Every finding on record at Siloam Healthcare, LLC

Based on observation, interview, and facility document review, the facility failed to ensure that food was prepared in accordance with professional standards for food service safety by not keeping the grease trap clean of charred food particles and spillage. The findings are: On 01/13/2025 at 11:33am during an observation of the facility's kitchen, the Food Service Director (FSD) pulled out the grease traps on the stove. When the FSD pulled open the slide out tray, there was a piece of aluminum foil covering the top of the tray that contained an 18 inch by 9 inch area of black spillage and charred particles. On 01/13/2025 at 11:35am, the FSD stated grease traps were checked and cleaned once a week by one of the kitchen staff and the kitchen has a cleaning schedule. On 01/13/2025 at 11:50pm, the FSD stated the grease traps should be checked and changed more frequently than once per week. The FSD stated that leaving the charred particles and spillage in the grease trap posed a fire risk in the kitchen and could attract pests. On 01/15/2025, in-service training on the kitchen's cleaning schedule was provided by the FSD dated 10/10/2024 and 12/12/2024. A review of dietary Cleaning Schedules, for the last 3 months indicated staff were to clean the range hood and hood filters. Cleaning of the stove and/or grease trap was not indicated. A review of dietary Cleaning Schedules, for the last 3 months indicated all staff were responsible for cleaning the stovetop and/or grill. Cleaning of the grease trap was not indicated. A review of Cleaning Assignments which indicated the morning and evening cooks were responsible for cleaning the grease traps, which were last cleaned by staff in July 2024. No other documents provided by the facility indicated staff were to clean the grease traps after July 2024, indicating July was the last documented time the grease traps were cleaned. On 01/15/2025, a facility kitchen cleaning policy was requested and was not provided to the surveyor prior to exiting the facility

Based on record review and interview, the facility failed to ensure a Facility-wide Assessment included pertinent information to determine what resources were allocated to care and to meet the needs of the residents competently during both day-to-day operations, and emergencies in 1 of 1 facility. This deficient practice had the potential to affect all residents of the facility. The total census was 83 residents. The findings are: A review of a facility document titled Facility Assessment Tool, indicated an update on 11/27/2024. The facility-wide assessment did not include the following: - The process of making admission or continuing care decisions for persons that have diagnoses, (dx) or conditions the facility are less familiar with, and have not previously supported. - Assessment of residents' ethnic, cultural, or religious factors that may need to be considered to meet resident needs, such as activities, food preferences, and any other aspect of care identified. - Other pertinent facts or descriptions of the resident population that must be considered when determining staffing and resource needs such as, daily schedules, bathing, activities, naps, food, going to bed, etc. - Review of staff assignments for coordination and continuity of care. - A description of staff training/education and competencies necessary to provide the level of care for the facility's resident population. - A description of how the facility evaluates what policies and procedures may be required in the provision of care, and how to ensure the facility meets current professional standards of practice. - The plan to recruit and retain enough medical personnel who are adequately trained and knowledgeable in the care of residents, and/or management of expectations for medical personnel. - How the management and staff familiarize themselves with what they should expect from medical practitioners and other healthcare professionals, related to standards of care and competencies that are necessary to provide the level and types of support and care needed for the facility ' s resident population. - List of contracts and memoranda of understanding or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies. - List heath information technology resources for managing resident records and sharing information with other organizations. - A description of how the facility would evaluate their infection prevention and control program, that included systems for preventing, identifying, reporting, investigating, and controlling infections. - A facility-based and community-based risk assessment, utilizing an all-hazards approach, focusing on capacities and capabilities critical to emergency preparedness. During an interview on 01/17/2025 at 9:17 AM, Administrator said I was not aware that all the bullet points of the facility assessment had to be completed. I will work on it and have it completed by the end of the day. The Administrator confirmed the facility assessment was not completed, and the facility would work on the facility assessment to complete it and make it more accurate.

Based on interviews and record review, it was determined that the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for 1 (Resident #88) of 22 residents reviewed for MDS accuracy. Specifically, the facility failed to ensure information regarding the resident's dialysis assessment was accurately completed for Resident #88. Findings include: A review of the facility's undated policy titled Comprehensive Assessment indicated, Comprehensive Assessment are conducted in accordance with criteria and time frame established in Resident Assessment instrument (RAI) User Manual. A review of the Admission Record, indicated the facility admitted Resident #88 with a diagnosis of dependence on renal dialysis. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2024, revealed Resident #88 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Upon further review the MDS did not indicate resident was receiving dialysis services. A review of Resident #88's care plan, initiated on 12/13/2024, revealed the resident received hemodialysis Monday, Wednesday, and Fridays. A review of Order Summary Report, revealed Resident #88 had a physician's order for hemodialysis with a start date the same as the admitted . During an interview on 01/15/2025 at 10:23 A.M. the MDS Coordinator stated Resident #88 was on dialysis when admitted , and dialysis was not indicated on the MDS, and Resident #88 was receiving dialysis prior to the admission assessment. The MDS Coordinator stated the failure to have an accurate assessment could affect care provided.

Based on record review and interviews, the facility failed to ensure physician order changes were immediately initiated for 1 (Resident #13) of 5 residents reviewed for anti-psychotic medications. The findings are: Resident #13 ' s Admission Record was reviewed and indicated resident had a diagnosis of major depressive disorder. Resident #13 ' s January Physician's Orders were reviewed and read in part [Brand name medication used to treat bipolar depression] oral capsule 42 milligrams (mg) Give 1 capsule by mouth at bedtime. Review of Resident #13 ' s quarterly MDS [minimum data set] with an ARD [assessment reference date] of 12/11/2024, indicated a BIMS [brief interview for mental status] of 14 [13-15 cognitively intact]. Resident #13's Care Plan with a review date of 12/12/2024, was reviewed and indicated resident was taking an antidepressant medication: uses antidepressant medication related to Major Depressive Disorder and administer antidepressant medications as ordered by physician Record review of a Psychiatric Evaluation for Resident #13 dated 10/28/2024, revealed Medication Change/Refill [Brand name medication used to treat bipolar depression] Dosage Change - 21 mg at bedtime. On 01/17/25 at 9:16 AM, the Director of Nursing (DON) was shown the Psychiatric evaluation dated 10/28/2024, with the order to decrease [Brand name medication used to treat bipolar depression], she stated she had not seen the form before and would have to check into it. On 01/17/25 at 10:00 AM, the DON was asked to explain the process for reviewing the consults or visits from providers and responded the process, if done properly, would obviously go through the charge nurse or DON. The DON reported that there was no actual process for outside consults, no specific process was in place for reviewing consultant progress notes. The DON was asked if the medication should have been reduced; DON ' s response was that it should have been reduced or had a risk versus benefit statement from the physician, and the physician should have been notified. When asked if the physician was notified, the DON stated that the physician was not notified. The DON was asked to explain the procedure for notifying a physician after a consult; the DON stated the physician would be notified by her or the charge nurse to let them know what the consult was unless they were in the facility and receive any changes the physician indicated. The DON was asked, who is responsible for ensuring new orders from provider visits have been recorded or changed; the DON remarked that normally would fall on the nurse managers, the DON, or the nurse on the floor who received the order. The DON was asked how long does the facility usually allow for new orders to be put into place; Her response was, immediately, upon notification. The DON was asked if the provider who wrote the order to change Resident #13's antidepressant order was an approved provider for the facility. The DON responded that yes, the NP [nurse practitioner] who prescribed the change in the [Name brand medication used to treat bipolar depression] was a recognized prescriber and the order should have been changed or documented in the record of why the change was not being initiated. A policy for reviewing consultant order changes was requested from the DON. On 01/17/25 at 10:28 AM, the DON stated there was no policy that addressed the review process for consultant changes in medications On 1/16/2025 at 10:49 AM, an Administering Medications policy was received from the DON. The policy was reviewed and read in part that medications were to be administered in a safe and timely manner, and as prescribed; 4. Medications are administered in accordance with prescriber orders, including any required time frame;5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication.

F689 Based on observations, record review, interviews, document review, and facility policy review, the facility failed to investigate to determine the causative factors of falls to facilitate development of effective interventions to prevent further falls and minimize the risk of fall-related injuries for 1 (Resident #35) of 3 sampled residents reviewed for accidents, which resulted in numerous abrasions and two separate hematomas to the forehead resulting from a fall for Resident #35. The findings include: A review of a facility policy titled, Care Plans, Comprehensive Person-Centered with a revision date of March 2022, indicated Care plans interventions are developed after data gathering, proper sequencing of events, consideration of relationships or the underlying source and problem. Also, assessments are on going and updated when condition changes. A review of the Admission Record, indicated the facility admitted Resident #35 with diagnoses that included cerebral infarction (stroke), dementia, diabetes mellitus, spondylolysis (a defect or damage via a stress fracture in one of the vertebrae of the spinal column), anxiety, and psychotic Disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/2024, revealed Resident #35 had a Brief Interview of Mental Status (BIMS) of 3 indicating severe cognitive impairment. Further review indicated the resident had two or more falls with no injuries since admission . A review of Resident #35 ' s care plan, revealed the resident was a fall risk related to impaired cognition, communication problems, impaired mobility and had actual falls on 02/12/2024, 02/24/2024, 06/27/2024, 10/08/2024, and 01/07/2025. Interventions included the following: - Observe the resident for appropriate footwear, initiated on 04/17/2022 - To have proper footwear intact while up in a wheelchair, initiated on 01/08/2025 - Staff were to assist the resident into merry walker (adaptive equipment that is utilized to help with a physical or cognitive impairment) instead of recliner, initiated on 10/09/2024 - To keep the bed in the lowest position with fall mat, initiated on 12/10/2023 - If the resident was restless in bed, to assist the resident into a merry walker, initiated on 04/09/2024 Further review of the care plan indicated the resident had poor safety awareness and required supervision, prompts, and cues for safety. A review of Resident 35 ' s tasks revealed the following: - Staff were educated to provide non-slip footwear daily to the resident on 10/08/2024 - Staff were to encourage the resident to get up for meals - The resident was to always wear Velcro strap tennis shoes when out of bed - To keep the resident ' s bed at lowest position - To ensure a floor mat was beside the bed - The resident was to wear a soft helmet at all times while out of bed. A review of the last 12 months of incident and accident reports indicated Resident #35 had the following falls: - 02/12/2024, the resident was found crawling on the bedroom floor after climbing out of bed and sustained a hematoma to the head and an abrasion to the knee. The fall intervention was continue with the bed in the lowest position, fall mat at bedside, and staff were educated to put the resident in a merry walker if the resident becomes restless. - 03/24/2024, the resident was found crawling on the bedroom floor after climbing out of bed and sustained abrasions to the elbow and a raised area to the forehead. Staff again were educated to put the resident in a merry walker if the resident becomes restless. - 06/27/2024, the resident was found on the bedroom floor. Staff were educated to encourage the resident to get up for meals. - 07/03/2024, the resident was found crawling on the bedroom floor. Staff again were educated to put the resident in a merry walker if the resident becomes restless. - 09/30/2024, the resident was found in the floor in a hallway. The resident had been sitting in the merry walker and staff noticed the safety buckle was undone. Staff educated to ensure safety belt and front bar were secured when the resident was in the chair. - 10/08/2024, the resident was found on the floor in the resident ' s room and had fallen out of the merry walker. The resident was not wearing non-skid socks. Staff were educated to provide non-slip footwear daily. - 01/07/2025, the resident was found on the floor in the TV room. The resident had fallen out of their wheelchair and the resident ' s helmeted head hit another resident ' s wheelchair. The resident was not wearing non-skid footwear. A review of fall assessments for the last 12 months were reviewed and indicated the following: - On 03/26/2024, the assessment indicated the resident did not have any falls in the past 3 months. - On 08/09/2024, the assessment indicated the resident had 1-2 falls in the past 3 months. - On 10/01/2024, the assessment indicated the resident was not at risk for falls, even though the resident had 3 falls within the last 3 months. - On 01/07/2025, the assessment indicated the resident did not have any falls within the last 6 months. During an observation on 01/13/2025 at 2:05 PM, Resident #35 was wearing a soft helmet and was sitting in a wheelchair. During an interview on 01/17/25 at 8:28 AM, Licensed Practical Nurse (LPN) #7 stated that Resident #35 was dressed by staff and unable to take footwear off by themselves. During an interview on 01/17/2025 at 8:47 AM, LPN #3 stated Resident #35 had slid of the bad a few times. LPN #3 stated that if the resident urinates in bed at night, the resident gets fidgety and crawls out of bed because the resident does not know how to use the call light for assistance. LPN #3 stated the resident was no longer in a merry walker and was in a regular wheelchair. During an interview on 01/17/25 at 9:11 AM, Registered Nurse (RN) #4 stated that Resident #35 was fully dependent on staff dressing them and had never seen them remove footwear. During an interview on 01/17/25 at 9:48 AM, Certified Nursing Assistant (CNA) #5 stated Resident #35 was a fall risk because the resident was unable to use their legs. CNA #5 stated staff dressed Resident #35 and the resident was not able to take off socks or shoes independently. CNA #5 stated that one of Resident #35 ' s fall interventions was non-slips socks on at all times. CNA #5 also stated that the resident used a walker and not a wheelchair for ambulation. During an interview on 01/17/25 at 9:56 AM, CNA #6 stated Resident #35 was a fall risk, the resident does not use to call light for assistance, and it had been approximately 5 months since the resident was changed from a merry walker to a wheelchair. CNA #6 stated Resident #35 was unable to take off socks and shoes by themselves. During an interview on 01/17/25 at 10:06 AM, Minimum Data Set (MDS) nurse stated Resident #35 already had proper footwear as a fall intervention prior to a fall on 01/07/2025and stated it was not acceptable to repeat a fall intervention that is already in place. MDS nurse stated the Director of Nurses (DON) formulates the fall interventions, and she places them on the care plan. The MDS nurse stated that the resident no longer used a merry walker and was changed to a wheelchair, however, the MDS nurse verified that the care plan had not been updated to reflect the change. The MDS nurse stated not all fall interventions are indicated on Kardex, where the CNAs complete their charting, so CNAs would not know all of the fall interventions. At the end of the interview, the MDS nurse stated Resident #35 ' s care plan was not accurate or up to date. During an interview on 01/17/25 at 10:34 AM, the DON stated that she was aware of proper footwear being on at all times was already a fall intervention, however, on 01/07/2025, Resident #35 did not have them on, so staff were not following interventions that should have been in place. The DON also stated that fall assessments should be completed correctly or it could affect the fall score, indicating if the resident was a fall risk or not. The DON stated the facility had not completed a root cause analysis of Resident #35 ' s falls for the last year and had only looked at the most recent falls.

Based on observation, interview and record review the facility failed to assess resident for edema and administer prescribed, as needed medication, according to physician's orders for 1 (Resident #7) of 1 sampled resident who had, as needed, diuretic therapy. The findings are: Resident #7 ' s Physician's January 2025 orders were reviewed and read in part that resident had diagnoses of cerebrovascular disease, hypertensive heart disease with heart failure, chronic diastolic heart failure and chronic kidney disease. [Name brand diuretic] Oral Tablet 40 MG [milligram] Give 1 tablet by mouth every 24 hours as needed for prn [as needed] swelling related to chronic diastolic congestive heart failure prn swelling. A significant change minimum data set [MDS] with an ARD [assessment reference date] of 11/13/2024, indicated a BIMS [brief interview for mental status] score of 03 [00-07 suggests severe impairment] On01/13/25 at 11:47 AM Resident #7 was observed sitting in a wheelchair, in the day area. Resident #7 was observed to have on shoes with straps, swelling to both feet that extended beyond both shoes approximately 1 to 1.5 inches. On 01/15/25 at 1:08 PM, Resident #7 was observed sitting in their wheel chair, in the dining room. Resident #7 was observed to have on shoes with swelling to both feet that extended beyond both shoes approximately 1 to 1.5 inches. Resident #7 ' s PCP [primary care physician] was notified of observations during phone conversation conducted on 01/15/2025 at 1:16 PM. On 01/15/25 at 11:04 AM, LPN #1 was asked to review Resident #7's record and relate the reason resident ' s diuretic was changed from routine, to as needed. LPN #1 was unable to locate any progress note that was related to the resident's edema, or [Brand name diuretic] change to as needed. LPN #1 denied knowledge of Resident #7 having edema, LPN #1 denied administering as needed diuretic for edema observed to bilateral lower extremities. LPN #1 unable to voice reasoning for medication change, or if the resident had edema. LPN #1 stated there was not an automatic assessment indicator on the facility electronic medical record to indicate a required assessment for edema. On 01/15/25 at 11:30 AM, DON [director of nursing] interview--reviewing record for reasoning behind diuretic change to PRN, the DON voiced recollection of the doctor making rounds on that Sunday, December 29, 2024, the physician changed the [Brand name diuretic] order from routine to PRN, due to weight fluctuations. DON verified there was not an indicator for nursing to assess for edema in the electronic medical record. On 01/15/25 at 1:16 PM, during a phone interview with Resident #7 ' s primary care physician [PCP] who stated he had been the residents PCP for 3 to 4 years. The PCP was asked about the change in the diuretic from routine to as needed. He remarked that the nursing staff had informed him of resident #7 ' s change in condition and lethargy, and the PCP was concerned that Resident #7 was becoming dehydrated due to the diuretic. PCP indicated Resident #7 had not been doing well and wanted to see if the change in the diuretic would make a difference. The PCP indicated that the diuretic was prescribed for Resident #7 due to a diagnosis of CHF [congestive heart failure]. The PCP expected nursing staff to assess resident for edema at least daily and stated, I should have written the order better. On 01/15/25 at 2:49 PM, LPN #1 was asked to assess Resident #7 ' s feet, after LPN #1 assessed Resident #7 ' s feet, LPN #1 reported that 1+ edema and wheezing lung sounds were assessed. LPN #1 was asked to confirm resident #7 ' s medication for edema. LPN #1 pulled up residents' information on the electronic medical record and indicated resident #7 ' s current order for [Brand name diuretic]40 mg 1 po [by mouth] q [every] 24 hours PRN [as needed]. LPN #1 was asked how often resident #7 should be assessed for edema and the response was daily. LPN #1 was asked to review the medication administration record from the electronic health record, LPN #1 confirmed resident #7 ' s PRN diuretic order. On 01/15/25 at 2:49 PM, LPN #2 was asked how often the assigned nurse should check for edema if they have an as needed diuretic; LPN #2 responded, they should check at least every shift. Resident #7 ' s January Medication Administration Record (MAR) was reviewed, and the as needed diuretic had not been documented as be administered for the entirety of January. On 1/16/2025 at 10:49 AM, an Administering Medications policy was received from the DON. The policy was reviewed and read in part that medications were to be administered in a safe and timely manner, and as prescribed; 4. Medications are administered in accordance with prescriber orders, including any required time frame; 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication.

Based on record review, observation and interview, the interdisciplinary team (IDT) failed to ensure 1 (Resident #29) of 1 sampled resident was assessed and deemed safe for self-administration of updraft treatments to prevent the potential of accidental overdose and or injury. The findings are: Review of a Diagnosis Record indicated the facility admitted Resident #29 with diagnoses that included heart disease, chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS), dated [DATE], revealed Resident #29 had a Brief Interview for Mental Status (BIMS score of 14, which indicated the resident was cognitively intact. The resident required extensive assistance for activities of daily living (ADLs). Review of a facility policy titled, Administering Medications , dated revised April 2019, specified, Medications are administered in a safe and timely manner, and as prescribed. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of Resident #29 Physician Orders, for the month of 12/2023, revealed an order, dated 9/8/2023, for ipratropium-albuterol solution 0.5 - 2.5 (3) milligram (mg) / 3 milliliter (ml) (breathing treatment) 1 vial inhale orally every 6 hours for Chronic Obstructive Pulmonary Disease (COPD). On 12/12/23 at 10:15 AM Resident #29 was observed self-administering an updraft treatment using a nebulizer. There were no licensed staff present. Resident #29 reached over and turned the nebulizer off, wrapped the nebulizer tubing in a circle, and placed the tubing in the compartment on the nebulizer. There is no order to self-administer. There is no assessment to self-administer. On 12/12/23 at 10:23 AM, Resident #29 the Surveyor asked how you get the medicine to put in your machine? Resident #29 stated, The nurses give it to me, and I put it in and turn it on. Resident #29 was asked how many times a day do you do updraft treatments? Resident #29 stated, About 2 times a day. On 12/14/23 at 9:53 AM, Licensed Practical Nurse (LPN) #2 was asked why there should be an order to administer oxygen to a resident. LPN #2 stated, Cause it's technically a medication. LPN #2 was asked who is responsible for obtaining orders for medications to be administered to the residents. LPN #2 stated, The nurses. On 12/14/23 at 3:43 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 have you ever observed Resident #29 self-administer up draft treatments? LPN#1 stated, yes. LPN #1 was asked does Resident #29 have an order to self-administer up draft treatments. LPN #1 stated, As far as I know, as of today. LPN #1 was asked why should a resident have an order to self-administer updraft treatments. LPN #1 stated, for independence. On 12/15/23 at 9:28 AM, the Administrator was asked why should a resident who self-administers up draft treatments, be assessed and have an order to self-administer medication. The Administrator stated, To ensure they know how, the frequency, and the side effects.

Based on record review, observation, and interview, the facility failed to ensure an order was obtained to administer oxygen therapy to 1 (Resident #94) of 1 sampled resident to minimize the potential for hypoxia or other respiratory complications. The findings are: Review of the facility policy titled, Oxygen Management, specified, It is the policy of this facility to require a physician's order for administering oxygen. A review of a Medical Diagnosis Record indicated the facility admitted Resident #94 with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of an Admission assessment dated [DATE], revealed the resident required oxygen at 3 liters per minute via nasal cannula due to shortness of breath (SOB). Review of Resident #94 Care Plan initiated on 12/4/2023, revealed the resident required supervision/limited assist for activities of daily living (ADLs). A review Resident #94's Physician Orders, for the month of December 2023, revealed no order for oxygen therapy. On 12/11/23 at 1:48 PM, Resident #94 was observed lying in bed with oxygen on and running at 2 liters a minute via nasal cannula. On 12/14/23 at 9:53 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 why should there be an order to administer oxygen to a resident? LPN #2 stated, Cause it's technically a medication. LPN #2 was asked who is responsible for obtaining orders for medications to be administered to the residents. LPN #2 stated, the nurses. On 12/15/23 at 9:28 AM, the Administrator was asked why should a resident receiving oxygen therapy have an order? The Administrator stated, It requires a physician order. The Administrator was asked when was an order for oxygen obtained for Resident #94. The Administrator stated, on 12/11/2023 at 3:45 p.m.

