Every finding on record at Sedgewood Manor Health Care Center

Based on observations, interviews, and policy review, the facility failed to ensure stored meat products were properly labeled and dated and failed to discard opened meat products that were stored in refrigeration for greater than four days in one of one kitchen. This failure had the potential to promote bacterial growth, impede identification of expired or unsafe food products, and increase the risk of food-borne illness for 26 residents who consumed food prepared from the facility's kitchen.Findings include:Review of the facility's undated policy titled, Date Marking for Food Safety, indicated, Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food . 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. 5. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1, (For example, food prepared on Tuesday shall be discarded on or by Friday.) . Observation during the initial kitchen inspection on 07/21/26 from 9:25 AM to 10:05 AM with the Dietary Manager (DM) present, revealed the following concerns with food storage: a. A kitchen reach-in refrigerator, located adjacent to the kitchen, contained one previously opened and undated package of bologna slices that had a spoiled odor and some of the slices of bologna were greenish in color, one previously opened and undated package of ham slices, one previously opened package of bologna slices that was dated 07/12/26, one previously opened and cut large processed turkey breast that was dated 07/12/26, one unopened and undated package of salami slices, and five unopened and undated packages of bologna slices which did not have a date of expiration on their packages. b. A second kitchen reach-in refrigerator, that was located inside the kitchen, contained one previously opened and undated package of turkey slices. During interviews on 07/21/26 at 9:45 AM, the DM confirmed the outdated and undated meat products that were observed stored in the two reach-in refrigerators. The DM stated the bologna, ham, salami, and turkey should have been dated by staff when opened and discarded if not utilized in three to five days. The DM stated if a food is removed from its original box which contains the food's expiration date staff should write the expiration date on the food's package when it is removed.

Based on interview, record review, and review of the facility's arbitration agreement, the facility failed to inform residents and/or resident representatives that they have the right to rescind the agreement within thirty calendar days and failed to inform the resident and/or resident's representative they are not required to enter into a binding arbitration agreement as a condition of admission, for three of three sampled residents (Resident (R) 5, R20, R29) reviewed for arbitration agreements. Findings include: Review of an undated document titled Policy, Binding Arbitration Agreements, provided to the survey team by the Administrator, reflects, The agreement must: .c. Explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it.d. Explicitly state that neither the resident nor his representative is required to sign an agree for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility. Review of a blank undated copy of Arbitration Agreement, provided by the facility, indicated, . this Arbitration Agreement may be rescinded by written notice to the facility from the Resident or Authorized Representative within three business days of signing the Agreement. Review of R5's Resident Face Sheet, located under the Resident tab of the electronic medical record (EMR), revealed R5 was admitted on [DATE] with diagnoses of hyperlipidemia, diabetes mellitus type 2, hypertension, and depressive episodes. Review of R5's admission Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 05/19/26, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R5 was cognitively intact. Review of R5's Facility – Resident/Representative Arbitration Agreement, located in the EMR under the Resident tab, revealed R5 signed the arbitration agreement on 05/18/26. During an interview on 07/23/26 at 10:10 AM, R5 confirmed her signature on the Facility – Resident/Representative Arbitration Agreement. R5 stated, I recall it was not required but not sure how long I got to change my mind. Review of R20's Resident Face Sheet, located under the Resident tab of the EMR, revealed R20 was admitted on [DATE] with diagnoses of chronic diastolic heart failure, acute kidney failure, type 2 diabetes mellitus, and bipolar disorder. Review of R20' s Facility – Resident/Representative Arbitration Agreement, located in the EMR under the Resident tab, revealed R20 signed the arbitration agreement on 07/10/26. During an interview on 07/23/26 at 10:30 AM, R20 confirmed her signature on the Arbitration Agreement. She stated that she, doesn't know what half of the admission paperwork was really about but knew that this didn't mean she couldn't suit. Review of R29's Resident Face Sheet, located under the Resident tab of EMR, revealed R29 was admitted on [DATE] with diagnoses of transient cerebral ischemic attack, hypertension, depression, and anxiety. Review of R29's admission MDS, located in the EMR under the RAI tab with an ARD of 047/14/26, revealed the resident had a BIMS score of 10 out of 15, indicating R29 was moderately cognitively impaired. Review of R29's Facility – Resident/Representative Arbitration Agreement, located in the EMR under the Resident tab, revealed R29 signed the arbitration agreement on 03/07/23. During an interview on 07/23/26 at 10:18 AM, R29 confirmed her signature on the Arbitration Agreement. R29 stated, It was a long time ago, I don't remember. During an interview on 07/23/26 at 12:46 PM, the Administrator reviewed the Arbitration agreement and facility policy and confirmed there was no mention of 30 days to rescind or that it was voluntary and not a condition of admission. She further stated that she, informed the residents that they had 30 days to decide if they didn't want to agree to it and that it wasn't necessary to be admitted , but did not see it in the written agreement. During an interview on 07/23/26 at 1:10 PM, the Admissions Nurse stated she was responsible for the arbitration agreements. She reviewed the Arbitration agreement and facility policy and confirmed there was no mention of 30 days to rescind or that it was voluntary and not a condition of admission.

Based on observations, interviews, record review, and policy review, the facility failed to ensure one of one shower room was clean and odor free. The base wall and floor of the shower room's shower stall was unclean with accumulated black substances, and an unpleasant odor was present in the shower room. This had the potential to affect the quality of life of 23 residents who received showers in the shower room. Findings include:Review of the facility's undated policy titled, Safe and Homelike Environment, indicated, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk . Policy Explanation and Compliance Guidelines: . 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment . 1. Review of Resident (R) 25's quarterly Minimum Data Set (MDS), located under the MDS tab in the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 07/03/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R25 was cognitively intact. During an interview on 07/21/26 at 1:15 PM, R25 stated there were ongoing issues with the facility's shower room not being clean. R25 specified the shower stall and the floor in the shower room were unclean with a black substance and there was a bad odor in the shower room. During an interview on 07/22/26 at 9:40 AM, R25 stated that the shower room smelled horrible and needed to be deep cleaned. R25 further stated, No one wants to take a shower in such a sticky nasty room. 2. Observations of the facility's shower room on 07/21/26 at 1:22 PM and at 2:17 PM, and on 07/22/26 at 4:15 PM revealed the base walls of the shower room's stall and floor were unclean with a black substance and an unpleasant odor was present which appeared to be coming from the shower stall's floor drain. During an observation and interview on 07/23/26 at 11:00 AM, the shower room was observed with the Physical Plant Manager (PPM), who oversaw the facility's maintenance and housekeeping departments, present. Observations revealed the base walls around the shower stall and the floor were unclean with a black substance and the interior of the floor drain, which had its metal drain cover removed, was unclean with accumulated brown and black colored substances. During the observation, this surveyor obtained a paper towel and wiped some of the black colored substance from the shower stall's base wall. The PPM confirmed the shower room was not clean and stated that he thought the observed black substance was accumulated dirt. The PPM stated the housekeeping staff were to clean the shower room daily and that he was not aware of the shower room's current condition. The PPM stated if staff had informed him the shower room was not clean, he would have used a mildew remover to clean the shower stall and floor. The PPM further stated that approximately two months ago he applied new white caulking to the shower stall's base wall and was not sure when the shower stall's floor drain was last cleaned.

Based on review of facility policy, record review, and interviews, the facility failed to ensure call lights were within reach for Resident (R)1, R2, R3, R8 and R9, 5 of 5 rooms reviewed for call light placement.Findings include:Review of the facility's policy titled, Call Lights: Accessibility and Timely Response with a copyright date of 2025 states, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.Policy Explanation and Compliance Guidelines5. Staff will ensure the call light is within reach of the residents and secured, as needed.Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with the diagnosis including but not limited to muscle weakness (generalized), unspecified sequelae of cerebral infarction, dementia, and essential hypertension.Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/17/2025 revealed that R1 has the Brief Interview of Mental Status (BIMS) score of 07 out of 15, which indicates R1 has severe cognitive impairment.During an observation on 12/30/25 at 01:23 PM revealed R1's call light was on the floor at the foot of the bed. The resident was lying in bed watching television.During an observation on 12/30/25 at 01:23 PM, R9's call light was found at the head of the bed, on the floor.During an observation on 12/30/25 at 03:30 PM, R8's call light was unreachable in their room.During an observation on 12/30/25 at 3:30 PM, R2's call light was found on the floor.During an observation on 12/30/25 at 3:30 PM, R3's call light was found on the floor.During an interview on 12/30/25 at 1:24 PM, R1 stated, They took the call light from me. They give you a hard way to go around here. They save me for last to help. They take a long time to change me. I am wet now from peeing on myself.During an observation on 12/30/25 at 01:26 PM, the Certified Nursing Assistant (CNA) in training came to cut off the call light. She stated she is in orientation, and she would go get the CNA who is taking care of R1. The surveyor informed the new CNA that the call lights were on the floor. The new orientee acknowledged that the call lights were on the floor but did not pick up the call light to make reachable for the resident. During an interview on 12/30/25 at 1:51 PM, CNA3 stated, R1 is not oriented. She usually pulls her call light out of the wall. Today is a good day. Most days she is screaming and tries to get out of bed.During an interview on 12/30/25 at 3:03 PM the Administrator stated, call lights are supposed to be within reach for all residents.During a second interview on 12/30/25 at 3:16 PM, the Administrator stated, With my team, we educate staff annually. When incidents occur, I have a meeting with the department heads and we decide on what we need to implement going forward. The training we used to educate our staff is completed via paper and/or electronically on Relias.

Based on review of facility policy, observations and staff interviews, the facility failed to properly label and discard expired food items in 1 of 1 main kitchen and 1 of 1 resident nourishment refrigerator. This failure to follow proper food storage protocols presents a potential risk to the health and safety of the 33 residents who consume food prepared in the facility's kitchen.Review of an undated facility policy titled Labeling, Dating, Rotating Foods revealed the following: Food must be rotated while in storage to maintain quality and limit the growth of pathogens. Food items must be rotated so the items with the earliest use-by or expiration dates are used before those listed with later dates. The first in, first out method (FIFO) is used to rotate foods refrigerated, frozen, and/or dry goods so that items dated earlier are used first. Identify food's use-by or expiration date. Identifiers include item name, date entering facility, and date of manufacturer expiration. Dispose of food on the date of expiration. Any food taken out of the original container must have a delivery date, a manufacturer's use-by date, and food identification.During an initial walkthrough of the main kitchen on 07/27/25 at 10:45 AM, the following was revealed,Multi-Tier Shelf: 11 dinner rolls in original packaging dated 04/22/25; label dated for 07/21. 2 hamburger buns in original packaging dated 07/18/25; label dated for 07/25/25. 1 bag of Corn Flakes, opened, not in original box; label dated for 02/14. 1 5 pound (lb.) bag of Quaker Grits, opened, with no open-date label.Freezer: 9 individual pieces of meat in a plastic bag labeled 06/28. 1 Ziplock bag labeled catfish nuggets, dated 07/25. 10 individual pancakes in a plastic bag; no label or date. 1 Ziplock bag containing what appeared to be half a ham, dated 07/20/25, no label. 1 plastic bag containing what appeared to be cinnamon rolls; date on bag: 03/05/25. 1 blue plastic bag containing approximately 12 pieces of flatbread; date of 06/03.Cooler: Three half-gallon containers of buttermilk with a use-by date of 7/22; labels dated for 06/24.During an observation on 07/28/25, at 12:30 PM of the resident refrigerator located behind the nurses' station, 1 bottle of Nutren 1.5 was found with a use-by date of 06/09/25.During an interview on 07/27/25, at 11:29AM, the Facility Administrator (FA) and the Director of Nursing (DON) revealed that the expectation is for all dietary staff to properly label and date food items and to discard any items that are past their use-by date.During an interview on 07/27/25, at 11:52 AM, the Dietary Manager (DM) revealed she has been the DM since 2023, and in addition to dietary duties, has overseen housekeeping for the past 8 to 9 months. She reported that staffing is currently limited, with two cooks and three aides, though she noted that staffing has been worse in the past. Despite this, mealtimes have not been affected. DM explained that the dietary area lacks sufficient storage space to keep items in their original boxes but follows the First-In, First-Out (FIFO) method for inventory management. Inventory is completed on Mondays and Thursdays, during which labeling is also checked. Daily staff meetings are held to ensure expired foods are discarded; however, she admitted this has not been consistently done in recent weeks. Regarding specific items, she stated that bread is received frozen, with a delivery date labeled and a shelf life of seven days from that date. Cereal received in February 25 was not in its original packaging and had no year indicated on the label. In the freezer, pancakes were present, as well as half of a ham that was not properly labeled. Cinnamon rolls dated 03/05/25 were identified and noted as items that should have been removed. She also identified flatbread stored in its original packaging and a second bag containing hamburger patties. The dietary labeling procedures are intended to be followed for all freezer items. One resident nourishment area is located on the unit, containing snacks and drinks for residents, which is restocked as needed by unit staff. Staff are expected to check for proper labeling weekly. The dietary staff are to follow the practice of using the oldest food first and placing newer shipments behind existing stock.

