Every finding on record at Silas Creek Rehabilitation Center

Based on record review, Nurse Practitioner (NP) #1, Regional Clinical Consultant, and staff interviews the facility failed to prevent a significant medication error by failing to transcribe and administer Furosemide (a diuretic, a medication used for excess fluid elimination) which resulted in five consecutive missed doses for 1 of 5 residents reviewed for medications (Resident #6). The findings included:Record review revealed Resident #6 (prior to hospitalization on 05/04/26) was taking Spironolactone Tablet 25 milligram (mg) give 0.5 tablet by mouth (po) one time a day for congestive heart failure (CHF) take a half tablet (12.5mg) po and Furosemide Tablet 40mg give 1 tablet po one time a day for fluid retention. Resident #6 was admitted to the hospital 05/04/26 for fall with fracture, chronic heart failure, diabetes, and hypertension. Resident #6 was hospitalized from [DATE]-[DATE]. Discharge summary orders dated 05/07/26 stated Resident #6 was discharged to her prior skilled nursing facility for continued rehabilitation and long-term care. The hospital Discharge summary dated [DATE] revealed Resident #6 was discharged with orders for Furosemide (diuretic) 40 mg tablet, to take one tablet po daily, and Furosemide 40 mg tablet, to take one tablet po every third day as needed for weight gain of 4 pounds or more. Further review of the hospital Discharge summary dated [DATE] revealed discharge medication orders which included Furosemide. The Furosemide on the discharge medication orders revealed one check. The one check indicated the medication had been verified by the nurse practitioner (NP) #1. Resident #6 was readmitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF), acute and chronic respiratory failure, pulmonary edema (a condition in which excess fluid accumulated in the lungs), and hypertension. An interview with the Director of Nursing (DON) on 06/12/26 at 11:00 AM revealed she received the discharge summary for Resident #6 by fax from the hospital. She stated the process required the transcribing nurse to verify each medication with the provider and place a checkmark once the verification was completed. A second checkmark was to be added when the medication had been transcribed by the nurse into the electronic medical record and sent to the pharmacy. The DON stated the provider signed the hospital discharge summary to validate the medications. The DON confirmed there was no second checkmark on the discharge summary indicating the Furosemide 40 mg had not been transcribed. In an interview on 06/12/2026 at 10:48 AM, Nurse #2 stated she reviewed the hospital discharge summary and completed the transcription for Resident #6's medications on 5/7/2026. She reported NP #2 reviewed the medications on 05/07/2026 and gave a verbal order to discontinue Furosemide. Nurse #2 indicated she did not document that NP #2 had discontinued Furosemide 40 mg either as a verbal order or on the hospital discharge summary.An attempt to contact NP #2 on 06/12/2026 at 11:20 AM was unsuccessful.A review of provider orders dated 05/07/2026 did not reveal an order to initiate, discontinue, or hold Furosemide 40 mg daily or Furosemide 40 mg every third day as needed.A review of the May 2026 Medication Administration Record (MAR) did not reveal an order for Furosemide 40 mg daily or Furosemide 40mg every third day as needed as being administered from 05/07/26 through 05/12/26.Review of NP#1 progress note on 05/08/26 revealed Furosemide 40 mg was indicated as ordered under Additional Medications. In a telephone interview with NP #1 on 06/11/26 at 3:20 PM, revealed NP #1 validated the hospital discharge summary medications on 05/07/26 to restart Resident #6's Furosemide 40 mg as it was listed on the discharge summary. NP #1 stated she was unaware the medication had not been restarted upon admission. NP #1 reported it was important for Resident #6 to receive Furosemide due to Resident #6's diagnoses of heart failure, since omitted doses could potentiate worsening fluid retention, blood pressure instability, and cardiac decompensation. NP #1 stated she reviewed the medication orders but did not review the administration record. A follow up interview with NP #1 on 06/12/26 at 12:19 PM revealed the facility had provided both NP #1 and NP #2 with the same discharge summary to verify the hospital discharge orders. NP #1 stated she signed the summary after verifying the medication orders. She also reported she signed the pharmacy consult form dated 05/08/26, indicating the medication had been restarted on the 05/07/26 admission. She stated NP #2 did not indicate or document an order to hold the Furosemide. NP #1 was unaware Resident #6 was not administered Furosemide 40mg from 05/08/26 through 5/12/26. NP#1 stated she had not been made aware of any negative findings as an outcome of Resident #6 having omitted doses of Lasix 40 mg by mouth from 05/08/26-05/12/26.The Significant Change Minimum Data Set (MDS) dated [DATE] revealed Resident #6 had moderate cognitive impairment. Resident #6 was also coded for receiving a diuretic during this period.In an interview on 06/12/26 at 11:55 AM with the Administrator and the Regional Clinical Consultant, the Regional Clinical Consultant stated Resident #6 was not on Furosemide before her hospitalization and that the facility would not have restarted it upon her return, even though it was included on the hospital discharge summary.

Based on record review, observation and staff interviews, the facility failed to conduct an evaluation to determine therapy needs. This was for 1 of 1 resident reviewed for rehabilitation services (Resident #10). The findings included:Resident #10 was readmitted to the facility on [DATE] with a diagnosis of stroke affecting the left side, contracture of left elbow and left hand and aphasia (a communication disorder caused by damage to the brain which results in the inability to speak, read, or write). The quarterly Minimum Data Set, dated [DATE] revealed Resident #10 was severely cognitively impaired with impairment to both sides of her upper and lower body. She was dependent on staff for all activities of daily living.Resident #10 had a limited physical mobility care plan dated 03/16/2026 related to late effects of stroke and left side weakness. She required total assistance with mobility. Interventions included to evaluate with physical therapy (PT), occupational therapy (OT) as ordered and as needed (PRN).Physician order dated 05/01/2026 order read, PT, OT, Speech Therapy (ST) to screen as needed.Review of Resident's Interdisciplinary Team (IDT) notes documented by the Infection Preventionist (IPC) dated 05/27/2026 revealed Referral to therapy for left hand splint and pain.Record review of the Rehabilitation Evaluation assessment, initiated on 05/27/2026 by the IPC, revealed that no completion date was documented.Review of IDT note written by the IPC and dated 06/03/2026 revealed Referral to therapy for left hand splint and pain. An observation was conducted on 06/08/2026 at 11:26 AM with Resident #10. Her hands were observed contracted towards her torso. No splinting device was observed on either hand. Resident #10 was unable to answer any questions.An interview with the IPC was conducted on 06/10/2026 at 11:30 AM. She stated that one of her responsibilities was to document and initiate decisions from the IDT meetings. She explained Resident #10 previously had orders prior to her hospitalization in March 2026 for splinting devices but refused due to pain. The IDT team decided to evaluate her contractures and determine available options. She submitted the electronic evaluation form on 5/27/2026 into the electronic medical record for therapy to complete. She recalled discussing Resident #10's therapy referral during the IDT meetings on 05/27/2026 and 06/03/2026. She stated that therapy attended the 05/27/2026 meeting but was unsure if they attended the 06/03/2026 meeting. She did not know why therapy had not completed the therapy evaluation for Resident #10.During an interview conducted on 06/10/2026 at 10:00 AM, Nurse #1 reported that upon receipt of the written therapy order, she hand delivered the order to the therapy department. Nurse #1 further stated that referrals to the therapy department may also be submitted through the electronic medical record system.An interview with the Regional Therapy Manager was conducted on 06/11/2026 at 12:08 PM. She reviewed the therapy screening request dated 05/27/2026 in the electronic record, along with the IDT notes from 05/27/2026 and 06/03/2026. She stated that the therapy referral should have been completed within 48 hours of being made. She also reported that she was unsure why Resident #10's referral fell through the cracks. An interview with the Director of Nursing was conducted on 06/12/2026 at 8:49 AM. She stated that the therapy referral should have been completed during the week of 5/27/2026.An interview with the Regional Clinical Manager was conducted on 06/12/2026 at 12:22 PM. She stated that waiting three weeks to complete the therapy referral was appropriate for Resident #10 because the resident had frequently refused to wear the splint in the past.

Based on observations and staff interviews, the facility failed to post a list of names, addresses (email and mailing) and telephone numbers of required state agencies and advocacy groups, such as the State Survey Agency, Department of Social Services, the State Long Term Care Ombudsman Program, the Resident Advocacy Network, home and community based service programs, and the Medicaid Fraud Control Unit. These observations occurred on 5 of the 5 days of the onsite recertification and complaint survey conducted on 06/08/2026 through 06/12/2026. The findings included:On 06/08/2026 at 3:46 PM, 06/09/2026 at 8:27 AM, 06/10/2026 at 8:16 AM, 06/11/2026 at 3:45 PM and 06/12/2026 at 10:33 AM an observation of the facility (inclusive of all hallways) revealed no postings of name or contact information for the following: the State Survey Agency, Department of Social Services, the State Long Term Care Ombudsman Program, the Resident Advocacy Network, home and community based service programs, and the Medicaid Fraud Control Unit.During the Resident Council meeting on 06/09/2026 at 1:30 PM, Resident Council attendees (Resident #59 and Resident #62) stated they did not know how to contact the State Agency to file a complaint or where that information would be found in the facility.During a walking tour of the facility and interview on 06/12/2026 at 11:25 AM with the Activities Director, there were no postings of name or contact information for the State Survey Agency, Department of Social Services, the State Long Term Care Ombudsman Program, the Resident Advocacy Network, home and community based service programs, and the Medicaid Fraud Control Unit. When asked about those specific required postings, the Activities Director stated she was not aware of the postings location and would need to consult the Administrator.06/12/2026 at 11:32 AM an interview was completed with the Administrator who stated the postings were removed for wall painting completed one week ago. She further advised that the postings were being stored inside her office, and she had overlooked signage replacement in resident common areas. The Administrator stated the information was important and should have been reposted in the common areas as an additional resource for residents, families, and visitors.

