Every finding on record at Ridgecrest Post Acute

Based on observations, staff interviews and policy review, the facility failed to ensure food items in the kitchen were not expired, labeled, and dated appropriately and food was prepared safely. The deficient practice could increase the risk of food-borne illnesses Findings include: -Regarding food labeling, dating and storage:During the initial kitchen observation conducted on February 24, 2026 at 8:38 a.m. with a dietary aide (Staff #99) and the assistant dietary manager (Staff #3), the following was observed: A 32 ounce can of vegetables with a small dent on the top and a large dent on the side was found in the dry storage. The can was not stored in the dented can area.Brown crusted food and grey fluff (dust-like) debris on top of 4 canned items were found in dry storage.A bag of sliced sandwich bread packaged in a clear plastic bag with twist ties labeled with a date of October 21, 2025 was found in dry storage. There was no indication of an expiration/use by date. Staff #99 was unable to identify what the manufactured dates represented.Two plastic sleeves of chocolate chip cookies containing twelve cookies each were unlabeled, and unmarked of expiration date, open date or delivery date were found in dry storage. One of the sleeves was opened and exposed to air.One two-quart container of jelly with plastic wrap over the top of it with no visible dates was found in the main walk-in refrigerator.One large cardboard box with a clear plastic bag containing frozen breaded steak fritters was found opened and exposed to air in the main freezer. The box did not have any visible dates to indicate a received date, opened date, or expiration date.An interview with Staff #99 was conducted on February 24, 2026 at 8:38 a.m. Staff #99 stated the date written on food items is the received date indicated by the R next to the date. Staff #99 noted that opened food items should be labeled with an expiration date. Staff #99 indicated that she would need to clarify with the manager for clarification regarding the bread loaves to understand what the dates meant. Staff #99 confirmed that when a dented item is identified it must be moved to the dented food storage area.An interview with Staff #3 was conducted on February 24, 2026 at 8:58 a.m. Staff #3 stated the department has new employees that may be unfamiliar with the proper dating and labeling policy. The Assistant Dietary Manager acknowledged that they may need to conduct some in-service training to familiarize staff with kitchen/dietary policies and procedures. Staff #3 stated kitchen staff are expected to label food items with a received date, opened date, and discard date. Per staff #3, unlabeled food items are thrown out to mitigate the risk of food-borne illnesses. Staff #3 said that food items left open to the air in the freezer could end up freezer burn. During an interview was with the Dietary Services Manager (Staff #206) conducted on February 25, 2026 at 11:18 a.m. Staff #206 stated that staff are expected to label food items with a received date, opened date, and use-by date as some food items are good for three days and some have seven days shelf life. Staff #206 stated that it is the standard practice at this facility for most food items to be discarded 6 days after received by date, use by date, or open date. However, Staff #206 noted she would be changing the discard by date to three days to limit the possibility of food-borne illnesses. Staff #206 stated the risks of not dating, labeling, and discarding food items properly could result in not knowing how long the food items have been in the refrigerator therefore increasing the risk of food-borne illnesses. An observation was conducted February 25, 2026 at 11:56 a.m. of the nourishment refrigerator and storage room located on 400 units with the Dietary Services Director (Staff #206). During the observation an undated and opened bag of Rold's pretzel sticks was found in the 400 unit resident food storage area. An interview with Staff #206 was conducted on February 25, 2026 at 11:56 a.m. Staff #206 stated that residents may store food in the refrigerator and on the shelves next to the refrigerator within the 400 unit. Resident's food items must be labeled with their room number, open date, and use by date. Staff #206 said that food should be properly stored or it will be thrown away.Review of the Foods Brought by Family/Visitors policy last revised May 28, 2025 revealed food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food. Review of the Food Receiving and Storage Policy last revised in November 2022 revealed food shall be received and stored in a manner that complies with safe food handling practices. Further review of the policy revealed all foods stored in the refrigerator or freezer foods are labeled, dated, and monitored so they are used by their use-by date, frozen or discarded date. Further review of the Food Receiving policy revealed dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. -Regarding Safe Food Preparation:During a tray line observation conducted on February 26, 2026 at 1:19 p.m., the temperatures of the steam table food items were taken. The following was observed: Egg noodles: 90 degrees Fahrenheit (F)Beef Meatballs: 116 degrees FGreen Beans: 128 degrees FPureed Meatballs: 122 degrees FPureed Bread: 122 degrees FPureed [NAME] Beans: 132 degrees FAn interview was conducted on February 26, 2026 at 3:14 pm with Staff #206. Staff #206 admitted that the steam table temperatures were lower than they should have been and the table should be maintained at a temperature of 135 F to maintain safe food temperatures. The Dietary Services Manager noted that there may not have been enough water to keep the table at the appropriate temperature. Staff #206 acknowledged that she may need to educate her staff regarding the use of the steam table. An interview was conducted on February 27, 2026 at 8:59 a.m. with the Administrator (Staff #221). Staff #221 stated the dietary director is responsible for the food served out of the kitchen. The expectations for the Dietary Services Manager is to follow the regulations and policies of the building. Review of the Maricopa County Environmental Services Hot Holding Policy Guidance revealed all time/temperature control for safety (TCS) foods must maintain a temperature of 135 degrees fahrenheit (F). TCS foods include meat, poultry, fish, eggs, milk and dairy products, and cooked starches.

Based on observations, resident and staff interviews, clinical record review, facility documentation, and policies and procedures, the facility failed to ensure that the facility's smoking policy was implemented for one resident (#102). The sample size was 38. The deficient practice could result in the smoking policy not being followed and increased risk of smoking related incidents. Findings include:Resident #102 was admitted on [DATE] with diagnoses of malnutrition, hypertension, hyperlipidemia, gastro-esophageal reflux disease, homelessness, mood disorder, epilepsy, muscle weakness, coronary heart disease, and adult failure to thrive. The Order Summary Report revealed the following:-Physician order dated July 17, 2025 indicated that resident may smoke following facility protocol-Physician order dated January 20, 2026 documented that resident was okay to smoke per facility policy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Additionally, the assessment revealed that the resident had not exhibited indicators of psychosis, or behaviors. Furthermore, the assessment did not indicate that the resident had physical impairments. A care plan dated December 17, 2025 revealed that Resident #102 was a smoker and was at risk for smoking related injuries. Goals for this resident included ask for staff assistance as needed with smoking and smoking materials; and continue to demonstrate safe smoking. Interventions included explaining risks and consequences of smoking, and explaining smoking policy and times to resident and family. The Smoking Observation/assessment dated [DATE] documented that the resident was an independent/supervision not required smoker. Per the assessment, the IDT (Interdisciplinary Team) determined that the resident may smoke without supervision. During an observation of Resident #102 conducted on February 24, 2026 at 1:11 p.m., a bag of loose tobacco was seen on the resident's bed. Resident #102 also had a carton of cigarettes and a flameless lighter in his possession. Additionally, the resident had a second greenish-yellow lighter. Resident #102 stated residents were not supposed to store smoking materials in their rooms. An interview with a lead Certified Nursing Assistant (CNA/staff #238) was conducted on February 26, 2026 at 10:47 a.m. Per the CNA behavioral units have their own separate smoking area. However, most residents smoked in the courtyard between stations one and two. The CNA said per the facility's smoking policy, residents cannot store their own smoking items. The smoking items are supposed to be secured in the smoking cart. During designated smoking times, the smoking cart is taken out to the courtyard where staff assist supervised smokers. A February 26, 2026 interview with a Licensed Practical Nurse (LPN/staff #238) at 10:457 a.m. revealed that per the facility's smoking policy, residents cannot store their own smoking items. The items are locked in a smoking cart so the resident's smoking materials are secured. During designated smoking times, the smoking cart is taken out to the courtyard where staff assists supervised smokers. The Director of Nursing (DON/staff #39) was interviewed at 2:44 p.m. on February 26, 2026. According to the DON, the smoking policy outlined that smoking is only allowed in designated areas, storage of smoking materials, evaluation of smoker, initiation of care plan, and education of smokers regarding facility policy. The DON's expectation is for staff to store resident's smoking materials in the smoking cart, and that staff monitor residents identified as supervised smokers. The DON stated that expectations are that staff assess Resident #102 quarterly, and allow resident to smoke unsupervised if determined to be alert, oriented, ambulatory, and responsible. Per the DON, this resident is allowed to keep smoking supplies in his room because he is alert, oriented, and independent. A follow-up interview with Resident #102 was conducted at 3:07 p.m. on February 26, 2026. Resident #102 stated that there were assigned smoking times, and that smoking supplies were stored in the smoking cart. Resident #102 also explained that they were allowed to smoke cigars but not pipes. Resident #102 occasionally goes to the store to purchase smoking supplies. Residents could also request Activities staff to purchase smoking supplies. The undated facility policy indicated that residents are not permitted to keep smoking materials in their possession. Additionally, smoking materials will be kept by the designated facility staff. Per the policy, smoking materials brought into the facility should be presented to the Charge Nurse responsible for the resident's care.

Based on observation, documentation, staff interview, review of policy and procedures the facility failed to ensure that corrective actions plans were set in place for legionella. The deficient practice could result in residents to have respiratory complications. Findings include: A review of the final report from the water sampling company testing collected on June 6, 2024 revealed that 3 residents' rooms and one nursing station tested positive for Legionella. According to the report, room [ROOM NUMBER] had a Legionella pneumophila serotype 2-15 at a concentration of 6.3 CFU (colony forming units)/ml (Milliliter). Room # 102 was found to have Legionella pneumophila serotype 2-15 at a concentration of 0.6 CFU/ml. Additionally, room [ROOM NUMBER] detected the presence of Legionella pneumophila serotype 2-15 at a concentration of 7.7 CFU/ml. The 400 Nurse ' s Station was also positive for the presence of Legionella pneumophila serotype 2-15 at a concentration of 25 CFU/ml. Review of the Legionella program and Infection Prevention and Control program did not reveal any documentation pertaining to the detection of Legionella in the facility ' s water system. An interview was conducted on December 04, 2024 at 10:24 AM with the Maintenance Director (Staff # 45). Staff #45 stated that for the process for legionella testing the water safety company would send a testing kit for legionella and from there the maintenance director would send back those water samples to the water safety company for results. The Maintenance Director (Staff #45) stated that the testing results of legionella would determine how often the testing needs to be completed. Staff #45 stated that when water testing results are positive for legionella then more testing will occur to determine if the levels of legionella have decreased. The Maintenance Director (staff #45) stated that he would monitor for legionella by flushing out the water system. A review of an email sent from the water safety company regarding the legionella testing done on June 6, 2024 was conducted with Staff #45 on December 4, 2024 at approximately 10:24 a.m. The email revealed that 4 out of the 5 locations sampled in the facility tested positive for legionella. In an interview with the Maintenance Director (staff #45) conducted on December 4, 2024 at 10:24 a.m., he stated that with positive legionella results the water testing company would come to the facility to test the water 3 additional times to ensure that the levels have decreased. Staff #45 stated that there were no previous records from the previous maintenance director in regards to results for legionella. A telephonic interview was conducted December 04, 2024 at 12:52PM with a water company representative (staff #477 ) stating that 3 out of 4 locations that were tested for legionella was greater than 1.0 CFU/ml. Staff # 477 stated that the water sample testing were completed on June 6, 2024. The results indicated that the facility water was controlled poorly. The water company representative stated that there should have been a corrective action plan set in place to put things back into control. Staff # 477 stated that there is no record of a corrective action plan being made to address legionella. A request for follow up documentation regarding the water sampling test was submitted on on December 04, 2024 at 1:07 PM. The request was returned with a signed statement from the administrator (staff #13) which stated no follow-up/not required. An interview was conducted on December 4, 2024 at 1:29PM with the Infection Control Preventionist (Staff # 27). Staff #27 stated that protocols for positive legionella testing consists of contacting the Center for Disease Control (CDC), State, and County. The Infection Control Preventionist stated that the Maintenance Director is the best person to explain the process since he would be the one to take the appropriate actions. During an interview with the Maintenance Director (Staff #45) conducted on December 4, 2024 at 1:51PM, he stated that he was not aware of the test results for legionella testing done on June 6, 2024 since he was not the Maintenance Director at that time. Staff # 45 stated that from his understanding there was no form of communication in regards to test results completed on June 6, 2024. The Maintenance Director (staff # 45) stated that with positive legionella test results, the Infection Control Preventionist , the Maintenance Director, and Administrator would be notified. An interview was conducted on December 4, 2024 at 2:34PM with Administrator ( Staff #13). Staff #13 stated that regarding the testing done June 6, 2024 for legionella, there was no communication and no need for follow up in regards to those results. The Administrator stated the facility does not have routine testing for legionella and there is no policy set in place.Staff # 13 stated that the risk to residents when there is legionella in the facility is increased respiratory risk.The Administrator acknowledged that if a resident tested positive then it would be a big thing. During a follow up interview with the Infection Control Preventionist conducted on December 5, 2024 at 7:56AM, staff #27 stated that legionella is a communicable disease, and when legionella occurs that the County, State, and Center of Diseases Control (CDC) would be contacted.

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment was accurate for one of three sampled residents (#139). The deficient practice could result in inaccurate discharge tracking information and data for quality monitoring. Findings include: Resident #139 was admitted on [DATE] with diagnoses that included altered mental status, catatonic disorder condition, anxiety disorder, and auditory hallucinations. A baseline care plan dated October 7, 2024 revealed that the resident's goal was to discharge to home. An order summary dated October 11, 2024, revealed that the resident's tentative discharge plan was to return home with family. A social services progress note dated October 16, 2024, revealed that the resident was discharged to home with her daughter and husband. The note further revealed that the home health was also arranged. A nursing progress note dated October 16, 2024, revealed that the resident was discharged home with home health. Despite this, a review of a discharge MDS assessment dated [DATE], revealed that the resident had been discharged to a short-term general hospital on October 16,2024. An interview was conducted on December 4, 2024 at 10:26 AM with a Registered Nurse (RN-Staff #218), who stated that a transfer form/e-interact transform form is completed when a resident is transferred to the hospital, along with Physician discharge notes. The RN reviewed the clinical record and stated that the resident had been discharged home. She further stated that a social worker's note revealed that the resident left by car with home health arrangements. An interview was conducted on December 4, 2024 at 10:41 AM with the MDS Coordinator (Staff #55), who stated that MDS data should be accurate as per the standard of care. He reviewed the resident's clinical record and stated that there was a discrepancy between progress notes, which indicated a discharge home, and the MDS discharge assessment, which indicated the resident was discharged to the hospital. He stated that the potential risk could result in inaccurate MDS data. An interview was conducted on December 4, 2024 at 10:57 AM with the Director of Nursing (DON/Staff #141), who stated that she expected MDS assessments to accurately reflect a resident's status. The DON reviewed Resident #139's progress notes, and stated that the resident was discharged home. She then reviewed the discharge MDS assessment dated [DATE] and stated that the assessment indicated that the resident had been discharged to a hospital. She further stated that the MDS was inaccurate and would need to be corrected. The DON stated uncertainty regarding the resident's final destination (Home or Hospital) and stated that she would have to look into it. The DON also stated that an inaccurate MDS assessment could result in incorrect MDS data. Further interview was conducted on December 4, 2024 at 12:20 PM with the DON (Staff #141) who stated that the clinical record contained a physician order to discharge the resident home, and a social service note to send the resident home. A facility policy titled, Comprehensive Assessments, revealed that a discharge MDS assessment is completed whenever a resident is physically discharged from the facility and is completed per RAI manual guidelines. Review of Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.19.1, dated October 2024, revealed that the RAI process has multiple regulatory requirements including that the assessment accurately reflects the resident's status.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure one resident (#113) is assessed for self-administration of medication. The deficient practice could result in residents having access to medications not authorized or contraindicated for their use. Findings include: Resident #113 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, anxiety disorder, obstructive sleep apnea, and arthritis. Review of the admission MDS (Minimum Data Set) assessment dated [DATE], revealed the resident has a Brief Interview for Mental Status (BIMS) score of 15.0 indicating cognitively intact. The MDS also indicated that the resident uses a walker and wheelchair. The MDS assessment also revealed that the resident needs setup or clean up assistance with eating, partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, and personal hygiene. During a medication administration observation with licensed practical nurse (LPN/Staff #176) on December 4, 2024 at 08:02 am, the following medications were observed prepared by Staff #176: - aspirin 81 mg (milligram), one tablet - duloxetine 30 mg, one capsule, - Eliquis 5 mg, one tablet - Lidocaine patch 4%, one patch - Protonix 40 mg, one tablet, - potassium 10 meq (milliequivalent), one tablet - oxycodone 10 mg, one tablet Upon entering the resident's room, an orange colored tube of medication labeled Neosporin and two packets labeled Calmoseptine was on top of resident #113's bed side table. Staff #176 identified the medication found on the table as Neosporin and Calmoseptine. Staff #176 stated that the resident is using the medication for itching around her groin area. Upon exiting the resident's room, a staff standing by resident#113 room door identified herself as the director of nursing (DON)/Staff #141, and stated that they are working on the self-administration. Review of the resident's clinical record did not contain any documentation stating that the resident has been assessed and cleared to self-administer medications. Furthermore, review of the resident's care plan did not reveal anything about self-administration of medication. Review of the resident's order summary report revealed that there were no orders for self-administration of medications. Additionally, the order summary did not contain a physician's order for Neosporin and Calmoseptine. Furthermore, the resident's medication administration record for December 2024 revealed no orders for resident to self-administer medication and no orders found for Neosporin and Calmoseptine. However, a Self-Administration of Medication Observation form with an effective date of December 4, 2024 timestamped 8:30 am was added to the resident ' s clinical record. The Self-Administration of Medication Observation form indicated that the medications the resident would like to self-administer were Neosporin and house stock zinc oxide. The storage of medication section documented that the resident was in the process of self-administration training for 2 ointments and that the education was in process. Additionally, during a follow-up review of the resident ' s clinical record it was observed that the order for Neosporin and Calmoseptine were added with a start date of December 4, 2024. An interview with Resident #113 was conducted on December 4, 2024 at 8:51 am. Resident #113 stated that the medication has been there for months. The staff pulled the medication out and had it set on top of her table. Furthermore, the resident said that the medication has been on her table since yesterday afternoon. During an interview with the Director of Nursing (DON/staff #141) conducted on December 4, 2024 at 3:15 pm, the DON stated that their residents have the right to self-administer medication. Staff #141 said her IDT (interdisciplinary team) which includes a nurse provides training to make sure their residents are able to self-administer competently. The IDT conducts assessments and care plan. The DON stated that they do training simultaneously, obtain orders, and create the care plan. In addition, staff #141 stated that her unit manager was in the process of doing self-administration training with the resident, and the training started today. A follow up interview was conducted with the DON on December 5, 2024 at 8:16 am. The DON stated that medications are stored in the nurse's cart. If self-administering, it is stored in the resident's room. The medication is stored in resident's room on their side where they have easy access, and where ever they have easy access. The DON declared that this is her final answer. Review of the undated facility policy titled, Self-Administration of Medications, stated that residents have the right to self-administer medications if the IDT has determined that it is clinically appropriate and safe for the resident to do so. The policy indicated that part of the evaluation is that the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The policy also indicated that if deemed safe and appropriate for resident to self-administer medications, it is documented in the medical record and the care plan. The policy also noted that any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