Based on observation, record review and interview, the facility failed to ensure medications were stored in accordance with state laws and accepted standards of pharmacy practice for 2 (Resident #94, and #39) of 2 sampled residents, to prevent the possible ingestion and or injury. The findings are: 1. A review of a Medical Diagnosis Record indicated the facility admitted Resident #94 with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of an Admission assessment dated [DATE], revealed the resident required oxygen at 3 liters per minute via nasal cannula due to shortness of breath. Review of Resident #94 Care Plan initiated on 12/4/2023, revealed the resident required supervision/limited assist for activities of daily living (ADLs). A review Resident #94's Physician Orders for the month of December 2023, revealed an order, dated 12/4/2023, for Symbicort inhalation aerosol, 160-4.5 micrograms (mcg) / actuation (act), 2 puffs, inhale orally two times a day for COPD. Review of a facility policy titled, Storage of Medications, dated November 2020, specified, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 2. On 12/11/23 1:48 PM, a Symbicort inhaler in a plastic bag was observed on Resident #94 ' s bedside table and was not securely stored. On 12/13/23 at 11:22 AM. Licensed Practical Nurse (LPN) #2 was asked where are medications stored when not in use and why? LPN #2 stated, In the locked storage room, medication rooms, or the locked medication cart so residents can't get to them. LPN #2 was asked if residents should have medications in their rooms. LPN confirmed no residents should have medications in their rooms. On 12/11/23 at 4:28 PM, a bottle of opened wound cleaner was observed at the end of the medication cart in front of room [ROOM NUMBER]. The bottle of wound cleaner was not contained or secured. There was no staff present. 3. A review of the Diagnosis Record indicated the facility admitted Resident #39 with a diagnosis of dementia. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The resident required set-up assistance for activities of daily living (ADLs). A review of Resident #39 Physician Orders, for the month of 12/2023, revealed an order, dated 9/5/2023, for antifungal external powder 2%, apply to affected area topically as needed for redness related to candidiasis, twice a day (BID) as needed (PRN). On 12/12/23 9:22 AM, a bottle of antifungal powder was observed on the sink counter in Resident #39 ' s room and not securely stored. The Surveyor asked Resident #39 do you use the antifungal powder and how often? Resident #39 stated, Yes, the nurses apply it when I ask them. Resident #39 said the antifungal powder is used to treat yeast and sometimes Resident #39 applies the powder on himself when he needs it. On 12/12/23 03:49 PM, a bottle of antifungal powder was observed from the hallway sitting on the sink counter in Resident #39 ' s room and not securely stored. On 12/13/23 at 11:22 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 where are medications stored when not in use and why? LPN #2 stated, In the locked storage room, medication rooms, or the locked medication cart so residents can't get to them.

Based on record review, observation and interview, the facility failed to ensure resident's personal food and beverage items stored in the 1 of 1 refrigerator were labeled and dated; and failed to ensure hand hygiene was performed during the passing of room meal trays to prevent potential cross-contamination and minimize the potential for food borne illness for residents who stored food items and beverages in the refrigerator; and, received meal trays delivered to their rooms. This failed practice had the potential to affect 16 residents who eat meals in their rooms on the 200 Hall, and had the potential to affect all 90 residents who have access to the refrigerator on 100 Hall. The findings are: Review of the facility policy titled, food Receiving and Storage dated October 2017, specified, Foods shall be received and stored in manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Review of the facility policy titled, Handwashing/Hand Hygiene, dated August 2019, specified, This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: o. Before and after eating or handling food; p. Before and after assisting a resident with meals. 1. On 12/13/23 at 12:26 PM, the resident refrigerator on 100 Hall was observed with the following items found. 1. A clear cup containing 240 cubic centimeters of clear liquid with no label, date, or cover. 2. A clear cup containing 240 cubic centimeters of orange liquid not labeled and not dated. 3. A cup containing 120 cubic centimeters or orange liquid not labeled and not dated. 4. A bottle of salad dressing with no open date and no name. 5. A 12 ounce can of soda with no name. 6. A clear cup from a local coffee shop containing 240 cc's of brown liquid with no name or date. 7. 1 opened soda bottle containing 100 cc's brown liquid with no name and date. 8. A tall purple mug with a handle and a straw with no name or labeled with contents. On 12/13/23 at 12:33 PM, Certified Nursing Assistant (CNA) #1 was interviewed and confirmed the refrigerator was for resident ' s food/drinks only, all items were to be labeled and dated. CNA #1 confirmed the soda drink, salad dressing, and the opened soda was not labeled or dated. CNA #1 confirmed the 2 cups of orange liquid looked like orange juice but could not be confirmed because it was not labeled. CNA #1 confirmed a cup of clear liquid looked like thickened water but was not sure because it was not labeled or dated. CNA #1 confirmed a clear cup from a local coffee shop and the purple mug could belong to a resident or an employee but was not sure because it was not labeled. CNA #1 was asked who was responsible for ensuring items in the refrigerator are labeled and dated? CNA #1 stated, I don't know anyone who is responsible. CNA #1 was asked why items in the refrigerators should be labeled and dated. CNA #1 stated, To make sure we are giving residents what we are supposed to be giving them, and to make sure it's in date and within their diets. 2. On 12/13/23 at 1:12 PM, Certified Nursing Assistant (CNA) #2 removed a meal tray from the meal cart and entered room [ROOM NUMBER] A and set the meal tray up for the Resident. CNA #2 did not perform hand hygiene before removing the meal tray from the meal cart. CNA #2 did not perform hand hygiene before setting up the meal tray for the Resident. On 12/13/23 at 1:14 PM, CNA #2 exited room [ROOM NUMBER]. CNA did not perform hand hygiene. CNA #2 removed a meal tray from the meal tray cart. CNA #2 did not perform hand hygiene before removing the meal tray from the meal tray cart. CNA #2 entered room [ROOM NUMBER] B and set up the meal tray for Resident. CNA #2 did not perform hand hygiene. On 12/13/23 at 1:15 PM, CNA #2 exited room [ROOM NUMBER] and did not perform hand hygiene. CNA #2 removed a meal tray from the meal tray cart and entered room [ROOM NUMBER] B. CNA #2 set up the meal tray. CNA #2 did not perform hand hygiene. CNA #2 exited room [ROOM NUMBER]. CNA #2 opened the meal tray cart door, shut the door, then pushed the meal tray cart down the hall. CNA #2 did not perform hand hygiene. On 12/13/23 at 1:17 PM, CNA #2 removed a meal tray from the meal tray cart and entered room [ROOM NUMBER] and set the meal tray up. CNA #2 did not perform hand hygiene. On 12/13/23 at 1:24 PM, the Surveyor asked CNA #2 why hand hygiene wasn ' t performed while passing the room meal trays? CNA #2 stated, It kinda didn't cross my mind. I forgot that step. CNA #2 was asked when passing meal trays, why should hand hygiene be performed between trays and set up of the meal tray. CNA #2 stated, To stop the spread of germs. On 12/14/23 at 9:57 AM, the Surveyor asked Dietary #1 why should the items in the residents refrigerators be labeled with contents, names, and dated. Dietary #1 stated, It's the same as dietary, dated to ensure that it doesn't set in the refrigerator too long, to ensure the residents are aware of what the item is, and labeled with names so there is no confusion. Dietary #1 was asked why should hand hygiene be performed before and after and while passing room trays. Dietary #1 stated, They are supposed to sanitize between each tray and they have been trained. On 12/14/23 at 10:46 AM, the Surveyor asked the Infection Control Preventionist (ICP) Nurse why should items in the resident ' s refrigerators be labeled with the contents, names, and dated. The ICP stated, So it's given to the right person, that it's not out of date, and for allergy reasons. The ICP was asked is the refrigerator on the 100 Hall specifically for resident use only. The ICP stated, yes. The ICP was asked when hand hygiene is performed? The ICP stated, Before entering and after exiting a room and before and after personal care. The ICP was asked, why should hand hygiene be performed before donning personal protective equipment (PPE) and entering a resident ' s room who has been placed on contact isolation? The ICP stated, We don't want to take anything into that room or bring anything out of that room. The ICP was asked when is hand hygiene performed while passing room meal trays? The ICP stated, They should sanitize before reaching into the tray cart to get a tray, and before exiting the room. They should wash hands after passing trays to 3 rooms, but we prefer after 2 rooms. On 12/15/23 at 11:33 AM, the Administrator was asked how many refrigerators are there for residents to use does the facility have. The Administrator stated, Just the one on the 100 Hall. The Administrator was asked, how many residents use the refrigerator on 100 Hall? The Administrator stated, All the residents have access to it.

Based on observation, record review and interview, the facility failed to ensure infection control measures, including hand hygiene, was performed, before entering a resident room on contact isolation, to prevent the spread and cross contamination, and potential infection, for 1 (Resident #91) of 1 sampled resident. The findings are: 1. Review of the Medical Diagnosis Record indicated the facility admitted Resident #91 with a diagnosis of diabetes mellitus. A review of Resident #91's Physician Orders, for the month of December 2023, revealed an order, dated 12/11/2023, for contact isolation as of 12/5/2023 for Vancomycin-resistant Enterococci (VRE) and Methicillin-Resistant Staphylococcus Aureus (MRSA). Review of Resident #91's Care Plan with an initiated date of 12/11/2023, revealed the resident required extensive assistance for activities of daily living (ADLs). On 12/11/23 04:29 PM, a sign outside Resident #91's room was observed and noted to read, Contact Isolation. A plastic cart outside Resident #91's room observed with personal protective equipment (PPE). Certified Nursing Assistant (CNA) #9 opened the plastic container and obtained a pair of gloves, an isolation gown, and a surgical mask. CNA #9 applied gloves to hands. CNA #9 did not perform hand hygiene before applying gloves. CNA #9 donned an isolation gown with gloved hands. CNA #9 donned surgical mask and entered Resident #91 room. On 12/11/23 at 4:32 PM, CNA #9 exited Resident #91's room and performed hand hygiene using an alcohol gel bottle obtained from the plastic 3 drawer container outside Resident #91's room. The Surveyor asked CNA #9 if staff should perform hand hygiene before applying gloves and why. CNA #9 stated, Yes, to make sure everything is clean. CNA #9 was asked if hand hygiene was performed prior to applying gloves and entering a contact isolation room. CNA #9 stated, No I did not. On 12/13/23 at 11:22 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 when is hand hygiene performed when assisting a resident on contact isolation and why? LPN #2 stated, Wash or sanitize before donning PPE and after doffing PPE you should wash hands. On 12/14/23 at 10:46 AM, the Infection Control Preventionist (ICP) Nurse was asked when is hand hygiene performed. The ICP stated, Before entering and after exiting a room and before and after personal care. The ICP was asked when is hand hygiene performed when entering a resident room on contact isolation. The ICP stated, They should sanitize hands before putting on personal protective equipment (PPE) and entering the room. The ICP was asked, why should hand hygiene be performed before donning PPE and entering a resident room who is on contact isolation. The ICP stated, We don't want to take anything into that room or bring anything out of that room.

Based on record review, observation and interview, the facility failed to maintain a safe, functional, sanitary, and homelike environment related to broken geriatric chairs, shower chairs, and door frames free of sharp, jagged edges, to prevent the potential injury and or spread of disease. The findings are: A review of the undated facility's Community Guide, revealed, Resident Rights, the residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. 1. A review of theMedical Diagnosis Record indicated the facility admitted Resident #72 with a diagnosis that included metabolic Encephalopathy. The quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #72 had a Staff Assessment for Mental Status (SAMS) score of 3, which indicated the resident was severely impaired. The resident required extensive assistance with activities of daily living (ADLs). On 12/12/23 10:45 AM Certified Nursing Assistant (CNA) #3 and CNA #4 were observed to assist Resident #72 to a shower chair in the Resident ' s room. The vinyl footrest of the shower chair is cracked and peeling with a wet, black substance that rubs off. A brown, dried, smeared substance was observed on the plastic pipe under the shower chair. The Surveyor asked CNA #3 what the black substance on the footrest of the shower chair was and how often was the shower chair cleaned. CNA #3 stated, It's cleaned after every shower. I didn't check it this morning. Not sure what that black substance is. This is the only laydown shower chair we have. On 12/12/23 at 3:44 PM, Resident #72 was sitting upright in a geriatric chair in the Resident ' s room. The footrest on the geriatric chair is broke, unsecured, loose, and hanging down. On 12/14/23 at 2:30 PM, R#72 was observed sitting in a geriatric chair in the Resident ' s room. The footrest on the geriatric chair is broken, unsecured, loose and hanging down. On 12/14/23 at 2:30 PM, the Surveyor asked Maintenance #1 to describe Resident #72 ' s footrest on the geriatric chair. Maintenance #1 stated, It's broke. No one told me. There are books everywhere and nobody writes it in the book. 2. On 12/12/23 at 9:14 AM, the lower inside doorframe in room [ROOM NUMBER] was observed with rusted metal areas/circles with sharp jagged edges. The door has a metal plate with sharp edges, approximately 8 inches in length and protruding outward approximately 1/10th of inch and not flush with door. On 12/13/23 at 9:55 AM, the Surveyor asked Housekeeping (HK) #1 what is the process for reporting things that need to be fixed and who is it reported to? HK #1 stated, There is a maintenance log book on every hall at the nurses station and it goes to Maintenance #1. On 12/13/23 at 9:59 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 what is the process for reporting things that need to be fixed and who is it reported to? LPN #2 stated, We write in the book and inform the Director of Nursing (DON) and then maintenance is notified. On 12/13/23 at 10:04 AM, the Surveyor asked Maintenance #1 what is the process for reporting things that need to be fixed? Maintenance #1 stated, If it's an emergency they page us overhead, if it's a non-emergency, they write it in the book. We check it (book) in the morning and off and on during the day. Maintenance #1 was asked what are some of the issues that are reported. Maintenance #1 stated, Environmental issues and things like resident beds or wheelchairs. On 12/13/23 at 10:43 AM, the Maintenance work order book obtained from the Maintenance Supervisor dated 12/12/23 through 10/23/23 was reviewed with no documentation/work orders for the shower chair, Resident #39 ' s room, or Resident #72 geriatric chair footrest. On 12/14/23 at 2:35 PM, the Surveyor asked Maintenance #1 was to describe the metal plate on the outside of the door of room [ROOM NUMBER]. Maintenance #1 stated, I call it a skid plate and it needs to be removed. It's sharp and it's bulged. Maintenance #1 was asked to describe the rusty holes near the floor on the inside of the door frame of room [ROOM NUMBER]. Maintenance #1 stated, I call that the threshold door jam. It's rusty, sharp, and protruding out. On 12/14/23 at 2:41 PM, the Surveyor asked Maintenance #1 what do you do with the shower chairs if they need to be repaired? Maintenance #1 stated, Shower chairs are not repairable. I heard we were waiting on a shower chair to come in. Maintenance #1 was asked to describe the footrest of the pink shower chair located in the shower room. The Maintenance Supervisor stated, Well it's used, and they should have been put in the maintenance log book.

Based on observation, interview, and record review, the facility failed to ensure the residents who were dependent on staff for personal hygiene were provided care to promote hygiene and dignity for 1 (Resident #3) of 3 (#1, #2, #3) sample mix residents. The findings are: 1. Resident #3 had diagnoses of Alzheimer's Disease, Kidney Failure, and Dysphasia. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/27/23 documented the resident scored 3 (0-7 severe impairment) on the Brief Interview for Mental Status (BIMS), required extensive assist of one for bed mobility, dressing, toilet use, and personal hygiene; required set up help with supervision for eating; and was frequently incontinent of bladder. a. On 05/08/23 at 2:29 p.m., Resident #3 was sitting in her wheelchair in the Dining Room. She had a thick, pink colored liquid, and food on her face and down the front of her shirt. The Surveyor asked her, Have you been sitting here long? Resident #3 replied, Yeah, a long time. b. On 05/08/23 at 2:34 p.m., the Surveyor asked Licensed Practical Nurse (LPN) #1, Who is responsible for cleaning the residents after meals? LPN #1 replied, Usually Certified Nursing Assistants (CNAs). The Surveyor asked, Should residents be left with food on their face and clothes? LPN #1 replied, No, they shouldn't. c. On 05/09/23 at 2:40 p.m., the Surveyor asked CNA #1, Were you taking care of Resident #3 on 05/08/23? CNA #1 replied, Resident #3 was not my resident. The Surveyor asked Why was Resident #3 still in the Dining Room at 2:30 p.m.? CNA #1 replied, I don't know, I was taking care of another resident. The Surveyor asked, Why did Resident #3 have food/liquid on her face and clothes? CNA #1 replied, I don't know. The Surveyor asked, Who is responsible for ensuring the residents are clean of food/liquid and kept clean and dry? CNA #1 replied, All of us. The Surveyor asked, Why should residents be free of food/liquid on their faces and clothes? CNA #1 replied, It's a dignity, hygiene issue. The Surveyor asked CNA #1, When do you provide residents with Activity of Daily Living (ADL) care? CNA #1 replied, As needed, before and after meals. d. On 05/09/23 at 3:52 p.m., the Surveyor asked the Director of Nursing (DON), Why was Resident #3 still in the Dining Room at 2:30 p.m.? The DON replied, I do not know. The Surveyor asked, Who is responsible for ensuring residents are clean of food/liquid kept clean and dry? The DON replied, Anyone. The Surveyor asked, Why should residents be free of food/liquid on the faces and clothes? The DON replied, It's a dignity concern. e. On 05/09/23 at 4:03 p.m., the Surveyor asked the Minimum Data Set (MDS) Coordinator, Why was Resident #3 still in the Dining Room at 2:30 p.m.? The MDS Coordinator replied, I do not know. The Surveyor asked, Who is responsible for ensuring residents are free for food/liquid and kept clean and dry? The MDS Coordinator replied, Everybody. The Surveyor asked, Why should the residents be free of food/liquid on their faces and clothes? The MDS Coordinator replied, It's a dignity issue. f. The facility policy titled, Activities of Daily Living (ADLs), Supporting, provided by the MDS Coordinator on 05/09/23 at 12:24 p.m. documented, .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out Activities of Daily Living (ADLs) .residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .

Based on observation, record review, and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; failed to ensure 1 of 1 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen, and dietary staff washed their hands before handling clean equipment. These failed practices had the potential to affect 97 residents who received meals from the kitchen (total census: 97) as documented on a list provided by Dietary Supervisor on 9/8/22. The findings are: 1. On 9/6/22 at 11:50 AM, during the initial tour of the kitchen with the Dietary Supervisor, the following observations were made in the dry storage room. There were dated items in boxes and plastic containers on the shelves that did not indicate whether the date was the opened or received date. a. Parsley 8/22. b. Barbeque sauce individual packets c. French dressing individual packets d. Ranch dressing individual packets e. Italian dressing f. Jellies - Grape, Apple, Mixed Fruit g. 7 packets of tortillas with no date. Dietary Supervisor stated, Those will be thrown away. h. 29 loaves of sliced bread with no date i. Barley dated received 5/31/21, no open date j. Box of cornbread dated 7/21 smeared and 8/16 written over and a second 7/21 date near the bottom front of the box. k. 6 bags of corn flakes with no date l. The Surveyor asked Dietary Supervisor Do you order the same items often? He stated Yes. Surveyor asked, Would you know what order a specific item came from? He stated, Maybe, because I like know what I order. Surveyor asked Dietary Supervisor what the date on the canister represented. He stated, It is usually the date it came in. I usually order just what we need for like a week, so nothing is old. m. The Surveyor asked when the cornbread was received. Dietary Supervisor stated, It looks like someone thought it came in July but then saw the dates on the other boxes and changed it to August. Surveyor asked, What does the date represent? Dietary Supervisor stated, When it came in. Surveyor asked, What does 7/21 represent? He stated, July 21st Surveyor asked, Does that represent month and year or month and day? Dietary Supervisor stated, Most of us write month and day. Surveyor asked, Is there a reason for some items to have a full date with month, day, and year and other items to have just a month and day or month and year? Dietary Supervisor stated, I have only been here a month and a half, and I need us like to have consistency. 2. The following items were noted on a shelf in the standing refrigerator, there were no dates of when the food items were received or when opened. a. A 5 lb [pound] rectangle block of mozzarella cheese b. Half log of bologna c. Dietary Surveyor stated, I was told that no date or sticker would stick to it. Surveyor asked, Do you know when it was received or opened? DM stated, I could ask like sometime this week. d. Leftovers of tomato soup dated 8/31. Surveyor asked, How long were leftovers good for? Dietary Supervisor stated, 3 days, usually. e. A Blue pitcher of reddish-brown liquid, no date or label f. A clear pitcher with white lid containing brown liquid, no date or label g. One cottage cheese tub 1/2 full of no open or received date h. Coleslaw dressing container 1/2 full no open or received date i. One container of soy sauce 1/3 full no open or received date j. A container of Chicken broth dated 6/02, no open date k. A bottle of balsamic vinegar 3/4 full no open date l. thickened apple juice with no open date m. Surveyor observed tan liquid pooling in the bottom of the refrigerator. The bottom white metal rack was sitting in pooled liquid and had boxes of food items getting wet from the liquid. Dietary Supervisor stated, I don't know what that is. Maybe from defrosting items. It like needs to be cleaned. 3. On 9/6/22 at 12:18 PM, the following observations were made in Freezer Unit 1 of food items not sealed and not dated when received or when opened: a. bag of green peas not tied b. bag of green beans not tied c. bag of California veggie blend not tied d. 2 bags of chopped spinach not dated 4. On 9/6/22 at 12:23 PM, the following observations were made in Freezer Unit 2 of food items not sealed and not dated when received or when opened: a. Ziploc of pizza dough dated 6/27, no open date b. A bag of corndogs not tied c. 8 packages of waffles not dated, 1 bag torn open - ice crystals covering the waffles. Dietary Supervisor stated, Those need to be thrown away. 5. On 9/6/22 at 12:26 PM, the following observations were made in Freezer Unit 1 of food items not sealed and not dated when received or when opened: a. Six bags of meat (Dietary Supervisor stated, Were fritters, chicken patties, fish fillets, and bone-in chicken) not labeled, or dated and had ice crystals and light patches on the meats b. 1 pork loin log not dated c. 10 ground beef logs not dated 6. On 9/6/22 at 12:28 PM, the following observations were made in food prep area of kitchen: a. Three bins with wheels on floor containing flour, sugar, and cornmeal not dated 7. On 9/6/22 at 12:31 PM, Surveyor asked the Dietary Employee to wipe the underside of the inside lip of the ice machine. He used a white rag to wipe inside of machine. He removed napkin from ice machine which had a yellow substance on it that had easily transferred from the ice machine onto the rag. Surveyor asked Dietary Supervisor to describe substance found inside the ice machine now located on the napkin. He stated, Build-up, yellowish, I don't know. Surveyor asked how often the ice machine is cleaned. He stated, It was cleaned last Monday. 8. On 9/08/22 at 7:07 AM, Dietary Employee #1 went to the clean side of the dish washing machine, picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. 9. On 9/08/22 at 7:13 AM, Dietary Employee #2 was wearing mittens over her gloves. She removed pans of French toast and placed them on the counter. She removed the mittens and placed them on the counter. Without changing gloves and washing her hands and placed her contaminated gloved hand on the French toast while transferring them into a pan. 10. On 9/08/22 at 7:19 AM, Dietary Employee #2 turned on the hand washing sink faucet and washed her hands, she removed tissue and used them to turn off the faucet. She then, used the same tissue papers to dry her hands. At 7:20 AM She turned on the stove and without washing her hands, she pulled gloves from the glove box and placed them on her hands contaminated the gloves. She picked up clean plates with her gloved fingers inside the plates and placed them on the counter. She then, placed fried eggs on the plates to be served to the residents who requested fried eggs for breakfast. 11. On 9/08/22 at 7:23 AM, an opened box of Sysco classic plain salt was stored on a counter in the kitchen. The box was not covered. 12. On 9/08/22 at 7:45 AM, an opened box of chocolate chip cookies and other desserts was stored on a shelf in the freezer. The box was not covered or sealed. 13. On 9/08/22 at 7:47 AM, an opened box of bacon and an opened box of sausage were on a shelf in the walk -in freezer. The boxes were not covered or sealed. 14. On 9/08/22 at 7:49 AM, an opened bag of okra was stored on a shelf in the freezer. The bag was not sealed. 15. On 9/08/22 at 7:58 AM, Dietary Employee #2 turned on the hand washing sink faucet and washed her hands. She then, pulled out tissue papers and dried her hands. She removed gloves from the glove box and placed them on her hands, contaminated the gloves. She picked up tray cards and placed them on the trays. Without washing her hands, she picked up plates to be used in portioning food and placed them on the plate covers with her thumb touching inside of the plates. 16. On 9/08/22 at 7:59 AM, Dietary Employee #1 used scissors to open a bag that contained slices of turkey ham. Without washing her hands, she removed slices of turkey from the bag and placed them inside a container to be used in preparing ham and cheese sandwich for residents who requested turkey and cheese. The Surveyor asked Dietary Employee #1 what should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 17. On 9/08/22 at 12:11 PM, Dietary Employee #3 was on the line assisting with lunch meal. She opened the cabinet then closed it back. She touched her mask, picked up tray cards and placed them on the trays. She picked up condiments and placed them on the trays and placed them on the trays. Without washing her hands, she picked beverages glasses by their rims and placed them on the meal trays to be served to the residents for lunch meal. The Surveyor asked the Dietary Employee, what should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 18. The facility's policy provided by the Dietary Supervisor on 9/09/22 at 12:16 PM documented, When to wash hands: Immediately before engaging in food preparation including working with exposed food, clean equipment or service utensils and after engaging in any other activity that contaminates the hands.