Based on resident and staff interviews and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) application for a resident who exhibited new behaviors which resulted in additional psychiatric diagnoses for 1 of 1 resident (Resident #38) reviewed for PASRR. Findings included: Resident #38 was admitted to the facility on [DATE] with diagnoses that included, in part, convulsions and congestive heart failure. She had a level one PASRR number upon admission. The medical record indicated Resident #38 was seen by psychiatry services in the facility on 10/7/21 and was noted to have a new onset of auditory delusions . and subsequently diagnosed with brief psychotic disorder and major depressive disorder. Additional visits with psychiatry were completed 12/28/21 and 7/25/22 and resulted in diagnoses of psychosis and schizophrenia. The medical record revealed a PASRR application was not completed to determine if a level two PASRR referral (the purpose of the Level two screening is to assure that individuals with serious mental illness entering or residing in Medicaid certified nursing facilities receive appropriate placement and services) was needed due to newly identified serious mental illness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 had moderately impaired cognition. She reported mood symptoms that included feeling down, feeling tired/little energy, trouble sleeping, and having trouble concentrating. Resident #38 refused care 1-3 days out of the seven day look back period. Additionally, she received antipsychotic and antidepressant medications for 7 of 7 days during the MDS look back period. The care plan, updated 11/23/22, included focused areas of verbal outbursts and being resistive to care. Interventions included, Observe for signs/symptoms of mania, racing thoughts, euphoria, increased irritability, frequent mood changes, pressured speech, and flight of ideas; psychiatric consult as needed. On 12/19/22 at 10:44 AM Resident #38's current PASRR number, dated 3/9/20, was provided by the Social Services Director and indicated a level one PASRR number. The cumulative diagnosis list was reviewed in the electronic health record and revealed diagnoses of major depressive disorder with an onset date of 5/5/21, psychotic disorder with delusion with an onset date of 4/23/22 and undifferentiated schizophrenia with an onset date of 7/25/22. On 12/19/22 at 2:23 PM an interview was completed with Nurse #1. She was familiar with Resident #38 and shared that the resident got angry at times, talked out loud to herself and demonstrated auditory hallucinations. She stated Resident #38 was successfully re-directed by staff when she hallucinated and was seen by psychiatry services every two weeks for therapy and medication management. MDS Nurse #1 was interviewed on 12/19/22 at 3:15 PM. She explained Resident #38's family member shared that the resident had exhibited psychiatric behaviors when at home but was never formally diagnosed with mental illness. MDS Nurse #1 said the resident exhibited visual and auditory hallucinations after she was admitted to the facility. The facility referred her to psychiatry and she was diagnosed with schizophrenia while at the facility. During an interview with the Social Services Director on 12/19/22 at 3:24 PM, she stated Resident #38 had diagnoses of psychotic disorder with delusions and schizophrenia and had outbursts at times. She acknowledged a new PASRR application was not completed for Resident #38 and said she wasn't aware one needed to be completed when a resident was newly identified with mental illness. On 12/20/22 at 9:55 AM an interview was completed with Resident #38. She confirmed she felt down sometimes and told staff if she wasn't feeling well. She denied auditory or visual hallucinations and could not recall if she had seen psychiatry services while at the facility. The Administrator was interviewed on 12/20/22 at 9:34 AM. He said Resident #38 had auditory hallucinations at times but was well controlled with routine psychiatric services and medication management. He shared when a resident was newly diagnosed with mental illness, the interdisciplinary team met and discussed the symptoms and treatment, reviewed psychiatric consults and the Social Services Director was responsible to complete a new PASRR application for possible level two referral. The Administrator stated the Social Services Director had been educated about the PASRR process.

Based on observations, record reviews and staff interviews the facility failed to provide nail care to 1 of 2 residents reviewed for Activities of Daily Living (ADLs) (Resident #17). The findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses which included: vascular dementia, generalized muscle weakness, transient cerebral ischemic attack, and cognitive communication deficit. Review of Resident #17's most recent Minimum Data Set (MDS) revealed a annual assessment with an Assessment Reference Date (ARD) of 11/23/22 revealed the resident's cognition was severely impaired. The resident required extensive or total staff assistance for all activities of daily living (ADLs). Review of Resident #17's care plan which was most recently reviewed on 11/23/22 revealed the resident was care planned as having required extensive assistance for all ADLs due to ADL self-care performance deficit related to weakness, cognitive deficit, and dementia. The goals listed for the resident were for the resident to be able to participate in part of ADLs as able and the resident would have her personal care needs met by staff daily through the next review. The interventions listed included one person to provide extensive assistance with personal hygiene, bathing, dressing, and grooming. An observation conducted on 12/18/22 at 2:22 PM revealed Resident #17's fingernails extended beyond her fingertips on all five fingers on each hand. All five fingernails on each hand were observed with dark debris caked under the free edge of each nail. An observation conducted on 12/19/22 at 4:04 PM revealed Resident #17's fingernails were freshly painted and extended beyond her fingertips on all five fingers on each hand. All five fingernails on each hand were observed with dark debris under the free edge of each nail. An observation of Resident #17 conducted on 12/20/22 at 9:25 AM revealed all five fingernails on each hand were observed with dark debris under the free edge of each nail. Resident #17 was up in chair, dressed appropriately and Nursing Assistant (NA) #1 was braiding Resident #17's hair. An interview with NA #1 was conducted on 12/20/22 at 9:30 AM. The NA stated Resident #17 was on her assignment. She further stated residents got a bed bath every day unless it was a shower day, or they refused. She explained a bed bath included cleaning nails. She further explained that residents received nail care during an activity provided by the Activity Department called Manicure Monday. The NA revealed during Manicure Monday a resident's nails got polished but sometimes they returned to the unit with food still under them. She said if she observed food under a resident's nails, she did the best she could at that time to clean them. An interview was conducted with the Activity Manager on 12/20/22 at 10:02 AM. She explained that during the Manicure Monday activity included filing, clipping, painting, and cleaning under the nails. She stated they did every resident who wanted to participate. If the resident couldn't go to the activity, they went to them and did a manicure. On 12/20/22 at 11:02 AM Resident #17 was observed in the dining room. An observation revealed her nails were neatly trimmed and no dark debris was observed under the free edge of the resident's nails. An interview was conducted with the Activity Manager on 12/20/22 at 11:20 AM. The Activity Manager revealed she painted Resident #17's nails on Manicure Monday. She said she may have missed cleaning under her nails. She stated I didn't have a stick and cleaned them with a wipe. The Activity Manager explained when a resident's nails are very caked with debris, they would need to soak and it was hard to do all that in one hour, when she had about 15 people to manicure. She further explained for Resident #17, she would have to sit and hold the resident's hands the whole time because of her cognition. An interview with the Director of Nursing (DON) was conducted on 12/20/22 at 11:31 AM. The DON stated the residents' nails should be checked and cleaned every day. She further stated it was her expectation for the residents' fingernails to be kept trimmed and clean. She explained nail care would be addressed with staff immediately.

Based on observations, record review and resident and staff interviews, the facility failed to provide residents access to turn on and off the overbed lighting as desired for 2 of 13 residents sampled. (Resident #21 and Resident #13). The findings included: 1. Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was made of Resident #21 ' s room on 4/13/21at 9:22 AM. Resident #21 was observed lying in her bed. The overbed light had a chain attached and a string attached to the chain but, was out of the resident ' s reach. During an interview conducted with Resident #21 on 4/13/21 at 9:22 AM, she stated she was unable to reach the chain and string attachment on the overbed light. She added she would like to be able to turn the light on and off herself. An interview was conducted with the Maintenance Director on 4/15/21 at 3:24 PM. He stated he made facility room rounds but did not check the overbed lighting because he thought it was a safety issue to attach the chain attached to the lighting to the resident ' s beds. He stated if a resident wanted the overbed light turned on or off, they had to ask the nursing staff. 2. An observation on 4/14/21 at approximately 8:20 AM during medication administration revealed Resident #13 was lying in her bed. Resident #13 ' s bed was turned horizontally against the wall. The overbed light had a chain attached and was located at the foot of Resident #13 ' s bed. Resident #13 was unable to reach the chain to turn the light on and off herself. An interview conducted with Resident #13 conducted on 4/14/21 at approximately 8:20 AM revealed Resident #13 stated she was unable to reach the chain attached to the overbed light and would like to be able to reach it. An interview was conducted with the Maintenance Director on 4/15/21 at 3:24 PM He stated he made facility room rounds but did not check the overbed lighting because he thought it was a safety issue to attach the chain attached to the lighting to the resident ' s beds. He stated if a resident wanted the overbed light turned on or off, they had to ask the nursing staff.

Based on observation, record review and staff interview the facility failed to apply Resident #45's immobilizer as ordered. This was evident in 1 of 1 resident in the sample with a leg immobilizer. Findings included: Resident #45 was admitted to the facility on [DATE] after a hospitalization status [REDACTED]. Review of the discharge summary dated 4/30/19 revealed in part a discharge follow-up action item per the vascular surgeon to keep knee immobilizer on right leg to prevent contracture. Record review of the admission physician orders [REDACTED]. Review of the 5/7/19 admission Minimum Data Set assessment coded the resident as having impaired cognition, no rejection of care and extensive assistance from staff for completion of activities of daily living. Review of the care plan dated 4/30/19 revealed there was no indication of a written care plan for the use of the immobilizer or non-compliance with the use of the immobilizer. Observation on 06/05/19 at 8:50 AM revealed no immobilizer was applied on the right BKA. Observation in the presence of Resident #45 assigned nursing assistant on 6/5/19 at 7:45 AM revealed no immobilizer was applied to the right BKA. Observation on 6/6/19 at 9:15 AM revealed no immobilizer was applied to the right BKA. Observation on 06/06/19 at 9:21 AM of the wound care performed by the wound care nurse revealed the immobilizer had not been present prior to the wound care and after the wound care had been completed. Observation on 06/06/19 at 10:46 AM revealed Resident #45 received personal care and no immobilizer was applied. Interview on 06/06/19 at 11:41 AM with Nursing Assistant (NA) #1 revealed she was not aware that Resident #45 required an immobilizer to be applied to her right BKA. NA #1 stated she usually will get a report from the nurse or a senior NA about what care a resident required. Interview on 6/6/19 at 12:00 noon with Nurse #10 (who was familiar with the resident) revealed the immobilizer should have been applied all the time. Interview on 06/06/19 at 5:09 PM with the Administrator stated she expected the physician orders [REDACTED].

Based on record review, resident and staff interviews the facility failed to honor the food choices for 10 of 10 residents (Resident #10, Resident #41, Resident #21, Resident #36, Resident #50, Resident #5, Resident #44, Resident #2, Resident #33 and Resident #8). Findings Included: A group interview with the resident council attended by 10 residents was conducted on 7/10/18 from 3:30 pm until 4:35 pm. The group expressed a concern that the facility would no longer provide them with peanut butter. The facility had told them the corporate office no longer allowed them to purchase or serve anything with peanut butter because there had been a choking incident at one of their other facilities. The group added hot dogs were also not allowed to be served to them. The group expressed they didn ' t feel like this was right and they should be provided with these food items if they were allowed on their diets and they weren ' t at risk for choking. The group unanimously agreed they would like to have hot dogs as a regular menu item and be available as a menu alternate item. They also missed being able to have peanut butter sandwiches and peanut butter crackers as a snack offering at night. The group expressed that many residents didn ' t have any family or financial resources to be able to access these food items on their own. They felt like their request for these food items was reasonable since they were not expensive food items. An interview on 7/10/18 at 4:45 pm with the Administrator revealed she had received a policy update from their corporate office that effective 6/1/18 the facility wasn ' t allowed to purchase or serve peanut butter to the residents. She stated it was her understanding there had been an issue at another facility that led to this policy. Review of a policy titled, Food from Outside Sources Use and Storage with a revision date of 6/1/18 stated No cylinder-shaped meats encased by a skin nor peanut butter will be ordered, purchased, prepared, served, supplied or stored in the center for resident meals, resident snacks, special meal events, family meals and / or employee meal events. Examples of cylinder shaped meats encased by a skin are hot dots and / or Vienna sausages. Examples of peanut butter include peanut butter sandwiches and peanut butter and crackers. An interview on 7/11/18 at 8:30 am with the Dietary Manager (DM) revealed they have not been able to serve hot dogs to the residents since he started at the facility, not quite a year ago. He stated it was his understanding that the corporate office didn ' t allow any of their facilities to serve hot dogs. He added the residents had made numerous requests for hot dogs and he wished he was able to serve them on the menu and for special cook outs. The DM explained he was informed through a conference call that effective 6/1/18 they could no longer purchase or serve peanut butter. He added he believed someone had choked at another facility and now that wouldn ' t let any facilities serve peanut butter. The DM stated the residents had voiced concerns to him about not being able to have peanut butter sandwiches and peanut butter crackers for their night time snacks. He added peanut butter was a good source of protein for their snacks at night, especially for diabetics. The DM explained he served other types of sandwiches but the residents still requested peanut butter and they didn ' t understand why they couldn ' t have it anymore. A phone interview on 7/11/18 at 4:02 pm with the Corporate Dietary Representative revealed their facilities were not allowed to purchase or serve hot dogs or peanut butter related to choking episodes at some of their other facilities. He stated neither of these food items can be provided by the facility or placed on the menu even at the request of the residents. An interview on 7/11/18 at 5:38 pm with the Administrator revealed it was her expectation that resident ' s food choices were met within their ordered diet restrictions. .

