and at minimum she should have received 12. Interview with S17CNA on 01/14/2026 at 10:10 a.m. revealed all baths are documented in the ADL/Task section of medical record when baths are completed. S17CNA stated any refusal should be documented in the task section as well. Interview with S18LPN on 01/14/2026 at 2:37 p.m. with a review of Resident #58's documented baths in the last 30days, confirmed the resident had received 7 baths, but should have received a bath 3 times per week. S18LPN confirmed if a resident refused, bath refusals should have been documented.

Based on record review and interview, the facility failed to ensure that a resident maintained acceptable parameters of nutritional status for 2 (#9 and #76) of 3 (#9, #52, and #76) residents reviewed for nutrition by:Failure to implement registered dietitian's recommendations for Resident #9; and Failure to provide tube feeding as ordered for Resident #76. Findings:Resident #9 Review of Resident #9's medical record revealed and admit to the facility on [DATE] with diagnoses that included: Schizoaffective Disorder, Unspecified Dementia, Bipolar Disorder, Paranoid Schizophrenia, and Anxiety Disorder. Review of Resident #9's Annual MDS with an ARD of 12/17/2025 revealed a BIMS score of 99, which indicated the assessment could not be completed. Resident #9 requires set up assistance with eating. Review of Resident #9's Care plan with a review dated 12/15/2025 read in part.Resident #9 needs to maintain adequate nutrition and hydration. Monitor weights, assess and address any significant weight changes. Document and report to medical director and registered dietician. Review of the S25RD registered dietician note dated 12/11/2025 read in part.Resident #9 triggered for monthly weight report due to weight loss. Add resident to weekly weights and monitor closely to make recommendations as needed. Review of Resident #9's weights records revealed the following weights: 12/12/2025- 173.0 lbs. 12/19/2025- 174.8 lbs. 01/13/2026 -173.2 lbs. An interview on 01/13/2026 at 10:16 a.m. with S25RD stated that resident has been having weight loss and made a recommendation for weekly weights on 12/11/2025. S25RD stated that she follows up on weights that are made available to her. S25RD stated that last weight she was notified of was 12/12/2025. An interview on 01/13/2025 at 1:40 p.m. S15RN stated that the recommendation made by the registered dietician are typically followed when written. S15RN confirmed there are no weekly weights completed for Resident #9 for the week of 12/21/2025, 12/28/2025 and 01/04/2026, but should have been. Resident #76 Review of Resident #76's EMR revealed an admission date of 08/21/2025 with diagnoses including COPD, Shortness of Breath, Diabetes, Dysphagia, Heart Failure, Acute Embolism and Thrombosis, and Hypotension of Hemodialysis. Review of Resident #76's Quarterly MDS with ARD of 11/27/2025 revealed a BIMS score of 15, which indicated intact cognition. Resident #76 required substantial/maximal assistance with toileting, bathing, dressing, personal hygiene, turning, position changes, and transfers. Review of Resident #76's Provider's Orders revealed Glucerna 50mL/hr via pump per peg tube, dated 01/09/2026. Observation of Resident #76 on 01/12/2026 at 9:51 a.m. revealed tube feeding infusing at 50mL/hr. The pump indicated 134mL had been infused. Observation of Resident #76 on 01/12/2026 at 10:44 a.m. revealed her tube feeding was disconnected, and she was leaving the facility for dialysis. Observation of Resident #76 on 01/12/2026 at 4:01 p.m. revealed the resident had returned to the facility. Resident #76's tube feeding pump was alarming and the display read pump inactive. Observation of Resident #76 on 01/12/2026 at 4:25 p.m. revealed tube feeding infusing at 50mL/hr. The pump indicated 187mL had been infused. Observation of Resident #76 on 01/12/2026 at 4:26 p.m. accompanied by S3LPN revealed Resident #76 had not received tube feeding while out of the facility for dialysis. S3LPN confirmed Resident #76 received 53mL of tube feeding from 9:51 a.m. to 4:26 p.m. Observation of Resident #76 on 01/13/2026 at 8:04 a.m. revealed tube feeding infusing at 50mL/hr. The label on the tube feeding indicated the bag had been hung on 01/13/2026 at 6:00 a.m. The pump indicated 82mL had been infused since that time. Observation of Resident #76 on 01/13/2026 at 12:17 p.m. revealed the tube feeding pump was alarming and the display read idle for 10 minutes. Observation of Resident #76 on 01/13/2026 at 12:35 p.m. revealed the tube feeding pump was alarming and the display read idle for 10 minutes. Observation of Resident #76 on 01/13/2026 at 12:46 p.m. revealed the tube was infusing at 50mL/hr. The pump indicated 203mL had been infused. Interview with S3LPN on 01/13/2026 at 3:31 p.m. revealed she stopped the tube feeding and Resident #76 left the facility for an appointment at 1:00 p.m. S3LPN revealed at 1:00 pm Resident #76 had received 221mL of tube feeding. S3LPN revealed Resident #76's tube feeding was ordered at 50mL/hour. S3LPN confirmed Resident #76 received 139mL of tube feeding from 8:04 a.m. to 1:00 p.m., but should have received 247mL. Observation of Resident #76 on 01/14/2026 at 8:50 a.m. revealed tube feeding infusing at 50mL/hr. The label on the tube feeding indicated the bag had been hung on 01/14/2026 at 6:00 a.m. The pump indicated 60mL had been infused since that time. Interview with S25RD on 01/14/2026 at 8:50 a.m. revealed Resident #76's tube feeding should have been provided as ordered to meet the nutritional requirements of the resident, but was not.

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #76) of 4 residents reviewed for respiratory care. The facility failed to ensure:Oxygen was administered at the prescribed flow rate; andRespiratory equipment was appropriately labeled. Review of the facility's policy titled Oxygen Therapy revised 08/2014, revealed, in part.Oxygen therapy is to be provided under the direction of a written physician's order. Change tubing weekly. Date tube when changed (weekly).Review of Resident #76's EMR revealed an admission date of 08/21/2025 with diagnosis including COPD, Shortness of Breath, Diabetes, Dysphagia, Heart Failure, Acute Embolism and Thrombosis, and Hypotension of Hemodialysis.Review of Resident #76's Quarterly MDS with ARD of 11/27/2025 revealed a BIMS score of 15, which indicated intact cognition. Resident #76 required substantial/maximal assistance with toileting, bathing, dressing, personal hygiene, turning, position changes, and transfers.Review of Resident #76's Provider's Orders revealed O2 at 2L/NC to keep oxygen saturation >92% as needed for Shortness of Breath, dated 08/21/2025.Observation of Resident #76 on 01/12/2026 at 9:51 a.m. revealed O2 at 4L/NC. The oxygen tubing and humidifier bottle were unlabeled.Observation of Resident #76 on 01/12/2026 at 4:01 p.m. revealed O2 at 4L/NC. The oxygen tubing and humidifier bottle were unlabeled.Observation of Resident #76 on 01/12/2026 at 4:26 p.m. accompanied by S3LPN revealed O2 at 4L/NC. The oxygen tubing and humidifier bottle were unlabeled. S3LPN revealed she did not know the prescribed flow rate for Resident #76's oxygen. S3LPN confirmed the oxygen tubing and humidifier bottle were not labeled with the date they were opened, but should have been.Interview with S3LPN on 01/13/2026 at 12:24 p.m. revealed Resident #76 was ordered O2 2L/NC. S3LPN confirmed Resident #76's O2 had not been administered at the prescribed flow rate, but should have been.

Based on observation, record review, and interview, the facility failed to ensure medications were stored properly in accordance with currently accepted professional principles by failing to ensure that expired medications were not available for use/administration to residents. Findings: Record Review of an undated facility policy on 01/14/2026 at 1:52 p.m. titled Medication Storage read in part. All drugs, treatments, and biologicals must be stored securely and following the manufactures labeled recommendations, or per facility policy. The following medications must be removed from stock and disposed of properly on a continuing basis: Outdated, Contaminated, recalled, deteriorated, unlabeled medications, or those with soiled or broken/cracked containers. Observation on 01/13/2026 at 11:31 a.m. of Room A medication storage room with S13LPN revealed the following:(3) E-kits (Emergency Medication Containers) were unlocked with expired medications within the kits. Record Review of the E-Kits directions for use read in part. Remove red plastic lock from front of box, remove needed supplies, and replace red lock on front of box and record new lock number on the lock change log. Observation of E-Kit #5 revealed its lock was broken and was not replaced. Review of the lock change sheet for E-Kit #5 revealed it was last changed on 05/08/2025.E-kit #5 contained the following expired medications: (2) 1/2 Normal Saline 1000ml bags with expiration date of 12/2025. (5) Swab Caps and (2) Biopatches with expiration dates of 10/2025. Observation of E-kit #14 revealed its lock was broken and was not replaced. Review of the lock change sheet for E-Kit #14 revealed it was last changed on 12/22/2025.E-Kit #14 contained the following expired medications: Promethazine 25mg, Kayexalate 15gm/60ml and Promethazine 25mg/1ml injectable, all with expiration date of 11/2025. Flomax 0.4mg, Desyrel 50mg and Toradol 30mg/1ml, all with expiration of 12/2025. Observation of E-Kit #17 revealed its lock was broken and was not replaced. Review of the lock change sheet for E-Kit #17 revealed it was last changed on 12/28/2025.E-Kit #17 contained the following expired medications: Norvasc 5mg, and Nitrostat 0.4mg, with expiration date of 11/2025. Cleocin 150mg, Catapres 0.1mg, Plavix 75mg, Depakote DR 250mg, Lasix 20mg, Vistaril 25mg, Namenda 5mg, Flagyl 250mg, and Toprol 25mg, all with expiration date of 12/2025. Observation of the over the counter stock cabinet in Room A revealed the following expired medications:Slo Mg Chloride, 60 tabs, with expiration date of 11/2025,Omeprazole 20mg, (2) 14ct boxes, with expiration date of 09/2025,Magnesium 250mg, 100 tabs, with expiration date of 08/2025,Mucus Relief 400mg, 100caps, with expiration date of 12/2025,Ferrous gluconate 324mg, 100 tabs, with expiration date of 12/2025,Ferrous gluconate 324mg, 100 tabs, with expiration date of 10/2025, and(4) Bottles of Meclizine 12.5mg, 100 caps, with expiration date of 10/2025. Interview on 01/13/2026 at 11:45 a.m. with S13LPN confirmed the above findings.

Based on interview and record review the facility failed to promptly obtain and notify the NP (Nurse Practitioner) of ordered lab results for 1 (Resident #58) of 42 Sampled Residents. Findings:Record Review of an undated facility policy on 01/14/2026 at 2:22 p.m. titled Laboratory Tests read in part. Lab tests are completed as ordered by the physician. The licensed nurse, or designee, will indicate when lab results are returned to the facility on the lab scheduling/tracking form. The physician or physician extender will be promptly notified of abnormal results according to facility policy. Review of Resident #58's Electronic Health Record revealed the Resident was admitted to the facility on [DATE]. Resident #58 had diagnoses that included in part. Generalized Muscle Weakness, Personal History of Pulmonary Embolism, Unspecified Sequelae of Cerebral Infarction, and Dysphagia. Review of Resident #58's admission MDS with an ARD date of 01/28/2026 revealed in part . Resident# 58 had BIMS of 06 and required substantial/maximal assistance from staff for personal hygiene, toileting, and bathing. Resident #58 had no behaviors or rejection of care. Review of Resident #58's 01/2026 orders read in part.01/07/2026 Chest X-ray, Flu Swab, CBC, BMP. Review of Resident #58's medical record revealed no documentation of results obtained for the above 01/07/2026 orders. Review of Resident #58's Departmental Progress Notes read in part.01/04/2026 9:00 a.m. S3LPN documented: Resident #58 complains of coughing and nausea. On-call NP notified. New orders for Geritussin cough syrup, give 10 mls as needed every 4 hours for 5 days, and Zofran 4 mg as needed every 6 hours for 6 days. Notified resident's son of new orders. 01/07/2026 S26NP documented: Resident #58 is seen today for follow-up visit after on-call was notified that the resident had a cough, at that time she was started on Tessalon cough medicine. She continues to report that she is just not feeling well overall, lethargic, malaise, and hurting in her joints and body with a cough. Her lung sounds are clear throughout. There has not been any imaging or labs ordered since she started this production on 01/04/2026. Plan: Chest X-ray, Flu Swab, CBC, BMP. 01/11/2026 6:20 p.m. S17LPN- Notified Resident #58 was positive for Influenza A. S26NP made aware, new orders received for Isolation Precautions per facility policy. Interview on 01/14/2026 at 12:05 p.m. with S17LPN revealed on 01/11/2026 she was notified by S26NP that Resident #58 was positive for Flu and asked how resident was doing. S17LPN stated at that time Resident#58 was doing well and was asymptomatic. S17LPN stated she did not know if the facility had the lab results from the orders on 01/07/2026 as she had not seen them, and it was actually S26NP who notified her of the results. S17LPN stated she did not know why there was a delay in receiving the lab results from 01/07/2026. Interview on 01/14/2026 at 12:57 p.m. with S2DON revealed Resident #58 had been symptomatic with respiratory symptoms, so S26NP ordered a Chest X-ray, Flu swab, and labs on 01/07/2026. S2DON confirmed the facility did not follow up to ensure orders were followed and the facility had not received a copy of the lab results on 01/07/2026, but should have. S2DON confirmed the facility received the lab results today 01/14/2026 when requested. S2DON stated S26NP notified the facility on 01/11/2026 that Resident #58 was Flu A positive, and at that time the facility initiated isolation.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect 68 residents who received meals from the kitchen. The facility failed to ensure:1. Food items in the refrigerators and freezers were labeled, dated, and stored in a sanitary manner; and 2. Dry Food items were labeled with an open date and stored in a sealed container.On 01/12/2026 at 8:55 a.m., observation of the kitchen walk-in refrigerator revealed 1 bag of green onions opened and undated, 1 bag of shredded lettuce opened and undated, and 1 Activia yogurt opened with yogurt present on the packaging. On 01/12/2026 at 08:55 a.m., S10Dietary confirmed 1 bag of green onion and 1 bag of shredded lettuce should have been sealed and labeled with an open date, but were not. S10Dietary confirmed that the 1 Activia yogurt should not have been present in the refrigerator, which was opened and should have been discarded, but was not. On 01/12/2026 at 9:03 a.m., the kitchen walk-in freezer was observed with S10Dietary, revealing 1 box of hamburger patties opened to air, not sealed, and undated. 1 box of chicken tenders open to air, not sealed and undated, 2 chicken tenders on the floor of the freezer, and one cup of ice cream on the floor of the freezer. On 01/12/2026 at 09:03 a.m., S10Dietary confirmed 1 box of hamburger patties and 1 box of chicken tenders were not stored in a sealed container with an open date, and should have been. S10Dietary confirmed 2 chicken tenders and 1 cup of ice cream were present on the freezer floor, and should not have been. 2. On 01/12/2026 at 09:10 a.m., observation revealed 1 clear plastic container of cereal stored on the kitchen prep countertop labeled ground meat and no open date present on the container. S10Dietary present at this time and confirmed 1 clear plastic container of cereal was without an open date, labeled incorrectly, and should not have been. On 01/12/2026 at 2:45 p.m., the above findings were discussed with S1ADM and S11RegionalDietitian. S1ADM and S11RegionalDietitian confirmed that the above food items identified in the freezer, refrigerator, and dry food storage were improperly stored and labeled, and should not have been.

Based on observations and interviews, the facility failed to ensure garbage and refuse were properly disposed of. This deficient practice had the potential to affect all 71 residents at the facility.Review of facility undated policy titled Garbage and Rubbish Disposal read in part. Garbage and rubbish will be disposed of to ensure a clean and sanitary kitchen does not encourage infest or rodents. All outside dumpsters will be maintained in a clean and sanitary condition. Outdoor trash receptacles will be kept covered, and the surrounding area kept free of litter.On 01/12/2026 at 9:16 a.m., observation of the facility's outdoor dumpster area revealed a moderate amount of empty boxes outside of the dumpster area, a moderate amount of litter outside of the dumpster area, and the dumpster door was open.In an interview on 01/12/2026 at 9:16 a.m., S10Dietary confirmed that the facility dumpster area was unkempt, with a moderate amount of empty boxes and litter surrounding it, and that this should not have been. S10Dietary confirmed the dumpster door should have been closed, and it was not.In an interview on 01/12/2026 at 2:45 p.m., S1ADM confirmed the facility dumpster area was unkempt, with a moderate amount of empty boxes and litter surrounding the dumpster, and that the dumpster door was open and should not have been.

Based on observation, record review, and interviews, the facility failed to implement a comprehensive person-centered care plan for 1 (Resident #2) out of 3 (Resident #1, Resident #2, Resident #3) sampled residents.Findings:Review of Resident #2's EMR (Electronic Medical Record) revealed an initial admission date of 12/23/2024 and diagnoses that included in part, Schizoaffective Disorder, Bipolar type, Type 2 Diabetes, Hypertensive Heart Disease without heart failure, Anxiety, History of falling, and Dementia in other diseases classified elsewhere, unspecified severity, with agitation. Review of Resident #2's Quarterly MDS (Minimum Data Set) dated 09/22/2025 indicated Resident #2 was dependent on staff for assistance with eating, mobility, transfers, and personal hygiene. Resident #2 has a BIMS (Brief Interview for Mental Status) score of 4, which indicates severe cognitive impairment.Review of Resident #2's Care Plan dated as initiated 09/19/2025 included but is not limited to, At risk for falls.resident to be up in dining room for all meals.On 12/01/2025 at 12:15 p.m., Resident #2 was observed in her room with a lunch tray on the over-the-bed table drinking milk, with all other food remaining untouched on her tray. On 12/01/2025 at 12:20 p.m., S3 CNA revealed in an interview she had not assisted Resident #2 to the dining room today for breakfast or lunch. S3CNA confirmed she should have assisted the resident to the dining room for all meals as instructed by the resident's care plan but did not.On 12/01/2025 at 12:25 p.m., in an interview S2LPN confirmed that Resident #2 was not assisted to the day room or dining room on 12/01/2025 for breakfast or lunch but should have been.On 12/01/2025 at 1:40 p.m., an interview with S1Administrator confirmed Resident #2 should have been up in the dining room for all meals according to the resident's fall care plan but was not.On 12/01/2025 at 2:42 p.m., an interview with S4CNA revealed should be up in the dining hall for all meals to prevent falls.

Based on record review and interview, the facility failed to ensure a resident's discharge was documented in the resident's medical record for 2 (Resident #1, Resident #R1) of 3 (Resident #1, Resident #R1, and Resident #R2) residents reviewed for discharge. The facility failed to:1. Ensure documentation in the medical record included the basis for discharge for Resident #1 and Resident #R1;2. Ensure documentation in the medical record included that written discharge instructions were given to and discussed with the Resident/Responsible Party for Resident #1 and Resident #R1; and3. Ensure documentation in the medical record included discharge planning that addressed caregiver support and referrals to local contact agencies for Resident #1.Findings:On 09/03/2025, a review of the facility's policy titled Discharge Plan/Summary last revised 04/2025 revealed in part.6. If the resident is discharging to a private home, social work should meet with the person accepting responsibility for the resident. Referrals needed should be made to home health, DHS, or others based upon the needs of the resident.11. Nursing should meet with the person responsible for the resident at home and provide instruction to that person as appropriate in regard to medication and treatments to be continued at home. Referrals should be ensured for home care as needed, and coordinate same with Social Services. Any unused medications that are currently ordered after discharge may be sent with the resident prior to discharge.17. There should be documentation in the Nurses Notes regarding resident status at the time of discharge.Resident #1Review of Resident #1's medical record revealed an admission date of 02/19/2025 with diagnoses including, in part.Other Fracture of Shaft of Right Tibia, Subsequent Encounter for Closed Fracture with Delayed Healing; Methicillin Resistant Staphylococcus Aureus Infection, Unspecified Site; Diabetes Mellitus due to Underlying Condition with Unspecified Complication; Personal History of Other Venous Thrombosis and Embolism.Review of Resident #1's Quarterly MDS with an ARD of 05/28/2025 revealed a BIMS Score of 15, indicating intact cognition. The resident was noted to be independent for ADLs and used assistive devices of a wheelchair and walker for mobility. Resident #1 was noted to be incontinent of bowel and bladder. Resident #1 participated in the assessment and goal setting. Resident #1 did not want to be a long-term resident and wanted to return to her home.Review of Resident #1's electronic and paper health record revealed that the resident did not have a documented discharge plan in place prior to her discharge. According to an interview on 09/03/2025 at 9:19 am with S6 SSD, on 08/01/2025, S4 BOM and S6 SSD went together to tell Resident #1 that her insurance had ended on 07/31/2025.In an interview with S6 BOM on 09/02/2025 at 10:57 a.m., she stated that she gave Resident #1 the fax confirmation of the resident's insurance coverage ending. S6 BOM stated the resident was given the choice to pay out of pocket to stay, but this amount and the resident's refusal were not documented by the facility in the resident's record. S4 BOM stated she gave the resident the amount she would be charged to stay, but couldn't verbalize the cost given to Resident #1.A review of Resident #1's closed record revealed that a discharge form was partially completed by S6 SSD and signed by Resident #1. No other discharge documentation, such as the basis for discharge, referrals, medication reconciliation, instructions for discharge, or coordination of care, was documented by the facility in Resident #1's record.An interview with S1 Administrator on 09/03/2025 at 9:25 a.m. confirmed that S6 SSD was responsible for discharge planning and documentation. In an interview on 09/03/2025 at 2:52 p.m., S2 DON stated Social Services was responsible for initiating the Discharge Summary and completing their part. S2 DON stated the nurse had a part to complete, also. S2 DON acknowledged Resident #1's medical record did not contain the reason for her discharge, nor any documentation that written instructions were given to or discussed with the resident regarding her medications at discharge. Resident #R1Review of Resident #R1's medical record revealed an admit date of 03/18/2025 and a discharge date of 06/10/2025. Resident #R1's diagnoses included Alzheimer's disease, Paroxysmal Atrial Fibrillation, Atherosclerotic Heart Disease, and Hemiplegia and Hemiparesis following Cerebral Infarction.Review of Resident #R1's 5 day MDS with an ARD of 03/25/2025 revealed a BIMS score of 15, which indicated intact cognition.Review of Resident #R1's medical record revealed no documentation stating why the resident was discharged . Further review revealed no documentation of the medications provided to the resident at discharge or any instructions given to the resident.Review of Resident #R1's progress notes revealed the following:6/10/2025 at 12:23 p.m. Nurses Note by S8 LPN: Note Text: 12:20 p.m. Resident is discharged out of facility with medications.6/10/2025 at 10:54 a.m. Discharge Summary by S6 SSD: Resident sitting up in wheelchair waiting for family to arrive so that he can discharge home with fiancee. He is alert and oriented to self. His speech is clear. His hearing is adequate. He understands and is understood. No behaviors noted nor observed. He has a diagnosis of Alzheimer's Disease, Cerebral Infarction, HTN, and Type 2 Diabetes. He is incontinent of bowel and bladder. He is aware of activities and will attend those that interest him. Resident's main mode of transportation is wheelchair. Resident has to be encouraged to socialize with other residents. He prefers to stay in room and isolate to his room. His family is active in his care and attentive to his needs. He is capable of voicing his preference regarding his care. He is a full code, no living will, no POA, non-smoker, and not at risk for elopement. Resident discharges home 6/10/25. LTPCS will evaluate resident on 6/23/25 to see what services that he can receive at home.In an interview on 09/03/2025 at 2:45 p.m., S3 LPN stated Resident #R1 was here for short term therapy after having a stroke. S3 LPN stated Resident #R1 wanted to go home after receiving therapy.In an interview on 09/03/2025 at 2:52 p.m., S2 DON stated Social Services was responsible for initiating the Discharge Summary and completing their part. S2 DON stated the nurse had a part to complete, also. S2 DON acknowledged Resident #R1's medical record did not contain the reason for his discharge nor any documentation that written instructions were given to or discussed with the resident regarding his medications at discharge.

Based on record review and interview, the facility failed to have a discharge summary that included the required information for 2 (Resident #1 and Resident #R1) of 3 (Resident #1, Resident #R1, and Resident #R2) residents reviewed for discharge. The discharge summaries for Resident #1 and Resident #R1 failed to include:1. A recapitulation of the residents' stay that included diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results;2. A final summary of the residents' status at the time of the discharge; and3. Reconciliation of all pre-discharge medications with the residents' post-discharge medications (both prescribed and over-the-counter).Findings:On 09/03/2025, a review of the facility's policy titled, Discharge Plan/Summary last revised 04/2025 revealed in part.12. The Discharge Summary form should be completed with care needs identified and documented as appropriate.14. Guidelines for completion of the Discharge Summary: Nursing: Identifies continuing nursing needs. Specifies level of nursing care needed. Verifies resident/family understanding of orders including all medications prescribed by physician. Detailed nursing care plan, special problems, teaching steps and level of progress and further teaching as appropriate. Social Services: May identify resident's personal, financial and social needs in relation to medical and psychological problems.15. A copy of the summary is given to resident/family upon discharge when resident is going home. 16. The original is placed in the resident Medical Record. 17. There should be documentation in the Nurses Notes regarding resident status at the time of discharge.Resident #1Review of Resident #1's medical record revealed an admit date of 02/19/2025 with diagnoses that included in part Other Fracture of Shaft of Right Tibia, Subsequent Encounter for Closed Fracture with Delayed Healing; Methicillin Resistant Staphylococcus Aureus Infection, Unspecified Site; Diabetes Mellitus due to Underlying Condition with Unspecified Complication; Personal History of Other Venous Thrombosis and Embolism. Further review revealed a discharge date of 08/01/2025.Review of Resident #1's Quarterly MDS with an ARD of 05/28/2025 revealed a BIMS Score of 15, which indicated intact cognition. Resident #1 was noted to be independent for ADLs and used assistive devices of a wheelchair and walker for mobility. Review of Resident #1's electronic record revealed there was no documented discharge summary, which should have included a recapitulation of Resident #1's stay, a final summary of the Resident #1's status, and a reconciliation of Resident #1's medications.Review of Resident #1's paper medical record revealed a partially completed document titled, Discharge Summary/Instructions, dated 08/01/2025 signed by S6 SSD and Resident #1.Interview with S6 SSD on 09/03/2025 at 9:19 a.m. confirmed the partially completed document titled, Discharge Summary/Instructions, dated 08/01/2025 was provided to Resident #1 at the time of discharge.Interview with S1 Administrator on 09/03/2025 at 9:25 a.m. revealed she did not provide any documentation to Resident #1 upon discharge and S6 SSD was responsible for discharge documentation.Interview with S2 DON on 09/03/2025 at 2:52 p.m. confirmed Resident #1's medical record did not contain a completed discharge summary and should have.Resident #R1Review of Resident #R1's medical record revealed an admit date of 03/18/2025 and a discharge date of 06/10/2025. Resident #R1's diagnoses included Alzheimer's disease, Paroxysmal Atrial Fibrillation, Atherosclerotic Heart Disease, and Hemiplegia and Hemiparesis following Cerebral Infarction.Review of Resident #R1's progress notes revealed the following:06/10/2025 at 10:54 a.m.: Discharge Summary by S6 SSD: Resident sitting up in wheelchair waiting for family to arrive so that he can discharge home with fiance. He is alert and oriented to self. His speech is clear. His hearing is adequate. He understands and is understood. No behaviors noted nor observed. He has a diagnosis of Alzheimer's disease, cerebral infarction, HTN, and type 2 diabetes. He is incontinent of bowel and bladder. He is aware of activities and will attend those that interest him. Resident's main mode of transportation is wheelchair. Resident has to be encouraged to socialize with other residents. He prefers to stay in room and isolate to his room. His family is active in his care and attentive to his needs. He is capable of voicing his preference regarding his care. He is a full code, no living will, no POA, non-smoker, and not at risk for elopement. Resident discharges home 6/10/25. LTPCS will evaluate resident on 6/23/25 to see what services that he can receive at home.06/10/2025 at 12:23 p.m.: Nurses Note by S8 LPN: Note Text: 12:20 p.m. Resident is discharged out of facility with medications.Review of Resident #R1's medical record revealed no documentation stating why Resident #R1 was discharged , no documentation of the medications provided to Resident #R1 at discharge, or any instructions given to the resident. Review of Resident #R1's Discharge Summary/Instructions form dated 06/10/2025 revealed no documentation of Resident #R1's diagnoses, course of illness/treatment, or therapy received and no medication reconciliation or summary of Resident #R1's status at the time of discharge. The Discharge Summary was not signed by Resident #R1.Interview with S2 DON on 09/03/2025 at 2:52 p.m. revealed Social Services was responsible for initiating the Discharge Summary and completing their part of the form and the nurse also had a part to complete. S2 DON confirmed Resident #R1's Discharge Summary and medical record did not contain a list of medications provided to Resident #R1 or documentation of written or verbal instructions provided to or discussed with Resident #R1 regarding his medications at discharge. S2 DON acknowledged Resident #R1's Discharge Summary did not contain a recapitulation of Resident #R1's stay or Resident #R1's status at time of discharge and should have.

