Every finding on record at Pioneer Health Care Center

Based on observations, record review and interviews, the facility failed to ensure two (#4 and #6) of four residents reviewed for abuse out of seven sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #4 from physical abuse by Resident #5; and, -Protect Resident #6 from physical abuse by Resident #2. Findings include: I. Facility policy and procedure The Abuse and Neglect policy, undated, was provided by the director of nursing (DON) on 3/4/25 at 11:14 a.m. It read in pertinent part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The physician and staff will help identify risk factors for abuse within the facility. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. II. Incident of physical abuse towards Resident #4 by Resident #5 on 2/8/25 A. Facility investigation The investigation documented the following: On 2/8/25 it was alleged that Resident #5 hit Resident #4 in the head while walking past her in the hall. The incident was witnessed by Resident #7. Both residents were placed on 15-minute checks. The facility substantiated the abuse. A. Resident #5 (assailant) 1. Resident status Resident #5, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnosis included schizophrenia, unspecified dementia with behavioral disturbances and wandering. The 1/16/25 minimum data set (MDS) assessment revealed, per staff assessment, the resident was rarely or never understood. He had short and long-term memory problems. His cognitive skills for daily living were moderately impaired. He had inattention and disorganized thinking which fluctuated. He required moderate assistance with bathing. He was independent with positioning, transfers and walking. He received an antipsychotic (medication to treat psychosis) and an antidepressant. 2. Record review Resident #5's comprehensive behavioral care plan, initiated 10/3/22, documented the resident had behaviors related to schizophrenia and dementia. He had verbal aggression, physical aggression, obsessive pattern walking and had had resident-to-resident aggression. Pertinent interventions included administering medications as ordered, redirecting the resident to a calm environment, responding to the resident calmly, distracting and redirecting the resident, using consistent direction to calm changes gradually, having a quiet area to walk and checking on the residents location and ensuring safety every 15 minutes. A nursing progress note, dated 2/8/25 at 7:33 p.m., documented at approximately 4:00 p.m. the nurse was informed of the incident. Resident #4 reported Resident #5 made contact with her right eye. Both residents were separated and no injury was noted to Resident #5. A nursing progress note, dated 2/9/25 at 11:28 a.m., documented it was reported to the mental health physician that Resident #5's pacing was more than usual and was irritable with the staff. Frequent checks were initiated on the resident. C. Resident #4 (victim) 1. Resident status Resident #4, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 CPO, diagnosis included bipolar disorder (mental illness), abnormalities of gait and mobility, weakness, unsteadiness on her feet, lack of coordination, difficulty in walking and delusional disorders. The 2/27/25 MDS assessment revealed, per staff assessment, her skills for daily decision making were moderately impaired. She had no behaviors and did not reject care. She used a wheelchair and required maximal assistance with toileting hygiene, bathing and lower body dressing. She required moderate assistance with personal hygiene, sit to stand and transfers. 2. Resident #4's interview Resident #4 was interviewed on 3/4/25 at 11:16 p.m. Resident #4 said Resident #5 was mean and had attacked other women in the facility as well. She said Resident #5 punched her for no reason causing pain, redness and swelling to her right eye. She said the staff applied ice to her right eye/forehead and the following days she was left with bruising to her forehead. 3. Record review Resident #4's social behavioral care plan, initiated 11/30/22, documented the resident expressed inappropriate social behaviors verbally/physically towards staff and other residents. She had the potential to be physically aggressive related to anger, depression, poor impulse control, refusing psychotropic medications, throwing dishes and breaking them while in a manic phase. Pertinent interventions included administering medications as ordered, notifying the psychiatrist if the resident was refusing medications, if resident was in a safe location and away from others while being verbally or physically aggressive let her decompress before reengaging with her or trying to redirect her to a different location, notifying the resident's family and physician of increased behavioral concerns, observing the resident during smoke breaks for potential triggers from other residents when she was manic and observing the resident often for self safety and the safety of others. Resident #4's behavioral care plan, initiated 2/8/25, documented the resident had a behavioral problem related to bipolar disorder and delusional disorder. Resident #4 had severe episodes of manic and depressive phases. She could become verbally aggressive/argumentative and had been physically aggressive. She had made inappropriate comments about other residents putting her at risk for harm. Pertinent interventions included acknowledging the resident's delusional beliefs and not arguing with the resident, administering medications as ordered, notifying the physician of refusals, anticipating and meeting the resident's needs, attempting/encouraging aromatherapy to de-escalate when manic and crisis intervention and advocacy as needed, encouraging/assisting the resident away from other residents as allowed when in a manic phase and monitoring behavior episodes and attempting to determine the underlying cause. A nursing progress note, dated 2/8/25 at 7:46 p.m., documented at approximately 4:00 p.m. the nurse was informed of the incident. Resident #4 reported Resident #5 made contact with her right eye. Both residents were kept separated. Resident #4 was assessed and noted to have a discolored reddish area above her right eye. The resident accepted ice wrapped in a towel. A nursing progress note, dated 2/9/25 at 10:36 p.m., documented Resident #4's neurological checks were being monitored and the site above her right eyebrow remained discolored yellow and green. D. Additional resident interviews Resident #7 was interviewed on 3/4/25 at 11:18 a.m. Resident #7 said she was walking down the hallway and witnessed Resident #5 hit Resident #4 in the face. E. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 3/4/25 at 11:20 a.m. CNA #2 said Resident #5 wandered at times and paced. She said he liked his personal space and usually stayed to himself. She said she had heard he had aggressive behaviors with his peers, but had never witnessed those behaviors herself. Licensed practical nurse (LPN) #1 was interviewed on 3/4/25 at 11:25 a.m. LPN #1 said Resident #5 usually kept to himself. She said when he rejected care or said no, the staff knew to reapproach at a later time to avoid aggressive behaviors. She said she assumed Resident #4 was sitting in her wheelchair in the hallway where Resident #5 was pacing at the time of the incident. She said Resident #4 was very friendly and probably said hi to him, and Resident #5 may not have understood. LPN #1 said Resident #4 yelled my eye, my eye he got me in the eye. She said she placed ice wrapped in a towel on her right eye which was red. She said bruising developed the following days. The social services assistant (SSA) was interviewed on 3/4/25 at 2:25 p.m. The SSA said he had only been in his position for three weeks. He said he had not had any interactions with Resident #5 and was still in his training process. He said he had not heard of Resident #5 having any behaviors. He said he was still trying to learn who the residents were. He said he was in the process of familiarizing himself with the resident care plans and it was a work in progress. The DON was interviewed on 3/4/25 at 2:36 p.m. The DON said Resident #5 liked to pace back and forth and could have verbal outbursts and physical aggression but never actually hit a resident. She said the last incident involved physical contact with Resident #4. She said the staff would redirect him when he escalated. She said they had even tried a sensory program with therapy to identify a root cause for his behaviors. III. Incident of physical abuse between Resident #6 and Resident #2 on 2/16/25 A. Facility investigation The investigation documented the following: On 2/16/25 it was alleged that Resident #6 pushed Resident #2. However, after review of the facility cameras, it was determined that Resident #2 pushed Resident #6. Resident #6 said Resident #2 hit and pushed her. Resident #2 was placed on line of sight monitoring. The facility unsubstantiated the abuse allegation. -However, abuse occurred when Resident #2 pushed Resident #6. A. Resident #2 (assailant) 1. Resident status Resident #2, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 CPO, diagnoses included unspecified dementia with behavioral disturbances, Alzheimer's disease, bipolar disorder, insomnia due to mental disorder, vascular dementia, restlessness and agitation. The 12/12/24 MDS assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. She required moderate assistance with bathing. She required set-up assistance with oral hygiene, upper/lower body dressing, personal hygiene, putting on/off footwear, sitting to stand, toilet transfers and walking. She received an antipsychotic medication and an antidepressant medication. 2. Record review Resident #2's mood/behavior care plan, initiated on 4/17/23, documented she had mood/behavior problems related to bipolar disorder, vascular dementia, Alzheimer's disease, insomnia, restlessness, agitation and making false accusations about other residents. She had resident-to-resident altercations which she initiated and was the aggressor. Pertinent interventions included administering medications as ordered, anticipating and meeting the residents needs, providing behavioral health consults, ensuring the resident was in line of sight when out of her room, providing frequent checks for the resident's safety, redirecting the resident and providing one-to-one care when needed. A nursing progress note, dated 2/16/25 at 9:28 p.m,. documented the staff reported a resident-to-resident altercation between Resident #2 and Resident #6 took place in the hallway. The residents were separated, interviewed and assessed for injury. No injuries were observed on either resident. Labs were ordered for Resident #6. A risk review note, dated 2/18/25 at 10:01 a.m., documented Resident #2 reported to staff that Resident #6 made contact with her on the previous shift. The incident was not observed by staff at the time of the report. Upon further investigation it was noted that in fact the initial alleged victim (Resident #2) was the aggressor. C. Resident #6 (victim) 1. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included major depressive disorder, unspecified dementia, anxiety disorder, muscle weakness, vascular dementia and collapsed vertebra (back). The 2/6/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of seven out of 15. She had hallucinations and delusions. She required maximal assistance with toileting hygiene and bathing. She was independent with positioning, transfers and walking. She received an antipsychotic medication. 2. Resident interview Resident #6 was interviewed on 3/4/25 at 11:03 a.m. Resident #6 said Resident #2 pushed her and she fell . She said she did not know why. She said it hurt, but she did not get injured. 3. Record review Resident #6's behavior care plan, initiated 4/17/23, documented she had mood/behavior problems related to vascular dementia, anxiety, major depressive disorder and could become aggressive with other residents. Resident #6 had become physically agitated with other residents. Pertinent interventions included administering medications as ordered, anticipating and meeting the residents needs, providing a psychiatric consult, assisting the resident to develop more appropriate methods of coping and interacting, providing frequent checks for the safety of others and keeping the resident in line of sight when she was out of her room. A nursing progress note dated 2/16/25 at 10:22 p.m. documented the alleged victim (Resident #2) claimed Resident #6 made contact with her. The altercation was not witnessed and the residents were separated and taken to separate rooms for assessments. There were no injuries observed. A risk review note, dated 2/18/25 at 10:02 a.m., documented Resident #2 reported to staff that Resident #6 made contact with her on the previous shift. The incident was not observed by staff at the time of the report. Upon further investigation it was noted that in fact the inital alleged victim (Resident #2) was the aggressor. 4. Staff interviews CNA #1 was interviewed on 3/4/25 at 11:08 a.m. CNA #1 said Resident #2 could get grumpy at times. He said he was not working the day of the altercation and had never seen Resident #2 become aggressive. LPN #1 was interviewed on 3/4/25 at 11:11 a.m. LPN #1 said Resident #2 liked to straighten and organize things. She said Resident #2 preferred to stay in her room. She said she was not working the day of the altercation. She said Resident #2 was not usually aggressive but could get frustrated. The SSA was interviewed on 3/4/25 at 2:25 p.m. The SSA said he was not aware of any aggressive behaviors from Resident #2. He said she usually just walked from her room to the dining room. He said he was not aware of the altercation. The DON was interviewed on 3/4/25 at 2:36 p.m. The DON said the previous nursing home administrator (NHA) conducted the investigation. The DON said Resident #2 would report false allegations and liked to fidget with things throughout the day even if the items were not hers. She said Resident #2 reported she fell , but when the NHA reviewed the cameras, Resident #2 pushed Resident #6, but she did not fall. She said she was not working the day of the altercation.

Based on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to take the appropriate measures to control a fly infestation in the facility. Findings include: I. Professional reference According to the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, updated 2/15/19, pp. 94-95, retrieved on 9/5/24 from https://www.cdc.gov/infection-control/media/pdfs/Guideline-Environmental-H.pdf, Cockroaches, spiders, and mice are among the typical pest populations found in health-care facilities. Insects and rodents can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects and rodents should be kept out of all areas of a health-care facility. From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on: -Eliminating food sources, indoor habitats, and other conditions that attract pests; -Excluding pests from entering the indoor environments; and, -Applying pesticides as needed. Insect habitats are characterized by warmth, moisture, and availability of food. II. Observations/resident interviews: On 8/27/24 at 9:50 a.m. room [ROOM NUMBER] was observed. The resident who resided in the room was lying in bed. The resident was swatting flies away from his face. On 8/27/24 at 9:55 a.m. room [ROOM NUMBER] was observed. One of the residents who resided in the room was sitting on the end of his bed and his roommate was sleeping. Flies were observed throughout the room flying on or around the residents' faces. There was a fly glue ribbon hanging from the ceiling. The fly trap was full of dead flies. On 8/27/24 at 9:57 a.m. room [ROOM NUMBER] was observed. Flies were observed throughout the room landing on resident's personal items, such as drinking cups. On 8/27/24 at 10:00 a.m. room [ROOM NUMBER] was observed. The resident who resided in the room was lying in bed with flies landing on his head and face. On 8/27/24 at 10:04 a.m. room [ROOM NUMBER] was observed. The resident who resided in the room was sitting on her bed and was swatting flies away from her face. The room had two glue fly ribbons on each side of the room. The fly traps were full of dead flies. On 8/27/24 at 10:07 a.m. room [ROOM NUMBER] was observed. Flies were observed throughout the room landing on the residents' personal belongings. On 8/27/24 at 10:12 a.m. room [ROOM NUMBER] was observed. The room had two glue fly ribbons hanging from the ceiling. The glue traps were full of flies. On 8/27/24 at 10:16 a.m. room [ROOM NUMBER] was observed. The resident who resided in the room was lying in bed sleeping with flies landing on his head and pillows. The resident had a drinking cup on his dresser with dead flies in the bottom of the glass. On 8/27/24 at 10:21 a.m. room [ROOM NUMBER] was observed. Flies were observed throughout the room landing on personal items. On 8/27/24 at 10:35 a.m. room [ROOM NUMBER] was observed. The resident who resided in the room was eating her breakfast and swatting flies away from her food. The resident said the flies were terrible but they were even worse when it was hotter. She said they got on her face and her food and they were just a bother. On 8/27/24 at 10:42 a.m. room [ROOM NUMBER] was observed. Flies were observed throughout the room landing on the resident who resided in the room and his personal belongings. The resident said the flies were a problem because they were all over the place. On 8/27/24 at 10:55 a.m. room [ROOM NUMBER] was observed. Flies were observed throughout the room landing on personal items of the resident who resided in the room. The resident had a fly swatter at the foot of his bed. The resident said the flies were the worst, especially since they got on his food. On 8/27/24 11:00 a.m. room [ROOM NUMBER] was observed. Flies were observed throughout the resident's room landing on the personal items of the resident who resided in the room. The resident said the flies were a problem but felt like the flies were only in his room. III. Building observations Throughout the survey (8/27/24 to 8/29/24) flies were observed in all areas of the secure unit and long term care living environment of the facility. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 8/28/24 at 11:20 a.m. RN #1 said the flies had been getting worse ever since the area had been getting a high amount of rain. She said the flies were mainly in the residents' rooms. Licensed practical nurse (LPN) #1 was interviewed on 8/28/24 at 11:40 a.m. LPN #1 said the flies had been getting worse in the secure unit. She said staff had been trying to keep the main doors closed to try to keep the flies from coming into the building. Housekeeper (HSK) #1 was interviewed on 8/28/24 at 11:58 a.m. HSKP #1 said the flies had been a problem and they seemed to be getting worse. She said facility staff tried not to let the doors stay open for any long periods of time but it was hard to keep them closed with the residents frequently going in and out. LPN #2 was interviewed on 8/29/24 at 8:59 a.m. LPN #2 said the flies seemed to be in the residents' rooms much more than anywhere else in the building. She said the facility had a blue light in the dining areas and that appeared to keep the flies out of the dining room. LPN #2 said the flies were bad in the residents' rooms. She said some residents' families got the residents fly swatters for their rooms. The maintenance supervisor (MS) was interviewed on 8/28/24 at 11:06 a.m. The MS said the flies were a problem because of the area the facility was located in. He said the weather had also been a factor in the increase of flies. He said the facility had placed glue fly traps in three rooms. He said the fly traps were high enough to be out of the residents' way and they were supposed to be changed regularly. The MS said the fly traps should have been changed monthly or as needed when they were full of dead flies. The NHA was interviewed on 8/29/24 at 8:40 a.m. The NHA said he was not aware of the fly issues in the facility but he would look into it.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for residents in 28 of 55 resident rooms. Specifically, the facility failed to ensure: -The walls, ceilings, baseboards and floors were properly maintained; -The resident's rooms were cleaned and free of mice feces, flies; and, -The wooden handrails in the hallways were cleaned and free of wood splinters. Findings include: I. Observations Observations of the resident's living environment were conducted on 8/27/24 at 9:44 a.m. and revealed the following: room [ROOM NUMBER]: The ceiling had three missing 12 inch by 12 inch tiles. The walls had several sections approximately four inches in circumference on the wall next to the bathroom. The resident had a five drawer dresser in the corner of his room with each drawer containing dried mice droppings. The floor was sticky. There were tissues and other trash under the resident's bed. room [ROOM NUMBER]: The wall next to the bathroom had chipped and peeling plaster approximately 14 inches high by four inches wide. The floors were sticky and there was a strong odor of urine. The window blinds had four broken slats with seven missing slats close to the bottom of the blinds. The ceiling tiles outside of room [ROOM NUMBER] had a large water stain approximately 48 inches long by 50 inches wide. room [ROOM NUMBER]: The bottom of the baseboard next to the bathroom was missing. The resident had a five drawer dresser, which had mice droppings in all of the drawers. There were three unpainted areas next to the bathroom approximately three inches in circumference. The floors were sticky and had not been cleaned, with remnants of spilled liquids. room [ROOM NUMBER]: There was a puddle of urine underneath the resident's bed. The walls in the room had five areas of unfinished repair work. The five drawer dresser had mice feces in all drawers. room [ROOM NUMBER]: The wall north of the sink had five areas of chipped and peeling paint. There were two other large chips above the sink approximately three inches in circumference. The ceiling had approximately six 12 inch by 12 inch tiles missing. The baseboard cover, which covered the joint between the wall and the floor next to the bed, was missing a section approximately 24 inches long by four inches wide. The floor was dusty, had dried urine stains, was cluttered and had debris underneath the beds. room [ROOM NUMBER]: The resident room had several areas of white repair work on the green wall which had not been completed. The floors were sticky and stained with urine. room [ROOM NUMBER]: The wall next to the bed was missing a section of the baseboard that was approximately 12 feet long by four inches wide. The wall had deep scratches. The corner edging, which protected the corners from damage, was missing a section which was approximately five feet high by four inches wide. The lights above the residents' beds had chipped and peeling paint approximately four feet long by six inches wide. The hand sanitizer next to the door had an area surrounding it that was approximately 12 inches long by six inches wide of chipped paint. The floor in the whole room was cluttered with trash, food packages, tissue and an empty plastic cup. room [ROOM NUMBER]: The wall underneath the sink had an area approximately 30 inches by 29 inches of bubbling paint from water damage. There were 10 areas of unfinished hole spackled repair work next to both beds. The corner wall next to the bathroom had chipped and cracked paint approximately 12 inches high by eight inches wide. The floors were sticky with urine stains. The floor in the whole room had dirt accumulation and was cluttered with debris underneath the beds. room [ROOM NUMBER]: The wall which the light fixture was mounted to had chipped and peeling paint approximately four feet long by six inches wide. The walls above both of the beds had chipped and peeling paint approximately five inches in circumference. The corner strip on the wall was missing a section which was approximately five feet high by four inches wide. The five drawer dresser had mice feces in all of the drawers. The floors were sticky with remnants of spilled liquid. room [ROOM NUMBER]: The wall behind the resident's bed was damaged from the bed being lifted and lowered. The wall which the light was mounted to had chipped and peeling paint approximately four feet long by six inches wide. The baseboard cover, which covered the joint between the wall and the floor, was missing next to the bathroom. There was a large chipped area approximately 10 inches long by five inches wide next to the door. The floor had an accumulation of dirt and was sticky from liquid being spilled. room [ROOM NUMBER]: The floors were stained with urine and sticky and the bathroom had a strong odor of urine. room [ROOM NUMBER]: The wall next to the closet had chipped and missing plaster approximately 12 inches high by six inches wide. The floors were sticky and had dirt build up under the bed. room [ROOM NUMBER]: The wall next to the door had an area approximately eight inches high by four inches wide of chipped and peeling plaster. There were several areas of chipped and peeling paint next to the sink. The window next to the resident's bed had a large piece of plywood covering the window. The floor was sticky and had remnants of spilled liquid. room [ROOM NUMBER]: The wall next to the bathroom had chipped and peeling plaster approximately six inches high by four inches wide. The wall behind the dresser had an area approximately 24 inches by 24 inches wide which had chipped and peeling paint. The room had a strong odor of urine. The floors were sticky and stained with urine. The resident had a five drawer dresser. There was mice feces in all of the drawers. room [ROOM NUMBER]: The room had a strong odor of urine. The floors were sticky and stained with urine. There was urine around the base of the toilet. The resident had a five drawer dresser. All of the drawers had mice feces. The floor was cluttered with used tissues, empty plastic cups and plastic silverware was underneath the beds. room [ROOM NUMBER]: The lights above the residents' beds had chipped and peeling paint approximately four feet long by six inches wide. The floors were dirty and sticky. The wall next to the dining room was missing a section of wood railing approximately eight feet long. room [ROOM NUMBER]: The air conditioner was not working and had a large amount of dust on the outside of the unit. The wall next to the resident's bed had four dime sized holes with an outline of the electrical system approximately 32 inches high by two inches wide when it was removed. The room was cluttered and the floors were sticky. room [ROOM NUMBER]: The wall next to the bathroom had chipped and peeling paint approximately 24 inches high by three inches wide. The floors were sticky and there was a strong odor of urine in the room. room [ROOM NUMBER]: The wall next to the resident's bed had three areas approximately three inches in circumference which had not been repaired. The floors were sticky and had remnants of spilled juice. room [ROOM NUMBER]: The room had approximately 14 areas of spackled hole repair work next to the resident's bed. room [ROOM NUMBER]: The room had several exposed glue traps on the floor with several large bugs on them. room [ROOM NUMBER]: The wall next to the bathroom had three dime sized holes and peeling paint. The wall next to the door had an area approximately six by three which was unpainted. room [ROOM NUMBER]: The floors had an accumulation of dirt built up with dust mites underneath the bed. room [ROOM NUMBER]: The window blinds were broken with six broken slats and approximately six slats missing and the floors were sticky with urine stains. room [ROOM NUMBER]: The floors were sticky and water stained. room [ROOM NUMBER]: The floors were sticky and had an accumulation of dirt and urine stains. There was a strong odor of urine in the bathroom. room [ROOM NUMBER]: The floors were sticky. There was a strong odor of urine and there were urine stains on the bathroom floor. The floor had chipped tiles approximately 12 inches by 12 inches. room [ROOM NUMBER]: The floors were sticky with remnants of spilled liquid. The hallway next to room [ROOM NUMBER] had damaged floor tile approximately 12 feet long by 12 inches wide. The shower room on the south hall had approximately 18 12 inch by 12 inch ceiling tiles missing. The sheetrock on the walls had water damage and repair had not been completed. The hand rail from room [ROOM NUMBER] to room [ROOM NUMBER] was dirty and sticky and had chipped and splintering wood. The plastic rail bracket was broken with sharp edges between room [ROOM NUMBER] and room [ROOM NUMBER]. The shower room on the south hall had approximately 18 12 inch by 12 inch ceiling tiles missing. The sheetrock on the walls had water damage and repair had not been completed. The maintenance closet had a glue trap with several large bugs in it. The wall next to the dining room was missing a section of wood railing approximately eight feet long. II. Environmental tour and staff interview The environmental tour was conducted with the maintenance supervisor (MS) on 8/28/24 at 11:06 a.m. The above detailed observations were reviewed. The MS said the facility utilized work orders as well as a computer system to identify environmental issues. The MS said he did not have work orders for the damage identified during the environmental tour. The MS said repairs should have been repaired and addressed in a timely manner. The MS said the mice were an ongoing problem. He said with the bad weather, the mice were coming into the facility. He said the building was old and the heat vents gave mice easy access to the facility. The MS said housekeeping had initiated a new program called safety culture. He said the program had been going on for about two months and he was hoping it would result in a better cleaning system. The nursing home administrator (NHA) was interviewed on 8/29/24 at 8:40 a.m. The NHA said he was not aware of the fly issues in the facility but he would look into it. He said the facility did have a mouse problem, but he said he did not know it was an ongoing issue. He said the mice dropping should have been cleaned with the cleaning schedule and he was surprised the droppings were still there. He said the residents were always spilling and making a mess on the floors in both units. He said cleaning these spills was an ongoing battle.

Based on observations, record review and interviews, the facility failed to ensure residents received proper respiratory treatment and care for three (#3, #2 and #7) of four residents reviewed for supplemental oxygen use out of 10 sample residents. Specifically, the facility failed to: -Administer oxygen in accordance with the physician's order for Resident #3 and #2; and, -Ensure a physician's order was in place for Resident #7's continuous use of oxygen. Findings include: I. Facility policy The Oxygen Administration Policy, revised October 2010, was provided on 8/29/24 at 10:47 a.m. by the corporate consultant (CC). It read in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. II. Resident # 3 A. Resident status Resident #3, age 74, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included depression, delusional disorder, chronic obstructive pulmonary disease (COPD). According to the 7/17/24 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. The resident had no upper or lower body impairment. The assessment did not identify the resident used oxygen. B. Observations and interviews On 8/28/24 at 4:00 p.m. Resident #3 was observed in the hallway sitting in her wheelchair with her oxygen nasal cannula on and connected to a portable oxygen concentrator. The resident's portable oxygen concentrator was set on 2 LPM. Resident #3 said she had been out of her room since lunch. She said she could not remember when anyone checked her portable oxygen concentrator last. At 4:00 p.m. registered nurse (RN) #2 was asked to check the resident's oxygen saturation level (measure of oxygen in the blood) and the resident's portable oxygen concentrator. RN #2 checked Resident #3's oxygen saturation level which read 90 % (percent). RN #2 checked Resident 3's portable oxygen concentrator. RN #2 said the portable oxygen concentrator was empty. RN #2 wheeled the resident into her room and placed the resident on her room's oxygen concentrator. RN #2 exited the resident's room and proceeded to take the portable oxygen concentrator to fill it up with oxygen. At 4:10 p.m. Resident #3 said, No wonder I was feeling a little loopy. C. Record review The care plan, initiated 3/22/21 and revised 8/25/24, identified the resident had oxygen therapy related to ineffective gas exchange due to COPD and impaired respiratory status related to hypoxia (low levels of oxygen in the body's tissues). Interventions included evaluating for signs and symptoms of respiratory distress and reporting to medical doctor (MD) as needed (respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough and, pleuritic pain). The August 2024 CPO included a physician's order dated 5/13/24 for the continuous use of oxygen at 2 liters per minute (LPM) via nasal cannula. D. Staff interview RN #2 was interviewed on 8/28/24 at 4:15 p.m. He said oxygen was a medication. RN #2 said Resident #3's oxygen concentrator was usually filled up in the morning and staff refilled all residents' portable oxygen concentrators again in the afternoon. RN #2 said a negative outcome for having an empty portable oxygen concentrator would be hypoxia and confusion. III. Resident #2 A. Resident status Resident #2, age 70, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included chronic respiratory failure whether with hypoxia or hypercapnia (too much carbon dioxide in the blood), schizoaffective disorder, bipolar, COPD. According to the 6/4/24 MDS assessment, the resident had severe cognitive impairment with a BIMS score of six out of 15. The resident had no behavioral symptoms. The assessment indicated the resident received oxygen therapy. B. Observation On 8/27/24 at 11:35 a.m. Resident #2 was sleeping with his nasal cannula on. His oxygen concentrator was at the foot of his bed and was set at 2 LPM. -However, the physician's order indicated the resident should be receiving 3 LPM of oxygen (see record review below). On 8/28/24 at 11:20 a.m. Resident #2 was lying in bed watching television in his room. He was wearing his nasal cannula with his oxygen concentrator set at 2 LPM. -However, the physician's order indicated the resident should be receiving 3 LPM of oxygen (see record review below). C. Record Review The care plan, initiated 6/3/23 and revised, on 8/1/24, identified the resident had altered respiratory status, difficulty breathing/ shortness of breath (SOB) related to COPD, chronic respiratory failure, unspecified and asthma. Interventions include providing oxygen as ordered. -The August 2024 CPO included a physician's order dated 7/27/23 for the continuous use of oxygen at 3 LPM via nasal cannula to maintain an oxygen saturation level at or above 88% percent. D. Staff interview RN #1 interviewed on 8/28/24 at 11:20 a.m. RN #1 said oxygen was a medication. She said Resident #2 was supposed to be on 3 LPM of oxygen continuously. RN #1 said she adjusted Resident #2's oxygen to 3 LPM per the physician's order, instead of 2 LPM. She said a negative outcome of receiving the wrong amount of oxygen could be the resident getting confused and hypoxic. IV. Resident #7 Resident #7, age 69, was admitted on [DATE] and readmitted on [DATE]. According to the August 2024 CPO, diagnoses included respiratory arrest, schizoaffective disorder, bipolar, COPD, acute respiratory failure with hypoxia, major depression. According to the 7/4/24 MDS assessment, the resident had no cognitive impairment with a BIMS score of 15 out of 15. The resident had verbal behaviors directed at others. The assessment indicated the resident received oxygen therapy. C. Record review The care plan, initiated 8/1/23 and revised 7/22/24, identified the resident had COPD related to smoking. The resident was encouraged to wear his oxygen and stated that staff were idiots and he did not need his oxygen. Interventions included administering 10 LPM of oxygen continuously as the resident allowed, observing for difficulty breathing on exertion, and reminding the resident not to push beyond his tolerated endurance. -The August 2024 CPO did not include a physician's order for oxygen. C. Observation On 8/27/24 at 10:35 a.m. Resident #7 was sleeping in his room. The resident was wearing an oxygen nasal cannula and an oxygen concentrator was next to his dresser and set to 3 LPM. On 8/28/24 at 8:50 a.m. Resident #7 was lying down in his bed. The resident was wearing an oxygen nasal cannula and his oxygen concentrator was set at 3 LPM. D. Staff interview Licensed practical nurse (LPN) #1 was interviewed on 8/29/24 at 9:00 a.m. LPN #1 said oxygen was a medication and required a physician's order. LPN #1 checked her computer to verify the physician's order for oxygen for Resident #7. She said Resident #7 did not have a physician's order for his oxygen. She said the resident should have had a physician's order to receive oxygen. V. Additional staff interview The assistant director of nursing (ADON) was interviewed on 8/29/24 at 12:13 p.m. The ADON said oxygen was a medication. She said staff should be checking all portable oxygen concentrators for all residents to ensure they were not empty. She said staff should ensure all oxygen was being administered in accordance with the physician's orders and all residents who were on oxygen should have a physician's order in place for the use of oxygen. The ADON said a negative outcome from not being administered oxygen when ordered could be altered mental status, dizziness, falls and hypoxic events. She said not receiving the correct amount of oxygen could put the residents in respiratory distress.

