Every finding on record at Ripley Crossing

Based on interview and record review, the facility failed to follow appropriate safety measures when assisting a resident in their wheelchair, resulting in the resident falling and sustaining injuries that required hospitalization for 1 of 3 residents reviewed for accidents. (Resident B)Findings include: A Health Status Note, dated 09/08/2025 at 11:17 A.M., indicated a nurse was pushing the resident in his wheelchair up to the front lobby to leave for a dialysis treatment. The resident's feet fell to the floor causing the resident to fall forward out of the wheelchair. The resident fell face first onto the floor and immediately began to bleed from the nose. The resident was assessed for injuries, and his nose was bleeding a large amount. Pressure was applied to the resident's nose, and the resident was assisted by two staff members to a sitting position back into the wheelchair. Staff applied ice and pressure to the bridge of the resident's nose. The facility Nurse Practitioner was notified, and the resident was sent to the local hospital for evaluation and treatment.The Hospital Discharge summary, dated [DATE], indicated the following: The resident was admitted to the hospital on [DATE] following a fall from his wheelchair resulting in facial trauma and epistaxis (nosebleed). On admission, the resident was found to have a nasal fracture and septal fracture. Evaluation revealed both anterior and posterior epistaxis, that was initially controlled. During the hospitalization, the resident experienced recurrent episodes of packing dislodgement and breakthrough bleeding, necessitating repeat interventions that included replacement of packing and ultimately the placement of Surgi Flo (an absorbable gelatine paste used in surgery) packing. The packing was removed on 09/15/2025, and no further bleeding was observed. The resident received antibiotics for sinusitis prophylaxis (as a preventative measure). Throughout the admission, the resident was managed with limb restraints due to agitation and repeated attempts to remove nasal packing and oxygen devices, with intermittent confusion and agitation noted. The resident's hospital course was complicated by anemia requiring blood transfusions, with hemoglobin levels trending down and subsequentially improving after transfusion and adjustment of the resident's dialysis regimen. Other chronic issues were addressed during the admission, and by 09/16/2025, all nasal packing had been removed. The resident was discharged with plans for outpatient clinical follow up.A Fall Care Plan, initiated on 11/13/2023, indicated the resident was at risk for falls related to weakness due to chronic obstructive pulmonary disease and end stage renal disease with hemodialysis. The interventions included, but were not limited to, a current intervention, with a start date of 11/13/2023, to assist the resident with transfers as needed.The Fall Care Plan was updated, on 09/09/2025, with an intervention to ensure foot pedals were used on the wheelchair when the wheelchair was propelled by staff. Staff were to remove the foot pedals when arriving at the destination due to the resident being able to propel himself in the wheelchair.During an interview, on 12/15/2025 at 10:10 A.M., Licensed Practical Nurse (LPN) 6 indicated she was pushing the resident in his wheelchair to the front lobby to meet his ride for dialysis. They stopped at the rug near the door. The resident's ride was outside, so she started to push the wheelchair again and the resident fell forward. The resident's feet skidded on the rug and he fell forward. It happened very fast. The resident always used the wheelchair, especially for longer distances like to the front of the building. He could propel himself short distances, but not long distances. She didn't put foot pedals on the wheelchair prior to pushing him to the lobby. If a res was non-ambulatory, leg rests/foot pedals would be in place on the wheelchair for positioning. Residents that propelled themselves to some degree may not have foot pedals on their wheelchair. The resident went to the hospital and was there for a few days. During an interview, on 12/15/2025 at 9:58 A.M., the Therapy Department Manager (TDM) indicated the resident was participating in therapy prior to the fall on 09/08/2025. At the time of the fall, the resident required moderate to maximum staff assistance with transfers and Activities of Daily Living (ADLs). He had been up walking with the rollator (walker), but as he got sicker, he was using the wheelchair more frequently. At the time of the fall, he could propel himself short distances in the wheelchair. Leg rests/foot pedals should be in place when staff were pushing residents in their wheelchairs regardless of the distance the resident was being pushed. She would recommend the foot pedals be in place while the resident was being propelled in the wheelchair by a staff member. She would recommend staff remove the foot pedals if the resident was just sitting in their wheelchair in their room or something because most residents could not remove the foot pedals on their own and that could be a fall risk.The current facility policy, titled Accidents and Supervision, dated 09/01/2022, was provided by the Director of Nursing (DON) on 12/15/2025 at 12:37 P.M. The policy indicated, .The resident environment will remain free of accident hazards as is possible.The current, undated facility policy, titled Policy and Procedure: Use of a wheelchair, was provided by the DON on 12/15/2025 at 12:37 P.M. The policy indicated, .Proper use of a wheelchair .Determine if a resident can self-propel .if not, ensure foot pedals are in place .This citation relates to Intakes 2611892 and 2666336.3.1-45(a)(2)

Based on observation and interview, the facility failed to appropriately store medications for 1 of 3 medication carts reviewed. (Wing 2 Medication Cart)Findings include: On [DATE] at 2:52 P.M., the Wing 2 Medication Cart was observed with RN 3. The Medication Cart contained a 1/4 full Humalog insulin pen for Resident 10. A sticker indicated the pen was opened on [DATE] and should be discarded by [DATE]. During an interview, on [DATE] at 2:53 P.M., RN 3 indicated the resident received insulin every day before meals. RN 3 used the pen to administer insulin to the resident before breakfast and before lunch that day. The resident probably got insulin from it yesterday too. The medication was expired and should have been discarded on [DATE].The current facility policy, titled Storage of Medications, with a revision date of [DATE], was provided by the Assistant Director of Nursing on [DATE], at 2:49 P.M. The policy indicated, .facility stores all drugs and biologicals in a safe, secure, and orderly manner.Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.3.1-25(o)

Based on record review and interview, the facility failed to notify the physician of a change in a resident's condition for 1 of 20 residents reviewed for notification of change. (Resident 82)Findings include:The clinical record for Resident 82 was reviewed on 12/11/2025 at 10:04 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 10/23/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, dementia, diabetes, depression, respiratory failure, and food in the respiratory tract. A Progress Note, dated 09/22/2025 at 8:30 A.M., indicated the nurse was called to the dining room by a Certified Nurse Aide (C NA) who reported the resident was choking. The Heimlich maneuver was attempted when the resident's face went pale in color. After three to five attempts, the resident began talking and color returned to her face. The resident eventually coughed up a soggy piece of waffle. The Assistant Director of Nursing (ADON) was called to the unit to help assess the resident. The resident's Power of Attorney (POA) was notified. The clinical record lacked documentation the physician was notified of the choking incident on 09/22/2025.During an interview, on 12/12/2025 at 11:10 A.M., RN 2 indicated if a resident had choked on their food, she would assess the resident and determine if the Heimlich maneuver needed to be initiated. After the resident was deemed safe, the family and physician would be notified. She would also notify the speech therapist. She would document in a Progress Note the event details and that the family and physician were notified.During an interview, on 12/12/2025 at 3:15 P.M., the Director of Nursing (DON) indicated she remembered talking to the Nurse Practitioner (NP) about the resident choking but there was no documentation the NP was notified after the resident choked on 09/22/2025. The current facility policy titled, Change in a Resident's Condition or Status with a revision date of 2021, was provided by the DON on 12/15/2025 at 12:37 P.M. The policy indicated, .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .3.1-5(a)(1)

Based on observation, interview and record review, the facility failed to identify a pressure ulcer in a timely manner for 1 of 3 residents reviewed for pressure ulcers. (Resident 1) Findings include:During an interview and observation, on 12/11/2025 at 10:25 A.M., RN 7 indicated Resident 1 had a pressure ulcer on her coccyx. The resident was sitting in their wheelchair and refused to be transferred to bed for the wound to be observed further.The clinical record for Resident 1 was reviewed on 12/12/2025 at 1:20 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/03/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, anemia, hypertension, heart failure, pneumonia, dementia, and schizophrenia. The resident was dependent on staff for personal hygiene and transfers.The current physician's order, with a start date of 08/06/2024, indicated the resident was to have weekly skin assessments completed on every Wednesday. The weekly skin assessments, for July 1 through August 3, 2025 indicated the resident had no new skin concerns. A Weekly Wound Observation Tool , dated 08/04/2025, indicated the resident had a Deep Tissue Injury (DTI) on her sacrum measuring 45 millimeters (mm) x (by) 20 mm. This was the first documented finding of the resident's new skin condition.A Weekly Wound Observation Tool, dated 08/06/2025, indicated the sacrum wound was now described as an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer was covered by slough).The Wound Doctor's Note, dated 08/12/2025, indicated the wound was an unstageable DTI on her sacrum measuring 5 centimeters (cm) x 3 cm with intact skin. A Quarterly MDS assessment, dated 08/26/2025, indicated the resident had a deep tissue injury (purple or maroon discolored skin) on her sacrum.The clinical record lacked documentation to indicate the resident's sacrum wound was identified prior to being found with necrotic tissue and moisture. During an interview, on 12/15/2025 at 2:09 P.M., Certified Nurse Aide (CNA) 5 indicated Resident 1 refused care at times. Prior to the DTI developing, a barrier cream was applied to the resident's buttocks. When a new skin area was found the nurse would be notified. The resident was verry weak and sick at the end of summer. During an interview, on 12/12/2025 at 12:36 P.M., the Nurse Practitioner (NP) indicated the resident had a wound on her sacrum that developed rapidly in August. At that time, the resident was very ill with pneumonia, was eating small amounts, and was refusing to be turned. During an interview, on 12/16/2025 at 10:10 A.M., the Director of Nursing (DON) indicated the resident had been very ill with pneumonia in August. She had developed a wound on her sacrum that was first observed on 08/04/2025. The wound doctor was consulted. The resident was refusing to be turned, to get out of bed, and was refusing to eat at times. She had been offered supplements but, refused those. The wound developed quickly related to the resident's overall poor condition. The current facility policy Prevention of Pressure Injuries, dated April 2020, was provided by the DON on 12/15/2025 at 12:37 P.M. The policy indicated .Inspect the skin on a daily basis when preforming or assessing with personal care or ADLs (Activities of Daily Living). Identify any signs of developing pressure injuries.3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure proper placement of urinary catheter tubing and drainage bag for 1 of 3 residents reviewed for urinary catheters . (Resident 37) Findings include:On 12/09/2025 at 11:55 A.M., Resident 37 was observed sitting in her recliner in her room. She had recently finished working with therapy in her room. The urinary catheter drainage collection bag was hanging from the side of the recliner with three inches of the bag touching the floor. On 12/09/2025 at 1:57 P.M., Resident 37 was sitting in her recliner in her room. The urinary catheter drainage bag was hanging from the side of the recliner with three inches of the bag touching the floor. During an interview on 12/15/2025 at10:14 A.M., Certified Nurse Aide (CNA) 3 indicated the urinary catheter collection bag should be hung lower than the resident's bladder and not touching the floor. The resident needed assistance transferring from the bed to the recliner. An admission Minimum Data Set (MDS) assessment, dated 11/24/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, hip fracture, end stage renal disease, hypertension, diabetes, and urinary tract infection in the last 30 days. The resident had an indwelling urinary catheter. The resident required assistance from staff for transfers. The current facility policy, titled Catheter Care, Urinary, dated September 2014, was provided by the Director of Nursing (DON) on 12/15/2025 at 12:37 P.M. The policy indicated, .Be sure the catheter tubing and drainage bag are kept off the floor.3.1-18(b)

Based on observation, interview, and record review, the facility failed to follow infection control guidelines during a dressing change and touching the floor related to hand hygiene for 1 of 4 residents reviewed for infection control. (Resident B) Findings include: During an observation, on 03/10/25 at 9:26 A.M., RN (Registered Nurse) 3 preformed hand hygiene and donned a gown and gloves to begin a wound dressing change on Resident B. She began removing the dressing from Resident B's right breast. The dressing was saturated upon removal. An egg sized wound was visualized on Resident B's right breast. A piece of the gauze, fully saturated in drainage, fell on to the floor. RN 3 picked up the saturated gauze off the floor and discard it with the used dressing in a bag. RN 3 then began cleaning the resident's wound. No hand hygiene was completed or removal of gloves. After cleansing the wound RN 3 began applying the new dressing to Resident B's right breast. RN 3 proceeded to a second dressing change on Resident B's right foot. No hand hygiene was completed in-between dressings or after picking up soiled gauze off the floor. The RN removed the dressing and cleansed the resident's right heel wound with cleanser, patted it dry, and then applied the new dated dressing. No hand hygiene was observed. The clinical record for Resident B was reviewed on 03/10/25 at 10:07 A.M. A Quarterly Minimal Data Set (MDS) assessment, dated 12/22/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, anemia, and cancer. A Progress Note, dated 10/27/23 at 2:04 P.M., indicated that Resident B was complaining of right breast pain. Upon an assessment it was swollen and tender to touch with a hard area noted. Resident B had a diagnosis of malignant neoplasm of the right breast. The family indicated that Resident B had refused treatment, and that the area flares up from time to time and will burst open and bleed. The area can get as large as a baseball during flare ups. A current physician's order, with a start date of 01/20/25, indicated the staff were to cleanse the wound to the right breast with wound cleanser, pat dry, apply petroleum jelly gauze, and apply a foam adhesive dressing every day and as needed for wound soilage/dislodgement. A current physician's order, with a start date of 11/12/24, indicated to staff were cleanse right heel with wound cleanser, pat dry, and apply a foam adhesive dressing every 3 days and as needed for soiled/dislodgement. During an interview on 03/10/25 at 1:52 P.M., Licensed Practical Nurse (LPN) 2 indicated that after removing a dressing she would dispose of it and immediately perform hand hygiene. She would put on new gloves before cleaning and applying the new dressing. She would never touch the floor and then touch a wound. If she were to touch the floor during a dressing change, she would perform hand hygiene and don new gloves. The current facility policy, with a revision date of 08/15/22, titled Standard Precautions Infection Control was provided by the Director of Nursing (DON) on 03/10/25 at 2:15 P.M. The policy indicated, .a. During the delivery of resident care services, avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces . The current facility policy, with a revision date of September 2013, titled Dressings, Dry/Clean was provided by the Director of Nursing (DON) on 03/10/25 at 2:15 P.M. The policy indicated, .6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. 9. Open dry dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 10. Label tape or dressing with date, time and initials. Place on clean field. 11. Using clean technique, open other products (i.e., prescribed dressing; dry, clean gauze). 12. Wash and dry your hands thoroughly. 13. Put on clean gloves. 14. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage. 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). 16. Use dry gauze to pat the wound dry. 17. Apply the ordered dressing and secure with tape or bordered dressing per order .Label with date and initials to top of dressing . This citation relates to Complaint IN00454176. 3.1-18(a)

