Every finding on record at Princeton Health Care Center

Based on record review and staff interview, the facility failed to ensure water and other liquids consistent with residents' needs and preferences were provided at bedside. This failed practice had the potential to affect more than a limited number of residents.Resident Identifiers: #10, #13, #39, #49, #81, #103, and #113. Facility Census: 110. Findings included: a) On 02/02/26, Resident #103 had no drinks at bedside. The resident stated, I'm burning up. I need a drink. Please .I need a drink. On 02/02/26 at 03:20 PM, Licensed Practical Nurse (LPN) #87 confirmed the resident had no drinks at bedside and stated, I'll bring her a drink. Resident #10 had no water pitcher or [NAME] Cup at bedside. LPN #87 confirmed there were no drinks at the resident's bedside for the resident or the roommate and stated, I will get them drinks. At 01:00 PM , Nursing Assistant (NA) #9 confirmed there was no water or water pitcher at bedside and reported they would get the water in [NAME] Cups for the following residents: Resident #81 - No water/water pitcher only juice in Kennedy cup from lunch at bedside Resident #49 - No water/water pitcher, only juice in Kennedy cup from lunch at bedside.Resident #39 - No water/water pitcher or [NAME] Cup at bedside.Resident #13 - No water/water pitcher or [NAME] Cup at bedside.Resident #113 - No water/water pitcher or [NAME] Cup at bedside. Policy and Procedure for the Hydration Program stated, It is the policy of this facility to follow a hydration program to ensure each resident has sufficient fluid intake to maintain proper hydration and health. The policy and Procedure for Bedside Water Containers stated, The facility will provide patients/residents with fresh drinking water at their bedside daily.The Procedure included:Each patient/resident should have two complete water container sets for water at bedside.Night shift will be responsible for collecting used water containers and replacing clean water containers, filled with fresh water and ice on a daily basis.Soiled water containers will be taken to the food and nutrition services department dish room to be cleaned and sanitized the next day.Clean water containers will be returned to the unit the following day.Clean water containers will be stored inverted in a designated location until needed.This procedure is to be followed on a daily basis. On 02/03/2026 at 11:40 AM, the Dietary Manager (DM) reported the water pitchers are replaced and washed in the morning. Dietary delivers the clean pitchers in the early morning and staff distributes the ice/water. The DM reported they just put additional water pitchers out of storage to be washed and they have another box in storage. 2/03/2026 at 09:41 AM, the Administrator reported, We do a hydration pass twice a day.

Based on observation and staff interview the facility failed to maintain an infection control program to aid in preventing the spread of disease. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Facility census: 110. Findings Include: a) Resident hand hygiene An observation of the noon time meal on 02/02/25 being served on 300 hall, revealed that room [ROOM NUMBER] thru #306 were served their lunch tray and no hand hygiene had been performed on the residents before eating their meal. During an interview on 02/02/25 at 1:10 PM, Nursing Assistant (NA) # 35 stated, We usually do wash their hands, but no I did not do it today. Now the one I just served I was gonna wash hers at the sink Further observation showed that the resident's hands NA #35 was going to wash at the sink, and was sitting in bed with her tray in front of her. b) Hall 200 ice pass On 02/02/26 during Lunch tray pass the surveyor observed Nurse Aide#39 (NA) passing ice by using a clear cup to dip the ice from the pitcher and leaving the cup in the ice pitcher while serving. When asked by NA #39 if this is how they pass ice she stated this is how i normally do it. An interview on 02/02/26 at 12:30 PM with the Administrator was completed and the Administrator confirmed the cup being left in the ice pitcher was an infection control issue.

Based on observations, staff interviews, and record reviews, the facility failed to maintain accurate and complete clinical records related to treatment documentation for two (2) of two (2) resident reviewed for brace use and one (1) resident for weight documentation. This failed practice had the potential to affect more than a minimal number of residents during the long term care survey process. Resident Identifier: #92, #4, and #7. Facility census: 110a) Resident #7 On 02/05/26 at 10:25 AM, during the record review a weight was documented on 01/15/2026 for Resident #7 in the electronic medical record. Progress Notes dated 01/08/2025 and 01/19/2026 documented the resident had refused to be weighed in January 2026.The Dietary Manager (DM) confirmed the progress note with weight refusal and the documented weight logged in the resident's electronic medical record The DM reported the resident was marked as refused in her note and on her weight sheet. The DM stated, I don't know how they got that weight. I have on my copy and note he refused . Not sure why that weight is in there. On 02/05/2026 at 10:35 AM, the DM stated, I'm going to go strike it out because I don't know why it is in there.b) Resident #4The initial observation and interview with Resident #4 on 02/02/26 at 3:11PM, revealed that Resident #4 had a contracture to the left hand. Resident #4 stated, I am supposed to have a carrot, but they don't always put it on. My boot for my right leg is broken and they have to order a new one. They do help when they are put on.A review on 02/04/25 at 9:42 AM, revealed that Resident #4 had the following orders:Right podus boot be worn for up to 6 hours on day shiftapply carrot orthotic to left hand for contracture every day shift.Further record review of the Treatment Administration Record (TAR), revealed that both devices were marked off, as if they were applied.An observation on 02/04/25 at 10:14 AM, revealed that neither the carrot to the left hand or the podus boot to the right foot were on, although they were checked on the TAR that both devices were applied.02/04/2026 10:31 AM During an interview and observation, the Administrator confirmed that the podus boot or carrot was not on Resident #4 as ordered, and as documented on the TAR. c) Resident #92Record review completed on 02/04/26 identified a physician order directing staff to apply a brace to the resident's right upper extremity for six (6) hours during day shift. Review of the Treatment Administration Record (TAR) indicated the brace was documented as applied per order.Surveyor observation on 02/02/2026 at 11:00 AM (day shift) revealed Resident #92 was not wearing the ordered brace to the right lower extremity. Continued observation on 02/04/26 revealed the brace remained off and was not applied until surveyor intervention at approximately 1:30 PM. The TAR continued to reflect the brace had been applied during this time period. This was confirmed by the Administrator who was present at the time the treatment nurse placed the brace on Resident #92.

Based on record review, staff interview and observation, the facility failed to ensure dishes were cleaned under sanitary conditions in accordance with professional standards This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 110 Findings included: a) The following are general recommendations according to the U.S. Department of Health and Human Services, Public Health Services, FDA Food Code for each method. High Temperature Dishwasher (heat sanitization): Wash - 150-165 degrees F; Final Rinse - 180 degrees F. b) The facility's policy stated, The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. The procedure included, Prior to use, proper temperatures and/or chemical concentrations and machine function should be verified. c) At 02/04/2026 at approximately 10:00 AM, the dishwasher temperatures were were observed during three cycles. The temperatures for the wash cycle ranged from 160-162 degrees Fahrenheit and the rinse cycles 140-142 degrees Fahrenheit. The facility's dishwashing log notes: Corrective action must be taken if wash temperature does not reach 152 degrees Fahrenheit, or if rinse does not meet 182 degrees Fahrenheit. Dietary Aide #163 reported they did not know the temperature while washing the breakfast dishes. At 9:50 AM the Assistant Dietary Manger confirmed the temperatures and asked Dietary Aide # 63 to drain it and refill the dishwasher. The Assistant Dietary Manager reported they take the dishwasher temperatures at the end of all the dishwashing. On 02/04/2026 at 10:05 AM, the dishwashing temperatures were rechecked and were found to be within the acceptable range. The was temperature was 162 degrees Fahrenheit and the rinse temperature was 195 degrees Fahrenheit. The Assistant Dietary Manager stated they know what to do if it doesn't temp . Drain it, refill it and re-temp. The dishwashing temperatures were confirmed with the Administrator at 10:08 AM At 11:05 PM, the Administrator and Maintenance Director reported the gauge does not appear to be working correctly and they have emailed Ecolab to come out to fix the problem. Moisture was observed in the gauge.

Based on record review and staff interview, the facility failed to revise two (2) of 23 resident care plans when changes occurred. This deficient practice had the potential to affect two (2) of 23 residents reviewed in the long-term care survey sample. Resident Identifiers: #64 and #7. Facility Census: 110. Findings included: a) Resident #7 Resident #7's diet order stated, :Mechanical soft diet ground meats diet, Mechanical Soft texture, Nectar/Mildly Thick consistency two handled sip cup for sugar substitute. The resident's care plan stated, Mechanical soft ground meat nectar thick per order. and Staff to offer additional fluids such as jello, ice cream and popsicles. On 02/05/2026 at 10:47 AM, the Director of Nursing (DON) confirmed the care plan stated the resident was to have nectar thickened liquids, but additional fluids such as jello, ice cream and popsicles were recommended which are not considered thickened liquids. The DON confirmed the additional fluids were thinner than nectar consistency liquids, especially popsicles. According to the National Dysphagia Diet, a patient receiving thickened liquids must avoid foods that melt into thin liquids such as ice cream and gelatin. According to the International Dysphagia Diet Standardization Initiative. liquids that are not allowed with the classifications of thickened liquids included: thin liquids, ice cream, and gelatin. b) Resident #64 Review of Resident #64's electronic health record showed he experienced a fracture of the ankle upon which a walking boot was placed on 01/12/26. Review of Resident #64's comprehensive care plan showed the following focus, [Resident] has an ADL self-care performance deficit r/t [related to] Disease Process. On 01/15/26, the following intervention was initiated, Mobility: Ambulate times one assist with roller walker, wheelchair long distance. Further review of Resident #64's comprehensive care plan showed the following focus, [Resident] is at risk for falls r/t [related to] history of falls, medication use and impaired mobility. On 05/23/23, the following intervention was initiated, Ambulate independently with roller walker. On 02/05/26 at 10:46, the Administrator confirmed Resident #64's comprehensive care plan contained two (2) different interventions related to mobility.

Based on record review and staff interview, the facility failed to offer pneumococcal vaccines in accordance with professional standards of practice. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of immunizations. Resident Identifier: #7. Facility Census: 110. Findings included: a) Resident #7 The facility's policy titled, Pneumococcal Vaccine with effective date 01/01/17 and revision date 10/10/23 stated it was the facility's policy to offer residents immunizations in accordance with current Centers for Disease Control (CDC) guidelines and recommendations. The policy also included the following recommendations for adults aged over [AGE] years old who received both pneumococcal conjugate vaccine (PCV) 13 and pneumococcal polysaccharide vaccine (PPSV) 23, and the PPSV 23 was administered at age [AGE] or older, Together, with the patient, vaccine providers may choose to administer a single dose of PCV20 The interval should be five (5) years or more since the last PCV13 or last PPSV23 dose. These recommendations are also the current CDC recommendations, which are available on-ine. Review of Resident #7's electronic medical record showed the resident had received a PSV13 vaccination on 12/26/16 and a PPSV23 vaccination on 01/27/18. The resident is currently [AGE] years old. He had been a resident at the facility since 2022. The resident's medical records contained no documentation that a PCV20 vaccination had been considered for the resident. On 02/05/2026 at 9:38 AM, Registered Nurse (RN) #14 confirmed PCV20 vaccination had not been considered for the resident in accordance with the facility and CDC policies. He stated he would contact the resident's health care provider.

Based on observation, record review, staff interview and resident interview the facility failed to provide care and services in accordance with professional standards of practice, by not applying devices ordered by the physician. This failed practice was found true for (2) two of (2) two residents reviewed for position and mobility during the Long-Term Care Survey Process. Resident identifiers: #4, and #92. Facility census: 110. .Findings include: a) Resident #4 The initial observation and interview with Resident #4 on 02/02/26 at 3:11 PM, revealed that Resident #4 had a contracture to the left hand. Resident #4 stated, I am supposed to have a carrot, but they don't always put it on. My boot for my right leg is broken and they have to order a new one. They do help when they are put on. A review on 02/04/25 at 9:42 AM, revealed that Resident #4 had the following orders: Right podus boot be worn for up to 6 hours on day shift apply carrot orthotic to the left hand for contracture every day shift. Further record review of the Treatment Administration Record (TAR), revealed that both devices were marked off, as if they were applied. An observation on 02/04/25 at 10:14 AM, revealed that neither the carrot to the left hand or the podus boot to the right foot were on, although they were checked on the TAR that both devices were applied. 02/04/2026 10:31 AM During an interview and observation, the Administrator confirmed that the podus boot or carrot was not on Resident #4 as ordered, and as documented on the TAR. b) Resident #92 Record review identified a physician order directing staff to apply a brace to the resident's right lower extremity for six (6) hours during the day shift. Surveyor observation on 02/02/2026 (day shift) revealed Resident #92 was not wearing the ordered brace to the right lower extremity as directed. Continued observation revealed the brace remained off and was not applied until 02/04/2026, after surveyor intervention. The facility's failure to ensure implementation of the ordered brace had the potential to result in decreased therapeutic effectiveness, decline in range of motion, discomfort, and increased risk for contractures and skin integrity concerns for Resident #92.

Based on record review and staff interview, the facility failed to develop and implement a comprehensive, person-centered care plan that provided sufficient and specific instructions to guide staff in the use of a prescribed splint/brace for Resident #92. This was a random opportunity for discovery and had the potential to affect more than a minimal number of residents residing in the Long Term Care Facility. Resident identifier:#92 Facility Census: 110 Findings include:Record review completed on 02/04/26 of the Care Plan Report revised 01/23/2026 identified multiple interventions related to splint/brace use, including ~monitoring effectiveness~ provide Range of Motion (PROM)prior to application~ observing for redness or skin breakdown~ washing hands prior to application of a hand splint~ reporting concerns to nursing or restorative staff.Further record review revealed the care plan failed to identify the specific anatomical placement/location of the splint/brace.The lack of clear placement instructions resulted in incomplete guidance for staff responsible for implementing the care plan and created the potential for inconsistent application and ineffective use of the splint/brace.On 02/04/26 at approximatly 1:00 PM the Administrator confirmed the care plan was not accurate regarding where to place the splint/brace.