Based on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for one (#13) of three residents reviewed for accidents/hazards out of 28 samples residents. Resident #13 had been evaluated and determined to be a supervised smoker, which included she was not able to keep smoking supplies with her. The supplies were to be kept and monitored by the facility. During the scheduled smoke breaks, the facility would provide the resident with the cigarette and light the cigarette with a lighter. On 3/29/24 at 12:30 a.m. certified nurse aide (CNA) #8 heard screams coming from Resident #13's room. When she went in the room to check on Resident #8 she found the dressing on her lower left leg on fire. CNA #8 yelled for help and put out the fire with a towel and water. Resident #8 was transferred to the emergency department (ED) where it was determined she had first and second degree burns. Upon investigation and a care conference with the family, it was determined that, during a family visit, a family member had left a lighter with the resident. The facility failed to implement safety procedures to prevent a family member from providing a lighter to a supervised smoker. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/15/24 to 4/18/24, resulting in the deficiency being cited as past noncompliance with a correction date of 4/2/24. I. Incident on 3/29/24 The facility failed to ensure Resident #13, who had been assessed and determined to be a supervised smoker who's smoking supplies were to be kept locked up by the facility, did not have a lighter in her personal possession. This resulted in Resident #13 attempting to use a lighter she had obtained from her family to burn a dangling thread off of a bandage on her leg in her room on 3/29/24. Due to the facility's failures, the bandage on Resident #13's leg caught on fire. CNA #8 was able to smother the bandage fire with a towel, however, Resident #13 was transferred to the hospital on 3/29/24 where she was discovered to have first and second degree burns to her leg. Record review and interviews during the complaint investigation confirmed the deficient practice had been corrected and the facility was in substantial compliance at the time of the survey from 4/16/24 to 4/17/24. II. Facility correction A. Immediate action The corrective action plan the facility implemented in response to Resident #13's lighter accident on 3/29/24 was provided by the director of nursing (DON) on 4/17/24 at 12:00 p.m. On 3/29/24 a sweep of the supervised smokers for lighters was completed. No lighters were found. On 3/29/24 staff were re-educated on safe smoking practices, ensuring supervised smokers did not have lighters and the facility smoking policy. B. Systemic changes On 3/29/24 the social services assistant (SSA) completed an audit of all the smokers to re-determine if the smoker was supervised or unsupervised. The facility implemented smoking aprons for all smokers regardless of smoking status. On 3/29/24 the facility reached out to families to provide education on the importance of not providing smoking supplies to the smoking residents. Families were educated to give the smoking supplies to the nurses. On 3/29/24 the one unsupervised smoker in the facility was re-educated on the importance of keeping control of his lighter and not giving it to supervised smokers. The unsupervised smoker was receptive to the re-education understanding the severity of the situation and agreed not to share his lighter with supervised smokers. On 3/29/24 housekeeping staff were educated to be more critical and observant for lighters when in a smoker's room. Education included, if a lighter was found, it was to be given to the nurse on duty immediately. On 3/29/24 nursing staff were educated if staff turned in a lighter from a supervised smoker to notify the DON. On 3/30/24 Resident #13 was moved to a different hall with more staff monitoring. Resident #13 was provided with a vape pen in lieu of cigarettes and the vape pen supplies were kept locked up by the facility. On 4/2/24 the facility completed a care conference with the family. During the conference, the family admitted they had given Resident #13 the lighter. The resident's family was educated on the importance of not providing the resident with a lighter. C. Monitoring On 3/29/24 audits of smokers were started and continued weekly to ensure lighters were not in the possession of supervised smokers and if found, family education was conducted. All audits and education were to be reviewed during weekly interdisciplinary team (IDT) meetings and during monthly quality assurance and performance improvement (QAPI) meetings. Interviews and record reviews during the recertification survey revealed corrective actions to identify the resident and other residents having the potential to be affected by the deficient practice, systemic changes to prevent its recurrence and monitoring to ensure sustained correction were in place. III. Resident status Resident #8, age younger than 65, was admitted on [DATE] and readmitted on [DATE]. According to the April 2024 computerized physician's order (CPO), diagnoses included hemiplegia on the right side, cerebral infarction (stroke) on the right side and need for assistance with personal care. The 3/1/24 minimum data set (MDS) assessment documented the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 10 out of 15. The assessment identified the resident had impairment on one side (right) and she utilized a wheelchair for mobility. She required one to two staff members for transfers. IV. Record review The care plan, initiated on 3/1/24, identified Resident #8 had impaired cognitive function. Interventions included to keep her routine consistent. The care plan, initiated on 3/12/24, identified Resident #8 was a supervised smoker. Interventions included notifying the charge nurse if the resident violated the facility smoking policy, observing the resident's clothing and skin for signs of cigarette burns, conducting a smoking assessment quarterly and as needed and smoking materials were to be kept by staff. The smoking safety screen assessment dated [DATE], documented the resident needed supervision for smoking which included supervised smoking with the staff, a smoking apron and the facility holding her smoking materials. The progress note dated 3/29/24 at 2:21 a.m. documented CNA #8 heard screams coming from Resident #8's room at 12:30 a.m. When she ran into the room she saw the dressing on Resident #8's leg was in flames. CNA #8 smothered the flame with a towel then doused the area with water. The dressing was removed. The provider was notified at 12:40 a.m. The assistant director of nursing (ADON) was notified at 12:45 a.m. The resident was transported by ambulance to the hospital at 1:16 a.m. The progress note written by registered nurse (RN) #4 on 3/29/24 at 5:01 a.m. documented the discharge report was taken from the ED nurse and the resident returned back to the facility with a kerlix (gauze) wrap intact to her lower left leg and it was clean and dry. The hospital records dated 3/29/24 documented Resident #8 was reportedly trying to burn a string hanging from her previous dressing when she lit her entire bandage on fire. The hospital identified the injuries as first and second degree burns. The hospital visit note dated 3/29/24 documented the nursing home staff said the resident had a lighter. The facility was unsure how she had one. The resident was reportedly trying to possibly burn a string on her previous dressing when she lit her entire dressing on fire. CNA (#8) was able to use a towel to put out the flames and the resident's wounds were soaked in cool water. On arrival to the ED, the resident had mid lower extremity circumferential first degree burns with a few second degree burns. The progress note written by RN #3 on 3/29/24 at 3:46 p.m. documented the wound to her lower left leg was 13.0 centimeters (cm) by 20 cm around the circumference of her ankle. The affected area appeared to be blistered to the medial (inner) aspect. Silvadene was applied as the ordered treatment regimen. She had been receiving ibuprofen 600 milligrams (mg) and had not complained of breakthrough pain. The progress note written by the wound care nurse (WCN) dated 3/29/24 at 8:24 p.m. documented the wound on the resident's shin was 13.2 cm by 10.8 cm by 0 cm. There was scant serous (pale yellow or transparent) drainage without odor. The provider note date 4/1/24 documented Resident #13 burned the bandage on her leg which apparently then erupted in flames. From the description given by staff, there seemed to be a loose thread hanging from the bandage and due to her extremely poor judgment and executive dysfunction, she decided to burn the dangling thread. Resident #13 was not able to foresee that the burning thread would soon burn the bulk of the bandage. She was sent to the emergency room where she was treated physically, as this did not appear to be a suicide attempt or a serious attempt at self harm. V. Interviews The nursing home administrator (NHA) was interviewed on 4/16/24 at 5:27 p.m. The NHA said after the resident was transported to the hospital, the staff completed a sweep of all the supervised smokers to ensure they did not have a lighter. He said immediately the facility decided all smokers would have to wear a smoking apron. He said the facility called the family and after a conversation about the resident burning herself, the family had admitted to leaving the lighter with the resident. The facility, along with the family, had decided to make all visits with the family supervised, and moved the resident to another hall. He said the family was educated on the importance of not providing supervised smokers with a lighter to ensure the safety of everyone. CNA #6 was interviewed on 4/16/24 at 5:29 p.m. She said when she was the staff member to go out with the supervised smokers, she walked around them during the break ensuring all the aprons were on correctly. She said all the supervised smokers used an apron. She said she did not know if during family visits if Resident #13's family would take her out for a cigarette without staff. She said the management were the people who determined if someone was a supervised smoker. She said the smoking supplies, including the lighter, were locked up at the nurses station. She said only the nurses had a key to the cigarettes. RN #2 was interviewed on 4/16/24 at 5:37 p.m. RN #2 said the residents had set times for smoking. He said the times were posted at the nurses station where the residents could see. He said he would delegate a CNA to assist the residents to the smoking area where they would ensure the oxygen was removed. He said the CNAs assisted the residents to the smoking area, put on the aprons, and handed them a cigarette and lit the cigarette for the resident. RN #2 said residents were not allowed to save the cigarette if they did not finish it and they were not given the lighter to light the cigarette themselves. He said Resident #13 was a supervised smoker. He said sometimes it was noted the family would come by and go outside to the smoking area to smoke with her. He said it was during one of those times that the family gave the resident the lighter. He said the smoking assessments were completed by social services. He said the smoking supplies were locked up in the medication room. CNA #3 was interviewed on 4/17/24 at 8:45 a.m. CNA #3 said she was new to the facility. She said she knew Resident #13 had a burn from an accident and knew she was a supervised smoker. She said she used a vape pen, not cigarettes. She said she had received education on smoking safety recently but could not recall the date. She said the smoking supplies were kept locked in the medication room and only the nurse could get them for the designated smoke breaks. CNA #4 was interviewed on 4/17/24 at 8:50 a.m. CNA #4 said she had not seen Resident #13's family visit since her room change. She said she knew there was an accident with a lighter and now she used a vape pen instead of a cigarette. She said right after the accident the facility did training on smoking and the use of lighters with supervised smokers and how the supervised smokers were not allowed to have a lighter. She said all the smoking supplies were locked in the medication room and only the nurse could get the smoking supplies. Licensed practical nurse (LPN) #2 was interviewed on 4/17/24 at 8:52 a.m. LPN #2 said since Resident #13 had moved to the new room, the family had not been over for a visit while she was there. She said she knew Resident #13 had an accident and now she used a vape pen instead of a cigarette during the scheduled smoke breaks. She said the facility completed training on smoking safety right after the incident. She said supervised smokers were not allowed to have a lighter, and if one was discovered with a supervised smoker, the charge nurse was to be notified immediately and to ask the individual if they could give it up, but not to fight with them. CNA #7 was interviewed on 4/17/24 at 9:10 a.m. CNA #7 said at the smoking times, the residents all lined up to go out. On their way outside, an apron was put on them. She said she would light the cigarettes and watch all of them to make sure they did not burn themselves. She said if they did not finish the cigarette, it was thrown away and the resident was not allowed to save it for the next break. She said residents were not allowed to light their own cigarettes. She said all the smoking supplies were locked at the nurses station in the medication room and only accessed by the nurse on duty. She said all staff were told if a lighter was found with a supervised smoker, to take it and report immediately to the charge nurse. On 4/17/24 at 10:30 a.m. wound care was completed with the wound care nurse practitioner (WCNP). She said the burn was a partial thickness burn (second degree) and it had improved from first treatment. CNA #1 was interviewed on 4/17/24 at 1:02 p.m. CNA #1 said seven to eight months ago a lighter was discovered with Resident #13. He said he reported it to the charge nurse who was no longer at the facility. He said she went and talked to Resident #13 and was able to retrieve the lighter. He said he did not know if the charge nurse told anyone. LPN #1 was interviewed on 4/17/24 at 1:02 p.m. LPN #1 said Resident #13 was found to have a lighter seven to eight months ago. He said he reported it to the charge nurse. He said the charge nurse had a good relationship with Resident #13. He said she talked to Resident #13 and was able to retrieve the lighter and educate the resident. He said he did not know if it was reported to the DON or not. The DON was interviewed on 4/17/24 at 1:30 p.m. She said Resident #13 was trying to burn off a stray thread and lit the bandage around her leg on fire. She said the staff put out the fire with a towel and then water. She said the RN cut off the bandage and called the provider and an ambulance. She said the resident went out to the hospital and returned with first and second degree burns. She said immediately the staff did a search of the supervised smokers for lighters and none were found. She said that day (3/29/24), the SSA started reinforcing the training on smoking safety with the staff, starting with the staff who were present. She said the facility determined all supervised smokers would use an apron going forward. She said Resident #13 was moved to another unit. She said during the care conference on 4/2/24 with the family, it was the family who said they had provided Resident #13 with the lighter. She said the facility and the family, after a lengthy conversation, mutually agreed to have supervised visits with the family during visits if smoking was involved. The facility provided education to the family about smoking and supervised smoking. The facility and family also agreed to use a vape pen for Resident #13. The facility determined the vape pen would be kept with the smoking materials and given during the smoking breaks and returned at the end of the break. The DON said education was immediately started with the staff and a sweep was completed of all the supervised smokers to ensure no other lighters were found for the safety of all the residents. She said the housekeeping staff were to do visual inspection of supervised smokers rooms keeping a lookout for lighters going forward. The DON said she had never been notified before the accident that the resident had ever had a lighter in her possession.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure the kitchen was clean and sanitary; and, -Ensure food was held at appropriate temperatures. Findings include: I. Ensure kitchen staff prepared and served food in a sanitary environment in the main kitchen. A. Facility policy and procedure The Sanitation policy, revised November 2022, was provided by the dietary supervisor (DS) on 4/18/24 at 11:45 a.m. It read in pertinent part, The food service area is maintained in a clean and sanitary manner. All kitchens, kitchen areas, and dining areas will be kept clean, free from garbage and debris. All equipment, food contact surfaces, and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. All utensils, counters, shelves, and equipment are kept clean, maintained in good repair, and are free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use. B. Observations During the initial tour of the kitchen on 4/15/24, beginning at 8:30 a.m. and ending at 9:15 a.m., the following was observed: -There was chipped paint and there was dust on the surface on the shelf below the three compartment sink. -There was dust and debris buildup on the exposed plumbing pipes, around the hand-washing sink and on top of the dishwashing machine. -The outside of the kitchen steamer was covered with dark greasy substances. -There was dirt and grime build up on the wall under and around the hand-washing sink located at the left side of the cooking area. On a follow-up visit to the kitchen on 4/17/24 at 11:30 a.m. the following was observed; -There was the same chipped paint and the shelf below the three compartment sink with items on it were covered in dust. -There was dust and debris build up on the exposed plumbing pipes, around the hand-washing sink, and on top of the dishwashing machine. -The outside of the kitchen steamer was covered with dark greasy substances. -There was dirt and grime build up under and around the hand-washing sink located at the left side of the cooking area. C. Staff interviews The dietary supervisor (DS) was interviewed on 4/17/24 at 2:34 p.m. The DS said there were areas in the kitchen where the facility could do better cleaning. He said it was important to maintain a clean food preparation area to avoid any foodborne illness. The DS said without a clean and sanitary kitchen environment the facility was at risk for contamination of food and food preparation surfaces. II. Food temperatures of cold and hot food items were not held at the proper temperature A. Tray line observation During a continuous observation on 4/17/9/24, beginning from 12:05 p.m. and ending at 2:00 p.m. the lunch meal service was observed from the tray line on the secured unit. Dietary aide (DA) #1 took the initial holding temperatures of the hot foods on the steam table and the cold foods were in a plastic bowl with ice cubes underneath the bowl in the serving area. DA #1 took food temperatures again at the end of the lunch service. The food holding temperatures did not hold to safe levels throughout the lunch service. The temperatures of the foods at the end of the service revealed: -The country fried steak was 116 degrees fahrenheit (F); -The mechanical soft country fry steak was 82 degrees F; -The puree vegetables were 96 degrees F; -The puree steak was of 90 degrees F; -The chocolate pudding was 67 degrees F. -The potato salad was 48 degrees F. -The temperatures taken at the end of service were outside the correct safe temperature zone to prevent foodborne illness. B. Staff interview DA #1 was interviewed on 4/17/24 at approximately 1:45 p.m. DA #1 said the food should be held on the steam table at 165 degrees F for hot foods and cold foods should be below 41 degrees F. He said he did not think the steam table was functioning properly. DA #1 said it was important to ensure the food items being served remained in the safe temperature zone to avoid contamination and the growth of harmful bacteria which could get the residents sick. The DS was interviewed on 4/17/24 at 2:34 p.m. The DS said he would complete a maintenance work order for maintenance to work on the steam table on the locked unit. He said it was important to ensure food items remained in the safe temperature zone to avoid harmful bacteria growth which could cause illness and serious health issues for the residents. The DS said he would ensure lids were utilized to help keep the food warm.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five of five staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #9, CNA #11, CNA #12, CNA #13 and CNA #14. Findings include: I. Record review CNA #9 (hired on 3/13/18), CNA #11 (hired on 7/1/16), CNA #12 (hired on 4/22/22), CNA #13 (hired on 5/7/21) and CNA #14 (hired on 7/1/16) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Staff interview The director of nursing (DON) was interviewed on 4/16/24 at 2:23 p.m. The DON said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of these reviews. She said going forward she would ensure the performance reviews were completed annually to ensure best care was being delivered to the residents.

Based on record review and interviews, the facility failed to notify the provider according to physician orders for one (#29) of three residents reviewed for unnecessary medications out of 28 sample residents. Specifically, the facility failed to notify and document Resident #29's elevated blood sugar levels to the provider as directed on the physician's order. Findings include: I. Facility policy and procedures The Diabetic Care Policy, revised November 2020, was provided by the director of nursing (DON) on 4/18/24 at 11:20 a.m. The policy read in pertinent part, The physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters into the medication administration record and care plan. II. Resident #29 A. Resident status Resident #29, over the age of 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included type II diabetes mellitus with diabetic autonomic polyneuropathy (occurs when there is damage to the nerves that control automatic body functions), chronic obstructive pulmonary disease, hyperlipidemia, and anxiety disorder. The 1/25/2024 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required staff supervision for bed mobility, grooming, toileting, and transfers. The resident had no behaviors. The assessment documented the resident received insulin and injections for seven days during the seven-day assessment look back period. B. Record review The physician's order dated 7/27/23 at 7:45 p.m. revealed to check blood glucose via finger stick at bedtime for diabetic maintenance. If blood glucose is less than 60 mg/dl (milligrams/deciliter) or greater than 350 mg/dl, notify the medical provider . The physician's order dated 2/28/24 at 9:31 a.m. revealed to administer Basaglar Kwikpen subcutaneous solution (insulin glargine) pen-injector 100 units/ml (milliliter). The physician's order dated 3/7/24 at 9:33 a.m. revealed to administer Trulicity Subcutaneous Solution pen-injector 4.5 milligrams (mg)/0.5 ml in the morning every Saturday for diabetes mellitus. A review of the March 2024 medications administration record (MAR) from 3/1/24 to 3/31/24 revealed the following: On 3/2/24 Resident #29's blood sugar was 430 mg/dl, which was above the parameter of 350 mg/dl set in the physician's order; On 3/3/24 Resident #29's blood sugar was 438 mg/dl, which was above the parameter of 350 mg/dl set in the physician's order; On 3/5/24 Resident #29's blood sugar was 421 mg/dl, which was above the parameter of 350 mg/dl set in the physician's order; On 3/8/24 Resident #29's blood sugar was 444 mg/dl, which was above the parameter of 350 mg/dl set in the physician's order; On 3/11/24 Resident #29's blood sugar was 480 mg/dl, which was above the parameter of 350 mg/dl set in the physician's order;. On 3/12/24 Resident #29's blood sugar was 445 mg/dl, which was above the 350 mg/dl set in the physician's order; On 3/13/24 Resident #29's blood sugar was 425 mg/dl, which was above the 350 mg/dl set in the physician's order; On 3/15/24 Resident #29's blood sugar was 484 mg/dl, which was above the 350 mg/dl set in the physician's order; On 3/16/24 was Resident #29's blood sugar was 505 mg/dl, which was above the 350 mg/dl set in the physician's order; On 3/17/24 was Resident #29's blood sugar was 402 mg/dl, which was above the 350 mg/dl set in the physician's order; On 3/18/24 Resident #29's blood sugar was 404 mg/dl, which was above the 350 mg/dl set in the physician's order; On 3/19/24 Resident #29's blood sugar was 398 mg/dl, which was above the 350 mg/dl set in the physician's order; On 3/20/24 Resident #29's blood sugar was 407 mg/dl, which was above the 350 mg/dl set in the physician's order; On 3/22/24 Resident #29's blood sugar was 37 .mg/dl, which was above the 350 mg/dl set in the physician's order; and, On 3/24/24 Resident #29's blood sugar was 437 mg/dl. A review of the April 2024 MAR (4/1/24 to 4/18/24) revealed the following: On 4/12/24 Resident #29 blood sugar was 392 mg/dl, which was above the 350 mg/dl set in the physician's order;. On 4/13/24 Resident #29's blood sugar was 418 mg/dl, which was above the 350 mg/dl set in the physician's order;. On 4/15/24 Resident #29's blood sugar was 416 mg/dl, which was above the 350 mg/dl set in the physician's order, and On 4/17/24 Resident's #29's blood sugar was 391 mg/dl, which was above the 350 mg/dl set in the physician's order. -A 45 day record review revealed Resident #29 had elevated blood sugar levels 19 times out of the 45 days and there was no documentation to indicate staff notified the physician. The care plan, initiated 8/7/22, revealed Resident #29 had limited physical mobility related to type II diabetes mellitus. The interventions included evaluating the resident, documenting and reporting to the physician, administering medications as ordered. The care plan revealed the resident was noncompliant with her diabetic diet. III. Staff interviews Registered nurse (RN) #1 was interviewed on 4/18/24 at 9:40 a.m. RN #1 said the dates reviewed on the resident's MAR revealed the resident insulin levels were elevated above the parameters indicated on the physician's order. She said there should be documentation in the resident's medical record that indicated the physician was notified. RN #1 said nurses should follow physician orders and inform the provider when results were over the physician's parameters. She said since there was not documentation indicating the physician was notified that Resident #29's blood sugar was not within parameters that indicated it did not happen. She said insulin parameters were important because the resident might have experienced high blood sugar levels which could require the physician to adjust the amount of insulin to administer. She said not notifying the physician for the proper dose of insulin could cause serious health complications. RN #1 said the resident could experience shock and have an increase in symptoms related to her diagnosis. The director of nursing (DON) was interviewed on 4/18/24 at 10:21 a.m. The DON said the dates reviewed on the resident's MAR revealed the resident's blood glucose levels were elevated above the parameters on the physician's order and the staff should have notified the provider and documented in the nursing progress note. The DON said there was no documentation indicating the physician was notified. She said she expected the staff to inform the physician and document in the resident's medical chart of the action taken. The DON said failing to notify the physician of elevated blood glucose levels could have serious health issues leading to death. The DON said she would educate nursing staff to ensure they followed the physician's orders and documented their actions. She said she would inform the physician to incorporate the insulin parameters with the insulin order to prevent such errors in the future.

Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) for one (#8) of five residents reviewed for ADL care out of 28 sample residents. Specifically, the facility failed to ensure Resident #8 received oral and personal hygiene daily. A. Resident status Resident #8, age 67, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included acute embolism and thrombosis of unspecified deep veins of right lower extremity (blood clot), unspecified fracture of lower end of right tibia (larger bone of the two lower leg bones) and multiple sclerosis (deterioration of the nerves). The 12/1/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set-up or clean up assistance with oral hygiene and eating. She required partial/moderate assistance with personal hygiene, showering/bathing and upper body dressing. B. Resident interview and observations Resident #8 was interviewed on 4/15/24 at 10:53 a.m. Resident #8 said the staff did not offer for her to wash her hands and face in the morning when she woke up. She said the staff did not bring her toothbrush for her to brush her teeth in the morning. She said it was important for her to have her oral hygiene completed in the morning because it made her feel complete. Resident #8 was interviewed again on 4/16/24 at 4:07 p.m. Resident #8 said she was not provided with oral and personal hygiene this morning (4/16/24). She said her care provider came to visit her this afternoon and wrote a note that stated, Morning and night give Resident #8 her pink basin with warm water and fresh washcloth daily for personal hygiene. The note was posted on the bathroom door. The resident said she was only provided with her toothbrush to brush her teeth last night (4/15/24). She said her face and hands were not washed before getting ready for bed. Resident #8 was interviewed again on 4/17/24 at 2:37 p.m. Resident #8 said staff did not provide her morning hygiene. She said she spoke with the nursing home administrator (NHA) this morning (4/17/24) and showed him her sign. She said the NHA said it was a great idea and he said he was going to work on it. She said when she was not provided with morning hygiene it made her feel incomplete for the day. She said it made her feel bewildered and surprised that oral and personal hygiene were not completed in the morning. Resident #8 said she did not let staff know about wanting her oral and personal hygiene done in the morning because she did not want to upset the staff. She said her care provider had voiced the concerns to staff. She said she was hoping the staff would look at the note and she would not have to say anything. C. Record review The activities of daily living (ADL) care plan, dated 11/25/23, documented Resident #8 had an ADL self-care performance deficit. The interventions included personal hygiene, providing moderate assistance by one staff with personal hygiene and oral care, encouraging the resident to participate to the fullest extent possible with each interaction, encouraging the resident to use her call bell to call for assistance and praising all efforts at self-care. The comprehensive care plan, dated 4/17/24 (during the survey), documented Resident #8 preferred to have her showers on Monday, Wednesday and Friday mornings. She liked to have a warm basin of water and wash cloth provided upon awakening to wash her face off and to promote independence in doing so. The interventions included offering showers in the morning on her preferred shower days. D. Staff interviews Registered nurse (RN) #3 was interviewed on 4/18/24 at 9:56 a.m. RN #3 said Resident #8 required set up assistance with her toothbrush and was able to brush her teeth on her own. He said when staff got her the supplies she was able to do everything on her own. He said ADL care should be provided every day. He said the certified nurse aides (CNA) were responsible for providing oral and personal hygiene care to the residents. He said the CNAs should be providing oral and personal hygiene every morning when the resident got up. He said Resident #8 should have received personal and oral hygiene care every morning. CNA #5 was interviewed on 4/18/24 at 10:13 a.m. CNA #5 said residents should be provided with personal and oral hygiene daily. He said he was responsible for providing personal and oral hygiene to the residents. He said Resident #8 required set-up assistance for personal hygiene as she was able to wash her own face. He said Resident #8 should be provided with personal and oral hygiene every day, however, he said he had never provided personal and oral hygiene for Resident #8. The DON was interviewed on 4/18/24 at 10:54 a.m. The DON said the CNAs were responsible for providing personal and oral hygiene for all the residents. She said personal and oral hygiene was part of the CNAs job duties. She said providing personal and oral hygiene should be done everyday. She said she spoke with Resident #8 on 4/17/24 (during the survey process) and put in an order to put her basin at her bedside upon awakening. She said Resident #8 required extensive assistance due to her physical functional ability. She said Resident #8 had good days and tried to be independent and other days she needed more help.

Based on observations, record review and interviews, the facility failed to ensure one (#40) of three residents out of 28 sample residents who required respiratory care were provided such care and services consistent with professional standards of practice. Specifically, the facility failed to ensure Resident #40's supplemental oxygen was on the correct ordered liter flow per the physician's order. Findings include I. Facility policy and procedure The Oxygen administration policy, revised October 2010, was received from the director of nursing (DON) on 4/18/24 at 11:40 a.m. It read in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify there is a physician order for this procedure. Documentation in medical records includes: rate of oxygen flow, route, frequency, and duration. Notify the supervisor if the resident refuses the procedure. Report other information in accordance with facility policy and professional standards of practice II. Resident #40 A. Resident status Resident #40, under the age of 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included type I diabetes mellitus, low vision, chronic obstructive pulmonary disease (COPD), end stage renal disease, and chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues). The 3/13/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He required supervision with personal hygiene, dressing, bed mobility, transfers, toilet use, and set-up assistance with eating. The assessment documented the resident required continuous oxygen therapy. B. Observations and resident interview Resident #40 was interviewed on 4/15/24 at 11:13 a.m. He was on 3 liters per minute (LPM) of oxygen. He said the physician had ordered continuous oxygen at all times at 2 LPM. Resident #40 was observed on 4/16/24 at 12:31 p.m. on 3 LPM of oxygen via nasal cannula. The resident was observed on 4/17/24 at 2:05 p.m. on 3 LPM of oxygen via nasal cannula. The resident was observed on 4/18/24 at 9:30 a.m. in his room on 3 LPM via nasal cannula. C. Record review The April 2024 CPO revealed a physician's order dated 3/7/24 for 2 LPM of oxygen via a nasal cannula. The oxygen care plan, revised 5/6/21, revealed the resident had oxygen therapy related to ineffective gas exchange due to chronic obstructive pulmonary disease (COPD). The care plan indicated the resident was on continuous 3 LPM of oxygen. -The resident' s comprehensive care plan did not match the physician' s order of 2 LPM. D. Staff interviews Registered nurse (RN) #1 was interviewed on 4/18/24 at 9:40 a.m. RN #1 said Resident #40 received supplemental oxygen via nasal cannula at 2 LPM. RN #1 reviewed Resident #40's physician orders and said the physician' s order indicated for the resident to receive 2 LPM via nasal cannula RN #1 verified the resident' s oxygen concentrator was at 3 LPM and adjusted the liter flow per minute to 2 LPM as the physician' s order specified. RN #1 took his finger pulse oximetry (a tool used to check the oxygen levels in the blood) to ensure he had an oxygen saturation (oxygen blood level) above 90%. Resident #40's pulse oximetry level was 92% on 2 LPM. The DON was interviewed on 4/18/24 at 10:51 a.m. The DON said residents receiving oxygen should have a physician's order in place. She said the orders should include the rate of oxygen, routes like a nasal cannula or mask and frequency of intermittent or continuous. She said staff should be monitoring the resident's pulse oximetry to ensure they were maintaining oxygen saturation above 90%. The DON said oxygen use should be included on the resident' s comprehensive care plan according to the physician' s order. The DON said failure to follow the physician' s order could result in oxygen toxicity which could cause a variety of health complications leading to death. The DON said she would re-educate the nursing staff to monitor and ensure they were following the physician' s order for oxygen therapy and ensuring the care plan and the physician' s order for oxygen matched. E. Facility Follow-up The DON provided an updated care plan for Resident #40 on 4/18/24 at 1:45 p.m. The care plan update reflected the right amount of oxygen as indicated on the physician' s order. It documented the resident would sometimes titrate his oxygen concentrator and the facility had notified the physician.

Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in two of two medication carts. Specifically, the facility failed to: -Discard an expired Anoro inhaler; -Date an Anoro inhaler when opened; and, -Date a Lantus insulin pen when opened. Findings include: I. Professional reference According to the Anoro inhaler manufacturer's guidelines, retrieved on [DATE] from https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Anoro_Ellipta/pdf/ANORO-ELLIPTA-PI-PIL-IFU.PDF, Discard Anoro Ellipta 6 (six) weeks after opening the foil tray or when the counter reads '0', whichever comes first. According to the Lantus insulin pen manufacturer's guidelines, retrieved on [DATE] from https://products.sanofi.us/lantus/lantus.html#section-15, Storage conditions for the 3 ml (milliliter) single patient use solostar pen in-use (opened) 28 days room temperature only. II. Observations and interviews On [DATE] at 3:30 p.m. the west medication cart was observed with registered nurse (RN) #2. The medication cart contained two Anoro inhalers. One inhaler was expired with an open date of [DATE] and one inhaler was not dated with the date it was opened. RN #2 said he did not know the Anoro inhaler was expired and the second inhaler belonged to a resident who had just moved rooms to his hall. He said it was important to date the inhalers when they were opened to ensure the medication was effective and safe. On [DATE] at 11:10 a.m. the south medication cart was observed with licensed practical nurse (LPN) #2. The medication cart contained an open Lantus solostar pen with no open date labeled on it. LPN #2 said she was not aware the insulin pen did not have an open date. She said it was important to date the insulin when it was opened to make sure it was safe to administer to the resident. III. Additional interview The director of nursing (DON) was interviewed on [DATE] at 11:40 a.m. The DON said it was important for all medications to be dated when opened and discarded when expired to ensure the medication was safe for the residents who received them.

Based on interviews and record review, the facility failed to ensure three (#2, #3 and #5) out of nine residents reviewed for abuse were kept free from abuse out of nine sample residents. Specifically, the facility failed to: -Prevent a resident-to-resident altercations between Resident #1 and #2; -Prevent a resident-to-resident altercation between Resident #3 and #4; and, -Prevent a resident-to-resident altercation between Resident #5 and #6. Findings include: I. Resident #1 A. Resident status Resident #1, age under 65, was admitted on [DATE] and discharged [DATE]. According to the April 2023 computerized physicians orders (CPO), diagnoses included delusional disorder, anxiety disorder and paranoid schizophrenia. The 2/15/23 minimum data set (MDS) assessment revealed the resident's mental status was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Physical and verbal behaviors were noted daily on the assessment. B. Record review The care plan, initiated 12/29/22 and revised on 2/17/23, identified the resident was a serious danger to self or others. Interventions included to attempt to redirect resident to another area of the unit when increased agitation was noted. The care plan, initiated 3/2/23, identified the resident suffered from schizophrenia with occasional physical aggression. Interventions included to redirect him to music with personal earbuds. II. Resident #2 A, Resident status Resident #1, age under 65, was admitted on [DATE] and passed away on 3/16/23. According to the March 2023 CPO, diagnoses included paranoid schizophrenia, obsessive compulsive disorder and depressive episodes. The 1/24/23 MDS assessment revealed the resident's mental status was cognitively intact with a BIMS score of 14 out of 15. No behaviors were noted on the assessment. III. Altercation on 2/15/23 The facility investigation included: On 2/15/23 staff reported Resident #1 told Resident #2 he owed Resident #1 $5.00. Resident #2 told Resident #1 he did not because he did not have $5.00. Resident #1 then hit Resident #2 on top of his head. No injuries noted and no reports of Resident #2 being afraid of Resident #1. The staff statement included, At about 11:40 a.m. after passing drinks, certified nurse aide (CNA) #3 went to the nurses station and could hear Resident #1 talk to Resident #2. As she walked into the dining room she heard Resident #1 ask Resident #2 about paying Resident #1 back his $5.00. Resident #2 said he did not have any money. When she turned the corner she saw Resident #1 make contact with an open hand on Resident #2's head. The residents were separated. Resident #2 had a staff member stay with him until he calmed down and was assisted back to his room to watch television per his request. Frequent rounding was completed. Resident #1 was provided resident focused activities by the activity aide who assisted him until transportation could arrive to transfer Resident #1 out to the hospital. The conclusion of the facility investigation substantiated Resident #1 hit Resident #2. IV. Resident #4 A. Resident status Resident #4, age under 65, was admitted on [DATE]. According to the November 2023 CPO, diagnoses included post traumatic stress disorder, psychoactive substance abuse and dementia. The 10/26/23 MDS assessment revealed the resident's mental status was cognitively intact with a BIMS score of 15 out of 15. No behaviors were noted on the assessment. B. Record review The care plan, initiated 8/4/17 and revised 2/19/23, identified the resident had a history of making sexually inappropriate comments/gestures toward staff and other residents. Interventions included: -Deter him from touching other's clothing for his safety as well as others. -Educate him on limits of keeping hands to himself as needed. -Staff are to provide close supervision when he was out of the room for meals, activities, or in hallways. The care plan, initiated 8/22/17 and revised on 2/17/23, identified the resident had a history of sexually inappropriate behavior of touching other males' penises. Interventions included: -Educate him on limits of keeping his hands to himself as needed. -Educate Resident #4 on respecting others boundaries and personal space. -Give generous, positive reinforcement for appropriate behavior. V. Resident #3 A. Resident status Resident #3, age 80, was admitted on [DATE] and discharged on [DATE]. According to the November 2023 CPO, diagnoses included dementia, vascular dementia and transient ischemic attack (TIA). The 8/21/23 MDS assessment revealed the resident's mental status was severely cognitively impaired with a BIMS score of three out of 15. No behaviors were noted on the assessment. VI. Altercation on 4/14/23 The facility investigation included: Resident #3 reported to the CNA of being touched inappropriately, on his private part over his clothes by another male resident (Resident #4). When Resident #4 was interviewed he stated he did touch Resident #3's crotch area. The facility conclusion to the investigation was that contact was made. VII. Resident #6 A. Resident status Resident 6, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the November 2023 CPO, diagnoses included dementia, schizophrenia and aphasia (difficulty with speech from brain damage). The 11/1/23MDS assessment revealed the resident's mental status was severely cognitively impaired and a BIMS was not completed. No behaviors were noted on the assessment. B. Record review The care plan, initiated 11/14/19 and revised on 6/4/21, identified the resident used psychotropic medications for schizophrenia with anxiety and dementia with behaviors. Interventions included to evaluate and document occurance of target behaviors symptoms and document. The care plan, initiated 10/3/22 and revised on 4/20/23, identified behaviors due to schizophrenia of verbal aggression. Interventions included to offer one to one activities daily. The care plan, initiated 4/17/23 and revised 7/10/23, identified the resident had the potential to be physically aggressive. Interventions included to document observed behavior and attempted interventions in behavior log, and observe, document, report as needed signs and symptoms of the resident posing a danger to self and others. VIII. Resident #5 A. Resident status Resident #5, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the November 2023 CPO, diagnoses included schizoaffective disorder bipolar type, Tourette's disorder (involves repetitive movements or unwanted sounds) and transient cerebral ischemic attack (TIA). The 8/31/23 MDS assessment revealed the resident's mental status was cognitively intact with a BIMS score of 14 out of 15. No behaviors were noted on the assessment. IX. Altercation on 5/16/23 The facility investigation included: CNA #4's witness statement included seeing Resident #6 walking up to Resident #5 really quick and hit him with a closed fist in his upper arm then took off quickly down the hall. Resident #5 denied any fear or pain. The facility found no injuries. The facility investigation conclusion documented there was no fear or harm intended. X. Interviews The director of nursing (DON) and the nursing home administrator (NHA) were interviewed on 11/13/23 at 2:35 p.m. The NHA said the altercations did happen and the facility had been working diligently to prevent any further abuse. She said it was important for all the residents to feel safe in their own home. She said the facility had increased staffing recently to include more activities staff, care coordinators and an additional social services staff. She said the facility had improved the behavior tracking and had an overall improvement with residents. She said all staff were encouraged to participate in care planning and meetings to help provide the best home for all the residents.