Based on interview, observation, and record review, the facility failed to provide safe water temperatures between 100 degrees and 120 degrees Fahrenheit per the federal guidelines for 10 of 11 residents' bathroom water access observed. (Rooms 201, 301, 302, 303, 304, 307, 308, 402, 403, and 404) Findings include: During an interview and observation on 10/17/24 at 10:35 A.M., Resident 61 indicated the water was hot but she had never been burned. The resident was standing at the sink in her room combing her hair and was able to safely walk around her room unassisted. The water stream was too hot to keep a hand under the water flow without discomfort. During an interview and observation on 10/17/24 at 10:58 A.M., Resident 33 indicated she had not had any problems with the water being too hot. The resident was able to propel herself in her wheelchair unassisted and walk with her walker. The water stream was too hot to keep a hand under the water flow without discomfort. During an interview and observation on 10/17/24 at 11:03 A.M., Resident 28 indicated the water took a while to get hot. She had never gotten burned by the water. The resident was able to propel herself in her wheelchair unassisted. The water stream was too hot to keep a hand under the water flow without discomfort. On 10/17/24 at 11:00 A.M., the following water temperatures were checked using a probe thermometer: - rooms [ROOM NUMBERS]'s shared bathroom sink, 120.4 degrees Fahrenheit, - rooms [ROOM NUMBERS]'s shared bathroom sink, 127.8 degrees Fahrenheit, and - rooms [ROOM NUMBERS]'s shared bathroom sink, 124.7 degrees Fahrenheit. Random water temperatures were observed with the Maintenance Director on 10/17/24 at 11:48 A.M. Upon entering room [ROOM NUMBER], he filled a plastic cup with hot water from the sink in the room and placed his thermometer in the cup. He indicated he thought the entire probe of the thermometer needed to be covered with water. He then tested the water temperatures by holding the tip of the facility's thermometer probe under the hot running water and obtained the following temperatures: - room [ROOM NUMBER], the sink in the room, 128 degrees Fahrenheit, - room [ROOM NUMBER], the sink in the room, 126 degrees Fahrenheit, the Maintenance Director said, Oww, while having his fingers under the flow of water, and - room [ROOM NUMBER], the sink in the room, 125 degrees Fahrenheit. The Maintenance Director indicated he tried to keep the water temperatures at 120 degrees. He tested random rooms once a month. Each wing had a separate water heater for the resident rooms. When he tested water temperatures, he would sometimes get 125 degrees, but he did not know why because the water was circulated. The hot water heater on the 400 Hall was observed with the Maintenance Director on 10/17/24 at 1:42 P.M. The Maintenance Director pointed out the thermometer in the main water line coming off the hot water heater. He indicated he had turned down the blending/mixing valve to cool down the water and it had felt a little stuck when he had adjusted the valve. Water temperatures in sinks in residents' rooms and bathrooms were observed with the Maintenance Director on 10/22/24 at 10:43 A.M., and included, but were not limited to, the following: - room [ROOM NUMBER], the sink in the private bathroom, 95.1 degrees Fahrenheit, - rooms [ROOM NUMBERS]'s shared bathroom sink, 99.3 degrees Fahrenheit, - rooms [ROOM NUMBERS]'s shared bathroom sink, 93.5 degrees Fahrenheit, - rooms [ROOM NUMBERS]'s shared bathroom sink, 102.3 degrees Fahrenheit, - room [ROOM NUMBER], the sink in the room, 109.5 degrees Fahrenheit, - room [ROOM NUMBER], the sink in the room, 108.8 degrees Fahrenheit, and - room [ROOM NUMBER], the sink in the room, 106.3 degrees Fahrenheit. The Water Temperature log sheets for 2024 were provided by the Administrator on 10/17/24 at 12:31 P.M., and indicated the following: - The 200 Hall residents' rooms ranged between 111 and 112 degrees Fahrenheit in August, September, and October, - The 300 Hall, all residents' rooms tested at 114 degrees Fahrenheit in August, September, and October, and - The 400 Hall, all residents' rooms tested at 112 degrees Fahrenheit in August, September, and October. During an interview on 10/22/24 at 11:06 A.M., the Maintenance Director indicated he had gotten a new thermometer for testing water temperatures, he had turned down the temperature on the water heaters because it was too hot, and the water temperatures should be between 110 and 120 degrees. During an interview on 10/22/24 at 11:09 A.M., the Administrator indicated they did not have a policy related to water temperatures, they followed the federal guidelines. 3.1-19(r)(1) 3.1-19(r)(2)

Based upon record review and interview the facility failed to accurately to complete Minimum Data Set assessments for 3 of 18 residents reviewed. (Residents 5, 57, and 61) Findings include: 1. The clinical record for Resident 5 was reviewed on 10/17/24 at 3:35 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 09/18/2024, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, diabetes, Alzheimer's disease, anxiety, and depression. Section O, Special Treatment and Programs, indicated the resident was receiving Hospice care. Section J, Health Conditions, indicated the resident did not have a terminal diagnosis. During an interview on 10/18/24 at 11:04 A.M., the Director of Nursing (DON) indicated a local Hospice company provided care to the resident. During an interview on 10/22/24 at 2:21 P.M., the MDS Coordinator indicated she received information related to Hospice care from the resident's paper chart. The resident did have a terminal diagnosis and the MDS assessment should have been marked as such. 2. The clinical record for Resident 57 was reviewed on 10/18/24 at 1:10 P.M. A Quarterly MDS assessment, dated 09/27/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, hypertension, dementia, anxiety, depression, and a psychotic disorder. Section N, Medications, indicated a gradual dose reduction (GDR) was attempted on 07/14/24 and the physician did not indicate it was contraindicated. A Consultant Pharmacist Communication to Physician form dated, 07/14/24, indicated Resident 57 received Olanzapine (an antipsychotic medication) 5 mg (milligrams) every morning for delusional disorder, and Risperidone (an antipsychotic medication) 0.25 mg every morning and 0.5 mg at bedtime for delusional disorder were to be continued as prescribed. The form was signed by the psychiatric nurse practitioner on 07/15/24. During an interview on 10/22/24 at 2:26 P.M., the MDS Coordinator indicated she received GDR information from the Social Service Director (SSD). During an interview on 10/22/24 at 2:28 P.M., the SSD indicated he was unsure why the MDS assessment documentation said a GDR had been done when it had not. During an interview on 10/22/24 at 2:42 P.M., the MDS Coordinator indicated the facility did not have a policy related to MDS assessments. She followed the Resident Assessment Instrument (RAI) manual. 34232 3. The clinical record for Resident 61 was reviewed on 10/21/24 at 9:16 A.M. A Quarterly MDS assessment, dated 09/10/24, indicated the resident was not assessed for section C, Cognitive Patterns, and section D, Mood. During an interview on 10/22/24 at 2:30 P.M., the MDS Coordinator indicated she was unaware as to why sections C and D, for the Quarterly MDS assessment, dated 09/10/24, were not assessed and the SSD completed those sections. During an interview on 10/22/24 at 2:34 P.M., the SSD indicated he filled out sections C and D on the MDS assessments. Sections C and D were completed on all Quarterly, Annual, and Significant Change assessments. He did not know why the sections were not completed. The Progress Notes for September 2024, were provided by the MDS Coordinator on 10/22/24 at 3:01 P.M., and included, but were not limited to, the following: - A Social Service note, dated 09/09/24 at 10:28 A.M., indicated the SSD had followed up with the resident. The resident voiced that she felt down due to their family being unable to visit due to their health. 3.1-31(c)(6) 3.1-31(c)(13) 3.1-31(c)(3) 3.1-31(c)(7)

Based on interview, observation, and record review, the facility failed to adequately monitor a dialysis access site for 1 of 1 resident that received dialysis treatments. (Resident 42) Findings include: During an interview on 10/16/24 at 1:29 P.M., Resident 42 indicated he received dialysis treatments three days a week. He had an arteriovenous (AV) shunt (an abnormal connection between an artery and a vein used for dialysis) in his left arm. The nurses at the facility did not assess the shunt, they did put a numbing cream on his arm before he went out to dialysis. The resident's left arm was observed on 10/22/24 at 2:07 P.M. there was no swelling, drainage, or signs of infection at the shunt site. During an interview on 10/22/24 at 9:56 A.M., Licensed Practical Nurse (LPN) 2 indicated the resident went out for dialysis on Mondays, Wednesdays, and Fridays. He had a shunt in his arm for dialysis. On dialysis days the nurses were to fill out a form that went with the resident to dialysis. They would check and document the resident's vital signs, weigh him, and assess the dialysis shunt before he left and then again when he returned from dialysis. She did not assess the shunt on days the resident didn't go out for dialysis. The resident's clinical record was reviewed on 10/21/24 at 11:13 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 08/07/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, End Stage Renal Disease (ESRD), diabetes, and heart failure. The resident received dialysis treatments. The resident's current physician's orders included an open-ended order, with a start date of 11/23/23, to assess the resident's dialysis shunt every shift for thrill and bruit, swelling, pain, and change in temperature. The physician's order did not appear on the resident's Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR ). The shunt assessment was documented on the dialysis form on the days the resident went out for dialysis but was not routinely assessed on non-dialysis days. During an interview on 10/22/24 at 1:22 P.M., the Director of Nursing (DON) indicated the nurses should be looking at the resident's dialysis shunt every shift. There was a physician's order in the computer but there was nowhere to document any assessments. The order didn't show up on the EMAR/ETAR. The nurses probably didn't assess the dialysis shunt every shift because the order wasn't there to tell them to do it. The resident's current dialysis care plan, initiated on 11/10/23, included, but was not limited to, the following interventions: - Assess bruit and thrill every shift. The current facility policy, titled Hemodialysis, dated 01/13/22, was provided by the DON on 10/22/24 at 1:32 P.M. The policy indicated, .The nurse will ensure that the dialysis access site (e.g. AV shunt or graft) is checked before and after dialysis treatments and every shift as ordered by nephrologist for patency by auscultating for a bruit and palpating for a thrill. If absent, the nurse will immediately notify the attending physician, dialysis facility and/or nephrologist . 3.1-37(a)

Based on record review and interview, the facility failed to ensure misappropriation of resident's medications did not occur for 3 of 5 residents reviewed for misappropriation. (Residents B, D, and E) Findings include: 1.The clinical record for Resident B was reviewed on 09/20/24 9:48 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 8/13/24, indicated the resident was cognitively intact. The diagnosis included, but were not limited to, anxiety and depression. A current physician's order, with a start date of 12/05/22, indicated the staff were to administer Norco (a pain medication), 5-325 mg (milligrams), 1 tablet by mouth every six hours as needed for pain. A controlled drug record for Resident B, dated 07/12/24, shows documentation for the resident's Norco medication being signed out by RN (Registered Nurse) 2 on 08/25/24 at 8:00 A.M. and at 2:00 P.M. The facility as worked schedule, provided by the Administrator on 09/23/24 at 11:30 A.M., showed that RN 2 was not working on 08/25/24. The electronic medication administration record (EMAR) for Resident B on 08/25/24 showed the medication was only administered at 8:00 P.M. by a second shift nurse. During an interview with resident B, on 08/20/24 at 8:42 A.M., she indicated that she had an order for Norco if she had pain, but she did not like to take it because it made her feel sick and loopy. It had been months since she had taken one and she had only taken one then at night because she can sleep it off. During an interview with the Assistant Director of Nursing (ADON) on 09/23/24 at 9:21 A.M., she indicated that they noticed on 08/27/24 that RN 2 had signed out medications on 08/25/24 when they were not scheduled. The Director of Nursing (DON) and ADON met with RN 2 asking if there was a reason they signed out medications for a day they were not scheduled. RN 2 admitted ,at that time, of taking the medications home. A facility document provided by the ADON on 09/20/24 at 2:23 P.M. labeled Employee Counseling Record Form indicated that RN 2 was discharged from the facility for misappropriation of resident property on 08/27/24. 2. The clinical record for Resident D was reviewed on 09/23/24 9:45 A.M. An Annual MDS (Minimum Data Set) assessment, dated 06/29/24, indicated the resident was severely cognitive impaired. The diagnosis included, but were not limited to, non-traumatic brain dysfunction, Alzheimer's disease, anxiety, and depression. A physician's order for Resident D, with a start date of 10/27/23, indicated that staff were to administer Percocet (a pain medication), 5-325 mg (milligrams), 1 tablet by mouth every twelve hours as needed for breakthrough pain. A controlled drug record for Percocet for Resident D showed documentation for the medication being signed out by RN 2 on 08/22/24 at 4:00 P.M. The facility as worked schedule, provided by the Administrator on 09/23/24 at 11:30 A.M., showed that RN 2 was not working on 08/22/24. The electronic medication administration record for resident D on 08/22/24 showed the medication was only administered at 3:02 P.M. by the nurse scheduled to care for the resident that day. 3. The clinical record for Resident E was reviewed on 09/23/24 2:21 P.M. An Annual MDS (Minimum Data Set) assessment, dated 06/20/24, indicated the resident was moderately cognitive impaired. The diagnosis included, but were not limited to, Alzheimer disease, hypertension, and atrial fibrillation. A physician's order for resident E, with the state date of 12/12/23, indicated that staff were to administer Norco (a pain medication), 5-325 mg (milligrams), 1 tablet by mouth every eight hours as needed for pain. A controlled drug record for Resident E, showed documentation for the Norco medication being signed out by RN 2 on 08/18/24 at 10:00 A.M., 08/20/24 at 1:30 P.M., and on 08/21/24 at 9:30 A.M. The electronic medication administration record for resident E showed the medication was not administered at any time on 08/17/24, 08/20/24, or 08/21/24. The current facility policy titled, Abuse and Neglect, dated August of 2018, was provided by the Administrator on 09/23/24 at 1:58 P.M. The policy indicated, .The facility will identify events, occurrences, patterns, and trends that may constitute .misappropriation of property . The deficient practice was corrected on 08/27/24 after the facility reviewed records, assessed residents, and educated staff on misappropriation of medication. The facility discharged RN 2 for misappropriation of resident's property. This Citation relates to Complaint IN00441965 3.1-28(a)

Based on observation and record review, the facility failed to ensure a resident was treated with respect and dignity for 1 of 5 residents reviewed for resident rights. (Resident F) Findings include: During an observation on 09/23/24 at 8:48 A.M., CNA (Certified Nurse Aide) 3 was observed standing beside Resident F's bedside and the CNA stated, I'm not dealing with people telling me to shut up . Well then someone else can deal with you then! and then exited the resident's room into the community living room. The CNA noticed she was being observed, then she turned around and walked back into Resident F's room and began asking what the resident would like to wear today. During an interview with Resident F on 09/23/24 at 12:59 P.M., she indicated that some of the staff are mean to her, but she can't remember their names. They come into her room and say what she needs to do in a nasty way. During an interview on 09/23/24 at 1:09 P.M., LPN (Licensed Practical Nurse) 4 indicated that Resident F was pretty alert and that she talked to family daily. Resident F has dementia, but it was more of a short-term memory issue. She talked about her home land and her children regularly with staff. The clinical record for Resident F was reviewed on 09/23/24 1:57 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 09/01/24, indicated the resident was severely cognitively impaired. The diagnosis included, but were not limited to, anemia, heart failure, and non-Alzheimer's dementia. A current facility policy titled Dignity, provided by the Administrator on 09/23/24 at 1:58 P.M., with a revision date of February 2021, stated .Each Resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self worth and self-esteem ., .Residents are treated with dignity and respect at all times . 3.1-3(t)

