Every finding on record at The Blossoms at Fort Smith Rehab & Nursing Center

Number of residents sampled:1Number of residents cited:1Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure a resident was not allowed to self- administer their medications for 1 (Resident #7) of 6 sampled residents (R#1, R#7, R#13, R#16 R#30 and R#72) who reside in a secure neighborhood.Findings include:Based on observations, record review, interviews, and facility policy review, it was determined that the facility failed to ensure a resident was clinically appropriate to self- administer medications for one (Resident #7) of six residents reviewed. The findings include: During an observation on 09/15/2025 at 1:30 PM, Resident #7 was lying in bed. As they talked to this surveyor they reached into their bedside table drawer and got out a box, with a prescription label on it, which contained a nasal spray, they then placed it back in the drawer. During a concurrent observation and interview on 09/16/2025 at 9:04 AM, Resident #7 was sitting on their bed as they talked with this surveyor, Resident #7 reached over to their overbed table and picked up a plastic medication cup which contained four unidentified medications as follows: a small round burnt-orange pill; a mustard-colored oval pill; a yellow small oval pill and a white round tablet. Resident #7 stated to this surveyor that they took their thyroid medication before breakfast and took the rest of the medications after they ate breakfast, so staff just left them on the overbed table in the cup until then. Review of Resident #7's admission Record, indicated the facility admitted Resident #7 on 07/03/2025 with diagnoses which included bipolar disorder, dementia with behavior disturbances (decline in cognition, memory, thinking and reasoning with behavior issues), hypothyroidism (low production of thyroid hormone from the thyroid gland), and allergic rhinitis (inflammation of nasal passages caused by allergies). Review of Resident #7's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/10/2025, indicated Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also indicated the resident was taking antipsychotic, antianxiety, and anticonvulsant medications on a routine basis. Review of Resident #7's Care Plan, revised on 07/31/2025, indicated the resident was noncompliant with medications at times, refused medications, and would pick & choose which medications they wanted to take. Review of Resident #7's Physician's Orders for September 2025, indicated an active order that all meds may be given at one time and that Resident #7 may not self-administer medications. Review of Resident #7's Medication Administration Record (MAR) for September 16th, 2025, revealed Resident #7 had received their morning medication at 8:00 AM. During an interview on 09/16/2025 at 9:13 AM, Licensed Practical Nurse (LPN) #2 accompanied this surveyor to Resident #7's room, where a confused resident had entered Resident #7's room and the four medications remained on the overbed table. LPN #2 confirmed medications should not be left in residents' rooms, and that any resident could get them. On 09/19/2025 at 9:25 AM, the Assistant Director of Nursing (ADON) indicated that medications should not be left with a resident because any resident could wander into the room and take them, and that the nurse needs to ensure medications were taken to maintain a therapeutic level of medications. The Administrator, who was present for this interview, voiced agreement with the ADON's statement. On 09/19/2025 at 10:15 AM, the Director of Nursing (DON) confirmed the expectation was medications were to be given in compliance with Physician Orders, following the rights of medications administration, and that the nurse who administered the medications would ensure the medications were swallowed. The DON confirmed if the medication was not given by Physician Order, that would be an error. Review of a facility policy titled, Medication Administration, revised on 11/25/2022, indicated, only persons licensed or permitted to prepare, administer and document the administration of medications may do so. a resident 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.

Number of residents sampled:1Number of residents cited:1Based on observations, interviews, record reviews, facility records and policy review the facility failed to ensure physician orders were consistently implemented for 1 (resident #111) of 1 final sample resident reviewed for position and mobility. The findings are:Based on observations, record review, and interviews, it was determined that the facility failed to ensure Physician Orders were consistently implemented for one (Resident #111) of one resident reviewed for position and mobility. The findings include: During an observation on 09/15/2025 at 1:19 PM, this surveyor observed Resident #111 sitting up in a chair in the residents' room after lunch. Resident #111's left hand was closed tightly with their thumb between the first and second finger and the arm was held close to the body. No handroll or splint was observed in the hand. A basket sitting in the room on a shelf held both a Handroll Carrot [a carrot shaped soft fabric device held within the hand to prevent contracture] and a splint [a device with hook and loop straps that fit a specific resident]. Certified nursing assistant (CNA) #10 had just finished assisting Resident #111 with the lunch meal and was asked if the resident could open the left hand. CNA #10 reported that Resident #111 could not open the left hand. CNA #10 indicated that Resident #111 had a carrot for the hand. This surveyor asked CNA #10 to ask the resident to demonstrate the ability to open the left hand, Resident #111 was unable to comply with opening the left hand. This surveyor asked CNA #10 when Resident #111 wore the handroll or splint and CNA #10 reported the Restorative Nurse Aide's (RNA's) applied it, but I do not know when. During an observation on 09/18/2025 at 12:34 PM, Resident #111 was observed sitting up in the dining room without a handroll carrot or splint in the left hand. Resident #111's left hand was held closed tightly and close to the chest. During an observation on 09/18/2025 at 2:10 PM, Resident #111 was observed sitting up in the day area, without a splint or hand roll in their left hand, the hand was closed tightly and held close to the chest. Review of an Annual Minimum Data Set with an Assessment Reference date of July 2, 2025, for Resident #111, indicated Resident #111 had a Brief Interview for Mental Status score of 00, which indicated the resident had severe cognitive impairment. The MDS also indicated Resident #111 had upper extremity limitation with functional range of motion. Review of an Order Summary Report active as of 09/18/2025, indicated Resident #111 had diagnoses which included decline in cognitive ability such as memory, thinking and reasoning affecting daily life. The Order Summary also included an active order as of 04/23/2025 for handrolls or equivalent to be applied to the effected hand daily every shift. Review of a Care Plan Report indicated Resident #111 had an alteration in their musculoskeletal status related to contracture. Resident #111 had a left-hand contracture with an initiated date of 04/24/2024. Resident #111's interventions included assisting the resident with the use of supportive devices (hand rolls) as recommended with an initiated date of 04/24/2025. Review of a Job Description for the position of Restorative Nursing Aide (RNA) indicated the RNA was responsible for providing nursing restorative care to ensure residents attain or maintain the highest possible physical wellbeing without decline. The RNA will provide care in accordance with the residents' Care Plan. Essential job functions included the following: -Assist residents to apply and remove splints or prosthesis. -Provide good body alignment with use of positioning device and contracture padding as appropriate. -Adhere to personnel policies. -Understand special needs and limitations of the elderly. Review of a Contracture List indicated that Resident #111 was on the RNA daily task list for left handrolls. Review of a sign off RNA Task-Contracture Care for Resident #111, from 8/20/2025 through 9/18/2025, indicated that out of 90 shifts possible, the splint applied box was checked 17 times, the resident refused 21 times and Not Applicable (NA) was checked 48 times. During an interview on 09/18/2025 at 1:09 PM, the Director of Nursing (DON) confirmed a Physician Order for hand rolls or equivalent to affected hand or hands daily every shift indicated that the resident should be wearing the hand roll or equivalent all day every day. During an interview on 09/18/2025 at 2:14 PM, LPN #7 was asked to review Resident #111's Physician Order for the handrolls. LPN #7 reviewed the Physician's Order in the Electronic Medical Record (EMR) for Resident #111, LPN #7 stated that it meant the hand roll should always be in Resident #111's hand. LPN #7 reported that the restorative Nursing assistants usually inserted the hand rolls, but the CNAs could also place them. LPN #7 was asked to observe Resident #7 while sitting in the day room, when LPN #7 observed the absence of a handroll, LPN #7 reported that they would ensure a handroll would be placed as soon as possible. During an interview on 09/18/2025 at 3:16 PM, RNA #5 and RNA #6 stated that when the NA box was checked on the sign off sheet for RNA task, it indicated that they did not have time to perform the activity. During an interview on 09/18/2025 at 3:16 PM RNA #6 stated when stepping out of a room at the end of the hall with RNA #5, we were shredding paper. This surveyor observed several bags of shredded paper and documents in boxes in the room the RNAs came out of. RNA #6 confirmed being trained to complete each resident's functional maintenance plan, and Resident #111 should always have a handroll or splint in the left hand. RNA #6 reported Resident #111 had a handroll in when she last checked the resident. RNA #6 was unsure of the time. RNA #6 indicated Resident #111 would pull the handroll out. RNA #6 confirmed that the RNA's were trained to follow the Physician's Order and that according to Resident #111's order, they were supposed to have a hand roll, carrot or a splint in every day. RNA #6 reported documentation was completed in the task section of the EMR. RNA #6 indicated the DON had been notified within the last two months verbally that the RNA's didn't have enough time to complete their tasks and were informed to do their best. RNA #6 reported that they were required to spend at least one hour a day on their eight-hour shift, shredding paper from the Administrator. During an interview on 09/18/2025 at 3:16 PM, RNA #5 confirmed that the RNA's were shredding paper prior to the interview. RNA #5 reported that the RNA's were trained to follow the Physician's Orders and that Resident #111 should have a handroll or splint in the left hand all day every day, except when in the shower. RNA #5 explained that when the handroll or splint was documented, in the task section of the EMR, a check in the box for yes indicated the handroll or splint was placed, a check in the resident refused meant the resident refused and a check in the NA box meant they did not have time to complete the functional maintenance plan. RNA #5 confirmed the DON had been informed during the times that the tasks could not be completed, and the RNAs were informed to do their best. During an interview on 09/19/25 at 10:09 AM, the DON indicated the RNA's have certain tasks assigned but were not certain of their daily schedule. The DON indicated the RNA's assist with unloading the truck, stocking the personal care supplies, deliver briefs to individual residents, weigh residents then perform their functional maintenance duties. The DON reported being aware that there was a problem with the RNA's completing Physician Ordered functional maintenance plans. During an interview on 09/19/25 at 10:40 AM, CNA #11 reported the RNA's usually set up their day to accommodate the residents on their list. The RNAs were responsible for assisting residents in the dining room, weighing residents, delivering supplies and completing their functional maintenance plans. The RNA's usually shred paper on Friday if they have nothing else to do. This surveyor handed CNA #11 task sheet for splint placement for Resident #111 and asked to explain what a check in the NA box meant. CNA #11 reported not knowing what it meant, and a blank area meant the task was not completed. CNA #11 reported that the RNA task completion was monitored by rounding and interviewing residents but denied any documentation of monitoring rounds. CNA #11 indicated these monitoring rounds were made three-four times a day. CNA #11 reported that RNA #5 and RNA #6 were both trained for their positions and were retrained every 30 to 90 days as well as yearly competency checks. During an interview on 09/19/25 at 10:44 AM, the Administrator indicated that along with their functional maintenance plan, the RNA's were responsible for stocking personal care supplies and weighing residents. The Administrator confirmed his expectation that the RNA's follow each resident's functional maintenance plan. This surveyor did request any facility policies related to implementing Physician Orders. No facility policies were provided.

Number of residents sampled:3Number of residents cited:2Based on observations of the 8:00 AM medication administration, interviews, record reviews and facility policy review, it was determined that the facility failed to ensure medications were administered according to the physician's orders for 2 (residents #30 and #85) of 3 residents who were observed during medication administration.The findings are:Based on observations, interviews, record reviews and facility policy reviews, it was determined that the facility failed to ensure medications were administered according to the physician's orders for two (Resident #30 and Resident #85) of three residents who were observed during medication administration, resulting in two medication errors in thirty-six opportunities, with a total error rate of 5.56%. The findings include: Resident #85 During an observation and concurrent interview on 09/17/2025 at 8:09 AM, LPN #3 gathered Resident #85's medication cards and bottles, checked them with the Electronic Medical Record (EMR), withdrew one multivitamin tablet from its bottle, and administered the multivitamin to Resident #85. LPN#3 confirmed that all medications ordered for Resident #85 had been administered at the completion of the observation. When the medications were reconciled with the Physician's Orders, the order was indicated to be for a multivitamin with minerals. Review of an admission Record for Resident #85 indicated the facility admitted Resident #85 on 09/15/2025 with diagnoses which included weakened immune system, diabetes mellitus, obesity and lipoprotein deficiency. Review of an Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/30/2025 indicated Resident #85 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #85 was cognitively intact. Review of an Order Summary Report for Resident #85 indicated a multivitamin with minerals be given one tablet by mouth one time a day for supplement. During an interview on 09/19/25 at 10:09 AM, the DON reported that plain multivitamins are different from multivitamins with minerals that were ordered for Resident #85. Resident #85 should have received the Physician Ordered multivitamin with minerals. Resident #30 During an observation and concurrent interview on 09/18/2025 at 8:06 AM, Registered Nurse (RN) #4 placed a needle on an insulin flex pen, RN #4 then dialed up two units and while holding the pen horizontally, depressed the plunger toward the medication cart, nothing was observed exiting the insulin pen. RN #4 then dialed up the sliding scale dose of four units and the routine dose of ten units before meals dose to equal 14 units. RN #4 administered the dialed dose to Resident #30's abdomen, depressed the plunger then released the plunger holding the pen to the skin for a count by the surveyor of six. After the administration, RN #4 was asked to explain the purpose of priming the insulin pen and the RN reported the purpose of priming the insulin pen was to relieve any air bubbles. When RN #4 was asked to explain how the pen should be primed, RN #4 reported that two units should be dialed up and ejected. RN#4 did not indicate the pen should be pointed up in a vertical position. RN #4 reported that when the pen was primed according to manufacturer instructions, that a drop of insulin should be seen otherwise the step should be repeated. RN#4 confirmed being trained on the proper procedure for administration of an insulin pen. Review of an admission Record for resident #30 indicated the facility admitted Resident #30 on 07/20/2018 with diagnoses which included diabetes mellitus type 2. Review of a Quarterly MDS with an ARD of 7/14/2025 indicated Resident #30 had a BIMS score of 08 which indicated Resident #30 had severe cognitive impairment. Review of an Order Summary Report was reviewed for Resident #30, indicated a Physicians Order for Aspart insulin flex pen subcutaneous solution 100 UNIT/ML [milliliter] inject as per sliding scale as follows: 150 - 200 = 2; 201 - 250 = 4; 251 – 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401 - 450 = 12 notify physician, subcutaneously before meals and at bedtime. Initiated 9/17/2025. Physician Order also indicated to administer Insulin Aspart Solution 100 UNIT/ML as follows: Inject 10 units subcutaneously with meals for diabetes before breakfast, hold if Capillary Blood Glucose (CBG) less than 90 or resident not eating. Review of a Laboratory Report dated 9/10/2025 for Resident #30 indicated a Glycated Hemoglobin Percentage (HbA1c %) result of 9.1H [high, normal 4.4-6.1%]. During an interview on 09/19/2025 at 10:00 AM, the Advanced Practice Nurse (APN) reported that Resident #30 had a diagnosis of diabetes, insulin prescribed and recently had lab that resulted in an elevated HbA1c and due to the residents' comorbidities could be negatively affected if the resident's insulin dose was not correct. The APN reported that medication administration staff are expected to administer Physician Ordered medications correctly and to follow the facility policy. The APN was asked how she provided instructions for patients related to the priming and administering of an insulin pen. She stated, I always instruct my patients to prime the pen with the point up and to hold the plunger in for a count of 5 or 6 seconds. During an interview on 09/19/25 at 10:09 AM, the Director of Nursing (DON) indicated the expectation for medication administration was for medications to be administered properly, following the medication rights and per the Physician's Orders. The DON reported that if the medication was not administered as ordered that would be a medication error. The DON confirmed that if an insulin pen was not primed correctly there would be potential for an inaccurate dose administered and the resident would not receive the ordered dose. The DON confirmed that all medications should be administered as ordered by the provider and that staff are expected to follow facility policy. The DON also confirmed that nursing competencies for medication administration were completed on hire, yearly, and as needed, and that RN #4 and LPN #3 had completed the competencies on 10/27/2025 [LPN#3] and 10/28/2025 [RN#4]. The DON reported that both LPN #3 and RN #4 had completed the competencies and were identified as being able to competently administer medications. During an interview on 09/19/25 at 10:44 AM, the Administrator reported his expectation of medications to be administered were for the medications to be administered according to Physician's Orders. The Administrator confirmed that if the medication was not administered according to the Physicians Orders, it would be considered a medication error. The expectation for staff was for them to follow the facility policies. The Administrator reported nursing competencies were performed on hire, yearly, and as needed. Review of a facility policy titled, Medication Administration with a revised date of 11/25/22, indicated that medications would be administered as prescribed to maintain a medication error rate less than 5%. Medications must be administered according to Physician's Orders. The staff administering the medications must check the label three times to ensure the right resident, right medication, right dose, right time and right method of administration prior to the administration of the medication. Review of manufacturer's Instructions for Use guidelines revealed in Step 7, Priming your FIASP FlexTouch Pen: Turn the dose selector to select 2 units. Step 8, Hold the Pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top. Step 9: Hold the Pen with the needle pointing up. Press and hold ibn the dose button until the counter shows 0. A drop pf insulin be seen at the needle tip. If you do not see a drop of insulin, repeat steps 7 to 9.

Number of residents sampled:1Number of residents cited:1Based on observation of the 8:00 AM medication administration, interviews, record reviews and facility policy review the facility failed to ensure that an insulin pen was prepared and administered according to manufacturer's instructions for 1 (resident #30) of 1 resident observed for insulin administration. The findings are: Based on observation, interviews, record reviews and facility policy review, it was determined that the facility failed to ensure that an insulin pen was prepared and administered according to manufacturer's instructions for one (Resident #30) of one resident observed for insulin administration. The findings include: During an observation of medication administration on 09/18/2025 at 8:06 AM for Resident #30, this surveyor observed Registered Nurse (RN) #4 placed a needle on the Aspart flex pen insulin. RN #4 then dialed up two units and while holding the pen horizontally, depressed the plunger toward the medication cart, nothing was observed exiting the insulin pen. RN #4 then dialed up the sliding scale dose of four units and the routine dose of ten units before meals dose to equal 14 units. RN #4 administered the dialed dose to Resident #30's abdomen, depressed the plunger then released the plunger holding the pen to the skin for a count by the surveyor of sic seconds. After the administration, RN #4 was asked to explain the purpose of priming the insulin pen and the RN reported the purpose of priming the insulin pen was to relieve any air bubbles. When RN #4 was asked to explain how the pen should be primed, RN #4 reported that two units should be dialed up and ejected. RN #4 did not indicate the pen should be pointed up in a vertical position. RN #4 reported that when the pen was primed according to manufacturer instructions, that a drop of insulin should be seen, otherwise the step should be repeated. RN #4 confirmed being trained on the proper procedure for administration of an insulin pen. Review of an admission Record for Resident #30, indicated the facility admitted Resident #30 on 07/20/2018 with diagnoses which included diabetes mellitus type 2. Review of a quarterly Minimum Data Set with an Assessment Reference Date of 7/14/2025 indicated Resident #30 had a Brief interview for mental status score of 08 [00-08 indicated severe cognitive impairment]. Review of an Order Summary Report was reviewed for Resident #30, indicated a Physicians Order for Aspart insulin flex pen subcutaneous solution 100 UNIT/ML [milliliter] inject as per sliding scale as follows: 150 - 200 = 2; 201 - 250 = 4; 251 – 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401 - 450 = 12 notify physician, subcutaneously before meals and at bedtime. Initiated 9/17/2025. Physician Order also indicated to administer Insulin Aspart Solution 100 UNIT/ML as follows: Inject 10 units subcutaneously with meals for diabetes before breakfast, hold if Capillary Blood Glucose (CBG) less than 90 or resident not eating. Review of a Laboratory Report dated 9/10/2025 for Resident #30 indicated a Glycated Hemoglobin Percentage (HbA1c %) result of 9.1H [high, normal 4.4-6.1%]. During an interview on 09/19/2025 at 10:00 AM, the Advanced Practice Nurse (APN) reported that Resident #30 had a diagnosis of diabetes, insulin prescribed and recently had lab that resulted in an elevated HbA1c and due to the residents' comorbidities could be negatively affected if the resident's insulin dose was not correct. The APN reported that medication administration staff are expected to administer Physician Ordered medications correctly and to follow the facility policy. The APN was asked how she provided instructions for patients related to the priming and administering of an insulin pen. She stated, I always instruct my patients to prime the pen with the point up and to hold the plunger in for a count of 5 or 6 seconds. During an interview on 09/19/25 at 10:09 AM, the Director of Nursing (DON) indicated the expectation for medication administration was for medications to be administered properly, following the medication rights and per the Physician's Orders. The DON reported that if the medication was not administered as ordered there would be a medication error. The DON confirmed that if an insulin pen was not primed correctly there would be potential for an inaccurate dose administered and the resident would not receive the ordered dose. The DON confirmed that all medications should be administered as ordered by the provider and that staff are expected to follow facility policy. The DON also confirmed that nursing competencies for medication administration were completed on hire, yearly, and as needed, and that RN #4 and LPN #3 had completed the competencies on 10/27/2025 [LPN#3] and 10/28/2025 [RN#4]. The DON reported that both LPN #3 and RN #4 had completed the competencies and were identified as being able to competently administer medications. During an interview on 09/19/25 at 10:44 AM, the Administrator reported his expectation of medications to be administered were for the medications to be administered according to Physician's Orders. The Administrator confirmed that if the medication was not administered according to the Physicians Orders, it would be considered a medication error. The expectation for staff was for them to follow the facility policies. The Administrator reported nursing competencies were performed on hire, yearly, and as needed. Review of a facility policy titled, Medication Administration with a revised date of 11/25/22, indicated that medications would be administered as prescribed to maintain a medication error rate less than 5%. Medications must be administered according to Physician's Orders. The staff administering the medications must check the label three times to ensure the right resident, right medication, right dose, right time and right method of administration prior to the administration of the medication. Review of a manufacturers document titled, Instructions for use indicated Priming your insulin pen: turn the dose selector to select two units, hold the pen with the needle pointing up, tap the top of the pen gently to allow air bubbles to rise to the top, hold the pen with the needle pointed up, press and hold the plunger until the dose shows 0, a drop of insulin should be observed at the tip of the needle. If you do not see a drop of insulin, repeat steps. Insert the needle into the skin, press and hold down the dose button until the dose counter shows 0. Keep the needle in the skin after the dose has reached 0 and slowly count to six. When the dose counter returns to 0 you will not receive the full dose until six seconds later. Review of a facility policy titled, Medication Administration with a revised date of 11/25/22, indicated that medications would be administered as prescribed to maintain a medication error rate less than 5%. Medications must be administered according to Physician's Orders. The staff administering the medications must check the label three times to ensure the right resident, right medication, right dose, right time and right method of administration prior to the administration of the medication.

Number of residents sampled:5Number of residents cited:1Based on observations, interviews, facility in-services, and facility policy review, it was determined that the facility failed to follow proper infection control precautions during wound care for 1 (Resident #79) of 5 residents reviewed for infection control.Findings include:Based on observations, record review, interviews, and facility policy review, it was determined that the facility failed to follow proper infection control precautions during wound care for one (Resident #79) of five residents reviewed for infection control. The findings include: During a concurrent observation and interview on 09/17/2025 at 10:31AM, signage for Enhanced Barrier Precaution (EBP) was hanging on Resident 79's door. Licensed Practical Nurse (LPN) #1 came to Resident #79's room and entered with wound care supplies on a sterile tray. LPN #1 sat the tray with supplies on the bedside table and placed a red biohazard bag at the end of the resident's bed. LPN #1 applied gloves and proceeded to take off Resident #79's shoes. LPN #1 did not wash hands or put on a gown prior to initiating wound care. LPN#1 took off gloves, sanitized hands, and applied new gloves. With safety scissors, LPN #1 cut off the dressing to left foot and ankle area. This surveyor observed LPN #1 leaning over the resident's bed while providing wound care and observed that LPN #1's shirt was touching the residents' blanket on the bed. LPN #1 took off gloves, sanitized hands, and applied new gloves. LPN #1 touched the inside of the biohazard bag that had dirty items in it with gloves on, then reached over and obtained clean 4x4's from a cup with wound care solution in it. LPN #1 stated, I should not have touched the bag. I should have changed my gloves and sanitized my hands after touching the bag. It could cause more infection. LPN #1 took off gloves, sanitized hands, and applied clean gloves. An ointment was applied with a clean cotton tip applicator to the wound. LPN #1 applied betadine to the wound via swab, sanitized hands, and used clean scissors to cut the ordered medicated patch in half. LPN #1 applied the medicated patch to the wound, then applied ordered wrap to the wound. LPN #1 then gathered trash and put in trash car, took off gloves, sanitized hands and dated dressing. LPN #1 indicated, When entering the room, I should have washed my hands and put on a gown. This is to protect the resident and I from germs and infections. I am an infection preventionist. I train the staff, I should have known better. Review of an admission Record indicated the facility admitted Resident #79 on 01/19/2023. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/05/2025, revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate cognitive impairment. Review of Resident #79's Care Plan, revised on 06/25/2025, revealed the resident had a Stage 3 Pressure Ulcer (PU) to right heel. Interventions included administer treatments as ordered and monitor for effectiveness. The Care plan also indicated that the resident required EBP due to wounds. Interventions included use of gloves and gown required prior to high-contact care. Review of an Order Summary revealed Resident #79, had on order for treatment for a stage 3 pressure ulcer to right heel. Staff were to cleanse the area with wound cleanser, pat dry, apply iodine to peri-wound, apply [an ointment used to remove dead tissue] to areas of slough, cover with calcium alginate and [abdominal] pad. Lastly, wrap with [a self-adherent wrap] every Monday, Wednesday, Friday, and as needed if soiled or missing. During an interview on 09/19/2025 at 08:37 AM, the Director of Nursing (DON) indicated EBP was to be used for anything with a line that goes into the body, wounds, etc. If the staff were performing care they needed to put on their gowns and gloves. It protects the resident and staff from germs and infections. The DON stated, My understanding, you change your gloves when they are dirty, and you lay your hands on the resident. If someone touched a dirty biohazard bag they need to change their gloves. During an interview on 09/19/2025 at 09:36 AM, LPN #7 indicated, EBP means you need to be gowned and gloved to provide physical care for the resident, such as peg tube. During wound care, definitely gown and glove and if you are dealing with any bodily fluid. Gloves should be changed after you remove dressing, any time you go dirty to clean surfaces. During an interview on 09/19/2025 at 09:44 AM, Certified Nurse Assistant (CNA) #8 indicated, We use EBP when we provide care to residents that have wounds or catheters or anything like that. We know which rooms to wear gown and gloves because there would be a sign on the doors with EBP precautions. We usually only just put on a gown and glove, but sometimes shoe covers and face mask as well. If resident has a wound and we provide care we are supposed to wear gown and glove. We are trained a lot. When I got hired back I had an in-service. There are tests and pamphlets we go over. During an interview on 09/19/2025 at 10:45 AM, the Administrator indicated, when following EBP staff should follow the protocol to protect the residents from infection and protect the staff from bodily fluids that could cause the staff infections. Staff should wear gloves and gowns when preforming care. During an interview on 09/19/2025 at 10:57 AM, the Assistant Director of Nursing (ADON), indicated, EBP was to be followed anytime someone has a wound, catheter, tracheostomy (opening into the trachea to assist with breathing). The ADON indicated it was to protect the staff from getting bodily fluids on them and protects the resident also from getting any kind of infection. The ADON stated, If I was providing care I would gown and glove up as soon as I enter the room. If someone is doing a treatment they must gown and glove. I may even put on a face mask. During wound care gloves should be changed anytime the staff touch anything dirty and then return to clean. Review of a facility in-service titled, Enhanced Barrier Precautions, dated 02/18/2025, indicated, If there is a sign on a resident's door EVERYONE MUST follow the EBP. Enhanced Barrier Precautions (EBP) are a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs). EBP are used in nursing homes and other long-term care facilities. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employees targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Review of a facility policy titled, Enhanced Barrier Precautions (EBP), revised on 03/21/2024, indicated, EBP requires gowns and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organism (MDRO) to staff hands and clothing. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Wound care: any skin opening requiring a dressing. Review of a facility in-service titled, Enhance Barrier Precautions, dated 05/26/2025, indicated, A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to $483.70(e) and following accepted national standards. Review of a facility policy titled, Infection Control, revised on 11/02/2022, indicated, Prevention of infection following established general and disease-specific guidelines such as those of the Centers for Disease Control.

Based on record review and interview, the facility failed to coordinate with the State Designated Authority. Specifically, the facility failed to notify the State Designated Authority when one (Resident #3) of one sampled resident was admitted on [DATE] and failed to request the level II PASARR (Pre-Admission Screening and Resident Review) to ensure Resident #3 was receiving all recommended care and services. The findings include: A review of the resident ' s Medical Diagnosis revealed Resident #3 had diagnoses that included catatonic schizophrenia, anxiety, and alcohol abuse. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/21/2025, Section A1600 and 1805 revealed resident was admitted from a Psychiatric facility on 01/15/2025. The Staff Assessment for Mental Status (SAMS) revealed Resident #3 had long and short-term memory problems, and Section C1000 revealed Resident #3's cognitive skills for daily decision making were severely impaired. Section E0900 revealed daily wandering behaviors. The Administrator provided a letter from the State Designated Authority, dated 01/08/2025, which approved nursing home placement, and requested to be contacted on admission for the PASARR II evaluation. The Administrator revealed that the hospital initiated the PASARR. During an interview with the Minimum Data Set (MDS) nurse on 04/15/2025 at 03:27 PM, the MDS nurse stated the facility did not get Resident #3's PASARR II evaluation, and that the Social Director was responsible for getting the evaluation. The MDS Nurse provided a copy of the forms 703, 780, and 787 the facility filled out, but did not submit on admission, and indicated there was no related policies or procedures on the matter. On 04/15/2025 at 03:30 PM, the Administrator stated the facility did not have a PASARR II evaluation on Resident #3 and knew they should have had an evaluation to see if Resident #3 had any recommended services. When asked the process for getting a PASARR II evaluation, the Administrator stated the Nurse Consultant told him the social director should have contacted the State Designated Authority on admission for the evaluation. On 04/15/2025 at 03:45 PM, the MDS Nurse stated Resident #3 did not qualify for PASARR II. On 04/15/2025 at 04:07 PM, this surveyor spoke with the State Designated Authority and confirmed Resident #3 was a PASARR II resident, and when [Resident #3] was ready for discharge from the current hospitalization , the facility would be contacted for a resident review, and the facility would not have the PASARR II evaluation, as it was revealed the facility contacted the State Designated Authority for the first time today and asked for the evaluation. On 04/16/2025 at 11:28 AM, the Social Director stated she had not been involved in obtaining the PASARR II evaluation but found out yesterday she was supposed to call for the evaluation. The Social Director said Admissions, the MDS nurse, or the Business Office Manager (BOM) should have been responsible for getting the PASARR II evaluation upon admission. On 04/16/2025 at 11:35 AM, the BOM said Admissions should have gotten a copy of the PASARR II evaluation on new admissions, because it let the facility know if a resident required special services. On 04/16/2025 at 11:38 AM, Admissions said she was responsible for finding out if a new resident had a PASARR II, but she was trained that the BOM was responsible for getting a copy of the PASARR II evaluation.

