Every finding on record at Seneca Trail Healthcare Center

Based on observation, record review, and staff interview, the facility failed to honor residents' rights to maintain respect and dignity. For Resident #29, the facility failed to ensure the resident's indwelling catheter urine collection bag was covered for privacy. This was true for one (1) of three (3) residents reviewed for the care area of urinary catheter. For Resident #57, the facility failed to ensure the resident received his meal drink when the other residents received their drinks. This was true for one (1) of eight (8) residents observed in the first floor dining room. For Resident #49, the facility failed to ensure the resident was not exposed to a staff member complaining about her job caring for residents. This was true for one (1) of two (2) residents reviewed for the care area of dignity. Resident Identifiers: #29, #57, and #49. Facility census: 78.Findings included:a) Resident #49 The facility's policy titled Catheter Care, with no dates of implementation or revision given, gave no guidance regarding privacy covers for urine collection bags for indwelling urinary catheters. Upon observation on 03/16/2026 at 3:00 PM, Resident #49's urine collection bag for his suprapubic catheter did not have a privacy cover. The urine collection bag was hanging from the bed frame away from the door and could only be visualized by people entering the room and walking around to the other side of the resident's bed. On 03/18/2026 at 9:27 AM, Resident #49's urine collection bag continued to not have a privacy cover. Although the urine collection bag continued to hang from the bed frame away from the door, the bag was visible from the hallway through the bed, which was slightly elevated. Light yellow urine was visualized in the urine collection bag. Unit Manager (UM) #34 confirmed Resident #49's urinary catheter urine collection bag did not have a privacy cover. UM #34 stated a privacy cover would be placed on the collection bag. b) 100 Hall Dining Room Observation On 03/17/26 at 12:15 PM, Resident #57 was observed in the dining room on 100 hall with no drinks. There were seven (7) other residents in the dining room who had drinks on the table in front of them. Interview with RN #64 confirmed Resident #57 did not have anything to drink while all of the others did. RN #64 stated Resident #57 did not have anything yet because he is on thickened liquids and gets his drinks when his tray comes out. c) Resident #49 Review of the facility's Resident's Rights policy revealed that each resident should be treated with respect and dignity and staff should care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. On 03/17/26 at 9:38 AM, Resident #49 reported Nurse Aide #68 complains as she is providing care to Resident #49 and her roommate that she has had enough of this place and these people. Review of the Quarterly Minimum Data Set, with an assessment reference date of 03/03/26, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that she was cognitively intact. An interview with Executive Director (ED) began at approximately 10:30 AM in which the resident's allegations were made known to ED. The fact that the Nurse Aide failed to refrain from making verbal comments made out of frustration which would be demeaning to residents who required extra assistance in carrying out their activities of daily of living was discussed and acknowledged by the ED.

Based on observation, record review, and staff interview, the facility failed to ensure activities of daily living were completed for dependent residents. This was true for two (2) of four (4) residents reviewed under the care area of activities of daily living throughout the Long-Term Care Survey Process. Resident Identifiers: #88 and #57. Facility Census: 79.Findings Included: a) Resident #88 On 03/19/2026 at 11:15 AM, a record review was completed for Resident #88. The documentation for 01/2025 and 02/2025 found showers and bed baths were not provided for Resident #88. The following dates show the length of time the resident did not receive showers or bed baths: --01/11/25-01/18/25 seven (7) days --02/12/25-02/22/25 10 days On 03/19/26 at 12:25 PM, the Director of Nursing (DON) confirmed showers and bed baths were not provided to the resident during the above-mentioned timeframes. b) Resident #57 On 03/16/2026 at 2:44 PM, it was observed that Resident #57 had long fingernails on both hands which also had limited range of motion (ROM). An interview with Occupational Therapist (OT) #66, at 2:05 PM on 03/18/26, confirmed Resident #57 needed nails trimmed. The Director of Nursing was interviewed, at 3:59 PM on 03/18/26, and stated Resident #57's nails definitely needed cut.

Based on observation, resident interview, and staff interview, the facility failed to ensure palatable food. The baked potatoes for the noon meal on 03/18/26 were not thoroughly cooked. This was a random opportunity for discovery that had the potential to affect more than a limited number of residents. Resident Identifiers: #18, #15, #60, #13, #4, #38, #74, #20, #40, #9, #73, #22, #37, #68, #66, and #10. Facility Census: 78.Findings included:a) Second Floor Dining Observation On 03/18/2026 at 12:25 PM, Resident #18 and Resident #15 were observed dining in their room. The residents stated the baked potatoes that were served to them were not thoroughly cooked and were too hard for them to eat. Resident #15 stated she was unable to eat the baked potato due to her dentures. Both residents demonstrated the potatoes were not thoroughly cooked by sticking their forks in them. The forks did not easily go into the potatoes. The residents stated the potato had been cut in half in the kitchen. On 03/18/26 at 12:27 PM, Resident #60, who was also dining in her room, stated her potato was not thoroughly cooked and she was unable to eat it. On 03/18/26 at 12:30 PM, the Director of Nursing (DON) was asked to observe Resident #18 and Resident #15's baked potatoes. She stated she would get replacements or substitutes for the residents. She was also informed that Resident #60 also could not eat her baked potato. On 03/18/26 at 12:33 PM, Resident #13 and Resident #4 were asked about the baked potatoes served to them. These residents were also dining in their room. Resident #13 stated her baked potato was too hard for her to eat. She stated she was full and did not want a replacement or substitute. Resident #4 stated her baked potato was hard, but she could eat it if she cut it into small pieces and put sour cream on it. She did not want a replacement or substitute. On 03/18/26 at 12:37 PM, Residents #38, #74, #20, and #40 were observed dining together in the second-floor dining room. They were noted to have not eaten their baked potatoes. They stated they could not eat the potatoes because they had not been cooked all the way through. Unit Manager #34 was notified and stated he would get some mashed potatoes for the residents. b) First Floor Dining Observation On 03/18/2026 at 12:45 PM, Resident #9 and Resident #73 were observed dining in their room. The residents stated the baked potatoes served to them were undercooked and were too hard for them to eat. Both residents stated they would rather have the mashed potatoes that were offered as a replacement. On 03/18/26 at 12:47PM, Resident #22, who was also dining in her room, stated her potato was not thoroughly cooked and she would like to have the mashed potatoes instead. On 03/18/26 at 12:50 PM, Resident #37 and Resident #68 were asked about the baked potatoes served to them in the dining room. These residents also requested mashed potatoes as a replacement. Resident #66 stated her baked potato was too hard for her to eat. She stated she was full and did not want a replacement or substitute. On 03/18/26 at 12:37 PM, Residents #75, and #10 were observed dining together in their room. They stated they were unable to eat their baked potatoes because they were not completely cooked all the way through and were too hard to cut. c) Staff Interviews On 03/18/26 at 12:55 PM, the Kitchen Account Manager stated she was made aware the baked potatoes were undercooked after the trays reached the previously served floor and the had started offering mashed potatoes as replacements. In an interview with the Dietary District Manager #117 at 3:40 PM, she stated the potatoes were temped at 148 degrees Fahrenheit and she had stopped the line and checked one of the potatoes before the tray carts were delivered to the floors. It was discovered the potatoes sent to the floors were under cooked too late to change the menu. After the discovery, the kitchen staff prepared mashed potatoes as a replacement and the Kitchen Account Manager then went to the floors and offered the replacement mashed potatoes for residents who wanted them. She also stated she felt the larger size of the potatoes caused them not to cook completely through.

Based on observation, interview and policy review the facility failed to properly store food in accordance with professional standards of practice.This had the potential to affect more than a limited number of residents in the facility. Facility census 79. Findings included: Cold Storage PolicyOn 03/17/26 at 3:30 PM a review facility policy labeled HCSG Policy 019, Food Storage: Cold Foods. Procedures, number 5 stated, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.a) Initial Tour of KitchenDuring initial kitchen visit, on 03/16/26 at 11:45 AM, the kitchen account manager acknowledged one (1) opened box of frozen omelets and one (1) opened box frozen biscuits with the inner plastic unsealed and left open to air.In an interview with the kitchen account manager on 03/16/26 at 11:50 AM, she acknowledged the frozen omelets and biscuits was left open to air after breakfast prep.b) Second Visit to KitchenOn 03/17/2026 at 11:30 AM, during the second Kitchen visit, the Dietary District Manager #117 acknowledged the following observation of unsanitary conditions during lunch preparations: -Employee #112 wiped up spilled soup off the counter using only her gloves, and returned to the tray line without changing her gloves or washing her hands.In a later observation, she walked over 3 feet away from the tray line, touched the out side of the food service cart twice and then returned to finish meal preparation also without changing her gloves or washing her hands.

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records in the areas of pneumococcal vaccination consents for four (4) of five (5) residents reviewed for immunizations. Additionally, the facility failed to ensure complete and accurate medical records in the areas of medication administration records (MARs), medication and supplement orders, and skin assessments for three (3) of 25 residents reviewed during the Long-Term Care Survey Process. Resident Identifiers: #47, #9, #83, #2, #6, #5, and #27. Facility Census: 78. Findings included:a) Pneumococcal vaccination consents - Residents #47, #9, #83, and #2 Review of the facility's policy titled, Resident Pneumococcal Vaccines, with effective date 03/01/17 and most recent revision date 06/15/23, stated residents who had not received any pneumococcal vaccines would be offered pneumococcal conjugate vaccine (PCV) 20. According to the Centers for Disease Control and Prevention (CDC), the Advisory Counsel for Immunization Practices began recommending the PCV20 vaccination in 2024. Review of Resident #47's medical records show the resident received the PCV 20 vaccine on 03/09/26. Verbal consent for the pneumococcal vaccine had been obtained from the resident's representative on 02/27/26. This consent form was effective 10/29/13 and had been revised on 03/01/17. The form gave consent for the pneumococcal conjugate vaccine (PCV) 13 or the Pneumococcal Polysaccharide Vaccine (PPSV) 23 to be administered. Review of Resident #9''s medical records show the resident representative had verbally declined for the resident to receive pneumococcal vaccination on 03/03/26. This consent form was effective 10/29/13 and had been revised on 03/01/17. According to the consent form, the resident had been offered the pneumococcal conjugate vaccine (PCV) 13 or the Pneumococcal Polysaccharide Vaccine (PPSV) 23. Review of Resident #83's medical records show the resident had declined pneumococcal vaccination on 03/13/26. This consent form was effective 10/29/13 and had been revised on 03/01/17. According to the consent form, the resident had been offered the pneumococcal conjugate vaccine (PCV) 13 or the Pneumococcal Polysaccharide Vaccine (PPSV) 23. Review of Resident #47's medical records show the resident received the PCV 20 vaccine on 09/15/25. A consent for the pneumococcal vaccine had been signed by the resident's representative on 09/12/25 This consent form was effective 10/29/13 and had been revised on 03/01/17. The form gave consent for the pneumococcal conjugate vaccine (PCV) 13 or the Pneumococcal Polysaccharide Vaccine (PPSV) 23 to be administered. On 09/17/26 at 3:00 PM, the Infection Preventionist stated old consent forms had been used for these residents. She stated the consent forms should have been for PSV20 vaccination. b1) Resident #6 - enteral nutrition documentation Review of Resident #6's physician's orders showed an order written on 12/31/25 for Enteral Feed Order at bedtime Enteral nutrition via G-tube [gastrostomy tube] for bolus feeding of bolus of Nutren 1.5 250 mls [milliliters], flushing 60 mls before and after to provide additional: 375 kcals [calories], 17g PRO [protein], and 191 mls free water. (Order typed as written.) This order was on Resident #6's Medication Administration Records (MARs) with a space for the nurse to document the amount of enteral nutrition given in mls. The amount of enteral nutrition given on the February and March MARs was documented as follows: - 250 mls on 02/02/26, 02/03/26, 02/04/26, 02/08/26, 02/12/26, 02/16/26, 02/17/26, 02/19/26, 02/23/26, 02/24/26, 02/25/26, 03/01/26, 03/02/26, 3/03/26, 03/04/26, 03/09/26, 03/10/26, 03/11/26, and 03/16/26. - 100 mls on 02/01/26, 02/06/26, 02/07/26, 02/09/26, 02/13/26, 02/14/26, 02/20/26, 02/21/26, 02/22/26, 03/06/26, 03/07/26, 03/08/26, 03/13/26, 03/14/26, and 03/15/26- 370 mls on 02/05/26, 02/26/26. 02/27/26, 02/28/26, 03/05/26, and 03/17/26- 95 mls on 02/10/26- 15 mls on 02/11/26- 0 mls on 02/15/26- 310 mls on 02/18/26 - 191 mls 03/12/26 On 03/19/2026 at 9:26 AM, the Director of Nursing (DON) agreed Resident #6's enteral feeding amount had not been accurately documented. She stated when 100 mls were documented, the nurse probably meant that 100 percent of the feeding had been given. She stated 250 mls being documented probably recorded only the enteral feeding given and 370 mls being documented probably recorded the amount of enteral feeding and the water flushes combined. The DON stated 191 probably correctly recorded the amount of free water contained in the enteral feeding and water flushes combined. She was unable to explain the remainder of the documented amounts. The DON stated Resident #6 sometimes refused part or all of his nightly enteral feedings. She agreed refusals should be documented in the progress notes. There were no progress notes regarding the enteral feedings for 02/10/26, 02/11/26, 02/15/26 or 02/18/26. No further information was provided through the completion of the survey process. b2) Resident #6 - modular protein order Review of Resident #6's physician's orders showed an order written on 08/31/25 for Modular Protein in the morning for protein. The amount to be given was not specified. On 03/19/2026 at 9:26 AM, the Director of Nursing (DON) confirmed Resident #6's modular protein order did not contain the amount to be given. She stated she would have the order revised. c) Resident #5 On 03/18/26 at 11:15 AM, a record review was completed for Resident #5. The review found incorrect diagnoses for two (2) medications in the physician's orders. The following medication are as follows: --Losartan Potassium--high cholesterol --Spironolactone--hypokalemia Also, the review found a physician's order for anticoagulant monitoring. However, the resident was not taking an anticoagulant. On 03/18/26 at 12:18 PM, the DON confirmed the diagnoses were incorrect for the medications; and, the resident was not taking an anticoagulant. d) Resident #27 On 03/16/2026 at 2:38 PM, Resident #27 stated she had two (2) open areas on her stomach. Resident #27 did not know how the open areas got there and states that nursing is not treating them. A record review was completed on 03/19/26 at approximately 12:00PM. The record review revealed:-A physician progress note, dated 03/05/26, which noted Resident #27 had abdominal wounds.-A skin assessment, dated 03/09/26, which noted Resident #27 had no skin areas noted.-A skin assessment, dated 03/16/26, which noted Resident #27 had no skin areas noted. State Surveyor Registered Nurse observed and confirmed Resident #27's abdominal wounds 03/19/26 at approximately 12:25 PM. During an interview on 03/19/26 at 1:15 PM, the Director of Nursing (DON) stated she was unaware of any open areas on Resident #27's abdomen, but she would check the resident's chart. The DON then pulled up Resident #27's electronic medical record, reviewed the most recent skin assessment and stated Resident #27 did not have any open areas on her abdomen. The State Surveyor requested the DON pull up the physician progress note, dated 03/05/26, which reflected Resident #27 was noted to have open areas on her abdomen at that time. The DON acknowledged it had been documented resident had open areas and stated she would want to see for herself. The DON observed abdominal wounds at 1:21 PM and confirmed they were not documented on the 03/09/26 and 03/16/26 skin assessments.

Based on observation, record review, and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Transmission based precautions were not followed. A nebulizer mask was not stored in an appropriate sanitary manner. Food was not served in a sanitary manner. Additionally, wheelchairs had holes, cracks, and exposed padding which made the wheelchairs unable to be thoroughly cleaned. These were random opportunities for discovery. Resident Identifiers: #29, #14, #23, #62, #68, #51, #66, and #14. Facility census: 79 a) Resident #29 The facility's policy titled Standard Precautions and Transmission Based Precautions, with no implementation or revision dates given, stated staff would utilize the proper personal protective equipment (PPE) upon entering the room before contacting the resident or environment for residents on contact precautions. On 03/17.26 at 12:17 PM, Nursing Assistant (NA) #67 went into Resident #29's room to deliver the resident's lunch tray. NA #67 did not wear PPE to enter the resident's room. Outside Resident #29's room was a sign which said the following: Stop. Contact Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. When questioned, NA #67 stated she only needed to wear gown and gloves when providing care to the resident. NA #67 was asked to read the contact precautions sign outside Resident #29's room. She stated, I probably should have worn a gown and gloves. Review of Resident #29's physician's orders showed an order written on 02/17/26 for enhanced barrier precautions (EBP) due to a suprapubic catheter. The resident had no order for contact precautions. However, the resident was noted to be receiving antibiotics for a catheter site infection until 03/19/26. On 03/17/26 at 12:42 PM, the Director of Nursing (DON) stated Resident #29 was no longer on contact isolation and was currently on EBP. She agreed that staff should follow the transmission-based precautions signage outside residents' rooms. The following order was written on 03/17/26, Contact Isolation related to: ESBL (extended spectrum beta-lactamase) every shift until 03/19/2026. On 03/17/26 at 3:00 PM, the Infection Preventionist confirmed Resident #29 was in contact isolation until 03/19/26, requiring staff to wear gown and gloves when entering his room. b) Resident #1 On 03/16/2026 at 12:50PM, Resident #1's nebulizer mask was observed lying on the bedside table. At 12:59 PM, Nurse Aide #43 confirmed the nebulizer mask was sitting on the bedside table and not inside of an oxygen bag. Nurse Aide #68 confirmed, at 12:20PM on 03/17/26, that Resident #1's nebulizer mask was left on the bedside table and not inside the oxygen bag. An interview with DON, on 03/18/26 at 3:30 PM, confirmed it is best practice for the nebulizer masks to be placed inside of the oxygen bag between treatments for infection control purposes. c) room [ROOM NUMBER] On 03/18/2026 at 11:22 AM, room [ROOM NUMBER] was on droplet precautions. Signage posted outside the door read as follows: EVERYONE MUST: including visitors, doctors and staff:-Clean hands when entering and leaving the room-Wear face mask (N-95 or higher, if available) -Wear eye protection (face shield or goggles)-Wear an isolation gown at door Nurse Aide #85 was observed going into room [ROOM NUMBER] with the gown open, draping down in front and not tied. Nurse Aide #85 also did not have a N-95 mask on nor eye protection. Nurse Aide #85 confirmed via droplet precaution signage on door that these items were necessary for entering room [ROOM NUMBER] and that she did not have them on at 9:46 AM on 03/18/26. Nurse Aide #76 was observed entering room [ROOM NUMBER] with no personal protective equipment (PPE). An interview with Nurse Aide #76 confirmed she was not wearing necessary PPE described on signage outside room [ROOM NUMBER] at 10:11AM on 03/18/26. Nurse Aide #20 was observed entering room [ROOM NUMBER] with gown not tied, no N95, and no eye protection. An interview with Nurse Aide #20 confirmed she did not wear necessary PPE described on signage outside of room [ROOM NUMBER] at 10:13 AM on 03/18/26. d) room [ROOM NUMBER] It was observed, on 03/18/2026 at 12:48 PM, Employee #20 delivered Resident #21's lunch tray with a contact isolation sign located outside the door without donning a mask, gown, and gloves. In an interview on 3/18/26 at 12:50 PM, Employee # 20 looked at the signage and stated, Oh. Even just to drop off trays? I wasn't doing any care. e) Resident #51 It was observed, on 03/17/2026 at 12:52 PM, Staff Member #21 removed Resident #51's tray from the food cart, the lid covering the bowl of vegetables fell into the floor. Employee #21 was observed to pick up the lid off the floor, place it back on the tray, and then started to deliver it. In an interview with Employee identifier #21, she acknowledged the lid had fallen off the tray and stated, I did do that and I need to get her (Resident #51) another tray. f) Wheelchairs and Geri-chairs for Residents #23, #62, #68, and #14 room [ROOM NUMBER]: During an interview with resident #62, on 03/16/26 at 11:45 AM, a wheelchair near the resident's bed had rips and holes in the plastic cover on the curve of the left armrest, exposing the inner padding. room [ROOM NUMBER]: During entrance interview and observations on 03/16/26 at approximately 12:45 PM, it was observed that resident #23's wheelchair had a two inch tear midway down the left side arm down to the edge. First floor hallway observation: On 03/17/26 at 2:30PM, during an observation in the first floor hallway near the nurses station, Residents #14 and # 51 were sitting and talking. Resident #14's Geri Chair had a 3 inch tear in the outside shoulder area and also it was observed Resident # 51's wheel chair had an attached plastic cushion on right leg with a broken open zipper exposing the inner padding. g) Staff Interview During a facility walk through and interview with the infection preventionist, on 03/17/26 at approximately 3:35 PM, she acknowledged the above-listed wheelchairs and Geri-chair with exposed padding and stated she would make a list and take care of the wheelchairs needing repaired or replaced.

Based on observation, record review, and staff interview, the facility failed to ensure residents were provided adaptive eating equipment as ordered by the physician. This deficient practice had the potential to affect one (1) of eight (8) residents reviewed for the care area of nutrition. Resident Identifier: #13. Facility Census: 78.Findings included: a) Resident #13Review of Resident #13's physician's orders revealed an order written on 01/23/26 for the resident to have a Kennedy cup with meals and at bedside. A Kennedy cup is a lightweight plastic cup with a handle and a lid to prevent spills. On 03/18/26 at 9:00 AM, Resident #13 was noted to have a plastic one-handled coffee cup on her overbed table. The cup did not have a lid. The cup appeared to have soda in it, as there was also a can of soda on her overbed table. On 03/18/2026 at 12:19 PM, Registered Nurse (RN) #69 was observed delivering Resident #13's lunch tray to the resident's room. The lunch tray did not have a Kennedy cup on it. The resident continued to have the coffee cup on her overbed table. The resident's meal tray ticket indicated the resident was to have a Kennedy cup with her meals. RN #69 confirmed Resident #13's tray ticket indicated the resident was to have a Kennedy cup. She obtained a Kennedy cup from the beverage cart in the hallway and provided it to the resident. The resident stated she would like some water, and RN #13 stated she would get that for the resident.