Based on record review and interviews, the facility failed to ensure level I and level II preadmission screening and resident review (PASRR) were completed for four (#31, #6, #64 and #68) out of 31 sample residents reviewed for PASRR to gain and maintain their highest practical medical, emotional, and psychosocial well-being. Specifically, the facility failed to: -Ensure Resident #31, with a known psychological disorder, was properly assessed with a PASRR level I assessment; -Ensure Resident #64 and #68 had a level II PASRR in place; and, -Follow level II PASRR recommendations for Resident #6. Findings include: I. Facility policy and procedure The PASRR completion policy, undated, was provided by the director of nursing (DON) on 12/28/22 at 3:50 p.m. It read in pertinent part, The facility will make sure that all admissions had the appropriate PASRR completed. The business office manager (BOM) must have copies of the PASRR in the business office resident file. II. Resident #31 A. Resident status Resident #31, under age 65, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), the diagnoses included paranoid schizophrenia, depressive episodes, and psychotic disorder with hallucinations. The 12/8/22 minimum data set (MDS) assessment revealed, the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. He had no behaviors and did not reject care. He required extensive assistance with most of his activities of daily living (ADLS). He received an antipsychotic daily. B. Record review Record review findings revealed no evidence that a PASRR level I or II was completed. The psychotropic medication care plan, initiated 9/23/22 and revised 11/30/22, documented the resident received psychotropic medication for a diagnosis of paranoid schizophrenia. The interventions included administering medications as ordered, monitor for side effects, consult with physicians to consider dosage reduction, discuss with family ongoing need for use of the medication, and review behaviors/interventions and alternate therapies attempted. C. Staff interviews The regional clinical consultant (RCC) was interviewed on 12/28/22 at 2:50 p.m. She said she was not able to find a PASRR level I for Resident #31. She said all new admissions should have a PASRR completed and she was not sure why one was not done for Resident #31. 43950 III. Resident #68 A. Resident status Resident #68, age 72, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), diagnoses included major depressive disorder, delusional disorders, anxiety disorder, hoarding disorder, and adjustment disorder with depressed mood. The 10/28/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance with one person for toilet use, personal hygiene, dressing, and bathing. She required limited assistance with one person for transfers, and walking in the room and corridor. The resident mood interview (PHQ-9) revealed a score of zero indicating no symptoms present. The behavior potential indicators of psychosis revealed delusions (misconceptions or beliefs that were firmly held, contrary to reality). No physical, verbal or other behavioral symptoms directed toward others. No rejection of care or wandering. Changes in behavioral symptoms, compared to prior assessment recorded as worse. She was coded as having a primary medical condition of non-traumatic brain dysfunction (damage to the brain by internal factors). Other coded active diagnoses included anxiety disorder, depression, and psychotic disorder. The resident received the following medications daily for seven days during the seven day review period: Antipsychotic, and antidepressant. She was identified as not being evaluated for a PASRR level II. B. Record review The PASRR level I screen, dated 4/19/21, revealed diagnosis of major depressive disorder and delusional disorders. There were no results or determination listed on the PASRR level I document as to whether a Level II was needed or required. There was no documentation of follow up by the facility. -Further documentation was requested from the facility on 12/28/22 at 10:49 a.m but not provided. The social services quarterly assessment dated [DATE] revealed PASRR level I completed, PASRR level II not completed. Review of the care plan related to depression revealed the resident had a potential for a decline in mood and was currently taking an antidepressant, initiated 3/24/21 and revised 4/15/21. Interventions included: administer antidepressant medications as ordered; encourage family involvement; encourage resident to express feelings of anger, frustration, and sadness; provide support and reassurance; encourage resident to attend activities of choice; notify social service of decline in mood as noticed; psychiatrist review upon admission, quarterly, and as needed; report signs or symptoms of depression, examples crying, tearfulness, withdrawal, changes in sleep pattern or appetite, and negative statements. Review of the care plan related to the resident's use of antidepressant medication related to depression, and mood disorder, date initiated 5/15/21. Interventions included administering antidepressant medication as ordered by the physician. Monitor/document side effects and effectiveness every shift. List non-pharmacological approaches to address depression. Monitor and record episodes of behavior per psychotropic policy. Monitor/document side effects for antidepressant therapy such as change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in activities of daily living (ADL) ability, continence, no voiding; constipation, fecal impaction, nausea, diarrhea; gait changes, rigid muscles, balance/movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, tremor, headache, anxiety, insomnia; appetite loss, weight loss, dry mouth, dry eyes, excessive sweating, fever. Review of the care plan related to behaviors due to reactive depressive disorder such as attention seeking and repetitive negative statements, date initiated 10/3/22. Interventions included to attempt these non-pharmacological interventions: reduce stimuli; provide meaningful activity; offer food; offer fluid; provide one on one validation; active listening; take for a walk; assist with calling friend/relative. C. Staff interview The social services director (SSD) was interviewed on 12/28/22 at 10:49 a.m. The SSD said she would look for further documentation regarding Resident #68's PASRR II since it was not uploaded to the chart and see if there was any other information regarding the PASRR level I and the recommendations. The SSD was interviewed on 12/29/22 at 10:01 a.m. She said that she did not have access to Telligen (the company that processes the PASRR), so she had not submitted any PASRR. The SSD said no one at the facility was processing the PASRRs. The SSD said she looked but could not find a PASRR level II for Resident #68 or any other PASRR level I information. 46849 IV. Resident #6 A. Resident status Resident #6, age 74, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), diagnoses included paranoid schizophrenia and chronic kidney disease. The 11/4/22 minimum data set (MDS) assessment documented the resident had a Level II preadmission screening and resident review (PASRR) for a serious mental illness. It also revealed that the resident had no cognitive impairments with a brief interview of mental status (BIMS) score of 15 out of 15. B. Record review The care plan dated 12/7/22 documented that the resident had a diagnosis of paranoid schizophrenia. It documented that the resident was to receive counseling as allowed/tolerated and was to be reviewed by the psychiatrist quarterly and as needed. Review of the resident's Level II PASRR dated 12/6/21 documented the resident had indicated to the evaluator that she would like mental health services. She also shared with the evaluator she had a history of inpatient psychiatric hospitalization s and had recently been homeless due to her untreated mental illness. The evaluator's recommendations to the facility were to obtain case and medication management from a mental health provider for the resident. The evaluator also concluded that the resident met the PASRR mental illness conditions. The social services progress notes reviewed from 9/26/21 through 12/30/22 did not document that the facility had reached out to a mental health provider to establish services. Review of progress notes for the facility's psychiatrist revealed he had never met with the resident. Review of the December 2022 CPO failed to show an order for the resident to be seen by the psychiatrist or the psychologist that provided services at the facility. V. Resident #64 A. Resident status Resident #64, age 74, was admitted on [DATE]. According to the December 2022 CPO, diagnoses included schizophrenia, panic disorder, major depressive disorder, unspecified dementia, post-traumatic stress disorder, and dissociative and conversion disorder. The 10/13/22 MDS section indicating if the resident had a Level II PASRR screen for a serious mental illness was not completed. It also revealed the resident had moderate cognitive impairment with a BIMS score of eight out of 15. B. Record review The care plan dated 12/10/22 revealed the resident was taking antidepressant medication for a diagnosis of dementia. No other mention of mental illness in the care plan. The social services progress notes were reviewed from 4/29/22 through 12/30/22. The progress notes did not reveal that a PASRR had been requested from her prior facility nor that a PASRR had been submitted by the current facility. The notes revealed that the social services director had not requested any mental health records from the prior facility. There was a note dated 5/25/22 that the resident had shown increases in behaviors but the physician nor the psychiatrist were notified. Review of progress notes for the facility's psychiatrist show revealed he never met with the resident. Review of the December 2022 CPO showed an order dated 4/26/22 for a consultation with the facility psychiatrist. The psychiatrist wrote an order dated 11/30/22 requesting that the facility obtain the resident's prior facility PASRR, psychology and neuropsychology records. -The facility failed to obtain the resident's prior PASRR. VI. Administrative interviews The social services director (SSD) was interviewed on 12/29/22 at 9:54 a.m. She said she had only been working at the facility for a month and a half and had not yet been trained on completing PASRRs. She said she did not think PASRRs had been completed. She said she did not know which residents needed a PASRR evaluation and did not have access to the system. The DON was interviewed on 12/29/22 at 9:54 a.m. She said the facility had not had a steady social worker from September to November 2022 when the new SSD started. She said no staff at the facility had current access to the PASRR system. She said the SSD was responsible for completing the PASRR paperwork. The SSC was interviewed on 12/29/22 at 12:18 p.m. She said that there had been several changes to the social services department at the facility and they had not had a consistent social worker for eighteen months to two years. The current SSD was still being trained.

Based on interviews and record review, the facility failed to conduct testing in a manner that was consistent with current standards of practice for conducting COVID-19 tests for six (#74, #17, #9, #16, #73 and #56) of six residents reviewed out of 31 sample residents. Specifically, the facility failed to document in the resident records the results of COVID-19 tests for Resident #74, #17, #9, #16, #73 and #56. Findings include: I. Record review Six residents (#74, #17, #9, #16, #73 and #56) were reviewed for COVID-19 testing results from 11/1/22 to 12/28/22. The medical record/chart did not have the testing results. II. Staff interview The infection preventionist (IP) was interviewed on 12/28/22 at 2:16 p.m. He said the facility kept track of the testing results, however they did not have the negative results in the resident's charts. He said going forward the facility would enter the results into the resident's chart to be in compliance and for consistent documentation.

Based on observations, record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (#5 and #43) of five out of 31 sample residents. Specially, the facility failed to: -Provide person centered activities for Resident #5 and Resident #43, who resided on the secured unit; and, -Provide meaningful and engaging activities for residents residing on the secured unit. Findings include: I. Facility policy The Activities Program policy, undated, was provided by the director of nursing (DON) on 12/29/22 at 1:43 p.m. It read in pertinent part; Activity programs designed to meet the needs of each resident are available on a daily basis. At least four group activities are offered per day Monday through Friday. Individualized and group activities are provided that; -Reflect the schedules, choices, and rights of the residents -Are offered at hours convenient to the residents, including evenings, holidays, and weekends -Reflect the cultural and religious interest, hobbies, life experiences, and personal preferences of the residents -Appeal to men and women as well as those of various age groups residing in the facility. II. Resident #5 A. Resident status Resident #5, age 89, was admitted on [DATE] and resided on the secure unit. According to the December 2022 computerized physician orders (CPO), diagnoses included unspecified dementia, acute kidney failure, and adult failure to thrive. The minimum data set (MDS) dated [DATE] revealed that the resident had severe cognitive impairments with a brief interview of mental status (BIMS) score of three out of 15. The resident required extensive assistance from staff with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Her vision was marked as highly impaired with glasses. The resident was not able to walk and was unable to move on or off the secure unit without staff assistance. The 3/19/22 MDS assessment documented it was very important to the resident to participate in religious services, keep up with the news, and listen to music. B. Record review The dementia care plan dated 4/23/21 stated the resident had impaired cognitive function related to dementia. Interventions were to use approaches that maximize her involvement in daily decision making and activity. The activities care plan dated 11/8/22 documented that the resident had been blind and required assistance to attend scheduled group activities and one-on-one visits. Her areas of interest were being around others, conversing with others, and music. Her interventions stated if the resident was alone in her room, staff were to encourage and invite her to come to socialize with others. Review of therapeutic one-on-one activity progress notes dated 2/19/21 through 12/28/22 revealed that there had not been an one-on-one visit with the resident from the activities staff since 9/30/22. The 2/18/22 activity assessment documented that the resident continued to respond well to one-on-one social visits. She had been a passive participant in group activities due to her poor vision however she did enjoy sitting and listening. C. Resident observations Resident #5 was observed in her bed at 12:20 p.m. on 12/27/22. She was not observed outside of her room nor was the activities assistant (AA) observed going into the resident's room. There was an activity of reminiscing on the calendar 12/27/22. The resident was not offered or encouraged to go to the activity. Resident #5 was observed in her bed at 1:06 p.m. on 12/28/22. She was not observed outside of her room nor was the AA observed going into the resident's room. III. Resident #43 A. Resident status Resident #43, age 85, was admitted on [DATE] and resided on the secure unit. According to the December 2022 CPO, diagnoses included chronic obstructive pulmonary disease and unspecified dementia. The 10/31/22 MDS revealed that the resident had severe cognitive impairments with a BIMS score of zero out of 15. The resident required extensive assistance from staff with transfers, walking, dressing, toileting, and personal hygiene. Her vision was marked as adequate without assistive devices such as glasses. The resident was unable to move on or off the secure unit without staff assistance. The 8/9/22 MDS assessment marked that it was important to the resident to participate in religious services, receive time outside, do things with groups, listen to music, and keep up with the news. B. Record review The dementia care plan dated 10/6/21 stated the resident had impaired cognitive function related to dementia or impaired thought processes. Interventions were to provide the resident with consistent routines and allow her to spend time with family, go to church, or go for walks. The social services care plan dated 11/8/22 revealed that the resident had impaired vision and had prescription glasses. The resident frequently refused to wear them and needed specific interventions due to impaired vision. The activities care plan dated 10/23/22 documented that the resident had been an active participant in scheduled group activities and enjoyed church service. The resident required verbal reminders of groups throughout the day and enjoyed adult coloring in her leisure time. Her interventions stated staff were to invite and assist the resident to church services and group activities. Review of therapeutic one-on-one activity progress notes dated 6/3/22 through 12/28/22 showed that no one-on-one visits had occurred. The 11/4/22 activity assessment documented the resident had been an active participant in low stimulation small groups and required verbal reminders and assistance to attend ongoing groups. She enjoyed crafts, bible reading, reading mail, listening to the radio, bingo and conversing with staff and other residents. Staff were to continue to encourage participation in scheduled group activities. C. Resident observations On 12/28/22 at 1:06 p.m certified nursing aide (CNA) #11 and CNA #12 were observed sitting in the activities room. CNA #12 was using the computer while CNA #11 was on her cell phone. Three residents were sitting in the activity room to include Resident #43. Two other residents were observed pacing the hallway near the exit door. Resident #43 sat in her wheelchair in front of the television in the activities room. She was not wearing her prescription glasses. On 12/28/22 at 1:42 p.m. the AA arrived and invited three of the 12 residents on the secure unit to bingo. Resident #43 was not invited to bingo. Three other residents remained and paced the hallway near the exit door. CNA #11 put on a western movie in the activity room for the remaining residents without providing any additional activity choice. Three residents, to include Resident #43, remained in the activities room but did not appear to be watching the television. Resident #43 was sitting in front of the television but was not wearing her glasses. IV. Additional observations Observations on secure unit 12/27/22 showed a lack of meaningful engaging activity for the residents residing in the secured unit. The activity board on the wall in the secure unit reflected that there were no group activities until 2:00 p.m on 12/27/22. At 9:18 a.m. five residents were observed pacing the hallways near the exit door. The behavioral health specialist (BHS) was observed at 9:30 a.m., 9:49 a.m., and 9:57 a.m. entering the secure unit. She walked from one end of the hallway to the other then exited the unit without engaging with the residents in a meaningful way. She did stop to ask one female resident if she wanted to participate in any activities that day but did not offer any activities of interest or inquiry from the resident what she would like to be offered. The resident declined. At 10:13 a.m. the AA invited two of the 12 residents on the secure unit to chair exercises in the activity room. At 1:50 p.m. the AA was observed changing the 2:00 p.m. activity from the painting craft to nails.'' She was continuously observed in the activities room painting one resident's nails from 2:00 p.m. until 3:42 p.m. The scheduled 3:00 p.m. activity of sorting was not conducted. Instead at 3:00 p.m, the AA took the resident whom she was painting nails outside for a cigarette break. They returned and resumed nails while five other residents sat in the activities room unoccupied. There was another female resident that had come into the activities room five times expressing verbal agitation between 3:00 p.m. and 3:30 p.m. asking what she was supposed to be doing and was not acknowledged by the AA. There were no observations on 12/27/22 of the staff setting up or encouraging activities for the residents. There were no observations of one-on-one therapeutic visits from the AA being provided to the residents that were inside or outside of their rooms. Observations on secure unit 12/28/22 The BHS was observed on 12/28/22 at 9:00 a.m. and 9:29 a.m. entering the secure unit. She walked from one end of the hallway to the other then exited the unit without engaging with the residents in a meaningful way. At 9:00 a.m. CNA #11 was speaking in the hallway to the BHS. A female resident approached them and was tearful expressing she needed to attend church. Both staff advised her that someone would be coming to take her to church service but the bible study was not on the calendar until 12/29/22. Neither staff stopped talking to offer an immediate alternative to the resident. The resident walked away still tearful. At 9:45 a.m. the AA came over to the secure unit and made changes to the activity calendar to remove the shopping outing with lunch and replace it with walk at 10:15 a.m. She then collected three of the 12 residents from the secure unit for a walk off of the unit. At 9:52 a.m. CNA #11 and CNA #12 were observed sitting in the activities room. CNA #12 was using the computer while CNA #11 was on her cell phone. During this time, one of the unit's female residents paced the hall by the exit door. A male resident who was also pacing the hallway near the door, walked very close to the female resident's face and she verbalized to him to leave her alone. He then walked away without incident however, the staff remained in the activities room nearby without noticing the interaction. On the long term care side of the building, the activity board reflected that bingo was scheduled for 1:30 p.m. At 1:36 p.m no residents had yet been invited from the secure unit. The activity calendar on the secure unit showed that there would be make Christmas cards at 1:30 p.m. on the unit. On 12/28/22 at 1:42 p.m. the AA arrived and took three residents to bingo on the long term care side of the building. At 2:25 p.m. the same two residents sat in the activities room in front of the western program with no other activity offered. There were no observations of staff setting up or encouraging activities for residents. There were no observations of one-on-one therapeutic visits from the AA being provided to the residents that were inside or outside of their rooms. V. Staff interviews CNA #11 was interviewed on 12/27/22 at 8:58 a.m. CNA #11 said the AA was their dedicated activity person for the secure unit. She verified there were no scheduled group activities on the secure unit for the day until 2:00 p.m. as reflected on the posted activity board. In between group activities provided by the AA, the CNAs on the unit had games that they had been provided to assist the residents with. The CNA was able to identify where the games were located and that there were several boxes of games on a cabinet in the activity room. She also stated they did not have activities on the secure unit before 10:15 a.m. because the residents were still sleeping. However, several residents had been observed out of their rooms on 12/27/22 from 9:18 a.m. through 10:13 a.m. and on 12/28/22 from 9:00 a.m. through 9:52 a.m. CNA #12 was interviewed on 12/28/22 at 10:07 a.m. CNA #12 said that the AA moved around the other units of the facility and was not really dedicated to the secure unit. She said that after the observations ended on 12/27/22 at 3:42 p.m., the AA had painted another resident's nails but could not say which resident. She also confirmed that the activity of sorting that had been scheduled at 3:00 p.m. and was canceled, not rescheduled. The activities director (AD) was interviewed on 12/28/22 at 2:31 p.m. She verified that the AA was the dedicated activity person for the secure unit. She said she should be on the unit providing group or one-on-one activities all day unless on her break or lunch. She said the AA should invite residents to activities off the unit and take the residents there. She said she had provided different games for the staff to offer to the residents when there was not a group activity scheduled. She was not aware the staff were not offering those games and she was not aware that the AA was not spending the majority of her time on the secure unit running group activities or providing one-on-one visits. She said the AA should have been doing those things on both 12/27/22 and 12/28/22. She stated that she would need to provide additional training to the AA of the expectation of the department. She acknowledged that she had not been checking on the activities on the secure unit. The director of nursing (DON) and the social services director (SSD) were interviewed with the regional clinical consultant (RCC) present on 12/29/22 at 9:55 a.m. The DON stated some residents had been placed on the secure unit due to needing the additional stimulation and activities provided by the unit. The DON said in regards to Resident #5, the resident was on the secure unit due to family preference and the facility had been unable to obtain consent from the family to move the resident off of the secure unit because the family enjoyed the increased staff supervision and activity stimulation. The DON said the staff on the secure unit should engage residents in activities of choice. She said when residents wandered the hallways and showed interest in the exit door, they were to be engaged in a meaningful activity by the staff and the AA. The DON said in regards to the resident who was tearful and requesting to attend church on 12/28/22, the staff should have stopped and offered to read the bible with her or offer another activity pertaining to her faith. She said she had not been checking on the stimulation or activities on the secure unit. The social services consultant (SSC) was interviewed on 12/29/22 at 12:18 p.m. She said as part of the psychosocial program of the secure unit, the residents would be taken off the unit as much as possible to engage with the other side of the building. The BHS was assigned the secure unit and was to engage with the residents as part of their stimulation.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as COVID-19 for two of three stations. Specifically, the facility: -Failed to ensure hand hygiene was performed between room cleaning; -Failed to sanitize hands between glove use; -Failed to don a gown prior to entering a COVID positive room; and, -Failed to ensure a COVID positive resident did not interact and expose non-COVID residents. Findings include: I. Professional reference According to the Centers for Disease Control (CDC) guidance, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 6/3/2020, retrieved on 9/7/22 from https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf. It read in pertinent part, -PPE must be donned correctly before entering the patient area. -PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted. -Face masks should be extended under the chin. -Both your mouth and nose should be protected. II. Facility policy The Handwashing/Hand Hygiene policy, revised August 2019, was provided by the director of nursing (DON) on 9/6/22 at 1:16 p.m. The policy included: Use an alcohol-based hand rub containing at least 62% alcohol; or alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: -After removing gloves. The Cleaning and Disinfecting Residents' Rooms policy, revised August 2013, was provided by the DON on 9/6/22 at 1:16 p.m. The policy included: General guidelines -Perform hand hygiene after removing gloves. The Personal Protective Equipment-Using Gowns policy, revised September 2010, was provided by the DON on 9/6/22 at 1:16 p.m. The policy included: Objectives -To prevent the spread of infections. III. Housekeeping observations and interviews Housekeeper (HSKG) #2 was observed on 9/6/22 at 10:15 a.m. cleaning rooms in the South hall. She completed cleaning room [ROOM NUMBER] and removed her gloves. She moved her cart to the doorway of room [ROOM NUMBER], and donned a new pair of gloves. She did not sanitize her hands between rooms. After completing room [ROOM NUMBER], she removed her gloves, placed a wet floor sign in the doorway or room [ROOM NUMBER], and moved the cart to the doorway of room [ROOM NUMBER]. She placed a new pair of gloves on, without performing hand hygiene in the doorway of 113. HSKG #2 was interviewed immediately after the observation and she said she did not sanitize her hands between glove use and between rooms. HSKG #1 was observed in the West hall on 9/6/22 at 11:36 a.m. She removed her gloves after finishing room [ROOM NUMBER] and did not sanitize her hands after. She moved her cart in front of the doorway to room [ROOM NUMBER]. She placed on a new pair of gloves. During the room cleaning/sanitization, she changed her gloves three times. She did not perform hand hygiene between glove changes. After the moping was completed, she removed her gloves and placed a sign in the doorway. HSKG #1 was interviewed immediately after the observation and she said she forgot to sanitize her hands between glove changes. IV. Donning PPE Certified nurse aide (CNA) #3 was observed entering a COVID positive resident room without a gown. She said she should have put a gown on. She said she was taking the breakfast tray to the roommate who was not positive. The curtain was drawn between the two sides of the room. She said the staff receive PPE training every day. She said she should have worn a gown to prevent the spread of COVID. V. COVID positive resident Resident #5 was observed walking outside on the sidewalk on 9/7/22 at 7:45 a.m. He walked to the main entrance of the West hall unit. He entered the code, donned a face mask, and entered the building. The resident identified himself as being COVID positive. He stated he took a walk everyday outside. He walked in front of a large fan blowing air from the entrance he had just entered from, becoming agitated, and walked down the hallway, in front of the nurses station, down the hallway of his room passing Resident #6 in the hallway. He was arguing with the therapy director (TD) as he was walking down the hallway. Resident #5 passed four rooms (two on either side of the hallway) to get back to his room. At 7:54 a.m. Resident #5 left his room, with a mask on, and went into the dining room and sat next to Resident #7. Resident #7 had been removed from isolation the previous day. At 7:57 a.m. the assistant director of nursing (ADON) talked to Resident #5. After the conversation, Resident #5 went to his room. He walked past Resident #6 again. Resident #5 and #6 had both been vaccinated. VI. Interview The director of nursing and the ADON were interviewed on 9/7/22 at 10:15 a.m. The DON said staff have had training on when to sanitize hands that included between glove use. She said it was important to sanitize hands to prevent the spread of infections. She said the staff had been trained to wear PPE when going into a COVID positive resident room. She said it was important to wear the proper PPE to prevent the spread of COVID. She said she would be working with the activities department to see how they could let the resident go for a walk while keeping the other residents safe from exposure to COVID. She said it was important to keep the COVID positive residents away from non-COVID residents to prevent the potential for spreading the infection. VII. Facility COVID-19 status The ADON was interviewed on 9/6/22 at 9:40 a.m. He said they had six COVID-19 positive residents.

Based on observations, record review and interviews, the facility failed to ensure that a resident who displayed or was diagnosed with mental disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for one (#5) out of 15 sample residents. Specifically, the facility: -Failed to develop person-centered individualized interventions for verbal aggression and non-compliance for Resident #7; and, -Failed to train staff on identified interventions. Findings include: I. Facility policy The Behavioral Assessment, Intervention and Monitoring policy, no revision date, was provided by the director of nursing (DON) on 9/7/22 at 1:00 p.m. The policy included in part, Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. Appropriate assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Assessment: -Any precipitating or relevant factors, or environmental triggers. Management: -The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. -Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. -Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. -How the staff will monitor for effectiveness of the interventions. II. Resident status A. Resident #5 Resident #5, age 67, was admitted on [DATE]. According to the September 2022 computerized physicians orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/1/22 minimum data set (MDS) assessment revealed the resident's cognitive status was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He had no identified behaviors or rejections of care during the assessment period. B. Record review The care plan, initiated 11/27/21 and revised 9/7/22, identified the resident would often be non-compliant with staying in his room and wearing a mask. Interventions included: -Resident #5 was encouraged to stay in his room and wear a mask; -Promote social distancing; and, -Resident to wear a mask in the room while staff present and when outside of the room in the facility. -The facility did not have a care plan or person-centered individualized interventions to address Resident #5's verbal aggression, or the psychosocial needs with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note dated 9/7/22 at 7:05 a.m. included, Resident #5 was educated on isolation and proper hand hygiene. Resident #5 was educated on staying in his room while on isolation. Resident (#5) often non compliant with care. The progress note dated 9/7/22 at 8:14 a.m. included, This writer spoke with this resident about his concerns with having to be in isolation due to being covid positive.This resident stated that he would like to be able to eat in the dining room still and go for walks. This writer educated this resident that while in isolation it is recommended that all meals are eaten in his room, however we would be able to schedule times to go for walks with activities dept (department).This resident agreed to that plan. The progress note dated 9/7/22 at 8:20 a.m. included, Resident #5 was approached by this nurse and by SSD (social service director) while sitting in the dining room. He was educated that while being covid positive he was to eat his meals in his room. Resident #5 verbalized understanding and agreed to go to room. Walked with SSD and nurse back to room. Resident #5 expressed concerns about being able to go for walks. Spoke with activities and made arrangements for staff to take him on walks throughout the day. Staff educated on encouraging Resident #5 to stay in room and wear a mask. The facility developed a pink sheet that included each resident's name, activities enjoyed, triggers, actions that might trigger others, and what may calm him. The identified activities listed: walks, talking with friends, shopping trips, and watching DVDs. The identified triggers: being told no. The identified actions listed that may trigger others: verbally aggressive at times, loud tones, and invasion of personal space. The identified activities that calm him: taking walks, one to one talks with staff, and activities. The behavior monitoring tracking form identified the targeted behaviors of [CONDITION(S)], rapid change in mood, and irritability. C. Observations Resident #5 was observed walking outside on the sidewalk on 9/7/22 at 7:45 a.m. He walked to the main entrance of the West hall unit. He entered the code, donned a face mask, and entered the building. The resident identified himself as being COVID positive. He stated he took a walk everyday outside. He walked in front of a large fan blowing air from the entrance he had just entered from, becoming agitated, verbally aggressive and yelling as he walked down the hallway, in front of the nurses station, and down the hallway where his room was located, passing Resident #6 in the hallway. He was arguing with the therapy director (TD) as he was walking down the hallway. Resident #5 passed four rooms (two on either side of the hallway) to get back to his room. At 7:54 a.m. Resident #5 left his room, with a mask on, and went into the dining room and sat next to Resident #7. Resident #7 had been removed from isolation the previous day. At 7:57 a.m. the assistant director of nursing (ADON) talked to Resident #5. After the conversation, Resident #5 went to his room. He walked past Resident #6 again. D. Interviews The TD was interviewed on 9/7/22 at 7:50 a.m. She said the staff were not going to make Resident #5 do anything he did not want to do. She said all the staff could do was to encourage him to stay in his room, but if the staff forced the issue, he would become upset. She said he would get amped up when not allowed to leave his room. Certified nurse aide (CNA) #6 was interviewed on 9/7/22 at 8:07 a.m. She Resident #5 had verbal outbursts all the time. She said she had not received any training on his behaviors and how to deal with him when he became upset. She said the only thing that worked was to call the DON and/or the ADON. CNA #3 was interviewed on 9/7/22 at 8:40 a.m. She said Resident #5 was an angry individual. She said he was allowed to go outside for walks. She said if he was not allowed, he would become verbally aggressive. She said she had not received any training on interventions when he became angry and verbally aggressive. Registered nurse (RN) #1 was interviewed on 9/7/22 at 12:10 p.m. She said when Resident #5 was asked to wear a mask he argued and blamed staff for making him wear one. She said he yelled and argued often. She said he threatened to call 911 when he became upset. She said she had not had any training specific to Resident #5 regarding interventions when he would have an outburst. She said she would call the DON and the ADON to talk to him. The SSD was interviewed on 9/7/22 at 12:30 p.m. She said interventions for Resident #5 would depend on the behavior. She said he became overwhelmed when told no. She said redirection worked well with him. She said he could calm down quickly. She said staff were to utilize the behavior tracking form required when a resident had behaviors. She said she had not developed person-centered interventions identifying the psychosocial impact of quarantine for COVID positive status. She said she had not provided staff on training for behaviors for Resident #5's outbursts. The DON was interviewed on 9/7/22 at 1:28 p.m. She said all the staff knew to read the pink sheets that identified interventions. She said Resident #5 could escalate and could possibly irritate the other residents. She said staff were trained on the pink sheets. She said staff need to know person-centered interventions for the best care for the resident.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in three of 21 resident rooms, and one of six bathrooms. Specifically, the facility: -Failed to have a functioning drain for the sinks in rooms 112 and 117; and, -Failed to have a functioning toilet for room 116. Findings include: I. Initial observations and interviews Observations of occupied resident living environment were conducted on 9/6/22 revealed: -At 10:15 a.m., room 112 had a plastic rectangular container in the sink below the faucet. Housekeeping (HSKG) #2 lifted the container to reveal dark stagnant water below the container. She said the sink had been backed up for a long time. -At 10:30 a.m., room 116 had do not enter signs attached to the bathroom door. In the bathroom, the toilet was full of waste. Certified nurse aide (CNA) #1 said she did not know the toilet was broken. She said the resident had another toilet available to her a couple of doors down the hallway. -At 10:34 a.m. room 117 had standing water in the sink that was not draining. CNA #1 said she did not know about the sink not draining. II. Administrative interviews The plant operations director (POD) was interviewed on 9/6/22 at 1:47 p.m. He said he was notified at 6:00 a.m. that morning of the sink in room 112 and the toilet in room 116. He said he was not aware of the sink issue in room 117. He said he had not received a work order. He said all staff were trained on how to submit a work order. He said he would repair the issues as soon as possible. He said all residents need to have functioning sinks and toilets. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed on 9/7/22 at 10:15 a.m. The DON said all staff were aware how to enter a work order. She said she was surprised the issues were not indicated on a work order. She said the residents need to have working facilities.