Based on interviews, the facility failed to hire a certified Social Worker with a bachelor ' s degree in social work or a Human Services-related field and at least one year of supervised social work experience in a healthcare setting when the number of beds in the facility exceeded 120. The findings are: During an interview on 04/16/2025 at 11:42 AM, the Administrator indicated that the facility had one hundred and thirty (130) physical beds, and one hundred and seven (107) residents. The Administrator indicated that the facility should have a certified Social Worker if there were more than one hundred and twenty (120) beds. The Administrator indicated that the Social Worker was not certified. The Administrator also indicated that the facility increased to over one hundred and twenty (120) beds in July 2024. During an interview on 04/16/25 at 11:50 AM, the Social Services staff member indicated that she had been employed at the facility for two and a half years. The Social Services staff member indicated that she did not have formal education or certification in social work. The Social Services staff member indicated that the facility should have had a certified social worker if they had more than one hundred and twenty (120) beds. The Social Services staff member indicated the Administrator had a degree in social work, and to her understanding, she could work under the Administrator's degree. The Social Service staff indicated that the facility has had more than one hundred and twenty (120) beds since July 2024. During an interview on 04/16/25 at 12:45 PM, the Administrator indicated that the facility did not have a policy for staffing a social worker.

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure staff reported allegations of verbal abuse to the Administrator within two hours of the allegation being made for 2 (Residents #2 and #3) of 3 sampled residents reviewed for abuse and/or neglect. The findings include: 1. A review of a facility policy titled, Abuse, Neglect, and exploitation revised on 12/2022 indicated, We are committed to the safety and well-being of all our residents. We believe that the resident has the right to be free from verbal abuse .The facility's goal is to prevent abuse through annual and ongoing in-service of staff .The facility has developed policies and procedures which provide essential components to an abuse prevention and intervention program. 1. Screening of potential hires .2. Training staff annually and on an ongoing basis in interventions, reporting detection, and prevention. 6. Protection for individuals from abuse during investigation of allegations. 7. Reporting/Response-assurance that incidents are reported, corrective actions are taken, and preventative measures are put into place .Reporting: All complaints, concerns or suspicions of abuse should be immediately reported to the Administrator .1. All personnel must immediately report suspected cases of abuse to the administrator. In the Administrators absence, suspected abuse should be reported to the Director of Nursing (DON) and immediate supervisor .2. Staff are trained upon hire during orientation . on the policy regarding reporting abuse, the types of abuse ., Types of Abuse: 1. Verbal abuse-Includes the use of oral, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. 2. A review of the Admission Record indicated the facility admitted Resident #2 with diagnoses that included Alzheimer's disease, dementia, malignant neoplasm of brain, anxiety disorder, dysphagia, and cognitive communication deficit. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/05/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. Section GG was reviewed and indicated the resident required maximum to total assist with toileting and hygiene. A review of Resident #2's Care Plan Report with a revision date of 05/18/2023, revealed the resident's history indicated resident had experienced serious trauma in [Resident #2's] lifetime. Specifically, trauma related to abuse. Resident #2 had a self-care deficit and was a Hospice resident with a terminal diagnosis. Interventions included assistance from 1-2 staff for daily care, and using simple short instructions. A review of Order Summary Report, as of 03/14/2025 revealed Resident #2 resided on the Secure Unit and was monitored for pain and medication side effects. 3. A review of the Admission Record indicated the facility admitted Resident #3 with diagnoses that included dementia, cognitive communication deficit, lack of coordination, history of falls, muscle weakness, and abnormal gait and mobility. The quarterly MDS, with an ARD of 01/15/2025, revealed Resident #3 had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. Section GG was reviewed and indicated resident #3 required oversight to moderate assistance from staff for daily care. A review of Resident #3's Care Plan Report with an initiated date of 10/07/2020, indicated the resident had a history of self-harmful behavior, had experienced trauma in [Resident #3's] lifetime, had an ADL [activities of daily living] self-care deficit, with assist of one for bathing, and is on the secure unit for safety. 4. During a phone interview on 03/17/2025 at 12:57 PM, CNA #3 was asked how long the CNA had been employed with the facility. CNA #3 responded approximately six or seven months. CNA #3 was asked to recount the incident that occurred on 01/29/2025 over to 01/30/2025 on the 11:00 PM-7:00 AM shift. CNA #3 stated, at around 12:00 AM, thinking a bug was seen on Resident #3's bed, Licensed Practical Nurse (LPN) #2 was notified. CNA #3 stated Resident #3 had to have a shower, but before Resident #3 could be given a shower, Resident #2 had to be taken to the toilet. Resident #3 was taken to the shower afterward. CNA #3 stated that Resident #3 was crying, because the resident had been gotten up in the middle of the night and was upset. CNA #3 stated Resident #3 was crying while in the shower. CNA #3 stated their [CNA's] voice was never raised to either one and they didn't jerk a wheelchair. CNA #3 denied any knowledge of why an allegation would have been made without cause. CNA #3 remarked that both CNA #3 and LPN #1 were arguing in front of resident #3. CNA #3 stated, That's when LPN #1 asked me if I needed to leave, and I said yes. CNA #3 denied using profanity in the presence of or to a resident. At no time during the shift did I raise my voice or curse at any of the residents. CNA #3 was asked if yelling at a resident was considered abuse. CNA #3 stating she didn't yell at anyone. CNA #3 was asked again if yelling or speaking loudly to a resident could be considered abuse? Again CNA #3 redirected and denied yelling or speaking loud to a resident. When asked if she had abuse training while in CNA classes, she stated yes, she did. CNA #3 denied having any type of abuse training, after being informed that the employee file had been reviewed and indicated the training for abuse had been documented to have occurred during orientation and again in November. CNA #3 began saying loudly Ok, yes, I had training! Just write it down, I had training alright! It doesn't matter anyway! They'll just say what they want! I ain't got time for this! CNA #3 hung up at that time. CNA #3's employee record was reviewed, and it revealed CNA #3 had abuse maltreatment training during orientation 07/2024. Facility in-service trainings were reviewed and indicated CNA #3 had retraining on abuse and neglect on 11/01/2024, 11/15/2024 and 01/07/2025 with CNA #3's signature indicating understanding of training. During a phone interview on 03/17/2025 at 2:34 PM, LPN #1 was asked how long she had been employed by the facility? LPN #1 responded over [AGE] years and had a total of [AGE] years of experience as a nurse. LPN #1 was asked to recount the incident that occurred on the night of 01/29/2025 going into 01/30/2025 on the 11:00 PM-7:00 AM shift, with Resident #2 and Resident #3. LPN #1 stated, I was called by LPN #2 from my station to check on a concern on the Secure Unit. When I got to the women's Secure Unit, I was walking past the shower and could here CNA #3 yelling loudly from inside. CNA #3 was yelling loudly to whomever was in the shower. LPN #1 denied being able to recall what was said, or if it was understandable, just that it was loud enough to hear through the door. LPN #1 entered the shower and saw that it was Resident #3. LPN #1 was asked if she removed CNA #3 from the resident. I went in and told CNA #3 she needed to calm down. Then LPN #1 stated I asked if she needed to go home? CNA #3 responded, Yes I do., and left. LPN #1 was unsure of the time that CNA #3 left the premises. I went back to the hall to check on LPN #2. And that's when she told me about the incident between CNA #3 and Resident #2. LPN #1 was asked to clarify the statement. LPN #1 confirmed that prior to notifying the Assistant Director of Nursing (ADON) of the incident that occurred between CNA #3 and Resident #3, LPN #1 had been made aware of an incident between CNA #3 and Resident #2 by LPN #2. LPN #1 stated, Yes. LPN #1 was asked if the incident with Resident #2 had been reported to the Assistant Director of Nursing (ADON) when the incident with Resident #3 had been reported. LPN #1 stated, No, I forgot, that's on me, it's my bad. LPN #1 recalled talking with the ADON on the phone, and couldn't recall the conversation, but thought they also discussed the incident with CNA #3. LPN #1 reported that it was several hours later when the ADON was contacted. LPN #1 indicated I got sidetracked and forgot. She was out of the building, and I forgot. CNA #3 was out of the building, so I didn't worry about it. LPN #1 was asked when allegations of abuse should be reported. LPN #1 stated, Immediately, I did not report the allegation to the Administrator immediately. LPN #1 was asked if yelling at a resident would be considered abuse. LPN #1 stated, It wasn't nice, [CNA #3] shouldn't have done it. LPN #1 was asked if yelling at a resident would be considered verbal abuse. LPN #1 responded, I guess it would, yes. LPN #1 was asked when the last time she had abuse/neglect training was. LPN #1 stated, Prior to the incident abuse/neglect training, [AGE] years in long term care I've had lots of training. With my years of experience and training, I know I should have reported the incident immediately. LPN #1's abuse training was reviewed for the last 5 months; retraining was indicated for the following dates: 11/15/2024, 11/18/2024, 01/07/2025, 01/26/2025, 01/28/2025, 02/07/2025, 02/24/2025 and 02/28/2025. Employee Disciplinary Action reports dated 01/31/2025 and 03/04/2025 were reviewed and indicated that on 01/30/2025 and 02/28/2025, LPN #1 was disciplined for failure to report an allegation of abuse immediately. During an interview on 03/17/2025 at 3:23 PM, the ADON was asked to recount the incidents with Residents #2 and #3 that occurred on the night of 01/29/2025 going into 01/30/2025. The ADON recalled being contacted after midnight, maybe around 1:00 AM. LPN #1 informed the ADON that CNA #3 was raising her voice at Resident #3, and that LPN #1 stated she had already sent her packing. The next day the ADON realized there was more to the story. The ADON was asked when she became aware that there was another resident involved. The ADON stated, When I came in, LPN #2 had provided a witness statement to the DON. The ADON was asked if LPN #1 had a habit of not reporting incidents of abuse. The ADON stated, Not really, she calls us all the time. This was a failure to report. I recall that LPN #1 reported at the initial phone call, that CNA#3 was talking loudly. I found out about the incident with Resident #2 that next morning. The ADON was asked when allegations of abuse should be reported. The ADON stated, Immediately, usually to the Administrator, but [LPN #1] called me. I didn't call the Administrator at that time. The ADON was asked when staff were expected to report allegations of abuse. The ADON stated, Immediately, we're constantly in-servicing. During a phone interview on 03/18/2025 at 9:02 AM, LPN #2 was asked to recount the incidents that occurred on 01/29/2025 to 01/30/2025 at around midnight. LPN #2 stated she saw CNA #3 grab Resident #2's wheelchair and rammed it into the toilet area with Resident #2 in the wheelchair. LPN #2 was asked what type of reaction Resident #2 had to this action. LPN #2 stated, Resident #2 started crying. LPN #2 stated then CNA #3 was overheard talking loudly to Resident #2 saying, pull your own [expletive] pants down. When Resident #2 was finished in the restroom, CNA #3 brought Resident #2 out and sat the resident next to the nurse's station. CNA #3 then brought Resident #3 out to the shower. LPN #2 stated the conversation could be heard, and Resident #3 could be heard crying. LPN #2 indicated being able to hear CNA #3 yelling at Resident #3. LPN #2 called for LPN #1. LPN #1 confronted CNA #3 at that time. CNA #3 left the facility. LPN #2 was asked about her nursing experience. LPN #2 stated that she had 7 years of nursing experience. LPN #2 was asked when her last abuse training had been completed. LPN #2 was unsure of the date of the last abuse training. LPN #2 was asked if she knew how to identify suspected abuse. LPN #2 responded Yes. LPN #2 was asked if a staff member yelling at a resident was considered abuse. LPN #2 responded, Yes, in my opinion, verbal abuse. LPN #2 was asked if CNA #3 was separated from Resident #2 when LPN #2 witnessed the incident with Resident #2's wheelchair and CNA #3 yelling at Resident #2. LPN #2 stated No. LPN #2 was asked why she did not stop CNA #3 when she first heard her yelling at Resident #2. LPN #2 responded, It was the first time I dealt with anything like that, I was kind of in shock. LPN #2 was asked how long Resident #2 had been sitting at the nurse's station before CNA #3 brought Resident #3 to the shower. LPN #2 stated, It was only a couple of minutes. LPN #2 was asked if she notified the Administrator or her supervisor of the incident. LPN #2 stated I was instructed to write a statement by LPN #1, who stated she would call the ADON. LPN #2 was asked if an alleged perpetrator should be removed from the facility to protect the residents, according to the abuse training that was provided by the facility. LPN #2 responded Yes. LPN #2 was asked, if CNA #3 had of been stopped or removed after the incident with Resident #2, would the incident with Resident #3 have occurred. LPN #2 responded, Probably not, that's why I went and got help. LPN #2 was asked if Resident #3 protected by the facility. LPN #2 responded, No ma'am. LPN #2's employee records were reviewed and indicated LPN #2 received abuse/maltreatment training on 01/26/2025, 01/28/2025, 02/7/2025 and 02/28/2025. During an interview on 03/18/2025 at 10:37 AM, the Director of Nursing (DON) stated she had been with the facility for 3 weeks but had [AGE] years of other nursing experience. The DON was asked to name the types of about, as outlined in the facility policy. The DON stated, verbal, sexual, financial, and injury of unknown origin. The DON was asked when suspected abuse should be reported. She stated immediately, it should be reported it to the charge nurse, and up the chain of command. The DON was asked what the procedure was for when abuse is suspected. The DON's response was to keep the resident safe, separate the alleged perpetrator and the resident. The DON was asked if abuse was witnessed, and if the alleged perpetrator wasn't removed, if that would protect the resident. The DON responded, No. The DON was asked if employees were expected to follow the facility policy. She responded, I expect it. If staff witness abuse, the DON stated she would expect the nurse to protect the resident. The DON stated yelling at a resident was a form of abuse, and she would expect it to be reported immediately and remove the staff immediately. During an interview on 03/18/2025 at 11:03 AM, the Administrator was asked what was considered abuse. The Administrator responded, according to the facility policy abuse/neglect, anything done with willful intent against the resident, the willful intent of injury was considered abuse. The Administrator was asked when abuse should be reported. The Administrator stated that abuse should be reported immediately upon any allegation. The Administrator was asked if yelling at a resident would be considered abuse. The Administrator stated, yelling at a resident to me is abuse. The Administrator was asked if facility staff witnessed another staff member yelling or screaming at a resident and using profanities would be considered abuse. The Administrator stated, Yes, and they should report the incident. The Administrator was asked if a staff member witnessed abuse what would be the process for protecting the residents. The Administrator stated, To protect, then report, make sure the resident is safe, get the staff member away from the resident. The Administrator was asked if a staff member didn't remove the perpetrator when abuse was witnessed, was that behavior protecting the resident. He responded No.

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure staff used safe laundry transport techniques to prevent accidents for 1 (Resident #1) of 11 residents reviewed for accidents and hazards. Findings include: A review of a facility policy titled, Resident Rights, dated 11/01/2022, indicated residents have a right to a safe environment. A review of Resident #1's Admission Record, indicated the facility admitted Resident #1 with diagnoses which included generalized anxiety disorder, psychosis, schizophrenia, abnormal gait and mobility, abnormal auditory perception, lack of coordination, cognitive communication, and a history of falls. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/2024, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 9 which indicated the resident was had moderate cognitive impairment. A review of Resident # 1's Care Plan, revisions as of 01/06/2025, revealed the resident was at risk for falls. Interventions included anticipating the resident's needs. Resident #1 was at risk for abnormal bleeding related to antiplatelet therapy. Interventions included protecting Resident #1's skin from accidental injuries. A progress note dated 10/23/2024 at 1:44 PM, revealed Resident #1 was walking to the bathroom with their head down while laundry staff was coming through the laundry entrance with a laundry cart. The resident ran into the cart and fell backwards onto the floor. Resident #1 complained of pain in the head and assessment revealed blood to the back of the resident's head. The provider was notified, and the resident was sent to the emergency room . A review of Resident #1 ' s Incident and Accident (I&A) Report dated 10/23/2024 indicated Resident #1 was ambulating to the bathroom when laundry person with a laundry cart was moving from the laundry to the nurses' station and the resident ran into the laundry cart. Resident #1 fell back striking her head on the ground. Resident #1 was sent to the emergency room for evaluation and treatment. It was found Resident #1sustained a hematoma. Immediate action taken by the facility was, instructed staff to be aware of residents at all times and make path to bathrooms free of carts and persons. During an interview on 01/07/2025 at 4:07 PM, the Laundry Tech #2 stated she was entering the women's locked unit from the laundry area and pushing the cart from behind. The Laundry Tech #2 stated she believed Resident #1 was walking towards the bathrooms and they collided. Laundry Tech #2 stated the cart was very tall and hard to see around, so she should have been on the side where she could have seen any residents in the path. During an interview on 01/08/2025 at 1:08 PM, the Housekeeping & Laundry Supervisor (H&L Supervisor) stated during transportation to prevent hitting the residents with the cart laundry techs should stand in front of the carts so any residents in the path can be seen. During an interview on 01/08/2025 at 2:41 PM, the Administrator stated to prevent accidents during transport of laundry carts the techs should stand in front of the cart to see everything in their path like residents. The Administrator stated yes, they are preventable accidents with education and training.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to maintain dignity by supplying toilet paper and paper towels for 1 (Resident #10) of 1 resident reviewed for resident rights with the potential to affect all 24 residents residing on the women's secured unit. Findings include: A review of a facility policy titled, Resident Rights, dated 11/01/2022, indicated residents had a right to a dignified existence and be treated with respect, kindness, and dignity. During an observation on 01/06/2025 at 4:30 PM, neither of two stalled bathrooms on the locked women's unit had toilet paper or paper towels available. Both bathrooms had signs on the paper towel dispenser which stated, NO PAPER TOWELS. A review of Resident #10's Admission Record, indicated the facility admitted Resident #10 with diagnoses that included intellectual disabilities, mental disorder due to know physiological condition, psychosis, schizophrenia, and anxiety. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/02/2025, revealed Resident #10 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident was had severe cognitive impairment. Assessment of Resident #10's toileting hygiene shows the resident required partial to moderate assistance. A review of Resident #10's Care Plan with revisions up to 01/06/2025, revealed the resident a history of trauma related to childhood abuse/mistreatment/abusive foster care/involuntary seclusion, homelessness living without food/medicine/shelter, living through depravation and now needing to be under Adult Protective Services (APS). Interventions included providing culturally competent, sensitive trauma-informed care in accordance with personal standards accounting for Resident #10's experiences and preferences to eliminate or mitigate triggers which may cause re-traumatization. Resident #10 had an Activities of Daily Living (ADL) self-care deficit interventions included extensive assistance of one staff member with toileting to check for incontinence, change brief, and perform peri care assistance every two hours and as needed. During a concurrent observation and interview on 01/06/2025 at 4:50 PM, Resident #10 walked into the bathroom while Certified Nursing Assistant #3 retrieved a new white brief from the nurses' station. CNA #3 entered a stall in the bathroom after Resident #10 only carrying a brief. A few minutes later Resident #10 left the stall and the bathroom followed by CNA #3 who was carrying a clear plastic bag with a small white article inside. No water was run in the bathroom and no toilet was flushed. CNA #3 went to a small hallway across from the women's unit shower room and came back without the clear plastic bag. CNA #3 stated due to residents using too much toilet paper and paper towels the toilets got clogged, so paper products were not available in either women's bathroom for their use. CNA #3 stated perineal care should be performed when changing residents brief to ensure residents don't get infections and their skin is clean. CNA #3 stated she forgot and that was my bad. During an observation on 01/06/2025 at 4:52 PM, on the women's secure unit an unidentified female resident who was ambulatory was seen using the bathroom. CNA #3 and another staff member were outside the bathroom, no offer of toilet paper or paper towels were made. During an observation on 01/07/2025 at 8:45 AM, an unidentified female resident of the women's secure unit was seen in a wheelchair taking herself to the bathroom. No toilet paper or paper towels were provided or accessible to the resident for hygiene use. A review of the facility's Certified Nursing Assistant Competency Skills Check-off for CNA #3 revealed, an orientation period from 10/06/2024-10/09/2024 signed off by both CNA#3 and her preceptor for demonstrating knowledge related to: hand washing policy and procedures, performs nursing care based on resident's needs, verbalized the importance of acting as a resident advocate, was competent in resident rights, personal centered care, and cultural competency. The competency skills check off packet was signed off by CNA #3's Unit Manager as completed on 10/09/2024. During an interview on 01/08/2025 at 1:48 PM, the Director of Nursing (DON) stated she had no idea who made the decision not to have paper products available to residents in the women's lock unit bathroom and was unaware it was happening. The DON stated the facility has angel rounds and each supervisor has a different area they round on, so a member of management would have been rounding through the women's unit routinely. The DON stated the residents on the locked units were there because they lack the ability to make good rational decisions. The DON stated the facility had immediately addressed the issue and she was mortified when she found out. A review of an in-service provided to staff on 01/07/2025 stated, Residents should have toilet paper and paper towels available to them at all times! and was signed by 40 staff members on 01/08/2025. During an interview on 01/08/2025 at 2:41 PM, the Administrator stated he was unaware the women's secure unit bathrooms were not providing toilet paper and paper towels to the residents. The Administrator stated the pipes were no excuse. The Administrator stated, few things make me mad, but I was mad. He stated he contacted the facility's former DON and when informed she was aware, the Administrator asked her, Why would you do that? The Administrator acknowledged it was the same plumbing throughout the facility and no other unit had quit supplying toilet paper.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure safe wheelchair transport techniques were used for 1 resident (Resident #6) and cigarettes were stored out of residents access for 1 resident (Resident #11) of 11 residents reviewed; the facility failed to ensure the women's secure unit shower was clean, sanitary, and decluttered; failed to repair broken tile in the doorway of room [ROOM NUMBER]; and the facility failed to ensure an employee's cigarettes were not securely stored away from residents of the 200 Hall and 300 Hall for 4 halls reviewed; and failed to provide adequate number of fitted sheets for resident beds in the men's secured unit when reviewed for a safe, clean, comfortable, homelike environment. Findings include: 1. A review of a facility policy titled, Resident Rights, dated 11/01/2022, indicated residents had a right to a safe, clean, homelike environment including but not limited to treatment and supports for daily living safely. On 01/07/2025 the Director of Nursing (DON) stated the facility had no policy or procedure for wheelchair transportation. A review of the Admission Record, indicated the facility admitted Resident #6 on 08/01/2024 with diagnoses that included Parkinson's disease with dyskinesia (uncontrolled, involuntary muscle movements), dementia, anxiety, depression, schizophrenia, post-traumatic stress disorder (PTSD), muscle weakness, abnormal gait and mobility, lack of coordination, and cognitive communication deficit. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/05/2024, revealed Resident #6 had a Staff Assessment of Mental Status (SAMS) score of 2 which indicated the resident was had moderate cognitive impairment. Resident #6 is non ambulatory and requires a wheelchair for mobility assistance. During an observation on 01/06/2024 at 3:28 PM, Certified Nursing Assistant (CNA) #4 was pushing Resident #6 in a wheelchair out of the resident's room towards the TV common area. CNA #4 had a clear bag with a white article inside, as CNA #4 approached the dirty laundry and trash receptacles he gave Resident #6's wheelchair a push forward then let go of the wheelchair handles. CNA #4 then lifted the lid off the receptacles and placed the plastic bag inside. CNA #4 then caught and turned the wheelchair handles towards the left just before Resident #6's right foot hit a door frame. Resident #6 was then taken to the common area to watch TV. A review of Resident #6's Care Plan with revision up to 01/06/2025, revealed the resident had experienced trauma in their life, specifically related to diagnosis of serious illness leading to the inability to care for themselves independently. Interventions included provide a culturally competent, sensitive trauma-informed care in accordance with professional standards accounting for the person's experience and preferences to eliminate or mitigate triggers which may cause re-traumatization of the resident. Resident #6 used an anti-anxiety medication related to diagnoses of anxiety, schizophrenia, PTSD, and dementia. Interventions included monitoring the resident for safety. Due to the anti-anxiety medications Resident #6 was at increased risk of confusion, loss of balance, falls such as broken hips and legs. Resident #6 is at risk for falls related to confusion, Parkinson's, schizophrenia, dementia, balance/gait problems, weakness, PTSD, lack of coordination, psychoactive drug use, and being unaware of safety needs. Interventions included anticipating resident's needs, and staff assistance with transfers. Resident #6 was at risk for mood and behavioral problems related to confusion, Parkinson's, schizophrenia, dementia, and anxiety. Interventions included caregivers should provide opportunities for positive interaction and attention. During an interview on 01/07/2025 at 3:18 PM, CNA #4 stated he remembered getting Resident #6 cleaned up and taking them to watch TV, but did not remember letting go of the wheelchair. CNA #4 stated he was in a rush due to other resident needing assistance. CNA #4 stated he was a bigger guy therefore he got pulled to other area to help. CNA #4 stated he was preoccupied at the time but apologized stating he usually comes to a complete stop. A review of the Certified Nursing Assistant Competency Skills Check-Off signed by CNA #4 on 10/24/2024 revealed CNA #4 met expectation for care areas: Performs nursing care consistent with resident's needs, resident's rights and the facility's responsibilities, person centered care, wheelchair locomotion, fall prevention, and specific knowledge of Parkinson's disease. The checkoff was not signed by a preceptor or unit manager, but the DON was named as the department head/supervisor. During an interview on 01/08/2025 at 1:48 PM, the DON stated safety precautions during wheelchair transport would be to assure the resident's feet are up and their extremities are inside the wheelchair and no clothing or other articles could get caught. The DON responded no; the CNA transporting should not let go of the wheelchair their hands should remain on it. The DON stated the CNA could run into a wall and cause an injury or hit another resident bystander. During an interview on 01/08/2025 at 2:41 PM, the Administrator stated during wheelchair transport of a resident he would not want to see a resident being pulled backwards. The Administrator responded yes; I would expect the CNA to always have control of the wheelchair. In response to CNA #4 response of helping in other area the Administrator stated, we are short nurse on the floor and use agency to cover, but we are never short CNA's. 2. A review of a policy titled, Resident Smoking, revised on 06/03/2023, indicated Smoking was not permitted inside the facility, and all smoking materials were to be kept by the facility in a secure location. Smoking for residents, staff, and visitors was only allowed outside 15 feet away from doorways, windows, or a vent system. Residents will have no smoking materials in their possession, Resident smoking materials will be labeled to keep an accurate inventory of each resident's supplies. All smoking materials will be kept in the facility's smoking cart/receptacle and secured. All residents will be under supervision while smoking. Residents must remain within eyesight of the smoking monitor, no more than 8-10 feet away. During a concurrent interview and observation on 01/07/2025 at 8:38 AM, Resident #11 was coming out of their room located on the men's secure unit in a wheelchair with a cigarette in their mouth. Licensed Practical Nurse (LPN) #5 was standing by the medication cart and also observed Resident #11 with the cigarettes. LPN #5 stated she was unaware of how the resident was getting the cigarettes, but it has been occurring lately. LPN #5 stated Resident #11 denies having a lighter, but I didn't do a body search. A review of the Admission Record, indicated the facility admitted Resident #11 on 11/01/2024 with diagnoses that included dementia, depression, muscle spasms, and neuropathy (weakness, numbness, and pain from nerve damage usually of the hands and feet). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/08/2024, revealed Resident #11 had a Brief Interview of Mental Status (BIMS) score of 9 which indicated the resident was had moderate cognitive impairment. Resident #11 was identified as not a current tobacco user. A review of Resident #11's smoking assessment dated [DATE] at 1:56 AM indicated, Resident does not use smoking/tobacco/nicotine products. A review of Resident #11's care plan does not identify smoking, or any safety precautions related to smoking. During an interview on 01/07/2025 at 9:01 AM, Resident #11 stated the cigarette was left over from last night's smoke break. Resident #11 stated the CNA was not watching so they brought it in with them. Resident #11 denied having a lighter and stated they would never smoke it inside. During an interview on 01/08/205 at 1:48 PM, the DON stated she was made aware of the cigarette Resident #11 had and the staff was unaware how the resident was getting the cigarettes, but thought family might be bringing them in. The DON stated staff had looked in Resident #11's room but could not find any cigarettes. The DON stated residents are not supposed to have access to cigarettes because it could be a safety and hazard issue. She denied knowing the procedure or location of where cigarettes are kept between smoke breaks because she was new to the facility. The DON ' s start date was 07/07/2024 as the MDS nurse and 08/17/2024 in her current position. During an interview on 01/08/2024 at 2:41 PM, the Administrator stated the facility had 4 or 5 smoke breaks a day and the facility oversaw storing all cigarettes at the nurses' station. The Administrator stated the family will bring in cigarettes to residents and they must remind them the facility must keep them. 3. During a concurrent observation and interview on 01/06/2025 at 4:58 PM, CNA #3 opened the women's secured unit shower room door. Two plastic tubs sitting on the back left floor had standing water in them, a black substance just above the bottom tile trim covered four tiles wide and up to the second cinder block high, a non-rolling shower chair had a stack on clean linens in it. The larger rolling shower chair had rust at the bottom, two bedside commodes were against the right wall, and one had personal hygiene products on the lid as well as a wet used towels, a luffa was on the floor in the corner under it. The other bedside commode which was rusted was sitting next to the rolling shower chair. A linen basket was in the front right corner with wet dirty linens falling out. The floor had dark colored scum covering it. When asked about the black substance on the wall, CNA #3 stated, I would call it mold. During an interview on 01/07/2025 at 8:43 AM, Housekeeping Assistant Supervisor (Housekeeping AS) stated a housekeeper was assigned to the women's secure unit every day from 8am-4pm. Their duties included cleaning, sweeping, mopping, and dusting in the two dining rooms, and down the hall including all resident rooms, both bathrooms, and the shower room. The housekeeper will also address anything which might come up during the day. Housekeeping cleans the shower with the mop and wipes down all surfaces. The blue cleaner is for the floor and the pink is for all surfaces including the tiled walls. Showers are cleaned once a day and all problems are reported to the Housekeeping & Laundry Supervisor (H&L Supervisor) who answers to the Administrator. The housekeeper fills out a paper at the end of their shift and identifies any issues. The Housekeeping AS reported no issues with the shower lately, but stated he had looked in there this morning and it needed to be swept. During a follow-up interview and observation on 01/07/2025 at 8:53 AM with the Housekeeping AS the 01/06/2025 check sheet was provided. No notes or issues identified on the sheet pertaining to the shower room which was turned in at the end of the housekeepers 01/06/2025 shift at 4:00 PM. The Housekeeping AS and the surveyor entered the women's secure unit shower room, the black substance on the wall was less than the previous day but still present. The wet used towels were still on the bedside commode lid and a used dirty glove was in the floor. The floor was still grimy with a dark colored substance and two bedside commodes were still present. The Housekeeping AS stated the substance on the wall was definitely black and looked like mold to him. Housekeeping AS stated he would not personally take a shower in there. During an interview on 01/08/2025 at 1:08 PM, the H&L Supervisor stated he had been to inspect the women's secure unit shower room. He was then shown the pictures from the 01/06/2025 4:58 PM observation and stated, the black area on the wall was not as bad today as in the picture. He observed missing tiles on the wall and the discoloration behind it, the shower chair had orange rings on it, and the wet towels were still present. The H&L Supervisor stated he would not take a shower in there and it was not a fair condition for the residents to live in. He stated they planned to take the shower chair apart tomorrow and clean it. A review of a job description for Director of Housekeeping signed on 11/21/2024 by the H&L Supervisor indicated, his responsibilities are for daily operation of the housekeeping department including staffing, supply ordering, and supervision, and the delegation of responsibilities and assigned duties in accordance with current state and federal regulation to maintain residents' rooms in a safe, comfortable, and maintained in an attractive manner. Supervises housekeeping personnel and schedules adequate coverage and assist with all aspects of cleaning and maintaining the facility's interior and grounds. During an interview on 01/08/2025 at 1:48 PM, the Director of Nursing (DON) stated the facility had angel rounds and each supervisor had a different area they round on, so a member of management would have been rounding through the women's unit routinely. During an interview on 01/08/2025 at 2:41 PM, the Administrator was shown pictures from the 01/06/2025 at 4:58 PM observation of women's secure unit shower room and stated the black area back wall looks like mold. The Administrator stated, No, I would not take a shower in there. During a concurrent observation and interview on 01/07/2025 at 8:59 AM, review of the 01/06/2025 housekeeping check sheet revealed room [ROOM NUMBER] was deep cleaned, but the comments stated the floor tiles were still broken. Housekeeping AS stated he was familiar with the room because it was his grandmother's room. He stated the floor tiles in the doorway had been broken and the facility process was to go tell the maintenance director or text him which had been done. Observations revealed all but one partial tile stretching the width of the doorway were broken down to the sub floor. Housekeeping AS stated he had personally told the Maintenance Director about the tile, but they could only work on it at night because the residents would walk on it. During an interview on 01/08/2025 at 1:08 PM, the H&L Supervisor stated any issues are placed into a logbook, maintenance has one at every nurse's station. We are supposed to log it in there and maintenance will check it then a paper report will come back to the person reporting it. He believed the process was being utilized, but right now the maintenance department is overloaded. The H&L Supervisor was surprised to hear he was the only one to acknowledge a maintenance logbook but admitted he had not received one back since he started in December. During an interview on 01/06/2025 at 5:18 PM, the Maintenance Director stated we learned of issue either through in person communication, a text message, or in a communication application utilized by the department heads. The Maintenance Director stated if you use paper, it gets put back and not always on the top of the pile, so he doesn't use a paper system, and it works good for the facility. The Maintenance Director stated some updating projects have been put on hold because of budget issues. He denied any current work orders in the women's unit. A review of a job description titles Maintenance Director, and signed by the Maintenance Director on 10/24/2024 indicated, responsibilities for planning, organizing, developing, and directing the overall operation of the maintenance department in accordance with current local, state, and federal regulations and to ensure the facility is well-maintained in a safe and comfortable manner. Completes carpentry and other building repairs within the scope of expertise, makes electrical and plumbing repairs within the scope of expertise, coordinates maintenance services and activities with other related departments, and reviews and develops a plan of correction for maintenance deficiencies noted during survey inspections. During an interview on 01/08/2025 at 1:48 PM, DON stated she report any maintenance issues to the Administrator or Maintenance Director. She stated, I know he is supposed to have a program, but I do not know the official process. During an interview on 01/08/2025 at 2:41 PM, the Administrator stated he was unaware the Maintenance Director did not use a paper tracking system and stated we need to tighten things up for closed communication. 4. During an observation on 01/07/2025 at 3:14 PM, a green pack of cigarettes was seen while walking past Resident #4's door. Resident #4 is a dependent, nonverbal resident and a nonsmoker. The pack of cigarettes was visible and accessible to resident ambulation in the hallway. Surveyor waited in doorway until staff was present to alert them hazard. During a concurrent interview and observation on 01/07/2025 at 3:18 PM, CNA #4 stated Resident #4 was bed bound and not a smoker. He retrieved the pack of cigarettes and stated it was a big no-no. CNA #4 suggested the pack could have fallen out of a first shift employee's pocket. CNA #4 left with the pack of cigarettes and stated he would turn them in. During an interview on 01/08/2025 at 1:48 PM, the DON stated yes, they did find out the pack of cigarettes in Resident #4's room belonged to a CNA and had fallen out of their pocket. The DON stated residents should not have access to cigarettes as it could be an accident or hazard. During an interview on 01/08/202 at 2:41 PM, the Administrator stated he was made aware of the pack of cigarettes in Resident #4's room and belonged to an employee who lost them out of their pocket. The Administrator stated residents should not have access to them. 5. During an observation on 01/06/2025 at 2:21 PM, Resident #6 had no fitted sheet on the bed, a folded flat sheet and blanket were on the mattress. During a concurrent interview and observation on 01/06/2025 at 2:30 PM, Resident #8 had no fitted sheet on the bed, a folded flat sheet and a blanket were on the mattress. Resident #8 stated they didn't believe the facility had fitted sheets and they put the blanket down to catch the water. Resident #8 explained they received a shower this morning and got dried off with only one little towel. During an interview on 01/08/2025 at 12:31 PM, H&L Supervisor stated a new facility wide linen count was completed in the middle of December which resulted in him placing two orders for towels, washcloths, fitted sheets, and bariatric sheets. Another order for towels, washcloths, and sheets was placed today (01/08/2025). During an interview on 01/08/2025 at 1:48 PM, when asked about CNAs on the men's unit yesterday unable to make beds due to lack of linens, the DON stated, Yes, that is an occurrence that has happened before. The DON stated it was about a month ago and they ordered new linens then too. During an interview on 01/08/2025 at 2:30 PM, CNA #6 stated earlier today the facility ran out of fitted sheets and she had to use flat sheets to make one or two beds.

