Every finding on record at Rivercrest Long Term Care

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and whose comprehensive plan of care indicated the call bell was to be within his/her reach when he/she was in his/her room, the Facility failed to ensure staff consistently implemented and followed this intervention, when on 10/15/24, Certified Nurse Aide (CNA) #1 left Resident #1 alone in his/her room without a call bell within reach, Resident #1 fell , later complained of pain, and was diagnosed several days later with a fractured finger. Findings include: Review of the Facility's policy, titled Care Planning-Interdisciplinary Team, dated 09/2013, indicated that an individualized, comprehensive care plan would be developed for each resident. Review of the Facility's policy, titled Fall Prevention and Management Plan, dated 11/02/18, indicated the Facility assesses each resident for his/her risk of falls, designs a plan for care, and implements procedures to minimize falls and/or injury. Resident #1 was admitted to the Facility in November 2023, diagnoses included history of falls, and abnormalities of gait and mobility. Review of Resident #1's Fall Risk Assessment, dated 08/01/24, indicated he/she was assessed by nursing as being at high risk for falls. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 08/01/24, indicated he/she required supervision/touching assistance for transfers and was moderately cognitively impaired with a score of 12 on the Brief Interview for Mental Status (BIMS- score of 13-15 suggests cognitively intact, 08-12 suggests moderately cognitively impaired, 00-07 suggests severe cognitive impairment). Review of Resident #1's Falls Care Plan, reviewed and renewed with his/her August 2024 Minimum Data Set (MDS) assessment, indicated he/she had an intervention, dated as initiated 12/21/23, for the call bell to be within his/her reach when he/she was in his/her room. Review of Resident #1's Certified Nurse Aide (CNA) Care Plan, undated, indicated to provide him/her with the call bell when in his/her room. Review of Resident #1's Post Fall Evaluation Form, dated 10/15/24 and completed by Nurse #2, indicated Resident #1 sustained an unwitnessed fall at 4:30 P.M., when he/she was found by nursing to be seated on the floor in his/her room. The Form indicated Resident #1's call bell was not within reach at the time of the fall and Resident #1 told nursing staff that he/she was trying to get into bed. The Form also indicated that Resident #1 had weakness/fatigue with recent fever/cold/cough due to recent Covid-19 illness. During a telephone interview on 11/14/24 at 3:42 P.M., Nurse #2 said she was the charge nurse on duty during the evening shift (3:00 P.M. through 11:00 P.M.) on 10/15/24 when she was told by another staff member that Resident #1 sustained a fall in his/her room. Nurse #2 said when she entered Resident #1's room, she observed the positions of the wheelchair, bed and bed side table, and she also observed that Resident #1's call bell was on the bed (toward the right side, opposite of where Resident #1 was seated). Nurse #2 said Resident #1 could not have reached his/her call bell from his/her wheelchair. Nurse #2 said Resident #1 used his/her call bell to request staff assistance. Review of the Post Fall Witness Statement, dated 10/15/24 and signed by Certified Nurse Aide (CNA) #1, indicated she had assisted Resident #1 to the bathroom at 4:10 P.M., then left Resident #1 in his/her room, per Resident #1's request. During a telephone interview on 11/14/24 at 2:14 P.M., Certified Nurse Aide (CNA) #1 said she worked at the Facility through a staffing agency and was assigned to care for Resident #1 on the evening shift of 10/15/24. CNA #1 said Resident #1 had used his/her call bell at 4:10 P.M. to request to go to the bathroom. CNA #1 said she assisted Resident #1 in the bathroom and following that, Resident #1 requested to stay in his/her room. CNA #1 said she left Resident #1 seated in his/her wheelchair in his/her room on the left side of his/her bed. CNA #1 said she did not know if Resident #1's call bell was left within his/her reach. CNA #1 said she was alerted by nursing a few minutes later that Resident #1 had sustained a fall in his/her room. Review of Resident #1's Nurse Practitioner (NP) note, dated 10/16/24, indicated Resident #1 reported discomfort to his/her left wrist which appeared to be bruised and discolored. During an interview on 11/14/24 at 11:30 A.M., Resident #1 said he/she used the call bell to request assistance from staff to go to the bathroom or to get in and out of bed. Review of Resident #1's x-ray report, dated 10/16/24, indicated there was no fracture of the left wrist, and no acute fractures throughout the left fingers. Review of Resident #1's Nursing Progress Note, dated 10/18/24, indicated Resident #1 continued to complain of left wrist and left finger pain. The Nurse Practitioner was notified and gave an order for another x-ray of Resident #1's left wrist and fingers to be done at the hospital. Review of Resident #1's hospital radiology report, dated 10/19/24, indicated an intra-articular fracture of the base of the proximal phalanx of the third digit (break in the bone between the second and third knuckle of the third finger). Review of Resident #1's Orthopedic Consult, dated 10/28/24, indicated to use a splint for comfort and weight bear as tolerated. During an interview on 11/14/24 at 1:55 P.M., Certified Nurse Aide (CNA) #3 said Resident #1 does use his/her call bell to alert staff of his/her needs. CNA #3 said staff were responsible to ensure Resident #1 had his/her call bell within reach when he/she was in his/her room. During a telephone interview on 11/15/24 at 2:37 P.M., the Director of Nurses (DON) said that Resident #1's call bell was not within his/her reach at the time of his/her fall on 10/15/24. The DON said it was her expectation that staff always follow each resident's plan of care.