Based on interviews and record reviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 5 residents sampled with behavioral health diagnoses by failing to: 1. Develop and implement a person-centered plan of care that addressed Resident #1's history of Substance Use/Abuse; 2. Ensure concerns identified in the provider's progress notes regarding drug diversion were addressed; and 3. Perform monthly UDS as ordered. Findings: Review of the facility's policy entitled Comprehensive Person Centered Care Plans, revised 01/2025, revealed, in part .each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. A resident-centered goal is to be developed for each problem. Staff approaches are to be developed for each problem. Review of Resident #1's medical record revealed an admission date of 01/17/2025 with diagnoses including, in part .Adverse Effect of Methamphetamines, Cannabis Abuse with Intoxication, Suicidal Ideations, History of Suicidal Behavior, PTSD, GAD, Bipolar Disorder, and MDD. Review of Resident #1's admission MDS with ARD of 01/24/2025 revealed, in part .a BIMS Score of 15, which indicated intact cognition. Resident #1 did not have PTSD. Substance use/abuse was not indicated. Review of Resident #1's Quarterly MDS with ARD of 04/22/2025 revealed, in part .a BIMS Score of 15, which indicated intact cognition. Resident #1 did not have PTSD. Substance use/abuse was not indicated. 1. Review of Resident #1's comprehensive care plan revealed, in part .resident was not care-planned for History of Substance Use/Abuse. Interview with S1ADM on 06/09/2025 at 2:36 p.m. revealed Resident #1 had been discharged from another facility due to abuse of methamphetamine. S1ADM confirmed Resident #1 was not care-planned for a History of Substance Use/Abuse, but should have been Interview with S11MDS on 06/12/2025 at 1:08 p.m. confirmed Resident #1 was not care planned for Substance Use/Abuse, but should have been. 2. Review of Resident #1's provider progress note dated 04/08/2025 revealed, in part .it was brought to the provider's attention that the resident had been diverting scheduled medications and taking medications that were not prescribed to him. Review of Resident #1's provider progress note dated 04/22/2025 revealed, in part .the resident was seen for active substance use. Resident #1 reported he had been actively abusing medications since being admitted to the facility. Review of Resident #1's provider progress note dated 04/29/2025 revealed, in part .klonopin, an antianxiety medication, had recently been discontinued due to active substance abuse. Interview with S9NP on 06/10/2025 at 11:10 a.m. revealed Resident #1 had been actively abusing drugs when admitted to the facility and was positive for methamphetamine on 01/22/2025. S9NP confirmed on 04/08/2025 she documented Resident #1 had been diverting scheduled medications and taking pain medications that were not prescribed to him since admission to the facility. S9NP stated Resident #1 stated he had been pocketing his klonopin and had been trading his medication. S9NP confirmed on 04/22/2025 she documented Resident #1 was seen for active substance abuse within the facility. S9NP confirmed her 04/29/2025 progress note for Resident #1 recorded active substance abuse. Interview with S1ADM on 06/10/2025 at 2:43 p.m. confirmed at the time of Resident #1's death she was unaware of S9NP's progress notes indicating Resident #1 had active substance abuse, had been diverting scheduled medications and taking pain medications that were not prescribed to him since admission to the facility, had been pocketing his klonopin, and trading his medication. S1ADM confirmed no actions had been taken to address these concerns. Interview with S9NP on 06/10/2025 at 7:58 p.m. revealed someone from the facility had called her and made her aware of Resident #1's drug diversion in the facility. S9NP declined to answer the surveyor when asked whom from the facility she had been notified by. 3. Review of Resident #1's orders revealed, in part .monthly UDS, dated 02/21/2025. Review of Resident #1's laboratory reports revealed a UDS collected on 01/22/2025 was positive for methamphetamine. Resident #1 had no UDS dated 02/21/2025 through 05/14/2025. Interview with S1ADM on 06/09/202025 at 4:13 p.m. revealed Resident #1 was ordered a monthly UDS on 02/21/2025. Interview with S1ADM on 06/10/2025 at 9:02 a.m. confirmed a monthly UDS was not performed, as ordered, for Resident #1, but should have been. Interview with S8LPN on 06/10/202025 at 9:18 a.m. revealed she entered the order for monthly UDS on 02/21/2025 at 1:01 p.m. S8LPN confirmed Resident #1 should have had a UDS on 02/21/2025, and then monthly thereafter, but did not.

Based on interviews and record review, the facility failed to ensure the admission and Quarterly MDS assessments accurately reflected a resident's status for 1 (Resident #1) of 5 sampled residents. Findings: Review of the facility's policy entitled MDS Assessment, revised 06/2023, revealed, in part .these assessments provide information on the resident's condition and facilitate development of an individualized plan of care. Review of Resident #1's medical record revealed an admission date of 01/17/2025 with admission diagnoses which included, in part .Adverse Effect of Methamphetamines, Cannabis Abuse with Intoxication, Suicidal Ideations, History of Suicidal Behavior, PTSD, GAD, Bipolar Disorder, and MDD. Review of Resident #1's Quarterly MDS with ARD of 04/22/2025 revealed, in part .a BIMS Score of 15, which indicated intact cognition. Resident #1 did not have PTSD. Further review of the MDS revealed Resident #1's history of suicidal behaviors, suicidal ideations, and substance use/abuse were not listed. Review of Resident #1's admission MDS with ARD of 01/24/2025 revealed, in part .a BIMS Score 0f 15, which indicated intact cognition. Resident #1 did not have PTSD. Further review of the MDS revealed Resident #1's history of suicidal behaviors, suicidal ideations, and substance use/abuse were not listed. Review of Resident #1's Psychiatric Initial Evaluation dated 02/13/2025 revealed, in part .Resident #1 was positive for methamphetamine upon arrival to the facility. Review of Resident #1's social services progress note dated 01/21/2025 revealed, in part .Resident #1 had a diagnosis of PTSD and a history of substance abuse. Interview with S6SSD on 06/10/2025 at 8:22 a.m. confirmed Resident #1's Social Services History and Initial Assessment completed on 01/21/2025 identified a diagnosis of PTSD, increased anxiety, and a history of substance use/abuse. Interview with S1ADM on 06/12/2025 at 12:50 p.m. confirmed Resident #1's admission and Quarterly MDS assessments did not include diagnosis of PTSD and substance use/abuse, SI, or History of Suicidal Behavior, but should have.

Based on interview and record review, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care that met professional standards of quality care for 1 (Resident #1) of 5 sampled residents. Findings: Review of the facility's policy entitled Comprehensive Person Centered Care Plans, revised 01/2025, revealed, in part .a baseline care plan is the initial plan of care to be used upon admission, until the comprehensive care plan is completed. The baseline care plan is to be developed within 48 hours. A resident-centered goal is to be developed for each problem. Staff approaches are to be developed for each problem. Review of Resident #1's medical record revealed an admission date of 01/17/2025 with diagnoses including, in part .Adverse Effect of Methamphetamines, Cannabis Abuse with Intoxication, Suicidal Ideations, History of Suicidal Behavior, PTSD, GAD, Bipolar Disorder, and MDD. Review of Resident #1's medical record revealed Resident #1 did not have a baseline care plan. Interview with S2DON on 06/12/2025 at 4:59 p.m. revealed she was unable to provide a baseline care plan for Resident #1. S2DON confirmed a baseline care plan was not developed for Resident #1, but should have been.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #1) of 5 sampled residents. Findings: Review of the facility's policy entitled Comprehensive Person Centered Care Plans, revised 01/2025, revealed, in part .each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. A resident-centered goal is to be developed for each problem. Review of Resident #1's medical record revealed an admission date of 01/17/2025 with diagnoses including, in part .Adverse Effect of Methamphetamines, Cannabis Abuse with Intoxication, Suicidal Ideations, History of Suicidal Behavior, PTSD, GAD, Bipolar Disorder, and MDD. Review of Resident #1's comprehensive care planned revealed Resident #1 was not care-planned for Suicidal Ideations, History of Suicidal Behavior, PTSD, or Substance Use/Abuse. Interview with S1ADM on 06/12/2025 at 12:50 p.m. confirmed Resident #1 was not care-planned for Suicidal Ideations, History of Suicidal Behavior, PTSD, or Substance Use/Abuse, but should have been. Interview with S7MDS on 06/12/2025 at 1:08 p.m. confirmed Resident #1 was not care planned for Substance Use/Abuse, but should have been.

Based on record review, observation, and interview the facility failed to ensure residents received adequate supervision to prevent accidents for 1 (#186) of 2 (#19, #186) residents reviewed for elopement. The facility failed to provide adequate supervision for Resident #186 who was a known elopement risk. This deficient practice resulted in an immediate jeopardy situation for Resident #186 on 09/17/2022 sometimes after 1:40 p.m. when she wandered off the facility grounds unnoticed by staff. Resident #186 had a history of exit seeking behaviors, had been identified as an elopement risk, and wore a wanderguard ankle bracelet. Resident #186 was picked up by a family friend in a neighborhood behind the facility and returned, uninjured, to the facility at approximately 2:05 p.m. on 09/17/2022. The immediate jeopardy situation ended on 09/17/2022 at approximately 2:05 p.m. when the resident was placed on 1 to 1 supervision around the clock. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's policy and procedure titled Missing Resident/Elopements revealed, in part, the following: Policy: The Unit Charge Nurse is responsible for knowing the location of their residents. When residents are participating in various programs, such as physical therapy, recreational activities, dining, etc., the staff in these programs will be responsible for the location of their participation. Procedure: 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as practical. Resident #186 Review of the medical record for Resident #186 revealed an admitted [DATE], with diagnoses that included, in part .unspecified [CONDITION(S)], anxiety disorder, and unspecified dementia with behavioral disturbances. Review of Resident #186's admission orders dated 09/06/2022, revealed an order to admit Resident #186 to the Behavioral Unit. Review of the facility's Risk of Elopement Evaluation dated 09/06/2022 and signed by S20 LPN revealed: Resident #186 had a diagnosis of unspecified [CONDITION(S)], was alert, and oriented to person only with hallucinations present. The Risk of Elopement Evaluation revealed Resident #186 ambulated independently, and was marked as-Yes, Resident is at risk for elopement. Resident Monitoring Bracelet applied and Door alarms were marked as an intervention. Review of the Admission MDS with an ARD date of 09/13/2022 revealed a BIMS score of 99, which indicated Resident #186 was unable to complete the interview. The MDS revealed Resident #186 required extensive assistance by one person physical assist with bed mobility, transferring, and toilet use. The MDS assessment revealed Resident #186's daily decision making was moderately impaired, and Resident #186 required supervision and cueing. Review of the baseline care plan (no date) revealed Resident #186 was care planned for elopement related to a history of exit seeking prior to admission to the nursing facility. Intervention listed: wanderguard. Review of Resident #186's physician's orders dated 09/2022 revealed there was no order for a wanderguard bracelet, or an order to monitor Resident #186's whereabouts prior to her elopement on 09/17/2022. Review of the nurses' notes for Resident #186 read as follows: 09/09/2022 at 9:00 a.m. documented by S21 LPN - Resident approached this nurse asking for a pair of scissors, this nurse stated to resident why do you need scissors and resident replied, I'm trying to cut this thing off my ankle. This nurse explained to resident that wanderguard could not be cut off and that it was there so we could monitor whereabouts. Resident stated but it's aggravating me, I got to get this off. Resident redirected to her room and is resting at this time. Call bell in reach. Will continue to monitor. 09/11/2022 at 7:36 p.m.: Resident is walking around hall way in a very confused state asking to cut the thing off her ankle .Will continue to document as needed. 09/12/2022 at 2:20 p.m. documented by S3 LPN - 9:00 a.m. - Resident states to this nurse I am going home tomorrow when my sister comes to get me. Can you please take this bracelet off of my ankle? This nurse explains to the resident that the bracelet will stay on until discharged , but will touch base with doctor and let him know that she doesn't want it. 09/13/2022 at 3:50 p.m. read in part BIMS and Pain Assessment: .Resident is confused. Daily decision making is moderately impaired. She requires supervision and cueing .Ambulates ad lib. Documented by S11 LPN. Review of progress note dated 09/14/2022 at 3:10 p.m. by S30 Nurse Practitioner, a private nurse practitioner who specializes in psychiatry, revealed an entry that read, Her nurse says she has an ankle monitor around the ankle-wander guard, which she would like removed. Her nurses say she repeats often during the day that she wants to go home. Further review revealed the resident had the following symptoms reported which are typical of moderately severe dementia: Poor judgment is creating safety issues when left alone. For example, Resident #186 may wander. Restless behaviors like pacing, and hallucinating. Diagnoses included anxiety disorder, mild cognitive impairment, and major depressive disorder, recurrent, with psychotic symptoms. This may be better if moved between 9/13 and 9/15, prior to the elopement .Supports culpability . 09/15/2022 at 6:41 p.m. documented by S15 LPN - Resident appeared to have hallucinations throughout the day. Resident has voiced to staff that we need to call 911, her brother and sister are dead, and they are dying and needs assistance. She needs to go to the hospital to check on her dead siblings. Resident was walking down the hall way, stopped walking and layed in the middle of the hallway, staff helped her up and she walked back to her room. 09/16/2022 at 4:11 p.m. by S19 SSD - SSD observed resident having hallucinations, resident stated that the devil told her that if she walked in the room he was going to kill her, another conversation was that if she sat in the chair he would kill her. SSD was able to redirect. 09/17/2022 at 6:31 p.m. by S3LPN - At approximately 2:00 p.m., Resident was intercepted and brought to facility through the front door of the facility. The alarm went off, as resident has wander guard in place to left ankle. Resident ambulates back to her room with staff at side. Resident is awake, alert and oriented x 1 at this time and has MOF at side, 108/64, 82, 18, 97.6, 98% room air. Skin warm and dry to touch, Respirations even and unlabored, ambulatory per self without signs or symptoms of distress. Wanderguard in place to left ankle. Abdomen soft, non-tender. Continent of Bowel and bladder. Resident had managed to open a door and exit the facility and wander guard did not alarm, however upon re-entering facility, wander guard set alarm off. Resident is immediately placed on 1:1 observation with staff at doorway with eyes on resident 1:1 documentation started and will remain in effect until further notice. Resident is calm and responds to all questions from this nurse with no acute distress noted. Maintenance in building checking all exit and entrance doors. Family aware. Management aware. Will monitor. In an interview on 09/21/2022 at 8:05 a.m., S5 RN/WCN confirmed she was working in the facility on 09/17/2022 when Resident #186 eloped. S5 RN/WCN reported she answered the phone when the family called and said Resident #186 was out of the facility, and they were bringing her back. S5 RN/WCN stated she didn't know if Resident #186 was out on pass, or what the family meant. S5 RN/WCN said she went and talked with the resident's nurse, S3 LPN. S5 RN/WCN reported they checked the doors and were able to push the door open across from Resident #186's room. S5RN/WCN said it wasn't ajar, but just pushed open. S5 RN/WCN stated about the same time, Resident #186 was being brought back in the front door, and the door alarm sounded as Resident #186 came back in the facility. S5 RN/WCN stated the door alarm never went off when Resident #186 eloped. S5 RN/WCN reported S3 LPN examined Resident #186 when she returned. S5 RN/WCN reported she had last seen Resident #186 about lunch when the resident asked her to cut the wanderguard off her ankle, and she had to tell her she couldn't do that. S5RN/WCN confirmed upon Resident #186's return, the wanderguard was still in place on her ankle. S5 RN/WCN also reported Resident #186's information was located in the elopement binder located at the nurses' station with her picture in it. Review of the elopement binder at the nurses' station on 09/21/2022 on Resident #186's hall with S3 LPN and S5 RN/WCN revealed the resident's Face Sheet with Resident #186's picture on it. The binder also contained the facility's elopement policy as well as other residents at risk for elopement. In an interview on 09/21/2022 at 9:15 a.m., S23 Admissions Director reported she was contacted by Resident #186's family and by the psychiatric hospital Resident #186 was in at the time, about being admitted to the facility. S23 Admissions Director reported the family had first tried to admit the resident to another facility who would not accept her due to her history of behaviors. S23 Admissions Director reported Resident #186 was admitted to the facility's locked behavioral unit on 09/06/2022 because it had been recommended by the psychiatric hospital upon referral, and due to her diagnoses and reported history of behaviors. S23 Admissions Director reported Resident #186 was moved to a regular room two days later because the family insisted, and Resident #186 had shown no behaviors on the unit. S23 Admissions Director further reported Resident #186's sister called her on 09/17/2022 to report the resident had eloped, and informed her that a family friend had picked Resident #186 up and was bringing her back to the facility. S23 Admissions Director stated she immediately called the Administrator to notify her, and confirmed no one at the facility was aware the resident was missing. In an interview on 09/21/2022 at 9:50 a.m., S3 LPN reported on 09/17/2022 at 2:05 p.m., S5 RN/WCN asked her where was Resident #186, and did her family check her out? S3 LPN said she told her no, Resident #186 was not out on a pass. S3 LPN said S5 RN/WCN told her Resident #186's family called and said someone picked Resident #186 up and was bringing her back. S3 LPN reported she started checking doors and discovered the door across the hall from Resident #186's room just opened up when she pushed on it, and the alarm did not go off. S3 LPN said it felt like the door wasn't catching. S3 LPN reported S25 Maintenance came in after the elopement that day and worked on it. S3 LPN reported Resident #186 had asked her several times to take her wanderguard off because it bothered her. However, S3 LPN reported she didn't think Resident #186 was an elopement risk. S3 LPN reported she last visualized Resident #186 some time that morning. S3 LPN stated she checks the resident's wanderguard by going to a door and opening it with the resident present to see if the alarm goes off. S3 LPN reported checking it every shift and said it was documented on the MAR. When asked to show the documentation, S3 LPN looked at the MAR and confirmed she could not find any documentation of the wanderguard being checked by staff prior to the elopement on 09/17/2022. S3 LPN stated CNAs were to check on residents every 2 hours. In an interview at 10:25 a.m. on 09/21/2022, Resident #38, who had a BIMS of 14 indicating he was cognitively intact, reported Resident #186 asked him three times on 09/17/2022, How do I get out of here? Resident #38 explained he told the resident, You can't get out of here. Resident #38 reported he had seen Resident #186 pushing the doors at the end of the hall earlier in the day on 09/17/2022 but she was unable to open them. Resident #38 denied reporting it to anyone. In an interview at 12:51 p.m. on 09/21/2022, S26 CNA confirmed she was working when Resident #186 eloped. S26 CNA reported she saw Resident #186 in the hall talking with Resident #38 between 1:30 p.m. - 1:40 p.m. S26 CNA reported Resident #186 was always asking everyone to take her to see her mom. S26 CNA stated she did not know that Resident #186 was an elopement risk, and stated she never saw Resident #186 push doors. S26 CNA stated rounds were completed every 2 hours on all residents who resided in general population, regardless of whether they wore a wanderguard bracelet. In an interview on 09/20/2022 at 08:53 a.m., S28 CNA who said she had been sitting with Resident #186 for 12 hours shifts since Sunday, 09/18/2022, yesterday, and today. S28 CNA acknowledged Resident #186 was an elopement risk and reported Resident #186 walked around the facility yesterday and tried to open doors unsuccessfully. S28 CNA reported Resident #186 was very confused. In an interview on 09/20/22 at 2:19 p.m., S27 CNA, confirmed she was an agency CNA caring for Resident #186 after the elopement on 09/17/2022, and stated she receives a Pocket Care Guide when she comes in the facility each shift that tells her information on the residents to guide her care. Review of the Daily Care Guide (pocket guide used by CNAs) dated 09/15/2022 for Resident #186 revealed no documentation or interventions listed to alert the CNA that Resident #186 was an elopement risk or that Resident #186 had a wanderguard in place. Interventions listed were: Family will do laundry, full code status, new admit to facility-approach in calm manner, regular diet-encourage to eat in dining room, requires minimal assistance with ADLS, and shower every other day and as needed and shave if needed. In an interview on 09/20/22 at 2:00 p.m., S1 Administrator confirmed the facility did not have a Wanderguard policy. When asked how staff knew who had a wanderguard on, when to check it, and what to do with it, S1 Administrator stated it would be on the MAR for the nurses to check, and the CNAs would know what resident had one because it would be on their pocket guide. When asked how agency staff would know who had a wanderguard on, when to check it, and what to do with it, S1 Administrator stated They just know. S1 Administrator confirmed Resident #186 was being cared for by an agency CNA (S29 CNA) at the time of elopement. #186's care on 09/17/202 at the time of elopement. Review of Resident #186's MAR for 09/2022 revealed no documentation of Resident #186's wanderguard being checked prior to the elopement on 09/17/2022. In an interview on 09/20/2022 at 12:46 p.m., S1 Administrator reported Resident #186 was admitted to the facility's locked, behavioral unit on 09/06/2022 from an inpatient psychiatric stay, and was transferred two days later to a regular room because the family insisted on it. S1 Administrator reported staff had not really had enough time to evaluate the resident on the behavioral unit, and said they discouraged the family from moving Resident #186 to the regular floor, but the family insisted. S1 Administrator acknowledged a wanderguard was placed on Resident #186 when she was moved off the locked unit because she was an elopement risk. S1 Administrator confirmed Resident #186 eloped from the facility on 09/17/2022 without staff becoming aware the resident was missing until the family called the facility to report it. Review of Resident #186's medical record revealed the intervention of the wanderguard bracelet was put in place when Resident #186 was moved from the locked behavioral unit to general population on 09/08/2022. There was no documentation to increase supervision of Resident #186 prior to her elopement on 09/17/2022. The surveyor was unable to interview the S29 CNA who was assigned to Resident #186's care on 09/17/202 at the time of elopement. Through observation, interview and record review, surveyors were able to verify that the facility has implemented the following actions to correct the deficient practice: 1. Resident was assessed immediately upon return to the facility. Resident was placed one to one immediately upon returning to facility at 2:05 p.m. on 09/17/2022. 2. 100% head count for all other Residents to ensure they were accounted for. 3. Staff interviewed on 09/17/2022. All staff denied that any door alarm sounding. 4. 100% elopement assessment was performed on all 87 residents on 09/17/2022. 5. Resident to be left 1:1 until an additional key pad is added that would separate the doors from being controlled by the wander guard panel. Frequency of monitoring will be determined by resident behavior after the additional locking system is added to the door. This effort will allow the doors to be controlled independent and doors will remain secure even if wander guard panel becomes malfunctioning. 6. Exit door by nurses' station was immediately assessed by Maintenance Director on 09/17/2022. Door was found to malfunction; alarm bracelets did not sound when exiting door, but did alarm when entering door. Door was placed out of commission immediately on 09/17/2022. Representative from _______Medical Company came to facility to check door by nurses' station and stated the door contacts were broken on the panel causing the door to not lock and alarm not to sound. New orders received for 1:1 until all doors checked by Medical Company to ensure working appropriately. 7. Additional alarms were added to both exit doors on hall #A until additional key pads are added. 8. 100% of all other exit doors with alarms were assessed on 09/17/2022 by Maintenance Director. No other issues noted. 9. 100% of all windows was assessed by Maintenance Director on 09/17/2022. No concerns were noted. 10. Reviewed TELS for weekly door functioning. Door functioning was completed on Friday, September 16, 2022. No issues identified. Facility initiated daily door functioning on 09/17/2022. Maintenance Director will check daily functions Monday-Friday and weekend Managers will check them on Saturday and Sunday. Executive Director will be responsible for ensuring daily checks are being performed. 11. In-service initiated 09/17/2022 for staff on Wandering/Elopement Policy and Abuse. 12. ________ Company repaired door contacts and wires between two mag locks on 09/18/2022. 13. New hires are oriented on wandering policy and Dementia training upon hire. As of 09/17/2022 at 2:05 p.m. and once the above interventions were all implemented, the past noncompliance was considered to be corrected.