Based on policy review, resident interview, observation, and staff interview, the facility failed to identify a resident's statement as an allegation of verbal abuse and report it to the appropriate state agencies according to state law. This was true of one (1) of two (2) residents sampled for abuse throughout the Long-Term Care Survey Process. Resident identifier: #49. Census: 79.Findings included:a) Resident #49 Review of the facility policy titled [NAME] Virginia Abuse, Neglect, and Misappropriation revealed:-The policy defined mental abuse as the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. -Under Section V, Investigation of Incidents, the policy stated:An event may not be perceived by staff to constitute resident abuse neglect or misappropriation of resident property; however, if a resident, family member or visitor perceives an event to be abuse, neglect or misappropriation, the facility must report the event.In the event a situation is identified as abuse, neglect or misappropriation, an investigation by the executive leadership will immediately follow.The Director of Nursing (DON) and Executive Director (ED) receives reports of resident incidences.Additionally,the policy stated the following steps would be followed as appropriate:In the event the alleged perpetrator is a staff member that staff member will be removed from areas of resident living and interviewed by nurse on duty and asked to put their statement in writing, signed and dated.The staff member will be escorted off of the premises by another staff member. The accused staff member will be suspended by the ED pending the outcome of the investigation of the incident.According to the Office of Health Facilities Licensure and Certification (OHFLAC) reporting requirements, a facility must report an allegation of abuse to the Office of Health Facility and Licensure (OHFLAC) and Adult Protective Services (APS) within two (2) hours of the allegation being reported.On 03/17/26 at 9:38 AM, Resident #49 reported Nurse Aide #68 complains as she is providing care to Resident #49 and her roommate that she has had enough of this place and these people. Review of the Quarterly Minimum Data Set, with an assessment reference date of 03/03/26, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that she was cognitively intact. An interview with Executive Director (ED) began at approximately 10:30 AM in which the resident's allegations were made known to ED. The fact that the Nurse Aidefailed to refrain from making verbal comments made out of frustration which would be demeaning to residents who required extra assistance in carrying out their activities of daily of living was discussed and acknowledged by the ED. A follow up interview with ED, at 1:30 PM on 03/17/26, was conducted and the ED stated the Social Worker interviewed the resident who made the same statement as to the surveyor. ED stated they did not see that the resident experienced any psychosocial harm, the facility did not identify this as abuse, and therefore had not reported the incident. Nurse Aide #68 was observed still working on the Resident #49's unit by state surveyors at this time. The facility's abuse and neglect policy was reviewed with the ED, specifically addressing the mental abuse definition and the investigation section of the policy. At 1:55 PM, the ED let the State Surveyors know she had reported the incident and sent Nurse Aide #68 home pending the investigation.

Based on resident interview, record review, and staff interview, the facility failed to honor a resident's choice about the schedule that was important to them, such as when the resident preferred to have a shower. This was true a random opportunity for discovery. Resident identifier: #49. Census: 79.Findings included: a) Resident #49 During an entrance interview, on Monday, 03/16/26 at 10:49 AM, Resident #49 stated staff told her she couldn't get her shower because State was in the building. She further stated that her husband visited daily, arrived around 4:00 PM - 5:00 PM, and she has repeatedly asked staff not to offer her to shower during her time with him, but they continued to do so. In an interview with Resident #49 at 1:45 PM on 03/19/26, she was in good spirits and stated she was excited and waiting for staff to take her for her shower.A record review, completed on 03/16/26, found that staff had documented Resident #49 had refused her shower at 17:59 PM. Further record review, completed on 03/19/26 at 9:00 AM, found the following showers were also documented as refused:-02/23/26 at 4:31 PM-02/26/26 at 4:56 PM -03/05/26 at 5:25 PM-03/09/26 at 5:18 PM-03/12/26 at 4:39 PM All offered shower times were documented during or around the times the resident's husband would have been visiting.b) Director Of Nursing (DON) Interview: On 03/19/26 at 11:53 AM, the DON stated the times on the electronic task records were when staff documents the showers given or refused for that day not the actual time the shower was offered and/or refused. The DON also stated there isn't log book with written sign off sheets providing actual times the showers are offered/refused and she was not able to provide documentations of actual offered shower or refusal times. c) Staff Interview During an interview on 03/19/26 at 12:03 PM, Nurse Aide #4 stated he does not give Resident # 49 showers as she prefers a female aide assist her. The nurse aide went on to state it is well known that her husband visits daily and arrives between 4:00 PM - 5:00 PM. He also stated that Resident #49 has refused her showers during her husband's visits on her scheduled shower days. Nurse Aide #4 offered to check with the resident about her shower scheduled that day. On 3/19/26 at 12:10 PM, during an observed conversation between Nurse Aide #4 and Resident #49, she stated she would like to shower right after lunch today. d) Interview with Resident #49's Husband During a phone interview with Resident #49's husband, on 03/19/26 at 1:30 PM, he stated the staff does often offer showers when he is visiting and she will refuse her shower.

Based on policy review, resident interview, and staff interview, the facility failed to ensure staff documented verbal grievances from residents and share the information with the grievance officer in order to ensure prompt efforts to resolve a grievance. This was true for one (1) of three (3) residents sampled for missing personal property throughout the Long-Term Care Survey Process. Resident identifier: 77. Census: 79.Findings included:a) Resident #77 Review of the facility's policy titled Resident Grievance revealed the following details:-Under Procedure: Upon admission and periodically throughout their stay, the facility will inform all residents of their right to file a grievance orally, in writing, or anonymously, about the care provided to or the treatment of any resident residing at the facility.-Under Preventing Ongoing Violations: Upon receipt of an oral, written or anonymous grievance submitted by a resident or other individual involved in resident care, the Grievance Official will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated, if indicated. During an interview on 03/16/26 at approximately 2:00 PM, Resident #77 stated she was missing several pajama tops. In a second interview, on 03/17/26 at approximately 12:00 PM, Resident #77 states she told Nurse Aide #61 on Sunday, 03/15/26 about the missing items. During an interview on 03/18/26 at 12:30PM, Nurse Aide #61 confirmed she was told on Sunday, 03/15/26, that Resident #77 was missing pajama tops. The Social Worker, who is also the facility's grievance officer, was interviewed on 03/17/26 at approximately 1:00 PM. The Social Worker stated she did not know that anything was missing. During an interview on 03/19/26 at 9:45 AM, the Social Worker stated she did not receive any information regarding missing items until the state agency made her aware on 03/17/26. The grievance policy was shown to social worker who confirmed the grievance system was not working and that staff were not always documenting verbal reports of a grievance/concern.

Based on record review and staff interview, the facility failed to ensure all diagnoses were included on the Pre-admission Screening and Resident Review (PASARR) for Resident #10. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #10. Facility Census: 79. Findings Included: a) Resident #10 On 03/16/2026 at 3:59 PM, a review of the PASARR, dated 04/08/25, for Resident #10 was reviewed. The review found all diagnoses were not included on the PASARR. The following diagnoses were not included: --Moderate Intellectual Disabilities, added to the medical record on 04/08/25--Vascular Dementia, moderate with anxiety and psychotic disturbance, added to the medical record on 02/02/26 On 03/19/2026 at 10:21 AM, an interview was held with the Director of Social Services #70. The Director of Social Services #70 stated, I must have missed the diagnoses .I'll have to redo it.

Based on observation, record review, and staff interview, the facility failed to implement the care plan regarding an indwelling urinary catheter. This was true for one (1) of three (3) residents reviewed for the care area of urinary catheters. Resident Identifier: #29. Facility Census: 78. Findings included: a) Resident #29Resident #29's comprehensive care plan had a focus relating to an indwelling suprapubic catheter related to obstructive uropathy and overactive bladder. An intervention/task was Position catheter bag and tubing below the level of the bladder and provide privacy bag. Upon observation on 03/16/2026 at 3:00 PM, Resident #49's urine collection bag for his suprapubic catheter did not have a privacy cover. The urine collection bag was hanging from the bed frame away from the door and could only be visualized by people entering the room and walking around to the other side of the resident's bed.On 03/18/2026 at 9:27 AM, Resident #49's urine collection bag continued to not have a privacy cover. Although the urine collection bag continued to hang from the bed frame away from the door, the bag was visible from the hallway through the bed, which was slightly elevated. Light yellow urine was visualized in the urine collection bag. Unit Manager (UM) #34 confirmed Resident #49's urinary catheter urine collection bag did not have a privacy cover as instructed in the comprehensive care plan. UM #34 stated a privacy cover would be placed on the collection bag.

Based on observation, staff interviews, and record review, the facility failed to ensure the retained documentation to reflect Resident #57 was given the choice on a daily basis to wear splints on both hands to prevent further decrease in range of motion. This was true for one (1) of three (3) residents sampled for limited range of motion (ROM) throughout the Long-Term Care Survey Process. Resident identifier: #57. Census: 79.Findings included:a) Resident #57 During an initial interview on 03/16/2026 at 2:43 PM. Resident #57 was observed to have limited ROM in both hands with no orthotics (externally applied medical device used to support, align, prevent, or correct deformities, or to improve the function of movable parts of the body) in place. Resident #57 was observed again on 03/17/26 and 03/18/26 with no orthotics in place. An interview with Occupational Therapist (OT) #66, at 2:15 PM on 03/18/26, confirmed Dynaflex splints were in Resident #57's closet. OT #66 stated education had been provided to aides for donning splints, but she has rarely seen them on the resident and his ROM has gotten progressively worse. The Director of Nursing (DON) was interviewed at 3:30 PM. The DON stated refusals of splints and donning of splints are not being documented at this time. The DON stated it was on the resident's Kardex (a quick-reference system used to organize and update essential patient information for Nurse Aides) that the splints should be donned on a daily basis. She went on to state it was just on the honor system as to whether or not the resident was asked about his splints and that the nurse should be documenting refusals in the progress notes on days he refused to wear them. Upon reviewing the last three (3) days of progress notes, there was no documented refusals regarding splints. A review of the electronic medical record revealed the donning of splints had been documented on the Treatment Administration Record (TAR) in March 2025 before a new physician order switched the type of splint being used to the Dynaflex splint. When the Dynaflex splint was ordered, it was not put on the TAR and therefore no documentation of splint wearing or resident refusal had been done since March 2025 on the TAR.

Based on record review, observation, and staff interviews, the facility failed to ensure Resident #57 was offered sufficient fluid intake to maintain proper hydration. This was true for one (1) of two (2) residents sampled for hydration throughout the Long-Term Care Survey Process. Resident identifier: #57. Census: 79.Findings included:a) Resident #57 Review of the facility policy titled General Hydration Services revealed the following expectations:-Provide fresh water at bedside in the proper consistency and drinking device, if appropriate. Review of physician orders revealed Resident #57 had an order for honey thickened liquids in a Kennedy cup with meals and at bedside. Review of Resident #57's care plan revealed the resident was at risk for dehydration and directed staff to provide assistance with fluid intake as needed. On 03/16/2026 from approximately 1:00PM until approximately 4:00PM it was observed that Resident #57 had no fluids available in resident's room. On 03/17/26 at Resident #57 was observed to have no drinks in the room at 10:02 AM. At 10:18 AM, Resident #57 had a drink placed on his bedside table at the foot of his bed out of reach of the resident. This was confirmed by Nurse Aide #44 at 12:10 PM. At 3:31 PM, Resident #57 was observed again in his room with no drink and witnessed by another state surveyor. An interview with Director of Nursing (DON), at 3:30 PM on 03/18/26, confirmed resident should have water available at his bedside for aides to assist resident with hydration.

Based on observation, record review, and staff interviews, the facility failed to ensure Resident #1 received oxygen therapy as ordered by physician. This was true for one (1) of one (1) residents sampled for respiratory care throughout the Long-Term Care Survey Process. Resident identifier: #1. Census: 79.Findings included:During an initial interview, on 03/16/26 at 1:15PM, it was observed by two (2) surveyors that Resident #1's oxygen concentrator was set on 5L/min (5 liters per minute). A review of Resident #1's physician orders reveal the following order: O2 [Oxygen] at 2L via NC [Nasal Cannula] continuous as needed. During a second observation, on 03/17/26 at 10:14 AM, Resident #1's oxygen was set at 5L/min. During a third observation, on 03/17/26 at 12:20 PM, Nurse Aide #68 confirmed the oxygen was set at 5L/min. Registered Nurse (RN) #22 was alerted that Resident #1's oxygen was set at 5L/min. RN #22 confirmed the physician order was for oxygen at 2L/min and that Resident #1 was set at 5L/min at 12:30 PM on 03/17/26.

Based on observation, record review and staff interview, the facility failed to update the daily staff postings at the beginning of the shifts regarding changes in staffing numbers. This was true for nine (9) of nine (9) daily staff postings reviewed under the care area of staffing throughout the Long-Term Care Survey Process. Facility Census: 79.Findings Included: a) Daily Staff Postings On 03/17/2026 at 11:00 AM, a review of nine (9) daily staff postings was completed. The review found all nine (9) daily staff postings had not been updated at the beginning of the shift to indicate changes in staffing. The dates were as follows: --02/15/25-a decrease in nurse aides from seven (7) to six (6) on the 6:00 PM-6:00 AM shift.--11/29/25-a decrease in licensed practical nurses from four (4) to three (3) on the 6:00 PM-6:00 AM shift.--11/29/25-a decrease in licensed practical nurses from three (3) to two (2) on the 7:00 PM-7:30 AM shift.--12/26/25-a decrease in licensed practical nurses from four (4) to three (3) on the 7:00 PM-7:30 AM shift.--12/26/25-a decrease in registered nurses from one (1) to zero (0) on the 7:00 AM-3:30 PM shift.--12/26/25-a decrease in registered nurses from one (1) to zero (0) on the 8:30 AM-5:00 PM shift.--01/02/26-a decrease in registered nurses from one (1) to zero (0) on the 5:00 AM-1:00 PM shift.--01/02/26-a decrease in registered nurses from one (1) to zero (0) on the 7:00 AM-3:30 PM shift.--01/02/26-a decrease in registered nurses from one (1) to zero (0) on the 8:30 AM-5:00 PM shift. An interview was held with the Nursing Staff Scheduler #33 on 03/17/26 at 1:15 PM. The Nursing Staff Scheduler #33 was asked, Why are the staffing numbers not changed at the beginning of shift? The Nursing Staff Scheduler stated, Sometimes I don't know about call-ins until 2 or 3 days later .the staffing numbers are not changed at the beginning of each shift. On 03/17/26 at 2:30 PM, an interview was held with the Administrator. The Administrator stated, She should be aware of the call-ins.

Based on observation and staff interview, the facility failed to ensure trash and debris were stored in a safe and sanitary manner to prevent harborage of pests. The facility failed to keep the dumpster closed when not in use. This failed practice had the potential to affect more than a limited number of residents. Facility census: 78. Findings included: a) On 09/09/24 at 12:43PM observation revealed the facility dumpster lid was open while not in use and no staff present. b) On 09/09/24 at 12:46PM during an interview, the Administrator acknowledged the dumpster lid was open on facility dumpster and that it should be closed. She had dumpster door closed after interview. c) 09/09/24 at 3:55 PM, during an interview the Culinary Director reported there was no policy or procedure on waste disposal regarding the dumpster or otherwise.

Based on observation, record review and staff interview the facility failed to ensure food was stored and served under sanitary conditons and that food temperatures were logged for three (3) meals. There were items not labeled, opened and expired. Census 78. Findings included: a) Initial Tour of Kitchen-Freezer -On [DATE] at 11:15 AM a bag of breakfast sandwiches were observed in the walk-in freezer having no label and no date. -On [DATE] at 11:15 AM interview with Culinary Director #3 (three), revealed that this was food served at that mornings breakfast and someone failed to label it. b) Initial Tour of Kitchen-Walk in Cooler -On [DATE] at 11:30 AM observed a large container of unknown beverage not labeled or dated. -On [DATE] at 11:30 AM an interview with [NAME] #17 who stated the liquid in the large container was tea, and acknowledged it was not labeled or dated and disposed of it. c) Initial Tour of Kitchen- Dry Storage -On [DATE] at 11:35 AM it was observed that 4 bags of grits with best by date of [DATE] and marked [DATE] were in the dry storage. -On [DATE] at 11:35 AM Culinary Director #3 (three) reported to be honest, these are no longer on the menu, they have just been overlooked and I will throw them out now. d) Tour of Floor Pantry -On [DATE] at 3:00 PM, an open packet of coffee exposed to the air was found in the shelf with no dates. -On [DATE] at approximately 4:00 PM, during an interview, the Administrator acknowledged the coffee had since been disposed of and normally the entire bag would be used at time of opening or remainder disposed of. e) On [DATE] at 11:15 AM review of Service Line Checklist temperature logs in kitchen revealed that cooking temperatures and holding temperatures were not recorded for the following days between [DATE] to [DATE] -[DATE] Dinner meal Chicken salad and peaches. -[DATE] BBQ Chicken, Macaroni and cheese, fruit and pea salad. -[DATE] Pork, Potatoes, and Lima Beans On [DATE] at 11:30 AM interview with Culinary Director #3 (three) who acknowledged the temperatures had been taken but failed to be recorded. He stated the person was new and he, himself should have ensured it was completed. On [DATE] a review of facility policy form titled Healthcare Services Group Policy 016 revealed under Food Preparation included the following: -Procedure #9 (nine) the cook will prepare all cooked food items in a fashion that permits rapid heating to appropriate minimum internal temperature. -Procedures #14 temperature for Time/Temperature Control for Safety (TCS) will be recorded at time of service and monitored periodically during meal and service periods. f) Staff handling of used cups. During a dining room observation in the second floor dining area on [DATE] at 12:00 PM a staff member was observed to assist a resident who had requested a refill of their thickened drink. The staff member was observed to take the adaptive equipment cup in her left hand and the staff member then asked another resident if they needed another thickened drink in their adaptive equipment cup. The staff member then placed both used adaptive cups together in her bare left hand. The staff member took the adaptive cups into the nutritional room adjacent to the dining room. When exiting the nutritional room with the refilled adaptive cups, Activities Leader (AL) #79 stated she had prepared the refill for both thickened drinks and acknowledged that she had held them together in her bare left hand into the nutritional room and prepared the refill of the thickened drinks. AL #79 stated she should have taken one cup at a time to refill and that she was returning both adaptive cups to the nutritional room to obtain clean adaptive cups for the requested refill of thickened drinks.

Based on record review and staff interview the facility failed to implement Resident #77's care plan. For Resident #77, the facility failed to implement the care plan to educate on end-of-life decisions. This was true for one (1) of two (2) residents reviewed for the Long-Term Care Survey Process. Resident identifier: #77. Facility census: 78. Findings include: a) Resident #77 On [DATE] at 11:37 AM, a review of Resident #77's medical record was conducted revealing that on [DATE], Resident #77 had been seen by the facility Nurse Practitioner (NP) after an acute hospitalization for urinary tract infection, pneumonia and chronic obstructive pulmonary disease. At that time, the facility Nurse Practitioner documented, Unable to perform complete chart review due to no hospital documentation available at this time. Code status was discussed with facility leadership and resident made decision to change Physician's Order for Scope of Treatment (POST) form to DNR-CC (Do Not Resuscitate-Comfort Care), no labs, no weights and do not send to hospital. In addition, a review of Resident #77's POST form revealed No CPR, comfort focused treatments, no artificial means of nutrition, no labs, no weights, do not transfer to hospital an no appointments. At this time, Resident #77's care plan was also reviewed revealing the following care plan: Focus: Resident has a DNR code status with comfort care. Goal: Resident's code status will be honored through review date. Interventions: Code status will be established at time of admission/readmission. To be reviewed quarterly and as needed (PRN). Obtain copies of advanced directives from resident/resident representative to have on file. Obtain medical provider order for code status. Obtain the state specific form regarding code status (state specific DNR forms). Provide resident/resident representative with education as needed regarding end-of-life decisions. On [DATE] at 12:40 PM, a review of the Policy and Procedure entitled, Advanced Directive (Resident's Right to Choose) revealed that should the resident refuse treatment of any kind, the facility will document what the resident refused, the reason for the refusal, the education provided to the resident about the consequences of refusing, offering of alternative treatments and the continuing of all other services provided in the resident's medical record. On [DATE] at 09:23 AM, an interview was conducted with the facility NP. At this time the NP stated that when educating resident's and/or resident representative's related to end-of-life decisions, I focus on the heart stopping and what they would want done. When asked if the resident or resident representative was educated on the risks verses benefits of discontinuing care such as weights, labs and sending to the hospital for an acute event, the NP responded, I document what I review with the resident and/or resident representative and their preference on what care to continue. If I see something on my end, that the resident is not doing well and they have all these co-morbidities, and the likelihood of surviving a cardiac arrest is poor, that's when I discuss what to do if the heart stops. On [DATE] at 01:53 PM, an interview was conducted with the facility Director of Nursing (DON), Administrator and Regional Director of Clinical Operations (RDCO). The Administrator acknowledged that the facility was unable to provide documentation related to the education provided to Resident #77 regarding end-of-life decisions.

Based on medical record review and staff interview the facility failed to ensure the Minimum Data Set (MDS) record was completed correctly for a resident's discharge. This was true for one (1) of 24 residents whose MDS records were reviewed during the long-term care survey process. Resident Identifier: #78. Facility Census: 78. a) Resident # 78 During a medical record review on 09/05/24 at approximately 9:00 AM the MDS dated [DATE] was reviewed and identified the following; * Section (A) A 0310- (f) that the discharge assessment anticipated the resident to return. * Section (A) A 2105 the resident is discharged to home/community. * Section (A) A 2123 was not completed to identify if the provision of the current reconciled medication list for the resident at discharge was provided at time of discharge. A review of the notes by Social Services Designee (SSD) #90 dated 09/17/24 at 9:03 AM revealed the resident admission paperwork was unable to be completed by the Social Services Designee (SSD) #90 because the resident had discharged against medical advice (AMA) shortly after arriving to the facility and that the discharge planning had not been completed. SSD #90 noted the resident discharged was unplanned/AMA on 06/15/24. An additional note was entered on 06/17/24 at 8:55 AM that an Adult Protective Services (APS) referral was completed due to the discharge being AMA. During an interview on 09/05/24 at approximately 12:50 PM the Director of Nursing and the Administrator agreed the MDS was not coded correctly and that the discharge was AMA.