Based on interviews, record review, facility document review, facility policy review, it was determined that the facility failed to obtain written authorization to manage personal funds, ensure a resident was aware of process to access personal funds, and had knowledge of facility charges for 1 (Resident #8) of 5 residents reviewed for personal funds. Findings include: A review of a facility policy titled, Resident Rights, dated 11/01/2022, indicated residents had a right to manage their own funds or choose to have the facility manager funds. A review of the Admission Record, indicated the facility admitted Resident #8 on 08/26/2024 with diagnoses that included injury at C7 level of the cervical spine, functional quadriplegia, depression, and panic disorder. Resident #8 was their own Power of Attorney (POA) and made their own decisions. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/05/2024, revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. During an interview on 01/06/2025 at 2:30 PM, Resident #8 stated they were unaware if the facility was managing money for them or not. No one had talked to the resident about it, Resident #8 did not know how to access their funds, or if there was a balance. Resident #8 stated they had received two haircuts since being in the facility but did not know the cost or who paid for it. The resident stated they thought they were to get $40 a month to spend but had never seen any money or any account information. During an interview on 01/08/2025 at 11:11 AM, the Business Office Manager (BOM) was unable to find an authorization to manage personal funds for Resident #8. The BOM stated she had spoken to the resident's brother at one time, but agreed Resident #8 was their own Power of Attorney and made their own decisions. During a concurrent observation and interview on 01/08/2025 at 1:20 PM, the BOM stated herself and the Social Services Director went to Resident #8's room and obtained an authorization to manager funds, explained how the resident could access their personal funds, and a current balance was provided.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to provide perineal care during a soiled brief change for 1 (Resident #10), and failed to ensure physician orders were followed for medication administration, specifically not crushing and administering iron tablets labeled DO NOT CRUSH for 1 (Resident #7) of 11 residents reviewed for Quality of Care. Findings include: 1. A review of a facility policy titled, Resident Rights, dated 11/01/2022, indicated residents have a right to a dignified existence and be treated with respect, kindness, and dignity. A review of Resident #10's Admission Record, indicated the facility admitted Resident #10 with diagnoses that included intellectual disabilities, mental disorder due to know physiological condition, psychosis, schizophrenia, anxiety, and lack of coordination. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/02/2025, revealed Resident #10 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Assessment of Resident #10's toileting hygiene shows the resident required partial to moderate assistance. A review of Resident #10's Care Plan with revisions up to 01/06/2025, revealed the resident a history of trauma related to childhood abuse/mistreatment/abusive foster care/involuntary seclusion, homelessness living without food/medicine/shelter, living through depravation and now needing to be under Adult Protective Services (APS). Interventions included providing culturally competent, sensitive trauma-informed care in accordance with personal standards accounting for Resident #10's experiences and preferences to eliminate or mitigate triggers which may cause re-traumatization. Resident #10 had an Activities of Daily Living (ADL) self-care deficit interventions included extensive assistance of one staff member with toileting to check for incontinence, change brief, and perform peri care assistance every two hours and as needed. During an observation on 01/06/2025 at 4:30 PM, neither two stalled bathrooms on locked women's unit had toilet paper or paper towels. Both bathrooms had signs on the paper towel dispenser which stated, NO PAPER TOWELS. During a concurrent observation and interview on 01/06/2025 at 4:50 PM, Resident #10 walked into the bathroom while Certified Nursing Assistant #3 retrieved a new white brief from the nurses' station. CNA #3 entered a stall in the bathroom after Resident #10 only carrying a brief. A few minutes later Resident #10 left the stall and the bathroom followed by CNA #3 who was carrying a clear plastic bag with a small white article inside. No water was run in the bathroom and no toilet was flushed. CNA #3 went to a small hallway across from the women's unit shower room and came back without the clear plastic bag. CNA #3 stated due to residents using too much toilet paper and paper towels the toilets got clogged, so paper products were not available in either women's bathroom for their use. CNA #3 stated peri care should be performed when changing residents brief to ensure residents don't get infections and their skin is clean. CNA #3 stated she forgot and that was my bad. A review of the facility's Certified Nursing Assistant Competency Skills Check-off for CNA #3 revealed, an orientation period from 10/06/2024-10/09/2024 signed off by both CNA#3 and her preceptor for demonstrating knowledge related to: hand washing policy and procedures, knowledge of infection control system, performs nursing care based on resident's needs, verbalized the importance of acting as a resident advocate, was competent in resident rights, personal centered care, cultural competency, and basic nurse aide skills of toileting assistance and perineal care/incontinence care. The competency skills check off packet was signed off by CNA #3's Unit Manager as completed on 10/09/2024. During an interview on 01/08/2025 at 1:48 PM, the Director of Nursing (DON) stated she had no idea who made the decision not to have paper products available to residents in the women's lock unit bathroom and was unaware it was happening. DON stated the facility has angel rounds and each supervisor has a different area they round on, so a member of management would have been rounding through the women's unit routinely. DON stated perineal care should be performed when a resident is changed from a soiled brief to a clean one for infection control management and hand hygiene should also be performed. The DON stated the residents on the locked units were there because they lack the ability to make good rational decisions. The DON wanted to know if the CNA went back to perform proper perineal care after they were questioned by the surveyor and the DON was informed no. 2. A review of facility policy titled Medication Administration with revision date of 11/25/2022 revealed the following: Medications must be administered in accordance with the orders. A review of the Resident #7 ' s Admission Record indicated the facility initially admitted Resident #7 on 05-28-2015 with current diagnosis of Metachromatic Leukodystrophy, gastrostomy status and dysphagia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2024, revealed Resident #7 had a Staff Assessment of Mental Status (SAMS) score of 1 which indicated the resident was severely cognitively impaired. Resident #9 required a feeding tube for nutrition, medications, and fluids. A review of Resident #7 ' s care plan with initiated date of 1-6-17 revealed the resident has need for feeding tube for nutrition and hydration. Resident #7 is at risk for malnutrition, dehydration and complications. Interventions included to check residual per physician orders and notify physician of any problems and to check placement prior to medication administration and flushes by auscultation and aspiration. A review of Resident # 7 ' s physician orders with active date of 12/24/24 revealed that Resident #7 was to receive Iron Oral Tablet 325 (65 Fe) MG (Ferrous Sulfate) Give 1 tablet via PEG-Tube one time a day for iron supplement Do not crush. (Percutaneous endoscopic gastrostomy is a surgery to place a feeding tube (PEG tube). PEG tubes allow you to get nutrition through your stomach.) A review of Resident # 7 ' s January 2025 medication administration record (MAR), revealed Resident #7 was to receive Iron Oral 325 (65 Fe) MG (Ferrous Sulfate) Give 1 tablet via PEG-Tube one time a day for iron supplement Do not crush. A review of December 2024/January 2025 Medication Administration Record (MAR) revealed Iron tab had been administered at total of 22 doses. During an interview on 01/07/2025 at 1:54 pm, Licensed Practical Nurse #1 reported that he used liquid Iron previously for Resident 7 but has run out. He reported he held the Iron that morning because Iron is not crushable. Reported that there was not a physician order for liquid Iron but substituted it and gave 7.5ml he thought to equal the dose ordered. During an interview on 01/07/2025 at 3:13 pm, Director of Nursing (DON) revealed that there is no liquid iron in the building. She reported the nurses had to have been crushing the Iron and giving it to Resident 7. She revealed that Iron should not be crushed because it is enteric coated. Revealed that if you crush an enteric coated medication, it could be all released at one time. Also, Iron should not be crushed because it could cause a Gastrointestinal bleed.

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to provide appropriate treatment and services to prevent complications from enteral feedings for 2 of 3 residents (Resident #7 and Resident #9) reviewed for tube feeding. Specifically, the facility failed to appropriately check tube placement prior to administering flushes and/or medications for Resident #7 and Resident #9. The findings include: A review of facility policy titled Enteral Feeding with revision date of 11/25/2022 revealed the following, Check enteral tube placement prior to each feeding and administration of medication and if resident is not alert and able to voice symptoms of bloating, nausea or abdominal pain then nurse is to monitor gastric residual volume prior to administration of feeding or medication. A review of the Resident #7's Admission Record indicated the facility initially admitted Resident #7 on 05-28-2015 with current diagnosis of metachromatic leukodystrophy, gastrostomy status, and dysphagia. A review of Resident's #9's Admission Record indicated the facility initially admitted Resident #9 on 11-04-2014 with a diagnoses of Huntington Disease, gastronomy status, and dysphagia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2024, revealed Resident #7 had a Staff Assessment of Mental Status (SAMS) score of 1 which indicated the resident had memory problem and severely cognitively impaired. Resident #7 required a feeding tube for nutrition and fluids. The quarterly MDS with ARD date of 10-16-2024 revealed that Resident #9 is in a vegetative state/no discernible consciousness and requires all nutrition and fluids through a feeding tube. A review of Resident #7's care plan with initiated date of 1-6-17 revealed the resident has need for feeding tube for nutrition and hydration. Resident #7 is at risk for malnutrition, dehydration and complications. Interventions included to check residual per physician orders and notify physician of any problems and to check placement prior to medication administration and flushes by auscultation and aspiration. A review of Resident #9's care plan with initiated date of 11-07-2014 revealed that Resident # 9 has need for PEG tube placement and requires staff assist with feedings/flushes per orders. Interventions included that PEG tube feedings/flushes are per physician orders. A review of Resident #7's physician orders with active date of 12/24/24. Revealed that GT/PEG tube placement to be checked every shift. A review of Resident # 7's January 2025 medication administration record (MAR), revealed Resident #7 was to have Gastronomy Tube (GT)/PEG tube placement checked every shift. A review of Resident #9's January 2025 MAR revealed that staff is to check PEG tube place every shift. During an observation on 01/07/2025 at 9:54 am, a surveyor observed Licensed Practical Nurse (LPN) #1 administering Resident #9 water through PEG tube without checking placement prior. After flushing LPN #1 realized he had not checked placement of PEG tube and then checked placement after flushing of water was completed. LPN #1 dropped stethoscope on floor and then hung back up on PEG tube pole without cleaning. During an observation on 01/07/2025 at 10:09 am, a surveyor observed LPN #1 used the same stethoscope that had not been cleaned, to check for air movement in the stomach of Resident #9 but did not aspirate gastric residual for placement check. PEG tube was clogged and instead of using tube clamp was bending tube together to stop flow of liquids. PEG tube plunged numerous times but due to being clogged had to milk tube to try and get it unclogged in order to administer medication/fluid through the PEG tube. After medications were administered LPN #1 then aspirated residual of PEG tube. During an interview on 01/07/2025 at 1:35 pm with Registered Nurse (RN) #2 revealed that PEG tubes should be checked for placement every shift and prior to medication administration through the PEG tube. She revealed it should be done several times a day. During an interview on 01/07/2025 at 1:54 pm, Licensed Practical Nurse (LPN) #1 revealed that the facility's policy is to check placement prior to medications through a PEG tube and prior to PEG tube feedings. He also revealed that the methods of verifying PEG tube placement is by auscultation and aspiration. He revealed that he did not verify placement by aspiration on Resident #7 and Resident #9 on 01/07/2025 while giving medicine via PEG tube. During an interview on 01/07/2025 at 3:13 pm, the Director of Nursing (DON) revealed that it is important to check placement of a PEG to prior to medication administration or PEG tube feedings because you want to make sure it is in the stomach and not going into other organs.

Based on observation, interview, and policy review, it was determined the facility failed to ensure an accident/hazard free environment, as evidenced by not keeping doors locked on rooms containing chemicals and hazards. The findings are: On 9/18/2024 at 5:30 am, observed the facilities hopper room door on the 300 Hall was not completely closed. When the door was pushed open, there were chemicals, sharps containers (a puncture-resistant waste container for sharp objects) that were overflowing with used razors, and the hopper had a brown substance covering the inside. The room had a foul odor. On 9/18/2024 at 5:37 am, observed the shower room door on the Administration Hall was not closed completely. When the door was pushed open, there were chemicals and razors inside. The chemicals included: rinse free body wash, deodorant, anti-perspirant, shaving cream, body oil, and skin protectant. The anti-perspirant contained alcohol, the skin protectant had a warning to contact poison control right away if ingested. All chemicals had a label with a warning to keep out of reach of children. On 9/19/2024 at 7:57 am, CNA #2 stated that hopper and shower room doors should always be closed and locked to keep residents from getting into chemicals and sharps containers. CNA #2 confirmed that if residents ingested chemicals or got ahold of sharps that they could suffer injuries. On 9/19/2024 at 8:33 am, LPN #3 confirmed that hopper room doors and shower room doors should always be shut and locked to keep resident ' s from accessing the room and getting into chemicals. LPN #3 confirmed that nurse ' s store full sharps containers in the hopper room and they are stored there until medical waste company picks them up. LPN #3 also confirmed that sharps containers should not be overflowing because they are supposed to be closed off. On 9/19/2024 at 8:22 am, the Administrator provided a policy on Accidents and Hazards which indicated the facility strives to ensure the environment is free from hazards. On 9/19/2024 at 8:44 am, the Administrator provided in-services dated 4/17/2024 and 5/10/2024, regarding all doors with locks must be shut completely.

Based on observations, interview, and policy review, it was determined the facility failed to ensure residents had reasonable accommodation of needs by not ensuring the residents call lights were within reach for 1 (Resident #6) sampled resident. The findings are: Review of the Medical Diagnosis portion of Resident #6's electronic health record revealed a diagnosis of hemiplegia, indicating paralysis on one side of the resident's body. Review of a 5-day Minimum Data Set with an Assessment Reference Date of 09/06/2024, Section GG, revealed Resident #6 had impaired function on one side of their body, utilized a wheelchair, and in the category Indoor mobility(ambulation) an assessment of Not Applicable was documented. On 9/17/2024 at 4:14 pm, while in Resident #6's room, the call light was observed behind the chair that the resident was sitting in, out of reach of the resident. On 9/18/2024 at 5:10 am, while in Resident #6's room, the call light was observed beside the resident's bed and under the wheel of the bedside table, out of reach of the resident. On 9/18/2024 at 5:27 am, while in Resident #15's room, call light was observed in the floor, up against the wall between the two resident's beds, out of reach of the resident. On 9/19/2024 at 7:40 am, Certified Nursing Assistant (CNA) #1 confirmed that the last thing staff should do before leaving a resident's room is make sure their call light is in reach because they may need something or have an emergency. On 9/19/2024 at 7:55 am, CNA #2 confirmed that the last thing staff should do before exiting a resident's room is make sure their call light is within reach because if they have an emergency and can ' t reach their button, the resident could become upset and could suffer harm. On 9/19/2024 at 8:30 am, Licensed Practical Nurse (LPN) #1 stated that residents should always have their call lights in reach when staff exit the room because they need to push it when they need or want something. If they have an emergency, they would need to get staff to respond quickly or it could cause them harm. On 9/19/2024 at 8:44 am, the Administrator provided an in-service that was issued to staff on 2/21/2024 that pertained to ensuring the residents had their call light within reach prior to staff leaving the resident's room. The facility was unable to provide a policy specifically related to call lights.

Based on observations, interviews, and record reviews, it was determined the facility failed to ensure 1 (Resident #13) of 4 sampled residents reviewed for activities of daily living (ADL) care was kept clean and dry. The findings are: A review of an Order Summary Report, indicated Resident #13 had a diagnosis of neuromuscular dysfunction of the bladder. The quarterly Minimum Data Set with an Assessment Reference Date (ARD) of 7/25/2024 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 09, which indicated the resident had moderate cognitive impairment and had occasional urinary incontinence. Review of Resident #13's, Care Plan, revised 7/29/2023, revealed Resident #13 was frequently incontinent of bladder and wore disposable briefs. Resident #13 required extensive assistance times one staff with toileting, check for incontinence, change brief, and provide care assistance every two hours and as needed. On 9/18/24 at 5:37 AM, Certified Nurse Aide (CNA) #4 removed the blanket from Resident #13 and placed it on the floor. Resident #13's brief, pad, and sheet were soaked with urine. On 9/18/24 at 5:39 AM, Resident #14 indicated that the staff hasn't checked on Resident #13 all night. Resident #14 indicated that no one checks on them at night. On 9/18/24 at 5:58 PM, CNA #5 came into Resident #13's room and finished providing incontinent care. Resident #13's skin was red on his lower abdomen, and on his inner thighs. On 9/18/24 at 6:00 AM, CNA #5 indicated that he changed Resident #13 at the beginning of his shift, and that his shift started at 11:00 PM, and he changed Resident #13 at approximately 12:00 AM. CNA #5 also indicated that Resident #13 should be checked on for incontinence every 2 hours. On 9/18/24 at 6:02 AM, CNA #4 indicated Resident #13 should be checked for incontinence every 2 hours. This morning was her first time checking on Resident #13 during her shift. She wasn't sure if CNA #5 had checked on him during the night.

Based on observation and interview, the facility failed to ensure food items stored in the freezer were covered or sealed to prevent potential freezer burn; expired food items were promptly removed/discarded by the expiration or use by dates; one of 2 ice scoops and 1 of 2 ice machines were maintained in clean and sanitary condition to prevent food and beverages contamination; staff washed hands prior to clean tasks and before handling clean equipment or food items to minimize the potential for contaminating food items; and cold food items were maintained at or low 41 degrees Fahrenheit while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 104 residents who received meals from the kitchen. The findings are: 1. On [DATE] at 9:15 AM, the following observations were made on a shelf in the refrigerator. a. A gallon of 2 % milk with an expiration of [DATE]. b. Two of 2 gallons of 2 % milk in the milk crate had expiration date of [DATE]. 2. On [DATE] at 9:18 AM, an opened box of French toast was on a shelf in the walk-in freezer. The box was not covered, and the bag was not sealed. 3. On [DATE] at 9:27 AM, the ice scoop on the right side of the ice machine has brown/black corroded water standing in it. The ice scoop was touching the residue. The surveyor asked the Dietary Supervisor to describe what was found in the ice scoop holder. She stated, It was a brown standing water gunk goo. The surveyor asked the Dietary Supervisor how often the ice machine is cleaned and who uses the ice from the machine? She stated, We use it to fill the beverages served to the residents at mealtimes. We clean it daily. 4. On [DATE] at 9:55 AM, Dietary Cook #13 wore gloves on her hands, when she picked up a can of peach halves and placed it on the counter. Without washing her hands, she 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. The surveyor asked Dietary Cook #13, what should you have done after dirty objects and before handling clean equipment? She stated, I should have washed my hands. 5. On [DATE] at 10:10 AM, Dietary Cook #14 lifted a metal rack meant for holding individual snack bags and set it on the counter between the and the steam table. Taking off the [NAME] papers covering the pans of cornbread, disposed of them in the trash, then grabbed gloves from the box, she donned them, contaminating them. Finally, she picked up the cornbread and packed them into separate bags. 6. On [DATE] at 10:44 AM, Dietary Aide #15 touched his beard cover and without washing his hands, he picked up a clean bade 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. 7. On [DATE] at 11:12 AM, Dietary Aide #15 pushed a plate warmer towards the clean area of the dish washing machine, without washing her hands. He picked up plates and placed them on the plate warmer to be used in portioning lunch meal to be served to the residents. 8. On [DATE] at 12:31 PM, the temperatures of the food item when tested and read by the Dietary Cook #14 were pureed corn bread with milk 112 degrees The above food item was not reheated before being served to the residents on pureed diets. 9. On [DATE] at 1:36 PM, the temperatures of the cold food items were tested and read by the Dietary Supervisor as follows: a. Cottage cheese 50 degrees Fahrenheit. b. Turkey with cheese sandwiches 55 degrees Fahrenheit. c. Turkey salad with cheese 60 degrees Fahrenheit. The surveyor asked the Dietary Supervisor how you should serve the cold foods? She stated, Put them on ice or in the refrigerator before serving them. 10. On [DATE] at 3:33 PM, the inside top panel of the ice machine had wet black residue on it. The surveyor asked the Dietary District Manager to wipe the wet-colored substances found on the panel. He did with tissue paper. The wet black substances easily transferred on the tissue papers. The surveyor asked the Dietary Manager who uses ice from the ice machine and how often the ice machine has been cleaned. She stated, We clean it biweekly. We use it to fill beverages served to the resident at mealtimes. 11. A facility policy titled Hand washing under when to wash hands documented, When entering the kitchen at the start of a shift. Before donning disposable gloves for working with food and after gloves are removed and after engaging in other activities that contaminate the hands.

43262 Based on observation, record review, and interview it was determined the facility failed to ensure a Resident who was lying in bed wearing only a brief, and a Resident who was receiving a brief change with perineal care, were not visually exposed from the hall in order to maintain dignity and privacy for 2 (Resident #7 and Resident #88) of 2 sampled residents reviewed who required total assistance. The findings include: 1. Resident #7 had diagnoses (dx) of Cerebral Palsy, Calorie Malnutrition. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/10/2024 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS). On 05/20/24 12:03 PM during initial rounds, Resident #7 was observed lying in bed on back, fully uncovered with only a brief on. The Resident's door was open to the hallway and the privacy curtain was not pulled closed. On 05/20/24 3:55 PM, Resident #7 was observed lying in bed on back fully uncovered, wearing only a brief. Certified Nursing Assistant (CNA) #9 walked past the Resident's room, looked in and continued down the hallway. On 05/20/24 3:56 PM, the nurse consultant walked past Resident's room, briefly paused, and looked in the room. Resident #7 was uncovered, only wearing a brief. The nurse consultant continued down the hallway looking in each room. On 05/20/24 3:58 PM, Certified Nursing Assistant (CNA) #1 was observed standing in doorway of room [ROOM NUMBER], across the hall from Resident #7. CNA #1 looked in Resident # 7's room then turned around and went back into another room. On 05/20/24 3:59 PM, the Surveyor observed the nurse consultant walk back up the hallway, look in Resident #7's room again for a moment, then continue toward the end of the hallway and stopped at the nurses' station. A staff member left the nurses' station and walked to Resident #7's room, paused before entering, entered and immediately pulled the privacy curtain. On 05/20/24 4:01 PM, the surveyor entered the room and the Business Office Manager (BOM) identified herself. The BOM said I pulled the privacy curtain, (Resident's name) always kicks the covers off. I put the covers back on to promote the Resident's dignity. On 05/23/24 9:47 AM, Registered Nurse (RN) #18 was asked if you observed a Resident in bed wearing only a brief, what would you do? RN #18 said I would cover the Resident up, put on a gown or ask the aid to take care of the situation for privacy and dignity. On 05/23/24 10:30 AM, the Director of Nurses (DON) asked if you observed a Resident in bed wearing only a brief, what would you do? The DON said, if you are talking about (Resident's name), that Resident is care planned to not use covers and Resident is scared to have the curtain pulled. The Surveyor asks How do you know Resident is scared to have the curtain pulled when Resident is nonverbal? The DON said, the Resident starts screaming when the curtain is pulled. For other residents, unless its care is planned differently, I would cover the Resident up or pull the privacy curtain to promote dignity. Review of Resident #7's Plan of Care saved on 5/20/24 at 12:42 PM did not mention Resident #7 preference to be uncovered or have the privacy curtain pulled. 2. A review of the Admission Record, indicated the facility admitted Resident #88 with diagnoses that included Signs and symptoms involving cognitive functions and awareness, arthritis, osteoarthritis, weakness, lack of coordination unsteadiness on fee, reduced mobility problems related to life management difficulty. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/26/2024, revealed Resident #88 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #88 was dependent on staff for all activities of daily living (ADL), including toileting transfer and hygiene. A review of Resident #88's Care Plan, revised, revealed the resident has an ADL self-performance deficit related to confusion and dementia. Resident #88 is incontinent of bladder and always incontinent of bowel and wears disposable briefs. Interventions included, requires extensive assistance of 1 staff to check for incontinence, change brief, and perform peri care assistance. During an observation on 05/21/2024 at 9:24 AM, Certified Nursing Assistant (CNA) #7 and CNA #8 had removed Resident #88's clothing and brief, performing peri care. CNA #10 knocked on door, opened without response stepped into room, immediately exited room, leaving the door open. CNA #8 stated CNA #10 just left the door so there is no privacy. CNA #7 replied, I know. CNA #8 closed the door. During an interview on 05/21/2024 at 9:33 AM, CNA #10 indicated the door was not pulled closed due to forgetfulness and should have closed the door to provide privacy. On 05/22/2024 at 12:41 PM, the DON provided a document stating, We do not have a policy on peri care. During an interview on 05/23/2024 at 2:19 PM, RN #12 stated staff should be providing privacy, closing shades, pulling curtains, and closing doors when providing care that exposes a resident.