Based on record review, observations and staff and resident interviews, the facility failed to provide an activities program that met the activity preferences of 4 of 4 residents reviewed for activities (Resident #50, Resident #65, Resident #41 & Resident #8). Findings included: Review of the activities schedule for May, (MONTH) and (MONTH) (YEAR) revealed there was only 1 to 2 activities scheduled in the evening time (after 5:00 PM), which was either bingo or a bible study and 3 to 4 activities scheduled a day, in which activities were mainly scheduled between 10:30 AM and 2:30 PM. Many of the activities such as bingo, bible study and room sessions were repeated week to week. Resident council minutes were reviewed for the last 6 months and did not reveal any concerns with activities. 1. Resident #50 (resident council president) was admitted to the facility on [DATE] with the current [DIAGNOSES REDACTED]. Resident #50 annual Minimum Data Set ((MDS) dated [DATE] revealed resident #50 was cognitively intact. The MDS revealed it was very important to the resident to have books, newspapers, magazines, music, to be around animals, do things with groups of people, go outside and participate in religious activities. The resident required extensive assistance with locomotion. Resident #50 was interviewed on 7/11/18 at 12:16 PM. She stated in the morning, there was an exercise activity but it was just a video that was put on the TV that residents could do if they wanted. She stated that residents do not usually go to that activity. She stated some residents had mentioned they wanted exercises and that was made available for them. She stated that on Wednesdays, they have people that come in and sing. She stated the activities are the same month to month unless there was a holiday. In the evenings, they only have BINGO on Mondays and bible study on Wednesdays. She stated there has been a lot of complaints in resident council that there are not activities in the evening times. She stated that different nursing assistants (NAs) do the activities in the evenings. She feels like the activities are the same each month and each activity was the same type of activity. The staff (activities director) doesn't want a lot of activities on the weekends because they don't want to come in. She stated they typically have 1 outing a month. She stated she was very involved in the activities and attends all the afternoon ones. She thinks the residents want activities that are a little more challenging. The Activities Director was interviewed on 7/10/18 at 3:18 PM. She stated there were 2 to 3 activities offered a day and 2 to 3 evening activities a week. She stated they also have an activities box where residents can grab activities out of. She tried to have a large variety of activities that were for a large age range. She stated they also have church groups that come out. They had a gardening activity this morning. She stated they also have bingo. She also added that they do an outing once a month. She stated there was a variety of activities such as gardening today. She stated she liked to do movement based activities. She stated they have 2 weekend activities on Saturday and Sunday each week and there was a weekend assistant or nursing assistant that does the weekend activities. An observation of activities was observed on 7/11/18 at 2:51 PM in the dining room. Resident #50 was participating in the trivia activity and the activity director was directing the activity. An interview was conducted with the Activities Director again on 7/11/18 at 3:50 PM. She reported that staff helped with activities if a lot of residents from their assignment went to the activity. The Activities Director reported she facilitated all the activities. She reported a NA usually helped with evening and weekend activities. She reported a few residents had voiced concerns in a one on one meeting with her regarding more activities in the evenings. She reported when she questioned the residents (in resident council) on activities about what they would like to do, she did not get any response. The Activity Director reported the activities she scheduled usually had 10-12 participants except Bingo, which was well attended. She reported she started an activity bin in the activity area of the dining room for the evenings, which had board games and cards. An observation was made on 7/11/18 at 4:00 PM of the activity area, which was located in the corner of the dining room. The activity area had a computer, piano, books, videos, magazines and the activity bin with a sign out sheet that indicated that nothing had been signed out. The Administrator was interviewed on 7/11/18 at 4:54 PM. She stated that residents had expressed that they wanted a Wii (a video type game) in the (MONTH) (YEAR) resident council meeting. She stated that the facility had a Wii and they were going to add it. They were listening to suggestions from residents. She also added that the residents really do enjoy planting plants. She stated that they heard about the Wii, and the issue was addressed. She would expect that the activities were resident centered, tailored to the needs, and cognitive abilities of the residents. 2. Resident #65 was admitted to the facility on [DATE] with the current [DIAGNOSES REDACTED]. Resident #65 admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and the resident could participate in assessment and goal setting. It was very important for the resident to do things with groups of people, go outside, listen to music, be around animals, and do her favorite activities. Resident #65 had a care plan (updated 7/5/18) in place for activities that stated the resident preferred to chose her activity, both group and independent activities. Resident #65 was interviewed on 07/09/18 at 11:29 AM. She stated she thought they needed to do more activities at the facility as there were rarely activities on the weekends. She stated that they do have activities at night but thinks they need more activities to get residents active. The Activities Director was interviewed on 7/10/18 at 3:18 PM. She stated that Resident #65 spent a lot of time outside. Resident #65 had been to a few activities since she was here and had a lot of visitors. She stated the resident was offered puzzle books and had declined. She stated there were 2 to 3 activities offered a day and 2 to 3 evening activities a week. She stated they also have an activities box where residents can grab activities out of. She tried to have a large variety of activities that were for a large age range. She stated that they also have church groups come out. They had a gardening activity this morning. She stated that they also have bingo. She also added that they do an outing once a month. She stated there was a variety of activities such as gardening today. She stated she liked to do movement based activities. She stated they have 2 weekend activities on Saturday and Sunday each week and there was a weekend assistant or nursing assistant that does the weekend activities. An interview was conducted with the Activities Director again on 7/11/18 at 3:50 PM. She reported that staff helped with activities if a lot of residents from their assignment went to the activity. The Activities Director reported she facilitated all the activities. She reported a NA usually helped with evening and weekend activities. She reported a few residents had voiced concerns in a one on one meeting with her regarding more activities in the evenings. She reported when she questioned the residents (in resident council) on activities they would like to do, she did not get any response. The Activity Director reported the activities she scheduled usually had 10-12 participants except Bingo, which was well attended. She reported she started an activity bin in the activity area of the dining room for the evenings, which had board games and cards. An observation was made on 7/11/18 at 4:00 PM of the activity area, which was located in the corner of the dining room. The activity area had a computer, piano, books, videos, magazines and the activity bin with a sign out sheet that indicated that nothing had been signed out. The Administrator was interviewed on 7/11/18 at 4:54 PM. She stated that residents had expressed that they wanted a Wii (a video type game) in the (MONTH) (YEAR) resident council meeting. She stated that the facility had a Wii and they were going to add it. They were listening to suggestions from residents. She also added that the residents really do enjoy planting plants. She stated that they heard about the Wii, and the issue was addressed. She would expect that the activities were resident centered, tailored to the needs, and cognitive abilities of the residents. 3. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #41's annual MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #41 was coded as minimally cognitively impaired. Active [DIAGNOSES REDACTED]. Resident #41's preferences for customary routine and activities were coded that the resident reported group activities, outdoor activities, and favorite activities were very important to her. The resident was coded as needing supervision with ambulation. A review of Resident #41's care plan dated 6/1/18 revealed the resident was care planned for activities and preferred bingo, socials, and church. An interview was conducted with Resident #41 on 7/9/18 at 3:41 PM. The resident reported it is boring here. She reported she participated in the activities offered but there aren't many activities here. Resident #41 reported there were very few evening activities offered. When Resident #41 was questioned if she had used the activity bin, she reported she had not. Resident #41 reported it would be nice to have some organized board games. An interview was conducted with the Activities Director again on 7/11/18 at 3:50 PM. She reported that staff helped with activities if a lot of residents from their assignment went to the activity. The Activities Director reported she facilitated all the activities. She reported a NA usually helped with evening and weekend activities. She reported a few residents had voiced concerns in a one on one meeting with her regarding more activities in the evenings. She reported when she questioned the residents (in resident council) on activities they would like to do, she did not get any response. The Activity Director reported the activities she scheduled usually had 10-12 participants except Bingo, which was well attended. She reported she started an activity bin in the activity area of the dining room for the evenings, which had board games and cards. An observation was made on 7/11/18 at 4:00 PM of the activity area, which was located in the corner of the dining room. The activity area had a computer, piano, books, videos, magazines and the activity bin with a sign out sheet that indicated that nothing had been signed out. The Administrator was interviewed on 7/11/18 at 4:54 PM. She stated that residents had expressed that they wanted a Wii (a video type game) in the (MONTH) (YEAR) resident council meeting. She stated that the facility had a Wii and they were going to add that in there. They were listening to suggestions from residents. She also added that the residents really do enjoy planting plants. She stated that they heard about the Wii, and the issue was addressed. She would expect that the activities were resident centered, tailored to the needs, and cognitive abilities of the residents. 4. Resident # 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #8's quarterly MDS dated [DATE] revealed that the resident had no cognitive impairments. Resident #8's preferences for customary routine and activities were coded that the resident reported he was interested in small and large groups, sports, trips, music, reading and watching television and movies. The resident was coded as needing a wheelchair for mobility. A review of Resident #8's care plan revealed the resident preferred both group and independent activities. An interview was conducted with Resident #8 on 7/11/18 at 4:48 PM. The resident reported that there were not enough activities. He reported the facility needed to have a Wii game or board games. Resident #8 stated he had nothing to do today but smoke and therapy. He reported milk and cake are not an activity to me. He reported he was not made aware of an activity box in the activity area. An interview was conducted with the Activities Director again on 7/11/18 at 3:50 PM. She reported that staff helped with activities if a lot of residents from their assignment went to the activity. The Activities Director reported she facilitated all the activities. She reported a NA usually helped with evening and weekend activities. She reported a few residents had voiced concerns in a one on one meeting with her regarding more activities in the evenings. She reported when she questioned the residents (in resident counsil) on activities they would like to do, she did not get any response. The Activity Director reported the activities she scheduled usually had 10-12 participants except Bingo, which was well attended. She reported she started an activity bin in the activity area of the dining room for the evenings, which had board games and cards. An observation was made on 7/11/18 at 4:00 PM of the activity area, which was located in the corner of the dining room. The activity area had a computer, piano, books, videos, magazines and the activity bin with a sign out sheet that indicated that nothing had been signed out. The Administrator was interviewed on 7/11/18 at 4:54 PM. She stated that residents had expressed that they wanted a Wii (a video type game) in the (MONTH) (YEAR) resident council meeting. She stated that the facility had a Wii and they were going to add it. They were listening to suggestions from residents. She also added that the residents really do enjoy planting plants. She stated that they heard about the Wii, and the issue was addressed. She would expect that the activities were resident centered, tailored to the needs, and cognitive abilities of the residents.