The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed practice included: the missed opportunity for hand hygiene was true for 29 of 193 documented hand hygiene observations made by the facility and for 1 (one) of 32 observations made during a medication pass for the medication administration portion of the long term survey process. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 114. Findings included: a) Facility On 05/07/24 at approximately 12:30 PM, a review of the facility Policy and Procedure titled, Infection Prevention and Control Program, section 4, Standard Precautions, dated 12/10/13 with a revision date of 05/18/23, noted the policy read, in part, Hand hygiene shall be performed in accordance with facility's established hand hygiene procedures. Further record review of the facility's Hand Hygiene Observation Tool for the months of February, March and April of 2024 revealed a total of 193 opportunities for hand hygiene with 29 missed opportunities indicating a no answer that hand hygiene was observed as performed. These missed opportunities were noted to occur on the following dates 02/12/24 02/14/24 02/22/24 03/01/24 03/12/24 03/19/24 03/22/24 04/04/24 04/05/24 04/06/24 04/24/24 04/29/24 During a staff interview conducted on 5/7/24 at 2:34 PM with the Infection Preventionist (IP), the IP stated There should be immediate education provided for all missed opportunities. When asked to provide documentation of education provided to the employees who had missed opportunities the IP acknowledged she was unable to provide proof that immediate education was performed.

Based on record review and staff interview, the facility failed to ensure residents were free from abuse which included misappropriation of medication. This was true for three (3) of three (3) residents reviewed during the survey. Resident identifiers: #10, #20, #81. Facility Census: 114. This will be cited as past non compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the of plan of correction were completed prior to this survey beginning. Findings included: a) Resident #10 Resident #10 had a narcotic medication borrowed for another resident five (5) times in the month of January, 2024. This was discovered when management performed an in house audit on 02/19/24. The facility reported it to the appropriate agencies on 02/19/24 and the five (5) day follow up was faxed on 02/22/24. The investigation started immediately on 02/19/24 at approximately 12:30 PM. A verbal and written statement was obtained from Licensed Practical Nurse (LPN) #104. The verbal statement relayed the nurse felt she had borrowed the medication for pain management and felt she had the best interest of the resident in pain at that time of judgement. The written statement states, I have borrowed medications in the past but have since been educated not to borrow any medications. On 02/19/24 Licensed Social Worker (LSW) #129 interviewed Resident #10. The resident was very pleasant, denies any needs and voiced no concerns. No mental anguish or distress noted during the visit. Education: A review of staff education was completed on 05/07/24 at approximately 09:00 AM. All staff signatures were obtained and included all employed nurses. The staff signatures were verified via the staff roster. System Change: New hires will be provided with education: Narcotics are not to be borrowed for any reasons. If a resident is scheduled a narcotic and you do not have it, first check with med dispense system. If the narcotic is not available in the med dispense then you are to contact pharmacy to see if they can send it or get it sent to back up pharmacy. If they are unable to send the narcotic from main pharmacy or to the back up pharmacy, you are to call the physician to see if there is another medication option available. If you are unable to get into the med dispense system you need to contact Staff Development Coordinator (name typed) to have him assist you. Please make sure to document every attempt to obtain the medication. An interview was conducted on 05/08/24 at approximately 10:00 AM with the Administrator and the Director of Nursing (DON). Both the Administrator and the DON confirmed the incident which involved Resident #10, #20 and #81 did happen as reported. The Administrator also stated Resident #10 did not miss any doses of her medication due to this finding. b) Resident #20 Resident #20 had a narcotic medication borrowed for another resident one (1) time in the month of July, 2023. This was discovered when management performed an in house audit on 02/19/24. The facility reported it to the appropriate agencies on 02/19/24 and the five (5) day follow up was faxed on 02/23/24. The investigation started immediately on 02/19/24 at approximately 12:30 PM. Two written statements were obtained from Licensed Practical Nurse (LPN) #63. They read (1) The reason a medication was borrowed due to the fact I was unable to obtain from pharmacy at time medication was dye because back up does not bring narcotics and was unable to obtain medication from med dispense due to med dispense not working correctly. (2) I did also receive education on not borrowing medications and correct way to obtain medications. On 02/19/24 Licensed Social Worker (LSW) #129 interviewed Resident #20. The resident was pleasantly confused, He was talkative but did nod off to sleep throughout the visit. Resident appeared to be comfortable by this LSW's observation. No needs voiced during visit. No mental anguish or distress noted. Education: A review of staff education was completed on 05/07/24 at approximately 09:00 AM. All staff signatures were obtained and included all employed nurses. The staff signatures were verified via the staff roster. System Change: New hires will be provided with education: Narcotics are not to be borrowed for any reasons. If a resident is scheduled a narcotic and you do not have it, first check with med dispense system. If the narcotic is not available in the med dispense then you are to contact pharmacy to see if they can send it or get it sent to back up pharmacy. If they are unable to send the narcotic from main pharmacy or to the back up pharmacy, you are to call the physician to see if there is another medication option available. If you are unable to get into the med dispense system you need to contact Staff Development Coordinator (name typed) to have him assist you. Please make sure to document every attempt to obtain the medication. An interview was conducted on 05/08/24 at approximately 10:00 AM with the Administrator and the Director of Nursing (DON). Both the Administrator and the DON confirmed the incident which involved Resident #10, #20 and #81 did happen as reported. The Administrator also stated Resident #20 did not miss any doses of her medication due to this finding. c) Resident #81 Resident #81 had a narcotic medication borrowed for another resident two (2) times in the month of January, 2024. This was discovered when management performed an in house audit on 02/19/24. The facility reported it to the appropriate agencies on 02/19/24 and the five (5) day follow up was faxed on 02/21/24. The investigation started immediately on 02/19/24 at approximately 12:30 PM. A verbal and written statement was obtained from Licensed Practical Nurse (LPN) #176. The verbal statement relayed the nurse felt she had borrowed the medication for pain management and felt she had the best interest of the resident in pain at that time of judgement. The written statement states, (Resident names) have the same order for (narcotic name). Medication would have been borrowed if (resident name) didn't have any left. Aware this is not the protocol, it is to look in the Pyxis, if there isn't any, contact Registered Nurse (RN) on call, then proceed to contact (Physician name) and pharmacy of needed. On 02/19/24 Licensed Social Worker (LSW) #129 interviewed Resident #81. The resident was friendly with LSW. She did not answer many questions asked except for ones she replied yeah to. Resident carrying what appeared to be some of her clothing. Was encouraged to rest and put clothing in her room. She did sit on bed and smiled at LSW. No needs acknowledge. No mental anguish or distress observed during visit. Education: A review of staff education was completed on 05/07/24 at approximately 09:00 AM. All staff signatures were obtained and included all employed nurses. The staff signatures were verified via the staff roster. System Change: New hires will be provided with education: Narcotics are not to be borrowed for any reasons. If a resident is scheduled a narcotic and you do not have it, first check with med dispense system. If the narcotic is not available in the med dispense then you are to contact pharmacy to see if they can send it or get it sent to back up pharmacy. If they are unable to send the narcotic from main pharmacy or to the back up pharmacy, you are to call the physician to see if there is another medication option available. If you are unable to get into the med dispense system you need to contact Staff Development Coordinator (name typed) to have him assist you. Please make sure to document every attempt to obtain the medication. An interview was conducted on 05/08/24 at approximately 10:00 AM with the Administrator and the Director of Nursing (DON). Both the Administrator and the DON confirmed the incident which involved Resident #10, #20 and #81 did happen as reported. The Administrator also stated Resident #81 did not miss any doses of his medication due to this finding.

Based on observation, medical record review and staff interview, the facility failed to revise the residents comprehensive care plan. Residents had one-on-one (1:1) interventions put in place without being care planned or being care planned timely. This was a random opportunity for discovery during the long term care survey process. Resident identifiers: #47, #75 and #101. Census: 114. Findings included: a) Resident #47 On 05/06/24 at 11:13 PM Resident #47 was observed to be sitting in her room with an apparent black eye. A staff member was observed at this time to be sitting in the room with the resident. On 05/07/24 at approximately 12:15 PM Resident #47 was observed to have a staff member sitting with her in her room. 05/07/24 at 07:45 PM during a medical record review, Resident #47 nursing note dated 05/03/24 identified that the resident had a fall as she was observed sitting in front of toilet in bathroom on floor, resident assessed for injuries noted to have skin tear to behind left ear and left side of face near chin, noted to have bump forming on top of left eyebrow noted to have purple coloring, resident started on neuro checks per facility protocol, vitals wnl. resident alarms in place and functioning. Resident denies any pain or discomfort. will continue to observe. On 05/07 at 08:00 PM during a medical review of the residents care plan for the focus it is noted that the resident is high risk for falls referenced to confusion, deconditioning and poor safety awareness. It also states that the resident often turns alarms off. The goal is identified for Resident #47 to be free of major injury through the review date of 07/31/24. Further review of the care plans, the intervention of a 1:1 sitter was not identified. On 05/08/24 at approximately 10:43 AM during an interview with the DON, she stated that Resident #47 has a 1:1 sitter as an intervention for her recent fall on 05/03/24. She further stated that the Interdisciplinary Team (IDT) determines if it is appropriate for the 1:1 sitter intervention and they did not get a physician order for this. The DON further agreed that the resident care plan does not include the 1:1 intervention and stated she would have that completed. 50552 b) Resident #75 During a facility tour on 05/06/24 at approximately 2:50 PM, it was noted Resident #75 had a Health Team Aide (HTA) sitting at her bedside. At that time, an interview with Resident #75 and the HTA #136 was conducted. HTA #136 revealed she was providing one on one care to Resident #75 and that a HTA sat with Resident #75 24 hours a day providing this service. When asked why, HTA #136 responded, I am not sure, I think she had a fall a while back. HTA #136 was unable to tell me when the one on one was initiated or how long it was to continue. Resident #75 was unable to provide further information. On 05/08/24 at 12:00 PM, a review of Resident #75 medical record was conducted revealing documentation of one on one care dating back to 09/18/23. Further review of Resident #75 record revealed a behavioral care plan with an intervention which read provide one to one observation as needed with an initiation date of 05/03/24. On 05/08/24 at 1:40 PM an interview with the Quality Assurance Nurse (QAN) was conducted. During this interview QAN acknowledged Resident #75's care plan had not been revised in a timely manner to reflect changes. 50801