Based on observation and interview, the facility failed to ensure resident call lights were in reach for residents to be able to notify staff of their needs for 1 of 1 (R#62) sample selected residents. This failed practice had the potential to affect all residents capable of using the call lights. The findings are: 1.Resident #62 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] & Pain. Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/12/2022 scored a 7 (0-7 severely cognitively impaired) and required supervision for bed mobility, transfers, & toilet use, and physical assistance for bathing. a. On 09/06/22 at 01:33 PM, R#62 attempted to get to call light attached approximately 5 1/2 feet off ground, on edge of curtain. R#62 stumbled back to the bed and surveyor introduced self. Surveyor asked why her call light was attached so high on the curtain. R#62 stated they told me it had to be there so both of us (pointing to roommate's bed) could reach it if we needed help. I just pushed it because it is 1:30 and I haven't got my lunch yet. Surveyor asked if she could always get to it (call light) there. R#62 stated, Some days I am too tired, and I am afraid I would fall, so I just have to lay and wait for someone to come. Surveyor stated her roommate had a call light too and that one was hers (pointing to one attached to curtain). R #62 slowly walked to curtain edge and looked around to where surveyor was pointing on roommate's side of bed. R #62 stated Oh goodness. Why would they tell me that? If she can have it next to her bed, then I need mine next to my bed. Certified Nursing Assistant (CNA)#1 walked in with R #62 lunch and R #62 asked about her call light and if it could be on her bed. CNA #1 attached the call light to the pillow with no response to R #62 about if she could have it on her bed and began talking about lunch. b. On 09/07/22 at 09:36 AM, R #62 was resting in bed, the call light was sitting on top of 4-5ft (foot) dresser, not within reach. 2. On 09/09/22 at 10:37 AM, During an interview in her office, the Surveyor asked the Director of Nursing (DON), where the call lights should be located in the residents' rooms on the 100 Hall. The DON stated, Somewhere on their bed usually. We wrap them to bed rails or clip them to the blanket or pillow. The Surveyor asked if attaching them to the divider curtain in the room was appropriate. DON stated, nuh uh and shook her head.

Based on observation, record review, and interview the facility failed to ensure a resident had the right to make a significant choice about his life in the facility to promote and facilitate self-determination for 1 (Resident #76) sampled selected resident. The findings are: 1. Resident #76 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 08/22/22 indicated the resident received a score of 15 (suggests cognitively intact) on the Brief Interview for Mental Status [BIMS] and required Physical assistance of 1 for bathing, Limited assistance of 1 for bed mobility, transfer, dressing, toilet use and personal hygiene, was Independent after setting up for eating, had indwelling Foley catheter and was always continent of bowel. a. On 09/06/22 at 01:42 pm, the Surveyors were given a list of smokers from the Director of Nursing (DON), documenting 2 residents who smoke. Smoke times: residents may smoke anytime if a staff member or family member is with them. Designated smoking area is in the courtyard. b. On 09/07/22 at 09:08 am, The resident stated, I have a complaint. The office won't let me go outside and smoke, but they have people that smoke. I know they smoke because they sit out there on the porch, and I can see them from my room. The surveyor asked, Who told you that you can't smoke? He stated, The person in the office across from Social. The surveyor asked, Have you ever complained to someone, or filed a grievance about not being able to smoke? He stated, I've complained. She, I don't know if it's the Administrator or not, told me it's a no smoking facility, and the residents that smoke have been grandfathered in and only smoke when their family or friends are here to take them. I talked to Social, who said that I would have to go off the property to smoke, but not to do that, because she was afraid I would get hurt. The Surveyor asked, How long has it had been since you smoked? He stated, I don't know for sure, maybe 5 months. I was admitted as a smoker and brought cigarettes in with me, but I was on so much pain medication, I barely remember coming in. The facility has 3 packs of cigarettes that a friend brought in for me but they won't let me smoke them. The surveyor stated, If it's been 5 months since you've smoked, it may be a healthier choice to not smoke. The resident stated, Yes, and I may not smoke but it's the principle of the thing. I want to be able to smoke if I want to. c. On 09/07/22 at 11:29 am, A resident and another person were smoking in the designated area. The Surveyor introduced herself and asked permission to ask questions. The Surveyor asked the Resident, Do you get to smoke anytime you want? He stated, Only when she (friend) is here to bring me outside. d. On 09/07/22 at 03:50 pm, The Administrator came to conference room and asked to speak to Team Coordinator (TC) in hallway. The Surveyor asked the Team Coordinator, Why would one of you tell a resident to file a grievance? The TC stated, It is their right to; what is this in reference to? The Administrator stated, Regarding smoking. We are a smoke free facility except for one gentleman that was grandfathered in. The DON walked up. The TC stated, There were 2 residents on the smoking list. The DON stated, I put the other one on there because he goes out and smokes when she [friend] is here. The TC asked, To clarify, it is ok to smoke at the facility but only if you are a staff, a grandfathered resident, or if your friend is here? The Administrator did not respond. Another surveyor joined conversation. The TC asked, Again to clarify, staff, grandfathered residents, and visitors may smoke here but not residents? The Administrator did not respond. The DON stated, Maybe we should have staff drive off the campus to smoke. The Administrator stated, I am only doing what the owners said. e. On 09/07/22 at 03:55 pm, A second surveyor joined the conversation and informed the Administrator During an interview, the resident had a complaint and was asked if he had voiced his complaint or filed a grievance? The resident told the surveyor, I've complained but have not filed a grievance. I am being discriminated against because I want to smoke and am told I can't because the facility is non-smoking. I see other residents smoking out on the porch. f. On 09/08/22 at 08:38 am, Resident #76 was seated in his wheelchair [w/c] out in the hall beside the Administrator's office. He stated, Well she told me that she had to find a form. I'm going to sit here all day if I have to. The surveyor asked What form is she looking for? He stated, She told me that I signed a no smoking form upon admission. I told her that I was on so much pain medication when I first got here that I don't remember what I signed. g. On 09/08/22 at 11:19 am, A staff and another person, possibly a visitor, were seated outside smoking in the designated area. The designated area had smoking aprons hanging from a post and a metal container to place cigarette butts. h. On 09/08/22 at 01:45 pm the resident was seated out in the hall. He stated, Well apparently I didn't sign that form because they haven't produced it yet. I don't think they have one. I smoked when I first got here. Surveyor stated, Maybe I misunderstood, I thought you haven't smoked in 5 months or so. He stated, I came in February from the hospital. I've smoked probably 5-6 times in the beginning when I was here but had some health issues since then. I don't want to smoke all the time, just ever now and then. I should be able to smoke when I want to. i. On 09/08/22 at 02:30 pm, The DON was smoking outside in a designated area. j. A Smoking Safety Screen was completed 05/20/22. The resident scored a 2.0 which indicated Safe to smoke with supervision. k. The Resident's plan of care initiated on 05/25/22 with a revision date of 06/25/22 documented, Smoking Safety .Educate me about smoking risks and hazards and about smoking cessation aids that are available .Educate me about the facility policy on smoking: locations, times, safety concerns .Ensure oxygen canisters/concentrators are not present when I am smoking .I require assistance and supervision with smoking. l. A facility policy titled, Smoking Safety provided by the Director of Nursing on 09/07/22 at 01:24 pm documented, .This facility provides a safe and healthy environment for residents .including safety as related to smoking .8. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas .at designated times, and in accordance with his/her care plan.

Based on observation, interview, and record review the facility failed to ensure walls were in good repair, the courtyard decking was in good repair, and the facility was maintained a safe, clean, and sanitary environment. This failed practice had the potential to affect 99 residents according to the resident census and conditions provided by the Assistant Director of Nursing on 9/6/22. The findings are: 1. Resident #76 had diagnoses of [CONDITION(S)] of Native Coronary Artery without [CONDITION(S)] Pectoris, Presence of Automatic (Implantable) Cardiac Defibrillator, Chronic Obstructive Pulmonary Disease, Neuromuscular Dysfunction of Bladder, History of (Healed) Traumatic Fracture, Contracture of Right Hip and Acquired Absence of Right Leg Above Knee. A Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 08/22/22 indicated the resident received a score of 15 (suggests cognitively intact) on the Brief Interview for Mental Status [BIMS] and required Physical assistance of 1 for bathing, Limited assistance of 1 for bed mobility, transfer, dressing, toilet use and personal hygiene, was Independent after setting up for eating, had indwelling Foley catheter and was always continent of bowel. a. On 09/07/22 at 09:15 am, the air conditioner vent in the ceiling over the resident's bed had an accumulation of 1-inch-thick brown dust build up inside the grid. He stated, Maintenance cleaned it a couple of weeks ago on the outside but I guess the inside wasn't cleaned. I have an infection in my leg, maybe that is the reason I have one, dust falls down on me. b. On 09/09/22 at 03:52 pm, The Surveyor asked the Maintenance Supervisor, How often are the air conditioner vents cleaned? He stated, This one was just cleaned not long ago. He was asked to look at the vent and describe what it looked like inside the grid. He stated, It has approximately 1/8-inch dust on the inside of it. I need to clean it out, but I told the resident that I will have to move his bed to do it. 2. On 09/06/22 at 12:03 PM, the Surveyor entered the Resident's room and observed dents, scraps and holes with sheetrock exposed in the wall behind the bedside table between the two resident beds. 3. On 09/06/22 at 3:12 PM, the Surveyor observed staff, the resident, and a visitor in the courtyard. The surveyor entered the courtyard and observed the wooden decking. The surface was uneven and wavy. An approximate 8-foot area of the edge adjacent to the sidewalk, was separated from the framework and sticking up approximately 5 inches and had nails exposed. 4. On 09/08/22 at 4:40 PM, the Director of Nursing (DON) was asked to go into resident room and was asked if she was aware of the condition of the wall. She stated, No, that shouldn't be like that. At 4:51 PM, the Surveyor asked the DON if she was aware of the decking in the courtyard being in disrepair. She stated, yeah, it just started. It's a trip hazard and nails are sticking out. The Surveyor asked the DON who has access to go out to the courtyard. She stated, anybody has access to go out. He [maintenance] could block it off, it is still a hazard. 5. On 09/09/22 at 9:20 AM the Maintenance Director was in the courtyard at the decking. He was working on the decking. The surveyor asked him if he was aware of the decking coming apart with nails exposed. He stated, Everybody knew. I have been working on other things and haven't gotten to it .I could have blocked it off. 6. A document provided by the DON on 9/9/22 documented, .Facility grounds shall be maintained in a safe and attractive manner .

Based on interview and record review, the facility failed to develop/implement a Comprehensive Care Plan to enable staff to properly care for residents for 2 of 2 (Resident 65 & 68) sample selected residents. This deficiency had the potential to affect 99 residents in facility per the Resident Census received from the Assistant Director of Nursing (ADON) 9/7/22 @ [at] 3:05 PM. The findings are: 1. Resident #65 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] & Contact with and (suspected) exposure to Pediculosis, Acariasis, & other infestations. Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/13/2022 scored a 10 (8-12) moderate cognitive impairment) and required extensive 2-person physical assistance for bed mobility, & toilet use, extensive 1-person physical assistance for transfers, and supervision and set-up for eating. a. 09/10/22 02:15 PM Record review documented R #65 admitted on [DATE]. As of 9/9/22, the Comprehensive Care Plan dated 8/18/22 was incomplete, as evidenced by documentation, Resident has potential for nutritional deficits related to (Specify) no additional information followed, other areas of comprehensive care plan with statements ending with rt (related to) had no additional information. 2. Resident #68 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/15/22 scored a 0 (0-7 severe cognitive impairment) and required extensive 2-person physical assistance for bed mobility, transfers & toilet use, and extensive 1-person physical assistance for eating. a. On 09/06/22 at 08:17 PM, a record review for Pre-Admission Screening and Resident Review (PASSR) showed, Care Plan (CP) was blank except for .at risk for exposure to and contracting COVID-19 . 3. On 09/09/22 at 09:48 AM, The Surveyor asked the MDS Coordinator how long the facility had to complete the baseline CP. MDS stated 48 hours. Surveyor asked MDS how long facility had to Complete Comprehensive Care plan. MDS stated 14 days. The Surveyor asked the MDS Coordinator when she reviewed CPs to ensure they were complete? The MDS Coordinator stated, with each MDS and any change of condition. Surveyor asked, What could happen if a baseline or comprehensive care plan was not completed? The MDS Coordinator stated, The staff does not have all the information needed to care for the resident. 4. On 09/09/22 at 10:37 AM, The Surveyor asked the Director of Nursing (DON) for the Admission Nursing Assessment for R #68. The DON printed a copy and Surveyor asked the DON to show the Surveyor the care plan portions. The DON turned the pages and stated, They are not completed. The Surveyor asked who marked this assessment as completed with the blanks. The DON stated she is a PRN [as needed] nurse. Surveyor asked when should Certified Nursing Assistants (CNA)s check care plans? DON stated, Throughout their whole shift. 5. On 09/09/22 at 10:46 AM, In an interview with the Administrator in her office, The Surveyor asked the Administrator who was responsible for ensuring the nursing assessments were completed. The Administrator stated, the DON handles all nursing aspects, so she would be. The Surveyor asked the Administrator, How often should CNAs check care plans? The Administrator stated, CNAs should check on a daily basis. The Surveyor asked the Administrator, Who is responsible for ensuring care plans are completed? The Administrator stated, At standup DON, ADON, ICP, and the Advanced Practical Nurse (APN) discuss care plan changes. What could happen if the baseline care plan or comprehensive care plan were not completed? The Administrator stated, We are not (paused then continued to speak) no one would know the care for a resident. 6. On 09/09/22 at 02:43 PM, The Care Plan policy received from DON documented .a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's psychosocial and functional needs is developed and implemented for each resident . and .12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS) .

Based on observation, interview, and record review, the facility failed to ensure residents were provided nail care for 3 (Resident #60, #237, and #73) of 24 sampled residents that required assistance with nail care according to a list provided by the Director of Nursing (DON) 9/9/22; and the facility failed to ensure showers or baths were provided as scheduled for 1 (Resident #3) of 21 (R2, R3, R4, R7, R9, R10, R12, R14, R17, R26, R27, R28, R29, R39, R41, R45, R47, R48, R50, R51, R55, R56, R59, R60, R62, R64, R65, R66, R68, R73, R75, R76, R77, R78, R138, R236, R237, & R238) sampled residents who required assistance for bathing according to the list provided by the DON 9/9/22 to promote good hygiene and prevent infections. The findings are: 1. Resident #60 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 8/8/22 documented the resident scored 0 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), required extensive physical assistance of one person for personal hygiene. a. The Comprehensive Plan of Care documented, .I have an Activity of Daily Living (ADL) selfcare performance deficit r/t (related to) impaired cognition, impaired balance & mobility, & anxiety Date Initiated: 03/06/2022 .I will be clean and well-groomed daily throughout review date Target Date: 08/22/2022 .Nail Care: Check nail length and trim and clean as necessary. Date Initiated: 03/06/2022 . b. On 09/06/22 at 01:08 PM, Resident #60 observed with fingernails varying lengths from 1/4 to 1/2-inch past tip of fingers with uneven edges. The fingernails had red polish that was chipped and partially off. c. On 09/07/22 at 10:15 AM, Resident #60 observed with fingernails varying lengths from 1/4 to 1/2-inch past tip of fingers with uneven edges. The fingernails had red polish that was chipped and partially off. d. On 09/08/22 at 4:45 PM, the Director of Nursing (DON) was asked to look at the resident's fingernails. She looked at the fingernails and polish. She said, That's been on there a while. They need to be taken care of .uneven edges . 2. Resident #237 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Baseline care plan dated 8/31/22 documented, . I have an ADL self-care performance deficit with potential for complications .The resident will maintain current level of function through the review date .Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . b. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 09/06/22 at 12:12 PM, Resident #237 was sitting in a wheelchair in her room. Her fingernails were approximately 4 inches past the tips of her fingers with jagged uneven edges, several nails had a dark dry substance under the nails. d. On 09/08/22 at 4:45 PM, the Director of Nursing was asked to look at the resident's fingernails. After looking at the resident's fingernails she stated, Those should be cleaned and shaped. 3. Resident #73 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set with an assessment reference date of 8/19/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required limited assistance of one person for personal hygiene. a. The plan of care documented, .I have an ADL self-care performance deficit r/t respiratory failure with [CONDITION(S)] .I will be clean and well-groomed daily throughout review date Target Date: 12/06/22 .Personal Hygiene: The resident requires limited assistance with personal hygiene . b. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 09/07/22 at 10:33 AM, Resident #73 was sitting in room, his fingernails were varied in length with jagged uneven edges, the left thumb nail approximately 1/2 in past the tip of the finger. The Surveyor asked the resident if his fingernails needed trimmed. He stated, .yeah . d. On 09/08/22 at 3:00 PM, Resident #73 was sitting in room, his fingernails were varied in length with jagged uneven edges, the left thumb nail approximately 1/2 inch in past the tip of the finger. e. On 09/08/22 at 4:40 PM the Director of Nursing was asked to look at Resident #73's fingernails. She stated, .they are jagged, they shouldn't be like that. could cause skin tears. A document titled, Fingernails/Toenails, Care of, provided by the Director of Nursing on 9/9/22 documented, .the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming .Proper nail care can aid in the prevention of skin problems .Trimmed and smooth nails prevent the resident from accidently scratching and injuring his or her skin . 4. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/2/22 scored a 15 (13-15 cognitively intact) and required limited physical assistance for bed mobility, transfers, toilet use, and bathing. a. On 09/07/22 09:37 AM, Surveyor asked R #3 how her care was. R #3 stated I don't get my showers often enough. My shower days are Tuesdays and Fridays, and I still haven't received my Tuesday shower. It's Wednesday ya know. Surveyor asked how often this happens. R #3 stated, We typically only get one a week. They don't have enough staff, but showers are important. Non-sampled roommate nodded and said yah one in agreement. Surveyor noted R #3's hair was tangled and slightly shiny, as if it was oily. 2. On 09/09/22 at 10:37 AM, the Surveyor asked the DON if the residents had set shower schedules. The DON stated, yes they do. Surveyor asked if the facility had shower staff or if Certified Nursing Assistants (CNA)s were responsible for showers. DON stated, We did have a specific shower staff but then they were pulling them to help on the halls. Then we assigned rooms and that was a disaster. Now we are going back to a primary CNA on each hall for showers. Surveyor asked how many showers a resident should receive a week. The DON stated, A minimum of 2. I'm not sure yet who for the 300 hall. I need a good assistant for that hall for showers. Surveyor asked for a list of residents on 300 hall that received showers Tuesday or Wednesday this week. Reviewed list from DON and R #3 was not documented as receiving a shower either day. 3. On 09/09/22 at 01:57 PM, Surveyor reviewed electronic records. No record of refusal by resident #3 this week. Tasks checked in electronic records and showers are documented to be on .Tuesdays and Fridays 7/3 shift . 4. On 09/09/22 at 02:43 PM, Bath, Shower/Tub policy received from DON documented, .to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin .

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing and/or nebulizers were dated and stored in a storage bag when not in use to prevent infections for 2 (Residents #238 and #59) of 8 sampled residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident #238 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/9/22 was in progress and not yet completed. a. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Every night shifts every Sun for Change and date Change, date and initial tubing and bottle and place in Ziploc bag every week on Sunday; Oxygen every 1 hours as needed for Shortness of Breath Oxygen @ [at] 2-3 Liters/Nasal Canula as needed may remove per self for Activity of Daily Living [ADL]'s. b. The resident's Care Plan documented, .The resident has altered respiratory status/difficulty breathing r/t [related to] [CONDITION(S)] Date Initiated: 09/04/2022, The resident will have no complications related to Shortness of Breath (SOB) though the review date. Date Initiated: 09/04/2022 Target Date: 12/03/2022, Administer medication/treatment as ordered. Observe for effectiveness and side effects . c. On 09/06/22 at 12:19 PM, Resident #238 was sitting on the side of her bed. An oxygen concentrator was on administering oxygen via nasal cannula at a rate of 2 Liters per Minute. The oxygen tubing attached to the concentrator was not dated. d. On 09/07/22 at 10:02 AM, Resident #238 was sitting on the side of her bed. An oxygen concentrator was observed on administering oxygen via nasal cannula at a rate of 2 Liters per Minute. The oxygen tubing attached to the concentrator was not dated. e. On at 09/08/22 04:40 PM, The Surveyor asked the Director of Nursing to observe R#238 oxygen administration. A plastic bag was attached to the concentrator; Resident #238 was sitting on the side of her bed. An oxygen concentrator was on administering oxygen via nasal cannula at a rate of 2 Liters per Minute. The oxygen tubing attached to the concentrator was not dated. The Surveyor asked the DON if the tubing was dated. She stated, It is supposed to be a new bag [for storage when not in use] and tubing, humidifiers, filters cleaned every Sunday, the tubing should be dated. f. The Director of Nursing provided a document on 9/9/22 titled, Department (Respiratory Therapy)-Prevention of Infection, that documented, .prevention of infection .Change the oxygen cannula and tubing every seven days, or as needed .Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use .store the circuit in plastic bag, marked with date and resident's name, between uses . 2. Resident #59 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 8/8/22 documented the resident scored 3 (8-12 indicates (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS). a. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Comprehensive Care Plan documented, .I have tested positive for COVID-19. This places me at high risk for developing Acute Respiratory Distress, secondary infections such as Pneumonia, increased fluid volume deficit. Date Initiated: 08/22/22 .Will remain free of signs and symptoms of Acute Respiratory Distress and secondary infections such as Pneumonia related to COVID-19 daily through the next 90 days .Observe for signs and symptoms of acute respiratory distress i.e., cyanosis, increase in shortness of breath, diaphoresis, congestion, increased coughing, retractions, etc. If symptoms are observed, notify Medical Doctor (MD) . Oxygen per order . c. On 09/06/22 at 01:41 PM, Resident #59 was sitting in room. An updraft machine was on a bedside table, the tubing and mask were lying beside the machine uncovered and not dated. d. On 09/07/22 at 10:17 AM, an updraft machine was on a bedside table, the tubing and mask were lying beside the machine uncovered and not dated. e. On 09/08/22 at 3:05 PM, an updraft machine was on a bedside table, the tubing and mask were in a plastic bag and dated 09/08/22. f. On 09/08/22 at 4:40 PM, the Director of Nursing was notified that the updraft tubing and mask were uncovered and not dated. She stated, The updrafts should be bagged and dated like the oxygen tubing.

Based on observation, record review, and interview, the facility failed to ensure that before a resident was allowed to smoke cigarettes unsupervised, an assessment was conducted and documented to determine if the resident could safely do so; failed to ensure the ability to safely smoke was re-evaluated at least quarterly; and failed to ensure interventions, to include supervision / monitoring of the resident while smoking and securing the smoking materials / cigarette lighters when not in use, were immediately developed, implemented and documented on the plan of care after the resident was observed by staff to be smoking with oxygen in use, to prevent the resident from causing potential serious burn injuries to herself or other residents for 1 (Resident #14) of 1 case mix resident who smoked tobacco products. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #14, and had the potential to cause more than minimal harm to 5 residents who smoked tobacco products, including 3 residents who required oxygen therapy, as documented on a list provided by the Assistant Director of Nursing (ADON) on 10/24/17. The Administrator was informed of the Immediate Jeopardy condition on 10/24/17 at 12:44 p.m. The findings are: 1. The facility's, Smoking Policy Agreement, provided by the Director or Nursing (DON) on 10/24/17 at 10:15 a.m., documented, .The facility will be responsible for performing a Smoking Assessment quarterly, change of condition, and/or as deemed necessary for the resident's safety . The facility will provide a container with a lock and key for each resident smoker to keep cigarettes and lighter in . The box will be kept in the smoking area in the courtyard . The resident agrees to keep their lighter and cigarettes in the box at all times and not to take them to their rooms or out of the smoking area. The resident agrees not to share their cigarettes with other residents. This is to protect all residents. In the event that any resident fails to follow this agreement, by signing below, the resident forfeits the right to smoke . 2. The facility's Resident Smoking Policy, provided by the Assistant DON (ADON) on 10/26/17 at 11:28 a.m., documented, Policy Statement: This facility shall establish and maintain safe resident smoking practices . 8. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 9. The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 10. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 11. The staff will review the status of a resident's smoking privileges periodically, and consult as needed with the Director of Nursing Services and the Attending Physician. 12 . d. Residents with independent smoking privileges may not give smoking articles to other residents with restricted smoking privileges. Note: Anyone who observes this happening shall report it to the On-Duty Charge Nurse immediately . 3. Resident #14 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 8/23/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and required limited assistance of one person for transfers and locomotion on and off the unit. a. A physician's orders [REDACTED]. A physician's orders [REDACTED]. b. A Care Plan dated 5/26/17 documented, .I have Dementia . Goal: Because of my dementia, I need assistance periodically throughout the day in helping me remembering my schedule of meals, activities, etc. (et cetera). Please keep me as oriented as possible and control my behaviors associated with my cognitive deficit . Please monitor me for behaviors associated with increased confusion including: Increased agitation, tearfulness, general disorientation . I can understand others and I can make my needs known but because of my cognitive loss, I need you to anticipate my needs in case I do not remember to do something throughout the day . My respiratory status needs monitoring because of my COPD [DIAGNOSES REDACTED]. I am to have O2 (Oxygen) (at) 2 L/min via NC continuously . The Care Plan did not address providing for the resident's safety while smoking. c. The Admission Packet signed 5/26/17 by Resident #14's daughter documented, .Smoking is not permitted in the patient's room and only is permitted in designated smoking areas. The Patient accepts full responsibility and absolves the Nursing Facility, its personnel and the attending physician of responsibility for any fires, burns, or other accidents occurring as a result of the Patient smoking while the patient is in bed, in the Patient's room, or in any other area that is not a designated smoking area . The Capacity Verification form dated 5/26/2017 documented, (Resident #14) is incapacitated and therefore is unable to sign forms and is unable to acknowledge whether he/she understands the content of the forms . This form was signed by the resident's daughter. d. A Physician's note dated 10/04/17 documented, .Pt (patient) still smoking but agrees to quit today. General exam . PSYCH: (Psychiatric) confused. e. Nurse's Notes dated 10/8/17 by Licensed Practical Nurse (LPN) #3 documented, Resident non-compliant with non-smoking order. Found resident outside smoking with oxygen tank. Removed and returned back inside facility . Nurse's Notes dated 10/9/17 by LPN #2, documented, Resident up for meals, refuses to stop smoking . f. On 10/24/17 at 8:18 a.m., Resident #14 was in a wheelchair, receiving oxygen at 2 liters per minute via a nasal cannula connected to a portable oxygen tank that was hanging on the back of the wheelchair. She self-propelled from the hallway to the outside of the building and into the smoking area. She stopped approximately 3 to 4 feet from the glass door facing the smoking gazebo. At 8:24 a.m., with her oxygen tank still in use, the resident lit and started smoking a cigarette. Three staff members, Housekeeping Staff #1, #2, and #3 were outside by the gazebo, and there was one other resident in a wheelchair who was smoking at this time. An unidentified staff member walked by the resident and spoke to her. The resident continued to smoke for approximately 1 minute after the staff member spoke to her, then extinguished the cigarette and placed the remainder of the cigarette in her purse. She turned her wheelchair toward the door to the facility, and Maintenance Staff #1 went outside and assisted the resident back into the building and went to inform nursing staff that the resident needed her oxygen removed to go outside to smoke. g. On 10/24/17 at 9:22 a.m., Resident #14 was asked about smoking a cigarette with oxygen in use that morning and stated, Sometimes, I forget it. They (the staff) have a fit and take the oxygen off if I leave it on. I have enough sense to take care of my cigarettes. I keep my cigarettes and lighter in my purse and then turn them in. The resident showed the surveyor a pack of cigarettes and a disposable lighter inside her purse, which was on her lap. She stated, I'm not supposed to have my oxygen on outside. I had to wait on someone to take my oxygen off to smoke. h. On 10/24/17 at 9:30 a.m., LPN #2 was asked about Resident #14 smoking with her oxygen on this morning and stated, I saw her yesterday and caught her smoking just as she went out the door, and I took her oxygen off. I spoke to her about it and I'm going to keep her cigarettes in a pencil box, so she has to come and get me to remove her oxygen before she goes out. The doctor is trying to get her to quit, but she wants to try to quit on her own. Our smoking policy is individualized to each resident. She has had no burns or incidents related to smoking. At 9:35 a.m., LPN #2 recalled that Maintenance Staff #1 had told her the resident was outside smoking this morning with her oxygen on. i. On 10/24/17 at 9:30 a.m., Maintenance Staff #1 stated, When I was going out to break, the resident was coming back in and had her oxygen on. I helped push the wheelchair into the building. I did not see her with a cigarette. I told the nurse that the Housekeepers told me that the resident was outside smoking while wearing the oxygen and (Housekeeper #2) told me she had told the resident to put the cigarette out. j. On 10/24/17 at 9:35 a.m., Housekeeping Staff #1 was asked if she had ever seen Resident #14 outside smoking with her oxygen in use. She stated she had seen her, .just a couple of times. She was unsure if the oxygen was on or not at the time and stated she informed the Certified Nursing Assistant or Nursing staff. On 10/25/17 at 8:08 a.m., she stated she was on her way outside to the smoking area on the morning of 10/24/17 and saw Resident #14 in the smoking area, after she saw the surveyor standing inside the door observing the resident and after the surveyor asked her to identify the resident. k. On 10/24/17 at 9:40 a.m., Housekeeping Staff #2 was asked about Resident #14 smoking outside this morning with her oxygen on and stated, I told her to put it out. She continued to smoke a little. She had just started smoking a cigarette. l. On 10/24/17 at 9:46 a.m., Housekeeping Staff #3 was about Resident #14 smoking this morning with her oxygen on and stated, I walked by her when I came into the smoking area and I asked her if her oxygen was on. I can't tell if her oxygen is on or not, and we can't mess with it. She said she forgot it. All of us told her, 'You need to have an aide check it '. m. On 10/24/17 at 9:25 a.m., the Assistant Director of Nursing (ADON) was asked about Resident #14's smoking and stated she was aware of Resident #14 going out to smoke and .The facility does not assist residents to smoke; they must be independent or be assisted by the family. She was asked for a copy of Resident #14's smoking assessment and stated, Well, this is how it goes with her; she's not supposed to smoke, but she bums cigarettes off of other residents, and if family brings her any, they are supposed to tell us, so there probably is not a smoking assessment on her. 1.) On 10/24/17 at 9:50 a.m., the ADON was asked about a smoking assessment for the resident and stated, We just did it (the smoking assessment). She bums (sic) them from other residents. A couple of residents have lock boxes with cigarettes. The facility doesn't assist residents to smoke; they must be independent or be assisted by family. She was asked if the resident should be going out with oxygen to smoke and if she had her own supply of cigarettes. She replied No to both questions. 2.) The Smoking assessment dated [DATE] at 10:06 a.m. documented, Does resident smoke? Yes . (But encouraged not to smoke per physician's orders [REDACTED].? No . (Resident asks other residents for cigarettes). Is Resident alert, awake, oriented to person, place, and date: No . (Alert and oriented times 2). Resident has been assessed and is able to smoke independently: No . (Resident is not supposed to smoke due to oxygen). Resident to wear smoking apron while smoking: No . At 3:02 p.m., the Smoking Assessment for Resident #14 was updated/ corrected to document, Is Resident capable of holding/using cigarette and lighter without assistance: Yes . Does the Resident exhibit motor skills required for smoking: Yes . Does Resident demonstrate ability to dispose of ashes/butts appropriately: Yes . Does family understand smoking policy/rules: Yes . The Resident has failed to demonstrate safe smoking protocol: Yes . 3.) On 10/26/17 at 9:12 a.m., the ADON stated, (Resident #14) never had a smoking assessment before 10/24/17. No one here uses a smoking apron, because we don't allow residents that are unsafe or not independent to smoke. No one has had any burns here in the last year. We knew she went outside and was trying to get cigarettes from other people. We never were told by staff that she went out on her own with her own cigarettes and lighter, or was smoking with the oxygen on prior to 10/24/17. n. On 10/24/17 at 4:31 p.m., the Administrator stated he was unaware of the resident having her own smoking supplies or of her smoking with oxygen until the 10/24/17 incident. o. On 10/25/17 at 8:42 p.m., LPN #3 was contacted via telephone and was asked about her documentation on 10/8/17 and stated, She (Resident #14) was found outside in the smoking area gazebo smoking with her oxygen on at 2 liters and her nasal cannula in place. I reminded her of the dangers of smoking while using oxygen. I took off her nasal cannula and turned the oxygen off as she wished to smoke for a little while. She wasn't supposed to be smoking at that time. p. On 10/26/17 at 3:01 p.m., the ADON stated, The smoking policy agreement given by the DON on 10/24/17 is what we use on the admission packet. I don't think she (Resident #14) has one in her admission papers, because we didn't have the smoking assessment. I don't know why it isn't there. 4. The Immediate Jeopardy was removed and the scope and severity lowered to E on 10/24/17 at 3:28 p.m., when the facility implemented the following Plan of Removal: a. Instant in-service to all staff to identify all smokers and smokers with O2 (oxygen). b. Day shift in-service was done at 1345 (1:45 p.m.) by DON . Evening team leader . was in-serviced by DON and will in-service evening staff upon arrival of their shift. Night-shift team leader . will be in-serviced by the ADON and all night shift will be in-serviced on the day they return back to work. With a full staff mandatory in-service on Friday 10/27/17. c. Closet care plans will now include a purple dot to identify all smokers. Purple dot with a black dot in the middle for residents with O2. This information will be included in our instant in-services and given to any staff that is not present on this date. d. Will update all smoking assessments on all smokers and potential smokers throughout the facility. e. All care-plans will be updated on all smokers and potential smokers throughout facility. f. All cigarettes and lighters will be locked up at the nurse's station and will only be given out the amount of cigarettes that they will smoke at each time. g. Families will be re-informed regarding smoking policy and to deliver cigarette to nurse only not the resident. h. A sign will be placed on the door to the smoking area for all residents, staff, and visitors to not give cigarettes to other residents. i. Identifying residents that smoke: (six residents' names were listed). j. Residents will now have their own designated areas for smoking, which will be posted. Staff will also have their own designated area which will be posted as well.

Based on observation, record review, and interview, the facility's Nursing Administration failed to ensure deficient facility practices regarding residents who smoked were promptly identified and corrected, as evidenced by failure to ensure that before a resident was allowed to smoke cigarettes unsupervised, an assessment was conducted and documented to determine if the resident could safely do so; failed to ensure the ability to safely smoke was re-evaluated at least quarterly; and failed to ensure interventions, to include supervision / monitoring of the resident while smoking and securing the smoking materials / cigarette lighters when not in use, were immediately developed, implemented and documented on the plan of care after the resident was observed by staff to be smoking with oxygen in use, to prevent the resident from causing potential serious burn injuries to herself or other residents for 1 (Resident #14) of 1 case mix resident who smoked tobacco products. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #14, and had the potential to cause more than minimal harm to 5 residents who smoked tobacco products, including 3 residents who required oxygen therapy, as documented on a list provided by the Assistant Director of Nursing (ADON) on 10/24/17. The Administrator was informed of the Immediate Jeopardy condition on 10/24/17 at 12:44 p.m. The findings are: 1. The facility's Director of Nursing job description, provided by the Business Office Manager on 10/24/17 documented, The Director of Nursing assumes authority, responsibility and accountability for the delivery of nursing services in the facility . Collaborates with other departments, medical professionals, consultants, and organizations, including government agencies and advocacy groups, to develop, support and coordinate resident care, related administrative functions, and to represent the interest of the facility . Ensure delivery of [MEDICATION NAME] quality care and . maintenance of optimal resident functions . 2. The facility's, Smoking Policy Agreement, provided by the Director or Nursing (DON) on 10/24/17 at 10:15 a.m., documented, .The facility will be responsible for performing a Smoking Assessment quarterly, change of condition, and/or as deemed necessary for the resident's safety . The facility will provide a container with a lock and key for each resident smoker to keep cigarettes and lighter in . The box will be kept in the smoking area in the courtyard . The resident agrees to keep their lighter and cigarettes in the box at all times and not to take them to their rooms or out of the smoking area. The resident agrees not to share their cigarettes with other residents. This is to protect all residents. In the event that any resident fails to follow this agreement, by signing below, the resident forfeits the right to smoke . 3. The facility's Resident Smoking Policy, provided by the Assistant DON (ADON) on 10/26/17 at 11:28 a.m., documented, Policy Statement: This facility shall establish and maintain safe resident smoking practices . 8. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 9. The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 10. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 11. The staff will review the status of a resident's smoking privileges periodically, and consult as needed with the Director of Nursing Services and the Attending Physician. 12 . d. Residents with independent smoking privileges may not give smoking articles to other residents with restricted smoking privileges. Note: Anyone who observes this happening shall report it to the On-Duty Charge Nurse immediately . 4. Resident #14 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 8/23/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and required limited assistance of one person for transfers and locomotion on and off the unit. a. A physician's orders [REDACTED]. A physician's orders [REDACTED]. b. A Care Plan dated 5/26/17 documented, .I have Dementia . Goal: Because of my dementia, I need assistance periodically throughout the day in helping me remembering my schedule of meals, activities, etc. (et cetera). Please keep me as oriented as possible and control my behaviors associated with my cognitive deficit . Please monitor me for behaviors associated with increased confusion including: Increased agitation, tearfulness, general disorientation . I can understand others and I can make my needs known but because of my cognitive loss, I need you to anticipate my needs in case I do not remember to do something throughout the day . My respiratory status needs monitoring because of my [MEDICAL CONDITION] [DIAGNOSES REDACTED]. I am to have O2 (Oxygen) (at) 2 L/min via NC continuously . The Care Plan did not address providing for the resident's safety while smoking. c. The Admission Packet signed 5/26/17 by Resident #14's daughter documented, .Smoking is not permitted in the patient's room and only is permitted in designated smoking areas. The Patient accepts full responsibility and absolves the Nursing Facility, its personnel and the attending physician of responsibility for any fires, burns, or other accidents occurring as a result of the Patient smoking while the patient is in bed, in the Patient's room, or in any other area that is not a designated smoking area . The Capacity Verification form dated 5/26/2017 documented, (Resident #14) is incapacitated and therefore is unable to sign forms and is unable to acknowledge whether he/she understands the content of the forms . This form was signed by the resident's daughter. d. A Physician's note dated 10/04/17 documented, .Pt (patient) still smoking but agrees to quit today. General exam . PSYCH: (Psychiatric) confused. e. Nurse's Notes dated 10/8/17 by Licensed Practical Nurse (LPN) #3 documented, Resident non-compliant with non-smoking order. Found resident outside smoking with oxygen tank. Removed and returned back inside facility . Nurse's Notes dated 10/9/17 by LPN #2, documented, Resident up for meals, refuses to stop smoking . f. On 10/24/17 at 8:18 a.m., Resident #14 was in a wheelchair, receiving oxygen at 2 liters per minute via a nasal cannula connected to a portable oxygen tank that was hanging on the back of the wheelchair. She self-propelled from the hallway to the outside of the building and into the smoking area. She stopped approximately 3 to 4 feet from the glass door facing the smoking gazebo. At 8:24 a.m., with her oxygen tank still in use, the resident lit and started smoking a cigarette. Three staff members, Housekeeping Staff #1, #2, and #3 were outside by the gazebo, and there was one other resident in a wheelchair who was smoking at this time. An unidentified staff member walked by the resident and spoke to her. The resident continued to smoke for approximately 1 minute after the staff member spoke to her, then extinguished the cigarette and placed the remainder of the cigarette in her purse. She turned her wheelchair toward the door to the facility, and Maintenance Staff #1 went outside and assisted the resident back into the building and went to inform nursing staff that the resident needed her oxygen removed to go outside to smoke. g. On 10/24/17 at 9:22 a.m., Resident #14 was asked about smoking a cigarette with oxygen in use that morning and stated, Sometimes, I forget it. They (the staff) have a fit and take the oxygen off if I leave it on. I have enough sense to take care of my cigarettes. I keep my cigarettes and lighter in my purse and then turn them in. The resident showed this surveyor a pack of cigarettes and a disposable lighter inside her purse, which was on her lap. She stated, I'm not supposed to have my oxygen on outside. I had to wait on someone to take my oxygen off to smoke. h. On 10/24/17 at 9:30 a.m., LPN #2 was asked about Resident #14 smoking with her oxygen on this morning and stated, I saw her yesterday and caught her smoking just as she went out the door, and I took her oxygen off. I spoke to her about it and I'm going to keep her cigarettes in a pencil box, so she has to come and get me to remove her oxygen before she goes out. The doctor is trying to get her to quit, but she wants to try to quit on her own. Our smoking policy is individualized to each resident. She has had [MEDICAL CONDITION] incidents related to smoking. At 9:35 a.m., LPN #2 recalled that Maintenance Staff #1 had told her the resident was outside smoking this morning with her oxygen on. i. On 10/24/17 at 9:30 a.m., Maintenance Staff #1 stated, When I was going out to break, the resident was coming back in and had her oxygen on. I helped push the wheelchair into the building. I did not see her with a cigarette. I told the nurse that the Housekeepers told me that the resident was outside smoking while wearing the oxygen and (Housekeeper #2) told me she had told the resident to put the cigarette out. j. On 10/24/17 at 9:35 a.m., Housekeeping Staff #1 was asked if she had ever seen Resident #14 outside smoking with her oxygen in use. She stated she had seen her, .just a couple of times. She was unsure if the oxygen was on or not at the time and stated she informed the Certified Nursing Assistant or Nursing staff. On 10/25/17 at 8:08 a.m., she stated she was on her way outside to the smoking area on the morning of 10/24/17 and saw Resident #14 in the smoking area, after she saw the surveyor standing inside the door observing the resident and after the surveyor asked her to identify the resident. k. On 10/24/17 at 9:40 a.m., Housekeeping Staff #2 was asked about Resident #14 smoking outside this morning with her oxygen on and stated, I told her to put it out. She continued to smoke a little. She had just started smoking a cigarette. l. On 10/24/17 at 9:46 a.m., Housekeeping Staff #3 was about Resident #14 smoking this morning with her oxygen on and stated, I walked by her when I came into the smoking area and I asked her if her oxygen was on. I can't tell if her oxygen is on or not, and we can't mess with it. She said she forgot it. All of us told her, 'You need to have an aide check it '. m. On 10/24/17 at 9:25 a.m., the Assistant Director of Nursing (ADON) was asked about Resident #14's smoking and stated she was aware of Resident #14 going out to smoke and, .The facility does not assist residents to smoke; they must be independent or be assisted by the family. She was asked for a copy of Resident #14's smoking assessment and stated, Well, this is how it goes with her; she's not supposed to smoke, but she bums cigarettes off of other residents, and if family brings her any, they are supposed to tell us, so there probably is not a smoking assessment on her. 1.) On 10/24/17 at 9:50 a.m., the ADON was asked about a smoking assessment for the resident and stated, We just did it (the smoking assessment). She bums (sic) them from other residents. A couple of residents have lock boxes with cigarettes. The facility doesn't assist residents to smoke; they must be independent or be assisted by family. She was asked if the resident should be going out with oxygen on to smoke and if she had her own supply of cigarettes. She replied No to both questions. 2.) The Smoking assessment dated [DATE] at 10:06 a.m. documented, Does resident smoke? Yes . (But encouraged not to smoke per physician's orders [REDACTED].? No . (Resident asks other residents for cigarettes). Is Resident alert, awake, oriented to person, place, and date: No . (Alert and oriented times 2). Resident has been assessed and is able to smoke independently: No . (Resident is not supposed to smoke due to oxygen). Resident to wear smoking apron while smoking: No . At 3:02 p.m., the Smoking Assessment for Resident #14 was updated/ corrected to document, Is Resident capable of holding/using cigarette and lighter without assistance: Yes . Does the Resident exhibit motor skills required for smoking: Yes . Does Resident demonstrate ability to dispose of ashes/butts appropriately: Yes . Does family understand smoking policy/rules: Yes . The Resident has failed to demonstrate safe smoking protocol: Yes . 3.) On 10/26/17 at 9:12 a.m., the ADON stated, (Resident #14) never had a smoking assessment before 10/24/17. No one here uses a smoking apron, because we don't allow residents that are unsafe or not independent to smoke. No one has had [MEDICAL CONDITION] in the last year. We knew she went outside and was trying to get cigarettes from other people. We never were told by staff that she went out on her own with her own cigarettes and lighter, or was smoking with the oxygen on prior to 10/24/17. n. On 10/24/17 at 4:31 p.m., the Administrator stated he was unaware of the resident having her own smoking supplies or of her smoking with oxygen until the 10/24/17 incident. o. On 10/25/17 at 8:42 p.m., LPN #3 was contacted via telephone and was asked about her documentation on 10/8/17 and stated, She (Resident #14) was found outside in the smoking area gazebo smoking with her oxygen on at 2 liters and her nasal cannula in place. I reminded her of the dangers of smoking while using oxygen. I took off her nasal cannula and turned the oxygen off as she wished to smoke for a little while. She wasn't supposed to be smoking at that time. p. On 10/26/17 at 3:01 p.m., the ADON stated, The smoking policy agreement given by the DON on 10/24/17 is what we use on the admission packet. I don't think she (Resident #14) has one in her admission papers, because we didn't have the smoking assessment. I don't know why it isn't there. 5. The Immediate Jeopardy was removed and the scope and severity lowered to E on 10/24/17 at 3:28 p.m., when the facility implemented the following Plan of Removal: a. Instant in-service to all staff to identify all smokers and smokers with O2 (oxygen). b. Day shift in-service was done at 1345 (1:45 p.m.) by DON . Evening team leader . was in-serviced by DON and will in-service evening staff upon arrival of their shift. Night-shift team leader . will be in-serviced by the ADON and all night shift will be in-serviced on the day they return back to work. With a full staff mandatory in-service on Friday 10/27/17. c. Closet care plans will now include a purple dot to identify all smokers. Purple dot with a black dot in the middle for residents with O2. This information will be included in our instant in-services and given to any staff that is not present on this date. d. Will update all smoking assessments on all smokers and potential smokers throughout the facility. e. All care-plans will be updated on all smokers and potential smokers throughout facility. f. All cigarettes and lighters will be locked up at the nurse's station and will only be given out the amount of cigarettes that they will smoke at each time. g. Families will be re-informed regarding smoking policy and to deliver cigarette to nurse only not the resident. h. A sign will be placed on the door to the smoking area for all residents, staff, and visitors to not give cigarettes to other residents. i. Identifying residents that smoke: (six residents' names were listed). j. Residents will now have their own designated areas for smoking, which will be posted. Staff will also have their own designated area which will be posted as well.