Based on resident interviews, staff interviews and record review the facility failed to provide supervision for 1 of 3 sampled residents (Resident #2) reviewed for supervision to prevent accidents (Resident #2). The facility failed to supervise Resident #2, to prevent him from entering another resident's room and choking Resident #1 and then failed to respond timely to Resident # 1's verbal calls for help and the activation of her call light to request staff assistance while she was being assaulted by Resident #2. Immediate jeopardy began on 9/15/17 when Resident #2 entered Resident #1's room, placed his hands around Resident #1's neck and verbally yelled at her to get out of the bed. The staff did not respond to Resident #1's verbal requests for help and when she turned on her call light to request help which resulted in Resident #1 being left alone for a reported 15 to 20 minutes trying to convince Resident #2 to let go of her neck and to get out of bed unassisted in order to get to her room's doorway to try to find someone to help her. As a result of the incident Resident #1 experienced neck pain when turning her head and voiced feeling fear about sleeping at the facility. She left the facility 2 days after the incident. The immediate jeopardy was removed on 10/13/17 at 4:39 pm when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings Included: Resident #2 was admitted to the facility on [DATE] and his [DIAGNOSES REDACTED]. A care plan dated 8/14/17 for Resident #2 identified him as an elopement risk, wanderer as evidenced by impaired safety awareness. Interventions included identify patterns of wandering, intervene as appropriate, provide re-orientation strategies and structured activities. A review of the admission comprehensive Minimum Data Set ((MDS) dated [DATE] for Resident #2 revealed his cognition was severely impaired, required supervision one person assist with mobility on and off the unit and demonstrated no behaviors during the look back period. A review of a nursing progress note dated 9/14/17 at 8:07 pm for Resident #2 revealed he was self-propelling in his wheelchair in the hallway. Resident #2 stated he was in a hotel and his wife was missing and she had all of his money. Resident #2 was brought to the nurse's station and called his wife so that resident could speak with her. Resident #2 calmed down after speaking to his wife. A review of a nursing progress note for Resident #2 dated 9/16/17 at 1:20 am (referencing the incident on 9/15/17), written by Nurse #1 revealed she was called to Resident #1's room by a staff member. Resident #1 reported to her that Resident #2 had come into her room and began to choke her, yelling that she was in his wife's bed and he paid for this room. Assigned nursing assistant (NA) reported when she attempted to remove Resident #2 from the room and take him to his room he pushed her and grabbed her arm. The MD for Resident #2 was notified and gave a verbal order to transfer Resident #2 to the emergency department. The Administrator on call was notified and reported that she would notify the Director of Nursing (DON). This nurse called 911 and Resident #2 was transferred via ambulance. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE] following gallbladder surgery. A review of the facility admission assessment, resident (MDS) data set [DATE] for Resident #1 revealed she was alert and cognition was intact. A review of the functional abilities and goals dated 9/15/17 for Resident #1 revealed she required supervision to moderate assistance with mobility, could walk but was not attempted due to health condition. A review of a nursing progress note for Resident #1 dated 9/16/17 at 1:51 am (referencing the incident on 9/15/17) written by Nurse #1 revealed Resident #1 had called for assistance and reported that Resident #2 came in her room and choked her. Resident #3 (the roommate of Resident #1) stated that Resident #2 had his hands around Resident #1's neck and was choking her. Resident #1 called her family and they arrived back at the facility. Resident #1 stated she was afraid. This nurse notified Resident #1's family that Resident #2 had been transferred out of the facility. A review of a nursing progress note dated 9/18/17 at 1:43 am for Resident #1 revealed Resident was quiet and had no complaints of pain. Assisted to the bathroom. Resident was afraid at hours of sleep (HS). A review of a nursing progress note dated 9/18/17 at 9:51 am, written by the DON, for Resident #1 revealed she saw Resident #1 and her daughter in with the Social Worker this morning. Writer walked into Social Worker's office to assess resident for mental anguish. Resident #1 stated she was fine, but her daughter stated that Resident #1 would be going home as she could provide care for her at home. Resident #1 reported that she ate and swallowed without issue. No bruising noted to neck. Observed full range of motion (ROM) of neck as resident turned to address writer. Daughter informed that resident would leave after her follow-up appointment with surgeon. A review of the physician's discharge summary dated 9/18/17 for Resident #1 stated She suffered an assault by another resident who had dementia but no history of violence. We discussed the assault by another resident that occurred over the weekend. Resident #1 still has soreness with rotating her head. The police did speak to the resident and her family when they came to take Resident #2 to the emergency room . A phone interview was conducted with Resident #1 on 10/12/17 at 10:51 am. During this interview Resident #1 stated that on 9/15/17 at approximately 10:00 pm she was in her bed, but was not asleep. She stated she heard someone enter her room and then felt the person put their hands around the back of her neck and applied pressure to her neck. Resident #1 explained that Resident #2 was choking her and he kept yelling at her to get out of his wife's bed that he had paid for it. She stated this went on for 2 to 3 minutes and Resident #2 continued to apply pressure to her neck. She added that she was able to locate her call light and turned it on to request staff assistance to help her. She also called out to her roommate that a man was attacking her and to call for help. Resident #1 stated that about 5 minutes went by and no one responded to the call bell or her yells for help, so she decided she needed to try to get up on her own to find someone to help her. Resident #1 explained she was able to sit up in bed and at that time the man moved his hands to the sides of her neck. She was able to scoot to the end of her bed and she told Resident #2 that she was getting out of the bed, so they could go find his wife. Resident #2 then let go of her neck. She stated she was able to walk to the doorway of her room and feared that she would fall because she wasn't supposed to be getting up on her own. Resident #1 added she got into the hallway, but didn't see any nurses. She did see another male resident and yelled to him to get her help. She stated another 2 to 3 minutes went by and then a nurse came down the hall and tried to get Resident #1 out of her room. Resident #1 explained that Resident #2 pushed the nurse into the wall as she took him back to his room. She stated it took approximately 20 minutes from the time Resident #2 entered her room until she got help from the staff. She added she was extremely scared and could not sleep after that. She also stated she continued to have soreness to her neck when she tried to turn her head. Resident #1 added she did not want to be alone in the room as she was afraid someone was going to come in and attack her again and her family took her home on 9/18/17. She stated her concern was that it took so long for anyone to come and help her. An interview was conducted on 10/11/17 at 6:30 pm with Resident #3 (the roommate of Resident #1 during the incident) who was identified as alert and oriented per Section C of her most recent MDS. Resident #3 stated she did recall the night that Resident #1 was choked by another resident. She stated it was Resident #1's first night at the facility and they were both in bed. She had the privacy curtain pulled between them, but at about 10:00 pm she heard Resident #1 call out there was a man in the room and he was choking her. Resident #1 yelled out to me for help and asked me to turn on the call light. The roommate stated she turned on her call light but no one came, she believed their NA was on her break. She explained it was too dark in her room to see her clock but estimated it was about 10 or 15 minutes before anyone came. The roommate stated that somehow Resident #1 was able to get loose from the male resident and went out into the hallway to call for help. The male resident remained in their room. She added eventually the NA came and got the male resident out of the room. She stated the male resident kept saying to Resident #1 that this was his wife's bed and you need to get out of it. The roommate stated Resident #1 was very upset about the incident and was afraid to go to sleep. She stated she didn't understand why it took so long for the staff to come because the door to their room was open and she thought someone would have heard them yelling for help. The roommate added after the incident they started keeping their door closed at night. An interview with the Director of Nursing (DON) on 10/11/17 at 4:30 pm revealed she was aware of the incident between Resident #1 and Resident #2. She stated she was notified on Sunday (09/17/17) about Resident #2 entering Resident #1's room and choking her on 09/15/17. She stated that she had spoken to the nurse and NA that were assigned to Resident #1 about the incident. The DON added she had spoken to Resident #1 on Monday and she thought the resident seemed okay. She stated she had not initiated any formal investigation of the incident. An interview on 10/11/17 at 7:50 pm with NA #1 revealed she was the NA for Resident #1 and Resident #2 the evening the incident occurred on 09/15/17. She stated she had taken her break, but couldn't remember exactly what time it was because they don't have a set break time. She believed it was about 9:00 pm or 9:30 pm. NA #1 explained that when they took their 30 minute break they were supposed to let the nurse and another NA know that they were off the unit so they could watch their residents and answer their call lights. She couldn't recall who covered for her that night when she went on break or if she had informed them that she was going on her break. NA #1 stated when she got back from her break she heard a male resident calling for someone to come and help Resident #1. NA #1 explained that Resident #1 was out in the hallway and Resident #2 was in Resident #1's room. She added that she tried to get Resident #2 back to his own room, but he was agitated and didn't want to leave the room. He pushed NA #1 up against the wall. She stated she eventually got him back to his room and stayed with him until the ambulance came. NA #1 added that Resident #1's family came to the facility and they were trying to get Resident #1 to go back into her room. She stated Resident #1 told her that Resident #2 had choked her and she didn't want to be alone in her room. NA #1 explained that she had cared for Resident #2 since he had been there and he was confused, but she had never seen him be aggressive before. She added that she had not observed Resident #2 wandering that evening and he had been in his room when she left to go on break. A phone interview on 10/11/17 at 8:10 pm with Nurse #1 confirmed she was the nurse for both Resident #1 and Resident #2 the evening of the incident on 09/15/17. She stated she was in the medication room getting Resident #1's medications together when a NA #1 came and got her and told her that Resident #2 had entered Resident #1's room and choked her. She went to Resident #1's room and assessed Resident #1's neck for any injuries. Nurse #1 explained Resident #1 was in her bed at that time and as far as she knew Resident #1 had never gotten out of her bed during the incident. She stated that NA #1 had gotten Resident #2 back in his room. She contacted the physician (MD) and he told her to have Resident #2 sent to the hospital. She arranged for transport and contacted both of the resident's families. Nurse #1 stated she also notified the administrator on call who contacted the DON. Nurse #1 added she did not recall the MD giving any new orders or instructions for Resident #1 after the incident. She explained that she had cared for Resident #2 and he had sundowners. She added that he would sometimes wander during the evening looking for his wife and they would let him call her on the phone. She stated Resident #2 would make statements like where was his wife going to stay and how was he going to pay for this, but he had not displayed any physically aggressive behaviors. She added that Resident #2 had been in his room the last time she had seen him during the evening of 09/15/17. Nurse #1 stated that when a NA goes on break one of the other NAs would cover their assignment and also the nurse should help answer call lights if needed. She stated the NAs were supposed to notify the nurse and another NA when they left the unit for their break, but she didn't recall if NA #1 notified anyone that evening that she was going on break. Nurse #1 added that they were fully staffed on their unit that evening. During an interview on 10/11/17 at 8:43 pm with NA #2 stated he was also working on the unit the evening of the incident on 9/15/17. He further stated he heard that Resident #2 had entered Resident #1's room and choked her, but he didn't know either of the residents and hadn't been assigned to them. He added there were typically 3 NAs scheduled for second shift on their unit and they had 10 to 11 residents on their assignment. NA #2 explained that they had a 30 minute break and they usually didn't start taking their breaks until 8:00 pm to 8:30 pm. He stated that the 30 minute breaks were not scheduled; they were just supposed to let their nurse and another NA know they were going on break so they could cover their assignments. An interview on 10/11/17 at 8:51 pm with NA #3 revealed she was assigned to the unit that Resident #1 and Resident #2 resided on the evening of the incident on 9/15/17. She stated the nurse had told her about what happened, but she had not been assigned to either of the residents. NA #3 added that she was somewhat familiar with Resident #2, she would occasionally see him roll around the unit in his wheelchair but the majority of the time she saw him in his room. NA #3 explained that there were 3 NA's assigned to their unit and they each typically had 4 or 5 rooms a piece (8 to 10 residents). She added that they were fully staffed the evening of the incident. NA #3 stated she would try and take her break about 8:30 pm and she would notify the nurse and NAs that she was going on break so they could watch for the call lights on her assignment. She added that she did not recall who was covering for NA #1 when she was on break the night of the incident, but she had not responded to any call lights on that assignment. NA #3 stated they did not have assigned break times. A review of the employee schedule for 9/15/17, provided by the DON, revealed there were 5 staff members assigned for second shift (3:00 PM to 11:00 PM) to the nursing unit that Resident #1 resided on. The 5 staff members consisted of 2 nurses and 3 NAs. The time card records dated 9/15/17 for the 5 staff members were provided by the DON. The records revealed that NA #1 went on break at 9:03 pm and returned at 9:35 pm. NA #2 went on break at 9:18 pm and returned at 9:48 pm. These records revealed that left only 1 NA (NA #3) on the unit for 34 residents. An interview on 10/12/17 at 3:25 pm with the DON revealed that the NA's were supposed to stagger their breaks so they weren't off the unit at the same time. She stated that their breaks were currently not scheduled. An interview on 10/13/17 at 10:30 am with the physician for Resident #1 and Resident #2 revealed he recalled being contacted about the incident between the two residents on 9/15/17. He stated he gave a verbal order to have Resident #2 sent to the emergency room and for him to be admitted to the behavioral health unit. The physician added he had seen Resident #1 on 9/18/17 and she had complained of soreness to her neck with movement of her head. He did not recall that she had any bruising or scratches to her neck. He clarified that the police had not been contacted regarding the incident as he had documented in his progress note for Resident #1 on 9/18/17. On 10/12/17 at 3:25 pm, the Administrator was informed of the immediate jeopardy. The facility provided a credible allegation on 10/13/17 at 1:42 pm. The allegation of compliance indicated: On 9/15/17 at approximately 9:45PM, Resident #2 entered Resident #1 ' s room, unobserved by staff. Per resident #1, Resident #2 attempted to choke resident #1. Once staff became aware of incident, staff responded to resident #1's room and resident #2 assisted away from the area. Between 9:18PM and 9:35PM, two nursing staff members were on meal break. During this timeframe three nursing staff members remained to provide care for the 34 residents on the unit. There were no incidents or grievances outside of this event. Resident #2 was discharged to the emergency room after the incident on 9/15/17 and did not return to the facility. Resident #1 was discharged from the facility on 9/18/17. An initial investigation began on 9-16-17, into the incident between Resident #1 and Resident #2, was conducted by the Director of Nursing to include interview of staff who were assigned to resident # 1 and resident #2 and all other staff working second shift (3:00PM - 11:00PM) on unit A, on 9-15-17. The investigation revealed that resident #1 stated she felt safe in the facility as long as resident #2 was not in the facility. Interviews by the Director of Nursing and Social Services with Resident #1 and her family member revealed there were no concerns regarding the timeliness of call light response. There was no reasonable foreseeability that the incident would occur based on the assessment of resident #2 prior to the incident. An additional investigation was initiated on 10/12/17 due to new information that was relayed to the nursing home administrator and director of nursing by the state surveyor. State surveyor stated that resident #1 stated her call light was on for twenty minutes, resident# 1's roommate stated the call light was on for fifteen minutes and nobody responded. This was the first time the facility was made aware of a delay in call light response time during the incident. Upon interviewing resident #1's roommate on 10/12/17, she stated the call light response time on the night of the incident was five or ten minutes, but more like five. Roommate stated she has never had a concern with call light response during her stay. An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted on 10/13/17 and included the Administrator, Director of Nursing, Medical Director, Staff Development Coordinator, Social Worker and Primary Care Physician, to analyze incident occurring on 9-15-17 and developed a Quality Assurance Improvement Plan. The policy for abuse prohibition was reviewed with the QAPI committee on 10/13/17. F-323 and allegation of compliance with supporting documentation was reviewed by the QAPI committee on 10/13/17. All residents currently residing in the facility were assessed utilizing the Minimum Data Set (MDS) - Section C (cognition) and Section E (behaviors) by the facility MDS nurse(s), Social Service Director or Director of Nursing, by 10-13-17 to ensure there is no reasonable foreseeability of resident to resident altercation, based on those resident's assessed cognitive status and assessed patterns of behavior. After review, no residents were found to have reasonable foreseeability with regard to resident to resident altercations. A questionnaire to include 100% of all alert and oriented interview able residents was conducted on 10/12/17 by Nursing Management asking each resident: · Is your call light answered in a timely manner? · Do you feel safe here in the facility? · Has anyone ever wandered into your room and made you feel threatened? · If you feel threatened do you know what to do? After review of all questionnaires, no patterns were identified that indicated lack of substantial compliance with regards to call light response, resident supervision and/or facility safety. In-servicing of 100% of all licensed and non-licensed staff to include; The Facility's Policy on Abuse, Call light response, Assigned staff break times, Rounding and supervision of assigned residents, and preventing aggressive resident injuries was completed by 10-13-17, by the Staff Development Coordinator, Social Services Director, and Human Resources Coordinator. The education consisted of the definition of abuse meaning; the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Additionally, education included call light response, rounding, and supervision of residents with emphasis on ensuring call lights are responded to as quickly as possible, performing unit rounds to supervise and identify any resident needs and strategies to manage residents with aggressive behaviors. On each shift, the Licensed Nurse will assign staggered break and lunch times to all scheduled Nurse Aides, as the Licensed Nurse acts as the Nurse Aides ' immediate supervisor. The Nurse Aides will verbally notify the Licensed Nurse they will be leaving the unit for their assigned break. Any staff member who was not in-serviced will not work and will be removed from the schedule until this in-servicing is completed with them. These in-services will be added to the general orientation of all new staff from this point forward. To remain in compliance and under the direction of the Administrator, beginning 10-12-17, on second shift (3:00PM - 11:00PM), call light monitoring commenced. This call light monitoring will be performed every shift (on first shift, 7:00AM-3:00PM, second shift, 3:00PM-11:00PM and third shift, 11:00PM-7:00AM), including weekends for 2 weeks, then 3x per week, all shifts, including weekends for 6 weeks, then weekly for 4 weeks all shifts. This monitoring will be performed by the Administrator, Director of Nursing, Staff Development Coordinator or Administrator's designee. A facility questionnaire will be conducted by Nursing Management asking each resident: · Is your call light answered in a timely manner? · Do you feel safe here in the facility? · Has anyone ever wandered into your room and made you feel threatened? · If you feel threatened do you know what to do? The questionnaire will be utilized to include 10 residents per day for 2 weeks, including weekends, then 10 residents 3x per week, including weekends for 6 weeks, then 10 residents weekly for 4 weeks. This monitoring will be performed by the Administrator, Director of Nursing, Staff Development Coordinator or Administrator's designee. Any areas of concern will be addressed through the facilities' grievance process. Director of Nursing, Unit Managers, Staff Development and Weekend Supervisor will validate the staff 's retention of the education presented by conducting education validation audits randomly throughout all three shifts including weekends. Licensed and Non-Licensed Staff will be presented with a series of questions regarding the education presented. Those noted with opportunities will be immediately re-educated. The Administrator and/or Staff Development Coordinator will review these audits weekly for 12 weeks. The title of the person responsible for implementing the acceptable plan of correction: Mark Farran, Administrator. The credible allegation was verified on 10/13/17 at 4:39 pm. Random observations were made through-out the facility on 10/13/17 from 1:45 pm through 3:45 pm and no concerns were identified related to resident supervision. The Ad Hoc QA meeting was reviewed and identified the meeting had been conducted on 10/13/17 at 9:30 am and was attended by the Administrator, DON, Medical Director (via phone), Vice President of Operations, Regional Clinical Director, Staff Development Coordinator, Social Worker and Primary Care Physician. The agenda for the meeting revealed the meeting was conducted to address the allegation of compliance for F-323 as it related to supervision to prevent accidents and timely response to call bells. The MDS audits for all residents residing in the facility were reviewed and confirmed that Section C (Cognition) and Section E (Behaviors) had been completed and the results of the audit did not identify any concern for resident to resident altercations. The results of the questionnaire that had been completed with alert and oriented residents residing in the facility were reviewed. 62 residents were able to complete the questionnaire. 7 of the 62 responses identified that call bells were not answered timely. No residents identified that they did not feel safe at the facility. Random staff interviews were conducted in person and via the phone on 10/13/17 from 3:05 pm through 3:45 pm. All staff members interviewed were able to confirm that they had been in-serviced on abuse, call light response, assigned staff break times, rounding / supervision and prevention of aggressive resident injuries. Immediate jeopardy was removed on 10/13/17.