Based on record review, staff interviews and observations, the facility failed to ensure that electronic records for one of twenty-eight sampled residents (#64) were accurately documented. The deficient practice could result in the medical record not reflecting the resident ' s condition and the care and services provided across all disciplines. Findings include: Resident #64 was admitted on [DATE] with diagnoses of dementia, type 2 diabetes mellitus, major depressive disorder and anxiety disorder. Review of Resident #64's medical record revealed a New Admission Medication Review dated June 12, 2023 that was for another resident, regarding Prednisone 20 mg. Further review of the form revealed another resident ' s name, date of birth, and medications, and was no longer a resident at the facility. An additional New Admission Medication Review dated June 12, 2023 was also in Resident #64 ' s medical record with the same resident ' s name that included: Evaluate: Bupropion 150 mg Modify: Prednisone 20 mg Evaluate: Rosuvastatin 20 mg Evaluate: Leader Nicotine gum 2 mg An interview was conducted with the Health Information Director (HID/Staff #33) on December 4, 2024 at 1:44 p.m., who stated documents are checked before and after they are uploaded into the medical records system. She stated that if incorrect records are found, the issue would be immediately corrected. She reviewed Resident #64 ' s clinical records and stated that New Admission Medication Reviews dated June 12, 2023 were that of another resident. She also indicated that the records were inaccurately placed in Resident #64 ' s records. An interview was conducted with the Director of Nursing (DON/Staff #141) on December 4, 2024 at 2:00 p.m., who stated that all resident records should be held privately in the online system. She reviewed Resident #64 ' s clinical record and stated that another resident ' s New Admission Medication Reviews were incorrectly placed in Resident #64 ' s clinical record. She also stated that this did not meet her expectations and should be corrected immediately, as this was private resident information. Review of a policy titled, Confidentiality of Information and Personal Privacy, document revealed that the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. Review of a policy titled, Resident Rights, revealed that Federal and State laws guarantee basic rights to all residents that include privacy and confidentiality. The policy further revealed that the unauthorized release and access to resident information is prohibited.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that residents are free from abuse from other residents. The deficient practice could result in residents being physically and emotionally injured. Findings include: Resident #8 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, mild cognitive impairment of uncertain or unknown etiology. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 13 indicating the resident was cognitively intact. A provider progress note dated August 13, 2024 revealed resident #8 and resident #26 who reside on Sunset Secured Behavioral Unit had a verbal altercation in the dayroom. The note stated that staff were present and able to immediately separate the two residents. The note stated Resident #8 currently was on one-on-one staff supervision and ongoing investigation was in progress to collect more details. The note stated DHS (Department of Health Services), APS (Adult Protective Services), Ombudsman, Police, Provider, Case manager and responsible parties were notified. The care plan dated June 24, 2024 revealed that the resident has potential for impaired thought processes r/t diagnosis of dementia. -Resident #26 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, recurrent, unspecified, post-traumatic stress disorder, unspecified, dementia in other diseases classified elsewhere, unspecified severity, with agitation, generalized anxiety disorder The care plan dated May 8, 2024 revealed that the resident is/has the is/has potential to demonstrate verbally abusive behaviors related to major depressive disorder, pos traumatic stress disorder, dementia with agitation, anxiety disorder as exhibited by thinking people are outside his window and trying to kill him, paranoid delusions, visual hallucinations. Review of the behavioral health care plan dated June 10, 2024 revealed a risk assessment for identified behavioral triggers. The identified triggers were being around people, noise, and when unable to express himself properly and/or loses his thought when speaking. The quarterly minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 10 indicating the resident had moderate cognitive impairment. Further review of the MDS revealed resident presented with delusional behaviors. A progress note dated August 13, 2024 revealed a Change in Condition/s (CIC) reported on this CIC Evaluation are/were: Behavioral symptoms (e.g. agitation, psychosis) and a verbal altercation between resident # 8 and #26. Staff present and able to immediately separate the two residents. [NAME] currently on one-on-one staff supervision. ON going investigation in progress to collect more details. DHS, APS, Ombudsman, Police, Provider, Case manager, responsible parties notified. Review of the Clinical Census revealed resident #26 was moved to a different secured unit August 16, 2024. Review of an interview statement dated August 13, 2024 by a certified nursing assistant (CNA/staff #241), revealed that she observed resident #26 swinging his fists in the air with (CNA/staff #209) and (LPN/registry staff #17) in between resident #26 and #8. She stated she never observed any physical contact between the two residents. Review of an interview statement dated August 13, 2024 revealed that a licensed practical nurse (LPN/registry staff #17) revealed that upon leaving another residents room she saw residents #26 and #8 about to get physical with (CNA/staff #209) trying to separate them by physically holding their chests apart as resident #8 was trying to defend himself and put his hand towards resident #26's face, to keep him away. The statement revealed the two were able to be immediately separated with no injuries. An interview was conducted on August 26, 2024 at 12:20 p.m. with resident #8 who stated he was sitting in the front area about approximately 15 ft from resident #26. He stated resident #26 stared at him for a full hour. Resident #8 stated he approached resident #26 and asked if he had an issue with him with no response. Resident #8 stated he changed places in the room, but he continued to stare at him. Resident #8 stated he approached resident #26 again and told him it really bothers him. He stated resident #26 used profanity and shoved him in the chest and hit him on the right side of his chin with a closed fist. Resident #8 stated he landed a closed fist twice on the chest and once in the face of resident #26. then it was broken up by staff. Resident #8 stated he walked away. He stated he saw him once following the incident, but nothing was said and that they moved him somewhere else. He said he had no bruises. An interview was conducted on August 26, 2024 at 12:28 p.m. with (CNA/staff #174) who stated resident #26 was moved to an all-male high acuity unit with a lower census. She stated she was informed resident #26 was moved due to an altercation with resident #8 and that resident#8 was placed on 1:1 supervision 24/7 for a period of 3-4 days until resident #26 was discharged from the unit. Staff #174 stated they are trained to de-escalate and make sure the residents are kept apart if there was an issue and to inform the supervisor. An attempt was made to interview resident #26 August 26, 2024 at 12:38 p.m., but was observed to be confused and unable to express his thoughts. An interview was conducted on August 26, 2024 at 12:40 p.m. with (LPN/staff #130) who stated resident #26 was moved to the unit one week prior due to an altercation with another resident. She stated resident #26, is extremely confused, can be physical and verbally aggressive and is easily agitated. She stated there have been no further incidents with resident #26 since his move to the unit. Staff #130 stated that she has received training on abuse and physical abuse includes striking, grabbing, and pulling. Review of the facility investigative report revealed it was unsubstantiated by the facility due to no willful intent and no actual physical contact between the two residents. It was noted resident #26 was being monitored for change of condition due to delusional behaviors. An interview was conducted on August 26, 2024 at 12:57 p.m. with the Director of Nursing (DON/staff #229), who stated that resident #26 and #8 were on the unit sitting on opposite sides of the room and resident #8 went up to resident #26 thinking he had spoken to him when the altercation happened. She stated the CNA was able to come between them and separated them and no one was hit. She stated abuse occurs when harm is inflicted on a resident and can be physical, mental, misappropriation, isolation, restrained, and sexual and it is the facility's responsibility to report within two hours, including providers. She stated that a 5-day investigation was completed and the allegation of abuse was unsubstantiated. The facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on clinical record review, staff interviews and facility documentation and policy review, the facility failed to ensure that 3 residents (#20,#15, #127) are free from abuse. The deficient practice could result in residents not protected from further abuse. Findings include: Regarding resident #20 and resident #152 -Resident #20 was admitted on [DATE] with diagnoses of Huntington's disease, schizoaffective disorder, anxiety disorder, major depressive disorder, and alcohol dependence. A review of the clinical record revealed a BIMS (Brief Interview for Mental Status) score of 0 indicating the resident had severe cognitive impairment. It also included that the resident had a history of yelling, throwing things, pacing, wandering, refusing cares, cursing and hitting staff. -Resident #152 was admitted on [DATE], with diagnoses that included Huntington's disease, bipolar disorder, PTSD (post-traumatic stress disorder), significant history of abuse and methamphetamine use. Review of the clinical record revealed the resident had a BIMS score of zero indicating the resident had severe cognitive impairment. The facility self-report submitted to the SA (State Agency) on December 6, 2022 revealed that resident #152 got up from her seat during dinner time and walked over to resident #20 and started punching resident #20 in the face with closed fists four to five times. Per the documentation, resident #152 then walked back to her chair in the day room and sat down. The facility report included a signed witness statement dated December 6, 2022 by the certified nurse assistant (CNA/staff #207) who wrote that during dinner time in the dayroom at 5:40 p.m., resident #152 got out of her seat, walked over to resident #20 who was sitting and watching television. According to the written statement, resident #152 started punching resident #20 in her face four to five times with a closed fist. Further review of the report included a signed witness statement dated December 6, 2022 by a registered nurse (RN/staff #212) who wrote that the RN left dayroom when dinner was winding down and went to chart at the nurses' station; and that, the CNA (staff #207) reported the attack to the RN; and that, both residents were separated immediately. The statement also included that resident #152 was removed from the dayroom and the RN administered an ice pack the PRN (as needed) pain medication to resident #20. Regarding resident #153 and resident #15 -Resident #153 was admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder due to alcohol related dementia, post-traumatic stress disorder, anxiety, depression, violent behavior, and alcohol abuse. The care plan dated September 6, 2022 revealed that the resident had impaired thought processes related to alcohol induced dementia and had a history of wandering and physical aggression. Review of the clinical record revealed the resident had a BIMS score of 13/15 indicating the resident was cognitively intact. -Resident #15 was admitted to the facility on [DATE], with diagnoses of schizoaffective disorder, personality disorders, anxiety disorder, severe dementia with agitation, alcohol dependence and insomnia. The care plan dated November 23, 2015 revealed that resident #15 exhibited intrusive wandering, had history of sexually inappropriate behavior, hallucinations, disruptive yelling, and exit-seeking. The clinical record revealed that resident #15 had a BIMS score of 1/15 indicating the resident had severe cognitive impairment. A review of the facility self-report that was submitted to the SA on June 2, 2023 revealed that resident #153 pushed resident #15. Per the documentation, on June 2, 2023, at 11:00 a.m. resident #153 reported that resident #15 came into his room; and that, resident # 15 started touching his stuff so he told resident #15 to get out of his room. It also included that resident #15 did not get out so he pushed resident #15 on her upper chest with his palms and resident #15 stumbled backwards and then left his room. The report included an interview the facility conducted on June 2, 2023 with a licensed practical nurse (LPN/staff #11) who reported that resident #153 reported to her that resident #15 was trying to go into his room; and that, he told resident #15 to stop but resident #15 continued to try to go into his room anyway so he pushed resident #15 who bumped the door. The report further included an interview with a registered nurse (RN/staff #165) conducted on June 2, 2023. Per the documentation, the RN stated that the RN was in the dayroom when LPN/staff # 11 came and saida resident # 15 had received physical aggression from resident # 153 and that resident # 15 went into resident # 153's room and was told by resident # 153 to get out but did not, so resident # 153 grabbed her and shoved resident # 15 towards the door. Regarding resident #127 Resident # 127 was admitted to the facility on [DATE], with diagnoses that included history of falls and alcohol use, altered mental status including hallucinations, asthma, COPD (Chronic Obstructive Pulmonary Disease), type 2 diabetes and anxiety. A review of resident # 127's clinical records revealed that resident # 127 had been assessed with a BIMS score of 10/15, indicating moderately impaired cognition. A review of the facility self-report to the SA on January 19, 2023, revealed that, CNA/staff # 210 observed LPN/staff# 211 attempted to administer medication to resident #127, then she observed LPN/staff# 211 open handedly hitting the side of resident # 127's head to arouse resident # 127. CNA/staff # 210 observed LPN/staff# 211 moved resident # 127's upper extremities in a circular motion in attempt to assist resident # 127 in getting resident # 127's medicine down and CNA/staff# 210 also observed resident # 127 was coughing after medication was administered by LPN/staff# 211. A review of LPN/staff # 211's witness statement dated January 19, 2023, stated that the LPN (staff#211) could not arouse resident # 127 by holding resident's #127 shoulder so the LPN shook resident #127 and called resident # 127's name. Then the statement stated the LPN tapped resident # 127 on the head with open hand with palms while calling resident #127's name to get resident # 127's attention. After the resident # 127 responded by verbal grunt, the LPN asked resident # 127 if he was okay, to which the resident # 127 responded with a yes. So, The LPN continued to pour lesser amounts of fluid, waiting for swallow reflux. The statement further stated the CNA/staff # 210 who was in the resident's room the whole time asked the LPN, aren't you being kind of rough? and the LPN answered stating that was the only way the LPN knew to make sure resident # 127 did not choke. The LPN stated of being rough. A review of CNA/staff# 210's witness statement dated, January 19, 2023, stated that the CNA questioned the LPN/staff # 211 if the resident was going to be medicated because the resident was not even waking up. The LPN/staff # 211 had replied saying yes because the doctor had told the LPN to medicate the resident. The CNA stated staying in resident #127's room, The CNA then stated with an open hand, using the whole inside of LPN/staff # 211 hand, LPN/staff # 211 started hitting resident # 127's right side of the head to try to wake up resident # 127 and then LPN/staff #211 palmed the top of resident # 127's head and started shaking resident #127's head in a circular motion so resident # 127's medicine could go down. The statement revelaed that the CNA told LPN/staff # 211, Hey what are you doing? You are hurting him and hitting him very hard. LPN/staff # 211 stated, Yes, I know. I know that is abuse. If you want to report me, go ahead. So then, LPN/staff # 211 gave resident # 127 juice to have the medicine go down and resident # 127 started coughing a little. I stayed in resident # 127's room until LPN/staff # 211 exited resident # 127's room together. Resident # 20 Resident # 20 was admitted to the facility on [DATE], with diagnoses that included Huntington's disease, schizoaffective disorder, anxiety disorder, major depressive disorder, and alcohol dependence. A review of resident # 20's clinical records revealed that resident # 20 had been assessed with a BIMS score of zero, indicating severe memory impairment. Resident # 20 had a history of yelling, throwing things, pacing, wandering, refusing cares, cursing and hitting staff. A review of the facility self-report submitted to the SA on December 28, 2022, revealed that night shift CNA/staff # 22 stated that she was scheduled to work on December 27, 2022 from 10:00pm to 6:00am. CNA/staff# 22 stated that when she walked in the doors, CNA/staff #22 saw registry CNA/staff# 212 and RN/staff# 213 in front of resident # 20's room. CNA/staff#22 saw staff # 212 holding resident #20's door shut with a resident gown tied from resident # 20's room doorknob to the hallway side rail. A review of a signed witness statement by registry CNA/staff # 216 on December 29, 2022, stated that, while coming on shift, I saw the evening shift had a night gown tied to resident # 20's room door. CNA/staff # 22 was by resident #20's room door, untying the gown from it. A review of a signed witness statement by night shift LPN/staff# 29 on December 27, 2022, stated that, I received report from CNA/staff # 22 and CNA/staff # 216 that they witnessed possible abuse towards resident #20. LPN/staff # 29 confirmed the statement by CNA/staff # 22 regarding CNA/staff 212 holding resident # 20's room door shut with a gown tied from the room doorknob to the hallway side rail. LPN/staff # 29 reported this allegation to the DON/staff # 149 (Director of Nursing). An interview regarding current practice on abuse with LPN/staff # 59 on June 12, 2024, at 12:45pm was conducted. LPN/staff # 59 stated that all staff receive training on abuse and neglect during new employee orientation and those are ongoing during meetings and individualized training. An interview regarding current practice on abuse with ADON/staff # 7, on June 12, 2024, at 10:40am, was conducted. ADON/staff # 7 stated that abuse and neglect procedures are taught during new employee orientation, then discussed at every staff meeting. Additional training is provided to staff, individually, based on need. A review of the facility's policy on abuse, dated April 2021, and it states, residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on clinical record review, staff interviews and facility documentation and policy review, the facility failed to identify residents who are at risk of unsafe wandering. The deficient practice could result in physical injury. Findings include: Resident #154 was admitted on [DATE] with diagnoses of aphasia, stroke, muscle weakness, abnormalities of gait and mobility, altered mental status and repeated falls. A review of the hospital history and physical note dated March 11, 2023 revealed that resident was alert and oriented to person and place only. The baseline care plan dated March 16, 2023 revealed that the resident was confused. The wandering risk assessment dated [DATE] revealed the resident was found to be disoriented and can be disturbed by environmental noise levels. The wandering risk assessment dated [DATE] included the resident was found to be forgetful/short attention span and known wanderer or had a history of wandering. A progress note dated March 21, 2023 revealed the resident was outside with the police due to wandering through a residential neighborhood south of the facility. Per the documentation, the resident was previously seen in his room at 5:55pm by a certified nurse assistant (CNA/staff # 208). The documentation also included that the resident was agitated, had a small skin tear to the posterior left hand, was resistive to returning to the facility; and, was placed on a one-on-one monitoring. A review of the facility self-report submitted to the SA (state Agency) on March 21, 2023, revealed that at approximately 6:40 p.m. on March 21, 2023, resident #154 was seen by a neighbor walking down the street just south of the facility; and, was returned to the facility by the police. Per the documentation, the resident exited the facility through his room window which had been opened and the screen was pushed out. An interview with the assistant Director of Nursing (ADON/staff #7) was conducted on June 12, 2024. The ADON stated that stations one and two were not locked or secured; and that, the level of independence of each resident in the unit was determined by risks and cognition levels of each resident. A review of the facility's policy on Wandering and Elopement dated March 2019 included that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; and, if identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to provide supervision for two residents (#1 and #2) that resulted in an altercation. The deficient practice could result in residents being injured. Findings include: Regarding Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses that included borderline personality disorder, anoxic brain damage, and unspecified psychosis. The care plan dated August 29, 2023 revealed that resident #1 had the potential to demonstrate verbally abusive behaviors related to anoxic brain injury, major depressive disorder, unspecified mood disorder, anxiety disorder, violent behavior, restlessness and agitation. Interventions included to intervene before agitation escalates; guide away from source of distress; and engage calmly in conversation. If the resident's response is aggressive, staff to walk calmly away, and approach later. The resident behavior plan dated January 1, 2024 revealed that the resident is at risk for the behavioral symptoms: striking out, grabbing others, combativeness, and being physically or verbally abusive. The resident will spit at staff when her requests aren't met; make allegations about staff and threaten to have them suspended. She's verbally abusive towards staff and refuse care. Behaviors are related to a personality disorder, anoxic brain injury, major depressive disorder, anxiety disorder, violent behavior, restlessness and agitation. Interventions included to observe whether the behavior endangers the resident and/or others, staff are to intervene if necessary, removing others from the surrounding area, and reduce stimulation: noise, crowding, and other physically aggressive residents to the extent possible. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score 15 indicating the resident was cognitively intact. A progress note dated March 12, 2024 at 4:26 p.m. by a licensed practical nurse (LPN/staff #602) revealed that it was reported to her that resident (#1) was seen kicking a peer. The peer was immediately removed from the situation, one-to-one staff to resident ratio was initiated immediately. Resident #1 continued to be combative with staff, striking staff in the chest and arms. A progress note dated March 12, 2024 at 9: 56 p.m. revealed a change of condition (COC), which included physical aggression, verbal aggression, and danger to self and others. Physician recommended that resident #1 be transferred to the emergency room for a psychiatric evaluation. A progress note dated March 13, 2024 at 4:26 p.m. stated that resident #1 arrived approximately at 3:55 p.m. via stretcher from the hospital. Resident is a one-to-one certified nursing staff (CNA) at all times and two staff to provide care for all needs. A physician's progress note dated March 14, 2024 at 9:10 a.m. revealed that resident #1 was transferred to a psychiatric unit due to alleged physical abuse to another resident and to a staff member. Resident #1 stated that she did not hit resident #2, who had wandered into her room. Resident #1 stated that she was trying to wake resident #2 up by tapping resident #2 with her hands, so resident #2 would go to her room. The accusation was that resident #1 was seen kicking resident #2; however, resident #1 had limited use of the lower left extremity and lacks the strength related to quadriplegia to kick the other resident. Review of facility documentation dated March 15, 2024 revealed that on March 12, 2024 at approximately 5:45 p.m., the Director of Nursing (DON) received a call from a LPN (staff #602). Staff #602 reported that resident #1 was yelling and threw a box of crayons across the dining room and it almost hit another resident. The DON instructed staff #602 to remove all the other residents from the dining room for safety and staff #33 would work on finding another staff, to provide one-to-one supervision with resident #1. Within several minutes, staff #602 contacted the DON a second time to report that a CNA stated that resident #1 had hit another resident. Regarding Resident #2 Resident #2 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, dementia with psychotic disturbance, and major depressive disorder. A care plan dated November 23, 2015 revealed that resident #2 had diagnoses of dementia with behavioral disturbances, anxiety, psychosis, hallucinations, insomnia, and a history of traumatic brain injury. She exhibits intrusive wandering, self-injurious behaviors by sticking her fingers in her throat to induce vomiting. She has a history of sexually inappropriate behavior, inappropriate urination/defecation, hallucinations, resistive/combative with care, disruptive yelling, and exit seeking by hovering and pushing exit doors. Review of a wandering risk assessment dated [DATE] revealed a score of 11 indicating the resident is a high risk for wandering. The MDS assessment dated [DATE] did not include a brief interview for mental status because the resident was not able to answer the questions. Review of the weekly behavior notes dated February 29, 2024 and March 7, 2024, revealed that resident #2 continues to be intrusive and wandering into peer's spaces on the unit. The resident continues to pace back and forth in the hallway. The resident is resistive at times when redirected from staff and will continue to exit seek. Staff redirects the resident multiple times per shift with coloring, word searches, and conversation with minimal effectiveness. A progress note dated March 12, 2024 revealed that resident #1 was seen kicking resident #2. Resident #2 was unable to verbalize appropriately, but did not appear affected during the evaluation. Resident #2 was removed from resident #1's bedroom and her safety was ensured. Review of the weekly behavior notes dated March 21, 2024 and May 4, 2024, revealed that resident #2 continues to be intrusive and wandering into peer's spaces on the unit. The resident continues to pace back and forth in the hallway. The resident is resistive at times when redirected from staff and will continue to exit seek. Staff redirects the resident multiple times per shift with coloring, word searches, and conversation with minimal effectiveness. An interview was conducted on April 5, 2024 at approximately 2:00 p.m. with (LPN/staff #602), who stated that resident #1 was in the dining room with the other residents for dinner and started yelling and threw colored pencils. She had staff remove the other residents because resident #1 was escalating. When resident #1 received her dinner, she began banging her silverware. She stated that she instructed (CNA/staff #404) to supervise resident #1 to make sure that the resident did not leave the dining room and disrupt the other residents who were eating dinner in the hallway, while she called the DON. She stated that the DON told her that she was going to work on getting a one-to-one staff to supervise resident #1. Resident #2 was eating dinner in the hallway by her room, which is just across from resident #1's room. Then the staff started cleaning up the dinner trays when she heard (CNA/staff #58) yelling help and she ran down to resident #1's room where resident #2 was lying on the floor and resident #1 was punching staff #58. She stated that (CNA/staff #404) was supposed to supervise resident #1 and she didn't know where staff #404 had gone. She stated that resident #1 was upset because resident #2 was in her room. An interview was conducted on April 5, 2024 at 2:22 p.m. with a CNA (staff #25), who stated that she was in a resident's room assisting the resident with eating, when she heard resident #1 yelling, get out. She went to resident 1's room, and saw CNA (staff #58) standing between resident #1 and resident #2, and resident #1 was still yelling, get out. She stated that she and a LPN (staff #602) got resident #2 off of the floor and took her out of the room. She stated that resident #2 is supposed to be supervised to keep her from wandering into other residents' rooms and there is supposed to be a CNA monitoring the hallway. She stated that resident #1 has a right to privacy and was upset because resident #2 was in her room. An interview was conducted on April 5, 2024 at 2:44 p.m. with a CNA (staff #58), who stated that she was assigned to monitor the hallway and could hear resident #1 yelling in the dining room. Then, staff were told to move the residents from the dining room into the hallway and their rooms for dinner. Resident #2 requires assistance with eating, but she didn't remember which staff was helping her, while she was assisting another resident. She stated that when the residents were done eating, she went into the dining room to pick up resident #1's tray and the resident was not there and then she heard yelling coming from resident 1's room. She ran to the room and resident #1 was in her wheelchair very close to resident #2, who was lying on the floor. Resident #1 was yelling at resident #2 to get up and tapping her very slowly and lightly with her foot. She stated that she tried to get resident #1 up and resident #2 starting hitting her in the chest. The nurse and another CNA came into the room and took resident #2 out of the room. She was aware that resident #1 was transferred to the hospital, but didn't know the reason for the transfer. An interview was conducted on April 5, 2024 at 3:26 p.m. with the DON, who stated that there are residents who wander on the unit and staff are trained to redirect the residents. She stated that one of the CNAs is supposed to monitor the hallway because some of the residents have behaviors and to prevent accidents. She stated that when she was notified about resident #1's behaviors, she began looking for a staff to provide one-to-one care. It was her expectation that staff monitor resident #1 and keep the other residents safe, which is what they did by removing the other residents from the dining room away from resident #1. The facility policy, Wandering and Elopement stated that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Based on observation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure one resident (#24) received the assistance needed, which was based on the comprehensive assessment, with teeth brushing. The deficient practice could result in tooth decay and gum disease. Findings include: Resident #24 was admitted to the facility on [DATE]. 2023 with diagnoses that included unspecified dementia, immunodeficiency, and anxiety disorder. A care plan dated December 14, 2023 for ADL mobility decline and requires assistance related to cognitive impairment, fracture, pain, recent hospitalization , weakness included the intervention to assist with setup for hygiene. The care plan for impaired vision function related to blindness dated November 25, 2023 included the intervention to monitor, document, and report to the physician changes in ability to perform ADLs. The minimum data set (MDS) dated [DATE] included an assessment for ADLs and the resident required substantial/maximal assistance with a goal of supervision or touching assistance. Review of the oral hygiene task sheet revealed: -November 28, 2023, brushed teeth one time with set-up assistance -December 3, 2023, brushed teeth one time independently and one time with set-up assistance -December 4, 2023, brushed teeth one time with substantial/maximal assistance -December 6, 2023, brushed teeth zero times -December 7, 2023, brushed teeth one time and was dependent -December 8, 2023, brushed teeth zero times -December 9, 2023, brushed teeth one time with supervision/touching assistance -December 10, 2023, brushed teeth with one time with partial/moderate assistance -December 11, 2023, brushed teeth one time with substantial/maximal assistance -December 17, 2023, brushed teeth one time with substantial/maximal assistance During an interview conducted on December 20, 2023 at 8:51 AM with resident #24, the resident's teeth were observed to be yellowish in color and there was white substance between the teeth and along the gum line. The resident stated that staff do not help him brush his teeth. An interview was conducted on December 20, 2023 at 10:22 AM with a Certified Nursing Assistant (CNA/staff #50), who stated that she was trained to assist the resident's with activities of daily living (ADL), which includes teeth brushing, and based on her training, the residents' teeth are supposed to be brushed in morning, after meals, and at night before bed. She stated that she has assisted resident #24 with brushing his teeth because he is blind and the resident will also ask to have his teeth brushed. She stated that after she assists the resident with brushing his teeth, she documents that the task was done on the task sheet and if the task sheet is marked as, not applicable, it means the task did not occur on that day. An Interview was conducted on December 20, 2023 at 10:46 AM with a Licensed Practical Nurse (LPN/staff #8), who stated that she has been trained to assist residents with ADL care, which includes brushing teeth, and should be done twice a day. She stated that the CNAs assist with teeth brushing and resident #24 needs assistance with setup. It is her expectation that the resident's teeth are brushed twice a day, once in the morning and once in evening, and if the resident requests it. If teeth brushing is not done, there is a risk of tooth decay. An interview was conducted on December 20, 2023 at 11:30 AM with the Director of Nursing(DON/staff #1), who stated that staff are trained to assist with oral care at least twice a day, as needed, and if the resident requests it. She also stated that if the staff are documenting, not applicable, on teeth brushing task sheet, it means that she needs to educate the staff on how to get credit for there work. She stated that there is a risk of dental decay and dentition if teeth are not being brushed at least twice a day. The facility's policy Activities of Daily Living (ADLs) Supporting dated March 2018 states that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on clinical record review, resident and staff interviews, and facility policy and procedures, the facility failed to ensure transportation arrangements to and from an outside appointment was provided to two residents (#60 and #98). to The deficient practice could result in residents being physically and emotionally harmed. Findings include: Resident #60 was admitted on [DATE] with diagnoses of hemiplegia affecting the left dominant side, morbid obesity, type II diabetes, and depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact. It also included the resident required a two-person assist with transfers and toileting, was totally dependent and was always incontinent of bowel and bladder. Mobility devices included a wheelchair. The care plan dated June 10, 2022 revealed the resident was incontinent of bowel and bladder and was at risk for skin breakdown. Interventions included to assist with toileting transfer and hygiene and incontinent pericare as needed. A pressure ulcer care plan initiated on June 10, 2022 included that the resident was a high risk or at risk for pressure ulcer development or skin impairment related to bladder and bowel impairment, diabetes, muscle weakness and impaired/decreased mobility and functional ability. Interventions included to apply cream to extremities as needed; to assist, remind, and encourage the resident to reposition frequently and as tolerated when in bed/chair; to identify potential causative factors and eliminate/resolve where possible; and, to provide incontinent care as needed. The care plan initiated on November 15, 2022 revealed that the resident had shortness of breath. Interventions included use of inhalers every 4 hours, encourage sustained deep breaths, and, to pace scheduled activities providing adequate rest periods. An outpatient progress note dated January 30, 2023 revealed that resident had an appointment with the therapy office for evaluation and treatment of left-hand contractures. It also included that the resident had spasticity to most of the upper extremity of unknown cause; and, had limited range of motion/strength that was limiting independence in daily occupations, such as grooming with left hand opening items, and writing. Per the documentation, the physician order was for 4 to 6 weeks of therapy, 3 times a week. The clinical record revealed that the resident was picked up from the facility on February 8, 2023 at 2:15 p.m. An outpatient progress note revealed the resident had a therapy appointment on February 8, 2023 at 3:30 p.m. Review of the facility's resident log in and log out sheet revealed that the resident signed out of the facility on February 8, 2023 at 2:15 p.m.; and, signed back into the facility at 8:00 p.m. (approximately 6 hours after) The therapy office documentation dated February 9, 2023 revealed the therapy office staff contacted the transportation company on February 8, 2023 at 3:48 p.m. and was told that the driver would arrive in 30 minutes. Per the documentation, the therapy office staff called the transportation company at 4:41 p.m. and was informed that a driver would pick the resident up in 30 minutes to an hour. It also included that the resident called the facility multiple times after 6:00 p.m. and was informed by the nurse that the transportation driver would arrive in about half an hour. The documentation included that the resident told the therapy staff that she would leave for the facility on her own if her ride did not show up. Further, the documentation included the resident called the therapy office on February 9, 2023 to inform the clinic that she left the clinic to go back to the facility in her wheelchair at 7:00 p.m. when the clinic closed. Further, the note included that a therapy staff stopped the resident her by the gas station and told the resident that the driver had arrived, that the driver was not able to pick the resident up at the gas station so the resident had to go back to the therapy clinic. It included that the resident was then transported back to the facility and arrived around 8:00 p.m. A resident grievance/complaint investigation report was filed by resident #60 on February 9, 2023 and it included that the resident expressed her concern with transportation not being timely. Per the documentation, the facility spoke to the resident, notified the insurance company, and notified the transportation company. The plan was for the insurance company to monitor the resident's transports for timeliness. Review of facility documentation revealed that the medical records assistant (staff #68) filed a complaint on behalf of the resident regarding the incident on February 8, 2023. The documentation included that the resident informed staff #68 that resident did not make it back to the facility until 8:00 p.m. at night and was cold, hungry, and very upset. It also included that resident #60 reported that she called the transportation company many times and was told that the driver would be there in 30 minutes from 3:48 p.m.; and that, the staff at the therapy office called the transportation company at 4: 41 p.m. and was informed that the driver would be there in 30 minutes to an hour. Per the documentation, resident reported that transportation showed up at 7:00 p.m. and the therapist stopped at the gas station where the resident was to let the resident know that the driver had arrived. It also included that the resident went back to the therapy office to be transported back to the facility. During an interview conducted with resident #60 on March 13, 2023 at 10:03 a.m. she stated that she was transported to a therapy appointment on February 8, 2023 at 3:30 p.m. and when the appointment was finished, the driver did not come to get her. She stated that she called the facility and told the nurse that no one came to get her. She stated she thought that she could make it back to the facility in her wheelchair and left the therapy office, but only made it to the gas station. She stated that the driver picked her up at 8:55 p.m. and she had to go back to the therapy office because the driver to pick her up at the gas station. Resident #60 further stated that she was cold and afraid at that time. An interview was conducted on March 14, 2023 at 9:46 a.m. with the medical records director (MRD/staff #60) who stated that once a medical appointment is scheduled, the medical records assistant (MRA/staff #68) is responsible for scheduling transportation to and from the appointment. The MRD stated that staff #68 uses the transportation company that was covered by the resident's insurance. She stated that a transportation form is completed and the information is provided to the resident, but it is usually the medical office that will call transportation when the appointment is completed. However, the MRD said that the resident may call if he/she have their own cell phone. The MRD said that staff #68 needs to call the office and confirm the appointment, and when she confirms the appointment, she asks how long the appointment is going to take (this is an estimate) and it is an expectation that transportation pick the resident up within 30 minutes of the appointment being completed. She stated that if the transportation company did not pick the resident up from his/her appointment, the facility staff would contact the transportation company to see how much longer the resident was going to wait; and, the facility could also use another transportation company who could usually get the resident picked up within 30 minutes. She stated that there was a risk of something happening to the resident if left after dark and/or the medical office is closed; and that is why the facility try to schedule early appointments. The MRD stated that the resident could fall, someone could get them, or a resident could go into traffic and get hurt. During the interview the MRD reviewed the calendar and confirmed that resident #60 had an appointment with an outside therapy office on February 8, 2023. The MRD stated that there was no documentation found in the record showing that staff #68 confirmed the therapy appointment, asked how long the appointment was going to last, or contacted the transportation company to arrange for transportation back to the facility after the therapy appointment was completed. The MRD stated that the lack of documentation meant that transportation from the appointment back to the facility was not arranged. She also stated that she was not able to find the binder with a copy of all the transportation forms, so she could not confirm if transportation to and from the therapy appointment had been arranged. The MRD stated that it was her understanding that resident #60 left the therapy office and attempted to get back to the facility, but only made it to the gas station; and that, the resident returned back to the therapy office because the transportation driver would not pick her up at the gas station. She stated that resident #60 told her it was already dark. An interview was conducted on March 14, 2023 at 12:58 p.m. with the Social Services Director (staff #4), who stated that resident #60 made a complaint that transportation not showing up to pick her up on February 8, 2023 at 3:48 p.m. Staff #4 stated that she received a statement from the therapy office staff stating that the therapy staff called the transportation company at 4:41 p.m. and was informed that transportation would arrive in 30 minutes to an hour. Staff #4 said that the therapy office staff also reported that the resident called the facility and was told by the nurse that transportation would be there in 30 minutes and the resident left in her wheelchair to the gas station. Staff #4 stated that the resident called the facility at 6:00 p.m. and was told that transportation would arrive at the therapy office in 30 minutes. Staff #4 said that when transportation arrived, therapy staff went to the gas station to tell the resident that transportation could not pick her up from the gas station; and that, the resident returned to the therapy office where she was picked up and returned to the facility around 8:00 pm. Staff #4 stated that the appropriate time to have a resident wait for transportation back to the facility was based on their person-centered needs along with safety. An interview was conducted on March 15, 2023 at 11:02 a.m. with the Director of Nursing (DON/staff #1) who stated that staff #68 was responsible for scheduling appointments and transportation; and that, her expectation was that the transportation form that includes the name of the transportation company, phone number, pick-up time is completed. The DON said that the transportation form should include the time the resident is going to be picked up once the appointment is completed. The DON also said that she was aware that resident #60 waited for more than 2 hours to be picked up from the therapy office. She stated that if transportation does not show up, the resident and/or the outside medical office can call the transportation company; and, the wait time for transportation depends on the individual needs of the resident. The DON said that a resident with no safety awareness, or a resident who is agitated, or wanders may need to be picked up sooner than others and wait time could be up to 30 minutes. She stated that if the resident is in a wheelchair and the family cannot transport resident, it would still be the facility's responsibility to provide the transportation; and that, the estimated arrival time back to the facility is monitored by the team. Further, the DON said that the nurse or medical records would be responsible for following up and determining where the resident is at. 47910 -Resident #98 admitted on [DATE] with diagnoses of end stage renal disease (ESRD), type 2 diabetes mellitus with diabetic chronic kidney disease, nephrotic syndrome with unspecified morphologic changes and dependence on renal dialysis. The care plan revised on September 20, 2022 revealed the resident required hemodialysis related to End Stage Renal Disease (ESRD) three day weekly. The goal was that the resident would have immediate intervention should any signs or symptoms of complications from dialysis occur. Interventions included checking and changing the dressing daily at the access site and documenting. The minimum data set (MDS) assessment dated [DATE] revealed resident had a Brief Interview for Mental Status (BIMS) assessment score of 14, indicating intact cognition. The assessment also included the resident required supervision with activities of daily living, and was receiving dialysis services. A physician order dated January 31, 2023 revealed an order for dialysis Monday-Wednesday and Friday at 1:45 p.m. through 5:15 p.m. with pick up times of 12:45 p.m. and return time of 5:45 p.m. Review of the hemodialysis flow sheets revealed that resident missed the following appointment dates: December 23 and 25, 2022; January 6 and 30, 2023; February 15 and 28, 2023; and, March 13, 2023. The nursing progress note dated March 13, 2023 revealed that the resident missed dialysis because transportation did not show up; and that, attempts were made to reschedule dialysis for the following day was not successful. A review of nursing progress notes dated March 13, 2023 included that there was a change in resident's condition; and that, at the time of the evaluation, the resident's vital signs, weight and blood sugar were as follows: Blood Pressure (BP) 90/53; Pulse 60; Respiratory rate (RR) 18.0; temperature 98.1 degrees Fahrenheit; weight 169.8 lbs. (pounds); pulse oximetry 94%; and blood glucose (BS) 187. A nursing progress note dated March 14, 2023 revealed that resident continued to be on change of condition for missing dialysis on March 13, 2023. An interview was conducted with a licensed practical nurse (LPN/staff #160) on March 16, 2023 at 9:29 a.m. The LPN stated she was given a morning report that resident #98 had a change of condition (COC) due to missing his dialysis appointment related to a transportation issue. She stated the resident received his dialysis on March 15, 2023 (two days after the scheduled dialysis). Staff #160 the risks associated with not receiving dialysis included electrolyte imbalance, fluid overload, tachycardia, shortness of breath, extreme swelling and potential long-term damage to the heart and kidney. An interview was conducted on March 16, 2023 at 11:42 a.m. with health information director (HID/staff #60) who stated that the health information assistant (HIA) who was on vacation at the time of the interview was responsible for arranging residents. She stated she supervises the HIA and arranges for transportation while HIA is away. She stated that when the scheduled transportation does not show up for a resident with a scheduled appointment, the facility will call transportation to see if transportation is on the way and let the resident know. She stated if transport is not coming she would try to find an alternative transportation for the resident. She stated if there was an issue with transportation while the resident is at dialysis, the dialysis center would call and notify the facility. Staff #60 further stated that if the resident was alert and oriented, the resident would also notify the facility; and that, the facility also have sister companies that have vans to use to transport residents. Staff #60 stated that she had not utilized the vans because she was only recently informed by the administrator that she could do so. Staff #60 also said that it was the facility's practice to confirm appointments the day prior the actual appointment; however, the facility was not responsible for this and it is done out of courtesy for the residents. Further, staff #60 stated that she was aware of issues and concerns with transportation companies not picking up residents for their medical appointments and stated there was concern of one company in particular. She stated she has informed the insurance company regarding these concerns. She stated that the previous administrator was also aware of these ongoing issues; and, the new administrator was just recently informed there was an issue with transportation for the residents. Staff #60 stated that her department tracks missed appointments by the sign in and out sheet at the receptionist desk; however, she stated that sometimes she was not aware of the missed appointments until the following day. Regarding resident #98, she stated that she contacted the insurance company on Friday, March 10, 2023 to confirm transportation for resident #98 for the dialysis appointment on March 13, 2023; and that, she was informed that resident #98 was on the transportation list. She stated she informed resident #98 that his appointment was confirmed; however, she said that she did not document in the record that the resident's appointment for Monday, March 13, 2023 was confirmed. She stated resident #98 was supposed to be picked up Mondays, Wednesdays and Fridays at 12:45 p.m. She stated she was aware of two missed appointments for resident # 98; and that, she was not able to find alternative transportation on Monday March 13, 2023 and dialysis did not have room for resident #98 on Tuesday March 14, 2023. She stated she was unable to reschedule the resident until Wednesday, March 15, 2023; and, the physician was notified. She stated that the facility was instructed that if the resident becomes symptomatic to send the resident to the emergency room . Further, staff #60 said that dialysis is very important and is a matter of life and death for a resident. An interview was conducted on March 16, 2023 at 1:38 p.m. with resident #98 who stated that his insurance arranges his transportation for his dialysis appointments. He stated he has never made arrangements for any of his appointments even when his phone worked. He stated that he had a scheduled dialysis appointment on Monday, March 13, 2023; however, transportation never showed up. He stated staff #60 told him that he was not on the insurance's list for transportation; and that, no one told him that the facility had confirmed his appointment for Monday, March 13, 2023 with his insurance. Further, resident #98 stated that he had missed dialysis appointments at least once a month. During an interview conducted with the DON (staff #1) and Administrator (staff #2) on March 16, 2023 at 4:00 p.m., the administrator stated he was aware of the transportation issues, but did not feel the facility should be held responsible when transportation does not show up. He stated the facility makes every effort to retrieve the resident or arrange alternative transportation. The administrator also said that missed dialysis appointments were a concern; and that, the facility was are working on an alternative process. Further, the administrator stated that the facility was not responsible for the transportation company's failure to pick up residents either to or from their scheduled dialysis appointments. The facility's policy titled Transportation, Medical Records revised December 2008 stated our facility shall help arrange transportation for residents as needed. Inquiries concerning transportation should be referred to social services and medical records.