Based on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 6 residents who received pureed diets. The findings are: 1. On 05/22/24 at 11:22 AM, Dietary Cook #14 used 4-ounce spoon to place 5 servings of cut green beans into a blender, pureed, added 2 tablespoons of thickened, pureed, added 4 more tablespoons of thickened, and pureed. At 11:32 AM, Dietary Cook # 14 added a tablespoon of thickened on cut green beans and pureed it more. At 1:33 AM, she poured the pureed cut green beans in the same pan. She covered the pan with foil and placed it in the oven. The consistency of the pureed cut green beans was running and not formed. 2. On 05/22/24 at 11:52 AM, Dietary Cook #14 used a 6-ounce spoon to place 4 servings of chili into a blender, added a tablespoon of thickener, added beef broth, and pureed. At 11:57 AM, Dietary Cook # 14 poured the pureed chili into a pan. At 11:58 AM Dietary Cook # 14 used a 6-ounce spoon to place 3 servings of chili into a blender, added 2 tablespoons of thickener and pureed. At 12:02 PM, Dietary Cook #14 poured the pureed chili into a pan using a 6-ounce spoon to place 3 servings more of chili into a blender, added 2 tablespoons of thickener and pureed. On 05/22/24 at 12:06 PM, Dietary Cook #14 poured the pureed chili in the same pan. Covered the pan with foil and placed it in the oven. The consistency of the pureed chili was thin and not formed. 3. On 05/23/24 at 8:15 AM, during the breakfast meal observation the residents who required pureed diets were served the following food items. a. Pureed sausage was gritty and not smooth. b. Pureed oatmeal was thin and was not formed. 4. On 05/23/24 at 8:20 AM, the surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items served to the residents on pureed diets at the lunch meal on 05/22/24 and breakfast meal on 05/23/24. She stated, For lunch yesterday. Pureed chili pureed cut green beans were thin. Pureed oatmeal was thin and pureed sausage was gritty. 5. On 05/23/24 at 8:25 AM, the surveyor asked Dietary Cook #16 to describe the consistency of the pureed sausage served to the residents on pureed diets. Dietary cook # 16 stated, It was gritty.

Based on observation, record review and interview, the facility failed to ensure a resident who was at risk for elopement was closely supervised and interventions to prevent elopement were developed and implemented to prevent the resident's elopement out a window of the Men's Secure Unit for 1 (Resident #6) of 1 case mix resident who was at high risk for elopement. The failed practices resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death to 1 (Resident #6), who eloped from the facility and was outside in freezing temperatures for an undetermined length of time, and had the potential to affect 5 residents who resided on the Men's Secure Unit and were ambulatory, confused and at risk for elopement, as documented on a list provided by the Administrator on 1/24/2019 at 3:47 p.m. The Administrator was informed of the past immediate jeopardy condition on 1/23/19 at 2:45 p.m. The findings are: Resident #6 had [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set with an Assessment Reference Date of 12/12/2018 documented the resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status; had signs and symptoms of [MEDICAL CONDITION], including inattention and disorganized thinking, which were present continuously and did not fluctuate; exhibited wandering behavior on 4 to 6 of the past 7 days; required supervision and no physical assistance from staff for transfer, walking in room and corridor, and locomotion on and off the unit; used tobacco; and had 2 or more falls without injury since admission or prior assessment. a. The Care Plan dated 10/10/2018 documented, (Resident #6) is an elopement risk/wanderer r/t (related to) history of attempts to leave facility unattended, Impaired safety awareness, Exit seeking . Wnaders (sic - wanders) . Goal . (Resident) will not leave facility unattended . Interventions: .Distract (resident) from wandering by offering pleasant diversion, structured activities, food, conversation, television, book . Identify pattern of wandering: Is wandering purposeful, aimless, or escapist . is resident looking for something . provide structured activities . The elopement risk care plan did not document an intervention to periodically verify the resident's whereabouts, nor any specific frequency at which the resident should be monitored. b. A physician order [REDACTED]. c. A Police Department Offense Report dated 01/19/2019 documented, On 1/19/2019 at 9:28 a.m., I was dispatched to (address) for a found person. Upon arrival, I spoke with (name of citizen who found resident) who said she was driving to work on (street name) and noticed a black male, wearing sweat pants and a [MEDICAL CONDITION] helmet. She stopped and asked the subject where he was headed to. He replied that he was headed home at (address) in Little Rock, AR (Arkansas). She said he was not making much sense after that, so she gave him a ride to her workplace at 3401 Cavanaugh and called the police. I asked the suspect what his name was and he told me (resident's name). He said he was trying to get home to (address) in Little Rock, AR. I asked him where he stayed last night. He told me he stayed here and there, but mostly outside. He was not making much sense with what he was saying, but the workers got him some food while attempting to locate where he lived. Dispatch started calling hospitals and (local service provider for the homeless) to see if he walked away from one of those locations without them knowing. I noticed his clothing was not wet, and if he had slept outside, this seemed odd. He was picked up on (street name) and (facility name) is very close to where he was picked up. Dispatch called them and it was confirmed that (Resident #6) was missing from this facility. I drove (Resident #6) back to (facility name). I spoke with Administrator (name), who said they were trying to figure out how he had gotten out the door. (Resident #6) has a history of getting out of places in his past facilities, so they were puzzled on how he got out the door. They were not aware he was missing until Dispatch called to ask if he was missing. (Administrator) informed me that there are no cameras in this facility, so tracking it down is going to be difficult. It was found that (Resident #6) entered a maintenance closet this morning and opened the window, moved the screen, jumped outside, then replaced the screen. There were footprints below the window leading to the road . d. A hospital record dated 1/19/19 at 11:44 a.m. documented, .presents to ED (Emergency Department) for a wellness check. Staff at bedside . says that the door did not lock fast enough and the pt (patient) slipped out the door . later, police returned the pt after he was walking outside in the cold and snow for about an hour . e. The facility's documented investigation included the following Office of Long Term Care (OLTC) Witness Statement forms: 1.) An OLTC Witness Statement form dated 1/19/19 at 11:00 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, I last saw (Resident #6) right after breakfast. 2.) An OLTC Witness Statement form dated 1/19/19 (not timed) and signed by Housekeeper #1 documented, I saw him while I was cleaning the hall & (and) dining area. Last time I saw him was about 9:00 a.m. in dining area. 3.) An OLTC Witness Statement form dated 1/19/19 at 12:45 p.m. and signed by Certified Nursing Assistant (CNA) #1 documented, The last time that I had seen (Resident #6) was in the TV room before 9:00 smoke break. 4.) An OLTC Witness Statement form dated 1/19/19 (not timed) and signed by CNA #2 documented, The last time I had saw (sic) him was after breakfast watching TV. f. On 1/23/19 at 9:10 a.m., the Administrator was asked about the resident's elopement on 1/19/19 and stated the resident was able to remove the screw from a window in, .an unlocked resident room used for storage . She stated the resident removed the screen, climbed out the window, replaced the screen and walked off. g. On 1/23/19 at 9:40 a.m., Maintenance staff #1 was asked about the resident's elopement on 1/19/19 and stated, .resident got out the window of a storage room. The room wasn't locked, was used for storage mostly of extra supplies . extra clothing . At 11:36 a.m., Maintenance staff #1 accompanied the surveyor to the aforementioned storage room and stated, When I came in here (on 1/19/19), the blinds were laid up on this shelf out of the way, the window was wide open, the screws were gone, and the screen was turned backward. I could see where he got out; there was snow on the ground. I could see his footprints . h. The facility removed the immediate jeopardy and corrected the underlying failed practices on 1/21/19, as evidenced by the following: 1.) The OLTC Incident & Accident Next Day Reporting form, Division of Medical Services (DMS) form 7734, dated 1/19/19 documented, .Steps Taken to Prevent Continued Abuse or Neglect During the Investigation . Maintenance to check all doors and windows for accuracy and functioning . Door alarm company requested to evaluate all points of exit 1/19/19 . Staff member at door of exit pending door alarm company review . Head count of facility with no other negative findings . Elopement policy in-service started immediately ongoing for all staff prior to working . Elopement drill completed on all three shifts within 24 hours . Elopement risk assessments completed on all residents . On resident's return from the ER (emergency room ) the resident will be placed on one-on-one until all systems have been checked and in-service completed . 2.) Elopement Risk Evaluation forms for the residents at risk for elopement documented the evaluation forms were completed on 1/19/19 at 2:44 p.m. 3.) A Daily Alarm Check Log sheet dated 1/19/19 documented all alarms were checked and found to be in proper working order. 4.) Inservice Education Reports and sign-in sheets dated 1/19/19, 1/20/19 and 1/21/19 documented all staff were in-serviced on, Elopement Protocol . elopement policy . 5.) The facility's Elopement policy, provided by the Administrator on 1/23/19 at 4:30 p.m. documented, .Prevention of Missing Residents and Elopement . Residents that are at risk of elopement will be provided at least one of the following safety precautions . staff supervision of facility exits either directly or by video camera . door alarms on facility exits . a personal safety device that notifies facility staff when the resident has left the facility without supervision . all personal safety devices, door alarms and video cameras will be tested and documented every shift . Any resident identified to be at risk of elopement will be placed on a resident At Risk List which shall be maintained in a binder at each nursing station . 6.) A typed statement dated 1/23/19 from the facility's alarm service company documented, (Company name) was at (facility name) on Monday, (MONTH) 21, 2019, and performed a walk-through to look over the magnetic lock doors to see if any problems existed. At this time, no issues were found . 7.) A facility floor plan provided by Maintenance staff #1 on 1/23/19 at 9:57 a.m. was labeled with the locations of windows and other points of exit and documented, All windows checked 1/19/19, 1/20/19 and 1/21/19 . Maintenance staff #1 was asked at 9:57 a.m. about further actions to prevent elopement and stated, I am personally checking every window in the secure units every day . All of the windows in the secure units have screws in them that limit their opening to about 6 inches . The surveyor made rounds through the secure units at this time to check the windows and screws; all windows and securement screws were intact. 8.) An invoice provided by Maintenance staff #1 on 1/23/19 at 11:44 a.m. documented the facility had ordered and was awaiting receipt of security screws for the windows on the secure units.

Complaints # (AR 018) and # (AR 025) were substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure necessary treatment and services were provided to promote healing of pressure ulcers, prevent potential infection and prevent development of new pressure ulcers, as evidenced by: Failure to ensure licensed nursing staff followed clean technique and nursing standards of practice during pressure ulcer treatments, to prevent potential infection or deterioration of existing pressure ulcers for 2 (Residents #1 and #3) of 3 (Residents #1, #2 and #3) case mix residents who had pressure ulcers and physician orders for wound care; Failure to ensure pressure ulcer assessments consistently included accurate wound measurements and staging, to facilitate tracking of healing progress or deterioration for 2 (Residents #2 and #3) of 3 (Residents #1, #2 and #3) case mix residents who had pressure ulcers; Failure to ensure waffle cushions were provided as ordered to relieve pressure and promote healing of existing pressure ulcers for 1 (Resident # 2) of 1 case mix resident who had a physician order for [REDACTED].>Failure to ensure Roho cushions were utilized in accordance with the manufacturer's instructions, by failing to instruct staff not to place lift slings or other items between the cushion and the resident's skin, which could result in decreased pressure relief and exacerbation of existing skin breakdown for 1 (Resident #1) of 1 case mix resident who had a Roho cushion in use; Failure to ensure a care planned air mattress was present to provide pressure relief and promote healing of pressure ulcers for 1 (Resident #3) of 2 (Residents #2 and #3) case mix residents who were care planned for air mattresses; Failure to ensure nutritional recommendations to promote wound healing were promptly and consistently implemented for 1 (Resident #2) of 1 case mix resident who had pressure ulcers and new dietary recommendations since 12/1/15; Failure to ensure daily required protein needs were based on the resident's actual weight to prevent potential protein malnutrition which could contribute to exacerbation or delayed healing of pressure ulcersfor 1 (Resident #2) of 3 case mix residents with pressure ulcers; Failure to ensure urine and feces were thoroughly cleansed from the skin to prevent exacerbation or infection of existing skin breakdown or development of new skin breakdown that could contribute to pressure ulcer development for 2 (Residents #3 and #4) of 3 (Residents #1, #3 and #4) case mix residents who were incontinent of urine and / or bowel; and, Failure to ensure residents who were at risk for pressure ulcers were turned/repositioned every two hours as per the plan of care, to minimize the potential for pressure ulcer development for 1 (Resident #4) of 4 (Residents #1, #2, #3 and #4) case mix residents who who were at risk for pressure ulcers and were care planned to be turned/repositioned every two hours. These failed practices resulted in patterns of actual harm to Residents #2 and #3, who experienced delayed wound healing of multiple pressure ulcers, and had the potential to affect 5 residents who had pressure ulcers and physician orders for wound care, 1 resident who had physician orders for a waffle cushion, 1 resident who had a Roho cushion in use, 2 residents with pressure ulcers and new dietary recommendations since 12/1/15, 31 residents who were incontinent of urine and / or bowel and 39 residents who were at risk for pressure ulcers and were care planned to be turned / repositioned every two hours, according to lists provided by the Director of Nursing (DON) on 3/4/16; plus, 3 residents who were care planned for air mattresses, according to a list provided by the Director of Nursing (DON) on 3/8/16. The findings are: 1. The facility's policy titled, Pressure Ulcer Treatment, documented, .The pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the current status of the pressure ulcer(s). b. Current support surfaces. c. Pressure ulcer care. d. Managing bacterial colonization and infection . Stage II Pressure Ulcer Intervention/Care Strategies . Follow-up. If wound does not improve in 2 to 3 weeks, notify physician. Re-evaluate nutritional support, off-loading/redistribution devices and advanced wound product changes . The following equipment and supplies will be necessary when performing this procedure . 1. Clean bedside stand. Establish a clean field. 2. Place the clean equipment on the clean field . 12. Using clean technique, open other products . 16. Cleanse the wound with ordered cleanser . Clean from the the least contaminated area to the most contaminated area (usually, from the center outward) . 2. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/16 documented the resident scored a 15 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status, required extensive assistance with bed mobility and toilet use, had no limitation in range of motion of the upper or lower extremities, had an indwelling catheter, was always incontinent of bowel, was at risk for pressure ulcers and had three Stage 2 pressure ulcers that were not present on admission or re-entry, with 1/21/16 as the date of the oldest Stage 2 pressure ulcer. a. The Care Plan dated 9/3/15 and reviewed / revised 11/28/15 documented, (Resident # 3) is at risk for skin break down and pressure ulcers (related to) decreased mobility, decreased sensation . Assess and record changes in skin status . Provide incontinent care after each incontinent episode . Provide/monitor effectiveness of pressure relieving or reduction device(s): Air mattress to bed . b. The Braden Scale for Predicting Pressure Sore Risk form documented, . Date: 2/1/16 . Total Score: 17. Total score of 12 or less represents HIGH RISK . c. A physician order dated 2/2/16 documented, Clean (right) (upper) thigh (with) wound cleanser of choice, pat dry, apply collagen, cover (with) [MEDICATION NAME] (dressing) (every) (Monday, Wednesday, Friday) . (and) (as needed) (times) 14 days. The February 2016 Treatment Administration Record (TAR) documented, Clean right upper thigh with wound cleanser. Pat dry. Apply Collagen to wound. Cover with [MEDICATION NAME] dressing. Change (every) (Monday, Wednesday, Friday) . until 2/16/16. Start Date: 2/3/16. Treatments were not initialed as done on 2/15/16. On 2/19/16 Treatment Nurse # 1's initials were documented for this treatment with (Re-evaluate) documented. There were no treatments documented to the resident's right (posterior) upper thighs between 2/12/16 and 2/22/16. There was no documentation that these areas had healed between 2/12/16 and 2/22/16. d. A physician order dated 2/19/16 documented, Cleanse (right) (upper) thigh (with) wound cleanser of choice, pat dry, apply collagen powder and then cover (with) [MEDICATION NAME] (dressing) (every) (Monday, Wednesday, Friday) . (and) (as needed) (times) 14 days then (re-evaluate). The February 2016 TAR documented, 2/22/16 Clean (right) upper thigh (with) wound cleanser of choice, pat dry, apply collagen to wound, cover (with) [MEDICATION NAME] (dressing) (every) (Monday, Wednesday, Friday . (times) 14 days. The first treatment was initialed on 2/22/16. e. Pressure Ulcer Records documented the following entries: Pressure Ulcer #1, located on the resident's right, inner, posterior thigh, per the anatomical diagram on the form: Date First Observed: 1/21/16 . Site (Right) (Upper) Thigh. Stage . II . 2/17/16. Site (Blank). Stage: Stage II. Size (Length x Width x Depth): 0.5 x 11.5 x 0.3 cm. 2/24/16. Stage: II. Length x Width: 0.5 x 11.5. Depth: 0.2 cm. 3/1/16. Stage: II. Length x Width: 0.5 x 11.5. Depth: 0.1 cm. On 3/1/16 at 10:05 a.m., Treatment Nurse # 1 measured Pressure Ulcer #1 from the right, upper, inner, posterior thigh to the upper mid-thigh area. There were multiple shallow open areas that appeared to this surveyor to follow along a line that would be where the edge of the brief rubbed the resident's skin. Treatment Nurse #1 stated, She has multiple areas with missing skin, but I'm going to measure them all as one. Treatment Nurse #1 measured the width and length. Treatment Nurse #1 then placed the wooden end of a Q-tip into the wound bed to measure depth. Treatment Nurse #1 measured the wound as 11.5 cm long, 0.5 cm wide, and 0.1 cm in depth. Treatment Nurse #1 stated this wound was a Stage II. Pressure Ulcer #2, located on the resident's right, medial, posterior thigh, per the anatomical diagram on the form: 2/17/16. Stage III . Size (Length x Width x Depth): 1.0 x 3.0 x 0.3 cm 2/24/16. Stage: III. Length x Width: (line drawn through what appears to be 113). Depth: 0.2 3/1/16. Stage: III. Length x Width: 1 x 2.8. Depth: 0.1 On 3/1/16 at 10:05 a.m., Treatment Nurse # 1 measured Pressure Ulcer #3, then placed the wooden end of the Q-tip into the wound bed to measure depth. Treatment Nurse #1 measured the wound as 2.8 cm long, 1.0 cm wide and 0.4 cm in depth. Treatment Nurse # 1 stated this wound was a Stage III. Pressure Ulcer #3, located on the resident's right, posterior, upper thigh (near or within the gluteal fold), per the anatomical diagram on the form: Date First Observed: 2/17/16. Site (Blank). Stage: III. Size (Length x Width x Depth): 1.2 x 3.0 x 0.2 cm. 2/24/16. Stage: III. Length x Width: 1.2 x 3.4. Depth: 0.2 cm. 3/1/16. Stage: III. Length x Width: 1 x 3. Depth: 0.2 cm. On 3/1/16 at 10:05 a.m., Treatment Nurse #1 measured Pressure Ulcer #3 as 1.2 cm long and 0.5 cm wide. The Treatment Nurse did not measure the depth of the wound at this time. f. On 3/1/16 at 10:05 a.m., Treatment Nurse #1 provided wound treatments to the resident's pressure ulcers as follows: The Treatment Nurse set up wound care supplies and placed a meal tray inside of a plastic bag. The plastic-covered tray was used as a clean field. Treatment Nurse # 1 placed a spray bottle of wound cleanser on the tray, removed scissors from the top of the opened Treatment Administration Record and placed them on the tray. The scissors were not cleaned prior to placing them on the clean field. Treatment Nurse #1 continued placing wound care supplies on the tray and stated, Last night she (resident) had a BM (bowel movement), and her bandages are dirty. Treatment Nurse #1 entered the resident's room with Certified Nursing Assistant (CNA) # 5. Treatment Nurse # 1 placed the tray / clean field on the resident's over bed table, after removing cups, a water pitcher, food items, an iPad and other personal items from the table top. Treatment Nurse # 1 did not sanitize the over bed table prior to placing the tray / clean field there. After washing hands and putting on gloves, CNA #5 assisted the resident to turn to the right side and Treatment Nurse # 1 pulled down the covers and opened the resident's brief. The resident's brief was white and appeared to have a ruffled edge with an elastic insert. There were no dressings on the resident's wounds. The inside of the brief appeared to be wet and there was a brown area approximately 6 inches long and 2 inches wide on the right edge of the brief at the perineal area. This surveyor asked Is the brief wet? Treatment Nurse # 1 stated It's drainage. Treatment Nurse # 1 left the soiled brief in place under the resident as she provided wound care. Treatment Nurse # 1 sprayed the right buttock fold with wound cleanser and wiped the wound with a 4 by 4 going from one edge to the other edge. This was repeated two more times. Treatment Nurse # 1 touched the resident's bottom sheet with the bottom of the spray bottle and then placed the spray bottle of wound cleanser on the over bed table. The Treatment Nurse then measured the wounds and changed gloves. Treatment Nurse # 1 used the contaminated scissors to cut open the package of collagen powder, then shook the powder out of the package into medication cups. Some of the powder shook out in clumps. Treatment Nurse # 1 opened 2 [MEDICATION NAME] dressings and removed a marker from her pocket to date both dressings. Treatment Nurse # 1 changed gloves, picked up the med cup of collagen powder and shook the powder out along the line of open skin from the right posterior upper inner thigh to the right posterior upper mid-thigh area. As Treatment Nurse # 1 was shaking the collagen powder onto the wound, a quarter sized clump of powder fell out onto the surrounding skin that had not been cleaned. Treatment Nurse # 1 picked up the clump of powder and put it in the med cup. Treatment Nurse # 1 then covered this wound with a [MEDICATION NAME] dressing. Treatment Nurse # 1 shook collagen powder out on to the right upper outer wound and what appeared to be the same quarter sized clump of collagen powder fell out onto the skin next to the wound. Treatment Nurse # 1 used the [MEDICATION NAME] dressing to push the clump of powder into the wound bed and then covered the wound with the dressing. Treatment Nurse # 1 failed to dry either of these wounds. Treatment Nurse # 1 stated, She was having bladder spasms but now it's just drainage. Treatment Nurse # 1 changed gloves and sprayed the lower right buttock / gluteal fold area with wound cleanser and wiped the wound with a 4 x 4 going from edge to edge. This cleaning process was repeated once with a clean 4 x 4. Treatment Nurse the patted the wound dry using multiple pats with the same area of the 4 x 4. Treatment Nurse # 1 changed gloves then shook collagen powder out of the packet into the med cup. Treatment Nurse # 1 measured the wound then removed her gloves and went to the treatment cart to obtain more Q-tips. Treatment Nurse # 1 washed her hands, put on gloves, removed the gloves and left the room to get a [MEDICATION NAME] dressing. Treatment Nurse # 1 returned to the room, washed her hands and put on gloves. Resident # 3 stated, Why don't you ask if I can get one of those gel beds? (Resident # 3 was on a standard mattress, not an air mattress.) Treatment Nurse # 1 stated, That would be a good idea, maybe an air mattress. Treatment Nurse # 1 shook collagen powder into the wound and covered the wound with a [MEDICATION NAME] dressing. Treatment Nurse # 1 pulled the soiled brief out from under the resident. As Treatment Nurse # 1 pulled the brief out, the resident stated, It hurt when you pulled that; it scraped over a sore I have there. Treatment Nurse # 1 was asked not to roll the brief up until this surveyor had seen it. The outside back portion of the brief had lines that darkened to blue when wet. The back side of the brief had a blue line from the lower back to mid perineal area. The inside of the brief was yellow in color and appeared to be wet with urine. Treatment Nurse # 1 was asked Is the brief wet? Treatment Nurse # 1 stated Yes. Treatment Nurse # 1 was asked With what? Treatment Nurse # 1 stated With that amount, I'd have to say it was urine. The soiled brief was bagged. CNA # 5 left the room for a clean draw sheet at 10:45 a.m. CNA # 5 returned with the sheet and Treatment Nurse # 1 placed the clean sheet and clean brief partially under the resident. The resident rolled onto her back, and CNA # 5 cleaned the resident's right and left groins. The resident's brief was then pulled up and closed. CNA # 5 and Treatment Nurse # 1 failed to clean the resident's labia, mid labia, buttocks, coccyx or rectal area of urine before or after wound care was provided. Treatment Nurse # 1 removed the plastic bag from around the tray, placed the tray on the over bed table and picked up the trash. Treatment Nurse # 1 placed the spray bottle of wound cleanser and scissors on the tray, took the tray to the treatment cart, placed the spray bottle of wound cleanser inside the treatment cart and placed the scissors in her pocket. g. On 3/2/16 at 2:45 p.m., CNA # 5 was asked, Did you do anything for (Resident # 3) before we came in to observe wound care on 3/1/16? CNA # 5 stated, I was going to check her and (Treatment Nurse # 1) said that you needed to see wound care. CNA # 5 was asked, Had you done any incontinent care or cleaned her on 3/1/16 prior to us entering the room? CNA # 5 stated, No, that was what I was going in there for. CNA # 5 was asked, Did you do any incontinent care prior to wound care from 7:00 a.m. to us entering the room? CNA # 5 stated, No and I was trying to tell (Treatment Nurse # 1) that and then you said the brief was wet and she still didn't listen. h. On 3/3/16 at 9:45 a.m., the Director of Nursing (DON) was asked, Do you know if anyone measures brief sizes to ensure the residents have the correct sized brief? The DON stated, No I'll have to check. i. On 3/3/16 at 10:30 a.m., the DON stated, There is no one person who ensures the residents have the correct brief size. j. On 3/3/16 at 3:33 p.m., Treatment Nurse # 1 was asked, You identified the resident had Stage 3 pressure ulcers on 2/17/16? Treatment Nurse # 1 stated, Yes. Treatment Nurse # 1 was asked, Did you put her on a specialty mattress? Treatment Nurse # 1 stated, She was on an air mattress up front (another unit / hall) and when they moved her to the northeast hall she didn't have one until 3/1/16. Treatment Nurse # 1 was asked, When did she move to the northeast hall? Treatment Nurse # 1 stated, Between 2/17/16 and 2/24/16. Treatment Nurse # 1 was asked, A physician order dated 2/2/16 for the right upper thigh documents to change the dressing on Monday, Wednesday, and Friday for 14 days. Where is the order for wound care after this? Treatment Nurse # 1 stated, It was re-evaluated on 2/19/16 per the TAR, those are my initials. Treatment Nurse # 1 was asked, Where is the order to continue wound care to the right upper posterior thigh after 2/16/16? Treatment Nurse # 1 stated, On 2/19/16 I re-evaluated and I wrote an order for [REDACTED].# 1 stated, No. Treatment Nurse # 1 was asked, For the wound care observed on 3/1/16, had the CNA been in the room before you started the treatment? Treatment Nurse # 1 stated, Yes, she was in there and I told her to wait because I was going to do wound care. Treatment Nurse # 1 was asked, What did you tell her to wait on doing? Treatment Nurse # 1 stated, To come out of the room. Treatment Nurse # 1 was asked, What did you tell me was on the brief? Treatment Nurse # 1 stated, Wound discharge. Her patch (dressing) had fallen off during the night and I was just then replacing it. Treatment Nurse # 1 was asked, After you turned the brief over and looked at the lines that indicate if the brief was wet, what did you think it was that made the brief wet? Treatment Nurse # 1 stated, Definitely urine, not discharge. Treatment Nurse # 1 was asked, What was the brown stuff at the edge of the brief? Treatment Nurse # 1 stated, I didn't see that. Treatment Nurse # 1 was asked, What did you do next? Treatment Nurse # 1 stated, Folded it (brief) over and cleaned a wound with wound cleanser. Treatment Nurse # 1 was asked, What was on the skin from the wet brief? Treatment Nurse # 1 stated, Urine. Treatment Nurse # 1 was asked, Did you do any incontinent care prior to wound care? Treatment Nurse # 1 stated, No. Treatment Nurse # 1 was asked, What did that cause when you cleaned the wound? Treatment Nurse # 1 stated, It contaminated it with urine from not being cleaned. Treatment Nurse # 1 was asked, What end of the Q-tip did you use to measure depth? Treatment Nurse # 1 stated, The wooden end. Treatment Nurse # 1 was asked, What end should you have used? Treatment Nurse # 1 stated, Q-tip end. Treatment Nurse # 1 was asked, Does the facility have a type of brief that does not have ruffles along the edge and is the resident in the correct sized brief? Treatment Nurse # 1 stated, I don't know. Treatment Nurse # 1 was asked, Could the posterior thigh skin problems be due to the brief cutting into her skin? Treatment Nurse # 1 stated, Now that you say that, yes. Why is it all so clear when you ask questions? Treatment Nurse # 1 was asked, Is your pocket a clean field? Treatment Nurse # 1 stated, Sure it's not. Treatment Nurse # 1 was asked, If you are going to use your scissors to cut open wound supplies what should you do before cutting / using them? Treatment Nurse # 1 stated, Wipe them down first. Treatment Nurse # 1 was asked, Did you do that? Treatment Nurse # 1 stated, No. Treatment Nurse # 1 was asked, What did you do with the piece of collagen powder that fell out of the med cup but was not in the wound? Treatment Nurse # 1 stated, I don't recall. Treatment Nurse # 1 was asked, Do you remember a clump of of collagen powder falling out on the surrounding skin for the first wound you dressed? Treatment Nurse # 1 stated, Yes. Treatment Nurse # 1 was asked, What did you do with it? Treatment Nurse # 1 stated, I don't remember. Treatment Nurse # 1 was asked, With the second wound, what appeared to be the same clump of collagen fell out of the med cup but not into the wound and you used the [MEDICATION NAME] dressing to? Treatment Nurse # 1 stated, I pushed it into the wound. Treatment Nurse # 1 was asked, What did that do to the wound? Treatment Nurse # 1 stated, Contaminated it. Treatment Nurse # 1 was asked, You took the wound cleanser spray bottle into the room and after you used it where did you put it? Treatment Nurse # 1 stated, Back on the tray I thought. Treatment Nurse # 1 was asked, No, it was on the over bed that you had not cleaned. Did you know that? Treatment Nurse # 1 stated, No. Treatment Nurse # 1 was asked, When you left the room with the wound cleanser spray bottle where did you put it? Treatment Nurse # 1 stated, Back in the treatment cart. Treatment Nurse # 1 was asked, What did that do to the treatment cart? Treatment Nurse # 1 stated, Contaminated it. k. On 3/3/16 at 5:25 p.m., the DON and this surveyor went to the brief room. There was a packet of XL (extra large) briefs that contained white colored briefs with a ruffle edge. The DON was asked to find out what size brief Resident # 3 should be wearing. On 3/4/16 at 10:20 a.m,. the DON was asked, What sized brief should (Resident # 3) be wearing? The DON stated, Bariatric (plus-sized) briefs. Green colored bariatric briefs were observed to be available in the facility at this time. 3. Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/5/16 documented the resident scored 6 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status, was at risk for pressure ulcers, had two Stage 2 pressure ulcers with one present on admit and had 2 unstageable pressure ulcers with 2 present on admit, with the largest pressure ulcer measuring 12.0 cm by 0.7 cm, 0.0 cm depth and with an eschar present. a. A physician order dated 2/2/16 documented, Schedule consult for wound clinic. b. The Care Plan dated 2/16/16 documented, (Resident # 2) has multiple pressure (ulcers) to coccyx, right and left hip and left ankle (related to) diabetes . Assess / record / monitor wound healing weekly. Measure length, width and depth, where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvement and declines to the (physician) . Encourage good nutrition and hydration in order to promoted healthier skin . Monitor nutritional status . There were no care planned pressure relieving devices documented. c. Pressure Ulcer Records documented the following entries: i.) .Date First Observed: 1/29/16. Site: (Right) hip. Stage: UTD (Unable To Determine). Size (Length x (by) Width x Depth): 12.0 x 7.0 x (UTD) cm (centimeters) . Date: 2/9/16. Stage: UTD. Length x Width: 12.0 x 6.0. Depth: UTD . There were no documented measurements of the right hip since 2/9/16. ii.) .Date First Observed: 1/29/16. Site: (Left) hip. Stage: II Size (Length x Width x Depth): #1 - 1.5 x 0.5 x (less than) 0.2 cm. #2 - 1.0 x 1.0 x (less than) 0.2 cm . Date: 2/9/16. #1 - Stage: II. Length x Width: 0.8 x 0.5 Depth: (less than) 0.2 . #2 - Stage: II. Length x Width: 1.0 x 0.8. Depth: (less than) 0.2 . There were no documented measurements of the wounds to the left hip since 2/9/16. iii.) .Date First Observed: 1/29/16. Site: Coccyx. #1. Unstageable. Size (Length x (by) Width x Depth): 2.0 x 1.2 x 8.5 cm. #2 - Stage II . 2.0 x 1.7 x (less than) 0.2 cm . Date: 2/9/16 . #1 - Stage: UTD. Length x Width: 2.0 x 1.4. Depth: 7.5 . Date: 2/9/16 # 3. Stage: II. Length x Width: 2.1 x 1.7. Depth: (less than) 0.2 . There were no documented measurements since 2/9/16. iv). .Date First Observed: 1/29/16. Site: (Left) inner ankle. Stage: II. Size (Length x (by) Width x Depth): 1.2 x 0.5 x (less than) 0.2 cm. Date: 2/9/16 Stage: II. Length x Width: 0.8 x 0.4. Depth: (less than) 0.2 cm . There were no documented measurements since 2/9/16. f. Hospital Wound Care Records dated 2/18/16 at 4:11 p.m. documented, Progress Notes . Left heel wound is a healing DTI (Deep Tissue Injury). Blister intact but deflating . Medial left foot wounds are improved from last check. Right hip ulcer: Thick eschar debrided from wound on right lateral hip . Remains unstageable . Stage 4 coccyxgeal pressure wound: Coccyxgeal wound had thin skin bridge. This was opened up as it was only dermal layer thick. Wound opened and large cavity revealed. Wound extends to bone . There is no healing noticeable in this wound.Left: medial ankle . Length: 0.5 cm. Width: 0.6 cm . Depth: scab . Left: medial foot . Length: 0.3 cm. Width: 0.3 cm . Depth: scab . Left: lateral heel . Length: 1.8 cm. Width: 1.7 cm . Depth: unable . Left hip . Length: 1.0 cm. Width: 0.8 cm . Depth: scab . Right hip . Length: 6.5 cm. Width: 10.7 cm. Depth: unable . Right thigh . Length: 1.0 cm. Width: 0.8 cm. Depth: scab . Lower sacral spine (coccyx) . Length: see photo . Wound Debridement: . Location: Right hip . g. On 3/3/16 at 8:05 a.m., the resident was up in a geri chair propelled by CNA # 1. CNA # 1 was asked where the resident was going. CNA # 1 stated, To the wound clinic. h. Hospital Wound Care Records dated 3/3/16 8:57 a.m. documented, .1 week follow up of her multiple pressure ulcers . Physical Exam: Left heel wound is a healing DTI . Medial left foot wound dry and stable. Right hip ulcer: Wound open with large amount of fatty tissue to center of wound. This is significantly decreased from previous visit. Moist pink healthy tissue at wound edges. Debrided large amount of fatty tissue from wound. Some tunneling. No bone exposure. Fascia intact. Stage 4 coccyxgeal pressure wound: Coccyxgeal wound open. Increase in moist red tissue. However, there is about 50% of slough to wound. Periwound area irritation improved . The wound clinic did not document any additional wound measurements on this clinic visit. i. On 3/3/16 at 11:50 a.m., the resident was up in a geri chair by the scale. The resident appeared to be in line for weights. At 12:08 p.m., CNA # 2 exited the resident's room with the resident's geri chair. There was no pressure relieving device in the geri chair. j. On 3/3/16 at 2:02 p.m., the Director of Nursing (DON) and Treatment Nurse #1 were asked, Do you have any wound measurements since 2/9/16? Treatment Nurse # 1 stated, Yes from the wound clinic and I did measurements yesterday. This surveyor asked Treatment Nurse # 1 to get yesterday's measurements and wound clinic documentation. The Treatment Nurse left the room at 2:15 p.m. The DON was asked, You started 9 days ago (2/23/16) as the DON? The DON stated, Yes. The DON was asked Did you have a Treatment Nurse when you started? The DON stated, Yes, (Treatment Nurse # 1). The DON was asked, When did (Treatment Nurse # 1) start? The DON went to Human Resources, returned to the conference room and stated, She started 2/15/16. The DON was asked, Have you looked at the wound care program since you started? The DON stated, I evaluated processes, the protocol used for wounds, looked at measurements and identified education was lacking. The DON was asked, Have you noticed there are no documented wound measurements? The DON stated, Yes. The DON was asked, Have you developed any plan to address wound issues? The DON stated, I've started that. It includes I hired a new Treatment Nurse that I trained and worked with for 4 years to start on Friday, 3/4/16. I'm implementing protocols at each nursing station. The protocol includes what to do for pressure ulcers, notifications, supplements, wound healing interventions, we plan to get pre-[MEDICATION NAME] levels on every resident with pressure ulcers. We identified residents at risk for breakdown. I reviewed treatment orders for residents with pressure ulcers to make sure it was the appropriate treatment. I audited the system to see if treatment orders had been changed every 14 days. At 3:15 p.m., Treatment Nurse # 1 had not returned with the requested wound measurements. The DON was asked to assist the Treatment Nurse to locate them. k. On 3/3/16 at 3:33 p.m., Treatment Nurse # 1 presented the resident's Pressure Ulcer Records, which included wound measurements done on 3/2/16. The Pressure Ulcer Records were reviewed. The Pressure Ulcer Records documented the following: A Pressure Ulcer Record documented, . Date First Observed: 1/29/16. Site: (Right) hip. Date: 3/2/16. Stage: UTD. Length x Width: 6.0 x 9.0. Depth: UTD . A Pressure Ulcer Record documented, . Date First Observed: 1/29/16. Site: (Left) hip. Date: 3/2/16. Healed . A Pressure Ulcer Record documented, . Date First Observed: 1/29/16. Site: Coccyx. Date: 3/2/16. Stage: UTD. Length x Width: 8.0 x 7.0. Depth: UTD. Tunneling/Undermining: 12 o'clock = 4 (cm), 3 o'clock = 4 (cm), 6 o'clock = 2 (cm), 9 o'clock = 3 (cm). Progress and/or Remarks: wound has merged into one wound . A Pressure Ulcer Record documented, . Date First Observed: 1/29/16. Site: (Left) inner ankle . There were no additional measurements or staging documented. l. On 3/3/16 at 3:33 p.m., Treatment Nurse # 1 was asked to review the wound clinic documented wounds versus the facility's documented wounds. The wound clinic records included measurements for an area on the top of the resident's right upper anterior thigh. This area was not a pressure area. The wound clinic records also included a deep tissue injury to the resident's left heel, which was not addressed in the facility's pressure ulcer assessments. Treatment Nurse # 1 was asked, Did you do any measurements from 2/15/16 to 3/2/16? Treatment Nurse # 1 stated, No, she went to the wound clinic. Treatment Nurse # 1 was asked, Do you have documentation of the thigh wound or left heel? The Treatment Nurse stated, No. Treatment Nurse # 1 was asked, Did you know about the order for a waffle cushion from the wound clinic? Treatment Nurse # 1 stated, Yes but I was told she didn't need one, since she was not up. m. On 3/4/16 at 9:10 a.m., the DON was asked, Are you working on getting wound measurements from the wound clinic for (Resident #2)? The DON stated, Yes. n. On 3/4/