Based on resident interview, and staff interview the facility failed to promptly investigate an alleged violation of verbal abuse and mistreatment and failed to prevent further potential neglect and mistreatment while the investigation is in progress. This had the potential to affect all residents at the facility. Resident identifier: #9. Facility census 76. The facility was first notified of the Immediate Jeopardy (IJ) on 09/27/23 at 4:33 PM. The State Agency (SA) received the Plan of Correction (POC) at 5:56 PM on 09/27/23. The SA accepted this POC at 5:59 PM on 09/27/23. The following is the facility's POC typed as written: Abatement Plan F610. On 09/28/23 the Nursing Home Administrator and the Director of Nursing implemented the following plan: Plan of correction accepted on 09/27/23 at 5:59 PM 1. (named Nurse Aide (NA) #80 by name) was immediately removed from the floor upon notification at 2:30 PM on 9/27/23 and suspended pending investigation. This incident was immediately reported on 9/27/23 at 3:00 PM to OHFLAC, APS, Ombudsman and Nurse Aide Registry by the Social Worker. 2. All alert residents were interviewed by DON on 9/27/23 to identify other concerns and no other issues were identified. 3. Social Worker was immediately re-educated on reporting allegations of abuse, including perceived threats of involuntary seclusion immediately to OHFLAC, Nurse Aide Registry, APS, and Ombudsman or other licensing board as warranted. All staff in the facility at this time were also re-educated on immediate reporting of abuse allegations and the definition of abuse and involuntary seclusion and staff on upcoming shifts will be educated upon arrival to facility. 4. Administrator/designee will round with all residents five times per week for two weeks and once per month for three months to identify residents with concerns of abuse and any allegations will be reported immediately to OHFLAC, Ombudsman, APS, Nurse Aide registry and other licensing board as warranted. All allegations of abuse and neglect will be reviewed at the facilities QAPI meeting each month. The SA observed for implementation of the POC and the IJ was abated on 09/28/23 at 11:00 AM. Resident identifier: #9. Facility census 77. Findings included: a) Resident #9 On 09/27/23 at 1:10 PM Resident #9 asked if the people here at the facility were allowed to threaten to closed her door if she does not do as she is told. She went on to say she is very claustrophobic and does not like her door closed and the staff know that. Resident #9 said she reported this two (2) days ago to the Social Worker (SW) #95. The resident identified nurse aide (NA) #80 as the person who threatened to close her door. During an interview on 09/27/23 at 2:15 PM, the Social Worker #95 was asked if Resident #9 had talked to her about Nurse Aide (NA) #80 closing her door? SW #95 said yes, she did, however, I have not had time to get NA #80's side of the story yet. SW #95 was asked what if anything has, she done about this allegation? SW #95 said nothing yet. On 09/27/23 at 2:25 PM, the Administrator was informed about the above information. When the survey team entered the facility at approximately 1:00 PM on 09/27/23, NA #80 was working. The event that was reported by the Resident 2 days ago had never been addressed or investigated. Due to the urgency of the situation the surveyor immediately alerted the administrator, and the employee was suspended after surveyor intervention. The SW never told anyone about the resident's report. No investigation was started, and no action was taken to protect the residents. During a brief telephone interview with SW #95 on 09/28/23 at 2:12 PM. SW said she spoke to Resident #9 sometime on Monday mid-morning between 10 AM and noon. On 09/28/23 upon entering the facility at 8:00 AM, this surveyor began interviewing staff about when and how to report an allegation of abuse: On 09/28/23 at 8:01 AM Licensed Practical Nurse (LPN)#89 was asked what she would do if a resident reported an allegation of abuse. LPN #89 said she would report it to the Social Worker (SW), Administrator, and the director of nursing (DON). On 09/28/23 at 8:02 AM Registered Nurse (RN)#26 was asked what he would do if a resident reported an allegation of abuse. RN #26 said she would report it to the Social Worker (SW), Administrator, and the director of nursing (DON). On 09/28/23 at 8:08 AM Nurse Aide (NA)#93 was asked what she would do if a resident reported an allegation of abuse. NA #93 said she would report it to the Social Worker (SW), Administrator, and the director of nursing (DON). On 09/28/23 at 8:12 AM NA #93 was asked what she would do if a resident reported an allegation of abuse. NA #93 said she would report it to the Social Worker (SW), Administrator, and the director of nursing (DON). On 09/28/23 at 8:13 AM Nurse Aide NA #47 was asked what she would do if a resident reported an allegation of abuse. NA #47 said she would report it to the Social Worker (SW), Administrator, and the director of nursing (DON). On 09/28/23 at 8:15 AM Licensed Practical Nurse (LPN)# 71 was asked what she would do if a resident reported an allegation of abuse. LPN #71 said she would report it to the Social Worker (SW), Administrator, and the director of nursing (DON). On 09/28/23 at 8:17 AM Activities Director (AD) #68 was asked what she would do if a resident reported an allegation of abuse. AD #68 said she would report it to the Social Worker (SW), Administrator, and the director of nursing (DON). On 09/28/23 at 8:01 AM Assistant Activities (AA) #36 was asked what she would do if a resident reported an allegation of abuse. AA #36 said she would report it to the Social Worker (SW), Administrator, and the director of nursing (DON). On 09/28/23 at 8:18 AM NA# 52 was asked what she would do if a resident reported an allegation of abuse. NA #52 said she would report it to the Social Worker (SW), Administrator, and the director of nursing (DON). On 09/28/23 at 8:19 AM Infection Preventionist (IP) #106 was asked what she would do if a resident reported an allegation of abuse. IP #106 said she would report it to the Social Worker (SW), Administrator, and the director of nursing (DON). On 09/28/23 at 8:21 AM Housekeeper (HK)#96 was asked what she would do if a resident reported an allegation of abuse. HK #96 said she would report it to the Social Worker (SW), Administrator, and the director of nursing (DON). On 09/28/23 at 8:23 AM Therapy Manager (TM) #111 was asked what she would do if a resident reported an allegation of abuse. MT #111 said she would report it to the Social Worker (SW), Administrator, and the director of nursing (DON). On 09/28/23 at 12:23 PM, the Administrator provided 70 re-education signed papers from staff that have worked since the beginning of the IJ, to current.

Based on medical record review, observations and staff interview, the facility failed to provide care and services to in accordance with the comprehensive assessments and plan of care for one (1) of three (3) reviewed for pressure ulcers and one (1) of five (5) reviewed for unnecessary medication. The facility failed to follow the physician's orders [REDACTED]. This failed practice resulted in actual harm for Resident #20. For Resident #93, the facility failed to administer a pain medication ([MEDICATION NAME]) as directed by the physician's orders [REDACTED].>Resident identifiers: #20 and #93. Facility Census: 75. Findings include: a) Resident #20 Observation of Surgeon #117's examination and wound care by Licensed Practical Nurse (LPN) #67 on 12/13/16 at 3:35 p.m., found the resident lying on her right side. When the surgeon palpated the wound and surrounding area on the resident's right upper buttocks, Resident #20 began to attempt to pull away from him and repeatedly said, OH, OH (First name of Resident's daughter) don't do that, OH, OH. LPN #67 completed the wound care at that time and during the packing of the wound with a wet gauze, Resident #20 again started attempting to pull away from the LPN and said, OH, don't do that that's home, no, no. Review of physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. During an interview on 12/13/16 at 3:50 p.m. concerning the resident's resistance and expression of pain and discomfort LPN #67 said, Yes, she does resist and expresses discomfort during wound assessments and treatments. This is normal for her. That is why we pre-medicate her for pain thirty (30) minutes prior to the treatment. She further explained the resident had been medicated at 1:30 p.m. due to the doctor had called and said he would be there in thirty (30) minutes, but had run late. During an interview on 12/14/16 at 9:45 a.m., Nurse Aide (NA) #38 confirmed she was present for the assessment and wound care for Resident #20 on 12/13/16. When asked if the resident resisted or expressed discomfort/pain during treatments/care, she replied, Yes she always try to pull away and yells out when they are touching and or cleaning/dressing the wound. It is not as bad as it was when she had the [DEVICE]. Further review of Resident #20's MAR, treatment administration record (TAR), and the individual control substance record for 07/18/16 through 12/13/16, found the [MEDICATION NAME] was not administered twenty- three (23) of thirty-five (35) times prior to the dressing change. Review of physician's orders [REDACTED]. On 09/17/16 the order for the dressing was changed to twice weekly on Tuesday and Friday. On 10/10/16 the order for the dressing was changed to twice weekly on Monday and Friday. On 12/01/16 the treatment for [REDACTED]. [MEDICATION NAME] was not administered to Resident #20 on the following occasions prior to dressing changes: 07/26/16, 08/16/16, 08/30/16, 09/20/16, 09/23/16, 09/27/16, 09/30/16, 10/14/16, 10/17/16, 10/21/16, 10/24/16, 10/28/16, 11/04/16, 11/07/16, 11/11/16, 11/14/16, 11/18/16, 11/21/16, 11/28/16, 12/02/16, 12/05/16, 12/09/16 and 12/12/16. An interview with the director of nursing (DON), at 1:30 p.m. on 12/13/16, confirmed Resident #20 was to receive [MEDICATION NAME] thirty (30) minutes prior to her dressing changes. She reviewed the MARs and confirmed the medication was not given on the twenty-three (23) dates which were days her dressings were scheduled to be changed. b) Resident #93 A review of Resident #93's medical record beginning at 7:46 a.m. on 12/08/16, found an order dated 11/20/16 for [MEDICATION NAME] 5/325 milligrams (mg) every 4 hours for pain. Review of the Medication Administration Record [REDACTED]#3 documented the medication was not administered because the drug was not available. In interviews with the Director of Nursing (DON) on 12/08/16 at 1:50 p.m. and again at 3:30 p.m. she confirmed Resident #93 missed three (3) doses of her scheduled pain medication on 12/06/16. She indicated the problem was the pharmacy was waiting to get a new prescription from the attending physician and they had not sent the medication to the facility. When asked if the narcotic emergency box contained [MEDICATION NAME] 5/325 mg, she stated that it did and provided the list of medications contained in the Emergency box. This list indicated the box contained 5 tablets of [MEDICATION NAME] 5/325 mg. The DON stated the nurse should have gotten the medication from the Emergency Narcotic Box and administered it to Resident #93.

Based on record review, observation, and staff interview, the facility failed to provide care and services in accordance with the written care plan for one (1) of three (3) residents reviewed for accidents. The resident's care plan for assistance of two (2) persons was not followed, resulting in actual harm to the resident. The resident experienced an avoidable fall resulting in a right shoulder fracture and a fractured pelvis. In addition, the care plan for oral health care was not implemented for Resident #5. Resident identifier #5. Facility census 72. Findings include; a) Resident #5 1. Review of the electronic record, in the afternoon of 09/16/15, revealed Resident #5 had medical [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS) assessment, with an assessment reference date of 05/21/15, indicated the resident required extensive assistance of two (2) staff members for bed mobility and toileting. The activity of daily living (ADL) care plan, with a problem start date of 11/22/13, stated Resident #5 required extensive to total assistance with all ADLs except eating. The approach, dated 02/03/15, noted Resident #5 required extensive assistance of two (2) staff members for toileting. On 09/16/15, review of a nursing progress note, dated 06/04/15, revealed at 1:40 p.m., a nurse was called to Resident #5's room by the nursing assistants (NAs). Upon entering the room, Resident #5 was found lying on the floor on her right side. A nursing evaluation revealed abnormal alignment of the right shoulder, and the resident was complaining of increased pain to the area. The resident was transported to the hospital for emergent treatment. On 06/04/15 at 4:18 p.m., the hospital was called and revealed Resident #5 had a right shoulder fracture and a fractured pelvis. The fall investigation documents were reviewed in the afternoon of 09/16/15. The documentation of the incident, dated 06/04/15 by NA #52 revealed while drying the resident, he found bowel movement (BM) all the way up her back. All of the wipes had been used. NA #33 came in the room and NA #52 requested her to get more wipes. When NA #33 returned to the room, the resident was already on the floor. A telephone interview regarding the fall was conducted with NA #52 on 09/17/15 at 2:57 p.m. NA #52 confirmed he was the only NA providing care at the time of the fall on 06/04/15. He said he started incontinence care without any other staff member present. NA #52 stated he read the resident profile on the electronic charting system and knew the toileting needs of Resident #5. 2. Review of the electronic medical record, on 09/17/15, revealed Resident #5 had medical [DIAGNOSES REDACTED]. The most recent annual MDS, with an ARD of 05/21/15 indicated Resident #5 had obvious or likely cavities or broken natural teeth. The ADL care plan noted Resident #5 had some teeth with cavities. An intervention, dated 11/22/13, was to use saline mouth wash after meals and at bedtime to help remove debris. On 09/16/15 at 11:30 a.m., an observation of the resident in the dining room revealed she had visible missing teeth, and the teeth present were yellow with darkened spots. On 09/16/15 at 4:02 p.m., Resident #5 was observed seated in a geri/Broda chair. She smiled when spoken to, and her teeth were yellow with darkened spots. An interview was conducted with NA #59 on 09/17/15 at 5:50 a.m. She stated she used pink swabs to cleanse the mouth of Resident #5. She stated she had already provided mouth care. At 10:38 a.m., an interview was conducted with NA #49. She stated she used mouth swabs at night. Upon inquiry, the NA stated she did not use saline mouth wash for the resident. She stated the resident care needs were documented under the Resident Profile in the electronic charting system. On 09/17/15 at 2:25 p.m., NA #49 was interviewed regarding the use of saline mouth wash for the resident after lunch. She stated she did not do a saline mouth wash after lunch, that she only brushed the resident's teeth. The ADL care plan referencing the saline mouth wash was shared with NA #49. She stated saline was a medication, and nursing should be doing the saline mouth wash after meals. LPN #22 was present at the time of the interview with NA #49. She stated the saline wash should be on the nursing sheet. Review of the nursing sheet and Medication Administration Record [REDACTED]. LPN #22 called MDS Nurse #7 regarding the saline mouth wash. MDS Nurse #7 stated since the saline wash was on the care plan, and the discipline was the NA, the NAs should be providing the care. On 09/17/15 at 5:15 p.m., an interview was conducted with the Director of Nursing (DON). She stated nurses should be doing the saline mouth wash. Upon review of the care plan, the DON verified the care plan had NAs as responsible for doing the saline mouth rinse. The DON said the nurses, not the NAs, should have been providing the saline wash mouth care.

Based on record review, observation, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for accidents was provided the identified required supervision to prevent an avoidable accident. The resident required the assistance of two (2) persons for bed mobility and toileting. This level of assistance was not provided, resulting in actual harm to the resident. The resident experienced an avoidable fall resulting in a right shoulder fracture and a fractured pelvis. Resident identifier #5. Facility census: 72 Findings include: a) Resident #5 On 09/16/15, at approximately 2:35 p.m., record review revealed Resident #5 had medical [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/15, indicated the resident required extensive assistance of two (2) plus staff members for bed mobility and toileting. Toileting is defined as the manner a resident changes him/herself after elimination or changing a pad. The activity of daily living (ADL) care plan, with a problem start date of 11/22/13, noted Resident #5 required extensive to total assistance with all ADLs except eating. The approach, dated 02/03/15, noted Resident #5 required extensive assistance of two (2) staff members for toileting. A review of the nursing progress notes, on 09/16/15, revealed a progress note dated 06/04/15 at 1:40 p.m. The note stated a nurse was called to Resident #5's room by nursing assistants (NAs). Upon entering the room, Resident #5 was found lying on the floor on her right side. The note indicated NA #52 stated the resident was incontinent of stool, so she was turned over onto her left side so she could be cleaned. The NA stated he turned around to get some wipes and Resident #5 slipped out of the bed and landed on her right side. The nursing evaluation revealed abnormal alignment of the right shoulder, and the resident complained of increased pain to the area. The note further indicated at 2:00 p.m. on 06/04/15, the hospital emergency room (ER) was called, made aware of transport of the resident, and was given a report on the resident. Emergency Services were called and made aware of the need to transport Resident #5 to the ER. On 06/04/15 at 4:18 p.m., the hospital was called. Hospital personnel informed the nursing home that Resident #5 had a right shoulder fracture and a fractured pelvis. The documentation, dated 06/04/15 at 4:56 p.m., noted staff received a call from the hospital indicating Resident #5 would return to the facility with a [DIAGNOSES REDACTED]. During an observation of incontinence care, on 09/17/15 at 8:46 a.m., Resident #5 was totally dependent upon two (2) NAs for turning and repositioning, as well as incontinence care. The right hand was contracted and there was no use of the right arm. The fall investigation documents were reviewed on the morning of 09/17/15. The documentation of the 06/04/15 incident by NA #52 revealed while drying the resident, he found bowel movement (BM) all the way up her back. All of the wipes had been used. NA #52 said NA #33 came in the room, and NA #52 requested her to get more wipes. NA #52 looked around to find something. The resident reached for the curtain and when he looked back, the resident was rolling off the bed. Review of the incident documentation, dated 06/04/15, from NA #33 revealed at 1:40 p.m., NA #52 asked her to get a box of wipes for him to use for the resident. When she (NA #33) returned to the room, the resident was already on the floor. NA #33 further documented that NA #52 stated Resident #5 was rolling down the bed when he was cleaning her. A telephone interview regarding the fall was conducted with NA #52 on 09/17/15 at 2:57 p.m NA #52 stated he was turning Resident #5 over and drying her. He looked around and the resident grabbed something. Resident #5 was on her left side at the time of fall. NA #52 confirmed NA #33 was not in room at the time he started incontinence care, or at the time of the fall. NA #52 said NA #33 came into the room and he (NA #52) requested she get more wipes. NA #52 stated he reviewed the resident profile in the electronic charting system to know the care needs of each resident The electronic resident profile was observed, on 09/17/15 in the afternoon. It revealed Resident #52 was a two (2) person assist for toileting. This was consistent with the MDS and the care plan. An interview regarding the fall was conducted, on 09/17/15 at 3:55 p.m., with NA #33 in the presence of the Administrator and Social Worker #63. NA #33 stated she went with NA #52 to assist with incontinence care because Resident #5 was a two (2) person assist. NA #33 said while cleaning the resident, Resident #5 had a blow out. NA #33 said she left the room to get wipes, and the resident was on her side facing the wall when she returned. She said NA #52 was alone in the room and Resident #5 was on the floor. The interview with NA #33 on 09/17/15 at 3:55 p.m., regarding who was in the room providing incontinence care for Resident #5, did not completely correlate with the information obtained during the telephone interview with NA #52 on 09/17/15 at 2:57 p.m. During the interview with NA #52, he stated NA #33 was not in the room at the time he started incontinence care. On 09/17/15 at 4:30 p.m., the most recent quarterly MDS, with an ARD of 08/15/15, was reviewed for changes in functional ability since the fall on 06/04/15. The functional status, including bed mobility and toileting, remained unchanged. There were no documented changes in functional ability, nor was there a significant change assessment completed since the fall.