Based on interview, record review, and observation, the facility failed to ensure a shower bed was comprehensively inspected for safety or function by the Maintenance staff or by the CNA prior to its use, failed to ensure a resident was repositioned on a shower bed using two staff in accordance with the plan of care, and failed to ensure the resident was rolled toward the CNA providing care in accordance with the CNA training record for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B falling from a shower bed and sustaining a subdural hematoma with midline shift (a potentially fatal traumatic brain injury), a fracture of the left humerus (the largest bone of the upper extremity), and a facial laceration. The immediate jeopardy began on [DATE], when the facility failed to ensure a resident's safety during a shower when a CNA (Certified Nurse Aide) did not follow proper procedure guidelines while turning a resident in a shower bed. The facility did not assess the shower beds for safety per the manufacturer's instructions and the Maintenance Director altered the shower bed by replacing pipes and putting the device back into service after the fall. The Administrator, DON (Director of Nursing), and ADON (Assistant Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 6:44 P.M. Findings include: The clinical record for Resident B was reviewed on [DATE] at 9:29 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, hemiplegia (one-sided muscle paralysis or weakness), hypertension, renal insufficiency, diabetes, non-Alzheimer's dementia, seizure disorder, anxiety, and depression. The resident was dependent on staff for bathing/showering, upper body dressing, lower body dressing, personal hygiene, rolling left/right, and tub/shower transfers. The resident required extensive assistance of two staff members for bed mobility. The resident had impairment on one side of the upper and lower extremity. The resident had no falls prior to the assessment. The resident's Care Plans were reviewed on [DATE] at 11:26 A.M., and included a care plan, with a most recent revision date of [DATE], that indicated the resident had an ADL self-care performance deficit related to impaired cognition, left sided hemiplegia, dementia, and history of a left humerus fracture. The interventions included, but were not limited to the following: - An intervention, dated [DATE], that indicated the resident required the use of a mechanical lift for transfers with the assistance of two staff members. - An intervention, dated [DATE], that indicated the resident required extensive assistance of one staff member for showers. - An intervention, dated [DATE], that indicated the resident required extensive assistance of two staff members for bed mobility. A Progress Note, dated [DATE] at 2:40 P.M., indicated the resident was in the shower room for her shower. CNA (2) reported that during the shower the side rail to the shower bed gave out. The resident fell while in the shower room. The fall report, dated [DATE] at 2:45 P.M., indicated Resident B was in the shower room. It was reported by CNA (2) that during the resident's shower the side rail to the shower bed gave out and the resident fell . The resident was awake and talking to the nurse. She verbalized some understanding of the incident. She was noted to have a one-inch laceration with a hematoma (bruise) present above the right eye. There was a mechanical failure with the shower bed rail. The resident was sent to the local hospital. A Local Emergency Department Physician's Note, dated [DATE] at 5:22 P.M., indicated the resident had fallen approximately three feet, hit her elbow, and left shoulder, and had a laceration to her right eyebrow and right elbow. The resident had a history of a stroke with left-sided weakness. The CT (Computed Tomography) scan of the resident's head showed a large acute subdural hematoma (a pool of mostly clotted blood caused by a broken blood vessel). An acute hemorrhage was also seen. There was a midline shift of the septum (thin wall separating the left and right sides of the brain) by about six to seven millimeters. The left humerus (upper part of the arm) was fractured. A Trauma History and Physical, dated [DATE] through [DATE], indicated the resident had a right forehead laceration and was disoriented. The CT scan of the head without contrast indicated the resident had a large right-sided subdural hemorrhage with significant midline effect and probable subfalcine herniation (midline shift) with a critical result if significant intracranial hemorrhage. The known injuries were SDH (subdural hemorrhage) with midline shift and humerus fracture. A Trauma Attending assessment, dated [DATE] at 7:13 P.M., indicated the resident's injuries by exam and radiographic findings/plan indicated the resident had a TBI (Traumatic Brain Injury) with SDH and MLS (Midline Shift), neurosurgeon consulted and non-operation with poor prognosis, and a left humerus fracture with no intervention and given comfort care. A Trauma Attending Addendum Physician Note, dated [DATE] at 9:04 A.M., indicated the resident had a fall resulting in a severe TBI that was non-survivable and inoperable per the neurosurgeon. The resident was awaiting hospice and palliative care input. The resident died at the hospital on [DATE]. During an interview on [DATE] at 9:17 A.M., LPN (Licensed Practical Nurse) 3 indicated Resident B passed away early that morning. She had been told the resident had a fall in the shower on [DATE] and was sent out to the hospital. During an interview on [DATE] at 9:53 A.M., LPN 6, while the DON was present, indicated on the day of the incident, [DATE], CNA 2 was giving Resident B a shower. The CNA started yelling for help in the shower room. She went into the shower room and the resident had fallen off the shower bed on to the floor, on Wing 3. The CNA indicated the bed rail had gave way on the shower bed. CNA 2 was the only staff in the shower room at the time of the fall. When she first observed the resident, she was lying face down on the floor. The resident was assessed and not moved, and the DON came and sat with the resident while she went and called EMS (Emergency Medical Services) to transport the resident to the hospital. The resident was breathing and stable after the fall. She didn't show any signs of distress. There was a small amount of blood present. The resident was able to squeeze her hand and had a laceration above her eye. The resident was transported to a local hospital. The physician and family were notified. The DON indicated due to the small amount of blood, she had placed a small towel under the resident's head prior to EMS arriving. During an interview on [DATE] at 10:01 A.M., the DON indicated when she entered the shower room the resident had fallen off the right side of the shower bed. The right-side rail had given way. One of the pins to the shower bed was lying on top of the bed. She wasn't sure how the pin got on the top of the bed. The right side of the rail was down. The pins were not to be removed while the resident was being showered only before and after the shower to get the resident in and out of the bed. There wasn't a problem with the shower bed. The Maintenance Director and Administrator checked the bed after the incident and there wasn't a problem with the shower bed. CNA 2 was terminated due to the incident. During an interview on [DATE] at 10:11 A.M., CNA 2 indicated she was giving Resident B a shower on the shower bed in the shower room alone. She was standing on the left side of the shower bed and turned the resident to her (the resident's) right side to rinse the soap off the resident. She understood the rail would be enough to hold the resident. The right-side shower bed PVC (Polyvinyl chloride) rail broke close to where the pin went in. She was unsure if the bed was broken prior to the shower. She had only moved the left side rail of the shower bed when she placed the resident on it. She never removed the pins or checked the pins on the right side. The shower bed had two to three inch pins that went into the four corners of the shower bed. When the resident fell , she called for help right away. She was the only staff member in the shower room at the time of the fall. She was re-educated via the telephone on rolling a resident towards the caregiver's body when another staff member wasn't present. A shower bed on Wing 3 that was used at the time of the fall on [DATE] was observed with the Maintenance Director, on [DATE] at 10:24 A.M. The bed frame and railings were made of PVC (polyvinyl chloride) pipes. The bed lacked any identifying markers related to the weight limit. The bed was approximately three feet high, with rails on both sides that were approximately six inches high. A metal pin was attached at each of the four corners of the bed with a stiff plastic strip. The pins went into holes in the rails and held the rails in place. The Maintenance Director indicated staff would remove both pins on one side to lower the railing. He recently installed the plastic strips that attached the pins to the bed. Originally, there were thin black rubber strips that held the pins onto the bed, but they were easy to break. He was not in the facility when Resident B fell out of the shower bed, and he did not see the bed immediately after the incident. He was told after the incident that one of the four pins were found in the shower bed. The bed was taken out of service, and he took the bed outside and checked it for problems, there were none. He went through the bed and made sure no screws were cracked or missing. There were no documented routine checks on the beds, but staff would lose the pins a lot, so he did go around and check to make sure there were four pins in the beds. The shower bed was back in service and was used as needed. The shower bed on Wing 4 was observed with the Maintenance Director on [DATE] at 10:37 A.M. The shower bed was similar to the one on Wing 3, except there was a sticker at the foot of bed that identified it had a 500-pound weight capacity. The bed had the same white plastic strips holding the pins in place. The Maintenance Director indicated he had recently installed the white strips and replaced all four pins in that bed. The shower bed was in service and used as needed. During an interview on [DATE] at 10:45 A.M., Maintenance Staff 5 indicated on [DATE] a housekeeper had told him a resident had just had a fall. He went and looked at the shower bed to see what happened. The shower bed was brought out of the shower room. Each stationary corner of the bed, where the side rails connected in the upright position, contained solid rounded caps. One of the caps was off and missing. Where the cap was off, the PVC was broken. So, when the resident had rolled, the side rail gave way, and the resident fell to the floor. There wasn't enough plastic on the stationary corner to hold the pin in place. The maintenance didn't have routine checks on the shower beds. They would just take a quick look at them to make sure the wheels were working. The Maintenance Director had fixed the broken pipe after the fall. During an interview on [DATE] at 12:58 P.M., CNA 7 indicated the use of the shower bed was really based on the mobility needs of the resident. It took two staff members to get a resident on and off of the shower bed. You would have two staff members because you would be using a mechanical lift to transfer the resident onto the shower bed. If a resident was using a shower bed they would be using a mechanical lift too. Once the resident was on the shower bed you didn't need two staff members present to shower the resident if a staff member could roll the resident by themselves. Staff were trained on using the shower bed when they first started working at the facility, it was part of their orientation. When she used the shower bed, she looked to make sure the four pins were in place. You would have to remove two of the pins to lower the rail on one side to get the resident on the shower bed, and ensure the pins were back in place once the resident was on the bed. The rail would fall if both pins weren't in place. If one pin was in place the railing would stay up, but it would be super flimsy. She didn't really check the shower bed for cracks in the tubing or loose pieces before she used it. She did make sure the pins were in place. She was unaware of any problems with a shower bed prior to the incident that occurred with Resident B. During an interview on [DATE] at 3:07 P.M., the Maintenance Director indicated he did, in fact, replace the pipes at the end of the shower bed observed on Wing 3 after Resident B fell out of it. A cap was off and it was nowhere to be found. There were two holes in one end of one of the pipes on the bed for the pins to be placed in, he didn't know if there was a good hole and a bad hole. He didn't know which hole was being used. He looked up the type of piping the bed was made of, but he used Schedule 40 PVC pipe on it instead. He replaced the pipes with heavier pipes he purchased from a local hardware store. He was unsure of how old the shower beds were, he couldn't find a purchase receipt or anything. In the last three months (May, June, and July) he had been using a Maintenance Checklist where he documented the rounds he did each month to check the rooms in the facility. At 6:07 P.M., the Maintenance Director indicated he checked the shower beds monthly. He checked to ensure the pins were present. He did not check the structure around the bed rails or around the pins for cracks. He only checked the bottom part of the frame for cracks and checked wheel function. During an interview on [DATE] at 1:35 P.M., CNA 8 indicated staff should roll a resident towards themselves when using a shower bed. There was no situation in which they would roll them away from themselves when they were alone and giving a shower. The current facility policy titled, Accidents and Supervision with an implemented date of [DATE], indicated, .The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: Identifying hazard(s) and risk(s). Evaluating and analyzing hazard(s) and risk(s) .Monitoring for effectiveness and modifying interventions when necessary .The facility shall establish and utilize systemic approach to address resident risk and environmental hazards to minimize the likelihood of accident .All staff .are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident . The current JOB ORIENTATION-CERTIFIED NURSE AIDE with a revised date of [DATE], was provided by the Administrator on [DATE] at 1:20 P.M. The orientation indicated, .assisting residents in/out tub/shower .Showering residents . CNA 2's training record indicated the CNA training curriculum .PROCEDURE #30: TRANSFER: TO STRETCHER/SHOWER BED, dated [DATE], .included but was not limited to, place stretcher/shower bed at bedside. NOTE: Make certain wheels are locks. After locking wheels, ensure bed and stretcher/shower bed are at the same height. Then lower side rails .Staff should be present at the bedside as well as on the opposite side of stretcher/shower bed. (Requires a minimum of two staff members .Center and align resident. Place pillow under his/her head and cover with a blanket and raise the rails of stretcher/shower bed . The current facility policy titled, Resident Showers with a revised date of [DATE], was provided by the Administrator on [DATE] at 1:20 P.M. The policy indicated, .It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice . The undated OPERATION INSTRUCTIONS for the shower bed was provided by the Administrator on [DATE] at 11:12 A.M. The record indicated, .UNLESS TRANSFERRING, WHEN THE PATIENT IS ON THE SHOWER BED, KEEP RAILS UP AT ALL TIMES .WHEN USING A LIFT TO TRANSFER THE PATIENT IN AND OUT OF THE SHOWER BED, MANUFACTURER RECOMMENDS KEEPING THE SIDERAILS UP AND LOCKED AT ALL TIMES .DO NOT ROLL USER AWAY FROM YOU UNLESS THERE IS A PARTNER CAREGIVER ON THE OTHER SIDE .SAFETY/MAINTENANCE INFORMATION .Check pipe and fittings for hairline fractures monthly .Check all junctures to make certain the pipe and fittings do not pull apart . The current, undated, manufacturer's PVC Healthcare Equipment catalog, indicated .[name of manufacturer] uses only top quality materials; a proprietary blend of PVC, strong and durable fittings specifically designed for healthcare and fabrics chosen for appearance and longevity .Surpasses all FDA [Food and Drug Administration] compliance standards . The Immediate Jeopardy, that began on [DATE], was removed on [DATE], when the facility conducted the following: The altered shower bed was taken out of service, the Maintenance Director received education to never alter medical equipment and to replace parts with the manufacturer's instructions, all residents who required the use of the shower bed were identified and the assignment sheet and care plan were updated, all staff were educated on the correct use, safety inspection, safety features of the bed and all safety measures to be taken related to the shower bed. This deficiency relates to Complaints IN00440484, IN00440575, and IN00440383. 3XXX,d+[DATE](a)(1) 3XXX,d+[DATE](a)(2)