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure causative factors for falls were identified and evaluated and interventions to prevent further falls or reduce the risk of injury were developed based on the identified causative factors; and planned interventions were consistently implemented and re-evaluated to determine effectiveness to reduce the risk of further falls or fall-related injuries for 1 (Resident #5) of 2 (Resident #3 and #5) case mix residents that were at high risk for falls. These failed practices caused a pattern of actual harm for Resident #5, who experienced multiple falls without appropriate interventions before sustaining multiple facial fractures due to a fall and had the potential to cause more than minimal harm to 34 residents who were at high risk for falls according to a list provided by the Director of Nursing on [DATE]. The findings are: Resident #5 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with Assessment Reference Date of [DATE] documented the resident had short term and long term memory problems; had severely impaired cognitive skills per a staff assessment for mental status, required extensive assistance of 1 person for bed mobility, transfers, eating and personal hygiene; was incontinent of bowel and behavior; and had 2 or more falls since admission with no major injuries. a. The Fall Risk Assessments dated [DATE] documented, "Assessed the resident status in the eight clinical condition parameters, with a total score of 20." The form documented a score of 10 or above represents high risk. b. The Comprehensive Care Plan reviewed/updated on [DATE] documented: "The Resident is at risk for falls d/t (due to) Alzheimer's Dementia and attempts to transfer self. ...1. Resident is up in w/c daily. Is able to propel self for short distances. Does fatigue easily...5. [DATE] change pressure alarm to safety clip alarm at all times. Resident with Alz (Alzheimers)/Dementia and unaware of safety measures. 6. Review every fall and provide intervention as indicated ... "The Resident with communication deficit d/t being HOH (hard of hearing), and is not always understood and shows little to no understanding to what is being told to her. Has Alzheimer's Dementia ... 1. Staff to anticipate and meet all resident ' s needs ... 3. Give simple commands and ask yes/no questions when communicating with resident. Speak directly to resident with increased vocal tones... " c. Incident/ Accident (I/A) Reports from [DATE] -[DATE] were reviewed: 1) I/A Report dated [DATE] at 0900 (9:00) a.m. documented, "Description of Incident: Pt (patient) tried to wheel her-self in the therapy room, w/c (wheel chair) tipped backwards and pt hit the back of her head on the floor. Small bump noted. No bruising or bleeding noted. Neuro checks started ...Steps to prevent reoccurrence (blank) ...Follow Up (Final Disposition): "No injury noted." 2) I/A Report dated [DATE] at 2230 (10:30) p.m. documented, "Description of Incident: Found in sitting position in floor in room. Pressure alarm intact/working but weak ...Steps to prevent Reoccurrence: Staff to watch more closely. " 3) I/A Report dated [DATE] at 2335 (11:35 p.m.) documented, "'Description of Incident: Resident was found in floor below bed scooting pressure alarm was on. ...No injuries ...Steps to prevent reoccurrence: Check pt often. " 4) I/A Report dated [DATE] at 1345 (1:45 p.m.) documented,"Description of Incident: Pt tried to get up by herself and fell in the floor. No injuries ...Steps to prevent reoccurrence (blank) ...Follow up (Final Disposition): Resident unable to understand directions. Make sure that pressure alarm is in place turned on and is working properly ..." 5) I/A Report dated [DATE] at 0600 (6:00 a.m.) documented, "Resident on floor in TV area. Resident alarm going off, resident had stood up by herself no visible s/s (signs/symptoms of injury) noted ...Steps to prevent reoccurrence: Close monitor by all staff d/t (due to) R (resident) is able to self propel around building." 6) I/A Report dated [DATE] at 1000 (10:00 p.m.) documented, "Description of Incident: Alarm was sounding-patient was in sitting position and scooting across floor of room. Bruising noted to outside of left foot and small bruise to upper back ...Steps to prevent reoccurrence: Staff to watch more closely ...Follow up (Final Disposition): Continue with pressure alarm. More frequent checks by staff ... " 7) I/A Report dated [DATE] at 1915 (7:15 p.m.) documented, "Description of incident: Resident was sitting on floor in her room in front of her w/c (wheelchair) by the sink pressure alarm was in place in place in w/c et. Sounding off ...Steps to Prevent Reoccurrence (blank) ....Follow up (Finial Disposition): Continue pressure alarm and frequent observation ..." 8) I/A Report dated [DATE] at 0630 (6:30 a.m.) documented, "Description of Incident: CNA (Certified Nursing Assistant) found res (resident) sitting in the floor in front of her w/c in common area. Res had taken her blouse off and her safety clip alarm were still attached. ..Steps to prevent reoccurrence: Have 02 (oxygen) on at all times. Monitor res. within view of staff ...Follow up (Final Disposition): Continue clip alarm and frequent observations ...Additional comments: On [DATE] sensor alarm was changed to safety clip alarm (at) all (tiems) ...Other investigation findings: O2 (oxygen) stats 73% on room air ..." 9) I/A Report dated [DATE] at 9:10 a.m. documented, "Description of Incident: Pt was found laying on floor on her back. (No) injuries. W/C was next to pt and alarm was sounding ...Steps to Prevent Reoccurrence: [DATE], Encourage res (resident) to keep 02 (oxygen on). Res frequently removes NC (nasal cannula) et gets upset when staff attempts to place NC back on ...Follow up (Finial Disposition): Continue with clip alarm and more frequent observations ...." 10) I/A Report dated [DATE] at 1600 (4:00 P.M.) documented, "description of Incident: Sitting in floor in front of w/c no apparent injury ...Steps to Prevent Reoccurrence: Encourage to keep 02 on. Res frequently removed NC (nasal cannula) et gets upset when staff attempts to place NC back on... Follow Up (Final Disposition): Continue clip alarm (and) frequent alarms checks. Resident's mental status is such that she cannot comprehend that she is unable to get up by herself. " 11) I/A Report dated [DATE] at 1700 (5:00 p.m.) documented, "Description of Incident: Patient in floor by dining room table. Small bruise to left inner arm and small bruise to left knee and bruise to right buttock able to move extremities as before ...Steps to prevent Reoccurrence: Staff to watch more closely. On [DATE] Dietary Consult completed to evaluate for proper nourishment. " 12) I/A Report dated [DATE] at 1530 (3:30 p.m.) documented, "Description of Incident: R (resident) stood up from wheelchair on patriot lobby and fell face first to the floor. R had blood coming from nose and inner L (left) eye. 911 called EMS (emergency medical system) transported R to... Hosptial ER (emergency room ). Report called into ER ... Clip alarm was in place ...Steps to Prevent Reoccurrence: Encourage CNA's to leave R for later if sleeping to avoid excess wheelchair time ... Follow Up (Final Disposition: Returned formER on comfort care only. Resident expired Monday [DATE] ... " On [DATE] at 8:55 a.m., CNA #6 was asked if she was familiar with (Resident #5). The CNA stated, "Yes." The CNA was asked if she had worked with this resident on [DATE]. The CNA stated, "Yes. I had gotten the resident up for supper and put her in the lobby on section II. I had a bag of dirty laundry and had taken it to the hamper. I had made sure the clip alarm was clipped to her shirt. The resident had already stood up. I ran to her, the clip alarm came unattached from her shirt. The alarm did not sound." The CNA was asked if the clip alarm came off her shirt completely. The CNA stated, "Yes, the alarm did not sound because the clip had became disconnected from her shirt. The resident stood up and fell face forward in the floor and I stayed with her and another CNA went to get the Nurse, there was blood on the floor by her head. The CNA was asked if the resident had frequent falls. The CNA stated, "Yes, she fell a couple days ago. but we were able to get to her." d. The ED (Emergency Department) Physician Documentation dated [DATE] at 1608 (4:08 p.m.} documented, "This 96 yrs (year) old white female presents to ED (emergency department) via EMS. Ground with complaints of fall injury ...This pt (patient) had a fall at the NH (Nursing Home) out of the wheel chair and injured the face. Pt has severe facial swelling and blood in the nose this is a trickle of blood from each nares. Pt is confused but this is baseline ....Differential Diagnosis, Fracture, laceration, multiple fractures. ...ED course: I discussed with this pt (patient) daughter, pt has several facial fractures. Pt is on Hospice care and she is [AGE] years old. I discussed with this daughter that the trauma her mother has suffered could very likely be fatal at her age, the bleeding in the nose has slowed, daughter has stated they do not want anything invasive done and would like sent back to NH (nursing home) with pain control. I discussed with daughter about difficulty getting a study of the C-spine to R/O (rule out) fracture and the complications of missing an unstable cervical fracture, including paralysis and death. The collar is bothering the pt and causing her to get anxious per family will D/C (discharge) home without C collar and give pain control. " A Radiology Report dated [DATE] documented, "Procedure: SP-Cervical Spine ,[DATE] (views) ...Impression: Limited examination, No obvious fracture. A Radiology Report dated [DATE] documented, "Procedure: Unenhanced CT Cervical Spine with Sagittal and Coronal Reconstructions ...Impression: Slight anterolisthesis of C4-C5 felt to be degenerative. Congenital Fusion at C5-C6. Degenerative changes C6-C7. No obvious fracture seen but the study significant degraded by patient motion." A Radiology Report dated [DATE] documented, "Procedure: CT Face with Sagittal and Coronal Reconstructions ...Impression: Fractures of the anterior wall and lateral walls of both maxillary sinuses. Fracture of the nasal bone. Fracture of the right Zygmatic arch. Fractures through both medical and lateral aspect of both pterygoid plates. The anterior aspect of the right floor of the orbit. There are air-fluid levels in the maxillary sinuses. Extensive soft tissue air is seen deep to the Zygomatic Arches. Extensive soft tissue air is seen deep to the Zygomatic Arches and faces anteriorly especially the right side." A Radiology Report dated [DATE] documented, "Procedure: CT Head without contrast. ...Impression: Atrophy white matter changes not unusual for age, old deep white matter ischemia left frontal lobe. No mass or hemorrhage. Facial fractures and hemorrhage in the maxillary sinuses as discussed above." f. The Nurses Notes dated [DATE] at 2000 (8:00 p.m.) documented, " ...the Resident was readmitted to the facility, with [DIAGNOSES REDACTED]. Family request comfort care only. Hospice notified and requested Hospice Nurse to come to the facility. The Hospice Nurse visited the facility and orders received to discontinue po (per mouth) meds (medications). And new orders received for complete bed rest ..." Physician order [REDACTED]. 2. Complete bed rest 3. Discontinue Risperdal and Trazodone. " g. The Neurological Checklist dated from [DATE] at 2000 (8:00 p.m.) through [DATE] at 2400 (12:00 a.m.) documented the following assessments: "Conscious State: the form indicated by a check mark drowsy and Stupor from [DATE] at 2000 (8:00 p.m.) through [DATE] at 1600 (4:00 p.m.), the form documented unconscious indicated by a check mark from [DATE] at 2000 through [DATE] 2400 (12:00 a.m.). Mental Status: the form indicated by a check mark the resident was disoriented from [DATE] at 2000 through [DATE] at 2400 (12:00 a.m.) and the form also documented indicated by a check mark restless from [DATE] at 2000 (8:00 p.m.) through [DATE] at 0400 (4:00 a.m.). Pupil Reaction: the form documented 'eyes swollen shut'from [DATE] at 2000 through [DATE] at 2400 (12:00 a.m.)." The Nurses Notes [DATE] at 2430 (12:30 a.m.) documented, "The Coroner pronounce time of death 2410." h. On [DATE] at 3:32 p.m., Licensed Practical Nurse (LPN) #1 was asked if she was familiar with Resident #5. The LPN stated, "Yes." The LPN was asked if the resident was at risk for falls. The LPN stated, "Yes." The LPN was asked how did the resident fall. The LPN stated, "From the bed and the wheelchair. She would stand up and get ,[DATE] feet from the wheelchair and fall and fell out of the bed." The LPN was asked what interventions were in place. The LPN stated, "Pressure alarm due to resident's weight (note: the resident's [DATE] weight was 86 pounds) wouldn't set off the alarm and was changed to a clip type alarm." The LPN was asked if the resident had sustained injuries related to her falls. The LPN stated, "Just bruises and skin tears before the last fall with multiple fractures to the face." i. On [DATE] between 3:30 p.m. and 4:00 p.m., interviews were conducted with Staff that cared for Resident #5. Four (4) LPNS (LPN #1, #2, #3 and #4) and 4 Certified Nursing Assistants (CNA #6, #7, #8 and #9) all stated that the resident had frequent falls and would get up from the wheelchair and that the wheelchair had an alarm. j. On [DATE] at 3:58 p.m., the Director of Nurses (DON) stated that the Resident had frequent falls, but there was no major injury until the last fall on [DATE]. The DON was asked what were the interventions that were put in place related to the resident's falls. The DON stated, "Pressure alarm that was changed to the tab alarm, Physical Therapy evaluations for positioning modification and the anti-tips bars that was placed on the resident's wheelchair. The anti-tip bars were placed on the wheelchair on ,[DATE]." On [DATE] at 9:10 a.m., the Director of Nurses (DON) was asked to review the Resident's Incident Reports for the falls over the past 5 months. The DON reviewed the Incident Reports and the Resident's clinical record. The DON reviewed the interventions and stated, "We had gone over the falls for not having appropriate interventions. On [DATE] we reviewed her falls and changed the pressure alarm to a clip alarm because of her weight might not be able to trigger the alarm. The DON was asked if the falls since [DATE] ([DATE], [DATE], [DATE] and [DATE]) had any new interventions put in place besides monitoring resident closely. The DON stated that they had a dietary consult on [DATE] due to resident ' s significant weight loss. The Resident ' s weight was reviewed by the surveyor and the DON. The resident ' s weight in [DATE] was 87 pounds, in February of 2014 the residents weight was 95.2 with a 4 month weight loss of 8.6%. The DON stated that Physical Therapy did see the resident in [DATE] and did attempt to tilt the seat of the wheelchair but this decreased her mobility and was reversed. The DON stated, "Of course this is not documented." The DON was asked if there were any other attempts to change the resident ' s position in the wheelchair. The DON stated, "No." The DON stated, "Looking at these interventions. I feel that this was the best we could do she was resistant to care. Even though she was weaker, she was determined. She was very mobile in her wheel chair. We didn't want her to lose her function or mobility. We put a lot of thought into her function and mobility ..."

