Every finding on record at Pioneer Memorial Nursing Home

Based on observation, interview, and policy review, the provider failed to ensure outdated food was discarded from inventory. Findings include: 1. Observation on [DATE] of the dry food storage room revealed there were: *Two containers of single serving sized macaroni and cheese with an expiration date of [DATE]. *Five containers of single serving sized macaroni and cheese with an expiration date of [DATE]. *Two five-pound containers of baking powder with an expiration date of [DATE]. -A container of thick and easy pureed bread and dessert mix with an expiration date of [DATE]. -A 12-ounce can of evaporated milk with an expiration date of [DATE]. -Twenty-two 12-ounce cans of evaporated milk with an expiration date of [DATE]. 2. An interview on [DATE] at 12:30 p.m. with dietary supervisor A revealed: *He was not aware of the expired items in the food storage room. *It was his expectation that food items would have been used or removed and discarded before their expiration date. *He reported there was no schedule for checking for outdated foods in the food storage room. 3. Review of the provider's ,d+[DATE] Food and Supply Storage policy revealed: *Purpose-To prevent contamination of foods that may occur through inappropriate storage. *Storeroom: All stock in the storeroom is rotated so the newest opened stock is on the bottom. The oldest stock is used first. *The policy did not address expired canned foods.

Based on observation, interview, record review, and policy review, the provider failed to ensure an allegation of sexual assault made by resident (8) toward resident (28) was thoroughly investigated and reported to the South Dakota Department of Health (SD DOH). Findings include: 1. Observation and interview on [DATE] at 10:25 a.m. with resident 8 about her experience in the nursing home revealed: *She alleged that she was raped at that facility and the perpetrator did not complete. *There was a laceration on her left shin and foot that she said she acquired from the alleged perpetrator being on top of her trying to get leverage. *She was able to remember the alleged perpetrator's name and said he was another resident at the nursing home. -That resident was now in a different part of the facility. *She remembered she had informed someone about the incident, but she could not remember who she had told. *When the incident happened, she had been in her chair asleep. She woke up and saw the alleged perpetrator in her bed. The next thing she knew, she was on the floor. *She said that several staff had known about her claims, but nothing was done to address them. *She expressed that she feared the males that would walk by her room. Interview on [DATE] at 11:22 a.m. with director of social services (DSS) D about the above incident revealed: *The alleged perpetrator was known to wander about the facility, and into other resident's rooms. *On [DATE], the male resident was found in resident 8's bed. *She explained that resident 8 usually slept in her recliner. *On that night, she woke up and saw a man in her bed; she thought that man was her deceased husband. *She got up from her recliner and fell . *DSS D confirmed that resident 8 did have a scratch on her foot. -She believed the scratch happened when resident 8 fell . *Since the resident's statements were inconsistent, and due to an internal investigation not finding evidence that a sexual assault had taken place, the management team did not contact the police or file a report with the SD DOH. -They did not feel it escalated to that level to report [the alleged rape]. *She confirmed that since the incident, resident 8 was apprehensive of other people walking up and down the hallways. *Resident 8 had not made any allegations of rape until a couple of weeks after [DATE]. -She mentioned there was a progress note on [DATE] written by a nurse that mentioned the alleged rape. -Social services had not been informed of the allegations until [DATE]. -She confirmed that there was at least one nurse who had known about resident 8's allegations and had not reported those allegations to anyone. -It was her expectation that any allegation such as rape should have been reported right away. *She confirmed that the alleged perpetrator was moved to a different part of the facility on [DATE]. 2. Record review of resident 8's electronic medical record (EMR) revealed: *There was a nurse's psychotropic drug review note on [DATE] which indicated resident 8 continues to talk about rape charge and scrape on her leg. *The [DATE] annual Minimum Data Set (MDS) assessment, her Brief Interview for Mental Status (BIMS) score was 11, which indicated moderate cognitive impairment. *The [DATE] quarterly MDS assessment, her BIMS score was 12, which indicated moderate cognitive impairment. *She had diagnoses of Alzheimer's disease, Parkinson's disease, and depression. Email communication with the SD DOH Complaint department on [DATE] at 10:54 a.m. confirmed there was no report submitted regarding the alleged rape. 3. IMMEDIATE JEOPARDY PSYCHOSOCIAL HARM Interviews with resident 8 and a review of her EMR showed continued signs of agitation and elevated emotional distress. She continued to believe the alleged rape was litigated through the court system. There was no police report. There was no report to the SD DOH. She had not been assessed physically or mentally regarding this incident. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on [DATE] at 4:10 p.m. to administrator A and director of nursing (DON) B. They were asked for an immediate removal plan. IMMEDIATE JEOPARDY REMOVAL PLAN On [DATE] at 2:15 p.m., administrator A provided the survey team with a final written immediate jeopardy removal plan. The removal plan had been approved by the long-term care advisor for the SD DOH on [DATE] at 2:26 p.m. The provider gave the following acceptable immediate jeopardy removal plan on [DATE] at 2:15 p.m.: Pioneer Memorial personnel contacted the Viborg City Chief Police at 10:38 am on [DATE] and are awaiting a reply. The State Department of Health Report was filed at 11:40 am on [DATE]. On [DATE] all internal investigative events were audited for accuracy in reporting to SD DOH from [DATE] [to] current. On ,d+[DATE] at 9:30 am LTC [Long-Term Care] Management including the administrator, Director of Nursing, Director of Social Services, and Risk Officer received training from Good Samaritan Society Regional Clinical Services Director and Accreditation Specialist Consultant regarding the abuse prevention policy, types of abuse, reporting any allegation of abuse, and timely reporting to SD DOH. On [DATE] at 2:00 [p.m.] all available LTC staff of nursing, social services, activities, dietary, housekeeping, laundry, maintenance, and therapy received education on the following: The Abuse Prevention Plan Policy including physical abuse, sexual abuse, psychosocial abuse, neglect, involuntary seclusion, exploitation, misappropriation of a resident's property, an attempt to commit a crime against a patient, physical harm or injury, profanity, and deprivation of goods or services. The responsibility of every employee to report a suspicion or allegation of abuse to LTC management immediately regardless of it is substantiated in their view. Staff not available on [DATE] will be tracked and additional trainings will occur, or a paper education will be provided with a sign off and quiz. Abuse allegations will be reviewed daily for appropriate reporting. All incident reports will be audited by the administrator weekly for 4 weeks, then biweekly x's 2, then monthly x's 2. Findings will be taken to QAPI [Quality Assurance and Performance Improvement] monthly for review and revision as warranted. The immediate jeopardy was removed on [DATE] at 11:30 a.m. after verification that the provider had implemented their removal plan. After the removal of the immediate jeopardy, the scope and severity of the citation level was G. 4. Review of the provider's [DATE] Abuse Prevention Plan policy revealed: *Under the Definitions section: -C. Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, sexual assault, or inappropriate touch. Sexual abuse is nonconsensual sexual contact of any type with a resident. -E. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. *Under the Responsibility section: -A. It is the responsibility of every employee to: --2. If the crime does not appear to cause serious bodily harm, report directly to the DOH and local law enforcement agency or to his/her department director who will document the information and initiate the investigation. -B. It is the responsibility of the Director of Nursing (DON) of Long Term Care Services or designee or the DON of the Hospital or designee to: --1. Monitor incident reports to identify residents who are repeatedly injured or involved in incidents to identify a trend. --2. Notify the family of the allegation of neglect or abuse of the resident. --3. Report to the DOH [email redacted] on-line reporting form or fax to [fax number redacted] ombudsman [ombudsman phone number redacted] and local law enforcement [phone numbers redacted] if not already reported by an individual, any allegation of mistreatment, neglect, or abuse within the required time frame of the alleged mistreatment, neglect, or abuse. --4. Submit REQUIRED NURSING FACILITY EVENT REPORT (on line) to DOH Complaint Coordinator per instructions of form. --5. Investigate reported allegations of mistreatment, neglect, or abuse and file the results of the investigation with DOH within five (5) working days on 5- DAY INVESTIGATIVE REPORT (on-line). *Under the Policy section: -A. PMH&HS [Pioneer Memorial Hospital and Health Services] will ensure the resident's right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion by anyone, including but not limited to staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, friends or other individuals. -C.3. According to South Dakota Administrative Rules, 44:73:01:07, PMH&HS shall also report to the (DOH) within 24 hours and any other licensed facility shall report to the DOH within 48 hours of the event using REQUIRED NURSING FACILITY EVENT REPORTING form on-line . Any allegation of abuse or neglect of any patient by any person.