Based on observation and staff interview, the facility failed to ensure the Daily Staffing Posting information was accurate and current. The Daily Staffing Posting Form was not posted in a prominent place readily accessible to residents and visitors; the Daily Staffing Posting Form did not accurately reflect the direct care staff; and the Daily Staffing Posting Form did not identify the actual number of staff and or the actual hours worked. This was identified during the long-term care survey process of reviewing the sufficient and competent nursing staff. This has the potential to affect potential to affect more than a limited number of residents and visitors. Identifiers: Accurate and current data of direct care, Accurate and current date of actual numbers of staff and or the actual hours worked; and the Daily Staffing Posting Form was not posted in a prominent place readily accessible to residents and visitors. Facility Census: 114. Findings included: a) Accurate and current data- direct care staff On 05/07/24 at approximately 10:15 AM during a review of the Daily Staffing Posting Forms with the Administrator it was identified that the total number of Registered Nurses (RN's) for direct care staff was more than one (1) eight (8) hour shift daily. The Administrator stated that the Registered Nurses with administrative duties are added to this number of RN direct care staff because they help with the floor staff throughout the day. The Labor Classification/ Job Title section of the Centers for Medicare & Medicaid Services- Electronic Staffing Data Submission- Payroll-Based Journal- Long-Term Care Facility- Policy Manual Version 2.6 was reviewed with the Administrator. This section defines that the Labor Classification/Job Title Reporting shall be based on the employee's primary role and their official categorical title. It is understood that most roles have a variety of non-primary duties that are conducted throughout the day (e.g., helping out others when needed). Facilities shall still report just the total hours of that employee based on their primary role. CMS recognizes that staff may completely shift primary roles in a given day. For example, a nurse who spends the first four hours of a shift as the unit manager, and the last four hours of a shift as a floor nurse. In these cases, facilities can change the designated job title and report four hours as a nurse with administrative duties, and four hours as a nurse (without administrative duties). The Administrator agreed that the RN staffing total and the RN total hours worked were not accurate. b) Accurate and current data-actual number of staff and staff hours worked. During a record review of the Staffing Posting Forms for 04/14/24, 04/21/24, 04/23/24, 05/01/24 and 05/04/24 and the Detail Hours Overview report of actual hours worked, the following staffing inaccuracies were identified; *04/14/24- -The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number of Certified Nursing Assistant (CNA) direct care staff was as nine (9) CNA and the total number of hours as 103.5. The Detail Hours Overview report identified the actual total number of CNA direct care was 10 and the actual total number of hours was 112.0. *04/21/24 -The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number of LPN hours was 64. The Detail Hours Overview report identified the actual total number of hours for LPN was 61.5. -The Daily Staffing form day shift 07:00 AM - 07:00 PM identified CNA total number of hours identified was 126.5. The Detail Hours Overview report identified the actual total number of hours was 135.75. *04/23/24 -The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number Registered Nurse (RN) staff was eight (8) and the total number of hours identified was 64. The Detail Hours Overview report identified the actual total number of RN staff was one (1) and the actual total hours was identified as 8 (eight). -The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number of LPN staff was eight (8) and the total number of hours identified was 56. The Detail Hours Overview report identified the actual total number of LPN staff was six (6) and the actual total hours was identified as 63.75. -The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number of CNA staff was eight (8) and the total number of hours identified was 134.5. The Details Hours Overview report identified the actual total number of CNA staff was 20 and the actual total hours was identified as 161.25. -The Daily Staffing form day shift 07:00 PM - 07:00 AM identified the total number of LPN staff was five (5) and the total number of hours identified was 52. The Detail Hours Overview report identified the actual total number of LPN staff was four (4) and the actual total hours was identified as 42.5. -The Daily Staffing form day shift 07:00 PM - 07:00 AM identified the total number of CNA staff was nine (9) and the total number of hours identified was 96. The Details Hours Overview report identified the actual total number of CNA staff was 10 and the actual total hours was identified as 116.75. *05/01/24 -The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number Registered Nurse (RN) staff was eight (8) and the total number of hours identified was 64. The Detail Hours Overview report identified the actual total number of RN staff was one (1) and the actual total hours was identified as eight (8). -The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number of LPN staff hours identified was 62. The Detail Hours Overview report identified the actual total number of LPN staff hours was identified as 64.75. -The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number of CNA staff was 22 and the total number of hours identified was 201. The Details Hours Overview report identified the actual total number of CNA staff was 22 and the actual total hours was identified as 209.25. -The Daily Staffing form day shift 07:00 PM - 07:00 AM identified the total number of LPN staff hours identified was 48. The Detail Hours Overview report identified the actual total number of LPN staff hours was identified as 46.25. -The Daily Staffing form day shift 07:00 PM - 07:00 AM identified the total number of CNA staff hours was 103.5. The Details Hours Overview report identified the actual total number of CNA staff hours was as 107. *05/04/24 -The Daily Staffing form day shift 07:00 AM - 07:00 PM identified the total number of CNA staff was nine (9) and the total number of hours identified was 103.5. The Details Hours Overview report identified the actual total number of CNA staff was 12 and the actual total hours was identified as 142.75. -The Daily Staffing form day shift 07:00 PM - 07:00 AM identified the total number of CNA staff was nine (9) and the total number of hours identified was 96.5. The Details Hours Overview report identified the actual total number of CNA staff was 10 and the actual total hours were identified as 114.75. On 05/08/24 at approximately 01:43 PM during an review of the inaccuracies of the Daily Staffing Form with the Administrator, she agreed that the Daily Staffing form reviewed did not reflect the total number of staff or the actual hours worked by the staff. c) Daily Staffing Posting Form not posted in a prominent place readily accessible to residents and visitors. On 05/08/24 at approximately 01:47 PM during an interview with the Administrator it was identified that the Daily Staffing Posting form was not posted in a prominent place readily accessible to residents and visitors. The Administrator agreed that the Daily Staffing Posting form is to be posted in a prominent place readily accessible to residents and visitors.

Based on observation and staff interview the facility failed to ensure cooking/serving pans were completely dry before storing them on the shelf wet nesting. Wet nesting occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow. Hot/Cold compress pack was stored in the resident pantry refrigerator where cold snacks are stored. This failed practice was found during the initial kitchen tour during the Long-Term Care Survey and had the potential to affect more than a minimal number of residents residing in the facility. Facility Census: 114 Findings Include: a) wet nesting During the initial Kitchen tour on 05/06/24 at 11:00AM with Certified Dietary Manager (CDM) #132 Pans were stacked under the counter, when one was pulled it was observed to be wet on the right side. CDM #123 confirmed staff should have ensured pans were dry before stacking and storing them. On 05/06/24 at 1:00 PM CDM provided educations signed by staff ensuring dishes are dry when putting them up. b) Hot/Cold compress in pantry refrigerator On 05/06/24 at approximately 12:30 PM during inspection of facility North Pantry surveyor observed in the freezer of the refrigerator a hot-cold pack with a resident's name and room number written on it. During interview with Licensed Practical Nurse (LPN) #22 on 05/06/24 at 12:33PM, LPN #22 confirmed the hot/cold pack should not be in the pantry freezer stating, oh no this should not be here, we have a fridge behind the nurses station for these.

The facility failed to create and sustain an environment that humanizes and individualizes each resident's quality of life as they were not provided a person-centered care to honor and support the residents individual preference, choices, values and beliefs. This was a random opportunity for discovery during the long term survey process. This had the ability to affect a limited number of resident's. Resident identifiers: #75, #47, #101. Facility census: 114. Findings include: a) During a facility tour on 05/06/24 at approximately 2:50 PM, it was noted Resident #75 had a Health Team Aide (HTA) sitting at her bedside. At that time, an interview with Resident #75 and the HTA #136 was conducted. HTA #136 revealed that she was providing one on one care to Resident #75 and that a HTA sat with Resident #75 24 hours a day providing this service. When asked why, HTA #136 responded, I am not sure, I think she had a fall a while back. HTA #136 was unable to tell me when the one on one was initiated or how long it was to continue. Resident #75 was unable to provide further information. On 05/08/24 at 12:00 PM, a review of Resident #75 medical record was conducted revealing documentation of one on one care dating back to 09/18/23, at which time she was noted to have had a fall. Resident #75 was sent to the hospital for evaluation after the fall with no injuries noted. Next, on 09/18/23 it was noted in a nurses note Resident #75 had a one on one sitter. A review of Resident #75's care plan for falls revealed no one on one sitter intervention initiated. However, a review of Resident #75's behavioral care plan revealed a one on one sitter intervention initiated on 05/03/24. Further review of Resident #75's physician's orders noted no physician's order for a one on one sitter. On 05/08/24 at approximately 10:43 AM during an interview with the DON, she stated Resident #75 has a one on one sitter as an intervention for her frequent falls. She further stated the Interdisciplinary Team (IDT) determines if it is appropriate for the one on one sitter intervention and they did not get a physician order for this nor does the facility have a policy related to this. When asked how the facility determines the length of time the one on one sitter intervention remains in place, the DON stated the IDT reviews each resident receiving one on one sitters to determine if the intervention is still appropriate, however they do not document this review. On 05/08/24 at approximately 11:45 AM an interview with the facility Social Worker (SW) was conducted. The SW verbalized she does not routinely assess the psychosocial well-being of residents receiving one on one sitters, stating There is no time frame set in stone, if they need something or there is a reportable I will assess them. The SW was unable to provide documentation she had assessed Resident #75's psychosocial well-being related to the one on one sitter. b) Resident #47 On 05/06/24 at 11:13 PM Resident #47 was observed to be sitting in her room with an apparent black eye. A staff member was observed at this time to be sitting in the room with the resident. On 05/07/24 at approximately 12:15 PM Resident #47 was observed to have a staff member sitting with her in her room. 05/07/24 at 07:45 PM during a medical record review, Resident #47 nursing note dated 05/03/24 identified that the resident had a fall as she was observed sitting in front of toilet in bathroom on floor, resident assessed for injuries noted to have skin tear to behind left ear and left side of face near chin, noted to have bump forming on top of left eyebrow noted to have purple coloring, resident started on neuro checks per facility protocol, vitals within normal limits. Resident alarms in place and functioning. Resident denies any pain or discomfort. will continue to observe. On 05/07 at 08:00 PM during a medical review of the residents care plan for the focus it is noted that the resident is high risk for falls referenced to confusion, reconditioning and poor safety awareness. It also states that the resident often turns alarms off. The goal is identified for Resident #47 to be free of major injury through the review date of 07/31/24. Further review of the care plans, the intervention of a 1:1 sitter was not identified. On 05/08/24 at approximately 10:43 AM during an interview with the DON, she stated that Resident #47 has a 1:1 sitter as an intervention for her recent fall on 05/03/24. She further stated that the Interdisciplinary Team (IDT) determines if it is appropriate for the 1:1 sitter intervention and they did not get a physician order for this. The DON further agreed that the resident care plan does not include the 1:1 intervention and stated she would have that completed. On 05/08/24 at approximately 11:15 AM during an interview with the DON, she stated that the IDT team had not met yet to discuss Resident #47's fall or the continued usage of the 1:1 sitter as a fall intervention. She further stated that they are scheduled to meet on 05/09/24. 50552 50801

Based on medical record review and staff interview the facility failed to ensure an informed consent was obtained for a psychotropic medication. This was true for one (1) of five (5) residents reviewed for unnecessary medication during the long term care survey. Resident identifier: #43 Census: 114. Findings included: a) Resident #43 On 05/07/24 at 12:50 PM during a medical record review for Resident #43, it was identified that the resident was prescribed aripiprazole 20 mg tablet for inappropriate sexual behaviors related to unspecified psychosis not due to a substance or known physiological condition. During this medical record review an informed consent for psychotropic medication use could not be identified for the use of aripiprazole 20 mg tablet. On 05/07/24 at approximately 2:45 PM during an interview with the Director of Nursing (DON), the DON agreed that the psychotropic medication aripiprazole 20 mg did not have an informed consent for psychotropic medication use and that she would have this corrected.

Based on observation and staff interviews the facility failed to provide a clean, comfortable, and homelike environment. A strong unpleasant odor was observed when entering a resident's room. This was a random opportunity for discovery during the long-term care survey process. Room Identifier: room [ROOM NUMBER]. Census: 114. Findings included: a) room [ROOM NUMBER] During a tour of the 200 hall on 05/06/24 at approximately 11:15 AM a strong unpleasant odor was observed when entering room [ROOM NUMBER]. During a tour of the 200 hall on 05/06/24 at 03:05 PM a strong unpleasant odor was again observed when entering room [ROOM NUMBER]. Licensed Practical Nurse (LPN) #91 was asked to help identify the odor in the room. LPN #91 stated that one of the residents will place her soiled undergarments in bags and put them in drawers and that may be what the smell is. She stated she would have the staff help check for what the odor is from and get it cleaned up. During a tour of the 200 hall on 05/07/24 at 09:06 AM a strong unpleasant odor was still present in room [ROOM NUMBER]. During an interview at this time with the DON, she agreed the room smelled bad and she would have someone come in to clean it. During an interview with the Administrator on 05/07/24 at 03:15 PM, she stated they had identified the smell to be coming from the packaged thermal air conditioner (PTAC) unit and was replacing the unit. During an interview with the Administrator on 05/08/24 at approximately 04:30 PM, she stated that the room still had a strong unpleasant odor and that they would continue to work on identifying the cause and correcting it.

The facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid. The PASARR was not resubmitted for residents with newly evident or possible serious mental disorder. This was true for two (2) of six (06) residents PASARR reviewed during the long term care process. This had the ability to affect a limited number of residents. Resident Identifier: Resident #67, Resident #80; Census: 114. Findings Included: a) Resident #67 During a medical record review on 05/07/24 at 11:02 AM for Resident #67, the PASARR was dated 05/04/22. Further record review of the residents diagnosis identified an updated diagnosis of delusions due to known physiological condition dated 5/06/22. No further PASARR's were identified to have been completed for this diagnosis dated 05/06/22. On 05/07/24 at 02:46 PM during an interview with Social Worker #129 she stated she did not have an updated PASARR for the diagnosis of delusions due to known physiological condition dated 5/06/22 and that she would need to complete one.

Based on observation and staff interview the facility failed to provide a dignified dining experience by not serving residents sitting together at the same time. This was a random opportunity for discovery and had the potential to affect a minimal number of residents in the facility. Facility Census: 114 Resident Identifiers: #14, #52, #106 Findings Include: On 05/08/24 at 12:20 PM in the South Dining room Resident #52 and #106 were observed setting together and Table one (1) and Resident #14 observed setting to herself at Table two (2). Further observation on 05/08/24 at 12:25 PM revealed Resident #52 was served first at table one (1) then Resident #14 was served at table two (2) at 12:26 PM. Resident #106 waited Three minutes at table one(1) while Resident #52 ate. Resident #106 was served at 12:29 PM. Staff interview was conducted on 05/08/24 at 12:33PM with Certified Nursing Assistant (CNA) #168 asking why Resident #14 was served before Resident #106 CNA #168 stated because there was a mix up with the ticket and did not want Resident #14's food to get cold. During Staff interview with the Administrator on 05/08/24 at 1:00 PM the Administrator confirmed Resident #106 should have been served with/after Resident #52 and not had to wait to be served while the other resident sitting at the same table ate their food.

Based on observation, record review and staff interview the facility failed to ensure residents' information was protected. This failed practice was found true for (1) one of (1) one resident looked at for privacy during the Long-Term Care Survey Process. Resident Identifiers #19. Facility Census 114. Findings include: a) Resident #19 An observation on 05/06/24 at 11:15 AM, found a sign posted behind Resident #19's bed that read: (Resident # 19 name) has an allergy to Latex.} Further observation found that the sign was visible from the hallway when the door and curtain were open. A record review on 05/08/24 at 1:00 PM, revealed that Resident #19 was in fact allergic to Latex. On 05/08/24 at 2:30 PM, a review of the facilities policy titled {Confidentiality of Personal and Medical Records}, number (8) eight reads: Paper notes or reminders with resident's personal or medical information shall not be left unattended or viewable by unauthorized persons. During an interview on 05/08/24 at 4:00 PM, the Administrator confirmed that the sign infringed on Resident #19's privacy.