Based on review of facility policy, record review and interviews, the facility failed to ensure that an allegation of abuse was immediately reported to the abuse coordinator for 1 of 3 residents, Resident (R) 31 reviewed for abuse. This failure had the potential to expose the victim to ongoing harm and allow harmful behavior to continue without intervention.Review of the undated facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revealed, It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations withing prescribed timeframes.Review of R31's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to: type 2 diabetes mellitus, schizoaffective disorder, chronic kidney disease, anxiety disorder, and muscle weakness.Review of R31's quarterly Minimum Data Set (MDS) with an Annual Reference Date (ARD) of 07/16/25 revealed R31 had a Brief Interview for Mental Status (BIMS) of 11 out of 15, indicating she has moderate cognitive impairment.Review of R31's progress notes dated 07/27/25 at 4:20 PM, revealed, I woke this resident by saying hello this am and asking her how she was. R31stated that a few days ago some girl sprayed air freshener in my face. I asked her if she had reported it to anyone and she replied no, I just thought about it. No eye irritation or redness noted. I offered her a cool wet cloth for her eyes and she said not right now. Encouraged resident to let me know if she changed her mind.During an interview on 07/27/25 at 12:05 PM, R31 stated that a nurse had allegedly sprayed aerosol in her eyes a couple of weeks ago, but she does not remember who the nurse was. She stated she reported to the Activities Director around supper time the day that it happened, but no one has come to talk with her about it. During an interview with the Facility Administrator (FA) on 07/27/25 at 2:30PM, the surveyor reported the allegation of abuse. FA stated he was not aware of an abuse allegation, and this is the first that he has heard of it. He included that there are no aerosol cans in the building and to his knowledge, no one in the facility has been treated for eye care due to irritants being sprayed or getting into their eyes. The FA provided the surveyor with the two-hour state reportable dated 07/27/25 at 2:55PM.During an interview on 07/27/25 at 2:40 PM, the Activities Director revealed that R31 had never reported anything to her about someone doing anything offensive to her. She states R31 is always pleasant to her, and she had not made any complaints about anything.During an interview on 07/28/25 at 4:07PM, Licensed Practical Nurse (LPN)5 revealed she was waking up R31 yesterday morning and speaking to her as normal and she asked her how she was doing and R31 responded stating that a girl sprayed air freshener in her eyes a couple of days ago. She includes she did not do anything with this information because she usually says weird things in the morning, and she thought that this was again the same case. LPN5 states that she should have immediately called her Director of Nursing (DON), she knows that she should report any signs of abuse or any sort of odd occurrence. She also states she spoke to R31 a lot and looked at her eyes to make sure there were no spots on her face. LPN5 also includes that she did not bring the situation back up to the resident and she did not report it, she wrote a progress note after the FA approached her about the incident and they asked her to write a statement.During an interview with the DON on 07/29/25 at 9:42 AM, she stated that staff should notify her and/or the FA of any allegation of abuse that should occur. An incident form should also be completed in the computer. The staff is educated to report anything from death, falls, altercations, just anything. The FA is the abuse coordinator, and all things should be reported to him immediately, all staff should be aware of this, and they train the staff annually for abuse.During an interview with the FA on 07/29/25 at 9:56 AM, he revealed that all staff are trained annually through Relias and periodically when thing come about. He includes he is the coordinator, and staff are aware that any allegations or cases of abuse should be reported to me or their immediate supervisor. All forms of abuse should be reported, and I then have two hours of being informed to report to the state agency.

Based on review of facility policy, record review, observations, and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for Resident (R4), 1 of 3 residents reviewed for ADL care. Specifically, staff failed to provide showers and nail care for R4, who was dependent on staff for assistance with ADLs.Review of the facility's undated policy titled Activities of Daily Living (ADLs) revealed, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE] with diagnoses including but not limited to: cerebral infarction due to thrombosis of the right middle cerebral artery, morbid (severe) obesity due to excess calories, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and unsteadiness on feet.Review of R4's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/02/25, revealed R4's Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderate cognitive impairment. R4 is dependent on staff assistance for personal hygiene and showering/bathing and had no refusals of care during the look-back period.During an observation and interview on 07/27/25 at 1:34 PM, R4 revealed that she has impairment on her left side. R4's fingernails were long with dried dirt and brown matter underneath. R4 had food crumbs on her face and gown. R4 stated that she requires assistance with personal hygiene due to her left-side impairment. She reported repeatedly asking staff to clean her nails, but they have not done so. R4 also expressed that she does not receive showers as often as she should and could not remember the last time she had an actual shower. While she acknowledged receiving good bed baths, it had been nearly a week since her last one. R4 shared that she has voiced her concerns to the Director of Nursing (DON) regarding staff not assisting her with showers and has also discussed this issue with her spouse. She emphasized that she does not want to seem like she is bothering the staff but simply wants the help she needs.During observations 07/28/25 8:36 AM and 07/29/2025 at 9:49AM, R4's fingernails remained long with dried dirt and brown matter underneath. R4 states that her aide told her they didn't have the supplies to cut or clean her nails. Review of the Resident Shower Book Log documented R4 received either a shower or a bed bath on the following dates: 03/14/25, 03/21/25, and 04/11/25. These dates were confirmed by the Assistant Director of Nursing (ADON).During an interview on 07/28/25, at 10:35 AM, the DON confirmed that R4 is compliant with care, including assistance with ADLs. She stated that R4 has a contracture in her left arm and is dependent with all ADL's. She stated that as far as nailcare, Certified Nursing Assistants (CNA's) are to cut and trim resident nails, during AM care or during a shower, if a resident requests.During a phone interview on 07/28/25 at 12:50 PM, R4's spouse confirmed that he is the primary contact for the facility and stated that R4 was admitted last year following a stroke. He reported that he has not observed his wife refusing care; however, he expressed concern that she tells him she does not receive showers on her scheduled shower days. He stated that he has observed her receiving bed baths rather than showers. He typically visits her after work, around 5:00 PM to 6:00 PM, before dinner. He also mentioned that R4 recently complained to him that her nails are not being cleaned. R4 is fully dependent on staff for all care and is bedridden.During an interview on 07/28/25 at 2:41 PM, in the presence of the DON and Facility Administrator (FA). The ADON stated that both nurses currently assigned to the unit are new, and this was their first day on the floor. She explained that ADL charting is completed in the electronic health record (EHR), except for showers, which are documented in a shower book maintained on the unit. Regarding R4, it was noted that the resident is scheduled to receive showers on Tuesdays and Fridays. CNAs are responsible for documenting each time a resident receives a shower or bed bath, and if a resident refuses, the refusal should be recorded on the shower sheet for that day or in a progress note. Additionally, a shower task is available in the EHR system. The ADON emphasized the expectation that CNAs honor resident preferences and document all care provided. She also added that CNAs are responsible for cleaning residents' nails as needed. When invited to observe the resident's nails, the ADON, DON, and FA declined.During an interview on 07/29/25 at 11:48 AM, the Activities Director (AD) revealed that CNAs are responsible for cleaning and cutting residents' fingernails upon request. The AD also stated that she will assist with nail polishing if the resident requests it.During an interview on 07/29/25 at 12:00 PM, CNA1 revealed that showers are supposed to be documented in the shower book, which is kept at the nurses' station. She acknowledged that she has been providing residents with showers but has not been documenting them in the book, which is why it appears empty. She also states she is not R4's CNA. She stated that moving forward, she will improve her documentation practices.During an interview on 07/29/2025 at 12:16 PM, CNA2 confirmed that she is R4's assigned CNA. She stated she would need to check with other staff and refer to the shower book to determine when R4 last had a shower, as she could not recall the dates offhand. CNA2 confirmed that R4's nails needed to be cleaned and cut. CNA2 acknowledged that R4 had been asking her for several days to attend to them. CNA2 stated she had informed the nurse about R4's nails because she did not feel comfortable cutting them herself.During an interview on 07/29/2025 at 4:26 PM, the FA revealed that his expectation regarding residents' personal hygiene including showers and nail care is that it should be provided both on scheduled days and as needed. He stated that this expectation is strongly emphasized with the DON and ADON. The FA also emphasized that if it's not documented, it's not done, and this applies to nail care as well if a resident requests it, staff are expected to complete it and ensure it is properly documented.

Based on interviews, and employee record reviews, the facility failed to provide yearly performance evaluations for Certified Nursing Assistants (CNAs), for 3 of 5 CNAs reviewed for yearly performance evaluations; CNA3, CNA4,and CNA5. Review of CNA3's employee record revealed she has a hire date of 04/20/23. She received her last performance review on 05/10/24. She received a rating of Excellent in all areas except one. Her 2025 performance review had not yet been completed as of 07/28/25. Review of CNA4's employee record revealed she has a hire date of 02/24/16. She received her last performance review on 02/28/24. She was rated Excellent and Good in all areas. When Surveyor initially asked for her file on 07/28/25, Human Resources (HR) revealed CNA4's 2025 review was not yet completed. Later in the day on 07/28/25, HR informed Surveyor CNA4's 2025 was completed. She was rated Good in all areas.Review of CNA5's employee record revealed she has a hire date of 04/25/24. When Surveyor initially asked for CNA5's employee record, HR revealed CNA5's 2025 review was not yet completed. On 07/28/25, HR informed Surveyor CNA5's 2025 review was now completed. During an interview on 07/28/25 at approximately 3:40 PM with HR about the missing evaluations, she revealed, I should have had them done. I need to have them (the supervisors) get them done. With regards specifically to CNA5, she stated, We are going to have to pro-rate her. I am going to give them the form to do.During an interview with HR on 07/28/25 at 4:28 PM, she revealed, I want to show you they now have CNA5's review done.During an interview with Regional Consultant on 07/28/25 at approximately 3:30 PM, he stated, Why are you asking for employee reviews? We've never been asked for those. In all my years of doing this, this is the first time someone has asked. It's not in the regulations, so I don't know why you want them. Surveyor informed Regional Director that yearly reviews for CNA staff are in the regulations. Additionally, he stated, I dislike the whole review process. It really doesn't mean anything. I have never had a performance evaluation in my 26 years of doing this.During an interview with Regional Consultant on 07/28/25 at 5:40 PM, he stated, I found the regulation about the performance reviews. I didn't know that it was a regulation.On 07/29/24 at 11:48 AM, Surveyor attempted to do a phone interview with CNA4 to confirm she had not had a performance evaluation this year. Voice mail message with call back number left. On 07/29/25 at 11:49 AM, Surveyor attempted to do a phone interview with CNA3 to confirm she had not had a performance evaluation this year. Voice mail message with call back number left. During a phone interview with CNA5 on 07/29/25 at 12:17 PM, she stated, No, I have not had an evaluation this year. It has been over a year since I have had one. I do get verbal feedback from the Director of Nursing (DON), but when I requested to get a formal evaluation so that I could get a raise, she replied, Good luck with that.

