Every finding on record at Salem Center

Based on observations and staff interviews, the facility failed to maintain and ensure infection control standards were followed in several areas. Specifically, there were issues with the suction machine, and wheelchairs with tears in the cushions. The laundry room ' s ventilation system was inoperable, and appropriate infection control protocols were not implemented while using the facility ' s transport van to transport soiled linen to the laundromat over a span of 3 to 4 months. Additionally, there were deficiencies in infection control practices related to the cleaning and disinfection of reusable resident equipment. In addition, the facility also failed to provide appropriate infection surveillance and did not implement measures for the surveillance and prevention of legionella and other opportunistic waterborne pathogens. This included a lack of control measures, such as flushing and draining dead legs and checking and flushing fixtures in unoccupied resident rooms, including unused showers and bedpan sprayers. Furthermore, soiled linen and trash were not removed from the shower rooms between uses. These failed practices had the potential to cause serious injury, harm, impairment, and even death due to the potential risk of bacterial, viral, and fungal infections. Mold-related infections, in particular, can be severe and life-threatening, potentially affecting the lungs, sinuses, skin, and, in rare cases, other organs. Resident Identifier #80 Facility Census 89 Findings include: a) Resident #80 On 06/04/25 an observation was made at 11:00 AM of resident #80's suctioning machine, the canister was about half full of clear/yellow thick substance and the cord was put over the machine, uncovered and exposed to the environment. An interview on 06/04/25 at 12:00 PM with Registered Nurse (RN) #28 regarding Resident #80's suctioning machine not being covered/cleaned after being used, RN #28 stated i am sorry i have not used it or noticed it today i will get it taken care of right away, (we were in the room looking at the suctionsing machine when RN#28 confirmed it was not clean and was left uncovered.) Based on observations and staff interviews, the facility failed to maintain and ensure infection control standards were followed in several areas. Specifically, there were issues with the suction machine, and wheelchairs with tears in the cushions. The laundry room ' s ventilation system was inoperable, and appropriate infection control protocols were not implemented while using the facility ' s transport van to transport soiled linen to the laundromat over a span of 3 to 4 months. Additionally, there were deficiencies in infection control practices related to the cleaning and disinfection of reusable resident equipment. In addition, the facility also failed to provide appropriate infection surveillance and did not implement measures for the surveillance and prevention of legionella and other opportunistic waterborne pathogens. This included a lack of control measures, such as flushing and draining dead legs and checking and flushing fixtures in unoccupied resident rooms, including unused showers and bedpan sprayers. Furthermore, soiled linen and trash were not removed from the shower rooms between uses. These failed practices had the potential to cause serious injury, harm, impairment, and even death due to the potential risk of bacterial, viral, and fungal infections. Mold-related infections, in particular, can be severe and life-threatening, potentially affecting the lungs, sinuses, skin, and, in rare cases, other organs. Resident Identifier #80 Facility Census 89 Findings include: a) Resident #80 On 06/04/25 an observation was made at 11:00 AM of Resident #80's suctioning machine, the canister was about half full of clear/yellow thick substance and the cord was put over the machine, uncovered and exposed to the environment. An interview on 06/04/25 at 12:00 PM with Registered Nurse (RN) #28 regarding Resident #80's suctioning machine not being covered/cleaned after being used, RN #28 stated I am sorry i have not used it or noticed it today I will get it taken care of right away, (we were in the room looking at the suctioning machine when RN#28 confirmed it was not clean and was left uncovered.) B1) Dirty Laundry Room: An inspection of the Laundry Room on 06/03/25, at approximately 1:20 PM, conducted alongside the Regional Director of Maintenance (RDM) #90, revealed the venting system in the dirty laundry room-which is essential for maintaining negative pressure-was not functioning. Additionally, the air conditioning unit in the clean laundry room was also inoperable. The failure to keep the venting system in proper working condition potentially posed a risk to the health and safety of residents, staff, and visitors at the facility. The venting system was designed to create a negative pressure environment in the dirty laundry room, which helps prevent microorganisms from entering the clean laundry room. Without this negative pressure, microorganisms from the dirty laundry room might transfer to the clean laundry room each time the connecting door is opened. During an interview with Housekeeping Staff (HS) #82, #84, and #87 on 06/04/25 at approximately 1:15 PM, they confirmed the venting system had not been operational for over one (1) month. RDM #90, on 06/04/25 at 11:55 AM, confirmed the venting system was not operational. He stated he was working to get the venting system in the laundry room operational before the end of the day. B2) Shower Rooms: On 06/03/25, at approximately 1:14 PM, an inspection of the two shower rooms was conducted with RMD #90. During the inspection, it was observed soiled linen and trash had not been removed from the shower rooms. RMD #90 confirmed the trash should have been collected and the shower rooms should have been cleaned. Additionally, the shower rooms were humid, had a musty smell, and displayed a black substance on the walls of the shower stalls. RDM #90 confirmed the shower rooms were warm, moist, and humid. He also confirmed the shower walls needed to be cleaned. B3) Laundry: The facility failed to implement proper infection control protocols while using its transport van to take soiled linen to the laundromat weekly for three to four months. During an interview on 06/04/25, at approximately 8:40 AM, Account Manager (AM) #85 mentioned she had been at the facility for about five months. She noted the washing machines have been frequently breaking down. When one or both of the machines are out of order, the laundry staff struggles to manage the daily volume of soiled linen. Since February, AM #85 has been taking loads of soiled linen to a laundromat in town at least once or twice a week. She last visited the laundromat on May 27, 2025, and stated, I can't go while you guys are here. When asked about the process of transporting soiled linen to the laundromat, AM #85 explained she would coordinate the trip with the Activities Director. She mentioned the Activities staff would drive the laundry staff along with the soiled linen to the laundromat. On 06/04/25, at approximately 10:00 AM, Activity Director (AD) #65 stated the following: I try to schedule trips to the laundromat for soiled laundry between taking residents to their appointments. It can be a bit challenging, but we usually take the residents to their appointments first. After , we return to drop off the laundry staff with the soiled laundry at the laundromat. Once we've dropped them off, we go back and take the residents wherever they need to go. Later, we return to pick up the laundry staff. The Administrator confirmed on 06/04/25 at 11:56 AM no arrangements had been made to ensure the van was cleaned and disinfected after transporting the soiled linen. B4) Infection Prevention: The facility failed to provide appropriate infection surveillance by not creating and implementing a plan to disinfect the van after transporting soiled laundry. During an interview with Infection Preventionist (IP) #14 at approximately 12:55 PM on 06/04/25, she indicated she was not aware the transport van was being used to carry soiled laundry to the laundromat before transporting residents to their appointments. IP #14 expressed her commitment to ensuring infection prevention protocols are followed in the future when the van is used for transporting soiled linen. The Administrator and Director of Nursing (DON) were notified of the lapse in infection prevention protocols on 06/04/25 at approximately 12:55 PM. B5) Water Management: On 06/04/25, at 2:55 PM, a review of the facility's records revealed the facility did not adequately implement surveillance and control measures. This included a lack of flushing, draining of dead legs, and maintenance of unused showers. While DM #11 provided water temperature monitoring logs and a maintenance service sheet for the ice machine, he was unable to supply logs documenting the flushing of dead ends or the actions taken when control limits were not met. Record review also revealed two (2) resident rooms at the facility had been unoccupied for an extended period of time. room [ROOM NUMBER] had been unoccupied from 05/10/25 to 05/24/25 room [ROOM NUMBER] had been unoccupied from 05/16/25 to 05/27/25 During an interview with DM #11 on 06/04/25 at approximately 11:25 AM, he stated he did not have any logs for the flushing of fixtures in the unoccupied rooms. Senior Administrator (SA) #91 at 12:25 PM on 06/04/25 confirmed there were no flushing or maintenance logs or documentation available. SA #91 further stated she was immediately implementing a policy for logging the flushing and draining dead ends, showers, bed pan sprayers, and fixtures in rooms unoccupied for any length of time. In addition, (SA) #91, on 06/04/25 at 1:35 PM, stated she had begun in-services and education for staff on following infection control protocols when using the van to transport soiled linen to the laundromat. c) Resident wheelchairs in the Hill Top Back Hall 06/03/25 at 2:45 PM, During an observation of Hill Top Back hallway, it was observed resident assigned wheel chairs and one geri chair which were lined up outside the resident's room's had cracks and tears in the arm pads exposing the inner padding. During a walk through and interview with facility Nurse Infection Preventionist, on 06/3/25 at approximately 2:50PM, she acknowledged the wheel chairs were assigned to residents in those rooms on hallway and agreed the wheel chairs and one geri-chair with cracked and torn areas on arm pads were an infection control issue and stated she would report them to the maintenance department for replacement arm pads. c) Resident wheelchairs in the Hill Top Back Hall 06/03/25 at 2:45 PM, During an observation of Hill Top Back hallway, it was observed resident assigned wheel chairs and one geri chair were lined up outside the resident's room's had cracks and tears in the arm pads exposing the inner padding. Staff Interview: 6/3/25 at 12:00 PM During a walk through and interview with facility Nurse Infection Preventionist, on 06/3/25 at approximately 2:50PM, She acknowledged the wheel chairs were assigned to residents in those rooms on hallway and agreed the wheel chairs and one geri-chair with cracked and torn areas on arm pads were an infection control issue and stated she would report them to the maintenance department for replacement arm pads.

Based on observation, resident, and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents in rooms 126, 127, 130, 162, and 163. This was also true for the kitchen and the Shower room, This was a random opportunity for discovery. Facility census: 87. Findings included: a) Upon survey entrance on 06/01/25 at 10:45 am , it was observed the following issues in these resident Rooms: Resident room [ROOM NUMBER]: - toilet seat broken and missing - 1/2 inch size chips in the drywall in bathroom below the light switch - scuff marks in drywall behind the head of resident B's bed Residnet room [ROOM NUMBER]: -Toilet tank lid missing, paint chipped above tissue holder, Scrapes in drywall below light switch Resident room [ROOM NUMBER]: - crack in chair rail behind bed A, - paint peeling right wall below the light switch, - unfinished drywall patch beside tissue paper holder, - brownish stains on the floor at the base of the toilet, - foot rail loose on resident A's bed, Bedside table drawer broken, -black spots on the wall under the sink Resident room [ROOM NUMBER]: - bathroom wall drywall patch unfinished below the light switch Resident room [ROOM NUMBER]: - unfinished drywall patch beside tissue paper holder, Resident room [ROOM NUMBER]: - Black stains in the bottom of toilet bowl, unfinished drywall patch beside tissue paper holder, During a walk through with the Administrator on 06/0/25 at 11:30AM , she acknowledged the unfinished drywall patches, broken, stained toilets, toilet tanks missing lids, loose footrail on bed and broken bedside table drawers in Resident Room #'s 126,127,130,136, and 162. She stated the facility recently hired a new maintenance director and she would make sure the room repairs would be placed on the TELS list. b) During Kitchen visits on 06/02/25 at 11:50 AM and on 06/03/25 at 11:35AM, The following equipment/enviromental issues were observed: - Exhaust fan above the stove and cooking area was not working - Air Conditioning not working in the kitchen causing Temps to be over 91 degrees. Staff was observed with perspiration dripping off their faces during lunch prep on 6/03/25 -Top convection oven broken - side line sink drain lever broken and being held up with a bucket stacked on boxes - Upright freezer empty and not working - spill left on the floor in front of the counter near the serving line area. - the hand washing station trash receptacle foot pedal broken, the kitchen staff are not able to lift the lid after washing hands without contamination. In an interview with the kitchen account manager, on 06/02/25 at 11:40 AM, she stated the exhaust fan had not been working for the past 7 months and the convection oven broke 6 months ago, the trash can in the hand washing station broke a few days ago, but she had not replaced it yet. She also stated the food spill was soup she had spilled earlier and would be cleaning it up after lunch was served. she did not know the staff had placed their drinks in the kitchen cooler but she felt they had put them there due to the heat. She stated it is so hot in the kitchen there hadn't been any air conditioning and there was no heat in the kitchen in the cooler months either and staff had to wear their coats while working last winter. In an interview with the facility administrator on 06/2/25 at 4PM she acknowledged the exhaust fan not working, the broken convection oven, and the broken air conditioning issue with staff dripping sweat and provided verification the exhaust fan parts were ordered on 5/30/25 and then another part ordered on today's date 6/20/25 now awaiting arrival. She stated kitchen staff had 2 ovens they could use the one until the other was fixed and the freezer had been replaced by a chest freezer. She stated she was not aware the trash receptical in the hand washing station was broken. c) Shower Rooms During an inspection of the two shower rooms on 06/03/25, at approximately 1:14 PM, accompanied by the Regional Maintenance Director (RMD) #90. It was observed the ventilation system was not operational. RMD #90 confirmed the system was indeed inactive and repairs were underway to restore functionality as quickly as possible. The shower rooms were humid and had a musty odor. The walls of the shower stalls displayed a black substance, and multiple shower chairs had a brown substance on the undersides of the seats and on the legs. During an interview with Nursing Assistant (NA) #44 on 06/03/25 at approximately 2:00 PM, NA #44 confirmed the venting system in the shower rooms had not been operational for over a month. An interview with the Director of Nursing (DON) was conducted on 06/03/25 at approximately 1:45 PM. She was notified of the findings. DON verbalized her understanding and stated she would check on it.

Based on observation and interviews, the facility failed to ensure there was adequate ventilation in the shower rooms and dirty laundry rooms. This failed practice had the potential to harm multiple residents at the facility. Location Identifiers: Shower rooms and Dirty laundry room. Facility Census:87 Findings include: a) Shower Rooms: On 06/03/25, at approximately 1:14 PM, an inspection of the two shower rooms was conducted, accompanied by Regional Maintenance Director (RMD) #90. It was observed the venting system was not operational. RMD #90 confirmed repairs were underway to restore the venting system as quickly as possible. The shower rooms were humid and had a musty odor. Additionally, the shower stall walls had a black substance present on them, and several shower chairs had a brown substance on the underside of the seats and on the chair legs. Warm, humid environments can increase the likelihood of mold growth on surfaces. Mold-related infections can impact the lungs, sinuses, skin, and in rare instances, other organs. These infections can be severe and potentially life-threatening. During an interview with Nursing Assistant (NA) #44 on 06/03/25 at approximately 2:00 PM, NA #44 confirmed the venting system in the shower rooms had not been operational for over a month. An interview with the Director of Nursing (DON) was conducted on 06/03/25 at approximately 1:45 PM. She was notified of the findings. DON verbalized her understanding and stated she would check on it. b) Dirty Laundry Room On 06/03/25, at approximately 1:20 PM, an inspection of the Dirty Laundry Room was conducted in the presence of the Regional Director of Maintenance (RDM) #90. During the inspection, it was found the venting system, which is crucial for maintaining negative pressure inside the room, was not operational. The failure to maintain a negative pressure in the dirty laundry room potentially allowed the transfer of microorganisms from the dirty laundry room into the clean laundry room every time the connecting door was opened. During an interview with Housekeeping Staff (HS) #82, #84, and #87 on 06/04/25 at approximately 1:15 PM, they confirmed the venting system had not been operational for over one (1) month. RDM #90, on 06/04/25 at 11:55 AM, confirmed the venting system was not operational. He stated he was working to get the venting system in the laundry room operational before the end of the day.

Based on observation, inspection, and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Location Identifiers: Laundry rooms and Shower rooms. Facility Census:87. Findings Include: a) Laundry Rooms On 06/03/25, at approximately 1:20 PM, an inspection of the laundry rooms was conducted, accompanied by the Regional Director of Maintenance (RDM) #90. During the inspection, it was noted the venting system in the dirty laundry room, which is responsible for maintaining negative pressure in the room, was not operational. Additionally, the air conditioning unit in the clean laundry room was also non-functional. The failure to maintain the venting system's operational status created a potential risk of harm to residents, staff, and visitors at the facility. The venting system was designed to create negative pressure in the dirty laundry room, which helped prevent microorganisms from moving into the clean laundry room. However, the lack of negative pressure in the dirty laundry room could potentially allow microorganisms to transfer into the clean laundry room whenever the connecting door is opened. During an interview with Housekeeping Staff (HS) #82, #84, and #87 on 06/04/25 at approximately 1:15 PM, they confirmed the venting system had not been operational for over one (1) month. RDM #90, on 06/04/25 at 11:55 AM, confirmed the venting system was not operational. He stated he was working to get the venting system in the laundry room operational before the end of the day. b) Shower Rooms: On 06/03/25, at approximately 1:14 PM, an inspection of the two shower rooms was conducted, accompanied by Regional Maintenance Director (RMD) #90. It was observed the venting system was not operational. RMD #90 confirmed this and stated repairs were underway to restore the system as quickly as possible. The shower rooms had high humidity and a musty odor. RDM #90 confirmed the shower rooms were warm, moist, and uncomfortable. He stated he was working to quickly get the ventilation system operational. During an interview with Nursing Assistant (NA) #44 on 06/03/25 at approximately 2:00 PM, NA #44 confirmed the venting system in the shower rooms had not been operational for over a month. The Administrator and DON were notified of the issues with the shower rooms on 06/03/25 at approximately 3:00 PM.

Based on observation and staff interview, the facility failed to provide sufficient hallway space and equipment r/t resident wheel chairs lined up down both sides of the hallway on Hill Top Front Hall leaving no direct path. This was a random opportunity for discovery. Facility Census 87 Findings Included: Observation: On 06/03/25 at 3:30 PM, it was observed in the Hill Top Front Hallway, the resident wheel chairs were lined up on both sides of the hallway leaving all who walked through without a direct path. Staff Interview: In an Interview with The Facility Administrator on 6/4/25 at approx 2:50PM, she acknowledged the insufficient space/direct path for walking down the Hill Top Front Hallway.

Based on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. This is true for the facility kitchen and nourishment pantries. This had the potential to affect all residents in the facility. Facility census 87. Findings Included: a) On 06/02/25 at 11:35 am during the Initial Brief Tour of Kitchen, with the Kitchen Account Manager the following issues were found in the kitchen pantry, cooler, and utensil drawers : Pantry: - Spices in the cooking area left open and exposed. - Corn muffins mix box was left open and exposed. - Box of elbow noodles stored labeled with no opening date or expiration date. - Spaghetti with an expiration date of 5/9/25 still in the pantry on 6/2/25. b) Cooler: - Staff personal drinks (An energy drink and a mountain dew) were found in the kitchen cooler c) Cleanliness: - Food spills in the floor at/near food prep area not cleaned up. _ Metal basin pan left in the floor next to the wall and stove. d) Utensil Drawers: - The bottom utensil drawer had dried food spots on the inside top and sides. The utensils were not stored correctly, not facing all in the same direction. e) Improper hair/beard covering: - Chef with hair and beard not completely covered. He was wearing a hat with hair exposed at the neck. Food Storage Policy: On 06/03/25 at 1:00 PM a review facility policy labeled HCSG Policy 018, Food Storage: Dry Goods Procedures #5 stated All packaged and canned food items will be kept clean, dry and properly sealed and #6 stated Storage areas will be neat, arranged for easy identification, and date marked as appropriate. Staff Interviews: During a walkthrough and interview with the Kitchen Account Manager, she acknowleged the Spices left opened, Corn muffins box mix left open, elbow noodles stored incorrectly dated, and the spaghetti with an expired date. She also stated she was not aware of the staff personal drinks left in the kitchen cooler and removed them. On 06/02/25 at 12:15PM, in an interview with The chef he acknowledged he was not wearing a beard or hairnet. He stated he did not know the cap/hat was not enough coverage and that his beard was too short to have to be covered. During a Kitchen Visit on 6/3/25 at 2:15PM, the kitchen room tempertures were taken and the temperatures in the kitchen were 91 degrees as the AC was broken. The Cooler temperature was checked and found that the cooler was at 51 degrees due to excessive heat in the kitchen. Staff interviews: Kitchen Account Manager: During an interview with the Kitchen Account Manager on 06/03/25 at 2:30PM, She acknowledged the high temperture in the kitchen and the cooler and stated the air conditioner had not been working and the cooler had trouble keeping the temperature correct for food storage. Facility Administrator: In an interview with the facility administrator on 06/2/25 at 4:00 PM she acknowledged the above Temperatures in the kitchen and in the cooler. b) Nutrition room one: - On 6/03/25 at 11:55AM, it was observed the refridgerater in the Nutrition Room One was at 44 degrees and a review of the refrigerator temp log, the tempertures on 06/03/2025 was 44 degrees, 6/02/25 was at 42 degrees, and 6/01/25 was at 44 degrees. The log stated the corrective action was ROOM HOT, and a bowl of oatmeal with the lid open and exposed was left from breakfast, sitting on the counter in Nutrition Room One, Not labeled. Staff Interview: - On 6/03/25 at 12:00PM, In an interview with Empolyee #26, she acknowledged the oatmeal on the counter and stated the Nutrition Room gets really hot due to the ice machine. When it is running, it causes the room to be really hot and the refrigerator can't keep up and once the ice machine stops making ice, the room cools down again. c) Nutrition room [ROOM NUMBER] On 06/03/25 at 12:35PM while checking Nutrition room [ROOM NUMBER], it was observed a tray of medicine pudding cups from food service was left in the refrigerator unlabeled without dates. Staff Interview: In an interview with The Nurse Infection Preventionist, she acknowledged the pudding cups in the fridge with out labels and dates. She stated these came from food service this way and said they should have been labeled and dated.

