Every finding on record at Signature Healthcare of Putnam County

Based on facility policy review, medical record review, and interviews, the facility failed to report an allegation of staff to resident abuse for 1 resident (Resident #68) of 24 residents reviewed for abuse. The findings include: Review of the facility's undated policy titled, Abuse, Neglect, and Misappropriation of Property revealed, .It is the organization's intention to prevent the occurrence of abuse .and to ensure that all alleged violations .which involve abuse .are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law .Any abuse allegation must be reported to State within 2 hours from the time the allegation was received .Review of the medical record revealed Resident #68 was admitted to the facility on [DATE] with diagnoses including Stroke, Dementia, and Depression.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #68 scored a 5 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of the Nurse's Note for Resident #68 dated 6/21/2026 at 6:42 AM, revealed .roughly 4:00 AM .This nurse [RN C] sitting at desk .heard CNA [Certified Nurse Assistant B] .with elder saying 'those are my pockets .why don't you keep your hands out of my pockets .Went into room and assessed the situation and elder [Resident #68] was agitated and holding on CNA B's arm and expressing that CNA B just hit her in the eye and she wanted her [CNA B] out of room. CNA B asked to leave while .[RN C] assisted to get elder cleaned up .[Resident #68] did not want to rest in bed anymore and said she wanted to go somewhere .[Resident #68] came and rested in stationary chair in foyer for rest of shift. No bruising noted upon initial examination. Day shift informed to monitor for delayed bruising .During an observation on 7/21/2026 at 11:15 AM, Resident #68 was in her wheelchair in the common area with no signs of distress noted. During an interview on 7/21/2026 at 11:30 AM, the Director of Nursing (DON) stated she was aware of the allegation of abuse on 6/21/2026 for Resident #68. The DON confirmed the allegation of abuse was not reported to the state or any other officials. During an interview on 7/21/2026 at 12:30 PM, the Administrator (ADM) stated she was notified of the allegation of abuse for Resident #68 on 6/21/2026. The ADM stated an investigation was started and the allegation of abuse was unsubstantiated. The ADM confirmed the allegation of abuse was not reported to the State or any other officials. During an interview on 7/22/2026 at 9:00 AM, the Registered Nurse (RN C) stated she recalled the allegation of abuse on 6/11/2026 and she reported it to her supervisor.

Based on facility policy review, medical record review, observations, and interview, the facility failed to ensure respiratory equipment was stored properly for 2 residents (Residents #51 and #89) of 4 residents reviewed for respiratory care. The findings include: Review of the facility's policy titled, Medication Administration Nebulizers [Updraft], dated 1/2023, revealed .store in plastic bag with the resident's name and the date on it . Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Dementia, and Asthma. Review of the physician orders for Resident #51 revealed .Albuterol Sulfate Solution [medication delivered by aerosol treatment] 2.5 MG [milligrams]/3ML [milliliters] 3 ml inhalation via nebulizer [device to deliver breathing treatments] two times a day-PRN [as needed] .start date 4/09/2026 .Budesonide Suspension for inhalation via nebulization 1mg/2 mL two times a day .start date 4/09/2026 . Review of the comprehensive care plan for Resident #51 dated 5/21/2026, revealed .r/t [related to] dx [diagnoses] of Asthma .Adm [Administer] meds [medications] as ordered . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #51 scored a 7 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident had COPD and Asthma. Review of the Medication Administration Record (MAR) for 5/1/2026-7/22/2026 revealed Resident #51 received breathing treatments as ordered. During an observation on 7/20/2026 at 11:13 AM, in Resident #51's room, revealed a nebulizer mask was uncovered, open to air, and laying on top of the bedside table. Review of the medical record revealed Resident #89 was admitted to the facility on [DATE] with diagnoses of Myasthenia Gravis and Dysphagia. Review of the physician orders for Resident #89 revealed .Albuterol Sulfate Solution 0.63 MG/3ML 3 ml inhale orally via nebulizer three times a day . start date 5/26/2026 . Review of a quarterly MDS assessment dated [DATE], revealed Resident #89 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the comprehensive care plan for Resident #89 dated 7/05/2026, revealed .meds[medications] as ordered . Review of the medication administration record (MAR) for 5/1/2026-7/22/2026 revealed Resident #89 received breathing treatments as ordered During an observation on 7/20/2026 at 10:54 AM, in Resident #89's room, revealed a nebulizer mask was uncovered, open to air, and laying on top of the bedside table. During an interview on 7/21/2026 at 8:09 AM, the Director of Nursing confirmed the nebulizer masks for Resident #51 and Resident #89 were not stored properly.

Based on facility policy review, medical record review, and interview, the facility failed to revise a care plan to include fall interventions after 2 falls for 1 resident (Resident #40) of 4 care plans reviewed for falls. The findings include: Review of the facility policy titled, Comprehensive Care Plans, revised 2/9/2024, revealed .facility will develop and implement a person centered care plan for each resident, that includes measurable objectives and time frames to meet resident's medical, nursing, mental, and psychosocial needs .maintains a comprehensive care plan participate in the development of and reviewing and revising of the Comprehensive Care Plan . Review of the facility policy titled, Falls, revised 1/31/2025, revealed .A comprehensive Care Plan will be implemented based on the resident's risk for falls .interventions will be revised as applicable, with each new review . Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Hypertension, Chronic Kidney Disease, Cerebral Infarction (stroke), Hemiplegia (total or partial paralysis of one side of the body), Difficulty Walking, and other abnormalities of gait and mobility. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment. Continued review revealed Resident #40 had impaired functional range of motion on one side of the upper and lower extremities. Resident #40 was dependent on staff for Activities of Daily Living (ADL) and for transfers. Resident #40 had a history of falls prior to admission. Review of a facility fall incident report for Resident #40 dated 8/25/2025, revealed .nurse was called to residents room per CNA [Certified Nursing Assistant] staff which reported Elder (Resident #40) was laying in the floor .observed him in the doorway of his room laying on his back feet facing the doorway, upper torso area resting in the leg rest of wheelchair. Elder stated he was trying to reach for something and was too far out .Elders seat cushion appeared to slide down with elder during the fall .New Interventions .remove cushion and move closer to nurses station . Review of a care plan for Resident #40 dated 8/25/2024, revealed no intervention to include remove cushion and move closer to nurses' station. Review of a facility fall incident report for Resident #40 dated 8/27/2025, revealed .Elder found by staff lying in the floor at foot of bed with head slightly under chair. Stated that he was trying to get to his dresser .nurse spoke with NP [Nurse Practitioner] r/t [related to] elder stating to social services that he stays dizzy a lot .New Intervention .medication review r/t elder stating to staff he is dizzy when he gets up . Review of a care plan for Resident #40 dated 8/28/2024, revealed .Encourage elder to be active with activities and out of room . There was no intervention to include medication review r/t elder stating to staff he was dizzy when he gets up or interventions related to the resident's complaints of dizziness. Continued review revealed the care plan was not revised to include the fall interventions from the 8/25/2025 fall of moving the resident closer to the nurses' station or to remove the cushion from wheelchair. During an interview on 4/3/2025, at 11:00 AM the Director of Nursing (DON) confirmed on 8/25/2024, the fall intervention for Resident #40 was to remove the cushion and to move the resident closer to the nurses' station and the interventions were not updated on the care plan. The DON further confirmed on 8/27/2024 the fall intervention related to the resident's dizziness and the medication review was not added to the care plan. The DON confirmed Resident #40's care plan was not updated on 8/25/2024 or 8/27/2024 to reflect the newly established fall interventions.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to timely implement interventions to reduce the risk of falls for 1 resident (Resident #43) of 4 residents reviewed for falls. The findings include: Review of the facility's policy titled, Falls, revised 1/31/2025, revealed .ensure the facility provides an environment that is as free from accident hazards, as possible over which the facility has control to prevent avoidable falls .based on the resident's risk for falls .interventions specific to each resident to attempt to reduce the risk . Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including Dementia, Altered Mental Status, Muscle Weakness, Abnormal Walking and Mobility, and Mood Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #43 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment and required maximum staff assistance for standing and transfers. Review of a Fall Event note dated 1/10/2025, revealed Resident #43 had a fall from the wheelchair in the hallway. Further review revealed Physical Therapy (PT) was to evaluate the resident's wheelchair as a new fall intervention. Review of a PT Evaluation and Plan of Treatment dated 1/14/2025, revealed Resident #43 was added to the PT case load (4 days after the fall). Continued review revealed Resident #43 received PT services for wheelchair propelling, upright posture while seated in the wheelchair, falls, and leg strength training for mobility. Review of a Fall Event note dated 2/16/2025, revealed Resident #43 had a fall from the wheelchair in the dining room. Further review of the Fall Event note revealed PT was to assess the resident for a different wheelchair as a new fall intervention. Review of a PT Discharge note dated 2/21/2025, revealed Resident #43 was discharged from therapy services (evaluation was 5 days after the fall). Further review revealed no new assessment, or evaluation was conducted for a different wheelchair as the intervention for the fall on 2/16/2025. Review of a Fall Event note dated 3/4/2025, revealed Resident #43 had a fall from the wheelchair. Further review revealed the fall intervention was for the resident's personal items to be moved closer to the resident for easier reach to prevent future falls. Review of a comprehensive care plan intervention for falls dated 1/29/2025, revealed .keep personal items within reach . and was not a new intervention after the fall on 3/4/2025. During an observation on 4/1/2025 at 6:00 PM, Resident #43 was observed in the resident's room seated in a tilted wheelchair which contained an anti-thrust cushion. During a medical record review and interview on 4/2/2025 at 10:00 AM, the Director of Rehabilitation (DOR) reviewed the medical record for Resident #43 and stated Resident #43 started physical therapy services on 1/14/2025 related to frequent falls from the wheelchair. The DOR also stated a specialty wheelchair was recommended during therapy services for Resident #43 after the falls in 2/2025 but the wheelchair had not yet arrived to the facility. During an observation on 4/2/2025 at 10:07 AM, Resident #43 was observed in the dining room seated in a tilted wheelchair which contained an anti-thrust cushion. During a medical record review and interview on 4/3/2025 at 5:30 PM, the DON reviewed the medical record with the surveyor for Resident #43 and revealed the following: On 1/10/2025, the resident fell from the wheelchair and the intervention was for PT to evaluate. Resident #43 was not admitted to therapy services until 1/14/2025 (4 days after the fall). On 2/16/2025, the resident had a fall from the wheelchair and the new intervention was for PT to evaluate for a different (specialty) wheelchair. PT did not evaluate for a specialty wheelchair until 2/21/2025 (5 days after the intervention). The DON also stated the specialty wheelchair had not been delivered to the facility, and no other interventions had been implemented after the 2/16/2025 fall. On 3/4/2025, the resident had a fall from the wheelchair, the interventions were to move personal items for easier reach and was noted as an intervention on the care plan on 1/29/2025 and was not a new fall intervention. During an interview on 4/3/2025 at 6:30 PM, the DON confirmed the facility failed to timely implement fall interventions after the falls on 1/10/2025, 2/16/2025, and on 3/4/2025.

Based on facility policy review, medical record review, facility documentation review, and interviews the facility failed to prevent loss or diversion of controlled medications (narcotics) for 1 resident (Resident #7) of 65 sampled residents reviewed for misappropriation of narcotics. The facility was cited as past non-compliance. Non-compliance began on [DATE] and ended on [DATE]. The facility is not required to submit a Plan of Correction for F-755. The findings include: Review of the facility's policy titled, Controlled Medications, dated [DATE], revealed .The facility will ensure Controlled Medications are handled, stored, disposed of, and recordkeeping is in place in accordance with federal, state, and other applicable laws and regulations .At each shift change or when keys are rendered, a physical inventory of all controlled medication is conducted by two staff members who are either licensed nurses, medication technicians, or appropriate staff per state regulations and is documented on the controlled medications accountability record .The licensed nurse .surrendering the keys along with the licensed nurse .assuming the keys will ensure the count of the remaining medication(s) match the medication accountability book. Both the licensed nurse .surrendering the keys along with the licensed nurse .assuming the keys will verify, together, the correct or incorrect accounting of medication(s). Any medication count discrepancies or medication card count discrepancies that can't be reconciled by the licensed nurse .need to be reported to the Director of Nursing (DON) immediately .Once the medication count is completed, both licensed nurses .will also count the number of individual narcotic control sheets, together and will sign the controlled medication accountability record .If a new medication is added or a medication is discontinued/removed, the controlled medication accountability record must reflect the above by completing the controlled medication accountability record by two licensed nurses . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Psychotic Disorder with Delusions, Vascular Dementia with Psychotic Disturbance, and Chronic Pain. The resident expired in the facility on [DATE]. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 scored 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. The resident received opioids. Review of the physician's orders dated [DATE] for Resident #7 revealed .oxycodone-acetaminophen [opiod pain medicine] XXX,d+[DATE] mg [milligrams]; amt [amount] .10mg; oral [by mouth] Every 4 Hours - PRN [as needed] . Discontinued [DATE]. Review of a pharmacy shipping manifest (invoice) dated [DATE], revealed the facility received 90 oxycodone-acetaminophen,d+[DATE] tablets for Resident #7. Continued review revealed Licensed Practical Nurse (LPN) B received and signed for receipt of the medication on [DATE]. Review of pain assessments for Resident #7 revealed the resident's pain levels on a scale of ,d+[DATE] (0 being no pain and 10 being the worst possible pain) revealed: [DATE]: day shift-0 night shift-0 [DATE]: day shift-2 night shift-0 [DATE]: day shift-3 night shift-1 [DATE]: day shift-3 night shift-0 [DATE]: day shift-0 night shift-0 [DATE]: day shift-0 night shift-0 Review of the medication administration record for Resident #7 revealed the resident received Oxycodone-Acetaminophen ,d+[DATE] mg for pain as follows: [DATE] at 8:09 AM; 12:28 PM; 4:53 PM; and 10:11 PM [DATE] at 11:29 AM and 4:47 PM [DATE] at 7:50 AM and 12:00 PM [DATE] at 4:49 AM; 9:03 AM; 1:23 PM; and 8:31 PM Review of the facility's documentation dated [DATE], revealed the facility reported the following information to the state designated authority: .Allegation Type .Misappropriation of Resident Property .staff became aware of the incident XXX[DATE] [at] 1:00 PM .Alleged Victim .[Resident #7] .Alleged Perpetrator .unknown .On [DATE], a bubble pack card of 30 Oxycodone/Acet. [Acetaminophen] ,d+[DATE] .noted to be missing during a count of narcotics .Upon counting of narcotics, it was noted that [Resident #7] was missing one card [of 30 tablets] of his Oxycodone. He still had a remaining card of medications and had not missed any doses . Review of a police report dated [DATE], revealed .Crime Incidents Theft Of Property (theft From Building) .On [DATE], [named officer] dispatched to [facility] in regards to missing medication .[Facility Administrator] explained the situation that medication had been missing from the building .[facility] noticed the medication gone at 1:30 PM today. The medication was 10mg Oxycodone and a whole bubble pack was gone. A bubble pack contains 30 Oxycodone. She stated that she was in contact with the company that delivered them on [DATE]th to see if it was a miscount and would call back on [DATE]th if they were found or the company's count was incorrect. She stated that the charge nurses are the ones assigned to the medicine carts and are the only ones that have access to the medications . During an interview on [DATE] at 2:33 PM, the Director of Nursing (DON) stated she became aware 1 card (30 tablets) of Oxycodone,d+[DATE] mg for Resident #7 was missing when she pulled discontinued controlled medications from the medication cart on the 100 hall on [DATE]. The DON stated .I counted .I did not get the same number she [Registered Nurse-RN A] got .[RN C] counted the sheets [individual resident narcotic record] while I counted the cards [cards with medications/bubble packs]. The numbers were not adding up to what was in the book [controlled medication accountability record] .[RN A] pulled out [Resident #7's card of 60 [oxycodone] and said he's missing his card of 30 [oxycodone] . During a telephone interview on [DATE] at 5:50 PM, RN A stated she and LPN B counted the hall 1 medication cart narcotics the morning of [DATE]. RN A stated she counted the pills on the card and LPN B checked the individual resident's narcotic record/sheet to ensure the pill count was correct. RN A stated LPN B .was in a rush and had to get her kids to school . RN A stated she and LPN B did not count the medication cards and individual resident narcotic record/sheets together the morning of [DATE]. During a telephone interview on [DATE] at 7:46 PM, LPN B stated the process for counting narcotics included the oncoming and off going nurse counted the cards/bubble packs in the cart and the individual resident narcotic records to ensure the numbers were the same. The pills in each card/bubble pack were to be counted and compared with the individual resident narcotic record to ensure the number of pills was the same as recorded on the resident's narcotic record. LPN B stated .We [LPN B and RN A] counted pills and counted the cards .the papers [individual resident narcotic record] were not counted .We did not count the papers that morning [[DATE]] . During an interview on [DATE] at 11:53 AM, the DON stated she became aware of the missing medication .around 11:30 AM [[DATE]], when I went to collect controlleds [narcotics] for destruction . The DON stated she and RN A counted the individual resident narcotic sheets and cards. Each counted 68 individual narcotic sheets and 68 cards/bubble packs instead of 69 (number indicated on the narcotic inventory shift count sheet for the morning count on [DATE]). The DON stated RN C and the Regional Nurse also counted 68 cards and 68 individual resident narcotic sheets. Continued interview revealed RN A, went through the cards and remembered Resident #7 was supposed to have 2 cards of oxycodone ,d+[DATE], 1 with count of 60 pills and 1 with count of 30 pills. The card of 30 oxycodone ,d+[DATE] was not in the medication cart. The DON stated when medication cart keys exchanged hands, the expectation was 1 nurse counts the pills on the cards and the other nurse compares the pill count with the number documented on the individual resident narcotic sheet. The nurses verbalize the count to ensure the numbers match. At the end of the count, the nurses do a full count of cards and individual resident narcotic sheets .both numbers have to match . The DON stated both nurses were to sign the inventory shift count sheet to confirm the count was completed and was accurate. Staff were expected to notify clinical leadership if there was a discrepancy in the counts. The DON stated .one of the steps [card count and individual narcotic record sheet count] was not completed accurately . The DON confirmed RN A and LPN C did not verify the narcotic count was accurate and confirmed the facility's controlled medications policy was not followed. During a telephone interview on [DATE] at 10:50 AM, the pharmacy representative stated the pharmacy received a script for Resident #7 for Oxycodone ,d+[DATE] mg, 90 tablets on [DATE]. The pharmacy representative stated the Oxycodone was delivered to the facility, were checked in and signed for by facility staff on [DATE]. The pharmacy representative stated the facility notified the pharmacy the card of Oxycodone for Resident #7 was missing on [DATE]. Continued interview revealed the pharmacy performed a narcotic count which verified the pharmacy's narcotic count was correct and confirmed 90 tablets of Oxycodone for Resident #7 had been sent to the facility on [DATE]. During an interview on [DATE] at 11:53 AM, the Administrator and DON confirmed the facility had identified the misappropriation of property for Resident #7 and had taken actions to correct the non-compliance. A plan of correction was developed to address the deficient practice identified. The corrective actions were validated on-site by the surveyor on [DATE]-[DATE] through interviews and review of facility documents. The facility's Plan of Correction for Misappropriation of Property was presented to the survey team and documented the following corrective actions were implemented: On [DATE], Resident #7, who had a BIMS of 15 was interviewed and assessed for pain with no pain noted or reported. There were 60 Oxycodone/Acetaminophen ,d+[DATE] mg tablets were available for administration. Resident #7 missed no doses of the PRN Oxycodone/Acetaminophen. Pain assessments for uncontrolled pain were completed for all residents on Hall 1. Results concluded there were no residents with uncontrolled pain. Residents on Hall 1 with a BIMS equal to or greater than 8 were interviewed to determine if their pain was controlled and PRN medication had been administered when requested. All residents reported their pain was controlled and they had received their pain medication when requested. On [DATE], the pharmacy was informed of the missing medications for Resident #7. The pharmacy replaced the 30 tablets of Oxycodone/Acetaminophen ,d+[DATE] mg for Resident #7 at the cost of the facility. On [DATE] and [DATE], controlled medications were reconciled on every medication cart by the DON, Assistant DON (ADON) , or Wound Care Nurse with no findings of additional medication count discrepancies. On [DATE], urine drug screens were performed for RN A and LPN C with negative results. RN A and LPN C were suspended pending results of the investigation. Controlled medication records for all residents in the facility from [DATE]-[DATE] were audited from [DATE]-[DATE]. Results concluded there were no other residents with missing medications. All staff were interviewed on [DATE]-[DATE] to inquire if they had knowledge of controlled medication unaccounted for or if they had suspicion of anyone working while impaired. There were no findings from the interviews. On [DATE]-[DATE], all staff received education regarding the Abuse and Misappropriation policy. Any staff/agency staff who were not educated were to be educated prior to working their next shift. On [DATE]-[DATE], all licensed staff received education on the Controlled Medication Policy and process changes for counting/receiving/removing controlled medication. The process included: .The Director of Nursing will remove all controlled medications with a witness (empty and discontinued) from the medication cart, reconcile the Controlled Substance Count Sheets and compare the Controlled Substance Count Sheets to the Controlled Drug Records as they are removed from the cart to be secured for destruction. No one will remove controlled medication card/sheets without the Director of Nursing, Assistant Director of Nursing or wound nurse witnessing . Every nurse completed a competency on medication pass started on [DATE] and was completed on [DATE]. Any licensed staff, including agency nurses, who were not education were to be educated prior to working their next shift. Beginning [DATE], the DON or designee observed every nurse complete a narcotic count competency. On [DATE], the DON or designee began auditing licensed nurse's complete narcotic counts at shift change during varying shift 5 times/week for 2 weeks, the 3 times/week for 4 weeks, and then 2 times/week for weeks. On [DATE], the DON or designee began auditing pharmacy delivery reports to ensure the delivered controlled medications were accurately added to the medication carts and controlled substance count sheets: 5 deliveries/week times 2 weeks, then 3 deliveries/week times 4 weeks, then 2 deliveries/week for 4 weeks. Ad Hoc QAPI meetings were held on [DATE], [DATE], [DATE], and [DATE]. QAPI meetings were held weekly beginning [DATE] for 4 weeks, then 2 times/month for the next 30 days, then monthly or until the QAPI Committed determined substantial compliance had been achieved. Audit results revealed no further concerns of misappropriation of resident property. The facility continued to perform random monthly audits. 1. Surveyor interviewed the Administrator and DON on [DATE] at 11:53 AM, in the Administrator's office. Interview confirmed there had not been any further incidents involving loss or diversion of resident controlled medications. 2. Surveyor interviewed multiple licensed staff members (day shift and night shift) for knowledge of the in-services provided in the corrective action plan, and no knowledge deficits were identified. 3. Observations of several narcotic audits performed by licensed nursing staff revealed the staff followed proper procedure for reconciling controlled medications. The deficient practice was cited as past noncompliance for F-755 and the facility is not required to submit a plan of correction.