Based on a review of the facility policy, record reviews, observations, and interviews, the facility failed to provide an ongoing resident-centered program designed to meet the resident's interests, hobbies, and cultural preferences in order to promote physical, mental, and psychosocial well-being for 1 of 2 residents reviewed for activities, Resident (R)35.Review of an undated facility policy titled, Activities states, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. Activities may be conducted in different ways: One-to-One Programs, Person Appropriate - activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for. Program of Activities - to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend. All staff will assist residents to and from activities when necessary. Activities can occur at any time and are not limited to formal activities provided by the activities staff and can include other facility staff members, volunteers, visitors, residents, and family members.Review of R35's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including but not limited to: type 2 diabetes mellitus, unspecified dementia, major depressive disorder, and episodes of syncope and collapse. Review of R35's Quarterly- Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/25, revealed R35 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating that she is cognitively intact. Additionally, no rejection of care was exhibited during the lookback period.Review of R35's Care Plan revealed, Focus- The resident will continue to be encourage to attend oor (out of room) activities that meet the emotional, intellectual, physical, and social needs r/t past and present interest. She is also the resident council president she enjoys spending time with peers/staff and sitting outside on front porch. Interventions- Invite the resident to scheduled activities. The resident needs assistance/escort to activity functions.Review of R35's progress notes documented by the Activities Department revealed the following:06/30/25 3:09PM Resident Preferences Evaluation Resident Preferences Evaluation: How important is it to you to choose what clothes you wear: Somewhat important. How important is it to you to take care of your personal belongings or things: Somewhat important. How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath: Somewhat important. It is somewhat important to the Resident to have snacks available between meals. It is somewhat important for Resident to choose their own bedtime. It is very important for the Resident to have their family, or a close friend involved in discussion about their care. It is somehow important for Resident to be able to use the phone in private. It is somewhat important to Resident to have a place to lock their things to keep them safe. Primary respondent for Daily and Activity: Resident. It is somewhat important for Resident to have books, newspapers and magazines to read. It is somewhat important for the Resident to keep up with the news. It is somewhat important to Resident to listen to music they like. It is not very important for the Resident to be around animals such as pets. It is somewhat important for Resident to do things with groups of people. It is somewhat important for Resident to do their favorite activities. It is somewhat important to Resident to go outside to get fresh air when the weather is good. It is somewhat important for Resident to participate in religious services or practices.07/08/25 3:35PM Quarterly note: Resident alert and oriented, able to make most needs known. Resident continue on a mech soft diet. Resident is very pleasant and nice. Ms. [NAME] continues to require a w/c for ambulation around unit. Ms. [NAME] has calendar in room for review but is informed of daily activities of interest by staff. Resident attends oor activities that of interest to her such as bingo and social events at times or sitting on front porch. Continues as Resident council President. Resident interact with others well. Resident has good family support. Well follow plan of care at this time.Review of the facilities activity calendar located on the unit in front of the main double doors revealed the following scheduled events: On Sunday, 07/27/25 at 10:00 AM, a worship service was scheduled. On Monday 07/28/25, at 10:00 AM, sittercise was scheduled, followed by finger painting at 2:00 PM. On Tuesday, 07/29/25, I-Spy was scheduled for 10:30 AM, and Bingo was scheduled for 2:00 PM.Observation on 07/27/25 from 9:58AM though 10:30 AM did not reveal any activities occurring during this time. During an interview on 07/27/25 at 2:14 PM, R35 revealed that she is dependent on staff for transfers and most of her Activities of Daily Living (ADLs). She stated that she typically receives an activity calendar from the AD at the beginning of each month; however, activities had not been provided for the past couple of days, and she was unsure why. She further reported that on other occasions, staff members have entered her room and told her they would return to escort her to activities, but they never followed through. R35 stated she would love to participate more in activities if staff came and got her.Observation on 07/28/25 at 10:27 AM, of activities held in the facility's main dining room, revealed five residents participating in group exercises along with the Activities Director (AD). Resident R35 was not observed in attendance.During an interview on 07/29/25 at 11:48 AM, The AD revealed that she has been employed at the facility for 13 years. She stated that all residents receive an activity calendar at the beginning of each month. Each morning, she conducts rounds to notify residents of the activities scheduled for that day. According to the AD, both she and the Certified Nursing Aides (CNAs) are responsible for assisting dependent residents if they choose to participate in activities. She explained that she is responsible for maintaining a participation log to document resident attendance and refusals. However, she acknowledged that she has not been documenting attendance for any of the residents and, therefore, could not produce a record for Resident R35. The AD also stated that church services are supposed to be held on Sundays, but she has not heard from the reverend in some time and is unsure whether he continues to come, as she is not present on weekends.Observation of the main dining room on 07/29/25 at 2:19 PM revealed that no residents were present or participating in the scheduled Bingo activity, which was confirmed by the AD. During an interview on 07/29/25 at 4:26 PM, the Facility Administrator revealed that his expectation is for staff to assist residents in getting up and participating in scheduled activities. He stated that activities should be conducted as outlined in the activity schedule. If, for any reason, an activity is canceled, residents are to be notified. Additionally, he emphasized that documentation is always expected, stating, If it's not documented, it's not done.

Based on observations, interviews, record review, and review of facility policy, the facility failed to follow physician orders for changing oxygen tubing and nasal cannulas for 3 of 3 residents (R) R7, R32 and R42 reviewed for respiratory care. This failure has the potential for harm due to increased risk of infection. Review of the undated facility policy titled Oxygen Administration revealed, 5b. Change Oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Review of R7's face sheet showed she was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: chronic obstructive respiratory disease (COPD; a lung disease causing shortness of breath), chronic respiratory failure, generalized anxiety disorder, and muscle weakness. Review of R7's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/09/25 showed she has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating she has no cognitive deficit. Her MDS indicated she receives continuous oxygen therapy. Review of R7's care plan revealed a focus on her diagnosis of COPD. Interventions included adjusting the head of bed and body positioning to assist with ease of respirations as able; assessing hydration status if indicated; encouraging rest periods if indicated, medications as ordered; labs if indicated; monitoring lung sounds, pallor (paleness), character of sputum (secretions), and cough; monitoring resident's anxiety and providing support and assistance as needed; monitoring respiratory rate, depth, and effort; reporting any abnormalities to Medical Director if indicated; and notifying Medical Director and family of change in condition if indicated. Review of R7's Order Summary Report noted the following order with a start date of 07/06/25, Cleansing oxygen concentrator filter with warm water, letting the filter dry and replacing weekly every Sunday and as needed; changing oxygen concentrator tubing and water bottle (and date) weekly on Sunday and as needed; and oxygen via nasal cannula at two liters per minute (LPM) continuously. Review of R7's Treatment Administration Record (TAR) for 07/01/25-07/31/25 revealed a blank/unsigned space for 07/27/25 indicating R7's tubing and nasal cannula were not changed. During an observation on 07/27/25 at 12:05 PM, R7's oxygen level was set at 2 liters per minute (LPM). R7 was wearing a dark green nasal cannula with dark green tubing. No label indicating the date the tubing and nasal cannula were changed was found on the tubing. During an interview with R7 on 07/27/25 at 12:05 PM, she revealed she uses oxygen continuously. She stated she liked a particular type of nasal cannula from Lincare. When asked the last time her oxygen tubing and nasal cannula had been changed, she revealed, It has not been changed. This is the one I came to the facility with. I use mouthwash to clean the nostril prongs. During an observation on 07/28/25 at 11:15 AM, R7 was wearing oxygen via nasal cannula. R7's oxygen level was set at 2LPM. No label was found on the tubing indicating the date and time of change. No label was found on the oxygen concentrator indicating the date and time of the tubing and nasal cannula change. During an interview with R7 on 07/28/25 at 11:15 AM, she was asked again if her oxygen tubing had been changed since admission, and she stated, No, it hasn't. This is the one I brought from home. I like the way it feels. When asked if she ever refused to have her oxygen tubing changed when staff offered or said they were going to, she stated, They never have told me they were going to change it, so no, I have never refused. During a phone interview with Licensed Practical Nurse (LPN)4 on 07/29/25 at 11:55 AM, he revealed, I must have missed changing R7's tubing and nasal cannula. I do it in the dark, so I guess I missed it. I had a lot of oxygen tubing to change out. When asked if R7 ever refused to have her oxygen tubing and nasal cannula changed, he stated, No, she has never refused. During an interview with Director of Nursing (DON) on 07/29/25 at 09:25 AM, she revealed, The tubing R7 is wearing came from when she was transported from the hospital. She has had it on since she has been here. She is refusing to change it. I am going to ask her to change it today. Review of R32's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to: hypoxemia, chronic obstructive pulmonary disease and anxiety disorder. Review of R32's five-day MDS with an ARD of 07/03/25 reveals he had a BIMS score of 8 out of 15, indicating he has moderate cognitive impairment. Review of R32's Physician Orders revealed an order dated 06/26/25, Keep Nebulizer mask/tubing covered when not in use every shift for protocol. Another order dated 06/29/25, Change [Oxygen] O2 concentrator tubing and [water] H2O bottle and date weekly on Sunday and [as needed] PRN every night shift every Sun for protocol and change O2 concentrator filter with warm water, let air dry and replace weekly on Sunday and PRN. Review of R32's Care Plan with an initiation date of 07/15/25, revealed a Focus of a diagnosis of COPD, with interventions including, Change nebulizer mask and tubing weekly on Sunday. Ensure to Record date of change, Cleanse O2 concentrator filter with warm water, let air dry and replace weekly on Sunday and PRN, and Change O2 concentrator tubing and H20 bottle and date weekly on Sunday and PRN. During an observation on 07/27/25 at 11:35 AM, R32's O2 concentrator and tubing did not have any labels or dates. During an observation on 07/28/25 at 8:53AM and 1:55PM, revealed the R32's O2 concentrator and tubing did not have any labels or dates. Also, R32's nebulizer face mask was exposed with no covering on the nightstand. Review of R42's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to: acute respiratory failure with hypoxia, generalized anxiety disorder, muscle spasm, and traumatic brain injury. Review of R42's Physician Orders revealed an order dated 07/27/25, Change Oxygen Concentrator tubing and H2O bottle (and date) weekly on Sunday and PRN, every night shift every Sun for Oxygen therapy and Cleanse O2 concentrator filter with warm water, let air dry and replace weekly on Sunday and PRN, every night shift every Sun for Oxygen therapy. Review of R42's Baseline Care Plan indicates special treatments of oxygen therapy. During an observation on 07/27/25 at 12:11 PM, R42 was sitting in the day room with oxygen nasal cannula on, there were no dates or labels on the tubing or the O2 concentrator. During an observation on 07/28/25 at 8:57AM and at 1:58 PM, R42 was observed lying in bed with oxygen nasal cannula on, there were no dates or labels on the tubing or the O2 concentrator. During an observation on 07/29/25 at 9:10 AM, revealed no labels or dating on R32's tubing or O2 concentrator. During an interview on 07/29/25 at 9:15 AM, LPN2 confirmed there were no dates on the tubing and concentrator. She states she is unsure if the facility is supposed to date tubing and concentrators, because some facilities do and some do not. During an interview on 07/29/25 at 9:20AM, LPN3 revealed this is her first day working here and she is not sure if the dates should be on oxygen tubing and/or O2 concentrators. During an interview on 7/29/25 at 9:38AM, the DON revealed that oxygen tubing and concentrators should be labeled and changed every Sunday night, and she wasn't aware that there were no dates on the machines and tubing, but she could find out why and get them labeled. The DON includes that face masks for nebulizers should be placed in a plastic bag when not in use. She further reveals that the nursing staff is responsible for ensuring that the items are properly labeled. She includes there is a staff member that is responsible for labeling oxygen tubing and concentrators on Sundays, and she just didn't check behind him. During an interview on 07/29/25 at 9:59AM, the facility Administrator revealed, he is aware that the tubing and concentrators should be changed out and dated and the Assistant Director of Nursing (ADON) and DON should oversee that task. He is unsure of who would be responsible on a daily basis. The Administrator states his expectation is that staff follow all orders, as written, for each resident.