Complaint # was substantiated (all or in part) in these findings. Based on record review, and interview, the facility failed to ensure staff responded to a request for chicken noodle soup which caused a catastrophic reaction that led to involuntary seclusion and mental anguish for 1 (Resident #5) of 2 (Residents #3 and #5) case mix residents with documented behaviors of throwing things. The facility failed to ensure a resident was not deprived of personal belongings which caused mental anguish for 1 of 1 (Resident #5) case mix residents who were moved to the South (closed/secure) unit for behaviors and safety. The facility failed to ensure a resident's bed was returned and a resident was placed back in bed upon request for 1 of 1 (Resident #5) case mix residents who were moved to the South (closed/secure) unit for behaviors and safety. These failed practices resulted in a pattern of actual harm for Resident # 5, who had continued behaviors and mental anguish from being moved to the South (closed/secure unit), being left on floor mats for an extended period of time, and being separated from his personal belongings. These failed practices had the potential to cause more than minimal harm for 3 residents who had behaviors of throwing items and 1 resident who was moved to the closed/secure unit as according to the listing received from the Director of Nursing (DON) on 1/9/14. The findings are: 1. The facility's policy titled "Resident Abuse - Staff to Resident" documented "... Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, or pain, or mental anguish, or deprivation by an individual, including a caretaker of goods and services that are necessary to attain or maintain physical, mental and psychological well-being. This includes ... involuntary seclusion ..." The facility's policy titled "Resident Abuse" documented "... e). Involuntary Seclusion - Separation of a resident from other residents or from his or her room OR confinement to his/her room (with or without roommates) against the residents will or the will of the resident's legal representative. ..." 2. Resident # 5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/13 documented the resident scored 15 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status, had no signs and symptoms of [MEDICAL CONDITION], had no behaviors, had no intellectual disability or developmental disability, required extensive assistance to total dependence for all activities of daily living, except eating and locomotion, had functional limitation in range of motion of both sides of the lower extremities, and had an indwelling catheter. a. The Durable Power of Attorney (POA) dated 12/8/11 documented, "Article I. Creation. I, (Resident # 5) ... designate the following persons, in order of preference and succession to serve as Attorney-In-Fact (my "Agent") for me and to act as the guardian or limited guardian of my estate should guardianship proceedings become necessary or desirable: 1) (Family member # 1), 2) (Family member # 2). Article II. Effectiveness: Effective Immediately. This Power of Attorney shall become effective immediately and shall survive and continue during my disability, incompetence, incapacity or partial incapacity ... Disability, incompetence, incapacity or partial incapacity shall include, without limitation, my inability to manage my property and affairs or caring for myself effectively for reasons such as mental illness, mental deficiency or other mental incapacity ... Article III. When Successor Agent is Entitled to Act. The successor Agent shall be entitled to act upon death, disability or incapacity determined by the same criteria above, ...". 1) On 1/8/14 at 3:20 p.m., the Acting Administrator and Regional Director of Operations asked this surveyor if a copy of the POA for (Resident # 5) had been received. This surveyor stated, "Yes." The Acting Administrator and Regional Director of Operations were asked, "I couldn't find anything in his chart that indicates (Resident # 5) is incompetent. Do you know if he is incompetent?" The Acting Administrator and Regional Director of Operations stated, "There's no documentation that he's incompetent at this time." 2) On 1/13/14 at 3:38 p.m. the Nurse Consultant was asked, "Did you find anything in (Resident # 5's) chart that indicates (Resident # 5) is incompetent?" The Nurse Consultant stated, "No and I looked when I was reviewing his POA." b. The Resident Care Plan dated 10/22/13 documented, " ...Focus: (Resident # 5) had impaired cognitive skills (as evidenced by)/(related to) poor or unsafe decision making, (history) of [DIAGNOSES REDACTED] tumor and [MEDICAL CONDITION] ((Motor Vehicle Accident)) ... Interventions: ... Throws objects and curses when angry ... Focus: (Resident # 5) is at risk for/has potential of mood state issues (as evidenced by)/(related to) had negative attitude, makes negative statements, and can be VERY demanding at times and manipulative of staff ... Interventions: ... Assess (Resident # 5) for physical/psychological causes for mood indicators, address as needed. Determine if (Resident # 5) mood may result in harm to self or others. Take necessary precautions. ... Monitor and record changes in mood state pattern ... Report to physician changes in mood status. Staff will assist (Resident # 5) as needed finding his personal belongings due to his immobility status. Cusses staff, hits staff, throws objects at staff (and) other residents. 12/21/13 Curses at other staff, throws things, redirect (as needed) ... Focus: (Resident # 5) is at risk for adverse reactions from behavior disturbances (as evidenced by)/(related to) is verbally abusive, is socially inappropriate, resist (Activities of Daily Living) care, resists medications/treatments, is manipulative ... Interventions: ... Anticipate needs and provide them before the resident becomes overly stressed. Date initiated 4/29/13. Educate resident on other effective coping skills for dealing (with) feelings. Date initiated 4/29/13. Encourage resident/family to increase involvement in activities to eliminate or reduce behaviors. Date initiated 4/29/13. ... Intervene during behavioral outburst to protect the safety of the resident and others. Date initiated 4/29/13. ... (Resident # 5) makes accusatory statements about staff, frequently these remarks are made when he does not get (his) way. Date initiated 4/29/13. (Resident # 5) will become agitated and demanding. He will throw his cell phone, remote and other items when he gets mad. Staff is (to) leave him alone until he quiets down. Then return to give care. Date initiated 4/29/13. ... Provide resident with diversional activities when behavioral symptoms arise. Date initiated 4/29/13. ... Involve (Resident # 5) in more activities to better occupy his time. Report to physician changes in behavioral status. Date initiated 4/29/13 ..." c. A physician progress notes [REDACTED]. History: This patient with mental [MEDICAL CONDITION] has a history of [MEDICAL CONDITION]. He has been stable and there have been no new events. ... Plan: We will continue present management and medications." d. Nurse's Notes dated 12/28/13 from 3:00 p.m. to 11:00 p.m. documented, "Resident is verbally aggressive (with) staff and (inappropriate) behaviors noted escalating to incident (with) Resident throwing things, yelling, cursing, threatening staff and threatening to hurt himself. At 3:30 p.m. resident was asking staff to re-arrange his room. When CNAs (Certified Nursing Assistants) told resident they could not do that at that time resident started cursing at staff and getting verbally aggressive. Resident was also stating sexual (inappropriate) things to CNAs. Told female CNAs to 'get hot and sexy for me'. At that time CNA started answering call light 2 at a time for a witness to behaviors and to protect staff from (inappropriate) behaviors and speech. At 4:00 p.m. resident refused meds (medications) stating to nurse 'I'm not taking[***]from you because you told the CNAs they didn't have to rearrange my room and you won't make the staff do what I want.' Resident was in dining room yelling at kitchen staff at 7:00 p.m. He became verbally aggressive with dietary staff and then started throwing items in kitchen at staff like cups from coffee tray and lids and then the coffee tray itself. Resident's responsible party was called and Resident started yelling at her on the phone. Resident was assisted to his room (with) staff pushing wheelchair. Resident then started hitting staff and threatening staff. Told male CNA 'I'm going to f..... kill you'. Also stating 'I'm gonna kick your a..'. Then resident threw a pitcher at nurses' head. Stated to nurse 'I'm mad at you because you won't make then give me what I want and do as I say'. Resident then began to take linen cart apart and throw it across room down hallway. Items were removed from resident reach. Administrator, DON (Director of Nursing) and physician notified. Administrator came to facility and new order received to place resident on one on one (with) CNA and then resident transferred to South hall on secure unit for safety." This entry was signed by Licensed Practical Nurse (LPN) # 1. 1) On 1/8/14 at 3:12 p.m. LPN # 1 was asked, "When you called the doctor on 12/28/13 about (Resident # 5) what did he say?" LPN # 1 stated, "I notified (DON) and she called (Administrator) and I talked with (DON) several times. (Administrator) came up, I don't know who notified the doctor." LPN # 1 was asked, "Did you talk with the doctor?" LPN # 1 stated, "No." LPN # 1 was asked, "Why did you chart the doctor was notified?" LPN # 1 stated, "I was told to." 2) An Office of Long Term Care (OLTC) witness statement dated (12/28/13) documented, "(Resident # 5) was rude towards us all day, because our nurse told us we couldn't rearrange thing in his room because we didn't have the staff. Later on he sat in the dining area, throwing cups and lids. Called me a 'stupid n.....' multiple times while threatening to kill me because I was pushing him to his room as instructed ..." This witness statement was signed by CNA # 1. On 1/8/14 at 3:22 p.m. CNA # 1 was asked, "Tell me what happened on 12/28/13 with (Resident # 5) in the dining room." CNA # 1 stated, "We started the shift and (Resident # 5) wanted the CNAs to stop and rearrange the room. He wanted me and another CNA to rearrange the flags on his door and I told him '(Resident # 5) I'm sorry we can't do that'. I was told when I first started that would be automatic termination. We told him we would talk to our nurse and (LPN # 1) said no we needed to get people up for dinner. (LPN # 1) said we were already short one CNA and we couldn't do what (Resident # 5) wanted done. He started cursing and then we passed trays and I took his dinner to him and he refused. So then he said he was going to the kitchen. He was sitting there cussing out the cooks. He was at the serving window and wouldn't move. When dinner was done I pushing empty carts to the dining room and one of the dietary staff people asked me if I could get the coffee cart because (Resident # 5) was sitting there by the piano and coffee cart and was throwing things off it onto the floor and there were other residents there also." CNA # 1 was asked "Who were the residents?" CNA # 1 stated, "(Resident # 15) and I can't recall who else." CNA # 1 was asked, "Were you around when (Resident # 5) went back to his room?" CNA # 1 stated, "(LPN # 1) tried to push him to his room and (Resident # 5) was hitting at her to leave him alone. He said he wasn't going anywhere. I offered to help and he hit me when I was taking him to his room and calling me n..... and on the way to his room he grabbed the linen cart and pulled the pink cover off and took the shelves out and threw them on the floor and when I got him to his room he started trying to tear the privacy curtains down." CNA # 1 was asked, "Why not leave him in the dining room?" CNA # 1 stated, "(Family Member # 1) told him to go to his room." 3) On 1/7/14 at 2:23 p.m. Dietary Staff # 2 was asked, "Did you work on 12/28/13 for supper?" Dietary Staff # 2 stated, "Yes." Dietary Staff # 2 was asked, "See anything with (Resident # 5) on 12/28/13?" Dietary Staff # 2 stated, "He was sitting at our door (serving window) and he wanted 2 bowls of chicken noodle soup and crackers." Dietary Staff # 2 was asked, "About when?" Dietary Staff # 2 stated, "We were just starting to serve so it was about 4:45 p.m. Chicken noodle soup was not on the menu so I call CDM (Certified Dietary Manager) (who is also Family Member # 1) and asked her if he could have it and she said no because we have our main course, alternate, and soup and sandwich of the day. So she told him he couldn't have it and he got aggravated and would not move away from the window and we couldn't push any of our carts out so we couldn't get any food to the rest of the residents. Our coordinating CNA (CNA # 7) moved him to the dining room. He was quiet for a little bit then he started throwing plates, cups, and coffee cups off of dirty carts and the coffee cart on the credenza. He was throwing them across the room." Dietary Staff # 2 was asked, "Did he stay in the dining room?" Dietary Staff # 2 stated, "Yes." Dietary Staff # 2 was asked, "Do you recall if residents were in the dining room when (Resident # 5) started throwing things?" Dietary Staff # 2 stated, "Yes, but not who." Another CNA (CNA # 1) was trying to calm him down and (Resident # 5) was screaming at him and yelling profanity. Then (CNA # 1) came up to the window and started coordinating ..." 4) On 1/7/14 at 2:37 p.m. Dietary Staff # 1 was asked, "Did you work on 12/28/13 for supper?" Dietary Staff # 1 stated, "Yes." Dietary Staff # 1 was asked, "What can you tell me about what happened with (Resident # 5) that night?" Dietary Staff # 1 stated, "He came to the window. We had already served his plate and he came to the window and said he didn't want it. He said he wanted chicken noodle soup and I told him the soup of the day was cream of potato soup and he didn't want that. So I told him (Resident # 5) it's the regular, the alternate, or the soup and sandwich of the day. Then he got mad and sat in the window in the way of our serving. I told him three times he was going to have to move so we could finish serving supper. He wouldn't move and we worked around him and we tried working around him. Then (CNA # 3) came and moved him and (Resident # 5) moved himself right back to the window the whole time we were serving. Once we got done serving he was still in the window so I asked (Resident # 5) do you want the soup and sandwiches or the alternative. He got even more mad and he started cussing at me. I said (Resident # 5) I'm not going to stay at this window and argue with you and have you talk with me like that. We started cleaning up the tray line and he got mad and pushed a cart with lids over to the floor. Then he went to the main dining room and took cups from the drink area on the credenza and threw them on the floor one by one. Then he threw the tray that the cups were on onto the floor, opened sugar packets and dumped then out on the ground. I went out there because we could hear him throwing stuff clear in the kitchen. I told him (Resident # 5) you are going to have to stop. This is unnecessary. (CNA # 1) and (CNA # 7) were in the main dining room trying to calm him down. He started saying racial things to (CNA # 1), so I told them this was not necessary that I was going to call (Family Member # 1) our CDM who is also his (Family member # 1). I called (CDM) and she told me told me to put it on speaker phone so he didn't get the phone and throw it and be all mad. (CDM) told him to stop acting that way and go to his room. He told her no and she just kept telling him to stop acting like that and to go to his room and by then his nurse (LPN # 1) had walked up and she heard (CDM) tell him to go to his room. (CDM) got off the phone and (LPN # 1) took him to his room." Dietary Staff # 1 was asked, "Did you ask her if you could fix chicken noodle soup for (Resident # 5)?" Dietary Staff # 1 stated, "Yes, and she told me no." e. The Social Service Progress Notes dated 12/28/13 and signed by the Administrator documented, "I was called to the facility this evening due to concerns by nursing of (Resident # 5's) behaviors. Nursing reported to me that he was entering the kitchen and throwing things at the kitchen staff. That he was going up and down halls yelling and cursing and throwing things. I found (Resident # 5) in his room and attempted to reason with him. He yelled and cussed me the whole time I tried to talk to him and he kept telling me about other residents that I needed to 'do things about them'. I called his POA and talked about the options and how his agitation has increased the last several weeks. She agreed he needed a psych (psychiatric) consult and for him to be moved to the south side (closed/secure unit) of the building to see if any positive results could be acquired. As we were moving him, he continued to cuss me and told me that he would kill himself and kill me for doing this. (Resident) was placed on 1:1 monitoring pending psych consult ... While awaiting the bed to be moved into room (number) for (Resident # 5), I observed (Resident # 5) banging his chair and his foot into the door that leads into laundry. I moved him away from the door." f. A physician telephone order dated 12/28/13 at 9:00 p.m. documented, "1. Transfer to memory unit for structured environment secondary to behaviors. 2. (Psych) consult. 3. Place resident 1:1 (One on one) until resident can be transferred to behavioral health unit." This order was signed by LPN # 2, as nurse receiving order. On 1/9/14 at 12:55 p.m. LPN # 2 was asked, "Did you talk to (Resident # 5's) doctor when you wrote the orders dated 12/28/13?" LPN # 2 stated, "No, my Administrator told me to write those orders and you have to understand I wrote those orders after he had been moved." LPN # 2 was asked, "Why was he moved to the closed unit?" LPN # 2 stated, "He was throwing things and was to move to (room number on the closed unit) to start with. I had the CNAs move the bed out of that room... " LPN # 2 was asked "Did you talk with (Family Member # 1) or any other family members on 12/28/13?" LPN # 2 stated, "No..." g. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 8:25 a.m. documented, "Awake in bed. Upset about not having his things." h. Nurse's Notes dated 12/29/13 at 8:45 a.m. documented, "Resident attempting to roll himself out of bed. Bed lowered to lowest position. Fall mats on both sides of bed. Resident had also wrapped tubing for Foley (catheter) around his legs and was attempting to pull suprapubic Foley out. Untangled tubing. Explained to resident we do not want him to hurt self. Resident calmed down for time being. Continues one on one." i. Nurse's Notes dated 12/29/13, untimed, documented "Resident attempted to roll out of bed. Staff assisted resident to floor fall mats. Responsible party notified. Continues on one on one." 1) The OLTC witness statement attached to the Fall Investigation form dated 12/29/13 documented, " ...Date: 12/29/13. Time: 10:30 a.m. ... (Resident # 5) was attempting to pull himself out of bed by pulling himself to the edge and pulling his legs off the side. I went in to push his legs back on the bed and he started to go off. I caught his bottom and torso. I attempted to put him back on the bed but he was too heavy so I eased him to the floor ..." This witness statement was signed by CNA # 2. 2) On 1/8/14 at 12:55 p.m. LPN # 4, the residents charge nurse for 7:00 a.m. to 3:00 p.m. on 12/29/13, was asked, "What was (Resident # 5) doing on 12/29/13?" LPN # 4 stated, "He was trying to get his bed rails off the bed and roll himself on to the floor." LPN # 4 was asked, "What did you do when he did that?" LPN # 4 stated, "We took his bed out and put him on mats on the floor." LPN # 4 was asked, "Did (Resident # 5) talk with you then, tell you why he was doing that?" LPN # 4 stated, "No, he was mad but he shrugged his shoulders and tried to not let me assess him." LPN # 4 was asked, "How many times did he get onto the floor?" LPN # 4 stated, "Just once." j. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 12:30 p.m. documented, "Resident goes unresponsive. I call hall nurse and (Weekend RN (Registered Nurse) # 1) was paged. Vital signs are good, staff realize symptoms were being faked by resident ..." This entry was initialed by CNA # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 1:05 p.m. documented "Family leaves. (Resident # 5) promises good behavior if we get him back in bed. Talked with (Administrator) about it." This entry was initialed by CNA # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 1:30 p.m. documented, "Resident asks again about being put back in bed. I call for south hall nurse to ask her about it." This entry was initialed by CNA # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 2:00 p.m. documented "Resident begins to complaining again about not being back in a bed yet." This entry was initialed by CNA # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 3:25 p.m. documented, "Was told we could put bed back in room. 4 of us lifted him up on bed." This entry was initialed by CNA # 4. The Nurse's Notes dated 12/29/13 at 4:00 p.m. documented "Resident in bed cursing and threatening staff. Resident requested (Family member # 2) be called to come to facility. LPN called (Family member # 2) on request. 4:10 p.m. call received from (Family member # 1). (Family member # 1) stated, 'Tell (Resident # 5) that (Family member # 2) was not coming to facility just because he was misbehaving. (Family member # 2) had children to take care of.' (Family member # 1) stated 'tell (Resident # 5) that if his behavior didn't stop he would be going to the hospital'. This entry was signed by LPN # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 4:20 p.m. documented, "Gave him his phone that was in closet. He is mad because it has no charge ..." This entry was initialed by CNA # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 4:21 p.m. documented, "(Resident # 5) has taken both rails off bed. He is holding one over his body. I told nurse. She said to take the rails. (Resident # 5) threatened staff saying to do (bodily) harm if we took rails. (CNA # 3) came in and helped take rails." This entry was initialed by CNA # 4. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 4:25 p.m. documented, "(Resident # 5) was trying to throw self in the floor. I placed legs back on bed. He said he was only trying to turn over." This entry was initialed by CNA # 4. Nurse's Notes dated 12/29/13 at 10:40 p.m. documented, "Resident remains 1:1 due to threats and behaviors. Resting in bed with eyes closed at present time ... Resident calmed down after bed rails were taken away ..." This entry was signed by LPN # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/30/13 at 8:35 a.m. documented, "I set up his breakfast. He seems to be calm. (Family member # 1) goes into room to talk to him." This entry was initialed by CNA # 6. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/30/13 at 9:00 a.m. documented, "No change. Talking to me and other residents. (Resident # 5) is calm and asking about his phone charger." This entry was initialed by CNA # 6. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/30/13 at 10:10 a.m. documented, "(Family member # 1) brought his laptop to him. I plugged it in for him and put his phone on the charger." This entry was initialed by CNA # 6. k. A Physician telephone order dated 12/30/13 at 4:00 p.m. documented, "1. (Discontinue) [MEDICATION NAME]. 2. Start [MEDICATION NAME] 4 (milligrams) (per mouth) (every) (hour of sleep)." l. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/30/13 at 4:10 p.m. documented, "Just got TV(television). Laying in bed watching TV now." This entry was initialed by CNA # 6. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/30/13 at 4:30 p.m. documented, "(Family member # 1) brought DVD player and I moved his bed at an angle." This entry was initialed by CNA # 6. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/31/13 at 3:30 p.m. was the last 1:1 entry documented. m. A physician telephone order dated 12/31/13 at 10:30 p.m. documented, "(Discontinue) 1:1. (Continue) to monitor behavior." The Nurse's Notes dated 12/31/13 at 11:00 p.m. documented, "Alert and oriented (times) 4. Denies any thought of suicide or of harming others. Stated, 'I never meant any of that. I was just mad. You know me.' (Family member # 1)/POA (Power of Attorney) in (agreement). Order obtained to (discontinue) 1:1. POA aware." This entry was signed by the DON. n. Nurse's Notes dated 1/2/14 at 1:25 p.m. documented, "... (Alert and oriented times) 3. ... Resident had refused to let laundry move his belongings into his room. He stated to nurse that (Administrator) is not his boss and he will have her job. ..." This entry was signed by LPN # 3. o. A physician telephone order dated 1/3/14 documented, "(Discontinue) admit to unit as ordered." p. On 1/7/14 at 8:35 a.m. Family Member # 1 asked to speak with this surveyor. Family Member # 1 stated, "I'm (Resident # 5's) POA and (Family Member # 2) is his second POA." Family Member # 1 was asked, "Tell me why (Resident # 5) was moved to the closed unit." Family Member # 1 stated, "He went to the closed unit because he was throwing a hissy fit. He was threatening to harm himself and other employees and they didn't know if he would try to harm another resident. So they moved him to the closed unit to calm him down, get him out of the general population and did 1:1 with him. I wanted him to get a shot to calm him down and was told they couldn't do that." Family Member # 1 was asked, "How long was he there?" Family Member # 1 stated, "One week. He was on 1:1 from Saturday (12/28/13) and they stopped it on Wednesday (1/1/14) or Thursday (1/2/14) and then they moved him back to the open unit on Friday (1/3/14). He said they told him he was there because he was being punished and he even called the police because of it." Family Member # 1 was asked, "Before they moved him over there did they talk with you about the move?" Family Member # 1 stated, "Yes but not immediately. They did call me on Saturday, later in the day after he'd been moved. When (Family Member # 2) came up on Sunday (12/29/13) he (Resident #5) had crawled out of bed and she found him on the floor, face down and his arms were all twisted under him. I don't know if they tried to get him up or if he refused. ... They had fall mats on the floor." Family Member # 1 was asked, "Did you see (Resident # 5) when he was on the closed unit?" Family Member # 1 stated, "Yes and they wouldn't let him have any of his stuff." Family Member # 1 was asked, "Nothing?" Family Member # 1 stated, "On Sunday (12/29/13) they got his TV in there and I had his movies and electronic stuff in my office and all of his other stuff was in the laundry. I asked them to give him his stuff because his biggest fear is stuff getting stolen. I got a dolly on Wednesday (1/1/14) and moved all his stuff into his room. On Monday (12/30/13) they did move his clothes in and then was still 1:1. By Wednesday (1/1/14) I got the impression when the 1:1 had been stopped that they were not going to move him out of that room and that's when I got his stuff and moved it in myself. I threw a fit and he threw a fit on Friday (1/3/14) and that's when they moved him back." Family Member # 1 who was also the CDM (Certified Dietary Manager) was asked, "Who was working in the kitchen 12/28/13 for supper?" Family Member # 1/ CDM stated, "(Dietary Staff # 1). She called me and told me (Resident # 5) went into the kitchen and they asked him not to come into the kitchen. (Resident # 5) threw a fit and started throwing things." Family Member # 1/CDM was asked, "What time was this?" Family Member # 1/CDM stated, "After supper between 6:00 to 6:30 p.m. when (Dietary Staff # 1) called me I called his nurse and asked if he could get a shot or something to calm him down and they said they couldn't do that. I do know (Resident # 5) took his bed rails off when they got him to his room on the North hall and he started trying to hit the employees with the bed rails and he said he was going to kill himself. So they moved him to the closed unit because they feared for his safety. Then (Family Member # 2) came up and got upset with how she found him. I feel he does get mistreated. It's things like when they moved him back there and he asked for his DVD to be hooked to the TV up so he could watch movies. The CNA asked the weekend RN (Registered Nurse) and she said no that the CNA couldn't do that for (Resident # 5). The CNA went ahead and did it because (Resident # 5) wanted to watch a movie." Family Member # 1 was asked, "Was there any mention of when or what had to happen before (Resident # 5) could be moved off the South unit?" Family Member # 1 stated, "No." q. On 1/7/14 at 2:13 p.m. the Housekeeping /Laundry Supervisor was asked, "For resident room changes, who moves the resident's belongings?" The Housekeeping /Laundry Supervisor stated, "I do almost always unless I'm not here or on a weekend." The Housekeeping/Laundry Supervisor was asked, "Do you know who moved (Resident # 5's) belongings from (room number on North hall) to (room number on South hall)?" The Housekeeping/Laundry Supervisor stated, "His TV and bed were moved that weekend and then I moved the rest of his belongings at a later date." The Housekeeping/Laundry Supervisor was asked, "When?" The Housekeeping/Laundry Supervisor stated, "Last Thursday (1/2/14)." The Housekeeping/Laundry Supervisor was asked, "Where was his stuff?" The Housekeeping/Laundry Supervisor stated, "In room (number on North hall, the room from which the resident was moved)." The Housekeeping/Laundry Supervisor was asked, "Was it ever in Laundry?" The Housekeeping/Laundry Supervisor stated, "Only for one hour, in the hall outside laundry. I tried to take his stuff to him and he said he was not moving to that room and we had to take his stuff back to room (number on north hall, the room from which the resident was moved). I called the Administrator and she said to put his belonging in the hall by laundry and she came and talked with him. (Family Member # 1) came and got them all." The Housekeeping/Laundry Supervisor was asked, "Why not move his belongings on Monday, Tuesday or Wednesday?" The Housekeeping/Laundry Supervisor stated, "I wasn't sure he was staying there and on Thursday (1/2/14) (Administrator) told me to move his belongings to room (number on South hall)." r. On 1/7/14 at 4:32 p.m. CNA # 11 was asked, "Do you know of any resident being moved to another room or closed unit without their belongings also being moved?" CNA # 11 stated, "Yes." CNA # 11 was asked, "Who?" CNA # 11 stated, "(Resident # 5)." CNA # 11 was asked "Tell me about this." CNA # 11 stated, "He was there a couple of days. He had a bed at first and he threw himself on the floor and then they took it out for a while. I know when they moved his stuff back in there because I saw (Family Member # 1) move his stuff into his room." CNA # 11 was asked to review the floor plan/assignment sheets for the date. CNA # 11 stated, "It was the second." CNA # 11 was asked, "Did anyone