Based on observation, record review and interview, the facility failed to ensure isolation precautions were followed to decrease the potential for the spread of infection and staff and visitors were informed of isolation precautions required for 4 (Residents #1,#2, #3 and #6), isolation linen and trash were handled in a manner to prevent possible cross contamination for 2 (Residents #2 and #3), isolation gowns which provided protection against liquid were consistently available for staff use and staff uniforms were not contaminated for 3 (Residents #1, #2 and #3) of 4 (Residents #1, #2, #3 and #6) case mix residents who required isolation precautions and disinfectant utilized was effective against Clostridium difficile (C. diff) for 3 of 3 (Residents #2, #3 and #6) case mix residents with Clostridium difficile. The facility further failed to ensure floors were disinfected after fecal contamination for 1 (Resident #12) of 7 (Residents #1, #3, #5, #6, #7, #11 and #12) who were incontinent. The failed practices resulted in actual harm for Residents #2, #3 and #6, who contracted or repeatedly contracted Clostridium difficile infections, and had the potential to cause more than minimal harm for 8 residents who received therapy services in the therapy gym, according to a list provided by the Assistant Director of Nursing (ADON) on [DATE] at 11:30 a.m., 54 residents who ate meals in the Gazebo dining room, according to a list provided by the Assistant Director of Nursing (ADON) on [DATE] at 9:47 a.m., 36 residents who were incontinent of bowel, according to the Resident Census and Conditions of Residents form received from the Administrator on [DATE] at 11:25 a.m. The findings are: 1. The Occupational Safety and Health Administration on-line article titled "CDC: 'C. difficile' Poses Threats Across All Medical Facilities" and found at <http://blogs.hcpro.com/osha/,[DATE]/cdc-c-difficile-poses-threats-across-all-medical-facilities/> documented, "The CDC's Vital Signs <http://www.cdc.gov/vitalsigns/HAI/index.html>, [DATE], reports that while 94% percent of [DIAGNOSES REDACTED]icile infections are related to medical care, only 25% of infections first show symptoms in hospital patients. That means that 75% of [DIAGNOSES REDACTED]icile infections first appear 'in nursing home patients or in people recently cared for in doctor's offices and clinics,' according to the report... 'Illness and death linked to this deadly disease do not have to happen. Patient lives can be saved when health care providers follow the 6 Steps to Prevention, which include key infection control and smart antibiotic prescribing recommendations.' The 6 Steps to Prevention are: ...Test for [DIAGNOSES REDACTED]icile when patients have diarrhea while on antibiotics or within several months of taking them. Isolate patients with [DIAGNOSES REDACTED]icile immediately. Wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. Clean room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there..." 2. The CDC Frequently Asked Questions about Clostridium difficile for Healthcare Providers found at <http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a6> documented, "...How is Clostridium difficile transmitted? Clostridium difficile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridium difficile spores. Clostridium difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item... How can Clostridium difficile infection be prevented in hospitals and other healthcare settings? ...Use Contact Precautions: for patients with known or suspected Clostridium difficile infection: Place these patients in private rooms. If private rooms are not available, these patients can be placed in rooms (cohorted) with other patients with Clostridium difficile infection. Use gloves when entering patients' rooms and during patient care. Perform Hand Hygiene after removing gloves. Because alcohol does not kill Clostridium difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs. However, early experimental data suggest that, even using soap and water, the removal of [DIAGNOSES REDACTED]icile spores is more challenging than the removal or inactivation of other common pathogens. Preventing contamination of the hands via glove use remains the cornerstone for preventing Clostridium difficile transmission via the hands of healthcare workers; any theoretical benefit from instituting soap and water must be balanced against the potential for decreased compliance resulting from a more complex hand hygiene message. If your institution experiences an outbreak, consider using only soap and water for hand hygiene when caring for patients with Clostridium difficile infection. Use gowns when entering patients' rooms and during patient care. Dedicate or perform cleaning of any shared medical equipment. Continue these precautions until diarrhea ceases. Because Clostridium difficile-infected patients continue to shed organism for a number of days following cessation of diarrhea, some institutions routinely continue isolation for either several days beyond symptom resolution or until discharge, depending upon the type of setting and average length of stay. Implement an environmental cleaning and disinfection strategy: Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. Consider using an Environmental Protection Agency (EPA)-registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (e.g., household chlorine bleach) also may be appropriately diluted and used. (Note: Standard EPA-registered hospital disinfectants are not effective against Clostridium difficile spores .) Hypochlorite-based disinfectants may be most effective in preventing Clostridium difficile transmission in units with high endemic rates of Clostridium difficile infection. Follow the manufacturer's instructions for disinfection of endoscopes and other devices. Recommended infection control practices in long term care and home health settings are similar to those practices taken in traditional health-care settings. 3. The facility's policy titled "Contact Precautions" documented, "...Contact Precautions shall be used in addition to Standard Precautions for residents with infections that can be easily transmitted by direct and indirect contact ...Gowns: I. A gown should be worn when entering the room if it is anticipate that clothing will have substantial contact with the resident, environmental surfaces, or items in the resident's room, or if the resident is incontinent or wound drainage is not contained by a dressing. ...3. After removal of the gown, clothing should not contact potentially contaminated environmental surfaces. ...Contact Precautions may be considered for ...Clostridium difficile." 4. Resident #2 had a [DIAGNOSES REDACTED]. a. The laboratory report documented, "...Collected: [DATE] ...Reported [DATE] ...C. Difficile ...positive (Normal (equals) negative)..." b. On [DATE] at 1:54 p.m., Certified Nursing Assistant (CNA) #8 stated the resident was in isolation for Clostridium difficile (C. diff). There was no sign on the door for isolation, nor a sign with a directive for staff and visitors to check at the nurse's station prior to entering the resident's room. There was a 3 drawer clear plastic bin outside the room with isolation supplies. There were no isolation gowns present. c. On [DATE] at 2:17 p.m., Licensed Practical Nurse (LPN) #6 entered the resident's room with a medication cup. The LPN did not don a gown or gloves. d. On [DATE] at 6:02 p.m. and [DATE] at 6:48 a.m., yellow disposable isolation gowns were noted in the 3 drawer clear plastic bin outside the room. There was no sign on the door for isolation or for staff and visitors to check a nurse's station prior to entering the resident's room. e. On [DATE] at 7:40 a.m., CNA #11 and CNA #14 put on gowns and gloves and then entered the resident's room. The resident was sitting on a bedside commode with a gait belt, pants and non-skid socks on. CNA #14 checked the resident's room for incontinent pads, stated there were none in the room, then removed her gown and gloves and left the room, without washing her hands. CNA #14 returned to the room wearing a gown and gloves and carrying an incontinent pad. CNA #11 removed the resident's pants and non-skid socks, which were soiled with stool, and left them on the floor. The CNA reached underneath her gown, removed a roll of trash bags, removed one bag and then placed the roll of trash bags back in her pocket underneath her gown. CNA #11 bagged the resident's pants and used her gloved hands to lift the lid of the bio-hazardous linen container in the resident's room. CNA #11, wearing the same gloves, and CNA #14 held onto the gait belt that was on the resident to assist the resident to stand and transfer to bed. The resident had loose stool on the back of her right leg and buttocks. As the resident stood, some of the loose stool fell to the floor. CNA #14 provided incontinent care, while CNA #11 supported the resident's right leg. During incontinent care, CNA #14's gown, which was not tied, kept sliding down and CNA #14 used her gloved hands to reposition the gown. CNA #14 bagged the peri wipes used for incontinent care, and then wiped off the seat of the bedside commode that was soiled with stool using only incontinent wipes. The CNA did not fully clean the stool from the left side of the seat of the commode. CNA #14 then removed her gown and gloves and picked up a walker from the floor that had fallen. CNA #14 put the bagged trash into the bio-hazardous container. CNA #14 put on new gloves, reached into CNA #11's pocket, removed the contaminated roll of bags, removed two bags, put the roll of trash bags on the resident's over bed table and bagged the gait belt in one bag. The bag with the gait belt was placed on the wheelchair seat, on top of the pressure relieving device which had an area of yellow/tan stool on the right corner approximately 3-inches long and 2-inches wide. CNA #11 removed her gown and gloves and washed her hands. CNA #11 reached for paper towels and stated, "No paper towels." CNA #14 handed CNA #11 the roll of contaminated plastic bags and CNA #14 placed the roll of plastic bags into her pocket. CNA #14 used the second trash bag to cover the bucket of the bedside commode, which still contained stool. CNA #14 then removed her gown and gloves and washed her hands, but did not dry them before leaving the resident's room. f. On [DATE] at 8:22 a.m., LPN #10 and CNA #8 entered the resident's room wearing gloves, but did not have gowns on. LPN #10 stated, "We are going to sit the resident up and give her medications." LPN #10 wrote on the communication board what she was going to do. The resident read the message and stated she needed a pain pill. LPN #10 removed her gloves and washed her hands. LPN #10 stated, "We are out of paper towels." The LPN picked up the medication cup that had been placed on the resident's over bed table, in the same area as the roll of contaminated plastic bags. LPN #10 then sat the medication cup down on the sink area, in an area of water. CNA #8 removed her gloves, used alcohol gel on her hands, stood at the doorway and requested another CNA to get a housekeeper for paper towels. CNA #8 then used Kleenex to turn the water off and put alcohol gel on her hands. g. On [DATE] at 8:37 a.m., Housekeeper #1 entered the resident's room wearing no gown or gloves. Housekeeper #1 unlocked the paper towel holder and placed a roll of paper towels inside the dispenser. Housekeeper #1 then locked the paper towel dispenser and placed the keys on the housekeeping cart outside the resident's room. Housekeeper #1 did not wash her hands prior to leaving the room. LPN #10 washed and dried her hands, picked up the medication cup from the sink area and put the medication cup on the top of the medication cart. LPN #10 got a pain pill from the narcotic drawer and punched it out into the contaminated medication cup that was on top of the medication cart. The LPN poured water into a cup and reentered the resident's room, with no gloves or gown on. LPN #10 shut the door, then opened the door and went back out to put on gloves from the box on top of the 3-drawer clear plastic bin outside the resident's room. The LPN did not put on a gown. CNA #8 removed her right shoe, put it in the bio-hazardous linen container, removed her gloves, hopped to the sink, washed her hands and hopped out of the room. CNA #8 stated, "I stepped in stool." At 8:40 a.m., CNA #9 entered the resident's room wearing gloves, but did not have on a gown or shoe covers. CNA #9 put a gait belt down on the resident's bed, at the resident's hip area, where LPN #10 had pulled back the resident's covers. LPN #10 and CNA #9 then used the resident's incontinent pad to pull her up and turn her over onto her back. CNA #9 pulled up the resident's covers, and the covers brushed against the CNA's back brace on the left side. CNA #9 rolled up the head of the bed, picked up the gait belt and hung it over her right shoulder. CNA #9 then removed her gloves and washed her hands. As she washed her hands, the ends of the gait belt were dragging along the edge of the sink. h. On [DATE] at 8:43 a.m., LPN #10 came of Resident #2 and #3's room; from 8:43 a.m. until 8:53 a.m., the LPN was observed passing medication without cleaning off the top of the contaminated medication cart. i. On [DATE] at 9:30 a.m., LPN #11 entered the resident's room to apply ointment to the resident's buttocks. The LPN wore gloves, but no gown. LPN #11 bumped a vase of roses with water off Resident #3's table when she pulled the privacy curtain for Resident #2. LPN #11 removed her gloves, obtained paper towels, picked up a roll of plastic bags and incontinent wipes from Resident #2's over bed table, holding them against the stomach area of her uniform as she wiped off the over bed table. LPN # 11 obtained more paper towels and wiped the water up from the floor. The LPN put the paper towels into the trash can at Resident #2's bedside and then left the room, without washing her hands. LPN #11 went to the shower room, approximately 30-feet from Resident #2 and #3's room. The LPN stated, "No towels." LPN #11 returned to Resident #2 and #3's room, did not put on gloves or a gown and started wiping up water with paper towels. A CNA passed a towel into LPN #11; the LPN used it to wipe up the water from the floor. LPN #11 picked up the wet towel, still with ungloved hands, and brushed the towel against the front of her uniform. The LPN started out of the room with the soiled towel when a CNA redirected her to place the towel in the bio-hazardous container in the resident's room. LPN #11 put the towel into the container and then left the room, without washing her hands. LPN #11 stated, "I don't have a gown." The LPN patted her legs with her contaminated hands, went back into the room and washed her hands. LPN #11 was asked, "What are the residents in isolation for?" LPN #11 stated "(Resident #2) had [DIAGNOSES REDACTED], but (Resident #3) does not." The LPN then stated, "I don't know, no one's told me anything." LPN #11 left the resident's room and went to the 3-drawer clear plastic bin outside Resident #1's room to get a yellow isolation gown. The LPN stated, "Now I can touch somebody." LPN #11 put on gloves and reentered Resident # 3's room. After applying ointment to Resident #3's buttocks, LPN #11 removed her gown and gloves and put them inside the bio-hazardous trash container. The LPN then reached into the container and pushed the trash down. LPN #11 washed her hands, went back to the resident's contaminated over bed table, picked up the communication board from the over bed table, and used a Kleenex to erase the communication board, while holding it with the left hand. LPN #11 left the room without washing her hands, went to the treatment cart, removed a pen from her uniform pocket, initialed the treatment, licked her right fingers with her tongue and turned Treatment Administration Record pages with her right fingers. j. On [DATE] at 11:08 a.m., Resident #2 was in the Gazebo dining room with the pressure relieving device in the seat of her wheelchair. k. On [DATE] at 2:15 p.m., Resident #2 was out of the room. The bedside commode still had a plastic bag over the soiled bucket of the bedside commode. There was still stool on the left edge of the bedside commode. l. On [DATE] at 2:32 p.m., Resident #2 was up in the wheelchair with the pressure relieving device in the seat of the wheelchair. m. On [DATE] at 2:40 p.m., the Assistant Director of Nursing (ADON) was asked to observe the resident's bedside commode. The ADON was asked, "Who is supposed to clean the bedside commodes that are soiled?" The ADON stated, "CNAs." The ADON was asked, "What do you think of the condition of this bedside commode?" The ADON stated, "Terrible, absolutely terrible..." n. On [DATE] at 3:40 p.m., the ADON was asked to observe the resident's wheelchair. The ADON was asked, "What is on the pressure relieving device in the wheelchair?" The ADON stated, "That's stool." The ADON was asked, "Do you know how long that's been there?" The ADON stated, "No." The ADON was informed the stool had been there since at least 7:40 this a.m., when it was observed by this surveyor. The ADON was asked, "Where do you think this wheelchair has been, with the stool on it, since then?" The ADON stated, "Up and down the halls, in the dining room, all over." The ADON was asked, "Why is (Resident #2) in isolation?" The ADON stated, "For [DIAGNOSES REDACTED]." The ADON was asked, "Is it a problem that the wheelchair with stool on the pressure relieving device was 'all over' the facility?" The ADON stated, "Yes it is..." The ADON was asked, "How do visitors or staff know a resident is in isolation? Do you see a sign to check at the nursing station or an isolation sign on (Resident's #2 and 3)'s room?" The ADON stated "No." The ADON was asked, "Should there be one?" The ADON stated, "Yes, when housekeeping put out the isolation bins they are supposed to put a sign on the door." The ADON was asked, "Do you see a sign on (Room of Resident #1, Room of Resident #2 and #3, Room of Resident #23)" The ADON stated, "No." The ADON was asked, "Are these residents in isolation?" The ADON stated, "Yes." The ADON was asked, "What type of isolation is required for residents with [DIAGNOSES REDACTED]?" The ADON stated "Contact." o. On [DATE] at 12:40 p.m., CNA #8 was asked, "Which residents are in isolation and for what?" CNA #8 stated, "...(Resident #2) [DIAGNOSES REDACTED]..." CNA #8 was asked "Why is [DIAGNOSES REDACTED] a problem?" CNA #8 stated, "It's very contagious, even if it dries it's still active and contagious." CNA # 8 was asked, "Why didn't you wear a gown when you were in the room on Tuesday [DATE] when I watched you?" CNA #8 stated, "I don't think there were any gowns for me to put on. But to be honest, I didn't even look for them. I knew we had an issue. They were short and we didn't have many in the building." 5. Resident #3 had a [DIAGNOSES REDACTED]. a. The laboratory report documented, "...Collected: [DATE] ...Reported [DATE] ...C. Difficile ...positive (Normal (equals) negative)..." b. The laboratory report documented, "...Collected: [DATE] ...Reported [DATE] ...C. Difficile ...positive (Normal (equals) negative)..." c. The laboratory report documented, "...Collected: [DATE] ...Reported [DATE] ...C. Difficile ...negative (Normal (equals) negative)..." d. The laboratory report documented, "...Collected: [DATE] ...Reported [DATE] ...C. Difficile ...positive (Normal (equals) negative)..." e. The "Overall Plan of Care" dated [DATE] documented, "...12. I have a history of [DIAGNOSES REDACTED]. I need to be monitored for (signs/symptoms) of [DIAGNOSES REDACTED] throughout the treatment of [REDACTED]. f. On [DATE] at 1:54 p.m., during initial rounds, there was no sign on the resident's door for isolation or for staff and visitors to check at the nurses' station prior to entering the resident's room. There was a 3 drawer clear plastic bin outside the room with isolation supplies. There were no isolation gowns present. CNA #8 stated the resident was in isolation for [DIAGNOSES REDACTED]. g. On [DATE] at 6:02 p.m., yellow disposable isolation gowns were noted in the 3-drawer clear plastic bin outside the room. h. On [DATE] at 6:48 a.m. and 9:03 a.m., there was no sign on the door for isolation or for staff and visitors to check at the nurses' station prior to entering the resident's room. i. On [DATE] at 9:03 a.m., CNA #9 and CNA #10 were in the resident's room; they took the resident to the door of her room. CNA #9 and CNA #10 obtained isolation gowns from the 3-drawer clear plastic bin, outside the room across the hall. CNA #10 reached under her gown with her gloved hands and removed a gait belt from the waist area. CNA #10 put the gait belt on the resident, then CNA #9 and CNA #10 transferred the resident into bed. After the resident was sitting on the side of the bed, CNA #10 removed the gait belt and placed it around her neck, over her isolation gown. CNA #9 and CNA #10 laid the resident down; CNA #10 then took a roll of plastic bags out of CNA #9's pants pocked on the outer right leg of the pants and put them on the over bed table. CNA #10 used peri wipes to clean the resident's rectal area. Brown smears were noted on the wipes. CNA #10 then took the resident's shoes and pants off, without changing gloves. CNA #10 picked up the roll of plastic bags and replaced them in CNA # 9's pants pocket, removed her gown, touching the gait belt with her contaminated gloves, removed her gloves and washed her hands. CNA #9 removed her gown and gloves, then removed her shoe covers and left the room, without washing her hands. CNA #9 used alcohol gel on her hands. CNA #10 left the room with the gait belt, which had been touched with the same gloves used for incontinent care, around her neck. j. On [DATE] at 9:55 a.m., LPN #11 applied JEP moisture barrier ointment to the resident's buttocks. Upon completion of the treatment, LPN #11 removed her gown and gloves and then washed her hands. LPN #11 did not put on a new pair of gloves. LPN #11 put a new plastic bag into the resident's bedside trash can, wiped up water from around the sink with a paper towel and then left the room, without washing her hands. k. On [DATE] at 3:12 p.m., LPN #11 put on a cloth-type hospital gown, donned gloves and entered the resident's room. CNA #14 entered the resident's room with gloves on and started to empty the trash. CNA #14 stood on the foot pedal of the linen container, reached into the container and started to pull the edges of the bio-hazardous bag up. CNA #14 stopped when LPN #11 asked for assistance with the resident. CNA #14 went outside the room and obtained a cloth-type hospital gown from the bottom drawer of the 3-drawer clear plastic bin, without removing her contaminated gloves. CNA #14 assisted in holding the resident over during the treatment provided by LPN #11. After the treatment, CNA #14 reached into the soiled linen container and started pulling out soiled linens from the bag inside the soiled linen container. CNA #14 had no covering from her wrist to her elbow area, due to wearing a short-sleeved cloth hospital gown. CNA #14 placed the soiled linens in a red bio-hazardous bag that was resting on the floor of the room. When the bag on the floor was approximately ,[DATE] filled, CNA #14 tied off the bag inside the soiled linen container and lifted it free of the container. The soiled linen container had brown smears on the inside sides of the container. CNA # 14 placed that bag on the floor next to the one that was filled by hand and then tied up the bio-bag that was on the floor. CNA #14 reached into the bio-hazardous trash container, pulled out trash and placed it in an opened bio-hazardous bag on the floor of the resident's room. After the bag on the floor was partially filled with trash, CNA #14 lifted the trash bag out of the bio-hazardous trash container, tied off both bio-hazardous bags of trash and placed new bio-hazardous bags into the linen bio-hazardous containers. LPN #11 pulled the hospital gown off over her head, removed her gloves and left the room for another bio-hazardous bag for CNA #14. LPN #11 left the room without washing her hands. LPN #11 then reentered the room, gave CNA #14 a bio-hazardous bag and left the room again, without washing her hands. CNA #14 pulled her gown off and put it into the bio-hazardous linen container. CNA #14 wore the same gloves to carry 2 contaminated trash bags down the 100-Hall to the Broadway nursing station, turned to the right down the hall to the 200-Hall, turned to the left, entered an alcove area that had a curtain covering, brushing the bags against the curtain. CNA #14 sat one bag down on the floor outside the bio-hazardous trash room. CNA #14 then got the key, which was attached to a piece of wood, from the hook outside the bio-hazardous trash room and unlocked the door with her contaminated gloves. CNA #14 opened and sat up a box, folding it into a box shape, then placed one bag of bio-hazardous trash into the box. CNA #14 then opened a second box, sat it up and placed the second bag of bio-hazardous trash into the second box. CNA #14 took off her gloves and put them under her right axillary area. CNA #14 used alcohol gel on her hands, closed the door to the bio-hazardous room and hung the key up. CNA #14 walked back to the resident's room and then put the gloves into the trash in the resident's room. CNA #14 put on new gloves and picked up the contaminated linen bags from the floor of the room. CNA #14 carried both bio-hazardous bags down the 100-Hall, to the Broadway nursing station, turned to the right down the hall to the 200-Hall, turned to the left and went to the laundry room at the end of the 200-Hall. CNA #14 reached up with her contaminated gloves to get a key from a hook outside the door and opened the laundry room. CNA #14 placed the contaminated bio-hazardous bags into a container in the laundry room. CNA #14 took her gloves off and left the laundry room. CNA #14 then went to the Broadway nursing station staff-bathroom to wash her hands. l. On [DATE] at 12:15 p.m., CNA #10 was asked, "Which residents are in isolation and what for?" CNA #10 stated, "...(Resident #3) [DIAGNOSES REDACTED] ..." CNA #10 was asked, "For [DIAGNOSES REDACTED], what do you know about it?" CNA #10 stated, "It's hard to get rid of, residents have diarrhea, stools have a foul odor." 6. Resident #1 had [DIAGNOSES REDACTED]. Aureus (MRSA). The Quarterly MDS with an ARD of [DATE] documented the resident scored 9 (8 - 12 moderate cognitive impairment) on the BIMS, had an indwelling catheter, had no infections, had two Stage II pressure ulcers and one Stage IV pressure ulcer. a. A physician order [REDACTED]." b. A physician order [REDACTED]. Then apply [MEDICATION NAME] gel (and) Calcium Alginate, cover (with) foam (dressing) (every day) til resolved." c. The laboratory report documented, "...Collected: [DATE] ...Reported [DATE] ...Culture, Urine ...(greater) than 100,000 CFU/ml (Colony Forming Units per milliliter) Pseudomonas aeruginosa ...(greater) than 100,000 CFU/ml MRS ..." d. The laboratory report documented, "...Collected: [DATE] ...Reported [DATE] ...Methicillin-Resistant Staphylococcus Aureus Screen: Source: Wound... Site: Buttocks... Light growth MRSA Methicillin-Resistant Staphylococcus Aureus (MRSA)..." e. The laboratory report documented, "...Collected: [DATE] ...Reported [DATE] ...Culture, Urine ...(greater) than 100,000 CFU/ml (Colony Forming Units per milliliter) [MEDICATION NAME] species..." f. On [DATE] at 1:45 p.m., CNA #10 exited the resident's room. CNA #10 was asked, "What is the resident in isolation for?" CNA #10 stated, "For MRSA in urine or nose." There was no sign on the door for isolation or for staff and visitors to check at the nurses' station prior to entering the resident's room. There was a 3-drawer clear plastic bin outside the room with isolation supplies. There were no isolation gowns present. g. On [DATE] at 10:43 a.m., LPN #11 and LPN #12 entered the resident's room to provide wound care. LPN #11 and LPN #12 wore cloth hospital-type gowns into the room. There were no isolation gowns in the 3-drawer clear plastic bin outside the resident's room. LPN #11 and LPN #12 were asked, "What is the resident in isolation for?" Both LPNs stated, "MRSA in urine." During irrigation of the resident's buttock wound, the solution splashed back on LPN #12. LPN #12 stated, "It splashed back on me; that's never happened before." 7. The Ecolab Product Specification Document for 20 Neutral Disinfectant Cleaner documented, "...Microbiology ...Disinfects, cleans and deodorizes ...Effective against the following pathogens..." Clostridium difficile was not listed as one of the pathogens the product was effective against. a. On [DATE] at 2:20 p.m., the Housekeeping Supervisor was asked, "Are your staff using 20 Neutral Disinfectant Cleaner in (Resident #2 and #3) 's room for residents with [DIAGNOSES REDACTED]?" The Housekeeping Supervisor stated, "They use that and sometimes they will use bleach in the bathroom and on the floor of men's bathrooms. I let them use bleach to help clean urine in some of the men's bathrooms. I'm trying to get away from bleach, so we don't use it very often." The Housekeeping Supervisor was asked, "Who monitors infection control procedures in the facility for your staff?" The Housekeeping Supervisor stated, "I don't know." The Housekeeping Supervisor was asked, "Do you or your staff know what kind of infections (Residents #2 and #3) have?" The Housekeeping Supervisor stated, "No, they never tell us." The Housekeeping Supervisor was asked, "Do you know what type of disinfectant kills [DIAGNOSES REDACTED]?" The Housekeeping Supervisor stated, "No, I can't tell you that." b. On [DATE] at 2:43 p.m., the Housekeeping Supervisor and ADON were asked "Does the 20 Neutral Disinfectant Cleaner state it is effective for [DIAGNOSES REDACTED]?" The ADON stated, "It doesn't specifically say that. It could be listed here with another name." The Housekeeping Supervisor and ADON were asked, "Do you let housekeeping know what pathogens they are dealing with for residents with infections?" The ADON stated, "No." The ADON was asked, "Who is responsible for the infection control?" The ADON stated "...the Director of Nurses, she's in Florida." c. On [DATE] at 4:00 p.m., the Administrator was asked "Did you know