Based on review of facility policy, record reviews, observations and staff interviews, the facility failed to ensure a medication error rate below 5% during medication administration for 2 of 25 opportunities for error; the error rate was 8 percent. Specifically, Resident (R) 30 did not receive two medications for which there were active physician orders, resulting in a medication omission error. Review of the undated facility policy titled, Medication Administration, states, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician.Observation of medication pass on 06/28/25 at 8:34 AM, Licensed Practical Nurse (LPN)1 was observed preparing to administer medications to R30. R30 had active physician orders for the following medications: Calcitriol Oral Capsule 0.25 mcg, to be administered by mouth once daily at 9:00 AM for renal disease and Sensipar (Cinacalcet HCl) Oral Tablet 30 mg, to be administered by mouth once daily at 9:00 AM for renal disease. At the time of observation, LPN1 confirmed that neither medication was available in the facility, and therefore they were not administered as ordered. Constituting an omission error due to unavailability.Interview with LPN 1 on 06/28/25 at 8:34 AM following a medication administration observation. LPN 1 reported that she is new to the facility and has been employed for only a few days. She stated she is not yet familiar with R30 or R30's medication regimen. LPN 1 confirmed she was unaware that R30 had run out of Sensipar (Cinacalcet HCl) and Calcitriol. She also reported that she does not know how long it will take for the pharmacy to replenish the missing medications. LPN #1 stated she planned to notify the Director of Nursing for assistance with ordering the missing medications.Interview on 07/29/25 at 10:35 AM, with the Director of Nursing (DON) and Associate Director of Nursing (ADON) revealed, The resident was admitted to the facility on a Friday following a hospitalization. The transition of care followed a continuum from home to the hospital and subsequently to the facility. The resident is a dialysis patient with a scheduled dialysis regimen on Tuesdays, Thursdays, and Saturdays. Upon admission, a medication reconciliation was completed. Calcitriol and Sensipar were among the medications the hospital provider intended to continue post-discharge. The resident was sent to dialysis the day after admission; however, the nephrologist did not evaluate the resident during that session. The DON and ADON reported they were under the impression that the resident should not receive certain medications until evaluated by the nephrologist. At this time, no documentation has been provided to support that claim. It was confirmed by both the DON and ADON that there are active orders for Calcitriol and Sensipar. However, these medications were not administered, as they had not yet been delivered by the pharmacy.

Based on review of facility policy, record review, observations and interviews, the facility failed to failed to provide appropriate assistive devices for 1 of 2 Residents (R) reviewed for food. Specifically, R22 did not receive an ordered cup with two handles and lid during meals. This failure has the potential for harm due the potential loss of independence with feeding self.Review of the undated policy titled, Use of Assistive Devices revealed, Assistive devices are tools, products, types of equipment, or technology that help individuals perform tasks and activities . Assistive devices include . g. Eating utensils. The policy also stated, The facility will provide assistive devices for residents who need them.Review of R22's face sheet showed she was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to: anxiety, dementia and dysphagia (trouble swallowing).Review of R22's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/25 showed she has a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating she has severe cognitive deficit. Her MDS indicated she had no complaints of difficulty swallowing, no choking during meals or when swallowing medications, and no special treatments.Review of R22's care plan revealed R22 Patient needs a cup with two handles and a lid with each meal. Review of R22's orders revealed that a order for a cup with two handles and lid with each meal was entered on 07/31/24.During an observation on 07/29/25at 08:50 AM, a 2-handled cup with lid was not present on R22's breakfast tray.During an interview with R22 on 07/29/25 at 8:50 AM, she stated, No, I've never had a special cup. I don't know what you are talking about. I've never seen anything like that.During an interview on 07/29/25 at 9:58 AM, when asked about the 2-handled cup with lid on R22's care plan, Dietary Manager revealed, The 2-handle cup would have to be in the orders. If I get an order for that, we will put the cup on her tray when it is set up. I usually get two for each resident who needs one. A two-handled cup is for adaptive purposes if they have a hard time grasping a cup. It allows her to be independent with dining and not have to rely on others to help her.During an interview on 07/29/25 at 10:08 AM with Certified Nursing Assistant (CNA) 2, she revealed, I've never noticed a 2-handle cup on R22's tray. I've never served her anything in that type of cup.During an interview on 07/29/25 at 09:58 AM, Director of Nursing (DON) revealed, R22 does have an order for a 2-handled cup with lid. She should have the cup. DON showed the order for a 2-handled cup with lid dated 07/31/24 to Surveyor.During an interview on 07/29/25 at 11:07 AM, Surveyor informed Dietary Manager of the order for a 2-handled cup with lid for R22 dated 07/31/24. She stated, Yes, I know that now. I've sent a message to the speech therapist to see what exact model she needs.

Based on observations, interviews, and Daily Nursing Hours sheet reviews, the facility failed to visibly post the Daily Nursing Hours sheets on a daily basis where residents, staff, and visitors could visibly access them. During an observation on 07/27/25 at 9:59 AM, the Daily Nursing Hours sheets were posted in one of two resident hallways outside the Director of Nursing (DON) office. The office was located within the facility and was not readily accessible to visitors as they entered the facility. The date on the sheet that was visible was 07/24/25. Under the Daily Nursing Hours sheet dated 07/24/25 was a Daily Nursing Hours sheet dated 07/21/25. During an interview with Regional Consultant on 07/27/25 at 4:30 PM, he revealed, We do not post the Daily Nursing Hours sheets in the front of the building. We have always posted these at the nurses' station. I do not know if the sheet would be visible to others that don't go to the nurses' station or past it if the resident's room is not down that hallway. He then agreed that all visitors would not actually see the Daily Nursing Hours sheets but reiterated that is where the sheet is posted in every building he oversees. During an interview with the DON on 07/28/25 at approximately 3:30 PM, she confirmed, We only post the Daily Nursing Hours sheets by my office. We do not have it posted anywhere else in the building.On 07/29/25, Surveyor requested the Daily Nursing Hours sheets for 01/01/25 through 03/31/25. During an observation on 07/29/25 at 4:28 PM, DON was in the business office and was observed writing the Daily Nursing Hours sheets. Surveyor asked if she was writing the sheets for Quarter 1. She responded, No. I'm just gathering them together. When surveyor questioned why there was an unfinished Daily Nursing Hours sheet with the date of 03/12/25 on it, she stated, There were some that were missing. Surveyor informed DON not to write up the missing ones. DON then gave surveyor a stack of Daily Nursing Hours sheets from 01/01/25 - 03/11/25.

Based on record review and interview, the facility failed to ensure the services of a Registered Nurse (RN) were used for at least eight consecutive hours a day, seven days a week. A review of the nursing schedule provided by the facility revealed an RN was not on site for eight consecutive hours a day on the weekends for seven (7) consecutive months, from January 2024 through July 2024. This failure had the potential to affect the provision of registered nursing assessments and services to all 32 residents in the facility. The findings included: A Review of the facility's undated policy titled, Nursing Services and Sufficient Staff revealed 8. Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. A review of registered nursing timecard reports revealed the following days of no RN on staff for at least eight consecutive hours with the resident census each day: January 2024 01/20/2024-37(census) 01/21/2024-37 (census) 01/27/2024-37 (census) 01/28/2024-37 (census) February 2024 02/03/2024-32 (census) 02/04/2024-35 (census) 02/10/2024-33 (census) 02/11/2024-33 (census) 02/17/2024-34 (census) 02/18/2024-34 (census) 02/24/2024-33 (census) 02/25/2024-32 (census) March 2024 03/02/2024-32 (census) 03/03/2024-34 (census) 03/09/2024-33 (census) 03/10/2024-33 (census) 03/16/2024-32 (census) 03/17/2024-33 (census) 03/23/2024-34 (census) 03/24/2024-34 (census) 03/30/2024-35 (census) 03/31/2024-35 (census) April 2024 04/07/2024-35(census) 04/13/2024-36(census) 04/14/2024-35(census) 04/20/2024-33(census) 04/21/2024-32 (census) 04/27/2024-34(census) May 2024 05/04/2024-34(census) 05/05/2024-34 (census) 05/18/2024-33 (census) 05/19/2024-32(census) 05/25/2024-32 (census) 05/26/2024-31 (census) June 2024 06/08/2024- 32 (census) 06/09/2024- 32 (census) 06/15/2024- 34 (census) 06/16/2024- 34 (census) 06/23/2024- 36 (census) 06/29/2024- 36 (census) 06/30/2024- 35 (census) July 2024 07/06/2024- 33 (census) 07/07/2024- 32 (census) On 07/09/2024 at 12:57 PM, an interview with the Director of Nursing (DON), revealed that there is no RNs (registered nurses) in the building on weekends. DON states she and another nurse are the only registered nurses in the building, and the other RN is only PRN (as needed), and its rare she will work on a weekend. DON states her schedule is works Monday through Friday, 8 hours a day. DON confirmed she does not come in on weekends, and if an emergency occurs she can be reached by phone. DON stated the facility does not use agency staff. DON stated no waivers were used for this facility. DON stated if there is a resident who requires an RN to provide care, she will come in, however, there has not been a time she has had to. DON stated weekend staffing schedules run the same as it would during the week. On 07/10/2014 at 2:12 PM, an interview with the Facility Administrator, (FA), revealed When an RN is not in the building, the DON is on call and can reached by phone if an emergency arises. No resident has been impacted, to his knowledge. If the DON who is an RN, can't make it into her scheduled shift, the Facility will try to utilize another RN who is PRN. If a PRN RN is also unable to make it in or take the shift, the facility will depend on LPNS, (Licensed Practical Nurses), who are scheduled. FA states he is working on trying to hire RN's for weekends, unfortunately, no one has accepted the job. FA states he had suggested DON come in on the weekends, unfortunately, it has not been working.

Based on observation, interviews and review of the facility policy, the facility failed to discard expired food items for 1 of 1 kitchen area. Findings Include: Review of the facility policy titled, Food Storage without a revision date, revealed, All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. Place new items behind supply in stock of the same item; in this way oldest stock is always used first. Supervision is necessary to make sure that the person designated to put stock away is rotating it properly. Review of Storage policy from Optima Solutions titled, Guidelines for Storage revealed, Bread must be stored in pantry area at room temperature for five to seven days. Review of Flowers Bakeries Sheet revealed, All European bakers thaw and serve bread or rolls have a 270-day shelf life when kept frozen at zero degrees and five to seven days when kept at room temperature. Flowers guarantees a minimum of 45 days product shelf life at time of delivery. During an observation on [DATE] at 10:35 AM revealed, nine bags of 12 count hamburger buns with an expiration date of [DATE]. Five bags of 12 count hamburger buns had an expiration date of [DATE] and eleven bags of 12 count hamburger buns had an expiration date of [DATE], in which five buns from one pack were molded. During an observation on [DATE] at approximately 10:30 AM revealed, expired bread on a tan cart in the hallway between kitchen area entrances. During an interview on [DATE] at 10:45 AM the Certified Dietary Manager (CDM) stated, The kitchen staff is responsible for removing outdated bread and I don't know the expiration date to anything. During an interview on [DATE] at 10:17 AM with the Kitchen Manager revealed, when items are open, she makes sure items have a date and put them in their proper place. She also checks daily for expiration dates to ensure it's right.

Based on the review of facility policy, interviews, and record review, the facility failed to develop, implement, and monitor the Antibiotic Stewardship Program. This failure placed all residents at risk for the potential transmission of infections and communicable diseases. Findings include: A review of the facility policy titled, Antibiotic Stewardship Program, with no revision date, revealed 11. Documentation related to the program is maintained by the Infection Preventionist, including, but not limited to: a. Action plans and/or work plans associated with the program. b. Assessment forms. c. Antibiotic use protocols/algorithms. d. Data collection forms for antibiotic use, process, and outcome measures. e. Antibiotic stewardship meeting minutes. f. Feedback reports. g. Records related to the education of physicians, staff, residents, and families. h. Annual reports On the following dates, a request was made to the administrative staff regarding documentation related to the Antibiotic Stewardship Program. Requested 07/08/2024 at approximately 1:00 PM. Regional Consultant. Requested 07/09/2024 at approximately 08:30 AM. Regional Consultant and Facility Administrator. Requested 07/09/2024 at approximately 2:25 PM. Regional Consultant. Requested 07/09/2024 at approximately 4:30 PM. Director of Nursing. Requested 07/10/2024 at approximately 09:00 AM. Director of Nursing. An interview with the Director of Nursing (DON) on 07/10/2024 at 12:53 PM, revealed, The ADON, Assistant Director of Nursing who is also the Infection Control Preventionist, is out on vacation. DON stated it's her and ADON's responsibility to ensure they keep up with the book with accurate information. DON stated the facility has a Line Listing they use which is sorted by resident's name and room number, type of infection, and the type of treatment the residents receive and the ADON is to keep track of the program monthly. DON stated they focus on physician orders and labs to determine if residents are receiving appropriate treatment. DON stated July 1st, 2024, the facility switched to a new lab. DON stated she only has 1 resident currently in the facility with an infection- Urinary tract, who completed her antibiotic treatment on July 9th, 2024. As of 07/10/024, no residents with a current infection. DON stated she could not produce documentation for 12 months in regard to antibiotic stewardship. An interview with the Facility Administrator (FA) on 07/10/2024 at 2:19 PM- Facility Administrator revealed that neither he, the regional consultant, nor DON can locate the antibiotic stewardship book. FA states that the facility uses the pharmacy input and its electronic medical record system (Point Click Care) to keep track of antibiotic use. FA states the trends are addressed in QAPI meetings, which are done quarterly. FA stated there has been no outbreak of infections that he is aware of. FA stated that his expectation is to document and have an organized system in place to prevent and treat infections when they arise.