Based on interview and record review the facility failed to ensure fall interventions were implemented for one Resident (#20) out of a total sample of 12 residents. Specifically, for Resident #20 the facility failed to ensure he/she was wearing non-skid socks and had a bed alarm in place, as indicated in the falls plan of care. Findings include: The facility policy titled Fall Prevention and Management, dated 11/2/18, indicated the following: -The Center assesses each resident for his or her risk for falls, designs a plan of care, and implements procedures to minimize falls and/or injury. B. Prevention. 1. General safety precautions and interventions may include: e. Promoting resident use of non-slip footwear/proper shoes when ambulating. 3. Prevention strategies to be implemented are listed on the plan of care. Resident #20 was admitted to the facility in November 2023 and had diagnoses that included a fall resulting in an L2 compression fracture and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/1/24, indicated that on the Brief Interview for Mental Status exam Resident #20 scored a 12 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #20 had no behaviors and for putting on/taking off footwear requires substantial/maximal assistance. Review of the record indicates that since admission Resident #20 has sustained 8 falls, including two that required hospitalization and one that resulted in a sternal fracture. Review of the current Falls care plan for Resident #20 indicated the following interventions: -Call light within reach when in room, start 12/21/23. -Offer/assist resident to BR (bathroom) upon rising after meals and before bed, start 12/21/23. -Keep room free of clutter, start 12/21/23. -Resident will have non-skid socks on at all times, start 1/21/24. -Non-skid markings to floor on each side of the bed, start 2/5/24. -Call, don't fall signs posted in room as a reminder to call for assistance, start 2/5/24. -Alarm mat to bed to remind resident to not rise unassisted, start 2/9/24. -Obtain urine to r/o (rule out) infection, start 3/18/24. -Consult Psych regarding aggressive behavior resulting in a fall, 3/18/24. -Alarm mat to w/c (wheelchair) as a reminder to not rise unassisted, start 6/3/24. -Staff reminders if a resident moves rooms, all equipment should go with them including alarms, start 6/27/24. Further review of the record failed to indicate Resident #20 refused to wear non-skid socks at all times. Review of the Falls report, dated 6/22/24, indicated the following: -Resident #20 sustained a fall in his/her bedroom on 6/22/24 at 7:15 P.M. A nurse was going to assist a resident in another room when she observed Resident #20 walking in his/her room from the bed to the wheelchair. According to the report Resident #20 was barefoot at the time of the fall and the bed alarm was not sounding because the Resident had had a recent room change and the alarm was not moved with the Resident. During an interview on 9/5/24 at 12:27 P.M., with Resident #20's Certified Nursing Assistant (CNA) #2, he said that Resident #20 is unsteady on his/her feet, requires staff assistance to put on socks and shoes and has no behavior of refusing assistance with dressing. CNA #2 said he was not working at the time of Resident #20's fall in June and was not sure what had occurred. During an interview 9/5/24 at 12:53 P.M., with the Nurse Unit Manager (#1) she said that when a resident has a room change, all their items and specialized interventions such as a bed alarm should be moved with them. She said that this had accidentally not happened when Resident #20 changed rooms in June, because the move was temporary. Nurse Unit Manager #1 said that if a resident is care planned to wear non-skid socks at all times, they should be wearing them and if not, the reason should be documented. During an interview on 9/5/24 at 1:14 P.M., with the Director of Nursing (DON) she said that she expects all care plan intervention to be followed and that Resident #20's bed alarm should have been moved with him/her when he/she changed rooms in June.

Based on observation, record review and interview the facility failed to ensure medications were properly labeled, topical medications were stored separately from oral medications in one of one medication carts and eye drops were properly labeled in one out of one medication rooms observed. Findings include: Review of the facility policy titled Medication Administration General Guidelines, not dated, indicated the following: *Do not store treatment preparations in the medication cart. *Do not pre-pour medications. Once medications are poured for administration, they are not to be stored in the medication cart. 1. On 9/26/23, at 2:00 P.M., the surveyor observed a medication cup in the top drawer of a medication cart containing 6 pills. The pills were not labeled. The surveyor also observed the following in the medication cart: 2 tubes of Diclofenac Sodium topical cream (used to treat pain). 1 bottle of wound cleanser. 4 tubes of Triamcinolone cream (used to treat eczema). 1 bottle of antifungal powder. 4 tubes Phytoplex cream. 1 tube Clobetasol Propionate shampoo (used to treat psoriasis and dermatitis). 1 bottle Ketoconazole shampoo (used to treat fungal conditions of the scalp) 1 tube Aquaphor cream 1 tube Lidocaine ointment 5% (used to relieve pain) 2 bottle of body lotion. 2 tubes of body cream. During an interview on 9/26/23, at 2:02 P.M., Nurse #1 said she was not aware that treatments were to be stored separately from oral medications. Nurse #1 said the medication cup containing 6 unlabeled pills were for a resident who was at a doctor's appointment. Nurse #1 then said that she should not have pre-poured the medication.

Based on observation and interview, the facility failed to perform hand hygiene to prevent cross contamination during observations of the breakfast meal. Findings include: During observations of breakfast service on 9/27/23 at 8:08 A.M. the cook was wearing gloves which he contaminated by touching a thermometer while taking the temperatures of the food items, and by touching the tops of food covers. With the same contaminated gloved hands the cook opened a package of bread and placed four slices of bread in the toaster. The cook then began plating foods with the same contaminated gloved hands touching utensils for items such as hot cereal or eggs, and with the same contaminated gloved hands, picked up ready to eat pieces of toast and scones to be served to the residents. At that time, the surveyor approached Team Leader #1 and inquired about the use of using gloved hands to touch the handles of utensils, the toaster and food items like toast and scones. Team Leader #1 said that the utensils are clean for the individual food items but that he/she should use tongs for the toast and scones. The cook then continued to plate two more plates using the same contaminated gloved hands picking up scones and toast.

Based on record review and interview the facility failed to accurately transcribe a physician's order related to the treatment of a pressure ulcer for one Resident (#7) out of a total of 12 sampled Residents. Findings include: Resident #7 was admitted to the facility in August 2021 with diagnoses including peripheral venous insufficiency and glaucoma. Review of his/her Minimum Data Set assessment dated [DATE] indicated Resident #7 scored 15 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she is cognitively intact and requires assistance with ambulation, transfers and personal hygiene. Review of the clinical record indicated Resident #7 had developed a pressure ulcer on his/her sacrum on 8/13/23 measuring 1 centimeter (CM) X .3 CM X .4 CM. Review of the Nurse Practitioner note dated 8/16/23 indicated: Complaint/Nature of presenting problem: Pressure ulcer to buttock. Patient is being seen for red sacrum .instructed to use Calazyme cream and use Calcium [Alginate] 3x a week. Review of Resident #7's Physician's orders for August 2023 indicated the Nurse Practitioner's instructions to use Calcium Alginate were never brought forward. During an interview on 9/26/23 at 12:59 P.M., Nurse #2 said that when a resident develops a pressure ulcer staff notify the physician who would then assess and prescribes treatment orders. Nurse #2 then reviewed the clinical record with the surveyor and said that she could not see that the Nurse Practitioner's instructions to use Calcium Alginate were added to Resident #7's physician's orders.

Based on observation, interview and policy review, the facility failed to ensure professional standards of practice were maintained during medication administration with 1 of 2 nurses observed. Findings include: Review of the facilities Mediation Administration-General Guidelines policy, revised December 2019, included the following: * Splitting of tablets should be avoided and every attempt should be made to obtain an alternative dosage form, medication or dosing schedule to avoid splitting. If breaking tablets is ultimately necessary to administer the proper dose, hands are washed with soap and water or alcohol gel {and examination gloves worn} prior to handling tablets and examination gloves must be worn to prevent touching of tablets during the process. The following guidelines are followed: * If using only one half of the tablet from a unit dose package, the remainder is disposed of according to facility procedure. On 9/29/22 at 8:25 A.M., the surveyor observed Nurse #1 prepare [MEDICATION(S)] (treats blood pressure and heart failure) for non-sampled Resident #3. During preparation, Nurse #1 removed a 100 mg tablet from a unit dose bubble pack, placed it into a tablet splitter and split the tablet into two halves creating two 50 mg half tablets. Nurse #1 placed one 50 mg tablet into a medication cup for administration and returned the other 50 mg tablet back into a bubble in the unit dose package that was labeled [MEDICATION(S)] 100 mg. During an interview on 9/29/22 at 8:40 A.M., Nurse #1 said that she was not aware of the facility policy and did not know the unused half should be disposed of.