A. Based on observation, interview, record review, and policy review, the provider failed to ensure one of one resident (8) had received the necessary care to meet her psycho-social needs after she made an allegation of sexual assault by resident (28). Findings include: 1. Observation and interview on [DATE] at 10:25 a.m. with resident 8 about her experience in the nursing home revealed: *She alleged that she was raped at that facility and the perpetrator did not complete. *There was a laceration on her left shin and foot that she said she acquired from the alleged perpetrator being on top of her trying to get leverage. *She was able to remember the alleged perpetrator's name and said he was another resident at the nursing home. -That resident was now in a different part of the facility. *She remembered she had informed someone about the incident, but she could not remember who she had told. *When the incident happened, she had been in her chair asleep. She woke up and saw the alleged perpetrator in her bed. The next thing she knew, she was on the floor. *She said that several staff had known about her claims, but nothing was done to address them. *She expressed that she feared the males that would walk by her room. Interview on [DATE] at 11:08 a.m. with certified nursing assistant (CNA) Q about the above incident revealed: *Resident 8 liked to talk and make accusations. *The alleged perpetrator had since been moved to a different part of the facility due to the accusations. Interview on [DATE] at 11:15 a.m. with licensed practical nurse (LPN) R about the above incident revealed: *She was aware of resident 8's allegations. *The incident happened on [DATE] at around 3:10 a.m. *She had been working at the facility on the night that the alleged rape happened. -She confirmed that resident 8 was found on the floor in front of her recliner and the alleged perpetrator was found asleep in resident 8's bed. *Resident 8's family was aware of the allegations. -LPN R explained that resident 8's family requested that staff inform her that the incident was being taken care of through the court system. -The incident was not actually in the court system. -She and the other staff members did comply with the family's request. *Resident 8 would frequently ask staff what the status of her case was in the court system. Interview on [DATE] at 11:22 a.m. with director of social services (DSS) D about the above incident revealed: *The alleged perpetrator was known to wander about the facility, and into other resident's rooms. *On [DATE], the male resident was found in resident 8's bed. *She explained that resident 8 usually slept in her recliner. *On that night, she woke up and saw a man in her bed; she thought that man was her deceased husband. *She got up from her recliner and fell . *DSS D confirmed that resident 8 did have a scratch and a scar on her foot. -She believed the scratch happened when resident 8 fell . *Since the resident's statements were inconsistent, and due to their internal investigation not finding evidence that a sexual assault had taken place, the management team did not contact the police or file a report with the South Dakota Department of Health (SD DOH). *She confirmed that since the incident, resident 8 was apprehensive of other people walking up and down the hallways. *Resident 8 had not made any allegations of rape until [DATE]. -Social services had not been informed of the allegations until [DATE]. -She confirmed that there was at least one nurse who had known about resident 8's allegations and had not reported those allegations to anyone. -It was her expectation that any allegation such as rape should have been reported right away to the management staff. It was up to the management staff to then report appropriate incidents to the SD DOH and law enforcement. *She confirmed that: -The alleged perpetrator was moved to a different part of the facility on [DATE]. -Resident 8 had not been evaluated by a physician or mental health practitioner in reference to her alleged sexual assault. 2. Review of resident 8's Minimum Data Set (MDS) assessments revealed: *On the [DATE] annual MDS assessment, she had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. *On the [DATE] quarterly MDS assessment, she had a BIMS score of 12, indicating moderate cognitive impairment. *She had pertinent diagnoses of Alzheimer's disease, Parkinson's disease, and depression. Review of a nurse's progress note on [DATE] at 11:14 p.m. revealed: *Resident upset this evening, concerned regarding man that lives down the hall from her as he stops to rest and looks in her room. Resident states that she needs to know where he is as she can't sleep if he is on the prowl. Provided reassurance that the gentleman has went [sic] to bed and he just goes up and down the hall and has not entered another [resident's] room. Resident asked nurse if nurse would take away the gentleman's w/c [wheelchair] so she can be assured to rest. Reassured resident that she was safe and that she did not need to worry. Resident then states 'well I thought I was safe before until that other man almost raped me.' Provided reassurance again that she was safe and that staff are here if she needs us. -That nurse had not reported the resident's comment of an alleged attempted rape. -The alleged rape was not reported until [DATE], when social services had received the report from an unidentified nurse. 3. IMMEDIATE JEOPARDY PSYCHOSOCIAL HARM Interviews with resident 8 and a review of her electronic medical record (EMR) showed continued signs of agitation and elevated emotional distress. She continued to believe the alleged rape was litigated through the court system. There was no police report. There was no report to the SD DOH. She had not been assessed physically or mentally regarding this incident. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on [DATE] at 4:10 p.m. to administrator A and director of nursing (DON) B. They were asked for an immediate removal plan. IMMEDIATE JEOPARDY REMOVAL PLAN On [DATE] at 4:09 p.m., administrator A provided the survey team with a final written immediate jeopardy removal plan. The removal plan had been approved by the survey team [DATE] at 4:17 p.m. with guidance from the long-term care advisor for the SD DOH. The provider gave the following acceptable immediate jeopardy removal plan on [DATE] at 4:09 p.m.: *Pioneer Memorial personnel contacted the Viborg City Chief Police at 10:38 am on [DATE] and are awaiting a reply. The State Department of Health Report was filed at 11:40 am on [DATE]. On [DATE] at 1:00 Director of Social Services spoke with [resident 8]. When asked if she feels safe and secure, resident responded with 'I think so'. When asked if she feels like it is a welcoming and friendly environment here, she responded with yes. When asked if she would have a loved one needing care like here, how likely would you be to recommend, and the resident answered with 4 (on a scale of ,d+[DATE] with 5 being the highest). SS [social services] also reassessed resident using the Trauma Screen on [DATE]. SS Director asked [resident 8] if she would like to speak more to someone, like a counselor, about her experiences and how they are affecting her and she said, 'no.' Social Services Director clarified that she is currently seeing a counselor and resident had no recollection of the fact that she does currently meet with two counselors regularly and are aware of this incident. Counselors have included in their visit notes from [DATE] and [DATE]. SSD/designee will meet with [resident 8] 2 x's/week for 4 weeks to allow resident to share concerns/feelings and to evaluate her psychosocial wellbeing. Resident's MD [medical doctor] notified [DATE] and assessing her [DATE] to advise for further medical needs. [Resident 8] will be offered interventions to deter uninvited residents from entering her room. i.e. Velcro stop sign, Motion sensor in doorway, etc. Interviewable nursing home residents were interviewed in July and asked if they felt safe and secure and 100% answered yes. On the morning of ,d+[DATE], Interviewable residents were interviewed individually and asked if they felt safe and secure and 100% answered yes. On ,d+[DATE] at 9:30 am LTC management received training from Good Samaritan Society Regional Clinical Services Director and Accreditation Specialist Consultant regarding the abuse prevention policy, types of abuse, reporting any allegation of abuse, and timely reporting to SD DOH. On [DATE] at 2:00 all available LTC staff of nursing, social services, activities, dietary, housekeeping, laundry, maintenance, and therapy will receive education on the following: The Abuse Prevention Plan Policy including physical abuse, sexual abuse, psychosocial abuse, neglect, involuntary seclusion, exploitation, misappropriation of a resident's property, an attempt to commit a crime against a patient, physical harm or injury, profanity, and deprivation of goods or services. The responsibility of every employee to report a suspicion or allegation of abuse to LTC management immediately regardless of it is substantiated in their view. Social Services Director provided specific examples of sexual, financial, physical, and verbal abuse while maintaining HIPAA [Health Insurance Portability and Accountability Act] protocols during the educational meeting. Staff not available on [DATE] will be tracked and additional trainings will occur, or a paper education will be provided with a sign off and quiz. Long Term Care Management will conduct 10 random staff interviews weekly for 4 weeks and then monthly for 3 months to determine understanding of our abuse policy. Long Term Care Management will conduct Abuse policy quizzes for staff competencies and/or abuse and neglect drills weekly for 4 weeks and then monthly for 3 months. Findings will be taken to QAPI monthly for review and revision as warranted. The immediate jeopardy was removed on [DATE] at 11:30 a.m. after verification that the provider had implemented their removal plan. After the removal of the immediate jeopardy, the scope and severity of the citation level was G. 4. Interview on [DATE] at 11:15 a.m. with DON B revealed: *That looking back she now knows that the incident should have been reported to both law enforcement and the SD DOH. *That her expectation was that all required incidents should have been reported to the proper authorities. Interview on [DATE] at 1:30 p.m. with administrator A revealed that her expectation was that the incident between both residents 8 and 28 should have been reported to both law enforcement and SD DOH when they occurred. 5. Review of a nurse's psychotropic drug review note on [DATE] revealed resident 8 continues to talk about rape charge and scrape on her leg. B. Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (20) had been protected from verbal and physical abuse by her husband, resident (19) while both resided in the facility. Findings include: 1. Observation and interview on [DATE] at 2:05 p.m. with resident 20 about her experience in the nursing home revealed: *She had been in her chair since 9:00 a.m. *She said she had had a stroke two years ago and could not move her right side. 2. Review of resident 20's EMR revealed: *Resident 19 was her husband and she had shared a room with him. *On [DATE] resident 19 had struck her on the right arm causing pain to her. *The incident was not reported to staff until [DATE] by their daughter. *Resident 20 stated that she felt safe and did not want her husband taken away. *The provider contacted law enforcement and reported the incident to the SD DOH. 3. Interview on [DATE] at 11:40 a.m. with resident 20's daughter revealed: *She was told by resident 20 that resident 19 had hit her and that it had hurt. *Resident 19 became angry at resident 20 due to him believing that resident 20 had a romantic relationship with another resident prior to their marriage, which led to resident 19 hitting resident 20. *The daughter explained that resident 19 had never hit resident 20 before. *When asked to repeat and clarify the incident, the daughter denied the incident and said it was an accident. *She explained that resident 20 would have defended resident 19, no matter what. Interview on [DATE] at 9:33 a.m. with resident 20 revealed when she was asked about resident 19 hitting her that she denied that he hurt her and that he only tapped her. Interview on [DATE] at 12:00 p.m. LPN R revealed: *Both residents 19 and 20 should have spent time together in public spaces. *If both residents 19 and 20 were in a room alone, the door should have stayed open. *If an incident occurred between residents 19 and 20, it should have been notated in resident 19's behavior log. *No incident had been recorded sine that last incident. 4. Review of resident 19's behavior logs on [DATE] at 1:38 p.m. revealed that on [DATE] resident 19 was seen yelling at resident 20 about him not being able to watch the football game. He was redirected and was fine after this incident. 5. Interview on [DATE] at 11:27 a.m. with DSS D revealed: *The incident was reported by both resident 19 and 20's daughter on [DATE]. *Resident 19 was moved from their joint room to a private room down the hall and around the corner from resident 20's room. *Resident 20 did not voice any safety concerns with having her husband in the facility. *Resident 20 later said that resident 19 did not hit her and that it was an accident. Interview on [DATE] at 1:28 p.m. with administrator A revealed after the incident was reported to a staff member, a report had been filed with SD DOH and law enforcement was notified. 6. Review of the provider's [DATE] Abuse Prevention Plan policy revealed: *Under the Definitions section: -C. Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, sexual assault, or inappropriate touch. Sexual abuse is nonconsensual sexual contact of any type with a resident. -E. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. *Under the Responsibility section: -A. It is the responsibility of every employee to: --2. If the crime does not appear to cause serious bodily harm, report directly to the DOH and local law enforcement agency or to his/her department director who will document the information and initiate the investigation. -B. It is the responsibility of the Director of Nursing (DON) of Long Term Care Services or designee or the DON of the Hospital or designee to: --1. Monitor incident reports to identify residents who are repeatedly injured or involved in incidents to identify a trend. --2. Notify the family of the allegation of neglect or abuse of the resident. --3. Report to the DOH [email redacted] on-line reporting form or fax to [fax number redacted] ombudsman [ombudsman phone number redacted] and local law enforcement [phone numbers redacted] if not already reported by an individual, any allegation of mistreatment, neglect, or abuse within the required time frame of the alleged mistreatment, neglect, or abuse. --4. Submit REQUIRED NURSING FACILITY EVENT REPORT (on line) to DOH Complaint Coordinator per instructions of form. --5. Investigate reported allegations of mistreatment, neglect, or abuse and file the results of the investigation with DOH within five (5) working days on 5- DAY INVESTIGATIVE REPORT (on-line). *Under the Policy section: -A. PMH&HS [Pioneer Memorial Hospital and Health Services] will ensure the resident's right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion by anyone, including but not limited to staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, friends or other individuals. -C.3. According to South Dakota Administrative Rules, 44:73:01:07, PMH&HS shall also report to the (DOH) within 24 hours and any other licensed facility shall report to the DOH within 48 hours of the event using REQUIRED NURSING FACILITY EVENT REPORTING form on-line . Any allegation of abuse or neglect of any patient by any person.

Based on interview, record review, and policy review, the provider failed to ensure events had been reported to the [STATE] Department of Health (SD DOH) in a timely manner for: *Two of two sampled residents (9 and 33) who had exhibited verbal or physical resident-to-resident altercations. *One of thirteen sampled residents (35) who had a fall that required medical attention. Findings include: 1. Review of resident 9's medical record revealed: *He was admitted to the memory care unit on [DATE]. *A 2/20/20 physician's orders [REDACTED]. *A [DATE] at 2:38 p.m. progress note by Minimum Data Set (MDS) assessment coordinator A revealed Resident on evening 02/18 was calling to staff, racial slurs, swatting a cane in the direction of staff and residents. No residents or staff were physically affected during this outburst. Nursing is continuing to monitor and follow up with residents change in behaviors. *A [DATE] progress note by licensed social worker (LSW) G indicated his family was notified of his recent behaviors. -They voiced concern that he would get out of control as he had in the past, throwing furniture, striking out at people, and out of control. *A [DATE] progress note by director of nursing (DON) B regarding his behaviors on 2/18/20. The DON had documented: -Attempted to hit another staff member and resident with a cane. Cane removed from his possession. -She had talked to the nurse practitioner and received orders to increase the resident's antidepressant and also an order [REDACTED].>-A staff member had remained one-to-one with the resident during the night of 2/18/20. *On 2/20/20 he moved out to the open unit. Interview on 2/27/20 at 8:30 a.m. with DON B regarding the resident-to-resident altercation with resident 16 revealed: *The altercation was not reported to the SD DOH, because she was not aware the provider was required to report resident-to-resident altercations. Refer to F610, finding 3. 2. Review of resident 33's medical record revealed: *His [DIAGNOSES REDACTED].>-Malignant neoplasm of prostate and bone. -[MEDICATION NAME] degeneration. -Hypertension. *He had: -Fluctuating cognition from moderate to severe impairment. -Documented episodes of resident-to-resident altercations with another resident. -Caused injury to another resident with some of those altercations. Refer to F740, finding 2. Interview on 2/26/20 at 5:01 p.m. with assistant administrator M and DON B concerning resident 33's resident-to-resident altercations revealed: *They had not: -Initiated Incident Occurrence Reporting documents. -Done internal investigations to rule out abuse. -Reported altercations to the SD DOH. *They agreed they should have initiated Occurrence Reporting Documents and done thorough internal investigations. *They did not think they had to report those altercations, because they did not think it was done intentionally. - But they had not done any investigations to identify they were unintentional. 3. Resident 35 had a fall on [DATE] and was later sent to the emergency department (ED). The investigation and report was not sent to the [STATE] Department of Health. Refer to F610, finding 2. Surveyor: 4. Review of the provider's [DATE] Incident Occurrence Reporting of Patient-Visitor-Employee policy revealed: *The purpose was to: -Inform the administration and department managers of any unusual variances. -Allow for proper analysis of the variances. -Provide a uniform system of reporting variances. -Provide a base of information for the proper study of risk management. *Incident and/or occurrence reports would be completed on all variances. *All incident reports would be reported to the safety zone (event documentation form). Review of the provider's 11/11/16 Abuse Prevention Plan policy revealed: *The purpose was to: -Prevent mistreatment, neglect, involuntary seclusion, exploitation, and/or misappropriation of patient/resident property. -Educate employees, residents, and their families and visitors how to identify and report any form of abuse. *Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. *In the absence of a criminal conviction, substantial evidence that one or more of the following had occurred resulting in harm, pain, or mental anguish including: -Physical harm or injury against a resident. -Use of profanity, making gestures, or engaging in other acts made to or directed at a resident. -Deprivation by an individual of good or services necessary to attain or maintain physical, mental, or psychological well-being. -Psychological abuse including humiliation, harassment, and threats of punishment, deprivation, restraints, and silence. *It was the responsibility of every employee to report a suspicion of serious injury immediately. *If the crime did not appear to cause serious bodily harm the provider was to report directly to the SD DOH or to their department director who would document the information and initiate the investigation, and cooperate with the investigation of alleged mistreatment, neglect, or abuse.