Based on record reviews and interviews, the facility failed to ensure all nurse aide personnel have completed the required 12 hours of training per employment year based on the hire date for 07 out of 14 Certified Nursing Assistants (CNAs). Findings include: A review of the undated facility policy titled, Competency Evaluation, revealed Policy: It is the policy of this facility to evaluate each employee to ensure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents. Policy Explanation and Compliance Guidelines: 1. The knowledge and skills required among staff to meet residents' needs are determined through the facility assessment process. 2. Evaluating the competency of staff is accomplished through the facility's training program. 4. Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations. 8. Employee competency forms are maintained in the Director of Nursing's office for the current training year, then forwarded to the Human Resources Director for placing into the employee's personnel file. A review of facility staff training revealed seven (7) staff members did not have the 12-hour required yearly training. CNA 1, hired 09/08/2022 10.25 hours CNA 2, hired 07/01/2019 9.00 hours CNA 3, hired 05/04/2023 4.75 hours CNA 4, hired 10/14/2002 6.25 hours CNA 5, hired 04/24/2023 4.75 hours CNA 6, hired 04/06/2023 2.00 hours CNA 7, hired on 08/05/2021 6.87 hours An interview with the Director of Nursing (DON) on 07/9/2024 at 4:09 PM revealed that she is over the staff competency, along with the Assistant Director of Nursing (ADON), who is out on leave. DON stated the facility conducted training on paper before the transition to an electronic system (Relias) mid-year in 2023. DON states her expectation 1 credit a month, however sometimes it doesn't always work that way. DON states she gives her staff a time frame to typically complete the credits. DON stated all staff is trained, particularly all of the CNAS, She just can't find the documentation for all training that was conducted on paper. Ultimately, DON states her expectation is that her staff completes training, and a better method of keeping track of all documentation of training requirements. An interview with the Facility Administrator (FA) on 07/10/2024 at 2:25 PM revealed training is done on Relias, a third-party system that has different courses, which is mandatory training. FA stated before Relias, competency were done on paper. FA stated that he expects all Certified Nursing Aides to either complete courses monthly or in a timely manner. FA stated that ADON and HR are typically responsible for keeping up with compliance of training requirements for all staff including new hires and existing. FA stated I'm unaware that my staff was not receiving training, I need to have a better oversight. I can't produce information I don't have.

Based on observations, interviews, record review and facility policy the facility failed to maintain an effective pest control program. Findings Include: Review of the undated facility policy titled, Pest Control Program, revealed, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Effective pest control program is defined as measures to eradicate and contain common household pests (e.g. bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats). During a review of the Service Inspection Reports for June 2024 revealed Open Conditions of unsealed cracks and crevices, doors have gaps allowing pest entry, back door has gaps, cracks and gaps in the ceiling, and there is standing water under appliance/machinery/equipment in the kitchen. During an observation on 07/08/24 at 10:15 AM in the common area, of which the surveyors were housed for survey, revealed approximately 10-15 flies throughout the day. During an observation on 07/08/24 at 10:57 AM in the kitchen, revealed multiple flies flying around the kitchen as food was being prepped for lunch. During an observation on 07/08/24 at 11:35 AM in room [ROOM NUMBER], revealed two flies flying around the resident's room. During an observation on 07/09/24 at 9:05 AM in the common area and the hall that leads to the kitchen revealed approximately 8-10 flies throughout the day. During an observation on 07/10/24 at 9:15 AM in the common area and the hall that leads to the kitchen revealed approximately 8-10 flies flying throughout the day. During an interview on 07/08/24 at 11:38 AM with R31 revealed that she sees flies all the time and she is going to ask her husband to bring her a fly swatter because no one else can seem to do anything. During an interview on 07/10/24 approximately 11:30AM with the Kitchen Manager, revealed that she sees flies all the time in the kitchen and she lets the Administrator know and he gets someone to come in and spray from time to time. During an interview on 07/10/24 at 3:33PM with the Facility Administrator revealed, that flies will be addressed in the next Quality Assurance and Performance Improvement (QAPI) meeting, he will also reach out to the pest control company to see what can be done to minimize the flies. The Administrator includes that flies have been a big problem recently with the amount of heat.

Based on observations, interviews, record review, and review of facility policy, the facility failed to ensure the environment remained as free from potential accident hazards as possible for 1 of 1 resident (R)23. Specifically medications were found at R23's bedside. Findings include: Review of the facility policies titled Medication Administration and Medication Storage with no revision date noted, states that medication are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 18. Observe resident consumption of medication. 1c. During medication pass, medications must be under the direct observation of the person administering medication or locked in the medication storage area/cart. Review of Medication Administration Policy with an in-service dated 07/08/2024, revealed a total of five licensed practical nurses and one registered nurse signatures that attest to reading of the Medication Administration Policy. Review of R23's face sheet revealed an admitted [DATE] with the diagnoses listed but not limited to cerebral infarction, left hemiparesis, dysphagia, dementia, major depressive disorder, presbyopia, and constipation. Review of R23's Care Plan with a revision date of 10/14/2022 revealed a focus of a confounding problem: R23 very slow and noncompliant with taking medication at times (will spit out and hide pills). Interventions listed, Stay with [R23] during medication administration and check mouth for medication holding if indicated. Check resident's environment as needed for any untaken medication. Reinforce importance of pros/cons of compliance with consumption of prescribed medications. Reproach as need when resident refuses. Review of R23's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/04/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. During an observation and interview on 07/08/2024 at 11:18 AM, R23 was sitting in a wheelchair next to her bed. The call light was not in reach and a medication pill was in a cup on the bedside table. The medication in the pill cup was round, orange, and small. R23 stated that the pill is a stool softener and revealed that nurses put it in her room all the time per her choice. During the interview R23 picked pill out of medication cup and placed it back in the cup. During an observation and interview on 07/08/2024 at 11:38 AM, Licensed Practical Nurse (LPN)2 revealed that medication administration was from 8:00 AM to 9:00 AM for R23. LPN2 stated R23 does not have a self-administration order, but she left medication at the bedside because R23 at times refuses to take medication during administration. LPN2 picked up the medication that was in the medication cup during the interview and placed it back on R23's table. LPN2 left the room with medication unattended 07/08/2024 at 11:39 AM. During an observation 07/08/2024 at 11:42 AM, Director of Nursing DON requested to R23's room to witness medication left at R23's bedside. LPN2 returned to R23's bedside and spoke with DON. During an interview on 07/08/24 at 04:08 PM, DON revealed expectation for the nurses to check their orders, six rights, and not leave the medications at the bedside. The DON stated, the nurse today got educated about the policy and my expectations. During an interview on 07/09/24 at 2:03 PM, the DON revealed an in-service was done yesterday with staff about leaving medications at bed side. During an interview on 07/10/24 at 03:53 PM, the Administrator revealed his expectation is for the nurses to be fully educated when administering medication to the residents. He stated, There should not be any medication left unattended at any resident's bedside.

Based on observation and interview, the facility failed to ensure a system of records of receipt of controlled drugs, in sufficient detail, to enable an accurate reconciliation until disposition of destruction and identification of the method of destruction used for controlled medications. Specifically, the facility had the potential for drug diversion with controlled substances and failed to ensure a system of receipt and disposition of all controlled drugs in sufficient detail to ensure an accurate reconciliation and the controlled drugs destruction log did not contain the destruction method for controlled medications. Findings include: Review of consultant pharmacy A contract dated [DATE] revealed no agreement related to destruction and/or supervision of controlled substances for destruction. Review of facility contract with [MEDICATION(S)] Health Senior Care PACE (Providing All inclusive Care for the Elderly) program dated [DATE] revealed no contracted services for pharmacy provided to the facility. 1. An observation on [DATE] at 10:45 AM revealed a locked file cabinet that the facility used for controlled medications until destruction. An observation of the locked file cabinet on [DATE] at 10:47 AM revealed the following medications awaiting destruction by pharmacy company A: Resident (R)1--[MEDICATION(S)]-Acetaminophen ,d+[DATE] mg (milligram), seven pills, dated [DATE] as the date of removal from the medication cart for disposal. R2-- A. [MEDICATION(S)] 10 mg/ml (milliter) solution, 240 ml remaining in the bottle, dated [DATE] as the date of removal from the medication cart for disposal. B. [MEDICATION(S)] 0.5 mg tablet, 18 pills, dated [DATE] as the date of removal from the medication cart for disposal. C. [MEDICATION(S)] [MEDICATION(S)] 2 mg/ml, 10 mls, dated [DATE] as the date of removal from the medication cart for disposal. R5-- [MEDICATION(S)] 5 mg, 7 pills, dated [DATE] as the date of removal from the medication cart for disposal. An observation of the locked file cabinet on [DATE] at 10:47 AM revealed the following medications awaiting destruction by pharmacy company B: R3--A. [MEDICATION(S)]-Acetaminophen ,d+[DATE] mg, 25 pills, dated [DATE] as the date of removal from the medication cart for disposal. B. [MEDICATION(S)]-Acetaminophen ,d+[DATE] mg, 31 pills, dated as [DATE] as the date of removal from the medication cart for disposal. R4--[MEDICATION(S)] 10 mg/1 ml, 200 ml, dated [DATE] as the date of removal from the medication cart for disposal. R5--[MEDICATION(S)] 2 mg, 1 pill, dated [DATE] as the date of removal from the medication cart for disposal. During an interview on [DATE] at 11:07 AM with the Director of Nursing (DON), she stated, The process for medication destruction is, it is brought to me by the nurses off the floor when the meds (medications) are either to be discontinued, discharged or expired. Narcotics are provided to me and all other meds are returned to the (2) individual pharmacies. Narcotics are locked up until the pharmacists comes once a month. (Pharmacy A hand delivers meds and Pharmacy B comes once a month). We started using the drug buster now to destroy the meds within the past year. Meds are removed from the pill packets and disposed of in the drug buster and it is kept locked up in the med room. Pharmacy B goes into their pharmacy system and print me out a list of the meds that are destroyed. Pharmacy A signs directly on the narcotic sheet the meds destroyed, the number, the date, and her signature. On that sheet it only contains her name (the pharmacist). The pharmacist have been here every month but we don't normally destroy every single time they come. Pharmacy B last came and destroyed (narcotics) in [DATE] and Pharmacy A last came and destroyed (narcotics) in 2020 . During an interview on [DATE] at 11:50 AM with Certified Pharmacy Technician (CPHT) 1, they stated, I come to the skilled side once a month. My role is to check the med carts, med rooms, medication open dates and narcotic destruction inventory. Narcotic destruction is based off of (Pharmacy B's medication system) with multiple people including the DON with multi-signatures. The actual Pharmacy B destruction sheet should have the DON, mine and the other nurses signatures and we destroy it (the narcotics) in the drug buster. I am alerted to medications that need to be destroyed by whatever they have locked up in the drawer is what is destroyed. I offer to destroy meds each time that I come to the facility and its up to the facility if they want me to destroy (narcotics). I was last there in February 2022 and I offered to destroy narcotics and she said they didn't have anything much. The last two times I've been there I was declined to waste narcotics and I try to let them know ahead of time that I'm coming. I do not got through their drawers for meds, I wait for them to hand me whatever they want to destroy. We don't always put in a reason for destruction but I just found out that the mode of destruction is supposed to be on it (controlled substance form). During an interview on [DATE] at 12:06 PM with Pharmacy A's Pharmacist, they stated, I deliver meds specifically for the PACE program. On the skilled side, we have eleven residents currently there. When we come to the facility, it is to deliver monthly meds. I review the previous months meds to see if they have directly what they have. Any extra meds I will discuss with the DON why the resident has excess meds for the month. Any excess is destroyed. Controlled substances is wasted with the DON. We haven't had to do that because there wasn't any meds that had to be destroyed on my visit. My last visit was on [DATE]. The meds to be wasted they are usually locked up in the DON's office. I usually send the DON a copy of my report once completed. I have been the primary person during the past several months. Normally the DON alerts me of any meds that need to be destroyed. The DON and I would document directly on the form what's wasted, amount on the card, manner of wasting, and the DON and I would sign the form together. The only person I have every wasted meds with is the current DON. The previous DON never wasted meds with me. 2. Review of the facility Controlled Substance Inventory Form dated [DATE] revealed the form does not identify the method of destruction used to waste controlled narcotics. During an interview on [DATE] at 11:07 AM with the DON, she stated, I was unaware about that as we do waste the narcotics in the drug buster.