Based on observation and staff interview, the facility failed to implement an infection control program to prevent, recognize, and control, to the extent possible, the onset and spread of infections within the facility. The facility failed to ensure infection control procedures were in accordance with the Centers for Disease and Control and Prevention (CDC) guidelines. Isolation rooms were not effectively cleaned and sanitized and staff did not effectively use personal protective equipment (PPE). Wound care for Resident #88 was not performed by methods which eliminated the potential for cross contamination. The chairs used for Residents #69, #42, #92, #46, and #50 had areas which could not be effectively sanitized. These deficits were determined an Immediate Jeopardy (IJ) to the health and well-being of all facility residents. The IJ was first called at 4:50 p.m. on 06/16/14. The facility had continued non-compliance with infection control practices until 06/25/14 at 5:48 p.m. At that time the facility was informed the IJ was abated. The scope and severity was reduced from a scope and severity of an "L" to an "F." The practices affected Residents #88, #69, #42, #92, #46, and #50, but had the potential to affect all residents. Facility census: 77. Findings include: a) On 06/16/14 at 12:45 p.m. observations were conducted on the long hall on second floor. A housekeeping staff member (Employee #87) entered room [ROOM NUMBER], an isolation room. At 12:50 p.m. on 06/16/14, the housekeeper exited room [ROOM NUMBER] wearing booties over her shoes. The booties were a part of the isolation personal protective equipment (PPE) required for room [ROOM NUMBER]. As she left the room, Employee #87 swept the debris (dust and debris, such as a napkin and paper products) with a dust mop, from the floor of room [ROOM NUMBER] down the middle of the hallway. She passed by six (6) resident rooms while pushing the dust mop and debris. The housekeeper went into a closet which was located between rooms [ROOM NUMBERS]. She came out without the dust mop and debris, but was still wearing the booties. On 06/16/14 at 12:54 p.m., the housekeeper was asked if the resident in room [ROOM NUMBER] was in isolation. She replied, "Yes." When asked what type of PPE was needed when she cleaned the isolation room, she stated she wore gloves and booties when cleaning the room. When asked why she was still wearing the booties, she said she should have removed her booties but she forgot. Employee #87 then walked from the closet, past the six (6) rooms again, to room [ROOM NUMBER] still wearing the booties. She removed the booties with an un-gloved hand, placed them in a trash can in room [ROOM NUMBER], and exited the room without sanitizing her hands. Employee #9, a licensed practical nurse (LPN), on the resident's unit (Second floor long hall) was interviewed at 12:57 p.m. on 06/16/14. She was asked what PPE should be worn when entering room [ROOM NUMBER]. She stated all staff should wear gowns, gloves, and booties when entering the room. She added the PPE should be discarded before leaving the room and placed in the red trash can in the room. Employee #9 verified the housekeeper should have removed the booties and should not have pushed the debris from room [ROOM NUMBER] down the hallway. At 3:55 p.m. on 06/16/14, Employee #19, a LPN, on unit two (2) long hall verified a resident in room [ROOM NUMBER] was positive for Clostridium difficile (c-diff). The nurse located the last culture, obtained on 05/21/14, which verified the resident was positive for[DIAGNOSES REDACTED]. The nurse also stated any staff member entering the resident's room should wear gloves, gown, and booties. Employee #83,the housekeeping supervisor (HKS) was interviewed at 4:35 p.m. on 06/16/14. When asked to describe the procedures used by her staff to clean an isolation room, she stated PPE including gloves, gowns, booties, and possibly a mask, should be worn. When the situation involving Employee #87 was described, Employee #83 stated the housekeeper should have removed the booties and left them in the room. She said the dust mop head should have been placed in a bag, tied, and removed from the resident's room. Employee #83 also confirmed the housekeeper should have washed her hands and should not have pushed the debris from any room down the hall. An immediate jeopardy (IJ) was called at 4:50 p.m. on 06/16/14. Employee #83, Employee #5, the infection control nurse, and the administrator were present to hear the discussion regarding breaches in infection control which resulted in the IJ. At 5:45 p.m. on 06/16/14, the facility provided an action plan for abatement of the IJ. The infection control nurse had already begun providing inservice to all staff regarding effective infection control regarding residents requiring isolation and the rooms in which they resided. Housekeeping personnel was the first group provided in-servicing. An area was set up in the facility's main lobby, and every employee had to give a return demonstration as part of the in-service. The in-services were going to be provided on each shift, before staff members went to work on that shift. Any employee who was scheduled off was going to be provided the in-service before they began work on their first day back. Observations were made of the information provided and the return demonstrations. On 06/16/14 at 7:45 p.m., the IJ was abated when the action plan was observed being implemented. b) The following day, at 2:34 p.m. on 06/17/14, Employee #92, a housekeeper, was observed mopping the floor in room [ROOM NUMBER], another isolation room. The resident in this room had a methicillin resistant Staphylococcus aureus (MRSA) infection. When asked what cleaning solution he was using to clean the floor, he stated he had put some bleach in his mop water. When asked how he cleaned room [ROOM NUMBER], the isolation room for a resident with confirmed[DIAGNOSES REDACTED]., he stated he also used bleach in his mop water to clean room [ROOM NUMBER]. He said he knew there was a formula, but he did not have a measuring device so he had to guess at the amount of bleach he added to the water. He said he "just put bleach in the water." At 2:45 p.m. on 06/17/14, the HKS was interviewed along with Employee #92, regarding how to prepare the bleach solution to clean a room where a resident had[DIAGNOSES REDACTED]. The HKS noted the directions on the housecleaning cart, which contained instructions on how to prepare the bleach solution for cleaning the isolation rooms. The administrator joined the interview and was made aware of the current situation. The directions, provided by the HKS, instructed staff to, "Mix 1 ? gallons and 1 cup water to ? cup of Clorox." She stated this was the solution used to clean all isolation rooms. The HKS verified this was the solution used to clean room [ROOM NUMBER], which housed a resident with[DIAGNOSES REDACTED]. She confirmed there was no measuring equipment, on second floor, to mix the solution. According to CDC, a 10:1 (ten parts water to 1 part bleach), solution is required to eradicate Clostridium difficile (c-diff) spores. The directions provided to staff by the facility, to mix the bleach solution, was a 50:1 (50 parts water to one (1) part bleach). A 50:1 mixture would not be of sufficient strength to ensure disinfection. At 3:30 p.m. on 06/17/14, the administrator, the housekeeping supervisor, and the infection control nurse, were informed the IJ was continued due to continuing non-compliance with infection control standards. The administrator stated the HKS would immediately purchase buckets and measuring devices to enable staff to clean with a 10:1 bleach solution. On 06/17/14 at 5:45 p.m. the continuation of non-compliance was abated when observations revealed staff had the necessary supplies and were correctly mixing the bleach solution. c) At 1:30 p.m. on 06/19/14, the facility was again found in a situation of non-compliance with infection control practices. Employee #41 came out of room [ROOM NUMBER], an isolation room where the resident had an infection with methicillin resistant staphylococcus aures (MRSA), with a mechanical lift, and went directly into room [ROOM NUMBER] with the mechanical lift. Observation revealed Employee #41 did not clean the lift, which had been in an isolation room, prior to taking it to another resident's room. When this was brought to the attention of Employee #2, a registered nurse (RN), she confirmed the lift should have been cleaned prior to being taken to another room. She approached Employee #41, who admitted she did not clean the lift. The RN instructed Employee #41 to immediately clean the lift. On 06/19/14 at 2:00 p.m., the administrator was informed the facility remained in non-compliance with infection control practices. d) Residents #69, #42, #92, #46, and #50 On 06/20/14, at 10:00 a.m., observations on the first and second floors revealed these residents had cracked wheelchair and/or Broda chair coverings, rendering them unable to be effectively sanitized to prevent the spread of infection. 1. The right arm of Resident #69's wheelchair was taped because the surface covering was cracked. 2. Resident #42's wheelchair had cracks in the surface on both arms. 3. Resident #92's Broda chair covering was torn and frayed. 4. Resident #46's right wheelchair arm was cracked. 5. An observation of Resident #50's wheelchair arms on 06/20/14 at 10:30 a.m. revealed they were cracked. At 11:45 a.m. on 06/20/14, the administrator was informed the Centers for Medicaid and Medicare concurred the facility remained in non-compliance with infection control practices. She was informed to do whatever was necessary to ensure all employees were retrained and implemented effective infection control procedures. On 06/23/14 at 4:30 p.m., the facility provided evidence all employees were educated on effective infection control procedures. Continuing observations were made for infection control deficits. Throughout the day, on 06/23/14, observations revealed no breaches of infection control. At that time, it was thought the facility had abated the infection control continuing non-compliance at an IJ level. The facility was informed the IJ, which was called at 4:50 p.m. on 06/16/14, was abated at 4:30 p.m. on 06/23/14. . d) Resident #88 On 06/25/14 at 2:30 p.m., continuing non-compliance regarding infection control was again observed. Employee #13, a Licensed Practical Nurse (LPN) was observed providing wound care to Resident #88. During the treatment, the LPN cleaned the wound and skin surrounding the wound with a 4 x 4 wet gauze, using a back and forth scrubbing motion, potentially transferring bacteria and /or infection into the wound. This provided an opportunity for the transfer of microorganisms from the skin, where they are less likely to do harm, to an open area where the microorganisms can proliferate. On 6/25/14 at 3:48 p.m., Employee #5, the Infection Control Nurse, was interviewed regarding cleansing of a wound. She confirmed ". . . the nurse should clean the wound with sterile water or whatever was ordered, using a circular motion from the inside of the wound to the outside and pat dry..." After the facility was informed, in-service training was provided for all nurses regarding infection control related to wound care. According to Lippincott Nursing Procedures (WOUND WISE: Basic wound cleaning step by step Nursing Made Incredibly Easy! September/October 2008 Volume 6 Number 5, Pages 30 - 31, found at www.nursingcenter.com/lnc/static?pageid= 4), to prevent contamination and potential infection when cleaning an open wound, such as a pressure ulcer, the area should be gently wiped in a circular motion starting directly over the wound and moving outward. e) Continuing observations for infection control deficits were made throughout the remainder of the day on 06/25/14. At 5:48 p.m. on 06/25/14, it was determined the IJ which was originally called at 4:50 p.m. on 06/16/14 was abated. The scope and severity was reduced from an "L" to an "F." .

Based on observations and staff interview, the facility failed to ensure the resident environment, over which the facility had control, was as free of accident hazards as possible. Free standing floor fans, with grills which allowed access to the blades were in use. In addition, it was not possible to immediately determine if each fan was UL (Underwriters Laboratories - an independent, not-for-profit product safety testing and certification organization) listed. This was determined an immediate jeopardy to resident safety. A random observation revealed a resident attempting to place her fingers inside of the grill of a free-standing floor fan, which was located in the dining room on the second floor. Observation revealed the grill of the fan was wide enough to insert a finger and touch the revolving fan blades. It was not known whether or not the fan would shut down if someone touched the blades, so a maintenance employee inserted a tongue depressor into the fan grill and touched the blades. The fan did not shut down. Further observations found free-standing floor fans in the dining areas in the basement and the first floor. Observation revealed the gaps in the grill of the fan would allow residents to insert a finger and touch the revolving fan blades. On 06/25/14 at 10:21 a.m., the administrator was notified of the unsafe conditions related to the use of the fans. She was informed it was an immediate jeopardy (IJ) which had the potential to affect more than an isolated number of residents. Additionally, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of accidents was provided adequate supervision. The resident required the assistance of two (2) staff members for transfers. He was transferred by only one (1) staff member and fell sustaining a head injury for which he was sent to the emergency room . Resident identifiers: #72 and #59. Facility census: 77. Findings include: a) Resident #72 On 06/25/14 at 9:15 a.m., Resident #72 was observed attempting to place her fingers inside the grill of an operating, free-standing floor fan, located in the second story dining room. At the time of this observation, no staff were present to redirect the resident away from the fan. Subsequent review of the resident's medical record found this resident's minimum data set (MDS) assessment, with an assessment reference date of 04/16/14, identified the resident could sometimes understand what was said to her and sometimes could be understood. The Brief Interview of Mental Status was not attempted. According to the assessment, the resident had inattention, disorganized thinking continuously and fluctuating psychomotor retardation. She also was coded as having hallucinations and delusions, wandering that significantly intruded on the privacy of activities of others. She was independent for walking in her room and in the corridors. Her [DIAGNOSES REDACTED]. At 9:44 a.m. on 06/25/14, upon inquiry, Employee #93, the maintenance director, stated he did not know if the fan would shut down if someone touched the blades. Observation revealed he inserted a tongue depressor into the fan grill and touched the blades. The fan did not shut down. Employee #93 confirmed the gaps in the grill of the fan would allow residents to insert a finger and touch the revolving fan blades. When asked if the fan was UL (Underwriters Laboratory - an independent, not-for-profit product safety testing and certification organization) listed, Employee #93 stated he was not sure. He looked at the tag and the fan, and said, "If it is, I can't find it." b) Between 9:44 a.m. and 10:10 a.m., observations of the dining areas on the first floor and the basement revealed the presence of additional free-standing floor fans with grills. Residents frequented these areas for meals and activities. At times, residents were observed in the areas without direct supervision by staff. c) The administrator was notified of the unsafe conditions related to the use of the fams on 06/25/14 at 10:21 a.m. She was informed it was an immediate jeopardy (IJ) which had the potential to affect more than an isolated number of residents. An accepatable plan of correction was provided and accepted on 06/25/14 at 11:10 a.m. The facility's plan involved the removal of all free standing fans until they could determine if the fans were safe and the UL listed. Observation on 06/25/14 at 1:00 p.m. revealed the fans were no longer in the building. At 1:20 p.m. on 06/25/14, the administrator was informed the IJ was abated. The citation was decreased from a "K" to an "E." . b) Resident #59 Review of the resident's medical record, on 06/18/14 at 9:00 a.m. revealed the resident had a fall on 03/11/14. The event summary report, reviewed on 06/18/14 at 2:30 p.m., indicated the resident fell on [DATE] at 8:20 a.m. Review of the nurses' notes, on 06/18/14 at 3:00 p.m., revealed a nursing assistant (NA) was called to the resident's room to take the resident to the bathroom. The note described the NA had the resident holding onto a bar while she moved the wheelchair out of the way. The resident fell on to the bathroom floor. The care plan was reviewed on 06/19/14 at 9:20 a.m. The ADL function / Rehabilitation Potential portion of the care plan, dated 01/20/14 indicated the resident required extensive assist of two (2) with transfers and total assist of two (2) with toileting. During an interview with Employee #2, a registered nurse (RN), on 06/19/14 at 1:21 p.m., an inquiry was made regarding how many staff members were assisting the resident when he fell . She confirmed Employee #32, a NA, was the only staff member assisting Resident #59 at the time of the fall. On 06/24/14 at 8:35 a.m., review of the resident's nurses' notes, revealed an entry dated 03/11/14 at 3:11 p.m., stating, "Resident pulled call bell out of wall and tipped over nightstand with drawers. Resident came out of room stating he had to piss. Aide called to room to take resident to bathroom. Aide had resident holding onto bar which she moved wheelchair out of way and resident fell in bathroom onto floor hitting back of head and bottom . . . Resident complained of pain in the back of head . . . Resident in bed lethargic, resting with eyes closed at times, not wanting to get up to use the bathroom. Resident pulled penis out of brief three times and urinated on self and in bed . . . Resident noted to have cough and congestion in throat and this nurse questioned the need for chest x-ray . . . Talked with physician at 11:45 AM and orders given to send resident to ER (emergency room ) . . . Sent out regarding changes in status, lung sounds and bump on head." (The time of the fall and the time the resident was sent to the emergency room was not indicated in the nurse's note.) Upon inquiry, at 10:00 a.m. on 06/24/14, as to the time Resident #59 was transported to the ER for evaluation, Employee #66, medical records personnel, provided the resident's transfer form. The transfer form contained a nurse's note, written by Employee #11, a licensed practical nurse on 03/11/14 at 12:24 p.m. The form included, "Resident lost balance due to weakness and fell in bathroom this morning. Hit head and had neck at abnormal angle upon observation of scene . . . Resident lethargic and unresponsive to voice stimuli . . . Dr. notified with order to send to emergency room for evaluation and treatment. CT scan of head and chest x-ray if needed." On 06/18/14 at 2:30 p.m., the event summary report related to the resident's accident was reviewed. The summary indicated the resident fell on [DATE] at 8:20 a.m., hitting his head, resulting in a lump. He was sent to the hospital for an evaluation where a "frontal lobe bleed" was identified. A review of the point of care history (information the nurse aides entered into the computer system related to staff support for toileting) on 06/24/14 at 1:10 p.m., identified NA entries dated from 02/28/14 - 03/10/14 consistently stated only one (1) person assisted the resident with toileting and transfers. .

Based on record review, resident observation, and staff interview, the facility failed to ensure the resident environment, over which the facility had control, was as free of accident hazards as possible for one (1) of three (3) residents reviewed for the care area of accidents during the Quality Indicator Survey revisit. Resident #56 had bilateral bedside floor mats in place as an intervention to prevent serious injury related to falls. Upon observation, Resident #56's bedside table and her wheelchair were sitting on the bedside mats while the resident was in bed. Resident Identifier: #56. Facility Census: 84. Findings Include: a) Resident #56 A review of Resident #56's care plan at 12:30 p.m. on 09/23/14, found the care plan related to Resident #56's risk for falls included, "Bilateral bedside floor mats." An observation of Resident #56 at 3:45 p.m. on 09/23/14, found the resident resting in bed. Her bilateral bedside floor mats were in place; however, on the right side of Resident #56's bed, her bedside table was sitting on the floor mat, and on the left side of her bed, her wheelchair was sitting on the floor mat. An interview with Licensed Practical Nurse (LPN) #8 at 3:50 p.m. on 09/23/14, confirmed Resident #56's bedside table and wheelchair should have not been sitting on the bedside floor mats. When asked why Resident #56 had bilateral beside floor mats, she explained the resident was at risk for falls from the bed and the mats were in place so if she fall she would "...hit a smooth soft surface instead of a hard surface." She continued by stating, "having the bedside table and wheelchair on the mats prevents the mats from doing what they were put in place to do." .

Based on record review, observation, resident interview, and staff interview, the facility failed to ensure services for two (2) of forty-three residents, whose care plans were reviewed, were provided according to the residents' care plans. Resident #59 was not provided assistance as required by his care plan. This resulted in harm to Resident #59 when he fell and injured his head. In addition, the care plan for positioning and support for Resident #40 was not implemented. Resident identifiers: #59 and #40. Facility Census: 77. Findings include: a) Resident #59 Review of the Nurses notes,on 06/24/14 at 8:35 a.m., revealed an entry dated 03/11/14 at 3:11 p.m.. It indicated the resident came out of his room and stated he needed to toilet. According to the nurse's note, "...Aide called to room to take resident to bathroom. Aide had resident holding onto bar which she moved wheelchair out of way and resident fell in bathroom onto floor hitting back of head and bottom. Resident complained of pain in the back of head. Physician notified....Resident in bed lethargic, resting with eyes closed at times, not wanting to get up to use the bathroom....Talked with physician at 11:45 AM and orders given to send resident to ER....Sent out regarding changes in status, lung sounds and bump on head." Upon request, Employee #66, medical records personnel, provided the resident's transfer to the hospital form at 10:00 a.m. on 06/24/14. It contained the following nurse's note, written by Employee #11 (nurse) on 03/11/14 at 12:24 p.m., "...Resident lost balance due to weakness and fell in bathroom this morning. Hit head and had neck at abnormal angle upon observation of scene....Resident lethargic and unresponsive to voice stimuli. Confused conversation with staff....Dr. notified with order to send to emergency room for evaluation and treatment..." Upon inquiry, at 10:00 a.m. on 06/24/14, as to the time Resident #59 was transported to the ER for evaluation, Employee #66, medical records personnel, provided the resident's transfer form. The transfer form contained a nurse's note, written by Employee #11, a licensed practical nurse on 03/11/14 at 12:24 p.m. The form included, "Resident lost balance due to weakness and fell in bathroom this morning. Hit head and had neck at abnormal angle upon observation of scene . . . Resident lethargic and unresponsive to voice stimuli . . . Dr. notified with order to send to emergency room for evaluation and treatment. CT scan of head and chest x-ray if needed." On 06/18/14 at 2:30 p.m., the event summary report related to the resident's accident was reviewed. The summary indicated the resident fell on [DATE] at 8:20 a.m., hitting his head, resulting in a lump. He was sent to the hospital for an evaluation where a "frontal lobe bleed" was identified. An interview with Employee #2, a registered nurse (RN), on 06/19/14 at 1:21 p.m., confirmed Employee #32, a nurse aide (NA) was the only staff member assisting Resident #59 at the time of the fall. On 06/20/14 at 9:20 a.m., the resident's care plan at the time of the fall, with a start date of 01/20/14 (edited on 02/28/14 and updated on 03/12/14) was reviewed. The care plan contained an intervention requiring the assistance of two (2) for toileting. The category of ADL function / Rehabilitation Potential stated the resident required extensive assistance of two (2) with transfers and total assistance of two (2) with toileting. The category related to falls identified the resident had five (5) falls from 02/10/14 - 03/11/14. Medical record review revealed the resident had a sixth fall, on 03/09/14, which was not identified on his care plan. The approach / intervention, dated 03/12/14, was for the resident to have assistance of two (2) for all transfers. This was the first time this intervention was listed under the falls category; however, this approach had been an active intervention since 01/20/14, under the ADL function / Rehabilitation Potential category. Upon inquiry, on 06/19/14 at 4:06 p.m., Employee #1, the director of nursing (DON) said the nurse aides (NAs) identified how much assistance was needed for each resident's individual needs by looking at the the resident profiles. She explained the resident profiles were based on the residents' care plans, and were accessible to the NAs on the computers located on each hall. On 06/24/2014 at 9:37 a.m., the resident profile which was to have been used by the NA to provide care for Resident #59 on 03/11/14 was reviewed. It indicated Resident #59 was to have extensive assist of two (2) with bed mobility, transfers, hygiene, and total assist of two (2) with toileting. . b) Resident #40 On 06/16/14 at 12:00 p.m., Resident #40 was observed sitting in her wheelchair with her lower extremities unsupported. The resident's feet did not reach the floor and no foot rests were observed on the wheelchair. The resident was observed in the same circumstances on 06/16/14 at 2:00 p.m., and again on 06/17/14 at 1:00 p.m. During an interview with Employee #2 (registered nurse), on 06/19/14 at 3:15 p.m., she stated the resident had diabetes and developed sores from the foot rests so they were removed. She said they had tried sheep skin protectors and the resident kicked them off. Review of the resident's care plan, on 06/19/14, revealed an intervention, dated 12/23/13, to "position for comfort with physical support as necessary". An interview with Employee #3 (registered nurse), on 06/23/14 at 3:25 p.m., revealed the facility had no evidence to show they provided the resident with support to the lower extremities after they tried the sheep skin protectors which the resident kicked off. On 06/24/14 at 9:00 a.m., an observation revealed Resident #40 was up in her wheelchair in the dining room with her legs elevated on a padded footrest. The resident was interviewed on 06/24/14 at 10:10 a.m. She stated "this is a lot better" when asked about her feet being elevated on the padded footrest. .

Based on medical record review and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for accidents was free from neglect. The resident was assisted with toileting by one (1) nurse aide; however, the resident's care plan indicated he required the assistance of two (2) for toileting. The resident fell while transferring to the toilet, resulting in a head injury and was subsequently sent to the emergency room . Resident Identifier: #59. Facility Census: 77. Findings Include: a) Resident #59 On 06/24/14 at 8:35 a.m., review of the resident's nurses' notes, revealed an entry dated 03/11/14 at 3:11 p.m., stating, "Resident pulled call bell out of wall and tipped over nightstand with drawers. Resident came out of room stating he had to piss. Aide called to room to take resident to bathroom. Aide had resident holding onto bar which she moved wheelchair out of way and resident fell in bathroom onto floor hitting back of head and bottom . . . Resident complained of pain in the back of head . . . Resident in bed lethargic, resting with eyes closed at times, not wanting to get up to use the bathroom. Resident pulled penis out of brief three times and urinated on self and in bed . . . Resident noted to have cough and congestion in throat and this nurse questioned the need for chest x-ray . . . Talked with physician at 11:45 AM and orders given to send resident to ER (emergency room ) . . . Sent out regarding changes in status, lung sounds and bump on head." (The time of the fall and the time the resident was sent to the emergency room was not indicated in the nurse's note.) Further review of the resident's medical record found the most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 03/03/14, found the Brief Interview for Mental Status (BIMS) was not attempted. The resident was noted to have short term memory problems, disorganized thinking was coded as continuously present and did not fluctuate, and he had trouble concentrating on things. According to the assessment, walking in his room only occurred once or twice in the look back period and walking in the corridor did not occur. For toilet use, he was coded as the extensive assist of one person and for balance, all areas were coded as "Not steady, only able to stabilize with staff assistance." The assessment also identified the resident had active [DIAGNOSES REDACTED]. (No additional assessments were conducted. The next record was a "Death in Facility" record dated 03/13/14.) Upon inquiry, at 10:00 a.m. on 06/24/14, as to the time Resident #59 was transported to the ER for evaluation, Employee #66, medical records personnel, provided the resident's transfer form. The transfer form contained a nurse's note, written by Employee #11, a licensed practical nurse on 03/11/14 at 12:24 p.m. The form included, "Resident lost balance due to weakness and fell in bathroom this morning. Hit head and had neck at abnormal angle upon observation of scene . . . Resident lethargic and unresponsive to voice stimuli . . . Dr. notified with order to send to emergency room for evaluation and treatment. CT scan of head and chest x-ray if needed." On 06/19/14 at 1:21 p.m., Employee #2, a registered nurse (RN), was asked how many staff members were assisting the resident at the time of his fall. She stated Employee #32, a nurse aide (NA), was the only staff member assisting Resident #59 at the time of the fall. The care plan was reviewed on 06/20/14 at 9:20 a.m. The ADL (Activities of Daily Living) function / Rehabilitation Potential portion of the care plan indicated the resident required the extensive assistance of two (2) with transfers and total assist of two (2) with toileting. This problem was dated 01/20/14, three (3) days after the resident was admitted . It was reviewed by the facility on 02/28/14, and remained the same. .