Based on observation, interview and record review, the facility failed to ensure that capillary blood glucose levels, and medications were administered in accordance with professional standards of practice, and residents' person centered plans of care. The facility failed to have a system in place to: 1. Ensure medications that included antihypertensive medication, narcotic analgesics, anticonvulsants, and [CONDITION(S)] medications were timely acquired and to be administered for 9 (#57, #2, R5, #34, #R6, #5, #42 and #R9) of 19 (#51, #57, #2, #5, #32, #34, #42, #47, #54, #R1, #R2, #R3, #R4, #R5, R6, #R7 #R8, #R9 and #R10) residents; 2. Obtain and/or monitor blood glucose levels, and administer hyperglycemic medication insulin as ordered for 9 (#51, #57, #2, #42, #R1, #R2, #R3, #R4, and #R5) of 12 residents diagnosed with Diabetes Mellitus (#51, #57, #2, #42, #47, #R1, #R2, #R3, #R4, #R5, #R7 and #R8); 3. Notify the physician as ordered for capillary blood glucose levels that were below 60 mg/dl or exceeded 400 mg/dl for 2 (#51 and #57) of 12 residents diagnosed with Diabetes Mellitus (#51, #57, #2, #42, #47, #R1, #R2, #R3, #R4, #R5, #R7 and #R8); 4. Administer anticonvulsant medications as ordered for 1 (#34) of 3 (Resident #34, #32, and #R11) diagnosed with Seizures; 5. Administer daily medications on the days of [CONDITION(S)] for 2 of 2 residents (#54 and #R6) who received [CONDITION(S)] treatment 3 times a week; 6. Ensure pain medications were administered ordered for 3 of 3 (Residents #5, #R9 and #34) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] This deficient practice resulted in an Immediate Jeopardy situation for Resident #51 on 09/01/2021 when nursing staff started to administer ordered insulin without his capillary blood glucose levels being done. Resident #57 capillary blood glucose levels was also not being done as ordered and he was not being administered his oral and subcutaneous antidiabetic medications ([MEDICATION(S)] [MEDICATION(S)], [MEDICATION(S)] R), hypertensive medication as ordered ([MEDICATION(S)], [MEDICATION(S)] HCL) and his pain medication ([MEDICATION(S)]). Residents (#51, #57, #2, #42, #R1, #R2, #R3, #R4, and #R5 diagnosed with Diabetes Mellitus and all receiving antidiabetic medications had missed doses of their medications. Residents (#34 and #5) diagnosed with pain also had missed doses of their pain medications as ordered resulting in Resident #34 being sent to the local ER for pain control; and Resident #5 unable to complete an interview due to being in severe pain. The S1 Administrator was notified of the Immediate Jeopardy on 11/06/2021 at 8:30 p.m. The Immediate Jeopardy was removed on 11/08/2021 at 7:10 p.m. when the facility submitted the following Plan of Removal, and the surveyor determined through observation, interview and record review that the Plan of Removal was being implemented: The facility submitted an acceptable plan of removal on 11/08/2021 at 7:10 p.m. The plan of IJ removal included the following: 1. IJ Removal Plan 11/08/2021 at 7:10 p.m. 2. S7 Vice President of Operations in-serviced S1 Adm. on ensuring that the facility was administered in a manner that uses resources to effectively and efficiently meet the needs of the residents. 3. An in-service was initiated on 11/06/2021 at 8:45 p.m. for licensed nurses' policies for Medication Administration, Ordering/Receiving Medications and Glucose Testing. 4. Re-ordering plan initiated on 11/08/2021 that includes that all medications will be reordered within 7 days prior of being depleted to the pharmacy on Mondays. 5. The facility will reconcile reorder list on Thursday to ensure all medications were received. 6. The facility will utilize the local pharmacy, Pharmacist services for all emergency refill or stat medications. 7. The facility has initiated exploring other pharmacy service options. 8. S2 DON/S14 LPN Nurse Manager will reconcile all medications carts weekly x 4 weeks, then 1 medication cart weekly x 4 weeks, then monthly to validate that medications are available and reordering plan is followed. 9. The Pharmacist Consultant will begin weekly visits x 4 weeks starting 11/08/2021 to audit 25% of Residents' Medication Administration Records and medication availability. 8. Pharmacist Consultant to initiate an additional in-service on 11/08/2021 for license nurses to include medication administration/following physician orders, accuracy of documentation on Medication Administration Records, and ordering/reordering of medications. 9. S2 DON/S14 LPN Nurse Manager will review 100% of Medication Administration Records 5x a week x 4 weeks, then weekly x 4 weeks, then monthly x 3 months to ensure accuracy of documentation related to medication administration and ensure availability of medications beginning on 11/08/2021. Any concerns will be immediately addressed. 10. On 11/08/2021, the facility initiated a shift to shift Medication Administration Records documentation review form, in which on-coming and off-going nurses will check Medication Administration Records for complete documentation. 11. On 11/08/2021, the facility initiated a Nurse Signature & Sign-In form which will be maintained in front of the Medication Administration Records for nurses to document his/her printed name, signature, and initial. S1DON/S14 LPN Manager will monitor weekly x 3 months for completion. 12. S1Adm. will be monitored by S7 Vice President of Operations weekly x 4 weeks, then monthly x 3 months. Findings: Review of the Medication Administration - General Guidelines Policy revealed in part: 2. Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications and professional standards of practice. 5. All current medications and dosage schedules are listed on the resident's medication administration record MAR/TAR and administered timely according to facility policy. 9. Only licensed or legally authorized personnel who prepare a medication may administer it. This individual records the administration on the resident's MAR or TAR after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/TAR to ascertain that all necessary doses were administered and all administered doses were documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications . 11. The resident's MAR/TAR is initialed by the person administering a medication, in the space provided under the date, and on the line for the specific medication dose following medication administration. Initials on each MAR/TAR are verified with a full signature in the space provided or on the signature log. 14. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g., resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR/TAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If several doses of a vital medication are withheld or refused, the physician and responsible party are notified and documentation of this notification is made in the nursing notes . Resident #51 Review of Resident #51's Face Sheet revealed an admitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #51's MDS with ARD of 10/25/2021 revealed the following in part . Section C - Cognitive Pattern - The resident's BIMS score was 15, which indicates resident #51 is cognitively intact. Review of Resident #51's Care Plan with a target date of 12/02/2021 revealed the resident was at risk for episodes of hypo/[CONDITION(S)] r/t Dx of DM. The goal noted was Will have no significant episodes of hypo/[CONDITION(S)]. Approaches noted were: Administer medications as ordered; FSBS or ordered and prn and observe for s/sx of unstable blood sugars, FSBS AC & HS; record results; if FSBS <60 give 4 ounces of juice with 1 pack of sugar and call MD then recheck in 30 minutes if alert and able to swallow. If unable to swallow, administer Glucogen Hypokit 1 mg IM and recheck in 30 minutes. If >400 notify MD. Review of Resident #51's 11/2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 10/18/2021 - FSBS AC & HS. Record results - <60 give 4 ounces juice with 1 packet sugar and call MD and recheck in 30 minutes, if alert and able to swallow. If unable to swallow, administer Glucogen Hypokit 1 mg IM and recheck in 30 minutes. If still less than 60 and > 400 notify MD. 10/18/2021 - [MEDICATION(S)] 2 mg pen inject, give 2 mg SQ q Wednesday 10/18/2021 - Treshiba Flextouch 100U/ml, give 150 units SW q HS - rotate sites 10/18/2021 - [MEDICATION(S)] N 100U/ml vial, give 50U SQ tid AC 10/19/2021 - [MEDICATION(S)] N 100U/ml vial, check FSBS 2 hours post meal and give [MEDICATION(S)] for correction - 10U for blood sugar 150-200 or 20U for blood sugar >200. Review of Resident #51's Diabetic Administration Record for September 2021 and October 2021 revealed the MD was not notified of FSBS greater than 400 mg/dl on the following scheduled times and dates: September 2021: 6:30 a.m. - 09/02/2021, 09/05/2021, 09/16/2021, 09/19/2021, 09/20/2021, 09/22/2021, 09/24/2021, 09/26/2021, 09/27/2021, and 09/28/2021. 11:30 a.m. - 09/01/2021, 09/02/2021, 09/06/2021, 09/08/2021, 09/10/2021, 09/11/2021, 09/15/2021, 09/16/2021, 09/20/2021, 09/21/2021, 09/25/2021, 09/26/2021, 09/29/2021, and 09/30/2021. 4:30 p.m. - 09/06/2021, 09/10/2021, 09/15/2021, 09/20/2021, 09/21/2021, 09/25/2021, 09/29/2021, and 09/30/2021. 9:00 p.m. - 09/04/2021, 09/07/2021, 09/10/2021, 09/20/2021, and 09/25/2021. October 2021: 11:30 a.m. - 10/09/2021. 9:00 p.m. - 10/01/2021 and 10/27/2021. Further review of Resident # 51's September 2021 and October 2021 Diabetic Administration Records revealed the resident's FSBS was omitted on the following scheduled times and dates: September 2021: 6:30 a.m. - 09/04/2021, 09/13/2021, 09/18/2021, 09/21/2021, 09/29/2021 and 09/30/2021. 11:30 a.m. - 09/07/2021. 4:30 p.m. - 09/07/2021, 09/14/2021, and 09/26/2021. 9:00 p.m. - 09/03/2021 and 09/24/2021. October 2021: 6:30 a.m. - 10/01/2021. 10/02/2021, 10/04/2021, 10/07/2021, 10/08/2021, 10/14/2021, 10/16/2021, 10/17/2021, 10/18/2021, 10/19/2021, 10/26/2021, and 10/27/2021. 11:30 a.m. - 10/16/2021, 10/17/2021, and 10/18/2021. 4:30 p.m. - 10/16/2021, 10//17/2021, 10/18/2021, 10/22/2021, 10/24/2021, 10/25/2021, and 10/28/2021. 9:00 p.m. - 10/15/2021, 10/16/2021, 10/17/2021, 10/20/2021, and 10/22/2021. Review of Resident #51's nurses' notes from September 2021 - October 2021 revealed no FSBS results for Resident #51, or evidence the physician had been notified. Interview on 11/03/2021 at 1:45 p.m. with S18 LPN revealed she performed finger sticks for blood sugar levels on Resident #51 four times a day. She stated these finger sticks were performed before meals and at bedtime. She stated the physician should be notified if the resident's blood sugar reading was above 400. She further revealed the physician notification should be documented in the nurses' notes and she confirmed that this had not been done. She further confirmed that she had been giving 20U of [MEDICATION(S)] N after meals without checking the resident's FSBS. Interview on 11/03/2021 at 3:34 p.m. with Resident #51 revealed his blood sugar was checked by finger stick four times a day only. He stated he felt hyper and had an increased heart rate when his blood sugar was elevated. He further revealed when his blood sugar was low, he felt sluggish. He stated that he had elevated blood sugar symptoms that occurred about 2 times per week. He further revealed he had symptoms of an elevated blood sugar last week and he reported these symptoms to the nurse. However, he stated a finger stick was not performed and nothing was done about his symptoms. Interview on 11/04/2021 at 2:10 p.m. with S2 DON confirmed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed that this had not been done. She further confirmed that the nurses had been giving 20U of [MEDICATION(S)] N to the resident after meals without checking his FSBS. Interview on 11/05/2021 at 8:05 p.m. with S17 LPN confirmed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed that this had not been done. She further confirmed that the nurses had been giving 20U of [MEDICATION(S)] N to the resident after meals without checking his FSBS. Review of Resident # 51's 11/07/2021 - 11/08/2021 Diabetic Administration Record revealed the resident had a FSBS of 415 on 11/07/2021 at 2:00 p.m. and there was no documentation of physician notification. During an interview on 11/06/2021 at 12:07 p.m. with S6 LPN, Resident #51's Diabetic Administration Record was reviewed and confirmed the resident's 6:00 am FSBS was not performed. Resident #57 Review of Resident #57's Face Sheet revealed an admitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's MDS with ARD of 09/23/2021 revealed the following in part . Section C - Cognitive Pattern - The resident's BIMS score was 15, which indicates resident #57 was cognitively intact. Review of Resident #57's 11/2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 05/03/2021 - [MEDICATION(S)] HCl 1000 mg po bid 05/03/2021 - [MEDICATION(S)] 100U/ml give 28U SQ daily-rotate sites 05/03/2021 - [MEDICATION(S)] R 100U/ml vial if blood sugar <60 give 4 ounces of juice with 2 sugar packs and recheck in 30 minutes; if still below 60 call MD; 201-250 give 2U, 251-300 give 4U, 301-350 give 8U, 351-400 give 10U, 401-499 give 12U 07/30/2021 - [MEDICATION(S)] 7.5-325 mg take 1 tab po q 8 hours 07/30/2021 - [MEDICATION(S)] 10 mg 1 tab po daily 08/06/2021 - [MEDICATION(S)] HCl 0.1 mg take 1 tab po bid 10/01/2021 - If FSBS is less than 60, give 2 packs of sugar in 4 ounces of juice and recheck in 15 minutes. If unable to swallow, give [MEDICATION(S)] 1 mg IM x 1 and repeat blood sugar in 15 minutes. If blood sugar is less than 60 or greater than 500 notify MD. Review of Resident's #57's September 2021 and October 2021 Diabetic Administration Record revealed the resident's FSBS had not been performed on the following days: 09/06/2021, 09/15/2021, 10/03/2021, 10/04/2021 and 10/23/2021. Further review of the Resident #57's September 2021 Diabetic Administration Record revealed on 09/23/2021, the resident had a FSBS of 56 mg/dl. There was no documentation of any interventions administered for his low blood sugar as ordered. Review of Resident #57's September 2021, October 2021, and November 2021 MARs revealed, the resident was not administered the following: September 2021: [MEDICATION(S)] - 9:00 a.m. on 09/12/2021 [MEDICATION(S)] - 6:00 a.m. - 09/05/2021, 09/10/2021, 09/18/2021 2:00 p.m. - 09/06/2021, 09/07/2021, 09/20/2021, 09/21/2021 [MEDICATION(S)] HCl - 9:00 a.m. - 09/26/2021, 09/27/2021, 09/28/2021, 09/29/2021, and 09/30/2021 9:00 p.m. - 09/26/2021, 09/27/2021 and 09/28/2021 October 2021: [MEDICATION(S)] HCl - 9:00 a.m. - 10/25/2021 and 5:00 p.m. - 10/25/2021, 10/27/2021 and 20/28/2021 ASA - 9:00 a.m. - 10/25/2021 [MEDICATION(S)] Powder - 9:00 a.m. - 10/22/2021, 10/23/2021, 10/24/2021, 10/25/2021, 10/27/2021 and 10/28/2021 [MEDICATION(S)] - 9:00 a.m. on 10/25/2021 November 2021: [MEDICATION(S)] - 9:00 a.m. on 11/05/2021. Interview on 11/04/2021 at 1:00 p.m. with S18 LPN after reviewing the MARs and Diabetic Administration Record, confirmed the resident did not receive the medications in September and October 2021. She further confirmed that the resident was out of [MEDICATION(S)] and [MEDICATION(S)] on the dates circled in September 2021. She stated when a medication was not available, the nurses circled their initials to indicate the med was not in the medication cart. She confirmed there was no documentation in the nurse's notes that revealed why Resident #57's had missed FSBS and medications. Interview on 11/07/2021 at 1:45 p.m. with Resident #57 revealed that on some days (resident did not remember the dates) his medication was not available and he was told that it had been ordered. Review of Resident #57's Nurses' Notes revealed on 09/23/2021 no interventions for a FSBS of 56 mg/dl as ordered by the physician. Interview on 11/04/2021 at 2:10 p.m. with S2 DON revealed that she had been working with the contracted pharmacy concerning medication availability. She stated it was the nurse's responsibility to call the pharmacy and make arrangements for the resident's medications to be delivered timely. She stated she had been having problems since she became the DON, 3 months ago. She further revealed that the agency nurses do not receive training/orientation at this facility. Interview on 11/04/2021 at 2:22 p.m. with S2 DON revealed she was unsure of what the circled initials on Resident #57's MAR meant. She stated she was not aware that it meant the medications were unavailable. Resident #R3 Review of Resident #R3's Face Sheet revealed an admitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #R3's 11/2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 03/18/2020 - FSBS AC/HS & prn with sliding scale coverage with Novolog insulin: 121-150 = 2U 151-180 = 4U 181-220 = 6U 221-280 = 8U 281-320 = 10U If >400 give 12U and recheck in 2 hours, if still >400 call MD 02/16/2021 - [MEDICATION(S)] 100U/ml give 29U SQ q HS Review of Resident #R3's October 2021 and November 2021 MARs revealed the resident did not receive his sliding scale insulin coverage or have his AC FSBS performed for the following: October Sliding Scale coverage not received: 6:30 a.m. - 11 of 31 days reviewed 11:30 a.m. - 4 of 31 days reviewed 4:30 p.m. - 5 of 31 days reviewed 9:00 p.m. - 13 of 31 days reviewed October AC FSBS not performed: 6:30 a.m. - 1 of 31 days reviewed 4:30 p.m. - 1 of 31 days reviewed 9:00 p.m. - 1 of 31 days reviewed November Sliding Scale coverage not received: 6:30 a.m. - 1 of 4 days reviewed 4:30 p.m. - 1 of 4 days reviewed 9:00 p.m. - 3 of 4 days reviewed October AC FSBS not performed: 6:30 a.m. - 1 of 4 days reviewed Interview on 11/04/2021 at 2:10 p.m. with S1 Administrator confirmed the resident had not received his sliding scale cover in 10/2021 and 11/2021 as ordered according to the MARs and Diabetic Administration Records reviewed. She revealed there should have been sliding scale coverage given per the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #R5 Review of Resident #R5's Face Sheet revealed an admitted [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #R5's Care Plan with target date of 12/30/2021 revealed in part: (1) Risk for pain r/t tingling legs, wound to right foot, involuntary movements, due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] (2) Risk for alterations in blood sugar due to DM with approaches including: administer medications as ordered, administer insulin as ordered and finger sticks as ordered, (3) Risk for alterations in blood pressure related to history of increased blood pressure due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] (4) Risk for psychosocial well-being r/t social isolation due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] (5) Risk for bleeding and/or abnormal bruising r/t anticoagulant/antiplatelet due to PVD and Bilateral Carotid artery disease - there were no approaches concerning medications administration. Review of Resident #R5's November 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 09/08/2021 - If BS <60, give 2 packs of sugar in 4 ounces of orange juice - if able to swallow and recheck in 15 minutes. If unable to swallow, give [MEDICATION(S)] 1mg IM x 1 and repeat BS in 15 minutes; If BS <60 & >400-notify MD 09/08/2021 - [MEDICATION(S)] R 100U/ml vial - FSBS AC & HS with insulin to sliding scale: 0-200 = none 201-250 = 2U 251-300 = 3U 301-350 - 4U 351-400 = 5U >400 = Notify MD 09/08/2021 - [MEDICATION(S)] HCl 500 mg tablet-take 1 tab po bid 09/08/2021 - [MEDICATION(S)] 75 mg tablet - take 1 po daily 09/08/2021 - [MEDICATION(S)] 400 mg capsule - take 1 cap po tid 09/08/2021 - [MEDICATION(S)] HCl 50 mg tablet - take 1 tab po bid 10/17/2021 - [MEDICATION(S)] 10 mg tab - 1 tab po q a.m. Review of Resident #R5's October 2021 and November 2021 MARs revealed the resident missed the following doses due to not being available in the facility: October 2021: [MEDICATION(S)] - 16 doses [MEDICATION(S)] - 5 doses [MEDICATION(S)] - 9 doses November 2021: [MEDICATION(S)] - 8 of 9 doses [MEDICATION(S)] - 7 of 9 doses [MEDICATION(S)] - 2 of 5 doses Review of the Resident R5's October 2021 Diabetic Administration Record revealed the resident had not received his sliding scale insulin coverage for elevated FSBS at the following times and on the following date: 6:00 a.m. - 10/03/2021, 10/28/2021, 10/29/2021 (3 out of 31 times). Further review of Resident #R5's October 2021 Diabetic Administration Record revealed the resident had no FSBS performed at the following times on the following dates: 6:00 a.m. - 10/01/2021, 10/04/2021, 10/15/2021 (3 out of 31 times) 4:00 p.m. - 10/19/2021, 10/24/2021 (2 out of 31 times) 9:00 p.m. - 10/05/2021 (1 out of 31 times). Resident #2 Review of the medical record revealed Resident #2 was admitted on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's MDS with ARD 07/22/2021 revealed a BIMS of 15 (which indicated the resident was cognitively intact). Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 1,000 mg give one tablet PO twice daily [MEDICATION(S)] 25 mg QD BID [MEDICATION(S)] 40 mg 1 tablet PO at HS [MEDICATION(S)] 1gm/10mL give 10mL to equal 1gm PO QID [MEDICATION(S)] 300 mg take 1 tablet PO BID pulse check with med [MEDICATION(S)] 0.5 mg give 1 tablet PO TID for anxiety [MEDICATION(S)] 60 mg po q am [MEDICATION(S)] 30 mg po hs [MEDICATION(S)] 25 mg po hs [MEDICATION(S)] 300 mg 1 po @ hs Requip 0.25 mg 2 tabs po bid [MEDICATION(S)] 100 Units/mL give 40 Units SQ at HS. Document site. Accucheck BID at 06:00 a.m. and 04:00 p.m. If FSBS <60 or greater then 400, Notify MD. If awake, give 4 oz. of orange juice with 2 packs of sugar and recheck FSBS in 15 minutes. If unable to swallow, administer [MEDICATION(S)] and recheck FSBS in 15 minutes. BP checks prior to BP med administration. Notify MD if systolic >180 or if diastolic > or equal to 100. Hold if systolic BP is < or equal to 90. Review of the Resident #2's Medication Administration Record from 10/01/2021 through 11/06/2021 revealed that the following medications were not administered as ordered: [MEDICATION(S)] - 3 blank boxes and 4 boxes with circled initials, [MEDICATION(S)] - 2 blank boxes, [MEDICATION(S)] - 1 blank box, [MEDICATION(S)] - 8 blanks boxes and one box with circled initials, [MEDICATION(S)] - 2 blank boxes and 9 boxes with circled initials, [MEDICATION(S)] - 5 blank boxes and 8 boxes with circled initials, Requip - 21 doses circled, [MEDICATION(S)] - 1 blank box, [MEDICATION(S)] - 1 blank box, [MEDICATION(S)] - 1 blank box, [MEDICATION(S)] - 4 blank boxes, Accucheck BID had 6 blank boxes for initials and 6 blank boxes for results, [MEDICATION(S)] pulse check with medication administration had 15 blank boxes and BP checks prior to administration of BP Med administration had 15 blanks. Review of resident #2's labs revealed there were no results for a [MEDICATION(S)] level for the months of April 2021 and October 2021 as ordered. Interview on 11/04/2021 at 02:30 p.m. with S2 DON, after reviewing the MARs for Resident #2, confirmed the nurses' had not administered the medications because there was no initials indicating they were administered for the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . She also confirmed the accuchecks and blood pressures were also not done according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated a medication was initialed and circled, that medication was not available for administration. Interview on 11/05/21 at 12:29 p.m. with S32 LPN stated she had been on agency assignment at the facility for approximately 1 month. She confirmed [MEDICATION(S)] was not available in the facility for Resident's #2's 9:00 a.m. dose on 11/02/2021 therefore it was initial and circled on the MAR. Interview on 11/05/2021 at 12:20 p.m. with S33 LPN stated if a medication was not available for administration, the medication is circled on the MAR and initialed. Interview on 11/05/2021 at 12:49 p.m. with S17 LPN stated if a medication was not available, it is initialed and circled. Observation on 11/06/2021 at 1:00 p.m. of Resident #2's MAR revealed on 11/06/2021 at 6:00 a.m. initials of FSBS being done but no result. Interview of Resident #2 revealed resident had finger stick done this morning at 5:00 a.m. and the nurse told her what her blood sugar level was but she could not remember it now. Resident #2 stated she sometimes have to remind the nurse to check her blood sugar. Resident #2 further stated she sometimes goes days without getting her [MEDICATION(S)] because the facility is out of the medication. Resident #2 stated when she is out of her [MEDICATION(S)] she gets very nervous and scared and feels like she is going crazy. She stated she does not like that feeling and the medication was ordered by a psychiatrist because of a childhood trauma she experienced. Resident 2's MAR revealed: 11/06/2021- 3:00 p.m. dose of [MEDICATION(S)] 0.5 mg was not initialed as being given 11/07/2021 - 6:00 a.m. FSBS was not initialed and did not have results Interview on 11/08/2021 at 10:30 a.m. with S2 DON confirmed on 11/06/2021 and 11/07/2021, there was no documented results of the 6:00 a.m. FSBS. She confirmed that on 11/06/2021, the 3:00 p.m. dose of [MEDICATION(S)] 0.5 mg po was not documented as being administered. Resident #42 Review of resident #42's medical record revealed an admitted [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's quarterly MDS with ARD 09/15/2021 revealed the resident had a BIMS of 15 (which indicated the resident was cognitively intact). Further review revealed the resident has active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's care plan with target date of 12/16/2021 revealed he was care planned for potential for alterations in blood sugar related to Diabetes Mellitus with an intervention to monitor blood sugar levels per finger stick per MD orders, notify MD as necessary. Review of Resident #42's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] FSBS M/W/F at 6 a.m. Record results. If FSBS <60, notify MD. If awake, give 4 oz. of orange juice with two packs of sugar and recheck FSBS in 15 minutes. If unable to swallow, administer [MEDICATION(S)] and recheck FSBS in 15 minutes. Call MD if greater than 400. Potassium 20 mEq give 1 tablet PO BID Review of Resident #42's Medication Administration Record for 09/01/2021 through 11/02/2021 revealed the following: Potassium - 4 doses had no initials in the designated box Review of Resident #42's Diabetic Administration Record from 09/01/2021 through 11/02/2021 revealed the following: FSBS - no initials or results for 9 scheduled days. Review of Resident #42's nurses' notes from 09/01/2021 through 11/02/2021 revealed no notes regarding why the potassium and FSBS were not done as ordered. Interview with S2 DON on 11/04/2021 at 10:45 a.m. revealed if there were no initials in the designated box on the Medication Administration Record and Diabetic Administration Record, which indicated the medication was not administered and the blood sugar was not obtained. S2 DON confirmed all of the blanks without initials or results on resident #42's Medication Administration Record and Diabetic Administration Record for 09/01/2021 through 11/02/2021 were not done or administered. Resident #R4 Review of the medical record for #R4 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of #R4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of #R4's October 2021 MAR revealed [MEDICATION(S)] [DATE] mg/5ml was scheduled to be given on 10/22/2021; however, it was not initialed as given. Interview of S2 DON on 11/05/2021 at 5:30 p.m. confirmed that the medication was not initialed as given. Resident #R1 Review of the Face Sheet for #R1 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of #R1's Significant Change MDS with an ARD date of 06/28/2021 revealed the resident had a BIMS score of 13 (cognitively intact). Review of the resident's September 2021 and October 2021 MAR revealed accuchecks for the following times and dates were not initialed as being done: For September: 6:30 a.m. - 09/09/2021, 09/10/2021, 09/11/2021, 09/17/2021, and 09/18/2021. 11:30 a.m. - 09/10/2021 and 09/11/2021. 4:30 p.m. - 09/10/2021, 09/11/2021, 09/21/2021, and 09/25/2021. 8:00 p.m. - 09/11/2021, 09/17/2021, 09/24/2021, and 9/28/2021. Further review of #R1's Medical Record revealed a telephone order dated 10/01/2021 to D/C FSBS at 6:00 a.m. and PRN, and to continue [MEDICATION(S)] R to sliding scale AC and HS. Review of Reside

Based on observation, interview and record review, the facility failed to have an effective system in place to provide routine drugs and biologicals to its residents by not having procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs to meet the needs of the residents of 4 (#57, #2, #5, #34, and #R9,) of 44 sampled residents. This deficient practice resulted in an Immediate Jeopardy situation for Residents #57, #2, #34, #R9, and #5 on 09/01/2021, when ordered medication by their physician for treatment and care of acute and chronic conditions were not made available at the facility. The facility failed to order residents medications from the pharmacy that was ordered for the treatment of diabetes, hypertension, seizures, anxiety and acute pain. Staff failed to order medication from the pharmacy resulting in residents not receiving ordered medications for days and weeks. The administrator was notified of the Immediate Jeopardy situation on 11/06/2021 at 8:40 p.m. The Immediate Jeopardy was removed on 11/08/2021 at 7:10 p.m. when the facility submitted the following Plan of Removal, and the surveyor determined through observation, interview and record review that the Plan of Removal was being implemented: The plan of IJ removal included the following: 1. IJ Removal Plan 11/08/2021 at 7:10 p.m. 2. S7 Vice President of Operations in-serviced S1 Adm. on ensuring that the facility was administered in a manner that uses resources to effectively and efficiently meet the needs of the residents on 11/08/2021. 3. An in-service was initiated on 11/06/2021 at 8:45 p.m. for licensed nurses' policies for Medication Administration, Ordering/Receiving Medications and Glucose Testing. 4. Re-ordering plan initiated on 11/08/2021 that includes that all medications will be reordered within 7 days prior of being depleted to the pharmacy on Mondays. 5. The facility will reconcile reorder list on Thursday to ensure all medications were received. 6. The facility will utilize the local pharmacy, Pharmacist services for all emergency refill or stat medications. 7. The facility has initiated exploring other pharmacy service options. 8. S2 DON/S14 LPN Nurse Manager will reconcile all medications carts weekly x 4 weeks, then 1 medication cart weekly x 4 weeks, then monthly to validate that medications are available and reordering plan is followed. 9. The Pharmacist Consultant will begin weekly visits x 4 weeks starting 11/08/2021 to audit 25% of Residents' Medication Administration Records and medication availability. 8. Pharmacist Consultant to initiate an additional in-service on 11/08/2021 for license nurses to include medication administration/following physician orders, accuracy of documentation on Medication Administration Records, and ordering/reordering of medications. 9. S2 DON/S14 LPN Nurse Manager will review 100% of Medication Administration Records 5x a week x 4 weeks, then weekly x 4 weeks, then monthly x 3 months to ensure accuracy of documentation related to medication administration and ensure availability of medications beginning on 11/08/2021. Any concerns will be immediately addressed. 10. On 11/08/2021, the facility initiated a shift to shift Medication Administration Records documentation review form, in which on-coming and off-going nurses will check Medication Administration Records for complete documentation. 11. On 11/08/2021, the facility initiated a Nurse Signature & Sign-In form which will be maintained in front of the Medication Administration Records for nurses to document his/her printed name, signature, and initial. S1DON/S14 LPN Manager will monitor weekly x 3 months for completion. 12. S1Adm. will be monitored by S7 Vice President of Operations weekly x 4 weeks, then monthly x 3 months. Findings: Review of the facility's Medication Administration - General Guidelines Policy revealed in part: 2. Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications and professional standards of practice. 5. All current medications and dosage schedules are listed on the resident's medication administration record eMAR/eTAR and administered timely according to facility policy. 9. Only licensed or legally authorized personnel who prepare a medication may administer it. This individual records the administration on the resident's MAR/eMAR or TAR/eTAR after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/TAR to ascertain that all necessary doses were administered and all administered doses were documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications . 11. The resident's MAR/TAR is initialed by the person administering a medication, in the space provided under the date, and on the line for the specific medication dose following medication administration. Initials on each MAR/TAR are verified with a full signature in the space provided or on the signature log. 14. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g., resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR/TAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If several doses of a vital medication are withheld or refused, the physician and responsible party are notified and documentation of this notification is made in the nursing notes . Resident #57 Review of Resident #57's Face Sheet revealed an admitted [DATE] with the following diagnoses: Type 1 DM with diabetic Chronic Kidney Disease, phantom limb syndrome with pain, [CONDITION(S)] and Hypertensive Heart Disease with Heart Failure. Review of Resident #57's 11/2021 Physician's Orders revealed the following including: 05/03/2021 - [MEDICATION(S)] 1000 mg po bid 05/03/2021 - [MEDICATION(S)] 100 U/ml give 28 U SQ daily-rotate sites 05/03/2021 - [MEDICATION(S)] R 100 U/ml vial if blood sugar <60 give 4 ounces of juice with 2 sugar packs and recheck in 30 minutes; if still below 60 call MD; 201-250 give 2 U, 251-300 give 4 U, 301-350 give 8 U, 351-400 give 10 U, 401-499 give 12 U 07/30/2021 - [MEDICATION(S)] 7.5-325 mg take 1 tab po q 8 hours 07/30/2021 - [MEDICATION(S)] 10 mg 1 tab po daily 08/06/2021 - [MEDICATION(S)] HCl 0.1 mg take 1 tab po bid 10/01/2021 - If FSBS is less than 60, give 2 packs of sugar in 4 ounces of juice and recheck in 15 minutes. If unable to swallow, give [MEDICATION(S)] 1 mg IM x 1 and repeat blood sugar in 15 minutes. If blood sugar is less than 60 or greater than 500 notify MD. Review of Resident #57's 09/2021 September 2021 and October 2021 MARS revealed the resident was not administered: [MEDICATION(S)] was not administered at 9:00 a.m. on: 09/01/2021 - 09/04/2021 09/08/2021 - 09/10/2021 09/13/2021 - 09/20/2021 09/22/2021 09/23/2021 09/26/2021 - 09/30/2021. In the month of October 2021, the MAR revealed the resident was not administered [MEDICATION(S)] at 9:00 a.m. and 3:00 p.m. on: 10/23/2021 - 10/25/2021 10/27/2021 -10/28/2021. [MEDICATION(S)] was not administered at 9:00 a.m. on: 09/12/2021 10/25/2021 [MEDICATION(S)] was not administered at 9:00 a.m. on 9/10/2021 09/28/2021 10/09/2021 [MEDICATION(S)] was not administered at 9:00 a.m. on 10/25/2021 and at 5:00 p.m. on 10/25/2021, 10/27/2021 and 10/28/2021. [MEDICATION(S)] was not administered at 6:00 a.m. on: 09/05/2021 09/10/2021 09/18/2021 [MEDICATION(S)] was not given at 2:00 p.m. on: 09/06/2021 09/07/2021 09/20/2021 09/21/2021. ASA was not administered at 9:00 a.m. on 10/25/2021. [MEDICATION(S)] was not administered at 9:00 a.m. on 0/25/2021. Resident #2 Review of Resident #2's medical record revealed an admitted [DATE]. The resident's diagnoses included in part: Other chronic pain, [CONDITION(S)] due to mental disorder, and Atherosclerosis of other arteries Review of Resident #2's November 2021 Physician Orders revealed in part: [MEDICATION(S)] (a diabetic agent) - 1,000 mg give one tablet po twice daily [MEDICATION(S)] (a gastrointestinal agent) - 1 gm/10ml give 10ml to equal 1 gm po qid [MEDICATION(S)] (an anti-convulsant) - 300 mg take 1 tablet po bid pulse check with med [MEDICATION(S)] (an anti-anxiety agent) - 0.5 mg give 1 tablet po tid for anxiety Requip (a [CONDITION(S)] Disease medications) - 0.25 mg 2 tabs po bid [MEDICATION(S)] (antihypertensive) 25 mg po bid [MEDICATION(S)] (statin for high cholesterol) - 40 mg po hs [MEDICATION(S)] Insulin (long acting Insulin) - 100 unit/ml Vial - 40 units sq at hs [MEDICATION(S)] (diuretic) - 40 mg po daily Review of Resident #2's October 2021 and November 2021 MARS revealed the following medications were documented as not administered on the following dates and times: [MEDICATION(S)] 1000 mg was not administered at 9:00 a.m. on: 10/01/2021 10/02/2021 [MEDICATION(S)] 1000 mg was not administered at 5:00 p.m. on: 10/01/2021 10/05/2021 10/16/2021 10/20/2021. [MEDICATION(S)] was not administered at 9:00 a.m. on: 10/09/2021 10/18/2021 10/19/2021 10/30/2021 [MEDICATION(S)] was not administered at 4:00 p.m. on: 10/05/2021 10/14/2021. [MEDICATION(S)] was not administered at 9:00 a.m. on: 10/04/2021 10/08/2021 10/09/2021 10/22/2021. [MEDICATION(S)] was not administered at 9:00 p.m. on: 10/02/2021 10/03/2021 10/04/2021 10/06/2021 10/08/2021 10/04/2021 10/08/2021 10/09/2021 10/10/2021 10/11/2021 10/12/2021 10/22/2021. [MEDICATION(S)] was not administered at 9:00 a.m. on: 10/20/2021 - 9:00 a.m. 10/21/2021 - 9:00 a.m. 10/22/2021 - 9:00 a.m. [MEDICATION(S)] was not administered at 3:00 p.m. on: 10/05/2021 10/19/2021 10/20/2021 10/21/2021 10/22/2021 [MEDICATION(S)] was not administered at 9:00 p.m. on 10/02/2021 - 9:00 p.m. 10/08/2021 - 9:00 p.m. 10/20/2021 - 9:00 a.m., 3:00 p.m. and 9:00 p.m. 10/21/2021 - 9:00 a.m., 3:00 p.m. and 9:00 p.m. Requip was not administered at 9:00 a.m. on: 10/13/2021 to 10/22/201 Requip was not administered at 9:00 p.m. on: 10/12/2021 10/13/2021 - 10/22/201 [MEDICATION(S)] was not administered at 9:00 a.m., 5:00 p.m. and 9:00 p.m. on: 10/05/2021 10/16/2021. [MEDICATION(S)] was not administered at 9:00 p.m. 10/02/2021. [MEDICATION(S)] Insulin was not administered at 9:00 p.m. on: 10/02/2021 10/08/2021 10/18/2021 10/24/2021. [MEDICATION(S)] was not administered at 3:00 p.m. on 11/04/2021. Interview on 11/04/2021 at 2:30 p.m. with S2 DON, after reviewing the 10/01/2021 through 11/06/2021 MARs for Resident #2, S2 DON reported if a medication is left blank on the MAR, that the medication was not administered due to not being available. S2 DON confirmed the circled initials on the MARs for [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and Requip indicated the medications were not administered. She further stated that medications that were not initialed as given were not. Interview on 11/05/2021 at 12:20 p.m. with S33 LPN revealed if a medication is not available for administration, the medication is circled on the MAR and initialed. Interview on 11/05/21 at 12:29 p.m. with S32 LPN revealed she had been on agency assignment at the facility for approximately 1 month. She stated on 11/01/2021 and 11/02/2021, [MEDICATION(S)] 1000 mg was not available for administration. She stated she called the Pharmacy on 11/01/2021 and was informed that the medication would be delivered later that day. She stated the Pharmacist stated that they do not deliver medication to the facility on weekends. She stated [MEDICATION(S)] 1000 mg had not been delivered on the evening of 11/01/2021. She confirmed [MEDICATION(S)] was not available in the facility for Resident #2's 9:00 a.m. dose on 11/02/2021 therefore it was initialed and circled on the MAR. Further interview of S32 LPN revealed she did not take action and notify the physician of the missing medication. Interview on 11/05/2021 at 12:49 p.m. with S17 LPN stated if a medication is not available, it is initialed and circled on the MAR. Interview on 11/06/2021 at 1:00 p.m. with Resident #2 revealed she sometimes goes days without getting her [MEDICATION(S)] because the facility is out of the medication. Resident #2 stated when she is out of her [MEDICATION(S)] she gets very nervous and scared and feels like she is going crazy. She stated she does not like that feeling and the medication was ordered by a psychiatrist because of a childhood trauma she experienced. Resident #34 Review of Resident #34's record revealed an admitted [DATE] and diagnoses that included: Diabetes due to underlying condition with skin complications, [CONDITION(S)] disorder, Depressive type, [CONDITION(S)], [CONDITION(S)], other seizures and [CONDITION(S)]. Review of Resident #34's November 2021 Physician Orders revealed in part: 08/07/2019 - [MEDICATION(S)] (an anti-convulsant) - 100 mg capsule give 1 cap po bid for seizures 08/31/2021 - [MEDICATION(S)] (narcotic [MEDICATION(S)]) - 5-325 mg 1 po every 6 hours prn pain 08/31/2021 - [MEDICATION(S)] HCL ER (narcotic [MEDICATION(S)]) - 50 mg 2 tabs po every 6 hours prn pain to equal 100 mg. Review of the facility's Controlled Medication Sign-out Log on 11/07/2021 at 2:10 p.m. revealed the last documented date/time that Resident #5 received [MEDICATION(S)] was on 11/06/2021 at 2:25 p.m. Further review revealed he had no [MEDICATION(S)] available on 11/07/2021 at 2:10 p.m. Review of Resident #34's MARS for October 2021 - November 2021 revealed [MEDICATION(S)] was circled as not administered at 9:00 a.m. on: 10/04/2021 10/19/2021 10/20/2021 10/28/2021 10/29/2021 [MEDICATION(S)] was circled as not administered at 9:00 p.m. on: 10/03/2021 10/04/2021 10/13/2021 10/14/2021 10/15/2021 10/17/2021 10/18/2021 10/19/2021 10/20/2021 10/21/2021 10/28/2021 11/03/2021 Review of resident #34's medical record revealed a routine [MEDICATION(S)] level was obtained on 07/14/2021 with a result of 5.8 (low). Further review of the medical record revealed the physician was notified of the [MEDICATION(S)] level on that day with no further orders. Interview on 11/04/2021 at 2:10 p.m. with S2 DON confirmed the resident did not get his [MEDICATION(S)] as prescribed during the months of October and November 2021. S2 DON further stated that there was no documentation in the nurses' notes concerning the missed dosages, and it should have been. Interview on 11/07/2021 at 2:02 p.m. with S10 LPN/MDS confirmed the resident did have an order for [MEDICATION(S)] q 6 hours prn pain and stated the resident had not had it today. Further interview revealed she did not know if the medication had been reordered or not. Resident #R9 Review of Resident #R9's medical record revealed an admitted d of 09/20/2021 with the following diagnoses including: [CONDITION(S)] Disorder, Systemic Lupus Erythematosus - Organ or System involved unspecified, and Anxiety. Review of Resident #R9's Admission MDS with an ARD date of 09/27/2021 revealed the resident had a BIMS of 15 (cognitively intact). Review of Resident #R9's November 2021 Physician's Orders revealed the following including: 09/20/2021 - [MEDICATION(S)] (anti-convulsant/pain) 75 mg one by mouth three times a day Review of Resident #R9's October 2021 MAR revealed the resident did not have [MEDICATION(S)] available for the 9:00 a.m., 3:00 p.m. and 9:00 p.m. doses for 10/24/2021 - 10/28/2021. Review of Resident #R9's November 2021 MAR revealed on 11/06/2021 the 9:00 a.m. dose of [MEDICATION(S)] was initialed and circled indicating the medication was not available. Interview on 11/02/2021 at 2:00 p.m. during the resident council meeting, Resident #R9 voiced her concerns over the facility running out of medications and revealed she had been out of one of her medications for 2 weeks. Interview with the Pharmacist Consultant on 11/05/2021 at 4:26 p.m. revealed he reviewed all residents' MARs monthly and had identified there were holes missing in the documentation for administration and omissions of medications He revealed he had reported these issues to the DON. He revealed he had observed these issues over the past 7 - 8 months. Interview with Resident #R9 on 11/06/2021 at 12:45 p.m. who was walking down the hall when S27 LPN stated, I have your [MEDICATION(S)] it was in the overstock room. Resident #R9 stated, thank you Lord, I have been without it for 2 weeks. Further interview with the resident revealed they had been telling her it was ordered. She stated the facility will run out of medications or will say it missing and they will try to find it. S27 LPN confirmed 11/06/2021 at 12:45 p.m. she had not been administered her 9:00 a.m. dose as ordered because she could not find it and forgot to circle it. Interview with S2 DON on 11/06/2021 at 5:15 p.m. revealed she and S29 Unit Manager were responsible for monitoring MARS at the end of each month. S2 revealed they had only monitored one of the hall's MARs for the month of October 2021. She confirmed she was aware there was a problem with acquiring medications. She stated the pharmacy does not deliver the medications in a timely manner after they are ordered. She stated they had no back up Pharmacy contract and when they run out of medication, they just have to wait until they come in from the contracted pharmacy. Resident #5 Review of Resident #5's Clinical Record revealed an admitted [DATE] with diagnoses including: functional [CONDITION(S)], cramp and spasm, other personality and behavioral disorders due to know physiology, and pain unspecified. Review of Resident #5's Quarterly MDS with an ARD of 08/04/2021 revealed the resident had a BIMS score of 15 (cognitively intact). Observation on 11/01/2021 at 12:15 p.m. revealed Resident #5 was lying in bed with his eyes closed. Interview of the resident at that time revealed he was not feeling well because he had not had his pain medication for 3 days - 10/30/2021-11/01/2021. He stated he had just finished with therapy today and was hurting, and they still did not have his pain medication. Resident #5 stated he was currently experiencing a pain level of 10 on a pain scale of 1-10 with 10 being the most severe. The resident further stated he was told the request was faxed to the MD; however, medications do not come in until tonight. Resident #5 further stated he also received therapy on Friday, 10/30/2021 and was not given pain medication for his severe pain. The interview ended because the resident was hurting and stated he wanted to rest. Review of Resident #5's Physician Orders revealed in part: 10/29/2020 - Oxycodone HCl (a narcotic [MEDICATION(S)]) - 10 mg 1 tab po tid for pain, unspecified Review of Resident #5's 10/2021 and 11/2021 MAR revealed in part: [MEDICATION(S)] 10 mg 1 tab po tid to be given at 9:00 a.m., 3:00 p.m., and 9:00 p.m. Further review revealed: 10/30/2021 - 3:00 p.m. and 9:00 p.m. doses of Oxycodone were recorded with circled initials. 10/31/2021 - 9:00 a.m., 3:00 p.m. and 9:00 p.m. doses of Oxycodone were recorded with circled initials. 11/01/2021 - 9:00 a.m. and 3:00 p.m. doses of Oxycodone were recorded with circled initials. Interview on 11/03/2021 at 11:00 a.m. with S16 LPN confirmed he worked on 10/30/2021 from 7:00 a.m. to 7:00 p.m., and did not give the 3:00 p.m. dose of Oxycodone because Resident #5 was out of the medication. He stated the circled initials on the MAR meant that the resident was out of the medication. S16 LPN stated a hard prescription was needed to get refills for Oxycodone, and he had assumed that the medication had been ordered, but had not been received from the pharmacy. Interview on 11/03/2021 at 11:10 a.m. with S14 LPN revealed she goes to each hall on Mondays and asks the hall nurse if any refills are needed so a hard prescription can be obtained if needed. She further revealed she was informed on Monday 11/01/2021 that Resident #5 was out of Oxycodone. At that time, she obtained a hard prescription from the MD and sent it to the pharmacy for a refill. She further stated the refill from the pharmacy was received on 11/01/2021 at 9:00 p.m. S14 LPN stated refills should be filled during the week because it is very difficult to get refills on the weekend. She confirmed the refill for Resident #5's medication should have been ordered before he ran out. Interview on 11/03/2021 at 11:20 a.m. with S2 DON confirmed Resident #5 had missed scheduled routine doses of Oxycodone on 10/30/2021 - 11/01/2021 due to medication not being available because refills were not obtained timely. Interview on 11/08/2021 at 12:45 p.m. with S22 RN confirmed Resident #5's Oxycodone was not available on the above stated days and should have been. S22 RN further confirmed circled initials on the MAR meant the medication was not available in the facility. Interview with S3 Medical Director on 11/9/2021 at 11:21 a.m. revealed he was not aware the facility was not acquiring resident's medications timely from the pharmacy, therefore, the resident had not received their medications as ordered. He revealed the facility should have notified him when residents did not have their medications. He also revealed he could not be certain that the facility called him every time someone's blood sugars were out of parameters. Interview with the Pharmacy Contract Pharmacy Technician on 11/6/2021 at 4:26 p.m. revealed the pharmacy had talked with staff from the NH to order medications when they were at least 4-5 days from running out of medications in the blister packs. She revealed refills were not filled the same day as the order was received. She revealed staff called and asked for refill medications to be sent over immediately because the resident had none available for administration. She revealed staff would call and ask if a medication had been sent for delivery and then turn around and call stating they had found the medications. She revealed she knew residents were going days without their medications due to the facility not ordering the medications timely. She also revealed the contract pharmacy ran a report on Mondays and sent the DON the medications that needed to be filled that week or which medications needed a physicians' order.