Based on record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#2) of two residents reviewed for hospice services out of two sample residents. Specifically, the facility: -Failed to allow hospice providers in the building to provide care as outlined in the care plan; -Failed to have a member of the interdisciplinary team (IDT) team who collaborated with hospice to provide coordinated care for a resident; and -Failed to orientate hospice aides to the facility including the policies and procedures. I. Facility policy The Hospice Program policy, provided by the nursing home administrator (NHA) on 3/3/22 at 3:32 p.m. included; Hospice providers who contract with this facility: are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. II. Resident #2 A. Resident status Resident #2, age 88, was admitted on [DATE]. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/18/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. She had no behaviors or rejections of care. The MDS identified hospice care. B. Record review The care plan, initiated on 9/3/21 and revised on 9/14/21, identified the resident was receiving hospice support for comfort treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospice care plan identified a hospice aide was to provide care twice a week, a licensed practical/vocational nurse (LPN/LVN) to provide visits three times a week, and a registered nurse (RN) to provide a supervisory visit for the hospice aides every 14 days. The progress note dated 1/25/22 at 11:12 a.m. identified that the hospice had a telehealth visit. The progress note dated 2/20/22 at 5:28 p.m. identified a phone conversation with the hospice and the facility regarding a medication change. The progress note dated 2/22/22 at 2:05 p.m. identified that the hospice had a telehealth visit. The progress note dated 3/1/22 at 11:00 a.m. identified that the hospice had a telehealth visit. The note also included Resident #2 would be discharged [DATE]. -The facility had no visit notes from the hospice aides. -The facility failed to allow the hospice aides, the hospice LPN/LVNs, and the hospice RNs in to provide care to Resident #2. -The facility did not have evidence of orientation to the hospice staff to include the facility's policies and procedures. -The facility did not have a member of the interdisciplinary team (IDT) team who collaborated with hospice to provide coordinated care for Resident #2. C. Interviews LPN #1 was interviewed on 3/3/22 at 10:10 a.m. He said when he had worked at a hospice provider a book was utilized for the visit notes. He said he did not know where Resident #2's book was. He said he did not know when the hospice providers were to visit. He said Resident #2 had moved to her room the previous day. He said he did not know much about her status. He said the facility was not letting anyone in due to the recent outbreak status. Hospice RN #1 was interviewed on 3/3/22 at 1:40 p.m. She the former nursing home administrator NHA) in mid-January 2022 had told hospice the facility was on outbreak status and would not allow the nurses or aides in. She said, if the facility said we are not allowed into the building, we cannot go in. She said hospice provided the facility with proof of vaccination, and the evidence of testing twice a week. The information was shared with the facility even when not going into the building. The hospice staff have their own PPE if needed. She said the facility told the hospice they preferred telehealth visits. She said hospice currently had one resident in the facility, however she (Resident #2) would be discharged on [DATE]. She said it was very difficult to communicate with the facility. She said none of the hospice staff had been orientated to the building to include the policy and procedures. She said no one knew who the hospice care coordinator was. She said hospice was still not allowed into the building. LPN #3 was interviewed on 3/3/22 at 2:40 p.m. She said since the outbreak, the facility would call the hospice and give them a report over the phone. She said it was the hospice policy not to go into buildings during an outbreak. She said the facility would call the hospice and notify them if there was any change of condition. She said she did not know who the hospice coordinator was. She said she thought it was the social service assistant (SSA) #1. SSA #1 was interviewed on 3/3/22 at 2:40 p.m. She said she thought nursing was responsible for coordinating care with hospice. The interim nursing home administrator (INHA) was interviewed on 3/3/22 at 3:00 p.m. She said the hospice staff have their own access to the electronic medical records for the individuals receiving hospice services. she said all nursing staff know to reach out to hospice at any time if there was a change of condition with Resident #2. She said the former NHA and the hospice staff did not always see eye to eye. When the facility went into outbreak, the former NHA asked hospice for telehealth visits. She said in the past the hospice coordinator was the social services director (SSD). She said the new SSD would be starting 3/4/22. She said to her knowledge the facility had not orientated hospice staff to the facility to include the facility policy and procedures. She said hospice had been informed they were allowed in the facility Hospice LPN (HLPN) #1 was interviewed 3/3/22 at 3:25 p.m. She said hospice was not allowed to do in-person visits. She said the visits were completed over the phone. She said the hospice staff had access to the electronic medical record of the hospice residents they were assigned to. She said the aides were not allowed in the building either.

Based on record review, interviews and observations, the facility failed to ensure one (#60) of three residents reviewed for post surgical wounds and monitoring out of 46 sample residents received treatment, care and monitoring in accordance with professional standards of practice. Specifically, the facility failed to monitor Resident #60's new post surgical wound and clinically monitor changes in vital signs timely for which she required rehospitalization . Resident #60 admitted to the facility on [DATE] and readmitted on [DATE] with an Intra-abdominal and pelvic mass (which required surgical repair with staples). The facility failed to monitor Resident #60's surgical site for infection for five days (from 9/5/21 to 9/10/21), Resident #60's wound dehisced (the wound had green/yellow discharge) and ultimately was sent to the emergency department and admitted for [CONDITION(S)] and septic shock, required intravenous (IV) antibiotics and an abscess draining procedure (see record review below). Findings include: I. Professional reference [NAME], R. D & Manna, B. (2021) Wound Dehiscence, pp. 1-13, retrieved on 9/27/21 from : https://www.ncbi.nlm.nih.gov/books/NBK 2/ it read, in pertinent part: Dehiscence is a partial or total separation of previously approximated wound edges, due to a failure of proper wound healing. This scenario typically occurs 5 to 8 days following surgery when healing is still in the early stages. The causes of dehiscence are similar to the causes of poor wound healing and include ischemia, infection, increased abdominal pressure, diabetes, malnutrition, smoking, and obesity. Superficial dehiscence is when the wound edges begin to separate and by increased bleeding or drainage at the site. The clinician should investigate the wound for worrisome signs, including infection or necrosis. Prompt identification is important for preventing worsening dehiscence, infection, and other complications. Evisceration is a complication of complete wound dehiscence, where intra abdominal organs herniate through the open wound. II. Resident status Resident #60, age 66, was admitted on [DATE], readmitted on [DATE] and discharged to the hospital on 9/10/21. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/6/21 admission minimum data set (MDS) assessment revealed the resident was mildly cognitively impaired with a brief interview for a mental status score of 11 out of 15. She required one person extensive physical assistance with walking on the unit, one person physical assistance with toileting and dressing and supervision with set up help for eating, bed mobility, transfers personal hygiene and bathing. III. Record review The care plan last updated on 8/10/21 did not have interventions or goals for the residents surgical incision. The 9/2/21 hospital discharge orders read the resident had a surgical incision to the lower middle abdomen after a total hysterectomy and tumor removal. The incision needed to be monitored, kept dry and clean and notify the provider about changes and signs or symptoms of infection. The 9/2/21 admission assessment to the facility read the resident was admitted with surgical incision to the midline of her abdomen with staples and it was open to air (did not have a dressing on it). -The record failed to indicate the facility had orders to monitor the surgical incision or other post surgical problems when she was readmitted to the facility. The 9/5/21 progress note read Resident #60 was a skilled resident and she did not have issues about her readmission to the facility from the hospital after her recent surgery. The 9/7/21 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no new orders for medications, treatments or laboratory requests reflected in the record. Her vital signs were documented as: temperature 98.2 degrees fahrenheit; respiratory rate 20 breaths per minute; heart rate 89 beats per minute; and blood pressure of 100 (systolic) over 80 (diastolic). The September 2021 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore, there was no documentation Resident #60 was being monitored from 9/5/21 to 9/10/21 (five days), post surgical care while she resided at the facility. The 9/10/21 progress note read the night shift nurse reported the resident had increased lethargy and the nurse attempted to administer medication at 3:30 p.m. the resident was cold and clammy and her vitals were obtained. Her abdominal incision started to dehisce (open) in the lower area and green/yellow discharge from the incision was seen. The 9/10/21 transfer form read the resident was discharged from the facility to the hospital because her blood pressure, heart rate and temperature were critically out of normal readings. Her vital signs were; Temperature 94.0 degrees fahrenheit; Respiratory rate 22 breaths per minute; Heart rate 123 beats per minute; and Blood pressure of 80 (systolic) over 40 (diastolic). -Resident #60's record did not have other documentation about her condition leading up to and including the reason for her transfer to the hospital. The 9/11/21 hospital admission records read Resident #60 was admitted to the inpatient critical unit (ICU) due to severe [CONDITION(S)] with septic shock from a post surgical intra abdominal abscess. She required intravenous antibiotics and an abscess draining procedure. Her midline surgical incision had staples and had some [CONDITION(S)] (red and swelling) and no significant drainage. IV. Interviews Certified nursing assistant (CNA) #13 was interviewed on 9/15/21 at 4:00 p.m. She said she worked with Resident #60 often and the day she went out to the hospital she was weak and was more sleepy and did not look good. She had a temperature of 100.8 degrees fahrenheit and it got better after she took medication. I let the nurse know she did not look good, she was pale and could not keep her head up. I was asked to take her vital signs and her blood pressure was really low and she was sent to the hospital right away. LPN #1 was interviewed on 9/15/21 at 4:30 p.m. She said she worked day shift from 6:00 a.m. to 6:00 p.m. She stated Resident #60 had an elevated temperature the last day she worked with her on 9/9/21 and before she left the facility at the end of her shift, her temperature was lowered with a dose of tylenol; however, she did not say how much she gave and there was no order documented in the record. The incision looked red however there was no drainage or other signs of infection. She reported to the night nurse about her elevated temperature. -LPN #1 said she did not document her wound findings or vital signs including fever in the resident's record as well as notification to the physician on 9/9/21 during her shift. The director of nursing (DON) was interviewed on 9/16/21 at 9:30 a.m. She confirmed Resident #60 did not have documentation about monitoring the recent surgical incision or skilled post surgical assessments as well as orders and care plans for the surgical incision from 9/5/21 to 9/10/21. -She said the nursing management team had since been provided education on order transcription and documentation of wounds including but not limited to surgical incisions. The physician was interviewed on 9/20/21 at 3:28 p.m. He stated Resident #60 had a massive surgical procedure to her abdomen on 8/30/21 then readmitted to the facility on [DATE] for skilled nursing care. She went back to the hospital on 9/10/21 when she began to decline and was admitted to the hospital for [CONDITION(S)] from an intraabdominal abscess in relation to her recent abdominal surgery. He expected the staff to monitor Resident #60 at a minimum of once a day for post surgical complications including monitoring the incision, an assessment and vital signs. He said he expected the staff to monitor the resident daily and report abnormal findings as needed until the resident had her follow-up surgical appointment (two week post surgery). He said staff should have transcribed Resident #60's discharge orders correctly to include monitoring of her incision. He said he ordered Tylenol for the resident when she had an elevated temperature on 9/9/21; however there was no order in the resident's record and this was not documented. He said he did not order blood laboratory tests because it would take about four days to have the sample taken and get the results back, even if he requested them emergently.

Based on observations, record review and interviews, the facility failed to ensure residents had the right to be free from physical abuse for four (#34, #62 #65 and #69) residents involved in three facility reported incidents on the South unit out of 46 sample residents. The facility failed to prevent an altercation between Resident #65 and Resident #34. Resident #34 was physically abused by Resident #65, which resulted in Resident #34 requiring hospital treatment where he received 12 staples to his head and medication for pain. Resident #62 was physically abused by Resident #34. Resident #34 pushed Resident #62's wheelchair into a wall resulting in Resident #62's bilateral lower extremities making contact with the wall. Resident #34 also made a comment he wanted to break Resident #62's legs. Resident #69 was physically abused by Resident #65 which in resulted in Resident #69 being shoved to the floor by Resident #65. Cross-reference F744, the facility failed to implement person centered approches to dementia care in order to prevent resident-to-resident altercations. Findings include: I. Facility policies and procedures The Abuse Prevention Program policy, dated 11/1/2017, was provided by the nursing home administrator (NHA) on 9/13/21 at 11:27 a.m. The policy revealed the residents have a right to be free from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. (1) The facility was committed to protecting the residents from abuse by anyone including but not necessarily limited to staff, other residents . (3) Comprehensive policies and procedures have been developed to aid the facility in preventing abuse, identification and reporting of abuse, stress management, and dealing with violent behavior or catastrophic reactions, ect. -Timely and thorough investigations of all reports and allegations of abuse, -The reporting and filing of accurate documents relative to incidents of abuse, -An ongoing review and analysis of abuse incidents, and -The implementation of change to prevent future occurrences of abuse. II. Altercation 7/23/21 A. Resident #34 status Resident #34, age 91, was initially admitted on [DATE] and was readmitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/12/21 minimum data set (MDS) assessment revealed the resident did not have a brief interview for mental status (BIMS) score. The resident did not have any behaviors. There was no evidence of an acute change in mental status or [CONDITION(S)]. The resident did have wandering tendencies that occurred daily. The resident required staff supervision for bed mobility, transfers, eating, and toileting. B. Record review Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan for potential abuse related to residing in a unit with residents who occasionally have behavioral disturbances was initiated on 4/29/2020. Some of the interventions were to redirect the resident from escalated residents by offering an activity of choice and/or a snack. Report any agitation/restlessness related to specific residents on the unit. When the resident desired to spend leisure time outside his room, direct the resident to the activity room that was away from the dining room. The care plan for the resident residing on the facility's secure unit for his safety and structure was revised on 4/22/21. The resident habitually wandered or would wander out of this environment and would be unable to find his way back to the facility, placing him in danger. His guardian consented to the secure unit placement. Some of the interventions were to assess the resident quarterly for the appropriateness of placement on the secure unit. Encourage the resident to participate in activities of choice and involve the resident/guardian in the resident's plan of care. The care plan for impaired cognitive function related to dementia was revised on 4/23/21. Some of the interventions were to face the resident when speaking and making eye contact. The resident understood simple, consistent and directive sentences. Reduce any distractions such as turning off the television, radio and closing the door as needed. A nurse note dated 7/23/21 at 5:43 p.m., by the director of nursing (DON) revealed at approximately 4:45 p.m., she received a call from the South Unit from licensed practical nurse (LPN) #2 that Resident #65 had made contact with Resident #34's head multiple times. This occurred in the main dining room and was witnessed by a certified nurse aide (CNA). The two residents were immediately separated and Resident #65 was put on one-to-one staff observations. Resident #34's vital signs and neurological assessments were initiated upon the DON's arrival. Resident #34's assessments were within his normal limits. The resident had abrasions to the top of the right and left side of his skull. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Also the order revealed to send Resident #65 to a named medical center for a psychological evaluation and treatment. A message was left for Resident #34's guardian. The local police department was called and a case number was issued. A nurse note dated 7/23/21 at 7:45 p.m., by LPN #2 revealed the resident left the facility at approximately 5:05 p.m., on a stretcher accompanied by three ambulance crew members and was transported by ambulance to the hospital. A nurse note dated 7/23/21 at 10:30 p.m., by a registered nurse (RN) revealed the resident arrived back to the facility at approximately 10:30 p.m. The resident was ambulatory, alert and oriented times three. The resident was accompanied by a staff member from the hospital. A report was given to this nurse. The resident was assessed and started on neurological assessments. The resident had 12 staples in his head with minimal bleeding. The on call provider was notified and orders were received. The wound was dressed as indicated and Tylenol was administered for his pain. The resident was educated to report any increased pain and any increased bleeding to the nurse. A nurse note dated 7/24/21 at 3:16 p.m., by LPN #2 revealed the resident removed the dressing to his head at mid-morning and refused to have it replaced. There was a scant amount of serosanguineous drainage. No signs or symptoms of pain or discomfort noted or reported. The resident was alert and oriented times three. The resident's neurological assessments were within normal limits. A nurse note dated 7/25/21 at 1:39 a.m., by an RN revealed the resident presented with a closed wound related to a resident to resident incident. The wound was dry and open to the air. The resident was educated about the need for wound dressing and he refused. The resident reported a pain scale level of 3/10 (three out of a zero to 10 scale, with 10 being the most severe pain). Tylenol was administered for the pain and his neurological assessments were within normal limits. The interdisciplinary team note dated 7/26/21 at 3:22 p.m., by the DON revealed the team met to discuss Resident #65's aggression related to the incident on 7/23/21 at 4:45 p.m. The staff heard a commotion from the South Hall dining room. Upon entering, the staff noted Resident #34 was bleeding from the top of his head and was in a seated position on the floor. Resident #65 and Resident #34 were separated immediately by staff. Resident #34 was interviewed and said he was unsure what had happened and he did not know Resident #65. Resident #34 said he was unsure why Resident #65 was upset. Both residents denied fear of the other. The DON assessed Resident #34 and neurological assessments were started. A CNA started vital signs on Resident #34. Pressure was applied to the top of the head of Resident #34 until the ambulance arrived. Resident #34 returned to the facility later that evening with 12 staples to the head. There was no brain bleed noted from the emergency room report. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Ombudsman, local police department and Adult Protection Services were also notified. The resident denied pain at the time of the incident, however he did have a complaint of a headache after arriving back at the facility. As needed Tylenol was administered. The resident's neurological assessments were within normal limits. Resident #34 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had not had any recent medication changes. Interventions implemented were to keep both residents separated, and place Resident #65 on immediate one-to-one staff observations. Send Resident #34 to the hospital for evaluation and treatment. Send Resident #65 to a specified medical center for psychological evaluation and treatment. Resident #65 was currently under the care of the medical center (transferred to hospital 7/23/21). The social services note dated 7/29/21 at 11:55 a.m., by the social service director (SSD) revealed Resident #34 was interviewed for a followup from the recent altercation with Resident #65. He continued to deny any fear and voiced he was doing rather well for being almost [AGE] years of age. He was told Resident #65 would be returning to the facility and he said it was fine with him. He again denied any fear of Resident #65. The resident was provided a personal television for his room. The social services note dated 8/31/21 at 4:33 p.m., by the SSD revealed she interviewed Resident #34 to ensure his safety about residing on the secure unit. He continued to deny any fear of any residents or staff. The SSD asked him if he felt safe living in the facility and he said oh sure. No concerns were voiced during the conversation. The social services note dated 9/1/21 at 2:59 p.m., by the SSD revealed during the weekly call with the Ombudsman the SSD was notified that Resident #34's sister had called the Ombudsman regarding a previous altercation involving the resident and another resident on the unit which resulted in a head injury. The Ombudsman detailed that the sister said Resident #34 voiced fear to the sister. The Ombudsman explained to the sister that during the follow up interactions, Resident #34 had denied any fear of the other resident. The SSD explained she had followed up with the resident as of yesterday and he had no fear at this time. The Ombudsman acknowledged and denied having any concerns with the facility or the resident safety. The Ombudsman wanted a zoom virtual meeting with the resident tomorrow to personally interview the resident. The zoom meeting was scheduled for tomorrow at 2:15 p.m. Immediately after this call, the SSD and a floor nurse interviewed the resident and asked him multiple times during the conversation if he was afraid of any residents or afraid of residing in the facility. He denied being afraid multiple times. The resident said he recalled the incident as being beaten by a tall man. He denied any fear and denied any pain at this time. During the conversation the resident was observed to pace near Resident #65 without any non-verbal signs of fear. The SSD asked the resident if he knew who he could speak to if he had any concerns regarding his safety. He denied any concerns of fear and said that he could speak to the SSD or to a nurse if he needed to. The resident denied he had reported to his sister that he was afraid. He said that he had informed his sister that he had been beaten, however he continued to deny he had told his sister he was afraid. The SSD informed the resident of the zoom meeting with the Ombudsman tomorrow. The resident acknowledged the meeting. The SSD notified the resident's guardian and the guardian also said each time she had talked with the resident he has denied any fear. The guardian was scheduled to visit the resident tomorrow and would ask him again about being afraid, during their conversation. The SSD initiated each shift nurse was to interview the resident regarding being afraid. The SSD informed the staff that if the resident should voice fear, he was to be removed from the unit and the DON and NHA were to be immediately notified for further interventions. C. Resident #65 Resident #65, age 73, was initially admitted on [DATE] and was readmitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/13/21 minimum data set (MDS) assessment revealed the resident was moderately impaired in cognition with a brief interview for mental status (BIMS) score of eight out of 15 with no behaviors. The resident required staff supervision of bed mobility, transfers, dressing, eating, toileting and personal hygiene. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan for occasionally displaying episodes of verbal or physical aggression was revised on 4/15/21. Some of the interventions were to allow the resident to vent his frustration and provide affirmation/validation. Encourage the resident to see staff assistance if/when another resident was disrupting him. Provide a personal television to the resident. Redirect the resident when escalated with one-to-one walks outside. Redirect the resident when escalated with a snack or drink of choice; the resident likes coffee and sweets. When the resident wanted to spend leisure time outside of his room, direct the resident to the dining room and away from the activity room. -No additional interventions were added to the care plan after the altercation on 7/23/21. D. Observations Observations during survey 9/12-9/16/21 revealed Resident #34 wandered often in the hallways and kept away from Resident #65. He was also observed smoking outside in the smoking areas during scheduled times with staff present. No verbal or physical outbursts were observed. Observations during survey 9/12-9/16/21 revealed Resident #65 was either in the common television area watching television or in his room interacting with his computer. He was also observed smoking outside in the smoking areas during scheduled times with staff present. Resident #65 kept away from Resident #34. No verbal or physical outbursts were observed. E. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 9/15/21 at 1:43 p.m. regarding the incident on 7/23/21. She said she heard yelling in the main dining room. She said she observed Resident #65 had Resident #34 on the floor. She said Resident #65 was standing over Resident #34. Resident #65 used his hands to grab onto the shirt of Resident #34 and was loudly pounding him onto the floor. Resident #34's head was hitting the floor during the pounding. CNA #1 said the altercation started because Resident #34 wanted to watch a football game and Resident #65 wanted to change the channel. She said when she saw the incident, she ran to go get a nurse and during that time Resident #65 walked out of the dining room and into his room. She said Resident #34's head was bleeding. She said a nurse arrived to assess the resident and an ambulance came to take him to the hospital. She said Resident #34 received staples to his head. CNA #1 said there had not been any further incidents with these two residents. The director of nursing (DON) was interviewed on 9/15/21 at 4:03 p.m. She said she received a call from the nurse on the South Unit that there was a resident to resident altercation in the main dining room. When she arrived both residents were already separated. She said CNA #1 reported that Resident #65 had made contact with Resident #34. She said both residents were watching the football game and Resident #65 asked Resident #34 to move out of the way of the television. The DON said when she entered the room the staff were performing vital signs on Resident #34. The resident had abrasions to the right and left side of his head. The resident did not know what happened. The ambulance service took the resident to the hospital. The resident received 12 staples to his head and the facility received physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The DON said Resident #65 was placed on one-to-one staff observations. Resident #65 was taken to a specified medical center for psychological and medication evaluations. She said the resident was out of the facility from 7/23/21 to 7/29/21. The DON said to her knowledge the residents had not had any additional interactions. She said neither resident had voiced any fear of the other resident. III. Altercation 9/3/21 A. Resident #62 status Resident #62, under age 55, was admitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/11/21 minimum data set (MDS) assessment revealed the resident had moderately cognitive impaired with a brief interview for mental status (BIMS) score of nine out of 15. The resident did not exhibit any behaviors. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. B. Resident interview An attempt was made to interview Resident #62 on 9/13/21 at approximately 10:30 a.m. The resident sat in his wheelchair in his room and mumbled at very low levels. The answers he provided to specific questions were undiscernible and vague in relationship to the questions. C. Resident #65 record review Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's guardian agreed with this voluntary placement. The care plan for the potential for abuse related to residing in a unit with residents who occasionally have behavioral disturbances was revised on 5/28/21. Some of the interventions included encouraging the resident to not invade another resident's personal space. Redirect the resident away from escalated residents by offering an activity of choice or a snack. Report any agitation/restlessness related to specific residents on the unit. The Behavior Monitoring book dated 9/2/21 at 10:00 a.m., revealed that the activity assistant (AA) wrote that Resident #34 was pushing Resident #62 in his wheelchair. Resident #34 pushed Resident #62 into the hallway wall. Resident #34 said he wanted Resident #62 to break his legs and get up from the floor on his own. When asked why he did this Resident #34 said we all sin sometimes. The incident note dated 9/3/21 at 2:12 p.m. by licensed practical nurse (LPN) #1 revealed that it was brought to her attention by the activity assistant (AA) that the resident was observed to make contact with the hallway glass door leading to the outside of the facility. The resident was being pushed in his wheelchair by Resident #34. The AA was taking the residents to attend a church service in the other building. The resident's bilateral lower extremities were observed to make contact with the glass doors. The AA overheard a comment by Resident #34, about his desire to break Resident #62's legs. The AA intervened and asked Resident #62 if he was okay and he stated he was. The AA resumed assisting the residents to the church service. Resident #62 was observed to continue his usual routine yesterday and he did not exhibit any signs or symptoms of fear and he did not report any fear. Today's assessment did not reveal any pain or injury. The resident denied any fear and did not report any pain or injury. Resident #34 was placed on 15-minute checks. The incident note dated 9/3/21 at 2:12 p.m., by LPN #1 revealed the director of nursing (DON), the resident's family, physician and the local police department were notified. All assessments were completed in the resident's computerized clinical record. The interdisciplinary team note dated 9/3/21 at 3:28 p.m., by the DON revealed she, the nursing home administrator, the assistant director of nursing and the social service director met to discuss the physical aggression Resident #62 received on 9/2/21 at 10:00 a.m. The resident was observed to make contact with the hallway glass door which led to the outside of the facility. Resident #62 was being pushed in his wheelchair by Resident #34 to attend a church service. Resident #62's bilateral lower legs were observed to make contact with the door. The AA overheard Resident #34 make the statement that he desired to break Resident #62's legs. The AA intervened and resumed assisting the residents to the church service. The AA asked the resident if he was okay and he stated yes. The resident continued his usual routine yesterday. He was not observed to have any signs or symptoms of fear and he did not report any fear. Today during an assessment he was not observed to have any signs or symptoms of fear nor did he report any pain, injury and he denied any fear. The resident's guardian, physician, ombudsman, SSD, DON and local police department were notified. Resident #62 resided in the facility related to a medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident also had dementia with behavioral disturbances. There were no recent medication changes. The intervention was to educate staff on not allowing residents to assist with the ambulation of other residents. The behavior note dated 9/4/21 at 6:03 a.m., by an LPN, revealed charting follow-up for a resident to resident interaction. This resident was being pushed in his wheelchair by another resident when he was pushed into the wall. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . D. Resident #34 record review Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan for potential abuse related to residing in a unit with resident's who occasionally have behavioral disturbances was revised on 4/22/2021. Some of the interventions were to redirect the resident from escalated residents by offering an activity of choice and/or a snack. Report any agitation/restlessness related to specific residents on the unit. When the resident desired to spend leisure time outside his room, direct the resident to the activity room that was away from the dining room. -No additional interventions were added to the care plan after the altercation on 9/3/21. The care plan for residing in the facility's secure unit for his safety and structure was revised on 4/22/21. The plan revealed the resident habitually wandered or would wander out of this environment and would be unable to find his way back to the facility, placing him in danger. His guardian consented to the secure unit placement. Some of the interventions were to assess the resident quarterly for the appropriateness of placement on the secure unit. Encourage the resident to participate in activities of choice and involve the resident/guardian in the resident's plan of care. -No additional interventions were added to the care plan after the altercation on 9/3/21. The care plan for impaired cognitive function related to dementia was revised on 4/23/21. Some of the interventions were to face the resident when speaking and making eye contact. The resident understood simple, consistent and directive sentences. Reduce any distractions such as turning off the television, radio and close the door as needed. -No additional interventions were added to the care plan after the altercation on 9/3/21. E. Observations Observations during survey 9/12-9/16/21 revealed Resident #62 was observed in his room interacting with his electronics or in the dining television room during meals with staff. He was also observed smoking outside in the smoking areas during scheduled times with staff present. No verbal or physical outbursts were observed. F. Staff interviews The AA was interviewed on 9/14/21 at 2:10 p.m. She reviewed her entry in the Behavior Monitoring book dated 9/2/21 at 10:00 a.m. She said the incident involved Resident #62 who used a wheelchair because he could not stand up. She said the resident was capable of using the wheelchair by himself. She said she was taking residents from the South Unit to a church service in the other building. She said Resident #34 was pushing Resident #62 in his wheelchair. She said Resident #34 pushed Resident #62 into the hallway wall. She said Resident #62's right side and the wheelchair contacted the wall. She said the resident did not call out in pain or state he experienced any pain from the incident. She said Resident #34 said he wanted to break Resident #62's legs because he wanted to see if he could get off the floor on his own. She asked Resident #62 if he was okay and he said yes. She asked Resident #34 why he pushed Resident #62 into the wall and he said we all have to sin sometime. She said they arrived from the church service to the South Unit about 45 minutes later. She said she then notified licensed practical nurse (LPN) #1 of the incident and the comments by Resident #34. The LPN came and assessed Resident #62. The LPN asked Resident #62 if he was afraid of the other resident and he said no. The AA said she wrote the note in the Behavior Monitoring Book at 4:00 p.m., at the end of her shift. The AA said after the incident both residents seemed fine with each other and did not show any fearful signs of being around each other. She said they usually get along well with each other. The AA said she had been working at the facility for almost a year and she did receive abuse training upon hire (4/30/2020). She said she received one-to-one abuse education on 9/3/21 regarding the immediate notification to the nurse and the abuse coordinator immediately after an incident. If she was unable to notify the abuse coordinator she must call the NHA or the SSD until she talked with one of them. Licensed practical nurse (LPN) #1 was interviewed on 9/14/21 at 2:54 p.m. She said the AA was taking the residents to the other building for church services. After they returned, the AA told her that Resident #34 pushed Resident #62 in his wheelchair into the hallway wall. She said she assessed Resident #62 and he had no pain or injuries. She said he was not afraid of the other resident. She said the DON and NHA were not notified at this time because she did not think it was abuse. She said Resident #34 made verbal statements all the time and then laughed about the statements. She said she thought this was his usual type of statement (break his legs) he had made in the past. LPN #1 said the social service director (SSD) reviewed the Behavior Monitoring Book and told her this incident and Resident #34's statement was abuse and she should have written up the incident yesterday, as soon as she became aware of the incident. The SSD said the statement of breaking Resident #62's legs, was intent to do harm. LPN #1 said she had received her initial abuse training upon hire (8/20/2020). She said the SSD provided her with one-to-one abuse education on 9/3/21 regarding the immediate notification to the nurse and the abuse coordinator after an incident. If she was unable to notify the abuse coordinator she must call the NHA or the SSD until she talked with one of them. The LPN said it did not occur to her that Resident #34's comment was an intent to do harm because of his past statements. She said neither residents were fearful of each other and they have not had any further incidents. The social service director (SSD) was interviewed on 9/14/21 at 4:07 p.m. She said the AA was taking a group of residents to a church service in the North building. Resident #34 was pushing Resident #62 in his wheelchair. Resident #34 pushed Resident #62 into the therapy hallway glass door. The AA overheard Resident #34 say he was trying to break Resident #62's legs. She said she became aware of the incident when she reviewed the Behavior Monitoring Book on 9/3/21. The SSD said she interviewed the AA. The AA said she immediately intervened after Resident #34 pushed Resident #62 into the glass door. She said the AA said they continued on to the church service. The AA assisted Resident #62 to the church service by pushing his wheelchair. The AA said she had mentioned the incident to the LPN #1 later in the afternoon. The SSD said LPN #1 did not recall charting on this event. She said she told the LPN #1 that the comment of the intent to break Resident #62's legs was abuse and she should have started an investigation. The SSD said she interviewed both residents and they were not afraid of each other. The SSD said she had a one-to-one conversation with the AA and all of the activity staff regarding abuse and the intent of abuse. She said she did a one-to-one with LPN #1 about the same issues. She said the two residents have not had any other incidents with each other. The DON was interviewed on 9/15/21 at 4:15 p.m. She said it was reported that Resident #34 was pushing Resident #62 in his wheelchair as they were going to a church service. Resident #34 pushed Resident #62 into a door. She said the AA was with them at the time of the incident. She said the AA witnessed the incident and intervened between the residents after the incident. She said the incident occurred on 9/2/21 at 10:00 a.m. The DON agreed the first note that described the incident was dated 9/3/21 at 2:12 p.m., by LPN #1. She agreed the AA wrote the incident in the Behavior Monitoring Book on 9/2/21 at 10:00 a.m. The note was written approximately 28 hours after the incident. She said the AA did make sure the residents were safe, however she should have notified the nurse immediately. The DON said both the AA and LPN #1 were in-serviced on what was abuse and who should be called/notified immediately. She said the LPN #1 should have called the abuse coordinator immediately. The DON said all of the administrative staff were notified of the incident during the next day's morning interdisciplinary team meeting when the Behavior Monitoring Book was reviewed. The SSD placed the information regarding the incident in the state portal reporting system after the meeting on 9/3/21 at 8:37 a.m. The NHA was interviewed on 9/16/21 at 11:13 a.m. She said the AA should have notified the nurse immediately. She said the nurse should have then notified the abuse coordinator and/or the NHA immediately after learning about the incident. She said as soon as the facility was aware of the incident, they did in-service training on all staff and reported the incident in the state portal reporting system. She said they have already completed a second round of abuse training/reporting with staff. The SSD was interviewed on 9/15/21 at 8:27 a.m. She said Resident #34 did have behaviors and dementia. She said to her knowledge he had never exhibited aggressive behaviors towards residents. IV. Altercation 9/7/21 A. Resident status Resident #69, age 91, was admitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/18/21 minimum data set (MDS) assessment revealed the resident was moderately impaired in cognition with a brief interview for mental