Based on observation, resident interviews, staff interviews, and record review, the facility failed to ensure three (3) of three (3) residents reviewed for activities of daily living (ADLs) were provided services to maintain and maximize each resident's functional abilities. Resident #2 demonstrated she was able to use the bed controls to which she had access, but was unable to reach the one that allowed her to raise and lower the head of the bed. Resident #98's responsible party stated the resident could turn and reposition himself independently with the side rails, but was unable to do this without the side rails. Resident #29 said she had used the side rails to get out of bed. Without the side rail, she feared she would fall and no longer was able to get out of bed and into her recliner independently. Residents #98, #2, and #29 were independent, or more independent, in transfers and/or positioning prior to the discontinuation of their side rails. The side rails for each of these residents were discontinued without assessment or implementation of alternatives to prevent an avoidable decline and/or to assist each resident in maintaining and maximizing his/her current independent functioning. The facility did not identify or address each resident's unique functional needs prior to the discontinuation of the devices these residents used for independent functioning. These residents and/or their families experienced psychological harm as the result of the facility's failure to provide an acceptable means to maintain each resident's independent functioning. Resident identifiers: #98, #2, #29. Facility census: 77. Findings include: a) Resident #2 During an interview with Resident #2, on 06/20/14 at 9:10 a.m., she demonstrated she could raise her bed, but was not able to reposition herself in bed or raise the head of the bed. She said this was because the controls for the bed were located on a lowered secured side rail. Observation revealed the side rails were still attached to the bed, but they were secured in a lowered position, rendering them unusable/inaccessible to the resident. The resident said she was able to independently reposition herself and raise the head of her bed, when the side rails were up. She said she could no longer do this herself, and now had to ask for help with repositioning and raising the head of the bed. The resident voiced discontentment with the decision by the facility to discontinue her side rail use. She stated facility staff told her "The State said we couldn't have them anymore." Review of the resident's most recent minimum data set (MDS) assessment, a quarterly assessment with an assessment reference date of 05/01/14, found this resident had no functional limitations in range of motion, and required limited assistance with bed mobility and transfers. An interview was conducted, on 06/24/14 at 9:30 a.m., with Employee #31 (nurse aide). She reported several residents, including Resident #2, were requiring more assistance with mobility and ADLs since the side rails were discontinued. b) Resident #98 On 06/23/14 at 1:47 p.m., during an interview with Resident #98 and his medical power of attorney (MPOA), the MPOA said a facility staff member informed them the resident could no longer use his side rails. The MPOA became visibly upset when discussing the matter. She said the staff member said, "State says we can't use side rails because someone may get their head caught in them." The MPOA said when the resident had his side rails in the up position, he could independently turn and reposition himself with them. She said now he had to call staff to assist him to turn and reposition. The MPOA said they now had to use the call light to get staff assistance to do things the resident was once capable of doing for himself. During the interview, the resident concurred with the MPOA and asked if he would again be able to use his side rails. Observation revealed the resident had 1/4 side rails on each side of the bed. Each was lowered and tied down with two (2) zip ties. Review of the resident's most recent MDS, a quarterly assessment with an ARD of 06/13/14, found the resident had a Brief Interview of Mental Status of 14 - indicating he was cognitively intact. His assessment indicated he needed extensive assistance of two (2) for bed mobility and transfers, which meant he was able to participate to some degree in these activities. On 06/23/14 at 4:20 p.m. Employee #44, NA, said prior to the removal of the side rails, Resident #98 was independent with turning and repositioning in the bed, and needed the assistance of only one (1) person for transfers into and out of the bed. Now, without the ability to utilize the side rails, the NA said the resident required the assistance of a NA to turn and reposition, and the assistance of two (2) persons to transfer in and out of bed. c) Resident #29 On 06/25/14 at 11:20 a.m. Resident #29 said she almost fell getting out of bed that morning because she did not have her side rail to assist her in getting up. She said she experiences a fear of falling when she attempts to get up without her side rail. The resident said she used to be able to get out of bed independently by using the side rail and the arm of her recliner. Resident #29 said she could no longer attempt to get out of bed without staff assistance, due to her fear of falling; however, she stated she was afraid of falling even with staff assistance. The resident said she felt safer and more secure when she independently transferred herself using her side rail and the arm of her recliner to balance herself. She said a staff member was with her that morning when she almost fell . The resident said her anxiety was higher now because she could not have her side rail to assist her. Review of this resident's quarterly MDS, with an ARD of 04/02/14, found her BIMS score of 14 indicated she was cognitively intact. She had functional limitation in range of motion to both lower extremities. According to the assessment, she had required the limited assistance of one (1) for bed mobility and transfers during the look back period of the assessment. During a telephone interview with Resident #29's MPOA, on 06/25/14 at 11:31 a.m., she said she really believed the resident needed her side rails. The MPOA feared the resident's risk of injury was greater without the side rails than with the side rails. She said she spoke with the administrator and expressed her desire for the resident to have side rails. The MPOA said the administrator told her, "State says side rails cannot be used, and she just can't go against state rules." The MPOA said she thought this decision had made the resident more dependent on staff assistance in areas in which she did not need assistance before. She also said this entire situation had made the resident's anxiety worse. On 06/25/14 at 3:08 p.m., Employee #51, NA, stated she had noticed a big difference in the functional ability of Resident #29 since the discontinuation of the side rails. The NA said the resident was not as dependent on staff for transferring prior to the discontinuation of the side rails. d) An interview was conducted, at 9:30 a.m. on 06/24/14, with the director of nursing (DON). When asked if an assessment was completed for each resident prior to the discontinuation of their side rails on 06/11/14, the DON said, "No." She stated the side rails were discontinued, at the request of the Medical Director (MEDIR), for safety purposes. The DON stated she ordered two (2) devices to assist with bed mobility, but they had not yet been received. During an interview with the administrator (NHA), on 06/24/14 at 10:55 a.m., she confirmed the side rails in the facility were discontinued on 06/11/14. She said the medical director (MEDIR), had spoken to facility staff and was very [MEDICATION NAME] about the reduction of side rail usage. The NHA said the MEDIR spoke of statistics related to entanglement. When asked about resident functioning levels declining while in bed because a resident could no longer turn or reposition independently, the NHA said she would defer that to the physician. The NHA said the facility planned to try two (2) different types of bed canes for the residents to use instead of the side rails. At that time, the residents had not been assessed for a device, the two (2) devices had not been ordered specifically for any particular resident, the devices had not arrived, and had not been tried for any resident. On 06/25/2014 at 8:00 a.m., the MEDIR was interviewed about the discontinuation of the side rails. She said she had been working on this for several months, since December 2013. She stated a solution for the bed control was being explored, but a viable solution had not yet been determined. The MEDIR also stated residents were to have been assessed by physical therapy (PT) for an alternative means for repositioning and/or transferring. She said the assessment by PT had not occurred. The MEDIR agreed there was a need for alternatives to the side rails to assist residents in attaining and/or maintaining independent functioning. She confirmed the side rails were discontinued without individual assessments and without the availability of an alternative for residents who had previously used their side rails for positioning and assistance in transferring themselves. .

Based on observations, record reviews, policy reviews, review of incident reports, review of reportable abuse allegations, review of personnel records, resident interviews, family interviews, and staff interviews, the quality assessment and assurance (QA & A) committee failed to identify and address quality deficiencies of which they were aware or should have been aware. These practices had the potential to affect all residents. Rights: The QA & A committee failed to identify the need to develop and implement processes to ensure residents were afforded the opportunity to exercise their rights. Resident Behavior and Facility Practices: The QA & A committee failed to identify the need to develop and implement processes to ensure a resident was free from a restraint used for staff convenience. The QA & A committee also failed to identify the need to develop and implement processes to implement their abuse and neglect policies, and failed to identify the need to develop and implement processes to ensure allegations of abuse and neglect were identified, reported and investigated. These failures resulted in substandard quality of care. Quality of Life: The QA & A committee failed to identify the need to develop and implement processes to ensure residents were treated with dignity and respect, failed to identify the need to develop and implement processes to allow residents to make choices regarding important aspects of their lives, failed to identify the need to develop and implement processes to ensure accommodation of individual resident needs, and failed to identify the need to develop and implement processes to ensure adequate housekeeping and maintenance services necessary to maintain an orderly, sanitary, and comfortable environment. Resident Assessment: The QA & A committee failed to identify the need to develop and implement processes to ensure the accuracy of assessments, failed to identify the need to develop and implement processes to ensure care plans were developed and/or revised as needed, and failed to identify the need to develop and implement processes to ensure care plans were implemented. Quality of Care: The QA & A committee failed to identify the need to develop and implement processes to provide services to promote each resident's highest level of well-being, such as care and services for a pressure ulcer and an effective program for influenza and pneumococcal immunizations. The QA & A committee also failed to identify the need to develop and implement processes to ensure the resident environment remained as free of accident hazards as possible, resulting in an immediate jeopardy. Dental Services: The QA & A committee failed to identify the need to develop and implement processes to provide emergency and routine dental services to residents and failed to identify the need to maintain a contract or agreement with a dentist to provide these services. Infection Control: The QA & A committee failed to identify the need to develop and implement processes to implement an effective infection control program to prevent, recognize, and control, to the extent possible, the onset and spread of infections within the facility. This failure resulted in an immediate jeopardy. Medical Records: The QA & A committee failed to identify the need to develop and implement processes to ensure medical records were readily accessible to facility staff and the survey team. Staff were not knowledgeable of how to access the pharmacist's monthly medication reviews. This lack of knowledge resulted in an inability for staff to use and/or provide essential information which was only available in the facility's computer program. These practices, which had the potential to affect all residents, were identified during the survey from June 16, 2014 through June 27, 2014. Resident identifiers: #2, #14, #21, #29, #40, #42, #46, #50, #56, #59, #64, #69, #71, #72, #88, #92, #95, #98, #100, and #110. Facility census: 77 Findings include: a) Residents #98, #71, #29, and #2 were not afforded the opportunity to exercise their rights regarding the use of side rails. These residents and families expressed serious concerns regarding the facility's decision to discontinue the use of side rails because the used the side rails for turning and repositioning. The side rails were discontinued without discussion with the residents and/or families, and without the provision of alternative assistive devices to maintain each resident's independence. b) Resident #64 was not free from a restraint used for staff convenience, and not used for an assessed medical need. The facility maintained the resident in a reclining Broda chair (a tilting and reclining positioning chair) with a pelvic sling applied. The sling was tied behind and under the seat of the Broda chair. There was no assessment for the restraint, and no plan to systematically and gradually reduce the use of the restraint. Neither the resident's current minimum data set (MDS) nor the current care plan reflected the resident had a physical restraint. c) Residents #100 and #95 were not afforded the right to be free from physical abuse. Each resident alleged staff treated them "rough" during care. The QA & A committee failed to recognize the abuse and failed to address the allegations of physical abuse. 1. Resident #100's family reported abuse to facility staff during a care plan meeting. Review of reported allegations of abuse and neglect found no evidence of a report or an investigation of any concerns related to the resident. This was further evidence the QA & A committee did not recognize the need to address alleged abuse. Employee #3, a registered nurse, was interviewed on 06/19/14 at 11:06 a.m. She stated she remembered the resident's family told the care plan team a staff member had been rough with the resident during care. Employee #3 said she believed the social worker investigated the situation. The social worker, Employee #63, was interviewed at 12:58 p.m. on 06/19/14. She confirmed the resident's wife told her, "Someone had been rough with him." The social worker did not report the incident because she said she was not able to "Confirm the who, what, where and when. I took this upon myself not to report it because some people are just rougher than others." She stated she did not think it was abuse, 2. Resident #95 was interviewed at 3:55 p.m. on 06/17/14. She reported a nursing assistant was rough with her when taking her to the commode, bruising her wrist and making her ribs sore. An interview with the resident's son, on 06/19/14 at 1:45 p.m., revealed his mom told him someone had been rough with her, and he reported this to Employee #61 (social worker). When interviewed on 06/19/14 at 2:20 p.m., Employee #61 confirmed she was notified of the resident's allegation. The social worker provided information that indicated she interviewed the resident, but there was no evidence of a thorough investigation.. She did not report the allegation to the required agencies because she did not feel the allegation was substantiated. d) The Q A & A committee failed to identify the need to develop and implement processes to ensure allegations of mistreatment, neglect, and/or abuse were reported and/or thoroughly investigated for Residents #59 and #110. In addition, the QA & A committee failed to ensure complete and thorough background investigations were conducted. Employee #103's background check was not thorough. 1. Resident #59 had a fall resulting in a head injury on 03/11/14. Review of the nurse's notes, on 06/18/14 at 3:00 p.m., revealed a note dated, 03/11/14 at 3:11 p.m., which described the resident fell on to the bathroom floor while being assisted in toileting. An interview with Employee #2, a registered nurse (RN), on 06/19/14 at 1:21 p.m., revealed only one (1) nursing assistant was assisting the resident when he fell . Review of the resident's care plan, on 06/19/14 at 9:20 a.m., found it indicated the resident required extensive assist of two (2) with transfers and total assist of two (2) with toileting. There was no evidence this incident was thoroughly investigated. At 2:47 p.m. on 06/19/14, the director of nursing said, "Social services reminded me we did not investigate the matter because the physician wrote a note that the resident was having a stroke prior to or during the fall." This did not negate the fact the resident was transferred by one (1) person instead of two (2). That part of the incident, neglect, required reporting and investigation. 2. Resident #110's medical record indicated she was sent to the hospital on [DATE] to have a Rape kit done. She had stated a male nursing assistant had raped her. There was no evidence the allegation was investigated by the facility. An interview with Employee #63, a Social Worker (SW), on 06/26/14 at 1:35 p.m., revealed the facility did not do an investigation of the allegation because the hospital report showed no evidence the resident was raped and the resident had no memory of the allegation. Upon inquiry, the SW confirmed she had not considered the possibility that something happened to the resident which required an investigation, even though it was not rape. 3. On 06/17/14 at 1:20 p.m., the personnel file review revealed Employee #103 (resident service provider) came to work at the facility on 06/01/10. This employee listed on her application she had worked in a neighboring state until 2007. The facility had completed a criminal background check for the state of West Virginia at the time the employee was hired. The personnel file contained no evidence showing the facility had conducted a criminal background check outside of West Virginia. On 06/23/14 at 1:30 p.m. Employee #99 (bookkeeper) said the facility had not conducted a criminal background check in the neighboring state for Employee #103. e) The QA & A committee failed to identify the need to develop and implement processes to ensure the operationalization of abuse policies and procedures (P & P) to prevent, identify, investigate, and report abuse and mistreatment. In addition, the policy referred to a Federal requirement which does not exist, and to an outdated State Licensure rule regarding abuse. The QA & A committee failed to ensure the facility operationalized their policies and procedures for Residents #95, #100, and #59, as the facility failed to investigate all alleged abuse and neglect; failed to obtain statements from all witnesses, employees, residents; and failed to document all interviews with witnesses. 1. Review of the facility's abuse policies and procedures found all aspects of the seven (7) required components were not accurate and/or developed. The QA & A committee failed to evaluate the policy to ensure all components were in accordance with current regulations: -- The procedures for reporting did not include the requirement to immediately (within 24 hours) report all allegations of abuse or neglect to the appropriate State agencies. -- The policy refers to F228, a regulation which does not exist. -- The policy refers to the Nursing Home rule dated June 18, 2001; however, this is not the most current rule. 2. Resident #95: The facility failed to operationalize their P & P to report and investigate an allegation of abuse regarding Resident #95. During an interview with Resident #95, at 3:55 p.m. on 06/17/14, she reported, a nursing assistant was rough with her, bruising her wrist and made her ribs sore, when she took her to the commode. The resident's family was interviewed on 06/19/14 at 1:45 p.m. The family member said Resident #95 told him someone had been rough with her. According to the family, this allegation was reported to Employee #61 (social worker). Upon inquiry on 06/19/14 at 2:20 p.m., Employee #61, social worker, provided a copy of the resident's allegation dated 01/14/14. Review of the document revealed Employee #61 was made aware of the alleged incident and interviewed the resident, but failed to conduct a thorough investigation. The social worker said she did nothing further because she did not feel the allegation was substantiated. Review of the facility's reportable allegations, on 06/19/14 at 3:00 p.m., revealed no record the allegation was reported to the required agencies. The review also revealed no evidence of a thorough investigation. 3. Resident #100: The facility failed to operationalize their P &P to report and investigate an allegation of abuse regarding Resident #100. On 06/16/14 at 6:32 p.m., the family member of Resident #100 stated staff had been rough with the resident during care. The family member said the incident was reported to facility staff during a care plan meeting, and the facility assured them the incident would be investigated. The facility's reported allegations of abuse and neglect, which had been reported to the State, contained no reporting or investigation of any concerns related to Resident #100. Employee #3, a registered nurse, was interviewed on 06/19/2014 at 11:06 a.m. Employee #3 stated she remembered the meeting when the resident's family told the care plan team a staff member had been rough with the resident during care. Employee #3 said she believed the social worker investigated the situation. The social worker, Employee #63, was interviewed at 12:58 p.m. on 06/19/14. She stated the resident's wife told her, "Someone had been rough with him." The social worker said she did not report the incident because she said she was not able to confirm the who, what, where and when. She said she took it upon herself to not report it "because some people are just rougher than others." 4. The facility's policy entitled, "Procedure for Patient Abuse Investigation" was reviewed on 06/25/14 at 3:00 p.m. It included: "The facility shall investigate and report alleged abuse as follows: -- Report incident to Administrator, Director of Nursing and Social Services Director. The Social Services Director, upon preliminary investigation, shall notify the Office of Health Facility Licensure and Certification and the Department of Health and Human Resources, Adult Protective Services about the alleged abuse. -- The facility will investigate reports of alleged abuse and neglect to determine if the conduct of the employee is in violation of any standard of care.... -- As part of the investigation process the following will be done: -- Obtain statement from all witnesses, employees, residents or visitors. -- The facility will document all interviews with witnesses...." The QA & A committee failed to identify staff were not implementing their written policies. 5. Resident #59 fell , on 03/11/14 (the time was not identified), while being assisted with toileting. Review of the resident's care plan revealed the resident required extensive assistance of two (2) with transfers and total assistance of two (2) with toileting. At 1:21 p.m. on 06/19/14, Employee #2, a registered nurse (RN), was asked how many staff members were assisting the resident at the time of his fall on 03/11/13. She stated only one (1) staff member was assisting Resident #59 at the time of the fall. At 2:47 p.m. on 06/19/2014, the DON reported the the facility did not investigate the matter. The facility failed to operationalize their P & P to report and investigate this alleged neglect of Resident #56. f) The QA &A committee failed to identify the need to develop and implement processes to ensure a dignified dining experience for residents who had their meals in the main dining room. Several residents were still eating when a staff member removed their plates without asking if they were finished. In addition, the staff member scraped unconsumed food and beverages into a bucket in view of the residents. g) The QA & A committee failed to identify the need to develop and implement processes to ensure residents were free to exercise autonomy regarding what the residents considered important aspects of their lives. Residents #2, #98, #71, and #29 were not free to exercise autonomy regarding the use of side rails. Residents #21 and #100 did not have a choice regarding the number of showers they received each week. 1. Resident #2 said she was "upset" on 06/17/14 at 4:25 p.m., because the facility discontinued her side rails. she said she felt safer with them. An observation and interview with Resident #2, on 06/20/14 at 9:10 a.m., revealed she could only raise the height of her bed. She was not able to reposition herself in bed or raise the head of the bed because the controls were located on the lowered side rail., which was secured in the lower position with two (2) plastic zip ties. Review of the side rail assessment, completed on 05/04/14, revealed the resident required side rails for turning and repositioning, as well as to transfer herself in and out of the bed. Review of the resident care plan revealed an intervention, dated 11/07/13, which stated: "May have 1/4 to 1/2 side rails to head of bed for mobility". 2. Resident #98 was interviewed, along with his wife, on 06/23/14 at 1:47 p.m. They were concerned because the facility informed them the resident could no longer use his side rails. Observation revealed the resident's two (2) 1/4 side rails were secured in the lowered position with two (2) zip ties on each side rail . The resident could not turn and reposition himself independently when the side rails were down. Without the side rails, the resident had to call staff to assist him to turn and reposition. During the interview, the resident asked if he would again be able to use his side rails. The resident and his wife said they were not consulted in the decision regarding discontinuation of the use of the side rails. 3) Resident #71 was observed in her bed on 06/25/14 at 3:30 p.m.. Her side rails were in the down position, and were secured with two (2) zip ties on each side rail . The resident said she wished she still had her side rails, because she used them to position herself in the bed. She asked if she would ever get them back. During a telephone conversation, on 06/25/14 at 5:00 p.m., with the MPOA for Resident #71, the resident's MPOA said the resident was very upset about losing her side rails, as she was able to turn and reposition independently while in bed. She said the resident longer feels safe in bed, and now requires assistance to turn and reposition. The MPOA said it was her opinion, the resident could do more and felt safer with the side rails. She said she wanted the resident to once again be able to utilize her side rails. 4. Resident #29, when interviewed on 6/17/14 at 4:20 p.m., said her side rails were removed about a week ago. She said she was informed by staff that she could no longer use them. On 06/25/14 at 11:20 a.m., during another interview, Resident #29 said she almost fell getting out of bed that morning because she did not have her side rail to assist her. Several times during the conversation, she expressed a fear of falling. The resident said she used to be able to get out of bed herself using the side rail and the arm of her recliner. She said she now no longer attempted to get out of bed, without staff, due to a fear of falling. The resident said when she had her side rails, she was not fearful of falling. She said her anxiety was higher now because she cannot have her side rails. During a telephone interview with the resident's MPOA, on 06/25/14 at 11:31 a.m., the MPOA said she really believed Resident #29 needed her side rails. She voiced fear the risk of injury to the resident was greater without the side rails than with the side rails. The MPOA said she thought the decision made the resident require staff assistance in areas in which she did not previously need assistance. The MPOA also said the entire situation has made the resident's anxiety worse. 5. During an interview with Employee #1 (director of nursing), on 06/24/14 at 9:30 a.m., she reported the side rails were discontinued on 06/11/14 at the request of the medical director. When asked what alternatives were offered the residents, she said the side rails were discontinued prior to the alternative devices being in place. An interview with the medical director, on 06/25/14 at 8:00 a.m., revealed residents were to be assessed by physical therapy and alternate bed control and positioning devices were to be in place prior to the discontinuation of the bed rails. She confirmed the facility had not completed the physical therapy evaluations, and did not have alternate positioning devices prior to the discontinuation of the side rails. h) The QA & A committee failed to identify the need to develop and implement processes to ensure residents were provided reasonable accommodations of individual needs and preferences. The environment and staff behaviors were not directed toward assisting each resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible. For Residents #2, #29, #71, #98, and #56, the facility did not evaluate each resident's unique needs and preferences, to ensure each resident was reasonably accommodated, when their side rails were removed from use. The plan was for residents to be assessed by physical therapy and alternate bed control and positioning devices were to be in place prior to the discontinuation of the bed rails. The facility had not done the physical therapy evaluations and had not provided alternatives to the side rails prior to discontinuing them. i) The QA & A committee failed to identify the need to develop and implement processes to to ensure residents were notified before a room change occurred. During an interview, at 1:16 p.m. on 06/17/14, Resident #21 stated he was moved from the first floor to the second floor without explanation. Review of the nurse's note, dated 06/06/14, confirmed the resident was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on 06/06/14. According to the note, the medical power of attorney was called about the room move; however, there was no evidence the resident was notified of the room move. The director of nursing was interviewed at 12:52 p.m. on 06/25/14. She was unable to provide evidence the room move was discussed with Resident #21 before he was moved. j) The QA &A committee failed to identify the need to develop and implement processes to ensure effective maintenance services in 20 of 39 resident rooms/bathrooms and a resident common area. The ceramic tiles around the sink area in resident rooms were cracked. Bathroom doors had deep scratches in the wood surfaces. Door facings going into bathrooms had chipped paint. Exhaust fans in the bathrooms were rusted. The ceiling in one (1) resident room had peeling plaster/paint. Doorknob plates were loose. Chairs in the dining area on first floor had scratched arms and legs. The hand rail across from the nursing station on second floor was loose. In addition, the QA & A committee failed to identify the need to develop and implement processes to ensure effective housekeeping and/or maintenance services. Two (2) of 77 residents, observed through random observations, had dirty wheelchairs. Five (5) of 35 census sample residents and one (1) resident observed through random observations had cracked wheelchair and/or Broda chair coverings. These cracks in the coverings rendered the equipment unable to be effectively cleaned. k) The QA & A committee failed to identify the need to develop and implement processes to ensure the Resident Assessment Instrument (RAI) was used to accurately assess residents using the Minimum Data Set (MDS), to develop care plans, to revise care plans as needed, and/or to implement care plans. 1. Resident #64's MDS was not accurate. The MDS did not indicate the resident used a restraint or that the resident had a fall. The resident was observed restrained with a pelvic sling in a reclining Broda chair (a tilting and reclining positioning chair). The sling was tied behind and under the seat of the Broda chair. The pelvic restraint was observed in use on 06/17/14 at 2:22 p.m., 06/18/14 at 12:30 p.m.,06/19/14 at 9:00 a.m., 06/20/14 at 10:17 a.m., and 06/23/14 at 1:26 p.m. On 06/24/14 the resident was observed with the sling in place continuously from 8:15 a.m. until 9:51 a.m. On 06/25/14 the resident was observed from 9:00 a.m. to 9:33 a.m., and at 5:13 p.m. with the sling in place. The resident was also observed seated in this manner on 06/26/14 at 11:46 a.m. Review of the medical record, on 06/24/14, found the resident's last annual MDS had an assessment reference date (ARD) of 03/06/14. Section P of the MDS was not coded to reflect the resident had a physical restraint. Medical record review, on 06/25/14, found the resident fell from her bed on 12/13/13. Review of the resident's annual MDS with an ARD of 03/06/14, Section J (Health Conditions), indicated the resident had no falls since her last assessment, which was a quarterly MDS with an ARD of 12/06/13. 2. Resident #14's MDS was not accurate. During an interview with the resident, on 06/16/14 at 2:00 p.m., she stated, "The dentist pulled some teeth a long time ago." When asked if her teeth hurt her, she replied "sometimes". review of the resident's medical record revealed [REDACTED]. Section (L) Oral Dental Status indicated the resident had no dental problems. Employee #12 (licensed practical nurse) was asked to assess the resident's mouth on 06/16/14 at 2:20 p.m. She confirmed several of the resident's bottom molars were missing, her teeth were discolored, an upper left tooth next to the front tooth was cracked, and food particles were on the resident's teeth. 3. Resident #56 did not have a comprehensive care plan to address the resident's [MEDICAL CONDITION]. On 06/20/14 at 8:56 a.m., medical record review showed Resident #56 was taking [MEDICATION NAME] 40 milligram (mg) 1 tablet every day for [MEDICAL CONDITION]. Review of medical records, on 6/24/14 at 8:50 a.m., revealed pertinent [DIAGNOSES REDACTED]. The resident's care plan did not identify [MEDICAL CONDITION] as a problem. The only mention of [MEDICAL CONDITION] was in a problem statement under dehydration, created on 1/14/14, which stated ". . . on a diuretic for [MEDICAL CONDITION] which puts her at risk for dehydration." Employee #18, a Licensed Practical Nurse (LPN), was interviewed, on 6/24/14 at 10:45 a.m. She reported the resident had bilateral lower extremity [MEDICAL CONDITION] that "comes and goes," and the resident was encouraged to keep her legs elevated The resident's care plan did not discuss elevating the resident's legs, or directives to monitor the resident's [MEDICAL CONDITION]. On 6/25/14 at 5:50 p.m., Employee #2, a MDS nurse, was interviewed. She reviewed Resident's #56's care plan and confirmed the only care plan concerning [MEDICAL CONDITION] was under dehydration. When asked how staff knew what care the resident required to address the [MEDICAL CONDITION] (such as elevating the resident's legs and monitoring), Employee #2 replied: ". . . they wouldn't, because it wasn't in the care plan..." 4. Resident #64 did not have a care plan related to the use of a restraint. Observation, on 06/16/14 at 12:45 p.m., revealed this resident was reclined in a Broda chair. The resident also had a pelvic sling tied under the Broda chair, and out of reach of the resident. Her legs were elevated with the foot rest of the chair. The pelvic sling, which was between the resident's legs and tied to the chair, rendered the resident incapable of turning and repositioning herself. The care plan was reviewed on 06/20/14 at 10:33 a.m. There were no interventions for position changes while the resident was in the Broda chair and using a pelvic sling. On 06/25/14 at 2:15 p.m., an interview was held with Employee #2, a MDS nurse. She reviewed the care plan and confirmed there was no care plan regarding how and when the resident should be repositioned. 5. Resident #59's care plan was not revised related to falls or to reflect the number of staff needed for assistance. The care plan, with a start date of 01/20/14, was reviewed on 06/20/14 at 9:20 a.m. The category of ADL function / Rehabilitation Potential stated: "extensive assist of two (2) with transfers and total assist of two (2) with toileting". It had an edited date of 02/28/14. The category of Falls, listed five (5) falls from 02/10/14 - 03/11/14. A fall that occurred on 03/09/14 was not identified on the care plan which was updated on 03/12/14. The approach / intervention, dated for 03/12/14, was for the resident to have assist of two (2) for all transfers. The MDS, with an assessment reference date (ARD) of 02/24/14, was reviewed on 06/19/14 at 10:32 a.m. It indicated a change/or correction in the resident's level of functioning was needed. The previous MDS, with an ARD of 02/03/14, indicated the resident was extensive assist of two (2) for transferring and toileting (weight bearing). The correction/or change, on the MDS with an ARD of 02/24/14, stated he was extensive assist of one (1) staff member for transferring and toileting. On 06/19/14 at 4:06 p.m., Employee #1, the director of nursing (DON) provided the MDS dated [DATE] that indicated the resident was extensive assist of one (1) for toileting. She stated that the MDS was correct and the care plan was incorrect. The care plan was not revised to reflect the resident's current assessed needs. 6. Resident #2's care plan revealed an intervention, dated 11/07/13, which stated "May have 1/4 to 1/2 side rails to head of bed for mobility". The care plan indicated the last review was done on 05/13/14. The facility discontinued this resident's side rails on 06/11/14. The care plan was not revised regarding the side rails and/or the need for an alternative device for bed mobility. 7. Resident #59's care plan was not implemented regarding the amount of assistance he needed, resulting in harm when he fell and injured his head. Review of the Nurses notes,on 06/24/14 at 8:35 a.m., revealed an entry dated 03/11/14 at 3:11 p.m. indicating the resident fell while being assisted in the bathroom. An interview with Employee #2, a registered nurse (RN), on 06/19/14 at 1:21 p.m., revealed Employee #32, a nurse aide (NA) was the only staff member assisting Resident #59 at the time of the fall. On 06/20/14 at 9:20 a.m., the resident's care plan at the time of the fall, with a start date of 01/20/14 (edited on 02/28/14 and updated on 03/12/14) was reviewed. The care plan contained an intervention requiring the assistance of two (2) for toileting. The category of ADL function / Rehabilitation Potential stated the resident required extensive assistance of two (2) with transfers and total assistance of two (2) with toileting. Upon inquiry, on 06/19/14 at 4:06 p.m., Employee #1, the director of nursing (DON), said the nurse aides (NAs) identified how much assistance was needed for each resident's individual needs by looking at the the resident profiles. She explained the resident profiles were based on the residents' care plans, and were accessible to the NAs on the computers located on each hall. On 06/24/2014 at 9:37 a.m., the resident profile which was to have been used by the NA to provide care for Resident #59 on 03/11/14 was reviewed. It indicated Resident #59 was to have extensive assist of two (2) with bed mobility, transfers, hygiene, and total assist of two (2) with toileting. 8. Resident #2's care plan for positioning and support was not implemented. On 06/16/14 at 12:00 p.m., Resident #2 was observed sitting in her wheelchair with her lower extremities unsupported. The resident's feet did not reach the floor and no foot rests were observed on the wheelchair. The resident was observed in the same circumstances on 06/16/14 at 2:00 p.m., and again on 06/17/14 at 1:00 p.m. During an interview with Employee #2 (registered nurse), on 06/19/14 at 3:15 p.m., she stated the resident had diabetes and developed sores from the foot rests so they were removed. She said they had tried sheep skin protectors and the resident kicked them off. Review of the resident's care plan, on 06/19/14, revealed an intervention, dated 12/23/13, to "position for comfort with physical support as necessary". An interview with Employee #3