Based on facility documentation, observation, and interview, the facility failed to have sufficient staffing for 1 of 4 (500) halls. The findings include: Review of the undated facility documentation revealed the 500 hall had 11 assisted diners (residents who required assistance with meals). Review of the facility schedule dated 5/15/2023, revealed 2 Certified Nurse Aides (CNA) and 1 CNA scheduled from 12:00 PM to 6:00 PM. Observations on the 500 hall on 5/15/2023 at 12:08 PM, revealed the tray cart arrived to 500 hall. Observations at the 500 hall nurse's station on 5/15/2023 at 12:24 PM, revealed Resident #114 was seated in a wheel chair in front of the nurse's station. Observations in the 500 hall dining room on 5/15/2023 at 12:25 PM, revealed CNA #8 was assisting one resident with the lunch meal while another resident was seated in a wheelchair. Observations in the 500 hall dining room on 5/15/2023 at 12:51 PM, revealed Resident #114 was assisted with dining by a CNA. During an interview on 5/15/2023 at 12:37 PM, CNA #8 stated the 500 hall was her assigned hall. CNA #8 stated there were 3 CNAs staffed on the 500 hall regularly, but there were only 2 CNAs staff this week. CNA #8 confirmed the residents would have lunch in the dining room if there was enough staff. CNA #8 stated the residents rarely had meals in the dining room, and since the Coronavirus disease (COVID) pandemic, the residents had their meals in their rooms. CNA #8 confirmed Resident #114 had not eaten yet because she needed assistance. During an interview on 5/16/2023 at 11:11 AM, CNA #9 stated the 500 hall had 8 assisted diners and two residents that required prompts while dining. CNA #9 stated the facility had instructed the staff not pass trays to independent diners and then the assisted diners, but the trays had to be passed at the same time. CNA #9 stated,To get them out fast, it is not enough CNAs or help with just three people. Many of the assisted diners could not sit up in a wheel chair. That is one of the reasons we don't offer dining in the dining room. All of the independent diners won't sit and eat. They will be wandering the halls. When we have a wanderer we try to sit them in the chairs by the nurse's station. It is hard to do with two people [staff] and a nurse. During an interview on 5/17/2023 at 3:31 PM, Licensed Practical Nurse (LPN) #2 stated it would not have been so bad if the unit did not house so many assisted diners. LPN #2 stated she felt the administration was aware of the acuity (level of residents' needs and requirement for nursing care) of the unit. LPN #2 stated the facility typically had 3 CNAs on the day shift from Monday through Thursday, but this week there were only 2 CNAs because 1 CNA was on vacation. During an interview on 5/18/2023 at 3:32 PM, the Director of Nursing (DON) stated, They [facility] have had meals in the dining room. It is not a staffing thing. It is a matter of those that want to stay seated for dining. It is hard to tell day by day because they [staff] have the ones [residents] that are ambulatory that won't stay seated, and they have to attend to them also. The DON stated the 500 hall had the highest number of admissions and assisted diners, but the staffing had not increased.

Based on facility document review, observation, and interview, the facility failed to serve food in a timely manner to 9 of 123 (Resident #9, #14, #15, #16, #39, #92, and #113) residents who ate food prepared by the facility. The findings include: Review of the undated meal times sheet revealed the serving times for meals for the dining rooms and the halls revealed breakfast was served to the main dining room (DR) at 7:00 AM, 100 hall 1st meal tray cart at 7:15 AM, hall 300/400 at 7:30 AM, hall 200 meal tray cart at 7:45 AM, 500 hall DR and hall at 8:00 AM, hall 100 2nd meal tray cart at 8:15 AM, and hall 200 2nd meal tray cart at 8:30 AM. Lunch was scheduled for the main DR at 11:30 AM, hall 100 1st meal tray cart at 11:45 AM, hall 300/400 at 12:00 PM, hall 200 1st meal tray cart at 12:15 PM, 500 hall DR 12:30 PM, hall 100 2nd meal tray cart at 12:45 PM and hall 200 2nd meal tray cart at 1:00 PM. Dinner was scheduled for the main DR at 5:00 PM, hall 100 1st meal tray cart at 5:15 PM, hall 300/400 at 5:30 PM, hall 200 1st meal tray cart at 5:45 PM, 500 hall DR at 6:00 PM, hall 100 2nd meal tray cart at 6:15 PM, and hall 200 2nd meal tray cart at 6:30 PM. Observations on the 300/400 hall on 5/15/2023 at 12:56 PM, revealed the first lunch tray was delivered at 12:56 PM and the last tray was delivered at 1:16 PM. The stated delivery time to the 300/400 hall for lunch was 12:00 PM. Observations in the kitchen on 5/15/2023 at 4:45 PM, revealed the Regional Food Service Manager (FSM) for the contracted food service group, removed a pan of hamburger patties and tater tots from the convection oven, placed them on a stainless counter top, opposite the oven, and checked the food temps of both items. The FSM took the pans to the steam table and placed each food item in metal pans and covered the pans. Observations in the kitchen on 5/15/2023 at 4:55 PM, revealed the FSM was preparing the pureed bread for the steam table. Observations in the kitchen on 5/15/2023 at 5:10 PM, revealed the food for dinner was in place on the steam table. The food temps were checked by Cook #1, with the contracted food service group. The following food and temps were noted to be below regulation: mechanical ground beef 131 degrees Fahrenheit (F), pureed ground beef 128 degrees F, and regular mashed potatoes 131 degrees F. Continued observation at 5:15 PM revealed the FSM removed the mechanical ground beef, pureed ground beef, and regular mashed potatoes for reheating in the convection oven for 15 minutes. The food temps of the reheated food on the steam table revealed the mechanical ground beef was 170 degrees F, pureed ground beef was 171 degrees F, and the regular mashed mashed potatoes was 171 degrees F. Observations in the kitchen on 5/15/2023 revealed the following: At 5:30 PM food was delivered to the main DR to be served to the residents. The stated time for delivery to the main DR was 5:00 PM. At 5:40 PM a meal tray cart was delivered to the 500 hall. The stated time for delivery to the 500 hall was 6:00 PM. At 6:00 PM the 1st meal tray cart was delivered to 100 hall. The stated time for delivery to the 100 hall was 5:15 PM. At 6:13 PM a meal tray cart was delivered to the 300/400 hall. The stated time for delivery to the 300/400 hall was 5:30 PM. At 6:31 PM the 2nd meal tray cart was delivered to 100 hall. The stated time for delivery of the 2nd cart to the 100 hall was 6:15 PM. At 6:30 PM a meal tray cart was delivered to the 200 hall. The stated time for delivery to the 200 hall was 5:45 PM for the 1st cart delivery and 6:30 PM for the 2nd cart. Observations of the meal tray cart on 5/15/2023 at 6:30 PM, revealed the tray cart was delivered to the 200 hall and contained 21 meal trays. Delivery of 17 meal trays was started by 2 Certified Nurse Aides at 6:32 PM and completed at 6:50 PM. Four meal trays remained on the meal tray cart for the residents requiring assistance with meals. Observations in the kitchen with the Assistant Dietary Manager (ADM, contracted with the food service group), on 5/16/2023 at 6:50 AM, revealed breakfast food temps on the steam table that were below regulation were pre-cooked sausage patties at 124 degrees F, pureed eggs 114 degrees, and pre-cooked bacon slices 118 degrees F. The breakfast food temp that was above regulation was the milk carton 8 ounces (oz) 48 degrees F. Continued observation with the ADM and Director of Operations (DOO) for the contracted food service group at 6:55 AM, revealed the ADM reheated the sausage patties and bacon slices by pouring hot water on the meat. Further observation revealed the ADM placed metal pans containing the sausage and bacon in the convection oven along with the pureed eggs for reheating. Observations in the kitchen on 5/16/2023 at 7:10 AM, revealed the ADM checked the temps of the reheated food while the food was still in the convection oven. After the reheated foods were returned to the steam table at 7:15 AM, the reheated temps were pre-cooked sausage patties 168 degrees F, pre-cooked bacon slices 151 degrees F, and reheated pureed eggs 164 degrees F. Observations of the meal tray cart on 5/16/2023 revealed the following: At 7:25 AM breakfast was delivered to the main DR to be served to the residents. The stated time for the main DR was 7:00 AM. At 8:20 AM the meal tray cart was delivered to the 200 hall. The stated delivery time was 7:45 AM for the 1st cart and 8:30 AM for the 2nd cart; only 1 meal tray cart was delivered to the 200 hall. At 8:28 AM the meal tray cart was delivered to the 300/400 hall. The stated delivery time was 7:30 AM. At 8:40 AM the meal tray cart was delivered to the 100 hall. The stated delivery time was 7:15 AM for the 1st cart and 8:15 AM for the 2nd cart; only 1 meal tray care was delivered to the 100 hall. At 8:50 AM the meal tray cart was delivered to the 500 hall/downstairs DR. The stated delivery time was 8:00 AM. Observations on the 300/400 hall on 5/16/2023 at 8:55 AM revealed the first meal tray was delivered at 8:28 AM and the last tray at 8:45 AM. The stated delivery time for the 300/400 hall was 7:30 AM. Observations in room [ROOM NUMBER] (100 hall) on 5/16/2023 at 2:00 PM, revealed a resident was being assisted with a meal tray. The stated delivery time for lunch on the 100 hall was 11:45 AM for the 1st cart and 12:45 PM for the 2nd cart. During an interview on 5/15/2023 at 11:30 AM, Resident #15 (alert, oriented, and interviewable) stated the food was not delivered on time and was usually cold by the time it arrived. During an interview on 5/15/2023 at 11:45 AM, Resident #9, #16, #39, and #92 (alert, oriented, and interviewable) stated the meal trays were hardly ever delivered on time, and the food was usually cold. During an interview on 5/15/2023 at 12:30 PM, Resident #14 and #113 (alert, oriented, and interviewable) stated the meal trays seemed to usually be delivered late, and the food usually tasted cold. During an interview on 5/15/2023 at 4:45 PM (time given by the FSM to check dinner food temps), the FSM revealed some food was still being prepared for the steam table. The FSM stated the hamburger patties and tater tots were still in the convection oven, and the dinner food service was late due to inaccurate food temps. During an interview on 5/16/2023 at 7:15 AM, the ADM and DOO confirmed the food service was delayed due to the inappropriate steam table temps.