Based on observation, record review, and staff interview, the facility failed to provide adequate supervision to a resident with impaired mobility and [MEDICAL CONDITION] and at high risk for falls. In addition, the facility failed to ensure the bed alarm worked properly for one of four sampled residents reviewed for accidents. Resident #1 was found on the floor with a hematoma above (his/her) left eye. Findings: The facility admitted Resident #1 on 1/23/17 with [DIAGNOSES REDACTED]. On 2/2/21 at approximately 10:00 AM Resident #1 was noticed in bed with the TV on. S/he has a pronounced hematoma above (his/her) left eye and bruising around it. Nurse's notes review on 2/2/2021 at approximately 10:15 AM indicates that on 1/17/21 at 10:30 AM Resident #1 was found on the floor on (his/her) right-side with a hematoma to the left side of forehead. Fall-risk evaluation dated 12/12/19 and reviewed on 2/2/21 at 10:25 AM indicates that Resident #1 scored a twenty-two. According to the evaluation form, a score of ten or above represents a high risk. No other fall-risk assessment provided by the facility. The facility's 5-day investigation report reviewed on 2/2/21 at 10:45 AM reveals the certified nursing assistant positioned the resident in bed for breakfast and left the room. The resident fell out of the bed and suffered a hematoma to the forehead. Care plan reviewed on 2/2/21 at 11: 10 AM states that Resident #1 has limited mobility due to bilateral knee contractures, impaired vision-related to [MEDICAL CONDITION] and (s/he) is at risk for falls. Resident fall prevention interventions including, but not limited to bed and chair alarm, bedside mat, and bed in the lowest position. In an interview with CNA #1 on 2/2/21 at approximately 1:20 PM (s/he) stated that (s/he) set the resident up for breakfast in bed and stepped out of the room to pass on food trays but before (s/he) stepped out of the room (s/he) raised the bed up and removed the floor mat. A few moments later the housekeeping person informed (him/her) that Resident #1 was on the floor. The CNA acknowledged (s/he) left the resident unattended and in a compromised position. In a phone interview with the housekeeping staff on 2/2/21 at approximately 2:00 PM (s/he) stated that sometime after breakfast (s/he) saw Resident #1 on lying on the floor while (s/he) was walking down the hall. Interview with the assistant director of nursing (ADON) on 2/2/21 at 2:35 PM (s/he) the Resident's #1's bed alarm was not working at the time of the fall. The ADON also acknowledged that the CNA left raised the resident's bed up, removed the floor mat and the resident unattended.

Based on interview, record review, and review of the facility's Cardiopulmonary Resuscitation (CPR) policy, the facility failed to ensure that care and services were provided for 1 of 1 sampled resident reviewed for a closed record review for death. Resident #36 was designated a full code status but did not receive CPR as ordered. The facility's Director of Nursing (DON), in the absence of the Administrator was informed on [DATE] at approximately 9:38 AM that Immediate Jeopardy existed on [DATE]. The facility provided an Immediate Jeopardy Removal Plan that was accepted on [DATE] at approximately 12:29 PM and the Immediate Jeopardy at F678 was removed with an effective completion date of [DATE] and lowered to the scope and severity of D. The findings included: Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], Resident #36 had a change in condition. CPR was not administered and the resident expired. A review of the medical record on [DATE] at 3:36 PM and [DATE] at 8:30 AM revealed Resident #36 had monthly cumulative physician's orders [REDACTED]. A review of nurse's notes dated [DATE] indicated the resident had a decline in status and had removed the [MEDICAL CONDITION] mask. A nurse's note dated [DATE] during the 7P-7A shift indicated the resident continued to remove [MEDICAL CONDITION] mask and attempt to get out of bed unassisted. A nurse's note dated [DATE] at 5:30 AM indicated the resident's [MEDICAL CONDITION] mask was again removed and upon attempting to reapply it, the resident was noted to be cold. A nurse's noted dated [DATE] at 5:30 AM indicated the resident was without pulse/respiration/blood pressure. There was no documentation to indicate that CPR was given as ordered. During an interview on [DATE] at 4:00 PM when asked to confirm what had occurred, Licensed Practical Nurse (LPN) #1 stated, I went into Resident #36's room and noted the [MEDICAL CONDITION] mask to be on the floor, I picked it up to replace it and when I touched the resident's arm, it fell to the floor. I remembered the resident was a full code, so I proceeded to walk down the hall to the utility room, grabbed the crash cart, went behind the nurses' desk and grabbed my stethoscope, checked the resident's medical record to verify the code status and then I called the Registered Nurse (RN) on call to verify what to do. Upon talking to the RN, I was told not to perform CPR because at this point I would be doing more harm than good. When asked by the surveyor if s/he was aware of the facility's CPR Policy, LPN #1 stated s/he was not. During an interview with the DON on [DATE] at 4:08 PM, s/he stated s/he was made aware of the incident regarding the death of Resident #36 on the following day. S/he confirmed there was no reprimand, neither was re-education provided to LPN#1 following the incident. On [DATE] at 4:45 PM, review of the facility's policy titled, Emergency Procedure- Cardiopulmonary Resuscitation it states, If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless; a. It is known that a Do Not Resuscitate (DNR) order specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis). The Immediate Jeopardy Removal Plan included the following: Deficiency: F678 failure to initiate CPR for Resident admitted [DATE] with a full code status. Corrective Action: 1. Immediate in-service held with two Nursing staff present in the facility to review CPR Policy and Procedure. 2. Social Service Director completed a chart review of all current residents to identify at risk residents with a full code status. 13 of 34 residents identified as having a full code status. 3. All licensed and registered staff off duty were contacted via phone and required to attend a facility mandatory in-service to be completed [DATE] by 7:00 PM. All staff received a mandatory in-service to review Policy and Procedure on CPR and review identified at risk residents with full code status. 4. Room rounds conducted on all identified full code residents. One resident was out of the facility to [MEDICAL TREATMENT]. All remaining resident showed no significant changes. 5. Disciplinary action to be administered on [DATE] to identified Nurse, for not following the facility's policy and procedure for initiating CPR on a resident with a full code status. 6. Staff will be required to notify DON when at risk residents have a significant change in status and/or when emergency procedures have been initiated. The facility has initiated the below education plan for all admission, social services and licensed nursing staff. Monitoring for Corrective Action: 1. Social Service Director to complete weekly chart review to identify changes in code status. Review to be reported to DON weekly for 12 weeks for submission to Q[NAME] DON will submit her findings to the QA committee monthly for 3 months. 2. CPR policy and procedure with acknowledgement signature included in new hire packet will be reviewed by HR during orientation. Completed new hire packet to be reviewed and recorded by DON weekly x 90 days and report findings to Q[NAME] 3. Mandatory CPR educational in-services will be conducted quarterly for all nursing staff, to include competency test and review of policy, recorded by DON for staff compliance. 4. DON will audit 2 floor nurses per week x 4 weeks for their ability to articulate the steps to addressing a change in condition with an at risk patient. Audit to include knowledge of steps to follow during an emergency and code status location on chart.\ 5. CPR policy and steps to follow during an emergency will be located with the nursing 24-hour report book to be maintained and audited by DON 5x per week for acute changes and notification of DON. Completion Date [DATE]

