Every finding on record at The Springs Batesville

Based on observation, record review and interview, the facility failed to ensure meals were served according to the planned written menu to meet the nutritional needs of the residents for one of one meal observed. The findings include: During an observation and interview on 08/25/2025 at 12:14 PM, this surveyor observed Dietary [NAME] (DC) #1 use a #8 scoop (4 ounces) to serve a single portion of regular ham, potato and cheese casserole, instead of an eight-ounce (oz) ladle which was equal to a cup, as per the menu. DC #1 stated she thought #8 scoop was 8 oz. During an observation and interview on 08/25/2025 at 12:30 PM, this surveyor observed DC #1 use a #8 scoop to scoop and serve a single portion of mechanical soft ham, potato and cheese casserole, instead of 8 oz ladle which was equal to a cup, as per the menu. DC #1 stated she thought #8 scoop was 8 oz. Review of the Noon Meal Menu indicated the residents on regular diets, mechanical soft diets, and residents on pureed diets were to receive one cup (8 oz) of ham, potatoes and cheese casserole.

Based on observation, interview and facility policy review, the facility failed to ensure the ice machine was maintained in a sanitary manner; expired food items were promptly removed or discarded on or before the expiration or use by date, that dietary staff washed their hands between dirty and clean equipment, and hot food items were maintained at required temperature for one of one meal observed. The findings include: During an observation and interview on 08/25/2025 at 10:43 AM, Dietary [NAME] (DC) #1 wore gloves on her hands while she picked up a box of plastic wrap from under the food preparation counter and placed it on the counter, contaminating her gloves. Without changing her gloves or washing her hands, DC #1 then used the same contaminated glove to pick up grilled cheese sandwiches and placed them into a pan to be served to the residents for lunch. DC #1 stated she should have removed the gloves and washed her hands after touching the plastic wrap box. During an observation and interview on 08/25/2025 at 10:51 AM, Dietary Aide (DA) #2 wore gloves on her hands while she opened the refrigerator and removed a clear bag that contained slices of cheese and placed it on the counter. Without changing gloves or washing her hands, DA #2 used her contaminated gloved hand to remove slices of cheese and placed them into a bowl to be served to the residents. During an observation and interview on 08/25/2025 at 10:53 AM, the ice machine in the kitchen had wet black residue underneath the panel where ice that sits in the ice collector touches. The Assistant Dietary Manager (ADM) stated that maintenance cleans it every 3 days. The ADM stated that the Certified Nursing Assistants used the ice for water pitchers in the residents' rooms. The ADM confirmed that the ice machine was dirty, with wet black residue. The Assistant Maintenance Man stated he cleaned the ice machine every week but has not cleaned the area where the residue was observed. During an observation and interview on 08/25/2025 at 10:57 AM, the ice holder, on the wall by the ice machine, had wet brownish residue at the bottom of it, and the ice scoop was resting on it. The ADM confirmed the scoop holder was dirty and had brownish residue and that the kitchen used it for the beverages served to the residents. During an observation and interview on 08/25/2025 at 11:19 AM, there were nineteen 24-ounce boxes of nectar thickened water on a shelf in the storage room, which had an expiration date of 08/05/2025. The ADM stated that all nineteen boxes of nectar thickened water were expired, and she would discard them. During an observation and interview on 08/25/2025 at 11:38 AM, the temperature of the food items on the steam table in the kitchen, when checked and read by ADM resulted as: hamburger patties 103 degrees Fahrenheit. The above meat item was not reheated before they were served to the residents who requested it. A review of a facility policy titled Food and Nutrition Services Quick Resource Tool: QRT Hand Washing indicated that it's important to wash your hands before starting to work with food, utensils, or equipment and as often as needed during food preparation and when changing tasks. A review of a facility policy titled Sanitation of ice scoop policy indicated that that the ice scoop shall be sanitized daily by dietary.

Based on record review and interview, the facility failed to ensure staff followed the Care Plan of a resident who was at risk for falls, as evidenced by intervention of a fall mat not being on the floor beside resident's bed to prevent injury for 1 (Resident # 1) of 3 sampled residents. The findings are: A review of an Admission Record indicated the facility admitted Resident #1 with diagnoses that included dementia with behavioral disturbances, restlessness and agitation, atrial fibrillation [heart condition where the heart beats rapidly and the upper and lower chambers beat out of sync causing poor blood flow], hypertension [high blood pressure] and history of falling. Review of an admission Minimum Data Set (MDS) with an ARD dated 03/21/24, revealed Resident #1 had a Staff Assessment for Mental Status (SAMS) which indicated the resident was severely impaired for their daily decision making. Review of Resident #1's Care Plan initiated 03/15/2024, revealed Resident #1 was at risk for falls r/t (related/to) weakness, muscle wasting and atrophy, impulsivity, Alzheimer's disease, dementia, seizure activity, restlessness and agitation, will roll out of bed onto floor, and was an unavoidable fall risk. Interventions included: a fall mat next to bed. Review of a Fall assessment dated [DATE], revealed Resident #1 had a score of 9, where summary of fall risk indicated a score of 10 or higher was considered At Risk. Review of a Fall assessment dated [DATE], revealed Resident #1 had a score of 9, where summary of fall risk indicated a score of 10 or higher was considered At Risk. Review of a Fall assessment dated [DATE], revealed Resident #1 had a score of 7, where summary of fall risk indicated a score of 10 or higher was considered At Risk. A review of a Nsg (Nursing) I&A (Incident & Accident) Note dated 11/13/2024 at 3:52 PM, revealed, Incident Description: A nurse walking by the room heard the resident moaning and looked into room and saw the resident's upper torso was on the floor with the forehead on the floor and legs still on the bed. There was no fall mat beside the bed. Immediate Intervention (to prevent reoccurrence): assisted from the floor to the bed and assessed for injuries with a red mark to left side of forehead noted, fall mat placed beside bed. During an interview on 02/05/2025 at 11:30 AM, the Director of Nursing (DON) said if a resident was at risk for falls, and was care planned for a fall mat beside the bed, then there should be a fall mat beside the bed. The DON stated she was familiar with Resident #1 and there had been a fall mat beside Resident #1's bed at all times. Review of a facility policy titled Care Plans, Comprehensive Person-Centered revised March 2022, indicated The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to properly transfer a resident using a mechanical lift and failed to investigate and educate to prevent possible injury for one (Resident #2) sampled resident who was transferred via mechanical lift. The findings are: Review of an electronic Medical Diagnosis Chart revealed Resident #2 had a diagnosis of paraplegia. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/19/2024 indicated Resident #2 understands and is understood, had a Brief interview of Mental Status (BIMS) score of 14 (13-15 cognitively intact), ambulated via wheelchair, and had no falls since their last assessment. Review of Resident #2's Care Plan showed the resident required a mechanical lift with assistance of 2 staff members for transfers. Review of Resident #2's Electronic Medical Record (EMR) did not document a fall on 06/10/2024. On 10/01/2024 at 8:49 AM, during an interview Resident #2 relayed that on the evening of 06/10/2024, while being transferred from the wheelchair to the bed via mechanical lift, they began to slide out of the lift sling. Resident #2 stated they tried to tell the two Certified Nursing Assistants (CNAs) they were sliding but the CNAs continued with the transfer and the resident slid out of the lift sling onto the floor with the lift sling under their arms holding their upper body up. Resident #2 said the two female CNAs got the assistance of two male CNA's and were able to use a sheet to lift the resident's lower body and position the lift sling under the resident and safely transfer them into the bed. Resident #2 denied any injury. On 10/01/2024 at 8:56 AM, during an interview CNA #1 said they were asked to come to room [ROOM NUMBER] to help with something, and that when they arrived, Resident #2 was sitting on the floor with mechanical lift pad slid up on back and under arms holding them up. They confirmed there was no in-service, retraining. or witness statements taken following this incident. On 10/01/2024 at 9:44 AM, during an interview LPN #2 stated the incident was not reported to her, but she remembered someone talking the next day about Resident #2 sliding out of the lift pad and onto the floor. On 10/01/2024 at 9:57 AM, during an interview LPN #3 stated she was unaware of an incident involving Resident #2 until the next day at approximately 6:30 AM. She stated she reported the incident to the Treatment nurse (LPN #4) who then reported it to the Director of Nursing (DON) and Assistant Director of Nursing (ADON). LPN #3 stated she questioned Resident #2's CNA (CNA #6), who reported that Resident #2 did not hit the floor. LPN #3 said the treatment nurse went and preformed a body audit and questioned the resident. LPN #3 did not know if a formal in-service was initiated but stated she educated her CNAs on proper transfer with a lift. On 10/01/2024 at 10:04 AM, during a phone interview CNA #7 stated he was not in the room when Resident #2 slid out of lift pad, and the CNA working that hall came and got him to help transfer a resident. He stated when he got the room, he saw Resident #2's lower body had slid out of the lift pad and onto the floor, the resident was sitting with their back to the wheelchair. He stated he and 3 other CNAs got the resident back onto the lift pad using a sheet and then resident #2 was lifted into wheelchair. When asked if he knew what time this was, CNA #7 replied, he was pretty sure it was before lunch. On 10/01/2024 at 10:07 AM, during a phone interview with CNA #5, who is no longer employed at this facility, she stated she had helped CNA #6 transfer Resident #2 from wheelchair to the bed. When they began lifting the resident up with the mechanical lift, the resident began to slide out of lift pad. She stated, Resident #2 never touch the floor. When asked if she reported this event, she replied, she didn't think it needed reporting. On 10/01/2024 at 10:10 AM, CNA #6, who no longer works at this facility, was contacted by phone for an interview. CNA #6 stated she did not remember the event that took place. CNA #6 called back at 10:11 AM and recalled she was transferring Resident #2 from the wheelchair to bed using a mechanical lift, when the resident slipped out of lift pad and slid down to the floor. She went on to say the resident did not touch the floor because they landed on pillows that were on the foot of the wheelchair. CNA#6 stated it was her , a nurse and another CNA in the room. When asked if she reported the incident to anyone stated she did not since the nurse was in the room at the time. On 10/01/2024 at 10:14 AM, during an interview with the Director of Nursing (DON) regarding the events of the evening of 06/10/2024, she stated she knew nothing about the incident, she was in the hospital at the time and does not recall knowing anything about incident. When questioned regarding staff training on operating the mechanical lift, she reported new hires are trained during orientation and staff re-trained yearly. When asked if an in-service had been performed after Resident #2 had slid from the lift seat, she replied not that she was aware of as she was just finding out about it. On 10/01/2024 at 10:33 AM, during an interview the Assistant Director of Nursing (ADON) stated she had also been in the hospital at the time of the incident, but when she found out about it later had questioned CNA #7 who told her the resident had never touched the floor. Review of CNA #1, #5, #6, and #7 employee files indicated training and check off of mechanical lift usage during new hire orientation. Review of the facility policy, Accidents and Incidents - Investigating and Reporting indicated, all accidents and incidents regarding residents or staff will be investigated and reported to the Administrator. The charge nurse, supervisor, or department head will initiate and document the investigation and any action taken. Review of the facility policy Lifting Machine, Using a Mechanical specified to ensure the lift sling is properly balanced, make sure the head, neck and back are properly supported and make sure the lift sling is properly balanced.