Based on observation, interview, record review and policy review, the provider failed to ensure care plans had been revised and updated to reflect the individual care needs for 3 of 13 sampled residents (23, 25, and 37). Findings include: 1. Review of resident 37's medical record revealed she was admitted on [DATE]. Review of her 2/12/20 Minimum Data Set (MDS) assessment regarding activities of daily living (ADL) needs revealed she required: *Extensive assistance of two staff members for: -Bed mobility. -Transfers. -Dressing. -Toileting. *Extensive assistance of one staff member for: -Bathing. -Hygiene. *Supervision and one staff member assistance with moving in her wheelchair (w/c). *Supervision and set-up assistance of one staff member for eating. Review of her updated 2/18/20 care plan revealed: *Remind resident that she needs assistance at this time. *Assistance with the following ADLs were not addressed: -Bed mobility. -Hygiene. -Bathing. -Eating. -Locomotion in her wheel chair. *Staff were to toilet her every two hours. -The care plan did not indicate how many staff members were required to assist her with toileting. Review of her undated pocket care plan regarding ADL assistance that was required revealed: *Stand-Aide for transfers. *Toilet every 2 hours & pericare (perineal care). The above certified nursing assistant (CNA) pocket care plan had not indicated the extent of assistance required and how many staff members were required to perform the following care: *Extensive assistance of two staff members for: -Bed mobility. -Transfers. -Dressing. -Toileting. *Extensive assistance of one staff member for: -Bathing. -Hygiene. *Supervision and one staff member assistance with moving in her w/c. *Supervision and set-up assistance of one staff member for eating. 2. Review of resident 25's medical record revealed she was admitted on [DATE]. Review of her 1/11/20 MDS assessment regarding ADL assistance revealed she required: *Physical assistance of one staff member for bathing. *Supervision and one staff member assistance for toileting. *Set-up assistance with: -Bed mobility. -Eating. *No assistance with: -Transfers and ambulation in and out of her room. -Dressing. *A walker for ambulation. Review of resident 25's updated 2/25/20 care plan revealed:*Offer assistance with activities of daily living as allows. *Her need for physical assistance of one staff member with bathing was not documented. *Her need for supervision and one staff member assistance with toileting was not documented. *Nothing was documented regarding her need for set-up assistance with: -Bed mobility. -Eating. *The need for a walker was not mentioned in the care plan. Review of resident 25's undated certified nursing assistant (CNA) pocket care plan regarding ADL assistance required revealed: *Independent. It had not indicated what ADLs she was independent with. *It had not indicated her ADL needs for assistance with: -Physical assistance of one staff member for bathing. -Supervision and one staff member assistance for toileting. -Set-up assistance with: --Bed mobility. --Eating. -A walker for ambulation. 3. Review of resident 23's 1/11/20 quarterly MDS revealed: *She had [DIAGNOSES REDACTED]. *The following sections revealed: -G, functional status: she required extensive assistance of two staff persons for bed mobility, transfers from one surface to another, dressing, and toilet use. Walk in room and corridor had not occurred. -H, bowel and bladder: she had frequent incontinence of bowel and bladder. -J, health conditions: she had three falls; two with no injury and one with injury. -M, skin condition: she had been at risk for pressure ulcers and had a pressure reducing device in her w/c. -P, restraints: she had a motion sensor alarm and a wander/elopement alarm. Interview on 2/26/20 at 1:19 p.m. with CNA J regarding resident 23 revealed she: *Had used a stand lift at around 12:30 p.m. to transfer the resident from the w/c to the bed. *Usually transferred her that way. Observation and interview on 2/27/20 at 11:46 a.m. with CNA H regarding resident 23 revealed: *She: -Was a traveling CNA. -Had been here a couple of weeks. -Had transferred the resident with a stand lift. -Used the pocket care plan to identify how she cared for her. *The resident's undated CNA pocket care plan read: -Assisted diner; 1-2 Assist; Wheelchair for locomotion; Hi-Lo bed with mat; DO NOT LEAVE UNATTENDED IN BATHROOM; Motion Alarm in room face towards bed and put on REMOTE no CHIME; Wandergaurd; Music & Memory. *The CNA: -Agreed she would not be sure how to transfer or provide personal care to the resident by the information provided on her pocket care plan. *Thought for a moment, then guided surveyor into the resident's room, and pointed to undated pictures posted above the resident's bed that included: -A stand lift. -Motion alarm. -Recliner chair with an alarm clock. -A position alarm. -Two stick people standing together. -A person falling. -A bed with an arrow over it. -Two open eyes looking at a toilet. *She used the pictures for more information on how to care for the resident. -Did not know how to access the resident's care plan in the computer system. *There had been no information on those pictures concerning: -Ambulation. -Dressing. -Cognition. -Oral care. -Toileting. -Continence. -Pressure reducing device in w/c. Interview on 2/27/20 at 12:00 noon with assistant director of nursing (ADON) E concerning how to care for resident 23's personal care revealed: *CNAs had the information they needed on the resident pocket care plan, the sign on the resident's door, and had access to the care plan in the computer for information concerning the resident's care. *The sign on the resident's door concerning her ADLs revealed: -Assisted diner. -One to two assist with transfers. -W/c for locomotion. -Do not leave unattended in bathroom. *There had been no information concerning: -Ambulation. -Dressing. -Cognition. -Oral care. -Toileting -Continence. -Bed mobility. -Pressure reducing device in w/c. *She agreed the resident needed a stand lift for transfers but did not agree the care plan should reflect that, because the staff could always go up a level with transfers if the resident had needed it. Interview on 2/27/20 at 12:00 noon with CNA H revealed she was unaware of the sign on the back of the resident 23's door She stated she did not know how to access the care plan in the computer. She only used the pocket care plan and pictures on the resident's wall for information about the resident's care. Review of resident 23's 1/22/20 revised care plan revealed the only interventions related to her ADLs were in the following focus areas: *At risk for skin breakdown: -Toilet every two hours and as needed. -Incontinence standards of care. -Do not leave unattended in bathroom -Pressure reducing device in w/c. *At risk for falls: Staff to lay resident down for a nap when resident is tired while in wheelchair. *Risk of decreased intake: Assist with oral cares am/pm. *Need for nursing home placement: Refer to standards of care related to [DIAGNOSES REDACTED]. *There had been no information concerning: -Ambulation. -Transfer with a stand lift. -Go up a level with transfers if resident needed it. -Dressing. -Bed mobility. 3. Review of provider's last reviewed and revised 2/4/20 Care Planning Process-LTC (long term care) policy revealed: *Each resident will have an individualized plan of care which addresses the resident's needs and severity of condition, impairment, disability, or disease. *It is the responsibility of the following interdisciplinary team members (or designees) to assess the resident, individualize the plan of care, evaluate the effectiveness of plan of care, revise the plan of care as the resident's needs change and attend care conferences: -RN, Social Services, Activity and Dietary will update Care Plan at time of notification of change in condition, behavior, diet, or activity preference. -MDS Coordinator: oversee and assure the completion of the MDS/CAAS/Care Planning process and day to day updating of the Care Plan is completed. -Certified nursing assistants offer input regarding residents' plan of care at the weekly standup meeting *The MDS coordinator will be responsible for updating the comprehensive care plan. The unit secretary will be responsible for updating the pocket careplan, the information sheet on the back of every resident's door and the symbols in the resident rooms.

Based on observation, interview, record review, and policy review, the provider failed to ensure investigations had been completed and reported to the [STATE] Department of Health (SD DOH) for: *Two of two sampled residents (9 and 33) who had exhibited verbal or physical resident-to-resident altercations. *One of thirteen sampled residents (35) who had a fall that required medical attention. Findings include: 1. Review of resident 33's medical record revealed: *His [DIAGNOSES REDACTED].>-Malignant neoplasm of prostate and bone. -[MEDICATION NAME] degeneration. -Hypertension. *He had: -Fluctuating cognition from moderate to severe impairment. -Documented episodes of resident-to-resident altercations with another resident. -Caused injury to another resident with some of those altercations. Refer to F 740, finding 2. Interview on 2/26/20 at 5:01 p.m. with assistant administrator M and director of nursing (DON) B concerning resident 33's resident-to-resident altercations revealed: *They had not: -Initiated Incident Occurrence Reporting documents. -Done internal investigations to rule out abuse. -Reported those altercations to the SD DOH. *They agreed they should have initiated Occurrence Reporting Documents and done thorough internal investigations. *They did not think they had to report those altercations, because they did not think it had been intentional. -But they had not done any investigations to identify they were unintentional. 2. Review of resident 35's medical record revealed: *She was admitted on [DATE]. *She had a percutaneous (PEG) feeding tube. *She was to have nothing by mouth (NPO). *Her [DIAGNOSES REDACTED].>-Pneumonitis due to inhalation of food and vomit. -Gastrostomy status. -Heart failure. -Localized [MEDICAL CONDITION]. -Dehydration. -Essential primary hypertension. *She had a history of [REDACTED]. -She had a fallen on [DATE] and was later sent to the emergency department (ED). Review of resident 35's 11/26/19 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BI[CONDITION]) score was fourteen, which indicating she was cognitively intact. *She required extensive assistance of two staff for bed mobility and transfers. *She required limited assistance of one staff person for walking in her room. *She required extensive assistance of one staff person for dressing, personal hygiene, and toileting. Review of resident 35's nursing progress notes revealed: *On 11/23/19 at 1:47 a.m.: Fall AT 2240 (10:40 p.m.) on [DATE] Found this resident sitting on the floor of her room next to her bed with bleeding noted from her right arm and elbow from skin tears. the right upper arm had a skin tear that was 4 cm (centimeters). the right elbow was 7.5 cm x 3.5 cm. skin was approximated the best as possible and cleansed with soap and water and dryed with a [MEDICATION NAME] applied on both sites. -ROM (range of motion) was fine and the resident denied pain and was assisted to get up. and then with the next time she was assisted to the bathroom she c/o (complains of) right knee pain with ambulation. there was no bruising or redness noted to the right knee. -(Certified nurse practitioner's name) CNP K was notified and order for ice pack ace bandage and [MED] was received and done. *On 11/23/19 at 2:55 a.m.: Patient had legs out of bed and said she wanted to go to the bathroom. She was assisted to get up to walk to the bathroom with gait belt and FWW (front wheel walker) and she had a great difficulty getting up and getting to the bathroom and rated the pain in her knee a 6/10. -Called the hospital and told them we would be bringing her to the ER (emergency room ) for evaluation. Review of resident 35's 11/23/19 hospital discharge summary revealed: *Physician's note stated: .presents to ED with reports of severe right knee pain. (name) was in her room at the nursing home earlier and fell . She reported some knee pain at that time and also had left arm skin tears. (name) was reporting some pain at rest along with inability to bear weight on her right knee. She has two large skin tears to her right upper arm that is covered with [MEDICATION NAME]. *She had an X-ray of her right knee and Dermabond was applied to her skin tears. -X-ray was negative for any acute changes. Interview on 2/26/20 at 3:57 p.m. with DON B revealed: *The fall events were in the facility's safety zone (event documentation form) documentation. *They did not report the fall on [DATE] to the SD DOH because they did not view it as a fall with a major injury. Review of resident 35's safety zone event report for her fall on [DATE] revealed: *The interventions that were in place before her fall were to have .all personal items within reach and other. -The other intervention was specified as the resident was currently on physical therapy and occupational therapy. *The report stated nothing was out of reach for the resident. *The interventions that were in place after the fall were: -Bed and chair alarm. -Education. -Informed resident/family. *Risk factor contributing to the fall was listed as history of fall and other. -Other was specified as hooked up to feeding tube at night and weakness. *Injuries were listed as abrasion and pain in right knee. *DON B on 11/26/19 at 11:24 a.m. had documented: Fall team met this date to review fall. TABS (personal alarm device) monitor implemented after fall due to impulsivity. Resident had skin tears from fall and pain to the knee. -X-ray completed to knee without injury noted. Resident currently on PT/OT services for strengthen and gait training. *Another entry from DON B on 11/26/19 at 11:31 a.m. stated: Resident being hooked up to feeding tube at night increases fall risk. Care plan updated to include TABS monitor alarm. Resident is already in a room close to the nurses station. *Entry from assistant DON E on [DATE] at 9:42 a.m. stated: Resident exhibiting safety awareness since fall, using call light system for staff assistance. Per interview with Charge RN resident no longer at this time in need of TABS monitoring system. No further follow up needed at this time. *The fall team had met on 11/26/19 to discuss the above incident. *Resident 35 also had another fall on 11/23/19 that did not result in any injuries. -The event report did not reveal why she fell . Review of the provider's June 2019 Post Fall Assessment policy revealed: .The initial assessment, contributing factors, and any change from the resident's norm are to be documented on the 'Safety Events-Falls' form located on Achieve Matrix. -In addition to the Safety Event form, it is the responsibility of the Charge Nurse to complete and incident report in Safety Zone. *Staff were also supposed to: Interview the resident and document resident's response in the 'What was the resident doing prior to the fall?' section of the 'Safety Events-Falls' form in Matrix. *Additionally: Interview the staff members who have knowledge of the fall and include the information in 'What was the resident doing prior to the fall' section of the 'Safety Events-Falls' form as appropriate. Review of the provider's November 2019 Fall Prevention Program policy revealed: Upon meeting the Fall Rounds Team will document investigation into the cause of the fall if not already known, completion of the environmental rounds if applicable, the resident's level of assistance needed after the fall, if the care plan was followed, interventions in place at the time of the fall and any interventions added or changed after the fall. -The Fall Rounds Team will make an additional note in Safety Zone regarding follow up from any new interventions put in place and their effectiveness, when applicable. -The Director of Support Services will be responsible for ensuring Safety Zone events are complete in their entirety. Review of the provider's November 2019 Safety policy revealed: *The facility had a fall prevention program which included: .identification of risk factors through resident and environmental assessment; implementation of interventions consistent with the resident's needs and environmental hazards; use of assistive devices; and evaluation of the effectiveness of the interventions with modifications of the interventions as necessary. *Residents are assessed for fall risk (fall risk assessment) upon admission, quarterly and with change in condition. Standard of Care interventions for all residents admitted are orientation to the environment, toileting schedule as indicated, provision of the appropriate level of assistance or assistive devices and call light, water, phone and personal items within reach. Interventions for residents assessed at a moderate or high risk are individualized to meet the resident's needs, goals, plan of care and current standards of practice. 3. Observation on 2/24/20 at 4:00 p.m. of resident 9 revealed he: *Was alert and talkative. *Reported he had been locked up until recently and he felt like he were in a jail. *Brought up discussion of his time in the war and hospitalization s at the VA hospital. Interview on 2/25/20 at 1:00 p.m. with registered nurse (RN) N regarding resident 9 revealed: *He resided on the Memory Unit until the previous week. *He was moved on 2/20/20 to main area from the memory unit. *Behaviors throughout his stay had included verbal aggression toward some of the staff and residents. *His behaviors had increased, and he had been verbally aggressive with another memory unit resident 16. *His medications had been adjusted due to his increased behaviors. Review of resident 9's medical record revealed: *He was admitted to the memory unit on [DATE]. *A 2/20/20 physician's orders [REDACTED]. *A [DATE] at 2:38 p.m. progress note by Minimum Data Set (MDS) coordinator A revealed Resident on evening 02/18 was calling to staff, racial slurs, swatting a cane in the direction of staff and residents. No residents or staff were physically affected during this outburst. Nursing is continuing to monitor and follow up with residents change in behaviors. *A [DATE] progress note by licensed social worker (LSW) G indicated his family was notified of his recent behaviors, and had voiced concern that he would get out of control as he had in the past, throwing furniture, striking out at people, and out of control. *A [DATE] progress note by DON B regarding his behaviors on 2/18/20 had documented: -Attempted to hit another staff member and resident with a cane. Cane removed from his possession. -She had talked to the nurse practitioner and received orders to increase the resident's antidepressant and also an order [REDACTED].>-A staff member had remained one-on-one with the resident during the night of 2/18/20. *On 2/20/20 he moved out to the open unit. Interview on 2/27/20 at 8:30 a.m. with the DON regarding resident 9's resident-to-resident altercation with resident 16 revealed: *The altercation had not been reported to the SD DOH, because she was not aware they had to report resident-to-resident altercations. *No internal event report or formal investigation of the above altercation had been completed. *Resident 9 tended to seek resident 16 out, but nothing more was documented in his medical record. *His verbal aggressiveness was escalating, and staff had decided to attempt a trial with the resident off of the memory unit. *His family had been notified of the altercation. *Resident 16's family had not been notified of the altercation. *There was no documentation in resident 16's medical record of the above event. Review of the provider's [DATE] Incident Occurrence Reporting of Patient-Visitor-Employee policy revealed: *The purpose was to: -Inform the administration and department managers of any unusual variances. -Allow for proper analysis of the variances. -Provide a uniform system of reporting variances. -Provide a base of information for the proper study of risk management. *Incident/occurrence reports were to have been completed on all variances. *All incident reports were to have been reported to the safety zone (event report documentation). Review of the provider's 11/11/16 Abuse Prevention Plan policy revealed: *The purpose was to: -Prevent mistreatment, neglect, involuntary seclusion, exploitation, and/or misappropriation of patient/resident property. -Educate employees, residents, and their families and visitors how to identify and report any form of abuse. *Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. *In the absence of a criminal conviction substantial evidence that one or more of the following had occurred resulting in harm, pain, or mental anguish including: -Physical harm or injury against a resident. -Use of profanity, making gestures, or engaging in other acts made to or directed at a resident. -Deprivation by an individual of goods or services necessary to attain or maintain physical, mental, or psychological well-being. -Psychological abuse, including humiliation, harassment, and threats of punishment, deprivation, restraints, and silence. *It was the responsibility of every employee to report a suspicion of serious injury immediately. *If the crime did not appear to cause serious bodily harm the provider was to report directly to the SD DOH or to their department director who would document the information and initiate the investigation, and cooperate with the investigation of alleged mistreatment, neglect, or abuse.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Two of five sampled residents (9 and 15) had an appropriate [DIAGNOSES REDACTED]. *One of five sampled residents (9) had an appropriate documented [DIAGNOSES REDACTED]. Findings include: 1. Observation on 2/24/20 at 4:00 p.m. of resident 9 revealed he: *Was alert and talkative. *Reported he had been locked up until recently and felt as though he were in a jail. *Brought up discussion of his time in the war and hospitalization s at the VA hospital. Interview on 2/25/20 at 1:00 p.m. with registered nurse (RN) N regarding resident 9 revealed: *He resided on the Memory Unit until the previous week. *He was recently moved on 2/20/20 to main area from the memory unit. *Behaviors throughout his stay included verbal aggression toward some of the staff and residents. *His medications had been adjusted due to his increased behaviors. Review of resident 9's medical record revealed: *physician's orders [REDACTED]. -[DATE]: [MEDICATION NAME] 500 milligrams (mg), four tablets daily for a [DIAGNOSES REDACTED]. -11/19/19: [MEDICATION NAME] 2 mg daily at bedtime for a [DIAGNOSES REDACTED]. -8/28/18: [MEDICATION NAME] XR (antidepressant) [AGE] mg daily for a [DIAGNOSES REDACTED]. -8/28/18: Quetiapine (antipsychotic) 25 mg daily for a [DIAGNOSES REDACTED]. -[DATE]: [MEDICATION NAME] (antidepressant) 7.5 mg daily for a [DIAGNOSES REDACTED]. --[DATE]: The above [MEDICATION NAME] 7.5 mg order was discontinued, and [MEDICATION NAME] 15 mg was ordered daily. -[DATE]: [MEDICATION NAME] solution (antipsychotic) 5 mg injection, give 5 mg IM (intramuscular) for agitation, as needed. --The above [MEDICATION NAME] solution order was reordered on [DATE] through 3/4/20. -2/23/20: [MEDICATION NAME] (antianxiety agent) 0.5 mg one time at 5:00 p.m. for a [DIAGNOSES REDACTED]. -2/24/20: [MEDICATION NAME] 0.5 mg was scheduled twice daily, later afternoon and bedtime. [DIAGNOSES REDACTED]. *Dementia without behavioral disturbance. *Unspecified mood (affective) disorder. *Visual hallucinations. *Primary [MEDICAL CONDITION]. A gradual dose reduction (GDR) for [MEDICAL CONDITION] agents medication (med) form was completed on 7/11/19 for resident 9's following [MEDICAL CONDITION] meds. The physician had documented at that time: *GDR not possible clinically without a negative effect on the underlying psychiatric illness. *Has worsening of symptoms with prior changes. Interview on 2/26/20 at 11:00 a.m. with Minimum Data Set (MDS) assessment coordinator A and licensed social worker (LSW) G regarding resident 9's [MEDICAL CONDITION] medications and [DIAGNOSES REDACTED]. *He was admitted with aggressive behaviors but had recently exhibited worsened behaviors. *LSW G reported the resident had witnessed a traumatic event during the war. *He had not currently reported hallucinations. *The visual hallucinations [DIAGNOSES REDACTED]. *He saw a psychologist at the time he was admitted , but had not seen him since. *His physician or nurse practitioner handled all of his psychoactive medication. Review of the 9/21/18 consulting psychologist note had included a single [DIAGNOSES REDACTED]. Interview on 2/27/20 at 9:30 a.m. with director of nursing (DON) B regarding resident 9's [MEDICAL CONDITION] medications and [DIAGNOSES REDACTED]. *Required an appropriate [DIAGNOSES REDACTED]. *Required a documented diagnosed specific condition prior to the use of as needed antipsychotic medication. Upon request for any physician, nurse practitioner, or further psychologist documentation regarding resident 9's behaviors or psychoactive medications DON B reported she was not able to locate documentation, other than orders for the psychoactive medication. 2. Observation on 2/24/20 at 3:45 p.m. of resident 15 revealed she:*Sat in a recliner in her room with her feet elevated. *Had a personal alarm device attached to her. *Was restless and moving about in her chair. *Stated she did not need any help. *Did not finish a sentence when she was asked questions. Interview on 2/24/20 at 4:30 p.m. with RN O regarding resident 15 revealed she: *Had been admitted after a fall in an assisted living center. *Had another fall soon after admission and had a fractured ankle. *Confirmed she was often restless. *Confirmed it was difficult to determine her cognition. Review of resident 15's medical record revealed: *physician's orders [REDACTED]. -2/4/20: [MEDICATION NAME] (antipsychotic) 5 mg daily for depression. [DIAGNOSES REDACTED]. *Major [MEDICAL CONDITION]. *Unspecified mood (affective) disorder. *Other amnesia. Review of resident 15's updated 2/4/20 care plan revealed: *She had been verbally and physically aggressive with staff members. *Due to the aggressiveness: -[MEDICATION NAME] and [MEDICATION NAME] meds had been initiated. -She would begin seeing a behavioral health therapist. Review of 2/5/20 documentation from the behavioral health therapist regarding resident 15 revealed: *She had been receiving [MEDICATION NAME]. *Her affect was anxious and depressed. *A [DIAGNOSES REDACTED]. *The therapist had not acknowledged the nurse practitioner's 2/4/20 order for Zyrexa. Interview on 2/27/20 at 9:45 a.m. with DON B regarding resident 15 confirmed: *The family had reported she had a long history of mental illness that was not treated. *Her documented [DIAGNOSES REDACTED]. *She did not know those [DIAGNOSES REDACTED]. *Other medications had not been attempted prior to initiating the antipsychotic medication. Upon request for any physician, nurse practitioner, or further therapist documentation regarding resident 15's behaviors or psychoactive medications the DON reported she was not able to locate documentation other than orders for the psychoactive medication. 3. Review of the provider's reviewed 10/25/19 Antipsychotic Drugs Use of policy revealed: *The purpose was to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. *The provider would ensure residents who had not used antipsychotic drugs were not given those drugs unless antipsychotic drug therapy was necessary to treat a specific condition as diagnosed and documented in the clinical record. *In an effort to discontinue antipsychotic drugs residents would receive gradual dose reductions and behavioral interventions unless clinically contraindicated. *The interdisciplinary care plan team and the DON would do a [MEDICAL CONDITION] drug review monthly. *Based on documentation and observation the team would evaluate the effectiveness of the medication. *An advanced practice provider would be involved in the monthly [MEDICAL CONDITION] drug review meeting and sign the report. *Behaviors would be documented on the appropriate observation. The observations would be reviewed by the care plan team quarterly and with any anti-[MEDICAL CONDITION] medication change.