Based on observation, medical record review, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed related to contractures during the re-visit to the Quality Indicator Survey, completed on 01/17/13, received treatment and services related to preventative care for contractures. Observation of the resident revealed the resident did not have a palm protectors in place as ordered by the physician. Resident identifier: #62. Facility census: 88. Findings include: a) Resident #62 Medical record review, on 03/19/13, found a physician's orders [REDACTED]. (left) hand at all times. Remove every shift for hand hygiene. Contracture-unspec. (unspecified)." Observation of the resident, at 9:25 a.m. on 03/19/13 with Employee #13, the licensed practical nurse-unit manager, found the resident had a rolled washcloth in her left hand. Employee #13 verified the resident did not have the palm protector in place. The palm protector was lying on the resident's night stand beside her bed. Employee #13 removed the washcloth and placed the palm protector on the resident's left hand. Review of the care plan, updated on 02/04/13, found a problem had been identified as, "Potential altered skin integrity as evidenced by impaired mobility,. . . ." An intervention for this problem was, "Palm protector to left hand at all times. Remove every shift for hand hygiene." Employee #2, the registered nurse minimum data set coordinator, was advised of the above observation at 10:35 a.m. on 03/19/13. She was unable to provide any evidence or explanation as to why the resident was not wearing the palm protector. .

Based on observation, medical record review, and staff interview, the facility failed to ensure one (1) of two (2) residents, reviewed related to contractures, maintained the highest level of range of motion. The facility failed to provide services to prevent a decrease in range of motion and failed to ensure the resident did not develop a new contracture. Resident #89. Facility census: 88 Findings include: a) Resident #89 On 01/15/13 at 11:00 a.m., a review of the resident's medical record was completed. The resident was total care for activities of daily living (ADLs). He was nonambulatory. [DIAGNOSES REDACTED]. The resident was observed at 11:15 a.m., in the resident dining room on 1st floor, on 01/15/13. The resident was up in a Broda Chair. He was observed having spontaneous movements of his head and lower extremities. His head was extended back a moderate degree. His eyes were shut, but opened partially when he was addressed by his name. There was no verbal response at that time. The resident's left hand was noted to be rigidly and slightly bent, and was partially closed. Interview with a licensed practical nurse (LPN), Employee #19, on 01/15/13 at 11:30 a.m., as well as review of the resident's restorative record, revealed the resident was currently receiving no range of motion (ROM) therapy from restorative staff. The resident received ROM therapy to both legs from May of 2012 to August of 2012. The last physical therapy (PT) evaluation was completed on 06/06/12. The physical therapist at that time, felt the resident was no longer a candidate for PT. An occupational therapy (OT) evaluation, dated 06/06/12 stated, "When OT has observed res., he has been sleeping and neck has been extended at 20 (degrees) to 30 (degrees). Res cognitive fxn'ing (functioning) has been steadily declining resulting in a (decrease) in ADL and mobility status. OT does not feel resident is appropriate for therapy due to cognitive - unable to follow any commands, and resident does not appear in distress or pain." The resident did receive PT from 09/16/11 to 11/01/11. The last OT evaluation was conducted on 12/05/12. It stated there were no changes from the previous review on 08/12/12. The restorative order for leg stretches ended on 08/01/12 after discussion between the restorative nurse and the physical therapist. The physical therapist felt the resident had reached his maximum potential and had no possibility for improvement past that point. There was documentation of this conversation between the restorative, registered nurse (RN) and the physical therapist. Review of the care plan, on 01/15/13 at 12:30 p.m., revealed there was no care plan in place to address further decline in ROM for this resident. In addition, there was no care plan to address potential pain for this resident with severely limited mobility. Observation of the resident was conducted in his room, at 1:05 p.m. on 01/15/13, accompanied by physical therapist, Employee #109, and restorative aide (RA), Employee #114. The physical therapist stated the resident's left hand had potential for contracture, but was not yet a contracture. He stated the hand was "tight." The resident attempted to pull his hand away when the physical therapist was touching it. The resident was verbal at this time and stated, "Your hands are cold." The physical therapist stated he would speak with occupational therapist, Employee #112 tomorrow, as she was not in the building that day, and see if she was aware of the drawing of the resident's left hand, since she stated "no changes" on her last OT Screen dated 12/05/12. At this time, the RA, Employee #114, stated the resident would "Resist stretching of the lower extremities, and he wouldn't relax his legs. We even tried to do stretches on the resident while he was lying down but he would become agitated. We would return later and try again. So we eventually stopped the restorative nursing program therapy." A discussion was held with the restorative nurse, an RN, Employee #8, at 2:10 p.m. on 01/15/13. She stated they had what was called a 'Pace Form' that was given to therapy for therapy screens on all residents. This screening was set for the date of the resident's quarterly MDS Assessment Reference Date (ARD). This way, it was assured all residents were evaluated by therapy every three (3) months. She presented a copy of the PACE schedule. This resident was due again for evaluation on 03/26/13, which was three (3) months since the last therapy screen. However, it was decided OT would evaluate the resident's left hand the following day, on 01/16/13. At 3:30 p.m. on 01/16/13, the DON presented a copy of a newly created policy addressing discontinued restorative therapy. The new policy was regarding continuing assessment of the resident by the restorative nurse. These assessments were to be done between therapy screens for this resident population. An interview was conducted with the occupational therapist, Employee #112, on 01/16/12 at 9:45 a.m.. She stated she had screened the resident for the issue with the left hand. She said the resident had some deviation to the thumbs. In her OT note dated 01/16/13, she stated the resident had "a palmer adduction contracture B of thumbs." According to the occupational therapist, splinting would increase pain for the resident. She stated she was able to open the resident's left hand without difficulty. She said she would speak to the restorative nurse, Employee #8, to see if the resident could be picked up again for restorative ROM. During an interview with the restorative nurse, at 10:30 a.m. on 01/16/13, she stated restorative nursing would pick this resident back up for ROM to all extremities three to five (3-5) times a week. .

Based on medical record review and staff interviews, the facility failed to ensure two (2) of five (5) Stage II sample residents, reviewed for urinary tract infections (UTIs), received necessary treatment and services to prevent urinary tract infections. There was no evidence causal factors for the urinary tract infections were assessed, and no evidence of individualized interventions to prevent the recurrent UTIs. In addition, the facility failed to provide prompt interventions when a UTI was diagnosed . Resident identifiers: #15 and #31. Facility census: 88. Findings include: a) Resident #15 On 01/14/13 this resident's medical record was reviewed. The minimum data sets (MDSs) with assessment reference dates (ARDs) of 10/01/12 and 12/23/12 , both revealed [DIAGNOSES REDACTED]. Review of medical records revealed episodic plans of care for UTI's dated 09/21/12, 12/07/12, 12/19/12 and 01/03/13; however, the facility did not have an ongoing care plan for this resident's recurrent UTIs. Review of laboratory (lab) results revealed Resident #15 was diagnosed with [REDACTED]. This included 06/08/12, 07/16/12, 09/19/12, 10/01/12, 12/03/12, 12/17/12, and 01/01/13. Six (6) of these seven (7) lab results were positive for Escherichia-coli. The UTI on 10/01/12 was positive for Proteus mirabilis. The only intervention for each of these infections was the provision of antibiotics. There were no interventions related to the prevention of UTIs for this resident. On 01/14/13, during Stage II of the survey, the facility was informed about the findings of multiple UTIs for Resident #15. The infection control nurse, Employee #7, was asked to provide evidence of staff education, care planning, and/or any interventions for Resident #15, in an effort to determine causal factors and/or provide interventions to prevent the recurrent UTIs. Instead of providing evidence of interventions, on 01/16/13 at 4:00 p.m., Employee #7 presented documentation of the provision of an in-service, regarding the prevention of UTIs/personal hygiene, which the facility provided nursing personnel on 01/15/13 and 01/16/13, after the problem was brought to the attention of the facility during the survey. No evidence was provided which verified the facility had addressed the recurrent UTI's Resident #15 was experiencing. Upon inquiry on 01/16/13, Employee #59, medical records, provided a copy of Resident #15's most recent urology consultation, dated 03/24/10. The consultation was scheduled due to the resident's UTIs. An antibiotic was ordered and a follow-up appointment was set for 03/31/11. The resident did not go to this appointment. As of 01/17/13, there was no evidence of a consultation after 03/24/10. On 01/16/13 at 4:00 p.m., Employee #59 stated the resident was too sick to go to the appointment on 03/24/10. Employee #59 confirmed the facility did not reschedule a urological follow-up appointment for the resident. . . b) Resident #31 Record review revealed a urinalysis, completed on 12/07/12, was positive for a urinary tract infection. The report indicated cloudiness, a large amount of blood, protein, leukocytes and white blood cells in the urine, and a 1+ (one plus) in bacteria. The accompanying urine culture reported a colony count of greater than 100,000 for two (2) organisms. A notation on the bottom of the urinalysis report and the culture report indicated the results were faxed to the physician on 12/08/12 and 12/10/12 respectively. A nurse progress note, dated 12/16/12 at 3:24 p.m., was reviewed. This revealed the resident's breaths on expiration were with grunts, and the spouse spoke her belief the resident might have a urinary tract infection. According to the same nurse progress note, a licensed nurse, Employee #16, called the physician and reviewed the urine culture results with him. "Results indicated IV (intravenous) antibiotics needed." Review of a nurse's progress note, dated 12/16/12 at 9:50 p.m., revealed the resident was short of breath at shift change. His wife requested he be transferred to a hospital for treatment, rather than receiving IV antibiotics at the facility. The emergency squad transported him out of the building. During interview with a licensed nurse, Employee #10, on 01/16/13 at 10:45 a.m., she said she faxed the urinalysis report to the physician on 12/08/12, and stated another licensed nurse, Employee #21, faxed the physician with the urine culture and sensitivity report on 12/10/12. Employee #10 said the physician had returned from deployment around that time and changed offices. She surmised the faxes sent may have gotten misplaced in the office building, or the fax numbers may have changed during the transition. Further review of the urine and culture laboratory results, found the physician signed and dated them on 12/26/12, and added he did not receive the results on the date noted on the lab forms. Review of a discharge summary, dated 12/26/12, found the resident left the facility at his wife's request to go to the hospital. Pertinent diagnostic findings included altered mental status and shortness of breath. During an interview with the Director of Nursing (DON), on 01/16/13 at 11:00 a.m.. she said she was not sure where "the ball was dropped." She said the urinalysis report and the culture and sensitivity report would have been known by the nurses who faxed them. Also, the infection control nurse would have received a copy of the results. Furthermore, the culture results should have been placed on the 24 hour shift report, and the nurse manager should have been alerted to the results of the colony counts over 100,000. As for the original laboratory forms, they should have been either placed in the physician's folder, or filed on the chart, with a sticker to note that the doctor needed to sign it upon his next visit to the facility. .