Based on observations, record reviews, interviews, and a review of the policy provided by the facility entitled "Falls-Clinical Protocol", the facility failed to ensure that the resident environment remained free of accident hazards for 1 of 3 sampled residents reviewed for falls. The facility failed to follow care plan interventions related to falls for Resident #17, resulting in an injury. Water temperatures greater than 120 degrees Fahrenheit were found in 4 resident rooms (Rooms 114, 116, 113/115, and 117/119) and in one of one shower rooms. Cross refer to F 282 as it relates to the failure of the facility to follow Resident # 17's plan of care to prevent falls. The findings included: The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Record review of the Fall Assessment, on 10/08/2014 at approximately 2:42 PM, revealed the resident was assessed as a high fall risk. Record review of the Nurses Risk Meeting Notes on 10/08/2014 at approximately 1:51 PM, revealed the resident had falls on 5/18/2014, 5/22/2014, and 08/01/2014. Record Review of the Care Plan on 10/08/2014 at approximately 3:08 PM, revealed the resident is at risk for falls and listed a bed alarm, a floor mat beside the bed, a Dycem (non-slip) mat for the wheelchair, and a wedge pillow for positioning while in bed as safety interventions. Record review of the Care Plan revealed that on 5/18/2014, the resident fell out of bed and that the floor mat was not in place and the bed alarm was disconnected. Record Review of the Nurses Notes dated 05/18/2014 on 10/08/2014 at approximately 3:08 PM, revealed that the resident was lying on his right side on the floor and yelling "I hit my head". The nurse noted there was a "nodule" and a small amount of "blood and pus" above the resident's right eye. Record review of the Care Plan revealed that on 05/22/2014, the resident had fallen out of bed onto the floor mat. The facility implemented the "wedge pillow for positioning when in bed" as a fall intervention after this fall. Further record review of the care plan revealed that on 08/01/2014, the resident fell out of bed and the "Wedge cushion was not positioned to resident's back." Record review of the Nurses Risk Meeting Notes on 10/08/2014 at approximately 3:08 PM, also indicated that the wedge cushion was not placed to the resident's back. Record review of the 10/01/2014 Treatment Record on 10/09/2014 at approximately 8:07 AM, revealed that the bedside mat, pad alarm to the bed, and pad alarm to the wheelchair were listed on the treatment record. The Dycem mat and the wedge cushion were not listed. In addition, "fyi" (for your information) was handwritten on the Treatment Record beside these safety interventions. There was no documentation to indicate that these safety devices were either functioning or in place. During an observation of the resident's wheelchair on 10/09/2014 at approximately 8:07 AM, no Dycem mat was observed on the seat of the wheelchair, the pad alarm to the wheelchair, or to the cushion on the wheelchair. The resident was observed up in his wheelchair in the dayroom near the nurses station on 10/09/2014 at approximately 4:42 PM. During an interview with Licensed Practical Nurse (LPN) #2, on 10/09/2014 at approximately 4:42 PM, LPN #2 confirmed by observation that there was no Dycem mat to the resident's wheelchair. During an interview with the Unit Manager on 10/09/2014 at approximately 9:20 AM, the Unit Manager stated that it was the responsibility of the Certified Nursing Assistants (CNAs) to ensure safety devices were in place and functioning at the start of their shift and on resident rounds throughout the shift. The Unit Manager also confirmed there was no place on the record to document that this was being done. During an interview with the Director of Nursing (DON) on 10/10/2014 at approximately 11:14 AM, the DON confirmed the bed alarm was disconnected and the fall mat was not in place when the resident fell out of bed on 5/18/2014. The DON also confirmed the wedge cushion was not in place when the resident fell out of bed on 08/01/2014. A review of the policy provided by the facility entitled "Falls-Clinical Protocol" revealed under "Cause Identification", that staff would attempt to define possible causes within 24 hours of the fall. If the cause is unclear, a physician would review the situation and help identify contributing causes. "...The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk...Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling." Under "Monitoring and Follow-Up, ...2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequence of falling....3. If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed ...4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. 5. As needed, the physician will document the presence of uncorrectable risk factors including reasons why any additional search for causes is unlikely to be helpful." On 10/06/14 at 4:23 PM during the inital tour of the facility, the water temperature in the hand sink of the only shower room was checked by thermometer and was 123.4 degrees Farenheit (F). On 10/06/14 at 5:08 PM the water temperature in the sink in the shower room was 128.6 F. On 10/06/14 at 5:17 PM, the Housekeeping Manager was made aware and checked the water temperature at the hand sink with his/her thermometer and verified that the temperature of 128 degrees F was above the acceptable level of 120 degrees F. The Maintenance Supervisor adjusted the hot water tank to the shower room. On 10/06/14 at 5:49 PM, after the adjustment, the Maintenance Supervisor checked the water temperature and it was 119 degrees F. On 10/06/14 at 5:52 PM, an interview was conducted with Certified Nurse Assistant (CNA) #1 regarding the protocol for checking water temperatures prior to showering/bathing the residents. CNA #1 stated s/he always checks the water temperature with his/her hand and adjusts the temperature. CNA #1 also stated that before showering or bathing a resident, s/he always has the resident feel the water by hand to see if the water is at a comfortable temperature. On 10/06/14 at 5:58 PM, an interview was conducted with CNA #2 regarding the protocol for checking water temperatures prior to showering/bathing the residents. CNA #2 stated s/he always checked the water temperature with the back of his/her hand or elbow and adjusted the temperature. CNA #2 also stated s/he always had the resident check the water and see if it was at a comfortable temperature. On 10/6/14 at approximately 5:00 PM, observations of the resident rooms with another surveyor revealed water temperatures in resident bathroom sinks above 120 degrees as follows: Room 114 - 124.4 degrees Room 116 - 124.5 degrees The temperature in the bathrooms was taken again on 10/6/14 at 6:30 PM by the Housekeeping Manager. The following temperatures were noted: Room 114 - 114.9 degrees Room 116 - 120.9 degrees The temperature in the bathrooms was taken again on 10/7/14 at 8:45AM. The water temperatures were as follows: Room 114 - 105 degrees Room 116 - 105.5 degrees Observation and a check of water temperatures in the even numbered resident rooms with another surveyor on 10/6/14 at 5:09 PM revealed the hot water temperature in the bathroom sink of Rooms 113/115 (shared bathroom) at 122.2 degrees Fahrenheit per surveyor. Upon recheck by the Housekeeping Manager at 5:16 PM, the hot water temperature was 122 degrees Fahrenheit by the facility's thermometer. At 5:10 PM, the hot water temperature in the bathroom sink of Rooms 117/119 was 121.4 degrees Fahrenheit (per surveyor). Upon recheck with the Housekeeping Manager using the facility's thermometer at 5:23 PM, the water temperature was 122 degrees Fahrenheit. During an interview on 10/6/14 at approximately 5:30 PM, Licensed Practical Nurse (LPN) #2 was asked which residents in the 4 rooms could independently use the bathroom sink. The nurse stated that Resident #7 in room 115, Resident #9 in room 117, and one resident (not sampled) in room 119 could independently use the bathroom sink. During an interview on 10/06/2014 at 5:36 PM, the Maintenance Director stated that s/he checked water temperatures on one side of the hall every Friday during the day shift and documented the findings on a log. According to the Maintenance Director, s/he had found no concerns related to elevated water temperatures. A review of the water temperature logs revealed the water temperatures for alternating sides of the hall had been checked weekly. There were no water temperatures documented over 120 degrees Fahrenheit. When asked, the Maintenance Director stated that the facility didn't like the water temperatures higher than 115 degrees Fahrenheit. S/he later clarified that according to regulation, the water temperatures shouldn't be over 120 degrees Fahrenheit. Observation on 10/6/14 at 6:32 PM with the Maintenance Director, revealed the bathroom sink hot water temperature for rooms 113/115 was 122 degrees Fahrenheit. A recheck of the bathroom sink hot water temperature with the Maintenance Director on 10/6/14 at 6:38 PM in rooms 117/119 was 112 degrees Fahrenheit. During an interview immediately after the hot water temperatures had been verified by facility staff on 10/6/14, the Administrator was notified of the concern related to the hot water temperatures in resident rooms and in the shower room sink basin. According to the Administrator, the water heaters had been recently serviced due to cool water temperatures but no concerns related to hot water temperatures had been noted. According to an invoice dated 2/4/14 provided by the facility on 10/7/14 at 9:52 AM, plumbing work had been completed to balance the hot water on hand sinks to approximately 100 degrees Fahrenheit. A review of the policy provided on 10/7/14 at 8:45 AM by the Maintenance Director, revealed the facility used Health Licensing regulations for direction related to hot water temperature controls. According to DHEC's (Department of Health and Environmental Control) Health Licensing Standards for Nursing Homes, Regulation Number 61-17; "...Temperature Control (ll) A. Plumbing fixtures that require hot water and that are accessible to residents shall be supplied with water that is thermostatically controlled to a temperature of at least one-hundred (100) degrees Fahrenheit and not to exceed one-hundred and twenty (120) degrees Fahrenheit at the fixture. (l)...".

Based on observations, interviews, and record review, the facility failed to implement the planned interventions for fall precautions for Resident #17, 1 of 3 sampled resident care plans reviewed for implementation of careplans related to accidents. Cross refer to F 323 as it relates to accidents/hazards as a result of the facility to implement Resident 17's plan of care, resulting in fall(s) with injury. The findings included: The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Record review of the Nurses Risk Meeting Notes and the Nurses Notes on 10/08/2014 at approximately 1:51 PM, revealed the resident had falls on 5/18/2014, 5/22/2014, and 08/01/2014. Record Review of the care plan on 10/08/2014 at approximately 3:08 PM, revealed the interventions on the careplan included a bed alarm, a Dycem (non-slip) mat to the seat of the wheelchair, a wedge pillow for positioning while in bed, and a floor mat beside the bed. Documentation on the Care Plan revealed that on 5/18/2014, the resident fell out of bed and that the floor mat was not in place and the bed alarm was disconnected. Record Review of the Nurses Note from 05/18/2014 on 10/08/2014 at approximately 3:08 PM, revealed that the resident was lying on his right side on the floor and yelling, "I hit my head". The nurse noted there was a "nodule" and a small amount of "blood and pus" above the resident's right eye. Documentation on the care plan revealed that on 08/01/2014 "Resident rolled OOB (out of bed) to mat, alarm sounding, Wedge cushion was not positioned to resident's back." Record review of the Nurses Risk Meeting Note, on 10/08/2014 at approximately 3:08 PM, also indicated that the wedge cushion was not placed to the resident's back. During observation of the resident's wheelchair on 10/09/2014 at approximately 8:07 AM, no Dycem was observed on the seat of the wheelchair, on the pad alarm or to the cushion on the wheelchair. Observation on 10/09/2014 at approximately 4:42 PM, revealed that the resident was sitting up in his/her wheelchair near the nursing station. During an interview with Licensed Practical Nurse (LPN) #2, on 10/09/2014 at approximately 4:42 PM, LPN #2 confirmed by observation there was no Dycem to the resident's wheelchair. During an interview with the Director of Nursing (DON) on 10/10/2014 at approximately 11:14 AM, the DON confirmed the bed alarm was disconnected and the fall mat was not in place when the resident fell out of bed on 5/18/2014. The DON also confirmed the wedge cushion was not in place when the resident fell out of bed on 08/01/2014.

On the days of the complaint inspection, based on record reviews, observations, and interviews, the facility failed to ensure that comprehensive assessments for behavioral symptoms were done for residents who displayed behavioral symptoms making them a risk of danger to other residents (#3) or making themselves potential victims of other residents (#1) for 2 of 3 residents who were involved in resident to resident altercations (Residents #1 and #3). The findings included: Cross Refers to F-323 Resident #3 admitted with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets (MDS), with assessment reference dates (ARDs) of 8/15/11 and 2/13/12 revealed the resident was severely cognitively impaired with BIMS (brief interview for mental status) scores of 6/15 and 7/15. The resident was independent in transfer and ambulation. Neither assessment showed coding for behavioral symptoms. Review of the resident's plan of care showed problems listed for his [DIAGNOSES REDACTED]. on 9/2/11; and a persistent pattern of behavior that violates the rights of others "thumps others (with) his fingers, goes into others room uninvited, scolds other residents", initiated 11/21/11. Approaches to assist the resident in managing his behaviors included: daily monitoring of behaviors; and "assess cues and warning signals such as behavioral changes, escalating anger or anxiety or recent changes in life." Review of the Nurse's Notes revealed the following resident to resident episodes: 11/3/11, "... Pt (patient) noted this AM slapping another patient across the hand. When ask Mr. ... why he slapped pt he stated 'I didn't, I don't know. ..." 11/7/11, 5 AM, "Res (resident) noted per dietary staff, while in dayroom (with) Resident ...., kicked @ him close to his face. When asked Resident denied doing it, but Res. ... stated he did. ..." 12/22/11, 2:30 PM, " Reported to me by CNA (certified nursing assistant) that on 12/21/11 around 1 PM, resident flipped hat off of another resident's head (with) his hand. ... Around 2 PM this resident returned to the day area and brushed his hand across the same resident's face, hitting his nose hard enough for the resident to respond, 'stop hitting me.' .." At 2:15, the resident forcefully slapped a CNA on the back, then began to laugh. Subsequent nurse's notes showed the physician ordered a psychiatric evaluation at local in-patient psychiatric facility but they would not accept the resident. The physician ordered monitoring for 72 hours, and to send the resident to the hospital for any further aggressive episodes. the resident was placed on 1 to 1 supervision. Staff made an appointment at Mental Health for 1/4/12, the earliest their physician could see him. The resident was a regular patient there. 12/30/11, 11:30 AM, "This AM Pt seen by a CNA flipping a Pt's hat of (sic) his head while sitting up in day room. No injury noted to other Patient. This nurse redirected Mr. ... et (and) explain to pt that he not (sic) allowed to put his hands on other Patients. Mr. ... stated 'I know.' ..." 3/7/12, 11:30 AM, "Pt seen by CNA coming up the hallway stopped @ another resident sitting in the day area. Mr. ... seen by CNA hitting pt. lightly on (L) (left) arm. ..." The resident was redirected and counseled by the nurse. He denied the incident. At 2:30 PM another entry said: "Pt coming up hallway from the dining area. Pt seen by CNA tapping Pt (with) open hand to (R) (right) arm. ..." The resident again denied doing anything to the other resident. The other resident stated "oh, he was just picking." 3/11/12, "CNA told nurse that resident ... grab resident ... by the back of neck and startled her. Resident ... was removed and told that was wrong to never put his hands on any one. ..." The resident was seen at Mental Health on 3/12/12. His dose of [MEDICATION NAME] was increased. 3/16/12, 6:45 PM, "Res. noted threatening another resident, stated, 'I'm gonna knock the[***]out of you.' Res did not come close to resident he was threatening and there was no contact." Fifteen minute checks of the resident were started. 3/20/12, 7:35 AM, "Resident caught in room ... Admonished and redirected." The Behavior/Intervention Monthly Flow Records for December 2011 and March 2012 were reviewed. Resident #3 was monitored for "Anger" and "Hitting." The December 2011 form showed zeros every day for each category. The March 2012 documentation was blank except for five lines in the space for 3/7/12 documentation under "Hitting." These lines indicated two behavioral episodes, with intervention provided that had a positive effect with no side effects. Review of the resident's care plan failed to show the facility tried different behavioral intervention to assist the resident manage his behaviors. The care plan showed the Mental Health evaluation ordered in December 2011, that the resident grabbed another resident by the neck on 3/11/12, and that 15 minute checks of the resident began on 3/12/12 and ended on 3/23/12. The approaches remained as listed when each problem was initiated. Review of the medical record failed to show evidence of any assessment of the resident's behavioral symptoms in an effort to identify any patterns or triggers of his behavior. There was no discussion of why the behaviors may have started in December 2011, why there was a lapse in the behaviors in January and February 2012, and why the behaviors escalated again in March 2012. Documentation in the medical record revealed the facility reacted to individual incidents, but in failing to thoroughly assess the incidents, individually and collectively, they failed to develop a proactive plan in an attempt to prevent future incidents. Resident #1 admitted with [DIAGNOSES REDACTED]. Review of the annual MDS with an ARD of 12/10/11 and the last quarterly MDS with an ARD of 3/12/12 revealed the resident had severe cognitive impairment, severe visual impairment, and required extensive assistance from the staff for transfer and ambulation. Neither assessment noted behavioral symptoms. Review of the medical record revealed that because the resident was almost blind, he used his hands to feel about the environment. He also had incidents of spitting or urinating on the floor. On 3/6/12, at approximately 7:45 AM, the resident was found in his room, bleeding from open areas on the back of his neck, and over the right eye lid. There were scratches on the left side of his face and an abrasion to the right elbow. The resident's roommate (#2) was sitting in his wheelchair, holding a belt. The roommate initially denied hitting the resident but later admitted it the staff at the hospital. According to the roommate, the resident was trying to get in bed with him after being incontinent of bowel and bladder, and he was touching the roommate's belongings. The two residents had been roommates since 1/2/12. Review of the medical records for both residents failed to show any evidence of any problems between them or of any past incidents of abuse from Resident #2 towards other residents. The facility's investigation discovered the roommate threatened the resident at approximately 2 AM that morning and a CNA removed the resident from the room. He was returned to bed at approximately 6 AM. Resident #1 was also involved in the incident on 12/22/11, when his hat was knocked off his head by Resident #3 and then hit in the nose by that same resident. During an interview with the Administrator, at 1 PM on 3/26/12, he stated the resident was now in a private room. He had lived in that private room before because past roommates would get upset with him for touching their things. The resident was moved out of the private room and into the room with the roommate due to the facility's need for an isolation room. He and the roommate seemed to be getting along fine, so the facility did not move the resident back to the private room. However, after the incident with the roommate, the resident was placed in a private room. When asked what the facility's plans were to keep Resident #1 safe from other residents and other residents safe from Resident #2, the Administrator stated Resident #1 would likely stay in the private room and Resident #2 would likely stay in his room but not be given any roommates. Review of the care plans of both residents failed to show any plan to keep Resident #1 safe from other residents, and to keep other residents safe from Resident #2. After the interview with the Administrator, information was added to each care plan showing that Resident #1 would remain in a private room and Resident #2 would not be given another roommate. Review of the medical record did not show any assessment of the resident's behaviors that put him at risk of abuse from other residents. No plan was in place to keep him safe from other residents.