Based on observations, staff and resident interviews, and record reviews, the facility failed to ensure food was palatable, visually appealing, and served in a manner consistent with residents' preferences. The facility was unable to incorporate individualized dietary preferences into the care planning process, was unable to deliver food met resident expectations for seasoning and appeal, and failed to ensure systemic measures were in place to verify meal quality through test trays. Environmental issues and kitchen disorganization further contributed to diminished quality of meal service. These failed practices had the potential to contribute to resident dissatisfaction, poor nutritional intake, and a decline in quality of life. This was true for Five (5) of five (5) residents reviewed for food satisfaction. Resident Identifiers: #31, #52. #66, #50 and #23. Facility census: 87. Findings: a) Resident #31 On 06/02/25 at 1:02 PM, Resident #31 was interviewed and stated meals were bland, sometimes cold, and sometimes served late. The resident stated individual preferences were not routinely accommodated and food options were generally not personalized. On 06/03/25 at 1:12 PM, the surveyor observed the resident's lunch tray. It was an egg salad sandwich with a vegetable mash side. The food lacked seasoning and visual appeal. There were no garnishings or condiments provided to enhance the flavor or presentation of the meal. A review of the care plan revealed no documentation of Resident #31's dietary preferences, food dislikes, or specific modifications related to cultural, personal, or medical food preferences. No interventions were listed to support resident satisfaction with meals. On 06/04/25, during an interview with the dietary manager, she acknowledged resident food preferences were not gathered routinely except during her semiannual walk-through and at biannual food committee meetings. She stated staff, such as CNAs were expected to relay resident concerns during mealtimes if preferences changed. She further commented due to the dilapidated kitchen conditions, she was doing everything [she] can to meet requests. Additionally, despite surveyor requests for test trays to assess food temperature, appearance, and taste due to resident complaints, no trays were provided on either 06/03/25 or 06/04/25. On 06/04/25 at 1:25 PM, the dietary manager stated she had placed the trays on the final meal cart but had not followed up to ensure delivery. She acknowledged , by time, food temperatures would not be accurate for evaluation. On 06/04/25 at approximately 1:15 PM, the facility administrator confirmed the survey team had not been notified when the trays were placed and had not received them. Environmental observations in the kitchen on 06/02/25 and 06/03/25 showed poor sanitation, broken equipment (non-functioning oven, inadequate refrigeration, and no ventilation or air conditioning), and unsafe food storage conditions. These issues further compromised food quality and the ability to provide meals consistent with acceptable standards. b) Resident #52 06/02/25 at 10:23 AM, Resident # 52 stated the food is cold and both over cooked and undercooked. The meat was tuff and potatoes were not done. The vegetables were mushy and overcooked. c) Resident #66 On 06/02/25 at 9:49 PM, Resident #66 was interviewed. He stated the food is bad. He stated he pays so much to live there and can't get a decent meal and the vegetables were mushy from being overcooked. He stated he would love to have some fresh vegetables. d) Resident #50 In an interview with Resident #50 on 06/02/25 at 09:30 AM She sated the food is terrible, It has no seasoning and is often cold and the vegetables are mushy. e) Resident #23 During an interview with Resident #23 on 06/02/25 at 10:04 AM, she stated the food is not good. The steak was cold and tough, but the potatoes were not done. f) Based on resident complaints regarding the taste of the food, test trays were ordered from the kitchen on 06/03/25 and on 06/04/25. The kitchen did not deliver the two requested test trays on 06/03/25 and 06/04/25. Staff interviews: On 06/03/25 at 1:45PM, in an interview with The Kitchen Account Manager, she stated the test tray was forgotten and would send one the next day. On 06/04/25 at 10:00AM in an interview with The Kitchen account Manager, she stated she would make sure a regular test tray and an optional test tray would be made for the survey team. On 06/04/25 at 1:20PM, during an interview with The Kitchen Account Manager, she stated she had made the test trays herself and did not know why the survey team had not received them. She checked the food carts and the test trays were still on the cart confirming they were not delivered to the survey team. On 06/04/25 at approximately 2:15 PM the facility administrator was asked about the Survey team not receiving a taste test tray, due to residents complaining about the taste of the food. Administrator stated I'm not sure why you all did not get a tray, they put it on the last cart going out, however the surveyors should have been notified by kitchen staff when the tray was sent to the hall. Confirming the surveyors did not get a tray to taste test on 06/03/25 or 06/04/25 was requested and made aware of by surveyors to the Dietary Manager.

Based on observations and staff interviews the facility failed to ensure kitchen staff were provided education/training on how to use the fire compression system. This had the potential to affect all residents in the facility. Facility Census 87 Findings included: During a kitchen visit on 6/3/25 at 2:15 PM, It was observed there was not a manual pull chain for the fire system. When asked, the kitchen staff did not know how to manually activate the fire hood to extinguish a fire. Upon speaking with maintenance department, he showed the staff and survey team the button to activate the fire hood, until that moment, the kitchen staff did not know how to activate the fire compression system . On 06/03/25 at 2:24 PM, in an interview with the Maintenance Director, he verified there was a button staff can push to activate the fire compression system in case of a fire.

Based on observation and staff interviews, the facility failed to dispose of garbage and refuse properly. This had the potential to affect all residents in the facility. Facility Census 87 Findings included: a) Kitchen side sink counter: On the initial vist to the kitchen on 06/02/25 at 11:45AM, it was observed that boxes and trash were in the floor next to a full trash cane beside the side sink counter and stacked containers of food left on the side sink counter in the kitchen during lunch prep. b) Dumpster Area: On 06/03/25, at approximately 1:40PM it was observed there were 3 dumpsters: - The left dumpster was found with a broken tree branch protruding from the drainage pipe, blocking drainage. - The middle dumpster was found with a garbage bag and used clear gloves scattered on the ground behind it. - The right dumpster was found to have a plastic garbage bag with trash in it, protruding from the drainage pipe blocking drainage. Staff interviews: In an interview with the Kitchen Account Manager on 06/02/25 at 11:45AM, she stated the stacked containers were expired food that was to be disposed of but the trash can was already over flowing and that all of it should have been be taken out. On 06/03/25 at 2:35PM, in an interview with the Kitchen Account Manager, she acknowleged the dumpster areas and issues and stated she did not know the dumpster drains were blocked and the trash littered on the ground was not from the kitchen. The kitchen does uses black gloves only.

Based on record review and staff interview, the facility failed to ensure transfer/discharge notice was given prior to residents leaving the facility. THis was found true for 1 of 2 residents reviewed for closed record review regarding hospitalization and discharge. Resident identifier: #89 Facility Census: 89 Findings Include: During a record review on 06/04/25 at 3:30 PM of Resident #89's record no transfer/discharge notice was found, documentation was requested from the Director of Nursing (DON)) and the Administrator. On 06/05/25 at 9:14 AM, the Administrator stated we do not have the transfer/discharge for Resident #89, they went out for a procedure then went home and I guess they (facility staff) didn't think they needed to do it for some reason. Confirming no transfer/discharge paperwork was completed.

Based on interview, record review and policy review the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for 0ne (1) of one (1) residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: #72. Facility census: 84. Findings Included: a) Policy review Record review of the facility's policy titled, grievance /concern, showed: -Upon receipt of the grievance / concern, the grievance / concern form will be initiated by staff member receiving the concern. -Upon receipt of the grievance /concern form, the Administrator or designee will document the grievance / concern on the grievance / concern log. - Immediate action will be taken to prevent further potential violations of any patient right while the alleged violation is being investigated. -Notify the person filing the grievance of resolution in a timely manner. b) Resident #72 On 10/23/23 at 12:52 PM during an interview with Resident #72 she stated that she made a complaint about another Resident peering in her room, a month ago. Resident #72 stated that nothing was ever done about the issue. 10/23/23 a record review of the grievances log revealed no issues were documented for Resident #72. A continued record review of Resident #72's Quarterly 09/07/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. Resident #72 has capacity. 10/25/23 at 9:29 AM during an Interview the Social Worker (SW) #67, stated she was aware of the concern, and she stated she educated the male resident #11 and followed up with resident #72 at the time of grievance. She was asked to provide documentation from the issue. On 10/25/23, at 12:25 pm SW #67 provided social services notes for Resident #72 with the effective date of 09/28/23 at 11:28 AM late entry with the created date today, 10/25/23 at 11:28 AM for the grievance noted. She also provided two (2) Social service notes, one dated 08/28/23 for Resident #11 revealing he was educated that he cannot sit outside female resident rooms. Second note with the effective date 09/28/23 at 2:00 PM late entry with the created date today, 10/25/23 at 11:51 AM with education about sitting outside female resident rooms particularly when they were sleeping. On 10/25/22 at 12:48 PM, an interview with the Administrator confirmed, there was no documentation for Resident #72's grievance and she advised the SW #67 to complete progress notes on this date about the 09/28/23 grievance.

Based on observation and staff interview the facility failed to have cans with uncompromised seals, dishware stored inverted or covered, supplies stored off the floor, and clean sanitized mobile utility food carts. This has the potential to affect all residents that get their nutrition from the kitchen. Facility census. 84. Findings included: a) Kitchen tour During Initial tour on 10/23/23 at 10:44 AM found: 1- two (2) food #10 cans with dented compromised seals. 2- two (2) mobile utility carts with food on them, having old food and other debris on all three (3) shelves. 3-dish stored inverted with dust and debris in bowls and cups. 4- Items such as open paper towels in the dry storage, stored on the floor. An Interview with the Dietary Manager during initial tour verified all issues noted. She stated that she was unaware of the issues, and she would fix the issues.

Based on observation, record review, resident and staff interview, the facility failed to ensure each resident received care consistent with professional standards of practice following physician's orders to treat pressure sores. This was true for one (1) of one (1) resident reviewed during the Long-Term Care Survey Protocol for the care area of pressure ulcers. Resident #17 was not provided the treatment in accordance with physician's orders. Resident identifier: Resident #17. Census: 84. Findings included: An interview, with Resident #17, on 10/23/23 at 1:27 PM, revealed the resident was receiving cream to an area on the back and buttocks due to having had problems with pressure ulcer development. An observation of the treatment , performed by Registered Nurse (RN) #74 on 10/24/23 at 12:30 PM, revealed RN #74, cleansed the area on Resident #17's back and buttocks with Wound cleanser and applied and Optifoam dressing to both areas. A record review , of the treatment orders, did not include an order for wound cleanser and an Optifoam dressing. for the area treated on the back and buttocks of Resident #17. An interview, with the Director of Nursing (DON) on 10/24/23 at 2:06 PM, revealed there was no current physician's order for the treatment performed by RN #74 and stated further she had reviewed the record and contacted the Nurse Practitioner for clarification. The DON explained after reviewing the medical record and discussion with Nurse Practitioner, there was no order for the resident to receive the treatment observed and the resident should not have received the Optifoam dressing to the two areas performed by RN #74 .

Based on observation, and staff interview, the facility failed to ensure personal privacy and confidentiality of personal and medical information contained in the electronic health record. This deficient practice was based on a random opportunity for discovery for Resident #17, whose Medication Administration Record (MAR) was not secured but left open and visible for all who passed by the area to view. Resident identifier: Resident #17. Census: 84. Findings included: a) Resident #17 A review of Policy 0PS209 Privacy Rights :Patient, dated 11/28/16. noted the patient has a right to personal privacy and confidentiality of there personal and medical records. An observation of medication administration, on 10/24/23 at 08:25 AM, revealed Registered Nurse (RN) #74 prepared the medications and entered Resident #17's room to administer the medications. RN #74 failed to secure the computer screen before leaving the cart, leaving the medical and personal information of Resident #17 available to view by any passerby. The information that was in plain view, included the resident's name and room number, diagnoses of the resident and medications the resident was being prescribed. An interview was conducted, with RN #74, when the nurse returned to the medication cart on 10/24/23 at 08:33 AM, RN #74 confirmed the Medication Administration Record for Resident #17 was left visible while administering the medications to the resident, remained visible when the nurse returned, and there were individuals present in the hallway that was not privileged to the personal and medical information of Resident #17. RN #74 stated my bad, I know to close that screen and failed to do so.

Based on record review and staff interview, the facility failed to identify a psychiatric diagnosis of depression for Resident #78. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #78. Facility Census: 84. Findings Included: a) Resident #78 On 10/24/23 at 9:43 AM, a record review was completed for Resident #78. The review found the resident was prescribed Cymbalta (antidepressant) 30mg (milligram) daily for depression with a start date of 09/22/23. The Minimum Data Set (MDS) with the assessment reference date (ARD) of 09/27/23 was reviewed and section I (psychiatric/mood disorder) found a no which indicates the resident did not have a diagnosis of depression. On 10/25/23 at 11:04 AM, an interview was held with the Director of Nursing (DON). The DON stated, there is no documented diagnosis of depression listed on the MDS. No further information was obtained during the long-term survey process.

Based on record review and staff interviews, the facility failed to ensure the resident's Pre-Admission Screening (PAS) reflected pre-admission diagnoses for one (1) of three (3) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier #77. Census 84. Findings Included: a) Resident #77 On 10/16/23, a record review of the resident's electronic medical record (EMR), found the resident's Admission PASARR, dated 06/09/23, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated None. A continued record also revealed the resident received a psych diagnosis of schizoaffective disorder on the diagnosis listed on admission 06/12/23 but did not receive a new PAS to address whether or not specialized services were needed. On 10/24/23 at 1:24 PM, an interview with the Administrator confirmed the admission PAS presented to the surveyor did not indicate a diagnosis of schizoaffective disorder and a new PAS was not completed for schizoaffective disorder upon Admission.

Based on observation, record review, resident interview and staff interview, the facility failed to develop and/or implement a care plan regarding refusal of care for Resident #82 and the use of a right hand splint for Resident #76. This was true for two (2) of 18 residents reviewed during the survey process. Resident Identifiers: #82 and #76. Facility Census: 84. Findings Included: a) Resident #82 On 10/23/23 at 11:15 AM, the resident was observed and appeared to be somewhat disheveled. A record review was completed on 10/23/23 at 12:16 PM. The review found multiple refusals of showers and bed baths documented. The resident had only two (2) showers documented in September, 2023 and one (1) shower and two (2) bed baths documented in October, 2023. The following dates of refusals are as follows: --09/18/23 --09/21/23 --09/27/23 --09/29/23 --09/30/23 --10/02/23 --10/03/23 --10/06/23 --10/09/23 --10/11/23 --10/16/23 --10/18/23 The care plan indicates the resident needs extensive assistance of one (1) staff member for bathing. However, the care plan does not list refusals of care under a behavior monitoring focus. On 10/24/23 at 1:10 PM, the Administrator was notified and confirmed a focus area of refusals of care had not been developed on the care plan. No further information was obtained during the long-term survey process. b) Resident #76 On 10/23/23 at 11:46 AM, an initial observation found a right hand splint laying on the night stand by Resident #76's bed. The resident was asked, when do you wear your splint? The resident responded, I haven't worn it since I've been out of therapy. On 10/24/23 at 12:18 PM, an additional observation was made of the right hand splint laying on the night stand. The resident was again asked, have you worn your hand splint? The resident responded, nope .they haven't put it on me. On 10/24/23 at 12:42 PM, a physician's order dated 09/06/23 was found. The physician's order stated, Patient to donn R (right) hand splint for up to 6 (six) hr/day (hours per day) or as patient tolerates to prevent contractures with skin checks prn (as needed). A record review on 10/24/23 at 1:00 PM, discovered physical therapy (PT) had been discontinued on 09/01/23 and occupational therapy (OT) was discontinued on 09/06/23. The care plan does not identify the use of a hand splint or prevention of contractures. On 10/25/23 at 9:30 AM, the Director of Nursing (DON) stated, there is no documentation of the splints being applied .therapy put the order in .and they are not allowed to put in orders. No further information was obtained during the long-term survey process.

Based on observation, record review and staff interview, the facility failed to revise a care plan for one (1) of 18 sampled residents, when an assessment was made with additional information obtained regarding resident's care and or behavior. Resident #47 was known by staff to adjust/alter oxygen flow rates but this behavior was not included in the resident's care plan revision. Resident identifier: Resident #47. Census: 84. Findings included: a) Resident #47 An observation, on 10/22/23 at 12:22 PM, showed oxygen was being administered to Resident #47 at a rate of 4.5 liters/minute (L/min). During the observation, the resident's spouse revealed, Resident #47 would adjust the flow rate depending on how he was feeling. Resident #47 confirmed this. A record review revealed Resident #47 was to receive oxygen at 3.0 L/min via nasal cannula continuously as resident will allow every day and night shift. A review of the current comprehensive resident centered care plan, last review of 08/11/23, showed the resident was diagnosed with Chronic Obstructive Pulmonary Disease, and was to be administered oxygen therapy in accordance with the physician's orders. There was no evidence the resident altered the flow rate and an intervention to ensure effective and correct implementation of the physician's orders. An observation, made with Registered Nurse (RN) #71, on 10/24/23 at 1:30 PM, revealed oxygen was being administered to Resident #47 at a rate of four (4) L/min. RN #71 confirmed the flow rate of 4 L/min. A review of the medical record by RN #71 and RN #74 on 10/24/23 at 1:38 PM, verified the physician's order was for Resident #47 to receive oxygen therapy with a flow rate of 3 L/min. RN #71 stated , at this time, Resident #74 must have turned it up. An additional interview with RN #74, on 10/24/23 at 1:45 PM, revealed Resident #47 was known to make adjustments to the oxygen flow rate and had been spoken to about the importance of not self adjusting the oxygen. A review of the care plan did not show any evidence Resident #47 made adjustments to the oxygen flow rate, or any goal or approaches to monitor the resident altering the treatment ordered by the physician. An interview, with the DON at 10/24/23 2:12 PM, verified the resident adjusting the oxygen incorrectly should have been care planned and the care plan had the current care plan not been revised to reflect the residents behavior of self adjusting the oxygen and should have been.