Based on Record review and staff interview the facility failed to notify the Ombudsman of resident #45's discharge to the hospital.This was true for one (1) of one(1) residents reviewed for the carrier of hospitalization . Resident identifier; #45. Facility census: 114. Findings include: A) Resident #45 A record review found The resident was discharged to the hospital 12/06/2024 at 12:48 pm. Interviewed Social Worker on 05/06/2024 to ask if the ombudsman was notified of resident discharge to the hospital and she said yes but could not provide verification of that notification.

Based on observation, record review, review of the Centers for Medicare and Medicaid Services Appendix PP State Operations Manual and staff interview the facility failed to ensure all residents were free from verbal and physical abuse from other residents. Resident #110, Resident #93, and Resident #105 have been identified as residents who have on several occasions demonstrated verbally and physically abusive behaviors towards other residents residing on the south wing of the facility. These incidents have been ongoing at least since at least 08/2018. The facility has not demonstrated that they provided enough protection to prevent resident to resident abuse and to protect the other residents currently residing on the south wing of the facility. Residents residing on the south unit have voiced fear of resident #110 and Resident #93 one resident has voiced that he is to fearful to sit in the hallway. Resident #24 was fearful of resident #110 and was afraid he was going to sexually assault her the facility failed to address this fear and failed to make this resident feel safe while residing in the facility. The facility has put into place interventions of redirection and medication changes, but the residents behaviors of physical and verbal abuse continue indicating the interventions have not been successful in changing the residents behavior and/or protecting the other residents residing on the South Wing. These failures have placed all residents currently residing on the South Wing of the facility at an immediate risk for serious harm. The facility was notified of the Immediate Jeopardy on 11/07/18 at 2:56 p.m. The facility submitted a plan of correction to the state agency at 4:52 p.m. on 11/07/18. The plan of correction was accepted by the state agency at 5:18 p.m. on 11/07/18. The state agency observed for implementation of the accepted plan of correction and the Immediate Jeopardy was abated at 6:58 p.m. on 11/07/18. Once the immediate jeopardy was abated a deficient practice remained and the scope and severity was decreased from a K to an E. A deficient practice remained for Resident #78 because the facility failed to address an allegation of possible alleged abuse from another resident. For Resident #85 the facility failed to ensure this wandering resident was supervised to prevent resident to resident abuse from other residents directed toward this resident. These failures have the potential to effect more than an isolated number of residents. Resident Identifiers: #110, #105, #93, #24, #78 and #85. Facility Census: 115. Findings include: a) Resident #110 Observations of Resident #110 at 11:00 a.m. on 11/05/18 found him entering the Room of Resident #60. The resident was in bed and she had visitor. Resident #110 began cursing Resident #60's visitor and waving his arms in the air. The surveyor alerted staff that this visitor needed some help. The staff intervened and removed Resident #110 from Resident #60's room. At 11:05 a.m. on 11/05/18 this surveyor entered the room of Resident #60 to speak with her visitor. During the interview with Resident #60's visitor Resident #110 returned to the room and again began cursing at this surveyor and Resident #60's visitor. He stated, You all are a bunch of God Damn idiots . I am going to [***] ing die . This is stupid God Damn[***]and you need to [***] ing die. Resident #110 was waving his arms in the air as he screamed the above statements. After about three (3) minutes staff came and again removed Resident #110 from Resident #60's room. Resident #60's visitor indicated this was the first time she had ever seen this gentleman, but he was obviously not happy. A review of Resident #110's incident reports regarding his behavior toward other residents at 12:00 p.m. on 11/06/18 found the following occasions where Resident #110 was in a resident to resident altercation: -- 07/07/18 - Resident #110 and Resident #80 (roommates at the time) got into a fight and Resident #80 received a bruise to top of his right hand and a laceration to his lip. No injuries were noted to Resident #110 and the staff indicated they would continue to monitor for other behavioral episodes. -- 08/28/18 - Resident #110 and nurse were walking down the hallway when Resident #98 who was standing at the nurses' station began yelling and pointing at Resident #110 stating that he had pushed him down. Resident #110 shouted back, You are damn right I did and I will do it again you stupid nigger. Resident #98 was assessed to have an 8 by 5 centimeter abrasion to his left side. Review of the progress notes beginning on 09/01/18 through present at 10:30 a.m. on 11/07/18 found the following notes concerning resident to resident incidents: -- 09/21/18 at 4:32 a.m. - Resident extremely agitated at beginning of shift. Every attempt to redirect was unsuccessful and resident became combative. Resident was given a sandwich for snack with a drink. Played music that resident likes but would not calm down. Resident is confused to the point of no talking down or redirecting. Resident began arguing and getting in the face of other residents. Both nurses attempted to just let resident walk freely and calm down but was unsuccessful. Unable to pass medication due to resident up on cart so close yelling in our faces. When asked to please back up resident would curse and throw things. Called (name of attending physician) at 9:45 p.m. to ask for orders. (Name of attending) physician ordered [MEDICATION NAME] 1 mg (by mouth) PO as a one time order. After resident was administered the [MEDICATION NAME] 1 mg the resident calmed down over the next 30 minutes and this nurse was able to get him to lay down and resident was cooperative. Resident rested throughout the remaining of the night with eyes closed. -- 09/23/18 10:39 p.m. - Resident came down 300 hall during my med pass and was going into other residents room yelling and cursing at them. When trying to redirect resident her cursed at me and smacked my arm. He continued to bother two (2) female residents that were standing in the hallway. I told the two female residents to return to their rooms and shut the door. (First name of Resident #110) could not be redirected. -- 09/23/18 11:02 p.m. Resident had medication at 8:00 p.m. Attempted to help resident to bed at 9:00 p.m. Resident got up shortly after and wandered down 300 hall. Went in several rooms and they would scream for him to get out and he would then get in their faces and when we got to the room he was cursing and drawing his fist back to hit a female resident. Resident was redirected but was only able to get him out of the side of the room where the woman was. Resident then grabbed this nurse and (First and Last Name of NA #102) and pushed us down and was punching us. NA (First and Last Name of NA # 118) came in room and resident also punched her and grabbed her arms while cursing and being out of control. Once Resident wandered down the hall this nurse told 1 CNA to stay on hall and 1 cna to close the fire doors and stay there until able to call (name of attending physician) for orders. (Name of attending physician) order to send resident out to the emergency room -- 10/10/18 10:33 p.m. - During HS med pass resident came up to this nurse and was very agitated resident yelling no you stupid [***] go [***] yourself, I offered resident a snack and that calmed him down for a while but resident began pacing up and down the hallway. I asked resident what was wrong and he said you don't know anything you [***] . Resident going by other residents doorways and hollering stupid [***] . Attempted to redirect resident without success. Will continue to monitor for behaviors. -- 10/21/18 at 8:40 a.m. Resident was visited in the South Lounge for P[NAME] (plan of care) assessment. He was reading (name of newspaper) and was able to identify orientation questions from this paper. Resident was friendly throughout assessment, but stated that he was mad at a peer. He pointed several times at different residents and said that he could blow them up with a airplane. Resident was redirected and completed the assessment. Resident scored an 11/15 (11 of 15) on his BIMS (Brief Interview for Mental Status)., and endorsed trouble sleeping and feeling tired at times. -- 10/30/18 12:39 a.m. - Resident entered into a verbal argument after wandering into another residents room. This nurse intervened and redirected both residents. Resident easily redirected. Will continue to monitor. Review of Resident #110's care plan found the following Problem statement: (First Name of Resident #110) has delusions of combat related to heavy drinking while watching war movies per family. He is aggressive with staff and other residents with delusions of people trying to kill him. The goal statement associated with this problem was: (First name of Resident #110) will not obtain any major injury. Target date of 01/23/19. Interventions related to this problem and goal statement included: -- Provide diversion activities for (First name of Resident #110). Added on 07/05/18. -- Approach (First name of Resident #110) positively and in calm, accepting manner. Added on 07/05/18. -- Assign staff to account for (First name of Resident #110) whereabouts throughout the day. Added on 07/05/18. -- Monitor and document (First name of Resident #110) behavior. Added on 07/05/18. -- Redirected (First name of Resident #110) to room or lounge when laying in inappropriate areas. Added on 07/05/18. -- Do not play war movies on lounge TV with (First name of Resident #110) in attendance. Added on 07/05/18 -- Send to emergency room . Added on 08/28/18 -- Redirect (First name of Resident #110) to a calm and quiet environment. Added on 08/28/18. -- Send to ER [DATE] for evaluations due to combative behaviors. Added on 09/21/18. -- Will see in house psychiatrist next visit. Added on 09/24/18. A review of Resident #110's Minimum Data Set (MDS) assessments with assessment reference dates of 07/19/18 and 10/18/18 found resident had Physical behavioral symptoms towards others 1 to 3 days during the seven day look back period. The MDS also indicated Resident #110 had verbal behavioral symptoms directed toward others 4 to 6 days during the look back period. These findings were discussed during an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) beginning at 1:14 p.m. and concluding at 1:41 p.m. The NHA stated that she would put together a time line to show what interventions they had put into place for Resident #110. Later that afternoon the NHA provided the following time line regarding Resident #110's behaviors and the facility's interventions. The NHA provided a time line to show what they had done for this resident to keep other residents safe: --08/13/18 redirection with music behind nurses station with staff --08/18/18 redirected and relaxed with music --08/18/18 redirected and resident to bed resting --08/21/18 successfully redirected by staff. --08/28/18 out to ER they gave him [MEDICATION NAME] and then he returned to us --08/29/18 [MEDICATION NAME] was increased by Dr. --09/20/18 Ordered one-time [MEDICATION NAME] --09/21/81 redirected successfully with food and music later [MEDICATION NAME] order changed, and [MEDICATION NAME] ordered. --09/23/18 TO (name of local hospital) ER and returned --10/02/18 redirected to his room and then rested quietly (nursing note for this date says redirection was not successful.) --10/03/18 redirected through change in environment. --10/10/18 Gave snacks and he calmed down --10/30/18 redirected Upon reviewing the in house psychiatrist schedule, Resident #110 had been placed on his list to be seen when he rounds here at the facility. Care plan interventions include: diversional activities, naps rest periods, snacks, meds as ordered, approach calmly, psych consult scheduled. Review of the in-house psychiatrist's visits to facility found visits occurred on 08/25/18, 09/15/18, and 10/27/18, but there was no evidence Resident #110 was seen. The list also indicated the resident was to be seen because he had [MEDICAL CONDITION] (post-traumatic stress disorder) and unable to redirect combative with staff and residents. A care plan intervention was added on 09/24/18 indicating the resident would be seen by the in-house psychiatrist on the next visit which would have been 10/27/18 but Resident #110 was not seen and he continued to have verbally and physically abusive behaviors. During an interview with Resident #24 on 11/05/18 at 1:33 P.M., she said a male resident (she was referring to Resident #110) came into her room and told her he was going to rape her. That really scared her. Further investigation found a nurse's note, dated 09/22/18 at 11:43 PM confirmed Resident #24's statement. The note included, Resident stated that (Resident #110's name) came into her room and stated that he was going to kill her and he wanted to have sex with her. She stated that she came to the facility to be safe and is now scared. Resident was assured that she is safe. No further investigation could be found as to the circumstances before, during or after the alleged incident occurred. The author of the nursing note was unavailable for contact. During an interview on 11/05/18 at 11:46 AM, Resident #80 stated, (Resident #110) wants to fight me .he makes fun of me and makes faces at me .he tries to get a rise out of me. When asked if he participated in facility activities, Resident #80 stated, I have to stay in my room . otherwise I would have a chair in the hallway. Resident #80 stated Resident #110 had never touched him. When asked if he was afraid of Resident #110, Resident #80 stated, You never know what is going to happen. During the Resident Council meeting on 11/06/18 at 11:05 AM, Resident #80 said Resident #110 and Resident #93 .are bad and makes it where they can't come out of room. Resident #80 stated they had reported it to nurses and they did nothing. Resident #80 stated Resident #83 beat him in the head. Resident #80 stated. when the two of them are together they are really bad. He said, They terrorize us. Resident #24 stated Residents #110 and #93 came in her in her room and would not leave. Resident #110 had told Resident #93 to hold the door closed, she said that she had to fight him, while Resident #93 was holding the door closed. She was pulling on the door and yelling for help, finally the workers came. They told her they had to pull Resident #93's hand off the door to help her. Another time Resident #110 also brought a blanket in her room and said he wanted to have sex with her and she said no and yelled for him to leave her room. He also was in her bed sleeping one day and when she told the staff, they told her to let him sleep he will get up when he wakes up. Resident #24 also stated that Resident #110 was beating Resident #62 and she and another male resident had to get him away from her. They took Resident #62 up to the offices by the lounge and when they reported it to staff, staff just said, Well he doesn't know what he is doing and told him to apologize. Resident #24 commented, (Name of Resident #110) is a big guy and he scares me. During an interview with Resident #78 on 11/06/18 at 11:14 a.m., she said Resident #110 was in her bed two times, she too was told that when he wakes up he will leave. She also stated that