Based on observation, interview, and record review, the facility failed to ensure resident care equipment was in safe operating condition for two of two shower beds reviewed. (Wing 3 shower bed and Wing 4 shower bed) Findings include: 1. The shower bed on Wing 3 that was being used when Resident B fell out of it on 08/05/24 was observed with the Maintenance Director on 08/08/24 at 10:24 A.M. The bed frame and railings were made of PVC (polyvinyl chloride) pipes. The bed lacked any identifying markers related to the weight limit. The bed was approximately three feet high, with rails on both sides that were approximately six inches high. A metal pin was attached at each of the four corners of the bed with a stiff plastic strip. The pins went into holes in the rails and held the rails in place. The Maintenance Director indicated staff would remove both pins on one side to lower the railing. He recently installed the plastic strips that attached the pins to the bed. Originally, there were thin black rubber strips that held the pins onto the bed, but they were easy to break. He was not in the facility when Resident B fell out of the shower bed, and he did not see the bed immediately after the incident. He was told after the incident that one of the four pins were found in the shower bed. The bed was taken out of service, and he took the bed outside and checked it for problems, there were none. He went through the bed and made sure no screws were cracked or missing. There were no documented routine checks on the beds, but staff would lose the pins a lot, so he did go around and check to make sure there were four pins in the beds. The shower bed was back in service and was used as needed. 2. The shower bed on Wing 4 was observed with the Maintenance Director on 08/08/24 at 10:37 A.M. The shower bed was similar to the one on Wing 3, except there was a sticker at the foot of bed that identified it had a 500-pound weight capacity. The bed had the same white plastic strips holding the pins in place. The Maintenance Director indicated he had recently installed the white strips and replaced all four pins in that bed. The shower bed was in service and used as needed. During an interview on 08/08/24 at 10:45 A.M., Maintenance Staff 5 indicated on 08/05/24 a housekeeper had told him a resident had just had a fall. He went and looked at the shower bed to see what happened. The shower bed was brought out of the shower room. Each stationary corner of the bed, where the side rails connected in the upright position, should have contained solid rounded caps. One of the caps was off and missing. Where the cap was off, the PVC was broken. There wasn't enough plastic on the stationary corner to hold the pin in place. The maintenance didn't have routine checks on the shower beds. They would just take a quick look at them to make sure the wheels were working. The Maintenance Director had replaced the pipe after a resident's fall. The fall report, dated 08/05/24 at 2:45 P.M., indicated Resident B was in the shower room. It was reported by CNA (Certified Nurse Aide 2) that during the resident's shower the side rail to the shower bed gave out and the resident fell . The resident was awake and talking to the nurse. She verbalized some understanding of the incident. She was noted to have a one-inch laceration with a hematoma (bruise) present above the right eye. There was a mechanical failure with the shower bed rail. The resident was sent to the local hospital. During an interview on 08/08/2024 at 3:07 P.M., the Maintenance Director indicated he did, in fact, replace the pipes at the end of the shower bed observed on Wing 3 after Resident B fell out of it. A cap was off and it was nowhere to be found. There were two holes in one end of one of the pipes on the bed for the pins to be placed in, he didn't know if there was a good hole and a bad hole. He didn't know which hole was being used. He looked up the type of piping the bed was made of, but he used Schedule 40 PVC pipe on it instead. He replaced the pipes with heavier pipes he purchased from a local hardware store. He was unsure of how old the shower beds were, he couldn't find a purchase receipt or anything. In the last three months (May, June, and July) he had been using a Maintenance Checklist where he documented the rounds he did each month to check the rooms in the facility. At 6:07 P.M., the Maintenance Director indicated he checked the shower beds monthly. He checked to ensure the pins were present. He did not check the structure around the bed rails or around the pins for cracks. He only checked the bottom part of the frame for cracks and checked wheel function. Maintenance Checklist documentation was provided on 08/08/24 at 6:07 P.M. The records indicated shower beds and shower chairs were checked in May, June, and July of 2024. The facility failed to provide any other documentation of monthly checks completed prior to May 2024. During an interview on 08/08/24 at 12:58 P.M., CNA 7 indicated staff were trained on using the shower bed when they first started working, it was part of their orientation. When she used the shower bed, she looked to make sure the four pins were in place. She didn't really check the shower bed for cracks in the tubing or loose pieces before she used it. She did make sure the pins were in place. The undated OPERATION INSTRUCTIONS for the shower bed was provided by the Administrator on 08/08/24 at 11:12 A.M. The record indicated, .UNLESS TRANSFERRING, WHEN THE PATIENT IS ON THE SHOWER BED, KEEP RAILS UP AT ALL TIMES .WHEN USING A LIFT TO TRANSFER THE PATIENT IN AND OUT OF THE SHOWER BED, MANUFACTURER RECOMMENDS KEEPING THE SIDERAILS UP AND LOCKED AT ALL TIMES .DO NOT ROLL USER AWAY FROM YOU UNLESS THERE IS A PARTNER CAREGIVER ON THE OTHER SIDE .SAFETY/MAINTENANCE INFORMATION .Check pipe and fittings for hairline fractures monthly .Check all junctures to make certain the pipe and fittings do not pull apart . The current, undated, manufacturer's PVC Healthcare Equipment catalog, indicated .[name of manufacturer] uses only top quality materials; a proprietary blend of PVC, strong and durable fittings specifically designed for healthcare and fabrics chosen for appearance and longevity .Surpasses all FDA [Food and Drug Administration] compliance standards . The current facility policy, titled Preventative Maintenance Program, with a revision date of 04/20/24, was provided by the Administrator on 08/08/24 at 1:20 P.M. The policy indicated, .A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public .The Maintenance Director is responsible for .maintaining a schedule of maintenance services to ensure .equipment are maintained in a safe and operable manner .follow the manufacturers guidelines in the manuals provided with such equipment . This deficiency relates to Complaints IN00440484, IN00440575, and IN00440383. 3.1-19(bb)

Based on interview and record review, the facility failed ensure staff reported an allegation of abuse in a timely manner for 2 of 3 residents reviewed for abuse. (Residents D and B) Findings include: During an interview on 06/04/24 at 2:08 P.M., CNA (Certified Nurse Aide) 3 indicated she had worked with CNA 5 on the evening of 05/18/24. The CNAs entered Resident B and D's room to assist Resident B with care. Resident D was holding onto Resident B's wheelchair. CNA 5 told Resident D to go to her own side of the room. CNA 5 said it again and started getting louder. Resident D told CNA 5 to shut up. Resident B was getting teary eyed. CNA 3 was helping Resident B, and she was unsure of what Resident D was saying, it seemed like she said she wanted to go home. CNA 3 tried to keep everyone calm. CNA 5 was speaking in a louder voice than normal. CNA 3 made CNA 5 get out of the room. CNA 3 didn't report the incident to the nurse on duty. CNA 5 worked the rest of the shift that night and worked the next day with CNA 3. CNA 3 indicated she was supposed to talk to the nurse in charge about what happened, and she failed to do that. During an interview on 06/04/24 at 1:38 P.M., LPN (Licensed Practical Nurse) 2 indicated she remembered the incident from 05/18/24. She heard some yelling in the direction of Resident B and D's room. When she entered the room, Resident B was in bed and Resident D was sitting on her own bed. The two CNAs were not in the room. Resident D indicated CNA 5 accused her of trying to help Resident B to walk. LPN 2 tried to lighten the mood because Resident D seemed a little shaky. Resident D indicated she wanted to go home. Resident D indicated those CNAs were always rude to her. LPN 2 made sure the residents had their call lights and left the room. CNA 5 and CNA 3 were just sitting at the nurse's station. It was getting close to time for their shift to be over. LPN 2 did not say anything to the CNAs. She reported what happened to the oncoming nurse at 10:00 P.M. A Progress Note written by LPN 4, dated 05/19/24 at 5:27 P.M., indicated Resident D had spoken with her about an incident that happened the night before. The resident was upset with the CNAs on the evening shift after she said she was trying to help her roommate get her call light within reach and a CNA entered the room believing she was trying to assist her roommate to bed. She said a CNA yelled at her to get to her own side of the room. Apparently, an argument ensued between the CNA and the resident at that time. The roommate became upset over the confrontation and started to cry. This nurse spoke with both residents in their room and received the same story. LPN 4 assured the residents that the incident would be addressed. There was no indication in Resident B or Resident D's records that the Administrator or SSD (Social Services Director) were notified of the incident. During an interview with the DON (Director of Nursing) and SSD on 06/05/24 at 9:46 A.M., the SSD indicated he came into work on 05/20/24 and found out about the incident when he was reviewing resident progress notes from over the weekend. Once he saw LPN 4's note about what happened, he immediately notified the Administrator and DON and started his investigation. He spoke with both residents. They remembered the incident. Both residents were very calm and showed no signs of psychological distress. The resident's families were notified, and the staff involved were interviewed. Staff were educated about reporting abuse. CNA 5 was initially suspended and then fired. During an interview on 06/05/24 at 2:14 P.M., LPN 7 indicated if she encountered a situation where a staff member was being abusive towards a resident she would immediately separate the two. She would make sure the resident was safe. She would call the Administrator and the Social Services Director at any time day or night. She would not wait, she would call them immediately, she wouldn't leave it for the next shift. During an interview on 06/05/24 at 2:11 P.M., CNA 6 indicated If she came upon a situation where a staff member was yelling at a resident or abusing a resident in any way, she would immediately intervene. She would make sure the resident was safe, she wouldn't leave the resident and she would tell the nurse what was going on. During an interview on 06/04/2024 at 10:30 A.M., the Administrator indicated the staff were in-serviced and educated on abuse and neglect upon hire, annually, and any time there was an allegation of abuse or neglect. Education on abuse and neglect was part of the staff's orientation upon hire. After that, education was done annually facility wide. Signs were posted on every wing, by the time clock, and in the break room regarding reporting abuse. The signs were bright orange in color. The SSD was the Abuse Coordinator for the facility. Staff were supposed to call him, day, or night, to report any allegations or suspected abuse immediately. The current policy and procedure for Abuse, Neglect and Exploitation was provided by the Administrator on 06/04/24 at 11:20 A.M. The policy indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .Verbal Abuse .means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .Mental Abuse .includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specific timeframes .Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or .Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . This citation relates to Complaint IN00434924. 3.1-28(c)

Based on record review and interview the facility failed to ensure residents were free from verbal and emotional abuse for 2 of 3 residents reviewed for abuse. (Residents D and B) Findings include: 1. The clinical record for Resident D was reviewed on 06/04/24 at 11:15 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 04/13/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, Parkinson's disease, and hypertension. During an interview on 06/04/24 at 9:49 A.M., Resident D indicated she had been mistreated by CNA (Certified Nurse Aide) 5 at the facility. Her roommate (Resident B) couldn't reach her call light and Resident D had been helping her with the blankets on her bed. CNA 5 came into their room and thought Resident D was trying to transfer Resident B into bed. CNA 5 yelled at her and told her to get back to the other side of the room. The resident indicated she wasn't doing anything wrong. CNA 3 was there when it happened. The resident had heard CNA 5 had been fired. The SSD (Social Services Director) did talk to her and had asked her about the incident. A Progress Note written by LPN 4 (Licensed Practical Nurse), dated 05/19/24 at 5:27 P.M., indicated Resident D had spoken with her about an incident that happened the night before. The resident was upset with the CNAs on the evening shift after she said she was trying to help her roommate get her call light within reach and a CNA entered the room believing she was trying to assist her roommate to bed. She said a CNA yelled at her to get to her own side of the room. Apparently, an argument ensued between the CNA and the resident at that time. The roommate became upset over the confrontation and started to cry. This nurse had spoken with both residents in their room and received the same story. LPN 4 assured the residents that the incident would be addressed, and both residents were satisfied. 2. The clinical record for Resident B was reviewed on 06/04/24 at 11:26 A.M. A Quarterly MDS assessment, dated 03/13/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, stroke, diabetes, anxiety, and depression. During an interview on 06/05/24 at 1:38 P.M., Resident B indicated on the night of the incident she was getting ready for bed. Her roommate (Resident D) was helping her with some things. CNA 5 came in and started yelling at Resident D. CNA 5 thought Resident D was assisting Resident B into bed and she was not. CNA 5 left the room and CNA 3 finished helping Resident B. The whole incident upset her a little. The residents were not doing anything wrong, and CNA 5 yelled at Resident D. CNA 5 shouldn't have yelled at the resident. During the interview, Resident D indicated the residents would always hear CNA 5 yelling in the facility, but they never told anyone about it. During an interview on 06/04/24 at 2:08 P.M., CNA 3 indicated she had worked with CNA 5 on the evening of 05/18/24. CNA 3 went in Resident B and D's room that evening because Resident B's call light was on. Resident D was upset and told her that Resident B had not had her call light all day, that it had been out of her reach. Resident D was aggravated. CNA 3 felt like she needed help and had CNA 5 come in to assist her. When the CNAs returned to the room, Resident D was holding onto Resident B's wheelchair. CNA 5 told Resident D to go to her own side of the room. CNA 5 said it again and started getting louder. Resident D told CNA 5 to shut up. Resident B was getting teary eyed. CNA 3 was helping Resident B, and she was unsure of what Resident D was saying, it seemed like she said she wanted to go home. CNA 3 tried to keep everyone calm. CNA 5 was speaking in a louder voice than normal. CNA 3 made CNA 5 get out of the room. Other residents had expressed concerns regarding CNA 5 complaining a lot in the past. CNA 3 thought CNA 5 told the nurse about the incident. CNA 3 didn't report the incident to the nurse on duty, her brain went into a fog, and she was trying to get to another call light that was going off. CNA 5 worked the rest of the shift that night and worked the next day with CNA 3. CNA 3 indicated she was supposed to talk to the nurse in charge about what happened, and she failed to do that. She just was trying to get her residents taken care of. The as worked nursing schedule for 05/18/24 and 05/19/24 was provided by the ADON (Assistant Director of Nursing) on 06/04/24 at 1:25 P.M. The record indicated CNA 5 and CNA 3 had worked on Wing 1 on both days from 2:00 P.M. to 10:00 P.M. During an interview on 06/04/24 at 1:38 P.M., LPN 2 indicated she remembered the incident from 05/18/24. It was in the evening; she was passing medications on Wing 1. CNA 3 was in the common area and asked CNA 5 to help her. Shortly after that, LPN 2 heard yelling. She went into the residents' room. Resident B was in bed and Resident D was sitting on her own bed. The two CNAs were not in the room. LPN 2 asked if everything was okay. Resident D indicated she would never do the things CNA 5 accused her of. She accused her of helping Resident B to walk. Resident D said she was just helping Resident B get her call light. LPN 2 tried to lighten the mood because Resident D seemed a little shaky. Resident D indicated she wanted to go home. Resident D indicated those CNAs were always rude to her. LPN 2 made sure the residents had their call lights and left the room. CNA 5 and CNA 3 were just sitting at the nurse's station. It was getting close to time for their shift to be over. LPN 2 did not say anything to the CNAs. She reported what happened to the oncoming nurse at 10:00 P.M. The Administrator had LPN 2 come into the facility on [DATE] and talked to her about the incident. During an interview on 06/05/24 at 2:14 P.M., LPN 7 indicated if she encountered a situation where a staff member was being abusive towards a resident she would immediately separate the two. She would make sure the resident was safe. She would call the Administrator and the Social Services Director at any time day or night. She would not wait, she would call them immediately, she wouldn't leave it for the next shift. During an interview on 06/04/2024 at 10:30 A.M., the Administrator indicated the staff were in-serviced and educated on abuse and neglect upon hire, annually, and any time there was an allegation of abuse or neglect. Education on abuse and neglect was part of the staff's orientation upon hire. After that, education was done annually facility wide. Signs were posted on every wing, by the time clock, and in the break room regarding reporting abuse. The signs were bright orange in color. They had not had any concerns with CNA 5 regarding abuse in the past. Residents B and D were alert and oriented. Both residents had the same story. CNA 3 came into the residents' room and had CNA 5 leave the room. The SSD was the Abuse Coordinator for the facility. Staff were supposed to call him, day, or night, to report any allegations or suspected abuse immediately. The current policy and procedure for Abuse, Neglect and Exploitation was provided by the Administrator on 06/04/24 at 11:20 A.M. The policy indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .Verbal Abuse .means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .Mental Abuse .includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specific timeframes .Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or .Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . This citation relates to Complaint IN00434924. 3.1-27(a)(1) 5.1-27(b)