Based on observation, interview, record review, and policy review, the provider failed to ensure 2 of 13 sampled residents (9 and 33) who exhibited symptoms of mental health instability had been assessed, monitored, and evaluated in a timely manner to ensure their psychosocial needs and well-being were being met. Findings include: 1. Observation and interview on 2/24/20 at 4:00 p.m. of resident 9 revealed he: *Was alert and talkative. *Reported he had been locked up until recently and felt as though he were in a jail. *Brought up discussion of his time in the war and hospitalization s at the VA hospital. Interview on 2/25/20 at 1:00 p.m. with registered nurse (RN) N regarding resident 9 revealed: *He resided on the Memory Unit until the previous week. *He was recently moved on 2/20/20 to the main area from the memory unit. Behaviors throughout his stay had included verbal aggression toward some of the staff and residents. *His medications had been adjusted due to his increased behaviors. Review of resident 9's medical record revealed: *He was admitted to the memory unit on [DATE]. *A 2/20/20 physician's orders [REDACTED]. *A [DATE] at 2:38 p.m. progress note by Minimum Data Set (MDS) coordinator A revealed: -Resident on evening 02/18 was calling to staff, racial slurs, swatting a cane in the direction of staff and residents. No residents or staff were physically affected during this outburst. Nursing is continuing to monitor and follow up with residents change in behaviors. *A [DATE] progress note by licensed social worker (LSW) G indicated: -His family had been notified of his recent behaviors, and had voiced concern that he would get out of control as he had in the past, throwing furniture, striking out at people, and out of control. *A [DATE] progress note by the director of nursing (DON) B regarding his behaviors on 2/18/20 had documented: -Attempted to hit another staff member and resident with a cane. Cane removed from his possession. -She talked to the nurse practitioner and received orders to increase the resident's antidepressant and also an order [REDACTED].>-A staff member had remained one-on-one with resident 9 during the night of 2/18/20. *On 2/20/20 he moved out to the open unit. Review of resident 9's 2/3/20 to 2/18/20 Behavior Tracking log revealed:*On 2/8/20: he was very rude to a new staff member. *On 2/10/20: he was saying (racial) terrible things about staff. Lots of swearing. *On 2/16/20: he was VERY VERY RUDE! *On 2/18/20: -He was very racial and mean to a staff member. -(Resident 9) and (resident 16) got into it, and he had been upset all night. -Tried to hit (resident 16) and (staff member) with his cane. Further review of resident 9's medical record revealed: *physician's orders [REDACTED]. -[DATE]: [MEDICATION NAME] 500 milligrams (mg), four tablets daily for a [DIAGNOSES REDACTED]. -11/19/19: [MEDICATION NAME] 2 mg daily at bedtime for a [DIAGNOSES REDACTED]. -8/28/18: [MEDICATION NAME] XR (antidepressant) [AGE] mg daily for a [DIAGNOSES REDACTED]. -8/28/18: Quetiapine (antipsychotic) 25 mg daily for a [DIAGNOSES REDACTED]. -[DATE]: [MEDICATION NAME] (antidepressant) 7.5 mg daily for a [DIAGNOSES REDACTED]. --[DATE]: The above [MEDICATION NAME] 7.5 mg order was discontinued, and [MEDICATION NAME] 15 mg was ordered daily. -[DATE]: [MEDICATION NAME] solution (antipsychotic) 5 mg injection, give 5 mg IM (intramuscular) for agitation, as needed. --The above [MEDICATION NAME] solution order was reordered on [DATE] through 3/4/20. -2/23/20: [MEDICATION NAME] (antianxiety agent) 0.5 mg one time at 5:00 p.m. for a [DIAGNOSES REDACTED]. -2/24/20: [MEDICATION NAME] 0.5 mg was scheduled twice daily, later afternoon and bedtime. [DIAGNOSES REDACTED]. *Dementia without behavioral disturbance. *Unspecified mood (affective) disorder. *Visual hallucinations. *Primary [MEDICAL CONDITION]. Interview on 2/27/20 at 8:30 a.m. with DON B regarding the resident-to-resident altercation of resident 9 with resident 16 revealed: *No internal event report or formal investigation of the altercation had been completed. *Resident 9 tended to seek resident 16 out, but nothing more had been documented in the medical record other than the 2/18/20 altercation. *His verbal aggressiveness had been escalating and staff decided to attempt a trial with resident 9 off of the memory unit. *Resident 9's family had been notified of the altercation. *Psychoactive medications had been increased and added due to his aggressive behaviors. Review of resident 9's updated 2/25/20 care plan revealed:*He could make rude and inappropriate comments to the staff. *He sometimes used a call light due to attention seeking behaviors. *He was on a two-week trial out of the memory unit. *Staff were to redirect him if he was making rude/inappropriate comments to staff. -There was no indication he had been directing his aggression to any residents. *Observe for changes in mood/behavior and report to charge nurse/provider. Resident's mood/behavior symptoms may include becoming irritable and agitated, and may holler and be difficult to redirect, throwing objects, physical aggression, as well as stating he wants to leave. *A 12/11/19 care plan problem indicated he voiced a trauma from the war. -The goal was that he would not exhibit any behaviors related to his war trauma. -Approaches had included: --Allowing him opportunities to talk about his experiences. --Informing the physician and the consultant behavioral health provider if he was having signs or symptoms of trauma-related experiences. --Observing for signs of: --- Increased anger or agitation. --- Becoming frustrated easily with other residents or staff. --- [ENTITY]ted talking about being a prisoner at the facility. ---Talking more about his war experiences. ---Demands to call his daughter repeatedly. Review of resident 9's 12/11/19 Trauma Assessment revealed: *He answered yes when asked if he had a traumatic experience. *He talked about his traumatic war experience. *The assessment area had not been completed regarding any coping strategies he might have used when reliving those strategies. *He had answered no when asked if he would like to talk to someone about how his experiences had affected him. Review of the 9/21/18 consulting psychologist note had included a single [DIAGNOSES REDACTED]. Upon request of DON B, no other psychologist documentation had been located. Interview on 2/26/20 at 11:00 a.m. with Minimum Data Set (MDS) coordinator A and licensed social worker (LSW) G regarding resident 9's [MEDICAL CONDITION] medications, behaviors, and [DIAGNOSES REDACTED].>*His behaviors included verbal aggressiveness toward staff and residents. *He was admitted with aggressive behaviors but had recently exhibited worsened behaviors. *LSW G reported: -The resident had witnessed a traumatic event in the war. -He did not currently exhibit hallucinations. -The visual hallucinations [DIAGNOSES REDACTED]. -The resident saw a psychologist at the time he was admitted , but had not seen him since. -The consulting psychologist did not think he needed to see the resident, but would have been available to evaluate his medication and behaviors if he was needed. -His physician or nurse practitioner handled all of his psychoactive medication. -The nurse practitioner made medication changes and moved him off the memory unit to try to reduce his agitation. -The resident had not been seen for his behaviors at the Veteran's Administration (VA) Hospital since he was admitted , because he had not handled returning back to the the facility well. -She was not aware of a VA program that came out to see a resident where they lived. -She confirmed she should have consulted the psychologist for an evaluation when his aggressive behaviors increased. Upon request for any physician, nurse practitioner, or further psychologist documentation regarding resident 9's behaviors or psychoactive medications the DON reported she was not able to locate documentation, other than orders for the psychoactive medication. Review of the provider's 10/28/19 Trauma Informed Care policy revealed:*The purpose was to address the impact of trauma on individuals and their needs. *Examples of trauma included: -Physical, sexual, emotional abuse. -Childhood neglect. -Having a family member with a mental health or substance abuse disorder. -Violence in the community. -Poverty and systemic discrimination. *To develop trauma informed care culture the provider would:-Screen all residents for trauma. -Train staff in trauma-specific approaches. -Engage referral sources in partnering organizations. *All residents were to have been screened using a trauma assessment. *Any answers of yes to the trauma assessment would have been added to the resident's care plan, so staff were notified of the resident's previous trauma, and of approaches to use when working with that resident because of the trauma. *The provider had an in-house contracted mental health service for the residents to assist with any trauma or mental health services the residents required. *The residents also had a choice to go to any mental health provider they chose, and the provider could arrange transportation to those services. 2. Review of resident 33's medical record and the 8/17/19 annual and 2/1/20 quarterly MDS assessment revealed: *His [DIAGNOSES REDACTED].>-[CONDITION]. -[MEDICATION NAME] degeneration. -Hypertension. *He had: -A Brief Interview for Mental Status (BI[CONDITION]) of six and ten revealing fluctuating cognition from severe to moderate impairment. -Been independent with transfers and ambulation. -Hearing loss. -Recently been admitted to hospice care. *He and resident 38 were roommates. Review of resident 38's medical record revealed: *Her [DIAGNOSES REDACTED].>-Alzheimer's. -Restless and agitation. *She had been: -admitted to hospice care on 2/8/20. -Severely cognitively impaired. -Malnourished. -Compromised. -Dependant with all care. -Nonverbal. Observation and interview on 2/25/20 at 11:10 a.m. with resident 33 and resident 38 revealed: *Resident 38 had been: -Confused to person, place, time, and situation. -Mildly contracted in her upper and lower extremities. -Non-verbal. -Transferred from the bed to a wheelchair (w/c) with a full body mechanical lift. -Made screaming and crying noises throughout the transfer. -Pushed and grabbed at certified nursing assistants (CNA) I and H during the transfer. -Usually acted this way during transfers according to the above CNA's. *Resident 33: -Had been seated in his recliner in the dark room before the above transfer. -Had a blank expression on his face. -Had not been doing any activities, neither the television nor the radio had been on. -Was alert with some confusion. -Watched intently when resident 38 was transferred. -Had a frightened look on his face and wiped tears from his eyes. *Surveyor asked, Are you ok? *He was silent.*Surveyor asked, Why are you crying? Do you think she is having pain or that they are hurting her? *He stated, Yes. *He remained quiet for the rest of the transfer and looked at her with a sad face and wiped tears from his eyes. Review of resident 33's progress notes from the nursing and social service departments from [DATE] thru [DATE] revealed: *He had: -Paced the hallways. -Delusions. -Accused resident 38 of being pregnant and cheating on him. -Threatened to sleep in his car because of all the trouble she was causing. -Yelled, hit, and shook her. -Caused bruising on her. -Was not easy to redirect. -Put her bed up in the high position which was not safe. -Hit his fist into the wall above her bed. -Tried to get her out of bed by himself. *Social service had made only four recorded visits with him during the above mentioned time. Review of resident 33's revised 2/24/20 care plan revealed: *He had been admitted to hospice on [DATE]. *He had been witnessed being rough with resident 38 and at times would try to assist her by trying to wake her up, by shaking her, and pulling on her to get her to stand up. *Interventions included: -Offer cueing and redirection during periods of confusion. -Offer support to resident. -Remove resident 38 from her room when he had negative delusions. -Remind and encourage husband not to argue or try to set resident straight during periods of increased confusion as that agitated her. -Encourage resident to share his feelings with those he trusted. -Offer support and encouragement. Interview on 2/26/20 at 10:23 a.m. with director of social services G concerning resident 33 confirmed: *The resident: -Was admitted to hospice last week. -Had not understood resident 38's declining condition. -Would need intervening from staff when there was hollering in the room. -Had delusions and behaviors towards resident 38. *She: -Had visited with him but nothing on a regular bases. -Thought he was on a depression medication, but he was not. -Was unaware that he had cried when he observed his wife's care. -Had not considered providing counseling with him regarding his wife's declining condition. -Had not recommended a behavioral health consultation. Review of the undated Director of Social Services Job description revealed: *Specific responsibilities: -Would provide and arrange provisions of appropriate counseling services and facilitate services with consultant mental health services.