Based on observation, record review, resident interview and staff interview, the facility failed to follow a physician's order regarding right hand splint application for Resident #76 and complete neurological (neuro) checks after a fall for Resident #17. This was true for two (2) of 18 residents reviewed during the long-term survey process. Resident Identifiers: #76 and #17. Facility Census: 84. Findings Included: a) Resident #76 On 10/23/23 at 11:46 AM, an initial observation found a right hand splint laying on the night stand by Resident #76's bed. The resident was asked, when do you wear your splint? The resident responded, I haven't worn it since I've been out of therapy. On 10/24/23 at 12:18 PM, an additional observation was made of the right hand splint laying on night stand. The resident was again asked, have you worn your hand splint? The resident responded, nope .they haven't put it on me. On 10/24/23 at 12:42 PM, a physician's order dated 09/06/23 was found. The physician's order stated, Patient to donn R (right) hand splint for up to 6 (six) hr/day (hours per day) or as patient tolerates to prevent contractures with skin checks prn (as needed). A record review on 10/24/23 at 1:00 PM, discovered physical therapy (PT) had been discontinued on 09/01/23 and occupational therapy (OT) was discontinued on 09/06/23. On 10/25/23 at 9:30 AM, the Director of Nursing (DON) stated, there is no documentation of the splints being applied .therapy put the order in .and they are not allowed to put in orders. No further information was obtained during the long-term survey process. b) Resident #17 1) A review of the Policy and Procedure, NSG204 Neurological Evaluation, with a revision date of 06/01/21, showed the Neurological evaluations would be performed when a resident sustained an injury to the face. The policy showed the neurological evaluation would be performed every 15 minutes for two (2) hours then every 30 minutes for two hours then every 60 minutes for four hours then every eight (8) hours until at least 72 hours had elapsed or as ordered by the physician. An observation, on 10/23/24, at 12:05 PM, revealed Resident #17 had bruising about the face. Resident #17 stated at this time, she had sustained a fall in the bathroom hitting her head. A record review on 10/24/23, revealed the resident had sustained a fall which involved hitting her head/face on 10/11/23. Further review of the documentation showed evidence of a neurological evaluation being completed at 11:30 AM with no evidence of another neurological evaluation for 10/11/23 at 11:45 AM, 12:00 PM, 12:15 PM, 12:30 PM, 12:45 PM, 01:00 PM, 01:15 PM, 01:45 PM, 02:15 PM, 02:45 PM, 03:15 PM. Additionally, there was no evidence of a neurological evaluation being completed on 10/12/23 for 07:15 PM and no evidence of a neurological evaluation being completed on 10/14/23 for the time frame of 11:15 AM or 07:15 PM. An interview, with the Director of Nursing (DON) on 10/24/23 at 03:15 PM, revealed a neurological evaluation was expected to be completed on the times designated based on the policy and procedure. It was stated by the DON, there was no evidence the staff completed the neurological evaluation for the designated time frames required and for 72 hours after the incident occurred and should have been. No further evidence was provided at the time of exit on 10/25/23. 45173

Based on record review and staff interview, the facility failed to complete an annual performance review for Nurse Aide (NA) #66. This was true for one (1) of five (5) employees reviewed under the care area of sufficient and competent staffing. Facility Census: 84. Findings Included: a) Nurse Aide (NA) #66 A review of nursing aide requirements was completed on 10/24/23 at 1:00 PM. The review found NA #66 did not have a current performance evaluation. The last documented performance evaluation was completed in 2019. An interview with the Director of Nursing (DON) on 10/24/23 at 1:50 PM was completed. The DON stated, NA #66 has not had a performance evaluation since 2019 .she worked infrequently while going to nursing school and she was prn (as needed), now she is back. On 10/24/23 at 2:00 PM, the Administrator confirmed a performance evaluation should have been completed. No further information was obtained during the long-term survey process.

Based on observation, record review, resident council meeting, resident interviews, policy review, review of incident reports and staff interview the facility failed to ensure that each resident in the facility had the right to be free from sexual, physical, psychological and verbal abuse. The facility failed to prevent Resident # 44 from wandering about the facility, entering other residents' rooms, evoking resident to resident altercations and causing fear amongst the other residents. These findings were determined to pose an immediate jeopardy and the health and well-being and represents a pattern to affect more than a limited number of residents. The facility administrator was notified of the immediate jeopardy on [DATE] at 10:45 AM. The facility provided an immediate jeopardy abatement plan of correction on [DATE] at 2:20 PM. The abatement plan of correction included: --Resident #44 was placed on one on one supervision on [DATE] at 10:45 AM until an alterntive and equally effective intervention is identified. One [DATE], Resident #44 was sent to the Emergency Department of a local hospital at 1:00 PM for evaluation due to behaviors. --All interviewable residents were interviewed by the staff of the social services department on [DATE] to ensure there were no other residents affected by Resident #44's behavior. The administrator will interview all staff on [DATE] to determine whether they observed any abusive behaviors affecting non-interviewable residents by Resident #44. --On [DATE] Regional Vice President reeducated the Administrator and Social Services Director regarding abuse prohibition and neglect. This abuse prohibition and neglect training and resident rights training was provided to all staff on [DATE], including a posttest. Staff not availble on [DATE] were to be trained and tested prior to their next work shift. The immediacy of this deficient practice was abated on [DATE] at 4:50 PM. The post-abatement scope and severity was at a level H. Resident identifiers: #44, #42, #27, #13 and #14. Facility census: 80. Findings included: a) Resident #44 Observations, [DATE] 01:55 PM, Resident wandering the halls and asking where is the train. Resident #44 is confused and stated he wanted to find a place to sit down and call his own. Further observations on [DATE] and [DATE] the resident was seen wandering in and out of multiple residents rooms. Multiple residents were heard yelling at Resident #44 to get out of their rooms. Resident #44 appeared to be confused and anxious. A medical record review, on [DATE], revealed the resident was admitted to the facility on [DATE] with Dementia with Behavioral Disturbance. A review of the residents nurses progress notes, on [DATE], revealed: - On [DATE] Resident obtained a pocket knife that his roommate had brought to him undetected, and cut the wonder guard off his ankle in hopes of eloping. Resident reports that he wants to go home and states he will leave when he has the opportunity to. Roommates pocket knife was removed from the facility. -On [DATE] Resident keeps trying to escape. Judgement is inappropriate - On [DATE] Dementia stable but expect a decline due to nature of disease process - On [DATE] Resident was seen by the nurse practioner due to nursing reports of increased behaviors of pilfering, pacing increased confusion and bothering other residents. - On [DATE] Resident ambulates independently around facility. He continues to have periods of aggression, agitation, and profound confusion. - On [DATE] resident has increased confusion and wandering throughout this shift - On [DATE] Resident reports from nursing staff reports increased behaviors including pilfering, pacing increased confusion and bothering other residents. - On [DATE] Resident showing aggressive behavior and confusion to his surroundings during dayshift. Resident is threatening to find a gun and utilize it on patients and staff. He continues entering other residents rooms. -On [DATE] Resident to staff altercation at night - On [DATE] Resident to resident altercation - On [DATE] Resident wandering in other resident rooms - On [DATE] Resident ambulates about the facility -On [DATE] Observed resident ambulating in hallway independently - On [DATE] Resident evaluated by nurse practioner for left perioibtal ecchymosis due to a resident to resident altercation - [DATE] Resident is aggressive and saying aggressive comments(IE.wanting to shoot people). Went to woodside and was in an altercation with another resident. - On [DATE] Resident had a resident to resident altercation - On [DATE] Resident continues to wander throughout the facility - On [DATE] Wandering tendency has increased Review of Care Plan, on [DATE], revealed the resident had no focus, goals or interventions for his behaviors and wandering since admission. A review of the physician orders, on [DATE], revealed no medical intervention addressing the residents wandering. Reviewed accidents and incidents reports, on [DATE] at 8:30 AM, revealed Resident #44 had the following multiple incidents: - On [DATE] Resident obtained a pocket knife from his roommate and cut his wonderguard off his leg. - On [DATE] Resident had combative behavior with no injury - On [DATE] Resident had a resident to resident altercation with alleged abuse victim - On [DATE] Resident had a resident to resident altercation with alleged abuse victim resulting in a black eye - On [DATE] Resident had a resident to resident altercation without abuse resulting in a skin tear - On [DATE] Resident wandered into a female resident's room with only a t-shirt on and climbed in bed with her. Resident was escorted out of room. Female resident's roommate had to assist getting Resident #44 out of her roomate's bed and out of their room. An observation, on [DATE] at 9:00 AM, revealed the resident wandering on the same hallway he was moved from on [DATE]. An immediate interview with the Administrator, on [DATE] at 9:05 AM, revealed the intervention for the incident on [DATE] was to move the Resident to another unit further away from the female resident he laid in bed with. The Administrator agreed the room change would not keep Resident #44 from wandering into the female's room again or any other resident's room. b) Resident Council A Resident Council meeting was conducted on [DATE] at 2:50 PM. The group expressed concerns of fear and frustration regarding the wandering behavior of Resident #44. The group discussed the fear that comes with being awakened in the middle of the night by Resident #44's presence in their room. The group stated how his behavior made them feel uncomfortable, anxious, and angry. Some residents even expressed they wanted to physically harm Resident #44. The residents stated they have informed the Administrator of their concerns an her response was to press the call light when Resident #44 enters your room and someone will come and remove him. A review of the facility's policy titled OPS300 Abuse Prohibition with revision date of [DATE] was conducted on [DATE]. The policy stated, Genesis Healthcare Centers will prohibit abuse, mistreatment, neglect, misappropriation of resident property and exploitation of all residents. The Center will implement an abuse prohibition program through the following: - Prevention of Occurrences - Identification of possible incidents and allegations which need investigation - Investigation of incidents and investigations - Protection of patients during investigations - - Reporting of incidents, investigations and Center response to all investigations. The Policy defines Physical Abuse as hitting, slapping, pinching, kicking etc. The Policy defines Mental Abuse as either verbal or nonverbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame agitation and degradation. The Policy defines Verbal Abuse as any use of oral written or gestured language that willfully includes disparaging and derogatory terms to patients regardless of their age, ability to comprehend or their disability. c) Resident #42 An interview was conducted on [DATE] at 11:30 AM with Resident #42. The resident's daughter was present at the time of the interview. Resident #42 said the wandering male resident who lived in the room beside them was in her bed Saturday night/Sunday morning. She said at first she thought it was her deceased husband as she was half asleep, and she tried to push him away from her to give her more room. She said she was on her right side facing the window, and the wandering resident also lay on his right side facing the window with his back toward her. She said she recalled that he wore a t-shirt. She said she did not realize he was nude except for the t-shirt until her room-mate told her so. She said her room-mate saw the wandering resident in Resident #42's bed and then got him out of the room. Resident #42's daughter spoke her belief that the wandering resident was not moved until this morning, and that he now resides on the other side of the building away from these ladies. Upon inquiry, Resident #42 said she was not afraid of the wandering male resident. Her daughter agreed with that statement, but added that the room-mate is afraid of him. Medical record review on [DATE] found this resident had a Brief Interview for Mental Scale (BIMS) score of fourteen (14) at the time of her quarterly minimum data set with assessment reference date [DATE]. A score of fourteen (14) indicates intact cognition. Further medical record review found that on [DATE] the physician determined that she lacked capacity to make medical decisions based on her dementia and the inability to process information. An interview with the administrator on [DATE] in the early afternoon found that the resident slept in his new room in another part of the building last night. She said that staff members are in the process of moving all of his belongings into the new room. On [DATE] at 3:10 PM an interview was conducted with the licensed social worker (LSW). She said she spoke with both the resident and the resident's daughter to see if there may be a need for supportive counseling. She said they told her that Resident #42 was not afraid of the wandering resident, nor was she having negative emotional effects after the incident which occurred Saturday night/Sunday morning. d) Resident #27 An interview was conducted on [DATE] at 11:19 AM with this capacitated resident. She said on Saturday night/Sunday morning a wandering, male resident who wore only a t-shirt wandered into their room. She said he lay down in her room-mate's bed alongside her room-mate. She said she heard him ask her room-mate if her husband was alive. She said she yelled at him to leave the room and he obeyed her. She said she did not have to physically touch him to get him out of the room-mate's bed and out of the room. Rather, she just gave verbal directives. She said she walked with him into the hallway where nursing staff heard them and came to get him. A stop guard net was observed in place at her doorway. The resident said the wandering resident can crawl beneath the stop guard. She said that particular night he entered her room through a bathroom that they share with two (2) other female residents in the next room. She said this wandering resident has been in her room multiple times before, but this was the first time he was naked. She stated I feel lost, afraid. She said she did not sleep well last night from worrying he would return to her room. During an interview with the administrator in the early afternoon on [DATE], she said the wandering resident slept in a room in another part of the building on Sunday night following the incident as they moved him on Sunday to protect this resident and her room-mate. Previously, the wandering resident resided in the room next to Resident #27's room. She said that some of his belongings are still in the former room, but staff is in the process of moving the remainder of his belongings. On Tuesday at 11:00 AM Resident #27 was overheard in the Hill top back hallway approach an unidentified nurse at the counter/med cart/treatment cart area in the hallway. Licensed practical nurse #76 (LPN #76) was also present. Resident #27 reported that she saw the wandering resident in her hallway today. The unidentified nurse told her that they are watching him closely, but that he has the right to walk about the building. Resident #27 told the nurse that she thought he had moved elsewhere in the building. The nurse reassured her that yes, he had moved to another part of the building. On [DATE] at 3:10 PM an interview was conducted with the licensed social worker (LSW). She said she did supportive counseling with Resident #27 who has capacity and who has a [DIAGNOSES REDACTED]. e) Resident #13 A review of the medical record for Resident #13, on [DATE] at 10:00 AM, revealed the latest Minimum Data Set Quarterly Assessment (MDS) was conducted on [DATE]. The Resident obtained a score of 15 on the Brief Interview for Mental Status assessment (BIMS). A score of 15 on the BIMS equates to little or no cognitive impairment. An interview with Resident #13, on [DATE] at 11:00 AM, revealed the Resident is scared of Resident #44. The Resident stated Resident #44 has come into her room daily for months. The Resident stated Resident #44 comes into her room and will not leave for up to 15 minutes at a time. The Resident stated Resident #44 pilfers through her belongings and screams at her. The Resident stated she is scared to sleep at night in fear Resident #44 will come into her room. The Resident is scared Resident #44 may become physical with her. The Resident stated she has told the staff numerous times about Resident #44 coming into her room and they do nothing. f) Resident #14 A review of the medical record for Resident #14, on [DATE] at 10:15 AM, revealed the latest Minimum Data Set Quarterly Assessment (MDS) was conducted on [DATE]. The Resident obtained a score of 15 on the Brief Interview for Mental Status assessment (BIMS). A score of 15 on the BIMS equates to little or no cognitive impairment. An interview with Resident #14, on [DATE] at 11:15 AM, revealed the Resident is scared of Resident #44. The Resident stated Resident #44 repeatedly comes into her room day and night. The Resident stated Resident #44 comes into her room and will not leave unless she screams and threatens to hit him. The Resident stated Resident #44 throws her belongings off her bed and table and yells at her. The Resident stated she does not feel safe in her room because of what Resident #44 may do when the staff is not around. The Resident stated her fear is affecting her sleep at night. The Resident stated she has told numerous staff members many times about Resident #44 invading her personal space. The Resident stated the staff does not care that Resident #44 comes into her room.