Based on facility policy review, observation, and interview, the facility failed to maintain appropriate temperatures (temps) for food served on a test tray dated 5/15/2023. The facility also failed to maintain appropriate temps for food on the steam table requiring re-heating and a delay in food service. The findings include: Review of the facility policy titled, Food: Preparation Policy 016, undated revealed .the Dining Service Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to techniques which minimize the amount of time that food items are exposed to temperatures greater that 41 degrees Fahrenheit (F) and/or less than 135 degrees F or per state regulation .all foods will be held at appropriate temperatures greater that 135 degrees F .for hot holding and less that 41 degrees F for cold food holding .temperatures .for foods will be recorded at the time of service . Observations in the kitchen on 5/15/2023 at 4:45 PM, revealed the Regional Food Service Manager (FSM) for the contracted food service group, removed a pan of hamburger patties and tater tots from the convection oven, placed them on a stainless counter top, opposite the oven, and checked the food temps of both items. The FSM took the pans to the steam table, placed each food item in metal pans, and covered the pans. Observations in the kitchen on 5/15/2023 at 4:55 PM, revealed the FSM was preparing the pureed bread for the steam table. Observations in the kitchen on 5/15/2023 at 5:10 PM, revealed the food for dinner was placed on the steam table. Cook #1, with the contracted food service group, checked the food temps. The following food temps were below regulation: mechanical ground beef 131 degrees F, pureed ground beef 128 degrees F, and regular mashed potatoes 131 degrees F. Continued observation at 5:15 PM revealed the FSM removed the mechanical ground beef, pureed ground been, and regular mashed potatoes for reheating in the convection oven for 15 minutes. Food temps of the reheated food on the steam table revealed the mechanical group beef was 170 degrees F, pureed ground beef was 171 degrees, and the regular mashed mashed potatoes was 171 degrees F. Observations of the test tray on the 200 hall on 5/15/2023 at 6:43 PM, revealed the tray was being carried by the FSM. The test tray was placed on the tray cart for the 200 hall. Observations of the dinner test tray on the 200 hall on 5/15/2023 at 6:50 PM, revealed an appetizing appearing plate of a hamburger patty on a bun with a cheese slice, lettuce and tomato, french fries and cole slaw. The plate was in an insulated plate holder with an insulated lid. Observations of the dinner test tray food temps on the 200 hall on 5/15/2023 at 6:50 PM, revealed the hamburger patty was 115 degrees F, french fries were 126 degrees F, cole slaw was 48 degrees F, and carton of whole milk was 52 degrees F. Observations in the kitchen with the Assistant Dietary Manager (ADM, contracted with the food service group), on 5/16/2023 at 6:50 AM, revealed breakfast food temps on the steam table that were below regulation were pre-cooked sausage patties at 124 degrees F, pureed eggs 114 degrees, and pre-cooked bacon slices 118 degrees F. The breakfast food temp that was above regulation was the milk carton 8 ounces (oz) 48 degrees F. Continued observation with the ADM and Director of Operations (DOO) for the contracted food service group at 6:55 AM, revealed the ADM reheated the sausage patties and bacon slices by pouring hot water on the meat. Further observation revealed the ADM placed metal pans containing the sausage and bacon in the convection oven along with the pureed eggs for reheating. During an interview on 5/15/2023 at 4:45 PM (time given by the FSM to check dinner food temps), the FSM revealed some food was still being prepared for the steam table. Continued interview at 4:55 PM, the FSM stated she usually checked food temps as the food was removed from the oven and before placing the food on the steam table. The FSM stated she was unsure if the temps documented on the food temp form was from checking the foods from the oven or on the steam table. The FSM stated the hamburger patties and tater tots were still in the convection oven, and the dinner food service was late due to inaccurate food temps. During an interview on the 200 hall on 5/15/2023 at 6:50 PM, the FSM confirmed the food temps on the dinner test tray were not appropriate per regulations. During an interview with the ADM and DOO on 5/16/2023 at 7:10 AM, the ADM stated he reheated pre-cooked meat with hot water. The ADM stated he usually checked food temps straight from the oven instead of on the steam table. The ADM confirmed the food service was delayed due to the inappropriate steam table temps. The DOO stated he was unsure of the reheating procedure. 38830 46252 46532 47127

Based on facility policy review, facility maintenance documentation, observation, and interview, the facility failed to provide proper storage dating of foods. The facility also failed to provide proper sanitation of equipment after use and maintenance of equipment in the kitchen. The facility further failed to provide appropriately dated foods and sanitized equipment in 1 of 3 (500 hall) nutrition rooms. The findings include: Review of the facility policy titled, Food Storage: Cold Foods Policy 019 revealed .all time/temperature control for .foods, frozen and refrigerated will be appropriately stored .foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination . Review of the facility policy titled, Ice policy 021, undated, revealed .the Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned, and sanitized quarterly and as needed or according to manufacturer guidelines .the exterior of the ice machine will be cleaned weekly .ice bins will be cleaned monthly and as needed .ice scoops will be cleaned and stored in a separate container that limits exposure to dust and moisture retention . Review of the facility policy titled, Equipment Policy 027, undated, revealed .all foodservice equipment will be clean, sanitary, and in proper working order .equipment will routinely cleaned and maintained in accordance with manufacturer's directions .all food contact equipment will be cleaned and sanitized after every use .the Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed . Review of the facility policy titled, Food Storage and Retention Guide posted on the front of walk-in (W/I) cooler #3, undated, revealed .shredded cheese (mozzarella, cheddar, Parmesan) .1 month . Review of the facility maintenance documentation titled, Work History Report dated [DATE], revealed the ice machine filters and coils were cleaned. The machine was de-limed as necessary. An invoice dated [DATE] for a ,d+[DATE] inch mixing valve (valve used to adjust the temperature of water that comes out of the hot water heater before it reaches the faucet) for the handwashing sink revealed a shipping date of [DATE]. Observations during the initial kitchen tour with the Registered Dietitian (RD), contracted with the contract food service group, on [DATE] at 10:30 AM, revealed the hot water pedal on the wash sink by kitchen office door and across from the hall door was inoperable and provided no hot water from the tap into the sink. Observations during the initial kitchen tour with the RD on [DATE] at 10:30 AM, revealed W/I Cooler #1 in the right back corner of the back food storage room had water on the floor. Also observed was a white/light beige colored, dried appearing, crusty debris under the milk cartons containing 8 ounce (oz) milk cartons. The initial kitchen tour was joined by the Assistant Dietary Manager (ADM) with the contract food service group on [DATE] at approximately 10:45 AM. Observations during the initial kitchen tour on [DATE] at 10:45 AM, revealed W/I Cooler #2 along the back wall of the back food storage room contained uncovered food: apple crisp (as verbally named by the ADM) in 12 single serving sized bowls. W/I Cooler #2 also contained expired foods of 1 used pastry icing bag of a cream appearing colored substance (verbally labeled by the ADM as cake icing) dated ,d+[DATE] and Parmesan cheese in a gallon carton, approximately ,d+[DATE] full dated ,d+[DATE]. Observations during the initial kitchen tour on [DATE] at 10:50 AM, revealed W/I Cooler #3 located in the main kitchen on the back wall revealed no dates for 3 plastic 8 (oz) jars of beef base, 1 plastic 8 oz jar of chicken base, ,d+[DATE] of a tomato, 1 onion, 5 single-size bowls of applesauce (as verbally labeled by the ADM), ,d+[DATE] oz plastic jar of applesauce, and 1 gallon can of fruit cocktail-,d+[DATE] full (the can was covered with plastic wrap in the original can container), watermelon-cut-up in chunks, pureed bread (verbally labeled by the ADM) in a metal pan, sliced bologna (verbally labeled by the ADM) and grated cheddar cheese ,d+[DATE] package. Expired dates were noted on 20 hot dogs-,d+[DATE], 6 strips of pre-cooked bacon-,d+[DATE], gravy (verbally labeled by the ADM) in a metal pan-,d+[DATE], chicken patties (labeled by the ADM) in 2 metal pans-,d+[DATE], chicken gravy (verbally labeled by the ADM) in 1 metal pan-,d+[DATE], and baked beans (verbally labeled by the ADM) in 1 metal pan-,d+[DATE]. A clear liquid substance was dripping from the interior top of W/I Cooler #3 onto plastic wrap covered metal pans of baked chicken legs and thighs, meat sauce (both verbally labeled by the ADM), and a pureed substance (unable to be labeled by the ADM). The clear liquid had gathered on the top of the plastic wrap causing the wrap to be unloosed from the sides of the metal pans and get onto the food. The chicken, meat sauce, and pureed substance were labeled with a red marker. The clear liquid had become red-pink tinted and caused the food it contacted to also be colored pink. Observations during the initial kitchen tour on [DATE] at 10:55 AM, revealed Cooler #1 along the back wall of the kitchen contained 9 cartons of nectar thickening. On the bottom left of the cooler were 2-gallon pitchers both with a whisk inside each pitcher (verbally labeled by the ADM) as thickened tea and thickened milk. There were no dates or coverings on either pitcher. Observations during the initial kitchen tour on [DATE] at 11:00 AM, revealed the milk cooler with a lift up lid, along the back wall of the kitchen had a soured milk odor with a black debris on the bottom of the cooler, both dried and moist appearing. Observations during the initial kitchen tour on [DATE] at 11:05 AM, revealed the ice machine had smears on the stainless steel front. The front reservoir under the grill contained gray, moist appearing debris noted in the corners and edges of the tray. The grill contained crusty, scaly cream/beige colored debris at all joints. On the side of the ice machine were 6 horizontal openings running up the side approximately 10 inches to 12 inches in length. This area was covered with light gray dust, easily swiped or blown from the surface. Observations during the initial kitchen tour on [DATE] at 11:10 AM, revealed the tea maker metal receptacle was empty under the filter basket with no plastic lid. The back of the tea maker had brown crusty, scaly, splattered appearing debris all over the back. Observations during the initial kitchen tour on [DATE] at 11:15 AM, revealed the dish machine had scaled build-up appearing debris all along each cornered and linear crevice. The stainless area of the dish machine had a build-up of dark tan to light brown colored debris covering the surface and into the corners and crevices. The open air shelving on the wall of the dish room on the side the dish trays exit had dark red, brownish debris noted at each joint of the shelving. Observations during the initial kitchen tour on [DATE] at 11:25 AM, revealed the 3-door freezer, located in the kitchen on the opposite wall from the dish room, had signs posted on the left and middle door which read the doors did not work due to broken hinges. The freezer contained 9 slices of French toast (verbally labeled by the ADM) in an opened, unsecured package and an undated package of 10 pancakes. Observations during the continued kitchen tour on [DATE] at 2:15 PM, revealed the Regional Food Service Manager (FSM) for the contract food service group and the Corporate Clinical Document Reviewer/Certified Dietary Manager (CDM) for the facility were present. The convection oven exterior stainless doors had several smears. The interior doors on the glass windows contained a caramel, brownish coating with streaks that ran from the top of the glass to the bottom. The substance had a sticky feeling. The bottom of the oven was covered with a blacken, crusty substance. The stove hood had dark reddish/brown spots, approximately a dime-sized on the left front edge or lip of the outer hood over the steamer and at the top left of the hood over the steamer. The stove backsplash had blackened-brown coating/covering from the base to approximately 3 to 6 inches up from the base. The stove top had dried/cooked appearing debris with a crumb type substance. The stainless front of the stove had multiple smears and smudges on the oven doors. Observations in the nutrition room of the 500 hall on [DATE] at 5:45 PM, revealed the ice machine had black debris on the top of the flap inside the machine. The refrigerator temp read 0 degrees F. Watermelon was in plastic cup without a resident name or date. Pudding was in a pudding container, covered and without a resident name or date. The ice scoop was located in the box of straws. The findings were observed and confirmed by Certified Nurse Assistant (CNA) #10 on [DATE] at 5:49 PM. During an interview on [DATE] at 10:30 AM, the RD confirmed .you're about to see some egregious behaviors . The RD confirmed the hot water was inoperable on the handwashing sink. The RD observed and confirmed the findings for W/I Cooler #1 listed above. The RD stated he was contracted with the contract food service group and was the interim RD until the regular RD returned from maternity leave. During an interview on [DATE] at 10:40 AM, the ADM observed and confirmed the findings listed above in W/I Cooler #2, W/I Cooler #3, Cooler #1, the milk cooler, the ice machine, tea maker, dish machine, dish room, and 3-door freezer. The ADM confirmed the uncovered pitchers in the 2-door cooler were thickened tea and thickened milk, and the pitchers should be covered and without the whisk left in the pitchers. The ADM confirmed the odor emitting from the milk cooler when the lid was raised was the odor of soured milk. The ADM also confirmed the ice machine had not been cleaned since he had been hired approximately 2 ,d+[DATE] months ago. The ADM confirmed he was unable to find the plastic lid for the tea container. The ADM confirmed the 3-door freezer had broken hinges on the left and middle doors and stated he was unsure how long the hinges had been broken or if the issue had been reported for repair. The ADM stated the maintenance company for the dish machine was here a couple of days ago, but he had received no paper work/invoices following the visit. During an interview on [DATE] at 2:45 PM, the FSM and Corporate CDM observed and confirmed the observations made for the convection oven, stove hood, stove backsplash, stove top, and stove front. The FSM confirmed she was unaware if repair requests had been made for the hot water pedal on the handwashing sink or the hinges for the left and middle doors of the 3-door freezer. During an interview on [DATE] at 3:00 PM, Dietary Aide #1 stated he had put in a maintenance order for the 3-door freezer broken hinges about 1 month and ,d+[DATE] ago. During an interview on [DATE] at 10:30 AM, the Maintenance Director confirmed the mixing valve to fix the handwashing sink had not been received.

Based on facility policy review, observation, and interview, the facility failed to serve silverware for 1 of 2 carts on the 500 hall during a meal. The findings include: Review of the facility policy titled, Resident Rights reviewed 4/17/2023 revealed .When providing care and services, the stakeholders will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with access to persons and services inside and outside the facility . Observations on the 500 hall on 5/15/2023 at 5:38 PM, revealed the first tray cart on the floor had 18 trays. Two of the trays on the cart had silverware, and the other 16 trays did not. Continued observation revealed Certified Nurse Aide (CNA) #9 had to go upstairs to the kitchen and retrieve silverware for the other trays on the cart. During an interview on 5/15/2023 at 6:34 PM, the Regional Food Service Manager (FSM) stated the staff had pulled the silverware off the trays because the cart was for residents eating in the dining room. The FSM thought the 500 hall dining room had silverware for the residents who ate in the dining room. The FSM confirmed all the trays on the tray carts were supposed to have silverware. During an interview on 5/16/2023 at 11:11 AM, CNA #9 confirmed the kitchen staff sent a tray cart without silverware for all of trays on the cart. CNA #9 stated the 500 hall dining room did not have silverware on hand to give to the residents when the cart arrived to the hall.

Based on facility policy review, observation, and interview, the facility failed to provide a homelike environment for 2 of 5 (100 and 500) halls. The findings include: Review of the facility policy titled, Resident Rights reviewed by the facility on 4/17/2023 revealed .All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life . Review of the undated facility policy titled, Housekeeping In-Service revealed .Spot clean walls: Vertical surface are not completely wiped down daily-but must be spot cleaned daily. Walls -especially by trash cans and light switches and door handles -will need special attention .Clean and sanitize sink and tub: The sink includes: the sink fixtures, pipes, under the sink, mirror and light above the mirror . Observations on the 500 halls on 5/15/2023 at 10:27 AM, revealed two vents located at the nurse's station and one vent located in front of the nutrition room were covered with black debris. Observations in room [ROOM NUMBER] on 5/15/2023 at 11:14 AM, revealed part of the wall in the corner was missing. Observations in room [ROOM NUMBER]'s bathroom on 5/15/2023 at 11:15 AM, revealed a ceiling tile was stained brown and sinking down. Observations on the 500 hall on 5/15/2023 at 11:56 AM, revealed Spa #1 had two vents which were covered with black debris. Observations in room [ROOM NUMBER] on 5/16/2023 at 10:20 AM, revealed various white spots of paint on the walls. Observations in room [ROOM NUMBER]'s bathroom on 5/16/2023 at 10:49 AM, revealed the left sink pipe and wall had brown and orange debris. Continued observation revealed white paint spots in the bathroom. Observations on the 500 hall on 5/18/2023 from 7:45 AM to 9:45 AM, revealed rooms 505, 507, 509, 511, 513, 515, 517, and 519 had scuffed closet doors. Rooms 501, 503, 505, 507, 509, 513, and 517 had chipped closet doors and frames. Continued observation revealed 500 hall had varnish scuffed off along the wooden hand rails. The 500 hall had scuffed and worn wooden hand rails toward the dining room. Observations on the 100 hall on 5/18/2023 from 9:49 AM to 10:19 AM, revealed rooms 102, 103, 108, and 115 had stained tubs. rooms [ROOM NUMBER] had scuffed doors and walls. Rooms 106, 107, 108, 109, 110, 111, 113, 114, 116, and 117 had scrapped walls and doors. rooms [ROOM NUMBERS] had chipped doors. room [ROOM NUMBER] had a missing towel bar. rooms [ROOM NUMBER] had dirty walls. room [ROOM NUMBER] had damaged ceiling walls and orange stained walls. room [ROOM NUMBER] had cracked walls. Observations in the Soiled Linen Room shared by 100/200 halls on 5/18/2023 at 4:45 PM, revealed the cabinet with a broken door handle on the upper right cabinet door and a broken handle on the drawer below the cabinet. During an interview on 5/15/2023 at 12:45 PM, the Director of Operations confirmed the black debris on the vents, and the vents were only replaced when the budget allowed. During an interview on 5/16/2023 at 9:55 AM, the Assistant Director of Operations confirmed the black debris was dust on the vents. During a telephone interview on 5/16/2023 at 2:45 PM, Family Member #2 stated room [ROOM NUMBER] could use a new paint job. During an interview on 5/18/2023 at 5:32 PM, the Director of Operations (DOO) observed all the above concerns and confirmed several rooms in the facility had issues which needed to be addressed. The DOO stated the facility only had two staff employees to address those issues at the facility. During an interview on 5/18/2023 at 5:45 PM, the Housekeeping Manager observed and confirmed the walls and tubs needed to be cleaned in the rooms listed above. The Housekeeping Manager stated each room should be deep cleaned (thorough scrubbing of all surfaces) once a week.