Based on observation, interview, and record review, the facility failed to store medications appropriately for 2 of 3 medication carts reviewed. (Wing 1 and Wing 3 medication carts) Findings include: 1. The medication cart on Wing 1 was observed on 08/21/23 at 3:42 P.M., with LPN 7. The top drawer of the cart contained several medication cups containing pills nested together. The LPN indicated it was medications for the 4:00 P.M. medication pass. The cups were labeled with the residents' initials only. She was unaware of the facility policy. The cups contained the following medications for the following residents as described by the LPN: - Resident 14, bupropion (antidepressant), - Resident 42, Protonix, Gabapentin (a nerve medication), - Resident 58, Xanax (antianxiety medication, a controlled substance), - Resident 13, two Metformin tablets, - Resident 6, two Tylenol, Metformin, Buspar (antianxiety medication), - Resident 22, Metformin, - Resident 49, two Tylenol, 1.5 tabs of Lasix, - Resident 39, two Demadex (a diuretic medication), two Tylenol, - Resident 3, two Tylenol, and - Resident 63, Buspar (an antidepressant). The LPN indicated she gets the pills out so she can help with the supper trays. She thought she could prepare for one medication pass. During an interview on 08/22/23 at 2:06 P.M., the DON (Director of Nursing) indicated staff were not allowed to preset medications. During an interview on 08/22/23 at 2:47 P.M., the DON indicated antianxiety and antidepressant medications were not kept in the double locked narcotics box in the medication carts if they were routinely scheduled medications. The were kept in the locked narcotics box only if they were ordered as needed. Xanax and Buspar were not narcotics. During an observation and interview on 08/22/23 at 2:51 P.M., the medication cart on Wing 1 was reviewed with RN 8. The RN indicated Xanax was kept in the narcotics drawer. Resident 58's card of Xanax pills was observed and in the double locked narcotics box. The medication was a routinely scheduled medication. Xanax should be double locked per the RN. The Controlled Drug Record for Resident 58's Xanax (alprazolam) was provided by RN 8 on 08/22/23 at 2:55 P.M. The record indicated the medication was scheduled, and the resident was to take one tablet by mouth twice a day. 38769 2. On 08/22/23 at 2:21 P.M., Wing 3's Medication Cart was observed with LPN 9. The following was observed: - A vial of Lantus (insulin) for Resident 29, that was 1/4 full had an open date of 7/22. LPN 9 indicated the medication was good for 28 days after it was opened and should have been discarded. During a Narcotic Count with the LPN the following was observed: - Resident 72 had 28 lorazepam (an antianxiety medication) tablets. Tablet 28 in the narcotic blister pack had been punched out and taped back into place. The LPN indicated the pill had probably been removed by accident and a staff member taped it back into the blister pack. If a pill had been removed from the blister pack, then it should be discarded appropriately. - Resident 70 had a bottle of Tramadol (a pain medication). The narcotic count sheet indicated the resident should have had 58 tramadol tablets. Inside the bottle of medication was a plastic pill crusher package that had whole pills inside. The package was stapled shut and had 30 written on the outside of it. There were other loose pills inside the bottle. LPN 9 indicated she didn't have a pill counter to be able to count the pills and had not counted them that morning. After a few seconds she retrieved a clean plastic spoon and clean plastic cup and started counting the loose pills. The loose pills totaled 28. She did not count the pills inside the plastic package. She indicated she did not count them that morning when she took over the medication cart from the other nurse. All narcotic medications should be counted at each shift change and the 30 tablets inside the plastic package should have been counted every shift. The current facility policy title, MEDICATION STORAGE IN THE FACILITY-CONTROLLED SUBSTANCE STORAGE, with a revision date of 02/2023, was provided by the DON on 08/17/23 at 3:39 P.M. The policy indicated, .Schedule medications and other medications subject to abuse or diversion are stored in a permanently affixed, [double-locked] compartment separate from all other medications or per state regulations .At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented .Any discrepancy in controlled substance counts is reported to the director of nursing immediately .Liquid narcotics will be overfilled in comparison to the quantity written on the label. This is a pharmacy industry standard. To account for excess amount, the nurse checking in the bottle of liquid controlled substance, should eliminate the quantity by using the measurement grid, located on the bottle .This amount should be recorded as the starting quantity . 3.1-25(b)(5) 3.1-25(e)(3) 3.1-25(m) 3.1-25(n)

Based on observation, record review, and interview, the facility failed to ensure appropriate oversight of a resident's medication during 1 of 11 medication administration observations. (Resident 1) Findings Include: An observation of medication administration with RN 5, on 08/16/23 at 2:41 P.M., of Wing 4 indicated the RN prepared a cup of medications for Resident 1. The cup contained one Gabapentin 100 mg (milligrams) tablet and two Tylenol 325 mg tablets. The RN walked into the resident's room at 2:49 P.M. The resident was brushing her teeth in her bathroom and the nurse asked if she just wanted her medications left at the bedside to take at her convenience and the resident indicated, Yes. The RN left the medication cup on her over the bed table and exited the room. During an interview on 08/18/23 at 2:18 P.M., the DON (Director of Nursing) indicated she was not aware of any residents on the Health Care side of the facility that self-medicated. During an interview on 08/22/23 at 11:30 A.M., RN 5 indicated there were seven residents on Wing 4 who were independently mobile. The clinical record for Resident 1 was reviewed on 08/22/23 at 12:12 P.M. An Annual MDS assessment, dated 07/05/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, anxiety, dysphagia, diabetes, and heart failure. The current physician's orders record was provided by the ADON on 08/22/23 at 12:17 P.M. The record lacked an order permitting the resident to self-medicate or leave medications at the bedside. The complete Care Plan was provided by the MDS Coordinator on 08/22/23 at 1:28 P.M. Care Plans included, but were not limited to, a Focus indicating the resident had a knowledge deficit related to short term memory loss with an initiated date of 02/13/18. The resident record lacked a Care Plan indicating she was assessed or permitted to self-administer her medications. During an interview on 08/22/23 at 2:06 P.M., the DON indicated staff were not allowed to leave residents' medications at the bedside unless they were Care Planned to do so. The current Administering Medications policy, with a revised date of April 2019, indicated, .Medications are administered in a safe .manner, and as prescribed .Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely . The current Accidents and Supervision policy with an implemented date of 09/01/22, was provided by the ADON on 08/22/23 at 1:15 P.M. The policy indicated, .The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: .Implementing interventions to reduce hazard(s) and risk(s) .Implementation of Interventions-using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: .Communicating the interventions to all relevant staff .Providing training as needed .Ensuring that the interventions are put into action . 3.1-11(a)

Based on record review and interview, the facility failed to notify the physician for a change in residents' condition related to the notification of weight changes for 2 of 5 residents reviewed for notification. (Residents 47 and 57) Findings include: 1. The clinical record for Resident 47 was reviewed on 08/21/23 at 3:05 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 07/29/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, chronic kidney disease, coronary artery disease, peripheral vascular disease, and hypertension. The resident received a diuretic (water pill) medication for seven of the seven days during the review period. The Care Plan, with an initiated date of 06/07/23, indicating the resident was at risk for decreased cardiac output related to chronic kidney disease stage three, peripheral vascular disease, and atherosclerotic heart disease. The interventions included, but were not limited to, .Daily weights; Notify physician if weight gain is greater than 3 pounds in 24 hours or 5 pounds in a week . The TAR (Treatment Administration Record) for June, July, and August 2023, were provided by the ADON (assistant director of nursing) on 08/22/23 at 10:09 A.M., and contained the following physician's order: - Obtain daily weight every day shift related to chronic kidney disease stage three and call for three pound weight changes, with a start date of 06/07/23. The records indicated the resident had weight changes of three pounds or more on the following dates: June 2023: - 06/19/23, weight was 258.5, - 06/20/23, weight was 249.5, a change of 9 pounds, and - 06/29/23, weight was 253.5, - 06/30/23, weight was 250, a change of 3.5 pounds. July 2023: - 07/29/23, weight was 246.6, - 07/30/23, weight was 243, a change of 3.6 pounds. August 2023: - 08/15/23, weight was 244.4, - 08/16/23, weight was 240.3, a change of 4.1 pounds. The Progress Notes for June, July, and August 2023, were provided by the ADON on 08/22/23 at 10:09 A.M. The record lacked documentation the physician had been notified of the changes in the resident's weights. 38769 2. The clinical record for Resident 57 was reviewed on 08/17/23 at 2:42 P.M. An Annual MDS assessment, dated 07/07/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, stroke, anemia, heart failure, hypertension, diabetes, anxiety, and depression. The resident received a diuretic medication for seven of the seven days during the review period. The TAR for June, July, and August 2023, was provided by the ADON on 08/22/23 at 10:13 A.M., and contained the following physician's order: - Daily weight at 6:00 A.M. If a weight gain greater than 3 pounds in a day or 5 pounds in a week, Call the MD, with a start date of 08/16/22. The records indicated the resident had weight changes of three pounds or more on the following dates: June 2023: - 06/08/23, weight was 195, - 06/09/23, weight was 198.2, a change of 3.2 pounds, and - 06/14/23, weight was 196.7, - 06/15/23, weight was 200.6, a change of 3.9 pounds. July 2023: - 07/14/23, weight was 200.2, - 07/15/23, weight was 204.5, a change of 4.5 pounds. August 2023: - 08/12/23, weight was 199.7, - 08/13/23, weight was 203.2, a change of 3.5 pounds. The Progress Notes for June, July, and August 2023, were provided by the ADON on 08/22/23 at 10:13 A.M. The record lacked documentation the physician had been notified of the changes in the resident's weights. During an interview on 08/21/23 at 2:33 P.M., LPN (Licensed Practical Nurse) 2 indicated when a resident was to have a daily weight, the resident would be weighed as soon as they awoke for the morning. If the physician needed notified due to a weight gain, they would call the physician. If no one answered she would leave a message. When the physician was notified a progress note would be entered that they had been notified. The current facility policy titled, Change in Resident's Condition or Status, with a revised date of February 2021, was provided by the ADON on 08/22/23 at 1:15 P.M. The policy indicated, .promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.) .The nurse will notify the resident's attending physician or physician on call when there has been a(an): .specific instruction to notify the physician of changes in resident's condition . 3.1-5(a)(3)

Based on interview and record review, the facility failed to ensure a care plan was initiated for a resident with an intravaginal device for 1 of 20 residents reviewed for care plans. (Resident 53) Findings include: During an interview on 08/16/23 at 1:41 P.M., Resident 53 indicated she took water pills and had to go to the bathroom often. The resident's clinical record was reviewed on 08/21/23 at 10:01 A.M. An Admission MDS (Minimum Data Set) assessment, dated 06/12/23, indicated the resident was moderately cognitively impaired. The resident required limited staff assistance for most ADLs (Activities of Daily Living), including toileting, but required extensive staff assistance with personal hygiene. The resident was occasionally incontinent of urine, and frequently incontinent of bowel. The diagnoses included, but were not limited to, congestive heart failure, atrial fibrillation, uterovaginal prolapse, and the presence of urinogenital implants. A facility Admission Assessment, dated 06/05/23, indicated the resident was incontinent of bladder. A note in the genitourinary section of the assessment indicated pessary maintenance. During an interview on 08/21/23 at 10:59 A.M., LPN (Licensed Practical Nurse) 7 indicated the resident did have a pessary (a device placed in the vagina to support the uterus or bladder and rectum that helped decrease urine leakage). The resident went to her Gynecologist in June 2023, and had a follow up appointment in four months. There were no issues with the pessary. There was a vaginal gel that was administered on night shift. A REPORT OF CONSULTATION, dated 06/26/23, indicated the resident's physician changed and cleansed her pessary device. The resident was to follow up in four months and nursing staff were to continue administering the vaginal gel twice a week. The resident's current MD orders included, but were not limited to, an open-ended order, with a start date of 06/30/23, for Oxyquinolone Sulfate vaginal gel, insert one application vaginally at bedtime every Tuesday and Friday for pessary maintenance. The resident's complete Care Plan was provided by the MDS Coordinator on 08/22/23, at 9:35 A.M. There was no indication the resident had a pessary, and there was no plan of care related to the resident's pessary device. During an interview on 08/22/23 at 10:19 A.M., the DON (Director of Nursing) indicated the resident did have a pessary and had MD orders for the vaginal gel. The resident should have a care plan that indicated she had a pessary device. The current facility policy, titled Care Plans, Comprehensive Person-Centered, with a revised on date of 12/2016, was provided by the ADON (Assistant Director of Nursing) on 08/22/23 at 1:15 P.M. The policy indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's .needs is developed and implemented for each resident . 3.1-35(a)

Based on observation, interview, and record review, the facility failed to follow manufacturer's guidelines related to insulin pen usage for 1 of 11 residents reviewed for Quality of Care. (Resident 135) Findings include: Medication administration was observed on 08/17/23 at 11:33 A.M., on Wing 5 with RN 3. The RN prepared to check the blood sugar level of Resident 135. The nurse took a basket of supplies, donned clean gloves, and checked the resident's blood sugar level. The level was 204. The nurse unlocked the medication cart, removed a bag containing a Lispro insulin pen, indicated the resident was to receive two units of insulin, used hand sanitizer, removed the pen from the bag, removed the pen cap, applied the needle to the end of the insulin pen, turned the dose knob to two units, and administered the insulin. The nurse did not clean the hub of the pen prior to applying the needle, nor did she prime the pen before use. During an interview on 08/17/23 at 11:44 A.M., RN 3 indicated she was not trained to clean the hub of the insulin pen before applying the needle. She looks at the pen to see if there was air in the pen. She did not prime the pen before each dose. During an interview on 08/22/23 at 2:02 P.M., the DON indicated insulin pens should be cleaned with alcohol before applying the needle to the pen. She had no comment regarding priming the insulin pens. The Medication Review Report was provided by the DON on 08/22/23 at 2:56 P.M. The report indicated the resident was to receive two units of Lispro insulin, subcutaneously, in the afternoon for diabetes. The Lispro insulin pen package insert was provided by the DON on 08/22/23 at 2:56 P.M. The directions for use indicated, .Pull the Pen Cap straight off .Wipe the Rubber Seal with an alcohol swab .Push the capped Needle straight onto the Pen .Prime before each injection .Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures the Pen is working correctly .If you do not prime before each injection, you may get too much or too little insulin .To prime your Pen, turn the Dose Knob to select 2 units .hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top . The current Facility Insulin Pen policy, with an implemented date of 03/2023, was provided by the DON on 08/22/23 at 2:56 P.M. The policy indicated, .Procedure .Remove the pen cap from the insulin pen .Wipe the rubber seal with an alcohol pad .Screw the pen needle onto the insulin pen .Twist open and remove outer cover from the pen needle .Prime the insulin pen .Dial 2 units .With the needle point up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle . 3.1- 37(a)