Based on observation, record review, interview, and job description review, the provider failed to identify and promote individualized approaches and social services that met the mental and psychosocial needs for two of thirteen sampled residents (9 and 33)). Findings include: 1. Interview on 2/25/20 at 1:00 p.m. with registered nurse (RN) N regarding resident 9 revealed: *He resided on the Memory Unit until the previous week. *He was recently moved on 2/20/20 to the main area from the memory unit. Behaviors throughout his stay had included verbal aggression toward some of the staff and residents. *His medications had been adjusted due to his increased behaviors. Interview on 2/26/20 at 11:00 a.m. with Minimum Data Set (MDS) coordinator A and licensed social worker (LSW) G regarding resident 9's [MEDICAL CONDITION] medications, behaviors, and [DIAGNOSES REDACTED].>*His behaviors included verbal aggressiveness toward staff and residents. *He was admitted with aggressive behaviors but had recently exhibited worsened behaviors. *LSW G reported: -The resident had witnessed a traumatic event in the war. -He did not currently exhibit hallucinations. -The visual hallucinations [DIAGNOSES REDACTED]. -The resident saw a psychologist at the time he was admitted , but had not seen him since. -The consulting psychologist did not think he needed to see the resident, but would have been available to evaluate his medication and behaviors if he was needed. -His physician or nurse practitioner handled all of his psychoactive medication. -The nurse practitioner made medication changes and moved him off the memory unit to try to reduce his agitation. -The resident had not been seen for his behaviors at the Veteran's Administration (VA) Hospital since he was admitted , because he had not handled returning back to the the facility well. -She was not aware of a VA program that came out to see a resident where they lived. -She confirmed she should have consulted the psychologist for an evaluation when his aggressive behaviors increased. Refer to F740, finding 1. 2. Review of resident 33's medical record revealed: *His [DIAGNOSES REDACTED].>-Malignant neoplasm of prostate and bone. -[MEDICATION NAME] degeneration. -Hypertension. *He had: -Fluctuating cognition from moderate to severe impairment. -Documented episodes of resident-to-resident altercations with another resident. -Caused injury to another resident with some of those altercations. -Not understood resident 38's declining condition. -Delusions and behaviors towards resident 38. Refer to tag F740, finding 2. Surveyor: 3. Review of the undated Director of Social Services job description revealed: *Job duties included: -Rounding on residents. -Ensuring quality care issues were addressed. -Communicating with employees, physicians, patients (residents)/families and healthcare team members. *Responsibilities included: -Respecting residents' rights. -Providing for residents' safety. -Providing or arranging provision for appropriate counseling services and facilitating services with consultant mental health services. -Educating and promoting actions by staff to maintain and enhance each resident's rights, dignity, and individuality. -Advocating for resident's rights. -Maintaining open communication with residents and families regarding the resident's condition and needs. -Assisting staff with finding alternatives to drug therapy by understanding and communicating to staff possible reasons for resident's behavior. -Conducting weekly observations and charting of residents currently in need of behavioral interventions. -Participating in the [MEDICAL CONDITION] drug review team. -Providing education to all staff on resident's rights and responsibilities, and abuse.

Based on interview, record review, and policy review, the provider failed to ensure one of one sampled resident (35) who was receiving nutrition and hydration by percutaneous endoscopic [MEDEQUIP] (PEG) feeding tube received timely interventions preventing weight fluctuations. Findings include: 1. Review of resident 35's medical record revealed: *She was admitted on [DATE]. *She had a PEG feeding tube. *She received nothing by mouth (NPO). *Her [DIAGNOSES REDACTED].>-Pneumonitis due to inhalation of food and vomit. -Gastrostomy status. -Heart failure. -Localized [MEDICAL CONDITION]. -Dehydration. -Essential primary hypertension. Review of resident 35's following recorded weights revealed: *She was admitted weighing of 138 pounds (lb). *Her weight on 2/25/20 was 146 lb. *Her weight had increased to 141.5 lb one week after admission. -Her weight stayed within 0.5 to 1.5 lb of 141.5 lb from 11/26/19 to 1/14/20. *She had a 6 lb weight loss recorded on 1/21/20 which was 135.5 lb. -Her next recorded weight was a week later on 1/28/20 that was also 135.5 lb. -She was weighed a week later on 2/4/20, and her weight was 135 lb. --She had two documented weights on 2/4/20 and both weights were are 135 lb. *From 2/4/20 to 2/25/20 her weight had increased from 135 to 146 lbs. -That was a 8.16 percent weight increase. Review of resident 35's nursing progress notes revealed there was no nursing documentation related to resident 35's weight fluctuations from 1/14/20 to 2/25/20. Review of resident 35's dietary notes revealed: *On 1/14/20 registered dietician (RD) F had documented: -Resident received 1500 ml (milliliter) [MEDICATION NAME] HN (high nitrogen) to run at 130 ml/hour until completed starting at 2000. Enteral feeding at this rate will provide 1[AGE]0 kcals (kilocalorie), 81g (gram) protein, 1212 ml free water, 100% (percent) USRDI (United States reference daily intake). Resident receives additional water through medication administration to meet estimated fluid needs. Resident has maintain (ed) weight status since admission (11/20/19). Current weight 142.5# (pounds). Will continue to monitor enteral feeding monthly or as needed. *On 2/5/20 RD F had documented: -Resident brought to attention of this writer by RN (registered nurse) related to weight loss and review of fluid requirements. Resident has had no change in feeding since December of 2019. -Resident had weights 140.5-143# from 11/26/19 to 1/14/2020. Resident decreased to 135.5# in one week from 1/14/2020 to 1/21/2020 and has been 135-135.5# since in weekly weights. (This represents a 3.9% to 5.6% weight loss in 30 days in this time period depending on which weekly weight is used.) --Review of records offers no etiology of weight loss, i.e. (that is) diuretic increase, decrease in [MEDICAL CONDITION], fluid losses from emesis or diarrhea., scale or weighing method change. Per nursing resident complains of thirst. --Upon review recommend increasing feeding by 1 carton of Fissure HN 1.2. delivered bolus during the day at resident's convenience and additional 300 ml water bolus in addition to amount given at medication pass. Will continue to monitor enterable feeding monthly or as needed. Interview on 2/26/20 at 3:57 p.m. with director of nursing (DON) B regarding obtaining re-weights of residents revealed: *Reweights of residents were not documented in the electronic medical record (EMR). -When a re-weight was done, another staff member went into the tub room to verify the weight. The correct weight is then put into the EMR. Interview on 2/27/20 at 8:35 a.m. with dietary manager D regarding resident 35's weight fluctuations revealed: *He ran a report every week on Monday mornings. -Interventions were not implemented unless they met the criteria of 5% or more in thirty days. --There was a 7.7% loss in one week, but the dietician would not be notified until 30 days had passed. Interview on 2/27/20 10:31 a.m. with assistant DON E and Minimum Data Set coordinator A regarding resident 35 revealed: *They had known her before she was a resident at the facility, and she had weight fluctuations in the past. *They agreed her weight had been relatively stable since she was admitted to the facility. Review of the provider's February 2013 Care of the Resident policy revealed: A resident's height and weight are obtained within 24 hrs (hours) of admission. Subsequent weights are obtained a minimum of weekly. If there is a weight change of three (3) pounds or more the resident is reweighed in the presence of another CNA (certified nursing assistant) or licensed nurse for accuracy.