Based on observation, interview and record review the facility failed to be administered in a manner that enables it to use it resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 9 (#2, #5, #34, #42, #51, #57, R5, R6, and R9) of 19 ( (#2, #5, #32, #34, #42, #47, #51, #54, #57, R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10) sampled residents reviewed. The facility failed to have effective systems in place to: 1. Ensure the facility accurately and safely provides or obtains pharmaceutical services to ensure medications were acquired in a timely manner, available, and administered to meet the needs of the residents; 2. Ensure capillary blood glucose levels were obtained, Insulin was administered as prescribed, and medications were administered in accordance with professional standards and residents' person centered plans of care; and 3. Ensure agency staff nurses were oriented in facility polices regarding medication administration and following resident person center care plan. This deficient practice resulted in an Immediate Jeopardy situation for Resident #51 on 09/01/2021 at 11:30 a.m. when nursing staff started to administer ordered insulin without his capillary blood glucose levels being done. Resident #57 capillary blood glucose levels was also not being done as ordered and he was not being administered his oral and subcutaneous anti-diabetic medications ([MEDICATION(S)] [MEDICATION(S)], [MEDICATION(S)] R), hypertensive medication as ordered ([MEDICATION(S)], [MEDICATION(S)] HCL) and his pain medication ([MEDICATION(S)]). Residents (#51, #57, #2, #42, #R1, #R2, #R3, #R4, and #R5 diagnosed with Diabetes Mellitus and all receiving anti-diabetic medications also had missed doses of their medications. The Administrator was notified of the Immediate Jeopardy on 11/06/2021 at 8:40 p.m. The facility submitted an acceptable plan of removal on 11/08/2021 at 7:10 p.m. The plan of IJ removal included the following: 1. IJ Removal Plan 11/08/2021 at 7:10 p.m. 2. S7 Vice President of Operations in-serviced S1 Adm. on ensuring that the facility was administered in a manner that uses resources to effectively and efficiently meet the needs of the residents. 3. An in-service was initiated on 11/06/2021 at 8:45 p.m. for licensed nurses' policies for Medication Administration, Ordering/Receiving Medications and Glucose Testing. 4. Re-ordering plan initiated on 11/08/2021 that includes that all medications will be reordered within 7 days prior of being depleted to the pharmacy on Mondays. 5. The facility will reconcile reorder list on Thursday to ensure all medications were received. 6. The facility will utilize the local pharmacy, Pharmacist services for all emergency refill or stat medications. 7. The facility has initiated exploring other pharmacy service options. 8. S2 DON/S14 LPN Nurse Manager will reconcile all medications carts weekly x 4 weeks, then 1 medication cart weekly x 4 weeks, then monthly to validate that medications are available and reordering plan is followed. 9. The Pharmacist Consultant will begin weekly visits x 4 weeks starting 11/08/2021 to audit 25% of Residents' Medication Administration Records and medication availability. 8. Pharmacist Consultant to initiate an additional in-service on 11/08/2021 for license nurses to include medication administration/following physician orders, accuracy of documentation on Medication Administration Records, and ordering/reordering of medications. 9. S2 DON/S14 LPN Nurse Manager will review 100% of Medication Administration Records 5x a week x 4 weeks, then weekly x 4 weeks, and then monthly x 3 months to ensure accuracy of documentation related to medication administration and ensure availability of medications beginning on 11/08/2021. Any concerns will be immediately addressed. 10. On 11/08/2021, the facility initiated a shift-to-shift Medication Administration Records documentation review form, in which on-coming and off-going nurses will check Medication Administration Records for complete documentation. 11. On 11/08/2021, the facility initiated a Nurse Signature & Sign-In form, which will be maintained in front of the Medication Administration Records for nurses to document his/her printed name, signature, and initial. S1DON/S14 LPN Manager will monitor weekly x 3 months for completion. 12. S1Adm. will be monitored by S7 Vice President of Operations weekly x 4 weeks, then monthly x 3 months. Findings: Interview with S2 DON on 11/04/2021 at 10:45 a.m. revealed if there are no initials in the designated box on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/04/2021 at 2:10 p.m. with S2 DON revealed S14 Unit Manager and S2 DON were responsible for monitoring the MARs and Diabetic Administration Records. Interview on 11/04/2021 at 2:10 p.m. with S2 DON revealed that she had been working with the contracted pharmacy concerning medication availability. She stated it was the nurse's responsibility to call the pharmacy and make arrangements for the residents' medications to be delivered timely. She stated she had been having problems since she became the DON, 3 months ago. S2 DON further revealed that the agency nurses do not received orientation at this facility. She stated they were trained by the agency, and the nursing home had no orientation training when a new agency nurse worked at the facility. Interview with the Pharmacist Consultant on 11/05/2021 at 4:26 p.m. revealed he reviewed all residents' MARs monthly and had identified there were holes missing in the documentation for administration, omissions of medications, and omission of blood glucose monitoring and administration of insulin as ordered. He revealed he had reported these issues to the DON. He stated he had observed these issues over the past 7 - 8 months. Interview with S2 DON on 11/06/2021 at 5:15 p.m. revealed she and S29 Unit Manager were responsible for monitoring MARs at the end of each month. S2 DON stated that they had not monitored all MARs for the month of October. She confirmed she was aware there was a problem with acquiring medications to be delivered timely. She stated the pharmacy did not deliver the medications after they are order timely. She revealed when the facility ran out of medications they had to wait until the pharmacy delivered them, because they had no backup pharmacy contract. S2 DON did revealed that the pharmacy delivered medications throughout the week but did not deliver medications on the weekends, unless it was for a new admission. Interview with the Contract Pharmacy, Pharmacy Technician on 11/6/2021 at 4:26 p.m. revealed the pharmacy had talked with staff from the NH and instructed them to order medications when they were at least 4-5 days from running out of medications in the bubble packs. She revealed refills were not filled the same day as the order was received. She stated staff would call and ask for refilled medications to be sent over immediately because a resident had none available for administration. The Pharmacy Technician revealed they would call and ask if a medication had been sent for delivery and then turn around and call stating they had found the medications. She revealed she knew residents were going days without their medications due to the facility had not ordered the medications timely. She also revealed the contract pharmacy ran a report on Mondays and sent the DON a list of medications that needed to be filled that week, or a list of medications they needed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Administrator on 11/09/2021 at 9:45 a.m. was asked if she was aware that the facility had not been receiving their medications timely, that staff were not following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with S3 Medical Director on 11/9/2021 at 11:21 a.m. revealed he was not aware the facility was not acquiring residents' medications timely from the pharmacy; therefore, the resident had not received their medications as ordered. He revealed the facility should have notified him when residents did not have their medications. He also revealed he could not be certain that the facility called him every time someone's blood sugars were out of parameters. Cross Refer to Tag F684. Cross Refer to Tag F755. Cross Refer to Tag F755.

Based on observations, interviews and record reviews, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 3 (#5, #34 and #R9) residents reviewed for pain in a total sample of 44 residents. This deficient practice resulted in an actual harm for resident #5 on 10/30/2021, when the resident who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .o. TID for severe pain, did not receive Oxycodone on 10/30/2021, 10/31/2021, and 11/01/2021. The resident complained that the facility was out of his Oxycodone on those days, and his pain level was 10 (worst pain possible) on a pain scale of 1-10 during that time. This deficient practice resulted in actual harm for Resident #34, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to administer the resident's [MEDICATION(S)] pain medication as ordered by the physician resulting in Resident #34 being sent to a local emergency roiagnom on [DATE] for pain control. Findings: 1. Review of the facility's Policy on Pain Evaluation/Management revealed in part . A. Routine Pain Evaluations 5) Notify physician if resident's response to their medication or treatment is not satisfactory to develop further interventions for relief of pain. Observation on 11/01/2021 at 12:15 p.m. revealed resident #5 was lying in bed with his eyes closed. Interview of the resident at that time revealed he was not feeling well because he had not had his pain medication for 3 days, Friday 10/30/2021, Saturday 10/31/2021 and Sunday 11/01/2021. He stated he had just finished with therapy today and was hurting, and they still did not have his pain medication. Resident #5 stated he was currently experiencing a pain level of 10 on a pain scale of 1-10, with 10 being the most severe. The resident further stated he was told the request was faxed to the MD; however, medications do not come in until tonight. Resident #5 further stated he also received therapy on Friday 10/30/2021, and was not given pain medication for his severe pain. The Surveyor ended the interview because the resident was hurting and stated he wanted to rest. Review of the clinical record revealed resident #5 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS with an ARD of 08/04/2021 revealed the resident had a BIMS score of 15 (which indicated intact cognition), and the resident understands and has the ability to understand others. The MDS revealed the resident was coded as requiring extensive assistance of two people with transfers, dressing, toilet use, personal hygiene and supervision with locomotion and eating. The MDS revealed the resident had upper and lower extremity ROM impairment, and used a wheelchair for mobility. The MDS further revealed the resident was on a scheduled pain medication regimen, received PRN pain medication, did not receive non-medication intervention, pain frequency almost constantly, pain intensity rating scale = 06 at the time of assessment, and received opioid 7 out of 7 days. Review of the Care Plan with a target date of 11/26/2021 revealed the resident has a Potential for Alteration in Comfort R/T Functional [CONDITION(S)], Cramps and Spasms, Pain, and Depression. Approaches included: Monitor for c/o pain daily; Reposition for comfort PRN and encourage frequent rest periods; Instruct resident to tell nurse when experiencing pain early before pain becomes intense; Provide medication as ordered by MD and Encourage participation in diversional activities to help divert attention from pain. Review Resident #5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's MAR for the month of October 2021 and November 2021 revealed Oxycodone APAP 10 mg 1 tab po TID to be given at 9:00 a.m., 3:00 p.m., and 9:00 p.m. Further review of Resident #5's MAR revealed: 10/30/2021 at 3 p.m. and 9 p.m. - dose initialed with a circle around it. 10/31/2021 at 9 a.m., 3 p.m. and 9 p.m. - dose initialed with a circle around it. 11/01/2021 at 9 a.m. and 3 p.m. - dose initialed with a circle around it. Interview on 11/03/2021 at 11:00 a.m. with S16 LPN confirmed he worked on 10/30/2021 from 7 a.m. to 7 p.m., and did not give the 3 p.m. dose of Oxycodone because resident #5 was out of the medication. He stated the initials on the MAR that were circled meant the resident was out of the medication. S16 LPN stated a hard script was needed to get refills for Oxycodone, and he had assumed that the medication had been ordered, but had not been received from the pharmacy. Interview on 11/03/2021 at 11:10 a.m. with S14 LPN nurse manager revealed she goes to each hall on Monday's and asks the hall nurse if any refills are needed, so a hard script can be obtained if needed. S14 LPN stated she was informed on Monday 11/01/2021 that resident #5 was out of his Oxycodone. At that time, S14 LPN stated she obtained a hard script from the doctor and sent it to the pharmacy for a refill. S14 LPN further stated the refill from the pharmacy was received on 11/01/2021 at 9 p.m. S14 LPN stated refills should be filled during the week because it is very difficult to get refills on the weekend. S14 LPN confirmed the refill for resident #5's medication should have been ordered before he ran out. Review of the Non-Emergency Communication Tool revealed a request for a hard script for Oxycodone 10 MG 1 Tab PO TID was faxed to the doctor on 11/01/2021. Interview on 11/03/2021 at 11:20 a.m. with S2 DON confirmed resident #5 had missed scheduled routine doses of Oxycodone 10 MG PO TID 10/30/2021, 10/31/2021 and 11/01/2021 due to medication not being available because refills were not obtained timely. Interview on 11/05/2021 at 4:10 p.m. with resident #5 revealed he received Tylenol for pain when he was out of Oxycodone, but it did not help. The resident stated on a pain scale of 0-10 with 10 being the worst pain possible, his pain was a 10. Review of October 2021 and November 2021 MARs revealed resident #5 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation on the MARs that [MEDICATION(S)]/Acetaminophen/[MEDICATION(S)] 50-325-40 had been administered to resident #5 during the time the Oxycodone 10mg was unavailable on October 30th-November 1st, 2021. Did we verify this with either the resident or staff? No, the surveyor did not. Review of Nurses' notes for October 2021 and November 2021 revealed the doctor was not notified of resident #5's pain on 10/30/2021, 10/31/2021 and 11/01/2021. Interview on 11/08/2021 at 12:35 p.m. with S16 LPN revealed the doctor had not been notified of resident's pain, or of the resident being out of Oxycodone. Interview on 11/08/2021 at 12:45 p.m. with S22 RN Corporate Nurse confirmed resident #5's Oxycodone 10 mg was not available on the above stated days and should have been. S22 RN Corporate Nurse further confirmed initials with a circle around them meant the medication was not available. Interview on 11/08/2021 at 1:00 p.m. with S19 PT revealed on Monday 11/01/2021 resident #5 stated it was a bad weekend because he had been out of his pain medication all weekend. S19 PT further stated resident #5 had been evaluated for neck pain and it was being addressed through nursing with pain medication. Resident #34 Review of resident #34's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of resident #34 on 11/06/2021 at 12:45 p.m. revealed he was propelling himself down the hall in his wheelchair. The resident had bilateral dressings to his lower extremities. Interview with resident #34 on 11/06/2021 at 12:46 p.m. revealed his legs were hurting and the pain was almost unbearable. The resident was asked if he had notified his nurse and he stated he had just notified her 15 minutes prior. What was causing the resident's pain? The surveyor did not ask him what caused his pain. Review of resident #34's November 2021 MAR revealed the resident had the following medications ordered for pain: [MEDICATION(S)] 5-325 mg one by mouth every 6 hours as needed for pain with a start date of 8/31/2021 and [MEDICATION(S)] HCL ER 50 mg two tabs by mouth every 6 hours as needed for pain to equal [MEDICATION(S)] 100 mg. Review of resident #34's November 2021 MAR also revealed that the resident was being assessed for pain each shift and his pain level ranged from a level five (moderate pain) to a level eight (very severe pain). On 11/06/2021 on the 7:00 a.m. - 7:00 p.m. shift, his pain level was rated a five and on the 7:00 p.m. - 7:00 a.m. his pain was rated an eight. On 11/07/2021 on the 7:00 a.m. - 7:00 p.m. shift, his pain level was rated a level four (moderate pain). Interview of resident #34 on 11/07/2021 at 1:55 p.m. revealed he was hurting so bad and had not had anything for pain since 11:30 a.m. The resident stated, I'll take anything, Tylenol or [MEDICATION(S)] if they would just give it to me. At that moment, S10 LPN/MDS who was working the medication cart at that time, yelled from another resident's room I have already told you, you do not have anything else for pain, you received your two [MEDICATION(S)] at 11:30 a.m., so you are going to have to wait. Interview was done on 11/07/2021 at 2:02 p.m. with S10 LPN/MDS when asked if she had checked resident #34's record to make sure he did not have something else he could have for pain. She then stated, That's what I'm doing now. S10 LPN/MDS was asked why she answered him without looking at his MARs. S10 LPN/MDS stated, Well I don't normally work the cart and I was given report that he had [MEDICATION(S)] 100 mg at 11:30 a.m. She went through the November 2021 MAR and confirmed that the resident did have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She then confirmed he had not had it today (11/7/2021). Review of the Controlled Medication Sign-out Log on 11/07/2021 at 2:10 p.m. revealed the last documented time the resident had received his [MEDICATION(S)] 5-325 mg was on 11/06/2021 at 2:25 p.m. Further review of the Log revealed the resident had (0) doses of [MEDICATION(S)] 5-325 mg available. Interview at the above time with S10 LPN/MDS revealed she did not know if the medication had been re-ordered or not. She confirmed she had not offered the resident any alternative interventions and had not contacted the physician about his pain. She stated she was going to have to verify what to do with her supervisor. Resident #R9 Review of resident #R9's medical record revealed an admitted d of 09/20/2021 and had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #R9's Admission MDS with an ARD of 09/27/2021 revealed the resident had a BIMS of 15. Further review of the MDS revealed she was assessed as having pain almost constantly, received pain medication and her pain level was an 08 (Severe Pain). Review of Resident #R9's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During the resident council meeting held on 11/02/2021 at 2:00 p.m. resident #R9 voiced her concerns over the facility running out of medications and revealed she had been out of one of her medications for 2 weeks now. Interview with resident #R9 on 11/06/2021 at 12:45 p.m. who was walking down the hall when S27 LPN/Agency Nurse stated, I have your [MEDICATION(S)] it was in the overstock room. Resident #R9 stated, thank you Lord, I have been without it for 2 weeks. Further interview with the resident revealed they had been telling her it was ordered. She stated being without her medication, she gets nervous, anxious, hurts all the time and just wants to stay in her room and hide under her covers. She stated the facility will run out of medications or will say it's missing and they will try to find it. Interview on 11/06/2021 at 12:45 p.m. with S27 LPN/Agency Nurse confirmed she had not administered resident #R9's 9:00 a.m. dose of [MEDICATION(S)] as ordered because she could not find it and forgot to circle it on the MAR. Review of Resident # R9's October, 2021 MARs revealed on 10/24/2021 - 10/28/2021 the resident did not have her medication available for administration on the 9:00 a.m., 3:00 p.m. and 9:00 p.m. shifts for 15 doses. Review of the November, 2021 MARs revealed on 11/06/2021 the 9:00 a.m. dose of [MEDICATION(S)] 75 mg was initialed and circled indicating the medication was not available. Interview with S4 Pharmacist Consultant on 11/05/2021 at 4:26 p.m. revealed he reviewed all residents' MARs monthly and had identified there were holes missing in the documentation for administration, omissions of medications, and omission of blood glucose monitoring and administration of insulin as ordered. He revealed he had reported these issues to the DON. He revealed he had observed these issues over the past 7 - 8 months. Interview with S2 DON on 11/06/2021 at 5:15 p.m. revealed she and S29 Unit Manager were responsible for monitoring MARS at the end of each month. S2 DON revealed they had only monitored one of the halls MARs for the month of October. She confirmed she was aware there was a problem with acquiring medications to be delivered timely. She stated the pharmacy does not deliver the medications after they are ordered timely. She stated they had no back-up pharmacy contract and when they run out of medication they just have to wait until the medication comes in from the contracted pharmacy. Interview with S5 Pharmacy Contract Pharmacy Technician on 11/6/2021 at 4:26 p.m. revealed the pharmacy had talked with staff from the NH to order medications when they were at least 4-5 days from running out of medications on the bubble pack. She revealed staff called and asked for refill medications to be sent over immediately because the resident had none available for administration. She revealed she knew residents were going days without their medications due to the facility had not ordered the medications timely.