Based on observation, interview, and record review, the facility failed to adequately implement care planned interventions and strategies for a resident with wandering behaviors and a [DIAGNOSES REDACTED].(Residents D and B) Findings include: On 11/19/19 at 8:03 P.M., the following was observed on Wing 2. Resident D was observed to be standing near Resident C in the common area by the recliners. Residents D and C then walked together, entered room [ROOM NUMBER] (neither residents' room), and went into that bathroom. CNA (Certified Nurse Aide) 2, CNA 3, and LPN (Licensed Practical Nurse) 6 were near the nurses' station. The staff were unable to visualize the residents once they entered a resident's room. At 8:08 P.M., Residents D and C had not emerged from room [ROOM NUMBER], and were not visualized by nursing staff. During an interview, CNA 2 indicated Resident B was in his room in bed sleeping. At 8:11 P.M., Residents D and C came out of room [ROOM NUMBER]. Resident C returned to the common area and eventually sat down in a recliner. Resident D had an empty cup and tissue in her hand. Resident D walked to a common area, discarded the cup and tissue, entered room [ROOM NUMBER] (not the resident's room) and shut to door. CNA 2 then went to Resident D, brought her out of room [ROOM NUMBER], and asked her if she was just taking a stroll and if she wanted a drink. CNA 2 walked with Resident D into the kitchen area and gave her a drink. Resident C remained in a recliner in the common area. During an interview on 11/19/19 at 9:39 P.M., CNA 3 indicated starting on 11/16/19, staff have had to document where Resident D was and what she was doing every 15 minutes every night, starting from 6:00 P.M. until 10:00 P.M. The Care Plan was recently updated, on 11/20/19. Staff were to document 15 minute checks starting at 3:00 P.M. until 10:00 P.M. every night. During an interview on 11/19/19 at 9:07 P.M., CNA 4 indicated she often worked on Wing 2. On the evening of 11/14/19, CNA 4 walked past Resident B's room and noted that the door was shut. Staff had been told to let Resident D sit in Resident B's room as long as the door was open and the residents were fully clothed. When she opened the door, she found Resident B sitting on the edge of his bed. Resident B was only wearing a brief, but that was what he wore to bed at night, so that was normal for him. Resident D was holding Resident B's blankets, so he couldn't cover up. Resident B was holding on to the blankets too, trying to keep them in place. Resident D had removed her top and was trying to take her pants off. CNA 4 calmly walked over to the residents to intervene. CNA 4 told Resident D that they needed to leave the room and let Resident B go to sleep. Resident B told Resident D to Please do what they say. Resident D said No, so CNA 4 called for assistance. Two more staff members arrived to help remove Resident D from Resident B's room, as it sometimes took more than one staff member to do so. Resident D was angry and yelled at CNA 4. She told the staff they didn't know what they were doing and that she took care of Resident B. It took around 20 minutes, but QMA (Qualified Medication Aide) 5 was eventually able to redirect Resident D and got her out of Resident B's room. This was an everyday occurrence on Wing 2. Staff always had to redirect Resident D from Resident B's room. Resident D would go in Resident B's room when he was trying to go to bed. It had been going on for a few months. CNA 4 indicated the aides were confused about what to do about Resident D and Resident B. They really didn't have a clear intervention, they've been told too many different things. Some nurses would tell them that Resident D was absolutely not supposed to be in Resident B's room, because it confused Resident D. The Social Services Director would tell them that if Resident B's door was open, Resident D could be in the room if she was fully clothed. Resident D often followed Resident B around, and it confused him. Sometimes Resident D would try to take Resident B's walker from him. Resident B would come up to the staff and he would say a man was following him, and would ask the staff to do something about it. Normally, they would remove Resident B from the situation; offer him a snack. Resident B would thank them when they did this. During an interview on 11/19/19 at 9:27 P.M., QMA 5 indicated she was in the medication room on Wing 2 on 11/14/19 when CNA 4 asked to her assist with Resident D. When she entered the room, Resident D had her shirt back on and was fidgeting with Resident B's blankets. QMA 5 told Resident D she needed to leave the room because Resident B was in bed and he needed to go to sleep. Resident D said No. QMA 5 asked Resident B if he wanted everyone to leave his room because he wanted to go to sleep and he said Yes. QMA 5 again told Resident D that they needed to leave the room. Resident D said they didn't know what they were talking about, they didn't know anything, and that she was taking care of Resident B. Resident D was angry, but they did finally get her to leave the room on her own. It took about 15 to 20 minutes and Resident D walked in the common area for a while after that. QMA 5 went to the shared bathroom between Resident B's room and another room in case Resident D tried to enter Resident B's room through the bathroom. Eventually, staff were able to get Resident D to focus on something else. There were no further incidents that night. Resident D used to live on a different Wing of the facility. Resident D did not exhibit sexual behaviors at that time, but was very possessive of a different resident on Wing 1. Interventions in place were to try and redirect Resident D; to try to get her mind on something else when she exhibited these types of behaviors. The clinical record for Resident B was reviewed on 11/19/19 at 6:42 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/16/19, indicated the resident was severely cognitively impaired. [DIAGNOSES REDACTED]. The resident exhibited wandering behaviors on 1 to 3 days of the assessment review period. The resident required supervision only for most ADLs (Activities of Daily Living), but required limited staff assistance for toileting and dressing, and extensive staff assistance for personal hygiene. The resident's balance was not steady during transitions and walking, but the resident was able to steady himself, and used a walker for mobility. The clinical record for Resident D was reviewed on 11/20/19 at 11:29 [NAME]M. A Quarterly MDS assessment, dated 10/25/19, indicated the resident was severely cognitively impaired. Physical behaviors directed towards others occurred 1 to 3 days during the assessment review period. [DIAGNOSES REDACTED]. The resident required supervision for most ADLs, but required limited staff assistance with toileting, and extensive staff assistance with dressing and personal hygiene. A Behavior Note, dated 11/14/2019 at 12:39 P.M., indicated Resident D was noted to hold onto Resident B's walker upon ambulation. Staff talking to Resident D and explaining why she should not do that was not successful. Resident D was successively redirected to sit next to Resident B and play a ball game. The redirection of Resident D was successful some times. A Behavior Note, dated 11/14/2019 at 8:13 P.M., indicated Resident D was noted in Resident B's room. Resident D had her shirt off and was attempting to take her pants off. Resident B was in bed. Resident D was pulling the covers off of Resident B and attempting to get in bed with him. Staff attempted to talk to Resident D to get her to leave the room. Resident D stated Don't tell me what to do. Resident D stared at the staff, and put her shirt back on. Resident D stated You don't know what he wants. I do. You don't know what you are doing. Resident B asked Resident D to leave the room. Staff were able to talk Resident D into leaving the room. Resident D remained agitated with staff. A Health Status Note, dated 11/14/2019 at 8:58 P.M., indicated that Resident D's family member, the SSD (Social Services Director), and the DON (Director of Nursing) were updated. A Social Services Note, dated 11/15/2019 at 2:27 P.M., indicated follow up regarding the incident that occurred on 11/14/19. The investigation was completed by SSD. Residents D and B had no recollection of the event. There was not a roommate in the room at the time of the incident, and the resident in the adjoining room was not in his room at the time of the incident. The SSD followed up with Resident D's family member, who voiced no concerns at that time in regards to the incident. There had not been any change in Resident D's mood, behavior, or routine. Staff would notify the SSD of any changes over the weekend. During an interview on 11/19/19 at 1:55 P.M., CNA 7 indicated she worked on Wing 2 on 11/16/19. That morning, the housekeeper indicated Resident D was in Resident B's room with Resident C. CNA 7 went to check on the residents. The door was open, and Resident D was rubbing on Resident C's arm. Resident B was not in the room. CNA 7 told Resident D to come with her and leave the room. Resident D said she needed a couple of minutes because Resident C wanted her to rub his penis. Both residents left the room without any issues. CNA 7 told the nurse about what happened and the nurse had her write it down so she could chart it. There were no further incidents with the residents for the rest of her shift. Interventions that were in place for Resident D were to keep an eye on her and redirect her if needed. Staff were to allow Residents D and B to visit with each other. Sometimes Resident B thought Resident D was a male, and would ask staff why he was trying to be with him. Resident B's family didn't mind that the residents talked, but they did not like the touchy feely behaviors. Now, Resident D was on 15 minute checks, but that was only in the evenings, not on day shift. A Health Status Note, dated 11/16/2019 at 9:20 [NAME]M., indicated A CNA reported to the nurse that Resident D was in Resident B's room with Resident C Resident C was laying in Resident B's bed. Resident D was rubbing Resident C's arm. The CNA asked Resident D to come with her to the common area. Resident D stated I just needed 2-3 minutes because he wants me to touch his penis. Resident D walked to the door with the CNA and was redirected to the common area without issue. A Health Status Note, dated 11/16/2019 at 10:30 [NAME]M., indicated Resident D had been sitting in common area and had shown no recall of the redirection given to her this morning. The resident was involved in routine, daily activities. The SSD had been updated. During an interview on 11/20/19 at 2:53 P.M., QMA 8 indicated on the evening of 11/16/19, Resident D was found in Resident B's room in bed with him. Staff entered Resident B's room and both residents were in bed, under the covers. Resident D was wearing only a brief. QMA 8 told Resident D she had to be in her own bed. She asked Resident B to get out of the bed, and they assisted him to the other bed in the room and pulled the curtain so they could get Resident D dressed and out of the bed. Resident D did not want to get out of the bed. She told the staff that they were adults, and refused to get up. She argued with the staff, then tried to exit the room without getting dressed. Staff finally got Resident D dressed and out of the room. Resident D paced a little bit, but eventually fell asleep in a recliner. After she woke up, they assisted her into her own room and she went to bed. Resident D was placed on every 15 minute checks at that time. Resident D didn't always behave this way, but it seemed like her behaviors had escalated recently. Resident B seems to be okay with spending time with Resident D, but sometimes he would say he just wanted to go to bed. During an interview on 11/20/19 at 3:00 P.M., QMA 8 indicated on the evening of 11/17/19, Resident B indicated he was ready to go to bed. Resident B headed towards his room, and Resident D started heading in that direction. Resident D said she was going in with him. QMA 8 told Resident D that she couldn't do that. Everyone needed to be in their own beds, she was not allowed, they would get into trouble. Resident D continued to try to go in Resident B's room. QMA 8 told her she could not go in. Resident D kind of snapped and told the staff that they couldn't keep her out, that the residents were adults, they could do what they wanted, and that staff were trying to break the residents up. QMA 8 had her hand in front of the door and Resident D hit her hand. It took a few staff members to get Resident D to move away from the room. Resident D paced a little. They got her to go sit in a recliner, and she dozed off. When she woke up, she was okay, and she headed to her room. A Health Status Note, dated 11/16/2019 at 8:14 P.M., indicated staff went into Resident B's room to give the resident his medications. Resident D was wearing only her briefs, and was in bed with Resident B. Staff directed Resident D to the other side of the room, got her dressed, and redirected Resident D to the common area. A Health Status Note, dated 11/16/2019 at 8:49 P.M., indicated the DON was informed of the earlier incident. Resident D was on 15 minute checks at this time. Resident D was sitting in a recliner in the common area at this time. There were no further behaviors noted. During an interview on 11/20/19 at 2:03 P.M., the Dementia Care Coordinator indicated the facility didn't have a policy in place related to wandering, it was more of a person centered approach to determine what unmet need was causing the wandering; if the resident was wandering because they needed to find a bathroom, or maybe the resident was wandering because they needed more exercise. They did have Care Plans in place for residents that wandered that listed interventions. She did not believe Resident D was wandering when she went into Resident B's room, because she had a purpose. The facility did not have a policy in place related to dementia care, but did have person centered Care Plans with interventions for residents that had dementia. In addition, the facility had Green Sheets, in a binder at the nurses' station. They included personal history about the resident and person centered strategies to use. Not all of the information on the Green Sheets was included in the EHR (Electronic Health Record) Care Plan. They kept the binders available to the staff so they could read about the residents and get ideas about how to interact with them. Current Care Plans for Resident D included, but were not limited to the following: A Care Plan, with a start date of 07/26/19, and a revision date of 08/23/19, titled Res (Resident) believes she is in a relationship with another male resident and family is aware. Interventions included, but were not limited to, .Intervene if Res is inappropriate .Allow privacy Educate family and staff r/t (related to) residents rights . A Care Plan, with a start date of 08/27/19, and a revision date of 09/18/19, titled Need to Monitor Behavior has potential for Altered behavior patterns, Disruptive verbally, cursing at staff, disrobing, Resistive to care, intrusive, aggressive behavior toward staff with redirection, and agitation related to Dementia with Behaviors. Interventions included, but were not limited to, .Allow resident to pace where he/she can be observed (initiated on 08/27/19) .Convey acceptance of resident during periods of inappropriate behavior (initiated on 09/05/19) .Have activity staff take Res for a walk around the building or have activities have Res assist with another activity (initiated on 10/22/19) . A Care Plan, with a start date of 09/06/19, and a revision date of 11/18/19, titled The resident chooses a peer on her wing and seeks that peer out for companionship and affection and will seek physical affection from peer .DX (Diagnosis) Sexual Dysfunction . Interventions included, but were not limited to, .Allow Res to sit next to peer of choice in common areas, in Res'/peers room and in the dining room if peer is in agreement; if not redirect Res by telling her other peers could benefit from her [MEDICATION NAME] and direct her to another open spot (initiated on 09/06/19) .talk to res as an equal, she feels she works at the facility and tone of voice can be a trigger for res at times (initiated 09/06/19) .sexual behavior toward peers occur in the evening more frequently, when able take Res off the wing for a walk and/or snack/drink while assisting peer that she is interested in to bed. If peer is already asleep when she returns she usually will not attempt to wake them (initiated on 11/14/19) .15 min (minute) checks from 6p-10p to ensure Res is not in peers' rooms when they are getting ready for bed (initiated on 11/15/19) . A Care Plan, with a start date of 08/27/19, and a revision date of 11/11/19, titled Resident wanders throughout the day D/T (due to) Dementia .Resident is on a secure, free roaming unit where she paces and will at times wanders (sic) into other rooms during care . Interventions included, but were not limited to, .Encourage activities (initiated 08/27/19) .Unit to maintain structured environment (initiated on 08/27/19) . Resident D's Special Care Focus (Green Sheet) indicated specifics about the resident's life history, person centered strategies to attempt, and successful strategies that worked when interacting with Resident D. THINGS NOT TO DO included, but were not limited to, .Don't argue with the person .Don't order the person around .Don't tell the person what he/she can't do . During an interview on 11/21/19 at 9:41 [NAME]M., The SSD indicated after the incident between Residents D and B on 11/14/19, they noticed Resident D was seeking out Resident B in the evenings. The intervention they put into place was to keep Resident D busy with an activity to keep her mind off Resident B until staff could get him into bed. Usually, once Resident B was in bed and appeared to be asleep, Resident D would leave him alone. The Activity Department staff were in the facility until 8:00 P.M. during the week, and Resident B usually went to bed by that time. They relied on the nursing staff to redirect Resident D and keep her busy on the weekends while another staff member assisted Resident B to bed. The Care Plan was updated to reflect the intervention, and they talked to the nursing staff about it. They were not able to speak to every staff member individually, so staff were asked to pass on the new intervention. After the incident on 11/16/19, the new intervention was the every 15 minute checks on Resident D starting at 6:00 P.M. through 10:00 P.M. They considered moving Resident D to a different Wing of the facility, but they thought Wing 2 was more appropriate at this time. They were in the process of adjusting Resident D's medication again. They were changing the resident's antidepressant medication to another one that was known to decrease sexual desire, and increasing her [MEDICATION NAME] (An anticonvulsant medication, often used to treat behavior symptoms in patients with dementia). The current facility policy, titled Resident MDS Assessment and Care Planning Policy, with a most recent revision date of 12/28/2016, was provided by the DON (Director of Nursing) on 11/21/19 at 4:35 P.M. The policy indicated, .RN Nurse Coordinator .coordinate with other team members to carry out the treatment for [REDACTED]. This Federal tag relates to Complaint IN 136. 3.1-37(a)