Based on clinical record review, staff interview, facility policy and procedure, the facility failed to ensure one resident (#33) was assessed for medication self-administration. The deficient practice could result in the inappropriate use of medications by residents. Findings include: Resident #33 was admitted on [DATE] with diagnoses of chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease unspecified (COPD), wheezing and cognitive communication deficit. The baseline care plan dated on March 4, 2023 revealed that the self-administration of medications box/section was unmarked. The comprehensive care plan dated March 6, 2023 stated resident had a diagnosis of COPD. The goal was that the resident will display optimal breathing pattern daily and will be free of signs and symptoms of respiratory infections. Interventions included to give aerosol or bronchodilators as ordered. Review of the admission/Medicare 5-day minimum data set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident had an intact cognition. Per the assessment, the resident had adequate hearing, understands verbal content and was able to see adequately with corrective lenses in adequate light. The current physician order recap revealed that the resident was prescribed with the following medications: -Wixela (respiratory inhalant) 500-50, 1 puff inhale orally two times a day for chronic obstructive pulmonary disease (COPD) and to rinse mouth with water after each use; and, -Spiriva Respimat (respiratory inhalant) 2.5 mcg (microgram) 2 puffs by mouth daily for COPD. The clinical record revealed no evidence that the resident was assessed for self-administration of medication. During an observation conducted a licensed practical nurse (LPN/staff #8) on March 13, 2023 at 11:36 a.m. the resident was inside the room and her Spiriva and Wixela inhalers were placed on the bedside table. The LPN immediately removed the inhalers from bedside and placed them back in the cart. An interview with the LPN (staff #8) was conducted On March 13, 2023 at 11:37 a.m. The LPN stated the Spiriva and Wixela inhalers were for the resident's COPD; and that they were accidentally left at bedside with resident #33. The LPN said that medications are brought into the resident room during administration of medication and removed unless resident had been evaluated for self-administration. The LPN said that residents are assessed for medication self-administration; and, whether or not residents can safely administer by following the proper steps. Regarding resident #33, the LPN said that she was not aware if resident #33 was evaluated for self-administration of medication. During the interview, a review of the clinical record was conducted with the LPN who stated that there was no self-administration evaluation found in the clinical record for resident #33. A physician order dated March 13, 2023 revealed that the order for Wixela and Spiriva were revised to include that resident #33 was okay to self-administer her respiratory inhalers without supervision. A self-administration assessment dated [DATE] included that the resident wanted to self-administer medications and was a candidate for a safe self-administration. Further, the assessment included that the resident was able to identify the inhalers, what they are used for and was able to demonstrate proper usage of inhalers and aftercare of medication administration. The comprehensive care plan was revised on March 13, 2023 to included that resident will be respected regarding his right to self-administer medications, Spiriva and Wixela. The goal was that the resident will be able to self-administer own medications safely daily. Interventions included to explain risks and benefits of medications and self-administration, to evaluate resident's ability to self-administrate own medications, medications will be kept at bedside, to monitor medication administration daily, and to re-evaluate resident's ability to self-administrate medications at least quarterly and PRN. An interview was conducted with MDS Coordinator (staff #125) on March 15, 2023 at 12:24 p.m. Staff #125 stated that when a resident is admitted , and MDS assessment is completed and the baseline care plan is developed which always includes the patients urinary, pain, skin and sensory impairment status of the resident. Staff #125 further stated that medication self-administration was also care planned; however, the physician must provide an order stating the resident was able to self-administer medications before having it care planned. Staff #125 stated that she does not do medication self-administration assessment because she does not work as a floor nurse. She stated that the nurses or unit managers are responsible for completing this assessment. During the interview, a review of the clinical record was conducted with staff #125 who stated that the MAR (medication administration record) revealed that Wixela inhaler was administered since March 4 and Spiriva was administered since March 6. However, staff #125 stated that the medication self-administration assessment for resident #33 was only completed on March 13, 2023; and that, a physician order for self-administration of the two inhalers for resident #33 was also only written on March 13, 2023. During an interview with a registered nurse (RN/staff #40) conducted on March 15, 2023 at 02:28 p.m., the RN stated that residents who self-administer medications need to have an assessment and physician order; and that, medications are kept in a locked box and the resident will have the key. The RN stated that she does not have any resident who self-administers medication at this time. The RN said that there was no option to check off in the MAR if the resident had taken the medication; and that, it automatically defaults to administered and it was assumed the resident took the medication. The RN said that if a resident was not taking their medications it would not be too risky as she has only seen rescue inhalers or artificial tears self-administered by the residents. Further, the RN said that if the medications were not left in a locked box, the medications should be removed from the room until a locked box was available in case there was a wandering resident that could get hold of the medications. In another interview conducted with the MDS coordinator (staff #125), she stated that if a resident was permitted to self-administer medication prior to completion of the comprehensive care plan, it would be written in the resident's baseline care plan. During an interview with the director of nursing (DON/staff #1) conducted on March 15, 2023 at 12:09 p.m., the DON stated that it was a resident's right to be able to self-administer medication; and that, the ability to self-administer medication is determined by the interdisciplinary team (IDT). The DON said that the IDT ensures that the resident is cognitively intact, able to carry out the responsibility, and, understands the timing and dose of medication and which side effects to report to staff as well. The DON further stated that the nurse has to perform education and teach-back as part of the education which would be in tandem with getting orders from the physician; and that, there should be a physician order for self-administration and it should be care planned. The facility policy on Medication Administration included that medications are administered as prescribed in accordance with the manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. The facility policy on Self-Administration by Resident revealed that residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration.

Based on facility documentation, observations, staff interviews, and policy review, the facility failed to ensure that refrigerator and freezer temperatures were consistently monitored. The deficient practice could result in unsafe food temperatures and placing residents at risk for foodborne illnesses. Findings include: Review of the temperature log for the walk-in refrigerator and freezer from February through March 13, 2023 revealed that temperatures for the refrigerator were not recorded on March 11, 12, and 13; and, there were no freezer temperature logs found. Further, temperature log included an instruction that the temperature was to be recorded once a day for the refrigerator. An interview with the dietary director (staff #91) was conducted on March 13, 2023 at 8:43 a.m. She stated the process included checking the temperatures of all refrigerators and freezers once a day in the morning. Staff #91 stated the logs were not completed on March 11 through 13 was over the weekend; and that, she did not know why the staff did not document the temperatures over the weekend. During an interview with the registered dietician (RD/staff #161) conducted March 16, 2023 at 2:22 p.m., the RD stated the facility has no policy for maintaining temperature logs for the freezer. She stated that it was the facility's best practice to record refrigerator and freezer temperatures; however, she said that it was not a regulation. She stated as long as the food is solid as a rock there was no problem; and that, the food code has not changed. Further, the RD stated that she felt that the cooks and majority of people know what solid means and if the food did not appear solid then they would inform the dietary director. The facility policy on Food safety and Sanitation included that all local, state and federal standards and regulations will be followed in order to assure a safe and sanitary department of food and nutrition services. Stored food is handled to prevent contamination and growth of pathogenic organisms. Refrigerated food is stored at or below 41 degrees F. Frozen food is stored at a temperature that keeps them frozen solid.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure used oil barrel was disposed of correctly. The deficient practice could result in unsanitary condition promoting the pest infestation. Findings include: During the kitchen observation with the dietary director (staff #91) conducted on March 14, 2023 at 9:28 a.m., there was a large overfilled oil barrel and approximately 2-3 feet of oil on the cement surrounding the oil barrel in the dumpster area. An interview with the dietary director (staff #91) was conducted immediately following the observation. Staff #91 stated she was aware of the spillage and the overflow and had tried to clean the area with no success. She stated the risks of having oil spillage with exposed oil and sediment can draw rodents and insects. She stated she would notify the administrator and have him contact the company that is supposed to take care of the oil barrel. An interview was conducted on March 15, 2023 at 2:40 p.m. with the administrator (staff #2) who stated that with the new purchase of the facility they are trying to correct a lot of issues. He stated he reached out to the previous company responsible for waste disposal, but they were no longer contracted with the facility. He stated he was able to have a company come out and dispose of the oil barrel and place a new one and clean the area. The administrator further stated that the area was unsanitary and could draw pests to the facility. The facility's policy, Food Safety and Sanitation states all local and federal standards and regulations will be followed in order to ensure a safe and sanitary department of food and nutrition services.

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure that medications were available for one resident (#12). The sample size was 24. The deficient practice could result in residents not receiving their medications in a timely manner which may cause adverse effects. Findings include: Resident #12 was admitted [DATE] with diagnoses that included [CONDITION(S)] and [CONDITION(S)] following a cerebral infarction, polyneuropathy and hypertension. The care plan initiated on [DATE] included interventions that medications are to be given as ordered. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident scored 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. Review of the MAR (Medication Administration Record) and the e (electronic)-MAR revealed that multiple medications, both pharmacy provided and facility provided medications, were unavailable for the resident use on multiple days, over a period of several months. The e-MAR contained notes that the medications were not available and, in some instances, that the facility was awaiting delivery from the pharmacy. Review of the orders and e-MAR revealed the following: -[DATE] [MEDICATION(S)] Tablet 5 mg (milligrams) by mouth 1 time a day for RA ([CONDITION(S)]) waiting on pharmacy [DATE] at 11:14 AM medication not available [DATE] at 12:19 PM medication unavailable [DATE] at 11:29 AM -[DATE] Refresh Tears Solution 1 drop in left eye every 4 hours for dry eye expired, reordered [DATE] at 11:10 AM awaiting delivery [DATE] at 7:07 PM reordered from [NAME] [DATE] at 6:18 PM awaiting delivery ,d+[DATE] at 7:28 PM medication unavailable [DATE] at 8:42 AM unavailable [DATE] at 12:34 AM, 12:35 AM not available, ordered [DATE] at 4:38 PM -[DATE] [MEDICATION(S)] Tablet Delayed release 40 mg 1 tablet 2 times a day for GERD ([CONDITION(S)]) not available [DATE] at 10:49 AM drug unavailable, waiting for pharmacy to deliver [DATE] at 9:28 AM medicine unavailable, waiting on pharmacy to deliver [DATE] at 9:23 AM drug unavailable, faxed order to pharmacy [DATE] at 9:31 PM -[DATE] [MEDICATION(S)] capsule 0.4 mg 1 capsule by mouth in the evening for urinary incontinence medication unavailable, pending pharmacy delivery [DATE] at 7:46 PM -[DATE] [MEDICATION(S)] Tablet 600 mg 1 tablet by mouth 2 times per day for [CONDITION(S)] Drug unavailable, waiting for pharmacy to deliver [DATE] at 9:23 AM Medication unavailable waiting for pharmacy to deliver [DATE] at 9:22 AM -[DATE] [MEDICATION(S)] Tablet 200 mg 1 tablet by mouth 2 times a day for RA not available, pharmacy called [DATE] at 8:39 PM not available, pharmacy called [DATE] at 8:39 PM pending pharmacy delivery [DATE] at 9:27 PM medication not received from pharmacy, ordered again this day [DATE] at 10:35 AM drug not available, pharmacy delivery pending [DATE] at 12:23 PM -[DATE] Immunocare Capsule 1 capsule by mouth one time a day for supplement Unavailable, ordered [DATE] at 9:01 AM awaiting delivery- [DATE] at 11:18 AM not available [DATE] at 9:04 AM not available [DATE] at 9:14 AM -[DATE] [MEDICATION(S)] Solution 0.5% instill 1 drop in left eye 4 times a day for allergies expired, reordered [DATE] at 11:09 AM awaiting delivery ,d+[DATE]/ 2021 at 12:00 PM awaiting delivery 12 ,d+[DATE] at 4:53 PM awaiting delivery [DATE] at 8:13 PM reordered from pharmacy [DATE] at 6:18 PM awaiting delivery [DATE] at 1:07 PM -[DATE] [MEDICATION(S)] 20 mg (d/c [DATE]) 1 tablet by mouth one time a day for [CONDITION(S)] drug unavailable, waiting on pharmacy to deliver [DATE] at 9:23 AM drug unavailable, waiting for pharmacy to deliver- [DATE] at 9:24 AM unavailable, ordered [DATE] at 9:04 AM -[DATE] [MEDICATION(S)] tablet 5 mg 1 tablet by mouth 1 time a day every Monday for RA not available [DATE] at 11:03 AM not available [DATE] at 9:07 AM -[DATE] [MEDICATION(S)] Calcium Tablet 10 mg at bedtime to prevent cardiovascular disease awaiting Delivery - [DATE] at 9:15 PM not Available- [DATE] at 9:19 PM medication not available [DATE] at 8:33 PM medication not available [DATE] at 8:15 PM -[DATE] [MEDICATION(S)] 25 mg by mouth 1 time a day for depression medication not available, ordered from pharmacy at this time used last dose from e kit yesterday am [DATE] at 9:59 AM medication unavailable [DATE] at 8:50 AM -[DATE] [MEDICATION(S)] [MEDICATION(S)] Cream 2.,d+[DATE].5% apply to left shoulder and neck topically 3 times a day for pain not available, on order [DATE] at 6:04 PM not available [DATE] at 8:24 PM -[DATE] [MEDICATION(S)] 5 mg 1 tablet by mouth at bedtime for RA waiting on pharmacy [DATE] at 11:14 AM drug/item unavailable -[DATE] at 8:51 PM medication not available-[DATE] at 8:57 PM medication not available [DATE] at 11:20 PM awaiting delivery [DATE] at 8:25 PM mot available [DATE] at 9:21 PM medication not available [DATE] at 10:31 PM -[DATE] [MEDICATION(S)] Ointment 0.44 -20.6 % apply to vaginal labia topically two times a day for labia ulcer not available [DATE] at 9:45 PM not available [DATE] at 11:52 AM -[DATE] Hemorrhoidal Ointment 0.[DATE].9% 1 application rectally 3 times a day for hemorrhoids not available [DATE] at 8:37 PM not available [DATE] at 11:08 PM -[DATE](d/c [DATE]) [MEDICATION(S)] HC Suppository - insert 1 suppository rectally 2 times a day for hemorrhoids for 14 days Medication unavailable [DATE] at 4:32 PM -[DATE] Hemmorex suppository 25 mg insert 1 suppository rectally 2 times a day for hemorrhoids not available [DATE] at 8:38 PM pending pharmacy delivery [DATE] at 9:27 PM medication not received from pharmacy, ordered again this day [DATE] at 10:35 AM drug not available. pharmacy delivery pending [DATE] at 12:23 PM -[DATE] (d/c [DATE]) [MEDICATION(S)] (immunosuppressant) tablet extended release 24-hour 15 mg 1 tablet by mouth 1 time a day new order, awaiting pharmacy delivery [DATE] at 9:17 AM On [DATE] at 1:58 PM, an interview was conducted with a Registered Nurse (RN/staff #128) regarding medication pass and medication availability. The RN stated that if during medication pass it was determined that a resident's medication was not available for administration, the nurse should check the e-(emergency) kit and use the medication contained in the e-kit if needed. She said that if the medication was a narcotic, she would obtain permission to use the medication. In any case, she stated that she would notify the physician and would also contact the pharmacy to check the status of the delivery. She said that there were occasions over time that staff were not giving the residents their medications per orders, because there were no medications in house to be given. The RN stated this could be that the registry staff could not find the medications or the supply did not come in. The RN stated that in this case, if a medication was not given a 9 is put in the MAR and the nurse should enter a note in the e-mar. She said that missing medications were a concern because the resident could have adverse reactions without ordered medications being administered. She stated that she was scheduled Monday through Friday so she tried to make sure everything was in place to help the registry staff. The RN stated that she also does her best to order medications in a timely manner and to ensure that the medications are received. She said she also communicates with other nurses to make sure medications are received. An interview was conducted with the Director of Nursing (DON/staff #112) on [DATE] at 2:41 PM. She stated that about a month ago, pharmacy services for the facility went electronic. She stated orders are now sent to the pharmacy electronically and the orders arrive by courier. The DON stated that medication refills are not automatic and that the nurses are responsible for reordering all medications. The DON stated nurses are expected to know what medications are low in count and ensure that they are reordered. She stated that her expectation is that the nursing staff use the e-kit if a resident's medication runs out. She stated that she had started an action plan on this issue. Additionally, she said that she conducted a lot of in-services for staff, and the facility is working closely with the pharmacy to determine the root cause for medications that were not available. The DON stated that an action plan was started on this issue and that she will provide a copy of the plan. The DON stated that it is dangerous for a resident to go without medications, and that it can be a potential problem depending on what the medication was. She said that a pharmacy representative had been in the building all week to help with the concern with medication availability. On [DATE] at 9:40 AM, an interview was conducted with the pharmacy representative (staff #171), administrator (staff #34), clinical compliance staff (staff #173) and DON (staff #112). The DON stated that in [DATE], integration preparations began which integrated the medication reordering system with the electronic records. She said that she and the administrator had been working with the pharmacy to resolve the issues of missing medications. The DON stated the electronic ordering system went live late [DATE] and that staff #171 had been in the facility since then to provide support and Pharm 101 (education and training). She said that in the last 3 to 4 weeks there has been improvement and the leadership team has been working hard to help get a hold of the situation. She stated that there was a call with their corporate office and the pharmacy on [DATE] to start a plan of correction. The DON further stated that the facility has access to reports to confirm when the medications were reordered and delivered and these reports are viewed by the DON and nurse managers. She said nursing looks at the medication card to know when to reorder medications and staff #171 does onsite visits to help ensure that staff and registry staff understand the process. Staff #171 stated that the communication between pharmacy and the facility was the problem as to why some medications were not available for use. She stated that the electronic integration required new orders and that there was no auto refill available. She said that she educated staff to follow up proactively to ensure the medications were available. Staff #171 stated that the staff were told to check the reports in view master in the portal regularly. The DON stated that over the counter medications are supplied through central supply and the nurse does notify central supply to obtain over the counter medications as needed. On [DATE] at 12:01 PM, an interview was conducted with a Licensed Practical Nurse (LPN/staff #2). She stated that if a resident's medication supply was low she knew to reorder the medication. She said that she had to reorder using the labels previously however, as of the last couple of months reordering was all electronic. She stated she has been educated as to the new process. The LPN stated she can view when a medication was ordered and when it arrived. She said over the last few months there has been a problem with medications being available for the residents at times. She stated that it seemed to mainly be a delivery issue from the pharmacy but it seems to have gotten better recently. On [DATE], approximately 20 minutes before the conclusion of the survey, the facility provided documentation regarding the facility action plan dated [DATE] and the internal plan of correction started [DATE]. The facility also provided medication audits for 2 medications at the exit. Review of the facility policy Consultant Pharmacist Services Provider Requirements (2007) revealed that the consultant pharmacist or designee was to assist in the identification and evaluation of medication related issues including prevention and reporting of medication errors as well as suspected adverse medical consequences. It further revealed that the pharmacy consultant was to assist the care center on development, implementation, evaluation and revision of pharmaceutical service procedures that address resident needs and follow the current standards of practice. The pharmacy consultant was to aid in resolving problems with pharmacy providers and suppliers at the request of the nursing care centers administrator or director of nursing. Review of the facility policy Medication Ordering and Receiving from Pharmacy Provider (2010) revealed that medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate records of medication order and receipt. It further revealed that if the first dose of the medication is scheduled before the next regularly scheduled pharmacy delivery, the pharmacy is to be notified of the order immediately and the pharmacy is to be informed of the need for prompt delivery. The policy further revealed that timely delivery of orders was required to not delay medication administration.