other residents just wander in and out of her home all the time. South wing Activities Director #105 was asked whether residents had come to her office and reported to her about Resident #110 hitting Resident #62. She said, These residents have dementia, so they are very forgetful and are not always reliable. She asked if this surveyor was familiar with caring for those with Dementia. On 11/08/18 after the notification of the Immediate Jeopardy on 11/07/18 Resident #110 was sent to see the in-house psychiatrist at his office in the community. The psychiatrist admitted Resident #110 to a psychiatric unit for medication stabilization on 11/08/18. At the time of exit on 11/12/18 at 5:00 p.m. no further information was provided regarding the management of Resident #110's behaviors. b) Resident #105 A review of Resident #105's incident reports at 12:00 p.m. on 11/07/18 found the following incidents which involved a resident to resident altercation (Resident identifier numbers have been substituted for residents' names and room numbers designated as XXX for confidentiality): -- 08/03/18 - Resident #105 gently slapped other resident with open hand. Resident #105 was very difficult to redirect. Combative with staff and cursing other residents. Resident redirected to her room. (Please note other resident not identified by facility) -- 08/19/18 4:40 p.m. - called to hallway in front of room XXX. Resident #105 smacked Resident #102 on the right hand. No injuries. Residents separated and redirected. -- 09/03/18 9:20 p.m. - Heard yelling from room XXX. Upon entering the room staff witnessed Resident #105 slap Resident #93 across the right cheek and was cursing at him. Resident #93 then in turn slapped Resident #105 across both her cheeks. -- 10/22/18 6:30 p.m. - Resident #105 and Resident #112 were overheard yelling at each other. Resident #105 was slapping Resident #112 in the face. Other resident attempted to kick Resident #105 but missed. -- 10/23/18 1:15 p.m. - Therapy staff observed Resident #105 go into Resident #112's room. Resident #112 asked Resident #105 to leave and Resident #105 became angry and slapped Resident #112 with an open hand across the face and grabbed the resident's left arm. Review of Resident #105's nursing notes found the following additional occasions when Resident #105 was involved in a verbal or physical altercation with other residents: -- 09/01/18 at 6:19 p.m. - according to Resident #98, Resident #105 entered his room and hit him in the stomach and scratched his left upper cheek and behind his left ear, and his left upper lip. Following that Resident #98 punched Resident #105 in the lower left jaw. Resident #105 then began to curse Resident #98. The housekeeper overheard and entered the room to separate the residents. -- 09/11/18 at 12:59 a.m. - Heard yelling coming from room XXX. Upon entering witnessed staff attempting to redirect 2 residents who were yelling at one another. The nurse redirected the other resident in one direction while staff redirected Resident #105 in the opposite direction. After talking to staff it was told to this nurse that Resident #105 had slapped the resident on the right cheek and was cursing him. Following her slap the other resident then slapped her on both cheeks. No injuries noted. -- 09/29/18 12:30 a.m. - Earlier this shift resident was loud. Yelling at other residents to get out of her room and she was in theirs. Resident easily redirected by staff. At time Resident was observed striking out at staff and other residents. No physical contact was made. -- 10/04/18 3:43 p.m. - Resident has been in an up and down mood today. One minute she will be happy and then the next moment the resident is heard down the hall saying you're a whore, growling at people, and hitting people. Resident has been easily redirected each time by different staff members. -- 10/03/18 6:20 a.m. - Resident has been wandering in and out of rooms this AM (morning). Resident repeatedly lying people are in her bed. Resident pointed to another residents room and said she was going to knock the hell out of them and show them what she was made of. Resident was redirected to her room and explained to her that other residents were not in her room. Resident was laying in bed with eyes closed at this time. -- 10/17/18 at 4:27 p.m. - Resident has been resting in bed most of shift. This am (morning) at breakfast this resident began yelling at the resident across the table at her. When staff went intervene resident stood up and started yelling at staff and hitting them and continued to yell at the other resident . -- 10/26/18 12:12 a.m. - Resident #105 wandered into another residents room and got in verbal altercation with that resident. Easily redirected. No complaints voiced -- 10/30/18 6:10 p.m. - Resident #105 out in the hallway and got into a verbal altercation with another resident when this resident attempted to go into that residents room. The resident began yelling that she was going to kill that [***] . When attempting to redirect Resident #105 began hitting and pulling this nurse's hair. A review of Resident #105's care plan found statement of: (First Name of Resident #105) displays physically aggressive behavior. The goal associated with this care plan was: (First name of Resident #105) displays physically aggressive behavior. This goal had a target date of 01/23/19. The interventions related to this problem and goal included: -- Social Services to evaluate and visit with (First name of Resident #105). Added on 08/08/18. -- Activities staff to visit with (First name of Resident #105) and provide diversional activities. Added on 08/08/18. -- Monitor and document (First name of Resident #105)'s behavior. Added on 08/08/18. -- Do not argue with (First name of Resident #105). Added on 08/08/18. -- Identify causes for behavior and reduce factors that may provoke (First name of Resident #105). Added on 08/08/18 -- Praise (First name of Resident #105) for demonstrating desired behavior. Added on 08/08/18. -- Talk with (First name of Resident #105) in calm voice when behavior is disruptive. Added on 08/08/18. -- Remove (First name of Resident #105) from public area when behavior is disruptive and unacceptable. Added on 08/08/18. -- Encourage responsible party/family to visit with (First name of Resident #105). Added on 08/18/18. -- Redirect (First name of Resident #105) when she is intrusive to other residents space. Added on 08/20/18. -- Encourage staff to spend time with (First name of Resident #105) to feel comfortable. Added on 09/14/18. -- Apply stop sign to door. Added on 09/12/18. -- When resistant to care provide (First name of Resident #105) with positive distractions. Added on 10/16/18. -- Try to identify triggers that cause behaviors. Added on 10/23/18. A review of Resident #105's Minimum Data Set (MDS) assessment with assessment reference dates (ARD) of 07/10/18 and 10/15/18 found Resident #105 had verbal and physical behaviors directed toward others one (1) to three (3) days during each look back period. During an interview with the Administrator (NHA) and the Director of Nursing (DON) beginning at 1:14 p.m. and concluding at 1:41 p.m. on 11/06/18, these findings were discussed. The NHA stated that she would put together a time line to show what interventions they had put into place for Resident #105. The following morning, on 11/07/18, the NHA provided a time line to show what they had done for this resident to keep other residents safe. The following is the timeline provided typed as written: -- 08/03/18 redirected. -- 08/05/18 redirected. -- 08/10/18 redirected. -- 08/17/18 redirected and snacks provided. -- 08/19/18 redirected. -- 08/22/18 permission to see psychiatrist obtained. -- 08/25/18 seen by (Name of in-house psychiatrist). No new medication changes. -- 08/30/18 redirected encouraged rest period. -- 09/01/18 redirected. -- 09/04/18 redirected, monitored, praise family was called and asked them to come and visit. -- 09/06/18 redirected to room, staff member sat with resident until she fell asleep. -- 09/09/18 seen by MD. No new orders offered snacks and provided rest period. -- 09/11/18 redirected. -- 09/12/18 spoke with RP (responsible party) about hearing aide declined. -- 09/12/18 applied stop sign to door. -- 09/29/18 redirected. -- 10/03/18 redirection and encouraged rest period. -- 10/15/18 used music for redirection and rest period. -- 10/16/18 environmental change. -- 10/23/18 snack/redirection. -- 10/27/18 saw (Name of in house psychiatrist) again and increase [MEDICATION NAME]. -- Care planned interventions include: activities, attempts to identify cause of agitation, calm approach, praise, change environment when needed, encourage family visits, psych consult, stop sign on door and med's as ordered. -- Med's include: [MEDICATION NAME], and [MEDICATION NAME]. Review of Resident #105's medications found she was started on [MEDICATION NAME] 125 mg by mouth twice a day on 10/27/18. Resident was started on [MEDICATION NAME] 25 mg twice a day and [MEDICATION NAME] 40 mg once daily beginning on 07/10/18, the date of her admission. Resident #105 received the [MEDICATION NAME] for a [DIAGNOSES REDACTED]. There was no evidence in the medical record that these medications were ever reviewed for effectiveness in controlling the residents behaviors. At the time of exit on 11/12/18 at 5:00 p.m. no further information was provided. c) Resident #93 Abuse During record review of nurses notes in the electronic chart the following notes were as listed below. On 4/19/18 at 6:19 AM Nursing notes, Resident # 93 agitated after Nursing Assistance NA dressed him this am. Afterwards he would run up to her and telling her he was going to beat the[***]out of her with his fist drawn back. Resident did this three times. On 4/19/18 at 1:38 PM, states Resident # 93 will ambulate to his desired location. He does need direction to his room at time. He is usually pleasant. Neither staff nor Resident have voiced any problems in room or roommate. by Social Services (SS) Emily Cozort On 5/07/18 at 8:34 PM, Resident # 93 grabbed a black marker from the nurse and went to a resident being fed, raised the marker above her head. As the nurse went to take the marker away for him he took his right elbow and rammed it into the nurses left breast then immediately hit the nurse in the right jaw with his fist with great force. On 5/ 8/18 at 3:43 PM, Resident # 93 was combative pouring his water on the floor chewing up his meds and spiting them on the floor. On 5/12/18 at 6:57 PM, Resident # 93 had struck another resident in the dining room. Unable to redirect Resident was immediately removed from the dining room, he was cursing and saying I will kill them Let me at em right now Registered Nurse (RN) in charge was notified and decision was made to send to the ER for evaluation. On 5/17/18 at 4:33 Pm Resident # 93 agitated wondering up and down hall keeps talking about people getting blown up On 5/18/18 at 10:23 PM, Resident # 93 pushed another resident to the floor. Resident # 93 observed with hands around the other resident's neck. Resident # 93 was assisted to his room. This was report and witnessed by the housekeeper. (This happened in the lounge). On 5/19/18 at 6:17 AM, Resident # 93 combative and uncooperative with others. Resident # 93 striking out at others. On 5/29/18 at 10:41 PM, Resident # 93 stated to fight with staff. Resident # 93 scratched, slapped and attempted to kick staff. On 5/31/18 at 11:59 PM Resident # 93 combative with staff striking out. Resident # 93 hit the nurse in the face he attempted to hit her several more times. Resident # 93 stated that he was in Cambodia we have to get them before they get us. On 6/9/18 at 10:37 PM, Resident # 93 told the nurse, I'm going to f*ck up your head. He then made a fist with his right hand and chased the nurse around the table. He was also going up to another resident's family and couldn't be redirected. On 6/11/18 at 3:41 PM, Resident # 93 has been agitated this shift. Resident # 93 has grabbed staff members wrist and neck. Is hard to redirect On 6/20/18 at 1:44 PM, Inter Department Team (IDT) met and discussed combative behaviors with other residents on 5/19 On 7/14/18 at 3:48 PM, Resident # 93 hit staff in the chest while trying to ambulate to the bathroom, On 7/26/18 at 6:38 PM Resident # 93 asked nurse if she would suck him off. On 8/24/18 at 10:31 PM, Resident # 93 was observed to try and go into another resident's room. the other resident was trying to get him out of his room, both residents hit each other. On 8/27/18 IDT Met about physical contact with another resident. On 8/28/18 at 7:05 PM, Resident # 93 became agitated after witnessing another residents agitation . required 2 NA to walk with him he was trying to strike out cursing and tried to kick the nurse. It took 45 minutes to calm down. On 9/3/18 at 3:45 AM, Resident # 93's roommate accused Resident # 93 of beating him up. When nurse entered the room both men sitting on the side of the bed facing each other. Resident # 93 had no brief on it was next to the other resident's bed. On 9/03/18 at 11:13 PM, NA trying to remove resident from another resident's room. On 9/9/18 at 6:56 PM, another resident yelled at Resident # 93 who was in the hallway. the two started yelling and pushing each other. Resident # 93 hit the other resident in the jaw. On 9/10/18 at 12:00 AM Resident # 93 was agitated On 9/11/18 at 12:43 PM, NA heard Resident # 93 cursing and yelling in another resident's room [ROOM NUMBER]. She saw the other resident slap this resident in the face then Resident # 93 slapped her on both sides of her face before he could be re-directed. On 9/18/18 at 4:58 PM, Resident # 93 was found on the floor of another resident's room, He was assisted off the floor. On 11/4/18 at 6:24 AM, Resident # 93 agitated and difficult to redirect moving chairs and flipping tables in the lounge. On 11/5/18 at 12:29 PM, told nurse she was going to get a give her a butt whoppin On 11/07/18 at 12:30 PM, Administrator and DoN was asked what they had done to protect the other Residents from Resident #93. The administrator said that, they have had IDT meeting about the problem. They were asked what steps they have put in place to keep him from hurting the vulnerable residents. They had no answers. On 11/07/18 at 3:19 PM, came out of his room walked across the hall was briefly in room [ROOM NUMBER] Staff member called him back to his room, He is receiving one on one supervision at this time. d) Resident #24 On 11/05/18 at 1:33 PM, the resident said she didn't like being at the facility because another resident came to her room and tried to have sex with her. She said she did not think she belonged in this place, locked up. This resident resided on the locked unit of the Dementia care unit. Record review found the resident was admitted to the dementia unit on 08/06/18, after a stay in a local hospital where she was diagnosed as having a Neurocognitive disorder, most likely secondary to Alzheimer's Dementia with behavioral changes. The physician determined the resident lacked capacity to make medical decisions. Review of the licensed nurses notes found the following entry dated 09/22/18 at 11:43 PM: Resident stated that (Name of resident #110) came into her room and stated that he was going to kill her and he wanted to have sex with her. She stated that she came to the facility to be safe and is now scared. Resident was assured that she is safe. There was no further information regarding this incident was provided in the nurses notes. On 11/06/18 at 10:56 AM, Registered Nurse (RN) #19, identified herself as the dementia units case manager. When asked if she or anyone conducted any interviews or investigation related to the alleged incident or identified the circumstances of what occurred prior to during or after the alleged allegation voiced by (TRUNCATED)