Based on interview and record review the facility failed to ensure each resident had the right to be free from abuse by other residents. The facility failed to intervene and protect two residents (#4 and #6) and other residents in the facility from the mental and verbal of resident #3. An Immediate Jeopardy situation was discovered for residents #4 and #6 on 8/7/2019 when the residents reported past, current and continuous mental and verbal abuse by Resident #3. Resident #6 expressed concerns of being afraid and feeling threatened by Resident #3. Resident #6 expressed concerns for his safety and well-being indicating that he was afraid that he would die if Resident #3 was to hit him in the head because he had an aneurysm. The interventions identified by the facility to address Resident #3's behavior were not appropriate and/or effective. The facility Administrator was notified of the deficient practice at the Immediate Jeopardy level on 8/9/19 at 11:45 a.m. The Immediate Jeopardy was removed on 8/9/19 at 4:10 p.m. after it was verified through observation, interview and record review that the facility submitted and implemented a Plan of Removal that read as follows: Problem Resident #3 was admitted to Winnfield Nursing and Rehabilitation Center, LLC on (MONTH) 29, 2019. On (MONTH) 01, 2019 was transferred to LaSalle Behavioral Health Center. Resident #3 was readmitted on (MONTH) 07, 2019. Upon readmission to the facility the IDT team held a meeting with Resident #3 in attendance. Resident #3 was discharge from the behavioral unit on (MONTH) 21, 2019 after IDT team met and deemed that resident no longer required services provided on the behavioral unit. On (MONTH) 06, 2019, facility was made aware that some residents had fear of residing in the facility based on Resident #3's behavior. Facility initiated interviews of cognitive and verbal residents. Based on results of residents' interviews, two residents verbalized issues with Resident #3's behaviors. On (MONTH) 06, 2019 the facility initiated in-services for staff that included Residents' Rights and Customer Services. The in-services detailed that staff should ensure that all residents are protected from abuse by anyone. On (MONTH) 08, 2019 the facility initiated in-service to ensure that residents who exhibit harmful behaviors are increased in supervision such as providing 1-1 and immediately notifying the Executive Director. On (MONTH) 08, 2019 the facility determined that Resident #3 warranted 1-1 monitoring and that psychiatric services should be contacted for recommendations for medication review. The Interdisciplinary Team met with the resident to discuss the results of the investigation to update Resident #3 of recommended plan of care to include 1-1 monitoring by the staff. Resident #3 no longer resides in the facility. Resident #3 did not agree to recommended changes to his plan of care and left facility AM[NAME] Resident #3 was his own responsible party. On 08/09/19, Regional Vice President in-serviced Executive Director and Interim Director of Nurses on ensuring that any resident whose behaviors affects other should be initiated for Immediate Discharge procedures. Based on record review, staff interviews and residents' interviews, the facility failed to ensure that Resident #3 behaviors were not harmful to others. All residents have the potential to be affected. Action: 1. Followed up with the two residents who felt unsafe in the facility due to resident #3's behavior on 8/9/19. The residents had no concerns and felt safe to reside in the facility. 2. In-services will continue for all staff on Residents Rights and Abuse/Neglect. No staff will be allowed to work until in-services are received. 3. Staff will be in-serviced on Residents Rights and Abuse/Neglect monthly x 2 and as deemed necessary by the facility. 4. The Director of Nurses will review all nurses notes daily to ensure that any documented behavior from residents are immediately addressed. 5. The Executive Director and Director will report all allegations of abuse/neglect per regulations. 6. The Executive Director will request to the President of the Resident Council to attend monthly meetings x two, starting in (MONTH) 2019 to any concerns of other residents' behaviors are being addressed and that residents feel safe to reside in the facility. 7. The facility will interview residents three times a week for four weeks to ensure residents feel safe to reside in the facility. Findings: Review of resident #3's Face Sheet revealed an admitted [DATE] and [DIAGNOSES REDACTED]. Review of a Discharge MDS for Resident #3 with an ARD of 5/2/19 revealed the resident had a BIMS of 15, which indicated he was cognitively intact. The MDS further revealed that the resident required supervision with no physical help from staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. The MDS revealed that Resident #3 had no upper extremity impairment, had lower extremity impairment on one side, and was mobile via wheelchair. Interview with Resident #3 on 8/5/19 at 7:15 a.m. revealed that he had been in this facility for about a year, and that he was a resident of another facility prior to his admission to the current facility. He also stated that he had no issues regarding the care he received or with any other residents in the facility. The resident further stated that he kept his own cigarettes, lighter and money on his person because he was level headed. Review of the resident's care plan with a target date of 8/8/19 revealed a problem of Socially Inappropriate/Disruptive Behavior related to verbal outburst, resistance to and refusal of care, and takes other residents' things. Also listed under problems : Behaviors - Impulse Control, [MEDICAL CONDITION], Generalized Anxiety Disorder, and Behaviors-[MEDICATION NAME] 1 mg BID and [MEDICATION NAME] 300 mg TID 7/18/19, Risk for side effects related to antidepressant and [MEDICAL CONDITION] medication use. Care plan approaches included: approach resident warmly and positively, talk with resident in calm voice when behavior is disruptive, remove resident from public area when behavior is disruptive, remove resident from area when behavior is unacceptable, assist resident in selection of appropriate coping mechanisms, monitor and document resident behavior, activities to assess resident and provide appropriate diversion activities, refer to Social Services, redirect if inappropriate, reinforce positive behaviors, psych referral, admit to behavior unit, and monitor for side effects/effectiveness of psychoactive/antidepressant medication every shift. review of the resident's medical record revealed [REDACTED]. The number of behavior episodes, intervention, and outcome were to be monitored daily on every shift. Further review of the above record revealed monitoring occurred only on 05/01/19 for the month of 05/19. Further review of the resident's medical record revealed [REDACTED]. The number of behaviors, intervention and outcome were to be monitored daily on every shift. However, as of 8/7/19 there was no evidence that this had been done for the month of (MONTH) 2019. Interview on 8/7/2019 at 12:10 p.m. with S4 RN Unit Manager confirmed the above findings. Review of resident #3's medical record revealed the facility did not have a Behavior/Intervention Monthly Flow Record for the months of 06/19 and 07/19. Review of resident #3's nurses' notes revealed he was transferred to a hospital behavior unit on 5/2/19 due to impulse control, increased manic behaviors and anxiety. The resident was readmitted to the nursing facility's secure unit on 5/7/19, and was to be evaluated in 4 weeks regarding return to a room outside of the secure unit. Review of the behavior hospital's discharge instructions dated 5/7/19 revealed the resident was admitted due to manic behaviors, verbally aggressive with staff and residents, and pocketing narcotics. Further review of the resident's nurses' notes revealed the following: 5/14/19 - resident #3 was verbally aggressive and threatened his roommate. 5/16/19 - resident continued to show aggression towards other residents and his roommate, and not easily redirected. 5/20/19 - resident showed aggression towards other residents. Review of an IDT meeting note with a late entry date of 8/7/19, revealed resident #3 would be transferred back to the general facility population on 5/21/19. The IDT meeting note further revealed that the resident's behavior was to be monitored daily per shift as this was a trial basis. Interview of resident #6 on 8/6/19 at 8:10 a.m. revealed that she was having a terrible problem with resident #3. She stated that resident #3 would knock on her door and roll away in his wheelchair when she answered the door. She stated that she was afraid of him and felt threatened since he (resident #3) was admitted to the facility. She stated he really scared her, and she was afraid that resident #3 would retaliate if he knew she was saying this. Resident #6 became tearful during the interview and stated that this was her home, and she should not have to feel threatened and scared by resident #3. Resident #6 further stated that she had talked to the DON and Administrator, but nothing had improved. Review of resident #6's Quarterly MDS with an ARD of 7/10/19 revealed a BIMS of 15, which indicated she was cognitively intact. Interview with resident #4 on 8/6/19 at 10:30 a.m. revealed that a couple of days ago he was approached by resident #3 on the patio while outside smoking. Resident #4 stated that resident #3 began cursing at him and told him to stand up like a man so that he could hit him, because he had reported resident #3 to a CNA after he witnessed the resident enter his room and steal his roommate's cigarettes. He further stated that since the incident a couple of days ago, he has been afraid of being hit by resident #3. Resident #4 stated that he could die if resident #3 hit him in the head because he had an aneurysm. Review of resident #4's Quarterly MDS with an ARD of 6/19/190 revealed a BIMS of 15, which indicated that he was cognitively intact. Interview with S15 CNA on 8/6/19 at 12:12 p.m. revealed that while on the secure unit, resident #3 bullied other residents, was mean to his roommate, and would often try to put the roommate out of the room. She further stated resident #3 pushed a female resident that had wandered into his room, and would curse staff when redirected. S15 CNA stated that resident #3 was difficult to deal with and cursed staff when redirected. She further stated that resident #3 and his roommate remained in the same room until resident #3 was moved to general population on 5/21/19. Interview of S4 RN/Secure Unit Manager on 8/6/19 at 1:32 p.m. revealed resident #3 yelled and cursed at staff and residents, and often had verbal altercations with other residents about cigarettes. She stated that resident #3 verbally bullied other residents for their cigarettes, and they gave in to him. S4 RN/Secure Unit Manager confirmed that resident #3 had aggressive behaviors toward other residents in the Secure Unit, and that she was unaware of an IDT meeting held regarding moving the resident out of the Secure Unit. Interview of S3 SSD on 8/6/19 at 1:42 p.m. revealed that the initial IDT meeting was facilitated by the past DON, and stated that there had been no other IDT meetings regarding the resident's behavior and transferring the resident out of the Secure Unit into the general nursing home population. Review of a Resident Status History List revealed resident #3 was transferred from the Secure Unit to the general nursing home population on 5/21/19. Review of resident #3's nurses' notes revealed the following:6/4/19 at 7:15 p.m. - resident #3 called another resident psychotic when he noticed that resident crying. 6/29/19 at 6:41 a.m. - behavior not easily altered. 6/30/19 at 5:52 a.m. - very threatening toward peers at times. 7/13/19 at 7:20 a.m. - resident arguing and cursing at male peer. Resident was asked to be mindful of other residents and to stop cursing or DON would be notified. Resident responded I don't give a f***. 8/1/19 at 8:44 p.m. - resident #3 takes other residents' money and other belongings. When redirection is attempted, the resident states it's none of your business. Interview of S1 Administrator and S2 Corporate Nurse on 8/7/19 at 8:00 a.m. revealed they were informed by S3 SSD on yesterday (8/6/19) that residents #4 and #6 complained of issues concerning resident #3. S1 Administrator further stated that she was unaware of the issues regarding resident #3 prior to yesterday, and that staff had not reported to her that they witnessed abuse of other residents by resident #3. Interview with S8 LPN on 8/7/19 at 8:15 a.m. revealed that resident #3 was verbally aggressive with staff and other residents, and that he would holler, curse, and threaten others when he didn't get his way. S8 LPN further stated that staff attempts to verbally redirect and reason with the resident did not work, and the environment changed for the better when the resident was moved off the Secure Unit back into his old room. Further interview with S4 RN/Secure Unit Manager on 8/7/19 at 9:11 a.m. revealed that she did in fact remember an IDT meeting regarding the transfer of resident #3 from the Secure Unit to the general population. Telephone interview of a former DON on 8/7/19 at 9:23 a.m. revealed she was DON at the facility from 7/6/19 to 8/1/19. She stated that resident #3 was manipulative and bullied other residents. She stated she felt that the residents were afraid of resident #3, and the residents didn't want the nurses to say anything to him for fear that he would harm them. She further stated that she thought that all staff and the Administrator were aware of resident #3's behavior. Telephone interview on 8/7/19 at 9:45 a.m. of a former DON revealed she was DON at the facility from 9/10/18 to 7/5/19. She stated that resident #3 had several psychiatric issues, was narcissistic, noncompliant with behavior modification even after psychiatric in-patient admission, and required constant redirection for verbal aggression. She stated residents reported issues involving resident #3 to staff, and one resident reported to staff that he was afraid of the resident; however, he later denied it. She further stated that she could never get the residents to speak up regarding their concerns about resident #3. Interview of S18 Interim DON on 8/7/19 at 12:55 p.m. confirmed that there were no Behavior/Intervention or Psychoactive Drug Monitoring Flow Records for resident #3 for the months of 06/19 and 07/19, and that there were no revisions to the resident's plan of care. Further interview with resident #4 on 8/7/19 at 1:00 p.m. revealed that he enjoyed playing cards, but no longer participated in facility card games because resident #3 would steal the game prizes and cursed people while they played. Interview of S17 Activities Director on 8/8/19 at 10:00 a.m. revealed resident #4 and at least 6 other residents use to attend Black[NAME]regularly, but many have stopped coming because resident #3 cursed at other residents during the game. She further stated that now only 4 residents attended the card game, and those residents leave if resident #3 shows up to play. She confirmed that resident #3 would take the card game prizes and cursed her if she attempted to redirect him. S17 Activities Director stated she did not report this to the facility's administrative staff.

Based on observation, interview and record review, the facility failed to maintain an acceptable parameter of nutritional status and usual body weight for one (#23) of two (#23 and #13) residents sampled for nutrition in a total sample of 29 residents. This deficient practice was evidenced by the facility's failure to provide a nutritional supplement recommended by the RD and ordered by the MD for resident #23. This failed practice resulted in an actual harm situation for resident #23 on 4/18/18 when the Registered Dietician (RD) identified a problem with weight loss for the resident and recommended the nutritional supplement of Ensure. During the period of 4/18/2018 through 9/19/2018, the resident did not receive the nutritional supplement as recommended by the RD and/or as ordered by the physician. On 6/6/2018, the RD identified a 14.97% weight loss for the resident from 4/18/2018 through 5/20/2018 (30 days). Findings: Review of the MD Orders dated (MONTH) (YEAR) revealed resident #23's [DIAGNOSES REDACTED]. Further review of the orders revealed a diet order for Mechanical Soft Diet with Thin Liquids, and Ensure 1 can po TID with meals. Review of the Evaluation of Dehydration Risk assessment dated [DATE] completed by the resident's nurse (S8 LPN) revealed the resident had a severe impairment in mental status, consumed 51-75% of food and fluids, was unable to make needs known, was able to drink from a cup/glass if was put in her hand, had a history of [REDACTED]. Review of the MDS Quarterly assessment dated [DATE] (ARD) revealed the resident required extensive assistance of 1 person for eating. Review of the Weight Change History revealed the following weights for the resident: 4/12/18 - 123.6 4/18/18 - 122 4/25/18 - 115.8 5/2/18 - 116.2 5/8/18 - 117 5/18/18 - 118 6/1/18 - 98.8 6/13/18 - 96.8 6/19/18 - 98.2 6/28/18 - 101.1 7/6/18 - 100.2 7/9/18 - 100.2 8/3/18 - 102.8 8/8/18 - 97.8 8/15/18 - 97.2 8/21/18 - 100. Review of the Departmental Notes revealed: 4/12/18 - S4 RD documented the resident was a new admit - weight 123.6 lbs. 4/18/18 - S4 RD documented a 1.29% weight loss in 1 week - weight 122 lbs. and made the recommendation to add the supplement Ensure 1 can q day. 4/25/18 - S4 RD documented a significant weight loss of 5.08% in 1 week - weight 115.8, and made the recommendation to increase Ensure to 1 can BID to combat weight loss and add additional nourishment. 5/20/18 - S4 RD documented a significant weight loss at 30 days of 6.31% - weight 118 lbs., receives Ensure 1 can BID to combat weight loss, and weight stable x 4 weekly weights, discontinue weekly weights. 6/6/18 - S5 RD documented a significant weight loss at 30 days of 14.97% - weight 98.8. The RD made the recommendation to increase Ensure to three times daily, and resume weekly weights. 6/13/18 - S5 RD documented a significant weight loss in 1 week of 2.02% - weight 96.8, and made the recommendation to add med-pass 4 ounces (oz.) q day for added nourishment. 6/22/18 S5 RD documented - weight 98.2. The RD documented the resident gets Ensure 1 can bid and med-pass 4 oz. q day. 7/6/18 - S5 RD documented - weight 101.1, significant weight loss of 18.2% over 90 days, gets 1 can Ensure bid and med-pass 4 oz daily. 7/10/18 - S5 RD documented - weight 100.2 lbs. 8/8/18 - S5 RD documented a significant weight loss of 4.86% for 1 week - weight 97.8, and made the recommendation to increase the med-pass to bid to help combat further weight loss. 8/23/18 documented by S5 RD - weight 100.0. 9/7/18 documented by S6 DM - weight 98 lbs., slight weight loss, on Ensure 1 can bid and med-pass 4 ozs. BID. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of the diet listed on the (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Further review revealed the nurses had initialed the spaces under the days of the month for their administration of the supplement. Interview on 9/19/18 at 11:16 a.m. with S8 LPN revealed the nurses were scheduled to give the resident med-pass supplement 4 oz. twice a day at 9:00 a.m. and 9:00 p.m., and the resident usually drank all of it. Further interview with S8 LPN revealed the only nutritional supplement provided by the nurses was the med-pass supplement. Observation on 9/19/18 at 12:30 p.m. revealed the resident was seated in a wheelchair in the dining room and the noon meal was served. Further observation revealed S3 CNA sat beside the resident and assisted the resident to eat her meal. S3 CNA fed the resident and offered sips of tea and water to drink. Observation of the meal tray revealed a can of Ensure was not provided with the lunch meal. Review of the resident's meal card (that was placed on the tray with the lunch meal) revealed Ensure was not listed on the card as an item to be served. Interview on 9/19/18 at 1:28 p.m. with S3 CNA confirmed the resident did not get Ensure with her lunch meal, and that the CNAs were not providing Ensure Supplements for the resident. Interview on 9/19/18 at 1:35 p.m. with S6 DM revealed that all canned supplements were supposed to be provided by the dietary department. S6 DM reviewed the resident's diet order and confirmed there was an order for [REDACTED]. S6 DM reviewed her records for dietary orders that had been provided to her by nursing, and stated she had not received an order or instructions from nursing to provide Ensure Supplements for the resident, and should have. S6 DM reviewed her records from the RD for Medical Nutrition Recommendations and stated there was a recommendation dated 4/18/18 for Ensure 1 can daily, 4/25/18 to increase Ensure to one can bid, and 6/6/18 to increase Ensure to 1 can to tid. Further interview with S6 DM confirmed the intervention for Ensure had not been provided by the dietary staff, was not started in (MONTH) (YEAR), and should have been. Further interview on 9/19/18 at 1:35 p.m. with S6 DM revealed the process used to make changes in a resident's diet involved their nursing staff sending them written information concerning the diet changes required, and the dietary department then makes the changes to the resident's diet based on the information that the nurses sent to her. Interview on 9/19/18 at 1:45 p.m. with S2 RN revealed she was the Unit Manager for the resident's Hall, and participated in the Weekly Weight Meetings. S2 RN stated she was aware the resident had experienced a significant weight loss. S2 RN reviewed the resident's orders and confirmed the resident originally had a MD Order for Ensure dated 4/18/18. S2 RN reviewed the Departmental Notes and confirmed the RD had assessed the resident on 4/18/18 and recommended the supplement Ensure 1 can daily due to weight loss; on 4/25/18 the RD recommended Ensure 1 can twice daily; and on 6/6/18 the RD recommended Ensure 1 can three times a day. Further interview with S2 RN confirmed the Ensure had not been started on 4/18/18 and provided as recommended from 4/18/18 to 9/19/18, and should have been. Interview on 9/20/18 at 3:05 p.m. with S7 Corporate RN confirmed the order to provide the Nutritional Supplement Ensure (recommended on 4/18/18 initially) remained in the plan of care and had not been provided as recommended/ordered, and should have been.

Based on interview and record review the facility failed to assess a resident and ensure the resident received the care and services to prevent the development of a pressure ulcer for 1 (#5) of 5 sampled residents reviewed for pressure ulcers in a total sample of 5. The facility's census was 83 according to the Resident Census and Condition of Residents form dated 11/30/16. This failed practice resulted in Actual Harm for resident #5. A change in the resident's buttocks and sacrum occurred on 11/4/16 when the S4 LPN Treatment Nurse and S3 RN documented that they had identified a foul, strong odor during the dressing change. During a dressing change on 11/5/16 and 11/6/16, the weekend RN observed a pressure ulcer to the resident ' s coccyx. The weekend RN described the wound as larger than a quarter with well-defined edges, drainage and an odor. There was no documentation of a comprehensive assessment of the pressure ulcer or documentation that the physician was notified of the change in the resident's wound status. Resident #5 was transferred to the hospital emergency roiagnom on [DATE] at 11:20 p.m. Review of the emergency room Record dated 11/7/16 at 12:20 a.m. revealed the resident had a pressure ulcer at the sacrum that traveled down the center of the buttocks, was unstageable, and had macerated edges. Wound cultures were obtained and revealed the wound was positive for Pseudomonas Aeruginosa [MEDICAL CONDITION]. The resident was admitted to the hospital on [DATE]. Findings: Review of the facility Policy for Assessment and treatment of [REDACTED]. 1) upon identification of a pressure ulcer, whether developed in the facility or upon admission, the area was to be assessed and documented, and a complete assessment was to be documented on the Wound Evaluation form; 2) if the skin condition was not an ulcer or incision, staff were to use the Skin Condition Form; 3) contact the physician, interdisciplinary team, family members as indicated; 4) initiate appropriate treatment per Treatment Protocol and physician order; 5) document wound status at least once a week; 6) the physician was to be notified if there was no improvement in the area, or if there were signs and symptoms of infection or deterioration noted. Review of resident #5' s Skin and Wound Evaluation Form dated 9/5/16 revealed the resident was admitted to the facility with a stage 3 pressure ulcer to the left buttock that was 8.5 x 5.5 x 0.1 cm in size, and 2 stage 2 pressure ulcers to the right buttocks that measured 1.0 x 0.8 x 0.1, and 0.8 x 1 x 0.1 cm in size documented by S12 LPN Treatment Nurse. Review of the Interdisciplinary Progress Note dated 9/5/16 by S11 RN revealed the resident had a Stage 3 Pressure Ulcer to the left buttock that measured 8.5 [MEDICAL CONDITION] x 0.1 cm with scarring noted to the peri-wound area, and 2 stage 2 pressure ulcers to the right buttock that measured 0.8 x 1.0 x 0 and 1 x 0.8 x 0 cms. Further review of the Progress Note revealed the areas had healthy granulation tissue in the wound beds, and had no signs or symptoms of infection. Review of the Pressure Ulcer Risk assessment dated [DATE] revealed the resident was at high risk for pressure ulcer development due to problems with bed mobility, bowel incontinence and skin desensitization. Review of the Admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 14, an impairment in ROM of both lower extremities, a functional limitation of both lower extremities, and required the use of a wheelchair for mobility. Further review of the MDS revealed the resident required extensive assistance of 2 people for bed mobility, transfers, toilet use and was totally dependent on staff for bathing. Review of the Departmental Note by S11 RN dated 9/17/16 revealed the 2 pressure ulcers to the resident ' s right buttock had healed. Review of the Weekly Wound Report dated 10/3/16 revealed the stage 3 pressure ulcer to the resident ' s left buttock had healed. Review of the Nurse's Note by S4 LPN Treatment Nurse dated 10/26/16 revealed S4 LPN and S3 RN discovered the resident had redness to the sacrum / coccyx area during the resident ' s weekly skin assessment and received a new order for a [MEDICATION NAME] dressing to the sacrum. There was no further description of the area. Review of the MD Order dated 10/26/16 revealed the order - may apply [MEDICATION NAME] dressing to the sacrum for preventative measure prn, and the order was added to the October and November, 2016 Treatment Records and signed off by the nurses. Review of the November, 2016 TAR revealed the order may apply [MEDICATION NAME] dressing to sacrum for preventative measure as needed (order dated 10/26/16), and the nurses had initialed the TAR daily through 11/6/16. Review of the Weekly Skin Assessment by S4 LPN Treatment Nurse dated 10/27/16 and 11/1/16 revealed documentation the resident had Incontinent [MEDICAL CONDITION] to the right and left buttocks. There was no further description of the area documented. Review of the Interdisciplinary Progress Note by S3 RN dated 11/2/16 revealed S3 RN and S4 LPN Treatment Nurse noted a small amount of yellowish drainage with an odor to the resident ' s wound; however there was no further description of the wound ' s location or wound characteristics. Further review of the note dated 11/2/16 revealed the MD was notified, and no new orders were given. Review of the Interdisciplinary Note by S4 LPN dated 11/4/16 revealed S4 LPN and S3 RN noted a strong, foul odor during the resident's dressing change, and initiated a referral to the Wound Clinic. Further review of the nurses ' notes dated 11/4/16 revealed there was no further description of the wound and the wound ' s characteristics. Review of the MD Orders revealed an order dated 11/4/16 to insert an indwelling Foley catheter, and to leave in place due to worsening of the wound of coccyx, written by S2 DON. Review of the Weekly Wound Assessments, Weekly Skin Assessments, Departmental Notes, Interdepartmental Notes and Nurses ' Notes from 10/27/16 through 11/6/16 revealed there was no further description/assessment of the resident ' s wound documented. Review of the hospital record revealed the resident was transferred to the hospital emergency roiagnom on [DATE] at 2320. Review of the emergency room Record dated 11/7/16 at 0020 revealed the resident had a pressure ulcer at the sacrum that traveled down the center of the buttocks, was unstageable, and had macerated edges. Review of the Emergency Physician Record dated 11/6/16 revealed the WBC was 27, and that the resident had a pressure ulcer to the sacrum, and a wound culture was obtained. Review of the lab reports dated 11/6/16 revealed the resident's WBC was 27.5 HC (5.0 - 10.0), Hgb 7.2 (14.0 - 18.0), Hct 22.9 (42.0 - 52.0), and the wound culture was positive for Pseudomonas Aeruginosa [MEDICAL CONDITION]. Further review of the emergency room record revealed the resident was transferred to a second hospital for additional treatment on 11/7/16 at 0415. Interview on 11/30/16 at 1:02 p.m. with S5 CNA confirmed she had worked with the resident, and reported he had a dressing to his buttocks and had an odor of the area the week before the resident went to the hospital. The CNAs were unable to state an actual day of the week. Interview on 11/30/16 at 1:18 p.m. with S6 CNA confirmed she had worked with the resident and reported he had a dressing to his buttocks and had a strong foul odor of the area the week before he went to the hospital. The CNA was unable to state an actual day of the week. Interview on 11/30/16 at 1:30 p.m. with S7 CNA revealed she had worked with the resident since his admission to the facility, and had assisted the resident with baths and in getting up to the wheelchair. Further interview with S7 CNA revealed that when the resident was first admitted the resident would get up every day and stay up for approximately 4 hours, but over the last few weeks of his stay the resident got up less and less and would only stay up for 1 to 2 hours. She further stated that during the week prior to him being sent to the hospital he only got up maybe 4 of the 7 days. S7 CNA stated the resident complained of pain to the buttocks, back and shoulders, and when he did she reported it to the nurses. S7 CNA reported she saw the resident ' s wound during the last couple of weeks before the resident went to the hospital (during dressing changes), and it was real red, and at first it was about the size of a quarter and then the size of 2 quarters. Further interview with S7 CNA revealed the area had a strong, foul odor during the last couple of weeks before admission to the hospital. Interview on 11/30/16 at 2:00 p.m. with S4 LPN Treatment Nurse confirmed she documented the Weekly Skin Assessment on 10/27/16 and had documented the resident had Incontinent [MEDICAL CONDITION] centrally on his right and left buttocks, and did not document any additional physical findings/assessment of the wound (to include size, color, description of wound bed) on 10/27/16. Further interview with S4 LPN Treatment Nurse confirmed there was no description of the wound to the buttocks / coccyx region documented from 10/27/16 through the time the resident was transferred to the hospital on [DATE], with the exception that on 11/2/16 there was documentation the wound had a small amount of yellowish drainage, and on 11/4/16 the wound had an odor that was strong and foul. The S4 LPN Treatment Nurse confirmed they had started the referral process for the wound care clinic on 11/4/16; however, had not communicated with the resident ' s primary physician concerning the wound and the foul odor of the wound at that time. Interview on 11/30/16 at 2:10 p.m. with S3 RN Supervisor confirmed there was no accurate description of the wound documented from 10/27/16 through 11/6/16. Interview on 11/30/16 at 2:10 p.m. with S4 LPN Treatment Nurse and S3 RN Supervisor confirmed they did not discuss the condition of the resident ' s wound with the resident ' s MD on 11/4/16, 11/5/16 or 11/6/16. Interview on 12/1/16 at 10:05 a.m. with S2 DON revealed the nurses had reported to the DON that the resident ' s wound had worsened on 11/4/16, and S2 DON called and notified the physician of the worsening, and then received the order for an indwelling catheter. However, further interview with S2 DON on the above date and time revealed that he (S2 DON) did not report that there was a strong, foul odor of the wound to the MD. Interview on 12/1/16 at 10:34 a.m. with S8 RN revealed the RN had worked 11/5/16 and 11/6/16, and provided wound care and a dressing change on those days for the resident. Further interview with S8 RN revealed she did not receive a report from staff related to the resident ' s wound and wound care and stated she had referenced the chart and the treatment TAR for his care. S8 RN stated she provided wound care for the resident ' s coccyx wound on 11/5/16 and at that time the resident had a Pressure Ulcer that was larger than a quarter, and had well-defined edges, drainage and an odor. S8 RN stated she did not perform / document a comprehensive assessment of the wound because her findings were not out of the ordinary for a resident with a pressure ulcer, and she did not know the pressure ulcer was a new finding for the resident. Further interview with S8 RN revealed she did not inform or consult the physician concerning the pressure ulcer finding on 11/5/16 or 11/6/16, and performed the wound care that was already in place. Interview on 12/1/16 at 12:00 p.m. with S2 DON confirmed the weekend RN Supervisor should have done a comprehensive wound assessment when she identified a pressure ulcer on the resident ' s coccyx on 11/5/16 because it was a new pressure ulcer finding for the resident, and should have notified the MD. Further interview with S2 DON revealed the order for treatment on the TAR was vague and not clearly defined and should have been specific concerning the treatment plan. The S2 DON confirmed the S4 LPN Treatment Nurse and S3 RN documented they identified a foul, strong odor during the dressing change on 11/4/16, but did not document any additional physical findings of the wound, and should have. Further interview with the DON revealed the resident was admitted to the hospital on [DATE], and was diagnosed with [REDACTED]. Interview on 12/1/16 at 1:30 p.m. with S3 RN revealed she had assessed the resident ' s wound on Friday, 11/4/16 and the wound on the resident ' s coccyx area was less than the size of her palm, appeared to be irritated skin / excoriation / diaper [MEDICAL CONDITION] and did not appear to be a pressure ulcer to her. Further interview with S3 RN revealed the Treatment Nurses do not have a formal way for communicating information to the weekend RN Supervisor and did not give the weekend RN a report related to the resident on 11/4/16. S3 RN stated that if there is a problem that they want to let the weekend nurse know about they write it on a sticky note and put it on the TAR. S3 RN stated that they did not provide any information related to the resident and his wounds to the weekend RN on 11/4/16. S3 RN stated the weekend RN (11/5/16 and 11/6/16) had the information in the chart, MD Orders and had the order for the [MEDICATION NAME] dressing to the sacrum for preventive measures on the TAR. Interview with S3 RN stated the information related to the wound type and findings was documented in the computer system. S3 RN stated the floor nurses used a 24 hour report document to communicate their findings and concerns to each other on, but the treatment nurses did not use a specific tool for communication. Interview on 12/1/16 at 1:50 p.m. with S2 DON revealed S8 RN Weekend Supervisor had access to the computerized wound documentation system but did not typically use it and confirmed they did not have a formal process for communicating information to the weekend RN Supervisors related to the residents with wounds, and should have.