Based on facility policy review, medical record review, and interview, the facility failed to revise the comprehensive care plan for 1 of 47 (Resident #22) sampled residents. The findings include: Review of the facility policy titled, Comprehensive Care Plans, dated 7/19/2018, revealed, .Care plans are ongoing and revised as information about the resident and the resident's condition change .The nurse/Interdisciplinary Team is responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes on the residents' status . Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses which included Unspecified Protein-Calorie Malnutrition, Unspecified Dementia, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Muscle Weakness (generalized), and Gastro-Esophageal Reflux Disease without Esophagitis. Review of the Comprehensive Care Plan dated 4/26/2023 for Resident #22 revealed the care plan had not been updated to include the interventions for weight loss. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status of 8 which indicated moderately impaired cognition. Review of the Progress Note dated 5/5/2023 revealed, .Interdisciplinary Team (IDT) met and discussed weight loss. Weight order changed to weekly times 4 weeks. Diet modified to FFP [Fiber, Fat, Protein]. Elder was noted to have pour [sic] intake. Health shakes ordered TID [three times per day]. Will continue POC. [plan of care] . Review of the Progress Note dated 5/11/2023 revealed, .IDT met and discussed elders weight loss. New interventions in place . During an interview on 5/17/2023 at 10:32 AM, the Social Service Director (SSD) confirmed that weight loss interventions should be documented on the care plan and that Resident #22's weight loss interventions were not on the care plan. During an interview on 5/17/2023 at 2:20 PM, the Administrator confirmed care plans should be updated to reflect any new interventions or preventions for residents.

Based on facility policy review, medical record review, observation, and interview, the facility failed to assess and treat impaired skin integrity for 1 of 1 (Resident #4) sampled residents observed during the initial tour. The findings include: Review of the facility policy titled, Skin Integrity Policy reviewed by the facility 7/11/2022 revealed, .A resident with impaired skin integrity receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent avoidable skin integrity issues from developing .The licensed nurse shall initiate applicable Skin Integrity documentation if a new area of impairment is identified .In addition, to ongoing observations of skin integrity, nursing stakeholders shall observe the skin for areas of impairment with bathing, daily dressing, and peri care notify and notify the nurse if an area is identified . Review of the medical record revealed Resident #4 was readmitted to the facility on [DATE] with diagnoses which included Vascular Dementia and Type 2 Diabetes. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the care plan intervention dated 3/7/2023, revealed, .Notify nurse immediately of any areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care . Observations in Resident #4's room on 5/15/2023 at 3:58 PM, revealed Resident #4 had raised red bumps and bumps with brown scabs in the center on the left upper arm. Observations and interview in Resident #4's room on 5/17/2023 at 3:12 PM, the Assistant Director of Nursing (ADON) observed and confirmed the raised bumps on Resident #4's left upper arm and in bilateral arm pits. During an interview on 5/17/2023 at 3:03 PM, the ADON stated the staff did not fill out skin observation forms after showers and baths. During an interview on 5/17/2023 at 3:19 PM, Certified Nurse Aide (CNA) #9 stated she had noticed the raised bumps and scabs on Resident #4's arm. CNA #9 stated, Those bumps and scabs had been on her arm for awhile. [Resident #4] picked at the bumps on her arm until they bleed. CNA #9 confirmed staff did not fill out observation sheets of the residents' skin after a shower or bath. CNA #9 confirmed she had not told the nurse of the bumps on Resident #4's arm. During an interview on 5/17/2023 at 3:31 PM, Licensed Practical Nurse (LPN) #2 stated, The nurses conducted weekly skin assessments and if someone identifies anything . LPN #2 stated Resident #4 had the bumps for a while, and they would not heal because she picked at them. LPN #2 confirmed Resident #4 was not receiving any medication for those areas. LPN #2 stated she gave Resident #4 some lotion last week for dry and itchy skin. LPN #2 stated she assessed the areas on Resident #4's left arm and saw the raised bumps. LPN #2 confirmed she did not document that she assessed the area or that she gave Resident #4 lotion. LPN #2 stated if there were new areas, she would have alerted the Director of Nursing (DON), Wound Care Nurse, and Physician. If the areas were old, she would have charted the findings and notified the ADON or DON. Continued interview revealed LPN #2 thought the Physician and Nurse Practitioner already knew of the areas on the left arm. During an interview on 5/17/2023 at 4:27 PM, the DON confirmed she expected the CNAs to notify the nurse of any skin impairments and the nurses to assess and document the findings.

Based on medical record review, observation and interview, the facility failed to supervise intrusive wandering for 1 of 6 (Resident #41) sampled residents and failed to provide supervision for transport of 1 of 1 (Resident #60) sampled residents. The findings include: Review of the medical record revealed Resident #41 was admitted on [DATE] with diagnoses which included Dementia with Behavioral Disturbances, Altered Mental Status, and Alzheimer's Disease. Review of the nursing progress notes dated 2/22/2023, revealed Resident #41 was found one evening lying in the floor of another resident's room, appearing to be asleep with her knees slightly bent without distress. Review of the nursing progress notes dated 2/25/2023, revealed Resident #41 was ambulating ad lib (without previous preparation) into another resident's room per normal, and was restless with anxiety and fidgeting. Review of the nursing progress notes dated 3/8/2023, revealed Resident #41 continued to have intrusive wandering with repetitive opening and closing of doors. Review of the nursing progress notes dated 4/14/2023, revealed Resident #41 continued to have intrusive wandering per normal behavior. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was not obtained due to the resident being unable to complete the interview. Short- and long-term memory problems and severely impaired decision making skills were noted. Daily administered medications which included antipsychotic and antianxiety medication were noted. Observations in Resident #43's room on 5/15/2023 at 11:19 AM, revealed Resident #41 was in Resident #43's room on the right side of Resident #43's bed rummaging through items on the bedside table and touching the pillow. Resident #43 began to cry out. This surveyor called Certified Nurse Aide (CNA) #1 to the room at 11:21 AM for assistance. Observations in Resident #371's room on 5/15/2023 at 12:33 PM, revealed Resident #41 touched Resident #371's bed while the resident was in the bed and Resident #371 told Resident #41 it was not her room. Observations on the 500 hall on 5/15/2023 at 6:05 PM, revealed Resident #41 wandered into Resident #79's room. During an interview on 5/16/2023 at 11:11 AM, CNA #9 confirmed Resident #41 wandered into Resident #43's room on 5/15/2023 at 11:19 AM. CNA #9 also confirmed Resident #43 and Resident #90 would get upset when an intrusive wanderer entered their room. CNA #9 further stated Resident #41 had, at times, been verbally and physically combative with the staff when attempting to provide care. CNA #9 stated many times they staff would leave Resident #41 to calm down and then return and continue her care. During an interview on 5/16/2023 at 11:32 AM, CNA #8 stated the unit had many residents that wandered including Resident #41. CNA #8 confirmed some of the residents got upset because of the wanderers. During an interview on 5/17/2023 at 3:31 PM, Licensed Practical Nurse (LPN) #2 confirmed Resident #41 was difficult to redirect. LPN #2 stated Resident #79 did not like Resident #41 in Resident #79's room. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] with diagnoses which included Vascular Dementia with Mood Disturbances and Legal Blindness as defined in USA (United States of America). Review of the Admission MDS assessment dated [DATE], revealed Resident #60 had a BIMS score of 8 which indicated moderate cognitive impairment. Review of the Transportation Request dated 3/10/2023, revealed, .Escort Needed . was not check marked by the nurse. The check mark indicated the need for an attendant to accompany a resident to an appointment. Review of a transportation document dated 3/10/2023, revealed, .Escort needed or riding with client . was marked .no . During a telephone interview on 5/16/2023 at 2:11 PM, Family Member #1 stated the [named transport company] lost Resident #60 because they dropped the resident off at the 2nd floor for a physician appointment instead of the 3rd floor. Family Member #1 stated Family Member #3 was supposed to meet Resident #60 on the 3rd floor and accompany Resident #60 to the eye appointment. Family Member #1 was told by Family Member #3 Resident #60 could not be found for an hour. During an interview on 5/17/2023 at 11:17 AM, Family Member #1 stated Resident #60 was not mobile, and she could not get around in the wheelchair unless someone pushed her. Family Member #1 stated the facility did not send anyone to accompany Resident #60 to the eye appointment. Family Member #3 called and informed Family Member #1 that Resident #60 had not arrived at the appointment. Family Member #1 called the facility, and the facility told her Resident #60 had already been picked up by [named transport service]. The facility called [named transport service] to see where Resident #60 was. Family Member #3 alerted the front desk clerk at the clinic on the 3rd floor, and the staff from the clinic helped find Resident #60. Family Member #1 stated, .I thought a staff member would accompany Resident #60 to the eye appointment .the family requested assistance with transportation from the facility . Family Member #1 and Family Member #3 had discussed with the facility before admittance about providing staff escorts to medical appointments for Resident #60. During an interview on 5/17/2023 at 12:14 PM, LPN #3 stated Family Member #3 had already scheduled the appointment but requested assistance with transportation. Whenever someone requested transportation, the nurses put the request on the calendar and filled out a transportation request sheet. Family Member #3 asked to meet Resident #60 at the doctor's office. LPN #3 confirmed staff did not accompany Resident #60 to her eye appointment. LPN #3 stated the Social Service Director (SSD) and DON decided if a resident required staff to accompany them to an appointment. A resident's BIMS score was reviewed and taken into consideration to make a decision. LPN #3 was not sure why a staff member did not accompany Resident #60 to the eye appointment. LPN #3 confirmed she did not mark on the transportation request form that Resident #60 would need accompaniment to the appointment because she was not told to do so. During an interview on 5/17/2023 at 12:23 PM, the ABOM stated once she got a request for transportation she contacted [named transport service] to set up the transportation. The nurses filled out the transport request and indicated whether the resident required an escort or not. The ABOM copied the request and sent it to the [named transport service]. Continued interview revealed the ABOM was asked to call [named transport service] to get with the driver to know where Resident #60 was dropped off. During an interview on 5/17/2023 at 12:45 PM, the Director Of Nursing (DON) stated the nurse working on a resident's medical appointment would fill out the transport sheet and indicate if an escort was needed. The nurses would then take the request to the ABOM. If a resident required an escort, it would be discussed at the morning meeting to determine which staff would accompany the resident. During an interview on 5/17/2023 at 1:01 PM, the Registered Nurse (RN) #1, also known as the Unit Manager, stated Family Member #1 called and said they could not find Resident #60. RN #1 called the eye clinic, and they said Resident #60 was not there. RN #1 called [named transport service], and they said they took her the appointment. The facility called back and informed RN #1 they had found Resident #60. During an interview on 5/17/2023 at 1:42 PM, the Administrator stated RN #1 informed her immediately that Resident #60 was missing, and the facility contacted [named transport service]. The ABOM communicated with the transport company, and RN #1 communicated with Family Member #3. Resident #60 was at a medical office building. The Administrator called and informed Family Member #3 that Resident #60 was at the the wrong office suite but had been located. The Administrator stated the charge nurse would decide if a resident needed staff accompaniment to an appointment because, They would know the patient best. 38830

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure safe handling, cleaning, and storage of breathing treatment and CPAP/BiPap (Continuous Positive Airway Pressure/Bilevel Positive Airway Pressure) equipment for 1 of 4 (Resident #44) sampled residents and failed to properly date and store oxygen equipment for 2 of 4 (Residents #66 and #77) sampled residents observed with oxygen therapy. The findings include: Review of the facility policy titled .Departmental (Respiratory Therapy) - Prevention of Infection Revised November 2011 .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators among resident and staff .Infection Control Considerations Related to Oxygen Administration .Obtain equipment (i.e., oxygen tubing, reservoir, and distilled water)Change the oxygen cannulae and tubing every seven (7) days, or as needed .Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol .After completion of therapy .store the circuit in plastic bag, marked with date and resident's name between uses . Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses which included Acute on Chronic (Diastolic), Congestive Heart Failure (CHF), Fibromyalgia, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the respiratory care plan dated 5/16/2023, revealed, .at risk for respiratory complications related to respiratory failure with hypoxia and hypercapnia, COPD, OSA [Obstructive Sleep Apnea], and CHF . Observations and interview in Resident #44's room on 5/17/2023 at 12:34 PM revealed Resident #44 had a CPAP/BiPAP mask and nebulizer (small machine that turns liquid medicine into a mist that can be easily inhaled) mask unbagged on the top of bedside table undated. Licensed Practical Nurse (LPN) #1 observed and confirmed the undated and unbagged masks. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure with Hypoxia, Chronic Combined Systolic and Diastolic Congestive Heart Failure, and Morbid Severe Obesity due to Excess Calories. Review of the physician order dated 3/28/2023, revealed, .Oxygen Therapy: Oxygen via NC [Nasal Cannula] @ [at] 2 L [liters] per minute, Oxygen Therapy: Change tubing every week Once a Day on Wed [Wednesday]; Night . Review of the Admission MDS assessment dated [DATE] revealed Resident #66 has a BIMS score of 15 which indicated no cognitive impairment. Continued review revealed Resident #66 had oxygen therapy. Review of respiratory care plan dated 4/27/2023, revealed, .at risk for respiratory complications due to dx [diagnosis] of respiratory failure with hypoxia and dx of CHF/SOB [Shortness of Breath] laying flat . Observations and interview in Resident #66's room on 5/15/2023 at 3:03 PM, revealed LPN #1 observed and confirmed there was no date present on the O2 tubing. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses which included Type II Diabetes Mellitus with Chronic Kidney Disease, Essential Hypertension and Systolic Congestive Heart Failure. Review of physician order dated 9/29/2021, revealed .Oxygen Therapy: Change tubing every week, and Oxygen Therapy: Oxygen via NC @ 2L per minute . Review of Annual MDS dated [DATE] revealed Resident #77 had a BIMS score of 6 which indicated a severe cognitive impairment. Review of the care plan dated 5/15/2023 revealed .oxygen therapy r/t [related to] my dx of CHF, SOB lying flat and with exertion . Observations and interview on 5/15/2023 at 2:59 PM and 3:03 PM, revealed Resident #77's O2 tubing was dated 4/19/2023. LPN #1 observed and confirmed the O2 tubing was dated 4/19/2023 (26 days old).

Based on review of facility policy, medical record review, observations, and interviews, the facility failed to ensure narcotics were stored under lock and key for one resident (#8) of 8 residents reviewed for medication storage and failed to follow procedures during narcotic reconciliation on 1 of 5 medication carts on 1 of 5 wings of the facility observed for narcotic reconciliation. The findings included: Review of facility policy Controlled Medication and Drug Diversion, last revised 7/24/18, revealed .2. At each shift change or when keys are rendered a physical inventory of all controlled medication is conducted by two staff .this is completed as follows .a. the nurse .surrendering the keys will read from the controlled substance accountability book the name of the resident and the medications to be accounted .oncoming nurse .will locate the medication .count the remaining medication and report .the amount of medication remaining .6. Controlled medications remaining in the facility after the order has been discontinued are retained in the facility in a securely locked area with restricted access until .destroyed by the facility's director of nursing, administrator, and consultant pharmacist . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged home 8/1/18. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] (narcotic) .10 (milligrams) .give one tablet by mouth four times a day as needed .pain . Interview with the Assistant Director of Nursing (ADON) on 8/20/18 at 2:30 PM, in the chapel, revealed on the evening of 8/1/18 she was given Resident #8's [MEDICATION NAME] for destruction by Licensed Practical Nurse (LPN #3), who had removed them from the medication cart after Resident #8 was discharged . Continued interview revealed the ADON did not immediately secure the narcotics in the secure medication storage lock box, but instead placed them in an unlocked desk drawer in her unlocked office and on 8/3/18 when the ADON attempted to retrieve the [MEDICATION NAME], the narcotics were missing from the desk drawer. Interview with the DON on 8/20/18 at 6:00 PM, in the chapel, confirmed the facility failed to secure Resident #8's discontinued narcotics under lock and key in a secure area and failed to follow facility policy. Observation of a narcotic drug reconciliation (narcotic count) with LPN #8 and LPN #9 on 8/21/18 at 12:03 AM, of the D wing medication cart, revealed LPN #8 and LPN #9 completed the narcotic count without naming the resident or the name of each narcotic and did not simultaneously verify the remaining quantity of each narcotic medication compared to the narcotic inventory control card. Interview with the DON on 8/20/18 at 6:00 PM, in the chapel, confirmed the facility failed to ensure narcotics were verified and reconciled during a narcotic count and the facility failed to follow facility policy.