Based on observation, record review and interview the facility failed to ensure professional standards of quality care by failing to identify a bruise on one Resident (#36) out of a total sample of 12 residents. Findings include: Review of the facility policy, entitled Incident Management with a review date of 4/27/22 indicated the following: -All incidents or adverse events occurring in the center or on center property must be reported immediately. -All incident/adverse events that occur in the center are investigated to assure appropriate actions are taken to prevent reoccurrence and/or reduce risk of injury. Resident #36 was admitted to the facility in April of 2021 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set Assessment (MDS) with an assessment reference date of 8/31/22 indicated that Resident #36 could make him/herself understood and could understand others. Further review of the MDS indicated Resident #36 had severe cognitive impairment with a score of 6 out of 15 on the Brief Interview for Mental Status and required extensive assistance from staff for bathing, dressing and personal hygiene. Review of Resident #36's medical record indicated a care plan dated 6/22/21 with the category of skin conditions indicating that Resident #36 has fragile skin with bruising noted, at risk for skin tears. Interventions dated 6/22/21 included: weekly skin checks, document results. Skin checks as need after injury or combative episodes, assess new areas for size and injury, report findings to Medical Doctor and family as indicated, investigate causes of injury/bruise/skin tear. Consider preceding activity and Resident's attention to safety. Decrease precursors when able, keep legs covered with geri sleeves, On 9/28/22 at 10:43 A.M., Resident #36 was observed being wheeled by staff to the dining/activity area. Resident #36 was observed with a dark discolored area on the top of his/her right hand that was consistent with a bruise. On 9/28/22 at 2:50 P.M., Resident #36 was observed resting in his/her bed. Resident #36's right hand was observed with a dark discolored area which was elongated and spread towards the outside of his/her hand. When asked about the bruised area on the top of his/her right-hand Resident #36 said he/she had thin skin. Resident #36 went on and said the area could have been caused by him/herself banging his/her hand or when staff pull on him/her when helping him/her getting out of bed. On 9/29/22 at 8:57 A.M., Resident #36 was observed sitting up in bed eating his/her breakfast. A dark discolored bruise on top of his/her right hand was observed on Resident #36's right hand. Resident #36 said when they (staff) get me out of bed, they pull on my hands, it is recent, and I do not let them do that anymore. Review of Resident #36's medical record indicated the following: -Weekly skin checks dated 9/1/22, 9/15/22 and 9/22/22 did not indicate findings of any skin irregularities on Resident #36's right hand. -Progress notes dated from 9/12/22 through 9//29/22 did not indicate the presence of bruising on Resident #36's right hand. During an interview on 9/29/22 at 8:11 A.M., CNA #2 said if during care any bruise or skin change observed needs to be reported to the nurse. During an interview on 9/29/22 at 9:44 A.M., CNA #3, who provided care to Resident #36 on 9/28/22, said when a skin change is identified on a resident it needs to be reported to the nurse. CNA #3 said the discolored area of Resident #36's hand is not new and has been there a few days and she did not report it to the nurse. During an interview on 9/29/22 at 9:50 A.M., Nurse #1 said the Resident #36 can make his/her needs known. Nurse #1 said she was not aware of any bruise on Resident #36. At this time Nurse #1 and the surveyor went to observe Resident #36. Nurse #1 acknowledged the bruised area on the top or Resident #36's hand. Resident #36 said to Nurse #1 that he/she did not know how he/she got the bruise and that he/she thinks it is when they (staff) pull on him/her during care. During an interview on 9/29/22 at 10:07 A.M., the surveyor told the Consultant Director of Nursing the observations made of Resident #36's bruised hand. He said any new skin changes should be reported and an incident report completed.

Based on observation, record review and interview the facility failed to ensure that adequate infection control practices were maintained to reduce the risk of infection for one Resident (#24) with a urinary catheter, out of a total sample of 12 residents. Findings include: The facility policy titled Catheter Care Urinary, revised September 2014, indicated the following: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Infection Control: Be sure the catheter tubing and drainage bag are kept off the floor. Resident #24 was admitted to the facility in June 2021 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated that on the Brief Interview for Mental Status (BIMS) exam Resident #24 scored an 8 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #24 required one-to-two-person extensive physical assistance with all aspects of Activities of Daily Living, had an indwelling catheter and had no behaviors. During a record review the following was indicated: * Resident #24 was tested for a urinary tract infection (urinalysis and culture and sensitivity [UA/CS]) on 9/22/22 * Resident #24's UA/CS was positive, and he/she was started on [MEDICATION(S)] (antibiotic) on 9/26/22. On 9/29/22 at 8:40 A.M., the surveyor observed Resident #24 in the main dining room for breakfast. The urinary catheter tubing was lying flat on the floor. The surveyor observed a staff member pushing the Resident's wheelchair to reposition him/her and the tubing dragged along the floor. Review of the Care Plan for Resident #24 indicated a care plan for the suprapubic tube, started 6/8/22, with a current intervention tubing off the floor at all times. On 9/29/22 at 9:56 A.M., the surveyor observed Resident #24 seated at an activity in the main dining room. His/her urinary catheter tubing was laying on the floor. On 9/29/22 at 10:45 A.M., the surveyor observed Resident #24 seated at an activity in the main dining room. His/her urinary catheter tubing was laying on the floor. During an interview with Resident #24's Certified Nursing Assistant (CNA) #1 on 9/29/22 at 10:55 A.M., she said that Resident #24 required one person assist with his/her Activities of Daily Living and did not have behaviors. CNA #1 said that she had been educated on the urinary catheter and that each morning, as a part of morning care, she emptied the urine collection bag, told the nurse how much urine was in the bag and placed the urinary collection bag in a privacy bag. She said that the catheter tubing should never be on the floor. During an interview with Resident #24's Nurse #1 on 9/29/22 at 11:12 A.M., the multiple observations of Resident #24's urinary catheter tubing lying flat on the floor were shared with her. Nurse #1 said that urinary catheter tubing should never be touching the floor due to the risk of causing an infection. During an interview with the facility's Infection Preventionist on 9/29/22 at 11:18 A.M., he said that the urinary catheter tubing should never be touching the floor. During an interview with the facility's Consultant Nurse on 9/29/22 at 11:24 A.M., he said that urinary catheter tubing should not be on the floor for infection control reasons as well as due to the risk of the tubing becoming dislodged.