Based on observations, record reviews and staff interviews the facility failed to ensure cookware, service ware and storage containers were clean, air dried and in good repair; freezer unit was free from an accumulation of ice; and food items were dated when opened. This had the potential to impact 69 of the 75 residents that resided in the facility. Findings included: Observation on 5/1/2017 at 11:15 AM with the interim Food Service Manager (FSM) during the initial tour of the kitchen revealed: The walk in freezer had a heavy accumulation of ice and frost on the shelves. An open ½ full (32 ounce) container of liquid whole eggs that was not dated when opened. In the prep refrigerator an open jar of garlic which was undated when opened. The green colored tops of plastic containers that stored dry cereal were sticky and soiled with a brown colored substance. Observation on 5/3/17 at 7:01 AM with Registered Dietitian (RD) #1 and the FSM (frequently joining and leaving during the observation) revealed Dietary Aide (DA) #2 was located at the steam table and used a towel to wipe dry (3) three wet food trays to be used for the breakfast meal. Further observations revealed 26 of 28 food trays were stacked wet. Fifteen (15) of thirty five (35) plate bases were stacked wet and in circulation for use. Six (6) of the (28) food trays were chipped. Four (4) of the fifteen (15) saucer dishes were stacked wet. One (1) of the four (4) divided plates were cracked. There was a round blue colored container stored with the divided plates on the steam table with brown particles inside the base of the dish similar to crumbs. This round blue colored container was sticky when touched. Interview on 05/03/2017 at 2:11 PM with DA #3 who stated after the dishes, utensils and cook wear have been washed, rinsed and sanitized, we (referring to the staff) should let them air dry. Interview on 05/03/2017 at 2:17 PM with DA #4 revealed any item washed should be air-dried. Interview on 05/03/2017 at 2:30 PM with the interim FSM who stated she expected staff to dispose of cracked dishes, items should be air dried and not stacked wet. Interview on 05/03/2017 at 3 PM with DA #2 who stated the food trays were stacked wet because there were not enough slots to air dry the food trays and was just not paying attention. Interview on 05/03/2017 at 3:09PM with the Director of Maintenance (DOM) revealed an expert came out and repair air holes in the freezer system. Continued interview with the DOM who stated there might be air holes in another part of the freezer system. Observation on 05/04/2017 at 10:10 AM witnessed by the FSM revealed the clean cooking utensils were stored in plastic containers. One (1) of the plastic containers had cooking utensils mixed with a dried fruit similar to a cranberry and pieces of a substance similar to crumbs. Another plastic container had ¼ cup, 1/3 cup, ½ cup and 1 cup measurers that were stacked wet. Interview on 5/04/2017 at 10:30 AM with the interim FSM who stated she had information from the administrator of the action plan regarding the dietary department and then pointed toward her office. Continued interview with the FSM indicated the action plan was posted on the bulletin board in her office. Immediately, an observation and record review of the board with the interim FSM revealed a list of environmental repairs and painting to be done in the kitchen. There was no evidence that the action plan addressed the storage of wet utensils, stacking of wet dishes or labeling of opened food items. Interview on 05/04/2017 at 2:45:21 PM with the administrator and corporate representative was held. The administrator indicated he initiated an action plan based on the county inspection dated 10/19/2016 and the last federal survey ending 6/30/16. Review of the action plan provided at the time of the survey revealed no interventions or systematic changes to address the storage of wet items or cracked dishes. Interview on 05/04/2017 at 2:55 PM with the administrator revealed he expected racks be used so that wet cooking utensils, dishes and trays could be air dried. Record review of facility documents included in the May 8, 2017 mailing from the administrator revealed: The Quality Assurance & Performance Improvement (QAPI) current and outgoing form dated 12/6/16 instructed the previous FSM to correct and then monitor to stay in compliance (as it related to the citations from the county and recertification survey of 2016. The previous FSM indicated this would be completed by 12/14/16. The QAPI review of current and outgoing form dated 1/24/17 revealed in service training was completed. The training was held on 1/20/17 which included drying pots, pans and to label and date open food products. The QAPI review of current and outgoing forms dated 2/14/17, 3/14/17and 4/14/17 included environmental concerns in the kitchen and did not reference storage of wet items, air drying and/or cracked dishes. The 4/14/17 date indicated on 4/11/17 the FSM no longer was employed at the facility and on 4/17/2017 an interim FSM was hired. A handwritten notation added to QAPI 4/18/17 indicated a problem of multiple chips in plates and bowls with a goal for all plates and bowls be free from cracks and chips for service. The targeted date for completion was immediately and ongoing.