Based on facility policy review, medical record review, observation, and interview, the facility failed to develop and implement a baseline care plan for the care and maintenance of a peripherally inserted central catheter (PICC) for 1 resident (Resident #250) of 1 residents reviewed for PICC lines of 30 residents reviewed. The findings included: Review of the facility policy Baseline Plan of Care, not dated, revealed .development and implementation of the Baseline plan of care will start at admission and within the first 48 hours .include the minimum healthcare information necessary to properly care for a resident including, but not limited to .goals based on admission orders [REDACTED]. Medical record review revealed Resident #250 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Admission assessment dated [DATE] revealed Resident #250 was admitted to the facility with a PICC line in the right upper extremity. Medical record review of the Baseline Admission Care Plan dated 4/18/18 revealed no care plan for care and maintenance of the PICC line. Observation of Resident #250 on 04/23/18 at 2:43 PM, in the resident's room, revealed a PICC line in the resident's right upper arm. Interview with the Director of Nursing on 4/24/18 at 5:09 PM, in the conference room, confirmed the facility failed to develop a baseline care plan to address the care and maintenance for Resident #250's PICC line.

Based on facility policy review, medical record review, observation, and staff interview, the facility failed to provide dignity covers for catheter bags for 2 (Resident #3 and Resident #10) of 3 sampled residents. This had the potential to affect all 15 residents who had catheters. Failure to provide dignity covers for catheter drainage bags had the potential to demean patients. The findings included: Review of the facility's policy titled, Catherization Care, revised of 9/7/17, indicated, .13. Routinely check to ensure .Drainage bag is covered with a privacy cover unless resident requests otherwise. 1. Resident #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/25/17 at 12:00 PM, Resident #3 was observed eating lunch in room [ROOM NUMBER]. The drainage bag for the catheter was attached to the bed. The catheter drainage bag which had approximately 300 cubic centimeters (cc) of urine was visible and did not have a dignity cover on it. 2. On 9/25/17 at 1:30 PM, Resident #10 was observed lying in his bed in room [ROOM NUMBER]. The drainage bag for the catheter which was observed hanging on the bed with approximately 200 cc's of urine was visible without a dignity cover. During an interview on 9/25/17 at 12:30 PM, on the 200 Hallway, Certified Nursing Assistant #1 confirmed the drainage bag for the catheter should have a cover over it. During an interview on 9/25/17 at 2:40 PM, in the conference room, the Director of Nursing (DON) stated all catheter drainage bags should have a dignity cover on them. The DON further stated the facility has ordered new dignity bags for the catheter drainage bags and the facility is currently using pillowcases to cover the catheter drainage bags until the new dignity bags arrive.

Based on observation and interview, the facility failed to maintain the ice machines in a sanitary manner in 2 of 3 Nourishment Rooms. The findings included: Observation on 2/28/17 at 9:01 AM in the 100/200 hall Nourishment Room revealed an ice machine. Further observation of the interior of the ice machine revealed rusty brown colored debris on the top of the ice slide. Interview with Licensed Practical Nurse (LPN) #6 on 2/28/17 at 9:13 AM in the 100/200 hall Nourishment Room confirmed the top of the ice slide had rusty brown colored debris. Observation on 2/28/17 at 9:04 AM in the 300/400 hall Nourishment Room revealed an ice machine. Further observation of the interior of the ice machine revealed pink colored debris on the bottom of the ice slide where the ice falls into the ice storage bin. Interview with LPN #7 on 2/28/17 at 9:04 AM in the 300/400 hall Nourishment Room confirmed the ice machine interior had pink colored debris on the bottom of the ice slide.

Based on facility policy review, medical record review, and interview, the facility failed to prevent resident verbal abuse for 1 resident (#193) of 3 residents reviewed for abuse. The findings included: Review of facility policy, Abuse, Neglect and Misappropriation of Property, revealed .It is .policy to prevent the occurrence of abuse .Verbal abuse is use of any oral, written or gestured language that includes any threat, or any frightening, disparaging or derogatory language, to residents .or within their hearing distance, regardless of age, ability to comprehend, or disability . Medical record review revealed Resident #193 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #193 had moderately impaired cognitive skills, had adequate hearing and clear speech, and could make himself understood and understood others. Review of facility documentation dated 12/28/16 at 1:20 PM revealed Licensed Practical Nurse (LPN) #8 was witnessed by Housekeeper #1 and Certified Nurse Aide (CNA) #6 calling Resident #193 inappropriate names. Continued review of the facility documentation revealed LPN #8 stated she was . burned out .I had reached my limit . and she confirmed she called Resident #193 inappropriate names. Review of the Witness Statement by CNA #6 dated 12/28/16 revealed LPN #8 .come up the hall and said He's a dick head as (and} yes I said it out loud . Review of the Witness Statement by Housekeeper #1 dated 12/9/16 revealed Resident #193 .said she (LPN #8) called him a son-of-a-[***] , she (LPN #8) looked back at him and told him God told her to do that . Review of LPN #8's employee record revealed she was hired on 11/29/16, and had passed the abuse registry verification and the background verification. Further review revealed LPN #8 had completed orientation including abuse training. Review of the work schedule for LPN #8 revealed 4 days of working with another LPN on 12/5, 12/6, 12/8, and 12/9/16. LPN #8 worked independently on 12/12, 12/14, 12/17, 12/18, 12/19, 12/22, 12/23 and 12/28/16. LPN #8 was scheduled to work and called out on 12/7, 12/13, 12/25, and 12/26/16. Interview with Resident #193 on 2/27/17 at 2:18 PM in the resident's room, when asked if anyone in the facility had abused him, revealed .a nurse cussing him and she was fired . Telephone interview with Housekeeper #1 on 2/28/17 at 2:26 PM revealed she had overheard Resident #193 and LPN #8 talking in the resident's room doorway and the . LPN was getting mad at him and was rolling her eyes . when the resident stated to the LPN .Yes you did call me a son-of-a-[***] . Further interview revealed the LPN stated .God told her to say it . as she walked away from the resident. Telephone interview with CNA #1 on 2/28/17 at 2:35 PM revealed she had overheard LPN #8 yelled at and cuss at .Resident #193 .said he was a son-of-a-[***] and then said he was a dick head as she (LPN #8) started to walk to the nursing station .she looked back down the hall and said Yes I just said that out loud . Telephone interview with CNA #3 on 2/28/17 at 2:46 PM revealed the CNA overheard a loud exchange between LPN #8 and Resident #193 but could not hear what was said. CNA #3 reported to LPN #2, seated at nursing station, of overhearing a loud exchange. The CNA stated LPN #2 went to LPN #8. Telephone interview with LPN #2 on 2/28/17 at 3:07 PM revealed CNA #3 came to her and told LPN #2 she was needed down the hall .something was said . Further interview revealed LPN #2 went to LPN #8, at the medicine cart in the hallway, and LPN #8 stated Resident #193 had cussed at LPN #8. LPN #2 went to check on Resident #193 who told LPN #2 that LPN #8 had cussed at him. Further interview revealed the resident was monitored by a CNA while LPN #8 was escorted to the ADON/RN #1 office. Interview with ADON/RN#1 on 3/1/17 at 8:40 AM in the chapel revealed LPN #2 reported to the ADON/RN #1 about LPN #8 being heard calling Resident #193 inappropriate names. Further interview revealed LPN #8 was brought to the ADON/RN #1's office and was informed the LPN was overheard calling Resident #193 inappropriate names. Further interview revealed LPN #8 confirmed she had called the resident inappropriate names. Further interview revealed LPN #8 was escorted to the Director of Nursing's (DON's) office where the allegation was discussed and LPN #8 confirmed she had called the resident a name and knew what she had done was not appropriate. Interview with CNA #6 on 3/1/17 at 9:19 AM in the chapel revealed she was in the hallway and had heard LPN #8 .say he's (Resident #193) a dick head and Yes I said that out loud . Further interview revealed the CNA went to the Assistant Director of Nursing (ADON)/Registered Nurse (RN) #1 to report the event when a staff member (unable to recall who) entered the RN's office to report the exchange between LPN #8 and the resident. Interview with the DON on 3/1/17 at 9:31 AM in the DON's office revealed the ADON/RN #1 informed the DON there was a situation involving LPN #8 and the LPN was escorted to the DON's office. Further interview revealed the DON, ADON/RN #1 and LPN #8 discussed what had been overheard and LPN #8 confirmed she had called Resident #193 inappropriate names, she knew it was wrong to do and was embarrassed. Further interview revealed LPN #8 stated she was burned out and wanted to leave . Further interview revealed the LPN was informed her employment was terminated and was escorted off the property.