Based on observation, review of self-reported events, staff interview, review of quality assessment and assurance (QAA) committee meeting minutes offered by the facility, medical record review, review of incident / accident reports, and review of the facility's policy and procedure room transfers, the facility's quality assessment and assurance (QAA) committee failed to implement an action plan to ensure the safety of residents sharing a room with Resident #26, upon his return from a psychiatric hospital after being evaluated for possible aggressive tendencies towards others. Resident #26 shared a 3-bed room with Residents #38 and #77. On the early morning of [DATE], staff responding to Resident #26's call light found Resident #38 on the floor positioned with his pads, bed linens, and positioning wedge placed on and under him as if he were still in bed; Resident #38 was not capable of having transferred out of bed himself. On the late night of [DATE], staff found Resident #38's legs had been repositioned in bed in a different position than one in which staff had put him during their previous rounds. The nurse directed staff to monitor all residents in this room every twenty (20) minutes, because Resident #38 was not physically able to move himself, Resident #77 was not physically able to independently transfer out of his own bed, and Resident #26 was behaving in a suspicious manner. During these monitoring rounds, in the early morning hours of [DATE], staff found Resident #38's legs again had been repositioned, and staff found a pillow had been placed over the face of Resident #77. In [DATE], Resident #26 had shared this same room with another resident (#87) who was also found by staff at that time to have a pillow placed over his face. In response to these findings, the facility met with Resident #26's guardian, who agreed to allow him to be evaluated at a psychiatric hospital. Prior to his transfer on [DATE], the facility stationed a staff member in the room at all times to monitor the residents for safety. Resident #26 returned to the facility on [DATE], to the same room shared with Residents #38 and #77. Although the aftercare plan from the psychiatric hospital included the recommendation that the nursing home "observe / assess need for further treatment", the facility failed to review / revise Resident #26's care plan to address this. Upon his return, no additional supervision and/or assistive devices were put into place to monitor Resident #26 (especially at night) and/or ensure the ongoing safety of Residents #38 and #77. This placed Residents #38 and #77 in immediate jeopardy. The facility's QAA committee failed, upon Resident #26's return to the facility, to implement measures to ensure the safety of Residents #38 and #77, even though staff strongly suspected Resident #26 of having removed Resident #38 from his bed on the early morning on [DATE], repositioned Resident #38 in his bed on the late evening of [DATE], and placed a pillow over the face of Resident #77 on the early morning of [DATE], especially in light of having found a previous roommate of Resident #87 with a pillow over his face in [DATE]. Facility census: 87. Findings include: a) Residents #26, #38, and #77 1. Observation, during tour beginning at 9:30 a.m. on [DATE], found Residents #26, #38, and #77 sharing the same 3-bed room. - 2. On [DATE] at 10:25 a.m., review of events self-reported by the facility to the State survey and certification agency during the previous three (3) months revealed the following "unusual occurrence": "On [DATE] at 2:30 a.m. the C.N.A. (certified nursing assistant) had entered the room to respond to Resident (#26) call light when Resident (#38) was found on floor beside his bed. Resident (#38) was found on floor still covered in blankets with pink pad under him and wedge cushion behind his back. " ... due to Resident (#38) need for total assistance with ADL's that (sic) this incident did not appear to be the result of the resident falling out of bed. There is concern that he may have had assistance from his roommate. ... Residents in room will be monitored by staff at more frequent intervals. ... "Another incident occurred in this same room on the this same date of [DATE] where Resident (#77) was observed by nursing staff with a pillow over his face during the early a.m. (morning) interval checks. Resident (#77) did not know how the pillow got on his face. There were no apparent injuries to either resident." According to a message confirmation report, this "unusual occurrence" was faxed to the State survey agency at 2:45 p.m. on [DATE]. - 3. Review of the medical records for Residents #38 and #77 found entries in the nursing notes relating the same information as stated in the unusual occurrence report mentioned above. - Review of Resident #38's most recent resident assessment, a Medicare 14-day assessment with an assessment reference date (ARD) of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was alert with long and short term memory problems, he was not oriented to person, place, or season, he was unable to communicate with others, and he was totally dependent upon staff for all ADLs, including bed mobility and transferring. - Review of Resident #77's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. He was alert and oriented and independent with his cognitive skills for daily decision-making, and he required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. His [DIAGNOSES REDACTED]. - Review of Resident #26's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being "modified independence"; he was independent with ADLs. His [DIAGNOSES REDACTED]. - Review of nursing notes in Resident #26's record found no entry by the nurse on the night shift from [DATE] to [DATE]. An entry, recorded by the nurse during the night shift from [DATE] to [DATE] (at 2:00 a.m. on [DATE]), stated, "Resident up most of the night walking around the room. Denies pain or discomfort." - Review of Resident #26's Plan of Care Kardex for the month of [DATE] found several notes recorded by nursing assistants, starting on [DATE], regarding Resident #26's behavior towards his roommates. On [DATE] (no time or shift noted), a nursing assistant wrote: "Res (resident) was standing behind the curtain between his bed and (Resident #38 ' s) bed, ask (sic) him what he was doing & Resident stated he wasn't doing anything. CNA (initials of nursing assistant) ask (sic) him to go lay down in his bed or if he couldn't sleep to sit in his chair, that he just couldn't mess with his Room-mate (sic) (Resident #38) or Room-mates (sic) things. He said all right." Another note on [DATE] (identified as being written on the 7:00 a.m. to 3:00 p.m. shift) stated, "Res stands behind curtains when your (sic) trying to give care to roommate." On [DATE], a nursing assistant wrote: "Res standing behind the curtain when giving care to roommate" Another entry (no date / time) stated, "Resident got upset when taking roommate to Bathroom (sic)." - On the reverse side of Resident #26's [DATE] ADL flow record, a nursing assistant wrote, on [DATE], "Resident behind curtain looking and trying to see the patient when staff was giving care." - Review of the physician's progress notes for Resident #26 found the following entries: - On [DATE]: "I was called last night by (facility) to call (name of administrator), which I did. She related they had a concern about (Resident #26), that in the room he has 2 other roommates, (Resident #38) and (Resident #77). (Resident #38) was found in the floor twice reported by staff. (Resident #38) is not able to move himself. The staff became suspicious then they went over to see (Resident #77) and a pillow was on his head. When they asked (Resident #77) if he was ok (sic) he said yes (sic) and they asked him how the pillow got there (sic) and he related he did not know how. (Resident #26) had been up during the night. He had gone to the bathroom, (sic) in the morning it was reported to (name of administrator) that something suspicious was going on and they fear it would be (Resident #26). They discussed it with the daughter (of Resident #26) who was upset. They discussed there was (sic) odd behaviors that had gone on with he (sic) and (Resident #87 - previous roommate who is now deceased ) (sic) however they did not get along. I called to talk to the daughter and she was at (facility). She wanted me to come down and talk to her (sic) which I did, this was about 8pm. ... I told her we should have an evaluation by doctor in (name of psychiatric hospital). ..." (Interview with the administrator, on the morning of [DATE], verified that Resident #38 was found on the floor only once, contrary to what was stated above, although his feet were found to have been moved towards the side of the bed on two (2) separate occasions - which the resident was not capable of doing himself.) - On [DATE]: "We had a family conference today with the daughter, sister, (name of regional ombudsman), Director (sic) of nurses and myself. We discussed (Resident #26). My recommendation is that he got to (city name) to be evaluated. ... I did discuss with her (daughter / guardian of Resident #26) the night before that he and (Resident #87 - previous roommate no longer at the facility) had some disagreements ... At one time there was a pillow that was found beside (Resident #87) and a pillow was found over his face. ... She knows (Resident #38) was found in the floor. He can not (sic) move himself. Then (Resident #77) was found with a pillow over his head. ... The daughter understands we did not see (Resident #26) do this. We do not know what happened. ... I told her to be safe it was important for him to evaluated. ..." - 4. A quality assurance (QA) committee plan of correction, generated on [DATE] and provided for review to the surveyor by the facility's administrator at 8:00 a.m. on [DATE], revealed the incident involving Resident #38 occurred on the night shift that ran from [DATE] to [DATE], and the incident involving Resident #77 occurred on the night shift that ran from [DATE] to [DATE]; they did not occur within the same 8-hour shift on [DATE]. This [DATE] QA committee plan of correction stated: "On Monday morning, [DATE], (name) DON (director of nursing) was notified by the nursing staff that there had been a concern with residents in room (Number of room shared by Residents #26, #38, and #77) on Sunday and in the early morning hours of Monday. At approximately 2:30 a.m. resident (#26) had rung his call bell. When the staff responded they observed resident (#38) lying in the floor. When they asked resident (#26) what he needed he said 'nothing'. Resident (#38) was lying in the floor with his under pads, covers and wedge cushion in place. On [DATE] at approximately 11:30 p.m. resident (#38) was observed with his feet over the right side of the bed and at 12:15 a.m. on [DATE] resident (#38) was again observed with his feet over the left side of the bed. Resident (#77) was observed at 12:30 a.m. with a pillow over his face. ... "INVESTIGATION FINDINGS AND INTERVENTIONS TO CORRECT THE PROBLEM: "- Resident (#38) is totally dependent upon staff for bed mobility, transfers, ADLS (activities of daily living) and feeding. "- Call bell is in place for resident (#38) at all times; however, resident does not use call bell independently. "- Resident (#38) is turned and repositioned q2hrs (every two hours) by staff. "- Resident (#77) voices needs and wants to staff, rings call bell independently, requires extensive assist of one with bed mobility, transfers with two and dressing, personal hygiene and bathing with the assist of one. "- Resident (#26) is independent with all ADLs, mobility, ambulates through out (sic) the facility independently, voices needs and wants to staff and rings call bell for assistance as needed. "- Resident (#26) has documented behaviors related to past roommates. ..." According to the administrator, due to Resident #26's past behaviors towards roommates and Resident #38's inability to move on his own and his position on the floor with covers and wedge in place, staff questioned whether Resident #26 was involved in removing Resident #38 from bed to floor and his moving feet over the sides of the bed. Staff also questioned whether Resident #26 placed the pillow over Resident #77's face. Checks of the room shared by these three (3) residents were made every twenty (20) minutes for the remainder of the night shift ending on the morning of [DATE]. Staff communicated with the responsible parties of all residents involved and made arrangements to transfer Resident #26 to a psychiatric hospital for evaluation. Until this transfer could be accomplished, the facility assigned a staff member to remain at all times in the room shared by these three (3) residents, since the responsible parties of the residents all refused to allow their family member to be relocated for safety. - 5. Resident #26's guardian agreed to allow him to be transferred to a psychiatric unit for evaluation. According to the nursing notes, the resident was transferred from the facility to the psychiatric hospital at about 2:30 p.m. on [DATE]. - 6. Resident #26 was readmitted to the facility on [DATE] and was placed back into the same room with his previous roommates, Residents #38 and #77. Review of the aftercare plan from the psychiatric hospital, dated [DATE], found the resident was initially admitted for agitation, aggression, and sexually inappropriate behavior. Under the heading "Patient Treatment Goals / Progress", staff at the psychiatric hospital wrote: "Patient has not displayed any agitation or aggression since admission and had not had any sexually inappropriate behavior for several days." Under the heading "Diagnosis" was written: "Axis I: Dementia, AD ([MEDICAL CONDITION]) type /c (with) depressed mood and behavioral disturbance. Axis II: Schizoid Personality D/O (disorder). ... Axis IV: NH (nursing home) placement. ..." Under the heading "Discharge Recommendations / Plan" was written: "NH to observe and assess for further treatment." An interview with the administrator, on [DATE] at 4:00 p.m., found Resident #26's guardian refused to allow the resident to be moved. She also indicated Residents #38's responsible party and Resident #77 (who had capacity) did not want to change rooms. - 7. In an interview on [DATE] at 8:30 a.m., the medical director acknowledged her awareness of the situation regarding Resident #26. She had questions about the ability to move a resident to another without the health care decision maker's consent. On [DATE] between 8:30 a.m. and 9:45 a.m., intermittent observations made with the medical director found all three (3) residents together in the same room with no specific measures in place to ensure the safety of the roommates. At 9:45 a.m. on [DATE], the facility's "Resident Transfer" policy (no date), was requested of and provided for review by the administrator. Review of the policy revealed the following: "Policy: 1. Transfer of Residents Within the Manor: ... C. In the case of emergency the facility reserves the right to make a move but will notify the resident or their responsible party." "Procedure: Transfer of Patient: ... 8. Due to changes in patient's condition, we reserve the right to transfer the patient to the area where we can best meet his or her needs." This information was shared with the medical director. - 8. One (1) of the facility's social workers, (Employee #52) was interviewed at 10:30 a.m. on [DATE]. She sat in on a meeting with Resident #26, his daughter / guardian, and his sister on [DATE]. The resident was sent to the psych unit to determine if he had tendencies to be physically aggressive towards other residents. - 9. Employee #19 (the LPN who completed the above-referenced incident reports for Residents #38 and #77) provided handwritten notes, as well as documentation of observations made by staff of Residents #26 and #38 every twenty (20) minutes from 1:00 a.m. to 6:20 a.m. on [DATE], to the director of nursing (DON) on [DATE]. The DON provided copies of this documentation for review to this nurse surveyor at 10:40 a.m. on [DATE]. The first note stated: "On [DATE] at 2:30 AM (sic) The CNA's were responding to (Resident #26)'s call light. When they went into the room he said he didn't need anything and that's (sic) when they found (Resident #38) lying on the floor. On the (L) side of the bed on his back. He still had his pads underneath him & his blankets were wrapped around him and the wedge they place behind his back was tucked under his (L) side. Both bedrails were also up. Prior to him being in the floor (sic) (Resident #38) was positioned in bed on his (R) side /c (with) the wedge behind his back. I am letting you know about this b/c (because) I find his falling in the floor suspicious and don't see how he could have ended up in the floor like that on his own." - The second note stated: "Just for clarification - On ,[DATE] @ 2:30 AM (Resident #38) was in the floor on the (L) side of his bed in between the bed & the rocker chair. He was on his back /c pads underneath him & blankets wrapped around his legs & the wedge was underneath his (L) hand side. His bed rails were up & his bed was in (sic) low position. Prior to him being in the floor he was positioned on his (R) side /c wedge behind him on the left side of his back. "On ,[DATE] @ 1130 PM when walking up the hall his feet were pulled to the (R) side of the bed and he was laying (sic) on his (R) side. "At 12:15 AM - now [DATE] Resident was lying on (R) side and his feet were pulled to the (L) side of the bed. "After that is when we found (Resident #77) with the pillow on his face. "That's (sic) when I initiated the 20 minute check paper for the CNA to fill out." (During an interview on [DATE] at 5:15 p.m., Employee #19 verified her statements.) - 10. The DON, when interviewed on [DATE] at 10:45 a.m., reported a resident service provider (RSP) was assigned to provide one-on-one supervision of Resident #26 from [DATE] at 2:30 p.m. through [DATE] at 2:30 p.m., when he went to the hospital. The DON reported became suspicious of Resident #26's behavior after she reviewed the 24-hour shift reports for [DATE] and [DATE], which indicated Resident #38 was found on the floor during the early morning hours on [DATE] (on the night shift starting on [DATE]) and was found two (2) times with his feet hanging off the bed during the night shift starting on [DATE]. Documentation on the 24-hour shift report for [DATE] stated, "[DATE] 2:30 a.m. Resident (#38) found in floor no apparent injury. Family (MPOA) needs to be notified" and "fell last noc (night). Be sure he is in middle of bed." For Resident #77, staff recorded "Lethargic". There was no entry for Resident #26. Documentation on the 24-hour shift report for [DATE] for Resident #38 stated, "Ntd (noted) feet off bed 2X's (two times) throughout night ... call family any time day and night." For Resident #77, staff recorded, "Lethargic [DATE]; wouldn't take 6 a.m. meds [DATE] c/o (complaint of) pain; admitted to hosp with UTI." For Resident #26, staff recorded, "Restless up in room several X's throughout night." - 11. Review of the closed record of Resident #87 (identified in the [DATE] physician ' s progress note as Resident #26's previous roommate) found a nursing note, dated [DATE] at 2:10 p.m., stating, "CNA reported as she came up the hall (sic) resident had a pillow across his face. ..." At the time of this occurrence, Resident #87 shared the same 3-bed room with Resident #26, and the third bed was unoccupied. The DON verified, in an interview at 10:30 a.m. on [DATE], there were no other residents in the room at the time of this incident. Review of Resident #26's thinned records from 2009 found the following regarding his interactions with Resident #87: On [DATE] (no time given), " ... Later, resident came up to nurse's med cart, watched as nurse was attempting to give roommate (Resident #87) his med. Roommate accidentally ran over nurse's foot. Resident then states to nurse (sic) know what you should do /c the 'bastard'. I've popped him a couple of times. (sic) I asked resident if (sic) had hit the roommate, he stated yes. ..." - 12. Review of Resident #26's care plan, revised on [DATE] with target dates for goal achievement of [DATE], found the following problem (P), goal (G), and interventions (I) with an initiation date of [DATE]: P: "Mood problem AEB (as evidence by): Resident becomes easily annoyed with staff and others (particularly his roommate) at times R/T (related to) depression, and dementia, [MEDICAL CONDITION] diagnosis, hx (history) of episodes of agitation." G: "Will have improved mood state AEB: calmer appearance, with no more then (sic) 2 episodes weekly of becoming easily annoyed with his roommate or any other S/S (signs / symptoms) of depression, anxiety or sad mood by review date." (The revised review date for this goal was [DATE].) I: "Assist in developing more appropriate methods of coping and interacting. Encourage to express feelings appropriately, let staff know when s/he (sic) is getting upset; Administer medications as ordered and monitor for side effects, effectiveness; Observed mood patterns and document S/S of depression, anxiety, sad mood; Ongoing assessment, attempt to determine if problems seems to be related to external causes, ie medications, treatments, concerns over diagnosis, noise level or pain; Spend time talking to resident, family. Encourage to express feelings; Assist resident to identify strengths, positive coping skills and reinforce these; Invite to attend activities and encourage participation." The interdisciplinary team also addressed the following problem, also with an initiation date of [DATE]: "Potential for increased behavior problems R/T: [DIAGNOSES REDACTED]." The goal for this problem statement was: "Resident will continue to have not episodes of socially inappropriate behavior weekly by review date." (The revised review date for this goal was [DATE].) The interventions included: " ... Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, situations. Document behavior and potential causes; Intervene as needed to protect the rights and safety of others. Approach / speak in calm manner. Divert attention. Remove from situation and take to another location as needed. ..." The care plan did not describe what these "socially inappropriate behaviors" were. There was no evidence to reflect the care plan was revised upon Resident #26's return to the facility on [DATE], to address the need to "observe / assess for further treatment" - as directed in the aftercare plan resulting from his stay at the psychiatric hospital. There was no plan to reinstitute either of the monitoring activities that had been in place prior to his transfer to the psychiatric facility (every twenty (20) minutes beginning on [DATE] or direct supervision of the room shared by these three (3) residents at all times beginning on [DATE]) - especially at night. - 13. At [DATE] at 11:00 a.m., the administrator, medical director, DON, social worker (Employee #52), and the clinical care coordinator (Employee 33) were informed the nurse surveyor identified that Residents #38 and #77 were in immediate jeopardy, as Resident #26 returned to the same room following his discharge from the psychiatric hospital, and the facility failed to implement any measures (e.g., additional monitoring / supervision) to ensure the residents in this room were safe. A plan of correction was requested. - 14. A plan of correction, given to the surveyor on [DATE] at 11:20 a.m., was reviewed and returned to the administrator for revision. At 11:40 a.m., a revised plan of correction was given to the surveyor, reviewed, and accepted at 11:45 a.m. The revised plan of correction stated: "To correct the safety issues identified during the survey this date, with residents (#26), (#18), and (#77), a room change will be made. Resident (#26) will be moved into room (number of room on second floor). Resident (name) who is currently in room (number of room now occupied by Resident #26) will be moved to (number of room previously occupied by Resident #26). "Monitoring of resident (#26) will be accomplished by the following: Resident will be in a room by himself. This room is located close to the nurses (sic) station in direct line of all traffic. Nurses or Certified Nursing Assistants will check on him on an hourly basis for any abnormal behaviors. Psychiatric evaluation or placement will be pursued if behavior warrants. Documentation of all abnormal behavior will be monitored on a daily basis by nursing staff." - 15. On [DATE] at 1:30 p.m., after Resident #26 was relocated and this was verified by direct observation, the administrator was notified the immediate jeopardy was lifted. - 16. During an interview on [DATE] at 6:45 p.m., a nursing assistant (Employee #34) confirmed he found a pillow over Resident #77's face at about 12:30 a.m. on [DATE]. He indicated he had last checked on the resident at 12:00 a.m. on [DATE]. He documented twenty (20) minute checks on Residents #26 and #38 from 1:00 a.m. through 6:20 a.m. on [DATE]. (A copy of this documentation was provided by the DON on [DATE] at 10:40 a.m.). - 17. On [DATE] at 9:00 a.m., the administrator presented evidence that inservices were held [DATE] with staff who provide care to Resident #26. The memorandum on which this inservice was documented, issued by the DON, had in its subject line: "Precautions related to (Resident #26)". In the body of the memorandum was: "(Resident #26) needs to be monitored every hour for behaviors that may affect self or others and documented on appropriate form. (Resident #26) needs to be documented on each shift in the nurses notes related to behaviors whether there are any or not. "Concerns for (Resident #26) possibly being of danger to other residents has (sic) prompted this." The bottom of the memorandum contained the signatures of nursing staff. - The facility also revised the care plan for Resident #26 on [DATE], to include the following: P - "Potential for increased behaviors (physical aggressive (sic) staff or residents) (sexual inappropriate (sic) with staff) (attempting to harm residents) R/T (related to) [DIAGNOSES REDACTED]." G - "Resident will have less than weekly episodes of socially inappropriate behaviors by review date." G - "Resident will have no episodes of attempting harm other residents through review date." Interventions included: "Nursing staff will do hourly checks on resident for behaviors. Nurses will document q (every) shift on behaviors; Resident has been moved to a private room. Psychiatric evaluation and treatment as ordered." - 18. The facility's QAA committee failed, upon Resident #26's return to the facility, to implement measures to ensure the safety of Residents #38 and #77, even though staff strongly suspected Resident #26 of having removed Resident #38 from his bed on the early morning on [DATE], repositioned Resident #38 in his bed on the late evening of [DATE], and placed a pillow over the face of Resident #77 on the early morning of [DATE], especially in light of having found a previous roommate of Resident #87 with a pillow over his face in [DATE].