Based on clinical record reviews, staff interviews, and policy and procedure, the facility failed to ensure that the PASRR (Preadmission Screening and Resident Review) Level 1 was updated for two residents (#33 and #44) when their stay exceeded 30-days. The sample size was 3. The deficient practice could result in specialized services needed not being identified and provided to residents. Findings include: -Resident #33 was originally admitted to the facility on [DATE] and recently readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a PASRR level one dated August 2, 2021, completed prior to readmission to the facility, which did not document that the resident had a serious mental illness to include [CONDITION(S)], major depressive disorder, [CONDITION(S)] and [CONDITION(S)] disorder. The PASRR level one also did not document that the resident had mental disorder that included anxiety disorder. Additionally, the document indicated that the resident met the criteria for 30-day convalescent care, no recommendation for a PASRR level two. Continued review of the clinical record did not reveal the PASRR level one had been revised/updated once the resident's stay exceeded 30 days. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed PASRR was marked 'NO' which indicated that resident was not currently considered by the stated level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS assessment also revealed that the resident had delusions and presence of behavioral symptoms. A comprehensive care plan dated January 5, 2022 included that the resident has a behavior problem of making false accusations against staff, threatening staff, history of calling the police, yelling at staff and calling them derogatory names, hitting, cursing, screaming related to [CONDITION(S)], [CONDITION(S)], [CONDITION(S)]. An interview was conducted on March 9, 2022 at 11:37 am with the social service director (staff #50). She stated that the PASRR level one is done prior to resident admission and is completed as a part of admission. She stated if the PASRR level one is not done, then the admissions will let the social service department know and it will be completed by social services. She stated if the resident needs a PASRR level two referral then she will send the referral to the PASRR coordinator within 48 hours. She stated for residents that are discharged to the hospital and then return, the resident should have a new PASRR level one completed. Staff #50 stated the PASRR Level one is important to determine if that is the best level of care and to see if the residents are placed appropriately. She reviewed resident #33 PASRR level one from August 2, 2021 and stated the resident needed a new PASRR level one after 30 days of her stay at the facility. She then stated she will be completing a new PASRR level one for resident #33. Staff #50 then provided a new completed PASRR level one for resident #33 dated March 9, 2022 which indicated referral for level two. An email copy was also provided from the PASRR coordinator stating that the resident was not appropriate for a level two evaluation. An interview was conducted with the Director of Nursing (DON/staff #112) on March 10, 2022 at 9:10 am. She stated the PASRR level one needs to be completed pre-admission and that the admission staff should review the documentation when the residents are admitted . -Resident #44 was admitted to the facility initially on June 11, 2020 and readmitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a completed PASRR Level One dated October 6, 2020, completed prior to readmission to the facility. The screening did not include the diagnosis [CONDITION(S)] Disorder. Additionally, the document indicated that the resident met the criteria for 30-day convalescent care, no recommendation for a PASRR Level Two. The PASRR also revealed that the facility must update the Level 1 at such time that it appears the resident's stay will exceed 30 days. However, review of the clinical record did not reveal the PASRR had been updated once the resident's stay exceeded 30 days. During an interview conducted on March 8, 2022 at 12:47 PM with a Licensed Practical Nurse, Unit Manager (staff #7), she stated that the resident is seen by a psychiatric provider who would determine the resident's need for services. She added that the facility social worker is the one who reviews the PASRR and that she was unaware that the resident would need to have a PASRR Level Two based on diagnosis. During an interview conducted on March 8, 2022 at 1:22 PM with a Social Worker (staff #50), she stated that she was not familiar with the resident as she had only been in the facility for two months. She stated that she was unaware of the resident's PASRR, but will complete a new PASRR Level One and submit the resident for a Level Two. She further stated that the current practice since her arrival is for her to review all new admissions for completed PASRR Level One. She added that the Admissions staff check to see if there is a PASRR, but that they do not review it. Staff #50 stated that they had identified issues with PASRRs and she was in the process of auditing all of the current residents. During an interview conducted on March 8, 2022 at 1:34 PM with the DON (staff #112), she stated that the nursing staff receives no training on PASRRs and that the admissions staff should be reviewing the documentation when the residents are admitted . She further stated that her expectation is that the facility policy is followed when the residents are admitted . She added that they had previously identified problems with PASRRs being completed correctly and currently have a Process Improvement Plan in place and that the Social Worker is auditing all of the resident records. Review of the facility's Preadmission Screening and Resident Review (PASRR) policy effective July 2016, stated it is the policy of the facility to complete and submit a PASRR screening online for new admissions to prevent individuals with Mental Illness, Developmental Disability, Intellectual Disability or other related conditions from being inappropriately placed in nursing homes for long term care. Additionally, it stated that the facility will update the existing PASRR when the resident's stay exceeds the 30-day exempted hospital discharge or there is a change in a resident's physical or mental condition. The policy also stated that a PASRR will be completed and submitted online for new admissions within 24 hours.

Based on clinical record review and staff interviews, the facility failed to ensure a blood pressure medication was administered as ordered to one resident (#92). The sample size was 5. The deficient practice could result in ineffective management of residents' blood pressure. Finding include: Resident #92 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold for systolic blood pressure (SBP) <110 or heart rate (HR)<60. Notify MD for 3 missed doses. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's blood pressure (BP) was 107/57. The MAR for February 2022 revealed the resident was administered [MEDICATION(S)] on February 9, 2022 for an SBP of 108, BP 108/55 and on February 16, 2020 for an SBP of 106, BP 106/55. A review of the MAR for March 2022 revealed that on March 7 the resident was administered [MEDICATION(S)] when the SPB was 109, BP 109/59 and on March 9 when the SBP was 106, BP 106/54. An interview was conducted with a Licensed Practical Nurse (LPN/staff #12) on 3/9/2022 at 11:21 AM. The LPN stated that she obtains the resident's blood pressure and pulse before administering a blood pressure medication ordered with parameters, to ensure the medication is administered within the parameters. She stated that if the BP and HR are not within the parameters, she would hold the medication and notify the physician. The LPN stated the risk of administering a blood pressure outside of parameters is that the blood pressure could drop too low. After reviewing the MARs for resident #92, she stated that she gave the medication outside of the parameters on four days. The LPN stated that she should have called the physician before she gave the medication. She said for today, 3/9/2022, she did call the physician when the resident's BP was out of parameters and the physician said to give the medication. An interview was conducted with the Director of Nursing (DON/staff #112) on March 10, 2022, who stated her expectation is that residents be administered blood pressure medication according to the ordered parameters. The DON stated the nurses can administer medications outside the parameters if they verify it with the physician.

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure that professional standard of practice was followed regarding oxygen for two out of three sampled residents (#33 and #28). The census was 119. The deficient practice could result in respiratory care needs not being met. Findings include: -Resident #33 was originally admitted to the facility on [DATE] and recently readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the order did not include the amount of oxygen needed to be administered. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed a score of 11 on the Brief Interview of Mental Status (BIMS), which indicated the resident had moderate cognitive impairment. The MDS assessment also revealed the resident was on oxygen therapy while a resident of the facility. A comprehensive care plan dated January 5, 2022 revealed the resident had altered respiratory status as evidenced by low oxygen saturations at nighttime. Interventions included to administer oxygen as ordered, administer medication/puffers as ordered, and monitor for effectiveness and side effects. The Medication Administration Records (MAR) for August 2021 to March 2022 revealed oxygen PRN was documented every shift and the resident oxygen saturations were above 92%. However, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's progress note dated February 15, 2022 at 4:16 PM stated resident #33 remained on 3.5 liters of oxygen via nasal cannula continuously for chronic respiratory failure/[CONDITION(S)]. An observation was conducted of the resident on March 7, 2022 at 9:36 AM. The resident was observed on 5 liters of oxygen via nasal cannula (NC). Another observation of the resident was conducted on March 9, 2022 at 12:12 pm. The resident was observed on oxygen via NC at 5 liters. Further review of the resident's clinical record did not reveal the amount of oxygen the resident was receiving or the reason oxygen was titrated to 5 liters. An interview was conducted with a Certified Nursing Assistant (CNA/staff #109) on March 9, 2022 at 12:15 pm. She stated that resident #33 has always been on oxygen via NC and is on 4 to 5 liters of oxygen. An interview was conducted with another CNA (staff #118) on March 9, 2022 at 12:26 pm, who stated that the resident has always been on oxygen. An interview was conducted with a Registered Nurse (RN/staff #111) on March 9, 2022 at 12:51 am. She stated that the facility uses a standing order for oxygen. She stated if a resident oxygen saturation is below 92%, the nurses can titrate the resident oxygen to maintain oxygen saturation above 92%. She stated the residents are kept on the lowest oxygen concentration setting as possible. The RN stated the physician is notified if the resident is needing higher amounts of oxygen. She stated the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN stated resident #33 is on 3.5 liters of oxygen. Staff #111 reviewed the oxygen order and stated the resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN stated the resident's oxygen saturation is normally good on 3.5 liters of oxygen. An interview was conducted with the unit coordinator (staff #7) on March 9, 2022 at 1:26 pm. She stated the resident is on PRN oxygen as the resident is known to remove the oxygen and the order allows the staff to put it back on the resident as needed. She stated the resident is typically on 3 to 4 liters of oxygen but sometimes the resident removes the NC and the resident's oxygen saturation drops. Staff #7 stated that in that case the staff can titrate the oxygen amount up just until the resident's oxygen saturation rises. She stated after the resident's oxygen saturation rises then the nurse should decrease the oxygen back down to the resident's baseline amount of oxygen that the resident needs. She stated when the nurse has to titrate resident's oxygen up then they should be documenting that in the progress notes. She stated the nurses should know the maintenance oxygen level a resident should be at and it should be reflected in the order. She stated if it is not reflected, it should be clarified with the physician. She stated resident's #33 PRN oxygen order is confusing and she will clarify it with the physician. She stated it is important for the PRN oxygen order to include how many liters of oxygen to administer the resident as it tells the nurses the amount of oxygen needed by the resident to maintain their oxygen level so that if there is an abrupt change, the nurses will know about the change and are able to notify the physician on time. An interview was conducted with the Director of Nursing (DON/ Staff #112) on March 10, 2022 at 9:10 am. She stated her expectation from nurses is to monitor the resident's oxygen saturation and follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the nurses can titrate the oxygen concentration up and down to keep the resident's oxygen saturation above 92%. She stated the amount of oxygen necessary for the resident varies resident by resident. The DON stated her expectation from nurses is to monitor resident's oxygen every shift. She stated it is important for the nurses to know the amount of oxygen the resident is on. -Resident #28 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set assessment (MDS) dated [DATE] revealed a BIMS score of 11, which indicated the resident's cognition was moderately impaired. The MDS assessment for section O, also revealed the resident did not receive oxygen therapy. Review of the Care Plan initiated on December 13, 2021 revealed the resident has oxygen therapy. The goal was that the resident would not have signs or symptoms of poor oxygen absorption. Interventions included oxygen settings as ordered. Review of the Treatment Administration Record dated March 2022 revealed the oxygen concentrator humidifier solution was changed on March 3 and March 8. Review of the MAR for March 2022 revealed that the resident received oxygen from March 1 through 9, 2022. An observation was conducted of the resident on March 3, 2022 at 8:23 AM. The resident was observed receiving oxygen at 5 liters, and no humidifier was observed on the oxygen concentrator. During an observation conducted on March 9, 2022 at 10:11 AM, the resident was observed receiving oxygen at 5 liters, no humidifier was observed, and the oxygen tubing was labeled March 7, 2022. During an interview conducted with a CNA (staff #77) on March 10, 2022 at 8:27 AM, the CNA stated resident #28 is on 2 liters of oxygen. An interview was conducted with a Licensed Practical Nurse (LPN/staff #174) on March 10, 2022 at 8:40 AM, who stated resident #28 is on oxygen continuous at 2 liters. The LPN stated she obtained this information from the resident's clinical record and from report. Staff #174 stated she was not sure the reason for a humidifier or what the risk would be if there was no humidifier. The LPN stated that when she checks the oxygen saturation, if the saturation is above 92% then you can titrate down depending on the order. Then an observation of the resident's oxygen was conducted with the LPN which revealed the oxygen concentrator was without a humidifier and was at 5 liters. An interview was conducted with the DON (staff #112) on March 10, 2022 at 9:10 AM. The DON stated she would have to check their policy regarding her expectation of nurses placing a humidifier on an oxygen concentrator and the importance of the humidifier. The DON also stated the reason for the humidifier is to protect the nares and prevent a dry nose. An interview was conducted with resident #28 on March 10, 2022 at 11:34 AM regarding the humidifier. The resident stated that it was the way it came and the way it was set up. Review of the clinical record revealed the care plan was revised on March 10, 2022 to state the resident prefers not to use the humidifier. The facility policy titled Oxygen revised November 2012 stated that the facility policy is to provide oxygen support via appropriate delivery device, in a safe manner to prevent accidents, to maintain adequate oxygenation to the respiratory compromised resident and to assure proper oxygen administration during any emergency situation of respiratory distress. The policy revealed that written orders for oxygen therapy are to include: mode of delivery, liter flow rate and duration of therapy, i.e. continuous, PRN shortness of breath, or per specific oxygen saturation range, as specified by the physician. The policy further stated to document acute episodes of respiratory distress, including respiratory assessment, resident response to treatment and notifications made to physician, resident or responsible party. The policy also revealed that a bubble humidifier device will be used for flow rates greater than 3 p.m. or per resident's request for comfort, or per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on clinical records, staff interviews, facility policy and the Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health, the facility failed to ensure antipsychotic medication administered to two of three sampled residents (#4 and #6) had clinical indication for its use. The deficient practice could result in residents receiving unnecessary antipsychotic medications that can potentially cause harm. Findings include: -Resident #4 was readmitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] and unspecified dementia. A Nurse Practitioner (NP) health status note dated January 11, 2021, included that resident #4 was oriented to self with flat affect. Assessments included [CONDITION(S)] and unspecified dementia without behavioral disturbance. Plan included to continue [MEDICATION(S)] (antipsychotic/brand name for [MEDICATION(S)]) and to continue to monitor for medication effectiveness. Per the documentation, the resident was taking [MEDICATION(S)] 5 mg (milligrams) via a PEG (for percutaneous endoscopic gastrostomy) tube three times a day. The consultant pharmacist's medication regimen review dated January 11, 2021 included the resident's medication were reviewed related to new admission or readmission status. The review included the hospital discharge records were not available at the time of the review. Further, the review did not include any recommendation related to the resident's use of antipsychotic, [MEDICATION(S)]. A late entry physician progress note dated January 12, 2021 included the resident was oriented x3, had calm behaviors, mood was okay, with blunted affect congruent to mood, had no delusional ideations verbalized, had low insight for illness and treatment and poor judgement. Assessment included [CONDITION(S)] with no acute [CONDITION(S)] and resident was physically declining. The note also included that there were no medication changes and tapering and that the resident was on LED (lowest effective dose). The antipsychotic care plan initiated on January 12, 2021 included use of an antipsychotic medication, [MEDICATION(S)] related to a diagnosis of [CONDITION(S)] as evidenced by refusal of care. The goals included that the resident would remain free of adverse reactions through the next review. The interventions included administering medications as ordered; quarterly evaluation by the IDT (interdisciplinary team) and pharmacist with recommendations for possible dose reduction; recording and tracking of medication side effects and behaviors in the MAR (medication administration record). The antipsychotic care plan also included a black box warning that [MEDICATION(S)] increased mortality in elderly patients with dementia-related [CONDITION(S)]. It also included that elderly patients with dementia-related [CONDITION(S)] treated with antipsychotic drugs were at increased risk of death. Further, the warning included that [MEDICATION(S)] was not approved for the treatment of patients with dementia-related [CONDITION(S)]. A Psychosocial Assessment and Social History dated January 13, 2021 included resident #4 had no mood or behavior of concern. A discharge MDS (Minimum Data Set) assessment dated [DATE] included the resident had an unplanned discharge to acute hospital with return anticipated. The clinical record revealed resident #4 was readmitted at the facility on January 20, 2021. The hospice certification and plan of care dated January 20, 2021 revealed the resident was disoriented and was prescribed with [MEDICATION(S)] 5 mg by mouth three times a day for [CONDITION(S)]. Review of the Consent for Medication Administration of [CONDITION(S)] Medications signed and dated January 20, 2021 included the resident had orders for [MEDICATION(S)] an antipsychotic for [CONDITION(S)] AEB (as evidenced by) refusal of care/medication. The consultant pharmacist's medication regimen review dated January 21, 2021 included the resident's medication were reviewed related to new admission or readmission status. The review did not include any recommendation such as adequate clinical indication and/or monitoring for psychotic behaviors related to the use of [MEDICATION(S)]. A physician order dated January 21, 2021 included an order to monitor for refusal of care/medication every shift. It also included an instruction to use 0 for none or record the number of episodes. The physician order dated January 23, 2021 revealed an order for [MEDICATION(S)] give 5 mg sublingually three times a day for [CONDITION(S)] AEB refusal of care/medication. A Significant Change in Status MDS assessment dated [DATE] included a BIMS (Brief Interview for Mental Status) score of 9 indicating severe cognitive impairment. Active diagnoses included Non-Alzheimer's dementia and [CONDITION(S)]. The assessment revealed the resident had no [CONDITION(S)] and potential indicators of [CONDITION(S)] such as hallucinations and delusions; and, had no physical, verbal and other behaviors directed towards others. Per the assessment, the resident received antipsychotic medications 7 days during the look-back period of the assessment; and, received antipsychotic medications on a routine basis. It also included the resident was not coded for rejection of cares. Review of the MAR for January 2021 revealed [MEDICATION(S)] was administered as ordered and the resident was coded 0 indicating no refusal of cares from January 10 through 31, 2021. The documentation in the MAR also included a code of 2 indicating the resident refused medication on January 21 (8:00 a.m. and 4:00 p.m. shift), January 27 (8:00 p.m. shift) and January 28 (8:00 a.m. shift). The clinical record revealed no evidence the resident was monitored for and/or exhibited psychotic behaviors such as disorganized speech/behaviors, delusions, hallucinations from January 10 through 31, 2021. The orders for [MEDICATION(S)] and monitoring for refusal of care/medication continued to be transcribed onto the MAR from February 1 through April 22 2021. According to the documentation in the MAR, [MEDICATION(S)] was administered as ordered; and, the resident refused cares/medication on different shifts on multiple dates from February 1 through April 22 2021. The documentation also included that non-pharmacological interventions were provided to the resident with either positive or negative outcomes on the dates the resident refused cares/medications. Further review of the clinical record revealed no evidence the resident was monitored for and/or had exhibited psychotic behaviors such as disorganized speech/behaviors, delusions, hallucinations from February 1 through April 25, 2021. An interview with a Registered Nurse (RN/staff #4) was conducted on April 26, 2021 at 2:20 pm. She stated resident #4 has behaviors that include calling out, attention seeking, and wanting to be turned a lot just to have staff in her room. She stated that refusal of care can be sign or symptom of [CONDITION(S)]. She stated resident #4 can still refuse care because it is a resident's right. She stated that assessments for refusal of care would be documented in the Electronic Health Record, however if resident #4 does not refuse care then the antipsychotic medication is working. -Resident #6 was readmitted on [DATE] with diagnoses of unspecified [CONDITION(S)], anxiety disorder and dementia with behavioral disturbance. The behavior care plan with revision date of June 27, 2019 revealed the resident had the following behavior problems: food seeking, self-propelling wheelchair very fast up and down the hallway related to diagnoses of [CONDITION(S)], pseudo-bulbar affect disorder, dementia with behavioral disturbance, and [CONDITION(S)]. According to the care plan, the resident will have outbursts of hysterical laughing while watching television, had a history of daily wandering with low level intrusiveness to peers' rooms and the nurses' station and was taking food from food carts. The goals included that the resident will be easily distracted to stop intrusive behavior and to wander in public areas only; and, not taking food inappropriately. Interventions included administering [CONDITION(S)] medications as ordered, distracting the resident from inappropriately taking food by offering preferred snack and foods within the prescribed diet; placing food cart in appropriately supervised area; utilizing universal dementia approaches; and, promoting calm and comfort. It also included an intervention to not focus on the intrusive behavior; but in a friendly manner, distracting the attention and directing the resident to self-propel wheelchair to common public area or his room. The active physician orders summary report included the following orders: -Monitor for intrusiveness every shift. Use 0 for none or record number of episodes; and, -[MEDICATION(S)] (antipsychotic) 40 mg by mouth at bedtime and 20 mg by mouth one time a day for AEB intrusiveness related to unspecified [CONDITION(S)]. (order date: November 24, 2020). A quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 indicating the resident had severe cognitive impairment. It included the resident received antipsychotic medications 7 days during the look-back period of the assessment; and had received antipsychotic medications on a routine basis. The assessment included the resident did not have potential indicators of [CONDITION(S)] such as hallucinations and delusions; and, had no physical, verbal and other behaviors directed towards others and wandering behaviors. There was no evidence found in the clinical record that the resident was monitored for and/or had exhibited psychotic behaviors such as disorganized speech/behaviors, delusions, hallucinations from January 1 through 31, 2021. The clinical record also revealed that [MEDICATION(S)] was continued to be transcribed onto the MAR for March 2021. The clinical record also revealed no evidence the resident had episodes of intrusiveness from March 1 through 31, 2021. There was also no evidence the resident was monitored for and/or had exhibited psychotic behaviors such as disorganized speech/behaviors, delusions, hallucinations from March 1 through 31, 2021. Despite the lack of evidence the resident had episodes of intrusiveness and/or psychotic behaviors, the MAR for March 1 through 31, 2021 documented [MEDICATION(S)] 20 mg daily and 40 mg at bedtime was administered as ordered. The quarterly MDS assessment dated [DATE] included a BIMS score of 3 indicating the resident had severely impaired cognition. The MDS included the resident received antipsychotic medications 7 days during the look-back period of the assessment and received antipsychotic medications on a routine basis. The assessment revealed the resident had no potential indicators of [CONDITION(S)] such as hallucinations and delusions; and, had no physical, verbal and other behaviors directed towards others and wandering behaviors. The NP progress note dated April 6, 2021 included the resident was oriented x 1 with impaired short-term memory; and, staff reported no change in the resident's mood and behaviors. Review of system included euthymic (no mood disturbances) mood, with spontaneous and fluent speech and no delusional ideations verbalized. Assessments included anxiety disorder and major neurocognitive disorder. It also included the resident's behaviors were at the same level as the last visit and staff were able to use behavioral interventions to provide care. Plan included no psychiatric medication changes and the resident was on LED. The [CONDITION(S)] medication use care plan was revised April 13, 2021 and included the resident an antipsychotic [MEDICATION(S)] for a diagnosis of [CONDITION(S)] as evidenced by intrusiveness. Goals included that the resident will have no adverse side effects related to the use of [CONDITION(S)] medication use; and that, the resident will have decreased episodes of food seeking, intrusiveness, manic behavioral diagnosis as evidenced by self-propelling wheelchair very fast up and down the hall. Interventions included giving of the antipsychotic as ordered, monitoring for adverse side effects, medication effectiveness, behaviors and diagnosis which warrant use of the [CONDITION(S)] medication. The [CONDITION(S)] medication care plan also included a black box warning that [MEDICATION(S)] increased mortality in elderly patients with dementia-related [CONDITION(S)]. It also included that elderly patients with dementia-related [CONDITION(S)] treated with antipsychotic drugs were at increased risk of death. Further, the warning included that [MEDICATION(S)] was not approved for the treatment of patients with dementia-related [CONDITION(S)]. The clinical record revealed no evidence the resident had episodes of intrusiveness from April 1 through 22, 2021. The documentation in the MAR from April 1 through 22, 2021 revealed the resident did not exhibit behaviors of intrusiveness. Despite the intervention in the care plan to monitor behaviors which warrant the use of the antipsychotic medication, there was no evidence the resident was monitored for psychotic behaviors such as disorganized speech/behaviors, delusions, and hallucinations from April 1 through 22, 2021. There was also no evidence found in the clinical record the resident had exhibited psychotic behaviors such as disorganized speech/behaviors, delusions, and hallucinations April 1 through 22, 2021. Despite the lack of evidence that the resident had intrusive and/or psychotic behaviors, the orders for [MEDICATION(S)] continued to be administered as ordered from April 1 through April 22 2021. During an interview with a certified nurse assistant (CNA/staff #20) conducted on April 26, 2021 at 8:15 a.m., the CNA stated aggression is a symptom of [CONDITION(S)]; and, attention seeking behavior, intrusion and/or refusal of care are not symptoms of [CONDITION(S)]. In an interview with another CNA (staff #11) conducted on April 26, 2021 at 8:45 a.m., staff #11 stated resident refusing care is a normal behavior and it does not mean the resident has [CONDITION(S)]. The CNA stated presence of hallucinations are more related to [CONDITION(S)]. Regarding resident #6, the CNA stated resident's behaviors included grabbing things and takes out the pillows and scratches or picks on himself. An interview with a Registered Nurse (RN/staff #33) was conducted on April 26, 2021 at 9:37 a.m. She stated she received training on dementia and behavioral health training when she was hired and also received additional in-service training multiple times a year. She stated residents with diagnosis of [CONDITION(S)] would exhibit behaviors that include screaming, hearing voices, random delusions, and talking to themselves. She stated refusal of care is not a symptom of [CONDITION(S)] and a resident has a right to refuse care. She also stated anyone can be intrusive and this is also not a symptom of [CONDITION(S)]. An interview with another RN (staff #22) was conducted on April 26, 2021 at 12:05 p.m. She stated residents with [CONDITION(S)] have behaviors that include paranoia and delusions of something they see or hear that she cannot. She stated resident's refusal of care or intrusiveness does not necessarily indicate [CONDITION(S)]. An interview with a Registered Nurse (staff #4) was conducted on April 26, 2021 at 2:20 pm. Staff #4 stated that symptoms of [CONDITION(S)] can include calling out, crying and being accusatory. She stated she does not know if intrusiveness is a sign or symptom of [CONDITION(S)]. Regarding resident #6, she stated before COVID, the resident gets up in the morning and he would self-propel wheelchair and always go into other resident rooms and get close to other residents. During an interview with the Director of Nursing (staff #60) conducted on April 26, 2021 at 3:20 p.m., the DON stated residents with [CONDITION(S)] have positive and negative behaviors. She stated the resident would exhibit hallucinations, apathy, withdrawn, self-isolation and depression. She stated a resident has the right to refuse care; however, if the refusal is associated with paranoia then that would be a symptom of [CONDITION(S)]. She stated that intrusiveness is not a symptom of [CONDITION(S)]; and, she was not sure if refusal of care or intrusiveness are in the Diagnostic and Statistical Manual of Mental Disorders. Further, the DON stated that [CONDITION(S)] medications are given for symptoms related to the disease process. Regarding resident #4, the DON stated she has not seen the resident having symptoms of [CONDITION(S)]. Regarding resident #6, the DON stated the resident had typical bad and good days with his behaviors. She further stated the resident was stable and not intrusive. The reference titled, Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health included . Substance Abuse and Mental Health Services Administration, Rockville, MD included [CONDITION(S)] is characterized by two or more of the following symptoms; delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, affective flattening, alogia, avolition, and diminished emotional expression. A facility policy titled Medication Monitoring Medication Management, dated January 2020, included each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug without adequate indications for its use. Based on a comprehensive assessment of a resident, the facility must insure residents who have not used [CONDITION(S)] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents who use [CONDITION(S)] drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. [CONDITION(S)] medications may be used to treat an enduring (i.e., non-acute; chronic or prolonged) condition. Before initiating or increasing a [CONDITION(S)] medication for enduring conditions, the resident's symptoms and therapeutic goals must be clearly and specifically identified and documented. Additionally, the facility must ensure that the resident's expressions or indications of distress are not due to a medical condition or problem, environmental and psychological stressors alone. The policy further included that the medical record must contain clear documentation that the resident's distress persists and his or her quality of life is negatively affected and, unless contraindicated, that multiple, non-pharmacological approaches have been attempted and evaluated in any attempts to discontinue the [CONDITION(S)] medication. Continued review of the policy included that indications for the use of antipsychotic medications must be thoroughly documented in the medical record. While antipsychotic medication may be prescribed for expressions or indications of distress, the IDT must first identify and address any medical, physical, psychological causes, and/or social/environmental triggers. Diagnoses alone do not necessarily warrant the use of an antipsychotic medications.