Based on observation, interview and policy review, the facility failed to ensure adequate infection control practices were maintained to reduce the risk of spread of infection during medication administration with 1 of 2 nurses observed. Findings include: Review of the facilities Mediation Administration-General Guidelines policy, revised December 2019, included the following: *Splitting of tablets should be avoided and every attempt should be made to obtain an alternative dosage form, medication or dosing schedule to avoid splitting. If breaking tablets is ultimately necessary to administer the proper dose, hands are washed with soap and water or alcohol gel {and examination gloves worn} prior to handling tablets and examination gloves must be worn to prevent touching of tablets during the process. On 9/29/22 at 8:25 A.M., the surveyor observed Nurse #1 prepare medications for non-sampled Resident #3. With bare hands, Nurse #1 remove a tablet from a unit dose package and placed it into a tablet splitter. She split the tablet in two halves, placed one half of the pill into a medication cup, completed the rest of the medication preparation and administered the medication to Patient #3. During an interview on 9/29/22 at 8:40 A.M., Nurse #1 said that she should not touch medication with bare hands, she should have worn gloves.

Based on observation and interview the facility failed to maintain infection control standards to prevent the further spread of COVID -19 in the facility. Findings include: On 9/22/21, at 8:15 A.M. the Administrator informed the surveyor that there were COVID-19 positive residents in the building. On 9/22/21, at 8:57 A.M., the surveyor observed Certified Nurse's Aide (CNA) #1 providing direct care to a resident without wearing a protective gown. CNA #1 was repositioning a resident in bed, touching the resident and lifting arms and legs. CNA #1 was also adjusting the bed linen that was in direct contact with the resident. During an interview on 9/22/21, at 9:01 A.M., CNA #1 said that she had just removed the gown and should have put another one on when she needed to continue to provide direct care. Review of the Centers for Disease Control and Prevention (CDC) web site titled Strategies for optimizing the supply of Isolation gowns and dated 1/21/21, indicated that protective gowns are to be worn when participating in activities that involve close and prolonged contact with the patient or their immediate environment including dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting.

Based on observation and interview the facility failed to ensure that (1.) A Housekeeper followed appropriate infection control practices after touching contaminated surfaces and (2.) Two Certified Nursing Assistants (CNA#1 and CNA#2) followed appropriate infection control practices to avoid the potential spread of COVID-19 after providing resident care. Findings include: The facility policy titled Handwashing/Hand Hygiene, undated, indicated: * All personnel shall follow the handwashing /hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. * Handwashing before and after direct contact with residents, after handling contaminated equipment , after contact with objects (i.e. medical equipment) in the immediate vicinity of the resident, before and after entering isolation precaution settings. * The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. * Single use disposable gloves should be used when in contact with a resident, or the equipment of a resident, who is on contact precautions. * When using gloves discard used gloves into the waste receptacle inside the examination or treatment room. On 7/7/20 at 6:55 A.M., the surveyor entered the facility's long term care unit. Three staff were observed in the hallway, one wearing no gloves, and two of the staff were wearing gloves on each hand. On 7/7/20 at 7:20 A.M., the surveyor observed a housekeeper exit the elevator on to the unit, wearing a glove on each hand and pushing an empty linen cart. He pushed the cart to the dirty utility room and without performing hand hygiene, used a gloved hand to enter the code on the keypad to unlock the door, potentially contaminating the keypad. The surveyor observed the housekeeper place the empty cart into the dirty utility room and without performing hand hygiene exit the dirty utility room with both hands still in the same gloves. He then walked to the elevator and without performing hand hygiene pressed the button to call the elevator, potentially contaminating the elevator button. When the elevator arrived, he stepped on to the elevator and then immediately pressed an elevator button to prevent the doors from closing and stepped off, potentially contaminating the elevator's inside button as well. Without performing hand hygiene, the surveyor observed the housekeeper walk to a precaution room, where a resident was on a 14 day quarantine and droplet precautions to rule out having had COVID-19. Without performing hand hygiene, the housekeeper used the same gloved hands to open a bin outside the resident's room containing Personal Protective Equipment (PPE), potentially contaminating the bin and PPE inside. On 7/7/20 at 7:25 A.M., the surveyor observed the same housekeeper, without performing hand hygiene, walk down the hall to a second room where another resident was on a 14 day quarantine and droplet precautions to rule out having had COVID-19. Without performing hand hygiene, the housekeeper used the same gloved hands to open the bin outside the resident's room containing PPE, potentially contaminating the bin and PPE inside. On 7/7/20 at 7:28 A.M., the surveyor observed a Certified Nursing Assistant (CNA #1) walking down the hall, wearing a glove on each hand, carrying clean towels in her left hand and a bag of soiled linen in the right hand. The surveyor observed CNA #1, without performing hand hygiene, use her right gloved hand to enter the code in the keypad to open the dirty utility room. She then used her foot to prop open the door, used the same gloved hand to open a laundry chute and deposit the bag of dirty linen into the chute. The surveyor then observed CNA #1 exit the dirty utility room without performing hand hygiene, wearing the gloves on each hand, carrying the clean towels and begin to walk down the hall. CNA #1 observed the surveyor, turned around and re-entered the dirty utility room, deposited the towels, removed the potentially contaminated gloves and perform hand hygiene. CNA #1 did not clean the keypad or door handle, both of which were potentially contaminated by the gloved hand. On 7/7/20 at 7:40 A.M., the surveyor observed a male nurse (Nurse # 1) exit room [ROOM NUMBER] , wearing a glove on each hand, and carrying medication items. As the Nurse #1 began to walk down the hall he viewed the surveyor, turned around and returned to the room. The nurse, without performing hand hygiene, used the right gloved hand to open the door and reentered room [ROOM NUMBER]. When the nurse re-exited room [ROOM NUMBER] he was not wearing gloves, or carrying items, however he did not clean the door handle he had touched with the gloved hand, potentially leaving the door handle contaminated. On 7/7/20 at 8:06 A.M., the surveyor observed CNA #2 standing in the hallway outside room [ROOM NUMBER]. CNA #2 had a glove on both hands, as she leaned against the wall, watching the TV in a nearby room. After a minute CNA #45, without performing hand hygiene, opened the door to room [ROOM NUMBER], potentially contaminating the door handle. On 7/7/20 at 8:26 A.M., the surveyor observed CNA #2 exit room [ROOM NUMBER], wearing a glove on each hand. CNA #2 walked to the clean utility closet and without performing hand hygiene opened the door, potentially contaminating the door handle. CNA #2 retrieved towels from the closet and without performing hand hygiene returned to room [ROOM NUMBER] and shut the door behind herself, potentially contaminating the door surface. On 7/7/20 at 8:44 A.M., the surveyor observed CNA #2 exit room [ROOM NUMBER] wearing a glove on each hand. The surveyor approached CNA #2 who said that she should not be wearing gloves in the hallway at any time. She acknowledged that she had done so and said it was a mistake. During an interview with the facility's infection control nurse/staff educator on 7/7/20 at 9:12 A.M., she said that staff should absolutely not be wearing gloves in the hall way at any time. She said that both the housekeeper and CNA # 1 and 2 all had been educated about the risk of contaminating the environment and had been instructed to remove gloves inside of rooms and to perform hand hygiene prior to returning to the hallway, particularly given the COVID-19 pandemic. During an interview with the Director of Nursing and facility Administrator on 7/7/20 at 9:51 A.M., both indicated that the staff were required to remove gloves and perform hand hygiene prior to exiting a room.