Based on observations and staff interviews, the facility's Quality Assessment and Assurance Committee failed to maintain procedures and monitor the interventions that the committee put into place on August 3, 2016. This was for recited deficiency, which was originally cited in Dietary Service (F371) on a Recertification and complaint survey on June 30, 2016. The deficiency was in the area of F371.This deficiency was cited again on 5/4/2017 on a Recertification Survey. The continued failure of the facility during two surveys showed a pattern of the facility's inability to sustain an effective Quality Assurance (QA) Program. This tag is cross referenced to Findings included: F-371: Based on observations, record reviews and staff interviews the facility failed to ensure cookware, service ware and storage containers were clean, air dried and in good repair; freezer unit was free from an accumulation of ice; and food items were dated when opened. This had the potential to impact 69 of the 75 residents that resided in the facility. During the recertification and complaint survey of June 30, 2016 the facility was cited for Dietary Services (F 371). Based on observations, record reviews and staff interviews the facility failed to label and date food items stored in the freezer, walk in refrigerator and nourishment refrigerator. (2) Failed to properly store a scoop used to obtain flour. (3) Failed to maintain clean floors and walls. (4) Failed to replace or repair broken water faucet, cracked or missing floor tiles, crumbling walls and missing cove molding. (5) Ten of fifty eight serving bowls were chipped. (6) Failed to maintain a clean nourishment refrigerator and repair partially detached door gasket. (Unit B). During an interview with the Administrator, on 5/4/2017 at 4:30 PM he wanted to discussed the Quality Assurance and performance Improvement Action Plan for the kitchen was done on 12/1/2016, he stated that kitchen: hire CDM repair all items list on the health department inspection dated 10/19/2016 and items list during 2016 annual Re-certification survey. Additionally, fix and paint all cracks in the ceiling, walls and throughout the entire kitchen. Replace hand was sink. Place hand wash sink. Place roller wheels on racks in the dry storage room and then re-paint floor and ceiling and walls. Replace worn out seals on coolers. Replace hanging pot rack. Replace or paint rusted metal on hoods and legs of all tables. Replace al racked tile on floor and wall. Repair walls in chemical closet ad kitchen bathroom. Replace any and all rusted trash cans. Replace and broken plastic trash cans. Update as 4/1/ 2017 I changed o Nutritious Lifestyles for RD services due to ongoing RD issues. Update On 4/11/2017 the CDM quit WON and I got an interim CDM to start 4/17/17 through Nutritious Lifestyles. Continuous Interview with the Administrator revealed that his expectation for the kitchen was that we have 100% (per cent) of compliance in the kitchen.

Based on record review, staff interviews, interviews with the Hospice representatives and interview with the attending physician the facility delayed obtaining a Hospice referral for 1 of 1 resident who were reviewed for Hospice services. (Resident #107) Findings included: Resident #107 was readmitted to the facility on [DATE] status [REDACTED]. Review of the hospital discharge summary dated 4/27/17 revealed resident's legal guardian was contacted prior to discharge from the hospital to affirm the return to the nursing facility with Hospice care. Review of the medical record at the time of the survey revealed a significant change Minimum Data Set (MDS) assessment was in progress. There was not a revised care plan developed associated with the significant change. Review of the physician orders [REDACTED]. Record review of the physical therapy (PT) and occupational therapy (OT) service screening form dated 4/28/17 revealed resident recently discharged from therapy on 4/7/17 and exhibits the same presentation as at discharge. The resident had met maximal potential and would not benefit from therapy services. According to the screening form the services of the PT and OT were not indicated. Review of the social work progress notes dated 4/28/17 at 11:17 AM revealed the social worker spoke with the guardian about Hospice services. The guardian indicated that she desired to waive Medicare benefits at this time and to transition resident to full Hospice services. Continued record review revealed the guardian preferred ________ (name of Hospice). Interview on 05/03/2017 at 9:14 AM with the Director of Nurses (DON) revealed she called the Liaison person of _________ (name of the Hospice services) on Monday 5/1/17 and was not able to make a direct contact with the Liaison person of the Hospice program. Further interview revealed the Hospice nurse will be in today referring to 5/3/17. Interview on 05/03/2017 at 9:15 AM with Nurse #4 revealed the usual practice was to inform the Social Worker (SW) of a Hospice referral but cannot remember whether she or someone else informed the SW of the Hospice referral. Interview on 05/03/2017 at 9:23 AM with the Director of SW revealed she was responsible for setting up the Hospice referral then call the family. During this initial interview the SW indicated that she had faxed (unsure of date) the referral papers to _________ (name of the Hospice services). Interview on 05/03/2017 at 10:48 AM with the Director of SW, DON and Regional Clinical Director was held. The DON stated during the 5/1/17 stand-up meeting with the interdisciplinary team, she noted that there was a new order for Hospice services and called the Liaison person from Hospice on 5/1/17 with no response. Continued interview the DON indicated on 5/3/17 she called the Hospice services. During this interview the Director of SW stated she knew about the referral on Friday (4/28/17) but could not answer why the information was not faxed or called into the Hospice service. The Director of SW stated I had to verify the order and make sure the family was in agreement. Continued interview the DON stated I did fax the information on 5/2/17 to the Hospice services. Interview on 05/03/2017 at 11:19 AM with the intake supervisory representative from the Hospice Services revealed she had not received a referral for Resident #107 until a facsimile was received on 5/2/17. The Hospice representative indicated the receipt confirmation for the fax was 5/2/17 at 11:39 AM. Continued interview with the Hospice representative revealed Hospice referrals are done during the week and weekends. Interview on 05/03/2017 at 12:02 PM with the Hospice admission nurse revealed she assessed Resident #107 today 5/3/17 and admitted the resident into the Hospice program. The Hospice admission nurse stated that a nursing assistant will be scheduled 2-3 times a week to assist with direct care and services. An attempt to interview Resident #107 on 05/03/2017 at 12:24 PM was unsuccessful due to the medical decline and declined cognition. Interview on 05/04/2017 at 9:42 AM with the attending physician revealed the Hospice referral should have been done sooner than 5/3/17.

Based on record review, observations and interviews the facility failed to update the resident's care plan to reflect the resident's pressure ulcer status for 1 of 3 resident's reviewed for pressure ulcers (Resident #9). Findings included: Resident #9 was admitted on [DATE]. The current [DIAGNOSES REDACTED]. The resident had a care plan updated 3/1/17 for potential impairment of skin integrity. The goal stated that the resident would not develop any new areas of skin breakdown through next review and staff would have interventions in place to prevent altered skin integrity. Interventions included encourage good nutrition, hydration, follow facility protocols for treatment of [REDACTED]. The resident had a quarterly Minimum Data Set ((MDS) dated [DATE]. It revealed the resident was cognitively intact and did not have any pressure ulcers but was at risk for a pressure ulcer. There was nothing on the care plan that indicated it had been reviewed after the completion of the 3/3/17 MDS. The resident's wound assessment dated [DATE] identified that the resident had a wound on her coccyx that measured 2 cementers (cm) x 2.6 cm and was a stage 3 pressure ulcer. A note from dietary dated 3/29/17 stated the resident was noted to have a wound to her coccyx. The dietary note indicated there would be a discussion with the resident about adding a supplement. Resident #9's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact. The resident had a stage 3 pressure ulcer that measured 2.0 cm x 2.6 cm x 0 cm and had eschar tissue present. There was nothing on the care plan that indicated it had been reviewed after the completion of the 3/31/17 MDS. The MDS nurse was interviewed on 5/3/17 at 11:44 AM. She stated the resident developed a pressure ulcer after her annual assessment. She stated when they do a quarterly MDS, she would update the resident's care plans that were talked about in morning meetings. She stated on 3/27/17, the resident developed another pressure ulcer. She stated she did the MDS assessment on 3/31/17 and did not update the resident care plan at that time. She wasn't sure why it was not updated. She stated the care plan for pressure ulcers should have been updated on 3/31/17. The wound care nurse was interviewed on 5/3/17 at 2:46 PM about Resident #9. She stated the most recent pressure ulcer was found on 3/20/17 and the Wound Care Nurse was aware the resident was admitted from home with 14 stage 4 pressure ulcers. The Wound Care Nurse stated she usually didn't update the care plans. She stated she would usually give wound care updates to the MDS nurse so that she could update the care plans. The DON was interviewed on 5/4/17 at 12:40 PM. She stated the resident was on an air mattress and refused to offload weight or be turned by staff. The resident also had treatment orders in place for the current ulcer. She would expect the care plan to be individualized for each resident and updated quarterly.