Based on observation, record review, and interview, the facility failed to ensure food items were discarded by their use by date; food items were stored and served in a manner to prevent cross contamination; and hair covering for the face and head were worn at all times in 1 of 1 kitchen. The findings are: On 05/20/2024 at 10:35 AM, Dietary Aide #5 was observed with facial hair which was uncovered. On 05/20/2024 at 10:45 AM, a previously opened package containing tortillas was observed on the top shelf of the bread rack. The use by date was 05/14/2024. On 05/20/2024 at 10:50 AM, a one-pound bag of diced onion was observed on the shelf of the walk in refrigerator. The use by date was 05/13/2024. A 5-pound container of cottage cheese which was 3/4 full was observed on a shelf in the walk-in refrigerator. The use by date was 05/19/2024. On 05/20/2024 at 10:52 AM, the Maintenance Director was observed to be working in the kitchen without a covering for facial hair. The Dietary Manager was asked if an individual in the kitchen with facial hair should have a face covering. The Dietary Manager confirmed a facial hair covering should be worn at all times in the kitchen. On 05/20/2024 at 10:55 AM, two pitchers of iced tea were observed in the drink refrigerator with the lids turned to open exposing the contents to air and contamination. On 05/20/2024 at 11:15 AM, the following items were observed in the dry storage area: a. A one pound bag of marshmallows, half full, with a use by date of 04/21/2024. b. A one pound bag of marshmallows with a use by date of 05/14/2024. c. A 50 pound bag of rice, 1/2 full, unsealed, and open to air and contaminates. d. A 50 pound bag of cake mix, 1/2 full, unsealed, and open to air and contaminates. On 05/20/2024 at 11:58 AM, Dietary Aide #6 was observed to enter the kitchen through the door in the dining room. Dietary Aide #6 walked through the entire length of the kitchen prior to arriving at the Dietary Manager's office where he put a covering over his head. On 05/20/2024 at 12:41 PM, a nourishment refrigerator on Hall 200 was observed to contain the following items: a. 2 plastic bags containing half a sandwich each. The bags were not dated. b. A 1/2 bottle of water, not labeled with a name or a date. c. A floral lunch container. CNA #7 confirmed that the lunch container was hers, however she was unaware of who the water belonged to, just that she was sure it belonged to an employee. On 05/21/2024 at 10:40 AM, a 20 ounce bottle of water, 1/3 full, was observed in the nourishment refrigerator on Hall 200. The bottle had no name or date. CNA #7 identified the water as belonging to her partner, CNA #9. On 05/21/2024 at 11:41 AM, Dietary Aide (DA) #3 was observed at the beginning of the tray line. DA #3's fingers and/or thumb were placed on the surface of the plate when the plate was picked up and the thumb remained in the plate as the plate was filled. DA #3 was also observed to place her fingers inside the bowls which were filled for a resident who required the meal be served in bowls. At 12:07 PM, DA #3 was observed to place her fingers inside a bowl and a cup prior to filling. On 05/21/2024 at 12:02 AM, DA #6 was observed to enter the kitchen through the door located in the dining room. The employee was observed to cross the length of the kitchen before obtaining and putting on a hair covering. On 05/22/2024 at 9:00 AM, the Dietary Manager was asked how long foods are kept after they are opened. The Dietary Manager described how the length depended on the food item; refrigerated foods are considered good after 5 days. When asked how dishes/utensils should be handled to prevent cross contamination, the Dietary Manager reported that nothing that enters the mouth should be touched. The Dietary Manager also confirmed that the inside of a plate, cup or bowl should not be touched. When asked when a hair covering should be applied, the Dietary Manager expressed that coverings for face and head should be applied prior to entering the kitchen. On 05/22/2024 at 9:25 AM, the Administrator supplied a policy concerning food storage titled, Food Receiving and Storage, which described that dry foods are stored in bins and will be removed from original packaging, all food in the refrigerator or freezer will be covered, labeled, and dated with a use by date. A policy titled, Preventing Foodborne Illness revealed hair nets or caps and or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.

Based on observation, record review, and interview, the facility failed to ensure that residents were free from any physical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms for 01 (Resident #06) of 01 sample mix resident. The findings are: On 05/20/2024 at 2:14 PM, the Surveyor observed Resident #06 lying in bed. Both half side rails were up at top of bed with the right side rail padded on top and sides with what appears to be a black foam pool noodle. Review of a Care Plan dated 10/22/2020 for Resident #06 revealed the resident had an (activity of daily living) ADL self-care performance deficit with an intervention of quarter side rails to promote independence. Review of Resident #06's Side Rail(s) Usage assessment dated [DATE] revealed Side Rail(s) Usage- Is the use of side rails(s) being considered? No. Are side rail(s) currently in use? Yes. If yes, what type- [quarter] side rail. Review of Resident #6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 03/13/2024 revealed 'Physical Restraints'- bed rail not used, and an Active Diagnosis of Seizure Disorder or Epilepsy. Review of Resident #06's Order Summary Report revealed no order for half side rails. On 05/20/2024 at 2:14 PM, the Surveyor observed Resident #06 lying in bed. Both half side rails were up with the right side rail padded on top and sides with what appears to be a black foam pool noodle. On 05/21/2024 at 11:44 AM, the Surveyor observed Resident #06's half side rails to be up at the top of the bed with the right side rail padded on top and sides with what appears to be a black foam pool noodle. On 05/22/2024 at 9:00 AM, the Surveyor observed Resident #06 lying in bed. Both half side rails were up at the top of bed with the right side rail padded on top and sides with what appears to be a black foam pool noodle. On 05/22/2024 at 2:56 PM, the Surveyor went to Resident #6's room and observed the resident sitting up on the side of the bed with the right leg leaning up against the half side rail that was up. On 05/22/2024 at 3:01 PM, the Surveyor took Certified Nursing Assistant (CNA) #10 to Resident #06's room. The resident was observed sitting up on the side of the bed with the right leg leaning against the half side rail that was up. CNA #10 confirmed she was familiar with Resident #06's care. CNA #10 confirmed both half rails were up on the bed but did not know why they were both up. CNA #10 confirmed the two half side rails were considered a restraint. CNA #10 confirmed the resident walks around the facility and is limited assistance of one. CNA #10 confirmed she has not been educated on the facility's restraint policy. On 05/22/2024 at 3:21 PM, the Surveyor took Licensed Practical Nurse (LPN) #12 to Resident #06's room. The resident was observed sitting up on the side of the bed with the right leg leaning up against the half side rail that was up. LPN #12 confirmed she was familiar with Resident #06's care and was sure the resident had a fall during the admission to the facility. LPN #12 confirmed both half side rails were up on the bed. LPN #12 confirmed Resident #06's care plan focus area self-performance deficit showed quarter rails. LPN #12 stated she had started back working for the facility on May 6, 2024, and confirmed the two half rails have been up since she has worked here. LPN #12 confirmed the risks of half side rails hinder resident independence, are restraint, and resident safety. LPN #12 confirmed the resident walks unassisted. LPN #12 confirmed the facility's policy on restraints is dependent on restraint and to check for safety. LPN #12 confirmed the side rail assessment revealed the resident was assessed for quarter side rail use. On 05/22/2024 at 03:27 PM, the Surveyor took the Director of Nursing (DON) to Resident #06's room. The resident was observed sitting up on the side of the bed with the right leg leaning up against the half side rail that was up. The DON confirmed she was familiar with Resident #06's care and she was aware the resident has had a fall. The DON confirmed the two half side rails were up on Resident #06's bed. The DON confirmed Resident #06 wanders into rooms with empty beds. The DON confirmed the use of the two half side rails for Resident #06 were for bed boundaries and the two half side rails have been in use for a while and that a waiver should be in place for their use, or they should not be in use. The DON stated the facility's restraint policy that unless they sign a waiver they are not to be used unless it's an assistive device. The DON confirmed Resident #06's side rail assessment noted quarter side rail on both sides, and quarter rails were the only ones that were supposed to use. On 05/23/2024 at 11:24 AM, the Surveyor interviewed the Maintenance Director who reported that he didn't install the half side rails on Resident #06's bed and that they have been there since his employment started two months ago. Review of the facility's Resident Matrix provided on 05/20/2024 at 1:01 PM by the Administrator, revealed Resident #06 did not use a physical restraint. The facility provided a policy titled, Proper Use of Side Rails with a revision date of 2016 that revealed, Purpose .The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical devices, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. (Note- The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect of on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint.) General Guidelines 1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/ her bed). 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's- a. bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. The facility provided a policy titled, Use of Restraints with a revision date of April 2017 that revealed, Restraints shall only be used for the safety and well-being of the resident(s) and only after alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Policy Interpretation and Implementation revealed 1. Physical Restraints are defined as any manual method or physical or mechanical devices, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/ her typical ability to change position or place, that device is considered a restraint. 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including- a. using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed. 5. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to- a. treat the medical symptom- b. protect the resident's safety- and c. help the resident attain the highest level of his/ her physical or psychological well-being. 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/ or representative (sponsor). The order shall include the following- a. The specific reason for the restraint (as it relates to the resident's medical symptoms)- b. How the restraint will be used to benefit the resident's medical symptom- and c. The type of restraint, and period of time from the use of the restraint. 14. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. 15. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). 16. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use.

Based on record review and interview, the facility failed to ensure residents individualize plan of care was revised to reflect the current needs of the resident and updated to include falls for 02 (Resident #06, #31) of 02 sample mix resident, and to include half side rail use for 01 (Resident #06) of 01 sample mix residents. The findings are: 1. On 05/20/2024 at 2:14 PM, the surveyor observed Resident #06 lying in bed. Both half side rails were up at top of bed with the right side rail padded on top and sides with what appears to be a black foam pool noodle. a. Review of Resident #06's Progress Notes dated 01/31/2024 revealed the resident was found on the floor beside the bed with lacerations to the top and bottom lip. b. Resident #06's Patient Registration Form [named medical center] dated 01/31/2022 revealed a maxillary closed fracture from a fall from the bed. Chief Complaint revealed resident stated, I fell off my bed and hit my nose. Computed tomography (CT) Scan revealed comminuted fracture of the anterior/lateral/ posterior right and left maxillary sinuses. 'Final Diagnoses' revealed fall with lip laceration repair, maxillary sinus fracture. c. The Care Plan dated 10/24/2022 for Resident #06 did not reveal falls on 01/18/2022; 10/21/2022; 10/31/2022; or use of half side rails. d. Resident #6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 03/13/2024 revealed 'Physical Restraints'- bed rail not used, and an active diagnosis of seizure disorder or epilepsy. e. Resident #06's Order Summary Report revealed no order for half side rails. f. On 05/22/2024 at 3:01 PM, the Surveyor took Certified Nursing Assistant (CNA) #10 to Resident #06's room. The resident was observed sitting up on the side of the bed with their right leg leaning up against the half side rail that was up. CNA #10 confirmed she was familiar with resident's care, and she was not aware of any fall the resident may have had. CNA #10 confirmed both half rails were up on the bed but did not know why they were both up. g. On 05/22/2024 at 3:21 PM, the Surveyor took Licensed Practical Nurse (LPN) #12 to Resident #06's room. The resident was observed sitting up on the side of the bed with their right leg leaning up against the half side rail that is up. LPN #12 confirmed she was familiar with Resident #06's care and was sure the resident had a fall during her admission to the facility. LPN #12 confirmed both half side rails were up on the bed. LPN #12 confirmed that Resident #06's care plan focus area self-performance deficit showed quarter rails. h. On 05/22/2024 at 03:27 PM, the Surveyor took the Director of Nursing (DON) to Resident #06's room and resident was observed sitting up on the side of the bed with her right leg leaning up against the half side rail that is up. The DON confirmed she was familiar with resident #06's care and she was aware the resident had fallen previously. The DON confirmed the two half side rails were up on resident #06's bed. The DON confirmed the use of the two half side rails for Resident #06 were for bed boundaries and the two half side rails have been in use for a while. DON confirmed that Resident #06 had falls on 10/18/2022 with neuros started no injuries; 10/21/2022 with the resident found on the floor beside the bed no injuries observed; and on 01/31/2022 sent to the emergency department (ED). i. On 05/23/2024 at 09:34 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator, and she confirmed that if a resident has and fall or a fall with injury in the facility should be on the care plan along with any interventions. She confirmed that Resident #06's care plan did not document falls on 01/31/2022; 10/18/2022; and 10/21/2022. She confirmed Resident #06's care plan did not accurately reflect half side rail use. 2. On 05/21/2024 at 10:48 AM, the Surveyor interviewed Resident #31 and asked if they had experienced a fall since being in the facility. Resident #31 confirmed a fall in the shower room with no injuries on 05/20/2024. a. Review of Resident #31's Progress Notes dated 05/20/2024 revealed and incident and accident (I&A) report noting resident #31's fall in the shower room with no injuries and immediate intervention for resident to ask for assistance and ensure that staff is there to assist. b. Review of Resident #31's Progress Notes dated 05/22/2024 revealed and I&A (Incident and Accident) follow up note that documented a long term intervention to educate staff for shower safety. c. Review of the care plan date 04/24/2024 does not document Resident #31's fall on 05/20/2024. d. On 05/23/2024 at 9:34 AM, the Surveyor interviewed the MDS Coordinator, and she confirmed that Resident #31's care plan did not document a fall on 05/20/2024. e. On 05/23/2024 at 9:46 AM, the Surveyor interviewed the Director of Nursing (DON) and she confirmed that Resident #06 had falls on 10/18/2022 with neuros started no injuries; 10/21/2022 with the resident found on the floor beside the bed no injuries observed; and on 01/31/2022 sent to the emergency department (ED) and those falls were not documented on the care plan. f. On 05/23/2024 at 9:46 AM, the Surveyor interviewed the DON, and she confirmed Resident #31 had a fall on 05/20/2024 that is not documented on the care plan. g. The facility provided a policy titled, Care Plans, Comprehensive Person-Centered with a revision date of March 2022 that documented, Policy Interpretation and Implementation .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan- a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment .

Based on observation, record review, and interview, the facility failed to ensure residents who required assistance with foot care were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure toenails were kept clean and trimmed for 1 (Resident #68) of 1 sampled resident. The findings are: Review of the Order Summary revealed that Resident #68 has diagnoses of paraplegia, venous insufficiency, and type 2 diabetes. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/09/2024 revealed that Resident #68 scored a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of the Care Plan reveals that Resident #68 has these interventions in place, Nail Care: I require substantial assistance with nail care. I am a diabetic. Check nail length, clean, trim and file on shower days and as needed. On 05/20/2024 at 11:04 AM, the Surveyor observed Resident #68 ' s feet were dry with skin peeling off. There was skin material observed on the pillow below the feet. The left great toenail was thick, half of the toenail was yellow. Around the edges of the nail bed there was a brownish black color observed. The second toenail was thick, yellow, with dry skin buildup around the nail area. A flesh colored area was observed in the middle of the toe. The third toenail was long, curving inwards towards the second toe, yellow, with a scabbed sore observed below the nail bed. The fourth toenail was curved under the third. The toenail was thick and yellowing. The fifth toe was thick with dry skin buildup around the nail bed. The Surveyor observed the toes on the left foot were close together, with dry skin buildup in between each one. The Surveyor observed the right foot, the right great toenail was thick, yellowing, with dry skin buildup around the nail bed. A scabbed sore was located above the nail bed. The second toenail was thick, yellow, with dry skin buildup around the nail. Three scabbed sores were observed on the toe. The third toenail was thick, yellowing, and in the corner was a brownish, black area. The toenail was curving under the second toe. The fourth toenail was long, thick, yellowing and the nail was curving. The fifth toenail was yellowing, and thick. The Surveyor observed the toes on the right foot were close together, with dry skin buildup in between each one. Both heels were observed to be dry and scaly. The Surveyor asked Resident #68 about the toenails. Resident #68 said the newer areas on the toes were from the mechanical lift during a transfer in the hospital. Resident #68 said they have mentioned podiatry coming into the building before, but it had been a while now, and they would like something done about my feet they are pretty rough looking. On 05/20/2024 at 2:40 PM, the Surveyor observed nail care or wound care had not been completed for Resident #68's feet. On 05/23/2024 at 10:28 AM, the Surveyor asked Certified Nursing Assistant (CNA) #15 to describe Resident #68's toes. CNA #15 said that she was not sure if Resident #68 was diabetic, the way the toes are it could cause infections or sores. The Surveyor asked what the process for reporting toenails was if the resident is diabetic. CNA #15 said to report to the nurse to make a podiatry appointment. On 05/23/2024 at 10:36 AM, the Surveyor asked Licensed Practical Nurse (LPN) #15 to describe Resident #68's toenails. LPN #15 stated the resident was a diabetic, the resident could lose those toes, for sure definitely needs interventions. LPN #15 stated the resident was compliant with heel protectors. The Surveyor asked if Resident #68 had ever refused toenail care. LPN #15 said from her experience the resident has not refused it. The Surveyor asked what interventions could be put in place for Resident #68. LPN #15 said to ensure heel protectors, assess daily, notify the treatment nurse immediately. A review of the facility policy Fingernails/Toenails Care of revealed, Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc .

Based on observation, record review, and interview, the facility failed to ensure interventions were utilized to prevent worsening of contractures in one of one sampled resident (Resident #8). The findings are: A review of the Order Summary revealed that Resident #8 had diagnoses of bipolar disorder, osteoarthritis, and left-hand contracture. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/12/2024 revealed that Resident #8 scored a 12 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Section GG reveals that Resident #8 has Function Limitation Range of Motion; Upper Extremity 2. Impairment on both sides. A review of the Care Plan reveals that Resident #8 has Interventions: contractures: The resident has contractures of the left hand. Provide skin care as needed to keep clean and prevent skin breakdown. On 05/20/2024 at 2:30 PM, the Surveyor observed Resident #8 sitting up on the side of the bed, the left hand was contracted with the middle and ring finger digging into the palm of the resident's hand. The index finger and the pinky finger were curved, no interventions were in place. The Surveyor asked about the contracture of the left hand and if it bothered the resident in any way. Resident #8 said that it did bother the resident, it hurts the resident's hand, and it stinks. The Surveyor asked Resident #8 if they would like a washcloth or a hand cone with a strap to help. Resident #8 said a washcloth usually falls out when the resident gets up and would prefer something with a strap to hold it into place. On 05/21/2024 at 10:28 AM, the Surveyor observed Resident #8 did not have any interventions in place for the left hand contracture. On 05/23/2024 at 10:00 AM, the Surveyor asked Certified Nursing Assistant (CNA) #10 if Resident #8 had any interventions in place for the left hand contracture. CNA #10 said that the resident had a brace, and it was here one day and gone the next day. The Surveyor asked what could happen with no interventions in place of contractures. CNA #10 said it could contract all the way and the resident would have no use of it. The Surveyor asked CNA #10 if they could smell Resident #8's contracted hand. CNA #10 put on a glove and put a finger in the contracted hand. The Surveyor observed Resident #8 grimacing. CNA #10 said that it had a small stench, the nails are digging into the palm, and it hurt the resident to mess with contracture. On 05/23/2024 at 10:15 AM, the Surveyor asked Licensed Practical Nurse (LPN) #12 if Resident #8 had any interventions for left hand contracture. LPN #12 said sometimes the resident does, sometimes the resident doesn't. The Surveyor asked what could happen with no interventions in place. LPN #12 said it could contract worse. A review of the facility policy, Resident Mobility and Range of Motion stated, .3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility .

Based on observation, record review, and interview, the facility failed to ensure residents were free from potential accidents from half side rail use for 1 (Resident #06) and failed to ensure bed side rails were properly padded for a resident with a seizure disorder for 1 (Resident #06) of 1 sampled resident, and failed to ensure a wheelchair was left unlocked to prevent an injury for 1 (Resident #294) of 1 sample mix resident. The findings are: 1. On 05/20/2024 at 2:14 PM, the Surveyor observed Resident #06 lying in bed on their right side with eyes closed. Both half side rails were up at the top of bed with the right side rail padded on top and sides with what appears to be a black foam pool noodle. The Care Plan dated 10/22/2020 for Resident #06 revealed the resident had an (activity of daily living) ADL self-care performance deficit with an intervention of quarter side rails to promote independence. No seizure precautions were noted on the care plan. Resident #06's Patient Registration Form [Hospital Name]' dated 01/31/2022 revealed a maxillary closed fracture from a fall from the bed. Chief Complaint revealed resident stated, I fell off my bed and hit my nose. Computed tomography (CT) Scan revealed comminuted fracture of the anterior/lateral/ posterior right and left maxillary sinuses. Final Diagnoses revealed fall with lip laceration repair, maxillary sinus fracture. The Care Plan dated 10/24/2022 for Resident #06 did not reveal falls on 01/18/2022; 10/21/2022; 10/31/2022; or use of half side rails. The Annual Minimum Data Set (MDS) with an Assessment Reference Date of 10/26/2022 revealed Resident #06 had a fall in the facility. Resident #06's Side Rail(s) Usage assessment dated [DATE] revealed, Side Rail(s) Usage- Is the use of side rails(s) being considered? No. Are side rail(s) currently in use? Yes. If yes, what type- [quarter] side rail. Resident #6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 03/13/2024 revealed 'Physical Restraints'- bed rail not used, and an Active Diagnosis of Seizure Disorder or Epilepsy. Resident #06's Order Summary Report dated 05/21/2024 revealed no order for half side rails. On 05/20/2024 at 2:14 PM, the Surveyor observed Resident #06 lying in bed on their right side with eyes closed. Both half side rails up with the right side rail padded on top and sides with what appears to be a black foam pool noodle. On 05/21/2024 at 11:44 AM, the Surveyor observed Resident #06's bilateral side rails up at the top of the bed with the right side rail padded on top and sides with what appears to be a black foam pool noodle. On 05/22/2024 at 9:00 AM, the Surveyor observed Resident #06 lying in bed on the right side with eyes closed. Bilateral half side rails up at the top of bed with the right side rail padded on top and sides with what appears to be a black foam pool noodle. On 05/22/2024 at 2:56 PM, the Surveyor went to Resident #6's room and observed the resident sitting up on the side of the bed with their right leg leaning up against the half side rail that is up. On 05/22/2024 at 3:01 PM, the Surveyor took Certified Nursing Assistant (CNA) #10 to resident #06's room. The resident was observed sitting up on the side of the bed with their right leg leaning up against the half side rail that is up. CNA #10 confirmed she was familiar with Resident #10's care and that she was not aware of any fall the resident may have had. CNA #10 confirmed both half rails were up on the bed but did not know why they were both up. CNA #10 confirmed the resident walks around the facility and is limited assistance of one. On 05/22/2024 at 3:21 PM, the Surveyor took Licensed Practical Nurse (LPN) #12 to Resident #06's room. The resident was observed sitting up on the side of the bed with the right leg leaning up against the half side rail that is up. LPN #12 confirmed she was familiar with Resident #06's care and was sure the resident had a fall during her admission to the facility. LPN #12 confirmed both half side rails were up on the bed. LPN #12 confirmed that resident #06's care plan focus area self-performance deficit showed quarter rails. LPN #12 stated she had started back working for the facility on May 6, 2024, and confirmed the two half rails have been up since she has worked here. LPN #12 confirmed the risks of half side rails hinder resident independence, are restraint, and resident safety. LPN #12 confirmed the resident walks unassisted. LPN #12 confirmed the residents side rail assessment noted the resident had previously had a fall with fracture. On 05/22/2024 at 3:27 PM, the Surveyor took the Director of Nursing (DON) to Resident #06's room. The resident was observed sitting up on the side of the bed with the right leg leaning up against the half side rail that was up. The DON confirmed she was familiar with Resident #06's care and that she was aware the resident had fallen previously. The DON confirmed the two half side rails were up on Resident #06's bed. The DON confirmed Resident #06 wanders into rooms with empty beds. The DON confirmed the use of the two half side rails for Resident #06 were for bed boundaries and the two half side rails have been in use for a while and that a waiver should be in place for their use, or they should not be in use. The DON confirmed having two half side rails up could cause resident #06 to fall. The DON confirmed quarter rails are the only ones that were supposed to be used. The DON confirmed Resident #06's side rail assessment noted quarter side rail on both sides and that the resident had a previous fall with fracture. The DON confirmed that Resident #06 had falls on 10/18/2022 with neuros (neurological signs) started, no injuries; 10/21/2022 with the resident found on the floor beside the bed no injuries observed; and on 01/31/2022 sent to the emergency department (ED). On 05/23/2024 at 9:34 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator who confirmed that Resident #06's Quarterly MDS with an ARD of 03/13/2024 was coded that the resident does not use a restraint even though half side rails have been in use and therefore the quarterly assessment is inaccurate. She confirmed that Resident #06's care plan did not document falls on 01/31/2022; 10/18/2022; and 10/21/2022. She confirmed Resident #06's care plan did not accurately reflect half side rail use. On 05/23/2024 at 09:46 AM, the Surveyor interviewed the Director of Nursing (DON) and she confirmed that Resident #06 had falls on 10/18/2022 with neuros started no injuries; 10/21/2022 with the resident found on the floor beside the bed no injuries observed; and on 01/31/2022 sent to the emergency department (ED) and those falls were not documented on the care plan. On 05/23/2024 at 11:24 AM, the Surveyor interviewed the Maintenance Director and he confirmed that he didn't install the half side rails on Resident #06's bed and that they have been there since his employment started two (02) months ago. He confirmed there is to be quarterly assessment completed for an entrapment report, but it was not completed for resident #06. On 05/23/2024 at 1:55 PM, the Surveyor interviewed the Assistant Director of Nursing (ADON) who confirmed that Resident #06 had a diagnosis of seizure disorder and should be on seizure precautions. The ADON confirmed resident #06's bed was not adequately padded to prevent injury in the event of a seizure. 49689 2. A review of the Order Summary revealed that Resident #294 had diagnoses of Huntington's disease and abnormal involuntary movements. A review of the Progress Notes revealed that Resident #294 N Adv [Abnormal Involuntary Movement Scale (AIMS)] - AIMS Evaluation: Muscles of Facial Expression: e.g. movements of forehead, eyebrows, periorbital area, cheeks, including frowning, blinking, smiling, grimacing: Severe. Lips and Perioral Area: e.g. puckering, pouting, smacking: Severe. Jaw: e.g. biting, clenching, chewing, mouth opening, lateral movement: Severe. Tongue: Rate only increases in movement both in and out of mouth. NOT inability to sustain movement. Darting in and out of mouth: Severe. Upper (arms, wrists, hands, fingers). Include chorei movements (i.e. rapid objectively purposeless, irregular, spontaneous) athetoid movements, DO NOT INCLUDE TREMOR (i.e. repetitive, regular, rhythmic): Severe. Lower (legs, knees, ankles, toes) Lateral knee movement, foot tapping, heel dropping, foot squirming, inversion, and eversion of foot: Severe. Neck, shoulders, hips, e.g. rocking, twisting, squirming, pelvic gyrations. Include diaphragmatic movements: Severe. Severity of abnormal movements overall: Severe. Incapacitation due to abnormal movements: Severe. Resident's awareness of abnormal movements. Rate only Resident's report: Aware, severe distress. Resident does not currently have problems with teeth and/or dentures. Resident does not usually wear dentures. Edentulous: No. Movements do not disappear in sleep. Resident cooperation level: Full. N Adv - AIMS Total score: 28.0 05/13/2024 at 13:41 [1:41 PM]. A review of the Progress Notes indicated Resident #294 BIMS Evaluation: Brief Interview for Mental Status should be conducted. Number of words repeated after first attempt: Three. Record Response: sock blue bed Able to report correct year. Record response (year): 2024 Able to report correct month: Missed by > 1 month or no answer. Record response (month): December Able to report correct day of the week: Incorrect or no answer. Record response (day): Thursday Able to recall sock: No, could not recall. Able to recall bed: No, could not recall. Able to recall blue: Yes, no cue required. N Adv - BIMS Summary score: 8.0 A review of the Care Plan revealed these interventions for Resident #294, Focus: The resident is at risk for falls r/t involuntary extremity movements, Interventions: Anti-tippers to wheelchair due to thrashing. On 05/20/2024 at 11:45 AM, the Surveyor observed Resident #294 in Dayroom, both brakes were locked, the back of the wheelchair had anti tippers in place. The Surveyor observed Resident #294 had involuntary movements causing the wheelchair to move. On 05/20/2024 at 12:40 PM, the Surveyor observed Resident #294 in the wheelchair in the dining area. The Surveyor observed Certified Nursing Assistant (CNA) #11 lock the brakes on the wheelchair while setting up the tray. The Surveyor observed Resident #294 was eating lunch, having involuntary movements and the wheelchair was moving back and forth still. On 05/23/2024 at 10:20 AM, the Surveyor asked CNA #13 if Resident #294's wheelchair had both brakes locked in the dayroom. CNA #13 said, yes both brakes were locked, they usually are. The surveyor asked what could happen to the resident with both brakes being locked. CNA #13 said with Resident #294's involuntary movements it could cause (the resident) to go backwards. The Surveyor asked what other interventions could be considered for the resident other than locking the brakes. CNA #13 said a different chair with foot pedals or an anti-roll back. On 05/23/2024 at 10:38 AM, the Surveyor showed Licensed Practical Nurse (LPN) #15 that both brakes were locked on wheelchair, and asked what could happen to the resident with both brakes being locked. LPN #15 stated that it is a restraint the resident cannot move. The Surveyor asked what interventions could be in place. LPN #15 stated that the resident is a newer admission, and they agree that the resident needs to be reassessed for a different chair. LPN #15 then stated that the resident needed more padding as well to prevent injury with involuntary movements.

Based on observation, interview, and record review, the facility failed to ensure bed rail assessments were performed before the use of bed rails for 1 (Resident #06) of 1 sampled resident reviewed for accidents. The findings are: Review of Resident #06's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 03/13/2024 revealed 'Physical Restraints'- bed rail not used, and an Active Diagnosis of Seizure Disorder or Epilepsy. Review of Resident #06's Side Rail(s) Usage assessment dated [DATE] indicated resident #06 did not use bed rails. On 05/21/2024 at 11:44 AM, the Surveyor observed both of Resident #06's side rails up at the top of the bed with the right side rail padded on top and sides with what appeared to be a black foam pool noodle. On 05/22/2024 at 9:00 AM, the Surveyor observed Resident #06 lying in bed on the resident's right side with eyes closed. Both half side rails up at the top of bed with the right side rail padded on top and sides with what appeared to be a black foam pool noodle. On 05/22/2024 at 2:56 PM, the Surveyor went to Resident #06's room and observed the resident sitting up on the side of the bed with the resident's right leg leaning up against the half side rail that was up. On 05/22/2024 at 3:01 PM, the Surveyor took Certified Nursing Assistant (CNA) #10 to Resident #06's room. The resident was observed sitting up on the side of the bed with the resident's right leg leaning up against the half side rail that was up. CNA #10 confirmed she was familiar with Resident #06's care. CNA #10 confirmed both half rails were up on the bed but did not know why they were both up. On 05/22/2024 at 3:21 PM, the Surveyor took Licensed Practical Nurse (LPN) #12 to Resident #06's room and the resident was observed sitting up on the side of the bed with her right leg leaning up against the half side rail that is up. LPN #12 confirmed she was familiar with Resident #06's care. LPN #12 confirmed both half side rails were up on the bed. LPN #12 stated she had started back working for the facility on May 6, 2024, and confirmed the two half rails have been up since she has worked at the facility. On 05/22/2024 at 03:27 PM, the Surveyor took the Director of Nursing (DON) to Resident #06's room. The resident was observed sitting up on the side of the bed with the resident's right leg leaning up against the half side rail that was up. The DON confirmed she was familiar with Resident #06's care. The DON confirmed the two half side rails were up on Resident #06's bed. On 05/23/2024 at 9:34 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator who confirmed that Resident #06's side rail assessment should be completed quarterly, and that Resident #06 had their most recent quarterly side rail assessment dated for 03/11/2024 when it was due, but it was actually completed on 05/22/2024 at 15:11 (3:11) PM. She also confirmed that when assessments are completed it should be at the bedside for observation purposes, so the assessment is accurate. On 05/23/2024 at 09:46 AM, the Surveyor interviewed the Director of Nursing (DON) who confirmed Resident #06's side rail assessment should have been conducted quarterly and was due on 03/11/2023 but was actually completed on 05/22/2024 at 15:11 PM and was not completed timely. On 05/23/2024 at 11:24 AM, the Surveyor interviewed the Maintenance Director who reported that he didn't install the half side rails on Resident #06's bed and that they have been there since his employment started two months ago. He confirmed there is to be a quarterly assessment completed for an entrapment report, but it was not completed for Resident #06. On 05/23/2024 at 9:34 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator, and she confirmed Resident #06's side rail assessment should be completed quarterly and that Resident #06 had her most recent quarterly side rail assessment dated for 03/11/2024 when it was due, but it was actually completed on 05/22/2024 at 15:11 PM. She also confirmed that when assessments are completed it should be at the bedside for observation purposes, so the assessment is accurate. Review of the facility policy tilted, Proper Use of Side Rails, with a revision date of December 2016 noted, General Guidelines .An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rail. When used for mobility or transfer, an assessment will include a review of the resident's- a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight . 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol . 13. When side rail use is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment .

Based on observation, interview and policy review, the facility failed to ensure controlled medications were stored in a permanently affixed container in the medication room. The findings are: On 05/23/2024 at 1:00 PM, the Assistant Director of Nursing (ADON) toured the medication room with the Surveyor. The refrigerator used to store medications was not locked. Once opened a black safe-style box with a combination lock was observed sitting on a glass shelf in the refrigerator. The Surveyor pulled on the narcotics box, which came out of the refrigerator and was not permanently affixed in the refrigerator. On 05/23/2024 at 1:10 PM, the ADON was asked why the narcotics box should be permanently affixed. The ADON indicated so that you can't take it out and carry it off. On 05/23/2024 at 1:16 PM, the Surveyor spoke with the Administrator regarding the narcotics box not being affixed in the refrigerator. The Surveyor asked why the narcotics box must be permanently affixed. The Administrator indicated because it has controlled substances in it. On 05/23/2024 at 1:37 PM, the Administrator provided a Storage of Medications policy, which read, .Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments .

Based on observation, interview, and policy review, the facility failed to ensure 5 sampled residents who have a physician's order for a pureed diet received food which was smooth, lump free consistency to minimize the threat of choking or other complications. The findings are: On 05/21/2024 at 11:49 AM, a pureed meal was observed being plated for a resident with an order for a pureed diet for the lunch meal. A scoop of the pureed baked ham was observed to be placed on the plate. The mixture was observed to be textured with bits of unprocessed ham remaining in the mixture. Water, which was escaping from the ham, was observed to run across the plate and form puddles around the cornbread and peas. What was identified as pureed cornbread was observed to be placed on the plate. The cornbread mixture was observed to not hold its form. What was identified as pureed black-eyed peas was observed to be placed on the plate and did not hold its form. At 11:51 AM, a second pureed lunch meal was observed to be placed on a tray to be served. The food items were observed to have the same issues with consistency and the unblended food particles as the first observation. On 05/21/2024 at 12:15 PM, the Dietary Manager (DM) was observed placing several pieces of ham in the bowl of a food processor as additional servings were needed. After processing the meat mixture was placed into the steam table pan for serving. At 12:21 PM, pureed items were placed on a plate for serving. The ham mixture was observed to consist of small ham bits. There was no part of the substance that appeared to be of a smooth consistency. The cornbread on the plate did not hold its form. The plate did not contain peas. The water escaping from the ham encapsulated the pureed bread and the potato mixture. The water on the plate was 1/8th to 1/4th inches deep. On 05/22/2024 at 9:10 AM, the DM verbalized that therapeutic diet, such as pureed is often ordered for a resident who has chewing or swallowing problems when asked the purpose of a therapeutic diet. The correct consistency was verbalized as somewhere between applesauce and pudding, that the pureed food item should hold its form. When asked to describe the ham that was served on 05/21/2024, the DM verbalized that the mixture was a little grainy. She continued that the mixture did not appear smooth and had water escaping from it. The cornbread mixture was described as not holding its form. The black-eyed peas were described as not so runny but surrounded by water from the ham. The DM reported that the facility has multiple machines, but none that will produce a smooth meat mixture. On 05/22/2024 at 9:25 AM, the Administrator provided a policy concerning therapeutic diets which revealed a therapeutic diet is ordered by the physician to support the treatment plan of care. A diet with an altered consistency is considered as one form of a therapeutic diet. On 05/22/2024 at 11:35 AM, Certified Nursing Assistant (CNA) #1 was asked to describe the pureed lunch meal. CNA #1 described the ham mixture as lumpy with dark specs that are either pepper or the rim of the ham slice. The word mush was used to describe the cornbread. CNA #2 was asked to describe the ham mixture. CNA #2 reported that the mixture looked chunky, not smooth, with particles of meat that were not processed. The cornbread was described as runny and floating in water which came from the ham.

Based on observation, record review, and interview, the facility failed to ensure a resident's preferences or allergies for a diet was implemented for 1 (Resident #79) of 1 sampled resident. The findings are: A review of the Order Summary revealed Resident #79 had diagnoses of dementia, functional intestinal disorder, and lactose intolerance. A review of the Order Summary revealed an order that stated, Regular Diet, Regular texture, Regular consistency, enhanced food all meals, offer high calorie lactose free snack TID [three time per day] (i.e. peanut butter sandwich); food served in bowls at meal times for Lactose Intolerant Do Not Send Milk. A review of the Food Dislikes/Likes stated, Resident is to receive soy milk. A review of the Progress Notes stated, Note Text: Ate 50% or less for 2 or more meals in the day. Offered [Nutritional Supplement Brand] supplement at hs [bedtime]. Consumed 237mL [milliliters] A review of the Certified Nursing Assistant Task Snacks states that for Resident #79 Task Nutrition-Snacks-Offer and encourage high protein low lactose free three times a day. A review of the Care Plan revealed Focus-Resident has potential for nutritional deficits related to dementia and lactose intolerance causing GI upset when consumed. Resident may require verbal cues to stay on task to complete eating, Interventions-Avoid dairy based foods/beverage. A review of the Care Plan revealed Focus-At risk for potential allergic reaction to known/unknown drugs/food. Allergies: Lactose Intolerant. Goal-Risk for allergic reaction to Drugs/Food will be minimized through review date. Interventions-If adverse side effect/allergic reaction or signs and symptoms of allergic reaction such as hives, rash, itching, difficulty breathing occur, Notify MD/Practitioner; Review allergies to foods when preparing diet/meals. On 05/20/2024 at 12:56 PM, the Surveyor observed dining on secure unit. Resident #79 was observed during lunch drinking whole milk. A review of the meal ticket revealed that Resident #79 had Allergies: Lactose, Dislike/Intolerances: Cheese; Notes: Enhanced; No Lactose, No Milk, No, Cheese; Sandwich Each Meal. The Surveyor observed that the resident had drank 50% of the liquid. On 05/20/2024 at 01:00 PM, the Surveyor asked Certified Nursing Assistant (CNA) #11 to review Resident #79's meal ticket for lunch. CNA #11 said it says that Resident #79 is lactose intolerant and the resident received milk. CNA #11 said that she was not aware Resident #79 was lactose intolerant, and that Resident #79 had received milk for lunch several times. The Surveyor asked what could be the issue for the resident to be drinking milk products. CNA #11 said well they are allergic to it and it could cause the resident to have diarrhea. On 05/23/2024 at 09:43 AM, the Surveyor asked the Dietary Manager why is it important to follow resident allergies for meals. The Dietary Manager said because they are allergic to the item, it's important that they do not receive that item as it could cause harm. A review of the facility policy, Food Allergies and Intolerances stated, For example, lactose intolerance is the inability to digest milk sugars due to a deficiency in the enzyme lactase. Lactose intolerance causes gas, bloating, cramping, and diarrhea. Assessment and Interventions: 5. Residents with food intolerances and allergies are offered appropriate substitutions for foods they cannot eat.

The facility failed to ensure a comprehensive, accurate assessment of the resident's side rail use was completed quarterly for 01 (Resident #06) of 01 sample mix residents. The findings are: On 05/20/2024 at 2:14 PM, the Surveyor observed Resident #06 lying in bed on their right side with eyes closed. Both half side rails were up at top of bed with the right side rail padded on top and sides with what appears to be a black foam pool noodle. The Care Plan dated 10/22/2020 for Resident #06 revealed the resident has an (activity of daily living) ADL self-care performance deficit with an intervention of quarter side rails to promote independence. Resident #06's Side Rail(s) Usage assessment dated [DATE] revealed Side Rail(s) Usage- Is the use of side rails(s) being considered? No. Are side rail(s) currently in use? Yes. If yes, what type- [quarter] side rail. Resident #6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 03/13/2024 revealed 'Physical Restraints'- bed rail not used, and an active diagnosis of seizure disorder or epilepsy. On 05/22/2024 at 3:01 PM, the Surveyor took Certified Nursing Assistant (CNA) #10 to Resident #06's room. Resident #06 was observed sitting up on the side of the bed with the right leg leaning up against the half side rail that was up. CNA #10 confirmed she was familiar with Resident #06 ' s care. CNA #10 confirmed both half rails were up on the bed but did not know why they were both up. On 05/22/2024 at 3:21 PM, the Surveyor took Licensed Practical Nurse (LPN) #12 to Resident #06's room. The resident was observed sitting up on the side of the bed with the right leg leaning up against the half side rail that was up. LPN #12 confirmed she was familiar with Resident #06's care. LPN #12 confirmed both half side rails were up on the bed. LPN #12 confirmed that Resident #06's care plan focus area self-performance deficit showed quarter rails. LPN #12 stated she had started back working for the facility on May 6, 2024, and confirmed the two half rails have been up since she has worked here. LPN #12 confirmed the resident walks unassisted. LPN #12 confirmed the side rail assessment revealed the resident was assessed for quarter side rail use. On 05/22/2024 at 03:27 PM, the Surveyor took the Director of Nursing (DON) to resident #06's room and resident was observed sitting up on the side of the bed with the right leg leaning up against the half side rail that was up. The DON confirmed she was familiar with Resident #06's care. The DON confirmed the two half side rails were up on Resident #06's bed. The DON confirmed Resident #06 wanders into rooms with empty beds. On 05/23/2024 at 9:34 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator, and she confirmed that Resident #06's side rail assessment should be completed quarterly and that resident #06 had her most recent quarterly side rail assessment dated for 03/11/2024 when it was due, but it was actually completed on 05/22/2024 at 15:11. She also confirmed that when assessments are completed it should be at the bedside for observation purposes, so the assessment is accurate. On 05/23/2024 at 09:46 AM the Surveyor interviewed the Director of Nursing (DON) and she confirmed Resident #06's side rail assessment should have been conducted quarterly and was due on 03/11/2023 but was actually completed on 05/22/2024 at 15:11 and was not completed timely. The DON confirmed that if a resident is able to sit up on the side of their bed unassisted that does not indicate the resident is unable to support their trunk, and that if the resident is able to ambulate down the hall unassisted that means they independently ambulate, and the assessment is inaccurate. The facility provided a policy titled Proper Use of Side Rails with a revision date of 2016 revealed General Guidelines 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's- a. bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; d. That the bed's dimensions are appropriate for the resident's size and weight. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. The facility provided a policy titled Use of Restraints with a revision date of April 2017 that revealed Policy Interpretation and Implementation revealed, 6. Prior to placing a resident in restraints there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms.

Based on record review and interview, the facility failed to complete an accurate Minimum Data Set (MDS) for 01 (Resident #06) of 01 sample mix residents. The findings are: On 05/20/2024 at 2:14 PM, the Surveyor observed Resident #06 lying in bed on their right side with eyes closed. Bilateral half side rails up at top of bed with the right side rail padded. Review of Resident #06's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/2024 noted, Physical Restraints- Used in Bed- Bed rail not used. On 05/20/2024 at 2:14 PM, the Surveyor observed Resident #06 lying in bed on their right side with eyes closed. Both half side rails were up with the right side rail padded on top and sides with what appears to be a black foam pool noodle. On 05/21/2024 at 11:44 AM, the Surveyor observed Resident #06's side rails up at the top of the bed with the right side rail padded on top and sides with what appears to be a black foam pool noodle. On 05/22/2024 at 9:00 AM, the Surveyor observed Resident #06 lying in bed on the resident's right side with eyes closed. Bilateral half side rails were up at the top of bed with the right side rail padded on top and sides with what appears to be a black foam pool noodle. On 05/22/2024 at 3:01 PM, the Surveyor took Certified Nursing Assistant (CNA) #10 to Resident #06's room. The resident was observed sitting up on the side of the bed with the right leg leaning up against the half side rail that is up. CNA #10 confirmed she was familiar with resident's care and that she was not aware of any fall the resident may have had. CNA #10 confirmed both half rails were up on the bed but did not know why they were both up. CNA #10 confirmed the two half side rails were considered a restraint. On 05/22/2024 at 3:21 PM, the Surveyor took Licensed Practical Nurse (LPN) #12 to Resident #06's room. The resident was observed sitting up on the side of the bed with the right leg leaning up against the half side rail that was up. LPN #12 confirmed she was familiar with Resident #06's care and was sure the resident had a fall during admission to the facility. LPN #12 confirmed both half side rails were up on the bed. LPN #12 stated she had started back working for the facility on May 6, 2024, and confirmed the two half rails have been up since she has worked here. 05/22/2024 at 3:27 PM, the Surveyor took the Director of Nursing (DON) to Resident #06's room. The resident was observed sitting up on the side of the bed with the right leg leaning up against the half side rail that was up. The DON confirmed she was familiar with Resident #06's care and that she was aware the resident had fallen previously. The DON confirmed the two half side rails were up on Resident #06's bed. On 05/23/2024 at 9:34 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator who confirmed Resident #06's Quarterly MDS with an Assessment Reference Date (ARD) of 03/13/2024 was coded to indicate the resident does not use a side rail restraint even though half side rails have been in use and therefore the quarterly assessment is inaccurate.