Based on observation, interview and record review the facility failed to implement procedures to prevent resident to resident mistreatment and resident to resident physical aggression. The facility neglected to protect residents on the locked behavioral unit from physically aggressive behaviors of other residents on the locked unit for 4 residents exhibiting physically aggressive behaviors (#1, 2, 5 and 6), and 1 resident with a history of eloping from the locked unit (2) out of 6 residents reviewed residing on the locked behavior unit. The facility failed to: 1) prevent resident to resident physical altercations (#6, 2, 1 and 5) and 2) increase supervision of a resident known to make homemade weapons (#6), 3) put measures in place to prevent resident #2 from eloping from the facility and 4) put measures in place to prevent resident #2 from interfering with other residents' care by using the mechanical lift to transfer another resident and emptying the resident's foley catheter. An Immediate Jeopardy situation began on 4/18/13 at 6:00 p.m. when resident #6 was observed by the staff on the behavior unit slapping a female resident in the face, and threatening to hit others with his dresser drawers and a chair. The resident had returned from an inpatient psychiatric stay the day before due to his aggressive behavior with other residents. There were no new interventions put in place to protect the other residents on the behavior unit from the aggressive behaviors of resident #6 when he returned to the facility. Physical aggression and altercations of this type continued by resident #6 and also by residents #1, #2 and #5 on multiple occasions as described in the findings below, without the facility re-evaluating and analyzing the effectiveness of planned interventions and the adequacy of the supervision and monitoring. Staff were not identifying triggers that were the cause of escalating behaviors in order to attempt interventions to de-escalate the situation. All residents on the locked behavior unit were placed in Immediate Jeopardy on 4/18/13 when the facility failed to implement interventions to protect them from the physically aggressive behaviors on the locked behavior unit. Review of the census list provided by the DON reflected the behavior unit's total census on 7/29/13 was 23. The Administrator was notified of the Immediate Jeopardy on 7/31/13 at 2:45 p.m. The facility submitted a plan of removal which included increasing the staff on the behavior unit to include placing resident #2 on 1:1 care and assigning a staff member to monitor residents #1, 5 and 6 every 15 minutes to reduce physical aggression, elopement and interference with resident's care. All residents at risk for potential aggressive behavior and elopements were reassessed and care plans updated. The staff received additional training on identifying triggers, approaches to reduce agitation and interventions for residents with aggression. The QA committee met to address elopement, staff training, scheduling, resident to resident abuse, care plans, and reportable incidents. Monitoring rounds will be made by administrative staff daily. The Immediate Jeopardy situation was removed on 8/1/13 at 12:00 p.m. when observations revealed that the plan was being implemented. Although the immediacy of the situation was removed, the deficient practice remains at a level of actual harm for resident #6 who was hospitalized for [REDACTED].#1 and for resident #5 who required evaluation at the hospital after a physical altercation with resident #2 which left the resident bleeding from the mouth due to his tooth being knocked out, dazed and unable to speak. Findings: 1. RESIDENT TO RESIDENT PHYSICAL ALTERCATIONS A. RESIDENT #6 Review of resident #6's face sheet reflected he was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission/Readmission form dated 3/20/13 reflected the [DIAGNOSES REDACTED]. 1. Review of an incident report dated 3/29/13 reflected the resident hit his roommate in the face twice after putting the roommate's pants on and being asked to take them off by the roommate. The immediate action taken was to separate the residents after the incident occurred. 2. Review of an incident report dated 4/10/13 at 11:40 a.m. reflected resident #6 entered an unidentified resident's room when the other resident asked him to leave numerous times. Resident #6 began to hit the other resident numerous times and the other resident bit him. The immediate action taken was to provide wound care. 3. Review of an incident report dated 4/10/13 at 1:05 p.m. reflected resident #6 mumbled something to another resident when the other resident said something back. Resident #6 hit the other resident on the side of the head. The fight was stopped by the nurse and CNA. The immediate action taken was to assess the resident. 4. Review of the Resident Transfer Form dated 4/11/13 reflected resident #6 was transferred to an inpatient psychiatric facility. Review of the Admission/Readmission Evaluation form dated 4/17/13 and the nurse' s note dated 4/17/13, reflected resident #6 returned to the facility following a stay at an inpatient psychiatric facility. Record review of the SSD note dated 4/18/13 reflected the resident's care planning meeting was held and a new care plan was put in place. Further review of the care plan revealed no changes were noted at that time. There were no approaches added to increase supervision of the resident's aggressive behaviors when he returned to the facility following hospitalization for aggression. 5. Review of the nurse's note dated 4/18/13 at 6:21 p.m. - at 1800 (6:00 p.m.) resident #6 was ambulating in the hallway, walked up to resident #7 and slapped her in the face. The two residents were separated and prn [MEDICATION NAME] 2 mg was given. The resident then started pulling dresser drawers out and trying to bring them into the hallway, threatening to hit people. The resident then went into the dayroom and picked up a chair and tried to hit the others. Another male resident then hit resident #6 three times. Review of the incident report dated 4/18/13 reflected the immediate action was "see above." The "see above" documentation contained a description of the incident that occurred but no actions taken by the staff. Review of the physician progress notes [REDACTED]. The documentation reflected the resident was still physically aggressive and had slapped another resident the previous night. Further review reflected the resident was refusing his medications and was still dangerous to others. 6. Review of the nurse's note dated 5/15/13 at 3:14 p.m. reflected at 1400 (2:00 p.m.) the resident walked up to another resident in the hall and punched them in the mouth. The altercation was unprovoked. Resident #6 was taken to his room by staff. Review of an incident report dated 5/15/13 reflected the immediate action taken for the 2:00 p.m. incident was to assist the resident to his room. 7. Review of the nurse's note dated 5/18/13 at 4:36 p.m. reflected at 12:30 p.m. resident #6 was standing in the hallway with blood above his right and left eyes. The resident stated that resident #1 had asked him for a lighter and they got into a fight. The CNA reported that resident #6 had hit resident #1 and they began to fight. Resident #6 was taken to his room. Further review reflected resident #6 was sent to theER on [DATE] at 1:15 p.m. The facility received a call at 4:00 p.m. that the resident was being transferred to a facility in Alexandria with a [DIAGNOSES REDACTED]. Review of the nurse's note dated 5/21/13 at 2:12 p.m. reflected a t 12:40 p.m. the resident returned to the facility. B. RESIDENT #2 Review of resident #2's face sheet reflected the resident was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the June 2013 physician's orders [REDACTED]. Review of resident #2's nurse's note dated 6/15/13 at 11:53 p.m. reflected at 9:00 p.m. the resident liked to instigate trouble between other residents and pick on other residents. Review of the nurse's note dated 6/16/13 at 12:42 p.m. reflected the resident had a history of [REDACTED]. Further review reflected a room search was done that a.m. due to a pocket knife was found in the resident's possession the day before. There was no other documentation regarding the resident having a pocket knife in his possession. Observation on 7/29/13 at 11:00 a.m. revealed resident #2 was lying in bed with the bed linens pulled over his head. The resident would not respond when spoken to. Interview on 7/29/13 at 11:00 a.m. with S7 CNA revealed the resident was capable of responding, and could be very combative. 1. Review of the nurse's note dated 6/18/13 at 7:11 p.m. reflected resident #2 grabbed another resident by the shirt and threw him to the bed. The residents were separated by the nurse. Review of the incident report dated 6/18/13 reflected the immediate actions taken were to separate the residents. 2. Review of the nurse's note dated 6/24/13 at 6:16 a.m. reflected on 6/23/13 at 10:25 p.m. resident #2 tried to assist another resident with a phone call. The other resident did not want assistance, snatched the phone from the resident's hand and began to swing at the resident. Resident #2 hit the other resident in the temporal area with a closed fist. The nurse tried to stop the resident from hitting the other resident but he continued to hit him until he fell to the floor. Resident #2 went to his room and the physician was notified. Review of the incident report dated 6/23/13 reflected the immediate action taken was to separate the two residents. 3. Review of the nurse's note dated 7/3/13 at 3:37 a.m. reflected the following incidents on 7/2/13: a. 8:00 p.m. - resident #2 assisted resident #1 in a physical altercation against another resident, b. 8:17 p.m. - a message was left for the DON, c. 8:25 p.m. - "psychiatrist notified, recommended to call the police and tell them he said arrest them. Stated that he was not going to be held accountable for these people if they hurt someone. Also, stated that these people were going to the bottom of the barrel to get these people that society does not want to deal with and they want us to be able to handle them. This place is not equipped to handle the type of people they are housing and it is just unsafe." d. 8:45 p.m. - the local police department was called, e. 8:55 p.m. - the DON returned the facility's call and was informed of the situation, f. 9:30 p.m. - 2 police officers entered the unit and stated they could not do anything to help because the resident was in a mental institution and there were rules that limited what they could do. The documentation reflected the police officers spoke with the resident about the dangers of fighting other residents and the resident voiced understanding, g. 9:45 p.m. - the resident was furious, passed by the nurses' station and stated "I got something for you, [***] ," h. 10:15 p.m. - the resident stated to other residents "if I don't get discharged tonight, I'm just going to start knocking people out in this [***] ," i. 10:30 p.m. - the resident became physically aggressive with a male staff member and the police were called again, j. 10:35 p.m. - 2 police officers arrived in the facility and stated there was nothing they could do. The police officers did agree to stay until the situation was defused, k. 10:40 p.m. - the psychiatrist was called again and recommended the police take the resident to the local ER where he could be PECed and transferred to another facility. The nurse spoke with the ER physician who instructed them not to bring the resident to ER for safety reasons. The nurse explained to the physician that the resident was very violent and out of control, l. 11:05 p.m. - the ER physician gave an order to give the resident [MEDICATION NAME] 20 mg IM and [MEDICATION NAME] 1 mg IM and instructed the nurse again to not bring the resident to the ER. The nurse explained again that the resident was violent, non-compliant and very aggressive with staff and residents, m. 11:15 p.m. - [MEDICATION NAME] 20 mg IM and [MEDICATION NAME] 1 mg IM was given, n. 11:30 p.m. - the resident was a little calmer and the police officers left the building, o. 11:45 p.m. - the resident was in bed with eyes closed. p. Review of the incident report dated 7/2/13 reflected the resident blocked the door while he and another resident physically assaulted another resident. The immediate action taken was to separate the residents and observe for injuries. 4. Review of the nurse's note dated 7/4/13 at 6:37 p.m. reflected at 3:30 p.m. resident #2 was at the window getting his cigarette when another resident began to curse and threaten a CNA. Resident #2 attempted to intervene and the other resident pushed him. Resident #2 began to hit the other resident causing the resident to fall to the floor. The resident was noted to be dazed, unable to speak and bleeding from the mouth. The resident was transported to the local ER for evaluation. Review of the incident report dated 7/4/13 reflected the immediate action taken was to separate the residents and triage for injuries. 5. Review of the nurse's note dated 7/22/13 at 11:40 p.m. reflected at 7:40 p.m. an incident occurred between the resident and resident #1 resulting in the police being called. Further record review reflected to see resident #1's notes. Review of an incident report dated 7/22/13 reflected an incident between resident #1 and resident #2 which escalated from loudness to pushing and then to resident #1 picking up a chair. The nurse called for assistance from the floor and called 911. The incident was broken up by a CNA. Resident #2 continued to taunt resident #1, threatening to kill him in his sleep. The immediate action taken was to separate the residents and increase supervision. However, there was no further documentation regarding the incident to reflect which staff member was assigned to provide the increased supervision, or that increased supervision was actually provided. Interview on 7/30/13 at 8:05 a.m. with S4 LPN confirmed she was working on 6/18/13. She stated resident #5 was cursing and speaking to her in a loud voice. She stated resident #2 didn't like it so he grabbed resident #5. Further interview revealed she separated the residents, and they went to their rooms where they calmed down. Telephone interview on 7/30/13 at 10:07 a.m. with S5 LPN confirmed that she found a pocket knife locked up in the narcotic cabinet that belonged to resident #2. She stated she thought the prn nurse working the day before had found it and locked it up but she had not documented it. Further interview revealed she was working on 7/4/13 when the resident began cursing and threatening her and she tried to redirect him. S5 LPN stated that the resident would become frustrated and would curse or threaten the staff. She stated that later that day, resident #5 began to curse and threaten staff, which was his personality, when resident #2 tried to intervene and resident #5 hit him. Resident #2 fought back and resident #5 had to be sent to the ER because he was dazed and bleeding from the mouth. Further interview revealed she was not aware of resident #2 being on 1:1 supervision during any of her shifts. Telephone interview on 7/30/13 at 10:50 a.m. with S9 LPN confirmed she was working on 7/2/13 when the resident had assisted another resident in an altercation with a third resident. She confirmed she was told by the ER physician not to send the resident to the ER because it would not be safe for the ER staff. She stated she gave the resident some medications which did help calm him down. C. RESIDENT #1 Review of resident #1's face sheet reflected he was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. 1. Review of the nurse's note dated 5/18/13 at 2:37 p.m. reflected at 12:15 p.m. the resident was in the dining room, bleeding from the nose. The CNA that witnessed the incident reported that resident #6 had punched him in the nose then resident #1 punched resident #6 in the face. Review of the incident report dated 5/18/13 reflected the immediate action taken was to separate the residents and apply pressure to resident #1's nose. 2. Review of the nurse's note dated 5/26/13 at 1:18 p.m. reflected at 12:10 p.m. the nurse was called to the behavior unit for extra assistance due to the resident making threats against the nurse working on the unit. The resident was standing across from the nurse with his arms folded over his chest, glaring in a threatening manner at the nurse. A CNA was attempting to de-escalate the situation but was not successful. The resident was angry and convinced the nurse had him admitted to the facility. The resident was pacing and watching the nurse in a menacing manner and would make quick advances towards her as she was attempting to draw up [MEDICATION NAME] in a syringe for him. The resident was cursing and threatening the nurse but did finally agree to let the second nurse administer the medication. The resident did draw up his fists as if to strike the nurse if the injection hurt. Afterwards, the resident continued to pace, mumbling threats and profanities to the nurse and CNAs. Review of the nurse's note dated 5/26/13 at 5:57 p.m. reflected at 1320 (1:20 p.m.) the resident continued to pace and make threatening remarks to the nurse. The [MEDICATION NAME] was noted to be ineffective and redirection was causing aggressive mood escalation. The resident was noted to wander into a peer's room as if he was looking for him. The peer was the same peer that he had beaten so badly 2 weeks prior that he was hospitalized in ICU with "internal cranial hemorrhages". The DON and psychiatrist were notified of the resident's dangerous behaviors towards staff and peers. An order was obtained to send the resident to the ER for PEC to an acute care psychiatric facility. Further review reflected report was called to the local ER, the police were notified of possible need for assistance and the EMS was activated. The ER physician called back and stated that he refused to accept the resident for evaluation. The police called and refused to assist in any way other than to follow the ambulance. The psychiatrist was notified and instructed the nurse to send the resident to ER despite the ER physician's refusal; however, the EMS refused to transport the resident due to the ER refusing and they left the facility. The Administrator was notified and he spoke with the ER physician who finally agreed to evaluate the resident. The EMS was activated and returned to the facility but would not transport the resident because he was refusing to go. The DON was informed. 3. Review of the nurse's note dated 6/15/13 at 1:32 a.m. reflected on 6/14/13 at 9:50 p.m. the resident choked another resident that had hit him in the face. 4. Review of the nurse's note dated 7/3/13 at 2:26 a.m. reflected the following incidents occurred on 7/2/13: cross refer to findings under B. RESIDENT #2 - incident 3. Review of the facility's Daily Assignment Sheet dated 7/22/13 reflected there was one LPN assigned to the behavior unit during the 7P - 7A shift, three CNAs assigned to the behavior unit during the 3-11 shift and one CNA (plus a floater) during the 11-7 shift. The documentation did not reflect an increase in the number of staff assigned to the unit to reflect increased supervision of the residents. D. RESIDENT #5 Review of resident #5's face sheet reflected he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Review of the nurse's note dated 5/23/13 at 10:26 a.m. reflected the resident was standing in the hallway yelling at an unidentified resident. The resident began to kick at the other resident and stated that the other resident had came up and hit him for no reason. There was no documentation to reflect the nurse attempted to intervene when the resident was yelling at another resident before it escalated to the resident kicking the other resident. Review of the incident report dated 5/22/13 reflected the immediate action taken was to separate the residents and redirect. 2. Review of the nurse's note dated 6/18/13 at 7:03 p.m. reflected at 4:00 p.m. resident #5 was standing in the doorway of his room, cursing loudly at another resident. The other resident walked up to resident #5 and threw him to the bed. The nurse separated the 2 residents. There was no documentation to reflect the nurse attempted to intervene when the resident was yelling and cursing at the other resident. Review of the incident report dated 6/18/13 reflected the immediate action taken was to separate the residents. 3. Review of the nurse's note dated 7/4/13 at 6:27 p.m. reflected at 3:30 p.m. resident #5 and resident #2 was standing at the window getting their cigarettes. Resident #5 was cursing and threatening a CNA when resident #2 asked him to stop. Resident #5 pushed resident #2 and then began to hit him. Resident #2 hit resident #5 causing him to be "dazed" and fall to the floor. The resident was noted to have active bleeding from his mouth and was unable to speak. The resident was taken to the ER for evaluation. Interview on 7/30/13 at 3:00 p.m. with S2 DON confirmed the resident's tooth had been knocked out. Review of the incident report dated 7/4/13 reflected the immediate action taken was to send resident #5 to the ER for eval and tx. 2. ELOPEMENT: Resident #2 Review of the Risk of Elopement Evaluation form dated 6/12/13 at 4:30 a.m. reflected resident #2 was alert, oriented to person, place and time and ambulatory. The resident was not considered at risk for elopement. Review of the nurse's note dated 6/12/13 at 2:30 a.m. reflected the resident was alert and oriented and had a steady gait. Review of the nurse's note dated 6/12/13 at 2:30 p.m. reflected the resident was ambulatory via wc. Review of the nurse's note dated 6/15/13 at 1:04 a.m. reflected at 9:00 p.m. the resident was attempting to learn the code several times from staff as they put in the code. Review of the nurse's note dated 7/2/13 at 7:48 a.m. reflected at 1:00 a.m. the resident ambulated in the hallway without his wc to the doorway to courtyard. The resident put the code in to unlock the door and let several residents out to smoke. The Administrator was notified. Further documentation reflected the resident was non-compliant and resisted all rules. Further review reflected at 1:30 a.m. the resident used the code to exit the unit and go to the kitchen to get some juice. The Administrator was notified again. Further review of the nurses' notes reflected there was no documentation to reflect increased supervision of resident #2 after he used the code to open the locked door to the unit twice. Review of the nurse's note dated 7/2/13 at 2:20 p.m. reflected a case of cigars was found in the resident's room. The resident stated he had walked to the store and got the cigarettes one night. There was no documentation to reflect the nurse followed up on the resident's claim of walking to the store, or that supervision was increased after his claim of eloping from the facility. Review of the nurse's note dated 7/7/13 at 7:43 a.m. reflected: late entry for 7/6/13 at 4:50 p.m. - the resident informed the nurse he was about to walk to a local store. (Although the resident was not from the area, he was able to call the store by name). The nurse told the resident if he left the building, she would call the police. The nurse then informed the resident that his supper would be there shortly. 5:00 p.m. - the nurse overheard a CNA giving the resident directions to a local store. 5:10 p.m. - the nurse was looking for the resident to administer medications and could not find him. The elopement as announced over the PA, and staff began to look for him. 5:30 p.m. - the resident was found near the courthouse. Review of the incident report dated 7/6/13 reflected the immediate action taken was to place a sitter with the resident for 1:1 supervision. Review of the facility's Daily Assignment Sheet dated 7/6/13 reflected there was one LPN assigned to the behavior unit during the 7A - 7P shift and 2 CNAs assigned to the behavior unit during the 3-11 shift and one CNA assigned during the 11-7 shift. The second CNA assigned during the 11-7 shift was a "no call, no show." There was no documentation to reflect staff assigned to the resident for 1:1 supervision after he had eloped during the 3-11 shift on 7/6/13. Review of the facility's Daily Assignment Sheet dated 7/7/13, the morning after the resident had eloped, reflected there was one LPN assigned to the behavior unit during the 7A-7P shift and three CNAs assigned during the 7-3 shift. Further review reflected the CNA assigned to be the smoke monitor was also assigned to help the housekeeper. There was no documentation to reflect additional staff for increased supervision of the resident following his elopement. Review of the nurse's note dated 7/7/13 at 6:52 p.m. reflected at 6:00 p.m. the resident was upset because staff would not take his debit card and get him some food. The resident told the staff to call the police because he was about to leave. Further review reflected at 6:30 p.m. the resident told the nurse he would be back in about an hour and a half. The nurse asked how he was going to leave and he stated through the window. The resident tried to pry the window open but was unsuccessful. The Administrator and DON were notified. There was no documentation to reflect supervision was increased although the resident had eloped the day before. Review of the SSD note dated 7/8/13 at 10:53 a.m. reflected the resident was refusing an elopement ankle bracelet. The resident stated that he knew the security code but would not repeat it. The resident remained an elopement risk. There was no documentation to reflect any other measures to prevent possible elopement attempts. Review of the nurse's note dated 7/8/13 at 1:30 p.m. reflected at 10:30 a.m. the resident was refusing a wander "alter" bracelet. There was no documentation to reflect any other measures to prevent possible elopement attempts. Review of the nurse's note dated 7/8/13 at 11:07 p.m. reflected at 9:30 p.m. the resident was asking the nurse if she had heard what happened over the weekend. The resident stated nobody would go to the store to get his cigars so he put the security code into the back door and left. The resident also stated if he did not have his money by the 16th, he would slam the Administrator through one of the glass doors. Review of the nurse's note dated 7/12/13 at 11:25 p.m. reflected at 8:30 p.m. resident #2 was knocking on the door to get into the unit. The nurse let the resident in and asked him how he got out but he wouldn't tell her. Further review reflected the nurse would continue to monitor. There was no documentation to reflect increased supervision of the resident or to investigate how he had left the locked behavior unit. Review of the nurse's note dated 7/15/13 at 6:43 p.m. reflected: 5:00 p.m. - the resident stated he would see the nurse in about an hour because he was going to the store, 6:00 p.m. - the resident stated he was sorry for what he was about to do. The nurse asked what was he about to do and he replied he was going to leave after the nurse's shift was over, 6:50 p.m. - the resident was telling other staff he was leaving after shift change. 6:51 p.m. - the administrator was called. Review of the nurse's note dated 7/16/13 at 6:32 a.m. reflected at 8:00 p.m. the resident was provided with 1:1 supervision. Further review of the nurse's note reflected at 10:30 p.m. the resident burst into the room as a CNA was trying to put the other resident to bed. The resident was asked to leave the room until she was finished but he refused and began to curse and threaten the CNA. The nurse was able to persuade the resident to leave the room until the CNA was finished. There was no documentation to reflect that the resident remained under 1:1 supervision at that time. Review of the facility's Daily Assignment Sheet dated 7/15/13 reflected there was one LPN assigned to the behavior unit during the 7A - 7P shift, three CNAs assigned to the behavior unit during the 3-11 shift and two CNAs during the 11-7 shift. There was no documentation to reflect additional staff for increased supervision of the resident following his threats to elope. Review of the nurse's note dated 7/22/13 at 6:44 a.m. reflected: 8:40 p.m. - received call from police that they had seen the resident walking down the street. A broken window pane was noted in the resident's room. 8:50 p.m. - the resident returned to the facility and stated he was going to the store to get cigarettes. The resident stated he would do it again and no one could stop him. 9:00 p.m.- the maintenance staff was at the facility to secure the resident's window and room. The resident took his computer, comforter and pillow to the day room. Review of the incident report dated 7/21/13 reflected the immediate action taken was to secure the resident's room and place on 1:1 supervision. Review of the facility's Daily Assignment Sheet dated 7/21/13 reflected there was one LPN assigned to the behavior unit during the 7P - 7A shift, three CNAs assigned to the behavior unit during the 3-11 shift and two CNAs during the 11-7 shift. There was no documentation to reflect additional staff for increased supervision of the resident during the night following his elopement and threats to do it again. Interview on 7/29/13 at 1:15 p.m. with S4 LPN revealed on 7/7/13, the date the resident tried to elope through the window without success, she called the Administrator and he sent S8 SSD to the facility to talk to the resident. S4 LPN also stated that she thought the resident had been placed on 1:1 supervision after she left on 7/15/13 due to threatening to elope. She stated a CNA would be assigned to the resident when they were placed on 1:1 supervision but the staff didn't document the supervision. She also stated that wasn't sure if the security codes were changed during that time. Interview on 7/30/13 at 8:05 a.m. with S4 LPN confirmed she did overhear a CNA giving the resident directions to the store prior to his elopement on 7/6/13. She stated she did not consider the resident an elopement risk because he was always threatening to leave but never did. Interview on 7/30/13 at 9:30 a.m. with S1 Admin revealed that the doors in the unit had all been changed to a card swipe system. The system was changed on 7/17/13, staff were trained on 7/18/13 and the system was implemented on 7/19/13. He stated the only door that continued to require a code was the door next to the nurses' station which led outside. He stated the door was not used by the staff and he was the only person who knew the code. Further interview revealed that prior to changing to the card swipe system, the codes to the locked doors would be changed every time a resident eloped through the doors or claimed to know the codes to the doors. He stated that he did not record when the codes were changed and was not sure if the maintenance man kept a record of the when the codes were changed. Telephone interview on 7/30/13 at 10:50 a.m. with S9 LPN confirmed she was working on 7/2/13 when the resident entered the code to the locked door to let other residents out of the building into the courtyard. She stated she contacted the Administrator who said the code would have to be changed.