Based on observation and interview, the facility failed to maintain food service safety and sanitary food storage conditions. Findings include: Review of the facility policy titled Labeling/Dating Food Items, and dated 4/24/19, indicated the following: *All refrigerated and frozen items will be clearly labeled and dated with receiving date. *All opened packages, dry, fresh, refrigerated or frozen will be covered tightly and clearly labeled and dated with the date the product was opened. *If food is obviously spoiled - is abnormally soft, discolored, moldy or has a strong unpleasant small - discard it, no matter how properly or how short a time it has been stored. Review of the facility policy titled Restocking and Cleaning of Resident Kitchen, and dated 6/11/12, indicated the following: *Dining services will check the refrigerator and freezer daily and remove all uncovered, outdated and unlabeled items. *Dining services staff will clean out the refrigerator/freezer daily. During the initial kitchen walk through, on 1/2/20 at 7:32 A.M., the following observations were made by the surveyor: *The refrigerator temperature was 53 degrees Fahrenheit. *An individual carton of [MEDICATION NAME] opened without an opened date in the refrigerator. *An unlabeled, undated carton of blueberries. * An unlabeled, undated carton of raspberries. * An unlabeled, undated carton of strawberries. * An unlabeled, undated carton of tomatoes. *The walk-in refrigerator had a yellow squash inside a box that was on the bottom shelf. The yellow squash had a white substance on the side of it. The surveyor attempted to pick up the squash and the squash was mushy in several places. *An unlabeled, undated bag of carrots in the walk-in refrigerator. The carrots were discolored. *1 package of wheat bread with an expiration date of 12/30/19. *1 package of rolls with an expiration date of 11/27/19. *1 package of rolls with an expiration date of 12/17/19. *The walk in freezer had two containers of ice cream covered with plastic wrap as a lid and stored on the floor. During the second kitchen walk through on 1/03/20 11:37 A.M., with the Food Service Director and head Chef, the following observations were made: *The refrigerator contained 1 unlabeled, undated carton of strawberries, 1 unlabeled, undated carton of blueberries, 1 unlabeled, undated carton of raspberries and 1 unlabeled, undated carton of tomatoes. *A bottle of lime juice with an expiration date of 12/7/19. *A plastic zip lock bag of 10 rolls not dated on the shelf above the cooking surface. *1 package of rolls with an expiration date of 11/27/19. *2 packages of wheat bread with an expiration date of 12/28/19. During observation of the dining room nutrient kitchen, the following was observed: *The refrigerator contained 2 personal drinks of staff. *There was an avocado that had significant discoloration and a white substance on it. *There was a bottle of whipped cream with an expiration date of 2019. The month of expiration had worn off.

Based on observation and interview the facility failed to ensure expired medications and supplements were not available for administration in 2 out of 2 medication carts inspected. Findings include: Review of the facility policy titled Storage of Medications with a revision date of April 2007, indicated the following: *The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or be destroyed. On 1/3/19, at 7:45 A.M., during inspection of the Neuro Memory medication cart the surveyor observed the following: *1 bottle of [MEDICATION NAME] sodium (a medication used to treat constipation) with an expiration date of 3/2019. *1 bottle of latanoprost eye drops (a medication used to decrease pressure in the eyes) opened and without a date, therefore unable to determine an expiration date. Manufacturer's instructions indicate that once opened the bottle should be discarded in 4 weeks. *1 bottle of [MEDICATION NAME] eye drops (a medication used to decrease pressure in the eyes) opened and without a date, therefore unable to determine an expiration date. Manufacturer's instructions indicate that once opened the bottle should be discarded in a month. During an interview with Nurse#1 on 1/3/19, at 7:50 A.M., she said that the [MEDICATION NAME] sodium was expired and the eye drops should of been dated when opened. On 1/3/19, at 8:07 A.M., during inspection of the Short Term medication cart the surveyor observed the following: *1 bottle of vitamin D with an expiration date of 1/2019. *1 bottle of [MEDICATION NAME] eyedrops ( a medication used to treat dry eyes) with an expiration date of 8/2019. *1 bottle of brimodine eye drops (a medication used to decrease pressure in the eyes) opened and without a date, therefore unable to determine an expiration date. Manufacturer's instructions indicate that once opened discard within 28 days. *1 bottle of promod liquid supplement (a liquid protein supplement) opened and without a date, therefore unable to determine an expiration date. Manufacturer's instructions indicate that once opened to discard within 3 months. During an interview with Nurse #2 on 1/3/19, at 8:15 A.M., she said that the vitamin D was expired and the eyedrops and promod liquid supplement should of been dated when opened.

Based on observation, record review and staff interview, the facility failed to ensure that care and treatment was provided in accordance with professional standards of practice and the facility policy for a peripheral catheter (a cannula/catheter inserted into a small peripheral vein for therapeutic purposes such as administration of medications, fluids and/or blood products) for 1 Resident (#191) out of a total sample of 12 residents. Findings include: Review of the facility's peripheral catheter flushing policy dated 2012, indicated the following: -Specific flush order must be documented. -Flushing is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions -A physician's orders [REDACTED]. The order must include the flushing agent, the amount, and the frequency. Resident #191 was admitted in December 2019 with the [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/26/19, indicated that Resident #191 scored 13 out of 15 on the Brief Interview for Mental Status exam (BIMS) which indicated that the resident was cognitively intact. On 1/2/20 at 10:48 A.M., the surveyor observed Resident #191 sleeping in bed and receiving 2 grams of aztreonam (an antibiotic used primarily to treat infections caused by gram-negative bacteria such as Pseudomonas) intravenously (IV). Review of Resident #191's medical record indicated on 12/29/19 the Physician ordered to insert a peripheral line and give aztreonam 2 grams via IV every 8 hours for 5 days for pseudomonas. Review of Resident #191's medical record failed to indicate a physician's orders [REDACTED]. Further review of Resident #191's medical record including nurse's notes, Electronic Medication Administration Record (EMAR) and Electronic Treatment Administration Record (ETAR), the surveyor was unable to locate any evidence that Resident #191's peripheral line was being flushed before and after IV medication administration from 12/29/19. On 1/2/20 at 2:18 P.M., Nurse #2 reviewed Resident #191's nurse notes, EMAR and ETAR and acknowledged that the nursing staff failed to obtain a physician's orders [REDACTED].