Based on clinical record review, hospital records, facility documentation, resident and staff interviews, review of the State Agency Complaint/Incident Tracking System, and review of policies and procedures, the facility failed to ensure that multiple residents on the Sedona Unit were protected from mental, verbal, and sexual abuse by one resident (#1), and that one resident (#2) was free from mental and sexual abuse from resident #1 which resulted in psychosocial harm. The sample size was two residents. Findings include: -Resident #2 was admitted to the facility on (MONTH) 25, 2019 and readmitted on (MONTH) 22, 2019. [DIAGNOSES REDACTED]. A written care plan initiated on (MONTH) 29, 2019 included that resident #2 had behaviors including paranoid statements, territorial behaviors and that she was afraid of men. Also, she had hallucinations that men come into her room at night. The care plan included a goal that the resident would have fewer than daily episodes of behaviors. The care plan interventions included to intervene as necessary to protect the rights and safety of others, to monitor behavior episodes and attempt to determine underlying causes, and to consider the location, time of day, persons involved, and situations. An Admission MDS (Minimum Data Set) assessment dated (MONTH) 31, 2019 included that resident #2 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated that the resident had severely impaired cognition. The MDS assessment included that the resident had symptoms of [MEDICAL CONDITION] that included hallucinations and delusions. Behavioral symptoms included verbal behaviors directed at others which put the resident at risk for significant injury, interfered with care, and interfered with participation in social interactions. Review of a hospital psychosocial assessment dated (MONTH) 4, 2019 included that the resident had a lifelong history of mental illness, including multiple past suicide attempts. The assessment included that resident #2 had made references to having been sexually assaulted at age 16, stating I was raped as a [AGE] year old and that the sexual assault had affected her life ever since. A behavioral plan updated on (MONTH) 17, 2019 included that resident #2 may be at risk for being traumatized due to poor orientation to place and situation, and that her history was significant for kidnapping and rape by several men which had a profound effect on her psychological well being. The plan included that resident #2 had difficulty interacting with most male staff and residents. A health status note dated (MONTH) 23, 2019 included that at 3:00 p.m. resident #2 had gone to the nurses station screaming and hollering that the crazy guy showed her his penis. Resident #2 identified resident #1 as the resident who had showed his penis to her. The note included that resident #1 was immediately placed on 1:1 (one to one) observation with staff, and that resident #2 had been walking up and down the hallway screaming for the entire shift. -Resident #1 was admitted on (MONTH) 7, 2019 with [DIAGNOSES REDACTED]. Review of the clinical record revealed a psychiatric evaluation completed prior to the resident's admission, dated (MONTH) 2, 2019. The evaluation included that resident #1 had been hypersexual, and had engaged in sexual activities at another other nursing facility. Review of a form titled Placement Referral Form completed prior to the resident's admission, dated (MONTH) 3, 2019, revealed that resident #1 constantly asks for sex and sexual acts from others and that he had masturbated in front of peers. The form included that resident #1 had a sexual encounter with a peer, and that police and APS (Adult Protective Services) had been notified. An admission MDS dated (MONTH) 14, 2019 included that resident #1 had a BIMS score of 3 which indicated that the resident had severely impaired cognition. The assessment included that resident #1 was ambulatory with supervision and had delusions that put him at risk for illness or injury and interfered with his care and participation in social interactions. The assessment included that the resident was intrusive to others and that his behavior significantly disrupted the living environment. Review of the behavior care plan, revised on (MONTH) 14, 2019, revealed the resident had behaviors including sexual requests, disrobing in public areas, inappropriate antisocial and sexual behaviors, and intrusive wandering. The care plan included a goal that resident #1 will have episodes of behaviors less than daily. Interventions included the following: -Administer medications as ordered. -Alarm placed above the resident's door to alert staff when the resident is exiting his room. -Assist the resident to develop more appropriate methods of coping and interacting with peers. Encourage him to express feelings appropriately. -Attempt to redirect sexual stimulation within the privacy of his room. -Caregivers to provide opportunity for positive interaction and attention. Stop and talk with him as passing by. -If reasonable, discuss his behavior. Explain/reinforce why (his) behavior is inappropriate and/or unacceptable to him. -Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to an alternative location as needed. -Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. -Staff to redirect as needed. An annual history and physical note dated (MONTH) 25, 2019 included that staff reported ongoing sexual behaviors towards self, staff and peers and the resident was receiving 1:1 monitoring. The note also included a plan that the resident would continue to receive close supervision and 1:1 monitoring until the behavior resolved. Review of the clinical record did not reveal additional documentation the the resident was provided close, or 1:1 supervision for sexual behaviors. A psychiatric progress note dated (MONTH) 26, 2019 included that staff reported resident #1 had been hypersexual. The note included that resident #1 had been pulling out his penis in public, urinating outside in front of others, propositioning female staff and residents to engage in sexual activity with him, and going into female resident's rooms and staring at them while they sleep. The note included that the resident continued to exhibit these behaviors despite repeated redirection from staff members, and that his [MEDICAL CONDITION] have been more frequent and severe. The note included that medications had been reviewed and changes made to the resident's psychoactive medications. A behavioral care progress note dated (MONTH) 8, 2019 for the p.m. shift included that resident #1 was very sexual acting, he had been observed in the courtyard and hallway taking out his penis and had tried to go into other resident rooms. A behavioral progress note dated (MONTH) 12, 2019 for the p.m. shift included that resident #1 had been pacing in the hallway with his hands in his pants, and had asked a female resident for some pussy. Review of the clinical record did not reveal any additional information regarding the female peer, or if staff had intervened. A behavioral progress note dated (MONTH) 16, 2019 at 11:00 a.m. included that resident #1 was harassing all of the residents, walked up to a resident and pulled down his pants and exposed himself right next to a resident. The note included that resident #1 pulled his pants down a total of 3 times, stole food from another resident, and that he was getting uncomfortably close to many residents. The note also included he did not listen to any of us which included CNA's (Certified Nursing Assistants) and a nurse. Review of the clinical record, facility documentation, and the State Agency Complaint/Incident Tracking System data revealed that the incidents on (MONTH) 8, 12, and 16, 2019 regarding the resident exposing himself to other residents and using sexual language to residents were not reported to the State Agency and there was no evidence that resident #1 was provided increased monitoring and supervision, including 1:1 close observation, or that the resident's care plan had been updated to include any additional interventions to prevent additional [MEDICAL CONDITION] towards peers. A health status note dated (MONTH) 21, 2019 at 9:01 p.m. included that resident #1 had made several sexual attempts towards other female residents, and that the resident had exposed his private parts five times to other residents and staff. The note included that the resident needed close monitoring around other residents. Continued review of the clinical record did not reveal any additional documented information regarding increased supervision or monitoring that had been provided to resident #1, including 1:1 or close observation for the resident's sexual behavior towards peers, or that the resident's care plan was updated at that time to include any additional interventions to prevent further sexual behavior towards peers. A health status note dated (MONTH) 23, 2019 at 9:49 p.m. included that at approximately 3:00 p.m. a resident (#2) had approached the nurses station and stated that another resident (#1) had exposed his penis to her. Resident #1 was immediately placed on 1:1 supervision and facility management was notified. Resident #1 was then transferred to another unit. Review of two investigative reports dated (MONTH) 25, 2019 included the following information: -During a clinical review on (MONTH) 22, 2019 a nurses progress note was found dated (MONTH) 21, 2019 at 9:00 p.m. that resident #1 had made sexual acts towards peers and flashed his private parts five times to staff and peers. An investigation was conducted, and the facility concluded that resident #1 had not acted sexually towards other residents, and that no other residents were involved in the incidents. -On (MONTH) 23, 2019 at 3:30 p.m. resident #1 and #2 were outside on the patio area. A CNA was monitoring the patio entrance to the hallway, and the CNA was watching resident #2 when she started screaming. The CNA entered the patio and saw resident #1 with his pants open. Resident #2 entered the hallway and reported that she had seen the private areas of resident #1 to the nurse. Resident #1 was placed on 1:1 supervision and moved to another unit. Education was provided to staff regarding the protocol for 1:1 supervision with residents. The report included that there was no intent to harm resident #2 when resident #1 exposed himself to her. However, the report stated that staff monitoring and redirection were unsuccessful with preventing resident #1 from disrobing. Review of the clinical record revealed a Discharge MDS dated (MONTH) 26, 2019 that included resident #1 had been discharged to a psychiatric hospital. An interview was conducted on (MONTH) 1, 2019 at 12:25 p.m. with a CNA/staff #48. Staff #48 stated that resident #2 was very afraid of men, and that resident #1 was known to take his pants down when he was outside on the patio. She stated that the residents on the Sedona Unit were confused and that two of them were able to answer questions. She stated resident #2 was one of the residents who was able to answer questions. An interview was conducted on (MONTH) 1, 2019 at 12:30 p.m. with resident #2. During the interview, staff #48 (who was female) remained in the room, standing next to the State Agency interviewer (who was male) due to the resident's fear of men. The resident stated she remembered two incidents that involved resident #1. She stated that one day when she was outside on the patio, resident #1 came outside and pulled his pants down in front of her and she became scared. She stated she shouted at him and a staff person who was at the door to the patio came and took resident #1 away. She stated repeatedly during the interview that resident #1 took down his pants in front of her and showed his thing to her and that she was scared. During the interview, she became increasingly fearful and anxious, and then stated I can't talk about this anymore. An interview was conducted on (MONTH) 1, 2019 at 2:14 p.m. with an RN (Registered Nurse/staff #93). He stated that he was the nurse on the afternoon shift on (MONTH) 21, 2019 and that resident #1 pulled his pants down and exposed himself to a male peer in a wheelchair, and the male resident did not react. He stated resident #1 had also walked around the dining room, repeatedly exposing himself to peers making statements the he wanted someone to lick or suck on his penis, and that he pulled his penis out of his pants and showed it to other residents. He stated that staff had redirected resident #1 repeatedly that afternoon, and that the resident continued to expose himself to residents and staff. He also stated the residents who he had exposed himself to did not react to his behavior and did not say anything as they were confused. The RN stated that it was his first day on the job, and although he had been provided abuse prevention training during orientation prior to his first day, he did not know what he was supposed to do. During an interview with the administrator/staff #185 conducted on (MONTH) 1, 2019 at 2:45 p.m. she stated that the note describing the behavior of resident #1 on (MONTH) 21, 2019 was discovered the next day during the morning meeting, and that it was investigated. She stated that none of the residents who were interviewed expressed that they had been abused. However, despite a witness statement that resident #1 had purposely targeted multiple residents when he exposed himself and made sexual comments, the administrator stated that through the facility investigation it was determined that resident #1 had not targeted other residents when he exposed himself. The administrator further stated that resident #1 was not placed on 1:1 supervision at that time, because when he had exposed himself multiple times on (MONTH) 21, 2019, his behavior was directed at staff and not other residents. She stated that resident #1 was placed on 1:1 supervision with staff after he had exposed himself to resident #2 on (MONTH) 23, 2019. An interview was conducted on (MONTH) 1, 2019 at 3:00 p.m. with an LPN (Licensed Practical Nurse/staff #117). She stated that on (MONTH) 23, 2019 when she was at the nurses station on the Sedona Unit resident #2 came running up to the nurses station screaming in the hallway he pulled it out. She described that resident #2 was very agitated and that a CNA (staff #85) had witnessed resident #1 pull his penis out and show it to resident #2. She stated that resident #1 was placed on 1:1 supervision, escorted to his room and remained in his room until he was moved to another unit. She stated that resident #2 remained anxious and upset for the remainder of the afternoon shift. She stated that when the incident occurred resident #1 was not being provided increased supervision or monitoring due to his known recent history of sexual behavior directed towards other residents. An interview was conducted on (MONTH) 1, 2019 at 3:30 p.m. with CNA/staff #85. She stated that on (MONTH) 23, 2019 resident #2 was on the patio and resident #1 also wanted to go onto the patio, she tried to discourage him from going on to the patio because resident #2 was there. She stated she was unable to prevent resident #1 from entering the patio because he became aggressive and she was the only staff at the end of the hallway. She stated she remained in the doorway of the patio, where she could monitor the patio and the hallway on the Sedona Unit. She stated resident #1 went behind the patio door and she could not see what he was doing. Resident #2 began screaming, and when she looked behind the door she saw resident #1 staring at resident #2, and he had his pants down as though he was showing his penis to resident #2. She stated that resident #1 was definitely hiding behind the door, and that he was purposefully showing his penis to resident #2. She immediately told resident #2 to leave the courtyard and to tell the nurse what had happened, and when she tried to assist resident #1 to pull his pants up he began to fight her. She stated resident #1 would not leave the courtyard until staff assistance arrived and he was escorted to his room. An interview was conducted on (MONTH) 2, 2019 at 8:50 a.m. with the ADON (Assistant Director of Nursing/staff #98) she stated that the reason resident #1 had not been placed on 1:1 supervision on (MONTH) 21, (YEAR) after he had exposed himself multiple times to other residents was that it sounded like the resident's behavior was directed at staff and not at other residents. She stated it was possible that resident #1 may have been placed on increased supervision at that time, she was not sure. She stated that if resident #1 had been placed on increased supervision on (MONTH) 21, 2019 the care plan for resident #1 would have been updated, and the increased level of supervision would have been communicated directly to the staff. She stated that resident #2 had a history of [REDACTED].#2 had [MEDICAL CONDITION] and was afraid of men. Review of a policy and procedure titled Abuse Prohibition and Prevention included a policy statement that the facility prevents abuse and exploitation of residents, each resident has the right to be free from mental/emotional, verbal, and sexual abuse, and residents must not be subjected to abuse by anyone including other residents. The policy noted that the supervisor shall immediately intervene, correct, and report identified situations where abuse may occur, conduct ongoing resident assessments and care planning for appropriate interventions to monitor resident needs, and address behaviors such as verbally aggressive behavior, intimidating sexually aggressive behavior including saying sexual things and inappropriate touching. The policy noted that facility staff will be able to identify the different types of abuse including mental/verbal and sexual abuse. The policy noted that occurrences, patterns, and trends will be assessed by administrative staff, licensed staff, and the interdisciplinary team to determine the corrective action based on the results of the investigation.

Based on closed clinical record review, staff interviews and policy review, the facility failed to ensure the necessary treatment and services were provided to one resident (#44) to prevent pressure ulcers from developing. Findings include: Resident #44 was admitted to the facility on [DATE], with a most recent readmitted [DATE]. [DIAGNOSES REDACTED]. A care plan included the resident was at risk for pressure ulcers related to decreased mobility, incontinence at times and diabetes mellitus. Interventions included to monitor skin during daily care and notify physician of changes. Another care plan revealed the resident was incontinent of bowel and bladder and was at risk for skin breakdown. Interventions included to assess skin condition during showers and ADLs (Activities of Daily Living), report changes or redness to nurse/physician and skin treatments as ordered. Review of a quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was cognitively intact. The MDS also included that the resident was at risk of developing pressure ulcers, but did not have any current unhealed pressure ulcers. A Braden Scale for Predicting Pressure Sore Risk was conducted on February 14, 2017, which indicated the resident was at low risk for developing a pressure ulcer. Review of the CNA (certified nursing assistant) shower documentation dated March 10, 2017, revealed a body diagram in which the buttock was circled and a note stated slight redness. A weekly skin check dated March 27, 2017 also included the resident had redness to the coccyx. However, review of the clinical record revealed no documentation that the physician was notified, nor that any treatments were provided and there was no documentation of any measurements of the redden area, from March 10 through March 27. Regarding the right ischial wound: A wound assessment dated [DATE] included the resident had an unstageable pressure ulcer to the right gluteal fold which measured 4.2 x 4.5 cm, with an immeasurable depth. Further documentation included that the specific location of the wound was on the right ischial tuberosity. The wound was described as having 50% red granulation tissue, 50% dark purple with defined edges and there was no undermining, tunneling, odor, or exudate noted. A physician's orders [REDACTED]. According to an IDT (interdisciplinary team) progress note dated May 18, 2017, the resident had a new right ischial tuberosity DTI (deep tissue injury) pressure related, which was noted on May 15, 2017. The next assessment of the right ischial wound was completed on May 31, 2017, which was 16 days after the previous assessment. The documentation included that the right gluteal fold (right ischial tuberosity) wound was an unstageable pressure ulcer which measured 3.5 x 4.0 cm, with immeasurable depth and now had undermining from 8 to 4 o' clock at 1 cm. The wound base was described as 90% yellow adherent slough and 10% pink [MEDICATION NAME] tissue, with a small amount of purulent exudate. A wound assessment dated [DATE] included the right ischial wound measured 4.0 x 4.0 cm with 2.0 cm depth, and was a stage 3 pressure ulcer, with no muscle or bone exposed. However, the documentation also included that the wound bed was covered with 100% slough. A care plan revised on June 6, 2017 revealed the resident had actual skin impairment to the right ischium. Interventions included to follow facility protocols for treatment, monitor and document location, size, and treatment of [REDACTED]. to the physician and treatment plan as ordered. A wound assessment dated [DATE] included the pressure ulcer measured 3.0 x 3.0 cm with undetermined depth and tunneling at 2 o' clock at 4.5 cm. The wound bed was described as having slough and pink/red granulation tissue, with a moderate amount of serosanguineous drainage, with a mild odor present. A wound assessment dated [DATE] included the wound measured 3.0 x 3.0 cm with undetermined depth and tunneling at 2 o' clock at 3.5 cm. The wound bed was described as having slough and pink/red granulation tissue, with a small amount of serous drainage and no odor. A physician's wound note dated June 19, 2017 revealed the wound measured 3.0 x 3.0 cm with a necrotic base and no tunneling. The note included that the slough was removed from the ulcer base with forceps. The next wound assessment was completed 14 days later on July 3, 2017. A physician's wound note included the right ischial ulcer measured 2.5 x 3.0 x 4.0 cm and had no necrotic tissue, no bone exposed and no slough. A wound assessment dated [DATE] described the wound as a stage 4 pressure ulcer to the right ischium measuring 2.0 x 2.0 x 4 cm, with a small amount of serosanguineous drainage and no odor, and the surrounding tissue was indurated. A wound assessment dated [DATE], described the wound as a stage 4 pressure ulcer to the right ischium measuring 3.0 x 3.0 x 4.0 cm, with a small amount of serosanguineous drainage with no odor, and the surrounding tissue was normal and the edges were distinct. A physician's wound note dated July 17, 2017 describes the wound as a stage 4 measuring 3.0 x 3.0 x 4.0 cm, with no necrotic tissue or bone exposed and granular tissue present. Review of a nurse's progress note dated July 17, 2017 revealed the wound physician assessed the resident's right ischial wound and a new treatment plan was received for a wound vac. physician's orders [REDACTED]. A wound assessment dated [DATE] included the stage 4 pressure ulcer to the right ischium measured 2.0 x 2.0 x 3.5 cm, with a small amount of serous drainage and no odor, and the surrounding tissue was normal and the edges were distinct. The note also included that the treatment had been changed to a wound vac three times weekly. A wound assessment dated [DATE], described the wound as a stage 4 pressure ulcer to the right ischium measuring 2.0 x 2.0 x 3.5 cm, with a small amount of serosanguineous drainage and no odor, and the surrounding tissue was normal and the edges were distinct. Review of the TAR (Treatment Administration Record) for May through August 2017 revealed changes in wound treatments. Further review revealed that there were several treatments where the nurse had documented a 9 in the space to indicate if the treatment was done. According to the TAR, a 9 indicated to see nurse notes. Review of the corresponding nurses notes from May through August 2017 revealed multiple notations that the wound treatments were to be done by the wound nurse. However, there was no corresponding documentation by the wound nurse that the treatments were done as ordered. A wound assessment dated [DATE], described the wound as a stage 4 pressure ulcer to the right ischium measuring 1.5 x 1.5 x 3.5 cm with a small amount of serosanguineous drainage and no odor and the surrounding tissue was normal and the edges were distinct. A physician's wound note dated August 7, 2017 described the wound as a stage 4 which measured 1.5 x 1.5 x 3.5 cm, with poor, unhealthy tissue and exposed sharp bone. A physician's wound note dated August 14, 2017 included the right ischium wound was a stage 4 and measured 1.5 x 1.5 x 3.5 cm, with more tunneling and undermining and exposed bone. The note further included that the resident may have possible osteo[DIAGNOSES REDACTED] and may need debridement. Review of a wound note by the wound nurse dated August 17, 2017 at 8:56 a.m. revealed the wound had frequent episodes of bleeding. New orders were received for a change in wound treatment. The note also included that the wound physician will inform the facility when the resident can be admitted to the hospital for wound intervention. Another nurses noted dated August 17, 2017 at 9:29 a.m. included that the IDT team met to discuss the resident's stage 4 pressure ulcer and that the treatment plan was changed by the wound physician, as the resident needs to be evaluated at the hospital for surgical debridement. Awaiting order to transfer the resident to the hospital. A nurse's note dated August 17, 2017 at 9:20 p.m. included to send the resident out to the hospital for wound debridement. Per the clinical record documentation, the resident was discharged to the hospital on August 17, 2017 and did not return to the facility. Regarding the left ischial pressure injury: A weekly skin check dated March 28, 2017 described an area on the left inner buttock as moisture associated skin damage (MASD), which measured 0.5 x 0.2 cm and described another area as MASD to the left buttock, which measured 0.5 x 0.3 cm. There was no further description of these areas. A weekly skin check dated April 3, 2017 indicated there were two open areas to the left buttock and that follow-up was needed. Shower documentation for April 7, 2017 included a body diagram with a circle to the buttocks area with a note stating slight redness, open area. A weekly skin check dated April 10, 2017, indicated there was an area of irregularity on the resident's left inner buttock, and another area described as moisture related also on the left buttock. The assessment indicated that follow up was needed. Shower documentation for April 12, 2017 again indicated that the resident had slight redness and an open area on the buttocks. Further review of the clinical record revealed that from March 28 through April 13, 2017, there was no documentation that the physician was notified or that any treatment was provided to the buttocks from March 28 through April 13. Also, there were no measurements of the area since March 28. A physician's orders [REDACTED]. Continued review of the clinical record revealed that from April 15 through April 24, 2017, there was no evidence that the area on the resident's left buttock was assessed or measured. A weekly skin check dated April 24, 2017 indicated there was an area of irregularity on the resident's left inner buttock, and another area described as moisture related also on the left buttock. The assessment indicated that follow up was needed. However, there was no clinical record documentation of any follow up at this time. A wound assessment was completed on April 27, 2017 and included that the resident now had a stage 3 pressure wound to the left gluteal fold, which measured 1.9 x 1.9 x 0.2 cm. The wound was described as circular in shape, with no undermining or tunneling, edges were defined and attached with 100% red granulation tissue. No exudate or odor was noted. A physician's orders [REDACTED]. In a dietary/nutritional progress note dated April 27, 2017, the Registered Dietitian (RD/staff #234) recommended the resident receive 4 oz of Med Pass (a nutritional supplement) twice a day to provide extra calories and protein. However, review of the clinical record revealed an order for [REDACTED]. A wound physician's consult note dated May 1, 2017 included the resident had a stage 3 left ischial pressure injury, which was pressure and moisture related. Per the wound assessment dated [DATE], the stage 3 pressure wound to left gluteal fold measured 1.9 x 1.9 x 0.2 cm. Additional documentation indicated that the specific location of the wound was the left ischial tuberosity. There was no undermining or tunneling noted, the wound edges were defined and attached and the wound base was 100% red granulation tissue. No exudate or odor noted. A progress note dated May 8, 2017 included the left gluteal fold injury area appeared larger and that the wound nurse was notified. Another dietary/nutritional progress note dated May 11, 2017 again included to add 4 oz Med Pass twice a day for additional calories and protein. The next wound assessment was not completed until May 15, 2017. Per the assessment, the stage 3 left ishcial tuberosity pressure ulcer measured 1.5 x 2.0 x 0.2 cm, and had 80% red granulation tissue and 20% yellow adherent slough. No exudate, odor, undermining or tunneling were present. A physician's orders [REDACTED]. The next assessment of the left ischial tuberosity wound was 16 days later on May 31, 2017. The wound assessment included the stage 3 pressure ulcer measured 0.9 x 1.0 x 0.2 cm and had 100% red granulation tissue with no exudate, odor, undermining, or tunneling. Review of the TAR for May 2017 revealed changes in wound treatments. Further review revealed that there were several treatments where the nurse had documented a 9 in the space to indicate if the treatment was done. According to the TAR, a 9 indicated to see nurse notes. Review of the corresponding nurses notes in May 2017 revealed a notation that the wound treatments were to be done by the wound nurse. However, there was no corresponding documentation by the wound nurse that the treatments were done as ordered. Review of the physician wound progress notes dated June 5, 2017 revealed the left ischial wound measured 0.9 x 1.0 x 0.2. The note indicated that the ulcer was almost closed. The wound documentation dated June 6, 2017, indicated that the left ischium wound had revolved. Regarding the right inner buttock pressure ulcer: A weekly skin check dated March 28, 2017 included the resident had moisture associated skin damage on the right inner buttock, which measured 1.0 x 0.3 cm. A weekly skin check dated April 3, 2017 indicated there was a small open area on the right buttock and that follow-up was needed. The documentation did not include a description of the wound bed. Review of the shower documentation for April 7, 2017 revealed a body diagram which had a circled area on the buttocks, with a note stating slight redness, open area. A weekly skin check dated April 10, 2017 indicated there was an area of irregularity on the resident's right inner buttock. The assessment indicated that follow up was needed. Shower documentation for April 12, 2017 again documented the buttocks had slight redness, with an open area. Further review of the clinical record revealed there was no documentation the physician was notified or that treatments were provided from March 28 through April 13, 2017. A physician's orders [REDACTED]. A weekly skin check dated April 24, 2017, indicated an area of irregularity on the resident's skin to the right inner buttock. There was no further description of the area. From April 14 through April 24, 2017, there was no clinical record documentation of any measurements of the redness to the right buttocks. Review of a wound assessment dated [DATE] revealed the resident had a stage 2 right inner buttock pressure ulcer, which measured 0.5 x 0.5 x 0.2 cm. The wound was described as having a circular shape, with no undermining or tunneling, edges were defined and attached with 100% red granulation tissue, no exudate or odor was noted. Additional notes indicated that the sacrum had blanchable dark redness. This was the first thorough assessment of the buttocks area since March 10, when the buttocks was identified to have redness. A physician's orders [REDACTED]. A wound assessment dated [DATE] documented the resident had a stage 2 pressure ulcer to the right inner buttock, which measured 0.8 x 0.8 x 0.2 cm. The wound base was described as having 100% red granulation tissue and there was no undermining, tunneling, odor, or exudate noted. The note included that wound rounds were done with the physician. Between May 1 and May 15, 2017, there was no clinical record documentation that the right inner buttocks pressure ulcer had been thoroughly assessed. The next wound assessment was completed 14 days later on May 15, 2017. The documentation included that the stage 2 pressure ulcer to the right inner buttock measured 1.0 x 1.0 x 0.1 cm and the wound base was 100% red granulation tissue and there was no undermining, tunneling, odor, or exudate noted. Further review of the clinical record revealed no documentation regarding the right inner buttock pressure ulcer until June 2, 2017. A wound note dated June 2, included that the right buttock stage 2 pressure injury had resolved. In an interview with the interim Director of Nursing (DON/staff #228) on September 20, 2017 at 12:10 p.m., she stated it is the expectation that the physician be notified of any new open areas. An interview was conducted on September 20, 2017 at 11:56 a.m., with the wound nurse (staff #50). Staff #50 stated that she does the wound assessments weekly, which includes a full assessment of the wound and measurements. Another interview was conducted on September 21, 2017 at 10:56 a.m., with staff #50. She stated that if a CNA identifies a new area of concern during a skin check on a resident, they should immediately report it to the nurse on duty. Staff #50 stated that the nurse should then assess the wound and call the physician to determine the next step and that this should be documented in the progress notes. Staff #50 stated that when a new area of concern is identified, the physician has to be notified in order to have a treatment put into place right away. After reviewing the resident's clinical record, staff #50 stated that something should have been put into place right away when the open areas were identified. She stated that her process would have been to notify the resident's physician of the open area and then discuss a treatment plan and whether the resident should be seen by the wound physician as well. An interview with a CNA (certified nursing assistant/staff #22) was conducted on September 22, 2017 at 9:12 a.m. She stated that she performs skin checks on residents during showers and if a new area is identified, it is written in the shower book, charted in the electronic charting system, and the nurse is notified right away. Another interview was conducted with the interim DON on September 22, 2017 at 10:13 a.m. She stated that the nurse who identified the open areas on the weekly skin checks did not do what he should have done, as far as reporting to the physician regarding the newly identified open areas. During an interview with a Licensed Practical Nurse (LPN/staff #54) on September 22, 2017 at 12:15 p.m., she stated that if a CNA were to report to her that a resident had a newly identified area of concern on the skin, she would contact the physician to inform them of the area and this would be charted. She also stated that if the wound nurse was available, she would inform her of the area and ask her to take a look at it. She also stated if she were to find a new area of concern on the resident's skin she would follow the same procedure. Review of a facility policy and procedure titled, Pressure Ulcer Risk Assessment included If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. The policy also included to Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. In a section regarding assessments the policy stated Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated .Staff will maintain a Stop and Watch while performing routine skin inspections daily or every other day as needed. Further, the policy described that a pressure ulcers onset for an at-risk resident can be within 2 to 6 hours, so need to be identified and interventions need to be implemented promptly in an attempt to prevent a pressure ulcer. Review of a facility policy titled, Medical Nutritional Therapy Recommendations included that recommendations which need nursing's or physicians attention will be forwarded to the nursing staff.