Based on observation, interview, record review, and policy review, the provider failed to implement and follow the comprehensive care plan for 2 of 13 sampled residents (15 and 17) to ensure they had received the appropriate care and services they required. Findings include: 1. Review of resident 15's medical record revealed: *She was admitted on [DATE] after a fall at the provider's attached assisted living center. *On [DATE] she fell again and was diagnosed with [REDACTED]. Review of resident 15's 1/1/20 MDS assessment regarding her ADL needs revealed she required the following assistance: *Extensive assistance of two staff members with: -Bed mobility. -Transfers. -Dressing. -Toileting. -Hygiene. *Extensive assistance of one staff member with locomotion on and off the unit. *Physical help of two staff members with part of her bathing. *Supervision and set-up from one staff member for eating. *A wheel chair was required for locomotion. Review of resident 15's 1/7/20 ADL CAA revealed: *She was previously independent with her care in an assisted living. *She had recent falls with a fracture and now required more staff assistance with her care. *A care plan decision indicated they would proceed to develop a care plan to meet her needs. Review of her updated [DATE] care plan regarding her ADL needs revealed: *A stand lift was to have been used by two staff members to transfer her. *The care plan had not indicated she required: *Extensive assistance of two staff members with: -Bed mobility. -Transfers. -Dressing. -Toileting. -Hygiene. *Extensive assistance of one staff member with locomotion on and off the unit. *Physical help of two staff members with part of her bathing. *Supervision and set-up from one staff member for eating. *A wheel chair was required for locomotion. Review of her undated CNA pocket care plan regarding ADL needs revealed: *She required a stand-aid for transfers. *She could bear weight on her right ankle while wearing a CAM boot. *The above pocket care plan had not indicated she required: -Extensive assistance of two staff members with: --Bed mobility. --Transfers. --Dressing. --Toileting. --Hygiene. *Extensive assistance of one staff member with locomotion on and off the unit. *Physical help of two staff members with part of bathing. *Supervision and set-up from one staff member for eating. *A wheel chair was required for locomotion. 2. Observation on 2/24/20 from 3:00 p.m. through 5:30 p.m., on 2/25/20 from 10:30 a.m. through 11:00 a.m., on 2/26/20 from 2:00 p.m. through 3:00 p.m., and on 2/27/20 from 9:47 a.m. through 10:30 a.m. of resident 17 revealed: *She required assistance of one staff person for: -Ambulation with a gait belt. -Standing from her recliner and her dining chair. -Using the toilet and personal care. Interview on 2/26/20 at 4:00 p.m. with Minimum Data Set (MDS) assessment coordinator A about resident 17's comprehensive care plan revealed: *The activities of daily living (ADL) functional/rehabilitation potential care area assessment (CAA) had not been triggered on her admission MDS 12/1/19 comprehensive assessment. -Since it had not triggered it had not been addressed on the comprehensive care plan. -That had occurred for another resident. and when she had exited out of the program and logged back in it showed as triggered. -She had not done that this time for resident 17. -She agreed it was odd that CAA had not triggered as she had required extensive assistance of one to two staff for most of her ADLs. -She said it would have applied for all of her ADLs. There was no interventions for continence, toileting, personal care, ambulation, transfer, and bed mobility. Interview on 2/27/20 at 9:30 a.m. with director of nursing B and MDS coordinator A agreed the ADL functional/rehabilitation potential care area assessment CAA should have triggered. Even if had not triggered those above areas it should have been addressed in her care plan. Interview on 2/27/20 at 9:47 a.m. with certified nursing assistant (CNA) C in the Haven memory care unit revealed resident 17 required the following assistance with her ADLs: *Ambulate with one staff person and gait belt to all areas in and out of her room. *She attempted to adjust her clothing during toilet use, but one staff person often needed to assist her. *She was able to do her own perineal care, wash her face and hands, oral care with set-up and stand by assistance of one CNA. Staff did take care of her partial denture. *A CNA did assist with combing/brushing her hair. *Extensive assistance of one staff person was required with dressing, but she would try to undress herself. *She was able to feed herself after one staff person set up her meal. *CNA C agreed her current care plan and the CNA's pocket care plan did not show what or how much assistance she required for her ADLs. Review of resident 17's 12/1/19 admission MDS assessment revealed: *Section G, functional status: she required extensive assistance of two staff persons for bed mobility, transfer from one surface to another, walking in and out of her room, dressing, eating, toilet use, personal hygiene, and bathing. *Section V, CAA summaries state the following: *Urinary incontinence and indwelling catheter CAA: Although resident was continent during this assessment period she did required staff assistance with toileting due to fall with fracture. *ADL functional/rehabilitation potential CAA had not been triggered, and it also had not been addressed in the care plan. *Falls CAA: Resident had a fall prior to admission with fracture. While here resident had another fall with fracture. Remains at risk for future falls due to needing staff assistance, taking mood altering medications, being unsteady, having pain, and lacks poor safety awareness. *Dental care CAA: Resident does require extensive assistance with personal hygiene. *Pressure ulcer/injury CAA: Although resident does not have a pressure ulcer she remains at risk due to spending most of her time in her chair or bed, needing staff assistance, and limited physical activity. Review of resident 17's undated pocket care plan used by the CNA staff included: *1 Assist with Gait Belt. *Glasses. *Lower Partial Dentures. *There were no other areas that had addressed what staff assistance she required with her ADL needs. Review of resident 17's 11/26/19 admission comprehensive care plan revealed the only intervention related to ADLs was in the problem area of falls. It stated two assist with walker and gait belt. 3. Review of the provider's last reviewed/revised 2/4/20 Care Planning Process - LTC policy revealed: *To ensure a comprehensive, individualized plan of care for each resident. *Using an interdisciplinary approach, each resident will have an individualized plan of care which addresses the resident's needs and severity of condition, impairment, disability, or disease based on the universal care standards identified by the PMNH ([REDACTED] Memorial Nursing Home) staff as the minimum standards for all residents.

Based on interview, record review, and policy review, the provider failed to ensure the appropriate Medicare notice had been provided to one of one sampled resident (28) who had remained in the facility following her discharge from skilled services. Findings include: 1. Review of resident 28's medical record revealed: *She had met her therapy goals and had been discharged from therapy services on [DATE]. *She had covered days remaining and continued to reside in the facility. *She had not received the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form as required. Interview on 2/26/20 at 2:28 p.m. with the Minimum Data Set assessment coordinator A regarding resident 28 revealed: *She had: -Not given the SNF ABN form to the resident. -Been instructed by her Medicare consultant to fill out the SNF ABN form only if the resident remained in the facility on private pay. The provider's 1/22/20 reviewed and revised Skilled Nursing Facility Issued Notices of Non-Coverage policy revealed: [REDACTED] Memorial Hospital and Health Services will issue CMC- (SNF ABN) whenever a beneficiary's Medicare coverage of current item and/or services is ending as well as Form C[CONDITION] (Notice of Medicare Non-Coverage).

Based on observation, interview, record review, and policy review, the provider failed to ensure activities were provided for three of three sampled residents (12, 30, and 38) in one of one memory care unit. Findings include: 1. Review of resident 12's medical record revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) score was four indicating her cognition was severely impaired. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] with behavioral disturbance. -Unspecified mood disorder. -Anxiety disorder. Review of Resident 12's care plan revealed: *Resident's activity goal was Resident will express satisfaction with level and variety of activities at quarterly review. *Interventions for activities included: -Resident would be asked to participate in activities that she preferred. -Resident likes: watching TV, the Twins & the Yankees, being active, reading, John Wayne. Doesn't like to listen to much religious music. Random observations from 1/7/19 through 1/9/19 of resident 12 revealed on: *1/7/19 at 5:05 p.m. she was eating supper with no interaction with her table mates. *1/8/19 at 9:28 a.m. she was sleeping in her recliner room with the lights off. *1/8/19 at 10:30 a.m. she was in her bed sleeping with the lights off. *1/8/19 at 10:49 a.m. she was in her bed sleeping with the lights off. She had not been invited to the activity on the unit. *1/8/19 at 4:34 p.m. she was reading the paper at the table in the dining room. *1/9/19 at 10:57 a.m. she was in bed sleeping with the lights off. *No activity calendar or schedule was observed in her room through the above dates. *The only observation of her engaging in preferred activities was on 1/8/19 when she was reading the news paper. *There were no observations of her TV on, staff talking to her about the Twins or the Yankees, she was not observed being active and no observations of her talking about John Wayne or watching his movies. 2. Review of resident 30's medical record revealed: *He was admitted on [DATE]. *His BIMS score was five indicating his cognition was severely impaired. *His [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] without behavioral disturbances. -[MEDICAL CONDITION], late onset. -Pain. *Resident's activity goal was Resident will express satisfaction with level of activities at quarterly review. *Interventions included: -Staff will verbally remind resident of activities available in Haven. -Staff will offer the busy board, read crossword hints, allow resident to walk around the unit agitated and assist resident with any self initiated activities. Observations from 1/7/19 through 1/9/19 of resident 30 revealed on: *1/7/19 at 5:05 p.m. he was sitting at the supper table eating and not interacting with staff or peers. *1/8/19 at 10:49 a.m. he had his eyes closed and appeared to be sleeping through the devotions activity. *1/8/19 at 10:58 a.m. he continued to sit in his wheelchair with his eyes closed in the dining room. *1/8/19 at 11:08 a.m. the fire alarm went off in the middle of the activity and he did not respond. *1/9/19 at 8:28 a.m. he was sitting at the breakfast table not conversing with others. *1/9/19 at 9:00 a.m. he was sitting at the table with three other residents and there was no interaction. *No activity calendar or schedule was observed in his room through the above dates. *There were not observations of resident being offered the busy board, staff reading him crossword puzzles, or him ambulating independently. 3. Review of resident 38's medical record revealed: *He was admitted on [DATE]. *His BIMS score was fifteen indicating he was not cognitively impaired. *His [DIAGNOSES REDACTED].>-Unspecified dementia without behavioral disturbance. -Unspecified mood disorder. -Visual hallucinations. *Resident's activity goal was Resident will express satisfaction with level and variety of activities at quarterly review. *Interventions included: -Staff will offer activities that resident enjoys and offer to come and see the activity. -Likes: visiting, reading his paper, getting mail and his family. Observations from 1/7/19 through 1/9/19 of resident 38 revealed on: *1/7/19 at 5:05 p.m. he was sitting at the supper table eating and not interacting with staff or peers. *1/8/19 at 8:52 a.m. he was in his room watching television. *1/9/19 at 8:28 a.m. he was eating breakfast with two other men and there was no conversation at the table. *1/9/19 at 8:53 a.m. He was sitting at the breakfast table, he exchanged pleasantries with another resident when he arrived to the table and they had no further interaction. *1/9/19 at 9:03 a.m. He was sitting in the dining room with five residents and one staff member. There was no interaction between the resident and staff member. *No activity calendar or scheduled was observed in his room through the above dates. *The only intervention that required staff engage him in an activity was visiting. He was not observed to be engaged by staff in conversations. Observations on 1/8/19 and on 1/9/19 of the organized group activities revealed on: *1/8/19 at 10:49 a.m. -There were four unidentified residents in the dining area. -The activity assistant read a devotion. -Two of the four residents appeared to be sleeping. -One of the four residents stared out the window. -One of the four residents stared at the table. *1/8/19 at 10:59 a.m. the activity assistant asked a resident what he thought of the devotion and he responded hello. *1/8/19 at 11:01 a.m. three of the four residents had their eyes closed as the activity assistant read a book. -At 11:08 a.m. the same three residents had not responded when the fire alarm went off during the activity. Interview on 1/8/19 at 9:22 a.m. with the activity assistant revealed: *Everyone in the memory care unit was provided with an activity calendar. *The activity calendar reflected activities held off the memory care unit in the nursing home. *There was no separate calendar for the memory care unit. *Activities were provided daily on the memory care unit at 10:45 a.m. and at 4:00 p.m. Interview on 1/8/19 at 5:00 p.m. with unlicensed assistive personal C revealed: *There was no activity schedule for the memory care unit. *She had to make up her own activities to do with the residents. *The residents enjoyed active activities that she engaged them in such as basketball or card games. *If a resident was laying or sitting in their room that counted as an activity, sometimes there was TV or music. Interview on 1/9/19 at 11:22 a.m. with the activities director revealed, there were no scheduled activities for the memory care unit. Interview on 1/9/19 at 3:15 p.m. with the director or nursing revealed: *Activities in the memory care unit should be geared towards the residents and what they were capable of doing. *Activities in the memory care unit should stimulate the residents. Review of the provider's 5/15/17 Activity Program policy revealed: *To provide a planned therapeutic activity program which will maximize remaining functions, enhance the quality of life, and meet the needs of each resident on an individual basis. *The activity coordinator will plan and coordinate the activity program for Pioneer Memorial Hospital & Health Services including the Alzheimer's Dementia Unit.

Based on observation, interview, record review, and policy review, the provider failed to ensure care plans included individualized interventions for four of twelve sampled residents (12, 30, 38, and 39). Findings include: 1. Review of resident 12's medical record revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) score was four indicating her cognition was severely impaired. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] with behavioral disturbance. -Unspecified mood disorder. -Anxiety disorder. Review of resident 12's care plan revealed: *Goal for mood altering medications Will be prescribed the lowest effective dose of medication. *Interventions included: -Medication as ordered. Review the need for medication with monthly psych ([MEDICAL CONDITION]) drug review. -Observe for changes in mood/behavior and report to charge nurse/provider. -There had been no interventions for monitoring or reporting mood altering medication side effects. -There had been no updates since 4/19/18. *Resident's activity goal was Resident will express satisfaction with level and variety of activities at quarterly review. *Interventions for activities included: -Resident would be asked to participate in activities that she preferred. -Resident likes: watching TV, the Twins & the Yankees, being active, reading, John Wayne. Doesn't like to listen to much religious music. *Interventions for activities were last updated on 8/22/18. Observation on 1/8/19 at 10:49 a.m. of resident 12 revealed she was in her bed sleeping with the lights off. She had not been invited to the reading activity on the unit. 2. Review of resident 30's medical record revealed: *He was admitted on [DATE]. *His BIMS score was five indicating his cognition was severely impaired. *His [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] without behavioral disturbances. -[MEDICAL CONDITION], late onset. -Pain. Review of resident 30's care plan revealed: *Goal for mood altering medications Will be prescribed the lowest effective dose of medication. *Interventions included: -Medication as ordered. Review the need for medication with monthly psych drug review. -Observe for changes in mood/behavior and report to charge nurse/provider. *There had been no interventions for monitoring or reporting mood altering medication side effects. *These interventions had not been updated since 11/29/18. *Resident's activity goal was Resident will express satisfaction with level of activities at quarterly review. *Interventions included: -Staff will verbally remind resident of activities available in Haven. -Staff will offer the busy board, read crossword hints, allow resident to walk around the unit agitated and assist resident with any self initiated activities. *These interventions had not been updated since 11/28/18. 3. Review of resident 38's medical record revealed: *He was admitted on [DATE]. *His BIMS score was fifteen indicating he was not cognitively impaired. *His [DIAGNOSES REDACTED].>-Unspecified dementia without behavioral disturbance. -Unspecified mood disorder. -Visual hallucinations. Review of Resident 38's care plan revealed: *Goal for mood altering medications Will be prescribed the lowest effective dose of medication. *Interventions included: -Medication as ordered. Review the need for medication with monthly psych drug review. -Observe for changes in mood/behavior and report to charge nurse/provider. *No interventions for monitoring or reporting mood altering medication side effects. *Resident's activity goal was Resident will express satisfaction with level and variety of activities at quarterly review. *Interventions included: -Staff will offer activities that resident enjoys and offer to come and see the activity. -Likes: visiting, reading his paper, getting mail and his family. All three of the above care plans included similar goals and objectives for mood/behavior and activities. These care plans had not addressed the resident's individual needs. Interview on 1/9/19 at 3:15 p.m. with the director of nursing (DON) revealed that she agreed the care plans were not person-centered. 4. Review of resident 39's medical record revealed: *Her admitted was 7/3/18. *Her [DIAGNOSES REDACTED].>-Mild cognition impairment. -Essential hypertension. -[MEDICAL CONDITION]. -Vitamin B12 deficiency [MEDICAL CONDITION]. -Hyperaldosteronism. -Nonheumatice [DIAGNOSES REDACTED]. -GERD. -Unspecified [MEDICAL CONDITION]. -Localized [MEDICAL CONDITION]. Review of resident 39's 12/15/18 Minimum Data Set assessment revealed: *Her BIMS was fifteen indicating her cognition was intact. *She required limited assistance of one staff member for bed mobility, transferring, walking in and out of her room, dressing, toilet use, and personal hygiene *She was frequently incontinent of bladder and always continent of bowel. *She was not at risk for developing pressure ulcers. *She did not have any current pressure ulcers. Interview on 1/8/19 at 10:27 a.m. with resident 39 revealed she had a sore on her bottom. She stated staff had put a dressing on it. She was unsure how long it had been there. She liked to sleep in her recliner and had requested the bed be removed from her room. Interview on 1/8/19 at 10:54 a.m. with performance improvement coordinator regarding resident 39 revealed: *She had noticed yesterday during her weekly skin check that her bottom had a red area. *She had an area that opened and closed frequently. *The area had not been opened yesterday but she had put a [MEDICATION NAME] dressing on for protection. *Resident 39 would sometimes refuse to attend activities or get out of her recliner which contributed to the area on her bottom being red. Review of resident 39's 12/27/18 care plan revealed: *She was at risk for skin breakdown. *The interventions had included: -Assist to the bathroom every 2 hours. -Incontinence standards of care. -Place a blue pad in her recliner at all times. -Gel cushion in (her) recliner. -Skin integrity standards of care. -Conduct a systemic skin inspection weekly. -Minimize skin exposure to moisture. -Use moisture barrier products after each incontinence episode. *There had been no interventions regarding: -Her refusal to go to activities or to get out of her recliner. -The current area on her bottom they were treating or the history of having pressure ulcers to her bottom. Interview on 1/9/19 at 1:24 p.m. with the DON regarding resident 39 revealed: *She had recently moved from the assisted living center due to incontinence issues. *She had issues with her bottom due to moisture and being incontinent. *She would refuse personal care at times but they had not care planned it. *The care plan had not included individuated interventions for her issue with her bottom. Review of the provider's 9/24/18 Care Planning Process policy revealed Each resident will have an individualized plan of care which addresses the resident's needs and severity of condition, impairment, disability, or disease and based on the universal care standards identified by the (provider name) staff as the minimum standards for all residents.