Based on observations, record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for five (#34, #62 #65, #50 and #69) of five out of 46 sample residents. Specifically, the facility failed to consistently provide person-centered approaches to Resident #65's dementia care services to address triggered physically aggressive behavior in order to prevent physical altercations with other residents on the secured unit. The facility was aware Resident #65 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan for Resident #65 revealed the facility was to ensure a calm environment, redirect the resident when escalated, and encourage him to seek staff assistance when another resident was disturbing him. Furthermore, due to the facility's failures, Resident #65 physically assaulted Resident #34 on 7/23/21, resulting in Resident #34 requiring hospital treatment where he received 12 staples in his head. Resident #65 also physically assaulted Resident #69 by shoving Resident #69 to the floor on 9/7/21, resulting in Resident #69 falling to the floor on his butt. Resident #69 received a small red spot to his elbow from the fall. Resident #62 was physically assaulted by Resident #34 on 9/2/21, who shoved Resident #62 into a wall in his wheelchair which resulted in Resident #62's legs coming into contact with the wall. Resident #34 made a verbal threatening comment that he wanted to break Resident #62's legs. Review of the care plans for Residents #34, #62 #65, and #69 indicated that the facility had failed to consistently follow and implement new person-centered interventions to prevent the residents from abusive altercations. (Cross-reference F600 failure to prevent abuse/neglect.) In addition, the facility failed to implement person centered approaches for Resident #50's behaviors. Findings include: I. Census and Conditions demographic The 9/14/21 Census and Condition form documented that 75 total residents resided at the facility. There were 42 residents with dementia and 50 residents with behavioral healthcare needs. The facility was designated with two long-term memory care units with 29 residents residing on the two units. II. Failure to provide person-centered dementia care for Resident #65's triggered physically aggressive behavior. A. Resident #65 Resident #65, age 73, was initially admitted on [DATE] and was readmitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/13/21 minimum data set (MDS) assessment revealed the resident was moderately impaired in cognition with a brief interview for mental status (BIMS) score of 8 out of 15 with no behaviors. The resident required staff supervision of bed mobility, transfers, dressing, eating, toileting and personal hygiene. B. Record review Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan for occasionally displaying episodes of verbal or physical aggression was reviewed on 4/15/21. Some of the interventions included: Allow the resident to vent his frustration and provide affirmation/validation. Encourage the resident to see staff assistance if/when another resident was disrupting him. Redirect the resident when escalated with one-to-one walks outside. Redirect the resident when escalated with a snack or drink of choice. When the resident wants to spend leisure time outside of his room, direct the resident to the dining room and away from the activity room. Provide a personal television to the resident. C. Altercation 7/23/21 A nurse note dated 7/23/21 at 5:43 p.m., by the director of nursing (DON) revealed at approximately 4:45 p.m., she received a call from the South Unit from licensed practical nurse (LPN) #2 that Resident #65 had made contact with the Resident #34's head multiple times. This occurred in the main dining room and was witnessed by a certified nurse aide (CNA). The two residents were immediately separated and Resident #65 was put on one-to-one staff observations. Resident #34's vital signs and neurological assessments were initiated upon the DON's arrival. Resident #34's assessments were within his normal limits. The resident had abrasions to the top of the right and left side of his skull. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Also the order revealed to send Resident #65 to a named medical center for a psychological evaluation and treatment. A message was left for Resident #34 guardian. The local police department was called and a case number was issued. D. Altercation 9/7/21 The incident note dated 9/7/21 at 10:50 a.m., by the licensed practical nurse (LPN) #1 revealed Resident #69 was overheard by staff with an elevated voice coming from the vicinity of his room. A certified nurse aide (CNA) was near the common television room and observed the resident land in the hallway on his butt. Resident #65 was seated in the common television room and admitted having a verbal altercation over the volume of the television. Resident #65 then reached out and made physical contact with Resident #69. This contact caused Resident #69 to fall backward onto the floor, landing on his butt. Resident #69 said he told Resident #65 the television volume was up too loud and Resident #65 put his hands on my shoulders and I fell backward. Both residents were separated immediately and Resident #65 was taken back to his room. A staff member came and sat with Resident #65 outside in the smoking area and then in the front lobby. Resident #69 was currently in the activity room with staff. The hospice staff were notified. The hospice agency ordered an as needed anti-anxiety medication and a dose was administered. Fall, pain and skin assessments were completed in the resident computerized clinical record. The director of nursing (DON), social services director (SSD), family and the local police department were notified. -The facility failed to identify person-centered interventions to address Resident #65's triggered physically aggressive behavior, which ultimately led to Resident #34 receiving 12 staples to his head resulting in harm on 7/23/21 and Resident #69 falling to the floor on 9/7/21 (cross-reference F600). E. Staff interviews The SSD was interviewed on 9/15/21 at 8:19 a.m. She said Resident #65 had a dementia diagnosis. She said the resident had verbal and physical aggressive outbursts. She said he had a specific care plan that dealt with his behaviors. She said the resident did redirect easily. She said he became angry in a moment and he calmed down quickly. She said the resident was deescalated by coffee, sweets, walks outside in nature, talking about his love for nature, talking about riding his mountain bike, watching television, and spending time using his computer. She said he had a television in his room. The DON was interviewed on 9/15/21 at 11:24 a.m. She said the resident had a dementia diagnosis. She said the resident did have agitated behaviors because he believed he did not belong in a secure unit. She said his care plan did reflect his behaviors. She said the resident deescalated by smoking, going outside in the fresh air, going for walks outside, and watching football on the television. She said he did redirect easily but if he was in an agitated state he was more difficult to redirect. Certified nurse aide (CNA) #1 was interviewed on 9/15/21 at 1:54 p.m. She said the resident did have dementia and did have behaviors. She said he did get mad and push people. She said he did at times scream at people. She said sometimes it took a long time for him to calm down. She said he needed some space and staff kept him away from the other residents. She said to deescalate the resident staff would take him on a long walk, out to smoke, and watch football on television. III. Failure to provide person-centered dementia care for Resident #34's triggered physically and verbally aggressive behavior. A. Resident #34 Resident #34, age 91, was initially admitted on [DATE] and was readmitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/12/21 minimum data set (MDS) assessment revealed the resident did not have a brief interview for mental status (BIMS) score. The resident did not have any behaviors. There was no evidence of an acute change in mental status or [CONDITION(S)]. The resident did have wandering tendencies that occurred daily. The resident required staff supervision for bed mobility, transfers, eating, and toileting. B. Record review Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan for potential abuse related to residing in a unit with resident's who occasionally have behavioral disturbances was initiated on 4/29/2020. Interventions included: Redirect the resident from escalated residents by offering an activity of choice and/or a snack. Report any agitation/restlessness related to specific residents on the unit. When the resident desired to spend leisure time outside his room, direct the resident to the activity room that was away from the dining room. Ensure a calm environment to include temperature, surrounding noises, and/or smells. The incident note dated 9/3/21 at 2:12 p.m. by licensed practical nurse (LPN) #1 revealed that it was brought to her attention by the activity assistant (AA) that the Resident #62 was observed to make contact with the hallway glass door leading to the outside of the facility. The resident was being pushed in his wheelchair by Resident #34. The AA was taking the residents to attend a church service in the other building. The resident's bilateral lower extremities were observed to make contact with the glass doors. The AA overheard a comment by Resident #34, about his desire to break Resident #62's legs. The AA intervened and asked Resident #62 if he was okay and he stated he was. The AA resumed assisting the residents to the church service. Resident #62 was observed to continue his usual routine yesterday and he did not exhibit any signs or symptoms of fear and he did not report any fear. Today's assessment did not reveal any pain or injury, The resident denied any fear and did not report any pain or injury. Resident #34 was placed on 15-minute checks. -The facility failed to identify person-centered interventions to address Resident #34's triggered physically aggressive behavior, which ultimately led to Resident #62's legs coming into contact with a wall and address Resident #34's verbal abusive comment that he wanted to break Resident #34's legs (cross-reference F600 for abuse). C. Staff interviews The social service director (SSD) was interviewed on 9/15/21 at 8:27 a.m. She said Resident #34 had behaviors but he really did not have any aggressive behaviors. She agreed the resident did push another resident in his wheelchair into a wall one time. She said the resident did have a behavior specific care plan that dealt with his behaviors. She said a care plan could be updated as needed. She said the resident really did not need to be deescalated because he did not have any behaviors. She said he enjoyed talking on the phone, drinking Pepsi, and shopping trips to Walmart. The director of nursing (DON) was interviewed on 9/15/21 at 11:40 a.m. She said the resident did have a dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said he loved to go outside, exercise and watch football. She said he could be confrontational but for the most part he was mellow (relaxed). She said he was very talkative to everyone. She said to deescalate the resident staff offered him frequent walks, coffee, exercise and watching sports on the television. She said care plans were updated to reflect the resident's behaviors. CNA #1 was interviewed on 9/15/21 at 1:43 p.m. She said the resident never got mad or escalated. She said he never caused any problems. She said he liked coffee, going outside, and watching football games on the television. She said she knew what the resident liked and how he wanted to be treated. IV. Failure to implement person centered appraches for Resident #50's behaviors A. Resident status Resident #50, age 68, was admitted on [DATE]. According to the 9/13/21 computerized physicians orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/30/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. The resident had delusions and rejected cares daily. The resident had verbal and physical behavioral symptoms directed toward others. The resident required supervision by oversight, encouragement or cueing for bed mobility, transfers, eating, dressing and personal hygiene. She required extensive assistance with toilet use. -The resident was documented not to have displayed behavioral symptoms during the seven day look back period. She was observed to display behavioral symptoms during the survey (see below). B. Observations On 9/12/21 at 6:00 p.m. the call light in the hallway for Resident #50 was turned on and visibly seen in the hallway above her door. The resident was heard loudly saying, This light stays on until I get cheese or a cheese board. You will never find where I hid the parts to turn the light off. On 9/12/21 at 6:15 p.m. certified nurse aides (CNAs) #10 and #11 entered Resident #50's room. CNA #10 asked if there was anything they could do for the resident. She told them she was protesting until she got cheese. She said she hid the call light part that would turn the light off and there was nothing they could do about it until she received a cheese board or some cheese she liked. She loudly told the CNAs to get the (expletive) out of my room. The CNAs informed licensed practical nurse (LPN) #3. The CNAs and the LPN did not utilize any strategies to deescalate Resident #50. The behavior was not documented (see below). C. Resident interviews Resident #50 was interviewed on 9/13/21 at 11:20 a.m. She said she would not be eating today because the water they cooked the food with was contaminated. She said she wanted special cheeses and that the facility should buy them for her. Resident #50 was interviewed again on 9/15/21 at 2:37 p.m. She said, I know how to take that call light out of the wall. I know how to unscrew it so that the light will stay on for hours and hours. They tell me to turn that light off. I say no, I am protesting. I am [NAME]. I will leave it on for hours. I want to go to the store and buy my own food but I was told I need transportation. I want cheese and a cheese board. I like raw hard noodles also and I soak the noodles in bottled water. I did not eat the hash browns for breakfast because they boiled the potato in regular water. I will only eat food cooked in bottled water. She said staff just leave her call light on because they do not know what to do to turn it off. D. Record review The 4/12/21 social service progress note revealed, the resident continued to vent about the facility poisoning the food, contaminating her boots, injecting the water with contaminants, and refusing the specially aged cheese she had requested. The 5/14/21 comprehensive care plan revealed: -Focus, the resident had behavior of refusing to allow staff to turn the call light off, and placing the call light on repetitively. -Goal, the resident will utilize call light appropriately and allow staff to turn light off when needs have been met. -Interventions, ensure all of (the) resident's needs are met by asking 'is there anything else I can do for you while I am here' before leaving the room when answering the call light. Remind (the) resident that (the) call light initiates assistance and staff must turn it off to inform other staff that her needs are being met. When refusing to allow light to be turned off, reassure (the) resident that staff are available to assist her needs and will continue to answer the light when initiated. -Focus, the resident chooses to eat vegetarian foods, and frequently orders plain oatmeal, canned and cooked carrots, corn on the cob, plain baked potato, and kidney beans. -Goal, resident's preferences will be honored as long as food will not cause illness being left out. -Interventions, explain to resident shopping trip available weekly to purchase specific food requests not able to be provided by the kitchen. Notify activities of resident's desired purchase requests or if she agreed to speak to activities regarding specific food requests The August 2021 behavior monitoring tracking form revealed: On 8/17/21 the resident was upset and pulled the call light out of the wall. The action taken was staff went in and changed the trash bag and asked are you going to replug the call light? The documentation revealed, light off and signed by registered nurse (RN) #1. No follow up from social services noted. On 8/23/21 the resident unplugged her call light until someone would take her to a nearby city. The action taken was to go in every 15 minutes and try and attempt to reason with her. Resident had no response. On 8/26/21 the resident unplugged the call light because she did not get the kind of bread she wanted from the kitchen. Action taken was to try and reason with her and the resident did not change her response. The September 2021 behavior monitoring tracking form in a behavior monitoring notebook at the nurses station revealed the resident's behavior tracking sheets had blank pages with no behaviors written for the month. There were no behavior monitoring tracking forms written for the evening of 9/12/21 (see observation above) when the resident made the call light stay on permanently because she wanted cheese or a cheese board. E. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 9/12/21 at 6:10 p.m. She said Resident #50 had turned on her call light and did something with the components in the wall which would leave the call light on permanently until the maintenance department would be able to turn it off the following day. LPN #3 said the resident did this quite often. She said the resident did it when she wanted a cheese board or special cheeses to eat. She said this behavior happened frequently and the staff just left the resident alone. She said if they had to go in the resident's room, the staff made sure they entered the room with two staff members so that the resident did not accuse them of anything. She said it was a safe way to protect themselves. She said the resident liked nice cheeses but the facility cannot afford to buy specialty cheeses for her. She said the resident felt the facility should be able to buy her fancy cheese. She said the resident somehow can get into the call light in the room and rewire it so that the light would remain on. She said staff did not know what to do on a Sunday to turn the light off so they leave it on until someone on Monday can come in and turn it off. She said the resident told staff it was her way of protesting that she wanted different types of cheese. LPN #3 said the resident often had behaviors due to her dementia and staff just did the best they could to help her but there was very little they could do to help. CNA #10 was interviewed on 9/12/21 at 6:20 p.m. She said she entered the room of Resident #50 with CNA #11. She said the staff went in the room together in pairs. She said they did it for their own safety in case the resident accused them of anything bad. She said they did not have any special skills to help the resident change her behavior (cross-reference F947 nurse aide training). She said she did the best she could to help the resident if she was allowed to help by the resident. The activity director (AD) was interviewed on 9/14/21 at 3:23 p.m. She said she was not trained to work with the residents with dementia; she just knew how to work with the dementia population because of her nature and personality. She said she just tried to think what she would feel like if her mom was in this place. She said she did not have a special talent to deal with dementia residents, it was just who she was as a person. She said she had activity training maybe two years before but not dementia training. She said, Before I leave (Resident #50's) room I will tell her, I love you. I know she hears me say that. She hates me one day and then we are friends again the next day. I cannot take anything personally with her. I tried to buy her food from the store once but she just threw it in the trash. The AD said she just did the best she could with Resident #50. Licensed practical nurse (LPN) #3 was interviewed on 9/14/21 at 3:35 p.m. She said she did not have dementia training since she started again at the facility at the end of July 2021. She said she had worked in a state hospital so she knew how to handle some uncommon behaviors. She said they were not trained in the facility to handle people like Resident #50. She said just over time working in health care she picked techniques up. She said a few years ago the facility had dementia training that was really good but nothing currently. She said the staff go in the resident's room in pairs in case she would accuse us of anything. She said the staff do that for our own safety. She said the resident did not like her usually but CNA #10 was able to communicate with her sometimes. She said it was helpful if CNA #10 was on the schedule to talk to Resident #50. CNA #2 was interviewed on 9/15/21 at 8:20 a.m. She said Resident #50 wanted a cheese board. She said the staff just keep going back in and try to redirect her. She said there is a behavior tracking book at the nurse's station. She said the staff can write in the behavior book anything that happens with the resident. She said in the morning the social service director (SSD) or someone from management came to get the behavior tracking book. She said the book was brought to manager meetings in the mornings. She said she usually did not know what management did with the behaviors that the staff wrote down. She said she thought the SSD would talk to the person in the behavior tracking book and handle the situation. She said sometimes the SSD shared with the floor staff what was done to handle a behavioral situation. The SSD was interviewed on 9/15/21 at 11:35 a.m. She said Resident #50 sometimes refused care from staff if a specific type of cheese was not supplied. The SSD said the behavior was written in the care plan. She said she did not know what written interventions meant on the written care plan. She said she had made a progress note a few months ago concerning the resident and her wanting cheeses. She said she would look in the electronic records to see if anything was documented on what to do for the resident's behaviors. She said the resident had a thing for cheeses but she did not know where in the record it was documented. She said during the week when she worked she took the behavior monitoring book off of the nurse's station every morning to read what may have happened the night before with behaviors. She said she did not work on the weekends and would read the behavior books on Monday mornings. She was unaware that Sunday night the resident took out the call light in a way to make it stay on until she received cheese. She said she was unaware why staff did not write the situation that happened in the behavior book so that she could handle it. She said no one left her a voicemail either. She said sometimes she would go and talk to a resident who had behaviors. She said other times if the behavior was already documented in the care plan she may not do anything to intervene. She said sometimes she would do on the spot training with floor staff so that the staff would know what she did with the resident. She said she did not have documentation of any on the spot training that she did with the staff. She said all staff can document Resident #50's behavior in the behavior tracking book including CNAs, nurses, activities staff, and anyone else who witnessed anything with behaviors. The nursing home administrator (NHA) was interviewed on 9/15/21 at 2:40 p.m. She said she had only been the NHA since July 2021. She said there was no documentation the facility provided dementia training for the staff (including CNAs, cross-reference F947) prior to her beginning the job and not since she began either. She said dementia training was scheduled on the staff monthly education calendar for April 2022 and she said maybe she could provide some training in the upcoming October 2021 training day. She said she was unaware Resident #50's behavior was not written in the behavior book for the evening of 9/12/21. She said that she and the SSD would update the resident's behaviors in the electronic medical records to reflect the observation on 9/12/21 F. Facility follow-up The SSD was interviewed on 9/16/21 at 9:37 a.m. She said she updated Resident #50's care plan today to include how to take care of her pulling the call light out from the wall. SSD said she updated the care plan to handle when the resident requests cheeses and cheese boards. She said she initiated a personal behavior care card for the staff to keep with them at all times for Resident #50. She said she did an education today for the staff concerning what to do when the resident refused to turn off the call light. The updated care plan revised on 9/15/21 revealed: -Resident #50 will refuse care to be provided if specific cheese was not supplied. -When Resident #50 pulled the call light out of the wall, staff were to do 15 minute checks. -When the resident pulled the call light out for cheese the staff was to offer her carrots, parmesan cheese, and dry oats. Offer her cheese from the kitchen such as grated parmesan, shredded mozzarella or sliced or shredded cheddar. The behavior card was provided by the NHA via email on 9/16/21 at 9:34 a.m. She said the card was to be carried by the staff at all times. The card revealed: -Resident #50 frequently has behaviors which include: Verbally aggressive outburst towards staff including derogatory statements. Refusing to allow call-light to be turned off. Pulling call light from the wall until specific request is honored. Refusing meal trays to be removed from room. -Please ensure behaviors are documented. Notify the SSD of any behaviors you are having difficulty with. The behavior card included a phone number to call. -Redirection techniques for Resident #50 -2 staff at all times, conversation topics: her knowledge of dietary/nutrition, natural remedies, and history of working for her father's shop. Alternatives to special food requests available in the kitchen: dry oats, raw carrots, shredded mozzarella, sliced or shredded cheddar. -When refusing call light to be turned off: attempt to honor request as able, initiate 15 minute checks if unable to, notify SSD of special request unable to honor.

Based on interviews and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible. This affected residents residing on two South building secure units, including Resident #1, all of whom were at risk for harm due to dementia and/or behavioral disturbances that placed their safety in danger. Record and video review and interviews revealed the facility experienced a fire in the dining room on 8/2/2020 and staff decided to evacuate the building. Resident #1, severely cognitively impaired with behavioral disturbances that placed him at risk for harm, including daily resistance to cares (cross-reference F742), refused to evacuate the building. Staff left Resident #1 in his room behind a closed door after evacuating all the other residents from the building. The facility failed to identify and address Resident #1's daily resistance to cares and failed to anticipate and plan for the difficulty in evacuating residents, including Resident #1, whose dementia and/or behaviors placed them at risk in an emergent situation such as fire. (Cross-reference EP 0007). The facility further failed to provide sufficient emergency preparedness training and testing of staff after the 8/2/2020 fire and the unsuccessful evacuation of Resident #1 on the South secure unit. (Cross-reference EP 0009, EP 0037 and EP 0039). These failures created the likelihood of serious adverse outcome for Resident #1 who staff were unable to evacuate in an emergent situation, as well as other residents potentially resistive to staff requests and/or staff assistance to evacuate. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Resident #1, with short-term and long-term memory loss, and modified independence making decisions regarding tasks of daily life, admitted to the facility on [DATE]. The facility had a fire on 8/2/2020 at approximately 8:15 a.m. on the South secure unit where Resident #1 and other residents with mental illness and behaviors resided. Interviews with facility staff and video review revealed the facility decided to evacuate the South unit. Staff, unable to get Resident #1 to evacuate the facility, shut his door and left him in his room without staff supervision. On 8/4/2020, the facility confirmed there had been a fire in the South unit and staff were unable to evacuate Resident #1. At the time, the facility had no plan in place on how to evacuate Resident #1 or any other resident who refused to evacuate. Certified nurse aide (CNA) #5, who attempted to evacuate Resident #1 on 8/2/2020, was unable to recall any fire training as of 8/2/2020, and observations of two mock fire drills revealed staff unprepared to respond properly to an emergent fire situation. On 8/4/2020 at 6:32 p.m., the nursing home administrator (NHA) and the interim director of nursing (IDON) were informed the facility failures above created the likelihood for serious harm for Resident #1 and other at risk residents on the secure units if the failures were not corrected immediately. B. Facility plan to remove immediate jeopardy On 8/5/2020 at 6:15 p.m., the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: All residents will be assessed by 8/7/2020 by the SSD (social services director) or designee to determine their level of awareness with fire safety drills and evacuation compliance. In the event specific interventions are determined to be needed by the SSD or designee such will be care planned by 8/10/2020 and staff will be educated on the interventions. Evacuation plan of all residents would be added to the emergency preparedness binder and the facility assessment binder on 8/5/2020 as indicated below: -In an emergency, all residents would be evacuated to an assigned safety location in the various locations of each unit. The alarm is not allowed to be shut off by anyone except the local fire department who has jurisdiction over the situation. -Prior to the arrival of the Fire department, it is required by facility staff to safely evacuate all residents to safety. -Residents are to be monitored and continuously reassured to calm down during these stressful times. -All residents must be evacuated to safety zone by any means possible. Residents Who Refuse to Evacuate -During an emergent situation you might encounter residents that refuse to evacuate. In this situation you will attempt every measure possible as identified in their individual care plan. Primary Goal -The Primary goal in an emergency is to rescue all residents from a life threating (sic) event. Staff education All staff would be educated on how to properly evacuate all residents to safety by 8/6/2020: -Residents who can ambulate would be directed by staff to a designated safety assembly area as identified on (the) evacuation plan for a head count after all residents are rescued/evacuated. -Bedbound/bariatric residents who can tolerate transfers by wheelchair would be evacuated by staff using appropriate wheelchair (regular or bariatric) to the designated safety area for a head count. -Bedbound residents who cannot tolerate wheelchair would be placed on a mattress by staff and transported out of their location to the designated safety area for a head count. Post evacuation measures -Evacuation signs that are kept on fire doors would be placed on all resident exterior door handle that has the resident evacuated to indicate that the resident is out of the room. -This education would be done prior to the shift start of staff by the DON, ADON, SDC or department heads completed by 8/6/2020. - Plan will be taken to AD HOC QAPI by 8/11/2020. Once 1135 waiver put in place by the President after of the declaration of a national emergency is lifted, facility staff will be trained through the following by Maintenance Director: -Thru In-service -Fire Drills -Relias (computerized training) -Return demonstration -Mock evacuation exercises -Actual evacuation exercise C. Removal of immediate jeopardy On 8/5/2020 at 6:15 p.m., the NHA and the IDON were notified the immediate jeopardy was abated, based on the abatement plan above. However, deficient practice remained at an E level, a pattern with the potential for more than minimal harm. II. Facility policy The NHA provided the facility's Emergency Response and Emergency Procedure: Fire on 8/4/2020 at 5:00 p.m. It read in pertinent part: The following procedure is utilized in the event of an actual fire, smoke conditions, or smell of smoke in the facility. -Staff begins evacuation according to the size of the fire and the amount of smoke production. The Incident Commander gives guidance on evacuation type . Phase I: Evacuate the rooms on either side and directly across from the room that is on fire. Move residents to an area away from the fire. This type of evacuation is used during the initial stages of a small fire. Additionally, rooms directly below or above the room of fire origin may be considered for evacuation, especially if fire sprinkler discharge has occurred. Phase II: Evacuate all residents from the smoke compartment where the fire has occurred to the opposite smoke compartment (through the smoke doors). This type of evacuation is used when moderate smoke conditions are present or the welfare of the residents is in jeopardy based on the situation. Additionally, wings or hallways directly below or above the room of fire origin may be considered for evacuation, especially if fire sprinkler discharge has occurred. Phase III. Fire Department Ordered Evacuation. Evacuate all residents from the building by whatever means possible. This type of evacuation is only used during a major fire or severe smoke conditions are present or the welfare of the residents is in jeopardy based on the situation. Additionally, wings or hallways directly below or above the room of fire origin may be considered for evacuation, especially if the fire sprinkler discharge has occurred. The order of evacuation is: -Ambulatory residents -Residents with assistive devices -Residents in wheelchairs -Bedridden residents III. Facility fire 8/2/2020 and facility response A. Video and timeline documented the fire and Resident #1's failure to evacuate According to recorded video provided by the facility and a written timeline provided by the IDON, there was an electrical fire on 8/2/2020 in the South building where residents resided on Pioneer secure hall and the South secure unit. The timeline revealed: -8:15 a.m. Fire starts in the dining room on South unit in an overhead fluorescent lighting fixture. -8:16 a.m. South unit residents began evacuating the dining room and moving behind smoke doors on South unit. -8:18 a.m. Unidentified staff member extinguished the fire, and staff began evacuating South unit residents to the South patio due to large amounts of smoke. -8:22 a.m. Staff members continue to check the resident rooms on the South unit, staff observed placing pillows on the outside of the evacuated resident rooms. -8:27 a.m. Residents on Pioneer unit begin to evacuate. -8:28 a.m. The fire department arrives and fire fighters escorted into the facility by one of the maintenance assistants. -8:49 a.m. According to written timeline provided by IDON, South smoke doors opened by fire fighters (attempt to re-direct Resident (#1) out of the room (refuses) smoke is now free from building. -8:49:17 a.m. According to the video recording provided by the assistant director of nursing (ADON), Resident (#1's) room door remained closed. At no time are any staff or firefighters noted opening and/or entering the resident room. Throughout the video recording, no staff members entered Resident #1's room. The door remained closed during the video recording provided by the Assistant DON. B. Interviews revealed Resident #1 refused to evacuate and remained in his room without staff supervision, contrary to Resident #1's safety as well as facility policy. 1. In an interview on 8/5/2020 at 12:40 p.m., CNA #5 said she was working the day of the fire on the South unit. She said there were approximately four residents in the dining room, and they had just finished their breakfast when the nurse started yelling fire. The CNA said she saw the light fixture in the dining room was on fire, so they removed the residents from the dining room and closed the door to the dining room. The CNA said staff working began moving all of the residents to the other side of the smoke doors, beyond the nurses ' station on the South unit. The CNA said a nurse made the decision to evacuate the South unit and Pioneer hallway in the South building, so all of the staff began evacuating the residents on the South unit to the South patio. The CNA said she came back into the building to continue to assist with evacuating, and she attempted to get Resident #1 (who resided on the South unit) to evacuate, but his reply was F*** (expletive) you, turn that s*** (expletive) off. The CNA said she told the nurse she was unable to evacuate Resident #1, so the nurse and the CNA made the decision to shut his door and place a pillow in front of the door. The CNA said she was unsure why she placed a pillow in front of the resident's door, and thought she should have placed a trashcan in front of the door. 2. In an interview on 8/6/2020 at 10:30 a.m., the local fire chief said there had been a lack of communication between the fire department and the facility for a couple of years. He said that in the past, the facility had communicated with the fire department about the access to codes for the secure doors on the South building, but currently the fire department did not have any of the access codes for the building. The fire chief said communication was important since both of the units in the South building were secure neighborhoods. The fire chief said his team was not aware of Resident #1's refusal to evacuate the building on 8/2/2020 during the fire. The fire chief said if the facility made the determination to evacuate any area of its campus (North or South building), they would be responsible for completing the evacuation. The fire chief said the fire department would assist with evacuation as needed, but the facility would need to complete the initial evacuation, as they were expected to be able to evacuate all of the residents safely. IV. Facility failures A. Failure to identify and address Resident #1's daily resistance to cares and failure to anticipate and plan for the difficultly in evacuating residents, including Resident #1, whose behaviors placed them at risk in an emergent situation such as fire. 1. Resident #1 Resident #1, age 70, admitted to the facility on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. According to the 7/20/2020 minimum data set (MDS) assessment, the resident had severe cognitive impairment; the resident could not complete the mental status exam. According to the staff assessment for mental status, the resident had modified independence making decisions regarding tasks of daily life. -The resident displayed inattention and disorganized thinking. He displayed physical behavior symptoms directed toward others one to three days and verbal behavior symptoms directed towards others daily. These behaviors put the resident at significant risk for physical illness and injury, significantly interfered with his care and significantly interfered with his participation in activities or social interactions. These identified behaviors put others at significant risk for physical injury, significantly intruded on the privacy or activity of others, and significantly disrupted care or the living environment. The resident rejected care on a daily basis. -The resident required set-up assistance with bed mobility, transfers, walking, and locomotion, one-person assistance with dressing, eating, and toileting, and two=person extensive assistance with personal hygiene. 2. Record review A review of Resident #1's medical record on 8/4/2020 at 5:00 p.m. revealed there was no documentation in the resident's progress notes regarding the fire on 8/2/2020, or the resident's refusal to evacuate during the fire. A review of Resident #1's care plan prior to 8/4/2020 and facility notice of immediate jeopardy, revealed no care plan for the resident's rejection to cares or his refusal to evacuate the facility during an emergency, or any interventions to respond and facilitate his evacuation if the resident refused. On 8/5/2020 at 6:15 p.m. after notification of immediate jeopardy, the facility updated Resident #1's care plan to read: The resident is at risk for severe bodily injury or death second to noncompliance for evacuation during an emergent situation, noncompliance with practical use of dishes or flatware and historical attempts to break windows. 8/5/2020-Resident #1 refused to leave his room during a fire despite prodding by staff and emergency personnel. -The goal was for the resident not to sustain any severe injury from emergency evacuations or attempt to evacuate him from any harmful situation. -Pertinent approaches included: during an evacuation explaining to the resident the need to leave the room, and if he refuses to have a staff member with a good relationship with him assist with the evacuation. Offering the resident his favorite snacks (cookies and ice cream) in an attempt to get him to evacuate. Calling the fire department or the police to assist with the evacuation. 3. Other residents at risk (cross-reference EP 0007) According to 4/28/2020 facility assessment, the facility resident profile included the following diseases/conditions, physical and cognitive disabilities: Psychiatric/Mood disorders including, [MEDICAL CONDITION], impaired cognition, [MEDICAL CONDITION], post-traumatic stress disorder, anxiety disorder and behaviors that need interventions. Services and care the facility offers based on resident's need included: hospice, bariatric care, palliative care and respite care. In an interview on 8/5/2020 at approximately 3:00 p.m., the NHA, interim director of nursing (IDON), and the regional maintenance supervisor (RMS) said they were unsure if their emergency preparedness plan (EPP) included information on what to do if a resident was unable or unwilling to evacuate the facility. They said the South building had two secure units, one specifically geared toward dementia, and the other for residents with more behaviors. The RMS said he was unable to locate any special provisions in the EPP that addressed residents with dementia and behaviors specifically, and the potential for them to be resistant to evacuating. Review of the Emergency Response: Emergency Procedure - Fire policy (see above) revealed no supporting policies, procedures, other guidance documents provided which addressed at risk residents or residents who refused to evacuate the facility. In an interview on 8/17/2020 at 9:00 a.m., the NHA and the corporate regional consultant (CRC) said the piece (evacuation of all residents including residents that may be difficult to evacuate) was missed as part of the EPP. B. Facility failure to provide sufficient emergency preparedness training and testing of staff after the 8/2/2020 fire and the unsuccessful evacuation of residents in the secure units. 1. On 8/6/2020 at 11:36 a.m., the NHA provided the following training, which she said all staff had completed: Staff education -Residents who can ambulate would be directed by staff to a designated safety assembly area as identified on (the) evacuation plan for a head count after all residents are rescued/evacuated. -Bedbound/bariatric residents who can tolerate transfers by wheelchair would be evacuated by staff using appropriate wheelchair (regular or bariatric) to the designated safety area for a head count. -Bedbound residents who cannot tolerate wheelchair would be placed on a mattress by staff and transported out of their location to the designated safety area for a head count. Post evacuation measures -Evacuation signs that are kept on fire doors would be placed on all resident exterior door handle that has the resident evacuated to indicate that the resident is out of the room. -This education would be done prior to the shift start of staff by the DON, ADON, SDC or department heads completed by 8/6/2020. -Plan will be taken to AD HOC QAPI by 8/11/2020. The NHA provided the signatures of all the staff in the building, showing they had completed the training. CNA #5, interviewed on 8/5/2020 at 12:40 p.m. said she had fire education on the morning of 8/5/2020, after the facility was notified of the immediate jeopardy, but was unable to recall any fire training prior to that. The CNA said during the 8/5/2020 training she was instructed to stay with any resident that was unwilling to evacuate the building. 2. Mock drill on Pioneer hall on 8/6/2020 (secure unit in the South building) - and staff's failure to properly respond. Observations: -At 11:14 a.m., the dietary manager (DM) was on Pioneer hall. Life Safety Inspector (LSI) #1 told the DM there was a fire in a resident room, and to do what you would do in a real fire, act like this is a real fire. -At 11:16 a.m., the DM removed Resident #10 from his room (where the mock fire was located). The DM left the door to the room open, not containing the fire in the resident room. -At 11:18 a.m., the DM was unable to get his key card to open the secure unit door. An unidentified CNA assisted the DM in opening the door. The DM did not tell the CNA there was a fire on the unit. -At 11:19 a.m., the DM walked the resident down the South unit to evacuate the resident to the South Patio. It took staff 16 minutes to evacuate the residents on the Pioneer hall. During the drill, the DM never called out there was a fire, told any other staff members working the hallway there was a fire, or pulled the fire alarm. Interview The DM was interviewed on 8/6/2020 at 11:23 a.m. He said he had fire training last night and said he was responsible for providing the training to all of the dietary staff. He said during the training, he learned about evacuating the residents and placing a tag on the resident's door after the room had been evacuated. The NHA was interviewed on 8/6/2020 at 11:26 a.m. She said the drill was not good. She said the DM never told any other staff there was a fire, the fire alarm was never pulled to notify the fire department of a fire, and the resident should have been evacuated past the smoke doors, not off the Pioneer Hall onto the South unit. The NHA said she would begin immediately re-training all of the staff to ensure they knew the proper procedure during a fire. 3. Mock drill on South unit on 8/6/2020 (secure unit in the South building)-and staff's failure to properly respond. Residents on the South unit were evacuated in six minutes. However, according to LSI #2, during the second mock fire drill, the facility kept the smoke barrier doors open when they were evacuating residents, which could lead to an increase in smoke, and requiring the facility to have to evacuate to the next smoke compartment. The staff also failed to pull the actual fire alarm, which would have notified the fire department, and staff failed to call the fire department to notify them of the fire, as a back-up. The result was the fire department was not made aware of the fire in the building. The NHA, IDON and the RMS were interviewed on 8/6/2020 at approximately 2:40 p.m. They stated there were still some concerns that needed to be addressed during drills (not pulling the alarm or notifying the fire department), as well as some things to work out on the best way to evacuate the residents in addition to getting them back into the facility after they had been given the all clear to re-enter the building. The NHA and the CRC were interviewed on 8/17/2020 at 9:00 a.m. They said as part of the immediate jeopardy process, they would be thoroughly looking into the emergency preparedness plan, and ensure it included all things like how to evacuate resistant residents. The CRC said the facility had begun the process of reaching out to the local fire department so they could have a collaborative approach to emergencies in the facility. (Cross-reference EP 0009, EP 0037 and EP0039 for failures in the facility's EPP and EPP training)