Based on clinical record review, hospital records, facility documentation, staff interviews and policy review, the facility failed to ensure one resident (#224) was offered sufficient fluids to maintain proper hydration. Findings include: Resident #224 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A care plan revised on May 12, 2016, identified that the resident was a nutrition and hydration risk, due to dementia, [MEDICAL CONDITION], a history of swallowing difficulty and the need for thickened liquids. One of the goals included for meal intakes to be greater than 75%. Interventions included assist with meals as needed, encourage fluids and to monitor meal intakes. Review of an ADL (Activities of Daily Living) care plan revised on June 8, 2016 revealed the resident had impaired decision making, hand tremors related to [MEDICAL CONDITION], and required assistance with ADL's. Interventions included the resident needed to be fed by staff and to set up/cue and assist with ADL's as needed. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], the resident scored a 9 on the Brief Interview for Mental Status section, which indicated the resident had moderate cognitive impairment. This MDS also assessed the resident to require extensive assistance with eating. Review of the clinical record revealed the resident was admitted to the hospital on September 29, 2016 and was readmitted on [DATE]. A review of the October 1, 2016 hospital History and Physical Report and Discharge Summary revealed the resident was hospitalized for [REDACTED]. The discharge [DIAGNOSES REDACTED]. The October 1, 2016 hospital transfer and physician orders [REDACTED]. The transfer orders also included for liquids to be nectar thick. A nursing progress note dated October 1, 2016 identified that the resident was readmitted from the hospital to the facility at 1:45 p.m. The note further included the resident ate 100% of dinner, drank three glasses of juice, continues on nectar thickened liquids and diet was changed to mechanical soft. A nursing progress note dated October 2, 2016 included that fluids were encouraged. A review of the resident's fluid intake records for October 2016 revealed the resident consumed the following amounts of fluids each day: -October 1 and 2 = no fluids documented for the day -October 3, 2016 = 900 cc -October 4, 2016 = 1200 cc -October 5 = no fluids documented for the day Review of an Interim Care Plan dated October 5, 2016 revealed the resident was at risk for dehydration. The goal was to provide adequate hydration. Interventions included encourage oral fluid intake and to monitor for sign and symptoms of dehydration. A nursing progress note dated October 6, 2016 included the resident accepts all meds and fluids. According to the October 7, 2016 Nutrition Risk Assessment, the resident had swallowing difficulty related to dysphagia and required nectar thick liquids. The assessment also included the resident had difficulty feeding self, related to [MEDICAL CONDITION]. Current food and fluid intake was between 50-75%. Interventions included to assist with meals, encourage meal intakes and monitor oral intakes. Per this assessment, the resident's weight was 83 kg and his estimated fluid needs were to be greater than 1660 cc's per day. Per the facility's policy regarding Hydration Assessments, a general guideline for determining baseline daily fluids needs is to multiple the resident's body weight in kg times 30 ml (2.3 lbs = 1 kg). Based on the resident's weight of 83 kg, his estimated fluid needs were 2,490 cc's per day, not 1660 cc's per day. Further review of the resident's fluid intake records from October 2016 revealed the resident consumed the following amounts of fluids each day: -October 6, 2016 = 700 cc -October 7 and 8 = no fluids documented for the day -October 9, 2016 = 720 cc -October 10 = no fluids documented for the day A nursing progress note dated October 10, 2016 at 10:31 a.m., identified the resident was seen pocketing food this morning during breakfast and usually took medications crushed in applesauce, but was unable to swallow at that time. The resident reported that he was not feeling well and the nurse noticed what seemed to be a deficit to the left side during hand grips and a slight left sided facial droop. The physician was notified and the resident was transferred by ambulance to the hospital for an evaluation. Review of the Hospital Admission History and Physical dated October 10, 2016, revealed that per the facility's nursing staff, the resident was lethargic and was not responding as usual. He was unable to swallow when taking pills and facial droop was noticed. Per the documentation, the resident presented as a stroke alert. Tests were completed and showed no infarct or mass. There were small vessel ischemic changes and cerebral atrophy. There was significant vascular calcification, but no significant stenosis and the stroke alert was downgraded. The hospital History and Physical further included that based on labs results, the resident appears profoundly dehydrated. The documentation further included the following under the section titled Impression and Plan: The resident had severe [MEDICAL CONDITION] (high sodium level) and it's suspected that it did not occur overnight and possibly not over the last few days; metabolic acidosis with profound dehydration and acute [MEDICAL CONDITION] secondary to dehydration. According to the October 14, 2016 Hospital Discharge summary, the resident was hospitalized from October 10, through October 14, 2016 with a principal [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. In interviews conducted on March 7, 2017 at 12:41 p.m. and on March 9, 2017 at 10:43 a.m., a CNA (Certified Nursing Assistant/staff #69) stated the resident required to be fed meals and received thickened fluids. Staff #69 stated that thickened fluids were provided on each meal tray and she could make thickened liquids for the resident, as there was thickener product readily available on the unit. Staff #69 stated fluids were offered, but the resident did not communicate verbally if he wanted a drink. Staff #69 further stated all residents' meal and fluid intake amounts are monitored by the CNAs and documented in the computer. In an interview conducted on March 9, 2017 at 10:24 a.m., a CNA (staff #80) said the resident was dependent on staff to be fed and required thickened fluids. Staff #80 stated that they had to provide the fluids, because the resident did not ask for fluids. Staff #80 stated the CNAs document a resident's fluid and meal intake amounts for every meal. Staff #80 said the resident also would drink fluids during snack time and that amount would be added to the fluid intake documentation. She stated if a resident was not drinking fluids, she would let the nurse know. Staff #80 said the resident loved milk and only maybe twice had refused food and fluids, and she would document it and report to the nurse when that occurred. On March 9, 2017 at 10:50 a.m., a LPN (licensed practical nurse/staff #193) stated she gets nectar thick fluids from the kitchen and that there is a supply in the refrigerator at the nurse's station. She said the CNA staff are to document meal intakes in the electronic record. She stated that if a resident was not drinking fluids, she would encourage the resident and notify the physician. In an interview conducted on March 9, 2017 at 11:02 a.m., the Assistant Director of Nursing (ADON/staff #9) confirmed that the resident's Interim Care Plan directed staff to monitor fluid intake. Staff #9 stated the expectation was for licensed staff to document fluid and meal intakes in the nursing progress notes and for the CNAs to document it in the electronic record. A review of the resident's fluid intake records and nursing progress notes was conducted and staff #9 confirmed the lack of documentation regarding intake amounts, and stated that the food and fluid intake was not adequate. In interviews on March 9, 2017 at 11:38 a.m. and 12:42 p.m., the consultant Registered Dietitian (RD/staff #194) stated that a former Registered Dietary Technician had completed the October 7, 2016 Nutrition Risk assessment and agreed with the estimated fluid needs of 1660 cc's daily for the resident. The RD further stated the fluid needs were calculated based on fluid in foods and free fluids, not just fluids alone. Staff #194 reviewed the resident's meal and fluid intake records from October 1, 2016 through October 10, 2016. Staff #194 confirmed there was no documented evidence the resident's meals and fluid intakes were monitored on October 1, 2, 5, 7, 8 and 10. At this time, staff #194 calculated the resident's daily total fluid amounts based on the menu. According to the Menu Analysis, the resident's daily total fluid from food and fluids were as follows: -October 3 = 1585 cc -October 4 = 2278 cc -October 6 = 1215 cc -October 9 = 1065 cc Staff #194 then stated that the fluids calculated were based on the menu for those days and not what the resident actually consumed. (Per the Nutrition Risk assessment dated [DATE], the resident's current food and fluid intake was 50-75%). Staff #194 further stated there was only one day (October 4) when the resident had received the estimated fluid needs. However, the resident's daily fluid needs were 2,490 cc's based on a weight of 83 kg, as per the guidelines from the Hydration Assessment policy. Based on this, the resident's daily fluid needs were not met from October 1 through 10, 2016. In an interview on March 9, 2017 at 1:07 p.m., the Director of Nursing (DON/staff #195) stated that CNAs and licensed nurses were to evaluate and communicate a resident's status. Staff #195 stated the monitoring of documentation was on the unit manager's to-do list. Staff #195 stated the ADON was not involved with the resident in October 2016 and the prior DON was no longer employed. Review of a nursing policy and procedure regarding Hydration and Nutrition Assessments revealed a general guideline for determining baseline daily fluids needs is to multiple the resident's body weight in kg times 30 ml (2.3 lbs = 1 kg). The policy included the specific amount of hydration needed is specific for each resident and fluctuates as the resident's condition fluctuates. Risk factors for dehydration included functional impairments that make it difficult to drink, reach fluids or communicate fluid needs (e.g. [MEDICAL CONDITION], dementia in which a resident forgets to drink or forgets how to drink and/or refusal of fluids). The policy further included factors impacting nutritional intake and hydration included ability to chew, swallow and feed self.

Based on clinical record reviews, staff interviews, facility documentation, and policy review, the facility failed to ensure fall interventions were in place for one resident (#31) who fell and sustained multiple fractures, and failed to ensure adequate supervision was provided in order to prevent multiple resident to resident altercations involving 16 residents (#'s 4, 25, 65, 73, 79, 84, 135, 141, 148, 163, 176, 214, 230, 231, 234, and 243). Findings include: -Resident #31 was admitted on [DATE] for a respite stay and was discharged to home on May 29, 2016. [DIAGNOSES REDACTED]. The hospital discharge summary dated March 1, 2016, included the resident had a fall at home and had sustained a fracture of the left humerus. The facility's fall risk assessment dated [DATE], identified that the resident was at moderate risk for falls. The assessment included the resident had 1 to 2 falls in the last 6 months, was confined to a chair and his medications included antihistamines and psychotropics. Despite the resident's fall risk, an interim fall care plan had not been developed. A review of the March 2016 recapitulation of physician orders [REDACTED]. -Bed bolsters to define the parameters of the bed. Monitor every shift for placement. The order date was March 1, 2016. -Bed to be in the lowest position. Monitor every shift. The order date was March 1. -Physical, occupational and speech therapy evaluations and treatment. The order date was March 1. However, review of the closed clinical record revealed there was no documentation that the resident ever received physical, occupational or speech therapy evaluations and treatments, as ordered by the physician. The admission MDS assessment dated [DATE], included the resident's BIMS score was 13, which indicated the resident was cognitively intact. The MDS also noted that the resident was non-ambulatory and required extensive assistance for activities of daily living. A nursing note dated March 14, 2016, included that at 10:00 a.m., the resident was found face down on the floor in his room. The resident was observed to have bruising to the right wrist, hand and knee. Per the documentation, the Nurse Practitioner was on site and was notified. The note further included that the resident had an ortho appointment already scheduled for this afternoon for follow up for the fractured humerous and that the ortho office agreed to take x-rays of his hand and wrist. A review of the orthopedic report dated March 14, 2016 revealed the following: -Possible right 5th metacarpal fracture. -Proximal fibular fracture, right knee fracture appears new. -Possible nondisplaced tibial fracture, need further imaging. The report also included that the radiographs of the right knee will be ordered, a Velcro splint was prescribed for the right wrist, a bulky dressing was applied around the right proximal fibula for cushioning, and a follow up appointment in two weeks was recommended. According to the diagnostic imaging report dated March 15, 2016, the resident sustained [REDACTED]. A review of the facility's investigative report revealed the resident had fallen out of bed on March 14, 2015 and was found face down on the floor in his room. The report included that the low air loss mattress was replaced, as the bolsters on the left side of the mattress were not staying upright, but were laying flat. Additional bed bolsters were added. This report also included a statement from a LPN, who had assisted the wound nurse with a skin check of the resident at 8:30 a.m. on March 14, 2016. The documentation included that the resident was on his back in the center of the bed (his upper body was slightly left of center) and the bed was lowered but not in the lowest position. Although the March 2016 Treatment Administration Record included documentation that the bed was in the lowest position on March 14, on the day shift, the above LPN statement reflected that prior to the fall, the bed was not in the lowest position, as ordered by the physician. The NP progress notes included the following: -March 18: right wrist and right lower extremity tenderness, the resident saw the orthopedist today and can wear a right lower extremity immobilizer. Will determine the correct immobilizer and order if needed, for the right tibial fracture. Continue with Tramadol and Tylenol for pain. -March 22: utilizing immobilizer for the right tibial fracture. -March 24: compression ace wrap on the right tibial fracture. -March 31: continue with pain management for right tibial and right metacarpal fracture. Another orthopedic follow up report dated April 20, 2016, included to discontinue the immobilizer/brace. An interview was conducted on June 6, 2016 at 9:45 a.m., with the Interim Director of Nursing/Corporate Clinical Manager (staff #256). Following a review of the physician's orders [REDACTED]., she stated that the physician's orders [REDACTED]. Staff #256 also stated she recalled that the upper left bed bolster was flat. An interview was conducted with the LPN (staff #109) whose statement was included in the facility's report. He stated that he recalled the resident and the fall that occurred on March 14, and that he was the nurse on duty at that time. He stated after he was notified that the resident was on the floor, he entered the resident's room and observed that the resident's bed was not in the lowest position, as ordered by the physician. He also stated that the low air loss mattress was replaced after the resident's fall, because the left side of the mattress was not upright, but was laying flat. On June 6, 2016 at 11:45 a.m., an interview was conducted with the wound nurse/Registered Nurse (staff #37), who had entered the resident's room after the fall on March 14. She stated the resident had an overlay type bed bolster, with two bolsters on the top and two on the bottom of the bed. She stated that she observed that the left upper bed bolster was flat and that the overlay bed bolster did not fit properly and so she switched them to the wedge type of bed bolsters, after the resident's fall. A facility policy titled Falls Management included that the physical environment remains as free of accident hazards as possible. Residents will be assessed for fall risk and interventions will be implemented to reduce the risk for falls. Regarding an altercation between resident #230 and resident #231: -Resident #230 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the clinical record revealed the resident resided on the dementia/behavior unit. A significant change MDS (Minimum Data Set) assessment dated [DATE] included the resident had a BIMS (Brief Interview for Mental Status) score of 2, which indicated the resident had severe cognitive impairment. -Resident #231 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the clinical record revealed the resident resided on the dementia/behavior unit. Review of the admission MDS assessment dated [DATE] revealed the resident had a BIMS (brief interview for mental status) score of 3, indicating the resident had severe cognitive impairment. The MDS further documented that the resident had physical behavioral symptoms directed towards others, such as; hitting, kicking, pushing, grabbing, and abusing others sexually, which occurred daily. A care plan included that resident (#231) had a high level of sexual behaviors directed towards staff and peers. Interventions were to monitor all interactions with peers and avoid seating in entry ways where potential contact may occur and to monitor resident closely in the common area. Review of a Health Status Note dated August 16, 2015 at 8:05 a.m. revealed that a female resident (#230) in a wheelchair was passing by resident #231 in the hallway near the day room, when the nurse observed resident #231 quickly touch/fondle resident #230's breast two times. The residents were immediately separated and resident #230 denied discomfort. According to the facility's investigative report, resident #231 was in his wheelchair in the hallway near the dayroom on August 16, 2015 at 7:30 a.m. At this time, resident #230 was self-propelling herself in her wheelchair past resident #231. A RN (registered nurse/staff #69) witnessed resident #231 quickly touch resident #230's breast. Staff #69 separated the residents with no further incidence. A care plan for resident #231 was revised after this incident and reflected that a recent isolated incident of sexual contact with a female peer had occurred. A telephone interview was conducted with staff #69 on June 3, 2016 at 12:03 p.m. Staff #69 stated she remembered witnessing resident #231 grab resident #230's breast and that she separated the residents, but did not remember if there were other staff in the area at this time. Regarding an altercation between resident #79 and resident #25: -Resident #79 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] included the BIMS section could not be completed, as the resident had memory problems. The MDS also noted that the resident had moderate cognitive impairment and poor decision making skills. Review of a care plan revealed the resident had behaviors of being very territorial and combative. An intervention was to keep the resident at arm's length apart from peers to prevent accidents. -Resident #25 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] included a BIMS score of 5, which indicated the resident had severe cognitive impairment. Review of the facility's investigation revealed that on April 23, 2015 at 12:07 p.m., a CNA was propelling resident #79 in the hallway and when they passed by resident #25, resident #79 reached out and hit resident #25 on the arm. Per the report, resident #25 stated He hit me. Why did he hit me? That hurt my arm. No physical injuries were sustained. An interview was conducted on June 8, 2016 at 11:11 a.m., with the CNA (staff #130) who had been pushing resident #79 in his wheelchair when he hit resident #25. The CNA stated she was aware of the resident's behaviors, but did not see resident #25 before he hit her on the arm. Regarding an altercation between resident #176 and resident #141: -Resident #176 was admitted [DATE], with [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] included a BIMS score of 4, which indicated the resident had severe cognitive impairment. The resident was also assessed to have severe vision impairment and exhibit behaviors that significantly intrude on the privacy or activity of others. A care plan dated November 23, 2015 included that the resident was legally blind and to provide a level of assistance as needed to maintain safety. -Resident #141 was admitted [DATE], with [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] included that the resident was unable to complete the BIMS section and that he exhibited physical behaviors (e.g. hitting, kicking, pushing, scratching, grabbing, abusing other sexually) toward others occasionally. Review of the clinical record revealed that resident #141 was not oriented to year, month, or day of the week, but was alert and had moderate impaired decision making skills, with disorganized thinking. A care plan included the resident had behaviors of verbal aggression and property destruction and that the resident's interaction with peers was to be monitored. An intervention was to keep resident #141 at arms length of other residents during socialization and meals. Review of the facility's investigative documentation revealed that on December 23, 2015, resident #176 bumped into resident #141 and resident #141 then hit #176 on the hand. Both residents were assessed and no injuries were found. During an interview conducted on June 6, 2016 at 10:18 a.m., a CNA (staff #23) stated that resident #176 likes to intrude on other residents' space and that staff try to intercede, before the other residents strike out. An interview was conducted with a Licensed Practical Nurse (LPN/staff #70) on June 6, 2016 at 2:53 p.m. The LPN stated resident #76 is easily distracted, but it is a matter of getting to the residents in time to prevent an altercation. Regarding altercations between resident #214 and resident #'s 4, 65, 84, and 135: -Resident #65 was admitted [DATE], with a [DIAGNOSES REDACTED]. A MDS assessment dated [DATE], documented the BIMS section was unable to be completed. Review of the clinical record revealed that the BIMS was unable to be completed, due to the resident having severe cognitive impairment and being non verbal. -Resident #4 was admitted [DATE], with a [DIAGNOSES REDACTED]. Review of a MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated the resident had severe cognitive impairment. -Resident #84 was admitted [DATE], with a [DIAGNOSES REDACTED]. A MDS assessment dated [DATE], documented the BIMS section was unable to be completed. Review of the clinical record revealed the BIMS section was unable to be completed, due to the resident having impaired cognition and being non verbal. -Resident #135 was admitted on [DATE], with a [DIAGNOSES REDACTED]. A MDS assessment dated [DATE], documented the BIMS section was unable to be completed. Review of the clinical record revealed the BIMS section was unable to be completed, due to impaired cognition and being non verbal. -Resident #214 was admitted [DATE], with a [DIAGNOSES REDACTED]. Review of an admission MDS assessment dated [DATE] revealed a BIMS score of 0, which indicated the resident had severe cognitive impairment. A behavioral care plan documented the resident had physical aggression toward peers. An intervention included to keep resident #214 at least arms length from peers that are known to cause resident to become upset and for staff to position themselves between the resident and her peers. Review of the facility's investigation revealed that on March 15, 2016 at 4 p.m., resident #214 put both hands around resident #65's neck while in the dayroom. A CNA (staff #95) redirected resident #214 away from other residents, but resident #214 jerked away and put both hands around three other resident's (#4, #84 and #135) neck. The resident was then placed on 1:1 supervision. During an interview conducted on June 6, 2016 at 12:51 p.m., CNA #95 stated she was taking residents vital signs in the dayroom, when resident #214 put her hands around four residents' necks. CNA #95 stated she intervened and separated resident's #214 hands from around resident (#65) neck, but the resident moves very quickly and was able to put her hands around the other three residents neck, even though she was intervening. She stated after the fourth incident she summoned the nurse and resident #214 was then monitored constantly by one staff member. Regarding an altercation between resident #243 and resident #163: -Resident #163 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed the resident was unable to complete the BIMS section, due to cognitive impairment. The resident was assessed as having short term and long term memory problems. The MDS included the resident had wandering behaviors and was able to walk on the unit with supervision. -Resident #243 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE], revealed the resident was not able to complete the BIMS section, as he was cognitively impaired. The MDS also noted that the resident wandered daily and had behaviors of hitting others daily. A care plan included that resident #243 had dementia with behavioral disturbance, wanders and has displayed physically abusive behaviors, by striking at peers. The goal was to have his needs met. Interventions included to distract the resident while wandering within the secured unit to prevent physical abuse, and at first sign of being upset, staff were to escort the resident to public areas to wander, if he refuses staff escort, staff are to position themselves between resident and peers and if the resident enters a peer's room, attempt to escort him out. Review of the nursing notes for September 2015 revealed the resident exhibited physically aggressive behaviors. On September 25, the resident was kicking staff during care and was trying to hit peers, as he passed them in the halls. On this same day, he also hit a staff member in the back and was sneaking behind peers and attempting to hit peers and staff. The documentation further included that the resident needed to be watched. On September 26, the resident was hitting and kicking staff. On September 29, the resident was chasing staff and peers and was trying to hit other residents and staff intervened. Review of the nursing notes dated October 4, 2015, revealed that resident #243 was punching a male peer (resident #163) who was standing in the day room hall area near his room. The incident was witnessed by staff. No physical injuries were noted. Review of the facility's investigation revealed that on October 4, 2015, resident #243 was observed by staff, hitting resident #163 in the stomach. This act was unprovoked. After the event, the residents were interviewed and neither could recall the event. No physical injuries were sustained. The documentation included that resident #163 walked up to resident #243 and asked him if he was talking to him and that is when resident #243 hit resident #163. The residents were separated. An interview with CNA (staff #177) was conducted at 12:50 p.m. on June 6, 2016. He did not witness resident #243 hit resident #163, but did observe that the residents were immediately separated after the incident. He said the intervention in the unit at the time was mainly to separate residents when they had incidents with other residents. He said this has changed and now residents have specific care plans and staff are aware of what they need to do to prevent altercations. He stated that at the time of this incident, there had been a staffing cut, so there were less CNAs on the unit, which made things more difficult because there were times when staff were busy with residents who needed care, which made it difficult to supervise the other residents in the main areas. He stated with the staffing cut at the time of the incident, the CNAs would alternate who watches the main area and since they were short, the nurse on the floor would have to watch at times as well. He said this was also difficult as the nurse could be busy with medications or meeting residents needs. He said that he was not aware of any specific specialized supervision that resident #243 required before or after the event. An interview was conducted with the regional behavior health director (staff #257) at 12:35 p.m. on June 7, 2016. She said that she is new in this role and is not entirely aware of the supervision pattern that was used in the building at the time of the incident. She said that resident #243 was new to the building at the time of the incident and had some history of aggression, and that staff should have been aware of this. She said that now, staff are educated on prior history of behaviors and interventions are put into place to prevent these behaviors. She said that this likely was not happening at the time of the incident. She also stated that the resident had wandering behaviors, so when he got close to other residents, staff should have been there to redirect him. In an interview with a CNA (Staff #196) at 1:30 p.m. on June 7, 2016, he said that he did not remember the incident between these two residents, but there was a time when there were less staff on the unit, only 3 CNA's instead of 4 and the facility was struggling to get enough staff hired. He said that this did influence how the unit ran and at times, it was hard to stop the residents from having altercations with each other. Regarding an altercation between resident #234 and resident #73: -Resident #234 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS quarterly assessment dated [DATE] included a BIMS score of 3, which indicated the resident had severe cognitive impairment. Review of a care plan revealed the resident had a history of [REDACTED]. Interventions included monitoring interactions with female peers and keeping the resident more than arms length away from female peers at all times. -Resident #73 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was alert and oriented to person and place. A care plan included that the resident had dementia with delusions and was physically abusive and exhibited verbal aggression toward peers by cursing, disruptive yelling and name calling. Interventions included to keep the resident at least arms length away from other residents; try to position staff between her and other residents when ambulating, supervise interactions with peers; and separate at first sign of being upset. According to the facility's investigative report, resident #73 and resident #234 were watching TV in the day room on June 24, 2015 at 3:25 pm., when resident #73 told resident #234 that the TV show they were watching was stupid and only stupid people watch that show. Resident #234 then got up and yelled at resident #73 and sat back down. Resident #73 made another statement and resident #234 got angry and got up and walked toward her and was yelling, with a raised fist. A nurse stepped between them, but resident #73 was able to hit resident #234 with her right fist in the hip area. Resident #234 then tried to hit her with his right hand, but the nurse stopped him. Resident #234 then reached around the nurse and hit resident #73 in the right eye with his left hand. The documentation included it was a light punch and there were no injuries to either resident. An interview was conducted with the interim Director of Nursing (DON/registered nurse/staff #256) regarding this incident. The DON stated that she was not working here at that time and is not familiar with this incident. She also stated that it is the facility's policy that the CNAs working on the unit are to be there to help and intervene in whatever way necessary. Regarding a resident to resident altercation between resident #234 and resident #148: -Review of the clinical record for resident #234 revealed the resident had a history of [REDACTED]. Interventions included to redirect or distract the resident, monitor closely when in common area, escort to and from room at all times, and supervise interactions with peers at all times. -Resident #148 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of clinical record revealed the resident resided on the dementia behavior unit. A health status note dated August 19, 2015 documented the resident got into a physical altercation with another resident (#234), causing resident #148 to loose his balance and fall. No physical injuries occurred. According to the facility's investigative documentation, resident #234 pushed resident #148, causing him to loose his balance and fall. The documentation included that the incident occurred on August 19, 2015 at approximately 7:15 p.m. in the day room. During an interview with a LPN (staff #208) on June 3, 2016 at 11:53 a.m., she stated that she had witnessed resident #234 push resident #148 and that there were no other staff present at the time. During an interview at 12:47 p.m. on June 3, 2016, CNA (staff #194) stated the resident did not have anyone supervising him at that time. Review of the facility's supervision policy and procedure revealed the facility was to have a standardized resident monitoring system which will be implemented to ensure safety of all residents and staff. The procedure included that beginning on admission, the interdisciplinary team will evaluate residents continually who present medical, cognitive or behavioral conditions which put them or others at risk. Any team member who observes that a resident presents a significant risk is responsible to implement immediate safety measures and inform the charge nurse as soon as possible, who will notify the clinical director, the director of nurses, and/or the physician to determine the level of supervision necessary and possible treatment alternatives. The charge nurse may increase the level of supervision as deemed necessary. The level of supervision is to be noted on the resident's treatment sheet to be initialed each shift. The policy further included three different supervision levels as follows: first level is general supervision for residents who pose little or no danger to self or others and these residents are checked every two hours; the second level includes periodic checks for residents who are at low risk to harm self or others, but have risky behaviors and these residents will be checked as ordered by the physician; and the third level of supervision is one to one supervision for residents at high risk of harm to self and others, which includes having a staff member assigned to the resident for constant safety monitoring. Another policy regarding the care of residents with dementia and behaviors included that each resident will be assessed and a care plan will be developed on a individualized approach. The residents who show signs of problematic behavior will be identified and managed appropriately.