Based on observation, review of self-reported events, staff interview, review of quality assurance (QA) committee meeting minutes offered by the facility, medical record review, review of incident / accident reports, and review of the facility's policy and procedure room transfers, the facility failed to provide adequate supervision and/or assistive devices to ensure the safety of two (2) residents who shared a room with a third resident whom staff believed placed the roommates at risk for harm. Resident #26 shared a 3-bed room with Residents #38 and #77. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being "modified independence"; he was also independent with activities of daily living (ADLs). Resident #38 was alert with severely impaired cognitive skills for daily decision-making; he did not communicate with others and was totally dependent with ADLs. Resident #77 was alert, oriented, and independent with daily decision-making, required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. On the early morning of [DATE], staff responding to Resident #26's call light found Resident #38 on the floor positioned with his pads, bed linens, and positioning wedge placed on and under him as if he were still in bed; Resident #38 was not capable of having transferred out of bed himself. On the late night of [DATE], staff found Resident #38's legs had been repositioned in bed in a different position than one in which staff had put him during their previous rounds. The nurse directed staff to monitor all residents in this room every twenty (20) minutes, because Resident #38 was not physically able to move himself, Resident #77 was not physically able to independently transfer out of his own bed, and Resident #26 was behaving in a suspicious manner. During these monitoring rounds, in the early morning hours of [DATE], staff found Resident #38's legs again had been repositioned, and staff found a pillow had been placed over the face of Resident #77. In [DATE], Resident #26 had shared this same room with another resident (#87) who was also found by staff at that time to have a pillow placed over his face. In response to these findings, the facility met with Resident #26's guardian, who agreed to allow him to be evaluated at a psychiatric hospital. Prior to his transfer on [DATE], the facility stationed a staff member in the room at all times to monitor the residents for safety. Resident #26 returned to the facility on [DATE], to the same room shared with Residents #38 and #77. Although the aftercare plan from the psychiatric hospital included the recommendation that the nursing home "observe / assess need for further treatment", the facility failed to review / revise Resident #26's care plan to address this. Upon his return, no additional supervision and/or assistive devices were put into place to monitor Resident #26 (especially at night) and/or ensure the ongoing safety of Residents #38 and #77. This placed Residents #38 and #77 in immediate jeopardy. On [DATE] at 11:00 a.m., the administrator, medical director, director of nursing, social worker (Employee #52), and the clinical care coordinator (Employee #33) were notified of the finding of immediate jeopardy. At 11:40 a.m. on [DATE], the administrator provided an action plan, which was reviewed and accepted by the nurse surveyor at 11:45 a.m. The action plan included the following steps: Resident #26 was transferred to a private room on another floor, staff was instructed to observe and record Resident #26's behavior on an hourly basis, and Resident #26's care plan was revised to reflect these actions. On [DATE] at 1:30 p.m., the nurse surveyor verified that Resident #26 was relocated, and the immediate jeopardy was removed with no deficient practice remaining. Facility census: 87. Findings include: a) Residents #26, #38, and #77 1. Observation, during tour beginning at 9:30 a.m. on [DATE], found Residents #26, #38, and #77 sharing the same 3-bed room. - 2. On [DATE] at 10:25 a.m., review of events self-reported by the facility to the State survey and certification agency during the previous three (3) months revealed the following "unusual occurrence": "On [DATE] at 2:30 a.m. the C.N.A. (certified nursing assistant) had entered the room to respond to Resident (#26) call light when Resident (#38) was found on floor beside his bed. Resident (#38) was found on floor still covered in blankets with pink pad under him and wedge cushion behind his back. "... due to Resident (#38) need for total assistance with ADL's that (sic) this incident did not appear to be the result of the resident falling out of bed. There is concern that he may have had assistance from his roommate. ... Residents in room will be monitored by staff at more frequent intervals. ... "Another incident occurred in this same room on the this same date of [DATE] where Resident (#77) was observed by nursing staff with a pillow over his face during the early a.m. (morning) interval checks. Resident (#77) did not know how the pillow got on his face. There were no apparent injuries to either resident." According to a message confirmation report, this "unusual occurrence" was faxed to the State survey agency at 2:45 p.m. on [DATE]. - 3. Review of the medical records for Residents #38 and #77 found entries in the nursing notes relating the same information as stated in the unusual occurrence report mentioned above. - Review of Resident #38's most recent resident assessment, a Medicare 14-day assessment with an assessment reference date (ARD) of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was alert with long and short term memory problems, he was not oriented to person, place, or season, he was unable to communicate with others, and he was totally dependent upon staff for all ADLs, including bed mobility and transferring. - Review of Resident #77's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. He was alert and oriented and independent with his cognitive skills for daily decision-making, and he required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. His [DIAGNOSES REDACTED]. - Review of Resident #26's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being "modified independence"; he was independent with ADLs. His [DIAGNOSES REDACTED]. - Review of nursing notes in Resident #26's record found no entry by the nurse on the night shift from [DATE] to [DATE]. An entry, recorded by the nurse during the night shift from [DATE] to [DATE] (at 2:00 a.m. on [DATE]), stated, "Resident up most of the night walking around the room. Denies pain or discomfort." - Review of Resident #26's Plan of Care Kardex for the month of [DATE] found several notes recorded by nursing assistants, starting on [DATE], regarding Resident #26's behavior towards his roommates. On [DATE] (no time or shift noted), a nursing assistant wrote: "Res (resident) was standing behind the curtain between his bed and (Resident #38's) bed, ask (sic) him what he was doing & Resident stated he wasn't doing anything. CNA (initials of nursing assistant) ask (sic) him to go lay down in his bed or if he couldn't sleep to sit in his chair, that he just couldn't mess with his Room-mate (sic) (Resident #38) or Room-mates (sic) things. He said all right." Another note on [DATE] (identified as being written on the 7:00 a.m. to 3:00 p.m. shift) stated, "Res stands behind curtains when your (sic) trying to give care to roommate." On [DATE], a nursing assistant wrote: "Res standing behind the curtain when giving care to roommate" Another entry (no date / time) stated, "Resident got upset when taking roommate to Bathroom (sic)." - On the reverse side of Resident #26's [DATE] ADL flow record, a nursing assistant wrote, on [DATE], "Resident behind curtain looking and trying to see the patient when staff was giving care." - Review of the physician's progress notes for Resident #26 found the following entries: - On [DATE]: "I was called last night by (facility) to call (name of administrator), which I did. She related they had a concern about (Resident #26), that in the room he has 2 other roommates, (Resident #38) and (Resident #77). (Resident #38) was found in the floor twice reported by staff. (Resident #38) is not able to move himself. The staff became suspicious then they went over to see (Resident #77) and a pillow was on his head. When they asked (Resident #77) if he was ok (sic) he said yes (sic) and they asked him how the pillow got there (sic) and he related he did not know how. (Resident #26) had been up during the night. He had gone to the bathroom, (sic) in the morning it was reported to (name of administrator) that something suspicious was going on and they fear it would be (Resident #26). They discussed it with the daughter (of Resident #26) who was upset. They discussed there was (sic) odd behaviors that had gone on with he (sic) and (Resident #87 - previous roommate who is now deceased ) (sic) however they did not get along. I called to talk to the daughter and she was at (facility). She wanted me to come down and talk to her (sic) which I did, this was about 8pm. ... I told her we should have an evaluation by doctor in (name of psychiatric hospital). ..." (Interview with the administrator, on the morning of [DATE], verified that Resident #38 was found on the floor only once, contrary to what was stated above, although his feet were found to have been moved towards the side of the bed on two (2) separate occasions - which the resident was not capable of doing himself.) - On [DATE]: "We had a family conference today with the daughter, sister, (name of regional ombudsman), Director (sic) of nurses and myself. We discussed (Resident #26). My recommendation is that he got to (city name) to be evaluated. ... I did discuss with her (daughter / guardian of Resident #26) the night before that he and (Resident #87 - previous roommate no longer at the facility) had some disagreements ... At one time there was a pillow that was found beside (Resident #87) and a pillow was found over his face. ... She knows (Resident #38) was found in the floor. He can not (sic) move himself. Then (Resident #77) was found with a pillow over his head. ... The daughter understands we did not see (Resident #26) do this. We do not know what happened. ... I told her to be safe it was important for him to evaluated. ..." - 4. A QA committee plan of correction, generated on [DATE] and provided for review to the surveyor by the facility's administrator at 8:00 a.m. on [DATE], revealed the incident involving Resident #38 occurred on the night shift that ran from [DATE] to [DATE], and the incident involving Resident #77 occurred on the night shift that ran from [DATE] to [DATE]; they did not occur within the same 8-hour shift on [DATE]. This [DATE] QA committee plan of correction stated: "On Monday morning, [DATE], (name) DON (director of nursing) was notified by the nursing staff that there had been a concern with residents in room (Number of room shared by Residents #26, #38, and #77) on Sunday and in the early morning hours of Monday. At approximately 2:30 a.m. resident (#26) had rung his call bell. When the staff responded they observed resident (#38) lying in the floor. When they asked resident (#26) what he needed he said 'nothing'. Resident (#38) was lying in the floor with his under pads, covers and wedge cushion in place. On [DATE] at approximately 11:30 p.m. resident (#38) was observed with his feet over the right side of the bed and at 12:15 a.m. on [DATE] resident (#38) was again observed with his feet over the left side of the bed. Resident (#77) was observed at 12:30 a.m. with a pillow over his face. ... "INVESTIGATION FINDINGS AND INTERVENTIONS TO CORRECT THE PROBLEM: "- Resident (#38) is totally dependent upon staff for bed mobility, transfers, ADLS (activities of daily living) and feeding. "- Call bell is in place for resident (#38) at all times; however, resident does not use call bell independently. "- Resident (#38) is turned and repositioned q2hrs (every two hours) by staff. "- Resident (#77) voices needs and wants to staff, rings call bell independently, requires extensive assist of one with bed mobility, transfers with two and dressing, personal hygiene and bathing with the assist of one. "- Resident (#26) is independent with all ADLs, mobility, ambulates through out (sic) the facility independently, voices needs and wants to staff and rings call bell for assistance as needed. "- Resident (#26) has documented behaviors related to past roommates. ..." According to the administrator, due to Resident #26's past behaviors towards roommates and Resident #38's inability to move on his own and his position on the floor with covers and wedge in place, staff questioned whether Resident #26 was involved in removing Resident #38 from bed to floor and his moving feet over the sides of the bed. Staff also questioned whether Resident #26 placed the pillow over Resident #77's face. Checks of the room shared by these three (3) residents were made every twenty (20) minutes for the remainder of the night shift ending on the morning of [DATE]. Staff communicated with the responsible parties of all residents involved and made arrangements to transfer Resident #26 to a psychiatric hospital for evaluation. Until this transfer could be accomplished, the facility assigned a staff member to remain at all times in the room shared by these three (3) residents, since the responsible parties of the residents all refused to allow their family member to be relocated for safety. - 5. Resident #26's guardian agreed to allow him to be transferred to a psychiatric unit for evaluation. According to the nursing notes, the resident was transferred from the facility to the psychiatric hospital at about 2:30 p.m. on [DATE]. - 6. Resident #26 was readmitted to the facility on [DATE] and was placed back into the same room with his previous roommates, Residents #38 and #77. Review of the aftercare plan from the psychiatric hospital, dated [DATE], found the resident was initially admitted for agitation, aggression, and sexually inappropriate behavior. Under the heading "Patient Treatment Goals / Progress", staff at the psychiatric hospital wrote: "Patient has not displayed any agitation or aggression since admission and had not had any sexually inappropriate behavior for several days." Under the heading "Diagnosis" was written: "Axis I: Dementia, AD (Alzheimer's disease) type /c (with) depressed mood and behavioral disturbance. Axis II: Schizoid Personality D/O (disorder). ... Axis IV: NH (nursing home) placement. ..." Under the heading "Discharge Recommendations / Plan" was written: "NH to observe and assess for further treatment." An interview with the administrator, on [DATE] at 4:00 p.m., found Resident #26's guardian refused to allow the resident to be moved. She also indicated Residents #38's responsible party and Resident #77 (who had capacity) did not want to change rooms. - 7. In an interview on [DATE] at 8:30 a.m., the medical director acknowledged her awareness of the situation regarding Resident #26. She had questions about the ability to move a resident to another without the health care decision maker's consent. On [DATE] between 8:30 a.m. and 9:45 a.m., intermittent observations made with the medical director found all three (3) residents together in the same room with no specific measures in place to ensure the safety of the roommates. At 9:45 a.m. on [DATE], the facility's "Resident Transfer" policy (no date), was requested of and provided for review by the administrator. Review of the policy revealed the following: "Policy: 1. Transfer of Residents Within the Manor: ... C. In the case of emergency the facility reserves the right to make a move but will notify the resident or their responsible party." "Procedure: Transfer of Patient: ... 8. Due to changes in patient's condition, we reserve the right to transfer the patient to the area where we can best meet his or her needs." This information was shared with the medical director. - 8. One (1) of the facility's social workers, (Employee #52) was interviewed at 10:30 a.m. on [DATE]. She sat in on a meeting with Resident #26, his daughter / guardian, and his sister on [DATE]. The resident was sent to the psych unit to determine if he had tendencies to be physically aggressive towards other residents. - 9. Employee #19 (the LPN who completed the above-referenced incident reports for Residents #38 and #77) provided handwritten notes, as well as documentation of observations made by staff of Residents #26 and #38 every twenty (20) minutes from 1:00 a.m. to 6:20 a.m. on [DATE], to the director of nursing (DON) on [DATE]. The DON provided copies of this documentation for review to this nurse surveyor at 10:40 a.m. on [DATE]. The first note stated: "On [DATE] at 2:30 AM (sic) The CNA's were responding to (Resident #26)'s call light. When they went into the room he said he didn't need anything and that's (sic) when they found (Resident #38) lying on the floor. On the (L) side of the bed on his back. He still had his pads underneath him & his blankets were wrapped around him and the wedge they place behind his back was tucked under his (L) side. Both bedrails were also up. Prior to him being in the floor (sic) (Resident #38) was positioned in bed on his (R) side /c (with) the wedge behind his back. I am letting you know about this b/c (because) I find his falling in the floor suspicious and don't see how he could have ended up in the floor like that on his own." - The second note stated: "Just for clarification - On ,[DATE] @ 2:30 AM (Resident #38) was in the floor on the (L) side of his bed in between the bed & the rocker chair. He was on his back /c pads underneath him & blankets wrapped around his legs & the wedge was underneath his (L) hand side. His bed rails were up & his bed was in (sic) low position. Prior to him being in the floor he was positioned on his (R) side /c wedge behind him on the left side of his back. "On ,[DATE] @ 1130 PM when walking up the hall his feet were pulled to the (R) side of the bed and he was laying (sic) on his (R) side. "At 12:15 AM - now [DATE] Resident was lying on (R) side and his feet were pulled to the (L) side of the bed. "After that is when we found (Resident #77) with the pillow on his face. "That's (sic) when I initiated the 20 minute check paper for the CNA to fill out." (During an interview on [DATE] at 5:15 p.m., Employee #19 verified her statements.) - 10. The DON, when interviewed on [DATE] at 10:45 a.m., reported a resident service provider (RSP) was assigned to provide one-on-one supervision of Resident #26 from [DATE] at 2:30 p.m. through [DATE] at 2:30 p.m., when he went to the hospital. The DON reported became suspicious of Resident #26's behavior after she reviewed the 24-hour shift reports for [DATE] and [DATE], which indicated Resident #38 was found on the floor during the early morning hours on [DATE] (on the night shift starting on [DATE]) and was found two (2) times with his feet hanging off the bed during the night shift starting on [DATE]. Documentation on the 24-hour shift report for [DATE] stated, "[DATE] 2:30 a.m. Resident (#38) found in floor no apparent injury. Family (MPOA) needs to be notified" and "fell last noc (night). Be sure he is in middle of bed." For Resident #77, staff recorded "Lethargic". There was no entry for Resident #26. Documentation on the 24-hour shift report for [DATE] for Resident #38 stated, "Ntd (noted) feet off bed 2X's (two times) throughout night ... call family any time day and night." For Resident #77, staff recorded, "Lethargic [DATE]; wouldn't take 6 a.m. meds [DATE] c/o (complaint of) pain; admitted to hosp with UTI." For Resident #26, staff recorded, "Restless up in room several X's throughout night." - 11. Review of the closed record of Resident #87 (identified in the [DATE] physician's progress note as Resident #26's previous roommate) found a nursing note, dated [DATE] at 2:10 p.m., stating, "CNA reported as she came up the hall (sic) resident had a pillow across his face. ..." At the time of this occurrence, Resident #87 shared the same 3-bed room with Resident #26, and the third bed was unoccupied. The DON verified, in an interview at 10:30 a.m. on [DATE], there were no other residents in the room at the time of this incident. Review of Resident #26's thinned records from 2009 found the following regarding his interactions with Resident #87: On [DATE] (no time given), " ... Later, resident came up to nurse's med cart, watched as nurse was attempting to give roommate (Resident #87) his med. Roommate accidentally ran over nurse's foot. Resident then states to nurse (sic) know what you should do /c the 'bastard'. I've popped him a couple of times. (sic) I asked resident if (sic) had hit the roommate, he stated yes. ..." - 12. Review of Resident #26's care plan, revised on [DATE] with target dates for goal achievement of [DATE], found the following problem (P), goal (G), and interventions (I) with an initiation date of [DATE]: P: "Mood problem AEB (as evidence by): Resident becomes easily annoyed with staff and others (particularly his roommate) at times R/T (related to) depression, and dementia, psychosis diagnosis, hx (history) of episodes of agitation." G: "Will have improved mood state AEB: calmer appearance, with no more then (sic) 2 episodes weekly of becoming easily annoyed with his roommate or any other S/S (signs / symptoms) of depression, anxiety or sad mood by review date." (The revised review date for this goal was [DATE].) I: "Assist in developing more appropriate methods of coping and interacting. Encourage to express feelings appropriately, let staff know when s/he (sic) is getting upset; Administer medications as ordered and monitor for side effects, effectiveness; Observed mood patterns and document S/S of depression, anxiety, sad mood; Ongoing assessment, attempt to determine if problems seems to be related to external causes, ie medications, treatments, concerns over diagnosis, noise level or pain; Spend time talking to resident, family. Encourage to express feelings; Assist resident to identify strengths, positive coping skills and reinforce these; Invite to attend activities and encourage participation." The interdisciplinary team also addressed the following problem, also with an initiation date of [DATE]: "Potential for increased behavior problems R/T: [DIAGNOSES REDACTED]." The goal for this problem statement was: "Resident will continue to have not episodes of socially inappropriate behavior weekly by review date." (The revised review date for this goal was [DATE].) The interventions included: "... Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, situations. Document behavior and potential causes; Intervene as needed to protect the rights and safety of others. Approach / speak in calm manner. Divert attention. Remove from situation and take to another location as needed. ..." The care plan did not describe what these "socially inappropriate behaviors" were. There was no evidence to reflect the care plan was revised upon Resident #26's return to the facility on [DATE], to address the need to "observe / assess for further treatment" - as directed in the aftercare plan resulting from his stay at the psychiatric hospital. There was no plan to reinstitute either of the monitoring activities that had been in place prior to his transfer to the psychiatric facility (every twenty (20) minutes beginning on [DATE] or direct supervision of the room shared by these three (3) residents at all times beginning on [DATE]) - especially at night. - 13. At [DATE] at 11:00 a.m., the administrator, medical director, DON, social worker (Employee #52), and the clinical care coordinator (Employee 33) were informed the nurse surveyor identified that Residents #38 and #77 were in immediate jeopardy, as Resident #26 returned to the same room following his discharge from the psychiatric hospital, and the facility failed to implement any measures (e.g., additional monitoring / supervision) to ensure the residents in this room were safe. A plan of correction was requested. - 14. A plan of correction, given to the surveyor on [DATE] at 11:20 a.m., was reviewed and returned to the administrator for revision. At 11:40 a.m., a revised plan of correction was given to the surveyor, reviewed, and accepted at 11:45 a.m. The revised plan of correction stated: "To correct the safety issues identified during the survey this date, with residents (#26), (#18), and (#77), a room change will be made. Resident (#26) will be moved into room (number of room on second floor). Resident (name) who is currently in room (number of room now occupied by Resident #26) will be moved to (number of room previously occupied by Resident #26). "Monitoring of resident (#26) will be accomplished by the following: Resident will be in a room by himself. This room is located close to the nurses (sic) station in direct line of all traffic. Nurses or Certified Nursing Assistants will check on him on an hourly basis for any abnormal behaviors. Psychiatric evaluation or placement will be pursued if behavior warrants. Documentation of all abnormal behavior will be monitored on a daily basis by nursing staff." - 15. On [DATE] at 1:30 p.m., after Resident #26 was relocated and this was verified by direct observation, the administrator was notified the immediate jeopardy was lifted. - 16. During an interview on [DATE] at 6:45 p.m., a nursing assistant (Employee #34) confirmed he found a pillow over Resident #77's face at about 12:30 a.m. on [DATE]. He indicated he had last checked on the resident at 12:00 a.m. on [DATE]. He documented twenty (20) minute checks on Residents #26 and #38 from 1:00 a.m. through 6:20 a.m. on [DATE]. (A copy of this documentation was provided by the DON on [DATE] at 10:40 a.m.) - 17. On [DATE] at 9:00 a.m., the administrator presented evidence that inservices were held [DATE] with staff who provide care to Resident #26. The memorandum on which this inservice was documented, issued by the DON, had in its subject line: "Precautions related to (Resident #26)". In the body of the memorandum was: "(Resident #26) needs to be monitored every hour for behaviors that may affect self or others and documented on appropriate form. (Resident #26) needs to be documented on each shift in the nurses notes related to behaviors whether there are any or not. "Concerns for (Resident #26) possibly being of danger to other residents has (sic) prompted this." The bottom of the memorandum contained the signatures of nursing staff. - The facility also revised the care plan for Resident #26 on [DATE], to include the following: P - "Potential for increased behaviors (physical aggressive (sic) staff or residents) (sexual inappropriate (sic) with staff) (attempting to harm residents) R/T (related to) [DIAGNOSES REDACTED]." G - "Resident will have less than weekly episodes of socially inappropriate behaviors by review date." G - "Resident will have no episodes of attempting harm other residents through review date." Interventions included: "Nursing staff will do hourly checks on resident for behaviors. Nurses will document q (every) shift on behaviors; Resident has been moved to a private room. Psychiatric evaluation and treatment as ordered." .