Complaint # was substantiated (all or in part) in these findings. Based on record review, and interview, the facility failed to implement the Abuse Prohibition Policies and Procedures as evidenced by the facility ' s failures to ensure staff responded to a request for chicken noodle soup which caused a catastrophic reaction that led to involuntary seclusion and mental anguish for 1 (Resident # 5) of 2 (Residents # 3 and #5) case mix residents with documented behaviors of throwing things. The facility failed to ensure a resident was not deprived of personal belongings which caused mental anguish for 1 of 1 (Resident # 5) case mix residents who were moved to the South (closed/secure) unit for behaviors and safety. The facility failed to ensure a resident's bed was returned and a resident was placed back in bed upon request for 1 of 1 (Resident # 5) case mix residents who were moved to the South (closed/secure) unit for behaviors and safety. These failed practices resulted in a pattern of actual harm for Resident # 5, who had continued behaviors and mental anguish from being moved to the South (closed/secure unit), being left on floor mats for an extended period of time, and being separated from his personal belongings. These failed practices had the potential to cause more than minimal harm for 3 residents who had behaviors of throwing items and 1 resident who was moved to the closed/secure unit as according to the listing received from the Director of Nursing (DON) on 1/9/14. The findings are: 1. The facility's policy titled "Resident Abuse" documented, "... 1. Definition of Resident Abuse: A. An abusive act is any act or omission, which may cause or caused physical, psychological or emotional harm or injury to a resident or any act which willfully deprives a resident of his rights by law or as stated herein...C. ... Any action that may cause or caused physical, psychological or emotional harm, which is not caused by simple negligence, constitutes abuse... D. Non-action, which results in emotional, psychological, or physical injury, is viewed in the same manner as that caused by improper or excessive action. All actions in which employees engage with residents must have as their goal, the healthful, proper, and humane care and treatment of [REDACTED]. The facility's policy titled "Resident Abuse - Staff to Resident" documented, "... Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, or pain, or mental anguish, or deprivation by an individual, including a caretaker of goods and services that are necessary to attain or maintain physical, mental and psychological well-being. This includes ... involuntary seclusion ...". The facility's policy titled "Resident Abuse" documented, "... e). Involuntary Seclusion - Separation of a resident from other residents or from his or her room OR confinement to his/her room (with or without roommates) against the residents will or the will of the resident's legal representative..." 2. Resident # 5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/13 documented the resident scored 15 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status, had no signs and symptoms of [MEDICAL CONDITION], had no behaviors, had no intellectual disability or developmental disability, required extensive assistance to total dependence for all activities of daily living, except eating and locomotion, had functional limitation in range of motion of both sides of the lower extremities, and had an indwelling catheter. a. The Durable Power of Attorney (POA) dated 12/8/11 documented, "Article I. Creation. I, (Resident # 5) ... designate the following persons, in order of preference and succession to serve as Attorney-In-Fact (my "Agent") for me and to act as the guardian or limited guardian of my estate should guardianship proceedings become necessary or desirable: 1) (Family member # 1), 2) (Family member # 2). Article II. Effectiveness: Effective Immediately. This Power of Attorney shall become effective immediately and shall survive and continue during my disability, incompetence, incapacity or partial incapacity ... Disability, incompetence, incapacity or partial incapacity shall include, without limitation, my inability to manage my property and affairs or caring for myself effectively for reasons such as mental illness, mental deficiency or other mental incapacity ... Article III. When Successor Agent is Entitled to Act. The successor Agent shall be entitled to act upon death, disability or incapacity determined by the same criteria above, ...". 1) On 1/8/14 at 3:20 p.m., the Acting Administrator and Regional Director of Operations asked this surveyor if a copy of the POA for (Resident # 5) had been received. This surveyor stated, "Yes." The Acting Administrator and Regional Director of Operations were asked, "I couldn't find anything in his chart that indicates (Resident # 5) is incompetent. Do you know if he is incompetent?" The Acting Administrator and Regional Director of Operations stated, "There's no documentation that he's incompetent at this time." 2) On 1/13/14 at 3:38 p.m. the Nurse Consultant was asked, "Did you find anything in (Resident # 5's) chart that indicates (Resident # 5) is incompetent?" The Nurse Consultant stated, "No and I looked when I was reviewing his POA." b. The Resident Care Plan dated 10/22/13 documented, " ...Focus: (Resident # 5) had impaired cognitive skills (as evidenced by)/(related to) poor or unsafe decision making, (history) of [DIAGNOSES REDACTED] tumor and [MEDICAL CONDITION] ((Motor Vehicle Accident)) ... Interventions: ... Throws objects and curses when angry ... Focus: (Resident # 5) is at risk for/has potential of mood state issues (as evidenced by)/(related to) had negative attitude, makes negative statements, and can be VERY demanding at times and manipulative of staff ... Interventions: ... Assess (Resident # 5) for physical/psychological causes for mood indicators, address as needed. Determine if (Resident # 5) mood may result in harm to self or others. Take necessary precautions. ... Monitor and record changes in mood state pattern ... Report to physician changes in mood status. Staff will assist (Resident # 5) as needed finding his personal belongings due to his immobility status. Cusses staff, hits staff, throws objects at staff (and) other residents. 12/21/13 Curses at other staff, throws things, redirect (as needed) ... Focus: (Resident # 5) is at risk for adverse reactions from behavior disturbances (as evidenced by)/(related to) is verbally abusive, is socially inappropriate, resist (Activities of Daily Living) care, resists medications/treatments, is manipulative ... Interventions: ... Anticipate needs and provide them before the resident becomes overly stressed. Date initiated 4/29/13. Educate resident on other effective coping skills for dealing (with) feelings. Date initiated 4/29/13. Encourage resident/family to increase involvement in activities to eliminate or reduce behaviors. Date initiated 4/29/13. ... Intervene during behavioral outburst to protect the safety of the resident and others. Date initiated 4/29/13. ... (Resident # 5) makes accusatory statements about staff, frequently these remarks are made when he does not get (his) way. Date initiated 4/29/13. (Resident # 5) will become agitated and demanding. He will throw his cell phone, remote and other items when he gets mad. Staff is (to) leave him alone until he quiets down. Then return to give care. Date initiated 4/29/13. ... Provide resident with diversional activities when behavioral symptoms arise. Date initiated 4/29/13. ... Involve (Resident # 5) in more activities to better occupy his time. Report to physician changes in behavioral status. Date initiated 4/29/13 ..." c. A physician progress notes [REDACTED]. History: This patient with mental [MEDICAL CONDITION] has a history of [MEDICAL CONDITION]. He has been stable and there have been no new events. ... Plan: We will continue present management and medications." d. Nurse's Notes dated 12/28/13 from 3:00 p.m. to 11:00 p.m. documented, "Resident is verbally aggressive (with) staff and (inappropriate) behaviors noted escalating to incident (with) Resident throwing things, yelling, cursing, threatening staff and threatening to hurt himself. At 3:30 p.m. resident was asking staff to re-arrange his room. When CNAs (Certified Nursing Assistants) told resident they could not do that at that time resident started cursing at staff and getting verbally aggressive. Resident was also stating sexual (inappropriate) things to CNAs. Told female CNAs to 'get hot and sexy for me'. At that time CNA started answering call light 2 at a time for a witness to behaviors and to protect staff from (inappropriate) behaviors and speech. At 4:00 p.m. resident refused meds (medications) stating to nurse 'I'm not taking[***]from you because you told the CNAs they didn't have to rearrange my room and you won't make the staff do what I want.' Resident was in dining room yelling at kitchen staff at 7:00 p.m. He became verbally aggressive with dietary staff and then started throwing items in kitchen at staff like cups from coffee tray and lids and then the coffee tray itself. Resident's responsible party was called and Resident started yelling at her on the phone. Resident was assisted to his room (with) staff pushing wheelchair. Resident then started hitting staff and threatening staff. Told male CNA 'I'm going to f..... kill you'. Also stating 'I'm gonna kick your a..'. Then resident threw a pitcher at nurses' head. Stated to nurse 'I'm mad at you because you won't make then give me what I want and do as I say'. Resident then began to take linen cart apart and throw it across room down hallway. Items were removed from resident reach. Administrator, DON (Director of Nursing) and physician notified. Administrator came to facility and new order received to place resident on one on one (with) CNA and then resident transferred to South hall on secure unit for safety." This entry was signed by Licensed Practical Nurse (LPN) # 1. 1) On 1/8/14 at 3:12 p.m. LPN # 1 was asked, "When you called the doctor on 12/28/13 about (Resident # 5) what did he say?" LPN # 1 stated, "I notified (DON) and she called (Administrator) and I talked with (DON) several times. (Administrator) came up, I don't know who notified the doctor." LPN # 1 was asked, "Did you talk with the doctor?" LPN # 1 stated, "No." LPN # 1 was asked, "Why did you chart the doctor was notified?" LPN # 1 stated, "I was told to." 2) An Office of Long Term Care (OLTC) witness statement dated (12/28/13) documented, "(Resident # 5) was rude towards us all day, because our nurse told us we couldn't rearrange thing in his room because we didn't have the staff. Later on he sat in the dining area, throwing cups and lids. Called me a 'stupid n.....' multiple times while threatening to kill me because I was pushing him to his room as instructed ..." This witness statement was signed by CNA # 1. On 1/8/14 at 3:22 p.m. CNA # 1 was asked, "Tell me what happened on 12/28/13 with (Resident # 5) in the dining room." CNA # 1 stated, "We started the shift and (Resident # 5) wanted the CNAs to stop and rearrange the room. He wanted me and another CNA to rearrange the flags on his door and I told him '(Resident # 5) I'm sorry we can't do that'. I was told when I first started that would be automatic termination. We told him we would talk to our nurse and (LPN # 1) said no we needed to get people up for dinner. (LPN # 1) said we were already short one CNA and we couldn't do what (Resident # 5) wanted done. He started cursing and then we passed trays and I took his dinner to him and he refused. So then he said he was going to the kitchen. He was sitting there cussing out the cooks. He was at the serving window and wouldn't move. When dinner was done I pushing empty carts to the dining room and one of the dietary staff people asked me if I could get the coffee cart because (Resident # 5) was sitting there by the piano and coffee cart and was throwing things off it onto the floor and there were other residents there also." CNA # 1 was asked "Who were the residents?" CNA # 1 stated, "(Resident # 15) and I can't recall who else." CNA # 1 was asked, "Were you around when (Resident # 5) went back to his room?" CNA # 1 stated, "(LPN # 1) tried to push him to his room and (Resident # 5) was hitting at her to leave him alone. He said he wasn't going anywhere. I offered to help and he hit me when I was taking him to his room and calling me n..... and on the way to his room he grabbed the linen cart and pulled the pink cover off and took the shelves out and threw them on the floor and when I got him to his room he started trying to tear the privacy curtains down." CNA # 1 was asked, "Why not leave him in the dining room?" CNA # 1 stated, "(Family Member # 1) told him to go to his room." 3) On 1/7/14 at 2:23 p.m. Dietary Staff # 2 was asked, "Did you work on 12/28/13 for supper?" Dietary Staff # 2 stated, "Yes." Dietary Staff # 2 was asked, "See anything with (Resident # 5) on 12/28/13?" Dietary Staff # 2 stated, "He was sitting at our door (serving window) and he wanted 2 bowls of chicken noodle soup and crackers." Dietary Staff # 2 was asked, "About when?" Dietary Staff # 2 stated, "We were just starting to serve so it was about 4:45 p.m. Chicken noodle soup was not on the menu so I call CDM (Certified Dietary Manager) (who is also Family Member # 1) and asked her if he could have it and she said no because we have our main course, alternate, and soup and sandwich of the day. So she told him he couldn't have it and he got aggravated and would not move away from the window and we couldn't push any of our carts out so we couldn't get any food to the rest of the residents. Our coordinating CNA (CNA # 7) moved him to the dining room. He was quiet for a little bit then he started throwing plates, cups, and coffee cups off of dirty carts and the coffee cart on the credenza. He was throwing them across the room." Dietary Staff # 2 was asked, "Did he stay in the dining room?" Dietary Staff # 2 stated, "Yes." Dietary Staff # 2 was asked, "Do you recall if residents were in the dining room when (Resident # 5) started throwing things?" Dietary Staff # 2 stated, "Yes, but not who." Another CNA (CNA # 1) was trying to calm him down and (Resident # 5) was screaming at him and yelling profanity. Then (CNA # 1) came up to the window and started coordinating ..." 4) On 1/7/14 at 2:37 p.m. Dietary Staff # 1 was asked, "Did you work on 12/28/13 for supper?" Dietary Staff # 1 stated, "Yes." Dietary Staff # 1 was asked, "What can you tell me about what happened with (Resident # 5) that night?" Dietary Staff # 1 stated, "He came to the window. We had already served his plate and he came to the window and said he didn't want it. He said he wanted chicken noodle soup and I told him the soup of the day was cream of potato soup and he didn't want that. So I told him (Resident # 5) it's the regular, the alternate, or the soup and sandwich of the day. Then he got mad and sat in the window in the way of our serving. I told him three times he was going to have to move so we could finish serving supper. He wouldn't move and we worked around him and we tried working around him. Then (CNA # 3) came and moved him and (Resident # 5) moved himself right back to the window the whole time we were serving. Once we got done serving he was still in the window so I asked (Resident # 5) do you want the soup and sandwiches or the alternative. He got even more mad and he started cussing at me. I said (Resident # 5) I'm not going to stay at this window and argue with you and have you talk with me like that. We started cleaning up the tray line and he got mad and pushed a cart with lids over to the floor. Then he went to the main dining room and took cups from the drink area on the credenza and threw them on the floor one by one. Then he threw the tray that the cups were on onto the floor, opened sugar packets and dumped then out on the ground. I went out there because we could hear him throwing stuff clear in the kitchen. I told him (Resident # 5) you are going to have to stop. This is unnecessary. (CNA # 1) and (CNA # 7) were in the main dining room trying to calm him down. He started saying racial things to (CNA # 1), so I told them this was not necessary that I was going to call (Family Member # 1) our CDM who is also his (Family member # 1). I called (CDM) and she told me told me to put it on speaker phone so he didn't get the phone and throw it and be all mad. (CDM) told him to stop acting that way and go to his room. He told her no and she just kept telling him to stop acting like that and to go to his room and by then his nurse (LPN # 1) had walked up and she heard (CDM) tell him to go to his room. (CDM) got off the phone and (LPN # 1) took him to his room." Dietary Staff # 1 was asked, "Did you ask her if you could fix chicken noodle soup for (Resident # 5)?" Dietary Staff # 1 stated, "Yes, and she told me no." e. The Social Service Progress Notes dated 12/28/13 and signed by the Administrator documented, "I was called to the facility this evening due to concerns by nursing of (Resident # 5's) behaviors. Nursing reported to me that he was entering the kitchen and throwing things at the kitchen staff. That he was going up and down halls yelling and cursing and throwing things. I found (Resident # 5) in his room and attempted to reason with him. He yelled and cussed me the whole time I tried to talk to him and he kept telling me about other residents that I needed to 'do things about them'. I called his POA and talked about the options and how his agitation has increased the last several weeks. She agreed he needed a psych (psychiatric) consult and for him to be moved to the south side (closed/secure unit) of the building to see if any positive results could be acquired. As we were moving him, he continued to cuss me and told me that he would kill himself and kill me for doing this. (Resident) was placed on 1:1 monitoring pending psych consult ... While awaiting the bed to be moved into room (number) for (Resident # 5), I observed (Resident # 5) banging his chair and his foot into the door that leads into laundry. I moved him away from the door." f. A physician telephone order dated 12/28/13 at 9:00 p.m. documented, "1. Transfer to memory unit for structured environment secondary to behaviors. 2. (Psych) consult. 3. Place resident 1:1 (One on one) until resident can be transferred to behavioral health unit." This order was signed by LPN # 2, as nurse receiving order. On 1/9/14 at 12:55 p.m. LPN # 2 was asked, "Did you talk to (Resident # 5's) doctor when you wrote the orders dated 12/28/13?" LPN # 2 stated, "No, my Administrator told me to write those orders and you have to understand I wrote those orders after he had been moved." LPN # 2 was asked, "Why was he moved to the closed unit?" LPN # 2 stated, "He was throwing things and was to move to (room number on the closed unit) to start with. I had the CNAs move the bed out of that room... " LPN # 2 was asked "Did you talk with (Family Member # 1) or any other family members on 12/28/13?" LPN # 2 stated, "No..." g. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 8:25 a.m. documented, "Awake in bed. Upset about not having his things." h. Nurse's Notes dated 12/29/13 at 8:45 a.m. documented, "Resident attempting to roll himself out of bed. Bed lowered to lowest position. Fall mats on both sides of bed. Resident had also wrapped tubing for Foley (catheter) around his legs and was attempting to pull suprapubic Foley out. Untangled tubing. Explained to resident we do not want him to hurt self. Resident calmed down for time being. Continues one on one." i. Nurse's Notes dated 12/29/13, untimed, documented "Resident attempted to roll out of bed. Staff assisted resident to floor fall mats. Responsible party notified. Continues on one on one." 1) The OLTC witness statement attached to the Fall Investigation form dated 12/29/13 documented, " ...Date: 12/29/13. Time: 10:30 a.m. ... (Resident # 5) was attempting to pull himself out of bed by pulling himself to the edge and pulling his legs off the side. I went in to push his legs back on the bed and he started to go off. I caught his bottom and torso. I attempted to put him back on the bed but he was too heavy so I eased him to the floor ..." This witness statement was signed by CNA # 2. 2) On 1/8/14 at 12:55 p.m. LPN # 4, the residents charge nurse for 7:00 a.m. to 3:00 p.m. on 12/29/13, was asked, "What was (Resident # 5) doing on 12/29/13?" LPN # 4 stated, "He was trying to get his bed rails off the bed and roll himself on to the floor." LPN # 4 was asked, "What did you do when he did that?" LPN # 4 stated, "We took his bed out and put him on mats on the floor." LPN # 4 was asked, "Did (Resident # 5) talk with you then, tell you why he was doing that?" LPN # 4 stated, "No, he was mad but he shrugged his shoulders and tried to not let me assess him." LPN # 4 was asked, "How many times did he get onto the floor?" LPN # 4 stated, "Just once." j. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 12:30 p.m. documented, "Resident goes unresponsive. I call hall nurse and (Weekend RN (Registered Nurse) # 1) was paged. Vital signs are good, staff realize symptoms were being faked by resident ..." This entry was initialed by CNA # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 1:05 p.m. documented "Family leaves. (Resident # 5) promises good behavior if we get him back in bed. Talked with (Administrator) about it." This entry was initialed by CNA # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 1:30 p.m. documented, "Resident asks again about being put back in bed. I call for south hall nurse to ask her about it." This entry was initialed by CNA # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 2:00 p.m. documented "Resident begins to complaining again about not being back in a bed yet." This entry was initialed by CNA # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 3:25 p.m. documented, "Was told we could put bed back in room. 4 of us lifted him up on bed." This entry was initialed by CNA # 4. The Nurse's Notes dated 12/29/13 at 4:00 p.m. documented "Resident in bed cursing and threatening staff. Resident requested (Family member # 2) be called to come to facility. LPN called (Family member # 2) on request. 4:10 p.m. call received from (Family member # 1). (Family member # 1) stated, 'Tell (Resident # 5) that (Family member # 2) was not coming to facility just because he was misbehaving. (Family member # 2) had children to take care of.' (Family member # 1) stated 'tell (Resident # 5) that if his behavior didn't stop he would be going to the hospital'. This entry was signed by LPN # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 4:20 p.m. documented, "Gave him his phone that was in closet. He is mad because it has no charge ..." This entry was initialed by CNA # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 4:21 p.m. documented, "(Resident # 5) has taken both rails off bed. He is holding one over his body. I told nurse. She said to take the rails. (Resident # 5) threatened staff saying to do (bodily) harm if we took rails. (CNA # 3) came in and helped take rails." This entry was initialed by CNA # 4. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 4:25 p.m. documented, "(Resident # 5) was trying to throw self in the floor. I placed legs back on bed. He said he was only trying to turn over." This entry was initialed by CNA # 4. Nurse's Notes dated 12/29/13 at 10:40 p.m. documented "Resident remains 1:1 due to threats and behaviors. Resting in bed with eyes closed at present time ... Resident calmed down after bed rails were taken away ..." This entry was signed by LPN # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/30/13 at 8:35 a.m. documented, "I set up his breakfast. He seems to be calm. (Family member # 1) goes into room to talk to him." This entry was initialed by CNA # 6. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/30/13 at 9:00 a.m. documented, "No change. Talking to me and other residents. (Resident # 5) is calm and asking about his phone charger." This entry was initialed by CNA # 6. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/30/13 at 10:10 a.m. documented, "(Family member # 1) brought his laptop to him. I plugged it in for him and put his phone on the charger." This entry was initialed by CNA # 6. k. A Physician telephone order dated 12/30/13 at 4:00 p.m. documented, "1. (Discontinue) [MEDICATION NAME]. 2. Start [MEDICATION NAME] 4 (milligrams) (per mouth) (every) (hour of sleep)." l. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/30/13 at 4:10 p.m. documented, "Just got TV(television). Laying in bed watching TV now." This entry was initialed by CNA # 6. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/30/13 at 4:30 p.m. documented, "(Family member # 1) brought DVD player and I moved his bed at an angle." This entry was initialed by CNA # 6. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/31/13 at 3:30 p.m. was the last 1:1 entry documented. m. A physician telephone order dated 12/31/13 at 10:30 p.m. documented, "(Discontinue) 1:1. (Continue) to monitor behavior." The Nurse's Notes dated 12/31/13 at 11:00 p.m. documented, "Alert and oriented (times) 4. Denies any thought of suicide or of harming others. Stated, 'I never meant any of that. I was just mad. You know me.' (Family member # 1)/POA (Power of Attorney) in (agreement). Order obtained to (discontinue) 1:1. POA aware." This entry was signed by the DON. n. Nurse's Notes dated 1/2/14 at 1:25 p.m. documented, "... (Alert and oriented times) 3. ... Resident had refused to let laundry move his belongings into his room. He stated to nurse that (Administrator) is not his boss and he will have her job. ..." This entry was signed by LPN # 3. o. A physician telephone order dated 1/3/14 documented, "(Discontinue) admit to unit as ordered." p. On 1/7/14 at 8:35 a.m. Family Member # 1 asked to speak with this surveyor. Family Member # 1 stated, "I'm (Resident # 5's) POA and (Family Member # 2) is his second POA." Family Member # 1 was asked, "Tell me why (Resident # 5) was moved to the closed unit." Family Member # 1 stated, "He went to the closed unit because he was throwing a hissy fit. He was threatening to harm himself and other employees and they didn't know if he would try to harm another resident. So they moved him to the closed unit to calm him down, get him out of the general population and did 1:1 with him. I wanted him to get a shot to calm him down and was told they couldn't do that." Family Member # 1 was asked, "How long was he there?" Family Member # 1 stated, "One week. He was on 1:1 from Saturday (12/28/13) and they stopped it on Wednesday (1/1/14) or Thursday (1/2/14) and then they moved him back to the open unit on Friday (1/3/14). He said they told him he was there because he was being punished and he even called the police because of it." Family Member # 1 was asked, "Before they moved him over there did they talk with you about the move?" Family Member # 1 stated, "Yes but not immediately. They did call me on Saturday, later in the day after he'd been moved. When (Family Member # 2) came up on Sunday (12/29/13) he (Resident #5) had crawled out of bed and she found him on the floor, face down and his arms were all twisted under him. I don't know if they tried to get him up or if he refused. ... They had fall mats on the floor." Family Member # 1 was asked, "Did you see (Resident # 5) when he was on the closed unit?" Family Member # 1 stated, "Yes and they wouldn't let him have any of his stuff." Family Member # 1 was asked, "Nothing?" Family Member # 1 stated, "On Sunday (12/29/13) they got his TV in there and I had his movies and electronic stuff in my office and all of his other stuff was in the laundry. I asked them to give him his stuff because his biggest fear is stuff getting stolen. I got a dolly on Wednesday (1/1/14) and moved all his stuff into his room. On Monday (12/30/13) they did move his clothes in and then was still 1:1. By Wednesday (1/1/14) I got the impression when the 1:1 had been stopped that they were not going to move him out of that room and that's when I got his stuff and moved it in myself. I threw a fit and he threw a fit on Friday (1/3/14) and that's when they moved him back." Family Member # 1 who was also the CDM (Certified Dietary Manager) was asked, "Who was working in the kitchen 12/28/13 for supper?" Family Member # 1/ CDM stated, "(Dietary Staff # 1). She called me and told me (Resident # 5) went into the kitchen and they asked him not to come into the kitchen. (Resident # 5) threw a fit and started throwing things." Family Member # 1/CDM was asked, "What time was this?" Family Member # 1/CDM stated, "After supper between 6:00 to 6:30 p.m. when (Dietary Staff # 1) called me I called his nurse and asked if he could get a shot or something to calm him down and they said they couldn't do that. I do know (Resident # 5) took his bed rails off when they got him to his room on the North hall and he started trying to hit the employees with the bed rails and he said he was going to kill himself. So they moved him to the closed unit because they feared for his safety. Then (Family Member # 2) came up and got upset with how she found him. I feel he does get mistreated. It's things like when they moved him back there and he asked for his DVD to be hooked to the TV up so he could watch movies. The CNA asked the weekend RN (Registered Nurse) and she said no that the CNA couldn't do that for (Resident # 5). The CNA went ahead and did it because (Resident # 5) wanted to watch a movie." Family Member # 1 was asked, "Was there any mention of when or what had to happen before (Resident # 5) could be moved off the South unit?" Family Member # 1 stated, "No." q. On 1/7/14 at 2:13 p.m. the Housekeeping /Laundry Supervisor was asked, "For resident room changes, who moves the resident's belongings?" The Housekeeping /Laundry Supervisor stated, "I do almost always unless I'm not here or on a weekend." The Housekeeping/Laundry Supervisor was asked, "Do you know who moved (Resident # 5's) belongings from (room number on North hall) to (room number on South hall)?" The Housekeeping/Laundry Supervisor stated, "His TV and bed were moved that weekend and then I moved the rest of his belongings at a later date." The Housekeeping/Laundry Supervisor was asked, "When?" The Housekeeping/Laundry Supervisor stated, "Last Thursday (1/2/14)." The Housekeeping/Laundry Supervisor was asked, "Where was his stuff?" The Housekeeping/Laundry Supervisor stated, "In room (number on North hall, the room from which the resident was moved)." The Housekeeping/Laundry Supervisor was asked, "Was it ever in Laundry?" The Housekeeping/Laundry Supervisor stated, "Only for one hour, in the hall outside laundry. I tried to take his stuff to him and he said he was not moving to that room and we had to take his stuff back to room (number on north hall, the room from which the resident was moved). I called the Administrator and she said to put his belonging in the hall by laundry and she c