Based on record review and interview the Facility staff failed to ensure the Minimum Date Set Assessment (MDS) was accurate for 1 Resident (#30) in a total sample of 12 residents. Findings include: Resident #30 was admitted to the Facility in 5/2017 and was readmitted from a hospital stay in 1/2019, with [DIAGNOSES REDACTED]. On 2/11/19 at 3:19 P.M., review of the significant change comprehensive MDS with and Assessment Reference Date (ARD) of 1/21/19 indicated under the bladder and bowel section that Resident 30 was frequently incontinent of urine. The Care Area Assessment (CAA) note for the MDS indicated that a care plan would be developed due to being frequently incontinent of urine and Resident is aware of the need to void. Review of the medical record indicated that Resident #30 was readmitted to the Facility after a hospital stay on 1/15/19. Review of the Nurses progress note, dated 1/15/19, indicated that Resident #30 had a Foley catheter (a tube inserted into the bladder to drain urine). Review of the bowel and bladder assessment, dated 1/23/19, indicated the bladder assessment was not rated and that the Resident had a catheter, the assessment further indicated the Resident had an indwelling Foley catheter. Review of the physician orders, dated 1/18/19 indicated an order for [REDACTED].>Further review of the medical record did not indicate that the Foley catheter had been removed prior to the ARD and was present. On 2/11/19 at 4:22 P.M., during an interview with the MDS nurse, she reviewed the chart with the surveyor and said she missed the nursing note that indicated the Resident had a Foley catheter.

Based on record review and interview the Facility staff failed to ensure a report of alleged abuse was immediately reported to the Department of Public health (DPH) in accordance with regulation requirements and the Facility's policies and procedures for 1 Resident (#23) in a total sample of 12 residents. Findings include; Resident #23 was admitted to the Facility in 11/2018 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set Assessment ((MDS) dated [DATE], indicated that Resident #23 scored 11 out of 15 on the brief interview of mental status, which indicated moderate cognitive impairment, required extensive assistance from staff members for activities of daily living including bathing, dressing and personal hygiene. On 2/12/19 at 11:36 A.M., review of the Facility's Policy and Procedure: Reporting Alleged Abuse, dated 10/17 with a revised date of 7/18, indicated the following. All alleged or suspected incidents involving mistreatment, abuse, neglect or misappropriation and all injuries of unknown origin will be immediately reported by anyone seeing or hearing of them to his/her direct supervisor or the Administrator, Director of Nursing or the person in charge of the unit. If the report alleges abuse or a result of serious bodily injury, the Director of Nursing will come in to the facility to file a report with the Department of Public Health within (2) two hours of the initial report. Review of the medical record on 1/12/19 indicated in a nursing progress note dated 12/26/18 and written at 9:55 P.M., the following: Pt (patient) ate 80 percent of his/her dinner, took his/her medication well but he/she has been confused towards the end of the shift calling for help that someone was raping him/her. Review of nursing progress notes dated 1/1/19 at 7:58 P.M., 1/1/19 at 9:30 P.M., 1/2/19 at 10:51 A.M., (indicated a late entry for 1/1/19 at 4:30 P.M.) and a Social Service note dated 1/2/19 failed to indicate that the incident on 12/26/18 was addressed or reported. A progress note written on 1/2/19 at 3:07 P.M., indicated it was an addendum for the nursing note dated on 12/26/18, it further indicated: this writer heard Resident #23 yelling, when I went in to the room, I turned on the light and the Resident was in his/her bed yelling help me and other things like: am being raped:, he/she was alone in his/her bed when I begun to talk to him/her, his/her voiced was softened and I asked him/her if he/she was OK he/she told me he/she was fine, I know this resident has had periods of delusions with dementia. He/she was very clear while talking to me and seemed to calm. I performed a wellness check which involved head to toe assessment, and communicated the delusional behavior to the oncoming shift. During an interview on 2/12/19 at 10:26 A.M., with the Director of Nursing (DON) she said she became aware of the 12/26/18 nursing progress note regarding Resident #23's statement of being raped on 1/2/19 and started an investigation. She said the nurse was new to the facility and had recently gone through orientation which included reporting all allegations of abuse. The DON said she did not report the allegation made by Resident #23 to DPH because it was determined that the nurse was just outside his/her room and in the room when the Resident made the statement that he/she was being raped. On 2/13/19 at 7:10 A.M., during an interview with the Administrator, she said the Facility followed their policy once they became aware of the allegation (8 days after the incident) and that it should have been reported immediately and the DON should have been called and notified.

Based on staff interview and record review, the facility staff failed to ensure ongoing communication and care coordination with the [MEDICAL TREATMENT] facility by failing to review the designated [MEDICAL TREATMENT] communication book (which accompanies residents to [MEDICAL TREATMENT] on treatment days) for 1 of 1 applicable resident (#343) out of of a total sample of 12 residents. Findings include: Resident #343 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 11/14/18, indicated that the resident scored a 15 out of 15 on the brief interview of mental status (BIMS), which indicated that the resident was cognitively intact. The resident required extensive assistance from staff for transferring, bathing and personal hygiene. This MDS also indicated that the resident was receiving [MEDICAL TREATMENT]. On 2/11/19, review of the resident's [MEDICAL TREATMENT] communication book included the following instructions: * 1/11/19 We ([MEDICAL TREATMENT] staff) administer: [MEDICATION NAME] (medication to treat [MEDICAL CONDITION] in [MEDICAL TREATMENT] patients), [MEDICATION NAME] (medication to treat [MEDICAL CONDITION]), [MEDICATION NAME] (a form of vitamin D used to treat [MEDICAL TREATMENT] patients with secondary [MEDICAL CONDITION]) and Liquicel (a protein supplement). * 1/16/19- Please do not give patient [MEDICATION NAME] or [MEDICATION NAME]- administered at [MEDICAL TREATMENT]. * 1/25/19 - [MEDICATION NAME] ([MEDICATION NAME]) should not be given at skilled nursing facility- when needed the patient receives it at [MEDICAL TREATMENT]- currently on hold. On 2/11/19, during review of the resident's Medication Record, dated (MONTH) 2019, indicated that the resident received [MEDICATION NAME] 60 milligrams (mg) by mouth daily on 1/26/19, 1/27/19, 1/28/19, 1/29/19, 1/30/19 and 1/31/19 (despite the [MEDICAL TREATMENT] staff instructions on 3 different occasions to not give the resident the [MEDICATION NAME]). On 2/11/19 during review of the resident's Medication Record, dated (MONTH) 2019, indicated that the resident received [MEDICATION NAME] 60 mg by mouth daily on 2/1/19, 2/2/19, 2/3/19, 2/4/19 and 2/5/19 (despite the [MEDICAL TREATMENT] staff instructions on 3 different occasions to not give the resident the [MEDICATION NAME]). On 2/12/19 at 11:00 A.M., during interview, the Director Of Nursing said she was not sure why staff did not review the [MEDICAL TREATMENT] communication book timely. She said that the resident should not have received the [MEDICATION NAME] medication at the end of (MONTH) 2019 or (MONTH) 2019 based on the [MEDICAL TREATMENT] staff instructions.