Based on observation, interview and record review the facility failed to reassess the effectiveness of the interventions and review and revise the care plan for 4 residents (#6, #2, #1 and #5) exhibiting physically aggressive behaviors towards other residents. The facility also failed to reassess the effectiveness of the interventions and review and revise the care plan for 1 resident with a history of eloping from the locked unit (#2). A total of 6 residents residing on the locked behavior unit were reviewed for these concerns. The care plans did not address the need to evaluate the precipitating triggers leading to the aggressive behaviors and elopements, and did not provide individualized non-pharmacological approaches to meet the resident needs. Resident behaviors included: 1) resident to resident physical altercations (#6, #2, #1 and #5); 2) the making of homemade weapons by one resident who verbalized fear of other physically aggressive residents he felt threatened by (#6); 3) interference and performance of nursing care by a resident (#2) on other residents in the locked unit; and 4) elopement from the locked unit (#2). An Immediate Jeopardy situation began on 4/18/13 at 6:00 p.m. when resident #6 was observed by the staff on the behavior unit slapping a female resident in the face, and threatening to hit others with his dresser drawers and a chair. The resident had returned from an inpatient psychiatric stay the day before due to his aggressive behavior with other residents. There were no new interventions put in place to protect the other residents on the behavior unit from the aggressive behaviors of resident #6 when he returned to the facility. Physical aggression and altercations of this type continued by resident #6 and also by residents #1, #2 and #5 on multiple occasions as described in the findings below, without the facility re-evaluating and analyzing the effectiveness of planned interventions and the adequacy of the supervision and monitoring. Staff were not identifying triggers that were the cause of escalating behaviors in order to attempt interventions to de-escalate the situation. All residents on the locked behavior unit were placed in Immediate Jeopardy on 4/18/13 when the facility failed to implement interventions to protect them from the physically aggressive behaviors of other residents on the locked behavior unit. Review of the census list provided by the DON reflected the behavior unit's total census on 7/29/13 was 23. The Administrator was notified of the Immediate Jeopardy on 7/31/13 at 2:45 p.m. The facility submitted a plan of removal which included increasing the staff on the behavior unit to include placing resident #2 on 1:1 care and assigning a staff member to monitor residents #1, 5 and 6 every 15 minutes to reduce physical aggression, elopement and interference with resident's care. All residents at risk for potential aggressive behavior and elopements were reassessed and care plans updated. The staff received additional training on identifying triggers, approaches to reduce agitation and interventions for residents with aggression. The QA committee met to address elopement, staff training, scheduling, resident to resident abuse, care plans, and reportable incidents. Monitoring rounds will be made by administrative staff daily. The Immediate Jeopardy situation was removed on 8/1/13 at 12:00 p.m. when observations revealed that the plan was being implemented. Although the immediacy of the situation was removed, the deficient practice remains at a level of actual harm for resident #6 who was hospitalized for [REDACTED].#1 and for resident #5 who required evaluation at the hospital after a physical altercation with resident #2 which left the resident bleeding from the mouth due to his tooth being knocked out, dazed and unable to speak. Findings: Interview on 7/31/13 at 10:50 a.m. with S10 MDS Coord and S11 MDS Coord revealed the residents' care plans were developed based on assessments, [DIAGNOSES REDACTED]. S11 MDS Coord stated the information to complete the MDS' was provided to the MDS Coordinators by the staff during the residents' "look back periods". She also stated she used a care plan book to locate approaches specific to problems that were triggered by the residents' assessment MDS. Further interview revealed the care plans were updated if they received additional paperwork regarding the residents or a new diagnosis. Interview on 8/1/13 at 8:00 a.m. with S3 CorpRN confirmed the residents' care plans had not been updated for specific approaches for the residents. She stated the staff had been instructed to reassess residents after admission if any changes occurred. She also stated the care plan staff had been instructed to ensure care plans were updated with specific resident problems and approaches as they occurred. Review of the facility's Preliminary Behavioral Unit Admission Criteria reflected behavioral concerns for admission included violence against staff and residents limited and managed (per DNS' review). However, the documentation in residents #1, 2, 5 and 6's records did not reflect the personal histories of the residents had been assessed to determine if they were at risk for abusing other residents. Also, specific intervention strategies to prevent occurrences, monitor for changes that would trigger abusive behavior, and reassess the interventions on a regular basis were not implemented. 1. RESIDENT TO RESIDENT PHYSICAL ALTERCATIONS A. RESIDENT #6 Review of resident #6's face sheet reflected he was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission/Readmission form dated 3/20/13 reflected the [DIAGNOSES REDACTED]. Review of the resident's care plan with a goal date of 10/11/13 reflected a problem of the resident residing in the facility's behavioral unit under MD orders. The resident was having episodes of anger/aggression with self/others, Dx: Anxiety, [MEDICAL CONDITION], Agitation and Depressive Psychoses. The approaches included: approach resident in a calm manner, meds as ordered and observe effectiveness, psych consult as ordered prn, encourage appropriate behavior, invite to activities of choice and observe resident for safety for self and others. Further review reflected the following handwritten additions to the identified problem: 4/18/13, 5/15/13, 5/18/13, 5/23/13, 5/27/13 and 5/28/13 - resident to resident physical. The approaches included: * 4/18/13 - remove resident as needed to prevent harm to self and others, * 5/15/13 - redirect/cue as needed to enforce positive behavior, * 5/18/13 - observe for changes in mental status, mood and behavior. Document and report to MD * 5/23/13 - administer prn medications as ordered. Monitor effectiveness and contact MD as needed, * 5/27/13 - observe resident for safety, appropriate behavior and use appropriate medication for increased agitation and * 5/28/13 - return at a later time if resisting care. 1. Review of an incident report dated 3/29/13 reflected the resident hit his roommate in the face twice after putting the roommate' s pants on and being asked to take them off by the roommate. The immediate action taken was to separate the residents after the incident occurred. 2. Review of an incident report dated 4/10/13 at 11:40 a.m. reflected resident #6 entered an unidentified resident' s room when the other resident asked him to leave numerous times. Resident #6 began to hit the other resident numerous times and the other resident bit him. The immediate action taken was to provide wound care. 3. Review of an incident report dated 4/10/13 at 1:05 p.m. reflected resident #6 mumbled something to another resident when the other resident said something back. Resident #6 hit the other resident on the side of the head. The fight was stopped by nurse and CNA. The immediate action taken was to assess the resident. 4. Review of the Resident Transfer Form dated 4/11/13 reflected the resident was transferred to an inpatient psychiatric facility. Review of the Admission/Readmission Evaluation form dated 4/17/13 and the nurse' s note dated 4/17/13, resident #6 returned to the facility following a stay at an inpatient psychiatric facility. Record review of the SSD note dated 4/18/13 reflected the resident's care planning meeting was held and a new care plan was put in place. Further review of the care plan revealed no changes were noted at that time. There were no approaches added to increase supervision of the resident's aggressive behaviors when he returned to the facility following hospitalization for aggression. 5. Review of the nurse's note dated 4/18/13 at 6:21 p.m. - 1800 (6:00 p.m.) resident #6 was ambulating in the hallway, walked up to resident #7 and slapped her in the face. The two residents were separated and prn [MEDICATION NAME] 2 mg was given. The resident then started pulling dresser drawers out and trying to bring them into the hallway, threatening to hit people. The resident then went into the dayroom and picked up a chair and tried to hit the others. Another male resident then hit resident #6 three times. Review of the incident report dated 4/18/13 reflected the immediate action was "see above." The "see above" documentation contained a description of the incident that occurred but no actions taken by the staff. Review of the physician progress notes [REDACTED]. The documentation reflected the resident was still physically aggressive and had slapped another resident the previous night. Further review reflected the resident was refusing his medications and was still dangerous to others. 6. Review of the nurse's note dated 4/19/13 at 3:59 a.m. reflected on 4/18/13 at 7:00 p.m. resident #6 was sitting in the dayroom when he broke 2 coffee cups and attempted to make sharp edges. The resident also broke a soda can and attempted to sharpen the edges. The items were taken from the resident and he was redirected to his room. There was no documentation to reflect supervision was increased due to the resident's history of physical aggression. 7. Further review of the nurse's note dated 4/19/13 at 3:59 a.m. reflected at 8:00 p.m. resident #6 was wandering in the hallway, going in and out of other residents' rooms. The nurse documented she would continue to monitor. There was no documentation of attempts to redirect the resident or increase supervision. 8. Review of the nurse's note dated 4/19/13 at 1:41 p.m. reflected at 8:50 a.m. the resident's psychiatrist was notified of the resident fighting and hitting other residents. New medication orders were obtained for [MEDICATION NAME] 16 mg po bid, start [MEDICATION NAME] 100 mg IM q 4 weeks, increase [MEDICATION NAME] 1 mg po bid and [MEDICATION NAME] 100 mg po bid. 9. Review of a nurse's note dated 4/20/13 at 6:04 p.m. reflected a late entry for 8:30 a.m. when resident #6 was banging on the nurses' station glass and prn [MEDICATION NAME] was given. 10. Review of the nurse's note dated 4/21/13 at 6:54 p.m. reflected at 12:00 p.m. the resident was banging on the walls as he was walking down the hallway and prn [MEDICATION NAME] was given. 11. Review of the nurse's note dated 4/27/13 at 3:34 p.m. reflected at 1415 (2:15 p.m.) resident #6 was threatening to beat people up because he believed someone had been in his room. The resident was agitated and redirected several times before prn [MEDICATION NAME] was given. 12. Review of the nurse's note dated 5/15/13 at 3:14 p.m. reflected at 1400 (2:00 p.m.) the resident walked up to another resident in the hall and punched another resident in the mouth. The altercation was unprovoked. Resident #6 was taken to his room by staff. Review of an incident report dated 5/15/13 reflected the immediate action taken for the 2:00 p.m. incident was to assist the resident to his room. 13. Review of the nurse's note dated 5/18/13 at 4:36 p.m. reflected at 12:30 p.m. resident #6 was standing in the hallway with blood above his right and left eyes. The resident stated that resident #1 had asked him for a lighter and they got into a fight. The CNA reported that resident #6 had hit resident #1 and they began to fight. Resident #6 was taken to his room. Further review reflected resident #6 was sent to theER on [DATE] at 1:15 p.m. The facility received a call at 4:00 p.m. that the resident was being transferred to a facility in Alexandria with a [DIAGNOSES REDACTED]. Review of the nurse's note dated 5/21/13 at 2:12 p.m. reflected a t 12:40 p.m. the resident returned to the facility. 14. Review of the SSD note dated 7/11/13 reflected a care planning meeting was held. The resident's care plan was reviewed and updated. The resident was noted to have resident to resident and resident to staff events. The resident would continue to receive plastic cutlery with meals as noted in the care plan. No other changes noted to the care plan at that time. Further review of resident #6's record reflected the resident was not assessed to identify specific triggers which led to his behaviors escalating into physical aggression; therefore, the care plan had not been reviewed or revised for individualized approaches for staff interventions to prevent the resident's behaviors. B. RESIDENT #2 Review of the resident's face sheet reflected the resident was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the June 2013 physician's order [REDACTED]. Review of the resident's record reflected it contained a copy of the June 2013 physician's orders [REDACTED]. Further review reflected a handwritten order dated 6/6/13 to consult Psych secondary to combative behavior towards other residents. Review of resident #2's care plan with a goal date of 10/10/13 reflected a problem of resident was on the behavioral unit under MD orders. The resident was experiencing combative behavior with other residents and needed increased supervision. The approaches included to provide meds as ordered, monitor and note behaviors as needed, place on behavioral unit for increased staff supervision, allow to express feelings about being on the unit, notify MD of changes in behaviors as needed. There was no documentation to reflect the resident's recent history of combative behaviors towards other residents in his previous facility was assessed with [REDACTED]. Further review reflected the following handwritten additions to the identified problem: 6/18/13 and 7/2/13 - resident to resident - physical with no injury. The approaches included: * 6/18/13 - encourage appropriate behaviors and * 7/2/13 - remove resident as needed to prevent harm to self or others. Review of resident #2's nurse's note dated 6/15/13 at 11:53 p.m. reflected at 9:00 p.m. the resident liked to instigate trouble between other residents and pick on other residents. Review of the nurse's note dated 6/16/13 at 12:42 p.m. reflected the resident had a history of [REDACTED]. Further review reflected a room search was done that a.m. due to a pocket knife was found in the resident's possession the day before. There was no other documentation regarding the resident having a pocket knife in his possession. Observation on 7/29/13 at 11:00 a.m. revealed resident #2 was lying in bed with the bed linens pulled over his head. The resident would not respond when spoken to. Interview on 7/29/13 at 11:00 a.m. with S7 CNA revealed the resident was capable of responding, and could be very combative. 1. Review of the nurse's note dated 6/18/13 at 7:11 p.m. reflected resident #2 grabbed another resident by the shirt and threw him to the bed. The residents were separated by the nurse. Review of the incident report dated 6/18/13 reflected the immediate actions taken were to separate the residents. 2. Review of the nurse's note dated 6/24/13 at 6:16 a.m. reflected on 6/23/13 at 10:25 p.m. resident #2 tried to assist another resident with a phone call. The other resident did not want assistance, snatched the phone from the resident's hand and began to swing at the resident. Resident #2 hit the other resident in the temporal area with a closed fist. The nurse tried to stop the resident from hitting the other resident but he continued to hit him until he fell to the floor. Resident #2 went to his room and the physician was notified. Review of the incident report dated 6/23/13 reflected the immediate action taken was to separate the two residents. 3. Review of the nurse's note dated 7/3/13 at 3:37 a.m. reflected the following incidents on 7/2/13: a. 8:00 p.m. - resident #2 assisted resident #1 in a physical altercation against another resident, b. 8:17 p.m. - a message was left for the DON, c. 8:25 p.m. - "psychiatrist notified, recommended to call the police and tell them he said arrest them. Stated that he was not going to be held accountable for these people if they hurt someone. Also, stated that these people were going to the bottom of the barrel to get these people that society does not want to deal with and they want us to be able to handle them. This place is not equipped to handle the type of people they are housing and it is just unsafe." d. 8:45 p.m. - the local police department was called, e. 8:55 p.m. - the DON returned the facility's call and was informed of the situation, f. 9:30 p.m. - 2 police officers entered the unit and stated they could not do anything to help because the resident was in a mental institution and there were rules that limited what they could do. The documentation reflected the police officers spoke with the resident about the dangers of fighting other residents and the resident voiced understanding, g. 9:45 p.m. - the resident was furious, passed by the nurses' station and stated "I got something for you, [***] ," h. 10:15 p.m. - the resident stated to other residents "if I don't get discharged tonight, I'm just going to start knocking people out in this [***] ," i. 10:30 p.m. - the resident became physically aggressive with a male staff member and the police were called again, j. 10:35 p.m. - 2 police officers arrived in the facility and stated there was nothing they could do. The police officers did agree to stay until the situation was defused, k. 10:40 p.m. - the psychiatrist was called again and recommended the police take the resident to the local ER where he could be PECed and transferred to another facility. The nurse spoke with the ER physician who instructed them not to bring the resident to ER for safety reasons. The nurse explained to the physician that the resident was very violent and out of control, l. 11:05 p.m. - the ER physician gave an order to give the resident [MEDICATION NAME] 20 mg IM and [MEDICATION NAME] 1 mg IM and instructed the nurse again to not bring the resident to the ER. The nurse explained again that the resident was violent, non-compliant and very aggressive with staff and residents, m. 11:15 p.m. - [MEDICATION NAME] 20 mg IM and [MEDICATION NAME] 1 mg IM was given, n. 11:30 p.m. - the resident was a little calmer and the police officers left the building, o. 11:45 p.m. - the resident was in bed with eyes closed. p. Review of the incident report dated 7/2/13 reflected the resident blocked the door while he and another resident physically assaulted another resident. The immediate action taken was to separate the residents and observe for injuries. 4. Review of the nurse's note dated 7/4/13 at 1:01 a.m. reflected at 12:00 a.m. the resident was at the nurses' station telling the nurse that he was going to knock another resident out. Resident #2 stated he could knock any and everybody out, and not go to jail. According to the nurse's note, the resident was bragging and unremorseful about the altercations he had been involved in. 5. Review of the nurse's note dated 7/4/13 at 9:42 a.m. reflected the resident was hollering, cursing and verbally threatening the nurse. The resident stated "I run this place and you will do as I say, or else." Further review reflected the nurse walked away. 6. Review of the nurse's note dated 7/4/13 at 6:37 p.m. reflected at 3:30 p.m. resident #2 was at the window getting his cigarette when another resident began to curse and threaten a CNA. Resident #2 attempted to intervene and the other resident pushed him. Resident #2 began to hit the other resident causing the resident to fall to the floor. The resident was noted to be dazed, unable to speak and bleeding from the mouth. The resident was transported to the local ER for evaluation. Review of the incident report dated 7/4/13 reflected the immediate action taken was to separate the residents and triage for injuries. 7. Review of the nurse's note dated 7/7/13 at 6:52 p.m. reflected at 9:00 a.m. a CNA reported to the nurse that the resident was threatening to harm other residents if did not get his smoke break when he wanted to smoke. 8. Review of the nurse's note dated 7/8/13 at 11:07 p.m. reflected at 9:30 p.m. resident #2 stated if he did not have his money by the 16th, he would slam the Administrator through one of the glass doors. 9. Review of the nurse's note dated 7/11/13 at 7:10 a.m. reflected at 6:00 a.m. the resident snatched a glass of water from the nurse and threw it across the room. 10. Review of the nurse's note dated 7/16/13 at 7:00 a.m. reflected at 9:00 p.m. the resident was emptying another resident's Foley catheter when the nurse told him that he shouldn't be doing that. The resident became agitated but complied. Further review reflected the CNA was providing incontinent care to another resident when resident #2 entered the room without knocking and would not leave. Resident #2 became very upset and began cursing when asked to leave. 11. Review of the nurse's note dated 7/22/13 at 11:40 p.m. reflected at 7:40 p.m. an incident occurred between the resident and resident #1 resulting in the police being called. Further record review reflected to see resident #1's notes. Review of an incident report dated 7/22/13 reflected an incident between resident #1 and resident #2 which escalated from loudness to pushing and then to resident #1 picked up a chair. The nurse called for assistance from the floor and called 911. The incident was broken up by a CNA. Resident #2 continued to taunt resident #1, threatening to kill him in his sleep. The immediate action taken was to separate the residents and increase supervision. However, there was no further documentation regarding the incident to reflect which staff member was assigned to provide the increased supervision, or that increased supervision was actually provided. Interview on 7/30/13 at 8:05 a.m. with S4 LPN confirmed she was working on 6/18/13 when resident #5 began cursing and speaking to her in a loud voice. She stated resident #2 didn't like it so he grabbed resident #5. Further interview revealed she separated the residents, and they went to their rooms where they calmed down. Telephone interview on 7/30/13 at 10:07 a.m. with S5 LPN confirmed that she found a pocket knife locked up in the narcotic cabinet that belonged to resident #2. She stated she thought the prn nurse working the day before had found it and locked it up but she had not documented it. Further interview revealed she was working on 7/4/13 when the resident began cursing and threatening her and she tried to redirect him. S5 LPN stated that the resident would become frustrated and would curse or threaten the staff. She stated that later that day, resident #5 began to curse and threaten staff, which was his personality, when resident #2 tried to intervene and resident #5 hit him. Resident #2 fought back and resident #5 had to be sent to the ER because he was dazed and bleeding from the mouth. Further interview revealed she was not aware of resident #2 being on 1:1 supervision during any of her shifts. Telephone interview on 7/30/13 at 10:50 a.m. with S9 LPN confirmed she was working on 7/2/13 when resident #2 had assisted resident #1 in an altercation with a third resident. She confirmed she was told by the ER physician not to send the resident to the ER because it would not be safe for the ER staff. She stated she gave the resident some medications which did help calm him down. Review of the resident's Behavior/Medication Monitoring Summary dated 7/3/13 reflected the resident had elopement attempts, outbursts and resident to resident behaviors. The documentation did not reflect the severity of the resident's behaviors or recommendations for the behaviors. Further review of resident #2's record reflected the resident was not assessed to identify specific triggers which led to his behaviors escalating into physical aggression. The care plan had not been reviewed or revised for individualized approaches for staff interventions to prevent the resident's behaviors. C. RESIDENT #1 Review of resident #1's face sheet reflected he was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's record reflected a psychiatric consult dated 5/1/13 during the resident's stay at another facility. The resident's presenting complaint was that he had eloped during the night and the staff was fearful. The mental status exam reflected the resident had aggressive behaviors, agitation, disorganized thoughts and paranoia. Review of the resident's plan of care with a goal date of 8/4/13 reflected a problem of resident was on the behavioral unit under MD orders. The resident wanders, has confusion, polysubstance abuse, unaware of safety, agitation, [MEDICAL CONDITION], aggressive behaviors, disorganized thoughts, paranoia and non-compliant with medication. The approaches included to provide meds as ordered, monitor and note behaviors as needed, place on behavioral unit for increased staff supervision, provide 1:1 supervision as needed and notify MD of changes in behaviors as needed. There was no documentation to reflect the resident's recent history of aggressive behaviors or agitation was fully assessed to identify possible triggers for those behaviors; therefore, there were no specific and individualized approaches put in place to address those behaviors. Further review reflected the following handwritten additions: 5/9/13 - staff physical contact, no injury, 5/18/13 - resident to resident physical, nose bleeding, 6/14/13 - resident to resident physical and 7/2/13 - resident to resident physical, no injury. The approaches included: 5/9/13 - remove resident as needed to prevent harm to self and others, 5/18/13 - observe for changes in mental status, mood and behavior. Document and report to MD, 6/14/13 - approach resident in calm manner and 7/2/13 - notify MD and obtain orders and carry out for behaviors. 1. Review of the nurse's note dated 5/6/13 at 12:12 p.m. reflected at 0900 (9:00 a.m.) the resident was confused and stating he would burn the facility down. The resident had a pair of nail clippers in his hand with the nail cleaner opened. The resident gave the nail clippers to the nurse without incident. There was no further documentation regarding the resident's threats. 2. Review of the nurse's note dated 5/9/13 at 7:30 a.m. reflected at 6:30 a.m. the resident became combative with the CNA that was assigned 1:1 to him after he eloped on 5/6/13. The resident had hit the staff and pinned them against the wall. The resident was redirected and moved away from the CNA. The documentation reflected the 1:1 staff remained with the resident. 3. Review of the nurse's note dated 5/15/13 at 6:41 a.m. reflected at 6:00 a.m. the resident was standing in the hallway. The resident was agitated and yelling and cursing at another resident. Resident #1 threatened to hit the other resident if she didn't shut up. The resident was redirected to the dining room. The documentation did not reflect if there were other residents in the dining room while the resident was agitated. 4. Review of the nurse's note dated 5/18/13 at 2:37 p.m. reflected at 12:15 p.m. the resident was in the dining room, bleeding from the nose. The CNA that witnessed the incident reported that resident #6 had punched him in the nose then resident #1 punched resident #6 in the face. Review of the incident report dated 5/18/13 reflected the immediate action taken was to separate the resident's and apply pressure to resident #1's nose. Cross refer to 1.A. Incident #13. 5. Review of the nurse's note dated 5/26/13 at 1:18 p.m. reflected at 12:10 p.m. the nurse was called to the behavior unit for extra assistance due to the resident making threats against the nurse working on the unit. The resident was standing across from the nurse with his arms folded over his chest, glaring in a threatening manner at the nurse. A CNA was attempting to de-escalate the situation but was not successful. The resident was angry and convinced the nurse had him admitted to the facility. The resident was pacing and watching the nurse in a menacing manner and would make quick advances towards her as she was attempting to draw up [MEDICATION NAME] in a syringe for him. The resident was cursing and threatening the nurse but did finally agree to let the second nurse administer the medication. The resident did draw up his fists as if to strike the nurse if the injection hurt. Afterwards, the resident continued to pace, mumbling threats and profanities to the nurse and CNAs. Review of the nurse's note dated 5/26/13 at 5:57 p.m. reflected at 1320 (1:20 p.m.) the resident continued to pace and make threatening remarks to the nurse. The [MEDICATION NAME] was noted to be ineffective and redirection was causing aggressive mood escalation. The resident was noted to wander into a peer's room as if he was looking for him. The peer was the same peer that he had beaten so badly 2 weeks prior that he was hospitalized in ICU with "internal cranial hemorrhages". The DON and psychiatrist were notified of the resident's dangerous behaviors towards staff and peers. An order was obtained to send the resident to the ER for PEC to an acute care psychiatric facility. Further review reflected report was called to the local ER, the police were notified of possible need for assistance and the EMS was activated. The ER physician called back and stated that he refused to accept the resident for evaluation. The police called and refused to assist in any way other than to follow the ambulance. The psychiatrist was notified and instructed the nurse to send the resident to ER despite the ER physician's refusal; however, the EMS refused to transport the resident due to the ER refusing and they left the facility. The Administrator was notified and he spoke with the ER physician who finally agreed to evaluate the resident. The EMS was activated and returned to the facility but would not transport the resident because he was refusing to go. The DON was informed. 6. Review of the nurse's note dated 6/15/13 at 1:32 a.m. reflected on 6/14/13 at 9:50 p.m. the resident choked another resident that had hit him in the face. 7. Review of the incident report dated 6/14/13 reflected the immediate action taken was to separate the residents. 8. Review of the nurse's note dated 7/3/13 at 2:26 a.m. reflected the following incidents occurred on 7/2/13: cross refer to findings under B. RESIDENT #2 - incident 3.. Review of the resident's Behavior/Medication Monitoring Summary dated 7/2/13 reflected the resident had resident to resident behavioral issues (verbal and physical). The documentation did not reflect the severity of the resident's behaviors. Further review reflected the recommendation and action plan addressed that the resident's [MEDICATION NAME] was increased

Based on observation, interview and record review the facility failed to ensure that 4 residents exhibiting physically aggressive behaviors (#1, 2, 5 and 6), and 1 resident with a history of eloping from the locked unit (#2) out of 6 residents reviewed residing on the locked behavior unit, received adequate supervision/monitoring to prevent accident hazards related to: 1) resident to resident physical altercations (#6, 2, 1 and 5); 2) the making of homemade weapons by one resident who verbalized fear of other physically aggressive residents he felt threatened by (#6); 3) interference and performance of nursing care by a resident (#2) on other residents in the locked unit; and 4) elopement from the locked unit (#2). An Immediate Jeopardy situation began on 4/18/13 at 6:00 p.m. when resident #6 was observed by the staff on the behavior unit slapping a female resident in the face, and threatening to hit others with his dresser drawers and a chair. The resident had returned from an inpatient psychiatric stay the day before due to his aggressive behavior with other residents. There were no new interventions put in place to protect the other residents on the behavior unit from the aggressive behaviors of resident #6 when he returned to the facility. Physical aggression and altercations of this type continued by resident #6 and also by residents #1, #2 and #5 on multiple occasions as described in the findings below, without the facility re-evaluating and analyzing the effectiveness of planned interventions and the adequacy of the supervision and monitoring. Staff were not identifying triggers that were the cause of escalating behaviors in order to attempt interventions to de-escalate the situation. All residents on the locked behavior unit were placed in Immediate Jeopardy on 4/18/13 when the facility failed to implement interventions to protect them from physically aggressive behaviors of other residents on the locked behavior unit. Review of the census list provided by the DON reflected the behavior unit's total census on 7/29/13 was 23. The Administrator was notified of the Immediate Jeopardy on 7/31/13 at 2:45 p.m. The facility submitted a plan of removal which included increasing the staff on the behavior unit to include placing resident #2 on 1:1 care and assigning a staff member to monitor residents #1, 5 and 6 every 15 minutes to reduce physical aggression, elopement and interference with resident's care. All residents at risk for potential aggressive behavior and elopements were reassessed and care plans updated. The staff received additional training on identifying triggers, approaches to reduce agitation and interventions for residents with aggression. The QA committee met to address elopement, staff training, scheduling, resident to resident abuse, care plans, and reportable incidents. Monitoring rounds will be made by administrative staff daily. The Immediate Jeopardy situation was removed on 8/1/13 at 12:00 p.m. when observations revealed that the plan was being implemented. Although the immediacy of the situation was removed, the deficient practice remains at a level of actual harm for resident #6 who was hospitalized for [REDACTED].#1 and for resident #5 who required evaluation at the hospital after a physical altercation with resident #2 which left the resident bleeding from the mouth due to his tooth being knocked out, dazed and unable to speak. Findings: 1. RESIDENT TO RESIDENT PHYSICAL ALTERCATIONS A. RESIDENT #6 Review of resident #6's face sheet reflected he was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission/Readmission form dated 3/20/13 reflected the [DIAGNOSES REDACTED]. 1. Review of an incident report dated 3/29/13 reflected the resident hit his roommate in the face twice after putting the roommate's pants on and being asked to take them off by the roommate. The immediate action taken was to separate the residents after the incident occurred. 2. Review of an incident report dated 4/10/13 at 11:40 a.m. reflected resident #6 entered an unidentified resident's room when the other resident asked him to leave numerous times. Resident #6 began to hit the other resident numerous times and the other resident bit him. The immediate action taken was to provide wound care. 3. Review of an incident report dated 4/10/13 at 1:05 p.m. reflected resident #6 mumbled something to another resident when the other resident said something back. Resident #6 hit the other resident on the side of the head. The fight was stopped by the nurse and CNA. The immediate action taken was to assess the resident. 4. Review of the Resident Transfer Form dated 4/11/13 reflected resident #6 was transferred to an inpatient psychiatric facility. Review of the Admission/Readmission Evaluation form dated 4/17/13 and the nurse's note dated 4/17/13, reflected resident #6 returned to the facility following a stay at an inpatient psychiatric facility. Record review of the SSD note dated 4/18/13 reflected the resident's care planning meeting was held and a new care plan was put in place. Further review of the care plan revealed no changes were noted at that time. There were no approaches added to increase supervision of the resident's aggressive behaviors when he returned to the facility following hospitalization for aggression. 5. Review of the nurse's note dated 4/18/13 at 6:21 p.m. - at 1800 (6:00 p.m.) resident #6 was ambulating in the hallway, walked up to resident #7 and slapped her in the face. The two residents were separated and prn Ativan 2 mg was given. The resident then started pulling dresser drawers out and trying to bring them into the hallway, threatening to hit people. The resident then went into the dayroom and picked up a chair and tried to hit the others. Another male resident then hit resident #6 three times. Review of the incident report dated 4/18/13 reflected the immediate action was "see above." The "see above" documentation contained a description of the incident that occurred but no actions taken by the staff. Review of the physician progress notes [REDACTED]. The documentation reflected the resident was still physically aggressive and had slapped another resident the previous night. Further review reflected the resident was refusing his medications and was still dangerous to others. 6. Review of the nurse's note dated 4/19/13 at 3:59 a.m. reflected on 4/18/13 at 7:00 p.m. resident #6 was sitting in the dayroom when he broke 2 coffee cups and attempted to make sharp edges. The resident also broke a soda can and attempted to sharpen the edges. The items were taken from the resident and he was redirected to his room. There was no documentation to reflect supervision was increased due to the resident's history of physical aggression. 7. Further review of the nurse's note dated 4/19/13 at 3:59 a.m. reflected at 8:00 p.m. resident #6 was wandering in the hallway, going in and out of other residents' rooms. The nurse documented she would continue to monitor. There was no documentation of attempts to redirect the resident or increase supervision. 8. Review of the nurse's note dated 4/19/13 at 1:41 p.m. reflected at 8:50 a.m. the resident's psychiatrist was notified of the resident fighting and hitting other residents. New medication orders were obtained for Perphenazine 16 mg po bid, start Haldol 100 mg IM q 4 weeks, increase Cogentin 1 mg po bid and Lamictal 100 mg po bid. 9. Review of a nurse's note dated 4/20/13 at 6:04 p.m. reflected a late entry for 8:30 a.m. when resident #6 was banging on the nurses' station glass and prn Ativan was given. 10. Review of the nurse's note dated 4/21/13 at 6:54 p.m. reflected at 12:00 p.m. the resident was banging on the walls as he was walking down the hallway and prn Ativan was given. 11. Review of the nurse's note dated 4/27/13 at 3:34 p.m. reflected at 1415 (2:15 p.m.) resident #6 was threatening to beat people up because he believed someone had been in his room. The resident was agitated and redirected several times before prn Ativan was given. 12. Review of the nurse's note dated 5/15/13 at 3:14 p.m. reflected at 1400 (2:00 p.m.) the resident walked up to another resident in the hall and punched the resident in the mouth. The altercation was unprovoked. Resident #6 was taken to his room by staff. Review of an incident report dated 5/15/13 reflected the immediate action taken for the 2:00 p.m. incident was to assist the resident to his room. 13. Review of the nurse's note dated 5/18/13 at 4:36 p.m. reflected at 12:30 p.m. resident #6 was standing in the hallway with blood above his right and left eyes. The resident stated that resident #1 had asked him for a lighter and they got into a fight. The CNA reported that resident #6 had hit resident #1 and they began to fight. Resident #6 was taken to his room. Further review reflected resident #6 was sent to theER on [DATE] at 1:15 p.m. The facility received a call at 4:00 p.m. that the resident (#6) was being transferred to a facility in Alexandria with a [DIAGNOSES REDACTED]. Review of the nurse's note dated 5/21/13 at 2:12 p.m. reflected a t 12:40 p.m. the resident returned to the facility. B. RESIDENT #2 Review of resident #2's face sheet reflected the resident was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the June 2013 physician's order [REDACTED]. Review of resident #2's nurse's note dated 6/15/13 at 11:53 p.m. reflected at 9:00 p.m. the resident liked to instigate trouble between other residents and pick on other residents. Review of the nurse's note dated 6/16/13 at 12:42 p.m. reflected the resident had a history of [REDACTED]. Further review reflected a room search was done that a.m. due to a pocket knife was found in the resident's possession the day before. There was no other documentation regarding the resident having a pocket knife in his possession. Observation on 7/29/13 at 11:00 a.m. revealed resident #2 was lying in bed with the bed linens pulled over his head. The resident would not respond when spoken to. Interview on 7/29/13 at 11:00 a.m. with S7 CNA revealed the resident was capable of responding, and could be very combative. 1. Review of the nurse's note dated 6/18/13 at 7:11 p.m. reflected resident #2 grabbed another resident by the shirt and threw him to the bed. The residents were separated by the nurse. Review of the incident report dated 6/18/13 reflected the immediate actions taken were to separate the residents. 2. Review of the nurse's note dated 6/24/13 at 6:16 a.m. reflected on 6/23/13 at 10:25 p.m. resident #2 tried to assist another resident with a phone call. The other resident did not want assistance, snatched the phone from the resident's hand and began to swing at the resident. Resident #2 hit the other resident in the temporal area with a closed fist. The nurse tried to stop the resident from hitting the other resident but he continued to hit him until he fell to the floor. Resident #2 went to his room and the physician was notified. Review of the incident report dated 6/23/13 reflected the immediate action taken was to separate the two residents. 3. Review of the nurse's note dated 7/3/13 at 3:37 a.m. reflected the following incidents on 7/2/13: a. 8:00 p.m. - resident #2 assisted resident #1 in a physical altercation against another resident, b. 8:17 p.m. - a message was left for the DON, c. 8:25 p.m. - "psychiatrist notified, recommended to call the police and tell them he said arrest them. Stated that he was not going to be held accountable for these people if they hurt someone. Also, stated that these people were going to the bottom of the barrel to get these people that society does not want to deal with and they want us to be able to handle them. This place is not equipped to handle the type of people they are housing and it is just unsafe." d. 8:45 p.m. - the local police department was called, e. 8:55 p.m. - the DON returned the facility's call and was informed of the situation, f. 9:30 p.m. - 2 police officers entered the unit and stated they could not do anything to help because the resident was in a mental institution and there were rules that limited what they could do. The documentation reflected the police officers spoke with the resident about the dangers of fighting other residents and the resident voiced understanding, g. 9:45 p.m. - the resident was furious, passed by the nurses' station and stated "I got something for you, [***] ," h. 10:15 p.m. - the resident stated to other residents "if I don't get discharged tonight, I'm just going to start knocking people out in this [***] ," i. 10:30 p.m. - the resident became physically aggressive with a male staff member and the police were called again, j. 10:35 p.m. - 2 police officers arrived in the facility and stated there was nothing they could do. The police officers did agree to stay until the situation was defused, k. 10:40 p.m. - the psychiatrist was called again and recommended the police take the resident to the local ER where he could be PECed and transferred to another facility. The nurse spoke with the ER physician who instructed them not to bring the resident to ER for safety reasons. The nurse explained to the physician that the resident was very violent and out of control, l. 11:05 p.m. - the ER physician gave an order to give the resident Geodon 20 mg IM and Ativan 1 mg IM and instructed the nurse again to not bring the resident to the ER. The nurse explained again that the resident was violent, non-compliant and very aggressive with staff and residents, m. 11:15 p.m. - Geodon 20 mg IM and Ativan 1 mg IM was given, n. 11:30 p.m. - the resident was a little calmer and the police officers left the building, o. 11:45 p.m. - the resident was in bed with eyes closed. p. Review of the incident report dated 7/2/13 reflected the resident blocked the door while he and another resident physically assaulted another resident. The immediate action taken was to separate the residents and observe for injuries. 4. Review of the nurse's note dated 7/4/13 at 1:01 a.m. reflected at 12:00 a.m. the resident was at the nurses' station telling the nurse that he was going to knock another resident out. Resident #2 stated he could knock any and everybody out, and not go to jail. According to the nurse's note, the resident was bragging and unremorseful about the altercations he had been involved in. 5. Review of the nurse's note dated 7/4/13 at 9:42 a.m. reflected the resident was hollering, cursing and verbally threatening the nurse. The resident stated "I run this place and you will do as I say, or else." Further review reflected the nurse walked away. 6. Review of the nurse's note dated 7/4/13 at 6:37 p.m. reflected at 3:30 p.m. resident #2 was at the window getting his cigarette when another resident began to curse and threaten a CNA. Resident #2 attempted to intervene and the other resident pushed him. Resident #2 began to hit the other resident causing the resident to fall to the floor. The resident was noted to be dazed, unable to speak and bleeding from the mouth. The resident was transported to the local ER for evaluation. Review of the incident report dated 7/4/13 reflected the immediate action taken was to separate the residents and triage for injuries. 7. Review of the nurse's note dated 7/7/13 at 6:52 p.m. reflected at 9:00 a.m. a CNA reported to the nurse that the resident was threatening to harm other residents if did not get his smoke break when he wanted to smoke. 8. Review of the nurse's note dated 7/8/13 at 11:07 p.m. reflected at 9:30 p.m. resident #2 stated if he did not have his money by the 16th, he would slam the Administrator through one of the glass doors. 9. Review of the nurse's note dated 7/11/13 at 7:10 a.m. reflected at 6:00 a.m. the resident snatched a glass of water from the nurse and threw it across the room. 10. Review of the nurse's note dated 7/16/13 at 7:00 a.m. reflected at 9:00 p.m. the resident was emptying another resident's foley catheter when the nurse told him that he shouldn't be doing that. The resident became agitated but complied. Further review reflected the CNA was providing incontinent care to another resident when resident #2 entered the room without knocking and would not leave. Resident #2 became very upset and began cursing when asked to leave. 11. Review of the nurse's note dated 7/22/13 at 11:40 p.m. reflected at 7:40 p.m. an incident occurred between the resident and resident #1 resulting in the police being called. Further record review reflected to see resident #1's notes. Review of an incident report dated 7/22/13 reflected an incident between resident #1 and resident #2 which escalated from loudness to pushing and then to resident #1 picking up a chair. The nurse called for assistance from the floor and called 911. The incident was broken up by a CNA. Resident #2 continued to taunt resident #1, threatening to kill him in his sleep. The immediate action taken was to separate the residents and increase supervision. However, there was no further documentation regarding the incident to reflect which staff member was assigned to provide the increased supervision, or that increased supervision was actually provided. Interview on 7/30/13 at 8:05 a.m. with S4 LPN confirmed she was working on 6/18/13 when resident #5 began cursing and speaking to her in a loud voice. She stated resident #2 didn't like it so he grabbed resident #5. Further interview revealed she separated the residents, and they went to their rooms where they calmed down. Telephone interview on 7/30/13 at 10:07 a.m. with S5 LPN confirmed that she found a pocket knife locked up in the narcotic cabinet that belonged to resident #2. She stated she thought the prn nurse working the day before had found it and locked it up but she had not documented it. Further interview revealed she was working on 7/4/13 when the resident began cursing and threatening her and she tried to redirect him. S5 LPN stated that the resident would become frustrated and would curse or threaten the staff. She stated that later that day, resident #5 began to curse and threaten staff, which was his personality, when resident #2 tried to intervene and resident #5 hit him. Resident #2 fought back and resident #5 had to be sent to the ER because he was dazed and bleeding from the mouth. Further interview revealed she was not aware of resident #2 being on 1:1 supervision during any of her shifts. Telephone interview on 7/30/13 at 10:50 a.m. with S9 LPN confirmed she was working on 7/2/13 when resident #2 had assisted resident #1 in an altercation with a third resident. She confirmed she was told by the ER physician not to send the resident to the ER because it would not be safe for the ER staff. She stated she gave the resident some medications which did help calm him down. C. RESIDENT #1 Review of resident #1's face sheet reflected he was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. 1. Review of the nurse's note dated 5/6/13 at 12:12 p.m. reflected at 0900 (9:00 a.m.) the resident was confused and stating he would burn the facility down. The resident had a pair of nail clippers in his hand with the nail cleaner opened. The resident gave the nail clippers to the nurse without incident. There was no further documentation regarding the resident's threats. 2. Review of the nurse's note dated 5/9/13 at 7:30 a.m. reflected at 6:30 a.m. the resident became combative with the CNA that was assigned 1:1 to him after he eloped on 5/6/13. The resident had hit the staff and pinned them against the wall. The resident was redirected and moved away from the CNA. The documentation reflected the 1:1 staff remained with the resident. 3. Review of the nurse's note dated 5/15/13 at 6:41 a.m. reflected at 6:00 a.m. the resident was standing in the hallway. The resident was agitated and yelling and cursing at another resident. Resident #1 threatened to hit the other resident if she didn't shut up. The resident was redirected to the dining room. The documentation did not reflect if there were other residents in the dining room while the resident was agitated. 4. Review of the nurse's note dated 5/18/13 at 2:37 p.m. reflected at 12:15 p.m. the resident was in the dining room, bleeding from the nose. The CNA that witnessed the incident reported that resident #6 had punched him in the nose then resident #1 punched resident #6 in the face. Review of the incident report dated 5/18/13 reflected the immediate action taken was to separate the resident's and apply pressure to resident #1's nose. Cross refer to findings under 1.A. Incident 13. 5. Review of the nurse's note dated 5/26/13 at 1:18 p.m. reflected at 12:10 p.m. the nurse was called to the behavior unit for extra assistance due to the resident making threats against the nurse working on the unit. The resident was standing across from the nurse with his arms folded over his chest, glaring in a threatening manner at the nurse. A CNA was attempting to de-escalate the situation but was not successful. The resident was angry and convinced the nurse had him admitted to the facility. The resident was pacing and watching the nurse in a menacing manner and would make quick advances towards her as she was attempting to draw up Geodon in a syringe for him. The resident was cursing and threatening the nurse but did finally agree to let the second nurse administer the medication. The resident did draw up his fists as if to strike the nurse if the injection hurt. Afterwards, the resident continued to pace, mumbling threats and profanities to the nurse and CNAs. Review of the nurse's note dated 5/26/13 at 5:57 p.m. reflected at 1320 (1:20 p.m.) the resident continued to pace and make threatening remarks to the nurse. The Geodon was noted to be ineffective and redirection was causing aggressive mood escalation. The resident was noted to wander into a peer's room as if he was looking for him. The peer was the same peer that he had beaten so badly 2 weeks prior that he was hospitalized in ICU with "internal cranial hemorrhages". The DON and psychiatrist were notified of the resident's dangerous behaviors towards staff and peers. An order was obtained to send the resident to the ER for PEC to an acute care psychiatric facility. Further review reflected report was called to the local ER, the police were notified of possible need for assistance and the EMS was activated. The ER physician called back and stated that he refused to accept the resident for evaluation. The police called and refused to assist in any way other than to follow the ambulance. The psychiatrist was notified and instructed the nurse to send the resident to ER despite the ER physician's refusal; however, the EMS refused to transport the resident due to the ER refusing and they left the facility. The Administrator was notified and he spoke with the ER physician who finally agreed to evaluate the resident. The EMS was activated and returned to the facility but would not transport the resident because he was refusing to go. The DON was informed. 6. Review of the nurse's note dated 6/15/13 at 1:32 a.m. reflected on 6/14/13 at 9:50 p.m. the resident choked another resident that had hit him in the face. 7. Review of the incident report dated 6/14/13 reflected the immediate action taken was to separate the residents. 8. Review of the nurse's note dated 7/3/13 at 2:26 a.m. reflected the following incidents occurred on 7/2/13: cross refer to findings under B. RESIDENT #2 - incident 3. Review of the facility's Daily Assignment Sheet dated 7/22/13 reflected there was one LPN assigned to the behavior unit during the 7P - 7A shift, three CNAs assigned to the behavior unit during the 3-11 shift and one CNA (plus a floater) during the 11-7 shift. The documentation did not reflect an increase in the number of staff assigned to the unit to reflect increased supervision of the residents. D. RESIDENT #5 Review of resident #5's face sheet reflected he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Review of the nurse's note dated 5/23/13 at 10:26 a.m. reflected the resident was standing in the hallway yelling at an unidentified resident. The resident began to kick at the other resident and stated that the other resident had came up and hit him for no reason. There was no documentation to reflect the nurse attempted to intervene when the resident was yelling at another resident before it escalated to the resident kicking the other resident. Review of the incident report dated 5/22/13 reflected the immediate action taken was to separate the residents and redirect. 2. Review of the nurse's note dated 6/18/13 at 7:03 p.m. reflected at 4:00 p.m. resident was standing in the doorway of his room, cursing loudly at another resident. The other resident walked up to resident #5 and threw him to the bed. The nurse separated the 2 residents. There was no documentation to reflect the nurse attempted to intervene when the resident was yelling and cursing at the other resident. Review of the incident report dated 6/18/13 reflected the immediate action taken was to separate the residents. 3. Review of the nurse's note dated 7/4/13 at 6:27 p.m. reflected at 3:30 p.m. resident #5 and resident #2 was standing at the window getting their cigarettes. Resident #5 was cursing and threatening a CNA when resident #2 asked him to stop. Resident #5 pushed resident #2 and then began to hit him. Resident #2 hit resident #5 causing him to be "dazed" and fall to the floor. The resident was noted to have active bleeding from his mouth and was unable to speak. The resident was taken to the ER for evaluation. Interview on 7/30/13 at 3:00 p.m. with S2 DON confirmed the resident's tooth had been knocked out. Review of the incident report dated 7/4/13 reflected the immediate action taken was to send resident #5 to the ER for eval and tx. 2. WEAPONS FOR PROTECTION: Resident #6 Review of the physician's progress note dated 5/22/13 reflected resident #6 had been in an altercation with another resident and sustained a facial and head injury which resulted in a subdural hematoma and subarachnoid hematoma. Review of the nurse's note dated 5/22/13 at 3:38 p.m. reflected at 10:00 a.m. the resident was continuing to ask who was going to take him to therapy. The nurse explained he would go to therapy the next day and they would pick him up when they were ready for him. Further review reflected at 12:20 p.m. resident #6 was hollering at another resident, swinging at the resident and attempting to hit him. Resident #6 had a butter knife in his hand. The resident stated that he hit the other resident in the face but that he didn't know why he had done it. The resident stated that he was trying to go to therapy and nobody would take him. Review of an incident report dated 5/23/13 at 12:50 p.m. reflected the resident was hollering at another resident, swinging at the resident and attempting to hit him. Resident #6 had a butter knife in his hand. The resident stated that he hit the other resident but didn't know why. The immediate action taken was to separate the residents. Review of the nurse's note dated 5/23/13 at 3:29 p.m. reflected at 10:00 a.m. resident #6 was found with an ice scoop in his pants. The resident stated it was to protect himself. The resident had been wandering into other residents' rooms and had been redirected back to his own room. The nurse documented he was difficult to redirect and then instructed him to call if he needed assistance. Review of the nurse's note dated 5/25/13 at 1:06 p.m. reflected at 11:30 a.m. resident #6 was stating that he did not want to hit other people and would try to "be cool." The nurse documented that due to his history of aggression toward other residents and being obsessed with these same comments in the past, prn Ativan 2 mg po was given. The resident did not make any other comments about hitting anyone. Review of the nurse's note dated 5/26/13 at 6:23 p.m. reflected at 12:15 p.m. resident #6 was exhibiting a suspicious, secretive mood. The resident had a fearful affect which alternated with a blunted affect. The resident's behavior was paranoid, suspicious and required constant redirection. The resident was found with a "shank" hidden in the belt loop of his pants which had been made out of a stick from a small tree limb. The resident gave the "shank" to the nurse and told her that he did not want anyone to hurt him. The resident asked the nurse to watch him closely because he was afraid of a resident that had beaten him a few weeks ago, leaving him hospitalized in ICU with intracranial hemorrhage. Further review reflected that within an hour resident #6 had broken a piece of plastic from a storage bin in his room and made another "shank" with it. The weapon was confiscated and the resident verbalized that he remained fearful. The nurse reassured the resident. After returning from the courtyard, the resident was found with several pieces of sharp plastic "shanks" made from a glass from the resident's lunch tray that he smashed while outside. The nurse asked the resident what he was going to do with the weapons and he stated he was going to stab anyone that messed with him. The resident continued to say he would stab them real quick in the face and then stab them over and over again. The resident was making stabbing motions with his hands as he talked. The resident was placed under close observation and the Administrator, DON and psychiatrist were notified. The psychiatrist ordered for the resident to be sent to the ER for evaluation for acute psychiatric care. The nurse called report to the ER, called for the EMS and contacted the police department in case of need for assistance. The ER physician returned the nurse's call and refused to accept the resident in the ER. The police refused to provide any assistance other than to follow the ambulance to the ER. Further documentation reflected the EMS refused to transport resident #6 due to the ER physician's refusal to accept the resident. The staff continued to maintain close observation of the resident and found another sharp "shank" made from a broken glass that the resident had in his pocket. The resident continued to verbalize that he would stab anyone that messed with him. Review of the nurse's note dated 5/26/13 at 1300 (1:00 p.m.) reflected prn Ativan 2 mg was given which was "very little effective." There was no documentation to reflect the staff attempted to have the resident taken to another emergency room when the local hospital refused to have the resident brought to their facility. There was no documentation to reflect increased supervision of the resident. Review of the nurse's note dated 5/27/13 at 4:11 p.m. reflected at 11:40 a.m. resident #6 was outside smoking when he began to hit another resident. The nurse separated the residents. The resident stated he knew that he was wrong but he was not going to let the others beat him up. The resident was sent to the ER at 12:10 p.m. Review of the incident report dated 5/27/13 reflected the immediate action taken was to send the resident to the ER. Review of the Resident Transfer Form dated 5/27/13 reflected the resident was transferred to the local ER. Review of the Emergency Nursing Record dated 5/27/13 at 1221 (12:21 p.m.) reflected the resident had hit another resident and was having violent behavior with paranoia. The resident was complaining of hand pain. Review o