Based on facility policy review, medical record review, and interview, the facility failed to notify the physician of psychotic behavior of a resident (#2) of 26 residents reviewed, which resulted in Resident #2 assaulting Resident #1 and caused Resident #1 to require emergency medical evaluation of acute injuries. The behavior placed all 36 residents of the G Wing in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, or death to a resident). The Administrator and Director of Nursing were informed of the Immediate Jeopardy on 3/30/15 at 2:30 PM in the Chaplain's office. The Immediate Jeopardy was effective on 03/10/15. The findings included: Review of the facility policy entitled "Behavior Management Program (BMP)" effective on 12/10/14, revealed "...Guideline...It is the intent of this facility to identify and assess complex behaviors in residents in order to develop effective management plans. This facility shall also identify, assess, monitor and manage manifested behaviors in residents to ensure the safety of all residents..." "...Procedure...When a new behavior is identified, it will be documented on the Behavior Monitoring Form/Psychoactive Medications...""...The Physician and the family/responsible party shall be notified of the new behavior..." Medical record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission (Minimum Data Set) MDS dated [DATE], revealed Resident #2 was severely impaired cognitively. Continued review of the MDS revealed the resident demonstrated daily incidents of physical behaviors directed toward others and rejecting care. Medical record review of the nursing notes dated 3/10/15 at 8:00 PM, revealed "...Resident #2 wandering throughout unit. Very difficult to redirect. Resident holding handles of another resident's wheelchair (w/c). Resident became agitated when attempted to redirect resident not to push another resident. Would not let go of handles. Hitting and punching at staff with redirection. Resident got the fire extinguisher and would not cooperate with redirection. Swinging extinguisher at staff. Resident requiring 1:1 (one staff person sitting with resident in a quiet room) supervision due to hitting and slapping at staff, non redirection concerning other residents..." Medical record review of nursing notes dated 3/11/15, on the day shift, revealed "...(Resident #2) is not easily redirected. Must be approached carefully and slowly..." Medical record review of nursing notes dated 3/12/15, at 11:00 PM, revealed "...Res (resident #2) up at nurses' desk, sat in chair. Res got up, sat on floor, and layed down. ask Res why laying on floor, stated 'I'm tired', told Res this nurse would take him back to bed..." Medical record review of a note by the Behavior Health Manager dated 3/13/15, revealed Resident #2 scored "0" on the Mini Mental Examination, indicating he was not oriented to person, place, or time. Continued review revealed the resident's cognitive stage was indicative of severe cognitive decline. Medical record review of nursing notes dated 3/13/15, at 7:45 PM, revealed "...(Res #2) refused to lay down in bed, was sitting on side of bed. Tried to sit on floor..." Continued review of nursing notes at 8:00 PM, revealed "Daughter stated dad was sitting on floor and she needed help getting him up..." Further review of nursing notes at 9:00 PM, revealed "...Res is now up in room, moving furniture around, moved chest of drawers in front of door, when ask what he was doing res stated 'I setting up stage'..." Medical record review of nursing notes dated 3/15/15, at 9:30 PM, revealed "...(Resident #2) wandering on unit, x1 (times) attempt to open exit door. Redirected by staff. Resident broke arm off chair and had wooden arm underneath shirt..." Medical record review of nursing notes from 3/10/15 to 3/15/15, revealed no documentation the physician was notified of any of the resident's behaviors. Medical record review revealed Resident #1 was admitted to the current facility on 5/21/09, with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident was moderately impaired cognitively with disorganized thinking. Continued review of the MDS revealed the resident was dependent for transfers, dressing, grooming, and bathing; was incontinent of bowel and bladder; and was unable to move lower extremities which were contracted. Medical record review of a nursing assessment for Resident #2 dated 3/16/15, at 3:15 PM, revealed the "...CNA (Certifed Nursing Assistant) entered the room to change (Resident #1) and noticed (Resident #2) had placed the chair cushion on (Resident #1) like a blanket. CNA redirected resident and told him it wasn't a blanket and walked him back to his side of the bed. CNA reported the issue with the cushion to charge nurse and immediately went back to check on Resident when she noticed (Resident #2) standing on the right side of the bed of (Resident #1) with a glass coke bottle in his hand (from the collection of Resident #1) and saw the motion of the bottle going down toward the face of (Resident #1). CNA immediately walked (Resident #2) from the room and yelled for help. (Resident #1) was noted to have bleeding from face area and bruising and swelling noted around eyes..." Continued review of the assessment revealed (Resident #1) was transferred to the hospital while (Resident #2) was placed on 1:1 until he was transferred to a gero-psych (geriatric psychological) unit. Interview with the Director of Nursing (DON) on 3/25/15 at 1:35 PM in the Chaplain's office, revealed (Resident #2) was admitted [DATE] and was disoriented and resistant to care. Continued interview revealed staff called the DON about the resident's behavior on 3/10/15, and she told the staff to place the resident on 1:1 until settled (not exhibiting behaviors). Continued interview with the DON revealed the behaviors exhibited by (Resident #2) on 3/10/15, was probably not reported to the physician. Further interview revealed the nurses only notify the physician if the behavior is ongoing. Interview with the Medical Director on 3/30/15, at 1:10 PM in the Chaplain's office, revealed "...If I am the resident's physician I would expect to be notified if he was swinging a fire extinguisher around..." Telephone interview on 4/1/15, with the resident's physician, revealed the physician was not notified of any behaviors of Resident #2 and stated he looked after the medical problems and expected psych services to manage the behaviors. An acceptable Allegation of Compliance removed the immediacy of the Immediate Jeopardy on 04/2/15. The interventions put in place were evaluated by the survey team on 4/2/15, and verified the Allegation of Compliance by: 1. Interviews of 10 nursing staff members selected from various units in the facility on all shifts. These interviews included verbal explanations of what constitutes a change in resident condition; what is required when a change occurs; who to be notified, by whom, how soon; and required documentation. 2. Review of the minutes of the Quality Improvement Committee dated 3/19/15, revealed Administrator, Director of Nursing, Regional Nurse Consultants, and Family Nurse Practitioner were in attendance to discuss the root cause of the event, education, interventions, and plans to prevent occurrence as described in the Allegation of Compliance. 3. Interview with the Administrator and Director of Nursing outlined the governing body's plan for ongoing supervision and follow up with the facility which would be conducted in response to the Immediate Jeopardy, by which means communication was to occur; how frequently corporate staff would be onsite; and for what duration corporate follow up would be performed on site. Noncompliance continues at an "E" level for evaluation of the monitoring by the Quality Assurance Committee. The facility is required to submit a Plan of Correction.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure residents were free from physical abuse by a resident (#2) of 26 residents reviewed, which resulted in Resident #2 assaulting Resident #1 and caused Resident #1 to require emergency medical evaluation for acute injuries. This failure places all 36 residents of the G Wing in Immediate Jeopardy. The Administrator and Director of Nursing were informed of the Immediate Jeopardy on 3/30/15 at 2:30 PM in the Chaplain's office. The Immediate Jeopardy was effective on 3/10/15. F223 constitutes Substandard Quality of Care. The findings included: Review of the facility policy entitled "Behavior Management Program (BMP)" effective on 12/10/14, revealed "...Guideline...It is the intent of this facility to identify and assess complex behaviors in residents in order to develop effective management plans. This facility shall also identify, assess, monitor and manage manifested behaviors in residents to ensure the safety of all residents..."Procedure...The Social Worker, or designee, shall initiate a behavioral assessment and management plan when staff or the MDS (Minimum Data Set) process identifies certain behaviors. The Behavioral Plan will be placed in the Behavior Management Program Book that is kept at the nursing station. A. Abuse risk-Does the behavior place this resident at risk for abusing or abusing others?...Does this resident's behavior result in abuse toward another resident?...B. Management Plan: Identify appropriate interventions to manage identified behavior(s) and the discipline responsible for implementing interventions. Review of the facility policy entitled "Abuse, Neglect, and Misappropriation" effective on 04/13, revealed: A. Verbal, sexual, physical, and mental abuse, corporal punishment, neglect, and involuntary seclusion of the resident, resident exploitation, as well as misappropriation of resident property are prohibited. B. All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines. Resident to resident: 1. If a resident is observed exhibiting any form of abuse towards another resident, staff will intervene immediately. 2. Residents will have physical assessments completed to determine any potential injuries. 3. Administrator and DON will be notified immediately. 4. Residents will be closely supervised. 5. Physician and families will be notified. 6. Social Services/Chaplain will be notified for follow up and continued monitoring. 7. Care plans will be updated as needed. Follow up: A. All allegations are to be reported within the time frame allotted by state agency. B. Social Service/Chaplain will follow up with resident to monitor resident's emotional well-being following the incident. C. Family will be notified of outcome of investigation. D. Physician will be notified of outcome of investigation. E. All allegations of abuse are reviewed at Quality Assurance meetings for any further resolution related to educational opportunities. Medical record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE], revealed the resident was severely impaired cognitively. Continued review of the MDS revealed the resident demonstrated daily incidents of physical behaviors directed toward others and rejecting care. Medical record review of facility nursing notes dated 3/10/15 at 8:00 PM, revealed "...Resident #2 wandering throughout unit. Very difficult to redirect. Resident holding handles of another resident's wheelchair (w/c). Resident became agitated when attempted to redirect him not to push another resident. Would not let go of handles. Hitting and punching at staff with redirection. Resident got the fire extinguisher and would not cooperate with redirection. Swinging extinguisher at staff. Resident requiring 1:1 (one staff person sitting with resident in a quiet room) supervision due to hitting and slapping at staff, non redirection concerning other residents..." Medical record review of nursing notes dated 3/11/15, on the day shift, revealed "...Resident #2 is not easily redirected. Must be approached carefully and slowly..." Medical record review of nursing notes dated 3/12/15, at 11:00 PM, revealed "...Res (resident) #2 up at nurses' desk, sat in chair. Res got up, sat on floor, and layed down. ask Res why laying on floor, stated "I'm tired", told Res this nurse would take him back to bed..." Medical record review of a note by the Behavior Health Manager dated 3/13/15, revealed Resident #2 scored "0" on the Mini Mental Examination, (determine orientation and ability to follow directions) not oriented to person, place, or time. Continued review revealed the resident's cognitive stage was indicative of severe cognitive decline. Medical record review of nursing notes dated 3/13/15, at 7:45 PM, revealed "...Res refused to lay down in bed, was sitting on side of bed. Tried to sit on floor..." Continued review of nursing notes at 8:00 PM, revealed "Daughter stated dad was sitting on floor and she needed help getting him up..." Further review of nursing notes at 9:00 PM, revealed "...Res is now up in room, moving furniture around, moved chest of drawers in front of door, when ask what he was doing res stated "I setting up stage"..." Medical record review of nursing notes dated 3/15/15, at 9:30 PM, revealed "...Resident #2 wandering on unit x 1 attempt to open exit door. Redirected by staff. Resident broke arm off chair and had wooden arm underneath his shirt." Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident was moderately impaired cognitively with disorganized thinking. Continued review of the MDS revealed the resident was dependent for transfers, dressing, grooming, and bathing; was incontinent of bowel and bladder; and was unable to move lower extremities which were contracted. Medical record review of a nursing assessment for Resident #2 dated 3/16/15, at 3:15 PM, revealed the "...CNA (Certified Nursing Assistant) entered the room to change (Resident #1) and noticed (Resident #2) had placed the chair cushion on (Resident #1) like a blanket. CNA redirected resident and told him it wasn't a blanket and walked him back to his side of the bed. CNA reported the issue with the cushion to charge nurse and immediately went back to check on Resident when she noticed (Resident #2) standing on the right side of the bed of (Resident #1) with a glass coke bottle in his hand (from the collection of Resident #1) and saw the motion of the bottle going down toward the face of (Resident #1). CNA immediately walked (Resident #2) from the room and yelled for help. (Resident #1) was noted to have bleeding from face area and bruising and swelling noted around eyes..." Continued review of the assessment revealed (Resident #1) was transferred to the hospital while (Resident #2) was placed on 1:1 until he was transferred to geriatric psychological (gero-psych) unit. Review of the hospital record for Resident #1 dated 3/16/15, from the Emergency Department, revealed the resident had been assaulted with a glass coke bottle. Further review of the Emergency Department record revealed the resident had "...bilateral black eyes; contusion of right eye, right cheek, nose, left cheek and left eye; bruising bilateral dorsal wrists; lacerations 2 centimeters (cm) on nose, 1 cm on right forehead. Continued medical record review of radiology results revealed multiple nasal bone fractures with some depression particularly on the right; fractures extend to and involve anterior bony septum. Probable distal maxillary spine fracture as well; minimally depressed right side pneumatic arch fracture. Small air-fluid level of left maxillary antrum that may represent a small amount of sinus bleeding. Mildly depressed anterior and left maxillary antral fracture. Minimal inferolateral right orbital rim fracture not excluded. Significant soft tissue swelling, right greater than left. Surgery was not recommended because the fractures were minimally displaced..." Continued review of the hospital record revealed the resident had no respiratory difficulty and he was discharged on [DATE] back to the facility. Review of the facility investigation dated 3/16/15, revealed Resident #1 stated "...it didn't have to happen, he was over there hitting the window shade, I told him to stop it, he started hitting me..." Continued review of the facility investigation revealed a statement from CNA #6 which stated "I had walked into the room and seen (Resident #2) putting a floor mat on top of (Resident #1). I walked over and took the mat from (Resident #2) and directed him over to his bed. I left the room for about 5 min (minutes) to tell my charge nurse what had happened. She put me on 1:1 (she was to stay with Resident #2 at all times) I walked back down to sit with (Resident #2) and walked in and (Resident #2) was standing over (Resident #1) hitting him in the face with the coke bottle I ran over turned (Resident #2) around and he left the room I screamed for my nurse she came in and called the Assistant Director of Nursing..." Further review of the facility investigation dated 3/16/15, revealed a statement by CNA #24 who stated "...I was at computer charting. I thought I heard a scream. I went down hall to see who it was. I heard (Resident #1) so I went running to room and seen (Resident #1) face bleeding. It was stated (Resident #2) had hit (Resident #1) repeatedly on face/head. I went to pull (Resident #2)'s pants. He grabbed my right arm and slung me around against wall and didn't want to let go of my arm..." Review of the facility investigation dated 3/16/15, revealed a statement from CNA #13 who stated "...At approx (approximately) 3:15 PM on 3/16/15, I was walking down the hall from the nurses' station. I heard screams from staff member (CNA #6). I called out for my charge nurse and ran toward room. I saw (Resident #2) coming out of room and setting a glass coke bottle onto the floor. As I reached out to get the coke bottle the resident drew back to hit me but staff member grabbed his arm to redirect him. (Resident #2) then grabbed CNA #24 and swung her around. I placed the coke bottle on (Resident #1)'s chest of drawers. And PT (physical therapy) took (Resident #2) with them..." Observation of Resident #1 on 3/24/15, at 1:30 PM, revealed a thin man lying in bed with purple bruises on the right neck below the ear; front of the neck; chin; right side of head by the eye; dorsum of right hand; nose and lips; nose up to right eyebrow; and left chin to neck. Interview with the Director of Nursing (DON) on 3/25/15 at 1:35 PM in the Chaplain's office, revealed (Resident #2) was admitted [DATE] and was disoriented and resistant to care. Continued interview revealed staff called the DON about the resident's behavior and she told the staff to place the resident on 1:1 until settled (not exhibiting behaviors). Further interview revealed the resident liked to push stuff. Continued interview revealed there was no mention of aggression in the notes received from the psychiatric hospital and the PASRR (Pre-Admission Screening and Resident Review) nurse did not see any issues; did not feel he was a risk to self or others; and recommended he remain in the facility. Continued interview revealed the DON was made aware of an incident at the psychiatric hospital, prior to admission to the facility, in which Resident #2 struck CNA #14 and Nurse #1 "...on Thursday or Friday of the week he was admitted ..." Continued interview revealed Resident #1 had a glass coke bottle collection at the bedside and Resident #2 took a bottle and was playing on the blinds as if playing a drum. Further interview revealed Resident #1 asked Resident #2 to stop so Resident #2 took the bottle and was banging it on the face and head of Resident #1. Further interview revealed the DON confirmed Resident #2 had a chair arm under his shirt and she didn't know what Resident #2 would have done with the chair arm if another resident had approached him. Continued interview revealed when a resident is admitted there is usually a psych (psychiatric) referral; someone has to come out from the psych group to check insurance; then the psychologist comes on Thursdays but is not on call for emergencies. Interview with CNA #9 on 3/26/2015, at 7:55 AM, in the Chaplain's office, revealed Resident #2 sat in a chair and played with the arm of the chair. Further interview revealed the arms are secured to the chair with two pegs. Continued interview revealed the resident worked the arm loose and put it under his shirt, just like a child who had done something wrong and tried to hide it. Interview with CNA #6 on 3/26/15 at 10:25 AM in the Chaplain's office, stated she was assigned both Resident #1 and Resident #2 on 3/16/15. Continued interview revealed she went in to change Resident #1 then briefly left the room. Further interview revealed CNA #6 returned to the room to find Resident #2 had placed a large chair mat over Resident #1 who was saying "Get that off me". Continued interview revealed CNA #6 sat Resident #2 on his bed; pulled the privacy curtain; opened the door and put a waste basket to keep the door open; and left the room to inform the charge nurse about the incident with the mat. Further interview revealed the charge nurse was calling the DON and ADON (Assistant Director of Nursing) to notify them of the incident. Continued interview revealed the charge nurse told CNA #6 she needed to 1:1 (stay with resident at all times) Resident #2 so CNA #6 returned to the room to find the door closed. Further interview revealed CNA #6 opened the door to find Resident #2 standing over Resident #1 with a glass coke bottle, lowering his arm toward the face of Resident #1, and heard the "thump" when the bottle hit his face. Further interview revealed Resident #1 said "He's trying to kill me" so CNA #6 escorted Resident #2 out of the room and screamed for the charge nurse. Continued interview revealed the privacy curtain had been pulled back. Further interview revealed Resident #2 didn't seem to realize what was going on and walked out of the room with the coke bottle in his hand. Interiew with the Administrator and DON on 3/30/15, at 8:50 AM in the Chaplain's office, revealed there was an incident of Resident #2 missing from his room. Continued interview revealed CNAs #2 and #11 searched for the resident. Further interview revealed Resident #2 was found in the bathroom of a room with two female residents who were asleep. Continued interview revealed Resident #2 had his clothes on inside out. During the week of 3/10/15 - 3/16/15, the facility failed to follow its policy on abuse by not reporting the incident with the fire extinguisher and the incident with the chair arm to the physician. The facility failed to see the fire extinguished and chair arm as potential weapons to be used against other residents or staff. The facility failed to protect the residents on G Wing by allowing Resident #2 to roam freely and wander in and out of other resident's rooms. The facility failed to protect Resident #1 by not ensuring staff remained in the room with both Resident #1 and Resident #2 after Resident #2 tried to cover Resident #1 with the chair mat. Interview with LPN (Licensed Practical Nurse) #5 on 3/26/15 at 10:40 AM in the Chaplain's office, stated she was the charge nurse on 3/16/15. Continued interview stated CNA #6 came to her with a concern Resident #2 had covered Resident #1 with a chair mat. Further interview stated she asked CNA #6 if she had removed the mat and redirected Resident #2, which she had. Continued interview with LPN #5 stated she told CNA #6 to go back to the room where CNA #6 saw Resident #2 with a coke bottle in his hand, going toward the head of Resident #1. Further interview stated two other CNAs escorted Resident #2 from the room, while LPN #5 assessed Resident #1 and called the ADON. Continued interview stated Resident #1 was in bed; was unable to walk; and was transferred with a mechanical lift. Telephone interview with the complainant on 3/26/15, at 2:15 PM, stated "...the facility let the ball drop and she was not happy with their choice (of roommate)..." Continued interview stated administration did not contact her to find out how Resident #1 was doing. Continued interview stated they have to have policies in place so this type of incident will not happen again. Further interview stated if a resident is aggressive then act on it to protect the other residents. Continued interview stated "...this needs to be an IJ (Immediate Jeopardy) because patients with problems should be alone in their rooms..." Interview with the PASRR (Pre Admission Screening and Resident Review) Nurse on 3/30/15, at 10:30 AM in the Chaplain's office, revealed she contracts to do the assessments for patients with mental illnesses. Continued interview revealed the nurse usually sees the resident before transfer and assesses the resident after transfer. Continued interview revealed Resident #2 "...looked more like a dementia patient and had behaviors coming from it..." Further interview revealed she noted he was exit seeking, confused, disoriented; pulled of his socks and would not let anyone replace them; and required 24/7 (24 hours a day, seven days a week) supervision due to wandering and exit seeking. Interview with the DON on 3/30/15, at 10:50 AM in the Chaplain's office, revealed most incidents with Resident #2 occurred in the evening but the DON did not track the incidents with the time of day. Continued interview with the DON stated 1:1 means the staff person must be within hand reach at all times; a resident is placed on 1:1 for whatever behavior we are trying to monitor such as wandering, getting up and down, verbal altercation with another resident. Further interview stated the staff person sits with the resident until he is calm and they are no longer 1:1 when their behavior improves. An acceptable Allegation of Compliance removed the immediacy of the Immediate Jeopardy on 4/2/15. The interventions put in place were evaluated by the survey team on 4/2/15, and verified the Allegation of Compliance by: 1. Interviewing all facility staff on all shifts regarding what constitutes resident abuse and neglect; how to report allegations; to whom allegations are reported; when to report allegations; what documentation was required; and the potential consequences of failure to report accurately any allegations of abuse or neglect. 2. Review of sign-in sheets from abuse education to determine all facility staff had been inserviced. 3. Review of the Quality Assurance Committee meeting minutes dated 3/19/15, to determine the areas of concern from the incident were discussed and corrective actions were identified as in the Allegation of Compliance. 3. Interview with the Administrator to outline the governing body's plan for ongoing supervision and follow up with the facility which would be conducted in response to the Immediate Jeopardy; by which means communication was to occur; how frequently corporate staff would be onsite; and for what duration corporate follow up would be performed on site. Non-compliance continues at an "E" level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction.