Based on water temperature measurements, observations, medical record reviews, staff interviews, and review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), the facility failed to ensure the resident environment, over which it had control, was as free from accident hazards as possible. Water temperature measurements taken between 6:00 p.m. and 6:30 p.m. on 05/23/16 with the maintenance department using their thermometer found the following water temperatures in the resident hands sinks in resident rooms: -- Room 310 the water temperature was 125.7 degrees Fahrenheit (F) -- Room 303 the water temperature was 126.4 degrees F -- Central Bath 300 hall the water temperature was 127.1 degrees F On 05/24/16 at 10:32 a.m., an additional temperature of 123.1 in room 313 by the maintenance department, was not within acceptable parameters. The maintenance director confirmed, during an interview on 05/23/16 between 5:30 p.m. and 6:30 p.m., the water temperatures had been all over the place, and had been erratic for a long period of time. The maintenance director expressed awareness that the water temperatures were erratic, indicated no intervention had been initiated to identify and correct the problem, and provided no evidence to indicate the facility had properly maintained the mixing valves. This discovery was determined an immediate jeopardy situation, with the potential to affect all residents who were able to independently wash their hands and who had cognitive impairments. At 3:10 p.m. on 05/24/16, the Associate Nursing Home Administrator (ANHA), and the Director of Nursing (DON) were notified of the immediate jeopardy due to the elevated water temperature, and the facility ' s culpability in knowing the problem existed without implementing a plan to correct the problem. The facility provided a plan of correction at 4:23 p.m. on 05/24/16. The State agency required revisions to the POC, and upon review, the immediate jeopardy was abated at 6:55 p.m. on 05/24/16. Sixteen (16) residents were identified as being at risk for immediate jeopardy or harm as a result of the elevated water temperatures. They suffered from cognitive impairments and were identified by facility staff as able to independently wash their hands in resident hand sinks. The 16 residents identified were Resident #104, #101, #112, #118, #98, #22, #90, #76, #71, #114, #29, #126, #125, #121, #120, and #34. Findings Include: a) At 4:13 p.m. on 05/23/16, during Stage 1 of the Quality Indicator Survey (QIS), the water in the hand sink in room 215 was felt by the surveyor by placing her hand under the running water. Within about five (5) seconds the water was too hot to place ones hands under comfortably. With continued hand washing for an additional ten (10) seconds, the surveyors ' hands turned a reddish color. The water in rooms 214 and 205 also felt uncomfortable. Due to this concern, the surveyor requested the maintenance department take the water temperature in rooms 214 and 215 and 205. The temperatures were 113.3 degrees Fahrenheit (F), 117.4 degrees F and 117.4 degrees F respectively. Another observation, on 05/23/16 at about 6:00 p.m., revealed uncomfortable water temperatures in rooms 303 and 310. Upon request, the maintenance director used the facility thermometer and obtained a temperature of 126.4 degrees F in room 303 and 125.7 degrees F in room 310. Resident #104, resided in room 303 and Resident #112 resided in room 310. These residents were able to independently wash their hands at the hand sink in their rooms. At 6:11 p.m. on 05/23/16, the maintenance director also obtained a temperature in the Central Bath 300 sink using the facility's thermometer. The water temperature was 127.1 degrees F. He indicated it was too hot. Due to this elevated temperature, additional water temperatures in other rooms throughout the facility were checked. The maintenance director confirmed room 303 was the room closest to the water heater on the south hall and room 310 was over half way down the hallway, on the opposite side of the corridor. All temperatures were obtained by the maintenance director, using the same thermometer. While obtaining temperatures, the temperature would spike, drop and rise again, within seconds. The director held the thermometer under running water, but did not utilize a cup for consistency. Upon request, he changed the position of the thermometer under the water stream, and the temperature raised. He agreed the temperatures obtained were dependent upon the position of the thermometer. If not positioned correctly, an accurate temperature was not obtained. According to Table 1 in the Guidance to Surveyors related to comfortable/safe water temperatures, found in Appendix PP of the CMS State Operations Manual, a third (3rd) degree burn can occur at 120 degrees F with an exposure time of five (5) minutes, at 124 degrees F with an exposure time of three (3) minutes, at 127 degrees F with an exposure time of one (1) minute, at 133 degrees F with an exposure time of 15 seconds, and at 140 degrees F with an exposure time of 5 seconds, noting that burns can occur even at water temperatures below that level depending on the exposed individual's condition and the length of exposure. Rooms 100 Central Bath, 108, 203 Central Bath, 205, 215, 303, 306, 310, 313, 409, were chosen to demonstrate this was a facility wide problem. Water temperatures were obtained on the north (100 and 200) and south (300 and 400) halls due to uncomfortable water temperatures. Since rooms 100 Central Bath, 203 Central Bath and 303 were closest to the water heaters and Room 217 furthest away from the water heaters, it was likely the water in the rooms between the two (2) were also elevated, placing additional residents at risk, resulting in a determination the problem was facility wide. The Director of Maintenance indicated the water temperatures were checked weekly. He confirmed the water was too hot, and the temperatures had been erratic, but did not know why. The director related the mixing valves were maintained every six (6) weeks and valves were changed out. He also related temperatures were more stable when staff used a lot of water such as when providing showers. During an additional interview with the maintenance director at 7:23 p.m. on 05/23/16, he related a work order was placed each time the mixing valves were cleaned and when water temperatures were obtained. Upon request, the director reviewed work orders from 05/01/15 through 05/23/16. He related he was unable to find any evidence the mixing valves had been maintained for either the north or south halls. He related a hot water heater had been changed due to leakage, but no other maintenance. Upon request, the maintenance director provided his water temperature log beginning on 02/01/6 through 05/23/16. Temperatures were completed weekly, and upon request when staff complained of hot water. The south hall temperatures included: --02/15/16 room 413 was 114.8 --02/22/16 south soiled utility was 114.0 --02/29/16 south soiled utility was 113.8 --03/07/16 south soiled utility was 114 --03/18/16 room 314 was 115.8 and room 410 was 113.5 --03/21/16 south soiled utility was 115.6 --03/28/16 south soiled utility was 112.9, room 314 was 115.8 and room 410 was 113.5 --04/11/16 south soiled utility was 114.5 --04/18/16 south soiled utility was 115.2, room 314 was 113.8 and room 413 was 114.5 --05/09/16 south soiled utility was 115.9, room 314 was 114.8 and room 410 was 116.5 --05/16/16 room 314 temperature was 114.8 and room 410 was 116.5 --05/23/16 south soiled utility was 115.8, room 312 was 115 and room 410 was 113.1 North hall temperatures included: --02/15/16 north soiled utility was 116.5 --02/15/16 north soiled utility was 116.5 --02/22/16 north soiled utility was 110.6 --02/25/16 room 109 was 118.3 and room 217 was 117.5. The director related the temperature was obtained due to complaints of hot water. --02/29/16 north soiled utility was 111.2 --03/07/16 north soiled utility was 116.4 --03/14/16 north soiled utility was 115.6 --03/21/16 north soiled utility was 104.9 --03/28/16 north soiled utility was 116.0 and room 109 was 114.1 --04/04/16 north soiled utility was 114.2 --04/11/16 north soiled utility was 114.1 --04/18/16 north soiled utility was 116.1, and room 112 was 112.1 --04/25/16 north soiled utility was 111.7 --05/02/16 north soiled utility was 115.8, room 112 was 113.9 and room 214 was 112.5 --05/09/16 north soiled utility was 117.4, room 112 was 113.1 and room 214 was 112.1 --05/16/16 north soiled utility was 117.8, room 112 was 113.3 --05/23/16 north soiled utility was 118.2 Upon inquiry, the maintenance director related the facility recorded the temperature obtained after the water stabilized, not at the temperature spike. Upon exiting the interview with the maintenance director, a list of residents who were capable of utilizing the sink in the room and the central bath were obtained from the South hall Registered Nurse Case Manager. During an interview with Maintenance #53, on 05/24/16 at 9:15 a.m., he related the process used for obtaining water temperatures, he stated he held the thermometer under the water and allowed the water to run over it. He confirmed he did not utilize a cup. Further inquiry revealed he had not calibrated the thermometer. Additionally, he did not utilize the same thermometer as the maintenance director. Upon request Maintenance #53 calibrated the thermometer and began to obtain temperatures. The surveyor also calibrated a thermometer to obtain temperatures simultaneously. Maintenance #53 confirmed the temperatures were not accurate, due to the thermometer was not always under the water. He obtained a cup and related the temperatures were more consistent. He related the director had adjusted the hot water temperature on 05/23/16 prior to exiting the facility, but he had turned it back up this morning. Temperatures were as follows: --Room 303 - 118 degrees F --Room 301 - 118.3 degrees F --Room 403 - 118.2 degrees F --Room 412 - 117.2 degrees F --Room 310 - 315.1 degrees F --Room 400 Central Bath - 116.1 degrees F --Room 300 Central Bath - 111.98 degrees F --Room 100 Central Bath - 115.5 degrees F --Room 113 - 115 degrees F --Room 108 - 119 degrees F The facility was asked to provide a list of all residents on the dementia unit who were able to independently wash their hands at the resident hand sinks and/or use the 300 central bath independently. This list contained the names of sixteen (16) residents. Of those 16 residents, only 8 were identified as being at risk for serious harm due to their severe cognitive impairments. The medical records of all 16 residents were reviewed and found the following eight (8) residents had a BIMS score less than seven (7) indicating a severe cognitive impairment. --Resident #101 had a BIMS score of 99. --Resident #118 had a BIMS score of 99. --Resident #98 had a BIMS score of four (04). --Resident #90 had a BIMS score of five (5). --Resident #76 had a BIMS score of four (04). --Resident #121 had a BIMS score of 99. --Resident #120 had a BIMS score of three (03). --Resident #34 had a BIMS score of seven (07). Three residents on the North hall were identified as independent and included: --Resident #86 had a BIMS score of six (06). --Resident #76 had a BIMS score of four (04). --Resident #75 had a BIMS score of four (04). Sixteen (16) residents were identified as being at risk for serious harm as a result of the elevated water temperatures. They suffered from cognitive impairments and were identified by facility staff as able to independently wash their hands in resident hand sinks. The sixteen (16) residents identified were: Resident #104, #101, #112, #118, #98, #22, #90, #76, #71, #114, #29, #126, #125, #121, #120, and #34. This discovery was determined an immediate jeopardy situation, with the potential to affect all residents who were able to independently wash their hands and who had cognitive impairments. At 3:10 p.m. on 05/24/16, the Associate Nursing Home Administrator (ANHA), and the Director of Nursing (DON) were notified of the immediate jeopardy due to the elevated water temperature, and the facility ' s culpability in knowing the problem existed without implementing a plan to correct the problem. The maintenance director expressed awareness that the water temperatures were erratic, indicated no intervention had been initiated to identify and correct the problem, and provided no evidence to indicate the facility had properly maintained the mixing valves. The ANHA related the temperatures were too hot, and a temperature of 127.1 was unacceptable. The facility provided a plan of correction at 4:23 p.m. on 05/24/16. The State agency required revisions to the POC, and upon review, the immediate jeopardy was abated at 6:55 p.m. on 05/24/16. No deficient practice remained after removal of the immediate jeopardy. b) Plan of correction The facility provided a plan of correction at 4:23 p.m. on 05/24/16. The State agency requested the facility to revise its plan of correction (POC) to include continued monitoring after the mixing valves were installed to ensure the facility could maintain a continuous water temperature of 110 degrees F; to ensure nursing staff had access to thermometers to check for hot water temperatures; when in-servicing staff on checking water temperatures would begin; and resubmit the POC. The plan of correction was resubmitted and approved. As the facility had already begun to implement the POC, the immediate jeopardy was abated at 6:55 p.m. on 05/24/16. The plan indicated all residents had been checked for potential injury and skin assessments were performed on all residents with no injury noted. All residents had the potential to be affected. Hot water was immediately turned off in every resident room. Signs were placed in rooms not to turn the hot water back on until further notice. The maintenance department turned the water temperatures down to 110 degrees F. Water temperatures will be checked every 30 minutes by the maintenance department until the water temperatures are at steady 100-110 degrees for 24 hours. Maintenance will be here to check water temperatures for the next 24 hours and longer if needed. New mixing valves have been ordered and are supposed to arrive 05/25/16. Valves are to be placed in service upon arrival. Water temperature checks will be performed after installation to ensure proper function. Expected completion date of installation will be 06/01/16. Water temperatures will be checked every eight (8) hours daily after installation one sink down each hallway and in utility rooms to ensure proper temperatures. Findings will be reported to the Administrator and reviewed by the safety committee monthly and reported to Quality Assurance (QA) for review. Logs have been started for water temperatures. All nursing staff will be in-serviced on how to check water temperatures properly and to check temperatures if they feel that the water may be too hot to check temperatures. Staff has been advised that water temperatures should be between 100-110 degrees. Thermometers have been supplied to the nursing department to be used for testing. Nursing staff are being trained at shift change daily until all nursing staff are in-serviced. Expected completion date of training will be 05/27/16. Water temperature logs will be reviewed with the administrator and reviewed by the safety committee monthly and reported to QA for review. A follow-up interview with the administrator, on 05/25/16 at 3:30 p.m., revealed the plan of correction had not been implemented as presented due to the facility received an e-mail indicating the parts had not been shipped as planned. The facility continued with 30 minute checks of water temperatures and ordered new thermostats for each hot water heater. The DON related on 05/25/16 she and the administrator made rounds with the maintenance department, and utilized the cup method to check water temperatures. On 05/26/16 at 9:30 a.m., an interview with the administrator revealed he had hired a plumbing company to analyze and fix the water temperature problem. During an interview with the plumber, he related the pressure tank was not big enough to support the system. He related the pressure caused the hot water to back flow into the cold water line. He was holding the pipe and related, It's (it is) red hot right now. He also indicated it was dangerous to turn down the heater temperature because it could cause the thermostat to stick. He related a check valve would be placed on the cold water line to prevent back flow and to change the expansion tank. The administrator told the plumber to change the mixing valve also. The administrator was informed a revised plan of correction would have to be submitted and accepted by the State agency. The revised plan of correction was submitted to the facility on [DATE] at 10:47 a.m. and was accepted. The facility continued its corrective actions including education and water temperature checks. During the time the staff were making revisions to the plan of correction, the State agency observed for implementation of the plan of correction. The facility's Policies and Procedures of water temperature safety were reviewed and noted to contain all required information including information pertaining to a process staff should follow should they notice the water temperature was too warm. The hand sinks of the facility were observed and noted to have the hot water turned off. The facility had placed signs on the sinks advising staff and residents not to use the hot water until further notice. The facility provided education sign in sheets for all staff currently working. Nurse stations contained several thermometers to check water temperatures. Finally, random staff interviews were conducted and the staff were knowledgeable of the water temperature situation and knowledgeable of the policy and procedure on which they were educated. The facility added the following information to the revised plan of correction, submitted by the facility at 10:47 a.m. on 05/26/16: The facility added the following information to the plan of correction, Per (Plumbing Company) current water temperatures should remain below 110 degrees with thermostats on each water tank set below 110 degrees. The maintenance department will continue to do 30-minute temperature checks on hot water until 06/02/16. Current tempering valves on water tanks are not working correctly. This will be replaced on 05/31/16 also with the installation of new and proper size expansion tanks and new high velocity bronze circulating pumps will be installed with proper plumbing. Expected completion date is 06/02/16. (Plumbing Company) will educate the maintenance department on operation and maintenance of tempering valve at completion of installation. (Plumbing Company) will be on call for any problems that may occur over the weekend and until installation has been completed. Water temperatures will be checked every eight (8) hours daily for two (2) weeks after installation, two (2) sinks down each hallway, one at the far end of the hallway and one down the middle of the hallway, and in utility rooms to ensure proper temperatures. Should testing show that temperatures are in the correct range testing of water temperatures will be added to the daily preventative maintenance log. Findings on these reports will be reported to the administrator weekly and reviewed by the safety committee monthly and reported to QA quarterly for review. No deficient practice remained after removal of the immediate jeopardy.