Based on observation, clinical record review, facility documentation, and staff and resident interviews, the facility failed to ensure that adequate supervision was provided to one resident (#3) who was at risk for falls and failed to ensure one resident (#9) was adequately monitored following an allegation of resident to resident abuse. The facility also failed to adequately supervise five residents (#s 1, 2, 5, 6 and 14) to prevent altercations. Findings include: -Resident #3 was admitted to the facility [DATE], with [DIAGNOSES REDACTED]. The resident resided on the secured behavior unit. Review of the resident's smoking care plan initiated on [DATE] revealed to provide supervision with smoking and report to MD (medical doctor) if symptomatic with vertigo, dizziness, presyncope, and syncope. A behavior care plan included the resident has a recent history of physical abuse to staff, by striking out and continues to exhibit self harm, by placing self on floor. One of the interventions was to provide two staff for care. According to the fall care plan dated [DATE], the resident was at risk for falls and injury, related to a history of falls, convulsions and the use of psychotropic medications. The care plan included that the resident has a behavior of throwing self to floor. An intervention listed was to follow the resident's behavior care plan. Review of the [DATE] quarterly Minimum Data Set (MDS) assessment revealed the resident had moderate cognitive impairment and required supervision with transfers and ADLs (activities of daily living). Review of a facility's investigation revealed that the resident sustained [REDACTED]. The report included that a CNA who was out on the smoking patio with the residents, had taken a resident into the building, leaving the other residents alone, and this was when resident #3 stood up and fell . Per the investigation, the resident was identified to be at moderate risk for falls and as part of her plan of care, she was to smoke under supervision only. A nursing progress note written by the LPN who had worked the 6 am-10 pm shift on [DATE], revealed the following: While coming in from patio, resident fell to ground. Staff did not see fall but heard it. Resident denied hitting her head, but this nurse noticed hematoma approx 2 cm (centimeters) to left temple .resident also had skin tear approx 1 cm to left wrist. Resident stated I tripped and fell , I didn't hit my head .Resident denied any pain or discomfort. ROM (range of motion) WNL (within normal limits) for resident. Neuro checks in place. Notified on call NP (nurse practitioner) no new orders, was advised to monitor patient, this nurse did advise NP that neuro checks are in place. Another nursing progress notes written on [DATE], by the same LPN included that At approx 12:00 noon, staff went to patients room to let her know lunch was here. Resident lying in bed unresponsive. This nurse assessed resident. Resident right pupil approx 2 mm (millimeters) and left pupil 4 mm, both unresponsive. Called 911 due to patient being unresponsive. Resident left facility at approx 12:30 p.m. Review of the hospital's emergency report dated [DATE] at 2:36 p.m., revealed the resident arrived via emergency services unresponsive and obtunded. A CAT (computerized axial tomography) scan of the head was obtained and showed an acute panhemispheric subdural hematoma (bleeding in the brain). The results of the CAT scan showed significant midline shift, with no neurosurgery intervention. Due to the resident having an inoperable brain injury, the resident was removed from the ventilator and expired on [DATE]. An interview was conducted on [DATE] at 2:15 p.m. with the LPN on duty the day the resident fell , while out on the smoking patio on [DATE]. He stated that there was one CNA on the patio to supervise the resident's who were smoking. He stated the CNA was pushing another resident into the building, when the resident fell and the fall was not witnessed by staff. He stated that he assessed the resident and found no change in cognition, and neuro checks were initiated. The LPN said the resident complained of a headache around 8:15 a.m. and he gave her the regularly scheduled Tylenol. He said that he did the resident's last neuro check at 11:45 a.m., with no change. At 12:00 p.m., he was alerted by a CNA, that the resident would not wake up for lunch. He attempted a sternal rub without response and then dialed 911. On [DATE] at 2:20 p.m., an interview was conducted with a registered nurse, who at the time of the resident's fall was a CNA. She stated that she was assigned to the activity/dining room that morning and that two other CNAs were getting a resident prepared for breakfast, while another CNA was monitoring the hall. The other CNA was out on the patio with the smokers. She said the CNA who was assigned to the smoking patio was pushing a resident through the door to the dining room, when she heard another resident yell that the resident had fallen. An interview was conducted on [DATE] at 2:50 p.m., with the CNA who was on the smoking patio on [DATE]. She stated that she was the only aide on the patio for five residents that morning. She said that at the time of the fall, she was pushing another resident in a wheelchair back into the dayroom. She said she did not see the resident go down, but heard another resident shout out that the resident had fallen. She said that during this period the facility only assigned one CNA to supervise the smoking patio. An interview conducted with a 300 Unit CNA on [DATE], who stated that at times the resident would get dizzy, but had never seen her fall. An interview was conducted on [DATE], with a resident who had witnessed resident #3 fall. He said resident #3 was sitting in a chair at the table near him and the resident stood up and almost immediately started to fall. He said the resident tried to prevent herself from falling by grabbing the table, but could not remain standing and fell hitting her head on the left side. Review of the facility policy and procedure for the Secured Behavior Unit stated that smoking times are to be directly supervised by staff and the assigned staff person will do the following at each smoking time: c. Supervise the entire smoking time ensuring the safety of everyone. -Resident #2 was admitted to the facility [DATE], with [DIAGNOSES REDACTED]. Review of the resident's clinical record nurses progress note dated [DATE], at 9:52 p.m. said that the resident was following resident #3 down the hallway trying to intimidate her, but staff was able to intervene and redirected the two residents. Review of the nurses progress note dated [DATE], at 2:03 p.m. said that the resident was again attempting to intimidate resident #3. The resident would step in front of her when she comes by and trying to back into her. Staff was able to intervene and step between the two residents. A behavior note dated [DATE], said that the resident was standing in the hallway. Resident #3 was being disruptive coming down the hallway and threw a glass of ice at the resident and hit him. The resident responded by grabbing resident #3 by her collar and knocking her to the floor before staff was able to intervene and separate the two residents. Review of the resident's care plan reveal a plan for, Potential to demonstrate physical behaviors related to poor impulse control, and history of harm to others. Two interventions noted were 1) When the resident becomes agitated: intervene before agitation escalates; Guide away from source of distress . 2) Will monitor resident closely while in hallway to prevent resident causing or resident receiving physical harm. Further review of the resident's care plan for Schizoaffective Disorder show that it was updated to include that he has history of physical abuse as demonstrated by grabbing peer by the collar and pushing peer. This was added to verbal abuse by threatening peers. -Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an MDS (minimum data set) assessment dated [DATE], documented the resident had a BIMS (brief interview of mental status) score of 13, which indicates the resident is cognitively intact. Regarding incident with resident #2: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an MDS quarterly assessment dated [DATE], document the resident as having a BIMS score of 15, which indicates the resident is cognitively intact. A behavioral health assessment note dated [DATE], documented that the resident has shown an increase in sexually inappropriate behaviors and the care team feels he requires and increased level of supervision and assistance. Per the Minimum Data Set (MDS) admission assessment dated [DATE], the resident was assessed as having a BIMS (brief interview of mental status) score of 13 which is cognitively intact. The MDS further documented that resident had verbal behaviors directed towards others and behaviors that significantly disrupt care or the living environment. Review of nurses notes from [DATE] through 22, 2015 revealed no inappropriate sexual behaviors towards other residents. However, nurses notes during the same time revealed several days of inappropriate sexual comments towards staff. Review of the residents care plan initiated in [DATE] for Bipolar/Schizoaffective and dementia as evidenced by (AEB) sexually inappropriate verbal comments to staff, hitting peers, physical and verbal sexual behaviors to peers and staff revealed interventions that included token program, supervise interactions with peers and separate at first sign of upset, use two staff at all times and coordinate with psychiatric provider for routine consultations. A social service progress note dated [DATE] document that social service and a certified nursing assistant (CNA) met with the resident to discuss the behavior care plan which involved receiving tokens for no sexually inappropriate contact. A nurses note dated [DATE] document that resident #1 was observed touching resident #2 buttocks. Review of a SBAR change of condition form dated [DATE] documented that an observation was made of resident #1 touching a male resident on the buttocks in the dayroom and staring at resident intensely while licking his lips and clapping his hands before approaching the resident. The SBAR further documented that physical separation, reminders about appropriateness and the token program made the symptoms better. Review of the bipolar/schizoaffective careplan was revised on [DATE] to include an intervention of redirecting resident as he self propels in wheelchair and/or escort resident to attempt to keep him at arms length from peers. An interview was conducted with a CNA on [DATE], who stated that she recalled resident #1 could be aggressive at times and grabbed the bottom of resident #2. She further stated that she immediately separated the two residents and tried to engage them in other activities. Regarding incident with resident #14: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a care plan that was initiated on [DATE] for psychotic disorder and dementia with depression documented that resident #14 had a BIMS score of 8, which indicates resident is moderately impaired. Review of a health status note for resident #1 that was written on [DATE] by a licensed practical nurse (LPN), documented that two CNA's reported that resident #1 was in the hallway and hit resident #14 on the left arm. Review of the facility incident report dated [DATE] revealed that the bipolar/schizoaffective careplan interventions for resident #1 were continued as appropriate and no new interventions were implemented. The incident report further stated that the case manager stated that she need to consider alternate placement due to the current situation. An interview was conducted with a CNA on [DATE], she stated she observed resident #1 coming down the hall towards his room while resident #14 was heading in the opposite direction. Resident #1 reached out and hit resident #14 for no reason. Resident #14 did not hit back and continued to go on to his room. CNA further stated that it happened so quickly that she could not get to the residents quickly enough to avoid the incident. -Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the annual MDS assessment dated [DATE], resident #14 has a BIMS score of 8 which is moderately impaired. Review of residents care plan initiated on [DATE] for psychotropic medication use related to behavior management revealed interventions that included monitor/record any occurrence of target behavior symptoms such as violence/aggression towards staff/others and document per facility policy. Review of the KARDEX form regarding behaviors that is used by CNA's, revealed to supervise interactions with peers and separate at first sign of upset, encourage resident to return to private room and assist with relaxation techniques or distract by turning on the television. A behavior note dated [DATE] documented that resident #14 was observed by staff hitting resident #1 on the left upper arm without injury on the patio during a smoke break. It further stated that resident #1 reacted by hitting resident #14 on the right arm without injury. Resident #14 was redirected/escorted back inside with no resistance or further aggression at this time. Review of an assessment summary progress note dated [DATE] documented that keeping the resident at a safe distance from other residents would make the condition or symptom better. Review of the facility investigative report regarding the incident between resident #14 and resident #1 occurring on [DATE] at 3:15 p.m., revealed an interview with a CNA who witnessed the incident. She stated that resident #14 came in with the smokers and as he passed by resident #1 he hit him on the left shoulder/arm. She further stated that resident #1 did not hesitate to hit resident #14 back on the right arm. An interview was conducted on [DATE] with the Director of Nursing (DON), she stated there is a staffing ratio of one CNA to two residents but previously it was decreased to one CNA to three residents. An interview was conducted with the administrator on [DATE], she stated that her corporate office reviewed the insurance contracts for the behavior unit and found the facility was high in CNA staffing. She also stated that the facility decreased the staffing but is now in the process of hiring for the CNA positions to increase the staffing on the unit. -Resident #6 was admitted [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a quarterly MDS (minimum data set) assessment dated [DATE], that documented the resident had been assessed with [REDACTED]. Resident #6's clinical record further revealed a care plan dated [DATE], that documented that the resident was status [REDACTED]. The resident expresses paranoid delusions and is unable to to recall the year, at times. The resident has a history of temper outbursts with physically aggressive behaviors that includes throwing items. The care plan documented interventions to supervise interactions with peers and separate at first sign of upset. Resident #3 was admitted [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a quarterly MDS assessment dated [DATE], that documented the resident was assessed with [REDACTED]. The clinical record revealed a care plan dated [DATE], that documented the resident had schizo-affective type schizophrenia and bi-polar disorder. The resident has a history of delusions and accusations and fluctuating depression severity. The resident has daily disruptive sounds and is intrusive to peers, resulting in risk to self. Interventions included, if the resident disruptive in public, encourage the resident to return to her private room and/or offer staff escort; monitor interactions with peers, and encourage resident to return to private room on verbal abuse to peers. A review of facility investigative and reporting documentation, revealed that on [DATE] at 5:00 a.m., resident #6 was observed to be sleeping in the day room on the Renaissance unit (high acuity non-dementia behavioral unit). Resident #3 was across the room in a chair, yelling. Staff observed resident #6 wake up, get up, and independently walk to resident #3, striking resident #3 with his fist to her head. Resident #6 was escorted to his room and resident #3 was assessed, by the LPN (licensed practical nurse) with a 0.5 cm (centimeter) skin tear on her right hand. The documentation further revealed that the facility reported the incident to the SA (State Agency) on [DATE], as an incident of resident to resident abuse. The report further documented that resident #6 had court orders for deemed incapacitated adult. A nursing note dated [DATE] at 6:58 a.m., documented that resident #3 was obsessing about ice, again and again, and counting down the minutes, loudly, in the day room. The LPN gave the resident ice and requested resident #3 to go to her room, but the resident refused and kept yelling. Resident #6 woke up and asked resident #3 to shut up, but resident #3 kept yelling. Resident #6 jumped up and hit resident #3, repeatedly, on her head. An interview was attempted on [DATE] at 9:30 a.m., with resident #6. Resident #6 had no recollection of hitting resident #3. Resident #6 was alert to self and unable to identify place or time. No interview was conducted with resident #3, as that resident had expired, unrelated to this incident. On [DATE], at 1:45 p.m., a telephone interview was conducted with the CNA (certified nursing assistant) who was present at the time of the [DATE], incident between resident #6 and resident #3. The CNA stated that resident #6 was on the couch in the day room with his eyes closed, as was his normal morning routine. Resident #3 was seated in a chair by the door to the smoking patio, yelling and screaming. The CNA stated she saw resident #6 get up from the couch and walk over to resident #3 and hit her. The CNA stated she was not close enough to resident #6 to get to him before he got to resident #3. The CNA stated there were two CNAs on the floor, herself and another CNA who was at the end of the hallway by the door. The CNA stated the LPN was either in the nurses' station or passing medications to the residents. -Regarding resident #6 and resident #1. See above for resident #6 information. Resident #1 was admitted [DATE], with [DIAGNOSES REDACTED].>bi-polar disorder, schizophrenia, dementia in other diseases classified elsewhere without behavioral disturbances, and mental disorder not otherwise specified. A review the resident's clinical record revealed a quarterly MDS dated [DATE], that documented the resident had a BIMS score of 14, that indicated the resident was cognitively intact. A review of the clinical record for resident #6 revealed a nurses' note dated [DATE] at 3:02 p.m., that the resident got up from a table in the day room after finishing his snack and walked over to resident #1, who was sitting down to consume his snack. Resident #6 hit resident #1 on the left side of his face with an open hand, in a back swing motion. Resident #6 then swiftly walked into his room and slammed the door shut. A review of the clinical record for resident #1 revealed a Behavior Note dated [DATE] at 3:02 p.m., that resident #1 was hit without provocation with an open hand, back swing motion, to left side of his face, while sitting at a table in the day room, quietly consuming his snack. Resident #1 was assessed with [REDACTED]. A review of the facility report dated [DATE], documented an incident of resident to resident abuse between resident #6 and resident #1. The incident occured on [DATE] at 3:00 p.m., on Unit 3 (high acuity non-dementia behavior unit) in the day room area. The report documented that a CNA witnessed resident #6 get up from his chair and approach resident #1, slapping him on the left cheek, as he was sitting at a table eating his snack. Resident #6 immediately went to his room. Resident #1 was assessed with [REDACTED]. An interview was attempted with resident #6 at 9:30 a.m. Resident #6 had no recollection of resident #1 or having hit resident #1. Resident #6 was alert to self only and not alert to time or place. Resident #1 was not able to be interviewed as he had discharged from the facility. An interview was conducted on [DATE] at 2:15 p.m., with one of the CNAs working at the time of the incident on [DATE]. The CNA stated she was passing out snacks in the day room area. There were four CNAs assigned to the unit that day, two CNAs were assisting a resident with a mechanical lift and one CNA was at the end of the hallway, monitoring the door. The CNA stated the LPN was in the nurses' station. The CNA stated she witnessed resident #6, who was seated at his own table in the corner of the dining/day room area, get up from his seat and walked to the area next to the nurses' station to drop off his plate and cup into the bin. The CNA stated the resident walked, as if going to his room or the couch to watch television. Resident #6 was then observed to walk to the table where resident #1 was seated, and slapped resident #1 on the face, then resident #6 ran to his room. The LPN came and assessed resident #1. The CNA stated she was the only staff in the day room area and could not have anticipated or stopped resident #6 from hitting resident #1. On [DATE] at 2:30 p.m., and interview was conducted with the LPN who was on the unit on the day of the incident between resident #6 and resident #1. The LPN stated she was seated in the nurses' station when she saw resident #6 walk past the door as he would do to walk back to his room after snack time. Then she heard resident #1 yelling out, he hit me, he hit me. -Resident #10 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of resident #10's quarterly MDS (Minimum Data Set), dated [DATE], reflected a BIMS (Brief Interview for Mental Status) score of 2, relating to severe cognitive impairment. Resident #9 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of resident #9's annual MDS assessment dated [DATE], documented the resident to have a BIMS score of 13, corresponding to cognitively intact. Review of the facility's final investigative report dated [DATE], revealed a report of resident-to-resident abuse, with the date of the event occurring on [DATE] (Sunday) at 7:00 a.m. Further review of the investigative report reflected that in the unit 2 day room, resident #9 was sitting in her wheelchair while resident #10 was also sitting in his wheelchair perpendicular to her in the day room area. The report continued that an LPN (Licensed Practical Nurse) witnessed resident #9's left hand appear to be inside resident #10's shorts on his right side. The LPN immediately separated the residents and stated that she did not observe any signs and symptoms of distress. The investigative report documented that sexual contact was observed by staff and that both residents had no recall of the event. Review of a Behavior Note dated [DATE] at 8:00 a.m., by another LPN (who was assigned to the residents), documented that resident #9 was in the day room sitting at a table next to resident #10. A nurse saw resident #9's hand up resident #10's shorts in the private area and pulled her hand away when she knew the nurse saw and became angry. The residents were separated. Further review of the clinical record reflected a late entry of an incident report, dated [DATE] at 8:02 a.m., by the LPN assigned to the residents. The incident report relayed the above nursing documentation with slight changes that included resident #9's hand under resident #10's shorts, touching his private area. Additionally, it was documented that resident #9's family was notified of the incident on [DATE]. In addition, review of a care plan for aphasia and vascular dementia, also documented to include a single occurrence on [DATE], of inappropriate sexual contact with a male peer by placing hands in peers shorts. The interventions listed were attempt to keep at more than arms length away from male peers and monitor interactions with peers in common areas. The interventions were dated as initiated on [DATE]. Despite this, there was no other documentation in the clinical record, including nursing/CNA (Certified Nursing Assistant) KARDEX information, that the resident was monitored following the incident on [DATE] to prevent another possible incident with resident #10 or other residents. In an interview with the Administrator on [DATE] at 1:25 p.m., she stated that following any resident-to-resident altercations/abuse, interventions should be put in place right away to maintain the safety of the residents. An interview was conducted on [DATE] at 2:22 p.m., with the LPN who witnessed the incident. The nurse stated that she did not contact anyone about the incident, except for the nurse who was assigned to both residents. She stated that she did not observe resident #9 touching the resident's genitals or private area, explaining that she only saw resident #9 place her hand under the other resident's shorts. She stated that both her and another LPN, who was assigned to both residents, separated the residents and that the other nurse later put the incident in writing. The nurse also stated that whenever there was a change in condition or an incident, residents would be placed on alert or change of condition charting for 72 hours. Despite this, the nurse stated that she did not think that this incident would have qualified placing the resident on alert charting and did not recall that the resident was placed on alert charting for monitoring. On [DATE], an interview with the assigned LPN was conducted. The LPN stated that she was the nurse on duty when the incident occurred, but did not observe it occur. She explained that the two residents were separated by her and another nurse when the other nurse had observed resident #9's hand under resident #10's short, near his private area. The nurse stated that resident #10 was not assessed to be in any distress. She stated that she placed a behavior note of the incident in the computer. The nurse further stated that the resident was not placed on any type of monitoring to prevent another possible incident with resident #10 or other residents. The nurse stated that she had not thought the incident was a big deal at the time and that documentation to include monitoring of resident #9 should have been completed. During another interview with the Administrator on [DATE] at 12:48 p.m., she stated that they continued to look for CNA notes or other documentation that resident #9 had been monitored/supervised, but no documentation could be provided. No other facility documentation was presented by the facility on the supervision/monitoring of resident #9 by the end of the survey exit, on [DATE]. A policy on supervision/monitoring of residents was requested from the Administrator. On [DATE], the Administrator stated that there were no other policies available regarding supervision/monitoring of residents.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#20) received appropriate treatment and services to prevent the development of contractures. The sample size was 3. Findings include: Resident #20 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's monthly progress notes from September 26, 2013 through August 26, 2014, revealed documentation that the resident was able to move all extremities, and had rigidity, but no contractures. Review of the physician's progress notes from October 28, 2014 through February 4, 2015, now included documentation that the resident's left hand was contracted. A review and comparison of the quarterly nursing mobility assessments dated August 1, 2014, November 1, 2014, and February 1, 2015, included the resident had moderate limitation of the left shoulder, but that the minimal limitation of the left elbow, wrist and fingers, that was present in August, had actually increased to moderate limitation in November 2014, and February 2015. A review and comparison of two quarterly MDS (Minimum Data Set) assessments dated November 11, 2014, and February 10, 2015, revealed that the resident's abilities had declined and that he now required total assistance for ADLs (Activities of Daily Living). In addition, the clinical record documentation revealed that the resident had not been screened by therapy since May 30, 2012. Although care plans had been developed to address the resident's multiple care issues, none of the care plans were revised to address the left hand contracture or the potential to develop further contractures. Furthermore, the clinical record did not include any documented evidence that an ongoing assessment of the left hand contracture had been provided or that a treatment plan had been developed and implemented to reduce further decline and prevent the development of new contractures. On February 27, 2015, an observation of the resident was conducted. The resident appeared to have a left hand contracture, which was confirmed by nursing staff. At this time, the nursing staff stated that the resident was not receiving restorative nursing services, and that a splint device was not used. Interviews were conducted on February 27, 2015, with administrative staff and the therapy director. Both stated that therapy screens for contractures were suppose to be provided to all residents quarterly, and based on the clinical record documentation, this resident had not been provided a therapy screen in more than two years. During a continued interview with the therapy director, he stated that according to the nursing mobility assessments, the resident's mobility had deteriorated. The therapy director stated that the licensed staff should have reported the decline to the therapy department to ensure that a therapy screen was provided. At this time, he stated that the resident would now be screened. Following the therapy screen, the physical therapy director stated that a physician's orders [REDACTED]. On February 27, 2015, both evaluations were provided. The physical therapy evaluation included that the resident had a history of [REDACTED]. The documentation included that per nursing, the resident has had ongoing difficulty with proper positioning leading to worsening of his contractures. The evaluation further included that multiple contractures of the bilateral upper and lower extremities were present, with the left side worse than the right. The occupational therapy evaluation included that the resident had contractures of most major joints of the body and that since August 2014, nursing had reported that the contractures have increased in severity. Based on the evaluation, the physical therapy director determined that physical and occupational therapies were required. A physician's orders [REDACTED]. A facility policy titled, Contracture Management included, "Residents will be assisted to maintain normal joint mobility, prevent complications associated with joint deformity and prevent worsening of existing contractures..." The policy also included the following: 1. Joint mobility limitations/contractures will be identified on the nursing admission assessment upon admit, the scheduled MDS assessment and Physical or Occupational Therapy evaluation forms, as applicable. 2. When new joint mobility limitations or increased contractures are identified during the resident's stay, the rehabilitation department will be consulted for further evaluation, treatment or recommendations. 3. Nurse or therapist will notify the physician and note orders, as applicable for rehabilitation and/or restorative nursing services to treat joint mobility limitations or contractures, (i.e. splints, OT, range of motion. 4. Document interventions implemented to meet the resident's immediate needs. 6. On going assessment and monitoring of new or exiting joint mobility limitations or contractures will be conducted no less than quarterly by a licensed nurse during the MDS assessment process with referral to rehabilitation as appropriate. 7. Between MDS assessments nursing will notify the rehabilitation department when new or increased limitations in joint mobility are observed...for further evaluation, treatment or recommendation.