Based on observation, and interview, the facility failed to ensure the kitchen floor was maintained in clean, sanitary condition for food preparation to prevent the potential for food borne illnesses for residents who received meals from 1 of 1 kitchen; the refrigerator temperature and dairy products stored in the refrigerator were maintained at 41 degrees Fahrenheit or below; food items stored in the freezer were sealed or covered to prevent the potential for cross contamination or freezer burn, employees washed their hands and changed gloves when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1 kitchen and the ice machine was maintained in clean condition to prevent the potential contamination of residents' beverages. These failed practices had the potential to affect 79 residents (total census: 81) who received meal trays from the kitchen as documented on a list provided by the Dietary Supervisor on 04/06/23 at 1:50 PM. The findings are: 1. On 04/03/23 at 11:31 AM, the following observations were made during the initial tour of the kitchen with the Dietary Manager: a. In the refrigerator, there were 12 eggs in an egg carton that were cracked. b. In the walk-in freezer, there was an opened box with 30 corndogs in it that was not dated. c. In the walk-in freezer, there was a bag of French fries with 3 puncture holes in the bag. d. The kitchen floor was dirty and had a lot of debris on it. 2. On 04/05/23 at 10:45 AM, the following observations were made in the refrigerator and the walk-in freezer: a. An opened box of cookies was on a shelf in the refrigerator. There was no opened or received date on the box. b. An opened box of corn dogs was on a shelf in the walk-in freezer. The box was not covered or sealed. There was no opened date on the box. c. An opened bag of pancakes was on a shelf in the walk-in freezer. The box was not covered or sealed. 3. On 04/05/23 at 10:55 AM, DE #1 turned on the hand washing sink faucet and washed his hands. He turned off the faucet with his bare hands. He pulled out tissue papers and dried his hands. He removed gloves from the glove box and placed them on his hands, contaminating the gloves. He used his gloved hand to attach a clean blade to the base of the blender to be used in pureeing food items to be served to the residents who received pureed diets for lunch. 4. On 04/05/23 at 11:01 AM, DE #1 was wearing gloves on his hands. He picked up a cup that contained thickener and placed it on the counter. He removed the gloves from his hands and threw them away. Without washing his hands, he picked up a pan with his thumb inside the pan and placed it on the counter. At 11:02 AM, he poured the pureed chicken into a pan and placed it in the food warmer to be served to the residents who receive pureed diets for lunch. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? He stated, I should have removed the gloves and washed my hands. 5. On 04/05/23 at 11:08 AM, the ice machine located in the Dining Room had an accumulation of wet brown/rusty sediment on the panel of the ice machine. The area had condensation that could possibly drip onto the ice. The Surveyor asked the Dietary Supervisor to wipe the accumulation of wet rusty sediment from the panel of the ice machine. She did, and the wet brown/rusty colored residue easily transferred to the tissue. The Surveyor asked the Dietary Supervisor, How often do you clean the ice machine? She stated, I think the Maintenance Man cleans it. At 12:31 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1, Who uses the ice from the ice machine? He stated, We use it for the water pitchers in the residents' rooms. 6. On 04/05/23 at 2:38 PM, DE #4 was wearing gloves on her hands. She opened the refrigerator door and closed it back. Without changing gloves and washing her hands, she picked up glasses and placed them on the trays with her gloved fingers inside the glasses. On 04/05/23 at 2:44 PM, DE #4 poured punch into the glasses to be served to the residents with their supper meal. At 2:46 PM, the Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have removed the gloves and washed my hands. 7. On 04/06/23 at 7:53 AM, the Surveyor asked CNA #2, Who uses the ice from the ice machine? He stated, We use it to fill the water pitchers in the residents' rooms. 8. On 04/06/23 at 12:57 PM, the Surveyor asked CNA #3, Who uses the ice from the ice machine? He stated, We use it to fill the water pitchers in the residents' rooms. 9. On 04/06/23 at 1:38 PM, the Surveyor asked the Maintenance Director, How often do you clean the ice machine and who uses the ice from the ice machine? He stated, I clean it out once every 3 months and check on it every week. 10. The facility policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, provided by the Interim Administrator on 04/06/23 at 1:41 PM documented, .Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness . 6. Employees must wash their hands: .f. after handling soiled equipment or utensils; g. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or h. after engaging in other activities that contaminate the hands . 37634

Based on observation, interview, and record review, the facility failed to ensure residents feet were kept clean for 1 (Resident #28) of 8 (Residents #16, #17, #21, #28, #40, #57, #66 and #130) sampled residents who required assistance or were dependent on staff for activities of daily living (ADL) and/or bathing. The findings are: Resident #28 had a diagnosis of Huntington's Disease, Senile Degeneration of Brain, Not Elsewhere Classified. The Quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 03/13/23 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive two plus person physical assistance for personal hygiene and in part of bathing activity. a. A Care Plan with a revision date of 01/04/22 documented, .The resident has an ADL self-care performance deficit r/t [related to] Huntington's Chorea Disease. Resident will be clean and well-groomed daily throughout review date . Bathing: Requires extensive assistance with bathing . Personal Hygiene: The resident requires extensive assistance with personal hygiene . b. On 04/03/23 at 2:07 PM, Resident #28 was lying in bed in a fetal position. The soles of his feet were black and dirty. c. On 04/04/23 at 1:09 PM, Resident #28 was lying in bed in a fetal position. The soles of his feet were black and dirty. d. On 04/06/23 at 4:30 PM, Resident #28 was lying in bed in a fetal position. The soles of his feet were clean. e. On 04/05/23 at 11:15 AM, the Surveyor asked the Treatment Nurse, How often does [Resident #28] get a bath? She stated, I think it's three times a week, but I'm not 100% sure. The Surveyor asked, Can you tell me why the bottom of [Resident #28's] feet are black and dirty? She stated, No I cannot. f. On 04/05/23 at 11:24 AM, the Surveyor asked Certified Nursing Assistant (CNA) #4, How often does [Resident #28] get a bath or shower? She stated, Three times a week, but I'm not always here on his bath days. The Surveyor asked, Can you tell me why the bottom of [Resident #28's] feet are black and dirty? She stated, I'm not sure. g. On 04/07/23 at 8:34 AM, the Surveyor asked Licensed Practical Nurse (LPN) #3, Can you tell me why the soles of [Resident #28's] feet were black and dirty on Monday and Tuesday? She stated, It's been several months since I worked on the 200 Hall. h. On 04/07/23 at 8:45 AM, the Surveyor asked CNA #5, Can you tell me why the soles of [Resident #28's] feet were black and dirty on Monday and Tuesday? She stated, We tried to keep socks on him, but he takes them off. He fights us on keeping his feet clean. He fights us on everything. i. On 04/07/23 at 9:12 AM, the Surveyor asked LPN #4, Can you tell me why the soles of [Resident #28's] feet were black and dirty on Monday and Tuesday? She stated, We tried to keep socks on him, but he takes them off. He fights us on keeping his feet clean. He fights us on everything. j. On 04/07/23 at 9:22 AM, the Surveyor asked the Director of Nursing (DON), Can you tell me why the soles of [Resident #28's] feet were black and dirty on Monday and Tuesday? She stated, We tried to keep socks on him, but he takes them off. He fights us on keeping his feet clean. He fights us on everything.