Based on observation, record review and interview, the facility failed to ensure a clean surface area was used for each cleansing motion to remove fecal matter from a resident's skin, contaminated items were disinfected prior to use and contaminated supplies were not placed next to clean supplies to prevent cross-contamination and continued infection for 1 (Resident #11) of 3 (Residents # 2, #3 and #11) case mix residents who had Clostridium difficile and were dependent for incontinent care. The failed practice had the potential to affect 4 residents with Clostridium difficile who were dependent for incontinent care (with a total census of 96), according to a list provided by the Director of Nursing (DON) on 5/4/12 at 9:15 a.m. The findings are: Resident #11 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 3/6/12 documented the resident scored 10 (8 - 12 moderate cognitive impairment) on the brief interview for mental status, required extensive assistance of one person for toilet use and personal hygiene, was continent of bowel and was occasionally incontinent of bladder. a. The residents Overall Plan of Care last updated 3/14/12 documented, "...I have CDIFF (Clostridium difficile) (Returned from (Hospital) on 2/28 with it)... Goal: Because CDIFF is highly contagious, proper precautions need to be taken to prevent me from infecting others and re-infecting myself... Encourage me to wash my hands and face frequently. d. ...iv. Only 'essential' ADLs (Activities of Daily Living) will be allowed outside of the room; bathing will be given in the designated bathing room with the isolation protocols being followed for the shower team. v. Staff follows proper contact precautions while caring for me..." b. On 5/2/12 at 8:52 a.m., the resident was lying in a low bed on her back; she had scooted down, midway on top of a winged pressure relieving device. Her feet were propped up on the end of the bed frame. The resident was wearing a hospital gown and bilateral heel protectors; there was fecal matter all over the gown, the heel protectors, as well as on her legs, feet, arms, hands and under her fingernails. The feces was all over her flat sheet and fitted sheet and had penetrated through to the top of the mattress. The resident was touching both sides of her face and up into her hair and touching her oxygen nasal canula with her feces covered hands and fingers. c. On 5/2/12 at 9:02 a.m., incontinent care was provided by Certified Nursing Assistant (CNA) #1 and CNA #2. CNA #2 removed the resident's soiled heel protectors and blanket and placed them into a red biohazard plastic bag on top of the over bed table. The resident was lying on her right side, in a fetal position, with smeared loose feces all over her from head-to-toe. CNA #1 took a washcloth dampened with warm water and peri wash and began cleaning the resident's hands, not changing position of the cloth with each wipe. CNA #1 did not clean under the resident's nails, which were also covered with feces. CNA #2 took another cloth dampened with warm water and peri wash and began cleaning the resident's feet and legs; Both soiled cloths were disposed of in the red biohazard bag on top of the over bed table. CNA #2 then took another cloth and cleaned the resident's right hand and down the mid forearm. The CNA then disposed of the cloth into the red biohazard bag on top of the over bed table. CNA #1 then took another cloth and began cleaning the back of the resident's left thigh, hip and the left side of the thigh. The CNA then tossed the cloth into the red biohazard bag. Both CNA #1 and CNA #2 continued cleansing feces from the resident, tossing the contaminated cloths into the bag on the over bed table. CNA #2 took a clean fitted-sheet, and dropping the edge onto the soiled fitted sheet, continued placing it on the bed that had been soiled with feces. The mattress was not cleaned. While CNA #1 left the room to retrieve more supplies, CNA #2 took the resident's feces-soiled gown and placed the gown with the soiled side down, over the resident, to cover her from her breast to her knees. d. On 5/2/12 at 9:37 a.m., immediately after care was completed, CNA #2 was asked if she cleansed the mattress that was soiled by the feces before placing the clean fitted sheet on the mattress. She stated, "No." CNA #2 pushed the over bed table over causing the soiled blanket and heel protectors to fall onto the floor. CNA #2 picked up the soiled blanket and heel protectors and placed them back into the red biohazard bag. The CNA then placed the bag back on top of the over bed table, next to two clean under pads, a clean plastic bag, a nail file and a wooden pick. The floor was not cleaned after the contaminated items fell on it. e. On 5/2/12 at 9:53 a.m., the Lead CNA was asked who was responsible for training the CNAs regarding incontinent care for a resident that had Clostridium difficile. She stated, "Myself and LPN #2. We have trained them on isolation precautions, but we have not checked them off regarding isolation precautions during peri care." f. On 5/2/12 at 11:10 a.m., when asked when the area of a cloth should be changed during incontinent care the DON stated, "CNAs ...they should change positions of the wipe/wet cloth with each swipe..." The DON was asked about contamination of items and what should be done about those contaminated items. The DON stated, "...they should disinfect all equipment/surface areas after being in contact with the contaminated feces..." When asked what should be done if a resident had fecal matter all over both hands and under their fingernails, the DON stated, "They should have not attempted to clean her up in bed since she had the feces all over her; they should have taken her to the isolation shower room..."

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure effective interventions were promptly developed/ implemented and reviewed for effectiveness to prevent resident to resident altercations and reduce the risk of serious injury for 4 (Resident #2, #3, #4, and #5) of 5 case mix residents (Resident #1 - #5) who were subjected to aggressive behaviors by Resident #1. The failed practice resulted in Immediate Jeopardy which caused or was likely to cause serious harm, injury or death to Resident #2, 3, 4 and 5 who resided on the 300 hall and Resident #1 who repeatedly displayed aggressive physical behaviors toward residents and staff and was likely to affect 35 residents who resided on the 300 hall and 33 residents who resided on the 200 hall according to the Facility's Roster Matrix dated 12/7/11. The facility was informed of the Immediate Jeopardy on 12/8/11 at 4:28 p.m. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The MDS with an assessment reference date of 11/18/11 documented the resident scored 11 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status. An Incident and Accident (I/A) Report dated 10/16/11 at 3:30 p.m. documented, "(Resident #1) was in hallway outside of Rm (Room number) when (Resident #5) from Station 3 was in a wheelchair bumped into (Resident #1). (Resident #1) started hitting (Resident #5)... no injuries or marks on either resident. ...Steps to prevent reoccurrence: Supervision ...family refused outside tx. (treatment)." A witness statement form dated 10/16/11 at 3:55 p.m. signed by (ex-housekeeping employee) documented, "(Resident #5) accidently bumped into (Resident #1) and (Resident #1) started to repeatedly hit (Resident #5) then (Resident #1) walked off." 2. Resident #2 had [DIAGNOSES REDACTED]. The MDS with an assessment reference date of 11/04/11 documented the resident scored 9 (8-12 indicated moderately impaired) on the Brief Interview for Mental Status. An Incident and Accident (I/A) Report dated 11/13/11 at 10:45 a.m. documented, "(Resident #1) was observed by staff hitting another res (Resident #2) to the head. ...Steps to prevent reoccurrence: Diversional Activity, frequent walking. Family approached about possible hospice eval. (evaluation) for Tx. of Dementia for pain control. Family refused. UA (urinalysis) collected, UTI tx. given." A witness statement form dated 11/14/11 at 7:30 a.m. documented, "(Resident #1) was in (Resident #7's) room, then left (Resident #2) entered room. Resident #1 came back in stood behind (Resident #2) and was digging in her hair. (Resident #2) took (Resident #1's) hand and put it up and tried to get (Resident #1) to leave her alone. Then (Resident #1) hauled off and slapped (Resident #2) in the right arm per (Resident #7)." 3. Resident #4 had [DIAGNOSES REDACTED]. The MDS with as assessment reference date of 11/04/11 documented the resident scored 10 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status. A Resident Grievances/Complaint Form dated 12/5/11 stated by Resident #4 documented, "(Resident #1) came in, (Resident #3) got up and tried to get her out, but she is so strong. She hit at her and smashed her hand. That's all I saw, but it was very scary. Something has to be done. I do not want any part of her. She is too violent and scares everyone. She should not be here." 4. Resident #3 had [DIAGNOSES REDACTED]. The MDS with an assessment reference date of 12/2/11 documented the resident scored 15 (13-15 indicated cognitively intact) on the Brief Interview for Mental Status. a. An Incident and Accident (I/A) Report dated 12/4/11 at 8:30 a.m. documented, "(Resident #1) was in (Resident #3's room number). (Resident #3) assist this (Resident #1) out her room. (Resident #1) closed door on (Resident #3) left hand. no injuries noted to this resident. ...Steps to prevent reoccurrence: Redirecting, diversional activities. No injuries noted to Resident, Residents to be separated. DON spoke with Doctor. Namenda increased to 5mg (milligrams) BID (twice a day) and Risperdal increased to .5mg every day." b. The Resident Grievances/Complaint Form dated 12/5/11 stated by Resident #3 documented, "Roomate and I were in chairs resting. Opened eyes and Resident #1 was standing in front of door. (Resident #1) closed door and stared at my roommate with a wild look in her eyes. I jumped up to get between them because my roommate was so scared. I spoke very nice to her and told her she didn't need to be in here and tried to guide her out of room. I got door open a little and (Resident #1) smashed my hand hard in the door. I thought it was broken. Then began striking me in upper body. I used my hand to pertect myself. I was so scared. Somehow my knee ended up in door and (Resident #1) closed it in door. I will need to have it x-rayed because something is not right. This is not right I am scared. (Resident #1) took a few steps back I was able to get out and close the door. I then went down the hall to get help, but I wasn't sure I would make it because I was hurting so bad. I can feel my BP (blood pressure) rising just think of how scary it was. She (Resident #1) should be confined so she will not be able to do that. The way I really feel is she shouldn't be here." A Physician's telephone order for Resident #1 documented a (T.O.) dated 12/5/11 documented, "...start Namenda 5mg BID (twice daily) , ...Start Risperdal .5mg everyday Dx. (diagnoses) Anxiety." On 12/6/11 a T.O. documented, "Seroquel 12.5mg now and BID Dx. Depression..." 5. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 11/25/11 documented the resident had short and long term memory problems, had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status, status, required supervision with ambulation, had verbal and physical behavior symptoms, refused care occurring 1 to 3 days in the past 7 days and exhibited wandering behaviors that occurred daily. a. An Incident and Accident (I/A) Report dated 7/10/11 at 4:00 p.m. documented, "Res (Resident #1) was in Rm. (room number). Knocked off some items from TV (television) ie; vase and it broke. Went to get a sash from TV when Res (Resident #6) told her no and to get out of her room. As Res (Resident #6) grabbed her sash Res. (Resident #1) slapped Res (Resident #6) and Res (Resident #6) states I slapped her back. ...Intervention: monitor R (resident) more closely. no injuries note to resident. Geri Psyche consult ordered. Family refused." b. An Incident and Accident (I/A) Report dated 8/4/11 at 6:30 a.m. documented, "Resident was being assisted with getting dressed when CNA #1 attempted to change her shirt. She hit the CNA on the arm. Steps to Prevent Reoccurrence: Medicate accordingly." c. An Incident and Accident (I/A) Report dated 8/16/11 at 8:00 a.m. documented, "Speech Therapist (ST) was by bathroom on Section 3 when she seen (Resident #1) in the bathroom with (noncasemix male resident). He was telling (Resident #1) get out that he was going to use the restroom. So ST grabbed (Resident #1's) hand and tried to remove her from the bathroom and (Resident #1) would not go. So then ST attempted again by putting her hand on (Resident #1) bicept and pulled her away from door. (Resident #1) then slapped her arm and left side of face. ...Steps to Prevent Reoccurrence: Keep continuing to redirect." A witness statement form dated 8/23/11 at 9:55 a.m. signed by the ST documented, "...I was walking from Section 3 toward dining room when I heard a man's voice holler "help". I found (non casemix male resident) attempting to close the bathroom door in the alcove just past nursing desk. (Resident #1) was holding onto the bathroom door and not allowing male resident to close door. I asked (Resident #1) to let him close the door, she then tried to go into the bathroom with him, put her foot in the door. I asked her again, taking her hand to redirect her. She continued. I then had to take her hands, place my hands on her mid-arms above the elbows, and move her away from door. (Non casemix male resident) closed the door. She then pulled loose and hit me on the left forearm and left face cheek. She then went for the bathroom door again. You could hear male resident going to the bathroom. I took her by the arm and asked her to come with me, putting myself between her and the bathroom door; she then walk away and immediately reported incident to Section 2 nurse." d. The care plan dated 8/31/11 documented, "Potential for confrontations with other residents/staff d/t (due to) invasive/combative behaviors. 11/3011 - (Resident #1) has had numerous encounters with other residents and staff. Her behavior was worse with the development of her UTI (Urinary Tract Infection). She is being treated for [REDACTED]. They're unwilling to consider alternative placement or an outpatient psychiatric rehab for behaviors. Hospice care was discussed with the family but the family is unwilling to meet with Hospice at this time. We will continue to monitor and "diffuse" the combative nature as it occurs. Approaches: Quickly divert (Resident #1) out of other resident's rooms as she will break things, move items, or eat their food. Ensure incident reports are filled out if something occurs. Educate fell ow residents of (Resident #1's) mentality; encourage them to be patient with her as she does not realize when she's being invasive. If you cannot all remove (Resident #1) from a situation, many times, a male aid or other male employee is more effective at getting her to come away than females." e. The Physician's Progress Note dated 9/6/11 documented, "Chief Concerns/Complaints: Since the most recent changes have been made, she seems to more alert and more pleasant. She is up and about. She is quite active. However, she still has episodes of getting a little bit agitated and upset. She does have a little bit of combativeness off and on, but the nurses are pretty well able to control it..." f. The Nurse Aide's Information Sheet (CNA care plan) dated 10/26/11 documented, "...Behavior: wanderer, combative at times..." There was no documented interventions on this form to address these behaviors. g. A Physician's Progress Note dated 11/22/11 documented, "...Chief Concern/Complaints: The patient has two problems. She had some behavior problems and a urine culture was done... ...Her behavior has actually been doing fairly well. ...She does suffer from ...Dementia with Confusion and she has had some wandering behavior in the past..." h. The Care plan Conference Meeting Notes dated 11/30/11 documented, "...Aides are tired of her behaviors - want it known that they are concerned and doing the best they can to care for her. SSD (Social Service Director) to continue to work with family." i. The facility's "Abuse Investigation and Reporting Nursing Facility Policy" received from Director of Nursing (DON) on 12/7/11 documented, "VI. Patient to Patient Incidents: ...the accused patient will not be allowed to visit other patient rooms unattended until his or her behavior is stabilized." j. On 12/8/11 Certified Nursing Assistants (CNA) who provided direct patient care for Resident #1 were asked about the behavior of Resident #1. These were there statements: 1) On 12/8/11 at 9:05 a.m., CNA #2 stated Resident #1 is always confused and wanders all over the whole facility. She tends to go in and out of resident rooms, "it's random." CNA #2 indicated that Resident #1's behaviors were unpredictable. CNA #2 was asked if the facility has had any formal inservices to address interventions with staff to prevent altercations with other residents. CNA #2 stated, "To be honest, not that I can remember." She was asked do the staff have a hard time keeping up with Resident #2. CNA #2 stated, "Sometimes we go crazy looking for her to keep an eye on her. If we are in another resident's room, we can't keep an eye on her." CNA #2 stated, "She (Resident #1) also has tendency to carry her butter knife around. We get it from her, but she will get it off another resident's plate." CNA #2 was asked based on the resident's behavior being so unpredictable, did she think at anytime Resident #1 could hurt other residents in the facility. CNA #2 stated, "Yes." 2) On 12/8/11 at 9:30 a.m., CNA #3 stated Resident #1 wanders in and out of residents ' room most of time. My nurse says that if 2 people go in and provide care to Resident #1, it makes her feel defensive, but 1 providing care is less intimidating to her. CNA #3 was asked if the facility has had any formal inservices to address interventions with staff to prevent altercations with other residents. CNA #3 stated, "No. ...At one point, a few months ago, (CNA #4) she was assigned to her (Resident #1). She was to write down everything that she did. They watched her for about a week. I think they were trying to find out what activities she could do. ...We have a hard time watching her, it's very hard to keep an eye on her. We got to care for other residents. ...She's very unpredictable, It's crazy. I'm scared I don't want her hurting others or those residents hurting her. It's a terrible ordeal." k. On 12/8/11 Licensed Practical Nurses (LPN) who provided direct patient care for Resident #1 were asked about the behavior of Resident #1. These were there statements: 1) On 12/8/11 at 10:05 p.m., LPN #1 stated, "(Resident #1) needs more closely monitored. She likes to wander, get into other resident's stuff, and get on my medication cart. She's a little pack rat. She gets aggressive, not to me yet. She has toward other staff and residents. ...a bunch of people are scared of (Resident #1). She was in a wheelchair because we increased her medications because of the incident that happen this week (12/4/11). (Resident #1's) behaviors are very unpredictable. She has full range of the facility, she is random whose room she will go into." LPN #1 was asked if Resident #1 ever had a psych evaluation. LPN #1 stated it was never done. LPN #1 was questioned about an intervention, providing diversional activities. LPN #1 stated, "But with her (Resident #1) attention span, we can't do that. ..We can't keep an eye on her. We're not 1 on 1. The staff here have a hard time keeping up with her, it gives us a scare... A couple of days ago, (Resident #1) was in the dining room. She had a butter knife in her hand. I was passing medications, I told the other LPN she's got a knife. The LPN told me, "You get it." There have been several times she's been walking around with a knife." LPN #1 stated, "...I was really pushing for a Geri psych eval., but the resident's daughter refused." LPN #1 was asked if she felt Resident #1's behaviors were putting herself and other resident's at risk for harm. LPN #1 stated, "Yes." LPN #1 indicated there has been no formal inservice regarding Resident #'1's behaviors. 2) On 12/8/11 at 11:10 a.m., LPN #2 stated , " Resident #1 is always grabbing things, she likes to take things, leave things in other resident rooms, like trading things. If you try to take things away from her she can become combative, swat at you, pinch you. " LPN #2 was asked about the incident that occurred on 12/4/11. LPN #2 stated, "(Resident #3's) hand was very red. She was really crying. (Resident #3) stated, ' I shouldn't have to be afraid in my own room ' and she's right." LPN #2 stated Resident #1's behaviors are unpredictable. LPN #2 was asked if she felt the facility failing to intervene appropriately is putting Resident #1 and other residents at risk for harm. LPN #2 stated, "Yes, residents say they are afraid of her. You have to watch her. She takes their belongings, if they try to take back their things, they are afraid of getting hit." LPN #2 stated she has not attended any formal inservicing regarding Resident #1's behaviors. LPN #2 indicated that staff has a hard time monitoring the resident because she wanders everywhere. Staff doesn't know where she's at (in the facility) at any given time, she walks. LPN #2 stated she was a little intimidated because of who the resident is (the Administrator's mother-n-law), ..."I've heard very important people have been trying to get him to do something about her." LPN #2 was asked who are the very important people? She stated, "The DON." l. On 12/8/11 at 11:50 a.m. during an interview, the DON was asked if the facility has had a formal inservice regarding Resident #1's behaviors. The DON stated, "No formal inservice, but we've tried to talk to the CNAs as the incidents occur. Nothing has been signed." The DON stated the facility has discussed with the family a geri psych evaluation, but they have refused. "We asked (Administrator) about 1 on 1 with Resident #1, we've recommended Hospice, but they refuse. A few months ago (around July), I had a CNA with Resident #1 on day shift and evening shift to monitor her 1 on 1 to see if we could figure out what was triggering her behaviors, a pattern. But there was none, nothing that set her off, there were no target residents or staff. We tried various medication changes but they're always getting decreased because the family wanted it back the way it was. Residents are afraid of her, staff is afraid of her. They all feel violated. (Resident #1) can go anywhere in the building, rooms and offices. The staff is frustrated. When she hits staff, they don't even fill out I/As any more because they think what good does it do." m. On 12/8/11 at 1:25 p.m., during an interview, the Assistant Director of Nursing (ADON) was asked what has the facility done to prevent Resident #1 wandering in and out of other resident rooms and resident to resident altercations involving Resident #1. The ADON stated, "We have done medication changes, we've done lab and UA, we've recommended behavior health unit and Hospice. But the family has refused. (Administrator) said that (Resident #1's daughter) stated the resident ' has lost her personality and wanted the medications reduced a little, they're too strong. ' I even recommended, half doors, but that didn't fly too good." The ADON also stated there had not been a formal inservice, but " We talked to certain ones and told staff on how to approach the resident. " The ADON stated, "It is difficult to keep up with (Resident #1). We've done 15 minute rounds, 20 minute rounds. (DON) suggested to (Administrator) to do 1 on 1, but nothing else was ever said about it. We've suggested till we don't know what to do. We suggested to (Administrator) a mini Alzheimer's Unit. (Administrator) said, ' They have to have an outside area to roam. ' Staff suggested how to develop an Alzheimer's Unit (within the facility). But (Administrator) didn't want to get into a unit right now." n. On 12/8/11 at 4:00 p.m., during an interview, the Administrator (Resident #1's son-n-law) was asked if the facility had any kind of action plan, if the facility had involved Quality Assurance and Assessment Committee with Resident #1's behaviors. He stated, "There has been discussion on what to do. The resident will not be sent out to a psych facility because we will not change (Resident #1's) behaviors. There's nothing to change. She has no memory. There's nothing there. The medication change is a shot in the dark and is being monitored closely. I see Hospice, in her case, as medication, medication, medication, just put her in the ground. She doesn't just walk up to residents and hit them. She's always provoked. Just like the deal with (Resident #3). (Resident #3) gets up and tries to open her door which agitated (Resident #1). And I (Administrator) said (Resident #1), what should you have done? She should've used her call light." The Administrator was informed that the other residents in the facility have rights too. Resident #3 should not have to worry about someone coming in her room and taking her belongings. It is not up to other residents to resolve the issue. The Administrator was informed of the numerous episodes of resident to resident altercations from 7/10/11 through 12/4/11 and asked why the physician's orders [REDACTED].#1's) medications and initiate Seroquel, why did it take so long to intervene? The Administrator stated, "...I don't have an answer." o. As of 12/9/11 at 11:00 a.m., no documentation had been provided by the facility regarding an action plan or quality assurance plan to prevent reoccurrence of resident to resident altercations involving Resident #1's behaviors. 6. On 12/8/11 at 6:45 p.m., the immediate jeopardy was removed and the scope and severity reduced to an "H" when the facility initiated the following plan of removal: a. (ADON) began 1 on 1 supervision of Resident #1 as of 12/8/11 at 16:45 by assigning (CNA #5) to her care. Instructions on monitoring included, but not limited to CNA must be within 6 - 12 feet of Resident at all times, documentation on current activity, behavior, ADL assistance, reporting any inappropriate behavior, and intervening if this Resident attempts to enter any other Residents room. b. 12/8/11 at 1645 (CNA #5) started every 15 minute documentation on Resident #1. c. 12/8/11 at 1900 Administrator provided an oral inservice to all employees present at the Christmas party on 1 on 1 care, monitoring for resident behavior problems, reporting behavior problems to appropriate staff members. d. 12/8/11 at 2000 Assistant Director of Nursing provided in-servicing on 1 on 1 care, behavioral problems and reporting to (CNA #6) who was taking over the 1 on 1 care of Resident #1. e. 12/9/11 at 0700 (DON) began in-servicing staff members on 1 on 1 care, monitoring and reporting Residents for behavior problems, and intervening if inappropriate behavior noted. f. 12/9/11 an in-service was scheduled for 12/12/11 at 7am, 2pm, and 3pm to in-service all staff members on 1 on 1 care, monitoring residents for behavioral problems, reporting and intervening if any behavioral problems are noted. g. ADON will ensure the 1 on 1 monitoring will continue indefinitely or until there is a change of condition in this resident that will prevent her from harming any other resident by scheduling a specific CNA for each shift. h. If at anytime another resident becomes violent, 1 on 1 care will be instituted immediately until the behaviors are resolved.