Based on staff interview, resident interview, record review, and observation, the facility failed to ensure two (2) of four (4) residents reviewed for nutrition maintained, to the extent possible, acceptable parameters of nutritional status. Resident #31 ' s weight was not accurately assessed. The resident had severe weight losses which were not identified and addressed in a timely manner. In addition the weight loss interventions suggested by the dietitian and/or those in the resident's care plan were not implemented. For Resident #85, the care plan for assistance at meals and the registered dietitian's recommendations for dietary supplements were not implemented. The failure to provide necessary care and services resulted in actual harm to these residents. Resident identifiers: #31 and #85. Facility census: 112. Findings include: a) Resident #31 Resident #31 was admitted to the facility on [DATE]. Review of the clinical record revealed documentation of an admission weight of 171 pounds on 08/12/14. The resident ' s weight was retaken, on 08/26/14 at 9:30 a.m. Her weight was 145 pounds, not 171 pounds as originally recorded. The resident ' s weight remained in the range of 145 pounds between 08/26/14 and 09/23/14. During this time period, the resident ' s weight went down to 140.2 pounds, then gradually up to 147.4 pounds on 09/23/14. There were no significant weight losses since the verified weight of 145 pounds. The resident ' s weight records for 10/01/14 showed two (2) different weights, 141.4 pounds and 146.8 pounds. There was no further weight assessment and nothing was found which clarified how much the resident actually weighed on 10/01/14. When the resident was weighed on 11/01/14, she weighed 134.6 pounds. There was no evidence the facility immediately recognized this weight loss was either a significant weight loss or a severe weight loss, depending on how much the resident actually weighed on 10/01/14. If the resident weighed 141.4 pounds on 10/01/14, and weighed 134.6 pounds on 11/01/14, she experienced a significant weight loss of 5% in one (1) month. On the other hand, if the resident weighed 146.8 pounds on 10/01/14, and weighed 134.6 pounds on 11/01/14, she experienced a severe weight loss of 8.3% in one (1) month. There was no evidence interventions were implemented to addresses the resident ' s new weight loss. On 11/03/14, the resident ' s recorded weight was 135.2 pounds. On 11/18/14, the resident weighed 129.4 pounds. This was an additional loss of 4.29% in 15 days (severe). If the resident weighed 141.4 pounds on 10/01/14, by 11/18/14 she had lost 9.27% between 10/01/14 and 11/18/14, which represented a severe weight loss. If the resident weighed 146.8 pounds on 10/01/14, the weight loss was 13.4% between 10/01/14 and 11/18/14. Between 11/18/14 and 01/01/15, the resident ' s weight remained stable. On 11/25/14, she weighed 130.6 pounds, on 12/01/14, she weighed 130.1 and on 01/01/15, she weighed 133.8 pounds. When the resident was weighed on 02/01/15, she weighed 120 pounds. This represented yet another severe weight loss of 10.31% between 01/01/15 and 02/01/15. There was no evidence this additional weight loss was identified and/or addressed. In four (4) months, between 10/01/14 and 02/01/15, the resident lost 15.13% of her total body weight if she weighed 141.4 on 10/01/14. She lost a total of 18.26% of her total body weight if she weighed 146.8 pounds on 10/01/14. The facility did not verify if the resident weighed 141.4 pounds or 146.8 pounds on 10/01/14. Either way, severe weight losses were not identified and promptly addressed. Review of the clinical record revealed a dietary progress note written, on 08/13/14, by the Registered Dietitian (RD), indicating Juven (a nutritional supplement) twice daily and milk shakes as needed would be ordered. Review of the clinical record revealed a dietary progress note, written on 08/26/14 at 7:16 a.m., by Employee #89, Certified Dietary Manager (CDM). It noted the resident's current weight was 171.2 pounds. This note was not amended or corrected to reflect that the resident's weight, taken on 08/26/14 at 9:30 a.m., was 145 pounds, not 171.2 pounds. The note indicated the resident's nutritional status would be monitored and referred to the RD as needed. The medical record contained no dietary progress notes or RD assessments between 08/26/14 and 11/20/14, a period of nearly three (3) months. During that period, the resident ' s weight records for 10/01/14 showed two (2) different weights, 141.4 pounds and 146.8 pounds which were not clarified. On 11/01/14, the resident weighed 134.6 pounds, and had lost either 5% (significant loss) or 8.3% (severe loss) in one (1) month, depending on which weight was used for calculation. On 11/03/14, the resident ' s recorded weight was 135.2 pounds; however, the resident weighed 129.4 pounds on 11/18/14, an additional loss of 4.29% in 15 days (severe). There was no evidence the DM or the RD promptly identified, assessed, and/or addressed the first significant (or severe) weight loss, which should have been identified after the resident was weighed on 11/01/14. The next dietary progress note, written by the RD, was not written until 11/20/14. By that time, the resident was losing weight at a faster pace. In fifteen (15) days she had lost an additional 4.29%, from 135.2 pounds on 11/03/14 to 129.4 pounds on 11/1814. The RD ' s 11/20/14 note included a recommendation for Ensure Clear (a nutritional supplement) three (3) times daily and Great Shakes with meals. The notes did not question the accuracy of the initial weight of 171 pounds. In fact, the RD used the weight of 171 pounds in her note on 11/20/14 which stated, "Concern with major weight loss. She is down 42 pounds since her admission 3 months ago. From 171 to 129." In addition, the progress note by the RD included a recommendation to, "Consider appetite stimulant at this time." There was no evidence the facility implemented these recommendations. As well, the clinical record revealed no orders or considerations for an appetite stimulant. Review of the resident's nutrition care plan revealed the following interventions: -- Ensure clear 200 ml 3 x daily, -- Great Shakes with meals, -- Dietitian to evaluate and follow up as needed, -- Juven 1 packet BID (twice daily), -- Weigh resident every week for 4 weeks or until weight is stable; -- Record results and report any loss to physician and dietitian; and -- Promptly offer resident food alternatives when appropriate for any meal served. There was no evidence the dietitian evaluated and followed up on the resident ' s nutritional status and needs as care planned. An interview with CDM #89 and Director of Nursing (DON) #91 was conducted on 02/18/15 at 3:30 p.m. Upon inquiry, CDM #89 stated she was notified of weight losses when residents were weighed, and made referrals to the RD. CDM #89 was unable to explain why the dietary progress note written on 08/26/14 was not corrected or amended to include the weight obtained later, on 08/26/14, of 145 pounds. CDM #89 was also unable to explain why the resident was not seen by the RD until 11/20/14. In addition, CDM #89 was unable to explain why new dietary interventions were not added until 11/21/14, a period of three (3) months. A subsequent interview was conducted with CDM #89 on 02/18/15 at 4:20 p.m. CDM #89 confirmed the resident was not referred to the RD until 11/04/14, and was not seen by the RD until 11/20/14. CDM #89 stated she did not refer residents to the RD until a resident lost 5% or more in 30 days. CDM #89 said that using the weight of 145 pounds on 08/26/14 as baseline, the 5% weight loss did not occur until 11/01/14. Observation of the resident eating breakfast, on 02/19/15, revealed the resident was not served a Great Shake with meals as directed by her care plan. An interview with the resident was conducted at this time. She said that she was not served Great Shakes with meals. Review of the clinical record revealed there was no evidence the resident was offered or received Great Shakes with meals. . . b) Resident #85 Resident #85 was re-admitted to the facility on [DATE] after being hospitalization for a [DIAGNOSES REDACTED]. Review of Resident #85's most recent Minimum Data Set (MDS), dated [DATE], revealed the resident had short and long term memory loss and her cognition was severely impaired. Her functional status documentation indicated she required the physical assistance of one (1) staff to eat. The MDS also noted Resident #85 weighed 143 pounds which was a 5% or more weight loss in the last month, and she was not on a physician prescribed weight loss regimen. She was noted to be on a mechanically altered therapeutic diet. Review of Resident #85's current care plan for nutrition dated 02/02/15 identified the resident had a potential for weight loss due to a decline in her appetite and she had experienced a recent weight loss while in the hospital for pneumonia. Interventions included the staff would provide the resident assistance with her meal, cue her to eat, monitor her food intake. Interventions included: -- determine resident's food preferences; -- allow ample time to consume food; -- provide the resident assistance with meals; -- cue the resident to eat; -- monitor the resident's food intake; -- record and report any decline to the physician and dietitian; -- promptly offer the resident food alternatives when appropriate; and -- the dietitian to evaluate and follow up as needed. Review of the nursing notes revealed Resident #85 became ill on 01/13/15 and was sent to the hospital with a [DIAGNOSES REDACTED].#85 weighed 159 pounds. She returned to the facility on [DATE]. Her weight on re-admission was noted as 145 pounds. This was a 14 pound (9.7%) weight loss from her weight prior to going to the hospital. Further review of the clinical record revealed the resident's health continued to decline after returning from the hospital, and she was placed on Hospice services on 01/30/15. Dietary notes, dated 02/03/15, revealed a referral for weight loss. Documentation on the note indicated Resident #85 was receiving hospice services and had not been eating or drinking well. The note indicated her weight was down to 145 pounds, from her pre-hospital weight of 159 pounds. The registered dietitian (RD) wrote a recommendation to stop all dietary restrictions, such as the current order for a no concentrated sweets diet, and placed the resident on a regular mechanical soft diet. The RD also documented the resident drank some Ensure for the nursing staff, and recommended that staff provide the resident a supplement as needed. There was no evidence this information regarding the supplement was relayed to nursing staff, to ensure staff were aware to offer the resident a dietary supplement as needed. A dietary note, dated 02/10/15, indicated Resident #85 had a significant change in her condition. The documentation described the resident's current weight was 145 pounds. It noted this was a 5% or more loss in the past 30 days. Employee #89, Certified Dietary Manager (CDM), documented the resident remained on hospice. The CDM documented the resident's average meal intake was 31%. The CDM indicated she would refer the resident to the dietitian if the resident experienced any further weight loss. Review of the weight records on 02/18/15 did not reveal any further weight loss. Review of the nutritional intake log for January 2015 and February 2015 revealed the resident consumed less than 25% of each of the 86 meals served during this time period. Review of the meal intake log indicated the following: If Resident #85: -- consumed 25% of the meal, there was a notation "alternative offered." -- consumed 0% of the meal, there was a notation "nurse was notified. " Interview with Employee #127, Licensed Practical Nurse (LPN) and Employee #135, MDS Registered Nurse (MDS/RN) Nurse #135, on 02/18/15 at 2:20 p.m., revealed the documentation of "alternative offered" and "nurse notified" on the meal intake log was generated by the computer. It was not something the nurse aide actually documented. Further interview with LPN #127 revealed if she was told by the Nurse Aide, that a resident refused to eat, she would look to see if the resident had an order for [REDACTED]. On 02/18/15 at 2:30 p.m., interview with LPN #110, who was providing care to Resident #85, revealed she was not aware if Resident # 85 had an order for [REDACTED]. LPN #110 stated she did not work on the 100 Hall very often, so she was not sure if the resident had been receiving supplements and/or how the resident had been eating. At that time, LPN #127 and MDS/RN #135 both stated if there was not an order for [REDACTED].#135 confirmed Resident #85 did not currently have an order for [REDACTED]. Observation of Resident #85, on 02/18/15 at 8:00 a.m., revealed the resident was in bed with her eyes closed. Her meal tray was on her over-the-bed table and nothing had been touched. Observation again on this date at 8:05 a.m., 8:10 a.m., and 8:15 a.m. revealed the resident's eyes were still closed. Staff were observed providing care and feeding other residents. Employees #23 and #15, Nurse Aides (NA), were asked if Resident #85 required assistance eating her meals. They both stated they were not sure what assistance she required. The NAs stated they did not usually work the 100 Hall. They indicated they would find out if the resident required assistance with her meals. NA #15 asked Employee #110, Licensed Practical Nurse Staff (LPN), what type of assistance Resident #85 required with her meals. The LPN stated she was not sure, so she went to ask a full-time NA (NA #21) assigned to the 100 Hall. NA #21 stated the resident required assistance with meals. She stated the resident used to be able to feed herself, but over the past few weeks she had not been able to do so. The NA said staff had been feeding her. NA #21 stated she worked the top half of the 100 Hall, and another full-time NA worded the bottom half of the hall. She stated the other NA had been off due to illness, so the staff working were not usually assigned to this hall. Observation at lunch, on 02/18/15 at 12:20 p.m., revealed NA #21 attempted to feed Resident #85. During this observation the resident refused to eat, but NA #21 was able to get her to drink a small amount of water. The NA stated she did not offer the resident any type of dietary supplement. She said she was not aware she should be giving the resident any type of supplement. The NA documented Resident #85 consumed 0% of her meal. Interview with NA #21, on 02/18/15 at 2:35 p.m., revealed she worked the top half of the 100 Hall, and another full-time NA worded the bottom half of the hall. She stated that NA had been off due to illness, so the staff working were not usually assigned to the hall. NA #21 stated she had never provided Resident #85 with any type of nutritional supplement. She said if a resident refused to eat, she documented it in the meal intake area in the computer and then she told the nurse. She stated the nurse would be the one to give a resident the additional supplement or to provide the nurse aide the supplement to give to the resident. On 02/18/15 at 3:15 p.m., an interview was conducted with MDS/RN #135 and In-Service Director #108 on 02/18/15 at 3:15 p.m. When asked if Resident #85 received any dietary supplements due to her decline in meal intake, MDS/RN #135 stated the resident received Hospice and indicated it was expected the resident would lose weight. She said they would never force a resident to eat or drink anything. When explained that the question being asked was if any resident refused meals or only ate 25% of their meal, would staff offer any type of dietary supplement. MDS/RN #135 said Resident #85 did not have a current order for a supplement, nor had there been any recommendations for the resident to receive any type of dietary supplement. The MDS/RN #135 was informed that there was a dietary note, dated 02/03/15, by the dietitian which contained documentation that it was "okay" to provide a supplement to Resident #85 as needed. She stated she was not aware the dietitian had written that recommendation. A discussion was held with MDS/RN #135, In-Service Director #108 and the Director of Nursing #91 on 02/19/15 at 10:00 a.m. At that time, they were informed that observations and record review revealed Resident #85 was not receiving assistance with her meals as the care plan indicated. They were also informed that although Resident #85 was consistently consuming less than 25% of her meal, there was no evidence she was receiving any type of dietary supplement. The nurses verified the system currently in place did not provide an area for documenting a supplement if the resident did not eat. They were not able to provide evidence, for the days on which Resident #85 consumed less than 25% of her meal, that she received a nutritional supplement of any kind. .