Based on clinical record reviews, facility documentation, staff interviews, hospital documentation, and review of facility policies and procedures, the facility failed to provide adequate supervision to one resident (#227) with a history of physical aggression and verbal threats, and failed to provide adequate supervision to one resident (#15) who exhibited behaviors that tend to disrupt and annoy others, and an incident ensued in which resident #15 sustained a nasal fracture and a fractured humerus. The sample size was four. Findings include: -Resident #227 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed a Behavior Plan dated January 30, 2013, which included the resident was verbally abusive (teasing, taunting) and physically aggressive toward peers. Approaches included when verbally abusive and or physically aggressive toward peers, staff should immediately separate them and try to take him to his room for a 15-minute time out, distract his attention to something pleasant and engaging, he loses his telephone privileges for two hours, and is not allowed to go on out on pass for a minimum of one week. A nurse's note dated February 7, 2013 documented, that "This resident became physically aggressive with another resident when the other resident was tossing his plastic cup into the trash and the resident missed and attempted again when this resident stood up from the table in the dayroom and punched the resident on the left side of his head. The other resident started swinging back at this resident. This writer separated the residents and per the behavior plan this resident was asked to go to his room which he did. Resident was also informed that he lost his pass for a week and lost his phone privileges for two hours. There were no injuries." A nurse's note dated February 27, 2013 documented, "Resident came out of his room and tried to take newspaper from table when male peer grabbed paper. Resident punched peer on left shoulder. Per CNA (certified nursing assistant)...who witnessed incident resident did not punch him hard but hit him sideways with closed fist. Then resident tried to hit him again but staff intervened and removed peer from situation. (Name of resident) went back to his room... " There was no clinical record documentation of any increased supervision for resident #227 that was implemented after these incidents. According to the MDS (Minimum Data Set) assessment dated [DATE], the resident had physical and verbal behavioral symptoms directed toward others four to six days out of a week. A care plan updated on March 14, 2013 revealed a problem of "...He exhibits behaviors, including...wandering/intrusive with history of directing peers, verbal abuse and physical abuse to staff and peers..." A goal included "...no injury to self and others." Approaches documented were to "Follow behavior plan, review mood and behavior with clinical director and care team on a regular basis. Clinical director to modify behavior plan as indicated...at the first signs of upset, separate him from peers...Provide medications as ordered with routine and as needed psychiatric follow up." Review of a psychiatrist progress note dated March 14, 2013, revealed "...Case was discussed with staff. He gets angry very easily. He will try to hit other patients but staff intervenes. I am afraid that he may hit someone one day and hurt them badly...It is a matter of time that he will hit someone and I can't do anything because brother will not allow me to medicate him properly...will discuss his case in treatment meeting...will make decision what to do...meanwhile continue on same meds except increase Neurontin to 200 milligrams by mouth three times a day..." The psychiatrist also documented that the resident was alert and oriented times three (fully oriented). A nurse's note dated March 14, 2013 documented "...this nurse told POA (power of attorney) that Doctor would like to try resident on Abilify or Clozaril. Brother stated 'That is not right way to go. More medicine he is on worse his behaviors get. We need to have a meeting about it.' Explained to brother that Dr. is concerned about this resident may hurt somebody." Despite the concerns that the resident may physically hurt someone, there was no documentation of any increased supervision that was implemented to ensure residents safety. A nurse's note dated March 20, 2013 at 9:05 p.m. documented the following; "This resident came out of his room and walking fast paced went aggressively towards (resident #15) stating 'I am going to kick her a--.' 'She never shuts the 'F' up.' 'I'm going to shut her the 'F' up.' Attempted to redirect this resident without success. Resident was very angry. Staff go on either side of him and held his arms while another staff member put his arms around his waist and took him back to his room. Resident was verbally abusive to staff stating, 'You are all 'F' Mexicans who don't know how to do your 'F' job.' 'I'll take care of her. I'll kick her 'F' a--.' Resident went into room and closed his door. Resident was in his room approximately 3 minutes when he came back out and started being verbally abusive to staff and continued to threaten (resident #15) even though she was in her room. Resident attempted to go down the hallway toward (resident #15) room. Staff escorted resident back to his room. Resident was in his room approximately 5 minutes then once again came out of his room walking down the hallway towards (resident #15) room. Staff surrounded resident on all sides and walked with him attempting to redirect him. Resident continued to be verbally abusive to staff. After several minutes resident walked back down the hallway, tore a paper off the wall and went into his room." Further review of the clinical record revealed the resident's physician was notified of the incident. However, there was no documentation of any increased supervision such as 1:1, that was provided to either resident, despite the repeated threats and aggressive behaviors exhibited by resident #227, toward resident #15. A nurse note dated March 21, 2013 at 6:55 p.m. documented "Resident came out to dayroom, walked toward female peer (resident #15) and without showing any signs of upset resident punched her on right side of her head with closed fist. Resident (#15) fell face down sustained laceration above her right eye, bruising and swelling to cheekbone and nose, also complained of severe pain right arm." A nurse's note dated March 21, 2013 at 7:05 a.m. documented, "While resident was on the floor bleeding the resident (#227) came out of his room laughing 'Ha, ha, ha, that is exactly what I wanted.' Resident redirected back to his room. Paramedics took female peer to hospital." Another nurse's note entry dated March 21, 2013 documented the resident's physician was notified and the resident was now placed on one to one supervision. Physician orders [REDACTED]." -Resident #15 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of an MDS assessment dated [DATE], revealed the resident had verbal behavioral symptoms directed toward others four to six days a week. A nurse's note dated March 21, 2013 at 6:55 a.m. documented "Resident was in dayroom, quiet, when male peer (resident #227) came out towards resident and without any signs of upset punched resident with closed fist on right side of face. Resident fell forward on the floor." Another nurse's note dated March 21, 2013 documented "This nurse assessed resident. Resident alert and oriented times three. Bleeding from the face. Cleansed and noticed large "L" shaped laceration above right eye. Bruising and swelling to right cheek, bone and nose. Paged Dr...Called 911. Pressure applied to laceration and ice packs..." According to the hospital documentation dated March 21, 2013, the resident sustained [REDACTED]. Resident #15 returned to the facility on [DATE] at 11:00 a.m. Review of the facility's investigative report submitted to the Department dated March 21, 2013, revealed the resident had an injury to her face and right shoulder, however, it did not mention that the resident had a nasal fracture and a fractured humerus. An interview was conducted with an LPN (licensed practical nurse) on November 19, 2013. The LPN stated that resident #227 was very impulsive and would not always show a sign that he was going to be aggressive. The LPN stated that resident #15's voice was very loud and the tone of her voice could be upsetting to others. The LPN further stated that after resident #227 made the verbal threat (to resident #15), resident #227 was not on one to one monitoring, as it was up to the clinical psychologist to make the decision for increased monitoring. An interview was conducted with the DON (Director of Nursing) on November 19, 2013. The DON stated that resident #227 would usually get angry when someone was doing something that would annoy him. The DON stated that resident #15 had a high voice and would repeat things over and over. The DON further stated that resident #227 was walking calmly with a newspaper and resident #15 was not making any sounds at the time of the incident. The DON also stated that the facility had no indication that resident #227 was going to hit resident #15. However, the facility documentation clearly shows the resident's aggressive behaviors, including hitting peers and making threats to resident #15, as well as a concern from the psychiatrist that this resident may hit someone and hurt them badly. An interview was conducted with a behavior program coordinator on November 19, 2013, who stated that resident #227 had shown aggression toward peers, since he was admitted The coordinator stated that the resident's physician had wanted to make some medication changes, but the resident's family refused. The coordinator stated that resident #227 was very impulsive and would usually have a trigger to his behavior such as a disruptive peer and that he would usually yell at somebody and make a physical sign that something was going to happen. The coordinator also stated that this was the first time that resident #227 caused this type of injury and that the facility never thought this would have occurred. The coordinator further stated that the physician was called after resident #227 made verbal threats toward resident #15, but did not feel that any additional monitoring needed to be done because he did not call the facility back. An interview was conducted with the administrator on November 21, 2013. The administrator stated that the morning shift, particularly the CNA's, should have received report on March 21, regarding resident #227's verbal threats toward resident #15 the evening of March 20. The administrator further stated that CNA staffing was two CNAs per resident at the time the verbal threat was made on March 20, and that it was not determined that additional supervision was required, as the behavioral unit was heavily staffed. Review of the facility's corrective action as identified through the Quality Assurance Committee, identified the following: The off-going nurse on the behavioral unit will give a brief (5 to 10 minute) behavioral report with the on-coming nurse and CNA prior to them working on the floor to ensure each and every person working on the unit is aware of any patient changes even if they are not assigned to that patient. This process was monitored and reviewed for effectiveness for three months. The QA documentation also included adjustments to unit policies regarding implementing a 1:1, as well as changes in contacting the physician and/or police in an emergency situation. Standing orders also included the following: An assigned 1:1 may be implemented by the charge nurse at any time per nursing judgement, and an automatic 1:1 will be implemented for any patient to patient contact. To discontinue the 1:1, the nurse, physician for the behavioral units or the director of nursing for non behavioral units must come to the decision collaboratively. This process was monitored for three months, by reviewing patient-to-patient altercations to ensure that a 1:1 was implemented. A review of the facility's policy on resident supervision dated August 26, 2011 stated, "...Any team member who observes that a resident presents significant risk is responsible to implement immediate safety measures and inform the charge nurse as soon as possible...The charge nurse will notify the unit clinical director, the unit coordinator and the physician to determine the level of supervision necessary and possible treatment alternatives..." The policy further described various levels of supervision as follows: general supervision, periodic checks and one-to-one supervision. Under one-to-one supervision it reads, "Residents with a high risk of self or other injurious behavior related to recent history or verbalization of intent will have a staff member assigned for constant safety monitoring. A review of the facility's policy regarding Physical Aggression documented "...Staff needs to pay particular attention to 'escalation phase cues's this is the time that the greatest likelihood of prevention exists: Verbalization of anger/threats ..."

Based on clinical record review, facility documentation, resident and staff interviews, and policy review, the facility failed to protect resident (#1) who had sustained a fractured finger from a staff member, and other residents from potential abuse during an investigation. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on December 6, 2012. The facility also failed to conduct a thorough investigation regarding abuse and failed to report the incident to the state agency. Findings include: Based on concerns for resident #1s immediate safety and for the safety of other residents, the condition of IJ was identified on December 6, 2012 at 4:00 p.m. The facility provided a plan of correction on December 6, 2012 at 4:15 p.m. Based on the facility's plan of correction and the verification of the implementation of their plan, the condition of IJ was abated on December 8, 2012 at 10:00 a.m. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Clinical record documentation revealed that the resident resided on a locked behavioral unit. Review of the nurse's note dated November 22, 2012, included the resident was in the shower area and starting grabbing resident items and being combative and then grabbed onto both door handles and would not let go. Staff then removed the resident's hand, and in the process the resident's left hand ring finger was injured. There was a large amount of swelling and the resident complained of pain on movement. Review of the facility Occurrence Report dated November 22, 2012 at 7:00 p.m., revealed the resident was walking from the shower room and started grabbing other resident's items, and then grabbed onto the door handles and would not remove his hands from the door handles. As a result, staff removed his hands from the door handles, as he had been combative. The resident was assessed and was able to move his left ring finger, but swelling was present from his left knuckle to the palm of his hand. The report further included the names of four CNAs (staff # 1, 2, 3 and 4), along with a brief written statement from each CNA. According to an x-ray report dated November 23, 2012, the resident sustained [REDACTED]. The facility was unable to provide any additional investigative documentation regarding this incident. Further review of the Occurrence Report revealed that it did not include that any staff members had been removed from providing care to residents, in order to ensure residents were protected during an investigation. The report also did not include which staff member had removed the resident's left hand from the door handle and there was no documentation that other staff and residents were interviewed. There was also no documentation that the state agency was notified. During an interview conducted on December 6, 2012, resident #1 stated that after a shower (on November 22), CNA #1 had grabbed his hand and finger and pulled them off the door. He stated two minutes after the incident he had pain and reported his finger might be broken. In an interview conducted on December 6, 2012, CNA #1 stated as the resident was exiting the shower area, he passed by the cubbies and tried to grab items. He said the resident then became physical and attempted to push the CNA out of the way. He said he positioned himself between the resident and the cubbies and then the resident grabbed onto the door handles that were positioned on each side of him. He said he had CPI (Crisis Prevention Institute, which are techniques used for personal safety) training and was taught to apply pressure on the knuckles to release ones grip. CNA #1 said that he applied pressure on the resident's knuckles to release his grip on the door handles, and that he pushed down while the resident was holding onto the door handle and the resident eventually let go. During an interview conducted on December 6, 2012, CNA #2 stated when the resident finished his shower, he passed by the cubbies on the wall and tried to grab items. She said as the resident tried to grab items, CNA #1 blocked the cubbies with his arms outstretched and she was in front of the resident. She said at this time, the resident then grabbed onto the door handles and leaned back and pushed on CNA #1 who was behind him. She said she then tried twice to loosen the resident's right hand, at which time the resident accidentally hit her on the chest with his shoulder. She stated that CNA #1 pushed on the resident for two to three minutes, with both hands on his back to get him out of the room to keep him from grabbing items. She further stated that she realized after the incident that they could have let him go and watched him to see what he was going to do. During another interview conducted on December 7, 2012, CNA #2 stated that the resident's behavior at the time of the incident was typical of the type of behavior that he exhibited before and staff would observe him and not utilize CPI techniques. Additionally, she stated that at the time of the incident she did not feel threatened by the resident. She said that if in a situation where a resident was not harming himself or threatening others, than they should back off. She added that CPI techniques are used if a resident was grabbing something and did not release their grasp, or to hold them if they were in danger. She stated that before using CPI techniques, the resident would be asked to release their grip. After the incident, she stated the resident was in the dayroom and was observed playing with his hand. When she asked him what happened he said it was broken and she notified the nurse. In an interview conducted on December 7, 2012, CNA #3 stated that he was called over to help as CNA #1 and #2 were having trouble getting the resident out of the room. He said CNA #1 was pushing the resident out of the room, as the resident was pushing back into CNA #1. He stated that CNA #1 was struggling with the resident's hand that was on the door handle and that CNA #4 was observed to have grabbed the resident's arm and tried to pull him out of the room. In an interview, a licensed staff member who was working on the unit when this incident occurred stated that this was typical behavior for this resident and she was not worried and did not feel anyone was in danger or was being threatened. On December 6, 2012, both CNA #1 and #2 were currently working in the facility and had never been removed from providing care to residents, while an investigation was conducted. As a result, the condition of IJ was identified. During an interview conducted on December 6, 2012, the administrator stated that the CNA's involved in the incident had continued to work their normal schedule from the date of the incident through the current date. She stated that this incident was not reported to the state agency, as it was not considered abuse, and that it was viewed as a behavioral incident, because the staff were trying to keep the resident safe. She further stated that physical mistreatment would be reported to the state agency. Review of a facility policy titled "Abuse Awareness, Prevention and Protection" included that the facility would protect residents from harm during the investigation, and that a staff member that was directly involved and or suspect in an abuse investigation and perceived as a possible threat to any resident, may be reassigned, suspended, or terminated until the investigation is complete. The policy further included that all investigated allegations and substantiated occurrences of abuse would be reported to the state agency and that all allegations of abuse would be promptly and thoroughly investigated, unless the facility can immediately determine the allegation to be false because of credible witnesses and would be done in a manner which promoted the safety and security of the resident.

Based on observation, staff interviews and review of facility documentation and policy, the facility failed to identify an incident of abuse regarding CNA #1, who had fractured the finger of resident #1 and pushed the same resident and failed to protect residents from the potential for further abuse, by allowing CNA #1 to continue to provide direct care. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on February 1, 2013. Findings include: During a complaint investigation conducted December 6, through December 8, 2012, the facility was cited for abuse regarding CNA #1 pushing resident #1 multiple times in the back and for applying pressure to the same resident's left hand ring finger, which resulted in a displaced fracture that required surgical intervention. Review of the facility's policy "Abuse Awareness, Prevention and Protection" revealed a section titled Prevention that included "Administrator and Supervisors are available to offer support and guidance to staff in all areas related to abuse...Any abuse, no matter how 'minor' will not be tolerated." During an onsite revisit, CNA #1 was observed to be providing direct care to residents on February 1, 2013. Based on concerns for the immediate safety of the residents, the condition of IJ was identified on February 1, 2013 at 2:45 p.m. The facility provided a plan of correction on February 1, 2013 at 4:00 p.m. Based on the facility's plan of correction and the verification of the implementation of their plan, the condition of IJ was abated on February 2, 2013 at 1 p.m. During an interview conducted on February 1, 2013, with the director of nursing and the administrator, they stated that they had not identified the actions of CNA #1 as abuse. Both staff members stated that the incident which occurred on November 22, 2012 was a behavioral event and not abuse therefore, CNA #1 was allowed to return to work. They stated that CNA #1 was protecting the resident from harming himself and that he was also protecting the other staff members from being harmed by the resident. However, review of the original deficiencies cited from the December 2012, abuse investigation revealed the following: Interviews with the direct care staff who were present at that the time of the incident included that resident #1 had a behavior of harming himself by consuming personal hygiene items. When CNA #1 and resident #1 passed by the storage area for these items resident #1 attempted to grab them, at which time CNA #1 blocked the storage area. Resident #1 then grabbed the handles of the two doors that were on each side of him (with both hands on the door handles the resident was no longer a danger to himself because he would not be unable to grab the personal hygiene items). While the resident had both hands on the door handles, CNA #1 pushed the resident in the back to get him out of the room. CNA #1 also applied pressure to the resident's left hand, while both of the resident's hands were on door handles. During the interview with CNA #3 (conducted during the original investigation) he stated while both of the resident's hands were on the door handles, CNA #1 pushed the resident with both hands in his back to get him out of the room. CNA #3 also stated that CNA #1 was struggling with the resident's hand that was on the door handle. During the interview with CNA #1 (conducted during the original investigation) he stated resident #1 grabbed onto the door handles at which time he applied pressure by pushing down on the resident's knuckles to release his grip, while he was holding onto the door handle. CNA #1 stated that he was taught this technique in the CPI (Crisis Prevention Institute, which are techniques used for personal safety) training. However, review of the CPI training materials provided by the facility revealed no such techniques. The training was for safety techniques, which did not include removing a hand from a door handle. Multiple interviews were conducted (during the original investigation) with the direct care staff who were present at the time of the incident. They all stated that they did not feel threatened by resident #1's actions. The licensed staff member who was present stated that she did not feel anyone was in danger or being threatened. She further stated that if she felt that staff members were in danger she would not have left the area to answer the phone. The above stated investigation was reviewed with the DON and administrator, including the fact that the resident's hands were on two separate door handles, so he was unable to reach the personal hygiene items therefore he was no longer a danger to himself. In addition all the staff members who were present at the time of the event stated that they did not feel that they were being threatened by resident #1. Despite these facts the DON and the administrator continued to state CNA #1 was protecting the resident and the other CNA's, and that CNA #1's actions were not abusive. They also stated that sometimes staff do not realize when they are being threatened. Further review of the facility's policy "Abuse Awareness, Prevention an Protection" revealed a section titled Identification of Abuse or Neglect that included "Definition: 'Means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm ...' Examples of abuse: The types of contact, which may constitute abuse include, but are not limited to...pushing, shoving...squeezing or pinching any part of the resident's body..."

Based on review of a facility investigation, staff interview and policy review, the facility failed to follow their Abuse policy and procedure regarding reporting to the state agency, conducting a thorough investigation, and protection of one resident (#1), as well as others from incidents of potential harm and or abuse. Findings include: Resident #1 was admitted to the facility May, 27, 2008. Review of the facility's investigative documentation regarding an incident that resulted in harm to resident #1, that occurred November 22, 2012, revealed that the facility did not follow their Abuse policy, in that the facility failed to produce documented evidence that an incident of potential abuse that resulted in an injury to the resident, was reported to the state agency in a timely manner. Furthermore, the facility failed to provide documented evidence that a complete and thorough investigation had been conducted in a timely manner. There also, was no documented evidence provided that the resident, as well as other residents were protected and kept safe from the further potential for harm and or abuse during the investigation. During an interview conducted December 6, 2012, the administrator stated that the incident was not reported to the state agency as she did not consider the incident an abuse situation and looked at it as a behavioral incident because the staff were trying to keep the resident safe, and also, that physical mistreatment would be reported to the state agency. Additionally, she stated that the CNA's involved in the incident had continued to work their normal schedule from the date of the incident through the current date, December 6, 2012. The facility produced investigative documentation regarding the incident that included the facility Occurrence Report, and a one page list of staff member names with brief handwritten notes regarding the incident, however, no further documented evidence was produced that a complete and thorough investigation had been conducted per their facility policy. According to the facility's Abuse policy, all allegations of mistreatment, abuse, neglect, and injury of unknown origin ...would be promptly and thoroughly investigated...and that the investigation would be done in a manner that promoted the safety, security, and dignity of the resident. Additionally, the same Abuse policy included that residents would be protected from harm during the investigation, and that if a staff member was directly involved and or suspected in an abuse investigation and perceived as a possible threat to any resident, the director of nursing and or administrator may authorize re-assignment, suspension or termination until the outcome of the investigation was complete.

Based on staff interviews and review of facility documentation and policy, the facility failed to implement their policy by failing to identify an incident of CNA to resident abuse and failed to protect resident's from the potential for further abuse, by allowing the CNA to continue to provide direct care. As a result, the condition of Immediate Jeopardy (IJ) was identified. Findings include: During a complaint investigation conducted December 6, through December 8, 2012, the facility was cited for abuse regarding CNA #1 pushing resident #1 multiple times in the back and for applying pressure to the same resident's left hand ring finger, resulting in a displaced fracture which required surgical intervention. According to the original investigation CNA #1 stated that resident #1 grabbed onto the door handles at which time he applied pressure by pushing down on the resident's knuckles to release his grip. During an onsite revisit, CNA #1 was observed to be providing direct care to residents on February 1, 2013. Based on concerns for the immediate safety of the residents, the condition of IJ was identified on February 1, 2013. During an interview conducted on February 1, 2013, with the director of nursing and the administrator, they stated that they had not identified the actions of CNA #1 as abuse and therefore they allowed the CNA to return to work. Both staff members stated that the incident which occurred on November 22, 2012 was a behavioral event and not abuse. However review of the facility's policy "Abuse Awareness, Prevention and Protection" revealed that it is the facility's policy "...to protect all residents from...physical, and mental abuse...Any abuse, no matter how 'minor' will not be tolerated...a section titled Identification of Abuse or Neglect that included "Definition: 'Means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm ...' Examples of abuse: The types of contact, which may constitute abuse include, but are not limited to...pushing, shoving...squeezing or pinching any part of the resident's body..."

Based on clinical record review, facility documentation, staff and resident interviews and review of facility policy and procedures, the facility failed to ensure that one resident (#1) who resided on a locked behavior unit was free from abuse. Findings include: Resident #1 was admitted to the facility May 27, 2008, with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident resided on a locked behavioral unit and was currently a resident in the facility. A nurse's note dated November 22, 2012, included that as staff were walking resident #1 back to the unit, the resident started to grab other residents' items from the cubbies and became combative. The resident then grabbed onto both door handles and would not let go, at which time staff attempted to remove the resident's hands. During the process the resident injured his left hand ring finger. The resident was assessed by the nurse and found to have a large amount of swelling and complained of pain on movement. Review of a facility Occurrence Report dated November 22, 2012 at 7:00 p.m., revealed that while the resident was walking back from the shower room, he began to grab other resident's items out of the cubbies. The resident then grabbed onto the door handles and would not remove his hands. The staff removed his hands from the door handles, as he became combative. The resident was assessed to be able to move his left ring finger, but swelling was present from his left knuckle to the palm of his hand. The report identified that CNA's (certified nursing assistants) #1, #2, #3, and #4 were involved in the incident. Continued review of the nurse's notes revealed there were no additional entries until over 12 hours later on November 23, 2012 at 9:15 a.m., which documented the resident's left hand was swollen with a purple bruise on the palm of the hand, range of motion was limited due to the swelling, and that the nurse practitioner had been paged. An entry at 10:40 a.m. included that an order for [REDACTED]. An x-ray report dated November 23, 2012, revealed that the resident had an oblique (at an angle) comminuted (multiple fracture lines) [MEDICAL CONDITION] finger, with displacement and soft tissue swelling. A nurse practitioner's monthly note dated November 27, 2012, included that the resident had fractured his fourth proximal phalanx, when he became combative with staff leaving the shower room. The same note included that the resident had moderate proximal swelling at the site on the injury, no ecchymosis, was non-tender, and that a tongue depressor splint was placed and that he was awaiting an orthopedic consult at a medical center. Another x-ray of the resident's left ring finger was obtained December 4, 2012. The final report indicated that the resident had a displaced [MEDICAL CONDITION] digit. Review of the external orthopedic consult progress note dated December 4, 2012, included that the resident stated he had injured his hand two to three weeks ago, as someone pulled him as he was holding a door and that he has had pain, selling, and stiffness since that time. The note further included that the resident had a swollen left ring finger, had decreased motion, was placed in a rigid orthotic and was to be scheduled to have surgery on the left ring finger on December 6, 2012. During an interview conducted on December 6, 2012, resident #1 stated that a couple weeks ago, after a shower, CNA #1 had grabbed his hand and finger and pulled it off the door. Additionally, he stated that two minutes after the incident he had pain and believed his finger may have been broken. During an interview conducted on December 6, 2012, the administrator stated that the incident was not considered abuse, that it was viewed as a behavioral incident because the staff were trying to keep the resident safe. She stated that the CNAs involved in the incident had continued to work their normal schedule from the date of the incident through the current date. The following staff interviews were conducted on December 6 and 7, 2012: -The director of nursing stated that to the best of her knowledge, the resident was leaving the shower room and would not let go of the doors. She stated that the CNAs involved felt he was a danger to himself or others and that's why they tried to remove him back to the unit, and that during the struggle his finger was injured. -CNA #1 stated that the resident was taken to the shower room for a routine shower and when finished the resident passed by the cubbies that contained personal toiletry items. He said the resident then started to grab at those items and he told him that he could not have them. He said the resident then became physical and attempted to push him out of the way. He said he positioned himself between the resident and the cubbies and the resident then grabbed onto the door handles that were on each side of him, placed his feet apart, and leaned backward into him. CNA #1 stated that CNA's #2, #3, and #4 were pulling the resident from the front and that he was pushing him out of the doorway. He stated that he applied pressure on the resident's knuckles to release his grip on the door handles, and that he pushed down while the resident was holding onto the door handle and the resident eventually let go. He further stated that he had CPI (Crisis Prevention Institute, which are techniques used for personal safety) training and was taught to apply pressure on the knuckles to release ones grip. He said the training included for example; when a resident pulled hair, by putting pressure on the knuckles, it would release their grip. He said afterward the resident went back to his room and he informed his nurse of his behavior. He stated that he had not observed any injury to the resident until an hour later when the resident stated something had happened to his finger. CNA #1 stated that he did know that the resident was injured during the incident, that the resident had not made him angry and that he did not intend to hurt the resident. Review of the facility's CPI training documentation revealed there were no instruction techniques that included to apply pressure to the knuckle area in order to release a persons grip. -CNA #2 stated that at the time of the incident the resident was alert and oriented, however, required the assistance of two staff related to his behaviors. She stated when the resident finished his shower, he passed by the cubbies on the wall in the shower area and tried to grab items. She said as the resident tried to grab items, CNA #1 blocked the cubbies with his arms outstretched. She said the resident then grabbed onto the door handles, leaned back, pushing on CNA #1, who was behind him. She said she then tried twice to loosen the resident's hand, at which time the resident accidentally struck her. She said CNA #4 pulled the resident's right thumb up from the door handle and the resident accidentally struck CNA #4. CNA #3 then arrived and was unable to help, as the resident was blocking the doorway. Then CNA #1 pushed on the resident for two to three minutes with both hands on his back. CNA #2 further stated that she realized after the incident that the staff could have let him go and observe his behaviors. In a subsequent interview, CNA #2 stated that the resident's behavior at the time of the incident was typical of the type of behavior that he exhibited before, and if he was not harming himself, the staff would observe him and not utilize CPI techniques. Additionally, she stated that at the time of the incident she did not feel threatened by the resident and that if a resident was not harming himself or threatening others, than they should back off. She added that CPI techniques are used if a resident was grabbing something and would not release their grasp, or to hold them if they were in danger. She said a resident would be asked to release their grip, prior to utilizing CPI techniques. -CNA #3 stated CNA #1 was pushing the resident out of the room, as the resident was pushing back onto CNA #1. He stated that the CNA #1 was struggling with the resident's hand that was on the door handle and that CNA #4 grabbed the resident's arm and tried to pull him out of the room. -CNA #4 stated that when the resident was leaving the shower room, he became combative and was struggling against the staff, as he was trying to grab items from the cubbies in the shower area. The resident then grabbed the door with his left hand and the cubbies with his right hand. She said that she and CNA #2 were struggling to remove the resident's right hand off the cubbies and CNA #1 was trying to remove his left hand from the door (according to the other interviews, the resident's hands were on the door handles). She said less than 10 to 15 minutes later the resident let go and walked out of the room. She further stated that usually staff observe the resident's behavior and when he gets tired he quits. -Licensed staff (#5) stated that after the resident's shower, CNA #1 told her that he thought the resident had hurt his finger, as he was combative, physically aggressive and grabbing items from the shelves in the shower room, and that he was holding onto two door handles. She said she assessed his fingers, he had good range of motion, mild pain, and minimal swelling, and applied ice to the area. When she asked the resident about his finger, he stated that it happened in the shower room and he gave no further specifics. -Licensed staff who worked on the Verde unit on the evening of this incident stated that she heard a commotion in the shower area and went into the hallway and observed the resident grabbing onto two door handles. She said as CNA #2 was trying to get the resident's hands off the door and then left to answer the phone. She stated that was normal behavior for the resident, the resident was not yelling out, that she was not worried about the behavior, and she did not feel anyone was in danger or being threatened. Review of the facility's Resident Rights information included that residents have the right to free from physical abuse, that the facility must provide a safe environment and must implement procedures that protect the resident from abuse or mistreatment. Review of a facility policy titled "Abuse Awareness, Prevention and Protection" included that their policy was to protect all residents from abuse, neglect, exploitation and psychological/emotional abuse. The policy further included that types of contact which may constitute abuse, included pushing and shoving.