Based on record review and interview, the facility failed to ensure a resident received appropriate care to achieve or maintain the highest practicable level of well being with resultant harm by not administering anticoagulation medication as ordered by the physician for 9 consecutive days (Resident B) resulting in the resident developing blood clots and requiring acute care hospitalization and treatment. This deficient practice practice affected 1 resident of 4 reviewed for appropriate care and services in a sample of 9. Findings include: 1. The record of Resident B was reviewed on 03/04/13 at 1:00 p.m. [DIAGNOSES REDACTED]. Hospital records indicated Resident B was discharged for m the hospital on [DATE] following surgical repair of a left [MEDICAL CONDITION]. She was noted to be allergic to [MEDICATION NAME] and [MEDICATION NAME] (anti coagulation medications). Following a hematology consult, discharge medications included [MEDICATION NAME], an anticoagulant, 2.5 mg (milligrams) daily for the prevention of [MEDICAL CONDITION] (clot formation) for 3 weeks. Facility hand written admission orders [REDACTED]. A facility "Fax-Incident Report Form-Follow Up" for Resident B with an incident date of 1/08/13 indicated: "[MEDICATION NAME] 2.5 mg sub-Q (Subcutaneous administration; under the skin) ordered upon admission on 1/7/13 to be given qd (daily) X (times) 3 wks (weeks) starting on 1/8/13. Pharmacy received all physicians orders and input them into accuflo (an electronic medical record tracking system). This med (medication) did not 'pop up' (appear in the computer system) on accuflo to be given. Nurse discovered medication not given on 1/17/13 and notified pharmacy and med then 'popped' to be given. Missed doses from 1/8/13 thru (through) 1/16/13. Res (resident) sent to ER (emergency room ) (symbol for "with") [DEVICE] (gastronomy or feeding tube) complications and admitted with dx (diagnosis) [MEDICAL CONDITION] emboli (blood clots in the lungs). Res returned to the facility on [DATE] with new orders to d/c (discontinue) [MEDICATION NAME] and started on Xarelto (an anticoagulant) qd. Type of Injury/Injuries: Res admitted into hospital with dx: [MEDICAL CONDITION] emboli on 1/19/13... Immediate action taken: Nurses counseled and reprimanded...Pharmacy had input order into accuflo on 1/07/13 but then d/c'd (discontinued) order since was (sic) not due until 1/8/13 but order was never dc'd. Pharmacy re-entered order on 1/8/13 using same rx# (prescription number) and accuflo recognized that number as dc'd. So therefore med would not 'pop' to be given. Pharmacy continues to investigate on their end." A printed Medication Administration Report generated by the Accuflo Electronic Medical Record System with a print date of 1/07/2013 did not contain an order for [REDACTED]. A hand written physician's telephone order dated 1/08/13 recorded by Nurse #20 indicated "May hold [MEDICATION NAME] until available." This order was signed by the physician on 2/20/13, 43 days after the order was taken. An undated letter signed by RN #20 indicated "On Thursday, January 17th...I glanced over a box of [MEDICATION NAME] that seemed unopened....Due to the acuity of care at that time , I had to continue what I was doing..I then went back to the medication cart to verify the administration of the injections...I went to the resident's chart to see if the order had been discontinued; it hadn't been. Then I started looking into the computer system to see if it was active in the system...it was discontinued out. I then went to our paper MAR's (medication administration record)...and looked to see if it was written in: it wasn't. This is when I got the other nurse on duty and we called the pharmacy to see what was wrong and to have the medication be put as active in the computer system. At this time, January 17th, it was made active again in the system. In the meantime, I went to the resident, assessed her for blood clots, and gave her the first dose of the injection, January 17th at 3pm. I then attempted to contact my director of nursing by calling and paging her...On Friday the 18th... I realized I did not get a hold of my director of nursing the day before. I then notified my director of nursing..." During an interview with the Administrator and Director of Nursing (D.O.N.) on 3/05/13 at 3:00 p.m. both indicated that RN #20 had administered the [MEDICATION NAME] to Resident B on 1/17/13 at 3:00 p.m. as stated in her letter. They noted that RN #20 had not obtained an order to administer this medication, and that the renewed order indicated it was to be given at 10:00 p.m. They also indicated that RN #20 did not properly document administration of the medication at 3:00 p.m., and that Resident B got a second dose of [MEDICATION NAME] at the scheduled time of 10:00 p.m. on the same day. Records indicated Resident B was discharged to an acute care hospital on [DATE] and admitted with a [DIAGNOSES REDACTED]. A hospital "History and Physical" dated 1/19/13 for Resident B indicated: "Chief Complaint: Pleuritic chest pain and possible clogged PEG tube ([DEVICE].). History of Present Illness: This is a (Resident B's age, race, and gender) who presented to the emergency room yesterday from (name of facility) where she had been having a couple day history of pleuritic chest pain...In the ER, patient was found to have bilateral [MEDICAL CONDITION] emboli. She was in the hospital about 2 weeks ago falling (sic) and fracturing her hip which she had surgery to repair, so it is quite possible that these PEs (pulmonary emboli) were developed status [REDACTED]. CT scan of the chest showed multiple large partial obstructing [MEDICAL CONDITION] emboli. Also, multifocal interspace density predominately involving the left upper lung, most likely representing [MEDICAL CONDITION] hemorrhage secondary to the patient's [MEDICAL CONDITION] emboli..." Resident B was interviewed on 3/05/13. She was alert, oriented, and appropriate. She indicated that in the days leading up to her hospitalization on [DATE] she was "Crying in pain-I told the nurses-the suffering was terrible...it felt like I had a lung torn." She also indicated she still had her feeding tube in place, and had been advised by her treating physician that this could not be removed while she remained on anticoagulants, and that this might be a permanent condition. She indicated she was "very sad" the tube could not be removed, as this was a high priority to allow her to return home. The facility's Director of Pharmacy Services was interviewed on 3/06/13 at 1:30 p.m. He indicated he had investigated the incident of Resident B not receiving the prescribed [MEDICATION NAME] for 9 days. He indicated the medication had been put on "hold" on 1/08/13 because of unavailability. He indicated the medication was obtained the same day and delivered to the facility. He indicated the pharmacy entered the medication in the Accuflow system using the original prescription number, but the system did not accept the entry, as this prescription number had been discontinued. He also indicated that his investigation led him to believe that the nurse who had accepted delivery of the medication had not scanned it into the system, and had not entered it on the hand written medication administration record. He indicated he had subsequently completed an audit of all resident charts without discovering any additional significant medication errors. A facility policy titled "Medication Administration-General Guidelines" dated 9/01/2007 was received from the Director of Nursing on 3/04/13 at 11:50 a.m.. It indicated: "Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Administration: ...4. Medications are administered at the time they are prepared. Medications are not pre-poured. 5. Medications are administered without unnecessary interruptions. 6. The person who prepares the dose for administration is the person who administers the dose. 7. Residents are identified before medication is administered.... 12. Medications supplied for one resident are never administered to another resident.... 15. The resident is always observed after administration to ensure that the dose was completely ingested." This federal tag relates to Complaints IN 298, IN 850, IN 918, and IN 998. 3.1-37(a)

Based on record review and interview, the facility failed to ensure 2 residents were protected from significant medication errors with resultant harm by not administering anticoagulation medication as ordered by the physician for 9 consecutive days (Resident B) resulting in the resident developing blood clots and requiring acute care hospitalization and treatment, and failing to ensure a resident (Resident C) was protected from a medication error when the resident took medications intended for another resident after a staff member dispensed the medications and left them unattended on a table in the dining room. Resident C suffered a drop in blood pressure and required emergent treatment at an acute care hospital. This deficient practice affected 2 residents of 4 reviewed for medication errors in a sample of 9. Findings include: 1. The record of Resident B was reviewed on 03/04/13 at 1:00 p.m. [DIAGNOSES REDACTED]. Hospital records indicated Resident B was discharged for m the hospital on [DATE] following surgical repair of a left [MEDICAL CONDITION]. She was noted to be allergic to [MEDICATION NAME] and [MEDICATION NAME] (anti coagulation medications.) Following a hematology consult, discharge medications included [MEDICATION NAME], an anticoagulant, 2.5 mg (milligrams) daily for the prevention of [MEDICAL CONDITION] (clot formation) for 3 weeks. Facility hand written admission orders [REDACTED]. A facility "Fax-Incident Report Form-Follow Up" for Resident B with an incident date of 1/08/13 indicated: "[MEDICATION NAME] 2.5 mg sub-Q (Subcutaneous administration; under the skin) ordered upon admission on 1/7/13 to be given qd (daily) X (times) 3 wks (weeks) starting on 1/8/13. Pharmacy received all physicians orders and input them into accuflo (an electronic medical record tracking system). This med (medication) did not 'pop up' (appear in the computer system) on accuflo to be given. Nurse discovered medication not given on 1/17/13 and notified pharmacy and med then 'popped' to be given. Missed doses from 1/8/13 thru (through) 1/16/13. Res (resident) sent to ER (emergency room ) (symbol for "with") [DEVICE] (gastronomy or feeding tube) complications and admitted with dx (diagnosis) [MEDICAL CONDITION] emboli (blood clots in the lungs). Res returned to the facility on [DATE] with new orders to d/c (discontinue) [MEDICATION NAME] and started on Xarelto (an anticoagulant) qd. Type of Injury/Injuries: Res admitted into hospital with dx: [MEDICAL CONDITION] emboli on 1/19/13... Immediate action taken: Nurses counseled and reprimanded...Pharmacy had input order into accuflo on 1/07/13 but then d/c'd (discontinued) order since was (sic) not due until 1/8/13 but order was never dc'd. Pharmacy re-entered order on 1/8/13 using same rx# (prescription number) and accuflo recognized that number as dc'd. So therefore med would not "pop" to be given. Pharmacy continues to investigate on their end." A printed Medication Administration Report generated by the Accuflo Electronic Medical Record System with a print date of 1/07/2013 did not contain an order for [REDACTED]. A hand written physician's telephone order dated 1/08/13 recorded by Nurse #20 indicated "May hold [MEDICATION NAME] until available." This order was signed by the physician on 2/20/13, 43 days after the order was taken. An undated letter signed by RN #20 indicated "On Thursday, January 17th...I glanced over a box of [MEDICATION NAME] that seemed unopened....Due to the acuity of care at that time , I had to continue what I was doing..I then went back to the medication cart to verify the administration of the injections...I went to the resident's chart to see if the order had been discontinued; it hadn't been. Then I started looking into the computer system to see if it was active in the system...it was discontinued out. I then went to our paper MAR's (medication administration record)...and looked to see if it was written in: it wasn't. This is when I got the other nurse on duty and we called the pharmacy to see what was wrong and to have the medication be put as active in the computer system. At this time, January 17th, it was made active again in the system. In the meantime, I went to the resident, assessed her for blood clots, and gave her the first dose of the injection, January 17th at 3pm. I then attempted to contact my director of nursing by calling and paging her...On Friday the 18th... I realized I did not get a hold of my director of nursing the day before. I then notified my director of nursing..." During an interview with the Administrator and Director of Nursing (D.O.N.) on 3/05/13 at 3:00 p.m. both indicated that RN #20 had administered the [MEDICATION NAME] to Resident B on 1/17/13 at 3:00 p.m. as stated in her letter. They noted that RN #20 had not obtained an order to administer this medication, and that the renewed order indicated it was to be given at 10:00 p.m. They also indicated that RN #20 did not properly document administration of the medication at 3:00 p.m., and that Resident B got a second dose of [MEDICATION NAME] at the scheduled time of 10:00 p.m. on the same day. Records indicated Resident B was discharged to an acute care hospital on [DATE] and admitted with a [DIAGNOSES REDACTED]. A hospital "History and Physical" dated 1/19/13 for Resident B indicated: "Chief Complaint: Pleuritic chest pain and possible clogged PEG tube ([DEVICE].). History of Present Illness: This is a (Resident B's age, race, and gender) who presented to the emergency room yesterday from (name of facility) where she had been having a couple day history of pleuritic chest pain...In the ER, patient was found to have bilateral [MEDICAL CONDITION] emboli. She was in the hospital about 2 weeks ago falling (sic) and fracturing her hip which she had surgery to repair, so it is quite possible that these PEs (pulmonary emboli) were developed status [REDACTED]. CT scan of the chest showed multiple large partial obstructing [MEDICAL CONDITION] emboli. Also, multifocal interspace density predominately involving the left upper lung, most likely representing [MEDICAL CONDITION] hemorrhage secondary to the patient's [MEDICAL CONDITION] emboli..." Resident B was interviewed on 3/05/13. She was alert, oriented, and appropriate. She indicated that in the days leading up to her hospitalization on [DATE] she was "Crying in pain-I told the nurses-the suffering was terrible...it felt like I had a lung torn." She also indicated she still had her feeding tube in place, and had been advised by her treating physician that this could not be removed while she remained on anticoagulants, and that this might be a permanent condition. She indicated she was "very sad" the tube could not be removed, as this was a high priority to allow her to return home. The facility's Director of Pharmacy Services was interviewed on 3/06/13 at 1:30 p.m. He indicated he had investigated the incident of Resident B not receiving the prescribed [MEDICATION NAME] for 9 days. He indicated the medication had been put on "hold" on 1/08/13 because of unavailability. He indicated the medication was obtained the same day and delivered to the facility. He indicated the pharmacy entered the medication in the Accuflow system using the original prescription number, but the system did not accept the entry, as this prescription number had been discontinued. He also indicated that his investigation led him to believe that the nurse who had accepted delivery of the medication had not scanned it into the system, and had not entered it on the hand written medication administration record. He indicated he had subsequently completed an audit of all resident charts without discovering any additional significant medication errors. 2. The record of Resident C was reviewed on 3/05/13 at 2:30 P.M. [DIAGNOSES REDACTED]. Nurse's progress notes indicated: 2/10/13 8:30 a.m.: "MD and DON (Director of Nursing) notified of Res (resident) consumes (sic) meds (medications) not ordered. NO: (new order) Hold (medications) monitor res BP (blood pressure) if SBC (systolic blood pressure) (symbol for "less than") 100 notify MD." 2/10/13 9:15 a.m. "Res (symbol for "up") to BR. (Bathroom). Res diaphoretic (sweaty) (symbol for and") skin clammy to touch Res c/o (complained of) dizziness BP 71/47. Res incontinent..." 2/10/13 9:25 a.m. "MD phoned re: (symbol for "low") BP." 2/10/13 9:25 a.m. "MD returned call NO: send Res to ER for eval (evaluation) (symbol for "and") tx (treatment)." 2/10/13 12:30 p.m. "(Acute care hospital) ER phoned res admitted for observation." A facility "Daily Report" Dated 2/11/13 indicated: "Chart review for (Resident C): 8:30 a.m. Nurse documented 'Resident consumed meds not ordered by physician... QMA (Qualified Medication Aide #21) wrote in a statement that she had placed (name of resident) medications on the dining room table and told (name of resident) 'Here are your medications'. She then walked away from the table to obtain next residents' medications. When she returned to the table (name of resident) said to her 'I didn't get my medications, she took them' and pointed to (Resident C). 9:30 a.m. Ambulance picked up resident and transported to ER. Resident returned to facility today (2-11-13). Nurse wrote in statement: She saw medicine cups on med. (medication) cart with resident's names on them, but was unsure if medications were in them. . When asked if she went to the medication chart (sic) to check and see if the QMA was pre-setting medications, she said 'no.' When asked if pre-setting medications was appropriate, she said 'no'. Asked if she knew she was responsible for the actions of the CNA's (Certified Nursing Aide) and QMA's on her unit, she said she did not realize her license could be in jeopardy if the CNA (sic) made an error... Due to the fact the resident was sent to the hospital for observation, IV (intravenous) fluids, and extensive monitoring; and due to the category of medications the resident inadvertently received this medication error would be considered a 'significant error.'" During an interview with the Administrator on 3/07/13 at 10:45 she indicated the nurse and QMA involved in Resident C's medication error had both been terminated secondary to not following accepted practice and facility policy and procedure related to medication administration. A facility policy titled "Medication Administration-General Guidelines" dated 9/01/2007 was received from the Director of Nursing on 3/04/13 at 11:50 a.m.. It indicated: "Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Administration: ...4. Medications are administered at the time they are prepared. Medications are not pre-poured. 5. Medications are administered without unnecessary interruptions. 6. The person who prepares the dose for administration is the person who administers the dose. 7. Residents are identified before medication is administered.... 12. Medications supplied for one resident are never administered to another resident.... 15. The resident is always observed after administration to ensure that the dose was completely ingested." This federal tag relates to Complaints IN 298, IN 850, IN 918, and IN 998. 3.1-25(b)(9) 3.1-48(c)(2)