Based on observations, record reviews and staff interviews the facility failed to label and date food items stored in the freezer, walk in refrigerator and nourishment refrigerator. (2) failed to properly store a scoop used to obtain flour. (3) failed to maintain clean floors and walls. (4) failed to replace or repair broken water faucet, cracked or missing floor tiles, crumbling walls and missing cove molding. (5) ten of fifty eight serving bowls were chipped. (6) failed to maintain a clean nourishment refrigerator and repair partially detached door gasket. (Unit B). The findings included: Observation on 06/27/2016 at 11:11 AM of the kitchen with the Food Service Manager (FSM) revealed: 1. A. Walk in refrigerator: There was an open plastic bag of meat stored out of the original undated and unlabeled. The bag contents was identified by the FSM as chopped ham. B. Walk-in Freezer: There was a plastic bag of French fries that were unsealed and exposed to the air. There was an open bag containing 14 hash brown potatoes that was unsealed and exposed. C. Reach in freezer 30 degrees There was a box which contained an unsealed plastic bag of uncooked frozen oatmeal cookie dough. Interview on 06/30/2016 at 1:31PM with the FSM revealed foods should be properly labeled and dated. 2. A. In the dry storage area: The scoop was stored directly into the flour and sugar containers. Observation on 06/29/2016 7:15 AM revealed the scoop remained stored in the flour. Interview on 06/30/2016 at 1:31PM with the FSM revealed the scoop for the sugar and flour handles should not be stored in the containers. The FSM indicated the facility did not have an acceptable place to store the scoops when not in use. 3. A. In the dry storage area: · Dried cereal was noted on the floor and under the shelves. · The cove molding was partially detached from the wall. · The ventilation exhaust unit had an accumulation of dust. · The corners of the floors had an accumulation of a black colored substance. · The wall paper was peeling off the wall. · There were cobwebs in the corner of the ceiling near the entrance to freezer door. · There was an accumulation of dust and dirt under the shelves in the dry storage area. · The floor paint was peeling. · There are 4 wall tiles missing. · The walls were soiled with dried brown colored splatter. Observation on 06/29/2016 at 10:22 AM of the dried storage area revealed the cove molding continued to be partially detached from the wall. The ventilation unit continued to have an accumulation of dust, dead crawling insect, and the corners of the floors remain with an accumulation of a black colored substance. The wall paper continued to peel off of the wall. Cobwebs continued in the corner of the ceiling near the entrance to freezer door. There continued to be an accumulation of dust and dirt under the shelves in the dry storage area. 4 wall tiles in the dry storage area continued to be missing. The walls remained soiled with a dried brown colored splatter. Interview on 6/30/16 at 9:25 am with Dietary Aide #1 revealed the person that stocks the delivered items were responsible to clean the stocked areas. B. In the Walk-in Freezer: · The landing of the entrance to the freezer had a heavy accumulation of a black colored substance in the floor corners. · There was an accumulation of ice on the floor from the dripping pipes C. In the Tray line refrigerator: There was a glass thermometer that was cracked and broken. Pieces of the glass thermometer was missing. Observation on 06/29/2016 at 10:22 AM the glass thermometer was still broken. D. Throughout the kitchen: · There was an accumulation of a black colored substance in the corners of the floor. · The walls were splattered with dried brown colored substances. · The open area under the fryer had an accumulation of brown, black and yellow debris. · There was chipped, crumbling wall plaster and missing cove molding in the kitchen near the office. · The entrance way from the kitchen to the dining room had missing floor tile. · There was an accumulation of a black substance at the location of the missing tiles. · The hot water faucet handle at the sink was missing. The water would not shut off and continued to flow in the sink. Observation revealed dietary staff was noted to be using a wrench to control the flow of the hot water at the sink. Interview on 6/29/16 at 6:50 AM with Cook #1 revealed the faucet had been broken for about a week (from 6/29/16) and was unaware of whether it was reported to maintenance for repair. · In the kitchen there was missing pieces of wall around the electrical outlet near the reach in refrigerator. An open can of ginger ale was on the floor near the reach in refrigerator covered with dust. · The accumulation of a brown colored substance and crumbling substance were noted on the floor near the walk in refrigerator. · There were 3 concrete blocks that were partially detached from the wall. Observation revealed when the dietary delivery door opened and closed the concrete blocks would move. · Chipped paint was noted on the wall behind the steam table. Observation on 06/29/2016 at 10:22 AM in the kitchen revealed there was still missing pieces of wall around the electrical outlet near the reach in refrigerator. A can of ginger ale remained on the floor near the reach in refrigerator. The accumulation of a brown colored substance and crumbling substance remained on the floor near the walk in refrigerator. The 3 concrete blocks continued to be partially separated from the wall. Interview at 6/29/16 at 10:30 am with Dietary Aide #1 revealed the concrete blocks had been partially detached from the wall for over a year (referring to 2015). Chipped paint continued to be noted on the wall behind the steam table. Interview on 06/29/2016 at 11:10 AM with the Director of Maintenance revealed he was unaware of the broken hot water fixture and the partially detached concrete blocks. Interview on 06/29/2016 at 11:40 AM with Director of Housekeeping revealed usually will clean the kitchen under the recommendation from the FSM. Had no special request but indicated that on 6/6/16 he performed the emerald floor cleaning. (Name after the product used). 2. Observation in the kitchen on 6/29/16 at 7:20 AM of the breakfast trayline revealed 10 (ten) of 58 (fifty eight) tan colored chipped bowls. Three (3) of the 10 had sharp edges. Interview on 6/29/16 at 8:01 AM with the FSM revealed the chipped bowls were the only bowls in the facility to use. Interview on 06/29/2016 at 11:00 AM with the FSM revealed the housekeeping staff cleaned the dry storage area every month. The FSM stated the dry storage area was just detailed cleaned by housekeeping last month (referring to May 2015). Additionally, the FSM indicated she swept and cleaned the dry storage area often. (No definitive time provided). Interview on 06/29/2016 at 12:03:30 PM with the consultant dietitian revealed she shared her reports to the previous administrator and there had been no follow-up. The consultant dietitian stated I will report to the maintenance person if the facility wants me to do so. Review of the dietitian's report for the last 5 months revealed needed repairs for the same items identified month to month. An inquiry was made about she identified issues were corrected. The consultant dietitian stated she was a contract employee and the administrator of facility and the FSM would address the issues. Observation on 06/28/2016 at 9:49AM of the Unit A nourishment refrigerator revealed dried brown colored spills on both shelves. The floor base of the freezer section had dried red colored substance. Observation on 06/28/2016 at 9:59 AM of Unit B nourishment refrigerator revealed a container of a yellow colored frozen substance in the freezer. There was no label or date. The white gasket around the door had an accumulation of brown and black colored particles within the grooves. The white coloredgasket molding was partially detached from the door. There was a rust colored substance on the bottom of the refrigerator door. Interview on 06/30/2016 at 10:48 AM with the Director of Housekeeping revealed the dietary staff were responsible for cleaning the nourishment refrigerators on the unit. Interview on 06/30/2016 at 4:07: PM with the administrator revealed expectations that the kitchen be clean and any required repairs be brought to the attention of maintenance.

Based on observation, staff interviews and record review, the facility failed to provide a maintained, safe, and comfortable interior on 3 of 3 resident halls (A hall, B Hall and C Hall). 1. On 06/27/2016 at 11:20 AM an observation of Resident # 21 ' s chair revealed the following: a. An accumulation of a brown substance on the metal portion of the leg rest attachment. 2. On 06/27/2016 at 2:50 PM an observation of room # 146 revealed the following: a. A tan substance accumulated on the cross member of an intravenous pole stand. b. The over bed table had a dried tan substance on the surface. 3. On 06/28/2016 at 10:35 AM an observation of room # 107 - B revealed the following: a. Three slats on the window blind were broken. 4. On 06/28/2016 at 11:14 AM an observation of room # 133-b revealed the following: a. The wheel chair padding on the left arm is was cracked and peeling 5. On 06/28/2016 at 11:45 Am an observation of room # 114 revealed the following: a. A black looking substance in the corners of the clothing bureau. 6. On 06/28/2016 at 01:20:37 PM an observation of room # 140 revealed the following a. In the bathroom there was an accumulation of a thick, dried, black substance around the commode. 7. On 06/28/2016 at 1:20 PM an observation of room # 142 revealed the following: a. The window sill had peeling paint. b. The bathroom door had chipped and peeling paint c. The toilet base had an accumulation of a black substance. 8. On 06/28/2016 at 1:37 PM an observation of room # 120-B revealed the following: a. The wall cabinets had chipped paint. b. There was peeling paint behind the bed and underneath the light. 9. On 06/28/2016 at 2:10 PM an observation of room # 125-B revealed the following: a. The clothes closet had chipped paint. 10. On 06/28/2016 at 3:04 PM an observation of room # 113-B revealed the following: a. Light brown and black substance on base of IV pole. 11. On 06/28/2016 at 3:05 PM an observation of room # 154 revealed the following: a. Bathroom floor tile cracked in the corner b. Missing cove molding at the door 12. On 06/28/2016 at 3:14 PM an observation of room # 156 revealed the following: a. Accumulation of brown colored substance in corners of bathroom b. The bathroom light was dim. 13. On 06/28/2016 at 3:22 PM an observation of room # 159 revealed the following: a. A hole in the bathroom door that measured 2 ½ in long x 1 ½ inches in width b. An accumulation of a brown substance in the corners of the bathroom. 14. On 06/29/2016 at 10:20 AM an observation of room # 112-A revealed the following: a. The seal around the toilet base appeared to have a rust colored stain and was not sealed. b. Discolored and damaged ceiling near the air conditioner ceiling vent. 15. On 06/29/2016 at 10:20 AM of room # 112-B revealed the following: a. A brown sticky substance at the right corner of the cabinet base. b. There were several spots of thick white looking substance on the surface of the mirror. 16. On 06/29/2016 at 10:45 AM an observation of room # 115 revealed the following: a. The seal around the toilet base had a rust colored looking stain. An interview was conducted with the Maintenance Director on 06/30/2016 at 7:30 AM. The maintenance director stated there was a plan in place to renovate three individual rooms quarterly. The maintenance director stated staff were instructed to write areas in need of repair in the maintenance book located at the nurse ' s station. The maintenance director stated the maintenance logs were checked daily. The maintenance director stated if immediate needs were known the repair would be made immediately. A walk through was conducted with the maintenance director. The maintenance director acknowledged the areas of concern. An interview was conducted with the Administrator on 06/30/201 at 9:36 AM. The administrator stated the maintenance and repair of the building was an ongoing task in an older facility. The administrator stated he knew the maintenance team was working on areas needing repair.

Based on observation, resident interview, staff interview, and record review the facility failed to provide palatable food during 1 of 3 meal observations in which chicken was served. Findings included: Review of the facility menus revealed the lunch meal on 6/27/16 featured garlic roasted chicken. Interview on 6/27/16 at 12:05 PM with 2 alert and oriented resident who requested to remain anonymous stated the facility did not serve food that was good. Both residents indicated the meat served was generally tough or not cooked enough. According to both resident ' s most recent minimum data set, their cognition was intact. Observation during the lunch dining on 6/27/16 at 12:05 PM in the main dining room revealed garlic roasted chicken was served to one of the residents. The chicken appeared dry and had a blacken crust on the top. Interview with the resident who was served the chicken revealed the chicken tasted dry but was able to eat the chicken after the dry parts and the blacken top were removed. On 6/27/16 at 12:50 PM a test tray of the chicken was done in the presence of the consultant dietitian. The chicken was a skinless thigh. Parts of the thigh were dry and dark brown in color. One side of the chicken thigh was blacken in color, dry and could not be chewed. Once the blacken portion of the chicken was removed the chicken was tender and was able to be chewed. The dietitian agreed that the top portion of the chicken was dry and residents would have a difficult time chewing that portion. Interview on 06/30/2016 at 4:00 PM with the administrator revealed the expectation was food served be of nutritive value and that is of the resident's expectation.