Based on record review and interviews, the facility failed to protect two of two residents reviewed out of nine total sample Residents (#3 and #4) from physical abuse by Resident #2. Record review and interview revealed on [DATE], Resident #3, who was severely cognitively impaired and known to take food and drinks from others, picked up Resident #2's juice and started drinking it. Resident #2 became upset and pushed Resident #3 several times in the face. One to one monitoring of Resident #2 was in place after the incident until [DATE], when the facility initiated 15-minute monitoring checks. On [DATE], while on 15-minute checks, Resident #2 hit Resident #4 when Resident #4, who was known to go into other residents' rooms and rummage through their things, entered Resident #2's room. Staff found Resident #4 on the floor in Resident #2's room and Resident #2 told the first staff at the scene, I beat the s*** out him because he was in my room. Hospital records revealed Resident #4 sustained bilateral subdural hematomas, four right-side rib fractures, four left side rib fractures, a L1 compression fracture, a nasal bone fracture and bilateral zygomatic arch (cheek bones) fractures. The facility failed to take steps to protect Resident #3 and Resident #4, both at risk for abuse due to their known behaviors, from physical abuse. Resident #4 sustained significant injuries. Findings include: I. Facility policy and procedure The nursing home administrator (NHA) on [DATE] at 3:30 p.m. provided the facility Abuse Prevention Program policy, revised [DATE], for review. It read in pertinent part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. As part of the resident abuse prevention, the administration will: -protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual; -develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED].>-require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. II. Resident-to-resident physical abuse [DATE] involving Residents #2 and #3 A. Residents #2 and #3 1. Resident #2, age 63, admitted to the facility on [DATE], and readmitted on [DATE]. According to the [DATE] CPO, [DIAGNOSES REDACTED]. The [DATE] MDS assessment revealed the resident was moderately cognitively impaired with a BIMS of ten out of 15. The resident required one-person limited assistance with dressing, toileting, and personal hygiene. He required supervision for bed mobility, transfers, and eating. The resident's care plan dated [DATE] with a revision date of [DATE] identified the resident as having extreme mood changes, manic episodes, and depressive episodes. Pertinent interventions included redirect with music when manic or experiencing increased agitation, counseling as tolerated, validate feelings and encourage him to talk about his feelings, encourage resident to sit and listen to music. 2. Resident #3, age 59, admitted to the facility on [DATE], readmitted on [DATE], and passed away on [DATE]. According to the April computerized physician orders [REDACTED]. The resident's minimum data set (MDS) assessment revealed that the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of 5 out of 15. The resident required two-person extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene and supervision with set up help for eating. The resident's care plan dated [DATE] identified the resident as having behaviors that disrupt the rights of others and the behaviors place him in danger. The care plan read the resident exhibited verbal aggression towards staff and others with no known triggers, took food and drink from others, he will take fluids (water, pop, coffee) from anyone and from anywhere he sees it. Pertinent inventions included ensuring that the resident was offered drinks outside of mealtimes and to offer finger foods. B. Resident-to-resident abuse [DATE] and facility response 1. Incident Resident #3's record revealed a nurse progress note written cord on [DATE] at 8:35 a.m. read: This nurse heard Resident #2 swiftly propelling himself in his wheelchair (w/c) back to the nurses station (NS). This nurse was at the medication cart in the NS and I turned around immediately. Resident #2 verbalized to Resident #3, Don't drink my juice! Don't drink my juice! Before I could reach area Resident #2 used his open hand several times to push on Resident #3's left cheek. Residents were separated immediately. Residents environment changed. As this nurse was propelling Resident #3 in the w/c he had no signs or symptoms of pain/discomfort or fear noted or reported. Skin assessed once back to room, remains intact, and no new skin concerns at this time . Police department called. 2. Facility response Resident #2's record revealed the interdisciplinary team (IDT) met [DATE] and Resident #2 was placed on one-to-one, a decision was made to have the psychiatrist review Resident #2's medications, and Resident #2 was educated on the importance of keeping his hands to himself. The resident agreed, he wouldn't hurt anyone. Further record review revealed the IDT met again on [DATE] and a decision was made to do 15-minute checks x 72 hours. It also read social services was pursuing counseling. The admissions coordinator (AC), who was acting as the interim social services director during the month of [DATE], was interviewed on [DATE] at 3:00 p.m. The social services director (SSD) and the interim director of nursing (IDON) were also present for the interview. The AC said that Resident #3 had picked up Resident #2's juice and started drinking it. She said that Resident #2 had become upset and pushed Resident #3 in the face. The AC confirmed Resident #2 was put on 1:1 monitoring after the incident. The SSD said that Resident #2 was taken off the 1:1 on [DATE] and placed on 15 minute checks. The NHA and the clinical regional consultant (CRC) were interviewed on [DATE] at 9:05 a.m. The NHA said that Resident #3 was known for wandering and he had a history of [REDACTED]. He should always have a drink with him. She said she was not sure if Resident #3 had just had a drink or not before he took Resident #2's juice. Resident #2 was placed on a 1:1 and when he did not have any additional behaviors, the decision was made to remove the 1:1. She said that abuse was substantiated. 3. Failures in facility response Review of Resident #2's care plan revealed no reference to the [DATE] incident, including what triggered it (perceived loss of juice) or to the need for and the plan to monitor the resident, first with a one to one sitter, and then for every 15 minutes checks around the clock. Further, review of Resident #3's record revealed that although the facility knew the resident had a behavior that placed him in danger (wandering and taking drinks), there was no monitoring plan for the resident and no update to his care plan after the incident to prevent further abuse. III. Resident-to-resident physical abuse [DATE] involving Residents #2 and #4 A. Resident #2 and #4 1. Resident #2 - see above 2. Resident #4 Resident #4, age 82, admitted to the facility on [DATE], readmitted on [DATE], and passed away on [DATE]. According to the [DATE] CPO, [DIAGNOSES REDACTED]. The [DATE] MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of four out of 15. The resident used a manual wheelchair and required extensive assistance of two for bed mobility and extensive assistance of one for transfers The resident's care plan dated [DATE] with a revision date of [DATE] identified the resident as having behavioral disturbances that seriously disrupt the rights of other residents and that he will go into other residents' rooms and rummage through their things, taking items at times. Pertinent interventions included in-service staff to monitor the resident's movements and surroundings and redirect as necessary, staff will frequently check residents' location and redirect if needed to the dining room or activities room, or wherever the resident wishes other than (other) residents' rooms. B. Resident-to-resident abuse [DATE] with significant injuries and facility response 1. Facility investigation A nurse progress note written in Resident #2's medical record on [DATE] at 1:02 a.m. documented the following: At 6:20 p.m. (on [DATE]) a certified nurse aide (CNA) yelled from down the hall that she needed help and wanted the nurse. This nurse went down the hall and saw Resident #2 sitting in the hall just outside of his room looking into the room. Resident #2 stated, He was in my room. Resident #4 was laying on the floor on his left side next to the heater/air conditioner (AC) unit. The first CNA at the scene stated that Resident #2 told her, I beat the s*** (explicit language) out of him because he was in my room. Skin assessment was done on Resident #2 with no injuries, no elevations or marks noted on hands or elsewhere. Resident #2 was wearing rings on both hands. Resident #2 denied pain. He was immediately placed on 1:1 observation, he remained in his room with door closed after Resident #4 was taken out of room for further assessment and treatment . A nurse progress note written in Resident #4's medical record by the ADON on [DATE] at 9:11 p.m. read Resident #4 had multiple discolored areas to his face, ears and head. When asked what happened, the resident closed his hand and pointed to his head. The local police department and the on-call physician were notified; the physician gave a verbal order to send the resident to the hospital for further evaluation. A nurse progress note written in Resident #4's medical record on [DATE] at 10:43 p.m. by the nurse who responded to the CNA's call read, At 6:20 p.m. a CNA yelled from down the hall that she needed help and wanted the nurse. This nurse went to the room. Resident #4 was laying on the floor on his left side near the heater/AC unit. Resident was breathing with mild grunting sound, eyes open, a moderate amount of blood was on the floor around his head. Resident was demonstrating range of motion (ROM) in his lower extremities and did move his right arm on his own. Resident #4 was alert, but initially appeared cognitively slow to respond. He demonstrated movement of his head and appeared to have no significant cervical injury. Resident appeared to want to get up, assisted to his w/c. Neurological checks initiated. Initial Glasgow Coma Score at 10, quickly improving to 15 after 10 to 15 minutes. Blood was cleaned to reveal injuries: Right temple laceration 3 centimeters (cm) x 0.3 cm laceration with elevation. Right earlobe discoloration. Right cheek discoloration 2 cm x 3 cm. Left temple superficial abrasion 1 cm x 1 cm. Left temple discoloration with elevation 5 cm x 4 cm. Left cheek discoloration 3 cm x 4 cm. Right chest discolored area 2 cm x 1 cm. Cold packs were applied to sites of elevation. Resident denied pain, but Tylenol 650 mg was given. Vital signs: temperature 97.3, heart rate 73, respirations 24, blood pressure ,[DATE]. Oxygen saturation (SaO2) 88% on room air, going up to 93% on room air within 15 minutes . A nurse progress note written in Resident #4's medical record on [DATE] at 12:43 a.m. documented the hospital notified the facility Resident #4 had a brain bleed considered serious bodily injury and that they would be stabilizing him, then sending him to another hospital. 2. Hospital reports An emergency department report [DATE] at 2:35 a.m. documented, An [AGE] year-old male came into the ED via emergency medical service (EMS) as a transfer from another hospital for traumatic subdural hemorrhage. Per transfer paperwork, the patient lives in a nursing home in the dementia care unit where he was assaulted by another resident. Patient has a laceration on the right side of his forehead that was stapled at the outside facility. He also has significant bruising to the left and right sides of his face and his right ear is swollen and bruised. Patient is normally confused secondary to his history of dementia and is unable to answer any questions here at the ED but he does mumble. Patient also has a history [MEDICAL CONDITION] left sided deficits. Patient was found to have a 5mm right subdural hemorrhage on his Computerized tomography (CT) of the head and was transferred here for a higher level of care . He is a full code. As he is unable to actually articulate where he is hurt and they had only done a head and neck CT at the other facility. I did a full trauma workup. This revealed nasal fractures, again the subdural hemorrhage, multiple rib fractures on each side of his chest. No pneumothorax or hemothorax. No evidence of visceral injury to his pelvis. L1 compression fracture that I'm not sure is actually acute however I also don't have any previous comparisons. He does have an auricular hematoma over the right ear however I do not think that this requires drainage at this time. I then discussed the case with the trauma surgeon on-call who agreed for admission. Due to the presence of multiple injuries he did request to have him be monitored in the neuro trauma unit. The patient was hemodynamically stable at this time and currently does not need oxygen although this may change given his multiple rib fractures. The [DATE] at 11:32 a.m. discharge summary report read in part, that the resident demonstrated bilateral small acute subdural hematomas, acute intraparenchymal hemorrhagic contusion on the right temporal lobe, bilateral nasal bone fractures, bilateral zygomatic arch fractures, rib fractures of right ribs ,[DATE], rib fractures of left ribs ,[DATE], and L1 (lumbar) compression fracture. The patient was admitted to service in the neurotrauma intensive care unit for further evaluation and care . The patient was ready for discharge and discharged back to his nursing facility in stable condition. The resident expired at the facility on [DATE]. 3. Facility operations director's statement written on [DATE] On the morning of [DATE], while interviewing Resident #2 on a grievance complaint filed by him, Resident #2 made reference to hitting Resident #4. During my interview with Resident #2 I made a statement that he shouldn't be beating up other residents and his reply was that he didn t beat him up, he only hit him. I told him that's the same thing. He then demonstrated how he hit Resident #4 by forming a fist with his left hand and placing his knuckles on his left chin. I asked him if he hit him with his rings on and he said he always has his rings on. 4. Staff interviews The AC, during her interview on [DATE] at 3:00 p.m. (see above) said that she interviewed Resident #2 on [DATE]. She said that Resident #2 voiced to her that he thought that Resident #4 came into his room and was trying to get something out of his drawers. She said Resident #2 told her that Resident #4 had fallen to the floor out of his w/c. The AC said that Resident #4 had a history of [REDACTED]. She said that Resident #2 was on 15 minute checks at the time of the incident, and that he was placed on 1:1 monitoring following the incident. The SSD, during her interview with the AC and the interim DON on [DATE] at 3:00 p.m. said adult protective services (APS) had investigated and filed a case against Resident #2 because the altercation with Resident #4 was considered an incident against an at-risk adult. The SSD said that she identified after the second resident to resident altercation involving Resident #2 that juice and food appeared to be triggers for him. She said that when other residents wander into his space with the perceived threat that they are going to take the food or drink from him, he gets upset. The SSD said that she had care planned that for Resident #2. The interim DON said that Resident #2 would remain on one to one for as long as it was necessary and he realized that what he had been doing was wrong. The ADON, during her interview on [DATE] at 2:18 p.m. (see above) she said that she thought Resident #2 had been on a one to one (on [DATE]) because of a previous altercation with a resident. She said she believed he was now on one to one indefinitely because the facility could not afford to have him hurt anyone else. The NHA during the interview on [DATE] at 9:05 a.m. with the clinical regional consultant (CRC), said Resident #4 was known to always be looking for snacks. She was not sure if he had been headed out to smoke and then veered into Resident #2's room. She said they knew something happened in the room, but there were just no witnesses to confirm. She Resident #2 said that Resident #4 fell initially, then he stated that he beat the s**** (explicit language) out of him. She said the second incident occurred between the 15-minute checks. She said abuse was substantiated. C. Failures in facility response Although the resident's care plan was updated [DATE] to include one on one due to behaviors, contrary to the SSD statement above, there was no evidence Resident #2's triggers - food and juice being taken from him - were added to his care plan. Moreover, staff knew Resident #4 had behaviors that disrupted the rights of others, placing him at risk for resident to resident abuse. Staff also were directed in his care plan to monitor Resident #4's movements and surroundings and to frequently check his location. However, there was no evidence in facility's investigation (see above) the facility had attempted to determine when staff had last checked on Resident #4 to ensure his safety. Finally, interviews indicated staff had not been trained to ensure one to one monitoring of Resident #2 would be effective. -Activity assistant (AA) #1 was interviewed on [DATE] at 4:55 p.m. She said she was currently providing Resident #2 a one to one. She said the resident was on one to one because he had girls over and they would give him drugs. The AA said she would sit outside the resident's room and make sure that nobody was throwing drugs through the resident's window, as that had happened in the past. The AA said she was unsure the last time she had any behavior training, but if she had any, it would have been on the computer. -CNA #1 was interviewed on [DATE] at 2:03 p.m. She said this was the first time she was assigned to the one to one for Resident #2. She said she was not sure why she was doing the one to one, but was told she just needed to make sure the resident did not need anything. The CNA said she had not received any training specific to the one to one of Resident #2, nor had she received any behavior training from the facility in the month she had been working in the facility.

Based on record review and interviews, the facility failed to provide appropriate treatment and services to five (#1, #2, #3, #4 and #9) of six out of nine total sample residents residing on the secured behavioral unit (South unit), all of whom displayed or were diagnosed with [REDACTED]. Specifically: Record review and interviews revealed the facility failed to accurately document and monitor resident behaviors on the South unit; failed to have an interdisciplinary team (IDT) that evaluated and discussed each resident on the South unit; and failed to develop a person-centered approach to each resident. Further, interviews revealed the facility failed to provide ongoing and specialized training to the staff members working on the South unit. These failures contributed to the facility's inability to effectively care plan and manage Resident #1's resistive behavior, and evacuate the resident during a fire in the dining room in the South unit (cross-reference F689 and F657). The facility failures also contributed to an inability to ensure residents were protected from Resident #2's rapid mood changes and Residents #3 and #4 were protected from unsafe behaviors that placed them in danger (cross-reference F600) and an inability of Residents #1, #2, #3, #4, and #9 to attain and maintain their highest practicable level of physical, mental and psychosocial well-being (cross-reference F585 and F679). Findings include: I. Failure to accurately document and monitor resident behaviors on the South unit (secure mental health unit), in order to identify changes in mental status, behavior and cognition; adjust interventions; and effectively manage unsafe behaviors. A. The facility Behavior, [MEDICAL CONDITION], Restraint, and Elopement Management policy and procedure, last revised April 2015, provided by the nursing home administrator (NHA) on 8/10/2020 at approximately 3:30 p.m., read, in pertinent part: Assessment: The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior and cognition, including: Onset, duration, intensity and frequency of behavioral symptoms; any precipitating or relevant factors or environmental triggers; and appearance and alertness of the resident related to observations. Monitoring: If the resident is being treated for [REDACTED]. Interventions will be adjusted based on the impact of behavior and other symptoms, including adverse consequences related to treatment. B. The facility's procedure for assessing and monitoring resident behaviors 1. Review of Resident #1, #2, #3, #4, and #9's records revealed handwritten and electronic behavior monitoring, some months both forms were completed and some months only one of these forms was completed. The manner of documentation was not consistent for all five residents (see below). 2. Interviews with the social services director (SSD) on 8/6/2020 at 12:30 p.m., the interim director of nursing (IDON) and SSD on 8/10/2020 at 3:05 p.m., the social services consultant (SSC) on 8/12/2020 at 1:44 p.m., and the corporate regional consultant (CRC) and NHA on 8/17/2020 at 9:00 a.m. revealed inconsistent expectations and understanding of behavior monitoring in the facility. The SSD reported nursing staff should be documenting all of a resident's behaviors on the electronic or handwritten behavior monitoring sheets. The IDON reported the facility charted behaviors by exception, therefore, documenting only when the resident exhibited a behavior. The SSC reported charting by exception should only be done when the facility had established a set of behaviors for the resident. She said the facility did not use baseline charting. The NHA reported that, ideally, behavior charting should be in the handwritten behavior monitoring and in nursing progress notes. The NHA agreed the facility did not use baseline charting. C. Residents #1, #2, #3, #4, and #9 Inconsistencies reported by staff (see above) were reflected in the residents ' behavior monitoring, and contributed to: staff's inability to manage Resident #1's resistive behavior, and evacuate the resident during a fire in the dining room in the South unit; staff's inability to protect Residents #3 and #4 from unsafe behaviors that placed them in danger; and the inability of Resident #1, #2, #3, #4, and #9 to attain and maintain their highest practicable level of physical, mental and psychosocial well-being. RESIDENT #1 1. Resident status Resident #1, age 70, admitted to the facility on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. According to the 7/20/2020 minimum data set (MDS) assessment, the resident had severe cognitive impairment; staff were unable to complete a brief interview for mental status (BIMS) with the resident. According to the staff assessment for mental status, the resident had modified independence making decisions regarding tasks of daily life. The resident displayed inattention and disorganized thinking. He displayed physical behavior symptoms directed towards others one to three days, and verbal behavior symptoms directed towards others daily. These behaviors put the resident at significant risk for physical illness and injury, significantly interfered with his care and significantly interfered with his participation in activities or social interactions. These identified behaviors also put others at significant risk for physical injury, significantly intruded on the privacy or activity of others, and significantly disrupted care or the living environment. The resident rejected care on a daily basis. The resident required set-up assistance with bed mobility, transfers, walking, and locomotion, one-person assistance with dressing, eating, and toileting, and two-person extensive assistance with personal hygiene. 2. Record review The secure unit care plan, initiated on 10/27/2018 and revised on 8/7/2020 during survey (8/4 - 8/17/2020), revealed the resident was on the secure unit for his safety/structure. The resident was a serious danger to himself or others due to his behaviors. The goal was for the resident to have his needs anticipated and met by the staff. The pertinent interventions included allowing the resident to leave the secure unit when he requested, and evaluating the appropriateness of the secure unit placement every quarter and as needed. The agitation care plan, initiated on 11/1/2018 and revised on 8/7/2020 during the survey, revealed the resident frequently became agitated about leaving the facility. He would state that he wished to return home, and he had a history of [REDACTED]. The goal was for the resident to cause no injury to himself or others due to his behaviors. The pertinent approaches included caregivers providing opportunity for positive interaction and attention, providing cookies to the resident, and providing music to calm/soothe the resident. The behavior care plan, initiated on 3/13/2017 and revised on 8/7/2020 during the survey, revealed the resident could become explosive with verbal outbursts with no identifiable triggers as evidenced by throwing cups, spitting on the walls, windows, and floors and cursing at staff related to his [DIAGNOSES REDACTED]. The resident frequently became agitated stating that a fat bastard who used to run the facility stole money from him, the resident is not currently taking any medications as he refuses. The goal was for the resident to cause no injuries to himself or other due to his behaviors, as well as to be redirected from behaviors before they increased and caused harm to himself or others. The pertinent approaches included, assessing for pain or discomfort as the reason for the increased behaviors. Caregivers provide the opportunity for positive interaction, attention by stopping and talking with the resident when they are passing by. Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential cause. A 6/10/2020 pre-admission screening and resident review or PASRR Level II Mental Health Review (a third-party assessment and care planning process to support nursing home residents with mental illness or developmental/intellectual disabilities) indicated the facility was providing the following specialized services for the resident: (Name of resident) has a behavior plan to decrease negative behaviors to keep himself and others safe. Staff should continue to support the behavior plan to encourage positive interactions and support (name of resident) with feeling safe and getting his needs met. 3. Behavior monitoring for Resident #1 - Conflicting and inconsistent documentation June 2020: A review of the June 2020 handwritten Behavior Monitoring documented the resident was monitored for: -Spitting at staff every shift (two shifts per day) for [MEDICAL CONDITION]. Staff documented spitting behavior as occurring 17 out of 60 shifts. -Verbally explosive with no identifiable triggers every shift (two shifts per day) for [MEDICAL CONDITION]. Staff documented verbally explosive behavior as occurring 28 out of 60 shifts. On both of the June handwritten behavior tracking sheets, staff were to document the number of times the behavior occurred on the shift. On several of the shifts, the staff documented C, which was not listed on the key to the Behavior Monitoring document. A review of the June 2020 electronic Behavior Monitoring documented staff monitored the resident for the same two behaviors, but listed separated monitoring for verbally explosive behavior for [MEDICAL CONDITION] and for [MEDICAL CONDITION]. In all, the frequency of the behaviors was documented as much less. -Spitting at staff every shift (two shifts per day) for [MEDICAL CONDITION] was documented as occurring two out of 60 shifts to document the behavior. -Verbally explosive with no identifiable triggers for [MEDICAL CONDITION] was documented as occurring three out of 60 shifts to document the behavior. -Verbally explosive behavior with no identifiable triggers every shift for [MEDICAL CONDITION] and use of [MEDICATION NAME], was documented as occurring one out of 60 shifts to document the behavior. July 2020: A review of the July 2020 handwritten Behavior Monitoring was not possible. The monitoring was not in resident's medical record and not provided by the facility when requested. A review of the July 2020 electronic Behavior Monitoring documented the resident was being monitored for: -Spitting at staff every shift (two shifts per day) for [MEDICAL CONDITION]. Staff documented spitting behavior as occurring 22 out of 62 shifts. -Verbally explosive with no identifiable triggers every shift for [MEDICAL CONDITION] and use of [MEDICATION NAME]. Staff documented this behavior as occurring 30 out of 62 shifts. August 2020: A review of the August 2020 handwritten Behavior Monitoring was not possible. The monitoring was not available in the resident's medical record and not provided by the facility when requested. A review of the August 2020 electronic Behavior Monitoring documented the resident was being monitored for: -Physical aggression including throwing objects every shift (two shifts per day) [MEDICATION NAME]/personality change due to TBI. (Added to the behavior monitoring on 8/12/2020, during the survey.) Staff documented physical aggression as occurring two out of 12 shifts. -Spitting at staff every shift (two shifts per day). (Added to the behavior monitoring on 8/12/2020, during the survey.) Staff documented spitting behavior as occurring one out of 12 shifts to document the behavior. -Spitting at staff every shift (two shifts per day) for [MEDICAL CONDITION]. (Discontinued from the behavior monitoring on 8/12/2020, during the survey.) Staff documented spitting behavior as occurring 10 out of 23 shifts. -Verbally explosive with no identifiable triggers every shift for [MEDICAL CONDITION] and use of [MEDICATION NAME]. Staff documented this behavior as occurring 18 out of 34 shifts. 4. Outcome Record review and interview revealed the facility had a fire on 8/2/2020 at approximately 8:15 a.m. Interviews with facility staff and video reviews revealed the facility decided to evacuate the South Unit where Resident #1 resided. Although assessed to resist care daily, staff was unable to get Resident #1 to evacuate the facility during the fire. Staff shut his door and left him in his room without staff supervision. Review of behavior monitoring (see above) revealed staff had not identified Resident #1 resistance to cares as a behavior to monitor and, likewise, had not developed effective interventions to address it, placing Resident #1 in immediate jeopardy. (Cross-reference F689) RESIDENT #2 1. Resident status Resident #2, age 63, was admitted on [DATE], and readmitted on [DATE]. According to the August 2020 CPO, [DIAGNOSES REDACTED]. The 7/28/2020 MDS assessment revealed that the resident was moderately cognitively impaired with a BIMS of ten out of 15. The MDS did not identify any behaviors that the resident displayed. The resident required one-person limited assistance with dressing, toileting, and personal hygiene. He required supervision for bed mobility, transfers, and eating. 2. Record review The long term care/secure unit placement care plan, initiated on 2/20/2017 and revised on 3/24/2020, revealed the resident was on the secure unit due to his behavior placing him in danger. The goal was for the resident to have his needs anticipated and met by the staff. The pertinent interventions included secure unit placement to be evaluated every 30 days, quarterly and as needed and to participate in activities of choice. The PASRR LEVEL II care plan, initiated on 4/12/2017 and revised on 4/17/2020, revealed the resident experienced extreme mood changes, manic episodes, and depressive episodes. He becomes very possessive regarding his belongings and will become physically aggressive. The goal was for the resident to remain stable and have a reduction in behaviors and symptoms, and no [MEDICAL CONDITION], and medication compliance through the next review date. The pertinent interventions included, placing the resident on a one to one until effects of medication changes are known and then reevaluate, encourage the resident to participate in activities of choice/interest, encourage the resident to verbalize his concerns before becoming physical, monitor the resident's mood and participation in care, redirect others away from the resident's belongings, redirect with music when manic or experiencing increased agitation, and report any concerns of behaviors and symptoms to physician or psychiatrist. The resident's anxiety care plan, initiated on 3/8/2017, and revised 8/21/2018, revealed the resident experienced extreme restlessness and verbalized inability to slow down thoughts and rest. The goal was for the resident to have decreased anxiety over the next review period as evidenced by statement of decreased anxiety, no increase in behaviors, ability to participate in activities of choice and ability to participate in his own care. The pertinent interventions included redirect the resident as able, away from stressful or chaotic situations to decrease risk of anxiety, staff will encourage/assist resident to participate in diversional activities to decrease anxiety, and staff will monitor for and report to nurse any noted triggers/precipitating factors/situations that increase resident's anxiety. 3. Behavior monitoring for Resident #2 - Conflicting and inconsistent documentation June 2020: A review of the June 2020 handwritten Behavior Monitoring documented the resident was being monitored for: -Mania to include rapid speech, restlessness or irritability, every shift (two shifts a day) for [MEDICAL CONDITION]/[MEDICATION NAME] use. Staff [MEDICAL CONDITION] times out of 60 shifts. -Episodes of rapid change in mood every shift for [MEDICAL CONDITION]/[MEDICATION NAME] use. Staff documented episodes of rapid speech behavior zero out of 60 shifts. A review of the June 2020 electronic Behavior Monitoring documented that the resident was being monitored for the same two behaviors and documented the same frequency as above; however, there were 55 shifts where there was no documentation completed for either behavior. July 2020 A review of the July 2020 handwritten Behavior Monitoring documented the resident was being monitored for: -Mania to include rapid speech, restlessness or irritability, every shift (two shifts a day) for [MEDICAL CONDITION]/[MEDICATION NAME] use. Staff documented this behavior two out of 60 shifts. There were no interventions or outcomes documented. There were 12 shifts where there was no documentation completed. -Rapid change in mood every shift (two shifts a day) for [MEDICAL CONDITION]/[MEDICATION NAME] use. Staff documented this behavior four shifts out of 60 shifts. There were 13 shifts where there was no documentation completed. A review of the July 2020 electronic Behavior Monitoring documented the resident was being monitored for the same two behaviors; however,[MEDICAL CONDITION] documented one out of 60 shifts, which are not the same shifts documented on the handwritten Behavior Monitoring sheets and there were 5 shifts where there was no documentation completed. Rapid change in mood behavior was documented one out of 60 shifts, which was not the same shift documented on the handwritten Behavior Monitoring sheets, and there were 5 shifts where there was no documentation completed. August 2020: A review of the August 2020 handwritten Behavior Monitoring was not available in the resident's medical record and not provided by the facility when requested. A review of the August 2020 electronic Behavior Monitoring documented the resident was being monitored for: -Mania to include rapid speech, restlessness or irritability, every shift (two shifts a day) for [MEDICAL CONDITION]/[MEDICATION NAME] use. [MEDICAL CONDITION] was documented three out of 33 shifts. There were four shifts where there was no documentation completed. 4. Outcome Record review and interview revealed on 4/5/2020, Resident #2 became upset and pushed Resident #3 several times in the face. Then, on 4/16/2020, Resident #2 hit Resident #4 when Resident #4 entered Resident #2's room. Staff found Resident #4 on the floor in Resident #2's room and Resident #2 told the first staff at the scene, I beat the s*** out him because he was in my room. Hospital records revealed Resident #4 sustained bilateral subdural hematomas, four right-side rib fractures, four left side rib fractures, a L1 compression fracture, a nasal bone fracture and bilateral zygomatic arch (cheek bones) fractures. (Cross-reference F600) Behavior monitoring revealed that despite the incidents in April 2020, Resident #2'[MEDICAL CONDITION] rapid mood changes were not accurately or consistently monitored to prevent future physical abuse, to adjust interventions, and effectively manage unsafe behaviors. RESIDENT #3 1. Resident status Resident #3, age 59, admitted to the facility on [DATE], readmitted on [DATE], and passed away on 4/25/2020. According to the April CPO, [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] revealed that the resident was severely cognitively impaired with a BIMS score of 5 out of 15. He displayed physical and verbal behavior symptoms directed towards others four to six days a week. Those behaviors put the resident at significant risk for physical illness and injury and significantly interfered with his care. Those identified behaviors put others at significant risk for physical injury, significantly intruded on the privacy or activity of others, and significantly disrupted care or the living environment. The resident required two-person extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene and supervision with set up help for eating. 2. Record review The secure unit care plan, initiated on 2/27/2020, revealed that the resident was moved to the secure unit on 11/19/18 after returning to the facility following an inpatient hospitalization at a behavioral health facility. The resident had behaviors that disrupted the rights of others. The behaviors placed him in danger and less restrictive alternatives had been unsuccessful. The goal was for the resident to have his needs anticipated and met by staff. Pertinent interventions included for the resident to be reviewed quarterly by the psychiatrist, and referrals as needed for mental health support. The PASRR Level II care plan initiated on 2/27/2020 and revised on 4/27/2020 after the resident passed away revealed the resident exhibited verbal aggression towards staff and others with no known triggers. He would make verbal threats, have a defensive stance, and exhibit rapid speech. The resident would take food and drink from others, and he would take fluids (water, pop, coffee) from anyone and from anywhere he saw it. The goal was for the resident to remain stable with reduction in behaviors and symptoms. Pertinent interventions included: to encourage the resident to verbalize his feelings and validate his feelings; to encourage/allow the resident to verbalize his concerns; to engage him in friendly conversation and redirection as tolerated; to ensure the resident was offered drinks outside of meal times; to redirect the resident as able when he had behaviors that may cause injury to himself; and to refill the resident's cup/glass when it was noted to be empty when in dining room for meals to decrease the risk of him taking/grabbing drinks from others. The anxiety care plan, initiated on 2/27/2020, revealed that the resident had episodes of anxiety as evidenced by rapid speech, repeating himself, shaking, and asking repetitive questions. The resident had a behavior of spitting on the walls of the unit. The goal was for the resident's acute episodes of anxiety to be relieved within ten minutes of staff intervention. Pertinent interventions included altering the resident's environment during an episode of anxiety by taking him on a walk, taking him to an activity or to another area, and reassuring the resident that his needs would be met. The sexually inappropriate behaviors care plan, initiated on 2/27/2020, revealed the resident would expose himself to urinate in inappropriate places and touch himself while out of his room. The goal was for the resident to refrain from exposing himself and/or touching himself while out of his room. Pertinent interventions included to ask/assist the resident to return to his room to do such acts in the privacy of his room, utilizing a two hour toileting schedule to assist the resident with exposing himself and urinating, redirecting the resident to engage in an activity or snack, and reminding the resident that such behavior is inappropriate and politely ask him to pull his pants up. A 1/17/2020 PASRR Level II Mental Health Review indicated the facility was providing the following specialized services for the resident: Staff at the nursing facility will provide an on-going evaluation of (name of resident) mood and psychiatric stability. Medication management is imperative. Close supervision of psychiatric symptoms will be reported to the primary care provider (PCP)/psychiatrist for further review and evaluation. Staff will need to monitor for any signs that he may be having an increase in his psychiatric symptoms as he does have a history of negative behaviors when not taking medications as prescribed. 3. Behavior monitoring for Resident #3 - Conflicting and inconsistent documentation February 2020: A record review revealed no handwritten Behavior Monitoring for February 2020. Per the assistant DON, the facility did not implement the handwritten Behavior Monitoring until March 2020. A review of the February 2020 electronic Behavior Monitoring documented that the resident was being monitored for: -Verbal aggression, throwing objects, every shift (two shifts a day) related to [MEDICAL CONDITION]. The order was discontinued on 2/24/2020 when the resident went out to the hospital, and was not reinstated upon his return. There were 47 opportunities for documentation of behaviors. There was no documentation completed for any of the 47 opportunities. -Aggressively pacing with clenched fists every shift (two shifts a day) related to [MEDICAL CONDITION]. The order was discontinued on 2/24/2020 when the resident went out to the hospital, and was not reinstated upon his return. There were 47 opportunities for documentation of behaviors. There was no documentation completed for any of the 47 opportunities. -Liquid seeking, resident will take liquids directly from others hands, every shift (two shifts a day) related to [MEDICAL CONDITION]. The order was discontinued on 2/24/2020 when the resident went out to the hospital, and was not reinstated upon his return. There were 47 opportunities for documentation of behaviors. There was no documentation completed for any of the 47 opportunities. -Sexual inappropriateness: exposing self, urinating in inappropriate places, every shift (two shifts a day) related to unspecified mood affective disorder. The order was discontinued on 2/24/2020 when the resident went out to the hospital, and was not reinstated upon his return. There were 47 opportunities for documentation of behaviors. There was no documentation completed for any of the 47 opportunities. -Confrontational, argumentative, demanding or threatening, every shift (two shifts a day) related to unspecified mood affective disorder. The order was discontinued on 2/24/2020 when the resident went out to the hospital, and was not reinstated upon his return. There were 47 opportunities for documentation of behaviors. There was no documentation completed for any of the 47 opportunities. -Physical aggression towards staff and/or others, every shift (two shifts a day) for frontal temporal dementia/[MEDICATION NAME] use. The order was discontinued on 2/24/2020 when the resident went out to the hospital, and was not reinstated upon his return. There were 47 opportunities for documentation of behaviors. There was no documentation completed for any of the 47 opportunities. -Physical aggression towards staff or others, every shift (two shifts a day) for [MEDICAL CONDITION]/iloperidone use. The order was entered on 2/27/2020 on the second shift. The physical aggression behavior was documented as occurring two shifts out of fives shifts. There were two shifts where no documentation was completed. -Uncontrollable laughing, pacing, causing irritability with inability to rest/calm, every shift (two shifts a day) for mixed [MEDICAL CONDITION]/[MEDICATION NAME] use. The order was discontinued on 2/24/2020 when the resident went out to the hospital, and was not reinstated upon his return. There were 47 opportunities for documentation of behaviors. There was no documentation completed for any of the 47 opportunities. -Urinating in inappropriate places, being hyper sexual and unable to redirect, every shift (two shifts a day) for mixed [MEDICAL CONDITION] disorder/[MEDICATION NAME] use. The order was discontinued on 2/24/2020 when the resident went out to the hospital, and was not reinstated upon his return. There were 47 opportunities for documentation of behaviors. There was no documentation completed for any of the 47 opportunities. March 2020: A review of the March 2020 handwritten Behavior Monitoring documented the resident was being monitored for: -Extreme agitation, threatening behaviors, unable to be redirected, every shift (two shifts a day) for agitation/[MEDICATION NAME] use. The extreme agitation, threatening behaviors were documented as occurring 26 shifts out of 62 shifts. There were two shifts documented that no behaviors occurred. On several of the shifts, the staff documented C, which was not listed on the key to the Behavior Monitoring document. There were 34 shifts where no documentation was completed. -Physical aggression towards staff or others, every shift (two shifts a day) for [MEDICAL CONDITION]/[MEDICATION NAME] use. The physical aggression behavior was documented as occurring 20 shifts out of 62 shifts. There were eight shifts documented that no behaviors occurred. On several of the shifts, the staff documented C, which was not listed on the key to the Behavior Monitoring document. There were 34 shifts where no documentation was completed. -Responding to internal stimuli (uncontrollable laughter, speaking to self), every shift (two days a shift) for paranoid [MEDICAL CONDITION]/[MEDICATION NAME] use. The responding to internal stimuli behavior was documented as occurring 13 shifts out of 62 shifts. There were ten shifts documented that no behaviors occurred. On several of the shifts, the staff documented C, which was not listed on the key to the Behavior Monitoring document. There were 34 shifts where no documentation was completed. A review of the March 2020 electronic Behavior Monitoring documented that the resident was being monitored for: -Extreme agitation, threatening behaviors unable to be redirected, every shift (two shifts a day)for agitation/[MEDICATION NAME] use. Contrary to the handwritten Behavior Monitoring documentation above, extreme agitation, threatening behavior was documented as occurring one shift out of 62 shifts. There were three shifts documented that no behaviors occurred. There were 58 shifts where documentation was not completed. -Physical aggression towards staff or others, every shift (two shifts a day) for [MEDICAL CONDITION]/[MEDICATION NAME] use. Contrary to the handwritten Behavior Monitoring documentation above, physical aggression behavior related to [MEDICATION NAME] use was documented as occurring one shift out of 62 shifts. There were two shifts documented that no behaviors occurred. There were 59 shifts where documentation was not completed. -Physical aggression towards staff or others, every shift (two shifts a day) for [MEDICAL CONDITION]/[MEDICATION NAME] use. The physical aggression behavior related to [MEDICATION NAME] use was documented as occurring one shift out of 62 shifts. There were six shifts documented that no behaviors occurred. There were 55 shifts where documentation was not completed. -Physical aggression towards staff and/or others, every shift (two shifts a day) for agitation/[MEDICATION NAME] use. The physical aggression behavior related to [MEDICATION NAME] use was documented as occurring zero shifts out of 62 shifts. There were five shifts documented that no behaviors occurred. There were 57 shifts where documentation was not completed. -Physical aggression towards staff or others, every shift (two shifts a day) for [MEDICAL CONDITION] /iloperidone use. The physical aggression behavior related to iloperidone use was documented as occurring four shifts out of 62 shifts. There were two shifts documented that no behaviors occurred. There were 56 shifts where documentation was not completed. -Responding to internal stimuli (uncontrollable laughter, speaking to self), every shift (two days a shift) for paranoid [MEDICAL CONDITION]/[MEDICATION NAME] use. Contrary to the handwritten Behavior Monitoring documentation above, responding to internal stimuli behavior was documented as occurring three shifts out of 62 shifts. There were seven shifts documented that no behaviors occurred. There were 52 shifts where documentation was not completed. -Verbal aggression with inability to be redire (TRUNCATED)