Based on observation, record review, resident council meeting, resident interviews, policy review, review of incident reports and staff interview the facility failed to ensure that each resident in the facility had the right to be free from sexual, physical, psychological and verbal abuse. The facility failed to prevent Resident # 44 from wandering about the facility, entering other residents' rooms, evoking resident to resident altercations and causing fear amongst the other residents. These findings were determined to pose an immediate jeopardy and the health and well-being and represents a pattern to affect more than a limited number of residents. The facility administrator was notified of the immediate jeopardy on [DATE] at 10:45 AM. The facility provided an immediate jeopardy abatement plan of correction on [DATE] at 2:20 PM. The abatement plan of correction included: --Resident #44 was placed on one on one supervision on [DATE] at 10:45 AM until an alterntive and equally effective intervention is identified. One [DATE], Resident #44 was sent to the Emergency Department of a local hospital at 1:00 PM for evaluation due to behaviors. --All interviewable residents were interviewed by the staff of the social services department on [DATE] to ensure there were no other residents affected by Resident #44's behavior. The administrator will interview all staff on [DATE] to determine whether they observed any abusive behaviors affecting non-interviewable residents by Resident #44. --On [DATE] Regional Vice President reeducated the Administrator and Social Services Director regarding abuse prohibition and neglect. This abuse prohibition and neglect training and resident rights training was provided to all staff on [DATE], including a posttest. Staff not availble on [DATE] were to be trained and tested prior to their next work shift. The immediacy of this deficient practice was abated on [DATE] at 4:50 PM. The post-abatement scope and severity was at a level H. Resident identifiers: #44, #42, #27, #13 and #14. Facility census: 80. Findings included: a) Resident #44 Observations, [DATE] 01:55 PM, Resident wandering the halls and asking where is the train. Resident #44 is confused and stated he wanted to find a place to sit down and call his own. Further observations on [DATE] and [DATE] the resident was seen wandering in and out of multiple residents rooms. Multiple residents were heard yelling at Resident #44 to get out of their rooms. Resident #44 appeared to be confused and anxious. A medical record review, on [DATE], revealed the resident was admitted to the facility on [DATE] with Dementia with Behavioral Disturbance. A review of the residents nurses progress notes, on [DATE], revealed: - On [DATE] Resident obtained a pocket knife that his roommate had brought to him undetected, and cut the wonder guard off his ankle in hopes of eloping. Resident reports that he wants to go home and states he will leave when he has the opportunity to. Roommates pocket knife was removed from the facility. -On [DATE] Resident keeps trying to escape. Judgement is inappropriate - On [DATE] Dementia stable but expect a decline due to nature of disease process - On [DATE] Resident was seen by the nurse practioner due to nursing reports of increased behaviors of pilfering, pacing increased confusion and bothering other residents. - On [DATE] Resident ambulates independently around facility. He continues to have periods of aggression, agitation, and profound confusion. - On [DATE] resident has increased confusion and wandering throughout this shift - On [DATE] Resident reports from nursing staff reports increased behaviors including pilfering, pacing increased confusion and bothering other residents. - On [DATE] Resident showing aggressive behavior and confusion to his surroundings during dayshift. Resident is threatening to find a gun and utilize it on patients and staff. He continues entering other residents rooms. -On [DATE] Resident to staff altercation at night - On [DATE] Resident to resident altercation - On [DATE] Resident wandering in other resident rooms - On [DATE] Resident ambulates about the facility -On [DATE] Observed resident ambulating in hallway independently - On [DATE] Resident evaluated by nurse practioner for left perioibtal ecchymosis due to a resident to resident altercation - [DATE] Resident is aggressive and saying aggressive comments(IE.wanting to shoot people). Went to woodside and was in an altercation with another resident. - On [DATE] Resident had a resident to resident altercation - On [DATE] Resident continues to wander throughout the facility - On [DATE] Wandering tendency has increased Review of Care Plan, on [DATE], revealed the resident had no focus, goals or interventions for his behaviors and wandering since admission. A review of the physician orders, on [DATE], revealed no medical intervention addressing the residents wandering. Reviewed accidents and incidents reports, on [DATE] at 8:30 AM, revealed Resident #44 had the following multiple incidents: - On [DATE] Resident obtained a pocket knife from his roommate and cut his wonderguard off his leg. - On [DATE] Resident had combative behavior with no injury - On [DATE] Resident had a resident to resident altercation with alleged abuse victim - On [DATE] Resident had a resident to resident altercation with alleged abuse victim resulting in a black eye - On [DATE] Resident had a resident to resident altercation without abuse resulting in a skin tear - On [DATE] Resident wandered into a female resident's room with only a t-shirt on and climbed in bed with her. Resident was escorted out of room. Female resident's roommate had to assist getting Resident #44 out of her roomate's bed and out of their room. An observation, on [DATE] at 9:00 AM, revealed the resident wandering on the same hallway he was moved from on [DATE]. An immediate interview with the Administrator, on [DATE] at 9:05 AM, revealed the intervention for the incident on [DATE] was to move the Resident to another unit further away from the female resident he laid in bed with. The Administrator agreed the room change would not keep Resident #44 from wandering into the female's room again or any other resident's room. b) Resident Council A Resident Council meeting was conducted on [DATE] at 2:50 PM. The group expressed concerns of fear and frustration regarding the wandering behavior of Resident #44. The group discussed the fear that comes with being awakened in the middle of the night by Resident #44's presence in their room. The group stated how his behavior made them feel uncomfortable, anxious, and angry. Some residents even expressed they wanted to physically harm Resident #44. The residents stated they have informed the Administrator of their concerns an her response was to press the call light when Resident #44 enters your room and someone will come and remove him. A review of the facility's policy titled OPS300 Abuse Prohibition with revision date of [DATE] was conducted on [DATE]. The policy stated, Genesis Healthcare Centers will prohibit abuse, mistreatment, neglect, misappropriation of resident property and exploitation of all residents. The Center will implement an abuse prohibition program through the following: - Prevention of Occurrences - Identification of possible incidents and allegations which need investigation - Investigation of incidents and investigations - Protection of patients during investigations - - Reporting of incidents, investigations and Center response to all investigations. The Policy defines Physical Abuse as hitting, slapping, pinching, kicking etc. The Policy defines Mental Abuse as either verbal or nonverbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame agitation and degradation. The Policy defines Verbal Abuse as any use of oral written or gestured language that willfully includes disparaging and derogatory terms to patients regardless of their age, ability to comprehend or their disability. c) Resident #42 An interview was conducted on [DATE] at 11:30 AM with Resident #42. The resident's daughter was present at the time of the interview. Resident #42 said the wandering male resident who lived in the room beside them was in her bed Saturday night/Sunday morning. She said at first she thought it was her deceased husband as she was half asleep, and she tried to push him away from her to give her more room. She said she was on her right side facing the window, and the wandering resident also lay on his right side facing the window with his back toward her. She said she recalled that he wore a t-shirt. She said she did not realize he was nude except for the t-shirt until her room-mate told her so. She said her room-mate saw the wandering resident in Resident #42's bed and then got him out of the room. Resident #42's daughter spoke her belief that the wandering resident was not moved until this morning, and that he now resides on the other side of the building away from these ladies. Upon inquiry, Resident #42 said she was not afraid of the wandering male resident. Her daughter agreed with that statement, but added that the room-mate is afraid of him. Medical record review on [DATE] found this resident had a Brief Interview for Mental Scale (BIMS) score of fourteen (14) at the time of her quarterly minimum data set with assessment reference date [DATE]. A score of fourteen (14) indicates intact cognition. Further medical record review found that on [DATE] the physician determined that she lacked capacity to make medical decisions based on her dementia and the inability to process information. An interview with the administrator on [DATE] in the early afternoon found that the resident slept in his new room in another part of the building last night. She said that staff members are in the process of moving all of his belongings into the new room. On [DATE] at 3:10 PM an interview was conducted with the licensed social worker (LSW). She said she spoke with both the resident and the resident's daughter to see if there may be a need for supportive counseling. She said they told her that Resident #42 was not afraid of the wandering resident, nor was she having negative emotional effects after the incident which occurred Saturday night/Sunday morning. d) Resident #27 An interview was conducted on [DATE] at 11:19 AM with this capacitated resident. She said on Saturday night/Sunday morning a wandering, male resident who wore only a t-shirt wandered into their room. She said he lay down in her room-mate's bed alongside her room-mate. She said she heard him ask her room-mate if her husband was alive. She said she yelled at him to leave the room and he obeyed her. She said she did not have to physically touch him to get him out of the room-mate's bed and out of the room. Rather, she just gave verbal directives. She said she walked with him into the hallway where nursing staff heard them and came to get him. A stop guard net was observed in place at her doorway. The resident said the wandering resident can crawl beneath the stop guard. She said that particular night he entered her room through a bathroom that they share with two (2) other female residents in the next room. She said this wandering resident has been in her room multiple times before, but this was the first time he was naked. She stated I feel lost, afraid. She said she did not sleep well last night from worrying he would return to her room. During an interview with the administrator in the early afternoon on [DATE], she said the wandering resident slept in a room in another part of the building on Sunday night following the incident as they moved him on Sunday to protect this resident and her room-mate. Previously, the wandering resident resided in the room next to Resident #27's room. She said that some of his belongings are still in the former room, but staff is in the process of moving the remainder of his belongings. On Tuesday at 11:00 AM Resident #27 was overheard in the [NAME] top back hallway approach an unidentified nurse at the counter/med cart/treatment cart area in the hallway. Licensed practical nurse #76 (LPN #76) was also present. Resident #27 reported that she saw the wandering resident in her hallway today. The unidentified nurse told her that they are watching him closely, but that he has the right to walk about the building. Resident #27 told the nurse that she thought he had moved elsewhere in the building. The nurse reassured her that yes, he had moved to another part of the building. On [DATE] at 3:10 PM an interview was conducted with the licensed social worker (LSW). She said she did supportive counseling with Resident #27 who has capacity and who has a [DIAGNOSES REDACTED]. e) Resident #13 A review of the medical record for Resident #13, on [DATE] at 10:00 AM, revealed the latest Minimum Data Set Quarterly Assessment (MDS) was conducted on [DATE]. The Resident obtained a score of 15 on the Brief Interview for Mental Status assessment (BIMS). A score of 15 on the BIMS equates to little or no cognitive impairment. An interview with Resident #13, on [DATE] at 11:00 AM, revealed the Resident is scared of Resident #44. The Resident stated Resident #44 has come into her room daily for months. The Resident stated Resident #44 comes into her room and will not leave for up to 15 minutes at a time. The Resident stated Resident #44 pilfers through her belongings and screams at her. The Resident stated she is scared to sleep at night in fear Resident #44 will come into her room. The Resident is scared Resident #44 may become physical with her. The Resident stated she has told the staff numerous times about Resident #44 coming into her room and they do nothing. f) Resident #14 A review of the medical record for Resident #14, on [DATE] at 10:15 AM, revealed the latest Minimum Data Set Quarterly Assessment (MDS) was conducted on [DATE]. The Resident obtained a score of 15 on the Brief Interview for Mental Status assessment (BIMS). A score of 15 on the BIMS equates to little or no cognitive impairment. An interview with Resident #14, on [DATE] at 11:15 AM, revealed the Resident is scared of Resident #44. The Resident stated Resident #44 repeatedly comes into her room day and night. The Resident stated Resident #44 comes into her room and will not leave unless she screams and threatens to hit him. The Resident stated Resident #44 throws her belongings off her bed and table and yells at her. The Resident stated she does not feel safe in her room because of what Resident #44 may do when the staff is not around. The Resident stated her fear is affecting her sleep at night. The Resident stated she has told numerous staff members many times about Resident #44 invading her personal space. The Resident stated the staff does not care that Resident #44 comes into her room.

Based on record review and staff interview, the facility failed to provide care and services to ensure two (2) of thirty-five (35) Stage 2 sample residents attained or maintained the highest practicable well-being. The facility failed to assess Resident #83 related to his ability to reside in a setting which was not secure (locked) and structured as when he resided in the facility's previous Alzheimer's unit. In addition, the facility failed to recognize and address the resident's adjustment difficulties to his new environment. These failures resulted in mental/psychological harm to the resident. For Resident #74, the facility failed to assess the efficacy of as needed (PRN) pain medications after its administration. Resident identifiers: #83 and #74. Facility census: 87. Findings include: a) Resident #83 This resident was admitted to the facility's Alzheimer's unit on [DATE]. His [DIAGNOSES REDACTED]. On [DATE], the facility mailed a letter to resident's family members informing them of the closure of the Alzheimer's unit, effective [DATE]. The letter stated: After careful considerations and evaluations of the patients we care for at Salem Center, it has been determined that current Alzheimer unit would better meet the needs of our patients and residents if it was converted to standard skilled nursing skilled nursing unit. Therefore on [DATE], we will convert this unit to skilled nursing. This will not represent a significant change for our residents who are currently cared for on this unit. (Name of company) physicians and clinical nursing leadership have evaluated the residents and believe that a skilled nursing unit is appropriate to meet our residents needs. On [DATE], the doors to the locked Alzheimer's unit were unlocked, and the facility no longer provided the services of an Alzheimer's unit. At 10:00 a.m. on [DATE], review of the medical records for Resident #83 revealed his [DIAGNOSES REDACTED]. The record was silent for evidence of an evaluation or assessment to determine if a change in the secured structured environment of an Alzheimer's unit would be detrimental to Resident #83's mental and psychosocial well being. The facility had no evidence of evaluations and/or assessments for Resident #83 to determine if his [DIAGNOSES REDACTED]. After the resident no longer received the services provided in an Alzheimer's unit, there was a delay in the facility recognizing and/or addressing a pattern of increased behaviors and resident-to-resident altercations. These behaviors began on [DATE]. It was not until [DATE], that his Medical Power of Attorney (MPOA) was first contacted regarding the need for a transfer to a facility with a secured unit. Resident #83 was transferred to a facility that could meet his physical, mental, and psychosocial needs on [DATE], after nearly four (4) months of psychosocial related behavioral events. Review of the resident's nursing progress notes found Resident #83 had only one (1) resident-to-resident altercation from [DATE] through [DATE]. The medical record showed progressive increased aggression toward staff and residents from [DATE] through [DATE]. During that period of time, fourteen (14) acts of aggression were documented: 1. On [DATE], the resident was involved in a resident-to-resident altercation with no injuries. 2. On [DATE], the resident . went to hilltop and went into solarium where (resident name) was sitting at a table. This resident punched (resident name) in the chest. Both residents separated . 3. On [DATE], Resident #83 . was pushing (resident name) wheelchair and rubbing her shoulders and (resident name) yelled stop and he started punching her in the right arm. (Resident name) was also present and was attempting to get this resident to let go of (resident's name) wheelchair and this resident also punched (resident name) in the right arm. This resident was redirected per nurse . 4. On [DATE], .Resident was on Hilltop. This resident was punching at another resident's face and grabbing his arm. The other resident started hitting this resident with his Foley catheter and hitting him in the face with his hand . 5. [DATE], Resident #83 . attempted to enter another resident's room which upset other resident who started to swing his arms at this resident and this resident started to swing back . 6. [DATE], Resident on Hilltop stated that (Resident #83) hit her . 7. [DATE], The Administrator stated she saw resident #83 . and (resident name) in front lobby and (Resident #83) touched (resident's name) left shoulder and she started screaming don't touch me, she then took her papers and slapped him on the hands . 8. [DATE], Resident to resident altercation. 9. [DATE], Resident #83 . wandering throughout hallways in facility. (Resident name) was heard yelling from her wheelchair in hallway. Hilltop back nurse observed (Resident #83) with his hands on the back of (resident's name) neck and was pushing her head forward. This resident was observed for injuries. top of left hand red with horseshoe shaped skin tear measuring 1.0 cm x 0.2 cm . 10. On [DATE], Resident #83 . was seen slapping another resident as she screamed at him . 11. On [DATE], Resident #83, I was just pushing him when wheelchair was observed on its side and (resident name) was sitting on his left side with his legs out in front of him cursing at resident . 12. On [DATE] at 2:22 p.m., Resident having increased aggression. Going into female residents rooms, pulling mattresses off the beds, combative with staff, hitting, kicking and trying to bite . 13. On [DATE], Resident in another resident's bed. Staff assisted him back to Solana side. The resident who's bed he was in was upset. Resident began swinging at staff, grabbed another staff member's hair after the other two staff walked away . 14. [DATE], This resident (#83) touched (resident name) on the shoulder and (resident name) started hitting him (Resident #83) in the right arm. On [DATE] at 10:05 a.m., a review of the incident/accident reports revealed they corresponded with the nursing progress note documentation related to Resident #83's behaviors. During an interview, on [DATE] at 2:35 p.m., Physician #105 stated the residents on the Alzheimer's unit were assessed before the closing of the unit, to determine if the facility could meet their needs. He could not say if Resident #83 met the criteria for a transfer to another facility before the discontinuation of the locked Alzheimer's unit. Upon inquiry, the physician acknowledged a safety issue existed for Resident #83, as well as for other residents. When asked whether the resident should have been transferred sooner due to safety concerns, Physician #105 stated, Yes, he probably needed to be sent out sooner for safety of other residents and also his own safety. On [DATE] at 9:45 a.m., an interview with the Administrator revealed incident/accident reports were reviewed daily by the team and discussed monthly in the Quality Assurance meeting. She did not reply when asked if the facility identified a pattern of increased aggression in resident-to-resident altercations by Resident #83 after the Solana unit doors were unlocked. b) Resident #74 Review of the medical record, on [DATE] at 9:00 a.m. , found this [AGE] year old resident came to the facility on [DATE] and expired on [DATE]. [DIAGNOSES REDACTED]. The resident refused continuation of [MEDICAL TREATMENT] services. The medical record contained a pain assessment interview dated [DATE], on which the resident responded that in the last five (5) days she experienced pain almost constantly. The assessment indicated her pain limited her day-to-day activities. She rated the intensity of her pain as a five (5), using the numeric rating scale of zero (0) to ten (10), with zero as no pain, and ten as severe pain. The assessment noted the resident's acceptable level of pain, using a zero to ten scale, was two (2), which is mild pain. A care plan focus identified the resident's expressed desire for palliative/comfort care measures only, related to end stage [MEDICAL CONDITION], and her refusal to continue with [MEDICAL TREATMENT] treatments. There was a care plan for pain with interventions to medicate for pain and monitor for effectiveness. Other care plan interventions were to evaluate pain characteristics, which included quality, severity, and location, and to utilize the pain scale. Review of the Medication Administration Record [REDACTED] -- [DATE], Tylenol 650 milligrams (mg) at 4:00 p.m. and 9:00 p.m. -- [DATE], Tylenol 650 mg. at 6:00 a.m., 11:30 a.m., and 9:00 p.m. -- [DATE], Tylenol 650 mg. at 9:00 p.m. -- [DATE], Tylenol 650 mg. at 8:00 p.m. -- [DATE], [MEDICATION NAME] 100 mg. at 6:00 a.m. and 9:00 p.m. -- [DATE], [MEDICATION NAME] 100 mg. at 7:30 a.m. -- [DATE], [MEDICATION NAME] 100 mg. at 6:00 a.m. -- [DATE], [MEDICATION NAME] 100 mg. at 8:00 p.m. Review of a nurse progress note, dated [DATE], revealed the family declined Hospice services. The note indicated the resident had an increase in yelling out today ([DATE]). A nurse progress note, dated [DATE] at 3:12 a.m., revealed the nurse administered a dose of Roxinal (a narcotic pain medication) at 3:00 a.m. The nurse did not provide an assessment as to how much, if any, pain relief was obtained. The next nurse progress note, dated [DATE] at 3:35 p.m., stated nursing assistants called the licensed practical nurse and the registered nurse on duty to the resident's room. The nurses assessed the absence of lung sounds and heart beat. The resident expired at this time. The PRN Pain Management Flow Sheet contained columns for documentation of pain assessments. The areas for documentation included: -- date and time -- pain intensity rating (use scale of ,[DATE] or pictures depicting feelings of pain) -- non-pharmacological treatment attempted -- location of the pain -- name and dosage of the PRN medication -- for cognitively impaired residents, signs and symptoms of pain were to be described and numbered from ,[DATE] The right side of the flow sheet assessed the effectiveness of the treatment. The areas for documentation included: -- date -- time -- pain ratings post-prn pain medication administration -- level of sedation. There was nothing documented in any of the columns and spaces related to Resident #74's pain. During an interview with the director of nursing (DON), on [DATE] at 3:30 p.m., she verified the dates and times of the noted administration of PRN pain medications. She also verified nursing staff did not complete assessments of the effectiveness of the pain medications the back of the MAR. She said she would review the nurses' progress notes for evidence of nurse evaluations for the effectiveness of the administered PRN pain medications. On [DATE] at 9:30 a.m., the DON said she was unable to find evidence of nurse evaluations for the effectiveness of the administered PRN pain medications. She said the facility was trying to get staff to document the results of the administered PRN pain medication on the backs of the pain administration sheets on the MAR. She agreed that for the most part, there was no assessment in the nurses' progress notes, and none on the back of the MAR, which described the effectiveness of the administered PRN pain medication for this resident. During the interview on [DATE] at 9:30 a.m. , the DON was asked if the facility had a policy related to nurse assessment and documentation of the results of PRN pain medication, or for the description of the location and severity of the pain. She said there was no policy, but it was a work in progress. The DON said the facility was trying to get staff to document the results of the PRN pain medication administration on the backs of the pain administration sheets on the MAR. She agreed that for the most part, there was no assessment in the nurse progress notes, and none on the back of the MAR, which reflected the effectiveness of the PRN pain medication provided Resident #74.