Based on family and staff interviews and record reviews, the facility failed to ensure a resident was free from unnecessary drugs by simultaneously administering a narcotic pain medication and two antipsychotic medications ordered on an as needed basis without the clinical need for these medications for one of three sampled residents (Resident #1). Findings Included: Resident #1 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE], revealed she was alert with a short term memory problem and was severely impaired with cognition for decision making. She was able to understand and could make her needs understood. Review of the physician orders [REDACTED]. · [MEDICATION NAME] tablet(an antipsychotic) 1 MG (milligram) Give 1 tablet by mouth as needed for Chronic [MEDICAL CONDITION] QD (every day) PRN (as needed). · [MEDICATION NAME] tablet 1 MG (an antipsychotic), Give 1 tablet by mouth every 6 hours as needed for Agitation. · [MEDICATION NAME] Tablet (a narcotic pain medication containing [MEDICATION NAME] and [MEDICATION NAME]) 5-325 MG Give 1 tablet by mouth every 6 hours as needed for pain. During an interview on 12/28/14 at 3:56 PM, Nurse #6 indicated Resident #1 was admitted late on 1st shift. She had no complaints of pain and was not disruptive. Nurse # 6 indicated the family requested that medications be administered for pain and to calm her down . Resident #1 was not symptomatic. No scheduled medication were due. She indicated that she and Nurse # 2 looked at the physician's order [REDACTED]. She gave her [MEDICATION NAME] 1 MG, [MEDICATION NAME] 1MG and [MEDICATION NAME] 1 MG. When asked why she gave the [MEDICATION NAME] and the [MEDICATION NAME] she responded, she felt intimidated by the family. During an interview 12/28/15 at 5:30 PM, Administrator indicated concern that [MEDICATION NAME] and [MEDICATION NAME] were all given without a need and expected the nurse to involve the nurse supervisor for guidance. During an interview on 12/28/15 at 6:08 PM, Aide #1 indicated she was with Resident #1 at 3:00 PM, and made the bed and assisted her to bed. Resident #1 verbalized pain, from the pressure ulcer when she was moved. Her behavior was cooperative. During an interview on 12/29/15 at 9:14 AM, family member indicated she was present during the admission on 12/16/15 between 2:00PM and 2:30 PM. She had requested Resident #1 receive the medications that were due. She indicated Resident # 1 was not agitated or in pain. She wasn ' t aware of what medications Nurse #6 had given. During an interview on 12/29/15 at 9:25 AM, Physical Therapist indicated she had completed the physical therapy evaluation on 12/16/15 at 4:00 PM. Resident #1 was cooperative and pleasant. She had no indication of pain. She participated in the therapy evaluation. During an interview on 12/29/15 at 10:56 AM, Nurse #2 indicated she admitted Resident #1, about 2:00 PM on 12/16/15. She was mildly confused and was peasant. She was cooperative and assisted with turning during her skin assessment. She wasn ' t in pain. The family repeatedly asked for Resident #1 ' s pain and antipsychotic medications. No scheduled medications were due. Nurse #2 indicated Resident #1 wasn ' t hollering or disruptive and wasn ' t complaining of pain. When asked why both of the antipsychotic medications were given simultaneously when Resident #1 was asymptomatic, Nurse #2 indicated the family insisted, and the family was more familiar with Resident #1. During an interview on 12/29/16 at 2:10 PM, Director of Nursing indicated her expectation was for the nurse to determine the need for an antipsychotic or pain medication.

Based on record review and staff interview the facility failed to ensure medications were accurately documented to the electronic Medication Administration Record [REDACTED]. (Resident #1) Findings included: Resident #1 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE] revealed she was alert with a short term memory problem and was severely impaired with cognition for decision making. She was usually able to understand and was able to make her needs understood. Review of the Med Pass with Medication Cart procedure dated 05/19/2015, revealed in part, 15. Document administration on the medication sheet or in the computer, and updated the Individual Control Drug Record for Schedule II drugs. Review of the physician orders [REDACTED]. · [MEDICATION NAME] tablet (an antipsychotic), 1 MG (milligram), Give 1 tablet by mouth as needed for Chronic [MEDICAL CONDITION] QD (every day) PRN (as needed). · [MEDICATION NAME] Tablet 1 MG (an antipsychotic), Give 1 tablet by mouth every 6 hours as needed for agitation. · [MEDICATION NAME] Tablet ([MEDICATION NAME] and [MEDICATION NAME] used as a pain medication) 5-325 MG. Give 1 tablet by mouth every 6 hours as needed for pain. Review of the facility emergency medication log for [MEDICATION NAME] 5/ 325 MG revealed one (1) tablet was dispensed on 12/16/15 at 3:45 PM for Resident #1 by Nurse #6. Review of the Emergency Medication Slips dated 12/16/15 at 3:45 PM, revealed [MEDICATION NAME] 1 MG 1 tablet and respiradol 0.25 MG four (4) tablets were dispensed for Resident #1 by Nurse #2. Review of the MAR for December revealed on 12/16/15, Nurse #6 and Nurse #2 failed to document on the E-MAR the administration of [MEDICATION NAME] tablet 1 MG (milligram), [MEDICATION NAME] tablet 1 MG and [MEDICATION NAME] tablet 5-325 MG. During an interview on 12/28/14 at 3:56 PM, Nurse #6 indicated she had administered one (1) tablet of [MEDICATION NAME] 1 mg , four (4) tablets of [MEDICATION NAME] 0.25 MG and one (1) tablet of [MEDICATION NAME] 5-325 MG. She indicated she had forgotten to document on the EMAR. She indicated she had not written a note. During an interview 12/29/15 at 2:10 PM, Director of Nursing indicated her expectation was medications to be documented accurately on the EMAR.

Based on record reviews, interviews with resident and staff, the facility failed to answer resident call bells for residents needing assistance, to maintain dignity for 3 of 4 residents (Resident # 1, Resident #53 and Resident#55) reviewed for dignity Findings Included: 1. Resident # 53 was admitted on [DATE] [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) dated [DATE] indicated that Resident #53 was cognitively intact, had adequate hearing and vision, clear speech, was able to be understood and understand others. She also was incontinent of bladder and bowels. Resident # 53 required extensive assistance of one person for toileting and two people for transfer from the bed to the chair. Interview with Resident #53 on 9/22/2015 at 9:45pm, Resident # 53 stated that her call bells were not being answered in a timely manner. Resident #53 indicated on Monday night, 9/21/2015, that she put her call bell on and waited over an hour, while wet, for someone to come in and change her. Resident indicated that this was always the problem during the evening shift; the staff was very slow about answering call bells. Resident #53 indicated that because of my [MEDICAL CONDITION] I speak very slowly, sometimes the staff act like what I need is not important to them and this hurts my feelings. Resident # 53 stated all I can do is lay here'. Resident # 53 indicated that staff talks disrespectful to her a lot. Resident # 53 indicated that she put her call light on 9/4/2015 and waited over 1 hour for staff to come and provide care to her and another aide come in and cut the light off but did not provide care. Resident #53 revealed that she urinates on herself a lot because it takes staff so long to help me. Resident # 53 stated This is a problem and the Director of Nursing (DON) was aware of staff not answering the call bell. Resident #53 stated that it ' s not a good feeling when you are wet. Resident # 53 indicated that she had completed a grievance report about the incident on the 4th of September. Resident # 53 stated that it ' s no better. Resident # 53 also indicated that staff do talk ugly and yell at her during care but she had not reported this. A Review of a grievance complaint report dated 9/4/2015 revealed Resident # 53 had complaints about NA (Nursing Assistant) not answering call bell. From the review of this grievance that NA was placed on another unit and consulted about prompt response to call lights and other care needs. NA was also consulted about Resident rights and dignity. And what her expectations are during working hours at the facility to ensure that continuity care was provided for her residents. On 9/22/2015 at 9:45pm an observation on of a clock was on the wall and observed to have the correct time on it. An observation of the resident ' s room on 9/22/2015: at 10:15pm the clock on the wall between the residents two TV ' s had been observed and indicated the correct time. The clock was within view of the resident ' s bed. An interview with Resident #53 on 9/22/2015 at 10:15pm indicated that that was how she knew how long it took for staff to answer her call bell and provide care for her. Resident revealed that she had waited up to one hour and a half, or longer, to be changed before, and revealed that this has been going on for months. During an interview with the Director of Nursing on 9/22/2015 at 11am revealed her expectation of staff answering call bell she stated that call bells are No Passing Zone She indicated that staff needs to be answering the call bell within a few minutes and that 1 hour was to long for any residents to wait to be cared for. DON stated we still have a problems with call bells not being answered. Interview with Nursing Aide #1 on 9/23/2015 at 4pm revealed that she been working with resident #53 for 3 months. NA # 1 stated that I had never been ugly to this resident and denied taking a long time to answer her call light. She also indicated that she never walked in her room and cut off the light without providing care. 2. Resident # 1 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated that Resident # 1 was cognitively impaired, had adequate hearing and clear speech, was able to be understood and understand others. There were behaviors exhibited and she rejected care. Resident # 1 required extensive to total assistance for all her activities of daily care, but Resident # 1 can fed herself. Resident # 1 was always incontinent of bowel and bladder. Resident # 1 sometimes used an in-and-out catheter. During an interview on 9/21/2015 at 4pm, when asked if staff treated her with dignity and respect, Resident #1 stated staff talked ugly to her and are very rough with her during care. Resident # 1 indicated that if she rings her call bell she ' ll wait for 45 min to 1hr for staff to come in and cut it off. When they cut off the bell, they say I will be back in a few and a few ended up being another hour or so. Resident # 1 also reported that one NA (Nursing Assistant) told her that none of the staff members want to help me or provide care for me because of my attitude and because I was mean. Resident # 1 revealed that she was not mean and didn ' t have a bad attitude. Resident # 1 revealed that this made her feel really bad and hurt her feelings because she hated that she could not do anything for herself. Resident # 1 indicated that she wanted to cry sometimes because of her situation. Resident # 1 also revealed that 2nd and 3rd shifts are the worst about answering call bells. Resident # 1 indicated that she told the Director of Nursing on Monday 9/21/2015 that she did not want one NA(Resident #1 named the NA and one of the Nurses(Resident #1 named the nurse) to work with her because of them being rough with her during care. Resident # 1 also stated that Nurse took over an hour or so to provide her with pain medication. Resident # 1 revealed that this happen all the time during the second shift. An observation of the resident's room on 9/22/2015 at 10pm revealed that the clock on the wall between the resident ' s TV indicated the current time. The clock was within view of the resident's bed. Resident indicated that this was how she knew how long it took staff to answer her call bell and provide care for her. Resident revealed that she had waited up to two hours or longer for someone to provide care for her and she did also state that this has been going on for months. During an interview with the Director of Nursing on 9/23/2015 at 9:30am, she indicated that Resident # 1 had informed her several times that staff was not answering call bells in a timely manner that she was not getting the assistance for her needs. DON indicated that this was why she conducted in service training about answering call bell in a timely manner on 9/18/2015. Interview with Nursing Aide #1 on 9/23/2015 at 4pm revealed that she been working with resident#1 for 3 months and indicated that she answered her call bell but, resident does not want anyone to assist her with her ADL's because she indicated that she was in pain. NA # 1 revealed that she had never been ugly to this resident and denies taking a long time to answer her call light. She also indicated that she never walked in her room and cut off the light without providing care for her. A review of Grievance/complaint report forms from July 2015 until present revealed concerns from 6 other residents indicated that staff are not answering the call bell in a timely manner which posed a major problem on second shift. Several of the grievance/complaint reports were on the same hall with Resident #1. During an interview with the Director of Nursing on 9/22/2015 at 11am revealed her expectation of staff answering call bell she stated that call bells are No Passing Zone She indicated that staff needs to be answering the call bell within a few minutes and that 1 hour was to long for any residents to wait to be cared for. DON stated we still have a problems with call bells not being answered. 3. Resident #55 was admitted [DATE], with [DIAGNOSES REDACTED]. He also required extensive assistance with transfers and toileting. During an interview with Resident # 55 on 9/23/2015 at 9:23 am, he was alert and oriented and able to answer questions without difficulty. He expressed that he had trouble getting staff to answer his call light on two occasions recently. He stated that he had used his call light to request a blanket. He said that staff had put him to bed and covered him with a sheet and he was cold. He asked for a blanket and timed the staff. He reported that it took staff 30 minutes to bring him a blanket. He also stated that he is sure of the time because he noted the time he called and when they brought him a blanket. He said he was cold and he has thin blood being [AGE] years old. He also stated that he had a fall recently. He said that he had called for assistance with toileting. The staff did not answer so he decided to get up on his own. He said he broke his foot in that fall. He said that he did talk to the Administrator and DON about that fall and the staff not answering the call light. He said their response was, I will talk to them. Record review showed that Resident #55 did have a fall with injury including broken toes on 8/28/2015 as he reported. During an interview with the Administrator and DON 9/23/2015 11:14 am, they both stated that they were unaware of Resident #55 ' s fall being related to staff not answering his call light.