Based on observation of the 8:00 AM and 12:00 PM medication passes on [DATE], record review, and interview, the facility failed to maintain a medication error rate of less than 5% to prevent potential complications for 2 (Residents #1 and #18) of 3 (Residents #1, #3 and #18) residents observed during the medication pass, resulting in medication errors. Medication errors were made by 2 Licensed Practical Nurses (LPN #1 and LPN #2) who were observed administering medications in the facility. The medication error rate was 5.88% based on the observation of 34 medication opportunities and 2 errors detected. The findings are: 1. Resident #1 had diagnoses of Parkinson's Disease, Urinary Tract Infection (UTI) and Alzheimer's Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 9 (,d+[DATE] indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. The Physicians Orders dated [DATE] documented, .Primaxin IV Intravenous Solution Reconstituted ,d+[DATE] MG (Imipenem-Cilastatin) Use 500 mg intravenously every 6 hours for UTI bacteria Proteus Mirabils related to URINARY TRACT INFECTION, SITE NOT SPECIFIED . until [DATE] 23:59 [11:59 PM] . b. The [DATE] MAR documented, .Primaxin IV Intravenous Solution Reconstituted ,d+[DATE] MG (Imipenem-Cilastatin) Use 500 mg intravenously every 6 hours for UTI bacteria Proteus Mirabils related to URINARY TRACT INFECTION, SITE NOT SPECIFIED . until [DATE] 23:59 [11:59 PM] . c. On [DATE] at 11:40 AM, Resident #1 was in the Common Area of the Unit. LPN #2 arrived on the unit with an intravenous (IV) tubing, a syringe labeled, Heparin, a bag of Saline, and a vial of medication. LPN #2 moved an IV pole with an attached infusion pump near Common Area. She used a laptop on the Medication Cart to verify the medication was to be administered to Resident #1. She used the bag of saline to reconstitute the vial of medication and shook it to mix it thoroughly. She spiked the bag of fluid with the IV tubing and hung the bag on the IV pole. She primed the tubing with the fluid and inserted the tubing into the infusion pump. She removed the cap from the peripheral IV port located on the resident's right forearm, cleaned the port with an alcohol wipe, and flushed the port with the syringe of heparin before attaching the primed tubing. She powered on the pump and set it to run at 200 milliliters per hour (ml/hr) for a 100 milliliter (ml) bag of fluid. The label identified the contents as Primaxin IV ,d+[DATE] MG. The bag contained 100 ml of fluid. The medication label on the bag of fluid did not specify a flow rate for the medication to be administered. The Surveyor asked LPN #2 how she knew what rate to administer the medication. She stated, I just set it at 30 minutes because he moves a lot. He's already pulled his IV out once this morning. The Surveyor asked LPN #2 to attempt to locate the medication flow rate on the laptop located on the Medication Cart. LPN #2 was not able to locate the flow rate on the laptop. The Surveyor asked if IV medications were often missing a flow rate in the orders. She stated, Yes, they leave it up to us. d. On [DATE] at 2:16 PM, the Surveyor asked the DON if orders for intravenous medication administration should include an administration rate. She stated, It should. The Surveyor asked the DON to pull up Resident #1's Physician Orders in the [Facility Computer Software]. She pulled up the Physician Orders and studied them for several minutes. She stated, That should be in there, I'll get the APN [Advanced Practice Nurse] to fix that right now. e. On [DATE] at 2:30 PM, the DON asked the Surveyor to look in [Facility Computer Software] and check to see if the flow rate for the Primaxin was in the order. The Physicians Order documented, Infuse 500mg (1 bag) IV over 60 minutes every 6 hours until [DATE] at 23:59 [11:59 PM]. The DON asked, Did she run it over an hour? The Surveyor stated he had observed it run over thirty minutes. She stated, Ok, and left the room. f. On [DATE] at 2:40 PM, the DON reentered the room and provided the Surveyor with a copy of Resident #1's orders. The Physicians Order documented, Use 500 mg intravenously every 6 hours for UTI bacteria Proteus Mirabils related to URINARY TRACT INFECTION, SITE NOT SPECIFIED . until [DATE] 23:59 Run at 200 mls/hr [milliliters per hour]; give over 30 mins. [minutes] . g. On [DATE] at 4:38 PM, the Interim Administrator provided a bottle of Resident #1's medication with a label attached. The label documented, Infuse 500mg (1 bag) IV over 60 minutes every 6 hours until [DATE] 23:59 [11:59 PM] . h. On [DATE] at 9:45 AM, the Surveyor asked the DON if IV medications should be administered at the ordered rate. She stated, Yes. The Surveyor asked the DON what the outcome of administering IV medications at an incorrect rate might be. She stated, An adverse reaction. 43982 2. Resident #18 had diagnoses of Osteoarthritis of Knee, Gout, and Morbid Obesity. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 15 (,d+[DATE] indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. A Physician's Order dated [DATE] documented, .Acetaminophen ER [extended release] Tablet Extended Release 650mg Give 650mg [milligrams] by mouth two times a day for CPPD [Calcium pyrophosphate deposition disease] in left knee . b. The [DATE] Medication Administration Record (MAR) documented, .Acetaminophen ER Tablet Extended Release 650 MG Give 650 mg by mouth two times a day for CCPD in left knee -Start Date- [DATE] 2000 . c. On [DATE] at 8:30 AM, during the 8:00 AM medication pass, the Surveyor observed LPN #1 preparing medication for Resident #18. LPN #1 retrieved 2 round tablets from an over the counter bottle. The label read, .Acetaminophen 325mg [milligram] tablets . d. On [DATE] at 9:10 AM, the Surveyor returned to the medication cart after verifying the medications given by LPN #1 with the MAR. The Surveyor asked LPN #1 to show the Surveyor the bottle of Acetaminophen she had given out of earlier during the medication pass. The Surveyor looked at the bottle and it was not extended release. The Surveyor asked, Is that extended release? LPN #1 looked at the bottle and stated, It doesn't say that. The Surveyor asked LPN #1 to pull up the Physicians Order for the scheduled dose and verified with LPN #1 that the order was for extended release. LPN #1 stated, That's all we ever get in our stock medications, so what are we supposed to do? e. On [DATE] at 9:54 AM, the Surveyor accompanied the Director of Nursing (DON) to the medication cart for the 100 and 600 Halls. The Surveyor asked the DON to review the label on the Acetaminophen bottle used during the 0800 [8:00 AM] medication pass on [DATE] at 8:30 AM and to review the Resident #18 ' s Physicians Orders. The Surveyor asked what the difference was between the medication given and the medication ordered. The DON stated, This one is not extended release. The Surveyor asked what this meant for the medication that was given. The DON responded, This one has a shorter life of 4 to 6 hours. The Surveyor asked what the duration was on the extended-release version of Acetaminophen. The DON stated, Up to 8 hours. 3. The facility policy titled, Administering Medications, provided by the Interim Administrator on [DATE] at 4:27pm documented, .Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders, including any required time frame . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 6 residents who received pureed diets and 17 residents who received mechanical soft diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 04/06/23. The findings are: 1. On 04/05/23, the menu for the lunch meal documented residents who received pureed diets were to receive 2 inch x 4 inch servings of pureed carrot cake and residents on mechanical soft diets were to receive ground herb chicken. 2. On 04/05/23 at 11:45 AM, Dietary Employee (DE) #2 placed nine 1 inch x 2 inch servings of carrot cake with frosting into a blender, added milk and pureed to be served to the residents who received a pureed diet, instead of a 2 inch x 4 inch serving for each resident. There was no ground herb chicken prepared as documented on the menu for the residents who were to receive a mechanical soft diet. 3. On 04/05/23 at 11:58 AM, the Surveyor asked DE #1 the reason mechanical ground meat was not prepared. He stated, We give them diced meat. At 12:20 PM, the residents on mechanical soft diets were served diced chicken, with gravy, instead of ground herb chicken. At 12:30 PM, the Surveyor asked the Dietary Supervisor the reason residents on mechanical soft diets were served diced chicken. She stated, We use diced chicken for the mechanical soft diets.

A. Based on observation, record review, and interview, the facility failed to ensure implementation of infection prevention and control practices to prevent the potential transmission of COVID-19, as evidenced by failure to ensure COVID-19 isolation precautions were followed and personal protective equipment (PPE) was readily available for staff caring for COVID-positive residents for 4 (Residents #3, 4, 5, and 6) of 4 sampled residents who resided on the 500 Hall Dementia Unit and were COVID-positive The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to 8 COVID-negative residents who resided on the 500 Hall Dementia Unit, according to a list provided by the Director of Nursing (DON) on 1/26/22 at 10:30 AM. The Administrator was informed of the Immediate Jeopardy condition on 1/24/22 at 5:45 p.m. The findings are: 1. A list of COVID-19 positive residents provided by Registered Nurse #1, the Infection Preventionist, on 1/24/22 at 3:30 PM was compared to the Midnight Census provided by the Administrator on 1/24/22 From the lists that were provided by the Infection Preventionist and the Administrator, it was determined that a COVID-19 positive resident (Resident #3) and a COVID-19 negative resident were housed in the same room. Additionally, a COVID-19 negative resident (Resident #7) in one room on the 500 Hall was sharing a bathroom with a COVID-19 positive resident in the adjacent room, and both residents were ambulatory. Based on a review of the vaccine records and COVID test results, Resident #3 tested positive for COVID-19 on 1/18/22 and was not separated from his COVID-negative roommate until 1/24/22 during the complaint survey. 2. The facility's policy titled, Isolation Precautions, provided by the Administrator on 1/24/22 at 4:20 p.m. documented, .Maintain an adequate supply of isolation supplies (gloves, gowns, masks, as needed) at the entrance of the isolation room so that appropriate personal protective equipment can be easily used. Post an isolation sign on the room entrance door instructing staff and visitors to report to the nursing station before entering room. Place a container for laundry and container for waste in the isolation room. 3. The facility's policy titled Infection Control and Prevention Plan for COVID-19 Positive Test Results for Residents, provided by the Assistant Director of Nursing on 1/26/22, documented, In the event a resident test positive for COVID-19, the resident will don a mask and be moved to the COVID-19 designated unit. The resident will remain in droplet isolation times 10 days following a positive test .residents who are symptomatic will have screening increased to every 8 hours. 4. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/21 documented the resident scored 5 (0-7 indicates cognitively impaired) on a Brief Interview for Mental Status (BIMS), used a wheelchair for mobility, and required limited assistance of one person for locomotion. a. The Plan of Care dated 8/6/21 documented, .Resident is at risk for exposure and contracting the Coronavirus . Observe for signs and symptoms of COVID-19 such as fever, coughing, shortness of breath, fatigue . b. The COVID-19 Positive Resident list provided by the Infection Preventionist on 1/24/22 documented the resident tested positive for COVID-19 on 1/18/22. c. The January 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an ARD of 12/22/2 documented the resident scored 7 (0-7 indicates severely impaired) on a BIMS and required supervision of 1 person with walking and locomotion. a. The Plan of Care dated 12/27/21 documented, .Resident is at risk for exposure and contracting the Coronavirus . Observe for signs and symptoms of COVID-19 such as fever, coughing, shortness of breath, fatigue . b. The COVID-19 Positive Resident list provided by the Infection Preventionist on 1/24/22 documented the resident tested positive for COVID-19 on 1/18/22. c. The January 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Plan of Care dated 12/27/21 documented, .Resident is at risk for exposure and contracting the Coronavirus . Observe for signs and symptoms of COVID-19 such as fever, coughing, shortness of breath, fatigue . b. The COVID-19 Positive Resident list provided by the Infection Preventionist on 1/24/22 documented the resident tested positive for COVID-19 on 1/14/22. c. The January 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Plan of Care dated 12/27/21 documented, .Resident is at risk for exposure and contracting the Coronavirus . Observe for signs and symptoms of COVID-19 such as fever, coughing, shortness of breath, fatigue . b. The COVID-19 Positive Resident list provided by the Infection Preventionist on 1/24/22 documented the resident tested positive for COVID-19 on 1/14/22. c. The January 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. On 1/24/22 at 3:00 PM, rounds were made on the 500 Hall, which housed the Dementia Unit on the back half of the hall. The doors were locked but, had no signage to let staff or visitors know that there were positive residents on the unit. After the surveyor entered the unit, there was a plastic sheet that was hanging from the ceiling in the back half of the hall. The sheet of plastic was attached to the ceiling and both walls on the side with a split in the middle. The residents on the hall pushed the plastic sheeting aside and wandered freely from the front to the back of the unit. There were no isolation bins with personal protective equipment for staff located on the hallway. 9. On 1/24/22 at 3:15 PM, Certified Nursing Assistant (CNA) #1 wore a KN95 mask as she walked out of a resident's room and was asked, Are there any COVID-positive residents on this hallway? She stated, Yes, we consider them all COVID-positive. She was asked, Do all the residents have COVID? She stated, I really don't know. She was asked, Do you wear gown and gloves when you do personal care? She stated, No, they just told us we had to wear these masks. She was asked, Have they told you that any resident on this unit was positive for COVID? She stated, No, I just returned today. I have had COVID and been at home. 10. On 1/24/22 at 3:25 PM, Nursing Assistant (NA) #1 was asked, Do any of the residents on this unit have COVID? She stated, I really am not sure; this is my third day here as a Nurse Aide. She was asked, What kind of personal protective equipment do you wear when taking care of the residents on this unit? She stated, They gave us these masks to wear. She was asked, Do you wear a gown and gloves when you do resident care? She stated, No, they didn't say we had to. 11. On 1/24/22 at 4:20 PM, Licensed Practical Nurse (LPN) #1 was asked, What hall are you working on? She stated, I work 500 Hall. She was asked, Are there any residents on the 500 Hall unit that are COVID-positive? She stated, Yes. She was asked, Which residents are positive? She stated, We have a list on our 24-hour report. The 24-hour report documented 10 residents on the unit were COVID-19 positive. She was asked, How are you keeping the positive residents and negative residents separated? She stated, We aren't, we are considering them all positive. 12. On 1/24/22 at 4:26 PM, LPN #2 was asked, Should the 500 Hall unit have personal protective equipment for the staff to use? She stated, I'm not sure. She was asked, Are there COVID-positive residents on the 500 Hall unit? She stated, Yes. She was asked, Who is responsible for making sure personal protective equipment is accessible to the staff? She stated, It's a group effort. She was asked, How are the staff made aware of the residents who are COVID-positive? She stated, It's on the 24-hour report. 13. On Monday, 1/24/22 at 5:00 PM, the Assistant Director of Nursing (ADON) and the Administrator were asked, Should staff have on personal protective equipment when on a hall with COVID [positive residents]? She stated, Yes. They were asked, Should personal protective equipment be accessible to staff on a hall with COVID-positive residents? She stated, Yes. They were asked, If a unit has COVID positive residents, should there be a sign indicating that? Both replied, Yes. They were asked, Are there COVID-positive residents on the 500 Hall unit? They stated, Yes. They were asked, Why is there no sign to indicate that? They both stated, There was on Friday [1/21/22]. They were asked if they had checked for signage today and, the Administrator stated, No. The Administrator and ADON accompanied the surveyors to the 500 Hall unit and observed that no signs were in place and there was no PPE available for the staff . 14. On 1/24/22 at 5:20 PM, Personal Protective Equipment was delivered to the 500 Hall unit, and bins to dispose of used PPE were placed on the unit behind the barrier. 15. The immediate jeopardy was removed, and the scope reduced to E on 1/24/22 at 6:15 PM when the facility implemented the following plan of removal: IJ - Plan of Removal: Step #1 Corrective Action: 500 Hall - a. On 1/24/2022, the administrator placed appropriate isolation signage on the entrance of 500 hall to alert of COVID positive residents. b. On 1/24/2022, the IP [Infection Preventionist] stocked appropriate and sufficient PPE on 500 hall unit to include gowns, gloves, KN95, goggles/face-shield. c. On 1/24/2022 at 5:30 p.m., the Maintenance Director replaced plastic barrier on 500 hall to clearly separate COVID negative and COVID positive residents to include securing barrier to the floor. d. Positive and negative residents on 500 hall were separated on 1/24/2022 by nursing staff and verified by Administrator. e. On 1/25/2022, the MDS coordinator supplied a list of active COVID positive, negative, recovered and vaccination status and placed on each unit for staff . Step #2 Identification of others with the potential to be affected: On 1/24/2022, the Administrator verified a census of 95 residents in house. The facility identified 40 positive residents, 11 recovered COVID positive residents, and 44 negative residents. The Administrator made observation rounds to ensure all COVID negative residents were separated from COVID positive residents. Step #3 To ensure deficient practice does not occur: On 1/24/2022, the Administrator initiated inservices for the following for all staff: a. Appropriate isolation signage for COVID units. b. Appropriate PPE for use by employees for COVID isolation and ensuring PPE is available. c. Ensuring COVID negative and COVID positive residents are not co-mingled [sic]. d. Ensuring residents are not brought off COVID units onto non COVID units. e. The MDS coordinator will maintain a current list of residents COVID status and vaccination status and will be updated as needed. Step 4 Monitoring: Administrator / designee will monitor all COVID units daily 7 days/week x 2 weeks, 5 days/week x 2 weeks, 3 days/week x 2 weeks, then weekly thereafter to ensure: a. Appropriate signage for COVID units. b. Appropriate PPE for use by employees and available. c. Ensuring COVID negative and COVID positives are no co-mingled. d. Ensuring residents are not brought off COVID units into non COVID units. e. Ensuring a current list of residents COVID status and vaccination status is posted and current. Monitoring will be documented on monitoring calendar and negative findings will be corrected immediately by Administrator / designee. Step 5 QA [Quality Assurance]: Administrator / designee will present findings to the monthly QA committee x 1 quarter for further review and recommendations. B. Based on observation, record review and interview, the facility failed to ensure signage for isolation precautions was posted to inform staff / visitors of the need for precautions to prevent the potential spread of infection for 1 (Resident #64) of 1 sampled resident who was on isolation precautions as of 1/3/2022. The findings are: Resident #64 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/21 documented the resident scored 7 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS). a. The Care Plan dated 12/22/21 documented, Resident is at risk for exposure and contracting the Corona Virus. Check temperature at least daily and as needed. Report any abnormal result to MD [Medical Doctor] and Nurse Management. Respiratory assessment for COVID-19 as indicated. Lab testing for COVID-19 as MD orders. Report all results to the MD. Observe for signs and symptoms of COVID-19 such as fever, coughing, shortness of breath, fatigue, etc. [et cetera] Initiate E-Interact if S/S [signs/symptoms] are noted. Consult with MD and Nurse Management if any signs/symptoms of COVID-19 are observed. b. The January 2022 Physicians Orders documented, Administer PCR [Polymerase Chain Reaction] COVID-19 test at frequency recommended by CMS [Centers for Medicare and Medicaid Services] and Arkansas Department of Health. Administer PRN [as needed] Antigen COVID-19 test in the presence of COVID-19 symptoms .for Potential COVID-19 PRN per CMS/DOH [Department of Health] recommendations, or as needed for symptoms . Vital signs and COVID 19 monitoring daily for residents not requiring quarantine every night shift . c. Nursing Progress Notes dated 1/3/22 documented a specimen for, [CONDITION(S)]-COV-2 [Severe Acute Respiratory Syndrome Coronavirus 2] by PCR was collected on Resident #64 on 01/3/22 at 6:45 AM. The specimen was received by a local hospital laboratory at 11:36 AM and the result was verified at 12:40 PM and documented, CoV-2 Negative. d. On 1/03/22 at 11:14 PM, a Personal Protective Equipment (PPE) container was noted outside a resident's room / door; no name was posted. Licensed Practical Nurse (LPN) #2 was walking by was asked, Is there a resident in that room? She replied, Yes there is a resident in this room; it's [Resident #64]. She was moved from the next room; she started having signs and symptoms this morning and was tested for COVID. The test was inconclusive, so we moved her to this room. Her roommate tested negative, no signs or symptoms, and is fully vaccinated. She was asked, What kind of isolation is she on? The LPN replied, Contact. The LPN was asked, Should there be isolation and PPE signs on the resident's door indicating she is on isolation and what type of PPE is required? She replied, Yes. e. The Hot Rack Charting dated 1/3/22 documented, .resident is on hot rack r/t [related to] elevated temp [temperature] on day shift . resident was tested for COVID . f. On 1/5/22 at 10:39 AM, the Director of Nursing (DON) was asked, When a resident is placed on quarantine or isolation, should the resident's door have signage that indicates the type of isolation and what PPE is required? She replied, Yes. She was asked, What was the resident's temperature and when was the resident moved to isolation? She replied, I do not know; there is no documentation found on her elevated temperature or when she was moved.