Based on record review, observation, resident interview, and staff interview, the facility's quality assessment and assurance (QA&A) committee failed to develop and implement plans of action, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained, to correct quality deficiencies of which it was aware, or should have been aware, in the daily operation of the facility. After unlocking the Alzheimer's unit and discontinuing services specific to the needs of residents with Alzheimer's dementia who resided on the unit, the QA&A committee failed to identify and act upon those residents' behaviors toward others, failed to ensure interventions to reduce negative behaviors, and failed to ensure appropriate activities for the residents formally residing on the Alzheimer's unit. The QA&A committee failed to identify that optimum care and services, to ensure the highest practicable well-being of each resident, was not addressed before and after the facility closed their Alzheimer's Unit. -- Resident #83 was not properly assessed for this transition. In addition, the resident's adjustment difficulties to his new environment were not identified and addressed. This resulted in psychological harm to the resident. -- There was a failure to develop care plans and/or activities to meet the activity needs and preferences for Residents #73, #99, and #50 who once had structured activities on the Alzheimer's unit. -- There was a failure to ensure the right to personal privacy, dignity, and respect for Residents #23, #120, #128, and #53 when residents who previously resided on the Alzheimer's unit began wandering into their rooms. Eight (8) thirty-five (35) sample residents (#83, #73, #99, #50, #23, #120, #128, and #53) were specifically affected; however, the practice had the potential to affect more than an isolated number of other residents. Facility census: 87 Findings include: a) Resident #83 This resident was admitted to the facility's Alzheimer's unit on 06/14/13. His [DIAGNOSES REDACTED]. On 04/20/15 the Alzheimer's unit was closed, the door to the Alzheimer's unit were unlocked, and the facility no longer provided the services of an Alzheimer's unit. Prior to the closure, the facility sent a letter to the affected families. It included, in part, This will not represent a significant change for our residents who are currently cared for on this unit. (Name of company) physicians and clinical nursing leadership have evaluated the residents and believe that a skilled nursing unit is appropriate to meet our residents needs. At 10:00 a.m. on 11/03/15, review of the medical records for Resident #83 revealed his [DIAGNOSES REDACTED]. The record was silent for evidence of an evaluation or assessment to determine if a change in the secured structured environment of an Alzheimer's unit would be detrimental to Resident #83's mental and psychosocial well being. The facility had no evidence of evaluations and/or assessments for Resident #83 to determine if his [DIAGNOSES REDACTED]. After the resident no longer received the services provided in an Alzheimer's unit, there was a delay in the facility recognizing and/or addressing a pattern of increased behaviors and resident-to-resident altercations. These behaviors began on 04/30/15. It was not until 08/26/15, that his Medical Power of Attorney (MPOA) was first contacted regarding the need for a transfer to a facility with a secured unit. Resident #83 was transferred to a facility that could meet his physical, mental, and psychosocial needs on 09/03/15, after nearly four (4) months of psychosocial related behavioral events. Review of the resident's nursing progress notes found Resident #83 had only one (1) resident-to-resident altercation from 01/01/15 through 04/29/15. The medical record showed progressive increased aggression toward staff and residents from 04/30/15 through 08/29/15. During that period of time, fourteen (14) acts of aggression were documented: 1. On 04/30/15, the resident was involved in a resident-to-resident altercation with no injuries. 2. On 05/06/15, the resident . went to hilltop and went into solarium where (resident name) was sitting at a table. This resident punched (resident name) in the chest. Both residents separated . 3. On 05/19/15, Resident #83 . was pushing (resident name) wheelchair and rubbing her shoulders and (resident name) yelled stop and he started punching her in the right arm. (Resident name) was also present and was attempting to get this resident to let go of (resident's name) wheelchair and this resident also punched (resident name) in the right arm. This resident was redirected per nurse . 4. On 05/21/15, .Resident was on Hilltop. This resident was punching at another resident's face and grabbing his arm. The other resident started hitting this resident with his Foley catheter and hitting him in the face with his hand . 5. 06/05/15, Resident #83 . attempted to enter another resident's room which upset other resident who started to swing his arms at this resident and this resident started to swing back . 6. 06/21/15, Resident on Hilltop stated that (Resident #83) hit her . 7. 06/22/15, The Administrator stated she saw resident #83 . and (resident name) in front lobby and (Resident #83) touched (resident's name) left shoulder and she started screaming don't touch me, she then took her papers and slapped him on the hands . 8. 07/08/15, Resident to resident altercation. 9. 07/18/15, Resident #83 . wandering throughout hallways in facility. (Resident name) was heard yelling from her wheelchair in hallway. Hilltop back nurse observed (Resident #83) with his hands on the back of (resident's name) neck and was pushing her head forward. This resident was observed for injuries. top of left hand red with horseshoe shaped skin tear measuring 1.0 cm x 0.2 cm . 10. On 07/24/15, Resident #83 . was seen slapping another resident as she screamed at him . 11. On 08/01/15, Resident #83, I was just pushing him when wheelchair was observed on its side and (resident name) was sitting on his left side with his legs out in front of him cursing at resident . 12. On 08/19/15 at 2:22 p.m., Resident having increased aggression. Going into female residents rooms, pulling mattresses off the beds, combative with staff, hitting, kicking and trying to bite . 13. On 08/27/15, Resident in another resident's bed. Staff assisted him back to Solana side. The resident who's bed he was in was upset. Resident began swinging at staff, grabbed another staff member's hair after the other two staff walked away . 14. 08/29/15, This resident (#83) touched (resident name) on the shoulder and (resident name) started hitting him (Resident #83) in the right arm. On 11/03/15 at 10:05 a.m., a review of the incident/accident reports revealed they corresponded with the nursing progress note documentation related to Resident #83's behaviors. During an interview, on 11/03/15 at 2:35 p.m., Physician #105 stated the residents on the Alzheimer's unit were assessed before the closing of the unit, to determine if the facility could meet their needs. He could not say if Resident #83 met the criteria for a transfer to another facility before the discontinuation of the locked Alzheimer's unit. Upon inquiry, the physician acknowledged a safety issue existed for Resident #83, as well as for other residents. When asked whether the resident should have been transferred sooner due to safety concerns, Physician #105 stated, Yes, he probably needed to be sent out sooner for safety of other residents and also his own safety. On 11/04/15 at 9:45 a.m., an interview with the Administrator revealed incident/accident reports were reviewed daily by the team and discussed monthly in the Quality Assurance meeting. She did not reply when asked if the facility identified a pattern of increased aggression in resident-to-resident altercations by Resident #83 after the Solana unit doors were unlocked. b) Residents #73, #99, and #50 The facility failed to develop care plans with measurable goals and interventions for these residents who previously resided on the Solana Alzheimer's unit, which was closed on 04/20/15 These residents no longer had a confined area to wander, and no longer were provided on-going structured activities based on their assessed needs. The residents' current care plans for activities did not contain specific interventions related to identified activity needs and preferences geared to meet the individual needs of these residents with dementia, short attention spans, and/or behaviors. 1. Resident #73 Review of the medical record, on 10/28/15 at 2:20 p.m., revealed Resident #73 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was identified at risk for limited meaningful engagement related to her cognitive loss, confusion, and short attention span. The resident was unable to make her needs known, and was at risk for falls. Her behaviors included pacing to the point of exhaustion. The resident's recreational assessment, dated 05/19/15, noted the resident was rarely/never understood. Her favorite activities included music, food, and social events. The accommodations listed related to her cognitive loss included small groups, decreased environmental clutter, verbal prompts, physical prompts (hand over hand), simple noncomplex directions, and sensory focused activities. The summary stated she was confused, had a short attention span, and often wandered. The assessment noted: She needs adapted activities to her cognition, with focus on sensory stimulation. The resident's prior care plan (used before the doors were unlocked), dated 01/21/15, stated the resident loved to dress up and wear boas, beads, and hats. It indicated staff should offer her activity beads during times of restlessness. Daily observations of Resident #73, during the survey, found her actively roaming the facility halls, talking in word salads, and entering other residents' rooms. Occasionally she was found sitting at the nurses' desk eating a snack or looking at a magazine. On one (1) occasion she was sitting at the desk with a stethoscope and a blood pressure cuff. She was never found dressed up or playing with activity beads. 2. Resident #99 Review of the medical record, on 10/29/15 at 9:00 a.m., revealed Resident #99 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was identified at risk for limited meaningful engagement related to cognitive loss, due to her [DIAGNOSES REDACTED]. Her behaviors included wandering, yelling at staff, and paranoia. The resident's recreation assessment, dated 07/16/15, identified her important preferences were snacks between meals, music, and going outside weekly. Her previous activity care plan (used before the doors were unlocked) was last reviewed on 01/28/15, It stated she liked to eat, read adventure and horror books, watch television, and do word searches. Throughout the survey, Resident #99 was observed walking the halls and verbally interacting with staff. She was never seen with a book or word puzzle. The resident was observed only once sitting in the television room with other residents. On 10/27/15, the resident repeatedly asked the surveyor to take her outside for a walk. There was no evidence she was offered a trip outside during the warm fall days. A review of the recreational assessment for Resident #99, with Activity Director (AD) #46 on 11/03/15 at 10:25 a.m., revealed the record was silent regarding the resident being taken outside for walks. 3. Resident #50 Review of the medical record, on 10/28/15 at 3:33 p.m., revealed Resident #50 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's medical record indicated she needed adaptive activities, had confusion, and had a short attention span. According to the medical record, the resident was often on the go, pacing the halls in her wheel chair. Her behaviors included exit seeking, crying for extended periods, and combative actions (hits, kicks, and grabs staff). The medical record contained evidence of a resident-to-resident altercation on 10/05/15. The resident's previous activity care plan (in place prior to the doors being unlocked) with a review date of 01/28/15, stated she liked cooking, cleaning, socializing, and playing Bingo and cards. It also indicated the resident sometimes carried a baby doll. The resident's recreation assessment, dated 09/01/15, listed her favorite activities as walking or wheeling, music, food activities, church or religious activities. and talking. It indicated she would benefit from accommodations for cognitive loss, including small groups and single step activities. The assessment noted her activity participation was limited, due to her short attention span. Observations throughout the survey found the resident continuously wheeling up and down the halls. At times she was observed repeatedly bending over and picking at unseen objects on the floor. She was never observed with a baby doll. There was no evidence cooking or cleaning activities were offered to her. 4. Licensed Practical Nurse (LPN) #54 was interviewed on 10/27/15 at 9:45 a.m. and again on 10/28/15 at 8:35 a.m. She reported the residents with dementia from the Solana unit wandered throughout the facility, now that the unit was no longer locked. She said Residents #73, #99, and #50 were kept busy with activities before the discontinuation of the Alzheimer's unit. LPN #54 said now there were no activities for the residents with dementia, and they just wandered around the facility. She said some of the residents entered other residents' rooms, climbed into their beds, and took their belongings. LPN #54 said the residents were previously kept busy with a long day of activities designed to meet the needs of a resident with dementia and with a short attention span. 5. Confidential interviews with nursing assistants on 10/28/15 revealed concerns with no scheduled activities that residents with dementia could attend to meet their needs. They said, It is sad to watch them wander around and enter other peoples' rooms. 6. When interviewed on 11/03/15 at 10:25 a.m., AD #46 confirmed there was only one (1) activity calendar for the facility. She confirmed these activities did not meet the needs of residents with Alzheimer's dementia, especially with their short attention spans. She agreed the facility did not offer individualized activity interventions for Residents #73, #99 and #50 after the Alzheimer's unit was closed. AD #46 confirmed these residents wandered, and were not capable of independent stress/relaxation as documented on their recreation activity logs. She confirmed the facility did not provide a space, or environmental cues, to encourage physical exercise, decrease behaviors, and/or reduce extraneous stimulation for these residents who once were provided these services. The facility had a single rocking chair in the office, and bags of therapy beads and lotion for aromatherapy; however, these items were not readily available for the residents to access and were not routinely offered on a daily basis. AD #46 agreed the activity program needed restructured to meet the individual needs of the residents who remained on the Solana unit. 7. Review of the Alzheimer's unit daily flow sheets, obtained from the administrator on 11/04/15, revealed the residents who resided on the Alzheimer's unit had scheduled activities from 7:00 a.m. to 8:00 p.m. daily. These activities included activities of daily living, small group socials with coffee and discussing current events, exercise, artistic expression such as painting, gardening, or drawing, cognitive sharpening exercises such as Bingo, puzzles, and mazes, sensor-motor activities which included making popsicles or pudding, spiritual singing, and community story telling. Beginning 04/20/15, the residents who resided on Solana unit, preciously a locked Alzheimer's unit, were only offered the scheduled activities planned for the higher functioning residents in the facility. The planned activities to meet the needs of residents with Alzheimer's dementia were no longer available. In addition, structured activities were no longer available to them from 7:00 a.m. to 8:00 p.m. daily. The November activity calendar listed activities from 9:45 a.m. to 4:45 p.m. It included Wifi games, horseshoes, and Bible study. There were also five (5) evening church services and two (2) evening Bingo games, one (1) evening movie, and two (2) resident choice events. 8. During the survey, observation revealed residents, who resided on the Solana unit, previously a locked Alzheimer's unit, wandered freely throughout the facility all day long. Observation revealed no planned activities to keep them busy, as they were previously provided when they resided in a setting for residents with dementia. c) Residents #23, #120, #128, and #53 The facility failed to ensure the right to personal privacy and failed to maintain an environment which promoted dignity and respect for private space for these residents. The facility provided no means to prevent wandering confused residents from entering these residents' rooms. 1. Resident #23 Observation on 10/26/15 at 2:30 p.m., revealed a female resident walked into Resident #23's room and climbed into his bed. He immediately screamed at her and she got up and walked out of the room. At 2:45 p.m., observation revealed a second resident, Resident #73, entered the room and attempted to sit on the resident's bed. After Resident #73 was assisted out of the room, Resident #23 said the residents who lived on the Solana unit, previously a locked Alzheimer's unit, repeatedly entered his room. Upon inquiry, Resident #23 said the facility had not offered him any means to deter the roaming confused residents from entering his room. 2. Resident #120 During a Stage 1 resident interview, on 10/26/15 at 2:30 p.m., two (2) female residents entered Resident #120's room between 2:30 p.m. and 2:45 p.m. The first resident climbed into the roommate's bed and exited after Resident #120 and the roommate yelled at her. The second non-communicating resident was assisted from the room by the surveyor. Resident #120 reported this was a continuous occurrence. He said the residents who resided on the Solana unit, previously a locked Alzheimer's unit, entered his room from either the bathroom door or the hallway door. He stated they often climbed into their beds, carried items out of the room, and sometimes attempted to take food off of their meal trays while they were eating in their room. Resident #120 reported he and his roommate requested a slide lock to at least keep the bathroom door closed, but the request was denied. He said he was never offered a means to deter the wandering confused residents from entering the room. 3. Resident #128 During an interview, on 10/27/15 at 8:40 a.m., Resident #128 reported the residents who resided on the Solana unit, previously a locked Alzheimer's unit, often wandered into his private room and walked around making muttering sounds. He said once a male resident entered his room and sat down in the chair for a while. Resident #128 said he also woke up one (1) night and found a resident standing over him looking at his face. He stated he reported these incidents to the nursing assistants. Upon inquiry, he said he was never offered a means to deter the wandering, confused residents from entering his private room. 4. Observation on Hilltop Wing revealed three (3) wooden swing gates were installed on residents' doorways to deter wanderers from entering the rooms. No such gates were located on Woodside hall where Residents #23, #120, and #128 resided. 5. Resident #53 Resident #53 was interviewed on 10/29/15 at 10:45 a.m. He reported several residents in the facility voiced concerns when they were informed the new ownership/management had decided to unlock the doors to the Solana unit, an Alzheimer's unit. He said the residents from the Solana unit began roaming throughout the facility, entering other residents' rooms and taking personal belongings. Resident #53 said these concerns were discussed at resident council. He said staff told them nothing could be done. Resident #53 reported a confused resident entered his room and climbed into his bed when he was not in the room. The resident said his roommate told him the resident defecated in his bed on that occasion. Resident #53 said he asked for a wooden triangular swing gate for his door, but was told he would have to wait until maintenance could make more. 6. Observations during the survey found three (3) wooden swing gates on the doors on the Hilltop wing. There were no swing gates on the Woodside hall, where Residents #23, #120, and #128 resided. 7. Maintenance Supervisor #27 was interviewed on 11/04/15 at 8:20 a.m. He was unaware of any resident's request for the triangular wooden swing gates used to deter the wandering residents from entering other residents' rooms. He said he made the wooden gates as they were needed, and did not currently have any to hang on the residents' doors. 8. Licensed practical nurse (LPN) #54 was interviewed on 10/27/15 at 9:45 a.m. She confirmed the residents with dementia wandered throughout the facility now that the Solana unit was no longer locked. She confirmed some of the residents entered other residents' rooms, climbed into their beds, and took their belongings. 9. During the survey, observation revealed residents, who resided on the Solana unit, previously a locked Alzheimer's unit, wandered freely throughout the facility all day long. They were not provided activities to keep them busy, as they were provided when they resided in a setting designed for residents with dementia. d) On 11/02/15 at 10:21 a.m., the facility administrator explained that when the Alzheimer's unit was unlocked on 04/20/15, the QA&A committee felt the biggest risk for the unit doors being unlocked was wandering residents. The administrator said they felt the other needs could be met through activities and social services. Each resident who resided on the locked Alzheimer's unit was also to receive an assessment of individual needs. On 11/04/15 at 9:45 a.m., another interview with the Administrator revealed incident/accident reports were reviewed daily by the team and discussed monthly in the QA&A meeting. She did not reply when asked if the facility identified a pattern of increased aggression in resident-to-resident altercations by Resident #83 after the Solana unit doors were unlocked. e) Evidence revealed the QA&A committee failed to ensure continued assessment, care planning, and monitoring to ensure the needs of all facility residents were met after the secured Alzheimer's unit, with structured daily activities for the residents, was closed. Neither the needs of residents with Alzheimer's dementia nor the needs of other residents who resided in the facility. were met when the Alzheimer's unit was closed.