On the day of the complaint inspection, based on record review, the facility failed to review and revise resident care plans to reflect changing care needs for 3 of 3 residents with behavioral symptoms either putting them at risk for abuse from other residents (#1) or putting other residents at risk from them (#2 and #3). The findings included: Cross Refers to F-323 Resident #3 with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets (MDS), with assessment reference dates (ARDs) of 8/15/11 and 2/13/12 revealed the resident was severely cognitively impaired with BIMS (brief interview for mental status) scores of 6/15 and 7/15. The resident was independent in transfer and ambulation. Neither assessment showed coding for behavioral symptoms. Review of the resident's plan of care showed problems listed for his [DIAGNOSES REDACTED]. on 9/2/11; and a persistent pattern of behavior that violates the rights of others "thumps others (with) his fingers, goes into others room uninvited, scolds other residents", initiated 11/21/11. Approaches to assist the resident in managing his behaviors included: daily monitoring of behaviors; and "assess cues and warning signals such as behavioral changes, escalating anger or anxiety or recent changes in life." Review of the Nurse's Notes revealed six incidents where the resident inappropriately touched other residents (slapping, hitting, grabbing), one incident of verbally threatening a resident, and two incidents of flipping the hats off other residents' heads. Review of the resident's care plan failed to show the facility tried different behavioral interventions to assist the resident manage his behaviors. The care plan showed the Mental Health evaluation ordered in December 2011, that the resident grabbed another resident by the neck on 3/11/12, and that 15 minute checks of the resident began on 3/12/12 and ended on 3/23/12. Otherwise the approaches remained as listed when each problem was initiated. Resident #1 with [DIAGNOSES REDACTED]. Review of the annual MDS with an ARD of 12/10/11, and the last quarterly MDS with an ARD of 3/12/12 revealed the resident had severe cognitive impairment, severe visual impairment, and required extensive assistance from the staff for transfer and ambulation. Neither assessment noted behavioral symptoms. Review of the medical record revealed that because the resident was almost blind, he used his hands to feel about the environment. He also had incidents of spitting or urinating on the floor. On 3/6/12, at approximately 7:45 AM, the resident was found in his room, bleeding from open areas on the back of his neck, and over the right eye lid. There were scratches on the left side of his face and an abrasion to the right elbow. The resident's roommate (#2) was sitting in his wheelchair, holding a belt. The roommate initially denied hitting the resident but later admitted it to the staff at the hospital. According to the roommate, the resident was trying to get in bed with him after being incontinent of bowel and bladder, and he was touching the roommate's belongings. Resident #1 was also involved in the incident on 12/22/11, when his hat was knocked off his head by Resident #3 and then hit in the nose by that same resident. Review of the resident's care plan showed problems included impaired vision and cognitive status, and self care deficits. A problem of potential for change in psychological well being related to room change was added on 1/2/12. There was no problem area addressing any behavioral symptoms, or how the resident's near [MEDICAL CONDITION] and his need to feel the environment affected other residents. Notations added to the problem of potential for change in psychological well being were made on 3/6/12: resident to resident incident - send to PRMC for evaluation related to a change in level of consciousness; and transfer to room [ROOM NUMBER] (safety measures). No other revision was made to the plan of care. Resident #2 with [DIAGNOSES REDACTED]. The significant change assessment with ARD of 10/9/11 showed moderate cognitive impairment with no behavioral symptoms. The quarterly MDS with an ARD of 1/6/12 showed moderate cognitive impairment and behavioral symptoms of verbal abuse and rejection of care. Review of the care plan showed problems including resisting care, and that the resident was receiving antipsychotic medications. After the incident on 3/6/12, where he struck his roommate, notes were added to the care plan under the problem for antipsychotic medications: 3/6/12, The entry said the resident was sent to the hospital for evaluation. 3/7/12, Visual checks, every fifteen minutes was started. 3/14/12, Medication change. 3/15/12, Discontinue fifteen minutes checks. There was no revision of the care plan to show how the facility planned to keep other residents safe from this resident. During an interview with the Administrator, at 1 PM on 3/26/12, he was asked what the facility's plans were to keep Resident #1 safe from other residents and other residents safe from Resident #2. The Administrator stated Resident #1 would likely stay in the private room and Resident #2 would likely stay in his room but not be given any roommates. He was made aware there was no plan in place to reflect this course of action. Review of the care plans of both residents after the interview with the Administrator revealed information was added to each care plan showing that Resident #1 would remain in a private room and Resident #2 would not be given another roommate.

On the days of the complaint inspection based on observation, record review and interview the facility failed to ensure that Residents received adequate supervision to prevent injury. Resident #1 was allegedly hit by his roommate, Resident #2 with a belt. Review of the facility investigation revealed that Certified Nurse Aide (CNA) # 1 removed Resident #1 from his room on 03/06/2012 at 2:00 AM after she heard Resident #2 threaten to hit him. CNA #1 failed to inform her supervisor of the threat made by Resident #2. Resident #1 was placed back in his room with Resident #2 at 6:00 AM on 03/06/2012; at approximately 7:45 AM Resident #1 was found bleeding from superficial puncture wounds to the back of the head. Resident #2 was sitting in the room holding a leather belt in his lap. The findings included Review of Resident #1's medical record revealed [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/2011 and the last Quarterly MDS with an ARD of 3/12/2012 revealed the resident had severe cognitive impairment, severe visual impairment, and required extensive assistance from the staff for transfer and ambulation. The medical record revealed that because the resident was almost blind, he used his hands to feel about the environment. He also had incidents of spitting or urinating on the floor. Review of the Nurse's Notes dated 03/06/2012 at 7:45 AM stated, "On AM rounds pt (patient) noted to be sitting on bedside, patting feet, humming. Return to room approximately 10 min (minutes) later. CNA called stated pt. was bleeding, pt noted to be standing over a chair in Room with blood dripping, on exam pt noted 2 superficial puncture wounds to back of head, (1) to back of neck, (1) over (R) (right) eye lid, (2) scratches to (L) (left) side face, abrasion to (R) elbow and (R) wrist, multiple bruises to upper and lower back areas cleansed with N/S (normal saline), ABT (antibiotic) ointment and bandaids applied, MD notified... 12:15 PM Pt noted to be sleeping a lot, when awake he is bent over, picking objects, slow to respond, overall change in normal activities. Spoke with daughter... sent pt. to hospital..." Review of the Emergency Department visit dated 03/06/2012 at 18:14 stated, "...Medical Decision Making: This is an [AGE] year-old with a history of dementia, who presents to the emergency department today with complaints of an alleged assault. He was struck in the head by a belt buckle. I think at this point we can obtain CT scan of the head to rule out any acute intracranial injuries, but other than that, he does not require further workup... Laboratories and studies: Head CT is negative. Emergency Department Course: The patient was evaluated and found to be stable. Vital signs remained stable throughout his entire ED stay. He was discharged back to his nursing home without difficulty..." Resident #2's medical record revealed [DIAGNOSES REDACTED]. The significant change assessment with ARD of 10/09/2011 showed moderate cognitive impairment with no behavioral symptoms. The quarterly MDS with an ARD of 01/06/2012 showed moderate cognitive impairment and behavioral symptoms of verbal abuse and rejection of care. Review of the Nurse's Notes dated 03/06/2012 at 7:45 AM stated, "On rounds resident noted sitting up in w/c (wheelchair) with back to door, continued rounds, upon re-entering room resident noted to be sitting in w/c with belt in his hand and roommate bleeding, resident became verbally aggressive... refused to let staff near him... Review of the Emergency Department visit dated 03/06/2012 at 21:24 stated, "...History of Present Illness: This is a [AGE] year-old gentleman with a history of schizophrenia who currently at Nursing Home who had an episode of behavioral disturbance at the nursing home. He states that his roommate has been attempting to sleep with him in his bed while urinating as well as having fecal incontinence. Due to this he was upset. He subsequently took off his belt and assaulted his roommate... he does not state that he was assaulted himself. Patient is somewhat difficult to get a history from due to the fact that he changes topics often... Emergency Department Course: The patient's course was unremarkable. Patient has been clinically stable throughout stay. MSU (medical social unit) did evaluate and deferred psych. Psych had stated that he does have some psychosis at this time. They will decide to hold him until the morning. They will do baseline workup and will reevaluate tomorrow for possible medication management..." Review of the facility investigation of the 03/06/2012 incident indicated that "CNA #2 worked the 11-7 shift on 3/5/12. He did not provide direct patient care but recalled around 2:00 am Resident #2 yelling for Resident #1 to get back in the bed... CNA #1 brought Resident #1 out of the room. CNA #1 reported that around 2:00 am Resident #2 was yelling at Resident #1 to get back in the bed and leave his things alone. Resident #1 was observed touching Resident #2's belongings and at that time Resident #2 had a belt in his hand and was threatening to hit Resident #1 if he did not go back to bed. Resident #1 was then brought out of the room and put back to bed around 6:00 am. CNA #1 reported that she did not inform the nurse of the threat and did not remove the belt. The nurse reported he did not witness the threat or observe a belt and CNA #1 had not reported this information to him..." In a facility obtained statement dated 03/08/2012 CNA #1 stated, "...Around two a.m. I heard Resident #2 screaming at Resident #1 to get back in his bed and leave his things alone. Resident #2 had a belt in his hand and was threating to hit Resident #1 if he didn't go back to bed. Resident #1 was on Resident #2's side of the room. He was feeling and touching the things Resident #1 had on the table. Resident #2 was brought out of the Rm (room). I did not see Resident #2 hit Resident #1 with it. Around six A.M. I took Resident #1 to his room, change him and put him to bed. I did not see any injuries on Resident #1 at that time. I got Resident #2 wash and dress, I helped him in his chair. I left the room around 5:40 AM. Resident #1 was in his bed." In a telephone interview with the surveyor on 04/12/2012 at 8:10 AM the Director of Nurses confirmed that CNA #1 failed to report the threat made by Resident #2 to hit Resident #1.