Based on record review and interview, the facility failed to ensure pharmacy services were provided to prevent a significant medication error with subsequent harm for 1 resident (Resident B) by not administering anticoagulation medication as ordered by the physician for 9 consecutive days resulting in the resident developing blood clots and requiring acute care hospitalization and treatment. This deficient practice affected 1 resident of 4 reviewed for medication errors in a sample of 9. Findings include: 1. The record of Resident B was reviewed on 03/04/13 at 1:00 p.m. [DIAGNOSES REDACTED]. Hospital records indicated Resident B was discharged for m the hospital on [DATE] following surgical repair of a left hip fracture. She was noted to be allergic to Heparin and Lovenox (anti coagulation medications.) Following a hematology consult, discharge medications included Arixtra, an anticoagulant, 2.5 mg (milligrams) daily for the prevention of deep vein thrombosis (clot formation) for 3 weeks. Facility hand written admission orders [REDACTED]. A facility "Fax-Incident Report Form-Follow Up" for Resident B with an incident date of 1/08/13 indicated: "Arixtra 2.5 mg sub-Q (Subcutaneous administration; under the skin) ordered upon admission on 1/7/13 to be given qd (daily) X (times) 3 wks (weeks) starting on 1/8/13. Pharmacy received all physicians orders and input them into accuflo (an electronic medical record tracking system). This med (medication) did not 'pop up' (appear in the computer system) on accuflo to be given. Nurse discovered medication not given on 1/17/13 and notified pharmacy and med then 'popped' to be given. Missed doses from 1/8/13 thru (through) 1/16/13. Res (resident) sent to ER (emergency room ) (symbol for "with") [DEVICE] (gastronomy or feeding tube) complications and admitted with dx (diagnosis) pulmonary emboli (blood clots in the lungs). Res returned to the facility on [DATE] with new orders to d/c (discontinue) Arixtra and started on Xarelto (an anticoagulant) qd. Type of Injury/Injuries: Res admitted into hospital with dx: pulmonary emboli on 1/19/13... Immediate action taken: Nurses counseled and reprimanded...Pharmacy had input order into accuflo on 1/07/13 but then d/c'd (discontinued) order since was (sic) not due until 1/8/13 but order was never dc'd. Pharmacy re-entered order on 1/8/13 using same rx# (prescription number) and accuflo recognized that number as dc'd. So therefore med would not "pop" to be given. Pharmacy continues to investigate on their end." A printed Medication Administration Report generated by the Accuflo Electronic Medical Record System with a print date of 1/07/2013 did not contain an order for [REDACTED]. A hand written physician's telephone order dated 1/08/13 recorded by Nurse #20 indicated "May hold Arixtra until available." This order was signed by the physician on 2/20/13, 43 days after the order was taken. An undated letter signed by RN #20 indicated "On Thursday, January 17th...I glanced over a box of Arixtra that seemed unopened....Due to the acuity of care at that time , I had to continue what I was doing..I then went back to the medication cart to verify the administration of the injections...I went to the resident's chart to see if the order had been discontinued; it hadn't been. Then I started looking into the computer system to see if it was active in the system...it was discontinued out. I then went to our paper MAR's (medication administration record)...and looked to see if it was written in: it wasn't. This is when I got the other nurse on duty and we called the pharmacy to see what was wrong and to have the medication be put as active in the computer system. At this time, January 17th, it was made active again in the system. In the meantime, I went to the resident, assessed her for blood clots, and gave her the first dose of the injection, January 17th at 3pm. I then attempted to contact my director of nursing by calling and paging her...On Friday the 18th... I realized I did not get a hold of my director of nursing the day before. I then notified my director of nursing..." During an interview with the Administrator and Director of Nursing (D.O.N.) on 3/05/13 at 3:00 p.m. both indicated that RN #20 had administered the Arixtra to Resident B on 1/17/13 at 3:00 p.m. as stated in her letter. They noted that RN #20 had not obtained an order to administer this medication, and that the renewed order indicated it was to be given at 10:00 p.m. They also indicated that RN #20 did not properly document administration of the medication at 3:00 p.m., and that Resident B got a second dose of Arixtra at the scheduled time of 10:00 p.m. on the same day. Records indicated Resident B was discharged to an acute care hospital on [DATE] and admitted with a [DIAGNOSES REDACTED]. A hospital "History and Physical" dated 1/19/13 for Resident B indicated: "Chief Complaint: Pleuritic chest pain and possible clogged PEG tube ([DEVICE].). History of Present Illness: This is a (Resident B's age, race, and gender) who presented to the emergency room yesterday from (name of facility) where she had been having a couple day history of pleuritic chest pain...In the ER, patient was found to have bilateral pulmonary emboli. She was in the hospital about 2 weeks ago falling (sic) and fracturing her hip which she had surgery to repair, so it is quite possible that these PEs (pulmonary emboli) were developed status [REDACTED]. CT scan of the chest showed multiple large partial obstructing pulmonary emboli. Also, multifocal interspace density predominately involving the left upper lung, most likely representing pulmonary hemorrhage secondary to the patient's pulmonary emboli..." Resident B was interviewed on 3/05/13. She was alert, oriented, and appropriate. She indicated that in the days leading up to her hospitalization on [DATE] she was "Crying in pain-I told the nurses-the suffering was terrible...it felt like I had a lung torn." She also indicated she still had her feeding tube in place, and had been advised by her treating physician that this could not be removed while she remained on anticoagulants, and that this might be a permanent condition. She indicated she was "very sad" the tube could not be removed, as this was a high priority to allow her to return home. The facility's Director of Pharmacy Services was interviewed on 3/06/13 at 1:30 p.m. He indicated he had investigated the incident of Resident B not receiving the prescribed Arixtra for 9 days. He indicated the medication had been put on "hold" on 1/08/13 because of unavailability. He indicated the medication was obtained the same day and delivered to the facility. He indicated the pharmacy entered the medication in the Accuflow system using the original prescription number, but the system did not accept the entry, as this prescription number had been discontinued. He also indicated that his investigation led him to believe that the nurse who had accepted delivery of the medication had not scanned it into the system, and had not entered it on the hand written medication administration record. He indicated he had subsequently completed an audit of all resident charts without discovering any additional significant medication errors. This federal tag relates to Complaints IN 298, IN 850, IN 918, and IN 998. 3.1-25(a) 3.1-25(b)

Based on record review and interview, the facility failed to provide medically - related social services to attain and maintain the highest practicable well-being of each resident in that residents (Resident #33 & #72) were admitted to the facility with behaviors, but there were no behavior management programs in place for staff to follow to ensure the safety of all the residents on the units where these residents were residing until after there was an incident of resident to resident abuse. Findings include: Review of an incident report, dated 8/26/12, indicated there was a resident to resident altercation between Resident #33 and Resident #72. This was a witnessed incident in which Resident #33 hit Resident #72 in the face with his fist. Resident #72 had a black eye during observation on 8/29/12 at 11:00 a.m. Resident #72's clinical record was reviewed on 8/29/12 at 11:30 a.m., and indicated the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The August 2012 monthly behavior monitoring flowsheet included "1. physical aggression" occurred on days - 8/17/12; on evening - 8/1 and 8/15/12, and none on nights. "2. verbal aggression" on days - 8/1 and 8/17/12, evenings - 8/1 and 8/2/12, on nights - 8/4/12. "3. spitting on floor on days - 8/1, 8/2, 8/3, 8/6, 8/7, 8/9, and 8/11/12. There were none on evenings or nights. There were no other behavior tracking logs available before the August 2012. The care plan for Resident #72 was reviewed on 8/29/12 at 11:35 a.m. The dates on the care plan were 6/3/12 and 8/22/12. The problem of "physical and verbal aggression with care esp (especially) at noc (night). Interventions - 1. approach warmly and friendly. 2. wake resident and explain what you are doing. 3. give resident a pillow or stuffed animal to hold during care. 4. play soft music as resident desires. 5. report changes in condition to MD (doctor) and family 6. record/monitor behavior patterns." In the nurses notes reviewed on 8/29/12 at 11:37 a.m., a note dated 4/20/12 indicated, "Res (resident) can be combative/resistant with toileting and incontinence care at night. Res. yells 'now just leave me be' Res (resident) spits on floor and the staff redirect him." There was no behavioral assessment found at this time. During record review for Resident #33 on 8/29/12 at 11:08 a.m., he was admitted on [DATE]. The [DIAGNOSES REDACTED]. A note in the initial assessment, dated 1/18/05, indicated this resident has a long history of behaviors. A care plan, dated 6/3/12, indicated problems of behaviors and interventions "1. Approach resident in a warm and friendly manner. 2. Explain intent before providing care. 3. reapproach 4. Support/reassurance 5. Antipsychotic per order 6. monitor for behaviors 7. follow-up with psych to renew meds for GDR 8. likes to talk about hunting and fishing 9. start anti-psychotic 10. send to (name of hospital) for eval 11. 8/27/12 psych to evaluate. This resident had been on Seroquel and then a gradual dose reduction was done. The medication was stopped 8/1/12 and then restarted on 8/14/12 "after behaviors began again." No mention of what behaviors had begun again. The behavior monitoring flowsheet, which was started the first of August 2012, showed "1. physical aggression 8/26/12 when he was aggressive to himself, others and his care. 2. Sexual behaviors - shows 11 times it occurred in August 2012 - 8/2, 8/6, 8/11, 8/12, 8/14, 8/16, 8/24/12 on days, 8/13, 8/14 and 8/17/12 on evenings, and none on nights. There was no mention on the flowsheet for the kinds of behaviors that were observed or what interventions were being used when behaviors did occur. A note in the progress notes indicated, "resident has sexual behaviors and staff is redirecting. MD (doctor) is aware. Initial Psych evaluation dated 8/27/12 done by (name of group)." Interview with CNA #1 on 8/29/12 at 11:10 a.m., indicated Resident #33 does have behaviors, especially sexual. He has reached over and grabbed my leg multiple times. He can usually be redirected. Interview on 8/31/12 at 10:30 a.m., with the Administrative Assistant who used to be the Social Worker regarding the behavior program. "LPN #2 coordinated all the psych visits and is the Dementia Coordinator. We used the care tracker, nursing report for new and unusual behaviors and expanded the care plan with different interventions. I collaborated closely with LPN #2 and Social Service Assistant to make necessary changes. The program has changed within the last two months. When I was SS I felt that we did have a behavior program. There was a policy in the Social Service Policy & Procedure Manual." On 8/31/12 at 10:37 a.m., interview with LPN #2, "I don't do anything in writing as far as behaviors, but I do observe. I just help. I did help coordinate psych visits and orders and recommendations made. Made sure the attending MD was made aware of issues. CNAs used care tracker to record behaviors. (name of Resident #33) had behaviors at the previous nursing facility. I believe he did have a psych eval at one time. He came here to Unit 2 and then seemed to get better and was moved to Unit 1. Later he had to be moved back to Unit 2. He has had sexual behaviors since he came here. We used the care tracker and would interview the CNAs and nurses. We would give the staff suggestions and guidance for any issues. We would schedule care plan meetings with his family if there were issues." On 8/31/12 11:06 a.m., an interview with the Social Service Director indicated the resident to resident incident was witnessed by staff. "The resident (Resident #72) does have a black eye where (name of Resident #33) hit him." The Administrator and DON (Director of Nursing) interviewed staff and family. She stated she "talked to CNAs to see what had happened. Not sure if staff were aware these two residents had behaviors. There will be staff education next week. This could have been avoided. (name of Resident #72) did not even recall the incident. I interviewed him the next day and he did not recall the incident at all. We are in the process of implementing a behavior program. The first part is a 100% audit - who is on psych meds and monitoring moods. If there are no psych meds we monitor moods and see what interventions are being used, and are they working. Care plans are updated. We did a lot of GDRs (gradual dose reductions) when I came. We collect information and see what needs to be done at this point. Going to implement a Psychoactive Medication Monitoring Summary and use it as a tool to evaluate what needs to be done. I have gathered 2 months of information and it is now time to review and assess. This will be implemented [DATE]. Education is desperately needed. Training of all staff. There will be constant education." Social Service Policy & Procedure Manual had a reviewed and revised date of 9/01/02. A policy titled, "Unusual Occurrence Report" had a note on it that said, "ignore this section." The Social Service Director indicated she didn't know who put it there but that all policies & procedures are being redone. "Policies are missing and some are not up to date. Some have a date of 2004." A policy titled, "Working with Challenging Behaviors" with a revised date of 11/28/07 was received on 8/31/12 at 2:30 p.m., from the Social Service Director. She indicated this was the policy prior to her coming full time to this facility in July. This policy indicated, "...Procedure: The nurse in charge at the time the resident exhibits a new or significantly worsening behavior is responsible for describing and acting upon the resident behavior. The nurse creates a charting note that includes the following: A description of the behavior that includes the location and time of occurrence. Identification of participants of the behavior including but not limited to: 1. people involved 2. Environment (this may include temperature, noise level, inappropriate lighting) 3. Resident verbal and non-verbal behavior...New and worsening behaviors to be hot racked and follow up charting performed for 72 hours...SSD will monitor the behavior weekly and make a charting note at mega meeting until the behavior is stabilized..." A policy was received from the Social Service Director on 8/31/12 at 2:30 p.m., titled, "Behavior Management/Psychotropic Medication Protocol." She indicated this was the new policy being implemented now. This policy indicates there will be a "Behavior Management Psychotropic Medication Review Committee" that will meet routinely to review all residents with any behaviors and those who receive anti-psychotic, anti-depressants, sedative/hypnotic, or anti-anxiety medications. Included with this policy was a form "Psychoactive Medication Monitoring Summary" with information to be placed for GDRs, a "Monthly Behavior Monitoring Flowsheet" and a "Behavior Communication Form." 3.1-34(a)