Based on record review, observation, resident interview, and staff interview, the facility was not administered in a manner to effectively provide care and services to ensure the highest practicable well-being for eight (8) of thirty-five (35) sample residents. The facility closed their Alzheimer's Unit, unlocked the secure unit, and discontinued the services previously provided the residents who resided on that unit. This resulted in a discontinuation of a structured environment and a discontinuation of the services specifically designed for residents with Alzheimer's dementia. -- Resident #83 was not properly assessed for this transition. In addition, the facility failed to recognize and address the resident's adjustment difficulties to his new environment. This resulted in psychological harm to the resident. -- The facility failed to develop care plans and/or activities to meet the activity needs and preferences for Residents #73, #99, and #50 who once had structured activities on the Alzheimer's unit. -- The facility failed to ensure the right to personal privacy, dignity, and respect for Residents #23, #120, #128, and #53 when residents who previously resided on the Alzheimer's unit began wandering into their rooms. Residents #83, #73, #99, #50, #23, #120, #128, and #53 were found specifically affected; however, the practice had the potential to affect more than an isolated number of other residents. Facility census: 87 Findings include: a) Resident #83 This resident was admitted to the facility's Alzheimer's unit on 06/14/13. His [DIAGNOSES REDACTED]. On 04/20/15 the Alzheimer's unit was closed, the door to the Alzheimer's unit were unlocked, and the facility no longer provided the services of an Alzheimer's unit. Prior to the closure, the facility sent a letter to the affected families. It included, in part, This will not represent a significant change for our residents who are currently cared for on this unit. (Name of company) physicians and clinical nursing leadership have evaluated the residents and believe that a skilled nursing unit is appropriate to meet our residents needs. At 10:00 a.m. on 11/03/15, review of the medical records for Resident #83 revealed his [DIAGNOSES REDACTED]. The record was silent for evidence of an evaluation or assessment to determine if a change in the secured structured environment of an Alzheimer's unit would be detrimental to Resident #83's mental and psychosocial well being. The facility had no evidence of evaluations and/or assessments for Resident #83 to determine if his [DIAGNOSES REDACTED]. After the resident no longer received the services provided in an Alzheimer's unit, there was a delay in the facility recognizing and/or addressing a pattern of increased behaviors and resident-to-resident altercations. These behaviors began on 04/30/15. It was not until 08/26/15, that his Medical Power of Attorney (MPOA) was first contacted regarding the need for a transfer to a facility with a secured unit. Resident #83 was transferred to a facility that could meet his physical, mental, and psychosocial needs on 09/03/15, after nearly four (4) months of psychosocial related behavioral events. Review of the resident's nursing progress notes found Resident #83 had only one (1) resident-to-resident altercation from 01/01/15 through 04/29/15. The medical record showed progressive increased aggression toward staff and residents from 04/30/15 through 08/29/15. During that period of time, fourteen (14) acts of aggression were documented: 1. On 04/30/15, the resident was involved in a resident-to-resident altercation with no injuries. 2. On 05/06/15, the resident . went to hilltop and went into solarium where (resident name) was sitting at a table. This resident punched (resident name) in the chest. Both residents separated . 3. On 05/19/15, Resident #83 . was pushing (resident name) wheelchair and rubbing her shoulders and (resident name) yelled stop and he started punching her in the right arm. (Resident name) was also present and was attempting to get this resident to let go of (resident's name) wheelchair and this resident also punched (resident name) in the right arm. This resident was redirected per nurse . 4. On 05/21/15, .Resident was on Hilltop. This resident was punching at another resident's face and grabbing his arm. The other resident started hitting this resident with his Foley catheter and hitting him in the face with his hand . 5. 06/05/15, Resident #83 . attempted to enter another resident's room which upset other resident who started to swing his arms at this resident and this resident started to swing back . 6. 06/21/15, Resident on Hilltop stated that (Resident #83) hit her . 7. 06/22/15, The Administrator stated she saw resident #83 . and (resident name) in front lobby and (Resident #83) touched (resident's name) left shoulder and she started screaming don't touch me, she then took her papers and slapped him on the hands . 8. 07/08/15, Resident to resident altercation. 9. 07/18/15, Resident #83 . wandering throughout hallways in facility. (Resident name) was heard yelling from her wheelchair in hallway. Hilltop back nurse observed (Resident #83) with his hands on the back of (resident's name) neck and was pushing her head forward. This resident was observed for injuries. top of left hand red with horseshoe shaped skin tear measuring 1.0 cm x 0.2 cm . 10. On 07/24/15, Resident #83 . was seen slapping another resident as she screamed at him . 11. On 08/01/15, Resident #83, I was just pushing him when wheelchair was observed on its side and (resident name) was sitting on his left side with his legs out in front of him cursing at resident . 12. On 08/19/15 at 2:22 p.m., Resident having increased aggression. Going into female residents rooms, pulling mattresses off the beds, combative with staff, hitting, kicking and trying to bite . 13. On 08/27/15, Resident in another resident's bed. Staff assisted him back to Solana side. The resident who's bed he was in was upset. Resident began swinging at staff, grabbed another staff member's hair after the other two staff walked away . 14. 08/29/15, This resident (#83) touched (resident name) on the shoulder and (resident name) started hitting him (Resident #83) in the right arm. On 11/03/15 at 10:05 a.m., a review of the incident/accident reports revealed they corresponded with the nursing progress note documentation related to Resident #83's behaviors. During an interview, on 11/03/15 at 2:35 p.m., Physician #105 stated the residents on the Alzheimer's unit were assessed before the closing of the unit, to determine if the facility could meet their needs. He could not say if Resident #83 met the criteria for a transfer to another facility before the discontinuation of the locked Alzheimer's unit. Upon inquiry, the physician acknowledged a safety issue existed for Resident #83, as well as for other residents. When asked whether the resident should have been transferred sooner due to safety concerns, Physician #105 stated, Yes, he probably needed to be sent out sooner for safety of other residents and also his own safety. On 11/04/15 at 9:45 a.m., an interview with the Administrator revealed incident/accident reports were reviewed daily by the team and discussed monthly in the Quality Assurance meeting. She did not reply when asked if the facility identified a pattern of increased aggression in resident-to-resident altercations by Resident #83 after the Solana unit doors were unlocked. b) Residents #73, #99, and #50 The facility failed to develop care plans with measurable goals and interventions for these residents who previously resided on the Solana Alzheimer's unit, which was closed on 04/20/15 These residents no longer had a confined area to wander, and no longer were provided on-going structured activities based on their assessed needs. The residents' current care plans for activities did not contain specific interventions related to identified activity needs and preferences geared to meet the individual needs of these residents with dementia, short attention spans, and/or behaviors. 1. Resident #73 Review of the medical record, on 10/28/15 at 2:20 p.m., revealed Resident #73 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was identified at risk for limited meaningful engagement related to her cognitive loss, confusion, and short attention span. The resident was unable to make her needs known, and was at risk for falls. Her behaviors included pacing to the point of exhaustion. The resident's recreational assessment, dated 05/19/15, noted the resident was rarely/never understood. Her favorite activities included music, food, and social events. The accommodations listed related to her cognitive loss included small groups, decreased environmental clutter, verbal prompts, physical prompts (hand over hand), simple noncomplex directions, and sensory focused activities. The summary stated she was confused, had a short attention span, and often wandered. The assessment noted: She needs adapted activities to her cognition, with focus on sensory stimulation. The resident's prior care plan (used before the doors were unlocked), dated 01/21/15, stated the resident loved to dress up and wear boas, beads, and hats. It indicated staff should offer her activity beads during times of restlessness. Daily observations of Resident #73, during the survey, found her actively roaming the facility halls, talking in word salads, and entering other residents' rooms. Occasionally she was found sitting at the nurses' desk eating a snack or looking at a magazine. On one (1) occasion she was sitting at the desk with a stethoscope and a blood pressure cuff. She was never found dressed up or playing with activity beads. 2. Resident #99 Review of the medical record, on 10/29/15 at 9:00 a.m., revealed Resident #99 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was identified at risk for limited meaningful engagement related to cognitive loss, due to her [DIAGNOSES REDACTED]. Her behaviors included wandering, yelling at staff, and paranoia. The resident's recreation assessment, dated 07/16/15, identified her important preferences were snacks between meals, music, and going outside weekly. Her previous activity care plan (used before the doors were unlocked) was last reviewed on 01/28/15, It stated she liked to eat, read adventure and horror books, watch television, and do word searches. Throughout the survey, Resident #99 was observed walking the halls and verbally interacting with staff. She was never seen with a book or word puzzle. The resident was observed only once sitting in the television room with other residents. On 10/27/15, the resident repeatedly asked the surveyor to take her outside for a walk. There was no evidence she was offered a trip outside during the warm fall days. A review of the recreational assessment for Resident #99, with Activity Director (AD) #46 on 11/03/15 at 10:25 a.m., revealed the record was silent regarding the resident being taken outside for walks. 3. Resident #50 Review of the medical record, on 10/28/15 at 3:33 p.m., revealed Resident #50 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's medical record indicated she needed adaptive activities, had confusion, and had a short attention span. According to the medical record, the resident was often on the go, pacing the halls in her wheel chair. Her behaviors included exit seeking, crying for extended periods, and combative actions (hits, kicks, and grabs staff). The medical record contained evidence of a resident-to-resident altercation on 10/05/15. The resident's previous activity care plan (in place prior to the doors being unlocked) with a review date of 01/28/15, stated she liked cooking, cleaning, socializing, and playing Bingo and cards. It also indicated the resident sometimes carried a baby doll. The resident's recreation assessment, dated 09/01/15, listed her favorite activities as walking or wheeling, music, food activities, church or religious activities. and talking. It indicated she would benefit from accommodations for cognitive loss, including small groups and single step activities. The assessment noted her activity participation was limited, due to her short attention span. Observations throughout the survey found the resident continuously wheeling up and down the halls. At times she was observed repeatedly bending over and picking at unseen objects on the floor. She was never observed with a baby doll. There was no evidence cooking or cleaning activities were offered to her. 4. Licensed Practical Nurse (LPN) #54 was interviewed on 10/27/15 at 9:45 a.m. and again on 10/28/15 at 8:35 a.m. She reported the residents with dementia from the Solana unit wandered throughout the facility, now that the unit was no longer locked. She said Residents #73, #99, and #50 were kept busy with activities before the discontinuation of the Alzheimer's unit. LPN #54 said now there were no activities for the residents with dementia, and they just wandered around the facility. She said some of the residents entered other residents' rooms, climbed into their beds, and took their belongings. LPN #54 said the residents were previously kept busy with a long day of activities designed to meet the needs of a resident with dementia and with a short attention span. 5. Confidential interviews with nursing assistants on 10/28/15 revealed concerns with no scheduled activities that residents with dementia could attend to meet their needs. They said, It is sad to watch them wander around and enter other peoples' rooms. 6. When interviewed on 11/03/15 at 10:25 a.m., AD #46 confirmed there was only one (1) activity calendar for the facility. She confirmed these activities did not meet the needs of residents with Alzheimer's dementia, especially with their short attention spans. She agreed the facility did not offer individualized activity interventions for Residents #73, #99 and #50 after the Alzheimer's unit was closed. AD #46 confirmed these residents wandered, and were not capable of independent stress/relaxation as documented on their recreation activity logs. She confirmed the facility did not provide a space, or environmental cues, to encourage physical exercise, decrease behaviors, and/or reduce extraneous stimulation for these residents who once were provided these services. The facility had a single rocking chair in the office, and bags of therapy beads and lotion for aromatherapy; however, these items were not readily available for the residents to access and were not routinely offered on a daily basis. AD #46 agreed the activity program needed restructured to meet the individual needs of the residents who remained on the Solana unit. 7. Review of the Alzheimer's unit daily flow sheets, obtained from the administrator on 11/04/15, revealed the residents who resided on the Alzheimer's unit had scheduled activities from 7:00 a.m. to 8:00 p.m. daily. These activities included activities of daily living, small group socials with coffee and discussing current events, exercise, artistic expression such as painting, gardening, or drawing, cognitive sharpening exercises such as Bingo, puzzles, and mazes, sensor-motor activities which included making popsicles or pudding, spiritual singing, and community story telling. Beginning 04/20/15, the residents who resided on Solana unit, preciously a locked Alzheimer's unit, were only offered the scheduled activities planned for the higher functioning residents in the facility. The planned activities to meet the needs of residents with Alzheimer's dementia were no longer available. In addition, structured activities were no longer available to them from 7:00 a.m. to 8:00 p.m. daily. The November activity calendar listed activities from 9:45 a.m. to 4:45 p.m. It included Wifi games, horseshoes, and Bible study. There were also five (5) evening church services and two (2) evening Bingo games, one (1) evening movie, and two (2) resident choice events. 8. During the survey, observation revealed residents, who resided on the Solana unit, previously a locked Alzheimer's unit, wandered freely throughout the facility all day long. Observation revealed no planned activities to keep them busy, as they were previously provided when they resided in a setting for residents with dementia. c) Residents #23, #120, #128, and #53 The facility failed to ensure the right to personal privacy and failed to maintain an environment which promoted dignity and respect for private space for these residents. The facility provided no means to prevent wandering confused residents from entering these residents' rooms. 1. Resident #23 Observation on 10/26/15 at 2:30 p.m., revealed a female resident walked into Resident #23's room and climbed into his bed. He immediately screamed at her and she got up and walked out of the room. At 2:45 p.m., observation revealed a second resident, Resident #73, entered the room and attempted to sit on the resident's bed. After Resident #73 was assisted out of the room, Resident #23 said the residents who lived on the Solana unit, previously a locked Alzheimer's unit, repeatedly entered his room. Upon inquiry, Resident #23 said the facility had not offered him any means to deter the roaming confused residents from entering his room. 2. Resident #120 During a Stage 1 resident interview, on 10/26/15 at 2:30 p.m., two (2) female residents entered Resident #120's room between 2:30 p.m. and 2:45 p.m. The first resident climbed into the roommate's bed and exited after Resident #120 and the roommate yelled at her. The second non-communicating resident was assisted from the room by the surveyor. Resident #120 reported this was a continuous occurrence. He said the residents who resided on the Solana unit, previously a locked Alzheimer's unit, entered his room from either the bathroom door or the hallway door. He stated they often climbed into their beds, carried items out of the room, and sometimes attempted to take food off of their meal trays while they were eating in their room. Resident #120 reported he and his roommate requested a slide lock to at least keep the bathroom door closed, but the request was denied. He said he was never offered a means to deter the wandering confused residents from entering the room. 3. Resident #128 During an interview, on 10/27/15 at 8:40 a.m., Resident #128 reported the residents who resided on the Solana unit, previously a locked Alzheimer's unit, often wandered into his private room and walked around making muttering sounds. He said once a male resident entered his room and sat down in the chair for a while. Resident #128 said he also woke up one (1) night and found a resident standing over him looking at his face. He stated he reported these incidents to the nursing assistants. Upon inquiry, he said he was never offered a means to deter the wandering, confused residents from entering his private room. 4. Observation on Hilltop Wing revealed three (3) wooden swing gates were installed on residents' doorways to deter wanderers from entering the rooms. No such gates were located on Woodside hall where Residents #23, #120, and #128 resided. 5. Resident #53 Resident #53 was interviewed on 10/29/15 at 10:45 a.m. He reported several residents in the facility voiced concerns when they were informed the new ownership/management had decided to unlock the doors to the Solana unit, an Alzheimer's unit. He said the residents from the Solana unit began roaming throughout the facility, entering other residents' rooms and taking personal belongings. Resident #53 said these concerns were discussed at resident council. He said staff told them nothing could be done. Resident #53 reported a confused resident entered his room and climbed into his bed when he was not in the room. The resident said his roommate told him the resident defecated in his bed on that occasion. Resident #53 said he asked for a wooden triangular swing gate for his door, but was told he would have to wait until maintenance could make more. 6. Observations during the survey found three (3) wooden swing gates on the doors on the Hilltop wing. There were no swing gates on the Woodside hall, where Residents #23, #120, and #128 resided. 7. Maintenance Supervisor #27 was interviewed on 11/04/15 at 8:20 a.m. He was unaware of any resident's request for the triangular wooden swing gates used to deter the wandering residents from entering other residents' rooms. He said he made the wooden gates as they were needed, and did not currently have any to hang on the residents' doors. 8. Licensed practical nurse (LPN) #54 was interviewed on 10/27/15 at 9:45 a.m. She confirmed the residents with dementia wandered throughout the facility now that the Solana unit was no longer locked. She confirmed some of the residents entered other residents' rooms, climbed into their beds, and took their belongings. 9. During the survey, observation revealed residents, who resided on the Solana unit, previously a locked Alzheimer's unit, wandered freely throughout the facility all day long. They were not provided activities to keep them busy, as they were provided when they resided in a setting designed for residents with dementia. d) On 11/02/15 at 10:21 a.m., the facility administrator explained that when the Alzheimer's unit was unlocked on 04/20/15, the facility felt the biggest risk for the unit doors being unlocked was wandering residents. The administrator said they felt the other needs could be met through activities and social services. Each resident who resided on the locked Alzheimer's unit was also to receive an assessment of individual needs. e) During the survey, evidence revealed the facility failed to continue to assess, care plan, and provide interventions to meet the needs of each of the residents who previously resided in a secured Alzheimer's unit with structured daily activities. The facility also failed to ensure they met the needs of other residents who were affected by the changes as the result of the closure of the Alzheimer's unit.

Based upon observation, record review, staff interview, and family interview, the facility fails to deploy sufficient nursing staff across all shifts to provide nursing and related services to minimize resident-to-resident altercations and/or accidents for five (5) of twelve (12) residents reviewed. There was not adequate monitoring and intervention by staff to consistently prevent or minimize the risk of injury to residents. Residents #91, #16, #38, and #85 did not receive supervision to prevent resident-to-resident altercations. The altercation involving Resident #91 resulted in actual harm to Resident #16, and the altercation involving Resident #38 resulted in actual harm to Resident #86. In addition, staff were not deployed to monitor Resident #57 to assist in the prevention of falls and/or injury. Resident identifiers: #91, #16, #38, #85, and #57. Facility census: 90. Findings include: a) Resident #91 This resident's medical record, reviewed on 11/04/13 at 11:00 a.m., found this [AGE] year old resident was admitted to the facility on [DATE]. Review of the Pre-admission Screening form found the resident was residing at a local geriatric behavioral health unit at the time of the initial referral. The [DIAGNOSES REDACTED]. The facility's social services history/admission assessment was completed on 08/06/13. Under the "Behavior: (check all that apply.)" section were checkmarks indicating "Physical behavior symptoms directed towards others. (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually.), and "Verbal behavioral symptoms directed toward others. (e.g., threatening others, screaming at others, cursing at others.)" Under the section "Impact on others - Did any of the identified symptoms:" was checked "Put others at significant risk for physical injury." Under the section "Discharge plan review" checkmarks were made that indicated discharge to the community was not feasible, and that long-term placement was anticipated. The resident's care plan contained a hand written addition, which was not dated, stating: "Resident to resident altercation" The goal associated with this item was: "To keep resident from injuring other residents". Interventions written were: 1. "redirect resident" 2. "Keep resident busy in activities" 3. "Instruct resident to ask for help if she feels threatened". The facility was unable to locate any KARDEX, or specific instruction to nursing assistants, to guide them in providing for the individualized care needs of Resident #91. There was an incident report regarding an altercation between Resident #91 and Resident #16 on 08/12/13 at 7:45 p.m. The report described the circumstances as (typed as written): "(#91) grabbed (#16) and tossed him down the hallway. He landed on his side hurting his right hip and receiving a skin tear to his right elbow." Resident #16 was found to have suffered a [MEDICAL CONDITION] as the result of this altercation. The report indicted the care plan of Resident #91 was updated. The question "Was there a change in behavioral status in the last 90-days?" was marked "No". There were no interviews, summary of findings, or corrective or proactive action noted in the text fields for those items. The status was marked "Not Complete". The medical record of Resident #91 contained a "Change of condition Documentation" form dated 8/12/13 at 8:30 p.m. The section of the form "Nursing Progress Note - A.P.I.E." was completed as follows (typed as written): "19:45 Resident witnessed resident (#12) hit (another female Resident #74) in the face. She reacted by grabbing (Resident #12) and tossed him down this hallway. (Resident #12) landed on his right side on his shoulder & hip. She then looked at (Resident #74) and said that's how you take care of that. Dr. (name) called @ 8 pm Family called @ 8:05 pm Left message to call back Called (director of nursing, employee #15) & left a message to call back." The note was written by licensed practical nurse (LPN), Employee #12. A family member of Resident #91 was interviewed on 11/6/13 at 11:00 a.m. This person stated when the family went for a tour of the facility, they were told the unit was designed to care for Alzheimer's patients like their mother, they had twenty-four (24) hour programming, and the staff was trained in monitoring and managing the behaviors that come with the disease. The family member said on the evening of the incident, Resident #16 had come down the hallway unnoticed and began to argue with Resident #74. They said their mother thought Resident #74 was her mother. During the argument, the male resident slapped Resident #74 in the face. Resident #91 tossed the male resident to the floor trying to protect Resident #74. The family said if staff witnessed the incident play out, why did they not intervene to de-escalate the situation, or redirect the residents to prevent the altercation from even occurring? The licensed practical nurse (LPN), Employee #12, who wrote the note describing the incident was interviewed on 11/06/13 at 1:19 p.m. She said she was passing medications on the evening of the altercation. She said there were two (2) nursing assistants and herself working in the Alzheimer's unit. There were thirty (30) residents on the unit. She said she did not think there was any activities staff working at that time. This was later confirmed by the director of the unit, Employee #88 on 11/06/13 at 4:00 p.m. Payroll records showed the activities staff had left at 5:04 p.m. on 08/12/13. She said they normally only work from 9:30 a.m. to 8:00 p.m. LPN #12 said that at that time of the evening, the nursing assistants (NAs) would be in resident rooms getting them ready for bed, and she would be passing medications. She said Resident #16 lived in a room down at the end of one of the two main wings that formed the "L" shaped unit. Resident #91 and Resident #74 lived at the end of the other wing. She said Resident #16 had gone from his room at the end of one hall and gone down the other hall to the end where the ladies were sitting and talking. No one noticed his whereabouts or attempted to redirect him, because the aides were in other residents' rooms and she was passing medications. She said she was approaching the corner of the "L" shaped wings when she heard the argument between Resident #16 and Resident #74. She said he had gone into the room the ladies were in talking, and they were trying to get him out. As she began to make her way down the hall, Resident #16 slapped Resident #74. She heard Resident #91 say, "He slapped my mother," and Resident #91 tossed the male resident to the floor. The LPN said she was not able to get to them in time to intervene or redirect Resident #16. She said, especially at that time of the evening, there were lots of fights and spats, but usually no injuries to the extent sustained by Resident #16. She said many of the residents exhibit "sundowners" behaviors. The LPN stated the normal scheduled staffing was one (1) nurse and two (2) aides, and it was just not enough staff to monitor and redirect all the residents in the evening while trying to do the individual care in the rooms and also pass evening medications. She said sometimes the aides or the nurse have to scream at the top of their voices to try to get help for situations like this, and there could be some that no one was ever aware of. She said Resident #91 was just trying to protect her "mother". Nursing assistant (NA), Employee #2, one of the NA's working the evening of the incident, was interviewed on 11/06/13 at 3:22 p.m. She said she was in another room caring for a resident when she heard the nurse scream for help. By the time she was able to get there, Resident #16 was on the floor. The ladies were just sitting there watching the situation. She said it is not uncommon for there to be spats and fights. The outcome was unusual with the extent of the injuries. She said they could have been separated and the incident avoided if there were more staff. With one (1) nurse doing medication pass and two (2) aides getting people ready for bed, it was not possible for residents to be monitored and interventions to be made promptly to prevent accidents. Staffing was not sufficient to ensure an environment which promoted each resident's physical, mental, and psychosocial well-being. The facility did not ensure adequate deployment of staff for implementation of the resident's care plan to redirect the resident and/or to keep the resident busy in activities. b) Resident #16 Review of the resident's medical record was begun on 11/4/13 at 11:47 a.m. This [AGE] year-old resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #16 was the aggressor in all but one of these altercations. 1) On 05/17/13, he struck another resident in the lower lip, causing her lip to bleed. 2) On 05/23/13, he struck another resident in the nose. 3) On 05/31/13, he struck a female resident on her right cheek. 4) On 07/27/13, he tried to take a broom away from a female resident and she struck him on the head with the broom. 5) On 08/02/13, he struck a female resident in the face. The corrective action described as being taken was "watch residents". 6) On 08/12/13, he struck resident #74 in the face, and was tossed to the floor by Resident #91, sustaining a [MEDICAL CONDITION]. The corrective action described as being taken was "watch residents". Review of the resident's care plan revealed a hand written undated entry to the care plan, presumably made after he was struck in the head by a broom, which stated (typed as written): "Resident will remain injury free retaining to altercation of another resident." The interventions were: 1. "Keep residents busy with activities" 2. "Redirection of the resident" 3. "Keep residents out of other residents rooms". The facility failed to ensure adequate deployment of staff to monitor the activities of a resident who was known to be the aggressor in resident-to-resident altercations. In addition, there was no evidence staff were sufficiently deployed to implement the interventions to keep the resident busy with activities, redirect the resident, and to keep residents out of other residents' rooms. c) Resident #38 This resident was admitted to the facility on [DATE]. She was a [AGE] year old female with [DIAGNOSES REDACTED]. The record was reviewed on 11/11/13 at 9:00 a.m. Resident #38 was involved in an altercation on the Alzheimer's unit on 09/20/13 at 2:45 p.m. The incident report stated she was seen pulling another resident, Resident #86, across the hallway. Resident #86 suffered multiple scratches to her face and neck, and was sent to the emergency room for treatment. The report noted that wandering was a factor in the incident, and that there had been no change in her behavior. The report further stated the incident was unwitnessed until Resident #38 was seen dragging Resident #86 out of her room across the hallway. There was no evidence staff was aware Resident #86 was wandering into other residents' rooms, or had entered Resident #38's room. It was not known how long she had been in the room, or if any other physical altercation may have taken place prior to staff seeing Resident #38 dragging Resident #86 across the hallway. Resident #86 suffered multiple scratches to her face and neck, and was sent to the emergency room for treatment. The facility failed to deploy sufficient staff to monitor this resident's wandering, to intercept the resident-to-resident altercation on 09/20/13. In addition, the facility did not deploy staff to monitor the resident after the altercation on 09/20/13, as the resident was subsequently involved in resident-to-resident altercations on 09/23/13 and 10/02/13. d) Resident #85 This [AGE] year old resident was was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The record was reviewed on 11/11/13 at 9:37 a.m. The review found Resident #85 was involved in a resident-to-resident altercation on 08/28/13 at 7:40 p.m., in which he struck a female resident in the face three (3) times. The incident report stated (typed as written): "CNA yelled for this nurse. Found resident sitting on the floor in a male resident's room. CNA stated she seen the male resident hit this resident in the face (L) eye 3 times but could not get to residents in time." Review of the care plan found one item dated 08/13/13 for "increased" (an arrow pointing up vertically) behaviors. The goal for the issue was (typed as written): "Behaviors will resolve" Interventions implemented toward meeting the goal were: 1. "[MEDICATION NAME] 500 mg BID" 2. "Monitor S/S adverse affects" 3. "Monitor behaviors". At the time of this altercation, sufficient staff were not deployed to monitor this resident, whose behaviors resulted in another resident being hit in the face. e) Resident #57 1) This [AGE] year old resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]." The record review was begun on 11/4/13 at 4:10 p.m. The resident had documented falls on 08/03/13, 08/05/13, 08/05/13, 08/20/13, 08/21/13, and 10/03/13. The licensed practical nurse (LPN), Employee #12, who worked the evening of 08/05/13, was interviewed on 11/06/13 at 1:19 p.m. She said the facility was chaotic the evening of 08/05/13, as there had been four (4) call-offs. She said there were several residents on the Hilltop wing that came out into the hallway in the evening. The LPN said there were frequent fall risks and incidents between the residents. She said when she has enough staff, she assigned one (1) NA to just stay there in the middle of them to monitor and redirect for safety until bedtime. The LPN said there was no way to do that on the evening of 08/05/13 because there were not enough aides. She confirmed it was not possible to maintain adequate monitoring. The fancily failed to ensure sufficient staff to provide identified needs for monitoring and redirecting of this resident, as well as other residents on the unit. 2) Resident #57 was observed on 11/04/13. The resident was alone in the hallway, sitting in his wheelchair. No staff were present at the time. The resident was slouched in his wheelchair, as if he was about to slide out. He was propelling himself throughout the hallway. At one point, he entered room [ROOM NUMBER]. The resident's assigned room was 103. Two (2) staff members, who were in a room at the end of the hallway on Woodside Hall, were informed Resident #57 had wandered into another resident's room. On 11/5/13, the resident was observed alone at the beginning of Woodside Hall, sitting in his wheelchair. Again, there were no staff present at that time. The resident had somehow managed to overturn an empty wheelchair. Observation revealed the resident grabbed onto the railing and pulled himself up to a standing position. The resident had a care plan for a tab alarm to all surfaces at all times; however, no alarm sounded at any time when the resident stood up. Because of the eminent risk for injury, Employee #74, the nursing scheduler, was alerted to the situation. She immediately went to the resident and assisted him to a sitting position in his wheelchair. The administrator, Employee #48 was informed of the incident. Staffing was not sufficient to monitor Resident #57 as he independently maneuvered himself around Woodside Hall. Although the resident had a history of [REDACTED]. .