Based on observation, interview, and policy review, the provider failed to ensure medications were not disposed of in two of two sharps containers located on the short/new hallway and long hallway medication carts. Findings include: 1. Observation and interview on 1/9/19 at 10:33 a.m. with registered nurse A revealed: *The short/new hallway medication cart sharps container contained used needles and three pills. *The long hallway medication cart sharps container contained lancets and one pill. *The provider's policy was not to dispose of pills in the sharps containers. *She confirmed there were pills in the above sharps containers. *All pills should have been destroyed in the medication room using the medication destroyer solution. Interview on 1/9/19 at 1:20 p.m. with the assistant director of nursing/education coordinator regarding the destruction of medications revealed: *Pills should not be disposed of in the sharps container. *All medications should be placed in the medication destroyer solution. Observation and interview on 1/9/19 at 2:30 p.m. with the maintenance supervisor in the basement boiler room revealed: *The door leading into the boiler room was not locked. *There was a large red barrel with four sharps containers inside of it. *Two of the four sharps containers contained pills. *The maintenance staff had access to the boiler room. *They were doing construction on the building so the electricians had access to the room. *The unidentified sharps containers in the red barrel were from the nursing home, hospital, and clinic. Interview on 1/9/19 at 3:15 p.m. with the director of nursing revealed It was against their policy to have medications disposed of in the sharps containers. Review of the provider's 10/8/18 Destroying Medications policy revealed: *Medications are destroyed by placing them in the rx (medical prescription) destroyer bottle. *The rx destroyer is an irretrievable medicine disposal system. *All medication formulations, excluding [MEDICATION NAME] and antacids, may be placed in the rx destroyer bottle, including tablets, capsules, patches, liquids, creams, syringe contents, and controlled substances.

Based on observation and interview, the provider failed to ensure safe operation and monitoring of one of one oven in the memory care unit. Findings include: 1. Random observations from 1/7/19 through 1/9/19 in the memory care unit revealed on: *1/7/19 at 5:05 p.m. there was power to the oven and it was not being used. *1/8/19 at 10:31 a.m., at 11:08 a.m., and at 4:34 p.m. there was power to the oven and it was not being used. *1/9/19 at 9:02 a.m., at 10:57 a.m., and at 11:06 a.m. there was power to the oven and it was not being used. *No residents were observed near the oven or attempting to open it during the above times. Interview on 1/9/19 at 11:07 a.m. with unlicensed assistive personal (UAP) B revealed: *There was a switch for the power to be shut off to the oven. *There was a key to operate the switch for the power to the oven. *She did not know if the power was to be shut off when the oven was not in use. *She shut the power off to the oven at that time. 2. Observation on 1/9/19 from 8:28 a.m. through 8:50 a.m. revealed: *Four unidentified residents in the dining room with no staff supervision. *The oven was on and the temperature was set at 170 degrees Fahrenheit (F). *No residents were near the oven nor attempted to open it. Interview on 1/9/19 at 10:58 a.m. with UAP B revealed: *Hot breakfast was served from 7:00 a.m. through 9:00 a.m. *Hot food was kept in the oven which was set at 170 degrees F. *There was nothing to prevent the residents from opening the oven. *She stated she left the dining area when the oven was on and left the residents unattended. Interview on 1/9/19 at 2:31 p.m. with the certified dietary manager revealed: *Breakfast items in containers were placed in the oven at 7:00 a.m. by dietary staff. *Dietary staff left the breakfast items in the oven for memory care unit staff to serve until it was picked up by dietary staff at 9:00 a.m. *The oven temperature was set at 170 degrees F from 7:00 a.m. through 9:00 a.m. *The memory care unit staff turned on the oven every morning and set the temperature at 170 degrees F. Interview on 1/9/19 at 3:15 p.m. with the director of nursing revealed: *The oven did not lock. *She was not aware of a way to secure the oven to prevent residents from opening it when it was in use. *The oven should not have been unattended when residents were in the dining area and it was on. *There was no policy on stove/oven usage in the memory care unit.

Based on interview, record review, and policy review, the provider failed to ensure four of five falls had been thoroughly investigated for one of three sampled residents (2). Findings include: 1. Review of resident 2's medical record revealed: *His admitted was 5/27/14. *His [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Essential hypertension. -Heart failure. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Type 2 diabetes. *He had fallen on 8/25/18, 9/5/18, 10/9/18, 10/22/18, and 11/25/18. Review of resident 2's 12/29/18 Minimum Data Set assessment revealed: *His Brief Interview for Mental Status score was fifteen indicating his cognition was intact. *He had falls since his prior assessment. *He had two or more falls with injury. Review of resident 2's fall investigations revealed: *On 8/25/18 he had an unwitnessed fall in his room while attempting to reach a light above his bed. -He had an abrasion to the middle of his back. --There had been no documentation regarding the level of assistance he required, if his care plan had been followed, interventions in place at the time of the fall, or interventions added or changed after the fall. *On 10/9/18 he was found sitting on the floor in his bathroom. -A small abrasion was found on his right shin. --There had been no documentation regarding the level of assistance he required, if his care plan had been followed, interventions in place at the time of the fall, or interventions added or changed after the fall. *On 10/22/18 he was found on the ground in front of the facility. -He had a skin tear on his right elbow along with bruising and a small bump to the top of his head. -The care plan had been reviewed to say he was independent outside. --There had been no documentation regarding the sidewalk condition or where he fell off the curb or new interventions implemented to prevent future falls. --Many of the answers on the investigation form had not been answered and read No answer. *On 11/25/18 he had been found in his room kneeling on his left knee after he had called for help. -He had been attempting to reach the light above his bed and had not been close enough. --There had been no documentation regarding the level of assistance he required, if his care plan had been followed, interventions in place at the time of the fall, or interventions added or changed after the fall. --Many of the answers on the investigation form had not been answered and read No answer. Interview on 1/9/19 at 1:24 p.m. with the director of nursing regarding resident 2 revealed: *She had noticed all the No answers when she printed off the investigation forms for this surveyor. *The nurse should have been filling those in when she completed the form/report. *The falls team would meet to discuss the falls but they had not addressed the incomplete documentation on the forms. *After the falls on 8/25/18 and 11/25/18 when he had been reaching for the light above the bed they had not moved his bed or added a string to the cord to his light to prevent future falls. *She agreed the reports were not complete or thorough investigations. Review of the provider's 11/1/18 Post Fall Assessment policy revealed it had not addressed investigations for falls. Review of the provider's 11/11/16 Abuse Prevention Plan policy revealed: *It is the responsibility of the Director of Social Services to: -Conduct or delegate an internal investigation of any alleged mistreatment, neglect, or abuse. Document investigation on Safety Zone Portal. -Keep on file the investigative report of alleged mistreatment, neglect, or abuse and the physician documentation form. -Maintain a written log of investigation of events. *The policy had not addressed investigating falls specifically.

Based on observation, interview, record review, and policy review, the provider failed to ensure care plans were updated and revised to reflect residents current plan of care for: *Two of six sampled residents (1 and 7) for fall interventions. *One of three sampled residents (5) for admission and care in the memory care unit. Findings include: Surveyor: Surveyor: 1. Observation of resident 7 on 10/10/17 at 4:50 p.m. revealed she: *Was brought to the dining room in a high back wheel chair referred to as a Rock-N-Go chair with a tab alarm attached to chair. *Was pivot transferred with the assistance of one staff person to the dining room chair, the personal alarm was attached to the chair prior to the aide leaving her at the table to eat her meal. *Remained at the dining room table with her head down and eyes closed for the majority of the meal. *Was approached by the aide and awakened three times during the meal to provide her with cueing and encouraged her to eat and drink. Observation on 10/11/17 at 9:00 a.m. of resident 7 in her room revealed: *She was still sleeping in bed. *The bed was: -In the low position and positioned against the wall. -Had a fall mat on the floor next to the bed. Observation on 10/11/17 at 10:20 a.m., at 11:50 a.m., and at 4:30 p.m. of resident 7 when awake and out of bed revealed: *She was put in the Rock-N-Go chair. -The personal alarm was on the chair and fastened to her clothing. -She was able to self-propel herself with her legs when she was up in the chair. *Her bedside table was positioned in front of her when she was in her room. -Her personal items were on the table within reach. -The newspaper was on the table and opened for her to read. Review of resident 7's complete medical record revealed: *On 8/2/17 she was admitted from the assisted living facility due to needing more assistance with care. *The admission Minimum Data Set (MDS) assessment on 8/9/17 revealed a Brief Interview for Mental Status score of eleven indicating her cognitive status was moderately impaired. *On 9/26/17 she was started on [MEDICATION NAME] 25 milligrams (mg) twice a day. *On 10/9/17 the [MEDICATION NAME] dose was changed to 25 mg once a day at breakfast and 50 mg once a day at bedtime. *She had fourteen documented falls between 8/3/17 and 10/10/17. *There had been an investigation completed for each fall. *Interventions listed on the investigations had included: -Low bed with bed in the lowest position. -Personal alarm to bed. -Mat at bedside. -Personal alarm to chair. -Ensure all personal items are within reach. -Monitor frequently. -Ensure wheels to bed are locked at all times. --On 10/9/17 it was documented by the nurse supervisor the care plan was current to include alarms for safety, hourly monitoring, hi/low bed, and Rock-N-Go wheelchair. Review of resident 7's 8/2/17 care plan revealed: *She was at risk for falls. *She would remain free from falls with injury and show improvement in ability to perform activities of daily living (ADL). *She was not be rushed and to be allowed time to respond and complete tasks. *TABs alarm. Reminders to call for assistance. Keep lift chair control in the pocket at all times. Therapies and restorative as ordered. Review of nurse communication documents referred to as 7 day nurse sheet and communication book revealed resident 7: *Should have a motion alarm on while in bed. *Neurological checks. *It did not reveal the resident was on hourly monitoring. *It did not reveal she was to be moved to the assisted diners table. *It did not reveal she was to be up in Rock-N-Go chair. Review of resident comments document referred to as the pocket care plan revealed resident 7 required: *One assist with pivot transfers with walker to wheelchair. *Motion alarm on when in bed. *TABs alarm in R(NAME)K-N-GO chair and in recliner. *TABs alarm in bed. *DO NOT LEAVE UNATTENDED IN RESTROOM *It did not reveal she was on hourly monitoring. *It did not reveal she was to be at the assisted diners table. Interview on 10/11/17 at 10:15 a.m. with certified nursing assistant (CNA) C revealed resident 7 was: *More tired lately, and staff allowed her to sleep in. *Indicated as a fall risk by the red dot on her door. *Awake during the night and was having trouble with sleeping. *An assist of one staff person with use of a gait belt when ambulating in her room. *Using the Rock-N-Go chair for mobility outside of the room. Interview on 10/11/17 at 10:25 a.m. with CNA D revealed resident 7 was: *More alert today. *Not to be left alone when she was in the bathroom. Interview on 10/11/17 at 4:20 p.m. with registered nurse (RN) B revealed resident 7 had: *Been on neurological checks every shift related to a recent fall. *Had recent medication changes, so she was adjusting and seemed to be more tired. *Been allowing staff to perform care without being belligerent or combative. Interview on 10/12/17 at 8:40 a.m. with licensed practical nurse (LPN) A revealed: *Care plan changes or updated resident information was communicated through 7 day nurse sheet, communication book, report, and daily stand-up. *Report was taped so any information or changes that happened after report were wrote in the communication book. *Care plan changes were communicated to the unit secretary, and then she would make the changes to the pocket care plan. Interview on 10/12/17 at 1:15 p.m. with the director of nursing (DON) revealed: *Hourly monitoring was communicated to staff on the back of the resident's door. *Fall follow-up was documented on the pocket care plan (Resident Comments sheet) and communication book. *The pocket care plan did not reflect the hourly monitoring due to fear of it not being removed from the care plan, the hourly rounding schedule changes depended on the resident's need, and might sometimes only be ordered for twenty-four hours. *The care plan and pocket care plan went hand-in-hand. *Pocket care plans were sometimes updated two to three times a day by the unit secretary. *Met weekly on Tuesdays with the fall team to discuss previous weeks falls and what could be done differently. *Met monthly with a larger group and discussed falls from a facility-wide approach. Interview on 10/12/17 at 1:30 p.m. with the MDS coordinator regarding care plan review and revision revealed: *She met with the unit secretary weekly and was updated on changes to the pocket care plan and communicated changes to the CNAs during the stand-up meetings. *Care plans were revised per the MDS requirements (quarterly, annually, or significant change) otherwise as changes occurred. *She was not aware the care plan was not updated to reflect the need for the hi/low bed for resident 7. *She acknowledged she tried hard to keep the care plans current, but things did fall through the cracks. Surveyor: 2. Review of resident 1's medical record revealed: *She had ten documented falls between 8/1/17 and 10/12/17. *There had been an investigation completed for each fall. *Interventions listed on the investigations had included: -Hourly rounds. -Appropriate footwear. -Toileting program. -All personal items within reach. -Evaluate for environmental hazards and remove if present. -Monitor frequently. -Provide education to the resident/family. -Bed in the lowest position. -Sign placed on walker to remind her to use it. -Chair alarm on recliner. -Place resident in highly visible area when out of room. -Provide a constant observer. -Encourage participation in group restorative therapy. -Medication review by medical director. -Frequent reminders to use call light. -Tab alarm use in the dining room. Review of the revised 12/3/14 pocket care plan fall interventions for resident 1 revealed: *Toilet every two hours. *Tab alarm should be used in recliner and moved to dining room chair. *Walker should be beside the resident in the dining room. *Bed should be placed in low position with no mat. Review of the 9/21/17 care plan fall interventions for resident 1 revealed: *She was at risk of falls and at times would ambulate without her walker. *Care plan approaches included: -Provide environment free of clutter. -Medications as ordered. -Verbal reminders to use walker when ambulating. -Alarm in chair. -Bed in low position. -Follow restorative program. Interview on 10/12/17 at 1:45 p.m. with the DON revealed: *They had considered the pocket care plans to have been an extension of the care plan. *The pocket care plan would have been the useable document. *Some interventions had been temporary and should have been communicated with staff as to when to start and stop. -There was no policy or formal process to indicate how that was communicated with staff. *Interventions that would have been used for employees to care for resident 1 should have been on the pocket care plan and the care plan. *She agreed all current interventions were not listed on the pocket care plan or the care plan. 3. Observation on 10/10/17 at 4:35 p.m. of resident 5 revealed: *She resided in the memory care unit. *Redirection of coaxing, waiting, and distraction had been provided before she would accept her medications. Review of resident 5's medical record revealed: *She had a 3/11/15 physician's orders [REDACTED]. *She had a 5/27/15 physician's orders [REDACTED]. Review of resident 5's care plan revealed: *She had a 3/11/15 problem area identified as need for nursing home placement. *Memory care unit placement was not listed on the care plan. *Intervention methods for refusal of medication acceptance had not been listed on her care plan. Interview on 10/11/17 at 12:15 p.m., 10/11/17 at 4:15 p.m., and 10/12/17 at 8:50 a.m. with the licensed social worker revealed: *Resident 5 had needed a low stimuli environment. -She had benefited from a structured environment. *Memory care unit placement should have been listed on the care plan. *She agreed that interventions to effectively assist residents with behaviors should have been on the care plan. Surveyor: Surveyor: 4. Review of the provider's July 2017 Falls Prevention Program policy revealed: *Purpose was to reduce the incidence of falls and fall related injuries. *The program would include the identification of risk factors, resident and environmental assessment, interventions, fall prevention devices, and ongoing performance improvement. *Resident would be reassessed should the resident develop additional risk factors. *Each resident would have an individualized plan for prevention. Review of provider's June 2017 Care Planning Process policy revealed the care plan would identify individualized care and treatment goals during the care planning conference. *It would be revised as the resident's needs changed. *Specific care needs would be transferred to the CNA pocket care plan. *RN, social services, activities, and dietary would update the care plan at the time of notification of a change in condition, behavior, diet, or activity preference. *The MDS coordinator would oversee and ensure the completion of the care planning process and day-to-day updating of the care plan was completed. *Certified nursing assistants offered input regarding residents at the weekly stand-up meeting.