Based on observations, interviews and record review, the facility failed to develop, implement, monitor and reevaluate its quality assurance performance improvement (QAPI) program to ensure the unique care and services the facility provided were maintained at acceptable levels of performance and continuously improved. Specifically, the facility's QAPI program failed to systematically self-identify, investigate, analyze and correct problems relating to quality of care, quality of life and resident safety. This failure contributed to serious adverse outcomes and the likelihood of further serious adverse outcome. Cross-reference F600, F742, and F689K Findings include: I. Facility policy The QAPI Committee policy and procedure, undated, was provided by the interim director of nursing (IDON) on 8/6/2020 at approximately 9:00 a.m., and read in pertinent part: Goals of the committee: the primary goal of the QAPI committee (is) to: -Establish and maintain and oversee facility systems and process to support the delivery of quality of care and services; -Promote the consistent use of facility systems and process during provision of care and services; -Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately; -Support the use of root causes to help identify where patterns of negative outcomes point to underlying systemic problems; -Help departments, consultants, and ancillary services implement systems to correct potential and actual issues in quality of care; -Coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals; and -Coordinate and facilitate communication regarding the delivery of quality resident care within and among departments and services, and between facility staff, resident, and family members. II. The complaint survey (8/4 to 8/17/2020) revealed multiple areas in which the facility failed to deliver care and services to its complex and unique resident population at an acceptable level of performance. According to 4/28/2020 facility assessment, the facility's resident profile included the following diseases/conditions, physical and cognitive disabilities: psychiatric/mood disorders including, [MEDICAL CONDITION], impaired cognition, [MEDICAL CONDITION], post-traumatic stress disorder, anxiety disorder and behaviors that need interventions. The services and care the facility offered based on resident need included hospice, bariatric care, palliative care and respite care. The complaint survey findings revealed deficiencies in the facility's level of performance in protecting residents ' rights, in ensuring residents ' safety, in delivering quality resident care and in promoting residents ' quality of life that were neither new nor uncommon. However, there was no evidence the findings had triggered a QAPI plan with corrective actions prior to survey. (Cross-reference F835 and F837). Specifically: A. Cross-reference F600 and F609 - failure to protect residents from abuse and to report abuse. F600 cited at a G level, actual harm and F609 cited at D level, potential for more than minimal harm. Survey findings revealed Resident #2 physically abused two cognitively impaired residents (#3 and #4) with known behaviors that disrupted the rights of others and placed them in danger. One incident occurred 4/5/2020 and another 4/16/2020. The 4/16/2020 incident resulted in Resident #4 sustaining bilateral subdural hematomas, four right-side rib fractures, four left side rib fractures, a L1 compression fracture, a nasal bone fracture and bilateral cheek bone fractures. Resident #4's [MEDICAL CONDITION] was not reported to the state. B. Cross-reference F742 and F657 for failure to provide appropriate treatment and services to five residents (#1, #2, #3, #4 and #9) residing on the secured behavioral unit (South unit), all of whom displayed or were diagnosed with [REDACTED]. F742 was cited at G level, actual harm and F657 was cited cited at E level, a pattern with the potential for more than minimal harm. Survey findings revealed the facility failed to accurately document and monitor resident behaviors on the South unit, failed to have an interdisciplinary team (IDT) that evaluated and discussed each resident on the South unit and failed to develop a person-centered approach to each resident and care plan new behavioral problems and concerns. Further, interviews revealed the facility failed to provide ongoing and specialized training to the staff working on the South unit. These failures contributed to the facility's inability to effectively care plan and manage unsafe behavior in an emergent situation and prevent physical abuse, as well as promote each resident's highest practicable level of physical, mental and psychosocial well-being C. Cross-reference F689 for failure to ensure resident safety from accidents, cited at K level, immediate jeopardy for serious harm, and EP 0007, EP 0009, EP 0037 and EP 039, failure to teach and train emergency preparedness. Survey findings revealed the facility experienced a fire in the South building dining room on 8/2/2020. Resident #1, severely cognitively impaired with behavioral disturbances that placed him at risk for harm, including daily resistance to cares, refused to evacuate the building. Staff left Resident #1 in his room behind a closed door after evacuating all the other residents from the building. The facility failed to identify and address Resident #1's known daily resistance to cares and failed to anticipate and plan for the difficulty in evacuating residents, including Resident #1, whose dementia and/or behaviors placed them at risk in an emergent situation such as fire. The facility further failed to provide sufficient emergency preparedness training and testing of staff after the 8/2/2020 fire and the unsuccessful evacuation of Resident #1 on the South secure unit. D. Cross-reference F584 for failure to maintain a safe, sanitary and homelike environment, cited at E level, a pattern with the potential for more than minimal harm and F924 for ineffective pest control, cited at D level, potential for more than minimal harm. Survey findings revealed the entire window and the middle two-thirds of the walls in Resident #1's room was covered with splatters in various shades of black, brown, pink and opaque material. Staff reported Resident #1 would frequently throw anything at the staff and at the walls in his room. She said he also frequently spit and yell at the staff and on the floor and his walls. She said staff would attempt to redirect him when he was throwing and spitting, but nothing really works, he'll just keep spitting and throwing things. Housekeeping staff said the walls, window and floor were covered in spit and everything Resident #1 threw at the wall, including food, drinks, and feces. Housekeeping staff were observed attempting to clean Resident #1's room using metal scrappers in an attempt to remove debris from the floor and the walls. Most of the debris was not removed easily; it appeared to have been on the walls and floor for some time. Observations further revealed standing water and mold in the South building basement. E. Cross-reference F679 for failure to provide activity programming to meet the interest and needs of each resident, cited at E level, a pattern with the potential for more than minimal harm. Survey findings revealed the facility failed to provide structured and meaningful activities to Residents #1, #2, #7 and #8, all of whom resided on the South secure unit and had displayed or were diagnosed with [REDACTED]. Record review revealed Resident #1, #2, #3, #4 and #5's quarterly/annual activity participation was not reviewed in a timely manner. Further, the unit lacked updated activity calendars to the and scheduled evening activities. Residents were observed unengaged in meaningful activities. F. Cross-reference F684 for failure to complete resident care (skin assessments) in a timely manner. The facility's failure to complete skin assessments timely, cited at a D level, potential for more than minimal harm. Cross-reference F686 for failure to provide adequate pressure ulcer care. The facility failed to provide treatment and services to prevent and heal pressure ulcers, cited at a D level, potential for more than minimal harm. III. Leadership interviews The nursing home administrator (NHA) and corporate regional consultant (CRC) were interviewed on 8/17/2020 at 9:00 a.m. The NHA said the facility currently had a QAPI committee which consisted of herself, the medical director, the director of nursing, the infection control nurse, the dietary manager human resources, the business office manager, the maintenance director, medical records, and a certified nurse aide if one is available. The NHA confirmed the QAPI committee had not identified and developed plans and corrective action for any of the deficiencies above in resident ' rights, resident ' safety, delivery of resident care and in promotion of residents ' quality of life. Rather, the NHA said the current issues the facility had identified were food and dining concerns, falls with fractures and residents wandering throughout the facility. The NHA said concerns from staff are generally brought up in morning meetings, and there was a concern from staff could fill out. The CRC said the corporation also provided a hotline telephone number that staff could use to report concerns. The CRC said she and the other corporate support for the facility would be inserting themselves into the facility to ensure everyone in the facility was on the same page. The CRC said QAPI would be one of the systems she and her team would be working on to ensure the facility was able to self-identify system failures, and hopefully implement systems to correct any problems.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to prevent the spread of the novel Coronavirus (COVID-19) in three of three neighborhoods. Specifically: Observations, record review and interviews revealed the facility failed to conduct active screening of staff in a manner to prevent the spread of COVID-19. Staff reported self-screening. Further review of screening logs and staff interviews revealed no follow up of one staff member after staff reported symptoms and no system to ensure all staff were screened, that screening logs were completed, and finally, that these logs were reviewed timely. Observations and interviews revealed additional infection control failures, including staff's failure to follow appropriate donning and doffing procedures when caring for residents on isolation precautions for COVID-19, and lack of hand hygiene practices for residents on secure/memory units. The above failures in infection control practices created an immediate jeopardy situation with the likelihood of serious harm to residents in three of three neighborhoods, staff, and others, if not corrected immediately. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Observations, record review, and interviews revealed the facility failed to conduct active screening of staff in a manner to prevent the spread of COVID-19. Staff reported self-screening. Further review of screening logs and staff interviews revealed no follow up of one staff member after staff reported symptoms, and no system to ensure all staff were screened, that screening logs were completed, and finally, that these logs were reviewed timely. Observations and interviews further revealed the facility failed to follow appropriate donning and doffing procedures when caring for residents on isolation precautions. In addition, the facility failed to offer residents on the behavior and memory care units the opportunity to wash or sanitize their hands prior to meals. The above failures in infection control practices created an immediate jeopardy situation with the likelihood of serious harm to residents in three of three neighborhoods, staff, and others, if not corrected immediately. On 7/28/2020 at 6:28 p.m. the nursing home administrator (NHA) was notified that the failures above created an immediate jeopardy situation that placed all residents in the facility at risk for serious harm (COVID-19). B. Facility plan to remove immediate jeopardy On 7/28/2020 at 8:43 p.m., the facility submitted an action plan to abate the immediate jeopardy. The abatement plan read: Identified current, positive and/or presumptive COVID-19 residents in the facility and 6 residents with pending test results placed on transmission-based precautions Post droplet precautions signs to identify transmission-based precautions for current, positive and/or presumptive COVID-19 residents In-services for staff initiated at 7/28/2020 at 6:50 pm and will be provided for all staff prior to start of shift or caring for resident (nursing, rehab, CNAs, housekeepers, social services, activities) on: -Current residents who are identified as COVID-19 positive and/or presumptive -Transmission-based Precautions: Droplet (posting of proper signs and keeping doors closed) -When to utilize PPE (i.e. passing medications, meal trays) -How to don/doff PPE -Cleaning/disinfecting of resident equipment (i.e. vital sign equipment-dispose of disinfectant wipe after one use). -Offer/remind residents on hand hygiene, masking, and social distancing Complete competencies for 100% staff by Friday, July 31, 2020 (nursing, rehab, CNAs, housekeepers, social services, activities): -Hand Hygiene -Don/Doff PPE -Cleaning/disinfecting of resident equipment The Corporate Chief Clinical Officer and Regional Director of Clinical Services will begin to monitor staff daily for 30 days beginning on 7/29/20, for hand hygiene, posting of signs for transmission-based precautions, use of PPE (donning/doffing), and cleaning/disinfecting of resident equipment. The facility nursing administrative staff will assume monitoring when back to work. Plan will be addressed at the next scheduled QAPI Committee Meeting August 2020. C. Removal of immediate jeopardy On 7/28/2020 at 9:10 p.m. the NHA, and corporate chief clinical officer (CCCO) were informed the immediate jeopardy had been abated, based on the facility's implementation of the above plan. However, deficient practice remained at F level (widespread with the potential for more than minimal harm). II. The facility failed to conduct active screening of staff in a manner to prevent the spread of COVID-19. A. Professional references 1. The Centers for Disease Control and Prevention (CDC) updated 6/25/2020, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, reads: Actively screen everyone for fever and symptoms of COVID-19 before they enter the healthcare facility. Screen all healthcare personnel at the beginning of their shift. Actively take their temperature and document the absence of symptoms consistent with COVID-19. 2. The Centers for Medicare and Medicaid Services (CMS) (4/2/2020) COVID-19 Long-Term Care Facility Guidance. Retrieved from: https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf read in pertinent part, Long-term care facilities should immediately implement symptom screening for all. Facilities should limit access points and ensure that all accessible entrances have a screening station. B. Screening process On 7/29/2020, observations of the facility's screening area for all healthcare, dietary, activities, and housekeeping personnel who entered the facility revealed the screening area was located at the time clock at the facility's south entrance and secured with a keypad code. The staff could access the building using the code and, thereafter, enter the facility for screening. The facility policy, Coronavirus/COVID-19, March 2020, was received from the nursing home administrator (NHA) on 7/29/2020. It read in pertinent part: Screening and self-monitoring: Staff will be educated on the facility's plan to control exposure to the residents. This plan will be developed with the guidance of the CDC and public health authorities. Staff will be reminded to stay home when ill. Screening of staff will be conducted prior to their shift and logged. If staff develop fever or symptoms while at work, they should put on a facemask (if not wearing one already), inform their supervisor, and leave the workplace. For COVID-19 naive facilities, staff who work at multiple locations may pose higher risk and should be asked about exposure to facilities with recognized COVID-19 cases. 1. Observations and interviews revealed deficiencies in the facility's screening process; specifically, self-screening by staff. a. Time clock observations were conducted on 7/20/2020 at 10:50 a.m. At the clock-in station, there was a thermometer, hand sanitizer, alcohol wipes, two folders containing the questionnaire logs (one folder for dietary and one for nursing staff), directions on the wall above the time clock, and a box of surgical masks. Three dietary staff members were observed screening themselves in before their shift. None called for nursing staff assistance on their personal phone and no walkie-talkie or facility phone was observed at the screening station. b. Observation of staff self-screening prior to starting their shifts. Dietary aid (DA) #1 clocked in at 10:58 a.m. He proceeded to take his own temperature, fill in the screening log, fill out his own sticker with the date and temperature of screening, doff the face mask worn into the building, use hand sanitizer, and don a surgical mask. DA #1 then proceeded to the kitchen to start his shift. DA #2 clocked in at 11:00 a.m. She proceeded to take her temperature, fill in the screening log, fill out her own sticker with the date and temperature of screening, doff the face mask worn into the building, use hand sanitizer, and don a surgical mask. She then proceeded to the kitchen to start her shift. At 11:00 a.m., two nursing staff members walked by the time clock area on their way out the south door. They did not stop to assist with screening the dietary staff members. Cook #1 clocked in at 11:05 a.m. He proceeded to take his own temperature, fill in the screening log, fill out his own sticker with the date and temperature of screening, doff the face mask worn into the building, use hand sanitizer, and don a surgical mask. He then proceeded to the kitchen to start his shift. c. Staff interviews confirmed staff self-screening by staff before starting their shifts. Cook #1 was interviewed on 7/29/2020 at 11:05 a.m. He said staff received training on the screening process in March. He said staff were supposed to call a certified nurse aide (CNA) or registered nurse (RN) to come and assist them with the screening but sometimes they did not come. He said they were to call the nursing staff with a walkie-talkie that was supposed to be at the screening station. He said he had been self-screening since June when the screening station was moved to the south entrance from the west entrance. He said there was always someone at the west entrance to screen staff in before a shift but there was no one to screen staff at the south entrance. He said he felt that self-screening was not safe and could enable someone to work who was sick. Dietary aid (DA) #1 was interviewed on 7/29/2020 at 11:15 a.m. He said he was supposed to call a CNA or RN to assist with the screening process. However, he said he had been self-screening in the two weeks he had been working at the facility. He said he had not been trained on the screening process, except on how to take his temperature. DA #2 was interviewed on 7/29/2020 at 11:15 a.m. She, too, said she was supposed to call a CNA or RN to assist with the screening process but said they did not respond timely when called. She said she would wait ten minutes before a nursing staff member would come to the time clock to assist with her screening. She said she had been self-screening for a couple of weeks. She said she had not been trained on the screening process. Activities assistant (AA) #1 was interviewed on 7/29/2020 at 11:30 a.m. She said a CNA or RN was supposed to screen them in before a shift. She said if a coworker was clocking in at the same time, they would screen each other. She said at times, she had self-screened before starting a shift because a walkie-talkie was not available to get in touch with the nursing staff or they took too long to respond to her call for assistance. AA #2 was interviewed on 7/29/2020 at 11:55 a.m. She said if she and a coworker arrived together, they would screen each other in. She said if no one else was at the screening station she screened herself in. She said she took her temperature, filled out the screening log, and gave herself a sticker. She said when the screening station was at the west entrance there always was someone to screen in staff. She said since staff screening moved to the south entrance in June, there had not been a designated person at the screening station. CNA #2 was interviewed on 7/29/2020 at 12:02 p.m. She said there was usually someone at the screening station to do staff screening. She said if employees arrived together, they would screen each other in. She said she has had to self-screen before starting her shift. She said there used to be a dedicated staff member screening employees at the west entrance. She said since the screening station was moved to the south entrance, there had not been a dedicated staff member to screen staff in. She said she received screening training a few months ago and she knew active screening was important to catch signs and symptoms of illness before staff started their shift on the floor. d. Administration interviews confirmed staff members were not to self-screen prior to starting their shifts. The dietary supervisor (DS), interviewed on 7/28/2020 at 4:00 p.m., said the dietary staff was to call a CNA or RN to complete their screening before they started their shift. He said dietary staff were not to screen themselves in. The director of nursing (DON) was interviewed on 7/29/2020 at 2:20 p.m. She said they assigned a CNA to screen staff in at shift change. She said the CNA was to ask the screening questions, take temperatures, and then fill out and give the stickers to the staff they screened. She said if the screening was clear (without signs or symptoms of illness) staff could go to work and if not, the CNA would call the nurse to conduct an assessment. -She said the infection preventionist coordinator (IPC) conducted training on screening in April and the training had been incorporated into new employee orientation. She said all departments participated. She said staff should always be screened by someone else; they should not self-screen. She said dietary, activities, and housekeeping staff were to call the CNA or RN on the walkie-talkie to screen them before a shift. -She said screening was important; it provided an objective eye to assess the staff member and get more details about symptoms. She said the screener was to inform a RN if a staff member presented with symptoms so he or she could be assessed. The IPC was interviewed on 7/29/2020 at 2:46 p.m. She confirmed the facility had changed the screening station recently, moving it from the west entrance to the south entrance. She also confirmed dietary staff was to be screened by a CNA or above from any department. -She explained staff were to be screened before they started their shift by a CNA or RN. She said a CNA or RN was to take temperatures, go through the screening log , and provide the screening stickers. She said if the staff did not present with symptoms, they then began their shift. -She said there was supposed to be a walkie-talkie at the screening station so staff could call for assistance with screening. She said on weekends and nights, a staff member was designated on the schedule to actively screen in employees. She said almost all staff had been trained in the screening process. She said an outcome of self-screening was [MEDICAL CONDITION]/illness could enter the facility. 2. Record review revealed additional deficiencies in the facility's screening process; specifically, missing, inadequate and/or incomplete staff screening logs. a. The Prevent COVID-19 Start of Shift Screening Log, updated March 2020, was provided by the NHA on 7/29/2020. A review of the screening logs revealed staff had their temperatures taken, were screened for a cough, sore throat, new shortness of breath or difficulty breathing, vomiting or diarrhea, chills or repeated shaking with chills, muscle pain, headache, a new loss of taste or smell, and if these symptoms were present, staff was asked to go home. The form did not include a space to document who provided the screening, the time the screening was completed, or if the person had washed their hands or used hand sanitizer. Moreover, the form did not include a space to document any follow up if the person reported symptoms. b. Staff daily screening logs from 7/10/2020 to 7/28/2020 were reviewed. All were found incomplete. No screening data was provided for July 12, 2020, and when there were multiple dates on a screening log, the log did not show where a new date started. Of the 42 staff screening logs reviewed, all of them were incomplete. Some of the logs had responses that should have triggered additional screening questions. Others had complete work units of staff missing. Forty-two (42) screening logs had no additional signature to indicate the temperature had been witnessed by another staff member. C. Potential adverse outcome related to the facility's screening deficiencies Review of screening logs and staff schedules revealed three CNAs, were not screened consistently and/or prevented from working with residents when symptomatic or when his/her COVID-19 status was unknown. 1. CNA #4, CNA #5, and CNA #6 a. CNA #4 was positive for COVID-19 on 7/29/2020. He had been providing direct resident care in the days leading up to the positive diagnosis. According to the screening logs, his last screening was completed on 7/22/2020, and revealed he was experiencing a cough, vomiting/diarrhea, a new loss of taste or smell, and no fever. No symptom follow up was documented on the screening log. CNA #4 worked on 7/12, 7/13, 7/17, 7/23, 7/24, 7/25, and 7/28/2020, without being screened before starting his shift. b. CNA #5 was rapid-tested for COVID-19 on 7/17/2020 and no confirmed positive date was provided by the facility. She provided direct resident care while awaiting test results. According to the screening logs, her last screening was completed on 7/20/2020, and it revealed she was experiencing no symptoms or temperature. CNA #5 worked on 7/12, 7/13, 7/14, 7/19, and 7/21/2020 without being screened before starting her shift. c. CNA #6 provided direct care to residents in the east unit. She was scheduled for COVID 19 testing on 7/31/2020. The screening logs revealed screening documentation for 7/16, 7/20, and 7/22/2020, three of 13 shifts the CNA worked between 7/10/2020 and 7/28/2020. The other ten shifts documented no screening data before starting her shifts. 2. On 7/29/2020, the IPC and health information manager (HIM) were interviewed regarding the screening failures identified involving CNA #4, #5, and #6. The IPC, interviewed at 2:46 p.m., said she was responsible for auditing the screening logs. She said she reviews the temperatures, symptom checks and whether all staff had screened in before their shift. She said she audited the screening logs daily. She said if she identified a staff member had not screened in, she would immediately go screen the staff. She said she has had to do some one-on-one training with some staff about the importance of screening. She said in her absence, since 7/22/2020, the HIM was responsible for auditing the screening logs. The HIM, interviewed at 3:10 p.m., said she was auditing the screening logs while the DON was out. She said the DON trained her to verify with the daily schedule that all staff had been actively screened before their shift, check the temperatures, and if any signs and symptoms were circled yes, have the staff assessed by a nurse. She said she had been able to collect the screening logs but had not been able to audit them thoroughly. She said when she picked up the logs, she checked the staff temperatures and to see if any symptoms had been checked off as yes. She said she had not had enough time to verify that all staff had been screened in because of her other job duties. III. Additional infection control failures - Failure to follow appropriate donning and doffing procedures for residents on isolation precautions, failure to properly clean vital signs equipment between the use, and offer hand hygiene to residents. A. Failure to follow appropriate donning and doffing procedures for residents on isolation precautions 1. Reference and facility policy The Centers for Disease Control and Prevention, Preparing for COVID-19 in Nursing Homes, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html (updated 6/25/2020) reads, in pertinent part: Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (health care providers) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission . Residents with known or suspected COVID-19 should be cared for using all recommended PPE (personal protective equipment), which includes use of N95 or higher level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front sides of the face), gloves, and gown. A copy of the facility's COVID-19 admissions policy, dated May 2020, was provided by the NHA on 7/29/2020, read in part, A resident diagnosed with [REDACTED]. 2. Observations of isolation rooms and interviews on the east unit a. Isolation rooms #24, #25, #26, and #27 on 7/28/2020 Isolation rooms # 24, #25, #26 and #27 had isolation carts next to them. Every room held two residents and doors to these rooms were completely open. One of the residents from room [ROOM NUMBER] was standing right outside room [ROOM NUMBER]. She said she was waiting for her dinner which was running late today. At 5:34 p.m., licensed practical nurse (LPN) #2 was observed passing medications to the residents in rooms #24, #25, #26, and #27. He parked a medication cart at the entrance of every room in a way that medication drawer would open towards the resident room. The LPN stayed inside the room while he was dispensing medications. He was wearing a N95 mask and glasses. Upon entering the resident rooms, he did not don gloves and gown. Around 5:40 p.m., CNA #6 observed passing Styrofoam meal boxes to residents on the east unit. She entered rooms #24, #26 and #27 without a donning gown or gloves. CNA #6 was interviewed around 5:50 p.m. She said isolation carts next to rooms meant that residents were on isolation precautions. She said she did not don gown and gloves when she entered the residents' rooms because she believed it was almost time to take them off the isolation precautions. She said only two residents on the unit require full personal protective equipment (PPE), identifying a newly readmitted resident in room [ROOM NUMBER] and resident in room [ROOM NUMBER] who tested positive for COVID-19. LPN #2 was interviewed around 5:55 p.m. He said it was his third day working on the unit. He said the isolation carts were parked next to the rooms of residents that were on droplet isolation precautions for testing positive for COVID-19. He said he had a total of seven residents who currently tested positive for COVID-19 and were on droplet isolation precautions on the east unit. He said droplet precautions meant [MEDICAL CONDITION] can be transmitted through air droplets. -He said all nurses and CNAs were expected to wear N95 masks, eye protection, gown and gloves when entering isolation rooms. He said N95 masks and eye protection were worn by everyone on the unit, and gown and gloves should be used when entering isolation rooms. He said he did not don gown and gloves when he was entering rooms on isolation precautions because he tried to keep a distance of several feet from the residents. Then he corrected himself and stated that he should have worn a gown and gloves when he was entering every room. He said he did not know why he did not don appropriate PPE for isolation rooms. -He said he passed medications to all residents on the east unit and he did not wear appropriate PPE when he was entered the rooms of all seven of the residents' on isolation precautions. He said some residents on the unit were still waiting for their test results, some refused to be tested , and few tested negative. The NHA was interviewed on 7/28/2020 around 4:00 p.m. She said prior to COVID outbreak in the building, all residents that were admitted or readmitted from hospital, other facilities or homes were housed in different units based on their needs. For example, if a resident required a memory care unit, he or she were placed in a memory care unit, and if residents were admitted for rehabilitation, they went to the west unit, and all readmissions went to their original rooms. -She said since the outbreak of COVID-19 on 7/15/2020, all admissions were placed on hold and the facility did not accept new residents. She said the DON and IPC were working from home as they were quarantined for exposure for COVID-19. The DON was interviewed over the phone on 7/29/2020 at 2:20 p.m. She said the IPC was in charge of providing education to the nurses and CNAs on proper PPE donning and doffing technique. She said the latest training was in March 2020. -She said after the outbreak beginning on 7/15/2020, the facility tested all staff members and all residents in the building every Friday for COVID-19. She said some results from the latest test on 7/24/2020 were still pending. From the results that were available on 7/29/2020, the facility has identified six staff members who tested positive for COVID-19 and eight residents. She said seven of these residents resided on the east unit and one resident was in the west unit. -She said the entire east unit could not be treated as COVID-19 unit because it still had residents who tested negative for COVID-19 or refused the test. She said individual rooms were placed in isolation and staff members were expected to don full PPE (facemask, eye protection, gown and gloves) prior to entering the isolation rooms The IPC was interviewed over the phone on 7/29/2020 at 2:46 p.m. She said she had been the IPC for three months and shared some responsibilities with DON. -She said she could not recall the date of the most recent training for nurses and CNAs on proper PPE use. She said she usually received her information from DON on results of COVID-19 testing and would enter it in her own log that she had separately from DON's log for infection tracking. -She said nurses and CNAs were expected to wear full PPE upon entering rooms with COVID-19 positive residents. B. Failure to properly clean vital signs equipment between resident use 1. References and facility policy A copy of the Cleaning and Disinfection of Resident-Care Items and Equipment, dated 10/2018, was provided by the NHA on 7/29/2020. It read in part, Reusable resident care equipment will be cleaned and disinfected between residents; using disinfectant wipes and the wipes discarded after one use. The Centers for Disease Control and Prevention, Responding to Coronavirus (COVID-19) in Nursing Homes, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html (updated 4/30/2020) read, in pertinent part: Assign dedicated resident care equipment (e.g., vitals machine) to the cohort unit. Cleaning and disinfection of shared equipment should be performed between residents and the equipment should not leave the cohort unit. 2. Observations and interview CNA #7 was observed on 7/28/20 at 2:38 p.m., on the west unit taking the vital signs of the resident in room [ROOM NUMBER]. After she completed vital signs, she cleaned the thermometer, blood pressure cuff and pulse sock with one sani cloth super germicidal wipe. Then she placed used wipe on top of her clipboard and moved to room [ROOM NUMBER], across from the room [ROOM NUMBER]. She checked vital signs for resident who was residing in room [ROOM NUMBER], picked up the used wipe from the clipboard and used it to clean the thermometer, blood pressure cuff and pulse sock device. After she was done cleaning the equipment, she discarded the wipe into the trash bin. CNA #7 was interviewed on 7/28/2020 around 2:48 p.m. after she exited room [ROOM NUMBER]. She confirmed she used the same wipe to clean the resident equipment she used to take the vital signs of two different residents. She said management had instructed her to use one wipe between several residents until it became dry. She said she disagreed with such practice and was reusing the wipe only between two residents. The DON was interviewed over the phone on 7/29/2020 at 2:20 p.m. She said resident care equipment was not designated to specific rooms and CNAs were expected to clean the equipment after every use. She said an individual wipe should be used to clean the equipment and it should not be reused. The IPC was interviewed over the phone on 7/29/2020 at 2:46 p.m. She said wipes for resident care equipment should not be reused. C. Failure to provide hand hygiene prior to meals 1. Reference and facility policy According to the CDC, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. CDC recommends using ABHR (alcohol-based hand rub) with 60-95% alcohol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. (Hand hygiene recommendations (May 17, 2020). Accessed 8/4/2020 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html The facility policy Handwashing/Hand Hygiene, May 2020, was provided by the NHA on 7/29/2020. It read in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of infections . Residents, family members, and visitors will be encouraged to practice hand hygiene. 2. Observation and interviews related to the dinner meal on the behavior and memory care units. Room tray delivery was observed on the behavior and memory care units on 7/28/2020 at 5:00 p.m. CNA #1 delivered eight room trays to residents in their rooms. No hand hygiene was offered to any of the eight residents before CNA #1 left the room. 2. Staff interviews CNA #1 was interviewed on 7/28/2020 at 5:30 p.m. She said she knew which residents washed their hands independently and which needed assistance. She said she also knew who would refuse hand hygiene, and did not offer it to those residents, although she acknowledged hand hygiene was important and she should offer to help with hand hygiene and encourage hand hygiene before the residents eat their meal. She said residents could become angry when hand hygiene was offered so sometimes she took a hand sanitizing wipe and wiped off their hands without offering to help them with hand hygiene. RN #1 was interviewed on 7/28/2020 at 6:23 p.m. She said hand hygiene was supposed to be offered to all residents. She said it should be offered even if staff know the resident will refuse. She said hand hygiene was important for the safety of the residents and staff. The DON was interviewed on 7/29/2020 at 2:20 p.m. She said CNAs should always offer and encourage hand hygiene to all residents before meals. She said hand hygiene was important to prevent the spread of illness among residents and staff. The IPC was interviewed on 7/29/2020 at 2:46 p.m. She said hand hygiene should be offered to all residents before meals, after using the restroom, after smoking, after coughing or sneezing, and when visibly soiled. She said if the residents refuse to use soap and water, staff should offer hand sanitizer. IV. Actions taken on and after the facility was notified of immediate jeopardy A. On 7/28/2020 at 5:52 p.m., the NHA, was interviewed about PPE use and care. She said they had been using the Center for Disease Control guidelines for everybody in the facility. The DON said all staff had been educated on the use of gowns, and she said the gowns were to be worn at all times in isolation rooms. She said they had N95 masks, gowns, gloves, and face protection for any staff member going into the isolation rooms. B. On 7/29/2020 at 2:37 p.m., NHA provided education logs for all staff members that received education on proper PPE use prior to (TRUNCATED)