Based on facility policy review, medical record review, and interview, the facility failed to update the Behavior Management Plan to reflect the ongoing behaviors of 1 resident (#2) of 26 residents reviewed which resulted in Resident #2 assaulting Resident #1 causing Resident #1 to require emergency medical evaluation of acute injuries. The facility also failed to update the Behavior Management Plan to address new sexually inappropriate behaviors for 1 (Resident (#6) of 26 residents reviewed. This failure placed all 36 residents of the G Wing in Immediate Jeopardy. The Administrator and Director of Nursing were informed of the Immediate Jeopardy on 3/30/15, at 2:30 PM in the Chaplain's office. The Immediate Jeopardy was effective on 3/10/15. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident was moderately impaired cognitively with disorganized thinking. Continued review of the MDS revealed the resident was dependent for transfers, dressing, grooming, and bathing; was incontinent of bowel and bladder; and was unable to move lower extremities which were contracted. Medical record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Interim Plan of Care dated 3/10/15, revealed Resident #2 had a problem of behaviors and the goals included: 1. Provide consistent caregivers and routine. 2. Provide and encourage activities for distraction. 3. Meds (Medications) as ordered. 4. Observe behaviors and try to determine cause 5. Redirect/reassure and reorient as needed. 6. Maintain calm voice and environment. 7. Observe for s/s (signs/symptoms) of acute episodes and resolve. 8. Provide therapeutic communication as needed. 9. Explain cares prior to providing care. Medical record of facility nursing notes dated 3/10/15 at 8:00 PM, revealed "...Resident #2 wandering throughout unit. Very difficult to redirect. Resident holding handles of another resident's wheelchair (w/c). Resident became agitated when attempted to redirect resident not to push another resident. Would not let go of handles. Hitting and punching at staff with redirection. Resident got the fire extinguisher and would not cooperate with redirection. Swinging extinguisher at staff. Resident requiring 1:1 (one staff person sitting with resident in a quiet room) supervision due to hitting and slapping at staff, non redirection concerning other residents..." Medical record review of nursing notes dated 3/11/15, on the day shift, revealed "...Resident #2 is not easily redirected. Must be approached carefully and slowly..." Medical record review of the Behavioral Assessment Management Plan dated 3/11/15, revealed Verbally Abusive Behavior Symptoms included Resident #2 cursing at staff. Continued review of the Plan revealed Physically Abusive Behavior Symptoms included: 1. Resident hitting at staff. 2. Resident swinging at staff. 3. Non compliant with redirection. 4. Wants to push other residents around in their w/c. 5. Laying/sitting on the floor. Further review of the Plan revealed precipitating factors were non-compliant with redirection, behaviors increase when trying to redirect. Continued review of the Plan revealed behavior warranting use of medication included non-compliant with redirection; hitting; swinging at staff; cursing at staff; pushing other residents around in w/c; non compliant with safety precautions. Continued review of the Plan revealed interventions included administer meds as ordered; 1:1 monitoring as needed; assess and meet needs (food, thirst, toileting); encourage/praise for positive behavior; in-house psych (psychiatric) services as needed. Medical record review of nursing notes dated 3/12/15, at 11:00 PM, revealed "...Res (resident) #2 up at nurses' desk, sat in chair. Res got up, sat on floor, and layed down. ask Res why laying on floor, stated "I'm tired", told Res this nurse would take him back to bed..." Medical record review of a note by the Behavior Health Manager dated 3/13/15, revealed Resident #2 scored "0" on the Mini Mental Examination indicating he was not oriented to person, place, or time. Continued review revealed the resident's cognitive stage was indicative of severe cognitive decline Medical record review of nursing notes dated 3/13/15, at 7:45 PM, revealed "...Res #2 refused to lay down in bed, was sitting on side of bed. Tried to sit on floor..." Continued review of nursing notes at 8:00 PM, revealed "Daughter stated dad was sitting on floor and she needed help getting him up..." Further review of nursing notes at 9:00 PM, revealed "...Res is now up in room, moving furniture around, moved chest of drawers in front of door, when ask what he was doing res stated "I setting up stage"..." Medical record review of the Behavior Management Plan revealed no new interventions were implemented for Resident #2's behaviors. Medical record review of nursing notes dated 3/15/15, at 9:30 PM, revealed ..."(Resident #2) wandering on unit. x1 attempt to open exit door. Redirected by staff. Resident broke arm off chair and had wooden arm underneath shirt. Resident was cooperative when item was obtained..." Medical record review of nursing notes for 3/10/15 - 3/16/15, revealed these issues were not included in the Behavior Management Plan. Medical record review of the Admission MDS dated [DATE], revealed the resident was severely impaired cognitively. Continued review of the MDS revealed the resident demonstrated daily incidents of physical behaviors directed toward others and rejecting care. Medical record review of a nursing assessment for Resident #2 dated 3/16/15, at 3:15 PM, revealed the "...CNA (Certified Nursing Assistant) entered the room to change (Resident #1) and noticed (Resident #2) had placed the chair cushion on (Resident #1) like a blanket. CNA redirected resident and told him it wasn't a blanket and walked him back to his side of the bed. CNA reported the issue with the cushion to charge nurse and immediately went back to check on Resident when she noticed (Resident #2) standing on the right side of the bed of (Resident #1) with a glass coke bottle in his hand (from the collection of Resident #1) and saw the motion of the bottle going down toward the face of (Resident #1). CNA immediately walked (Resident #2) from the room and yelled for help. (Resident #1) was noted to have bleeding from face area and bruising and swelling noted around eyes..." Continued review of the assessment revealed (Resident #1) was transferred to the hospital while (Resident #2) was placed on 1:1 until he was transferred to gero-psych (geriatric psychological) unit. Interview with the Social Worker on 4/1/15, at 8:50 a.m., in the Chaplain's office, revealed the Social Worker assessed the behavior of Resident #2 and implemented the Behavior Management Plan. Continued interview revealed the Social Worker was made aware of the incidents with the fire extinguisher and the arm of the chair. Further interview with the Social Worker confirmed the care plan was not updated to include these interventions for behaviors. An acceptable Allegation of Compliance removed the immediancy of the Immediate Jeopardy on 4/2/15. The interventions put in place were evaluated by the survey team on 4/2/15, and verified the Allegation of Compliance by: 1. Review of 26 current resident records to determine if care plans were updated, accurate, and reflecting behaviors and appropriate interventions. 2. Interviews with nursing staff, Minimum Data Set nurses, and Social Worker regarding updating care plans to reflect accurately the behaviors of the residents. 3. Review of Quality Assurance Committee meeting minutes dated 3/19/15, to ensure care plans were discussed with corrective actions needed as well as ongoing monitoring as identified in the Allegation of Compliance. Non-compliance continues at an "E" for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a Plan of Correction. Medical record review for Resident #6 revealed facility admission on 9/5/14, discharged to a psychiatric hospital on [DATE], and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record of the Admission Minimum (MDS) data set [DATE] documented Resident #6 was severely cognitively impaired, displayed verbal behavioral symptoms directed toward others daily, did not display physical behavior directed at others, did not reject care, and wandered daily. Review of the medical record revealed the care plan with the problem dated 9/15/2014 for Resident #6 had "...potential to have Behavior Problems r/t (related to) Dx (Diagnosis). [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION], paranoia, and [MEDICAL CONDITION] Verbally Abusive Behaviors (cursing) daily...history of having physical behaviors (hitting, slapping). Is resistive to care at times (meds)...history of having delusional episodes..." Further review documented approaches dated 9/15/14 included "...chaplain services...Report to physician changes in behavioral status...Explain care to resident in advance, in terms resident understands...reinforce positive behavior...usually easily re-directable during verbal behaviors with 1:1 (one to one) attention...In-house psych eval (evaluation) as needed. Dc'd (discontinued) from psych services as needed on 10/10/14...administer and monitor effectiveness and side effects of medications as ordered...and dated 9/18/14 the approach provide quiet environment for sleep..." Further review of an undated handwritten notation documented "See attached Behavioral Monitoring Care Plan" and the problem was crossed through. Review of the medical record revealed the Behavior Assessment/Management Plan dated 10/2/14 included "...Behavior Identified: Wander Hallways...Verbally Abusive Resident Cursing at staff...Physically Abusive not filled out...Resist Care refuses to take medications @ (at) times..." Further review documented the approaches of "...report changes in behaviors (did not specify to whom to report), Explain care to Resident in advance, Reinforce positive behavior...Administer meds as ordered...Provide quiet environment for sleep..." Medical record review of the Situation Background Assessment Request (SBAR) Communication Form dated 1/30/15 documented Resident #6 had a change in condition/symptoms of "...behaviors (verbal) c (with) potential to harm others...Mental Status Changes (compared to baseline...) New or worsening behavioral symptoms...Assessment...to have increased behaviors verbal with potential to harm others grabs staff inappropriately...Request Provider visit (MD/NP...) (Medical Doctor/Nurse Practitioner)...Nursing Notes Resident noted to have increased behavior (verbal/physical) c potential to harm others. Resident inappropriately touches staff during care + (and) while passing in hallway. Unable to redirect. Resident often curses at staff during attempts to redirect. Attempted to trip other residents' c no apparent reason. MD called + made aware...to visit + review current orders tonight..." Review of the medical record revealed the care plan with the behavior problem dated 9/15/2014 for Resident #6 documented no updated problem addressing sexually inappropriate behavior after the 1/30/15 SBAR. Review of the medical record revealed the Behavior Assessment/Management Plan dated 10/2/14 revealed the facility failed to update the Behavior Assessment/Management Plan for the 1/30/15 sexually inappropriate behaviors. Review of the medical record of the 2/2015 and 3/2015 Behavior/Intervention Monthly Flow Records failed to document the inappropriate sexual behavior monitoring to determine the effectiveness of the mediation per the care plan. Interview with LPN (Licensed Practical Nurse) #3 on 3/30/15 at 9:43 AM at the G wing nurse's station stated Resident #6 "...hyper-sexuality was a new behavior and behavior monitoring sheet (Behavior/Intervention Monthly Flow Record) should have been updated..." per the care plan to determine the medication effectiveness. Interview with Social Worker (SW) #1 and the Corporate Clinical Consultant on 3/30/15 at 10:45 AM in the G wing dining room stated any nurse could update the care plan as needed. Interview with LPN #5 on 4/1/15 at 8:19 AM in the Chaplain's Office confirmed LPN #5 had written the SBAR dated 1/30/15. Further interview stated LPN #5 failed to updated the care plan to address the sexually inappropriate behavior. Interview with SW #1 on 4/1/15 at 8:40 AM in the Chaplain's Office stated the SW was not aware of and had not seen the SBAR dated 1/30/15 addressing the inappropriate sexual behavior toward staff. Further interview confirmed "...I failed to update the Behavior Management Plan regarding the sexually inappropriate behavior on 1/30/15..."

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to supervise and put measures in place for a resident (#2) of 26 residents reviewed, who had aggressive behaviors to prevent harm to other residents. This failure resulted in Resident #2 assaulting Resident #1 and caused Resident #1 to require emergency medical evaluation of acute injuries, and which placed all 36 residents on the G wing in Immediate Jeopardy. The Administrator and Director of Nursing were informed of the Immediate Jeopardy on 3/30/15 at 2:30 PM in the Chaplain's office. The Immediate Jeopardy was effective on 3/10/15. F323 constituted Substandard Quality of Care. The findings included: Review of the facility policy entitled "Behavior Management Program (BMP)" effective on 12/10/14 revealed "...Guideline...It is the intent of this facility to identify and assess complex behaviors in residents in order to develop effective management plans. This facility shall also identify, assess, monitor and manage manifested behaviors in residents to ensure the safety of all residents..." B. Management Plan: Identify appropriate interventions to manage identified behavior(s) and the discipline responsible for implementing interventions. The facility does not have a policy for residents on 1:1. Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident was moderately impaired cognitively with disorganized thinking. Continued review of the MDS revealed the resident was dependent for transfers, dressing, grooming, and bathing; was incontinent of bowel and bladder; and was unable to move lower extremities which were contracted. Medical record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Interim Plan of Care dated 3/10/15, revealed Resident #2 had a problem of behaviors and the goals included: 1. Provide consistent caregivers and routine. 2. Provide and encourage activities for distraction. 3. Meds (Medications) as ordered. 4. Observe behaviors and try to determine cause 5. Redirect/reassure and reorient as needed. 6. Maintain calm voice and environment. 7. Observe for s/s (signs/symptoms) of acute episodes and resolve. 8. Provide therapeutic communication as needed. 9. Explain cares prior to providing care. Medical record of facility nursing notes dated 3/10/15 at 8:00 PM, revealed "...Resident #2 wandering throughout unit. Very difficult to redirect. Resident holding handles of another resident's wheelchair (w/c). Resident became agitated when attempted to redirect resident not to push another resident. Would not let go of handles. Hitting and punching at staff with redirection. Resident got the fire extinguisher and would not cooperate with redirection. Swinging extinguisher at staff. Resident requiring 1:1 (one staff person sitting with resident in a quiet room) supervision due to hitting and slapping at staff, non redirection concerning other residents..." Continued review of nursing notes revealed the resident was placed on 1:1 after behaviors were documented at 8:00 PM. Further review of the nursing note revealed the resident went to bed at 1:15 AM, but there is no exact time documented the resident was taken off 1:1. Continued review of the nursing note revealed there was no documentation of the person designated to be 1:1 with the resident and there was no documentation of the actual 1:1 describing the resident's behaviors. Medical record review of nursing notes dated 3/11/15, on the day shift, revealed "...Resident #2 is not easily redirected. Must be approached carefully and slowly..." Medical record review of nursing notes dated 3/12/15, at 11:00 PM, revealed "...Res (resident) #2 up at nurses' desk, sat in chair. Res got up, sat on floor, and layed down. ask Res why laying on floor, stated "I'm tired", told Res this nurse would take him back to bed..." Medical record review of nursing notes dated 3/13/15, at 7:45 PM, revealed "...Res #2 refused to lay down in bed, was sitting on side of bed. Tried to sit on floor..." Continued review of nursing notes at 8:00 PM, revealed "Daughter stated dad was sitting on floor and she needed help getting him up..." Further review of nursing notes at 9:00 PM, revealed "...Res is now up in room, moving furniture around, moved chest of drawers in front of door, when ask what he was doing res stated "I setting up stage"..." Medical record review of nursing notes dated 3/15/15, at 9:30 PM, revealed ..."Resident #2 wandering on unit. x1 attempt to open exit door. Redirected by staff. Resident broke arm off chair and had wooden arm underneath shirt. Resident was cooperative when item was obtained..." Continued medical record review revealed this was the first attempt to open the exit door but the level of supervision was not changed and no new interventions were put in place. Further medical record review revealed the resident was allowed to move about freely on the G Wing and wander in and out of resident rooms. Medical record review of a nursing assessment for Resident #2 dated 3/16/15, at 3:15 PM, revealed the "...CNA (Certified Nursing Assistant) entered the room to change (Resident #1) and noticed (Resident #2) had placed the chair cushion on (Resident #1) like a blanket. CNA redirected resident and told him it wasn't a blanket and walked him back to his side of the bed. CNA reported the issue with the cushion to charge nurse and immediately went back to check on Resident when she noticed (Resident #2) standing on the right side of the bed of (Resident #1) with a glass coke bottle in his hand (from the collection of Resident #1) and saw the motion of the bottle going down toward the face of Resident #1. CNA immediately walked (Resident #2) from the room and yelled for help. (Resident #1) was noted to have bleeding from face area and bruising and swelling noted around eyes..." Continued review of the assessment revealed (Resident #1) was transferred to the hospital while (Resident #2) was placed on 1:1 until he was transferred to a gero-psych (geriatric psychological) unit. Review of the hospital record for Resident #1 dated 3/16/15, from the Emergency Department, revealed the resident had been assaulted with a glass coke bottle. Further review of the Emergency Department record revealed the resident had "...bilateral black eyes; contusion of right eye, right cheek, nose, left cheek and left eye; bruising bilateral dorsal wrists; lacerations 2 centimeters (cm) on nose, 1 cm of right forehead. Continued medical record review of radiology results revealed multiple nasal bone fractures with some depression particularly on the right; fractures extend to and involve anterior bony septum. Probable distal maxillary spine fracture as well; minimally depressed right side pneumatic arch fracture. Small air-fluid level of left maxillary antrum that may represent a small amount of sinus bleeding. Mildly depressed anterior and left maxillary antral fracture. Minimal inferolateral right orbital rim fracture not excluded. Significant soft tissue swelling, right greater than left..." Review of the facility investigation dated 3/16/15, revealed Resident #1 stated "...it didn't have to happen, he was over there hitting the window shade, I told him to stop it, he started hitting me..." Continued review of the facility investigation revealed a statement from CNA #6 which stated "I had walked into the room and seen (Resident #2) putting a floor mat on top of (Resident #1). I walked over and took the mat from (Resident #2) and directed him over to his bed. I left the room for about 5 min (minutes) to tell my charge nurse what had happened. She put me on 1:1 I walked back down to sit with (Resident #2)) and walked in and (Resident #2) was standing over (Resident #1) hitting him in the face with the coke bottle I ran over turned (Resident #2) around and he left the room I screamed for my nurse she came in and called the Assistant Director of Nursing..." Further review of the facility investigation dated 3/16/15, revealed a statement by CNA #17 who stated "...I was at computer charting. I thought I heard a scream. I went down hall to see who it was. I heard (Resident #1) so I went running to room and seen (Resident #1) face bleeding. It was stated (Resident #2) had hit (Resident #1) repeatedly on face/head. I went to pull (Resident #2)'s pants. He grabbed my right arm and slung me around against wall and didn't want to let go of my arm..." Review of the facility investigation dated 3/16/15, revealed a statement from CNA #13 who stated "...At approx 3:15 PM on 3/16/15, I was walking down the hall from the nurses' station. I heard screams from staff member (CNA #6). I called out for my charge nurse and ran toward room. I saw (Resident #2) coming out of room and setting a glass coke bottle onto the floor. As I reached out to get the coke bottle the resident drew back to hit me but staff member grabbed his arm to redirect him. (Resident #2) then grabbed CNA #17 and swung her around. I placed the coke bottle on (Resident #1)'s chest of drawers. And PT (physical therapy) took (Resident #2) with them..." Continued review of the facility investigation dated 3/16/15, revealed all staff were immediately inserviced on abuse, how to recognize it and means to prevent it. Further review of the investigation revealed residents with a Brief Inventory of Mental Status (BIMS) less than 8 were given a skin assessment and were assessed for changes in behavior. Continued review of the investigation revealed residents with a BIMS score greater than 8 were asked three questions on how they were being treated; if they felt safe; and if they had any concerns. Observation of Resident #1 on 3/24/15, at 1:30 PM, revealed a thin man lying in bed with purple bruises on right neck below the ear; front of the neck; chin; right side of head by the eye; dorsum of right hand; nose and lips; nose up to right eyebrow; and left chin to neck. Interview with Resident #1 on 3/30/15, at 9:15 AM in the resident's room, revealed the resident was not afraid of (Resident #2) until (Resident #2) was banging on the blinds and (Resident #1) told him to stop. Continued interview revealed (Resident #2) stopped banging on the blinds and started hitting (Resident #1) with the glass bottle. Further interview revealed (Resident #1) thought (Resident #2) was going to kill him. Interview with the Director of Nursing (DON) on 3/25/15 at 1:35 PM in the Chaplain's office, stated (Resident #2) was admitted [DATE] and was disoriented and resistant to care. Continued interview stated staff called the DON (time unknown) about the resident's behavior and she told the staff to place the resident on 1:1 until settled (no longer exhibiting behaviors). Continued interview revealed the DON stated the facility did not have a policy on 1:1 and corporate would not allow them to write a policy for one facility - the policy has to come from corporate. Further interview with the DON revealed a resident is placed on 1:1 for various behaviors and is usually taken off 1:1 when he/she goes to sleep, or when the behaviors cease. Continued interview with the DON revealed 1:1 means the staff person has to stay within touching distance from the resident, and must accompany the resident wherever he/she goes. Further interview revealed the 1:1 is documented in the nursing notes and the staff person initials a monitoring sheet every hour, but there is no actual description of what the resident is doing during the 1:1. Further interview stated the resident liked to push stuff. Continued interview stated the DON was made aware of the incident at the psychiatric hospital where Resident #2 had been prior to his admission to the facility on [DATE], in which Resident #2 was violent and struck staff "...on Thursday or Friday of the week he was admitted ..." Continued interview revealed Resident #2 pulled the dresser in front of the door and said he was setting up a stage. Further interview stated Resident #2 may have thought the fire extinguisher was a musical instrument. Continued interview revealed Resident #2 had a chair arm in his hand and put it under his shirt, and the DON didn't know what Resident #2 would have done with the chair arm if another resident had approached him. Further interview with the DON revealed she did not feel the fire extinguisher and chair arm could hurt someone and cause serious harm. Continued interview with the DON revealed the resident's life had been music and he "...probably thought the fire extinguished and chair arm were musical instruments..." Interview with CNA #9 on 3/26/2015, at 7:55 AM, in the Chaplain's office, confirmed she was on duty on 3/15/15, on nights, stated Resident #2 sat in a chair in the dining room and played with the arm of the chair while CNA #9 observed him. Further interview revealed the arms are secured to the chair with two pegs. Continued interview revealed Resident #2 worked the arm loose and put it under his shirt, "...just like a child who had done something wrong and tried to hide it..." Interview with CNA #6 on 3/26/15 at 10:25 AM in the Chaplain's office, revealed she was assigned both Resident #1 and Resident #2 on 3/16/15, on the day shift. Continued interview stated she went in to change (Resident #1) then briefly (5-10 minutes) left the room. Further interview revealed CNA #6 returned to the room to find (Resident #2) had placed a large chair mat over (Resident #1) who was saying "Get that off me". Further interview revealed CNA #6 removed the mat from (Resident #1) and explained to (Resident #2) not to do that. Continued interview revealed CNA #6 sat (Resident #2) on his bed; pulled the privacy curtain; opened the door and put a waste basket to keep the door open; and left the room to inform the charge nurse about the incident with the mat. Further interview revealed the charge nurse was calling the DON and ADON to notify them of the incident. Continued interview revealed the charge nurse told CNA #6 she needed to 1:1 (Resident #2) so CNA #6 returned to the room to find the door closed. Further interview revealed CNA #6 opened the door to find (Resident #2) standing over (Resident #1) with a glass coke bottle from the collection of (Resident #1), lowering his arm toward the face of (Resident #1 and heard the "thump" when the bottle hit his face. Further interview revealed (Resident #1) said "He's trying to kill me" so CNA #6 escorted (Resident #2) out of the room and screamed for the charge nurse. Continued interview revealed the privacy curtain has been pulled back. Further interview revealed (Resident #2) didn't seem to realize what was going on and walked out of the room with the coke bottle in his hand. Interview with LPN #5 on 3/26/15 at 10:40 AM in the Chaplain's office, stated she was the charge nurse on 3/16/15. Continued interview stated CNA #6 came to her with a concern Resident #2 had covered Resident #1 with a chair mat. Continued interview with LPN #5 stated she told CNA #6 to go back to the room where CNA #6 saw Resident #2 with a coke bottle in his hand, going toward the head of Resident #1. Continued interview stated Resident #1 was in bed; was unable to walk; and was transferred with a mechanical lift. Interview with the DON on 3/30/15, at 10:50 AM in the Chaplain's office, revealed any behavior the staff could not de-escalate would be a problem but she did not see Resident #2's swinging the fire extinguisher on 3/10/15, as a problem. Further interview revealed the CNA watched Resident #2, on 3/13/15, working at the chair arm, trying to get it off. Continued interview stated Resident #2 is a musician and he liked to know how things worked. Further interview stated most incidents with Resident #2 occurred in the evening. Continued interview with the DON stated 1:1 means the staff person must be within hand reach at all times; a resident is placed on 1:1 for whatever behavior we are trying to monitor such as wandering, getting up and down, or verbal altercation with another resident. Further interview stated the staff person sits with the resident until he is calm and they are no longer 1:1 when their behavior improves. An acceptable Allegation of Compliance removed the immediacy of the Immediate Jeopardy on 4/2/15. The interventions put in place were evaluated by the survey team on 4/2/15, and verified the Allegation of Compliance by: 1. Interviews of all facility staff on all shifts regarding the meaning of 1:1; behaviors exhibited by the residents to warrant 1:1; when a resident is removed from 1:1; and documentation. 2. Review of inservice sign-in sheets documented all facility staff have received education on 1:1 with behaviors warranting 1:1; who determines when resident no longer needs 1:1; what criteria is used to determine 1:1 can be discontinued; and documentation of behaviors while on 1:1. 3. Review of the Quality Assurance Committee meeting minutes dated 3/19/15, in which the Corporate Nurse, Administrator, Director of Nursing, and Family Nurse Practitioner reviewed the incident; corrective actions taken; and measures still to be instituted. Non-compliance continues at an "E" level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a Plan of Correction.