Based on record review, review of the facility's bowel management protocol, and staff interview, the facility failed to provide care and services to attain or maintain the highest practicable well-being for one (1) of twenty-five (25) residents reviewed in Stage 2 of the Quality Indicator Survey (QIS). There was no evidence the facility assessed and monitored Resident #60's bowel movements resulting in a transfer to the hospital. This practice resulted in actual harm for Resident #60. Resident identifier: #60. Facility census: 114. Findings include: a) Resident #60 Medical record review, on 04/17/14 at 2:15 p.m., revealed this resident was readmitted to the facility on [DATE]. Further review of records revealed on 04/13/14, the resident was had a hard and very distended abdomen. The resident experienced vomiting when given her medications at 11:11 p.m. on 04/13/14, and was transported to a local emergency room (ER) for treatment. During her visit to the local emergency room the resident received two (2) liters of fluid intravenously and had a radiology test (CT scan) of the abdomen. The CT resulted in the [DIAGNOSES REDACTED]. According to the hospital records, the resident had a large loose stool while in the ER. Review of Resident #60's bowel movement records, dated 03/01/14 through 04/17/14, found only two (2) bowel movements were recorded. A medium bowel movement was recorded on 03/14/14 and a large bowel movement on 04/16/14. A review of the "No bowel movement" report, dated 03/01/14 through 04/17/14, revealed Resident #60's name was not contained on the report. This report was generated by the evening shift nurses daily and was used to determine if the bowel protocol should be initiated for a resident. The facility's bowel protocol was to be initiated it a resident had no bowel movements for a period of three (3) days. Resident #60's medication administration records (MAR), for the time period of 03/01/14 through 04/17/14, were reviewed. This review found the bowel protocol was not initiated for the resident. Review of the facility's bowel protocol (standing orders) found it included, (typed as written): "Constipation. Check bowel movement record for bowel elimination: If no bowel movement in three (3) days the administer: 1. Milk of Magnesia 30cc (cubic centimeters) po (by mouth) daily prn (as needed) x (times) 1 dose. If no results in 8 hrs (hours) . . . 2. [MEDICATION NAME] 15mg (Give 3 tabs of 5mg) po q (every) 3days or [MEDICATION NAME] 10mg R/S (rectal suppository) 10mg q3days x 1 if no results in in 8 hours . . . 3. May check for constipated stool, If present remove manually 4. [MEDICATION NAME] (Fleets) enema prn x 1. If no results after implementing steps 1-4 above, notify physician. Hemocult on any resident with dark/tarry stool or vomitus." At 6:10 p.m. on 04/17/14, the Director of Nursing (DON), Employee #5, Staff Development Coordinator, and Employee #102, Registered Nurse Minimum Data Set Coordinator (MDS Coordinator) were interviewed. This interview revealed they had determined why Resident #60's bowel movements had not been documented by the nurse aides (NAs). Employee #102 stated the bowel movement scheduled care task assignment had not been initiated. She stated the NAs where not prompted by the Kiosk to enter whether or not Resident #60 had a bowel movement. They confirmed the NAs were trained to enter every bowel movement into the computer system. They stated the NAs would have to select the task themselves and make the entry, if the computer did not prompt them to do so. Employee #5 stated all staff were trained on how to document bowel movements into the system when the system did not prompt them to do so. This could happen if a resident had more than one (1) bowel movement a shift. In this situation, the NAs would have to manually document that in the system. Employee #3 stated the reason Resident #60 did not pull to the "No BM (bowel movement) report" was because this report was driven by the "bowel movement button" which was not initiated for Resident #60. She confirmed they could not prove Resident #60 had a bowel movement, because there were none documented. She stated not all the NAs had the foresight to manually document a bowel movement when they were not prompted to do so. She confirmed they did not monitor Resident #60's bowel movement status due to this error in the computer. .

Based on record review, staff interview, and review of the facility's fall prevention program, the facility failed to provide adequate supervision to prevent avoidable accidents for one (1) of ten (10) sampled residents. Review of her minimum data set (MDS) assessments, with assessment reference dates (ARDs) of 12/06/10 and 01/12/11, revealed Resident #78 was "not steady, only able to stabilize with human assistance" when moving from a seated to a standing position, moving on and off the toilet, and completing surface-to-surface transfers. Review of the resident's fall risk assessment dated [DATE] revealed a score of 9. Persons receiving a score of 10 or greater are considered at high risk for falling; Resident #78 was not considered to be at high risk for falls at that time. Resident #78 was hospitalized from [DATE] until 01/05/11. On 01/06/11, Resident #78 was assessed as having poor sitting balance. On 01/14/11, she scored 16 on the fall risk assessment, indicating she was now at high risk for falls. Safety measures were not implemented to promote fall prevention in accordance with the facility's fall prevention program, and neither Resident #78's care plan nor the nursing assistant worksheet was revised to address her high risk for falling. On 01/23/11, Resident #78 was placed on the bedside commode and left unattended. She was later found on the floor. She was sent to the hospital and diagnosed with [REDACTED]. Resident #78's care plan and nursing assistant worksheet were not revised, to address the need for staff to remain with her when using the toilet, until after she fell and sustained injuries requiring medical intervention. Resident identifier: #78. Facility census: 115. Findings include: a) Resident #78 1. Record review revealed Resident #78 was an [AGE] year old female who was transferred to the hospital on [DATE] for cardiac arrest, and she was readmitted from the hospital on [DATE]. [DIAGNOSES REDACTED]. Further record review revealed, on 01/23/11, Resident #78 was placed by staff on a bedside commode and left unattended. Staff later found her in the floor. She was sent to the hospital and diagnosed with [REDACTED]. Review of the facility's internal investigation into the 01/23/11 fall revealed the following (quoted verbatim): "... LSW (licensed social worker - Employee #62) spoke with various staff, from all 3 shifts, answered varied on whether or not resident should or could be left alone on toilet. For example, (name of Employee #100), LPN did not know that resident should be assisted by staff 'once on toilet, staff had left alone several times that night'. (Name of Employee #97) stated '(she) was aware had had to stay with resident. CNA's statements also varied between shifts. CNA worksheets had not been updated from time resident had been readmitted following prior hospital stay on 1/05/2011, as to change from w/c to c/v chair, or 2 assist during toileting. ..." The internal investigation contained the following statement from a nursing assistant (Employee #119) related to the incident on 01/23/11 (quoted verbatim), "... I was not told I could not leave her in her room alone nor do we receive report half the time. Our worksheets are wrong more than half the time too so there isn't much to go by ..." - 2. According to an abbreviated quarterly MDS with an ARD of 12/06/10, in Section G0300 (balance during transitions and walking), the assessor encoded Resident #78's performance on Items A, D, and E (moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer, respectively) as "2", meaning she was "not steady, only able to stabilize with human assistance". Elsewhere in Section G, the assessor noted Resident #78 required the limited assistance of two (2) or more persons with transferring and toilet use. When assessing the resident's sitting balance using a form titled "Tinetti Assessment Tool: Balance" (completed on 01/06/11), the assessor scored Resident #78 as "1", indicating she "(l)eans or slides in chair". According to a significant change in status MDS with an ARD of 01/12/11, in Section G0300, the assessor again encoded Resident #78's performance on Items A, D, and E as "2", meaning she was "not steady, only able to stabilize with human assistance". Elsewhere in Section G, the assessor noted Resident #78 now required the extensive physical assistance of two (2) or more persons with transferring and toilet use. On 01/14/11, the assessment coordinator (Employee #85) completed a falls risk assessment on Resident #78, resulting in a score of "16". (Note: A score above "10" indicates the resident is at risk for falls.) On her last fall risk assessment dated [DATE], she scored "9", indicating she was not at high risk for falls at that time. She had experienced a decline since her previous fall risk assessment. - 3. According to the facility's fall prevention program, once the falls risk assessment is complete, interventions should be set in place and the resident's should be care plan updated. Review of the resident's care plan revealed the following problem statement dated 06/16/09 - 04/19/11: "Decrease in physical mobility due to left sided weakness, tremors, deconditioning." The goal associated with this problem statement, dated 06/16/09 - 04/19/11, was: "Will remain free of complications related to decreased mobility, including contractures, thrombus formation, skin breakdown, fall related injury thru next 90 days." Interventions to achieve this goal were: "Observe, report to MD prn (as needed) s/sx (signs and symptoms) of immobility (contractures, forming of (sic) worsening, thrombus formation, skin breakdown, fall related injury. PT/OT referrals as indicated. Provide supportive care, assistance with mobility as needed. Document assistance needed. Keep items within easy reach of functional side (right), if one sided weakness is present. Administer medications and treatments as ordered and monitor for side effects." Only after the resident's fall on 01/23/11 was a plan developed to specifically address falls. The following problem statement was added on 01/24/11: "At risk for falls related to antidepressant, weakness, and past history of falls." The goal associated with this problem was: "Resident will not have any additional falls with injury thru the next 90 days." The interventions to achieve this goal were: "Ensure resident has on footwear with non-skid soles prior to getting up. Resident is two assist for transfers, up to C/V chair for mobility. Observe fatigue level: do not tire resident, report C/O (complaints of) weakness / intolerance, dizziness, pain or confusion. Allow for rest periods during the day. Resident is not to be left unassisted while toileting. Observe for side effects associated with medication use. PT treatment as ordered to improve functional status." - 4. In an interview on 03/09/11 at 10:00 a.m., Employee #85 confirmed she had not updated Resident #78's care plan upon her readmission to the facility, to reflect her need for additional staff assistance with ADLs. The care plan was updated on 01/24/11, the day after the fall. Employee #85 also stated the nursing assistant worksheet (a tool used to inform nurse aides of resident-specific care needs) was not updated until 01/28/11.