Based on observation, record review, interview, and policy review, the provider failed to follow the written menus portion sizes correctly at: *Two of three observed meals for all residents who were to have received regular portions of potatoes on oral diets. *One of three observed meals for all residents who were to have received fruit servings on oral diets. Findings include: 1. Observation and review of the written menu on 8/8/16 at the evening meal in the kitchen revealed cook E: *Served one-third cup of the mashed potatoes for all residents on regular portions who received the mashed potatoes. -The written menu for that item was to have been one-half cup for the regular/no added salt, reduced calorie, two gram sodium, consistent carbohydrate, heart healthy, liberalized renal, pureed, and mechanical soft diets. *The mashed potatoes serving size had not been followed and served per the written menu for Cycle: Pioneer Revised 3rd week Day Number:16. *At no time during the above serving of the meal was the written menu observed to be reviewed by cook E. 2. Observation and review of the written menu on 8/9/16 at the noon meal in the kitchen revealed cook F: *Served one-third cup of the mashed potatoes for all residents on regular portions who received the mashed potatoes. -The written menu for that item was to have been one-half cup for the regular/no added salt, reduced calorie, two gram sodium, consistent carbohydrate, heart healthy, pureed, and mechanical soft diets. *The mashed potatoe serving size had not been followed and served per the written menu for Cycle: Pioneer Revised 3rd week Day Number:17. *At no time during the above serving of the meal was the written menu observed to be reviewed by cook F. 3. Observation and review of the written menu on 8/9/16 at the evening meal in the kitchen revealed cook G who was training dietary assistant H revealed: *They served one-fourth cup of the fruit serving of cinnamon baked apple slices for all residents that received the fruit. -The written menu for that item was to have been one-half cup for the regular/no added salt, reduced calorie, two gram sodium, consistent carbohydrate, heart healthy, pureed, liberalized renal, and mechanical soft diets. *The fruit serving size had not been followed and served per the written menu for Cycle: Pioneer Revised 3rd week Day Number:17. *At no time during the above serving of the meal was the written menu observed to be reviewed by cook G and dietary assistant H. Interview on 8/9/16 at 4:50 p.m. with cook G regarding the serving of the above fruit portion revealed she always used the blue one (scoop) when she had served fruit portions to the residents. Interview on 8/9/16 at 5:00 p.m. with the dietary manager regarding the serving of the fruit portion revealed the above blue scoop was a one-fourth cup serving size. 4. Interview on 8/10/16 at 9:20 a.m. with the dietary manager and the consultant registered dietitian regarding the written menus portion sizes revealed they agreed and confirmed: *The written menu needed to have been followed for the correct food portion sizes to have been served. *Any deviation from the written menu for each resident needed to have been documented on the menu cards. *The portions had not been consistently served to those residents who received them. *That had been an area that needed improvement for the dietary staff to have followed the scoop serving sizes. *The menu needed to have been reviewed by the dietary staff for the correct serving size. Review of the provider's revised 4/9/14 Menu policy revealed the menu was to have been followed as written unless changes had been approved by the dietary manager.

Based on observation, interview, and record review, the provider failed to accurately assess and code a significant change in depressive symptoms for one of eight sampled residents (5) with depression. Findings include: 1. Observations on 8/9/16 at various times throughout the day from 8:10 a.m. through 5:00 p.m. of resident 5 revealed: *She spent her day primarily at meals or in her room. *She had a flat affect and did not respond to conversation with this surveyor. Review of resident 5's 4/23/16 quarterly Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BIMS) assessment score of 99, meaning she was unable to complete the interview. Per staff assessment she was moderately impaired. *A depression severity score of 9 which was mild depression. Review of resident 5's 7/16/16 annual MDS assessment revealed: *Her BIMS was unchanged. *Her depression severity score was now 20 which showed severe depression. *That was a significant change from the previous three months. Review of resident 5's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She was on medication to treat those issues. *Counseling had been tried in the past but was no longer effective. *There were activities and social services involvement. *Per nurses and physician's notes there had not been much change in her depression. *A 7/25/16 [MEDICAL CONDITION] drug review meeting note revealed no changes in her depression or treatment. -That meeting was held nine days after the significant change assessment. Interview on 8/9/16 at 2:10 p.m. with the director of nursing (DON) and the MDS coordinator regarding resident 5 revealed: *The physician had not increased her medication for depression because of excessive sleepiness. *Social services completed the MDS assessment portion for mood and behaviors that included an assessment of depression. *They were unaware there had been a significant change in resident 5's MDS coding for depression. Interview on 8/9/16 at 4:30 p.m. with licensed social worker (LSW) A regarding resident 5's MDS depression assessment revealed: *She thought they were currently doing all they could for her depression. *She was unaware of the significant change in assessment. *The other LSW who completed the assessment was not currently available. Interview on 8/10/16 at 10:45 a.m. with certified nurse practitioner D regarding resident 5 revealed: *She verified the medication had not been increased due to excessive sleepiness of the resident. *She had attended the 7/25/16 [MEDICAL CONDITION] drug review meeting. *She was unaware there had been any change in resident 5's depression and had thought it was better. Interview on 8/10/16 at 12:30 p.m. with the DON, MDS coordinator, and LSWs A and C regarding resident 5's significant change in her MDS depression severity score revealed: *LSW C completed the assessment based on the seven day lookback from staff. -She had missed the change and had not thought to look into it further by questioning the staff's assessment. *None of them had been aware of the significant change in the assessment. -Such a change should have been assessed for causes, and changes should have been made for the resident if needed. *They agreed that should have been looked into. *Per the DON they had no policy other than the MDS manual to address the above situation.

Preceptor: Based on observation, interview, record review, and policy review, the provider failed to ensure necessary treatment had been completed to prevent the development of a new pressure ulcer for one of three sampled residents (2) with pressure ulcers (an area of skin that breaks down when something keeps rubbing or pressing against it causing a sore). Findings include: 1. Interview on 11/19/13 at 8:15 a.m. with registered nurse (RN) A regarding resident 2 revealed when she had been asked how often he had an assessment done regarding his pressure ulcer care she had replied "We try once a week." Observation, interview, and record review on 11/19/13 from 9:52 a.m. through 10:15 a.m. with RN A regarding resident 2's pressure ulcer care revealed: *He had been wearing a Rooke boot (sheepskin boot used to protect the foot from pressure) on his left foot and a regular shoe on his right foot. *He had treatments ordered for two ulcerated areas: one had been on his left great toe and the other had been behind his left ankle. *RN A had removed a Band-Aid from his left great toe revealing a macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture) area. She had stated, "This is new." *She had applied [MEDICATION NAME] (an antiseptic) to his left great toe. *She had re-applied a Band-Aid to his left great toe. -The physician's orders [REDACTED]. *She had used paper tape to secure the foam dressing behind the left ankle. -The physician's orders [REDACTED]. *She had completed pressure ulcer care. *When asked why she had not performed her daily pressure ulcer assessment as ordered she stated "I usually do." *Review of the resident's record with RN A revealed: -Staff had initialed the treatment record indicating the assessment had been completed daily. -She had recorded that previously before she had actually performed the assessment. She had stated "I just do it even if I don't always complete it." -She agreed she should not have marked the resident's record if the assessment had not been completed. *When asked why she used a Band-Aid on the left great toe and paper tape behind the ankle instead of following orders she had replied "We change it sometimes." *She stated it had not been her usual practice to change the physician's orders [REDACTED]. *She agreed she should have followed physician's orders [REDACTED]. *When asked about the new pressure ulcer on resident 2's right great toe, she had stated: -She had not been aware of it. -The note documenting a new ulcer on his right great toe on 11/15/13 had been her signed progress note. -There had not been any assessment, intervention, or monitoring of the new ulcer. -The physician was "probably not" notified of the new ulcer. -Refer to F 157, finding 1. Interview and record review on 11/19/13 at 10:41 a.m. with the director of nursing (DON) regarding resident 2's new ulcer on his right great toe revealed: *The resident had been readmitted to the facility from the hospital on [DATE] after having had his left leg re-vascularized (surgical correction of absent or diminished blood flow to a limb.) *No ulcer on his right great toe had existed at the time of re-admission. *A new ulcer on his right great toe had been documented by RN A on 11/15/13. *RN A's responsibilities included completing skin/ulcer assessments on all residents in the facility. *An order to check feet and toes daily for sores, and keep pressure off the feet was listed on the treatment plan. -She agreed RN A should have not initialed the treatment record if an assessment had not been done. *an order for [REDACTED]. *He had been wearing a shoe on his right foot since re-admission from the hospital. *She had been unaware of the physician's orders [REDACTED]. *She agreed the care plan had not been individualized for the resident regarding his pressure ulcer care. Observation and interview on 11/19/13 at 2:00 p.m. through 2:15 p.m. with the DON regarding resident 2's new ulcer on his right great toe revealed: *A Band-Aid had been on his right great toe. *The toe had a stage 2 pressure ulcer (stage described a pressure ulcer where the skin was not intact.) The pressure ulcer had been approximately 1 centimeter (cm) in diameter on the tip of his toe. *The toe had been macerated. *She agreed the Band-Aid had caused the maceration since it had not been changed. *She agreed there had been no interventions, monitoring, or outcomes documented or completed by staff regarding that new pressure ulcer. Interview and record review on 11/19/13 at 4:00 p.m. with the DON regarding resident 2's new pressure ulcer revealed: *There had been an order written [REDACTED]. *After she had reviewed the above order she had stated "We caused this ulcer." *She had agreed the new pressure ulcer on the tip of his right great toe had been caused by: -Nursing staff not following physician's orders [REDACTED]. -RN A not reporting the new right great toe ulcer to the physician once it had been found. -Nursing staff not providing interventions for the above mentioned ulcer. Review of the provider's 3/22/10 Skin Integrity policy revealed it had not included notification of the physician. Review of the provider's undated Documentation policy # NH700, page 3, section C stated "Events are required for safety incidents and skin integrity conditions i.e. pressure sores. These events require creating an Event/Occurrence Report." No report had been created for resident 2.