Complaint # was substantiated (all or in part) in these findings. Based on record review, and interview, the facility Administration failed to ensure staff provided effective and appropriate interventions in response to resident behaviors in order to maintain the highest practicable mental and psychosocial health for 1 (Resident #5) of 2 (Residents #3 and #5) case mix residents who had a history of [REDACTED].# 5) case mix residents who was involuntarily moved to the South (closed/secure) unit for behaviors. The facility Administration failed to ensure a resident's bed was returned and a resident was placed back in bed upon request for 1 of 1 (Resident # 5) case mix residents who had their bed removed and lay on fall floor mats for an extended period of time after being moved to the South (closed/secure) unit for behaviors. These failed practice resulted in a pattern of actual harm for Resident # 5, who had continued behaviors and mental anguish from being moved to the South (closed/secure unit), being left on floor mats for an extended period of time, and being separated from his personal belongings. These failed practices had the potential to cause more than minimal harm for 3 residents who had behaviors of throwing items and 1 resident who was moved to the closed/secure unit as according to the listing received from the Director of Nursing (DON) on 1/9/14. The findings are: 1. The Administrator Job Description documented, "... Summary: ... Responsible for monitoring regulatory compliance to assure high quality of resident care ... Essential Duties and Responsibilities: ... Serves as member of the Grievance Committee and conduct investigations in accordance with facility policy and state regulation ..." 2. The facility's policy titled "Resident Abuse" documented, "... 1. Definition of Resident Abuse: A. An abusive act is any act or omission, which may cause or caused physical, psychological or emotional harm or injury to a resident or any act which willfully deprives a resident of his rights by law or as stated herein. ... C ... Any action that may cause or caused physical, psychological or emotional harm, which is not caused by simple negligence, constitutes abuse. ... D. Non-action, which results in emotional, psychological, or physical injury, is viewed in the same manner as that caused by improper or excessive action. All actions in which employees engage with residents must have as their goal, the healthful, proper, and humane care and treatment of [REDACTED]. Identification...This information will be forwarded to the Administrator, who will serve as the facility's Abuse Coordinator..." The facility's policy titled "Resident Abuse - Staff to Resident" documented, "... Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, or pain, or mental anguish, or deprivation by an individual, including a caretaker of goods and services that are necessary to attain or maintain physical, mental and psychological well-being. This includes ... involuntary seclusion ..." The facility's policy titled "Resident Abuse" documented, "... e). Involuntary Seclusion - Separation of a resident from other residents or from his or her room OR confinement to his/her room (with or without roommates) against the residents will or the will of the resident's legal representative ..." 3. Resident # 5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/13 documented the resident scored 15 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status, had no signs and symptoms of [MEDICAL CONDITION], had no behaviors, had no intellectual disability or developmental disability, required extensive assistance to total dependence for all activities of daily living, except eating and locomotion, had functional limitation in range of motion of both sides of the lower extremities, and had an indwelling catheter. a. The Durable Power of Attorney (POA) dated 12/8/11 documented, "Article I. Creation. I, (Resident # 5) ... designate the following persons, in order of preference and succession to serve as Attorney-In-Fact (my "Agent") for me and to act as the guardian or limited guardian of my estate should guardianship proceedings become necessary or desirable: 1) (Family member # 1), 2) (Family member # 2). Article II. Effectiveness: Effective Immediately. This Power of Attorney shall become effective immediately and shall survive and continue during my disability, incompetence, incapacity or partial incapacity ... Disability, incompetence, incapacity or partial incapacity shall include, without limitation, my inability to manage my property and affairs or caring for myself effectively for reasons such as mental illness, mental deficiency or other mental incapacity ... Article III. When Successor Agent is Entitled to Act. The successor Agent shall be entitled to act upon death, disability or incapacity determined by the same criteria above, ...". 1) On 1/8/14 at 3:20 p.m., the Acting Administrator and Regional Director of Operations asked this surveyor if a copy of the POA for (Resident # 5) had been received. This surveyor stated, "Yes." The Acting Administrator and Regional Director of Operations were asked, "I couldn't find anything in his chart that indicates (Resident # 5) is incompetent. Do you know if he is incompetent?" The Acting Administrator and Regional Director of Operations stated, "There's no documentation that he's incompetent at this time." 2) On 1/13/14 at 3:38 p.m. the Nurse Consultant was asked, "Did you find anything in (Resident # 5's) chart that indicates (Resident # 5) is incompetent?" The Nurse Consultant stated, "No and I looked when I was reviewing his POA." b. The Resident Care Plan dated 10/22/13 documented, " ...Focus: (Resident # 5) had impaired cognitive skills (as evidenced by)/(related to) poor or unsafe decision making, (history) of [DIAGNOSES REDACTED] tumor and [MEDICAL CONDITION] ((Motor Vehicle Accident)) ... Interventions: ... Throws objects and curses when angry ... Focus: (Resident # 5) is at risk for/has potential of mood state issues (as evidenced by)/(related to) had negative attitude, makes negative statements, and can be VERY demanding at times and manipulative of staff ... Interventions: ... Assess (Resident # 5) for physical/psychological causes for mood indicators, address as needed. Determine if (Resident # 5) mood may result in harm to self or others. Take necessary precautions. ... Monitor and record changes in mood state pattern ... Report to physician changes in mood status. Staff will assist (Resident # 5) as needed finding his personal belongings due to his immobility status. Cusses staff, hits staff, throws objects at staff (and) other residents. 12/21/13 Curses at other staff, throws things, redirect (as needed) ... Focus: (Resident # 5) is at risk for adverse reactions from behavior disturbances (as evidenced by)/(related to) is verbally abusive, is socially inappropriate, resist (Activities of Daily Living) care, resists medications/treatments, is manipulative ... Interventions: ... Anticipate needs and provide them before the resident becomes overly stressed. Date initiated 4/29/13. Educate resident on other effective coping skills for dealing (with) feelings. Date initiated 4/29/13. Encourage resident/family to increase involvement in activities to eliminate or reduce behaviors. Date initiated 4/29/13. ... Intervene during behavioral outburst to protect the safety of the resident and others. Date initiated 4/29/13. ... (Resident # 5) makes accusatory statements about staff, frequently these remarks are made when he does not get (his) way. Date initiated 4/29/13. (Resident # 5) will become agitated and demanding. He will throw his cell phone, remote and other items when he gets mad. Staff is (to) leave him alone until he quiets down. Then return to give care. Date initiated 4/29/13. ... Provide resident with diversional activities when behavioral symptoms arise. Date initiated 4/29/13. ... Involve (Resident # 5) in more activities to better occupy his time. Report to physician changes in behavioral status. Date initiated 4/29/13 ..." c. A physician progress notes [REDACTED]. History: This patient with mental [MEDICAL CONDITION] has a history of [MEDICAL CONDITION]. He has been stable and there have been no new events. ... Plan: We will continue present management and medications." d. Nurse's Notes dated 12/28/13 from 3:00 p.m. to 11:00 p.m. documented, "Resident is verbally aggressive (with) staff and (inappropriate) behaviors noted escalating to incident (with) Resident throwing things, yelling, cursing, threatening staff and threatening to hurt himself. At 3:30 p.m. resident was asking staff to re-arrange his room. When CNAs (Certified Nursing Assistants) told resident they could not do that at that time resident started cursing at staff and getting verbally aggressive. Resident was also stating sexual (inappropriate) things to CNAs. Told female CNAs to 'get hot and sexy for me'. At that time CNA started answering call light 2 at a time for a witness to behaviors and to protect staff from (inappropriate) behaviors and speech. At 4:00 p.m. resident refused meds (medications) stating to nurse 'I'm not taking[***]from you because you told the CNAs they didn't have to rearrange my room and you won't make the staff do what I want.' Resident was in dining room yelling at kitchen staff at 7:00 p.m. He became verbally aggressive with dietary staff and then started throwing items in kitchen at staff like cups from coffee tray and lids and then the coffee tray itself. Resident's responsible party was called and Resident started yelling at her on the phone. Resident was assisted to his room (with) staff pushing wheelchair. Resident then started hitting staff and threatening staff. Told male CNA 'I'm going to f..... kill you'. Also stating 'I'm gonna kick your a..'. Then resident threw a pitcher at nurses' head. Stated to nurse 'I'm mad at you because you won't make then give me what I want and do as I say'. Resident then began to take linen cart apart and throw it across room down hallway. Items were removed from resident reach. Administrator, DON (Director of Nursing) and physician notified. Administrator came to facility and new order received to place resident on one on one (with) CNA and then resident transferred to South hall on secure unit for safety." This entry was signed by Licensed Practical Nurse (LPN) # 1. 1) On 1/8/14 at 3:12 p.m. LPN # 1 was asked, "When you called the doctor on 12/28/13 about (Resident # 5) what did he say?" LPN # 1 stated, "I notified (DON) and she called (Administrator) and I talked with (DON) several times. (Administrator) came up, I don't know who notified the doctor." LPN # 1 was asked, "Did you talk with the doctor?" LPN # 1 stated, "No." LPN # 1 was asked, "Why did you chart the doctor was notified?" LPN # 1 stated, "I was told to." 2) An Office of Long Term Care (OLTC) witness statement dated (12/28/13) documented, "(Resident # 5) was rude towards us all day, because our nurse told us we couldn't rearrange thing in his room because we didn't have the staff. Later on he sat in the dining area, throwing cups and lids. Called me a 'stupid n.....' multiple times while threatening to kill me because I was pushing him to his room as instructed ..." This witness statement was signed by CNA # 1. On 1/8/14 at 3:22 p.m. CNA # 1 was asked, "Tell me what happened on 12/28/13 with (Resident # 5) in the dining room." CNA # 1 stated, "We started the shift and (Resident # 5) wanted the CNAs to stop and rearrange the room. He wanted me and another CNA to rearrange the flags on his door and I told him '(Resident # 5) I'm sorry we can't do that'. I was told when I first started that would be automatic termination. We told him we would talk to our nurse and (LPN # 1) said no we needed to get people up for dinner. (LPN # 1) said we were already short one CNA and we couldn't do what (Resident # 5) wanted done. He started cursing and then we passed trays and I took his dinner to him and he refused. So then he said he was going to the kitchen. He was sitting there cussing out the cooks. He was at the serving window and wouldn't move. When dinner was done I pushing empty carts to the dining room and one of the dietary staff people asked me if I could get the coffee cart because (Resident # 5) was sitting there by the piano and coffee cart and was throwing things off it onto the floor and there were other residents there also." CNA # 1 was asked "Who were the residents?" CNA # 1 stated, "(Resident # 15) and I can't recall who else." CNA # 1 was asked, "Were you around when (Resident # 5) went back to his room?" CNA # 1 stated, "(LPN # 1) tried to push him to his room and (Resident # 5) was hitting at her to leave him alone. He said he wasn't going anywhere. I offered to help and he hit me when I was taking him to his room and calling me n..... and on the way to his room he grabbed the linen cart and pulled the pink cover off and took the shelves out and threw them on the floor and when I got him to his room he started trying to tear the privacy curtains down." CNA # 1 was asked, "Why not leave him in the dining room?" CNA # 1 stated, "(Family Member # 1) told him to go to his room." 3) On 1/7/14 at 2:23 p.m. Dietary Staff # 2 was asked, "Did you work on 12/28/13 for supper?" Dietary Staff # 2 stated, "Yes." Dietary Staff # 2 was asked, "See anything with (Resident # 5) on 12/28/13?" Dietary Staff # 2 stated, "He was sitting at our door (serving window) and he wanted 2 bowls of chicken noodle soup and crackers." Dietary Staff # 2 was asked, "About when?" Dietary Staff # 2 stated, "We were just starting to serve so it was about 4:45 p.m. Chicken noodle soup was not on the menu so I call CDM (Certified Dietary Manager) (who is also Family Member # 1) and asked her if he could have it and she said no because we have our main course, alternate, and soup and sandwich of the day. So she told him he couldn't have it and he got aggravated and would not move away from the window and we couldn't push any of our carts out so we couldn't get any food to the rest of the residents. Our coordinating CNA (CNA # 7) moved him to the dining room. He was quiet for a little bit then he started throwing plates, cups, and coffee cups off of dirty carts and the coffee cart on the credenza. He was throwing them across the room." Dietary Staff # 2 was asked, "Did he stay in the dining room?" Dietary Staff # 2 stated, "Yes." Dietary Staff # 2 was asked, "Do you recall if residents were in the dining room when (Resident # 5) started throwing things?" Dietary Staff # 2 stated, "Yes, but not who." Another CNA (CNA # 1) was trying to calm him down and (Resident # 5) was screaming at him and yelling profanity. Then (CNA # 1) came up to the window and started coordinating ..." 4) On 1/7/14 at 2:37 p.m. Dietary Staff # 1 was asked, "Did you work on 12/28/13 for supper?" Dietary Staff # 1 stated, "Yes." Dietary Staff # 1 was asked, "What can you tell me about what happened with (Resident # 5) that night?" Dietary Staff # 1 stated, "He came to the window. We had already served his plate and he came to the window and said he didn't want it. He said he wanted chicken noodle soup and I told him the soup of the day was cream of potato soup and he didn't want that. So I told him (Resident # 5) it's the regular, the alternate, or the soup and sandwich of the day. Then he got mad and sat in the window in the way of our serving. I told him three times he was going to have to move so we could finish serving supper. He wouldn't move and we worked around him and we tried working around him. Then (CNA # 3) came and moved him and (Resident # 5) moved himself right back to the window the whole time we were serving. Once we got done serving he was still in the window so I asked (Resident # 5) do you want the soup and sandwiches or the alternative. He got even more mad and he started cussing at me. I said (Resident # 5) I'm not going to stay at this window and argue with you and have you talk with me like that. We started cleaning up the tray line and he got mad and pushed a cart with lids over to the floor. Then he went to the main dining room and took cups from the drink area on the credenza and threw them on the floor one by one. Then he threw the tray that the cups were on onto the floor, opened sugar packets and dumped then out on the ground. I went out there because we could hear him throwing stuff clear in the kitchen. I told him (Resident # 5) you are going to have to stop. This is unnecessary. (CNA # 1) and (CNA # 7) were in the main dining room trying to calm him down. He started saying racial things to (CNA # 1), so I told them this was not necessary that I was going to call (Family Member # 1) our CDM who is also his (Family member # 1). I called (CDM) and she told me told me to put it on speaker phone so he didn't get the phone and throw it and be all mad. (CDM) told him to stop acting that way and go to his room. He told her no and she just kept telling him to stop acting like that and to go to his room and by then his nurse (LPN # 1) had walked up and she heard (CDM) tell him to go to his room. (CDM) got off the phone and (LPN # 1) took him to his room." Dietary Staff # 1 was asked, "Did you ask her if you could fix chicken noodle soup for (Resident # 5)?" Dietary Staff # 1 stated, "Yes, and she told me no." e. The Social Service Progress Notes dated 12/28/13 and signed by the Administrator documented, "I was called to the facility this evening due to concerns by nursing of (Resident # 5's) behaviors. Nursing reported to me that he was entering the kitchen and throwing things at the kitchen staff. That he was going up and down halls yelling and cursing and throwing things. I found (Resident # 5) in his room and attempted to reason with him. He yelled and cussed me the whole time I tried to talk to him and he kept telling me about other residents that I needed to 'do things about them'. I called his POA and talked about the options and how his agitation has increased the last several weeks. She agreed he needed a psych (psychiatric) consult and for him to be moved to the south side (closed/secure unit) of the building to see if any positive results could be acquired. As we were moving him, he continued to cuss me and told me that he would kill himself and kill me for doing this. (Resident) was placed on 1:1 monitoring pending psych consult ... While awaiting the bed to be moved into room (number) for (Resident # 5), I observed (Resident # 5) banging his chair and his foot into the door that leads into laundry. I moved him away from the door." f. A physician telephone order dated 12/28/13 at 9:00 p.m. documented, "1. Transfer to memory unit for structured environment secondary to behaviors. 2. (Psych) consult. 3. Place resident 1:1 (One on one) until resident can be transferred to behavioral health unit." This order was signed by LPN # 2, as nurse receiving order. On 1/9/14 at 12:55 p.m. LPN # 2 was asked, "Did you talk to (Resident # 5's) doctor when you wrote the orders dated 12/28/13?" LPN # 2 stated, "No, my Administrator told me to write those orders and you have to understand I wrote those orders after he had been moved." LPN # 2 was asked, "Why was he moved to the closed unit?" LPN # 2 stated, "He was throwing things and was to move to (room number on the closed unit) to start with. I had the CNAs move the bed out of that room... " LPN # 2 was asked "Did you talk with (Family Member # 1) or any other family members on 12/28/13?" LPN # 2 stated, "No..." g. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 8:25 a.m. documented, "Awake in bed. Upset about not having his things." h. Nurse's Notes dated 12/29/13 at 8:45 a.m. documented, "Resident attempting to roll himself out of bed. Bed lowered to lowest position. Fall mats on both sides of bed. Resident had also wrapped tubing for Foley (catheter) around his legs and was attempting to pull suprapubic Foley out. Untangled tubing. Explained to resident we do not want him to hurt self. Resident calmed down for time being. Continues one on one." i. Nurse's Notes dated 12/29/13, untimed, documented "Resident attempted to roll out of bed. Staff assisted resident to floor fall mats. Responsible party notified. Continues on one on one." 1) The OLTC witness statement attached to the Fall Investigation form dated 12/29/13 documented, " ...Date: 12/29/13. Time: 10:30 a.m. ... (Resident # 5) was attempting to pull himself out of bed by pulling himself to the edge and pulling his legs off the side. I went in to push his legs back on the bed and he started to go off. I caught his bottom and torso. I attempted to put him back on the bed but he was too heavy so I eased him to the floor ..." This witness statement was signed by CNA # 2. 2) On 1/8/14 at 12:55 p.m. LPN # 4, the residents charge nurse for 7:00 a.m. to 3:00 p.m. on 12/29/13, was asked, "What was (Resident # 5) doing on 12/29/13?" LPN # 4 stated, "He was trying to get his bed rails off the bed and roll himself on to the floor." LPN # 4 was asked, "What did you do when he did that?" LPN # 4 stated, "We took his bed out and put him on mats on the floor." LPN # 4 was asked, "Did (Resident # 5) talk with you then, tell you why he was doing that?" LPN # 4 stated, "No, he was mad but he shrugged his shoulders and tried to not let me assess him." LPN # 4 was asked, "How many times did he get onto the floor?" LPN # 4 stated, "Just once." j. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 12:30 p.m. documented, "Resident goes unresponsive. I call hall nurse and (Weekend RN (Registered Nurse) # 1) was paged. Vital signs are good, staff realize symptoms were being faked by resident ..." This entry was initialed by CNA # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 1:05 p.m. documented "Family leaves. (Resident # 5) promises good behavior if we get him back in bed. Talked with (Administrator) about it." This entry was initialed by CNA # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 1:30 p.m. documented, "Resident asks again about being put back in bed. I call for south hall nurse to ask her about it." This entry was initialed by CNA # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 2:00 p.m. documented "Resident begins to complaining again about not being back in a bed yet." This entry was initialed by CNA # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 3:25 p.m. documented, "Was told we could put bed back in room. 4 of us lifted him up on bed." This entry was initialed by CNA # 4. On 1/9/14 at 12:55 p.m. LPN # 2, the South hall (closed unit) charge nurse for Resident # 5 on 12/28/13 and 12/29/13 for the 3:00 p.m. to 11:00 p.m. shift, was asked: "When did (Resident # 5) get his bed back?" LPN # 2 stated "12/29/13 on my shift after (Administrator) gave the okay." LPN # 2 was asked "Did (Resident # 5) have any behaviors after the move to the closed unit?" LPN # 2 stated, "Yes on 12/29/13 after he got his bed back, he was trying to use the bed rails on staff and the staff wanted me to take them away. I told them I'm not taking nothing away from him, I didn't have the right to do that." Nurse's Notes dated 12/29/13 at 4:00 p.m. documented "Resident in bed cursing and threatening staff. Resident requested (Family member # 2) be called to come to facility. LPN called (Family member # 2) on request. 4:10 p.m. call received from (Family member # 1). (Family member # 1) stated, 'Tell (Resident # 5) that (Family member # 2) was not coming to facility just because he was misbehaving. (Family member # 2) had children to take care of.' (Family member # 1) stated 'tell (Resident # 5) that if his behavior didn't stop he would be going to the hospital'. This entry was signed by LPN # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 4:20 p.m. documented, "Gave him his phone that was in closet. He is mad because it has no charge ..." This entry was initialed by CNA # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 4:21 p.m. documented, "(Resident # 5) has taken both rails off bed. He is holding one over his body. I told nurse. She said to take the rails. (Resident # 5) threatened staff saying to do (bodily) harm if we took rails. (CNA # 3) came in and helped take rails." This entry was initialed by CNA # 4. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/29/13 at 4:25 p.m. documented, "(Resident # 5) was trying to throw self in the floor. I placed legs back on bed. He said he was only trying to turn over." This entry was initialed by CNA # 4. The Nurse's Notes dated 12/29/13 at 10:40 p.m. documented "Resident remains 1:1 due to threats and behaviors. Resting in bed with eyes closed at present time ... Resident calmed down after bed rails were taken away ..." This entry was signed by LPN # 2. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/30/13 at 8:35 a.m. documented, "I set up his breakfast. He seems to be calm. (Family member # 1) goes into room to talk to him." This entry was initialed by CNA # 6. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/30/13 at 9:00 a.m. documented, "No change. Talking to me and other residents. (Resident # 5) is calm and asking about his phone charger." This entry was initialed by CNA # 6. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/30/13 at 10:10 a.m. documented, "(Family member # 1) brought his laptop to him. I plugged it in for him and put his phone on the charger." This entry was initialed by CNA # 6. k. A Physician telephone order dated 12/30/13 at 4:00 p.m. documented, "1. (Discontinue) [MEDICATION NAME]. 2. Start [MEDICATION NAME] 4 (milligrams) (per mouth) (every) (hour of sleep)." l. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/30/13 at 4:10 p.m. documented, "Just got TV(television). Laying in bed watching TV now." This entry was initialed by CNA # 6. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/30/13 at 4:30 p.m. documented, "(Family member # 1) brought DVD player and I moved his bed at an angle." This entry was initialed by CNA # 6. The CNA 1:1 documentation (written on a Nurse's Notes form) dated 12/31/13 at 3:30 p.m. was the last 1:1 entry documented. m. A physician telephone order dated 12/31/13 at 10:30 p.m. documented, "(Discontinue) 1:1. (Continue) to monitor behavior." The Nurse's Notes dated 12/31/13 at 11:00 p.m. documented, "Alert and oriented (times) 4. Denies any thought of suicide or of harming others. Stated, 'I never meant any of that. I was just mad. You know me.' (Family member # 1)/POA (Power of Attorney) in (agreement). Order obtained to (discontinue) 1:1. POA aware." This entry was signed by the DON. n. Nurse's Notes dated 1/2/14 at 1:25 p.m. documented, "... (Alert and oriented times) 3. ... Resident had refused to let laundry move his belongings into his room. He stated to nurse that (Administrator) is not his boss and he will have her job. ..." This entry was signed by LPN # 3. o. A physician telephone order dated 1/3/14 documented, "(Discontinue) admit to unit as ordered." p. On 1/7/14 at 8:35 a.m. Family Member # 1 asked to speak with this surveyor. Family Member # 1 stated, "I'm (Resident # 5's) POA and (Family Member # 2) is his second POA." Family Member # 1 was asked, "Tell me why (Resident # 5) was moved to the closed unit." Family Member # 1 stated, "He went to the closed unit because he was throwing a hissy fit. He was threatening to harm himself and other employees and they didn't know if he would try to harm another resident. So they moved him to the closed unit to calm him down, get him out of the general population and did 1:1 with him. I wanted him to get a shot to calm him down and was told they couldn't do that." Family Member # 1 was asked, "How long was he there?" Family Member # 1 stated, "One week. He was on 1:1 from Saturday (12/28/13) and they stopped it on Wednesday (1/1/14) or Thursday (1/2/14) and then they moved him back to the open unit on Friday (1/3/14). He said they told him he was there because he was being punished and he even called the police because of it." Family Member # 1 was asked, "Before they moved him over there did they talk with you about the move?" Family Member # 1 stated, "Yes but not immediately. They did call me on Saturday, later in the day after he'd been moved. When (Family Member # 2) came up on Sunday (12/29/13) he (Resident #5) had crawled out of bed and she found him on the floor, face down and his arms were all twisted under him. I don't know if they tried to get him up or if he refused. ... They had fall mats on the floor." Family Member # 1 was asked, "Did you see (Resident # 5) when he was on the closed unit?" Family Member # 1 stated, "Yes and they wouldn't let him have any of his stuff." Family Member # 1 was asked, "Nothing?" Family Member # 1 stated, "On Sunday (12/29/13) they got his TV in there and I had his movies and electronic stuff in my office and all of his other stuff was in the laundry. I asked them to give him his stuff because his biggest fear is stuff getting stolen. I got a dolly on Wednesday (1/1/14) and moved all his stuff into his room. On Monday (12/30/13) they did move his clothes in and then was still 1:1. By Wednesday (1/1/14) I got the impression when the 1:1 had been stopped that they were not going to move him out of that room and that's when I got his stuff and moved it in myself. I threw a fit and he threw a fit on Friday (1/3/14) and that's when they moved him back." Family Member # 1 who was also the CDM (Certified Dietary Manager) was asked, "Who was working in the kitchen 12/28/13 for supper?" Family Member # 1/ CDM stated, "(Dietary Staff # 1). She called me and told me (Resident # 5) went into the kitchen and they asked him not to come into the kitchen. (Resident # 5) threw a fit and started throwing things." Family Member # 1/CDM was asked, "What time was this?" Family Member # 1/CDM stated, "After supper between 6:00 to 6:30 p.m. when (Dietary Staff # 1) called me I called his nurse and asked if he could get a shot or something to calm him down and they said they couldn't do that. I do know (Resident # 5) took his bed rails off when they got him to his room on the North hall and he started trying to hit the employees with the bed rails and he said he was going to kill himself. So they moved him to the closed unit because they feared for his safety. Then (Family Member # 2) came up and got upset with how she found him. I feel he does get mistreated. It's things like when they moved him back there and he asked for his DVD to be hooked to the TV up so he could watch movies. The CNA asked the weekend RN (Registered Nurse) and she said no that the CNA couldn't do that for (Resident # 5). The CNA went ahead and did it because (Resident # 5) wanted to watch a movie." Family Member # 1 was asked, "Was there any mention of when or what had to happen before (Resident # 5) could be moved off the South unit?" Family Member # 1 stated, "No." q. On 1/7/14 at 2:13 p.m. the Housekeeping /Laundry Supervisor was asked, "For resident room changes, who moves the resident's belongings?" The Housekeeping /Laundry Supervisor stated, "I do almost always

Based on record review and interview, the facility failed to ensure an injury of unknown origin was thoroughly investigated, reported to the Office of Long Term Care (OLTC) and other state agencies in accordance with state law and protection was provided to prevent further potential for abuse for 1 of 1 case mix resident (Resident #1) who sustained an injury of unknown origin while away from the facility and against medical advice. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who had left the facility against medical advice then returned to the nursing home with an injury of unknown origin and had the potential to affect 21 residents who have permission to go out on pass according to a list provided by the Administrator on 1/19/11. The facility was informed of the Immediate Jeopardy condition on 1/19/11 at 4:40 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minumum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/21/10 documented a Brief Interview for Mental Status (BIMS) score of 3 (0-7 indicates severely impaired) and required extensive to totally dependence on staff for activities of daily living. a. Nurses Notes dated 9/22/10 at 2:30 p.m. documented, "Res (resident) son @ (at) nurses desk requesting Res. medications stated, 'he was taking his mother out of here' directed son to Administrator Res is on m'care (Medicare) (and) previous Hx (history) of Res. son taking her in (and) out. son had Res outside (without) supervision (and) then left (with) mother after being advised it would be against medical advice. APS (Adult Protective Services) notified per Administrator." b. Nurses Notes dated 9/22/10 at 10:00 p.m. documented, "Resident has not returned to facility." c. physician's orders [REDACTED]. d. Nurses Notes dated 9/23/10 at 9:15 a.m. documented, "Res returned to facility via son. Awake, alert (and) oriented to person (and) place. Skin W/D (warm and dry) upon body assessment multiple bruises noted to Bilat (bilateral) forearms (and) hand - most old. A new bruise was noted below (right) shoulder approx (approximately) the size of a quarter. A newer bruise to (left) upper arm approx the size of a dollar coin. Multiple bruises to Bilat (lower) legs, discoloration (and) old wounds that are scabbed over, none of them new. Bright red blood, noted on a hand towel (and) paper towel Res had in panties between her legs. Vaginal (and) rectal assessment done. Only found redness. Order to send to (hospital) ER (emergency room ). APS has been called by Administrator prior to this event. Son was not notified of sending Res to ER. Awaiting res return." e. The hospital Emergency Department (ED) Note dated 9/23/10 at 9:34 a.m. documented, "History of Present Illness The patient is an [AGE] years old Female who presents with vaginal bleeding. Duration [MEDICATION NAME] pt (patient) checked out of nursing home yesterday by relative for overnight visit, upon return to nsh (nursing home) this am noted to have vaginal bleeding and some bruising. The onset was unknown. The course is unknown. Quality: bright red. ...Social history: Family/social situation: Nursing home resident. ...Physical Examination ...Vagina: deferred to women's crisis center... Diagnosis: [REDACTED]. f. Nurses Notes dated 9/23/10 1:00 p.m., documented, "Res returned from Emergency Rm. (no) new orders..." g. Social Progress Notes dated 9/23/10 documented, "On 9/22/10 Son came to nurses station (and) requested mothers medications, stated was taking her home, Resident's son was directed to Admin (Administrator) Res. on Medicare was advised that he would be taking her against medical advice, APS notified, Resident discharged from Medicare, son took! clothes still remain in closet. Resident has not returned to the facility" Social Progress Notes dated 9/23/10 documented, "Resident return to facility via son car." Social Progress Notes dated 9/23/10 documented, "Social note: Around 2:30 p.m. on 9/22/10 charge nurse reported to administrator that (Resident #1) son was discharging her home (with) him. I ask son what was going on. Son stated he was taking his mother home for a few days. I explained to the son that he could not cont (continue) to move his mother around. He got mad and walked off. I went to Resident Room and Resident was gone. (Registered Nurse) came to me and stated he had his mother in car and had left (with) her. I, Administrator, called APS hotline and reported this to them. APS stated that they would notify a caseworker. On 9/23/10 at 8:45 son brought (Resident #1) back to the facility. stated, (the son) that his mother was confused. Charge nurse on hall was completing a body audit. When the supervise (supervisor) asked me to come to resident room. Bruises were find (found), hand towel (and) paper towel was find (found) in panties between legs. Order received to send resident to ER. APS notified." h. Social Progress Notes dated 9/24/10 documented, "Son may visit (Resident #1) but may not take out of facility on pass or otherwise. If he attempts Admin. is to be notified, ASAP (As soon as possible)." i. Social Progress Notes dated 9/28/10 documented, "Son here, wanting to know how much notice he needed to give before he took her out of here. It was explained to him that APS was involved (and) he would need to consult (with) them." j. Social Progress Notes dated 10/5/10 documented, "...Spoke with APS contact which stated she is not under APS custody..." k. Nurses Notes dated 10/13/10 at 10:00 p.m. documented, "Residents son here to visit this eve..." l. Nurses Notes dated 12/7/10 (no time) documented, "Son came to the office and stated he was curious about something his mother told him a few days..." m. On 1/19/11 at 4:10 p.m., the Administrator was asked if there had been an investigation and report written of the incident and the Administrator stated, "No, I didn't. I didn't do it." The Administrator was asked if the resident was in APS custody and the Administrator stated "No." The Administrator was asked if the resident was under a 72 hour hold by APS. The Administrator stated, "Under a 72 hour hold and released and that if we had any more problems to call." n. On 1/19/11 at 4:25 p.m., the Administrator was asked if the son visited the resident and the Administrator stated, "Yes." The Administrator was asked if the son had restricted or supervised visitation and the Administrator stated, "No, he did not." The Administrator was asked if the incident was discussed with APS about their investigation and the Administrator stated, "No. They were going to put hold on her. It never went to court." The Administrator was asked if the hospital records were reviewed for a facility investigation and the Administrator stated, "No. I talked to someone at the women's crisis center." The Administrator was then asked who she had spoken to and the Administrator stated, "I don't know but they told me the rape kit was negative." The Administrator was asked if there were statements obtained for any of this and the Administrator stated, "No." The Administrator was asked if a copy of the rape kit documentation was obtained to review. The Administrator stated, "No, I didn't" o. On 1/19/11 at 5:55 p.m., the Administrator was asked if the son still visited the resident and the Administrator stated, "Yes about 2 times weekly." The Administrator was asked when the son last visited and the Administrator stated, "I don't know. He comes in daytime." The Administrator was asked if the son's visits were documented and the Administrator stated, "No. He has no restrictions to his visits. No, his visits are not supervised." The Administrator was then asked if there was an investigation and the Administrator stated, "No when we found the vaginal bleeding we sent her to the hospital. I was concerned that she had been raped." The Administrator was asked when the son began visiting again and the Administrator stated, "I don't know a date." The Administrator was asked if the son visited resident with supervision and the Administrator stated, "No. He had unsupervised visits with resident." p. On 1/19/11 at 10:50 p.m., the Administrator was asked if injuries of unknown origin were to be investigated and the Administrator stated, "Yes." The Administrator was asked if she was present when the resident returned to the facility and the Administrator stated, "Yes." The Administrator was then asked if an Incident and Accident report and investigation was done concerning the resident and the Administrator stated, "No." q. As of 1/19/11 at 10:50 p.m., there was no additional documentation available from the Emergency Department Note or women's crisis center. 2. The Immediate Jeopardy was removed and scope/severity reduced to a "E" on 1/19/11 at 8:40 p.m. when the facility implemented the following Plan of Removal: a. On 1/19/11 at 4:52 p.m., Licensed Practical Nurse (LPN) Supervisor is monitoring resident one-on-one to ensure son does not visit resident unsupervised b. On 1/19/11 in-service of all current staff members on duty was started regarding Abuse Investigation and Reporting Policy and Procedure and recognizing signs and symptoms of abuse. How and to whom incidents of mistreatment, neglect or abuse should be reported. All staff in-serviced on supervised visits. Son will be on scheduled supervision visits. Scheduled visitations will be monitored and scheduled through the Social Service Director and/or Designee. Staff will be in-serviced that if resident received any visitors that the charge nurse will notify Administrator or Designee immediately. All staff on medical leave or vacation will be in-serviced before returning to work. c. On 1/19/11 at 5:15 p.m. examination of resident was completed by the Director of Nursing with no negative findings. d. On 1/19/11 a note was placed in the front of the chart stating son will have scheduled supervised visits and visits will be supervised by Social Service Director or Designee. Social Service will notify son of scheduled visits e. On 1/19/11 at 5:30 p.m., Business Office Manager spoke with son regarding Visitation with his mother. Business Office Manager explained to son that when he comes to the facility his visits will be supervised. Son did agree to these arrangements. f. On 1/19/11 at 5:30 p.m.. the physician discontinued the one-on-one Supervision per the physician order [REDACTED]. g. On 1/19/11 Social Service Director or Designee will monitor daily to ensure Son does not visit resident without supervisor by checking with charge nurses daily X (times) 3 weeks and 2 Xs weekly thereafter. All findings will be reported to the Q & A meeting monthly.