Based on observation, interview and record review the facility failed to ensure there was sufficient nursing staff on the locked behavior unit, to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 4 of 6 sampled residents (#6, #2, #1, and #5). The facility failed to: 1. provide sufficient staff to prevent resident to resident physical altercations on the locked behavior unit (#6, #2, #1, and #5), 2. provide sufficient staff to prevent the making of homemade weapons by one resident, who verbalized fear of other residents in the locked unit (#6), 3. provide sufficient staff to prevent interference and performance of nursing care by a resident (#2) on other residents in the locked behavior unit and 4. provide sufficient staff to prevent elopement from the locked behavior unit (#2). An Immediate Jeopardy situation began on 4/18/13 at 6:00 p.m. when resident #6 was observed by the staff on the behavior unit slapping a female resident in the face, and threatening to hit others with his dresser drawers and a chair. The resident had returned from an inpatient psychiatric stay the day before due to his aggressive behavior with other residents. There were no new interventions put in place to protect the other residents on the behavior unit from the aggressive behaviors of resident #6 when he returned to the facility. Physical aggression and altercations of this type continued by resident #6 and also by residents #1, #2 and #5 on multiple occasions as described in the findings below, without the facility re-evaluating and analyzing the effectiveness of planned interventions and the adequacy of the supervision and monitoring. Staff were not identifying triggers that were the cause of escalating behaviors in order to attempt interventions to de-escalate the situation. All residents on the locked behavior unit were placed in Immediate Jeopardy on 4/18/13 when the facility failed to implement interventions to protect them from the physically aggressive behaviors of other residents on the locked behavior unit. Review of the census list provided by the DON reflected the behavior unit's total census on 7/29/13 was 23. The Administrator was notified of the Immediate Jeopardy on 7/31/13 at 2:45 p.m. The facility submitted a plan of removal which included increasing the staff on the behavior unit to include placing resident #2 on 1:1 care and assigning a staff member to monitor residents #1, 5 and 6 every 15 minutes to reduce physical aggression, elopement and interference with resident's care. All residents at risk for potential aggressive behavior and elopements were reassessed and care plans updated. The staff received additional training on identifying triggers, approaches to reduce agitation and interventions for residents with aggression. The QA committee met to address elopement, staff training, scheduling, resident to resident abuse, care plans, and reportable incidents. Monitoring rounds will be made by administrative staff daily. The Immediate Jeopardy situation was removed on 8/1/13 at 12:00 p.m. when observations revealed that the plan was being implemented. Although the immediacy of the situation was removed, the deficient practice remains at a level of actual harm for resident #6 who was hospitalized for [REDACTED].#1 and for resident #5 who required evaluation at the hospital after a physical altercation with resident #2 which left the resident bleeding from the mouth due to his tooth being knocked out, dazed and unable to speak. Findings: STAFFING ON THE LOCKED BEHAVIOR UNIT Review of the census list provided by the DON reflected the behavior unit's total census on 7/29/13 was 23. Review of the residents' face sheets reflected there were 7 female residents and 16 male residents residing on the behavior unit. Their [DIAGNOSES REDACTED]. Further review reflected the residents' ages ranged from 30 to [AGE] years old. Review of the Staffing Requirements for the Behavioral Unit - 32 beds reflected: * Nurses: 1:32 and as needed based on patient acuity * CNAs: Minimum staffing - day: 2, evening: 2 and night: 1. Optimum staffing - day: 3, evening: 3 and night: 2. * The day and evening was to include a smoke monitor. The staffing was subject to change due to patient acuity. Review of the facility's Daily Assignment Sheet for the behavior unit revealed the following: * On 6/18/13; 6/23/13; and 7/15/13 there was one LPN assigned during the 7P - 7A shift, three CNAs assigned during the 3-11 shift and two CNAs during the 11-7 shift. * On 7/2/13 there was one LPN assigned during the 7P - 7A shift and three CNAs assigned during the 3-11 and 11-7 shifts. According to the assignment sheet, one of the CNAs on the 11-7 shift was in orientation. * On 7/4/13 there was one LPN assigned during the 7A - 7P shift and two CNAs assigned during the 3-11 and 11-7 shifts. * Review of the facility's Daily Assignment Sheet dated 7/6/13 reflected there was one LPN assigned to the behavior unit during the 7A - 7P shift and 2 CNAs assigned to the behavior unit during the 3-11 shift and one CNA assigned during the 11-7 shift. The second CNA assigned during the 11-7 shift was a "no call, no show." There was no documentation to reflect staff assigned to the resident #2 for 1:1 supervision after he had eloped during the 3-11 shift on 7/6/13. * Review of the facility's Daily Assignment Sheet dated 7/7/13, the morning after the resident #2 had eloped, reflected there was one LPN assigned to the behavior unit during the 7A-7P shift and three CNAs assigned during the 7-3 shift. Further review reflected the CNA assigned to be the smoke monitor was also assigned to help the housekeeper. There was no documentation to reflect additional staff for increased supervision of the resident following his elopement. * Review of the facility's Daily Assignment Sheet dated 7/21/13 reflected there was one LPN assigned to the behavior unit during the 7P - 7A shift, three CNAs assigned to the behavior unit during the 3-11 shift and two CNAs during the 11-7 shift. There was no documentation to reflect additional staff for increased supervision of the resident #2 during the night following his elopement and threats to do it again. * On 7/22/13 there was one LPN assigned during the 7P - 7A shift, three CNAs assigned during the 3-11 shift and one CNA (plus a floater) during the 11-7 shift. Observation on 7/29/13 at 11:15 a.m. revealed there was one LPN and three CNAs working on the behavior unit. Observations during the survey from 7/29/13 through 8/1/13 revealed there was no male staff working on the unit during those dates. Interview on 7/30/13 at 3:00 p.m. with S1 Admin revealed if a resident became physically aggressive with another resident, they would usually be put on 1:1 supervision by staff until they calmed down. He confirmed there was no specific time frame for keeping a resident on 1:1 supervision, or additional staff added to the unit to provide the 1:1 supervision. The assigned 1:1 staff were instructed to stay with the resident until they were calm. Review of the facility's Daily Assignment Sheets for the behavior unit did not reflect an increase in the number of staff assigned to the unit that would allow for an increase in the supervision of the residents that exhibited a pattern of aggressive behaviors. Cross refer to findings at tag F323 which indicates an ongoing problem with resident to resident physical altercations (#6, #2, #1, and #5), the making of homemade weapons by one resident who verbalized fear of other physically aggressive residents he felt threatened by (#6), the interference and performance of nursing care by a resident (#2) on other residents, and elopement issues (#2) from the locked unit.

Based on observation, interview and record review the facility failed to ensure it was administered in a manner that enabled it to use its resources to effectively attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This failure affected 4 of 6 sampled residents (#1, #2, #5 and #6) exhibiting physically aggressive behaviors. All 23 residents residing on this unit had the potential for injury from physically aggressive behaviors exhibited by residents #6, #2, #1, and #5. Administration failed to ensure that: 1. policies and procedures that prohibited mistreatment, neglect and abuse of residents for 4 of 6 sampled residents (#1, #2, #5 and #6) out of 23 residents residing on the facility's behavior unit were implemented; 2. all alleged violations involving neglect or abuse were thoroughly investigated and reported to officials, including the State survey and certification agency, in accordance with State law through established procedures; 3. the care plans of 4 residents exhibiting physically aggressive behaviors (#1, #2, #5 and #6), and 1 resident with a history of eloping from the locked unit (2) out of 6 residents reviewed residing on the locked behavior unit, were periodically reviewed and revised with specific individualized approaches to address their needs; 4. 4 residents exhibiting physically aggressive behaviors (#1, #2, #5 and #6), and 1 resident with a history of eloping from the locked unit (#2) out of 6 residents reviewed residing on the locked behavior unit, received adequate supervision/monitoring to prevent accident hazards; 5. there was sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 4 of 6 sampled residents (#1, #2, #5 and #6) out of 23 residents residing on the facility's behavior unit; and 6. plans of action were developed and implemented to correct identified quality deficiencies related to resident to resident physical altercations for 4 of 6 sampled residents (#1, #2, #5 and #6) out of 23 residents residing on the facility's behavior unit. An Immediate Jeopardy situation began on 4/18/13 at 6:00 p.m. when resident #6 was observed by the staff on the behavior unit slapping a female resident in the face, and threatening to hit others with his dresser drawers and a chair. The resident had returned from an inpatient psychiatric stay the day before due to his aggressive behavior with other residents. There were no new interventions put in place to protect the other residents on the behavior unit from the aggressive behaviors of resident #6 when he returned to the facility. Physical aggression and altercations of this type continued by resident #6 and also by residents #1, #2 and #5 on multiple occasions as described in the findings below, without the facility re-evaluating and analyzing the effectiveness of planned interventions and the adequacy of the supervision and monitoring. Staff was not identifying triggers that were the cause of escalating behaviors in order to attempt interventions to de-escalate the situation. All residents on the locked behavior unit were placed in Immediate Jeopardy on 4/18/13 when the facility failed to implement interventions to protect them from the physically aggressive behaviors of other residents on the locked behavior unit. Review of the census list provided by the DON reflected the behavior unit's total census on 7/29/13 was 23. The Administrator was notified of the Immediate Jeopardy on 7/31/13 at 2:45 p.m. The facility submitted a plan of removal which included increasing the staff on the behavior unit to include placing resident #2 on 1:1 care and assigning a staff member to monitor residents #1, 5 and 6 every 15 minutes to reduce physical aggression, elopement and interference with resident's care. All residents at risk for potential aggressive behavior and elopements were reassessed and care plans updated. The staff received additional training on identifying triggers, approaches to reduce agitation and interventions for residents with aggression. The QA committee met to address elopement, staff training, scheduling, resident to resident abuse, care plans, and reportable incidents. Monitoring rounds will be made by administrative staff daily. The Immediate Jeopardy situation was removed on 8/1/13 at 12:00 p.m. when observations revealed that the plan was being implemented. Although the immediacy of the situation was removed, the deficient practice remains at a level of actual harm for resident #6 who was hospitalized for [REDACTED].#1 and for resident #5 who required evaluation at the hospital after a physical altercation with resident #2 which left the resident bleeding from the mouth due to his tooth being knocked out, dazed and unable to speak. Findings: 1. Cross refer to findings at tag F224. 2. Cross refer to findings at tag F225. 3. Cross refer to findings at tag F280. 4. Cross refer to findings at tag F323. 5. Cross refer to findings at tag F353. 6. Cross refer to findings at tag F520. Interview on 7/30/13 at 3:00 p.m. with S1 Admin revealed if a resident became physically aggressive with another resident, they would usually be put on 1:1 supervision by staff until they calmed down. He stated the 1:1 supervision wasn't a formal plan. He confirmed there was no specific time frame for keeping a resident on 1:1 supervision, or additional staff added to the unit to provide the 1:1 supervision. S1 Admin stated he would either notify the CNA supervisor to tell the staff member they were being assigned 1:1 supervision of a resident or he would tell the staff himself. The assigned 1:1 staff were instructed to stay with the resident until they were calm. The staff were not required to document the 1:1 supervision; although, the nurses would occasionally mention it in their notes. Review of the facility's Daily Assignment Sheets for the behavior unit did not reflect an increase in the number of staff assigned to the unit that would allow for an increase in the supervision of the residents that exhibited a pattern of aggressive behaviors. Review of the facility's Preliminary Behavioral Unit Admission Criteria reflected behavioral concerns for admission included violence against staff and residents limited and managed (per DNS' review). However, the documentation in residents #1, 2, 5 and 6's records did not reflect the personal histories of the residents had been assessed to determine if they were at risk for abusing other residents. Also, specific intervention strategies to prevent occurrences, monitor for changes that would trigger abusive behavior and reassess the interventions on a regular basis were not implemented. Interview on 7/30/13 at 2:00 p.m. with S1 Admin revealed that he and the DON were responsible for assessing the residents for appropriate placement in the behavior unit prior to admission. S1 Admin stated that he or the DON would review at least 2 to 3 weeks of the residents' nurses' notes and/or psychiatric evaluations regarding any resident to resident or resident to staff altercations. Further interview confirmed they were unaware of resident #2 having a history of combative behavior with other residents. S1 Admin stated they had not seen the documentation from the previous facility regarding the resident being combative to another resident. Further interview with S1 Admin revealed that the police have been called to the facility due to the resident to resident altercations on the locked behavior unit. He stated that the police would respond but would not make any arrests. He also revealed that the local ER had refused to accept residents after orders had been received to send them to the ER due to violent behaviors. S1 Admin confirmed the residents had to remain on the locked unit after exhibiting violent behaviors because the police would not arrest them and the local emergency room would not accept them.

Based on observation, interview and record review the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies for 4 of 6 sampled residents (#1, 2, 5 and 6) out of 23 residents residing on the facility's behavior unit. The facility's total census was 70 according to the Resident Census and Condition of Residents form. The facility failed to: 1. develop, implement and monitor a plan of action to prevent resident to resident physical altercations on the locked behavior unit (#1, 2, 5 and 6); 2. develop, implement and monitor a plan of action to prevent a resident with observed physical aggression towards other residents from making homemade weapons on the locked behavior unit (#6); and 3. develop, implement and monitor a plan of action to prevent resident elopement from the locked behavior unit (#2). An Immediate Jeopardy situation began on 4/18/13 at 6:00 p.m. when resident #6 was observed by the staff on the behavior unit slapping a female resident in the face, and threatening to hit others with his dresser drawers and a chair. The resident had returned from an inpatient psychiatric stay the day before due to his aggressive behavior with other residents. There were no new interventions put in place to protect the other residents on the behavior unit from the aggressive behaviors of resident #6 when he returned to the facility. Physical aggression and altercations of this type continued by resident #6 and also by residents #1, #2 and #5 on multiple occasions as described in the findings below, without the facility re-evaluating and analyzing the effectiveness of planned interventions and the adequacy of the supervision and monitoring. Staff were not identifying triggers that were the cause of escalating behaviors in order to attempt interventions to de-escalate the situation. All residents on the locked behavior unit were placed in Immediate Jeopardy on 4/18/13 when the facility failed to implement interventions to protect them from the physically aggressive behaviors of other residents on the locked behavior unit. Review of the census list provided by the DON reflected the behavior unit's total census on 7/29/13 was 23. The Administrator was notified of the Immediate Jeopardy on 7/31/13 at 2:45 p.m. The facility submitted a plan of removal which included increasing the staff on the behavior unit to include placing resident #2 on 1:1 care and assigning a staff member to monitor residents #1, 5 and 6 every 15 minutes to reduce physical aggression, elopement and interference with resident's care. All residents at risk for potential aggressive behavior and elopements were reassessed and care plans updated. The staff received additional training on identifying triggers, approaches to reduce agitation and interventions for residents with aggression. The QA committee met to address elopement, staff training, scheduling, resident to resident abuse, care plans, and reportable incidents. Monitoring rounds will be made by administrative staff daily. The Immediate Jeopardy situation was removed on 8/1/13 at 12:00 p.m. when observations revealed that the plan was being implemented. Although the immediacy of the situation was removed, the deficient practice remains at a level of actual harm for resident #6 who was hospitalized for [REDACTED].#1 and for resident #5 who required evaluation at the hospital after a physical altercation with resident #2 which left the resident bleeding from the mouth due to his tooth being knocked out, dazed and unable to speak. Findings: 1. Record review of the nursing notes and incident reports revealed a current and ongoing problem with resident to resident physical altercations on the locked behavior unit (#1, 2, 5 and 6). Cross refer to the findings in F323 - 1; A. Resident #6, 1 - 13; B. Resident #2, 1 - 11; C. Resident #1, 1 - 8; and D. Resident #5, 1 - 3. There was no formal and ongoing plan of action to address this issue. 2. Record review revealed that resident #6 was found on more than one occasion making " shanks " which he verbalized was for his protection after being beaten by another resident a few weeks prior. This was a current and ongoing issue. There was no formal plan of action to address the resident ' s fears and his need to protect himself by making weapons as evidenced in the findings below: a. Record review of the physician ' s progress note dated 5/22/13 reflected that resident #6 had been in an altercation with another resident and sustained a facial and head injury which resulted in a subdural hematoma and subarachnoid hematoma. b. Record review of resident #6 nurse's note dated 5/23/13 revealed that at 10:00 a.m. the resident was found with an ice scoop in his pants and that is was to protect himself. c. Review of the nurse's note dated 5/26/13, revealed that at 12:15 p.m. resident #6 was exhibiting a suspicious, secretive mood. The resident had a fearful affect which alternated with a [MEDICATION NAME] affect. The resident ' s behavior was paranoid, suspicious and required constant redirection. The resident was found with a " shank " hidden in the belt loop of his pants which had been made out of a stick from a small tree limb. The resident gave the " shank " to the nurse and told her that he did not want anyone to hurt him. The resident asked the nurse to watch him closely because he was afraid of a resident that had beaten him a few weeks ago. d. Further review reflected that within an hour resident #6 had broken a piece of plastic from a storage bin in his room and made another "shank" with it. The weapon was confiscated and the resident verbalized that he remained fearful. The nurse reassured the resident. After returning from the courtyard, the resident was found with several pieces of sharp plastic "shanks" made from a glass from the resident's lunch tray that he smashed while outside. The nurse asked the resident what he was going to do with the weapons and he stated he was going to stab anyone that messed with him. The resident continued to say he would stab them real quick in the face and then stab them over and over again. The resident was making stabbing motions with his hands as he talked. The resident was placed under close observation and the Administrator, DON and psychiatrist were notified. The psychiatrist ordered for the resident to be sent to the ER for evaluation for acute psychiatric care. The nurse called report to the ER, called for the EMS and contacted the police department in case of need for assistance. The ER physician returned the nurse's call and refused to accept the resident in the ER. The police refused to provide any assistance other than to follow the ambulance to the ER. e. Further documentation reflected the EMS refused to transport resident #6 due to the ER physician's refusal to accept the resident. The staff continued to maintain close observation of the resident and found another sharp "shank" made from a broken glass that the resident had in his pocket. The resident continued to verbalize that he would stab anyone that messed with him. f. Review of the nurse's note dated 5/26/13 at 1300 (1:00 p.m.) reflected prn [MEDICATION NAME] 2 mg was given which was "very little effective." g. There was no documentation to reflect the staff attempted to have the resident taken to another emergency room when the local hospital refused to have the resident brought to their facility. There was no documentation to reflect increased supervision of the resident. 3. Record reviews of the nurses' notes for resident #2 indicate a problem with the resident eloping from the building. Cross refer to the finds at tag F323 under 4. ELOPEMENT, Resident #2. There was no action plan developed or implemented to address the expressed reasons for the elopements and ways in which the facility could address these. Interview on 7/30/13 at 3:00 p.m. with S1 Admin revealed the QA committee did look at resident to resident altercations during the meetings but they did not formally track the incidents. He stated residents' incident reports were reviewed with the facility's risk management company weekly. Review of the incident reports reflected there were no incident reports completed when homemade weapons were found on resident #6. Interview on 7/30/13 at 3:00 p.m. with S2 DON revealed the only manner in which the QA committee tracked the resident to resident physical altercations was by discussing the residents' incident reports at the quarterly QA meetings. The DON confirmed they did not know if the resident to resident physical altercations increased or decreased during each month. S2 DON did not indicate that the QA team was identifying and addressing specific, individualized approaches to prevent the escalation of the residents' behaviors on the unit or for the protection of the residents residing on the unit. Further interview on 8/1/13 at 10:25 a.m. with S2 DON revealed the QA team met quarterly with the Medical Director but they also had morning meetings to discuss residents' behaviors on the unit, incidents and accidents and time/location of incidents. She stated measures had been put in place to address the residents' learning the codes to the unit's locked doors, and the hospital staff and police department had been contacted regarding providing assistance with combative residents. There were no indications the QA team had identified and implemented immediate measures to prevent resident #2 from eloping from the unit after he had broken a window to elope on 7/21/13.