Based on interview and record review, the facility failed to ensure services provided met professional standards of practice by failing to provide medications per the physician order [REDACTED].#343 and #30) in a total sample of 12 residents. Findings include: Resident #343 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 11/14/18, indicated that the resident scored a 15 out of 15 on the brief interview of mental status (BIMS), which indicated that the resident was cognitively intact. The resident required extensive assistance from staff for transferring, bathing and personal hygiene. This MDS also indicated that the resident was receiving [MEDICAL TREATMENT]. During review of the resident's Medication Record, dated (MONTH) 2019, indicated a physician's orders [REDACTED].M. Further review of the 1/2019 Medication Record included the following: * 1/25/19 - [MEDICATION NAME] was due at 10:00 A.M., this was a [MEDICAL TREATMENT] day. The licensed nurse charting indicated at 3:49 P.M. that the resident was out of the facility and the resident did not receive the [MEDICATION NAME] which was due at 10:00 A.M. * 1/26/19- [MEDICATION NAME] was signed off by a licensed nurse as administered - this was not a [MEDICAL TREATMENT] day and should not have been administered. * 1/27/19- [MEDICATION NAME] was signed off by a licensed nurse as administered - this was not a [MEDICAL TREATMENT] day and should not have been administered. During review of the resident's Medication Record, dated (MONTH) 2019, indicated a physician's orders [REDACTED]. Further review of the 2/2019 Medication Record included the following: * 2/1/19 and 2/4/19- not given as indicated with an x. there was no further documentation on the Medication Record to indicate why the resident did not receive the [MEDICATION NAME] as these were both [MEDICAL TREATMENT] days. * 2/6/19- not charted as given- box on the Medication Record was blank. There was no further documentation on the Medication Record to indicate why the resident did not receive the [MEDICATION NAME]. During interview on 2/12/19 at 11:00 A.M., the Director of Nursing(DON) said that the resident should have received the [MEDICATION NAME] on 1/25/19 and should not have received it on 1/26/19 and 1/27/19. The DON said she would need to further investigate. The DON also said that there was a data entry error which caused the physician order [REDACTED]. 2. For Resident #30 the Facility staff failed to identify a [MEDICATION NAME] medication patch at the time of readmission following a hospital stay. Resident #30 was admitted to the Facility in 5/2017 and was readmitted from a hospital stay in 1/2019, with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set Assessment (MDS) dated , 1/21/19, indicated that Resident #30 had a brief interview for mental status (BIMS) score of 6 out of 15, which indicated a severe cognitive impairment, required extensive assistance from staff members for activities of daily living including dressing, transfers and hygiene. On 2/13/19 review of the medical record indicated in a nursing progress note dated 1/15/19, that Resident #30 arrived to the Facility at 1:30 P.M. Further review of the note indicated that skin integrity was reviewed, but failed to identify or document findings of a [MEDICATION NAME]. Further review of the medical record failed to indicate a readmission nursing assessment was completed. A nursing progress note dated 1/16/19, indicated that at 9:30 P.M., (20 hours after Resident #30 was readmitted from the hospital) a neupro patch (a prescription medication applied to the skin to treat [MEDICAL CONDITION]) was noticed on the left chest with no initial or date, no order in the discharge summary or in the previous discharge summary, the family member said the Resident had it in the hospital but the records did not indicate that. The physician was called and gave a new order to reinstate. Review of the hospital discharge summary, dated 1/15/19, did not indicate that neupro was on the discharge medication list. On 2/13/19 at 10:30 A.M. during an interview with the Director of Nursing (DON) she said she just became aware on 2/11/19 that a nursing readmission Assesserment was not completed when Resident #30 returned from the hospital. She said that the readmission nursing progress note was comprehensive but did not indicate the [MEDICATION NAME] medication patch was present. The DON said she the nurse who wrote the nursing progress note had done a full body check and did not see the patch. The DON said that Resident #30 had an order for [REDACTED]. Review of the the Medication Administration Record [REDACTED].M. Review of the MAR, dated 12/2018 indicated an order and administration, with a start date of 11/15/18 and end date of 12/27/18, for neupro 2 milligrams/24 hour [MEDICATION NAME] daily.

Based on observation, record review and interview the Facility Staff failed to ensure dignity and privacy for 1 Resident (#30) who used a Foley indwelling catheter (a tube inserted in to the bladder to drain urine), in a total sample of 12 residents. Findings include: Resident #30 was admitted to the Facility in 5/2017 and was readmitted from a hospital stay in 1/2019, with [DIAGNOSES REDACTED]. The Surveyor observed the following for Resident #30: -On 2/11/19 at 7:40 A.M., the Foley urine collection bag was observed to be visible from the hall and was affixed to the bed with no privacy cover. -On 2/11/19 at 9:34 A.M., and 10:25 A.M., the Foley urine collection bag was visible from the hall and was observed to contain urine. -On 2/11/19 at 10:39 A.M., a staff member was observed to be shaving Resident #30, the Foley bag was observed to be visible from the hallway. -On 2/12/19 at 8:46 A.M., the Foley catheter drainage bag was observed to be in view for anyone to see from the hall. -On 2/12/19 at 9:08 A.M., Resident # 30 was observed in bed, the Foley urine collection bag was observed to be in view from the hall. 2 staff members were in the Resident room, 1 assisting the Resident with eating, the other providing care to the roommate. -On 2/13/19 at 9:04 A.M., the Surveyor observed the Foley urinary drainage bag of Resident #30 to be in a Privacy bag. On 2/13/19 at 10:20 A.M., during an interview with Nurse #1, she said a Foley catheter bag should be handled discreetly and a privacy bag should be provided. Surveyor told her that multiple observations were made with the urinary drainage bag facing the door and was in view to others.

Based on record review and interview the Facility staff failed to ensure the quarterly Minimum Data Set Assessment (MDS) was transmitted per the required time frames established by the Centers for Medicare and Medicaid Services (CMS), for 1 resident record out of a total sample of 12 residents. Findings include: On 2/13/19 at 12:16 P.M., a medical record review for 1 resident indicated that a quarterly MDS, with an assessment reference date of 12/19/18 and a completion date of 12/31/18 was submitted on 1/28/19, 17 days passed the required transmittal to the CMS system. On 2/13/19 at 1:18 P.M., during an interview with the MDS nurse, she said a problem occurred with her computer file and the transmission did not occur. On 2/13/19 at 4:19 P.M., during an interview with the MDS nurse, she provided an email document that indicated the concern about the computer file was dated 2/6/19, after the required transmission date.