Based on record review and interview, the facility failed to ensure their abuse policy and procedure was implemented as evidenced by the facility's failure to ensure an injury of unknown origin was thoroughly investigated, reported to the Office of Long Term Care (OLTC) and other state agencies in accordance with state law and protection was provided to prevent further potential for abuse for 1 of 1 case mix resident (Resident #1) who sustained an injury of unknown origin while away from the facility against medical advice. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who had left the facility against medical advice then returned to the nursing home with an injury of unknown origin and had the potential to affect 21 residents who have permission to go out on pass according to a list provided by the Administrator on 1/19/11. The facility was informed of the Immediate Jeopardy condition on 1/19/11 at 4:40 p.m. The findings are: 1. The Abuse Investigation and Reporting Policy & Procedures received from the facility on 1/19/11 documented, "...Policy Statement: All reports of resident neglect and abuse, including injuries of unknown origin, shall be promptly reported and investigated by Facility management. All incidents of alleged or suspected resident mistreatment, neglect or abuse, including injuries of unknown source ...must be reported immediately to the Administrator or the Administrative Designee by a Facility employee ...The Administrator or Administrative Designee will complete an Investigation Report and submit a copy to OLTC within five (5) days of the incident's discovery, or as otherwise mandated by law. Protecting Residents from further incidents and preventing further occurrences during investigation ...If it seems that if a resident has been injured by an unidentified person, the nursing staff will be instructed to conduct close observation of employees, residents, and visitors as required by the circumstances ...Dealing with resident, family member or visitor suspected of mistreatment of [REDACTED]. (See Section 111) - 111. IDENTIFYING, INVESTIGATING, & REPORTING: Policy Statement: All reports of resident neglect and abuse, including injuries of unknown origin, shall be promptly reported and investigated by Facility management. All incidents of alleged or suspected resident mistreatment, neglect, or abuse including injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator or the Administrative Designee by a Facility employee. The Administrative Designee will conduct an immediate investigation of all alleged, suspicious, or actual incidents of abuse, including injuries of unknown origin; neglect or misappropriation of property. The investigation should determine whether an incident has occurred, to what extent the resident has been mistreated, by whom, and the measures needed to protect residents from further Incidents. The facility Administrator or designee is responsible for the investigation. The identification and investigation process will include interviews with appropriate persons, including: a) Facility employees; b) The resident; c) The resident's roommate; d) Other residents; e) Family members; f) Visitors in the Facility; or g) Other persons who may have knowledge of the incident. The DON (Director of Nurses) is responsible for assessing residents who are the victims of alleged, suspected, or actual mistreatment. The resident's Medical Record and Overall Care Plan will also be reviewed. The resident will be re-assessed as frequently as required by the circumstances. If physical abuse is alleged or suspected, vital signs will be taken and a skin audit will be completed by a licensed nurse. Residents will be referred for further medical treatment, if circumstances indicate. The resident's Medical Record will contain documentation of objective clinical findings. All alleged or suspected incidents must also be reported according to state and federal law. The following persons or entities may be notified by the Charge Nurse on duty at the time of the incident: a) Administrator; b) OLTC; c) State, county, or city police; d) Physician; e) Family members; f) Ombudsman; g) Coroner, if death has occurred; (and) h) Appropriate licensing boards. Reports are made according to current state and federal law. Any person in the Facility suspecting the Charge Nurse, Director of Nursing, or the Facility Administrator of abuse, or failing to report abuse, is encouraged To notify ...(President or Regional Managers). An Incident and Accident Report form will be completed by the Charge Nurse. Administrator or Administrative Designee will complete an Investigation Report and submit a copy to the OLTC within five (5) days of the incident's discovery, or as otherwise mandated by law. If the alleged or suspected abuser is still in the Facility, he or she will be asked to leave the resident's room, or area of the Facility where the resident is located. If the person will not leave the area, then one or two staff persons will also stay in the area until law enforcement officials arrive. Persons suspected of abuse will not be allowed unsupervised visits with the residents. 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minumum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/21/10 documented a Brief Interview for Mental Status (BIMS) score of 3 (0-7 indicates severely impaired) and required extensive to totally dependent on staff for activities of daily living. a. Nurses Notes dated 9/22/10 at 2:30 p.m. documented, "Res (resident) son @ (at) nurses desk requesting Res. medications stated, 'he was taking his mother out of here' directed son to Administrator Res is on m'care (Medicare) (and) previous Hx (history) of Res. son taking her in (and) out. son had Res outside (without) supervision (and) then left (with) mother after being advised it would be against medical advice. APS (Adult Protective Services) notified per Administrator." b. Nurses Notes dated 9/22/10 at 10:00 p.m. documented, "Resident has not returned to facility." c. physician's orders [REDACTED]. d. Nurses Notes dated 9/23/10 at 9:15 a.m. documented, "Res returned to facility via son. Awake, alert (and) oriented to person (and) place. Skin W/D (warm and dry) upon body assessment multiple bruises noted to Bilat (bilateral) forearms (and) hand - most old. A new bruise was noted below (right) shoulder approx (approximately) the size of a quarter. A newer bruise to (left) upper arm approx the size of a dollar coin. Multiple bruises to Bilat (lower) legs, discoloration (and) old wounds that are scabbed over, none of them new. Bright red blood, noted on a hand towel (and) paper towel Res had in panties between her legs. Vaginal (and) rectal assessment done. Only found redness. Order to send to (hospital) ER (emergency room ). APS has been called by Administrator prior to this event. Son was not notified of sending Res to ER. Awaiting res return." e. The hospital Emergency Department (ED) Note dated 9/23/10 at 9:34 a.m. documented, "History of Present Illness The patient is an [AGE] years old Female who presents with vaginal bleeding. Duration [MEDICATION NAME] pt (patient) checked out of nursing home yesterday by relative for overnight visit, upon return to nsh (nursing home) this am noted to have vaginal bleeding and some bruising. The onset was unknown. The course is unknown. Quality: bright red. ...Social history: Family/social situation: Nursing home resident. ...Physical Examination ...Vagina: deferred to women's crisis center... Diagnosis: [REDACTED]. f. Nurses Notes dated 9/23/10 1:00 p.m., documented, "Res returned from Emergency Rm. (no) new orders..." g. Social Progress Notes dated 9/23/10 documented, "On 9/22/10 Son came to nurses station (and) requested mothers medications, stated was taking her home, Resident's son was directed to Admin (Administrator) Res. on Medicare was advised that he would be taking her against medical advice, APS notified, Resident discharged from Medicare, son took! clothes still remain in closet. Resident has not returned to the facility" Social Progress Notes dated 9/23/10 documented, "Resident return to facility via son car." Social Progress Notes dated 9/23/10 documented, "Social note: Around 2:30 p.m. on 9/22/10 charge nurse reported to administrator that (Resident #1) son was discharging her home (with) him. I ask son what was going on. Son stated he was taking his mother home for a few days. I explained to the son that he could not cont (continue) to move his mother around. He got mad and walked off. I went to Resident Room and Resident was gone. (Registered Nurse) came to me and stated he had his mother in car and had left (with) her. I, Administrator, called APS hotline and reported this to them. APS stated that they would notify a caseworker. On 9/23/10 at 8:45 son brought (Resident #1) back to the facility. stated, (the son) that his mother was confused. Charge nurse on hall was completing a body audit. When the supervise (supervisor) asked me to come to resident room. Bruises were find (found), hand towel (and) paper towel was find (found) in panties between legs. Order received to send resident to ER. APS notified." h. Social Progress Notes dated 9/24/10 documented, "Son may visit (Resident #1) but may not take out of facility on pass or otherwise. If he attempts Admin. is to be notified, ASAP (As soon as possible)." i. Social Progress Notes dated 9/28/10 documented, "Son here, wanting to know how much notice he needed to give before he took her out of here. It was explained to him that APS was involved (and) he would need to consult (with) them." j. Social Progress Notes dated 10/5/10 documented, "...Spoke with APS contact which stated she is not under APS custody..." k. Nurses Notes dated 10/13/10 at 10:00 p.m. documented, "Residents son here to visit this eve..." l. Nurses Notes dated 12/7/10 (no time) documented, "Son came to the office and stated he was curious about something his mother told him a few days..." m. On 1/19/11 at 4:10 p.m., the Administrator was asked if there had been an investigation and report written of the incident and the Administrator stated, "No, I didn't. I didn't do it." The Administrator was asked if the resident was in APS custody and the Administrator stated "No." The Administrator was asked if the resident was under a 72 hour hold by APS. The Administrator stated, "Under a 72 hour hold and released and that if we had any more problems to call." n. On 1/19/11 at 4:25 p.m., the Administrator was asked if the son visited the resident and the Administrator stated, "Yes." The Administrator was asked if the son had restricted or supervised visitation and the Administrator stated, "No, he did not." The Administrator was asked if the incident was discussed with APS about their investigation and the Administrator stated, "No. They were going to put hold on her. It never went to court." The Administrator was asked if the hospital records were reviewed for a facility investigation and the Administrator stated, "No. I talked to someone at the women's crisis center." The Administrator was then asked who she had spoken to and the Administrator stated, "I don't know but they told me the rape kit was negative." The Administrator was asked if there were statements obtained for any of this and the Administrator stated, "No." The Administrator was asked if a copy of the rape kit documentation was obtained to review. The Administrator stated, "No, I didn't" o. On 1/19/11 at 5:55 p.m., the Administrator was asked if the son still visited the resident and the Administrator stated, "Yes about 2 times weekly." The Administrator was asked when the son last visited and the Administrator stated, "I don't know. He comes in daytime." The Administrator was asked if the son's visits were documented and the Administrator stated, "No. He has no restrictions to his visits. No, his visits are not supervised." The Administrator was then asked if there was an investigation and the Administrator stated, "No when we found the vaginal bleeding we sent her to the hospital. I was concerned that she had been raped." The Administrator was asked when the son began visiting again and the Administrator stated, "I don't know a date." The Administrator was asked if the son visited resident with supervision and the Administrator stated, "No. He had unsupervised visits with resident." p. On 1/19/11 at 10:50 p.m., the Administrator was asked if injuries of unknown origin were to be investigated and the Administrator stated, "Yes." The Administrator was asked if she was present when the resident returned to the facility and the Administrator stated, "Yes." The Administrator was then asked if an Incident and Accident report and investigation was done concerning the resident and the Administrator stated, "No." q. As of 1/19/11 at 10:50 p.m., there was no additional documentation available from the Emergency Department Note or women's crisis center. 3. The Immediate Jeopardy was removed and scope/severity reduced to a "E" on 1/19/11 at 8:40 p.m. when the facility implemented the following Plan of Removal: a. On 1/19/11 at 4:52 p.m., Licensed Practical Nurse (LPN) supervisor is monitoring resident one-on-one to ensure son does not visit resident unsupervised b. On 1/19/11 in-service of all current staff members on duty was started regarding Abuse Investigation and Reporting Policy and Procedure and recognizing signs and symptoms of abuse. How and to whom incidents of mistreatment, neglect or abuse should be reported. All staff in-serviced on supervised visits. Son will be on scheduled supervision visits. Scheduled visitations will be monitored and scheduled through the Social Service Director and/or Designee. Staff will be in-serviced that if resident received any visitors that the charge nurse will notify Administrator or Designee immediately. All staff on medical leave or vacation will be in-serviced before returning to work. c. On 1/19/11 at 5:15 p.m. examination of resident was completed by the Director of Nursing with no negative findings. d. On 1/19/11 a note was placed in the front of the chart stating son will have scheduled supervised visits and visits will be supervised by Social Service Director or Designee. Social Service will notify son of scheduled visits e. On 1/19/11 at 5:30 p.m., Business Office Manager spoke with son regarding Visitation with his mother. Business Office Manager explained to son that when he comes to the facility his visits will be supervised. Son did agree to these arrangements. f. On 1/19/11 at 5:30 p.m.. the physician discontinued the one-on-one Supervision per the physician order [REDACTED]. g. On 1/19/11 Social Service Director or Designee will monitor daily to ensure Son does not visit resident without supervisor by checking with charge nurses daily X (times) 3 weeks and 2 Xs weekly thereafter. All findings will be reported to the Q & A meeting monthly.

Based on record review and interview, the facility Administration failed to ensure that facility policies and procedures were implemented regarding the investigation of injuries of unknown injury, reporting potential family member to resident abuse, and protecting from further potential abuse for 1 (Resident #1) when the resident left the facility then returned to the facility's care with injuries of unknown origin. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who had left then returned to the facility with injuries of unknown origin and had a potential to affect 21 residents that had left and returned to the facility for care as documented by the Administrator on 1/19/11. The facility was informed of the Immediate Jeopardy condition on 1/19/11 at 4:40 p.m. The findings are: 1. The Job Description of the Administrator received on 1/19/11 documented, " ...Position Summary: The Administrator ...is responsible for providing leadership staff development, and management of key services in accordance with policies and procedures and current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to ensure each resident receives the necessary nursing, medical and social services to attain and maintain the highest possible mental and physical functional status ...Inspects the facility routinely to assure that established policies and procedures are being implemented and followed ...Must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies and procedures, etc .necessary for providing quality care and maintaining a sound operation. Must be able to communicate policies, procedures, regulations, reports, etc. to staff, residents, family members, visitors and government agencies/personnel. Must possess the ability to seek out new methods and principles and be willing to incorporate them into existing. " 2. The Abuse Investigation and Reporting Policy & Procedures received from the facility on 1/19/11 documented, "...Policy Statement: All reports of resident neglect and abuse, including injuries of unknown origin, shall be promptly reported and investigated by Facility management. All incidents of alleged or suspected resident mistreatment, neglect or abuse, including injuries of unknown source ...must be reported immediately to the Administrator or the Administrative Designee by a Facility employee ...The Administrator or Administrative Designee will complete an Investigation Report and submit a copy to OLTC within five (5) days of the incident's discovery, or as otherwise mandated by law. Protecting Residents from further incidents and preventing further occurrences during investigation ...If it seems that if a resident has been injured by an unidentified person, the nursing staff will be instructed to conduct close observation of employees, residents, and visitors as required by the circumstances ...Dealing with resident, family member or visitor suspected of mistreatment of [REDACTED]. (See Section 111) - 111. IDENTIFYING, INVESTIGATING, & REPORTING: Policy Statement: All reports of resident neglect and abuse, including injuries of unknown origin, shall be promptly reported and investigated by Facility management. All incidents of alleged or suspected resident mistreatment, neglect, or abuse including injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator or the Administrative Designee by a Facility employee. The Administrative Designee will conduct an immediate investigation of all alleged, suspicious, or actual incidents of abuse, including injuries of unknown origin; neglect or misappropriation of property. The investigation should determine whether an incident has occurred, to what extent the resident has been mistreated, by whom, and the measures needed to protect residents from further Incidents. The facility Administrator or designee is responsible for the investigation. The identification and investigation process will include interviews with appropriate persons, including: a) Facility employees; b) The resident; c) The resident's roommate; d) Other residents; e) Family members; f) Visitors in the Facility; or g) Other persons who may have knowledge of the incident. The DON (Director of Nurses) is responsible for assessing residents who are the victims of alleged, suspected, or actual mistreatment. The resident's Medical Record and Overall Care Plan will also be reviewed. The resident will be re-assessed as frequently as required by the circumstances. If physical abuse is alleged or suspected, vital signs will be taken and a skin audit will be completed by a licensed nurse. Residents will be referred for further medical treatment, if circumstances indicate. The resident's Medical Record will contain documentation of objective clinical findings. All alleged or suspected incidents must also be reported according to state and federal law. The following persons or entities may be notified by the Charge Nurse on duty at the time of the incident: a) Administrator; b) OLTC; c) State, county, or city police; d) Physician; e) Family members; f) Ombudsman; g) Coroner, if death has occurred; (and) h) Appropriate licensing boards. Reports are made according to current state and federal law. Any person in the Facility suspecting the Charge Nurse, Director of Nursing, or the Facility Administrator of abuse, or failing to report abuse, is encouraged To notify ...(President or Regional Managers). An Incident and Accident Report form will be completed by the Charge Nurse. Administrator or Administrative Designee will complete an Investigation Report and submit a copy to the OLTC within five (5) days of the incident's discovery, or as otherwise mandated by law. If the alleged or suspected abuser is still in the Facility, he or she will be asked to leave the resident's room, or area of the Facility where the resident is located. If the person will not leave the area, then one or two staff persons will also stay in the area until law enforcement officials arrive. Persons suspected of abuse will not be allowed unsupervised visits with the residents. 3. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minumum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/21/10 documented a Brief Interview for Mental Status (BIMS) score of 3 (0-7 indicates severely impaired) and required extensive to totally dependent on staff for activities of daily living. a. Nurses Notes dated 9/22/10 at 2:30 p.m. documented, "Res (resident) son @ (at) nurses desk requesting Res. medications stated, 'he was taking his mother out of here' directed son to Administrator Res is on m'care (Medicare) (and) previous Hx (history) of Res. son taking her in (and) out. son had Res outside (without) supervision (and) then left (with) mother after being advised it would be against medical advice. APS (Adult Protective Services) notified per Administrator." b. Nurses Notes dated 9/22/10 at 10:00 p.m. documented, "Resident has not returned to facility." c. physician's orders [REDACTED]. d. Nurses Notes dated 9/23/10 at 9:15 a.m. documented, "Res returned to facility via son. Awake, alert (and) oriented to person (and) place. Skin W/D (warm and dry) upon body assessment multiple bruises noted to Bilat (bilateral) forearms (and) hand - most old. A new bruise was noted below (right) shoulder approx (approximately) the size of a quarter. A newer bruise to (left) upper arm approx the size of a dollar coin. Multiple bruises to Bilat (lower) legs, discoloration (and) old wounds that are scabbed over, none of them new. Bright red blood, noted on a hand towel (and) paper towel Res had in panties between her legs. Vaginal (and) rectal assessment done. Only found redness. Order to send to (hospital) ER (emergency room ). APS has been called by Administrator prior to this event. Son was not notified of sending Res to ER. Awaiting res return." e. The hospital Emergency Department (ED) Note dated 9/23/10 at 9:34 a.m. documented, "History of Present Illness The patient is an [AGE] years old Female who presents with vaginal bleeding. Duration [MEDICATION NAME] pt (patient) checked out of nursing home yesterday by relative for overnight visit, upon return to nsh (nursing home) this am noted to have vaginal bleeding and some bruising. The onset was unknown. The course is unknown. Quality: bright red. ...Social history: Family/social situation: Nursing home resident. ...Physical Examination ...Vagina: deferred to women's crisis center... Diagnosis: [REDACTED]. f. Nurses Notes dated 9/23/10 1:00 p.m., documented, "Res returned from Emergency Rm. (no) new orders..." g. Social Progress Notes dated 9/23/10 documented, "On 9/22/10 Son came to nurses station (and) requested mothers medications, stated was taking her home, Resident's son was directed to Admin (Administrator) Res. on Medicare was advised that he would be taking her against medical advice, APS notified, Resident discharged from Medicare, son took! clothes still remain in closet. Resident has not returned to the facility" Social Progress Notes dated 9/23/10 documented, "Resident return to facility via son car." Social Progress Notes dated 9/23/10 documented, "Social note: Around 2:30 p.m. on 9/22/10 charge nurse reported to administrator that (Resident #1) son was discharging her home (with) him. I ask son what was going on. Son stated he was taking his mother home for a few days. I explained to the son that he could not cont (continue) to move his mother around. He got mad and walked off. I went to Resident Room and Resident was gone. (Registered Nurse) came to me and stated he had his mother in car and had left (with) her. I, Administrator, called APS hotline and reported this to them. APS stated that they would notify a caseworker. On 9/23/10 at 8:45 son brought (Resident #1) back to the facility. stated, (the son) that his mother was confused. Charge nurse on hall was completing a body audit. When the supervise (supervisor) asked me to come to resident room. Bruises were find (found), hand towel (and) paper towel was find (found) in panties between legs. Order received to send resident to ER. APS notified." h. Social Progress Notes dated 9/24/10 documented, "Son may visit (Resident #1) but may not take out of facility on pass or otherwise. If he attempts Admin. is to be notified, ASAP (As soon as possible)." i. Social Progress Notes dated 9/28/10 documented, "Son here, wanting to know how much notice he needed to give before he took her out of here. It was explained to him that APS was involved (and) he would need to consult (with) them." j. Social Progress Notes dated 10/5/10 documented, "...Spoke with APS contact which stated she is not under APS custody..." k. Nurses Notes dated 10/13/10 at 10:00 p.m. documented, "Residents son here to visit this eve..." l. Nurses Notes dated 12/7/10 (no time) documented, "Son came to the office and stated he was curious about something his mother told him a few days..." m. On 1/19/11 at 4:10 p.m., the Administrator was asked if there had been an investigation and report written of the incident and the Administrator stated, "No, I didn't. I didn't do it." The Administrator was asked if the resident was in APS custody and the Administrator stated "No." The Administrator was asked if the resident was under a 72 hour hold by APS. The Administrator stated, "Under a 72 hour hold and released and that if we had any more problems to call." n. On 1/19/11 at 4:25 p.m., the Administrator was asked if the son visited the resident and the Administrator stated, "Yes." The Administrator was asked if the son had restricted or supervised visitation and the Administrator stated, "No, he did not." The Administrator was asked if the incident was discussed with APS about their investigation and the Administrator stated, "No. They were going to put hold on her. It never went to court." The Administrator was asked if the hospital records were reviewed for a facility investigation and the Administrator stated, "No. I talked to someone at the women's crisis center." The Administrator was then asked who she had spoken to and the Administrator stated, "I don't know but they told me the rape kit was negative." The Administrator was asked if there were statements obtained for any of this and the Administrator stated, "No." The Administrator was asked if a copy of the rape kit documentation was obtained to review. The Administrator stated, "No, I didn't" o. On 1/19/11 at 5:55 p.m., the Administrator was asked if the son still visited the resident and the Administrator stated, "Yes about 2 times weekly." The Administrator was asked when the son last visited and the Administrator stated, "I don't know. He comes in daytime." The Administrator was asked if the son's visits were documented and the Administrator stated, "No. He has no restrictions to his visits. No, his visits are not supervised." The Administrator was then asked if there was an investigation and the Administrator stated, "No when we found the vaginal bleeding we sent her to the hospital. I was concerned that she had been raped." The Administrator was asked when the son began visiting again and the Administrator stated, "I don't know a date." The Administrator was asked if the son visited resident with supervision and the Administrator stated, "No. He had unsupervised visits with resident." p. On 1/19/11 at 10:50 p.m. the Administrator was asked who was responsible to ensure that unknown origin incidents are investigated and reported and the Administrator stated, "Me." The Administrator was asked if injuries of unknown origin are to be investigated and the Administrator stated "Yes." The Administrator was asked if had been present when the resident returned and the Administrator stated, "Yes." The Administrator was asked if an Incident and Accident (I & A) report was to be done. The Administrator stated "Yes." The Administrator was asked if an I & A report was done when Resident #1 returned to the facility and the Administrator stated, "No." The Administrator was then asked who had the responsibility to ensure residents are protected following an incident and during an investigation. The Administrator stated, "It's mine." q. As of 1/19/11 at 10:50 p.m., there was no additional documentation available from the Emergency Department Note or women's crisis center. 4. The Immediate Jeopardy was removed and scope/severity scope/severity reduced to a "E" on 1/19/11 at 8:40 p.m., when the facility implemented the following Plan of Removal: a. On 1/19/11 at 4:52 p.m., Licensed Practical Nurse (LPN) supervisor is monitoring resident one-on-one to ensure son does not visit resident unsupervised b. On 1/19/11 in-service of all current staff members on duty was started regarding Abuse Investigation and Reporting Policy and Procedure and recognizing signs and symptoms of abuse. How and to whom incidents of mistreatment, neglect or abuse should be reported. All staff in-serviced on supervised visits. Son will be on scheduled supervision visits. Scheduled visitations will be monitored and scheduled through the Social Service Director and/or Designee. Staff will be in-serviced that if resident received any visitors that the charge nurse will notify Administrator or Designee immediately. All staff on medical leave or vacation will be in-serviced before returning to work. c. On 1/19/11 at 5:15 p.m. examination of resident was completed by the Director of Nursing with no negative findings. d. On 1/19/11 a note was placed in the front of the chart stating son will have scheduled supervised visits and visits will be supervised by Social Service Director or Designee. Social Service will notify son of scheduled visits e. On 1/19/11 at 5:30 p.m., Business Office Manager spoke with son regarding Visitation with his mother. Business Office Manager explained to son that when he comes to the facility his visits will be supervised. Son did agree to these arrangements. f. On 1/19/11 at 5:30 p.m.. the physician discontinued the one-on-one Supervision per the physician order [REDACTED]. g. On 1/19/11 Social Service Director or Designee will monitor daily to ensure Son does not visit resident without supervisor by checking with charge nurses daily X (times) 3 weeks and 2 Xs weekly thereafter. All findings will be reported to the Q & A meeting monthly.

Complaint # was substantiated, all or part, in these findings. Based on record review and interview, the facility failed to ensure the correct doses of sliding scale insulin were administered as ordered by the physician for 2 (Resident #1 and 4) of 4 case mix residents (Resident #1-4) who had a physician order [REDACTED]. 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making and had received injections in the last 7 days. a. A physician order [REDACTED].=2U) (171-210=3U) (211-250=5U) (251-290=6U) (291-330=7U) (331-360=8U) >(greater than) 360 Give 9U and notify MD (medical doctor)." b. The care plan updated on 8/10/10 documented, "...monitor for signs of ketoacidosis: unusual thirst, polyuria, extreme elevated blood glucose levels... Notify MD per parameters of CBGS." c. The August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 1) On 8/10/10 at 4:00 p.m., the CBGS was 188 and the resident was administered 8U of insulin. According to the sliding scale the resident should have received 3U. 2) On 8/19/10 at 4:00 p.m., the CBGS was 383 and the resident was administered 8U insulin. According to the sliding scale the resident should have received 9U. 3) On 8/20/10 at 4:00 p.m., the CBGS was 388 and the resident received 8U insulin. According to the sliding scale the resident should have received 9U. d. Nurses' notes dated 8/21/10 documented, "...5:40 a.m. CBG X (times) 3 all read 'Hi' ...continues with projectile vomiting. (physician) notified new order received to send to ER (emergency room )..." e. The history and physical from the hospital dated 8/21/10 documented, "...Assessment and Plan: 1. The patient is a [AGE] year old gentleman who presents with diabetic ketoacidosis. We will admit, put him on an insulin drip and aggressive IV (intravenous) fluid hydration..." 2. Resident #4 had [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] and did not have an MDS available for review. a. A physician order [REDACTED].=2U) (171-210=3U) (211-250=5U) (251-290=6U) (291-330=7U) (331-360=8U) >360=9U and notify MD." b. The September 2010 MAR indicated [REDACTED] 1) On 9/6/10 at 4:30 p.m., the CBGS was 133 and the resident received 3U. According to the sliding scale the resident should have received 2U. 2) On 9/07/09 at 4:30 p.m., the CBGS was 324 and the resident received 8U. According to the sliding scale the resident should have received 7U. 3. On 9/9/10 at 1:30 p.m., the Director of Nursing was asked about the medication errors and she stated, "...I asked the LPN (Licensed Practical Nurse) ...she admitted she had given the wrong insulin dose. We have completed medication error reports and are in the process of inservicing..."