Based on record review and interviews, the facility failed to ensure residents who are diagnosed with [REDACTED].#1 and #3) of four sample residents. Specifically, the facility failed to: -Effectively identify person-centered approaches for dementia care for Resident #1 to prevent his wandering; -Monitor and prevent Resident #1 from wandering into Resident #2's room and getting pushed down; -Ensure behavior monitoring documentation was initiated for Resident #1's wandering; -Effectively identify person-centered approaches for dementia care for Resident #3's behaviors leading to resident to resident altercations; and -Ensure behavior monitoring documentation was complete for Resident #3's multiple behaviors. The facility failures resulted in Resident #1 suffering bruising to his arm after being pushed to the floor by Resident #2; and Resident #3 suffering scratches and redness to his neck after being grabbed by his shoulder and neck by Resident #2. Cross reference F[AGE]0: failed to prevent abuse Findings include: I. Resident #1 A. Resident #1 status Resident #1, age [AGE], admitted [DATE]. According to the February 2020 CPO, [DIAGNOSES REDACTED]. The 2/10/2020 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BI[CONDITION]) score of 10 out of 15. Wandering occurred one to three days during the assessment period that significantly intruded on the privacy or activities of others. B. Observations On 2/20/2020 at 1:00 p.m. Resident #1 was observed wandering throughout the dementia unit in the dining area and sitting areas. When he would attempt to go into a room the staff would redirect him away from the door. He was not directed towards any activities. Observations in the dementia unit throughout the day on 2/20/2020 revealed no structured activities being provided to the residents. An activity aid was in the unit but was mostly providing one to one with a different resident. C. Record review The care plan, last revised 2/8/2020, revealed an elopement risk/wandering related to impaired safety awareness. The resident wandered aimlessly, intruding on the privacy or activities of others. He had an impaired cognitive function and a [DIAGNOSES REDACTED]. Interventions included: - Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books; - Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes; -Communicate with the resident/family/caregivers regarding resident's capabilities and needs; -Cue, reorient and supervise as needed; -Always approach in a friendly, calm manner; -Anticipate resident needs; -Attempt to engage resident in activities of interest throughout each day; and -Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. The resident did not have a care plan to address his dementia. According to the 2/5/2020 Wandering/Elopement Risk Assessment the resident scored an 11- high risk for wandering. According to a 2/6/2020 nursing note, the CNA reported that the resident got up tonight and was wandering around at midnight. According to a [DATE]20 nursing note, the resident was pleasantly confused, up wandering some this night and slightly difficult to redirect due to dementia and confusion. Another [DATE]20 nursing note revealed the resident was able to be redirected with encouragement. He tended to get up to void then wandered around often going into other resident's rooms. According to a 2/9/2020 nursing note, the resident was pleasantly confused, calm and cooperative. He redirected with encouragement. His routine seemed to be that when he got up to void he would then wander around often going into other resident's rooms. According to the 2/11/2020 nursing note, Resident #1 wandered into Resident #2's room. He thought it was his room. Resident #2 woke up startled and pushed Resident #1 away from the bed causing Resident #1 to fall backward. A 3 centimeter (cm) by 5 cm bruise was noted to the resident's left forearm. According to a 2/12/2020 nursing note, the resident ambulated with his shirt off for a short time because the resident refused to don the shirt. The resident was cooperative with dressing a short time later. The resident attempted to enter a peer's room but staff monitoring the hallway were able to easily redirect him. According to the CNA the behavior monitoring under tasks, the resident was documented wandering on five days since admission, 2/5, 2/9, 2/10, 2/13, and 2/18/2020. The wandering incident documented in a nursing note on 2/11/2020 was not documented under tasks. II. Resident #3 A. Resident #3 status Resident #3, age [AGE], admitted [DATE] and readmitted [DATE]. According to the February 2020 CPO, [DIAGNOSES REDACTED]. The 12/30/19 MDS assessment revealed the resident had severe cognitive function with a BI[CONDITION] score of three out of 15. The resident had fluctuating inattention, trouble falling or staying asleep, feeling tired or having little energy during the assessment period. The resident had delusions and verbal behaviors directed towards others that occurred daily. B. Observations Observations throughout the day on 2/20/2020 revealed no structured activities being provided to the behavior unit. The activity aid was doing one to one activities with a resident in the dementia unit. C. Record review The care plan, last revised 6/13/19, revealed impaired cognitive function. The resident habitually wanders or would wander out of the environment and be unable to find his way back. He is a serious danger to himself and others. Less restrictive alternatives would be unsuccessful. He has episodes of anxiety as evidenced by talking fast, repeating self, constant motion, and unable to relax or rest. He has the potential to be verbally aggressive and will hit walls and tables with his hands. Interventions included: -Appropriateness for secure unit placement will be evaluated quarterly and as needed; -Encourage to participate in activities of choice and preference to keep him occupied; -Alter the environment during any episode of anxiety, take a walk, take to an activity or other area; -Encourage to discuss interests or concerns; -Listen attentively to resolve or discuss area of upset; -Redirect to the television area and turn on show of choice; -Prefers activities which do not involve overly demanding cognitive talks. Engage in simple, structured activities; -Preferred activities are bingo, music, parties/socials and watching television in the day room; -Needs verbal invites and direction to scheduled activities; -Analyze key times, places, circumstances, triggers and what de-escalates his behavior and document; -His triggers for verbal aggression are when he can't remember where the restroom or dining room is. His behaviors de-escalate by redirecting him, giving him his spaced and allowing him time; -Offer an activity or snack/fluids to redirect him when he is hitting tables and walls; and -Offer the resident something to hold and manipulate, as he will allow, to keep from hitting objects. According to a 2/2/2020 nursing note, the resident had periodic mild agitation noted per his norm, however easily redirected with conversation and drinks of water. According to a [DATE]20 incident note the resident had a resident to resident altercation at 11:00 a.m. when Resident #2 was entering the [REDACTED] hallway (locked dementia unit) from the south unit (locked behavior unit) with a certified nurse aide (CNA) and invited Resident #3 to follow. Resident #2 proceeded to put his bent arm across the shoulder and neck area of Resident #3. Staff immediately intervened and separated the residents. The [REDACTED] hallway door (keypad locked) was closed immediately. A skin assessment for Resident #3 was completed and a very small scratch was noted to the left side of his neck and another scratch was noted the length of the back of his neck. He had redness to the front of his neck that resolved. According to the February 2020 behavior monitoring record, the resident was to be monitored for behaviors of: -Physical aggression towards staff and/or others; -God telling him to refuse care; -Verbal aggression when demands are not met immediately; and -Verbal aggression when not answered immediately. The resident was to be monitored on day and night shift. The resident's behaviors were not documented on 2/9/2020 for either shift, 2/12/2020 and [DATE]20 on day shift, [DATE] on night shift, [DATE]20 on day shift, and 2/18/2020 on either shift. III. Staff interviews Laundry staff was interviewed on 2/20/2020 at 12:58 p.m. She said she received dementia training through the computer via Relias but could not remember when. She said the facility reviewed the information with the staff about once a year. Certified nurse aide (CNA) #1 was interviewed on 2/20/2020 at 1:02 p.m. She said there were only two CNA's on [REDACTED] hallway, which was the dementia unit, and the nurse only came back when the residents needed medications or an assessment. She said she worked all the units of the facility and was only occasionally on the dementia unit. She said Resident #1 was the only resident on the [REDACTED] hallway that wandered. She said the staff tried to keep him busy with activities such as basketball or corn hole. She said he also liked to take walks. She said the staff tried not to let him go into the other resident's room by redirecting him. She said when one of the CNA's went on break, it left only one CNA back on the unit and if they were in a room assisting a resident, they would not be able to keep Resident #1 from wandering into others rooms. She said she received dementia training through the Relias system on the computer when she was hired. She said this training taught them how to manage dementia residents. CNA #2 was interviewed on 2/20/2020 at 1:11 p.m. She said she had been a CNA for [AGE] years and had taken several classes over the years for dementia and psych care. She said she specialized in Alzheimer's units. She said the only training she received from the facility on dementia care was through Relias on the computer but could not remember when. She said she thought the training was once a year. Registered nurse #1 was interviewed on 2/20/2020 at 1:20 p.m. She said the facility had staff do basic dementia training when they were hired in orientation and then yearly through Relias on the computer. She said the training taught them how to deal with the behaviors of dementia residents. The nursing home administrator (NHA) was interviewed on 2/20/2020 at 2:55 p.m. She said the facility had been trying to implement environmental changes to the secure units to assist with deferring resident to resident conflicts. These included a scale put onto the [REDACTED] hallway so the residents back there would not have to leave their unit. She said they had a dedicated activity aide for the secure units with more activities being offered. She said they put a portable basketball hoop and a Velcro dart board up in the dementia unit and shadow boxes outside the rooms to assist the resident to recognize their rooms. She said all new hires received the basic abuse and dementia training and then monthly training was provided through the Relias program. She said she was coordinating with the ombudsman to become a resource for educating the staff.

Based on record review and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one of 39 sample residents (#49). Specifically: The facility failed to ensure resident #49 received appropriate care after a fall. The resident's condition following a fall to the floor was not comprehensively assessed by a registered nurse (RN) prior to moving the resident from the floor to a wheelchair. Although the resident was transported to the hospital approximately an hour later, his report of pain at the time of the fall (10/10 with 10 being the worst pain) was not addressed prior to transport, contributing to unrelieved pain during this time. Findings include: Resident #49, a [AGE] year old male, originally was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was transferred to the hospital after a fall with [MEDICAL CONDITION] on 1/16/13. He returned to the facility on [DATE] following surgery on his hip. The resident's most recent Minimum Data Set (MDS) completed, on 2/22/13, showed that he had a BIMS (cognition) score of 11, which indicated moderate cognitive impairment. He required extensive physical assistance of one staff member for ADLs (Activities of Daily Living) which included bed mobility, transfers, and ambulation, dressing, bathing and personal hygiene. 2. Falls in 2012 Review of facility incident reports revealed the resident fell three times in 2012. Review of the facility incident reports revealed in pertinent part: -"11/8/12 - 6:40 p.m. - Resident was found lying on the floor in his bathroom. Another resident stated he opened the bathroom door and that (resident #49) fell down. Res said he hit head, his neighbor (who shared the bathroom) stated he did not hit his head. Neighbor said res(ident) #49 was leaning against the BR door, he opened it and res fell . Assessed - no injuries noted. Neuros done per facility policy." -"11/19/12 - 11:58 a.m. - Resident was in bed, trying to get up and reach his walker. Stood up and tripped on his walker and went to the floor. Staff unable to reach resident in time. When staff helped him up and he pivoted, then fell to his knees (after the initial fall). Assessed - 1 1/2 cm ST (skin tear) to right wrist. The fall was witnessed by LPN (licensed practical nurse) that came in to give him noon medications. Stated resident stood up, grabbed his walker & started to ambulate. He then tripped on walker and fell to knees. He immediately used bed and walker and got up." -"12/4/12 - 3:06 p.m. - (Activity Director) was walking with resident out of the dentist office when resident stated that he "was dizzy." (Activity Director) grabbed his backside to assist in lowering him to the ground to sit on his bottom. Resident sat for a few minutes then (Activity Director) went back inside to get help to assist getting him up and back onto the van. No injuries and no c/o of pain. He had some teeth pulled during that visit." 3. Fall With Injury 2013. a. Review of the Facility Incident Report revealed in pertinent part: "1/16/13 11:01 a.m. - Resident approached nurse at nurse's station for prn (as needed) Tylenol. LPN gave med(ication) and turned away. Heard noise seconds later and noted resident was on the floor, lying on left side with head near wall. Head to toe assessment. Noted (male from SS/social services) coming in unit and was asked by nurse to assist transferring resident into w/c (wheelchair). Resident's walker was up and near resident at time of incident. Resident was kept near nurse's station for observation." Further review of the incident report revealed the resident was assessed (head to toe) by a LPN and reported significant pain. Specifically the incident report read: "Noted pain 10/10 when ROM (Range of Motion) done to L (left) leg and hip area. Noted no bruising, noted 0.5 cm abrasion on L (left) elbow. Head to toe assessment, started neuros, vital signs taken, BG (blood glucose) done, notified supervisor (Unit Manager -UM/RN). Signed by LPN. Another entry on the incident report by the LPN at 11:15 a.m. read, "Res was c/o pain 10/10 in left hip area. His FSBG (Finger Stick Blood Sugar) was 360, he was shaking and diaphoretic." b. Review of the nurses' note written by the Unit Manager (UM/RN) reflected the LPN assessment above; it did not indicate she comprehensively assessed the resident prior to moving him from floor to wheelchair or prior to his transfer to the hospital. Specifically: "1/16/13 12:17 p.m. Was informed by the charge nurse (LPN above) that this resident had fallen by the nurse's station and was very shaky and complaining of hip pain. On initial assessment by this nurse, resident was diaphoretic, shaky, did not respond as quickly as he usually does. When asked about pain he stated his left hip was hurting." Charge nurse stated she did a BG based on him not eating this am and the ss (referring to the recommendation of SW to check his BG). BG was 360. Resident does not have a DX (diagnosis) of DM (diabetes mellitus) but is on [MEDICAL CONDITION] meds." Further review of the Unit Manager's note revealed the physician's office was contacted and the physician requested the resident be transferred to the hospital for a full work up of labs and x-ray of the hip. An order was written for transport and the Director of Nurses (DON) notified and consulted. The resident left for hospital at approximately 12:15 p.m. c. Review of the hospital transfer form revealed no evidence that the UM/RN comprehensively assessed the resident prior to his transfer from the floor to the wheelchair. d. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 3. Failures in Response to 1/16/13 Fall (1) Failure to ensure a comprehensive resident assessment by a RN See above; there was no documentation that the UM/RN assessed the resident prior to his transfer from floor to chair. Cross-reference F282; qualified staff. The scope of practice of an LPN to assess health status. (2) Failure to follow facility policy Review of the facility's Falls Management Policy (undated) revealed it reads in pertinent part, "Move resident in to bed or chair ONLY if no obvious injury." See above; the resident complained of pain 10/10 with ROM. Nonetheless, he was transferred from the floor to the wheelchair where he stayed until transfer to the hospital. (3) Failure to address resident's pain See above; review of the resident's MAR indicated [REDACTED]. 4. Interviews On 2/27/13 at 11:10 a.m., the Director of Nursing (DON) was interviewed. When asked about expectations of staff when a resident falls, the DON replied that the first step is a resident assessment by the charge nurse. She indicated this nurse could be either a registered nurse or licensed practical nurse. On 2/27/13 at 11:30 a.m., the Unit Manager (UM), a RN, of the secure unit was interviewed. She said a nurse needs to conduct an assessment after a resident falls. She indicated the nurse could be a RN or LPN. She said that, here, with the resident in pain with ROM at 10/10, she would have contacted the ambulance before moving the resident to a wheelchair and would have more promptly transferred to the hospital for evaluation. On 2/27/13 at 1:00 p.m., the Nursing Home Administrator (NHA) was interviewed. She stated she was unfamiliar with the LPN scope of practice. The LPN who cared for the resident at the time of his fall on 1/16/13 was not available for interview. The resident declined an interview during survey 2/25/13 to 3/6/13.

Based on observation, record review and staff interview, the facility failed to ensure one of 39 sample residents (#65) received proper respiratory treatment and care. Specifically, the facility failed to adequately address the resident's respiratory needs, contributing to the resident's respiratory distress. The findings include: A. Oxygen saturation According to "Medical Surgical Nursing," by Lewis & Collier, 3rd Edition, pages 445 and 814: "The SaO2 is expressed as a percentage. For example, if the SaO2 is 90%, then 90% of the hemoglobin attachments for oxygen have oxygen attached to them." Refer to the following: "SaO2 (%) Considerations a. >94 Adequate unless client is hemodynamically (refers to the monitoring of blood flow and pressure within the cardiovascular system) unstable. b.90 Adequate in almost all clients. c. 88 Adequate for clients with chronic hypoxemia (refers to a blood oxygen level that is lower than normal) if no cardiac problems occur. d. <75 Inadequate: Tissue [MEDICAL CONDITION] (refers to a deficiency in tissue oxygenation and is associated with symptoms that reflect inadequate oxygen delivery to vital organs, such as the heart and brain) and cardiac [MEDICAL CONDITION] (irregular heart beat) can be expected." B. Resident Failure 1. Resident #65, [AGE] years old, was admitted to the facility on [DATE]. According to the facility face sheet, the resident's [DIAGNOSES REDACTED]. According to the MDS dated [DATE] the resident was coded; a 0 (rarely to never understood) a 3 (severely impaired, rarely/never makes decisions) on cognitive skills for daily decision-making, a 1 (behavior consistent, does not fluctuate) on section A. inattention under [MEDICAL CONDITION], a 2 (behavior present, fluctuates) on section B. disorganized thinking under [MEDICAL CONDITION], a 0 (behavior not exhibited) in section a. physical, section B. verbal and section C. other behavior symptoms, a 0 (same) in does the residents current behavior status, care rejection, or wandering compare to prior assessments, a 3 (extensive assist) 3 (two person physical assist) for (activities of daily living, ADLs) in functional status. 2. History of pneumonia a. Review of the nurse's note (NN) dated 12/29/10 at 10:30 a.m. revealed the resident's oxygen saturation level was 79%, oxygen was applied at this time and the physician was notified. The NN revealed the physician wanted the family notified and wanted to know what their desire for treatment might be, message left for family. According to the Physician's Telephone Order dated 12/29/10, the resident had an order for [REDACTED]. b. Failures in response to [DIAGNOSES REDACTED]. Review of the treatment administration record (TAR) for January 2011 revealed the 12/29/10 order for oxygen to maintain saturation above 90% was not transcribed. The resident's oxygen saturation levels were not documented on the TAR or Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of the resident's record revealed the resident did not have an acute care plan for pneumonia or comprehensive care plan for the use of oxygen. On 1/6/11 at 2:00 p.m., the Assistant Director of Nursing (ADON) indicated the facility protocol and her expectations were that the resident's oxygen saturation level be monitored and recorded every shift on the Treatment Administration Records (TARS), that all infections be care planned and the use of oxygen be care planned. Upon review of the resident's January TAR, the ADON was unable to locate the monitoring and recording of oxygen saturation or upon review of the resident's care plan, she was unable to locate a care plan for the pneumonia, or the use of oxygen. 3. Events on 1/5/11 a. Observations On 1/5/11 at 2:00 p.m., resident #65 was observed in her room. The resident was hunched over forward in her wheelchair; she had oxygen applied via nasal cannula connected to a portable tank that was hanging tilted on the back of her wheelchair. The resident's wheezing on inhalation and expiration was audible from the doorway of the room. Her respirations were labored; she was using accessory muscles for breathing and was slightly lethargic. Her skin was pale and ash in color. The surveyor immediately exited resident's room to get a nurse and asked on-coming shift LPN to come to the resident's room and to please bring a pulse oximetry (ox). On 1/5/11 at 2:02 p.m. the LPN and surveyor entered resident #65's room. The LPN stated, "Oh, she is wheezing." According to the pulse ox the resident's oxygen saturation level was 83% and her pulse was 122 beats per minute (bpm); the average pulse rate for the elderly population is between 60-80 bpm. The LPN checked the portable O2 tank and stated "Oh, its empty." He applied oxygen via concentrator at 3 liters/min. The LPN reported the resident's normal oxygen flow was 2 liters/min. He indicated the resident needed a nebulizer treatment. He removed the portable oxygen tank from the back of the resident's wheelchair. Once the tank was placed straight up, oxygen was flowing but the tank read empty. The nurse exited the room. A nebulizer treatment was not administered and the resident's oxygen saturation level was not rechecked. On 1/5/11 at 2:10 p.m. the day shift and evening shift LPN went into a non-resident room and shut the door. On 1/5/11 at 2:17 p.m., the resident was observed in her room. She continued to have audible wheezing, labored respirations, and her skin remained pale and ashen. The surveyor remained in resident's room. On 1/5/11 at 2:25 p.m. the surveyor observed, from the doorway of the resident's room, that the LPN was in hallway outside of resident's room. The LPN was asked to check on the resident and to recheck resident's oxygen saturation with the pulse ox. He stated "That's what I was about to do. I just finished report and I can only do one thing at a time." The LPN entered the resident's room. He checked her oxygen level. According to the pulse ox, the resident's oxygen level was 84%. Her pulse was between 122-125 bpm. On 1/5/11 at 2:30 p.m., LPN administered the resident's nebulizer treatment. The LPN remained with resident during the treatment. According to the pulse ox, the resident's oxygen level while receiving the nebulizer treatment was 98%. On 1/5/11 at 3:30 p.m., the resident was observed again in her room. She was audibly wheezing and at 3:32 p.m., the surveyor requested that LPN to come to the room to check on the resident. The LPN came to the room with the pulse ox. According to the pulse ox, the resident's oxygen level was 86%-87%. The LPN increased the resident oxygen flow to 3.5 liter/min. and left the room. On 1/5/11 at 4:43 p.m. the resident was observed sitting in common area. - The resident's nasal cannula was placed above her nose. A certified nurse aide (CNA) was sitting next to the resident. The CNA looked up as the surveyor approached the resident and placed the resident's nasal cannula back into her nose. The resident did not resist; however, the resident promptly removed the cannula from her nose and the CNA did not attempt to put the nasal cannula back in her nose. The resident was audibly wheezing. - At 4:45 p.m., the LPN checked the resident's oxygen level. According to the pulse ox, the resident's oxygen level was 74%. The LPN placed the nasal cannula back into the resident's nose. The resident did not exhibit any resistive behavior when the nurse applied the nasal cannula. After approximately 1-2 minutes, according to the pulse ox, the resident's oxygen level increased to 79%-80% and her pulse was registering at 193 bpm. b. Failures See observations above; staff failed to respond promptly to the resident's respiratory distress and failed to ensure the resident's oxygen cannula remained in place. On 1/5/11 at 4:50 p.m., a licensed practical nurse (LPN) familiar with the resident was interviewed. The LPN indicated the facility protocol was to titrate oxygen flow liters to keep oxygen saturation levels above 90% for all residents receiving oxygen. If the resident's oxygen level fell below 90%, staff should call the physician and administer a nebulizer treatment if the resident had an order for [REDACTED].#65's) lungs and (breath sounds) were diminished in the lower lobes with crackles." He indicated he had given the resident a nebulizer treatment and it had helped a little, but they were still diminished. On 1/5/11 at 5:15 p.m. the acting director of nursing (ADON) was informed of the findings related to resident #65. She indicated the nurse should have stayed with the resident until her oxygen saturation level reached 90% or higher and provided intervention and follow-up as appropriate. She stated she would have expected to see some kind of improvement in the resident's condition at this point because the resident had received 8 doses of [MEDICATION NAME]. When asked what she would expect her nurses to do if a resident presented with audible wheezing, labored breathing and pale ashen colored skin, she replied, "It's basic practice, do an assessment, notify the doctor." On 1/5/11 at 5:45 p.m. the ADON and LPN stated the physician was notified about the resident's condition and had ordered a tapering dose for [MEDICATION NAME]. Review of physician orders [REDACTED]. 4. Events on 1/6/11 On 1/6/11 at 1:26 p.m. the resident was observed sitting in the dining room at a table. A CNA sat next to her. - The resident's nasal cannula and oxygen tubing were in the wheelchair, stuck behind the resident's back. The resident's breathing was labored. The CNA did not attempt to place the resident's cannula in her nose or get up from the table to notify the nurse that the resident was having labored breathing. - The surveyor notified the LPN that the resident was not wearing her oxygen and that she was having labored breathing. The LPN came to the dining room and checked the resident's oxygen saturation level and, according to the pulse ox, her oxygen level was 86%. The nurse removed the oxygen tubing from behind the resident's back and applied the nasal cannula to her nose. The resident did not resist application of the oxygen cannula. According to the pulse ox, with the cannula in place, the resident's oxygen saturation level increased to 90%-91%. b. Facility failures See observations above; staff failed to ensure the resident's oxygen cannula remained in place. On 1/6/11 at 1:30 p.m. the resident's LPN was notified of the above observations and stated that she would expect the CNA to notify her if the resident was refusing to wear her oxygen or having labored breathing. She said she had not been notified of either. On 1/6/11 at 1:35 p.m. the CNA who was sitting next to resident during the above observation was interviewed. She indicated she was aware the resident was supposed to have oxygen on and that she was sick and being treated for [REDACTED]. 5. Observations 1/11/11 On 1/11/11 at 8:30 a.m., the resident was observed in the dining room. She had her nasal cannula in place and was not attempting to remove it. Her skin color was good and she was audibly wheezing. On 1/11/11 at 12:00 p.m. and until 1:00 p.m., the resident was observed in the dining room with her nasal cannula in place. She did not attempt to remove the nasal cannula or exhibit any behaviors during this time. On 1/11/11 at 1:10 p.m. the resident was observed wearing her nasal cannula and self-propelling around the unit, grunting with breathing. The resident's LPN, interviewed at the time of the observation, stated grunting was normal for the resident. According to the pulse ox, the resident's oxygen level was 93%.