Based on medical record review, facility investigation review, and interview, the facility failed to be administrated in a manner to ensure residents were safe from assaults and free from physical abuse. This failure resulted in one resident (#2) of 26 residents reviewed, assaulting Resident #1 which caused Resident #1 to require emergency medical evaluation of acute injuries and placed all 36 residents of the G Wing in Immediate Jeopardy. The Administrator and Director of Nursing were informed of the Immediate Jeopardy on 3/30/15 at 2:30 PM in the Chaplain's office. The Immediate Jeopardy was effective on 3/10/15. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident was moderately impaired cognitively with disorganized thinking. Continued review of the MDS revealed the resident was dependent for transfers, dressing, grooming, and bathing; was incontinent of bowel and bladder; and was unable to move lower extremities which were contracted. Medical record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE], revealed the resident was severely impaired cognitively. Continued review of the MDS revealed the resident demonstrated daily incidents of physical behaviors directed toward others and rejecting care. Medical record of facility nursing notes dated 3/10/15 at 8:00 PM, revealed "...Resident #2 wandering throughout unit. Very difficult to redirect. Resident holding handles of another resident's wheelchair (w/c). Resident became agitated when attempted to redirect resident not to push another resident. Would not let go of handles. Hitting and punching at staff with redirection. Resident got the fire extinguisher and would not cooperate with redirection. Swinging extinguisher at staff. Resident requiring 1:1 (one staff person sitting with resident in a quiet room) supervision due to hitting and slapping at staff, non redirection concerning other residents..." Medical record review of nursing notes dated 3/11/15, on the day shift, revealed "...Resident #2 is not easily redirected. Must be approached carefully and slowly..." Medical record review of nursing notes dated 3/12/15, at 11:00 PM, revealed "...Res (resident) #2 up at nurses' desk, sat in chair. Res got up, sat on floor, and layed down. ask res why laying on floor, stated "I'm tired", told res this nurse would take him back to bed..." Medical record review of nursing notes dated 3/13/15, at 9:00 PM, revealed "...Res is now up in room, moving furniture around, moved chest of drawers in front of door, when ask what he was doing res stated "I setting up stage"..." Medical record review of nursing notes dated 3/15/15, at 9:30 PM, revealed ..."Resident #2 wandering on unit x1 attempt to open exit door. Redirected by staff. Resident broke arm off chair and had wooden arm underneath shirt..." Medical record review of a nursing assessment for Resident #2 dated 3/16/15, at 3:15 PM, revealed the "...CNA (Certifed Nursing Assistant) entered the room to change (Resident #1) and noticed (Resident #2) had placed the chair cushion on (Resident #1) like a blanket. CNA redirected resident and told him it wasn't a blanket and walked him back to his side of the bed. CNA reported the issue with the cushion to charge nurse and immediately went back to check on Resident when she noticed (Resident #2) standing on the right side of the bed of (Resident #1)( with a glass coke bottle in his hand (from collection of Resident #1) and saw the motion of the bottle going down toward the face of (Resident #1). CNA immediately walked (Resident #2) from the room and yelled for help. (Resident #1) was noted to have bleeding from face area and bruising and swelling noted around eyes..." Continued review of the assessment revealed (Resident #1) was transferred to the hospital while (Resident #2) was placed on 1:1 until he was transferred to gero-psych unit. Review of the hospital record for Resident #1 dated 3/16/15, from the Emergency Department, revealed the resident had been assaulted with a glass coke bottle. Further review of the Emergency Department record revealed the resident had bilateral black eyes; contusion of right eye, right cheek, nose, left cheek and left eye; bruising bilateral dorsal wrists; lacerations 2 centimeters (cm) on nose, 1 cm of right forehead. Review of the facility investigation revealed Resident #1 stated "...it didn't have to happen, he was over there hitting the window shade, I told him to stop it, he started hitting me..." Continued review of the facility investigation revealed a statement from CNA #6 which stated "I had walked into the room and seen (Resident #2) putting a floor mat on top of (Resident #1). I walked over and took the mat from (Resident #2) and directed him over to his bed. I left the room for about 5 min (minutes) to tell my charge nurse what had happened. She put me on 1:1 I walked back down to sit with (Resident #2) and walked in and (Resident #2) was standing over (Resident #1) hitting him in the face with the coke bottle I ran over turned (Resident #2) around and he left the room I screamed for my nurse she came in and called the Assistant Director of Nursing..." Further review of the facility investigation revealed a statement by CNA #24 who stated "...I was at computer charting. I thought I heard a scream. I went down hall to see who it was. I heard (Resident #1) so I went running to room and seen (Resident #1) face bleeding. It was stated (Resident #2) had hit (Resident #1) repeatedly on face/head. I went to pull (Resident #2)'s pants. He grabbed my right arm and slung me around against wall and didn't want to let go of my arm..." Review of the facility investigation revealed a statement from CNA #13 who stated "...At approximately 3:15 PM on 3/16/15, I was walking down the hall from the nurses' station. I heard screams from staff member (CNA #6). I called out for my charge nurse and ran toward room. I saw (Resident #2) coming out of room and setting a glass coke bottle onto the floor. As I reached out to get the coke bottle the resident drew back to hit me but staff member grabbed his arm to redirect him. (Resident #2) then grabbed CNA #24 and swung her around. I placed the coke bottle on (Resident #1)'s chest of drawers. And PT (physical therapy) took (Resident #2) with them..." Observation of Resident #1 on 3/24/15, at 1:30 PM, revealed a thin man lying in bed with purple bruises on right neck below the ear; front of the neck; chin; right side of head by the eye; dorsum of right hand; nose and lips; nose up to right eyebrow; and left chin to neck. Interview with the Director of Nursing (DON) on 3/25/15 at 1:35 PM in the Chaplain's office, stated (Resident #2) was admitted [DATE] and was disoriented and resistant to care. Continued interview stated staff called the DON about the resident's behavior and she told the staff to place the resident on 1:1 until settled. Further interview stated the resident liked to push stuff. Continued interview stated the DON was made aware of the incident at the psychiatric hospital, where the resident was prior to admission to the facility on [DATE], in which (Resident #2) was violent and struck staff "...on Thursday or Friday of the week he was admitted ..." . Continued interview stated (Resident #1) had a glass coke bottle collection at the bedside and (Resident #2) took a bottle and was playing on the blinds as it playing a drum. Further interview stated (Resident #1) asked (Resident #2) to stop so (Resident #2) took the bottle and was banging it on the face and head of (Resident #1). Continued interview stated (Resident #2) pulled the dresser in front of the door and said he was setting up a stage. Further interview stated (Resident #2) may have thought the fire extinguisher was a musical instrument. Continued interview stated (Resident #2) had a chair arm in his hand and put it under his shirt, and the DON didn't know what (Resident #2) would have done with the chair arm if another resident had approached him. Interview with CNA #9 on 3/26/2015, at 7:55 AM, in the Chaplain's office, revealed Resident #2 sat in a chair in the dining room, and played with the arm of the chair. Further interview revealed the arms are secured to the chair with two pegs. Continued interview revealed the resident worked the arm loose and put it under his shirt, "...just like a child who had done something wrong and tried to hide it..." Interview with CNA #6 on 3/26/15 at 10:25 AM in the Chaplain's office, stated she was assigned both Resident #1 and Resident #2 on 3/16/15. Continued interview stated she went in to change (Resident #1) then briefly left the room. Further interview stated CNA #6 returned to the room to find (Resident #2) had placed a large chair mat over (Resident #1) who was saying "Get that off me". Continued interview stated CNA #6 sat (Resident #2) on his bed; pulled the privacy curtain; opened the door and put a waste basket to keep the door open; and left the room to inform the charge nurse about the incident with the mat. Further interview stated the charge nurse was calling the DON and ADON (Assistant Director of Nursing) to notify them of the incident. Continued interview stated the charge nurse told CNA #6 she needed to 1:1 Resident #2 so CNA #6 returned to the room to find the door closed. Further interview stated CNA #6 opened the door to find (Resident #2) standing over (Resident #1) with a glass coke bottle, lowering his arm toward the face of (Resident #1), and heard the "thump" when the bottle hit his face. Further interview stated (Resident #1) said "He's trying to kill me" so CNA #6 escorted (Resident #2) out of the room and screamed for the charge nurse. Continued interview stated the privacy curtain has been pulled back. Further interview stated (Resident #2) didn't seem to realize what was going on and walked out of the room with the coke bottle in his hand. Interview with LPN (Licensed Practical Nurse) #5 on 3/26/15 at 10:40 AM in the Chaplain's office, stated she was the charge nurse on 3/16/15. Continued interview stated CNA #6 came to her with a concern (Resident #2) had covered (Resident #1) with a chair mat. Further interview stated she asked CNA #6 if she had removed the mat and redirected (Resident #2), which she had. Continued interview with LPN #5 stated she told CNA #6 to go back to the room where CNA #6 saw (Resident #2) with a coke bottle in his hand, going toward the head of (Resident #1). Further interview stated two other CNAs escorted (Resident #2) from the room, while LPN #5 assessed (Resident #1) and called the ADON. Continued interview stated (Resident #1) was in bed; was unable to walk; and was transferred with a mechanical lift. Interview with the DON on 3/30/15, at 10:50 AM in the Chaplain's office, revealed any behavior the staff couldn't de-escalate would be a problem but she did not see (Resident #2)'s swinging the fire extinguisher as a problem. Further interview stated the CNA watched Resident #2 working at the chair arm, trying to get it off . Continued interview revealed most incidents with Resident #2 occurred in the evening but the DON did not track the incidents with the time of day. Continued interview with the DON stated 1:1 means the staff person must be within hand reach at all times; a resident is placed on 1:1 for whatever behavior we are trying to monitor such as wandering, getting up and down, verbal altercation with another resident. Further interview stated the staff person sits with the resident until he is calm and they are no longer 1:1 when their behavior improves. Continued interview with the DON revealed the behaviors exhibited by Resident #2 on 3/10/15, was probably not reported to the physician since 1:1 de-escalated the behavior and the nurses only notify the physician if the behavior is ongoing. Interview with the Medical Director on 3/30/15, at 1:10 PM in the Chaplain's office, stated "...If I am the resident's physician I would expect to be notified if he was swinging a fire extinguisher around..." Interiew with the Administrator and DON on 3/30/15, at 8:50 AM in the Chaplain's office, revealed there was an incident of Resident #2 missing from his room. Continued interview revealed CNAs #2 and #11 searched for the resident. Further interview revealed Resident #2 was found in the bathroom of a room with two female residents who were asleep. Continued interview revealed Resident #2 had his clothes on inside out. Resident #2 began exhibiting behaviors on 3/10/15, the day of admission, and continued until the incident on 3/16/15. During this time period, the physician was not notified of the behaviors and swinging a fire extinguished and concealing a chair arm under his shirt were not considered items which could cause harm to other residents. Resident #2 was allowed to ambulate freely on the G Wing and wander into other resident's rooms. The facility failed to provide the required level of supervision to prevent Resident #2 from assaulting Resident #1. The facility failed to update the Behavioral Management Plan to reflect all behaviors with appropriate interventions. The facility failed to recognize behaviors of Resident #2 as having the potential to cause serious harm. An acceptable Allegation of Compliance removed the immediacy of the Immediate Jeporady on 4/2/15. The interventions put in place were evaluated by the survey team on 4/2/15, and verified the Allegation of Compliance by: 1. The Corporate Care Consultant has been in the facility continuously since 3/17/15 to provide oversight to the facility. 2. Interview with the Administrator and Director of Nursing regarding daily review of abuse investigation, along with the Social Services Director, to ensure the resident is protected; the perpetrator is removed form the resident care area; reports to appropriate agencies are completed timely; and a thorough investigation is completed. 3. A Quality Assurance Committee meeting was held on 3/19/15, to discuss the incident and determine Corporate Administrative oversight of the meetings. 4. Interviews with the Administrator and DON in which they outlined the governing body's plan for ongoing supervision and follow up with the facility which would be conducted in response to the Immediate Jeopardy; by which means communication was to occur; how frequently corporate staff would be onsite; and for what duration corporate follow up would be performed on site. Non-compliance continues at an "E" level for monitoring the effectiveness of corrective actions and evaluation of monitoring of the Quality Assurance Committee. The facility is required to submit a Plan of Correction. (Refer to F157, F223, F279, F323)