Based on observation, record review and staff interview, the facility failed to provide adequate supervision to keep 2 sampled residents safe, Resident (#2) and (#5) as well as 1 Non-Sampled (NS) resident (NS#1), in a total sample of 10 residents. 1. For Resident #5 and NS Resident #1, the facility failed to provide proper supervision to both residents, resulting in Resident #5 sustaining a fractured left 5th finger on his/her left hand. NS Resident #1 has a history of wandering into other residents rooms, including Resident #5, provoking him/her at times. Review of Resident #5's clinical record on 9/15/14 indicated that the resident was admitted to the facility in 5/2008. The resident's [DIAGNOSES REDACTED]. The resident's annual Minimum Data Set (MDS), dated [DATE], identified the resident as having a Brief Interview for Mental Status (BIMS) score of 11 (meaning the resident's cognition was moderately impaired), was non-ambulatory and had a depressed mood. Review of a 9/10/14 nursing note (no specific time of day given) indicated the resident complained of pain in his/her left hand. The note further indicated the following: noticed that the left smallest finger was swollen; joint was swollen; bruise was purplish, greenish in color; the left palm was bruised and swollen and bluish in color. The physician was notified and the physician ordered an X-Ray. The results of the X-ray showed a fracture of the left 5th proximal phalanx (finger) with mild displacement. Review of a subsequent nursing note written on 9/10/14 at 3:00 P.M. indicated that upon further investigation, the injury was caused by an altercation with another resident. The other resident was sent to the hospital for a psychiatric evaluation and was admitted for treatment. On 9/15/14, a review of the Investigation Report, included the following information: Resident #5 (identified as Resident #1 in the facility's investigation) was in his/her bed for the evening when NS Resident #1 (identified as Resident #2 in the investigation) entered Resident #5's room in his/her wheelchair. NS Resident #1 went over to Resident #5's bed and started touching the sheets. Resident #5 became angry, started yelling at him/her and finally banged the side rail with his/her hand. The Investigation Findings included the following information: NS Resident #1 was intrusive and touching Resident #5's space. Resident #5 said that he/she became annoyed and attempted to swat NS Resident #1 away. A statement written by Nurse #1 on 9/10/14 at 12:30 P.M. indicated that Resident #5 told Nurse #1 that this incident occurred the previous evening on 9/09/14. Resident #5 told Nurse #1 that NS Resident #1 kept wandering into his/her room in his/her wheelchair, bumping into his/her siderail and eventually bumping his/her hand. Resident #5's 5th digit finger on his/her left hand was X-rayed and was found to be fractured. The Corrective Measures Narrative within the Investigation included the following information: The Certified Nurse Aide (CNA) removed NS Resident #1 from Resident #5's room. NS Resident #1 was evaluated at the emergency room for medical clearance for possible admission to a psychiatric facility for medication evaluation. NS Resident #1 did have a previous psychiatric admission for intrusive behavior. Further review of the Investigation included a statement written by Nurse #2 who was on duty during the time of the incident. Nurse #2 said that he recalled seeing NS Resident #1 self-propelling himself/herself frequently into Resident #5's room during the 3:00 P.M.-11:00 P.M. shift on 9/09/14. Information written by the Unit Manager (U.M.) on 9/10/14 indicated the following: NS Resident #1 was known to be a wanderer and intrusive. Further statement in the UM's Investigation Report indicated that the evening staff were interviewed and they recalled that NS Resident #1 was being intrusive. However they reported that he/she was easily verbally re-directed with no difficulty. On the night of 9/09/14 NS Resident #1 kept going into Resident #5's room and that was what led to the altercation between the two residents. Record review indicated NS resident #1 was admitted for psychiatric care following this altercation. Observations were made of Resident #5 on 9/15/14 at 12:15 P.M and 4:40 P.M. as well as on 9/16/14 at 7:45 A.M. and 9:45 A.M.-10:30 A.M. During each observation, the resident was seated in the Day room and his/her pinky finger on his/her left hand was heavily bandaged. Although the nursing staff identified NS #1 as being intrusive, the nursing staff failed to provide the necessary supervision to NS Resident #1 to keep him/her from wandering repeatedly into Resident #5's room. An altercation between them occurred on 9/09/14, resulting in Resident #5 sustaining a fracture of his/her left 5th finger. 2. For Resident #2, the facility failed to provide adequate supervision that ensured that he/she would not wander out of the facility unsupervised. Findings include: Review of the Resident's medical record indicated that Resident #2 was admitted to the facility 6/2013 with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS), dated [DATE], indicated that the resident was unable to participate in cognitive testing and therefore was considered severely impaired. The MDS also indicated that the resident had significant long and short term memory loss and required supervision when ambulating in his/her room, on the unit and off the unit. Review of the Resident's Elopement Assessment Form, dated 6/19/14, indicated that the Resident required a wanderguard for safety. Review of the resident's Elopement plan of care, dated 6/9/13 with updates to 9/3/14, indicated that the resident had decreased cognition and decreased safety awareness. The facility goal was that the resident would remain within the facility unless supervised, remaining free from harm. Some of the facility approaches are as follows: * wanderguard for safety * evaluate the need for additional supervision; staff aware of wander risk. Review of the resident's Behavior plan of care, dated 6/9/13 with updates to 12/2014, indicated that the resident had a problem with intrusive wandering in and out of resident's rooms. In addition, the care plan indicated that the resident had a history of [REDACTED]. One of the facility's approaches was as follows: * staff supervise ambulation on unit. Review of the nurses notes, dated 7/24/14, indicated that the Resident was found outside of the facility in the outer parking lot and was returned by another resident's family at 5:15 P.M. The note indicated that there were no injuries. The note indicated that the Resident's wanderguard was working fine but that the main front door's alarm was not working or responding to wanderguards. The nurses note then indicated that activities and some staff had known that the resident had wandered out of the building earlier in the day around 4:00 P.M. The nurses note then indicated that the evening nurse had not been notified of the previous episode of wandering. Review of the facility Incident Report, dated 7/29/14, indicated that the resident eloped from the front door at 4:00 P.M. and again at 5:15 A.M. Review of a staff statement of the first elopement, dated 7/24/14, indicated that the resident was sighted in the facility parking lot between 3:50 P.M. and 4:00 P.M. It indicated that a staff member responded and escorted the resident back into the facility. This statement indicated that within one minute, three other staff members were informed that the resident was at a continued risk to elope. The statement indicated that it was later determined (after the second elopement) that the security code on the exit door was not functioning properly. The Incident Report also indicated that the resident was found for the second time in the parking lot of the facility at 5:15 P.M. The Incident Report indicated that the resident was assessed after the 5:15 P.M. elopement and there were no injuries or harm noted. The Incident Report indicated that Maintenance checked the doors after the second elopement and found the door alarm system to be functioning inconsistently. The Incident report indicated that the facility administration then identified other residents who were at risk for elopement and provided 15 minute checks for safety. The alarms for the doors were fixed that night. On 9/2/14 at 3:25 P.M., the Administrator said that the wanderguards and doors were checked intermittently prior to the resident's elopement incidents. Discussions with the Administrator on 9/16/14 at 2:00 P.M. indicated that the facility now has a policy and process to check the wanderguards and the functioning of the exit doors on a daily basis.