Based upon observation, record review, staff interview, family interview, and interview with outside behavioral health professionals, the facility failed to ensure five (5) of twelve (12)residents reviewed received adequate supervision and/or assistive devices to prevent avoidable accidents. Residents #91, #16, #38, and #85 did not receive supervision to prevent resident-to-resident altercations. The altercation involving Resident #91 resulted in actual harm to Resident #16, and the altercation involving Resident #38 resulted in actual harm to Resident #86. In addition, Resident #57 did not receive supervision or assistive devices to prevent accidents involving himself. Resident identifiers: #91, #16, #38, #85, and #57. Facility census: 90. Findings include: a) Resident #91 Review of this resident's medical record, on 11/04/13 at 11:00 a.m., found this [AGE] year old resident was admitted to the facility on [DATE]. Review of the Pre-admission Screening form found the resident was residing at a local geriatric behavioral health unit at the time of the initial referral. The [DIAGNOSES REDACTED]. The facility's social services history/admission assessment was completed on 08/06/13. Under the "Behavior: (check all that apply.)" section were checkmarks indicating "Physical behavior symptoms directed towards others. (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually.), and "Verbal behavioral symptoms directed toward others. (e.g., threatening others, screaming at others, cursing at others.)" Under the section "Impact on others - Did any of the identified symptoms:" was checked "Put others at significant risk for physical injury." Under the section "Discharge plan review" checkmarks were made that indicated discharge to the community was not feasible, and that long-term placement was anticipated. There was no evidence the information regarding behavior issues, which was available to the facility, was ever included in a care plan for Resident #91. There was no interim care plan or formal care plan with any interventions designed to monitor or manage behavioral issues. There was a hand written addition to the care plan, which was not dated, stating: "Resident to resident altercation" The goal associated with this item was: "To keep resident from injuring other residents". Interventions written were: 1. "redirect resident" 2. "Keep resident busy in activities" 3. "Instruct resident to ask for help if she feels threatened". The facility was unable to locate any KARDEX, or specific instruction to nursing assistants, to guide them in providing for the individualized care needs of Resident #91. There was an incident report regarding an altercation between Resident #91 and Resident #16 on 08/12/13 at 7:45 p.m. The report described the circumstances as (typed as written): "(#91) grabbed (#16) and tossed him down the hallway. He landed on his side hurting his right hip and receiving a skin tear to his right elbow." Resident #16 was found to have suffered a fractured hip as the result of this altercation. The medical record of Resident #91 contained a "Change of condition Documentation" form dated 8/12/13 at 8:30 p.m. The section of the form "Nursing Progress Note - A.P.I.E." was completed as follows (typed as written): "19:45 Resident witnessed resident (#12) hit (another female Resident #74) in the face. She reacted by grabbing (Resident #12) and tossed him down this hallway. (Resident #12) landed on his right side on his shoulder & hip. She then looked at (Resident #74) and said that's how you take care of that. Dr. (name) called @ 8 pm Family called @ 8:05 pm Left message to call back Called (director of nursing, employee #15) & left a message to call back." The note was written by licensed practical nurse (LPN), Employee #12. A family member of Resident #91 was interviewed on 11/6/13 at 11:00 a.m. This person stated when the family went for a tour of the facility, they were told the unit was designed to care for Alzheimer's patients like their mother, they had twenty-four (24) hour programming, and the staff was trained in monitoring and managing the behaviors that come with the disease. The family member said on the evening of the incident, Resident #16 had come down the hallway unnoticed and began to argue with Resident #74. They said their mother thought Resident #74 was her mother. During the argument, the male resident slapped Resident #74 in the face. Resident #91 tossed the male resident to the floor trying to protect Resident #74. The family said if staff witnessed the incident play out, why did they not intervene to de-escalate the situation, or redirect the residents to prevent the altercation from even occurring? The licensed practical nurse (LPN), Employee #12, who wrote the note describing the incident was interviewed on 11/06/13 at 1:19 p.m. She said she was passing medications on the evening of the altercation. She said there were two (2) nursing assistants and herself working in the Alzheimer's unit. There were thirty (30) residents on the unit. She said she did not think there was any activities staff working at that time. This was later confirmed by the director of the unit, Employee #88 on 11/06/13 at 4:00 p.m. Payroll records showed the activities staff had left at 5:04 p.m. on 08/12/13. She said they normally only work from 9:30 a.m. to 8:00 p.m. LPN #12 said that at that time of the evening, the nursing assistants (NAs) would be in resident rooms getting them ready for bed, and she would be passing medications. She said Resident #16 lived in a room down at the end of one of the two main wings that formed the "L" shaped unit. Resident #91 and Resident #74 lived at the end of the other wing. She said Resident #16 had gone from his room at the end of one hall and gone down the other hall to the end where the ladies were sitting and talking. No one noticed his whereabouts or attempted to redirect him, because the aides were in other residents' rooms and she was passing medications. She said she was approaching the corner of the "L" shaped wings when she heard the argument between Resident #16 and Resident #74. She said he had gone into the room the ladies were in talking, and they were trying to get him out. As she began to make her way down the hall, Resident #16 slapped Resident #74. She heard Resident #91 say, "He slapped my mother," and Resident #91 tossed the male resident to the floor. The LPN said she was not able to get to them in time to intervene or redirect Resident #16. She said, especially at that time of the evening, there were lots of fights and spats, but usually no injuries to the extent sustained by Resident #16. She said many of the residents exhibit "sundowners" behaviors. The LPN stated the normal scheduled staffing was one (1) nurse and two (2) aides, and it was just not enough staff to monitor and redirect all the residents in the evening while trying to do the individual care in the rooms and also pass evening medications. She said sometimes the aides or the nurse have to scream at the top of their voices to try to get help for situations like this, and there could be some that no one was ever aware of. She said Resident #91 was just trying to protect her "mother". Nursing assistant (NA), Employee #2, one of the NA's working the evening of the incident, was interviewed on 11/06/13 at 3:22 p.m. She said she was in another room caring for a resident when she heard the nurse scream for help. By the time she was able to get there, Resident #16 was on the floor. The ladies were just sitting there watching the situation. She said it is not uncommon for there to be spats and fights. The outcome was unusual with the extent of the injuries. She said they could have been separated and the incident avoided if there were more staff. With one (1) nurse doing medication pass and two (2) aides getting people ready for bed, it was not possible for residents to be monitored and interventions to be made promptly to prevent accidents. During the interview conducted on 11/05/13 at 12:10 p.m., the therapist from the (local behavioral health unit) said facility staff had come to the unit on 08/27/13 to re-assess Resident #91. The therapist stated Resident #91 is "basically the same today as she was on the day before they admitted her on 08/05/13. She has Alzheimer's disease with behavioral disturbances that require monitoring and management." The facility had knowledge of Resident #91's behavioral history; however, no interventions, including adequate supervision, were planned or implemented to reduce the risk of an accident. b) Resident #16 Review of the resident's medical record was begun on 11/4/13 at 11:47 a.m. This [AGE] year-old resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #16 was the aggressor in all but one of these altercations. 1) On 05/17/13, he struck another resident in the lower lip, causing her lip to bleed. 2) On 05/23/13, he struck another resident in the nose. 3) On 05/31/13, he struck a female resident on her right cheek. 4) On 07/27/13, he tried to take a broom away from a female resident and she struck him on the head with the broom. 5) On 08/02/13, he struck a female resident in the face. The corrective action described as being taken was "watch residents". 6) On 08/12/13, he struck resident #74 in the face, and was tossed to the floor by Resident #91, sustaining a fractured hip. The corrective action described as being taken was "watch residents". The review found no evidence of any care plan to address the monitoring or management of aggressive behaviors. There was a hand written undated entry to the care plan, presumably made after he was struck in the head by a broom, which stated (typed as written): "Resident will remain injury free retaining to altercation of another resident." The interventions were: 1. "Keep residents busy with activities" 2. "Redirection of the resident" 3. "Keep residents out of other residents rooms". The KARDEX, or specific instruction to nursing assistants to guide them in providing for the individualized care needs of resident #16 had not been updated since 7/4/13, and included no instructions to monitor for location or for aggressive behaviors. Beginning 05/17/13, the facility had knowledge Resident #16 had aggressive behaviors toward other residents on the unit; however, no interventions, including adequate supervision, were planned or implemented to reduce the risk of an accident. c) Resident #38 This resident was admitted to the facility on [DATE]. She was a [AGE] year old female with [DIAGNOSES REDACTED]. The record was reviewed on 11/11/13 at 9:00 a.m. Resident #38 was involved in an altercation on the Alzheimer's unit on 09/20/13 at 2:45 p.m. The incident report stated she was seen pulling another resident, Resident #86, across the hallway. Resident #86 suffered multiple scratches to her face and neck, and was sent to the emergency room for treatment. The report noted that wandering was a factor in the incident, and that there had been no change in her behavior. The report further stated the incident was unwitnessed until Resident #38 was seen dragging Resident #86 out of her room across the hallway. There was no evidence staff was aware Resident #86 was wandering into other residents' rooms, or had entered Resident #38's room. It was not known how long she had been in the room, or if any other physical altercation may have taken place prior to staff seeing Resident #38 dragging Resident #86 across the hallway. The record of Resident #38 was reviewed on 11/11/13 at 9:00 a.m. Resident #38 was involved in an altercation on the Alzheimer's unit on 09/20/13 at 2:45 p.m. The incident report stated she was seen pulling another resident, Resident #86, across the hallway. Resident #86 suffered multiple scratches to her face and neck, and was sent to the emergency room for treatment. The resident-to-resident altercation with injury requiring medical intervention was never reported as required by State law. On 11/11/13 at 10:00 a.m., the administrator, Employee #48 confirmed the allegation had not been reported as required Resident #38's care plan was revised following the incident to include interventions such as (typed as written): 1. "Document behaviors/interventions as indicated" 2. "Initiate behavior charting to identify why the resident becomes angry or agitated (note time of day, who was present, & what preceded the incident) 3. "Involve resident in 1:1 recreational activity". The KARDEX, or specific instruction to nursing assistants to guide them in providing for the individualized care needs of Resident #38, included no instructions to monitor for location or for aggressive behaviors. She was subsequently involved in resident to resident altercations on 09/23/13 and 10/02/13. d) Resident #85 This [AGE] year old resident was was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The record was reviewed on 11/11/13 at 9:37 a.m. vThe review found Resident #85 was involved in a resident to resident altercation on 08/28/13 at 7:40 p.m., in which he struck a female resident in the face three (3) times. The incident report stated (typed as written): "CNA yelled for this nurse. Found resident sitting on the floor in a male resident's room. CNA stated she seen the male resident hit this resident in the face (L) eye 3 times but could not get to residents in time." Review of the care plan found one item dated 08/13/13 for "increased" (an arrow pointing up vertically) behaviors. The goal for the issue was (typed as written): "Behaviors will resolve" Interventions implemented toward meeting the goal were: 1. "Depakote 500 mg BID" 2. "Monitor S/S adverse affects" 3. "Monitor behaviors". There were no revisions following the altercation of 08/28/13. The KARDEX, or specific instruction to nursing assistants to guide them in providing for the individualized care needs of Resident #85, included no instructions to monitor for location or for aggressive behaviors. e) Resident #57 1) This [AGE] year old resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]." The record review was begun on 11/4/13 at 4:10 p.m. The resident had documented falls on 08/03/13, 08/05/13, 08/05/13, 08/20/13, 08/21/13, and 10/03/13. The facility submitted an immediate reporting of an allegation of neglect on 08/06/13 after the the falls on 08/05/13. The allegation noted a nursing assistant (NA), former Employee #97, neglected to provide incontinence care for three to four hours, which resulted in the resident attempting to get up unassisted and falling first at 7:30 p.m. and for a second time at 9:35 p.m. The licensed practical nurse (LPN), Employee #12, who worked the evening of 08/05/13, was interviewed on 11/06/13 at 1:19 p.m. She said the facility was chaotic the evening of 08/05/13, as there had been four (4) call-offs. She said there were several residents on the Hilltop wing that came out into the hallway in the evening. The LPN said there were frequent fall risks and incidents between the residents. She said when she has enough staff, she assigned one (1) NA to just stay there in the middle of them to monitor and redirect for safety until bedtime. The LPN said there was no way to do that on the evening of 08/05/13 because there were not enough aides. She confirmed it was not possible to maintain adequate monitoring. 2) Resident #57 was observed on 11/04/13. The resident was alone in the hallway, sitting in his wheelchair. No staff were present at the time. The resident was slouched in his wheelchair, as if he was about to slide out. He was propelling himself throughout the hallway. At one point, he entered room 110. The resident's assigned room was 103. Two (2) staff members, who were in a room at the end of the hallway on Woodside Hall, were informed Resident #57 had wandered into another resident's room. On 11/5/13, the resident was observed alone at the beginning of Woodside Hall, sitting in his wheelchair. Again, there were no staff present at that time. The resident had somehow managed to overturn an empty wheelchair. Observation revealed the resident grabbed onto the railing and pulled himself up to a standing position. The resident had a care plan for a tab alarm to all surfaces at all times; however, no alarm sounded at any time when the resident stood up. Because of the eminent risk for injury, Employee #74, the nursing scheduler, was alerted to the situation. She immediately went to the resident and assisted him to a sitting position in his wheelchair. The administrator, Employee #48 was informed of the incident. Although the resident had a history of [REDACTED]. .