Complaint # was substantiated (all or in part) with these findings: Based on record review and interview, the facility Administration failed to maintain and implement operational policies and procedures to meet residents' needs in compliance with federal requirements as evidenced by facility's failure to ensure effective interventions were promptly developed/ implemented and reviewed for effectiveness to prevent resident to resident altercations and reduce the risk of serious injury for 4 (Resident #2, #3, #4, and #5) of 5 case mix residents (Resident #1 - #5) who were subjected to aggressive behaviors by Resident #1. The failed practice resulted in Immediate Jeopardy which caused or was likely to cause serious harm, injury or death to Resident #2, 3, 4 and 5 who resided on the 300 hall and Resident #1 who repeatedly displayed aggressive physical behaviors toward residents and staff and was likely to affect 35 residents who resided on the 300 hall and 33 residents who resided on the 200 hall according to the Facility's Roster Matrix dated 12/7/11. The facility was informed of the Immediate Jeopardy on 12/8/11 at 4:28 p.m. The findings are: 1. The Administrator's Job Description documented, "Job Summary: "...Develop, maintain and implement operational policies and procedures to meet residents' needs in compliance with federal, state and local requirements. 33. Observed all facility policies and procedures relating to residents' rights. 35. Assume responsibility for identification, investigation and follow up on concerns identified in the facility Quality Indicator report. 36. Assume responsibility for implementation of an effective Quality Assurance program. 40. Consistently work cooperatively with residents, ...facility staff..." 2. Resident #5 had [DIAGNOSES REDACTED]. The MDS with an assessment reference date of 11/18/11 documented the resident scored 11 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status. An Incident and Accident (I/A) Report dated 10/16/11 at 3:30 p.m. documented, "(Resident #1) was in hallway outside of Rm (Room number) when (Resident #5) from Station 3 was in a wheelchair bumped into (Resident #1). (Resident #1) started hitting (Resident #5)... no injuries or marks on either resident. ...Steps to prevent reoccurrence: Supervision ...family refused outside tx. (treatment)." A witness statement form dated 10/16/11 at 3:55 p.m. signed by (ex-housekeeping employee) documented, "(Resident #5) accidently bumped into (Resident #1) and (Resident #1) started to repeatedly hit (Resident #5) then (Resident #1) walked off." 3. Resident #2 had [DIAGNOSES REDACTED]. The MDS with an assessment reference date of 11/04/11 documented the resident scored 9 (8-12 indicated moderately impaired) on the Brief Interview for Mental Status. An Incident and Accident (I/A) Report dated 11/13/11 at 10:45 a.m. documented, "(Resident #1) was observed by staff hitting another res (Resident #2) to the head. ...Steps to prevent reoccurrence: Diversional Activity, frequent walking. Family approached about possible hospice eval. (evaluation) for Tx. of Dementia for pain control. Family refused. UA (urinalysis) collected, UTI tx. given." A witness statement form dated 11/14/11 at 7:30 a.m. documented, "(Resident #1) was in (Resident #7's) room, then left (Resident #2) entered room. Resident #1 came back in stood behind (Resident #2) and was digging in her hair. (Resident #2) took (Resident #1's) hand and put it up and tried to get (Resident #1) to leave her alone. Then (Resident #1) hauled off and slapped (Resident #2) in the right arm per (Resident #7)." 4. Resident #4 had [DIAGNOSES REDACTED]. The MDS with as assessment reference date of 11/04/11 documented the resident scored 10 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status. A Resident Grievances/Complaint Form dated 12/5/11 stated by Resident #4 documented, "(Resident #1) came in, (Resident #3) got up and tried to get her out, but she is so strong. She hit at her and smashed her hand. That's all I saw, but it was very scary. Something has to be done. I do not want any part of her. She is too violent and scares everyone. She should not be here." 5. Resident #3 had [DIAGNOSES REDACTED]. The MDS with an assessment reference date of 12/2/11 documented the resident scored 15 (13-15 indicated cognitively intact) on the Brief Interview for Mental Status. a. An Incident and Accident (I/A) Report dated 12/4/11 at 8:30 a.m. documented, "(Resident #1) was in (Resident #3's room number). (Resident #3) assist this (Resident #1) out her room. (Resident #1) closed door on (Resident #3) left hand. no injuries noted to this resident. ...Steps to prevent reoccurrence: Redirecting, diversional activities. No injuries noted to Resident, Residents to be separated. DON spoke with Doctor. [MEDICATION NAME] increased to 5mg (milligrams) BID (twice a day) and [MEDICATION NAME] increased to .5mg every day." b. The Resident Grievances/Complaint Form dated 12/5/11 stated by Resident #3 documented, "Roomate and I were in chairs resting. Opened eyes and Resident #1 was standing in front of door. (Resident #1) closed door and stared at my roommate with a wild look in her eyes. I jumped up to get between them because my roommate was so scared. I spoke very nice to her and told her she didn't need to be in here and tried to guide her out of room. I got door open a little and (Resident #1) smashed my hand hard in the door. I thought it was broken. Then began striking me in upper body. I used my hand to pertect myself. I was so scared. Somehow my knee ended up in door and (Resident #1) closed it in door. I will need to have it x-rayed because something is not right. This is not right I am scared. (Resident #1) took a few steps back I was able to get out and close the door. I then went down the hall to get help, but I wasn't sure I would make it because I was hurting so bad. I can feel my BP (blood pressure) rising just think of how scary it was. She (Resident #1) should be confined so she will not be able to do that. The way I really feel is she shouldn't be here." A Physician's telephone order for Resident #1 documented a (T.O.) dated 12/5/11 documented, "...start [MEDICATION NAME] 5mg BID (twice daily) , ...Start [MEDICATION NAME] .5mg everyday Dx. (diagnoses) Anxiety." On 12/6/11 a T.O. documented, "[MEDICATION NAME] 12.5mg now and BID Dx. Depression..." 6. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 11/25/11 documented the resident had short and long term memory problems, had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status, status, required supervision with ambulation, had verbal and physical behavior symptoms, refused care occurring 1 to 3 days in the past 7 days and exhibited wandering behaviors that occurred daily. a. An Incident and Accident (I/A) Report dated 7/10/11 at 4:00 p.m. documented, "Res (Resident #1) was in Rm. (room number). Knocked off some items from TV (television) ie; vase and it broke. Went to get a sash from TV when Res (Resident #6) told her no and to get out of her room. As Res (Resident #6) grabbed her sash Res. (Resident #1) slapped Res (Resident #6) and Res (Resident #6) states I slapped her back. ...Intervention: monitor R (resident) more closely. no injuries note to resident. Geri Psyche consult ordered. Family refused." b. An Incident and Accident (I/A) Report dated 8/4/11 at 6:30 a.m. documented, "Resident was being assisted with getting dressed when CNA #1 attempted to change her shirt. She hit the CNA on the arm. Steps to Prevent Reoccurrence: Medicate accordingly." c. An Incident and Accident (I/A) Report dated 8/16/11 at 8:00 a.m. documented, "Speech Therapist (ST) was by bathroom on Section 3 when she seen (Resident #1) in the bathroom with (noncasemix male resident). He was telling (Resident #1) get out that he was going to use the restroom. So ST grabbed (Resident #1's) hand and tried to remove her from the bathroom and (Resident #1) would not go. So then ST attempted again by putting her hand on (Resident #1) bicept and pulled her away from door. (Resident #1) then slapped her arm and left side of face. ...Steps to Prevent Reoccurrence: Keep continuing to redirect." A witness statement form dated 8/23/11 at 9:55 a.m. signed by the ST documented, "...I was walking from Section 3 toward dining room when I heard a man's voice holler "help". I found (non casemix male resident) attempting to close the bathroom door in the alcove just past nursing desk. (Resident #1) was holding onto the bathroom door and not allowing male resident to close door. I asked (Resident #1) to let him close the door, she then tried to go into the bathroom with him, put her foot in the door. I asked her again, taking her hand to redirect her. She continued. I then had to take her hands, place my hands on her mid-arms above the elbows, and move her away from door. (Non casemix male resident) closed the door. She then pulled loose and hit me on the left forearm and left face cheek. She then went for the bathroom door again. You could hear male resident going to the bathroom. I took her by the arm and asked her to come with me, putting myself between her and the bathroom door; she then walk away and immediately reported incident to Section 2 nurse." d. The care plan dated 8/31/11 documented, "Potential for confrontations with other residents/staff d/t (due to) invasive/combative behaviors. 11/3011 - (Resident #1) has had numerous encounters with other residents and staff. Her behavior was worse with the development of her UTI (Urinary Tract Infection). She is being treated for [REDACTED]. They're unwilling to consider alternative placement or an outpatient psychiatric rehab for behaviors. Hospice care was discussed with the family but the family is unwilling to meet with Hospice at this time. We will continue to monitor and "diffuse" the combative nature as it occurs. Approaches: Quickly divert (Resident #1) out of other resident's rooms as she will break things, move items, or eat their food. Ensure incident reports are filled out if something occurs. Educate fell ow residents of (Resident #1's) mentality; encourage them to be patient with her as she does not realize when she's being invasive. If you cannot all remove (Resident #1) from a situation, many times, a male aid or other male employee is more effective at getting her to come away than females." e. The Physician's Progress Note dated 9/6/11 documented, "Chief Concerns/Complaints: Since the most recent changes have been made, she seems to more alert and more pleasant. She is up and about. She is quite active. However, she still has episodes of getting a little bit agitated and upset. She does have a little bit of combativeness off and on, but the nurses are pretty well able to control it..." f. The Nurse Aide's Information Sheet (CNA care plan) dated 10/26/11 documented, "...Behavior: wanderer, combative at times..." There was no documented interventions on this form to address these behaviors. g. A Physician's Progress Note dated 11/22/11 documented, "...Chief Concern/Complaints: The patient has two problems. She had some behavior problems and a urine culture was done... ...Her behavior has actually been doing fairly well. ...She does suffer from ...Dementia with Confusion and she has had some wandering behavior in the past..." h. The Care plan Conference Meeting Notes dated 11/30/11 documented, "...Aides are tired of her behaviors - want it known that they are concerned and doing the best they can to care for her. SSD (Social Service Director) to continue to work with family." i. The facility's "Abuse Investigation and Reporting Nursing Facility Policy" received from Director of Nursing (DON) on 12/7/11 documented, "VI. Patient to Patient Incidents: ...the accused patient will not be allowed to visit other patient rooms unattended until his or her behavior is stabilized." j. On 12/8/11 Certified Nursing Assistants (CNA) who provided direct patient care for Resident #1 were asked about the behavior of Resident #1. These were there statements: 1) On 12/8/11 at 9:05 a.m., CNA #2 stated Resident #1 is always confused and wanders all over the whole facility. She tends to go in and out of resident rooms, "it's random." CNA #2 indicated that Resident #1's behaviors were unpredictable. CNA #2 was asked if the facility has had any formal inservices to address interventions with staff to prevent altercations with other residents. CNA #2 stated, "To be honest, not that I can remember." She was asked do the staff have a hard time keeping up with Resident #2. CNA #2 stated, "Sometimes we go crazy looking for her to keep an eye on her. If we are in another resident's room, we can't keep an eye on her." CNA #2 stated, "She (Resident #1) also has tendency to carry her butter knife around. We get it from her, but she will get it off another resident's plate." CNA #2 was asked based on the resident's behavior being so unpredictable, did she think at anytime Resident #1 could hurt other residents in the facility. CNA #2 stated, "Yes." 2) On 12/8/11 at 9:30 a.m., CNA #3 stated Resident #1 wanders in and out of residents ' room most of time. My nurse says that if 2 people go in and provide care to Resident #1, it makes her feel defensive, but 1 providing care is less intimidating to her. CNA #3 was asked if the facility has had any formal inservices to address interventions with staff to prevent altercations with other residents. CNA #3 stated, "No. ...At one point, a few months ago, (CNA #4) she was assigned to her (Resident #1). She was to write down everything that she did. They watched her for about a week. I think they were trying to find out what activities she could do. ...We have a hard time watching her, it's very hard to keep an eye on her. We got to care for other residents. ...She's very unpredictable, It's crazy. I'm scared I don't want her hurting others or those residents hurting her. It's a terrible ordeal." k. On 12/8/11 Licensed Practical Nurses (LPN) who provided direct patient care for Resident #1 were asked about the behavior of Resident #1. These were there statements: 1) On 12/8/11 at 10:05 p.m., LPN #1 stated, "(Resident #1) needs more closely monitored. She likes to wander, get into other resident's stuff, and get on my medication cart. She's a little pack rat. She gets aggressive, not to me yet. She has toward other staff and residents. ...a bunch of people are scared of (Resident #1). She was in a wheelchair because we increased her medications because of the incident that happen this week (12/4/11). (Resident #1's) behaviors are very unpredictable. She has full range of the facility, she is random whose room she will go into." LPN #1 was asked if Resident #1 ever had a psych evaluation. LPN #1 stated it was never done. LPN #1 was questioned about an intervention, providing diversional activities. LPN #1 stated, "But with her (Resident #1) attention span, we can't do that. ..We can't keep an eye on her. We're not 1 on 1. The staff here have a hard time keeping up with her, it gives us a scare... A couple of days ago, (Resident #1) was in the dining room. She had a butter knife in her hand. I was passing medications, I told the other LPN she's got a knife. The LPN told me, "You get it." There have been several times she's been walking around with a knife." LPN #1 stated, "...I was really pushing for a Geri psych eval., but the resident's daughter refused." LPN #1 was asked if she felt Resident #1's behaviors were putting herself and other resident's at risk for harm. LPN #1 stated, "Yes." LPN #1 indicated there has been no formal inservice regarding Resident #'1's behaviors. 2) On 12/8/11 at 11:10 a.m., LPN #2 stated , " Resident #1 is always grabbing things, she likes to take things, leave things in other resident rooms, like trading things. If you try to take things away from her she can become combative, swat at you, pinch you. " LPN #2 was asked about the incident that occurred on 12/4/11. LPN #2 stated, "(Resident #3's) hand was very red. She was really crying. (Resident #3) stated, ' I shouldn't have to be afraid in my own room ' and she's right." LPN #2 stated Resident #1's behaviors are unpredictable. LPN #2 was asked if she felt the facility failing to intervene appropriately is putting Resident #1 and other residents at risk for harm. LPN #2 stated, "Yes, residents say they are afraid of her. You have to watch her. She takes their belongings, if they try to take back their things, they are afraid of getting hit." LPN #2 stated she has not attended any formal inservicing regarding Resident #1's behaviors. LPN #2 indicated that staff has a hard time monitoring the resident because she wanders everywhere. Staff doesn't know where she's at (in the facility) at any given time, she walks. LPN #2 stated she was a little intimidated because of who the resident is (the Administrator's mother-n-law), ..."I've heard very important people have been trying to get him to do something about her." LPN #2 was asked who are the very important people? She stated, "The DON." l. On 12/8/11 at 11:50 a.m. during an interview, the DON was asked if the facility has had a formal inservice regarding Resident #1's behaviors. The DON stated, "No formal inservice, but we've tried to talk to the CNAs as the incidents occur. Nothing has been signed." The DON stated the facility has discussed with the family a geri psych evaluation, but they have refused. "We asked (Administrator) about 1 on 1 with Resident #1, we've recommended Hospice, but they refuse. A few months ago (around July), I had a CNA with Resident #1 on day shift and evening shift to monitor her 1 on 1 to see if we could figure out what was triggering her behaviors, a pattern. But there was none, nothing that set her off, there were no target residents or staff. We tried various medication changes but they're always getting decreased because the family wanted it back the way it was. Residents are afraid of her, staff is afraid of her. They all feel violated. (Resident #1) can go anywhere in the building, rooms and offices. The staff is frustrated. When she hits staff, they don't even fill out I/As any more because they think what good does it do." m. On 12/8/11 at 1:25 p.m., during an interview, the Assistant Director of Nursing (ADON) was asked what has the facility done to prevent Resident #1 wandering in and out of other resident rooms and resident to resident altercations involving Resident #1. The ADON stated, "We have done medication changes, we've done lab and UA, we've recommended behavior health unit and Hospice. But the family has refused. (Administrator) said that (Resident #1's daughter) stated the resident ' has lost her personality and wanted the medications reduced a little, they're too strong. ' I even recommended, half doors, but that didn't fly too good." The ADON also stated there had not been a formal inservice, but " We talked to certain ones and told staff on how to approach the resident. " The ADON stated, "It is difficult to keep up with (Resident #1). We've done 15 minute rounds, 20 minute rounds. (DON) suggested to (Administrator) to do 1 on 1, but nothing else was ever said about it. We've suggested till we don't know what to do. We suggested to (Administrator) a mini Alzheimer's Unit. (Administrator) said, ' They have to have an outside area to roam. ' Staff suggested how to develop an Alzheimer's Unit (within the facility). But (Administrator) didn't want to get into a unit right now." n. On 12/8/11 at 4:00 p.m., during an interview, the Administrator (Resident #1's son-n-law) was asked if the facility had any kind of action plan, if the facility had involved Quality Assurance and Assessment Committee with Resident #1's behaviors. He stated, "There has been discussion on what to do. The resident will not be sent out to a psych facility because we will not change (Resident #1's) behaviors. There's nothing to change. She has no memory. There's nothing there. The medication change is a shot in the dark and is being monitored closely. I see Hospice, in her case, as medication, medication, medication, just put her in the ground. She doesn't just walk up to residents and hit them. She's always provoked. Just like the deal with (Resident #3). (Resident #3) gets up and tries to open her door which agitated (Resident #1). And I (Administrator) said (Resident #1), what should you have done? She should've used her call light." The Administrator was informed that the other residents in the facility have rights too. Resident #3 should not have to worry about someone coming in her room and taking her belongings. It is not up to other residents to resolve the issue. The Administrator was informed of the numerous episodes of resident to resident altercations from 7/10/11 through 12/4/11 and asked why the physician's orders [REDACTED].#1's) medications and initiate [MEDICATION NAME], why did it take so long to intervene? The Administrator stated, "...I don't have an answer." o. As of 12/9/11 at 11:00 a.m., no documentation had been provided by the facility regarding an action plan or quality assurance plan to prevent reoccurrence of resident to resident altercations involving Resident #1's behaviors. 7. On 12/8/11 at 6:45 p.m., the immediate jeopardy was removed and the scope and severity reduced to an "H" when the facility initiated the following plan of removal: a. (ADON) began 1 on 1 supervision of Resident #1 as of 12/8/11 at 16:45 by assigning (CNA #5) to her care. Instructions on monitoring included, but not limited to CNA must be within 6 - 12 feet of Resident at all times, documentation on current activity, behavior, ADL assistance, reporting any inappropriate behavior, and intervening if this Resident attempts to enter any other Residents room. b. 12/8/11 at 1645 (CNA #5) started every 15 minute documentation on Resident #1. c. 12/8/11 at 1900 Administrator provided an oral inservice to all employees present at the Christmas party on 1 on 1 care, monitoring for resident behavior problems, reporting behavior problems to appropriate staff members. d. 12/8/11 at 2000 Assistant Director of Nursing provided in-servicing on 1 on 1 care, behavioral problems and reporting to (CNA #6) who was taking over the 1 on 1 care of Resident #1. e. 12/9/11 at 0700 (DON) began in-servicing staff members on 1 on 1 care, monitoring and reporting Residents for behavior problems, and intervening if inappropriate behavior noted. f. 12/9/11 an in-service was scheduled for 12/12/11 at 7am, 2pm, and 3pm to in-service all staff members on 1 on 1 care, monitoring residents for behavioral problems, reporting and intervening if any behavioral problems are noted. g. ADON will ensure the 1 on 1 monitoring will continue indefinitely or until there is a change of condition in this resident that will prevent her from harming any other resident by scheduling a specific CNA for each shift. h. If at anytime another resident becomes violent, 1 on 1 care will be instituted immediately until the behaviors are resolved.