Based on record review and staff interview, the facility failed, for two (2) of forty-four (44) residents reviewed, to provide adequate supervision and/or assistive devices to prevent accidents, resulting in actual harm to one (1) of these residents. The interdisciplinary team developed a care plan to address risk of falls for Resident #84, who was admitted on [DATE] with poor coordination, impaired balance, unsteady gait, moderately impaired cognitive functioning, and multiple psychiatric diagnoses. Interventions to prevent falls included both environmental modifications (e.g., keep room clutter-free, keep commonly used items nearby, etc.), as well as interventions that relied on the resident to remember to ask for assistance and to exercise good judgment to promote her own safety. After she experienced her first fall in the facility on 07/11/11, a physical therapy screen recognized that the resident's poor safety awareness and impulsive behavior, as well as her instability, put her at risk for falling; however, the care plan was not revised to address these issues. Resident #84 sustained a second fall on 07/28/11, resulting in a contusion to the forehead requiring transfer to the emergency room . The interdisciplinary team also developed a care plan to address risk of falls for Resident #34, who had a [DIAGNOSES REDACTED]. The care plan interventions to promote safety required the resident to recall information (such as reminding her to ask for staff assistance, relying on her to remember to use a call bell, and educating her on safety risks), which were not appropriate for this resident. Review of incident / accident reports revealed she sustained fourteen (14) falls since her admission to the facility on [DATE]. Resident identifiers: #84 and #34. Facility census: 100. Findings include: a) Resident #84 When reviewed on 08/24/11, the medical record for Resident #84 divulged this resident was admitted to the facility on [DATE]. According to her admission minimum data set assessment (MDS) with an assessment reference date (ARD) of 05/31/11, the assessor determined her brief interview for mental status (BIMS) score was "12", indicating this resident's cognitive status was moderately impaired. Additionally, the assessor noted the following [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined by facility staff, on Page 6 of 13 of the care plan, to be at: "Risk for falls related to: Use of psychotropic medications, impaired balance, poor coordination, unsteady gait, potential for pain, involuntary movements r/t (related to) psychotropic medications." This problem had been recognized on 06/06/11, according to the care plan document. Interventions to promote safety included: "Have commonly used articles within easy reach. Resident to wear non slip footwear. Remind resident to use call light prior to ambulating or transfer. Reinforce need to call for assistance. Place call light within easy reach of resident. Evaluate effectiveness and monitor for side effects of psychotropic drugs. Ensure environment is free of clutter. Encourage resident to transfer and change positions slowly. Encourage resident to communicate needs / ask for assistance. Educate resident on Safety Risks." - The facility incident / accident reports, when reviewed, disclosed this resident had experienced her first fall on 07/11/11, with the report stating: "resident observed lying on the floor in front of the commode. ..." The resident's care plan made no mention of this fall, with no new interventions developed. Further review of facility incident / accident reports revealed the resident sustained [REDACTED]. (resident) lying in front of her w/c (wheelchair). ..." With this fall, the resident required transfer to the emergency room with a raised nodule and contusion to the forehead. - The unit manager for the Hilltop Unit (Employee #104), when interviewed on the afternoon of 08/24/11, stated that, although she found no direct update to the care plan, a physical therapy (PT) evaluation was completed following this fall. This PT evaluation was reviewed. Dated 07/12/11, the screening form stated a referral was received from nursing following a recent fall. The comments section of this form stated: "Res. (resident) recently d/c (discharged ) from PT /c (with) known risk for falls (symbol for 'secondary to') instability & poor safety awareness / impulsive behavior. No (symbol for 'change') to warrant PT re-eval (re-evaluate)." - Documentation on the PT screening form identified this resident's poor safety awareness and impulsive behavior contributed to falls; however, no changes were made to the resident's care plan to address this, with many interventions still relying on the resident to recall instructions or exercise good judgment (such as remembering to use the call light, asking for staff assistance prior to transferring / ambulating, recalling education given at an earlier date on safety risks, etc.). -- b) Resident #34 The medical record of Resident #34, when reviewed on 08/29/11, revealed the resident had been admitted to the facility on [DATE]. At the time of admission, the resident's active medical [DIAGNOSES REDACTED]. On the resident's initial care plan dated 03/30/11, the resident was recognized by facility staff to be at "risk for falls related to: use of psychotropic medications, unsteady gait, history of multiple falls, generalized weakness, decreased safety awareness, non-compliance with requesting assistance with c/b (call bell) usage." Interventions determined to be necessary to decrease the number of falls, or to prevent injury, included: "Alarming floor mat. Alarming sensor pad to bed or c/c (cardiac chair). Up in chair for rest periods. Have commonly used articles within reach. Resident to wear non-slip foot wear. Ensure environment is free of clutter. Encourage resident to transfer and change position slowly. Encourage resident to communicate needs / ask for assistance. Educate resident on Safety Risks. Evaluate effectiveness and monitor for side effects of psychotropic drugs: Depakote, Klonopin." All of the interventions were dated as initiated on 03/30/11, with the exception of a concave mattress to her bed which was initiated on 06/10/11, after the resident had already fallen eleven (11) times. - Review of the facility incident / accident reports revealed that, since the time of her admission, the resident had fallen fourteen (14) times. With many of the falls, an entry was handwritten on the care plan which stated the problem as being the resident had experienced a fall and the date of the fall. The goals that were added were: "Will remain free of injury", "Will have no serious injury', and "Will have no complications". Approaches were to assist as needed, keep call bell in reach, monitor the frequency of falls and/or re-direct as needed. There was no evidence that the resident had been evaluated for cause of the falls, patterns of times of falls, etc. in an attempt to prevent the falls. No different or additional interventions had been attempted when the resident continued to fall. - Review of her admission MDS with an ARD of 03/21/11 revealed a BIMS score of "03", with no ability to recall three (3) words spoken to her earlier during the interview. A significant change in status MDS with an ARD of 06/06/11 revealed a BIMS score of "04", with the ability to recall only two (2) of three (3) words spoken to her earlier in the interview only after cuing. According to the resident assessment instrument user's manual for the MDS 3.0, a BIMS score of "0" to "7" indicates the resident's cognitive status is severely impaired. Therefore, interventions that required the resident to recall information (such as reminding her to ask for staff assistance, relying on her to remember to use a call bell, and educating her on safety risks) were not appropriate for this resident. .

Based on record review, observation, and staff interview the facility failed to identify and initiate treatment of [REDACTED]. This was evident for one (1) of fourteen (14) sampled residents. Resident identifier: #3. Facility census: 97. Findings include: a) Resident #3 Review of the care plan revealed Resident #3 was to have podiatry services every sixty (60) days and as needed (PRN). Review of the medical record found the most recent podiatry progress note was dated 08/25/11. In this progress note, the podiatrist described this resident's toenails as elongated, thick, crumbly, yellow, mycotic, and painful. [DIAGNOSES REDACTED]. Review of the 08/25/11 podiatry progress note revealed the physician planned to see the resident again for a follow-up appointment in two (2) months. During an interview with a licensed nurse (Employee #92) on 11/02/11 at 9:40 a.m., she said the podiatrist comes to the facility monthly, and Resident #3 was supposed to see the podiatrist on 10/25/11; however, for some reason he was not seen. She agreed his most recent podiatry visit was 08/25/11, and she stated Resident #3 will be put on the list to see the podiatrist in November. - Observation of his toes, with Employee #92 on 11/02/11 at 2:39 p.m., found his toenails were as the podiatrist had described in his 08/25/11 podiatry progress notes - thick, yellow, crumbly, and mycotic. At this time, the left foot was observed by the nurse surveyor to have three (3) small, dried scabs on the second, third, and fourth toes down toward the bases of each of those toes. Employee #92 agreed they looked like dried scabs. - Interview with the facility's wound care nurse (Employee #50), on 11/02/11 at approximately 4:00 p.m., found she was not aware Resident #3 had skin issues on his feet; she had not needed to do skin assessments as he was not a new admission or a new re-admission, and she had not been informed by staff of his having any skin issues. When asked what she would do if she observed small dried scabs on the toes of a diabetic resident, she stated she would follow protocol and assess the areas, measure and record the assessment on a vascular non-pressure ulcer form, and provide follow-up. When informed that Resident #3 had three (3) small scabs on the toes of his left foot, she stated she would assess him, accompanied by another nurse. - Interview with Employees #50 and #79 (also a licensed nurse), on 11/02/11 at approximately 4:25 p.m., revealed their plans to be aggressive with treatment. They reported having found a difference in temperature of the resident's feet, the right foot being cooler than the left foot. There were also some moisture problems on the right foot between the toes, which they planned to address through staff education. They measured the scabbed areas on the three (3) toes of the left foot and planned to notify the physician for his assessment, and they recommended the resident follow up with the wound care center if the resident were agreeable. - During a meeting with the corporate nurse (Employee #109) and the person-in-charge (Employee #69) on 11/02/11 shortly after 4:30 p.m., they stated the wound care nurses had informed them of their findings. At mid-morning on 11/03/11, facility staff produced a weekly skin audit report for October 2011 that was initialed as having been completed on 10/06/11 and 10/27/11 - the latter indicating his skin was intact. There were blank spaces on 10/13/11 and 10/20/11 - indicating either no skin audit was completed or one was not documented. At this time, a copy of the resident's October 2011 treatment administration record (TAR) noted A&D Ointment was initialed as having been applied by nurses at 9:30 a.m. daily to the bilateral lower extremities (including the feet) and a monthly skin audit was completed on 10/11/11 per the Interdisciplinary Team (IDT) . Review of the resident's care plan found an episodic revision was completed on 11/02/11, addressing the problem of second, third, and fourth toes having unstageable areas to toes of the left foot and identifying the intervention to apply Sure Prep to those toes daily. .

Based on medical record review, observation and staff interview the facility failed to assure residents received the services and care necessary to promote their highest level of physical well being, resulting in ineffective pain management for two (2) of forty-four (44) residents reviewed during Stage II of the survey. For Resident #68 (a terminally ill patient receiving hospice services), the facility failed to assess, monitor, and modify the pain management plan when the resident voiced continued pain. Additionally, the facility failed to administer routine and as needed (PRN) pain medications as ordered to relieve pain, and in one (1) instance, staff failed to administer PRN medication for breakthrough pain until prompted by the hospice nurse. For Resident #116 (who returned to the facility after sustaining a fall which resulted in a fractured left radius), the facility failed to assure consistency in assessing the resident's pain; the nursing staff rated the resident as having no pain, but nursing notes documented the resident had pain. Documentation in the nursing notes revealed the resident received pain medication on dates and times for which there were no corresponding entries on the Medication Administration Record [REDACTED]. Resident identifiers: #68 and #116. Facility census: 100. Findings include: a) Resident #68 Medical record review revealed the resident was initially admitted to the facility on [DATE]. On 07/25/11, the resident began receiving hospice services for end-stage liver disease. The resident was also receiving outpatient paracentesis for comfort. Observation, during Stage I of the survey process on 08/23/11 at 3:28 p.m., found the resident was in bed with his wife at his bedside. The resident stated he did not wish to be interviewed because he was in too much pain. His wife responded by telling him it was about time for his pain pill. - Review of the medical record revealed, on 08/11/11, the resident began receiving one (1) [MEDICATION NAME] Patch 12 mg [MEDICATION NAME] every seventy-two (72) hours for abdominal pain. Review of the physician's notes revealed the nurse practitioner visited the resident on 08/18/11 and recorded the following note: "[MEDICATION NAME] 50/0.5 two (2) tablets now. Please contact Hospice nurse. Pain level 8/10. Diagnosis: [REDACTED]." - On 08/18/11, the facility contacted the hospice agency, and a new order was obtained to increase the [MEDICATION NAME] from 12 mg to 24 mg every seventy-two (72) hours. an order for [REDACTED]. The hospice nurse visited the resident on 08/18/11. Documentation on the nursing assessment completed by the hospice nurse revealed the resident rated his pain as an "8" on a pain scale of "0" to "10" (indicating severe / horrible pain), with his worst pain being rated as "10" (indicating excruciating pain) and his best pain rated as "2" to "4" (mild to moderate pain). The assessment contained the Abbey Pain Scale (used for residents with dementia or who cannot verbalize pain), which was not completed. The information regarding the resident's pain level was obtained from the resident. On 08/23/11, the hospice nurse visited the resident and completed an assessment in which the resident's pain was documented as a "5" (indicating moderate / severe pain). The information regarding the resident's pain level was again obtained from the resident. The resident's vital signs were documented as pulse - 66; respirations - 16; temperature - 97.9. There were no changes made to the resident's current pain medication. On 08/30/11, the hospice nurse again visited the resident and rated the resident's pain as an "8" (indicating severe / horrible pain), with his worst pain rated as "10" and the best rated as "3". The information was obtained from the resident, and the location of the pain was the lower back. Again, no changes were made to the resident's pain medication. - Review of the medical record revealed the resident was sent to a local hospital for outpatient paracentesis at 9:00 a.m. on 08/24/11. The resident returned to the facility at 2:35 p.m. on 08/25/11. Hospital documentation found the resident had four and one half (4-1/2) liters of fluid removed from his abdomen. - Review of the MAR indicated [REDACTED]. According to documentation on the MAR, the resident did not receive the patch at the facility on 08/25/11, and there was no documentation to indicate whether the resident received the patch while at the hospital. Further review of the MAR indicated [REDACTED]. - A nursing note, dated 08/30/11 at 2300 (11:00 p.m.), revealed: "Alert resp. (responds) to care verbal able to make needs known and cont. (continue) to receive Hospice care. Med. (medicated) with [MEDICATION NAME]/[MEDICATION NAME] at 2230 for anxiety and pain with relief noted. Resting quietly in bed with eyes closed. ..." Further review of the medical record revealed the PRN pain management flow sheet had not been completed for the [MEDICATION NAME] that was administered at 2300. The nurse failed to rate the resident's pain prior to administering the [MEDICATION NAME] and failed to rate the resident's pain after one (1) hour of its administration, to evaluate the effectiveness of the medication. - The interm administrator (Employee #119) and the interim director of nursing (DON - Employee #120) were interviewed on 08/30/11 at approximately 10:35 a.m. and were made aware of the above information for Resident #68. No further information was provided. The interim administrator was also unable to locate any documentation or provide any explanation as to whether the resident received the [MEDICATION NAME] Patch on 08/25/11 as ordered. - Shortly after the above interview with facility staff on the morning of 08/30/11, the hospice nurse arrived at the facility. The hospice nurse made the following note after the visit: "Received call (name of social worker) at (name of nursing home) stating pt. (patient) rated pain an 8, asked if he received any [MEDICATION NAME], she didn't know and transferred me to (name of nurse). (Name of nurse) had not given any meds (medications), instructed to give [MEDICATION NAME] and I would come and assess patient. Patient lying in bed, when asked if had pain said, yes, here and pointed to abdomen, when asked to rate, he rated pain as 8. He then closed his eyes. I spoke his name, he opened eyes. I explained pain scale and he said his pain wasn't the worst, it's in the middle. ..." No changes were made to the resident's medications after this visit. The facility failed to effectively control the resident's pain. The resident continued to verbalize pain even after the pain medication was increased. The facility failed to provide documentation to reflect the resident's pain was assessed and addressed, and failed to assure interventions were implemented to control his pain. There was no evidence any non-pharmacological interventions were implemented in an attempt to reduce the resident's verbalization of pain. The facility failed to assure the [MEDICATION NAME] Patch was applied according to physician orders, and failed to administer PRN [MEDICATION NAME] for breakthrough pain on the morning of 08/30/11 until prompted to do so by the hospice nurse. -- b) Resident #116 Medical record review revealed this [AGE] year old female initially admitted to the facility on [DATE]. Further medical record review revealed the resident fell at the facility at 12:25 a.m. on 08/26/11. Review of the incident / accident report revealed she was "... found laying on her left side with a puncture wound noted to her left eyebrow. Her left eye was swollen shut. Resident had lost a copious amount of blood from her left ear and left eyebrow. ..." She was transferred to the hospital as a result of the fall on 08/26/11. The resident returned to the facility at 5:30 a.m. on 08/26/11, with a temporary cast to her left wrist and three (3) stitches to area above the left eyebrow. According to hospital records, the resident fractured her left radius. She returned with a new order for [MEDICATION NAME] 5-325 mg one (1) tablet every four (4) hours PRN for three (3) days for pain associated with the fractured left radius. Review of the nurses notes revealed the following entries: - On 08/26/11 at 4:30 p.m. - "... Res. c/o (complaints of ) pain and moaning. ..." - On 08/26/11 at 10:45 p.m. - "... PRN (as needed) pain given with relief noted. ..." - On 8/27/11 at 9:30 a.m. - "...Voiced no complaints of pain or discomfort." - On 8/28/11 at 1:00 p.m. - "... Resident medicated with [MEDICATION NAME]" - On 08/28/11 at 4:00 p.m. - "... Resident resting quietly to this point. Awake at this time crying in pain. Medicated with [MEDICATION NAME]." Review of the MAR indicated [REDACTED]. There was no documentation on the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. In summary: - On 08/26/11, the resident complained of pain at 4:30 p.m., and pain medication was not administered until 8:00 p.m. (according to documentation on the MAR). The nurse assessed the pain on 08/26/11 and coded the MAR indicated [REDACTED]. - On 08/27/11, the nursing notes stated the resident had no pain and the MAR indicated [REDACTED] - On 08/28/11, the nursing note indicated the resident was "crying in pain" and that [MEDICATION NAME] was administered. The MAR indicated [REDACTED]. The nurse's assessment of pain on the MAR indicated [REDACTED]. There was also no documentation as to the severity of the resident's pain and no documentation to reflect the [MEDICATION NAME], when administered, was effective in relieving the resident's pain. - A registered nurse (RN - Employee #96), when interviewed on the afternoon of 08/28/11, was unable to explain the conflicting documentation on the MAR, nursing notes, and pain assessment. - On 08/30/11 at approximately 11:35 a.m., the interim DON and the interim administrator were made aware of the above discrepancies related to the resident's pain. No further information or explanation was provided. .

Based on staff interview, observation, resident interview, and record review, the facility failed to provide appropriate treatment and services to increase range of motion (ROM) and/or prevent further decrease in range of motion for a resident with limited ROM for one (1) of thirty-seven (37) Stage II sample residents. There was no evidence a resident, who developed bilateral knee contractures since her admission to the facility, received the necessary care and treatment to increase her ROM and/or prevent a further decline. This deficient practice resulted in actual harm to Resident #72. Facility census: 94. Findings include: a) Resident #72 1. The registered nurse (RN - Employee #74), when interviewed on the afternoon of 04/14/10, reported Resident #72 did have contractures with no current order for a splint or range of motion (ROM) therapeutic exercises. 2. Record review, on 04/19/10 at 9:30 a.m., revealed a quarterly minimum data set assessment (MDS) with an assessment reference date of 03/19/10, on which the assessor noted the resident had limited range of motion (ROM) to one (1) leg with no loss of voluntary movement. This assessment information was contradicted by the physician's annual history and physical examination ...severe contracted at hip and knees...". The assessment and care planning nurse (Employee #31), when interviewed on 04/19/10 at 10:15 a.m., reviewed the 03/19/10 quarterly MDS and acknowledged it was inaccurate with respect to limitations in the resident's ROM. Employee #31 stated she "just missed the contracture on the nurse's quarterly assessment, and the therapy screen reported no changes". (See citation at F272.) 3. Resident #72's current care plan, dated 03/31/10, did not address the presence of bilateral knee contractures. Employee #31, when interviewed on 04/19/10 at 10:15 a.m., reviewed the current care plan and acknowledged the resident's bilateral knee contractures were not addressed, stating she would revise the care plan to include knee contractures. (See citation at F279.) 4. Resident #72 was observed in bed at 10:00 a.m. on 04/19/10. The resident was alert and verbal. The resident's knees were observed to be flexed in a fixed position. When asked if she could extend her legs, she reported she could not. The resident denied pain. 5. Medical record review, shortly after 10:00 a.m. on 04/19/10, revealed this [AGE] year old female resident did not have bilateral knee contractures at the time of her original admission to the facility on [DATE] or upon her return from a hospital stay on 03/04/08, and she did not have contractures at the time her physical therapy services were discontinued on 02/14/08. An order was written on 07/16/09 to discontinue both active-assist and passive ROM activities to her upper and lower bilateral extremities due to "noncooperative behavior and c/o (complaints of ) pain"; however, there was no recognition of the presence of contractures of the lower extremities as noted by the physician on 03/03/09, nor was there evidence in the medical record the resident received treatment and services to prevent further decline in joint mobility after her discharge from restorative nursing services on 07/16/09. Review of her rehabilitation screening form found the following consecutive entries in the comments section: - On 12/16/08 - "No changes in functional status. Pt (patient) would not benefit from skilled PT @ this time." - On 12/24/08 - "Pt not appropriate for skilled PT services @ this time. However, recommend Pt to get out of bed daily to promote socialization and mobility." - On 03/21/09 - "Pt not appropriate for skilled PT services 2 (secondary to) behaviors." (This entry did not acknowledge the presence of severe bilateral contractures at the knees and hips as noted by the physician on 03/03/09.) (As of the morning of 04/19/10, there were no further entries reflective of any rehabilitation screening having occurred after 03/21/09.) 6. The rehabilitation services manager, a physical therapy assistant (PTA - Employee-#105), when interviewed on 04/19/10 at 3:30 p.m., revealed she had worked with the resident at the time she was admitted to the facility. The PTA confirmed the resident received physical therapy soon after her admission to the facility and was discharged from physical therapy to restorative nursing services on 02/14/08. The PTA further reported the resident was able to ambulate one hundred and fifty (150) feet with the assist of one (1) person at the time of her discharge to restorative nursing services. The PTA stated she was unaware of the resident's current bilateral knee contractures, and she reported there were treatments that could be helpful to prevent further decline and alleviate pain if present. The director of nurses (DON - Employee #89), when interviewed on 04/20/10 at 3:00 p.m., did not provide any additional evidence to reflect the resident received treatment and services to prevent bilateral knee contractures after 07/16/09, when she was discharged from the restorative nursing services. 7. Interview with the physical therapist (PT - Employee #106), on 04/20/10 at 3:15 p.m., revealed the resident was found to have "bilateral knee contractures". The PT acknowledged the resident currently was not receiving any therapy services. Subsequent review found an additional entry made on a rehabilitation screening, dated 04/19/10, stating, "Resident exhibits profound bilateral full flexion contractures and confusion..." Review found a physician's orders [REDACTED]. .