Based on record review and interview, the facility failed to ensure a resident was promptly transferred to the hospital as ordered by the Hospice Physician after a fall with injury to prevent a delay in treatment and failed to ensure neurological assessments were consistently completed after the fall with injury occurred to monitor for any delayed signs and symptoms of head injury for 1 (Resident #2) of 5 (Residents #1, #2, #3, #4 and #5) case mix residents who were at risk for falls and were dependent on staff for their care. This failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #2, who fell and hit her mouth on a bedside table and had the potential to cause more than minimal harm for all 88 residents who could experience a fall or change in condition, according to the Midnight Census Report dated 10/5/2021. The Administrator was notified of the Past Immediate Jeopardy on 10/07/2021. The findings are: 1. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set with an Assessment Reference Date of 08/26/2021 documented the resident scored 7 (0-7 indicates severe impairment) on a Brief Interview for Mental Status; required limited 1-person assistance with bed mobility, transfers and toileting; was not steady and required staff assistance to stabilize when moving from a seated to standing position, moving on and off the toilet, and surface-to-surface transfers; and had no falls since admission, reentry or prior assessment. a. A Nursing Progress Note by Licensed Practical Nurse (LPN) #1 documented, .Effective Date: 9/28/2021 21:13 [9:13 p.m.]; Type: I&A [Incident and Accident] note; Description of incident: aide came and alerted this nurse that resident had fell and hit her mouth on the bedside table, upon assessment resident had blood coming from mouth and top lip looked to be gashed, no other injuries noted at this time, vitals WNL [within normal limits] . PERRL [pupils equal, round and reactive to light], grip equal and strong, gait weak unsteady. Immediate intervention: resident was assisted back into bed, nonskid socks were applied, wounds were cleaned.; Physician notified / response: [Nurse Practitioner]- no new orders.; Family notified/response: [sister] - thanked this nurse for letting her know . There was no documentation in the Progress Notes of any further assessments or monitoring of the resident's condition until 9/29/21 at 9:48 A.M. b. A Nursing Progress Note by LPN #2 on 9/29/2021 at 9:48 A.M. documented, .day 1/3 r/t [related to] fall - witnessed on prior shift, 0 [no] c/o [complaints of] pain to lip area, 0 bleeding, bruising to right area noted, alert x [times] 1 [oriented to name], resp [respirations] even nonlabored, responds to verbal commands, assist [assistance] with adls [activities of daily living], cont [continues] to rest, bed, room, cl [call light] in reach, encouraged to use cl for assistance. cont current poc [plan of care], cont to observe, cont hospice care . There was no documentation a neurological (neuro) check (assessment of pupillary response, vital signs, and hand grips) was completed at this time. c. A Nursing Progress Note by LPN #2 on 9/29/2021 at 12:00 (P.M) documented, .neuro checks started r/t fall on 9/28/21 2nd shift, will brief oncoming sfhit [shift] . No further Progress Notes were documented until 9/29/21 at 6:27 P.M. d. The Neuro Check entry dated 9/29/21 at 12:00 P.M. documented, Initial Neuro Check #1 . Instructions for Documentation: Neurological assessment requires documentation at the following intervals: Q [every] 15 min [minutes] for first hour, Q 30 minutes x [times] 2; Q Hour x 2; Q 4 Hours x 2; Q Shift for the remaining 72 hours and until stable . This neuro check was completed over 14 hours after the fall with injury occurred. e. A Hospice Physician's Telephone Order Form dated 9/29/21 documented, .eval [evaluate] post fall .C/T [Computed Tomography scan] without contrast - Head .Bill to: [Hospice] . f. A Nursing Progress Note by LPN #2 on 9/29/2021 at 18:27 [6:27 p.m.] documented, .[Hospice Nurse #2] called and gave new order per [Hospice Physician] to send resident to ER [emergency room ] via ambulance for CT of head r/t fall and family concerned as well, also [Hospice Nurse #2] will be at nh [nursing home] and will follow ems [Emergency Medical Services] to er, 1830 [6:30 p.m.] notified adon [Assistant Director of Nursing] of hospice order, 1835 [6:35 p.m.] notified ems for transfers, 1840 notified ER and gave [emergency room Nurse] report, 1845 [6:45 p.m.] ems here for transfer and also [Hospice Nurse #2] here at nh, don [Director of Nursing] called nh and spoke to [Hospice Nurse #2] and was informed by [Hospice Nurse #2] not going to send resident to er, ems informed, oncoming shift brifed [briefed] . g. A Nursing Progress Note by LPN #1 on 9/29/2021 at 21:15 [9:15 p.m.] documented, . Cops came to facility talked to this nurse and family had called police to do a welfare check to make sure their mother was alive, this nurse and [other staff] assured police that resident was safe and secure in her bed sleeping, the cop stated that he was going to 'have dispatch call family and let them know that resident was ok and sleeping'. This nurse called DON and alerted her as to what was going on . h. A Progress Note dated 9/30/21 at 12:39 a.m. documented, .Hot rack charting r/t fall . lip laceration, bruising of eyes . neuro checks WNL [within normal limits] . i. A Nursing Progress Note by LPN #1 on 9/30/2021 at 09:05 (A.M.) documented, .don [DON] informed this nurse to send resident to [Hospital] ER per family request, 0910 [9:10 A.M.] notified ems for transfer . informed by don family here at nh and aware of transfer, 0912 [9:12 A.M.] notified ER report to rn [Registered Nurse], 0917 [9:17 A.M.] notified [Hospice Staff] and informed [Hospice Nurse #1] at nh and don informed this nurse hospice rn aware of transfer, 0925 [9:25 A.M.] ems here at nh, resident, 0935 [9:35 A.M.] resident departs nh via ems, cont with laceration type to lip, bruises to eyes area, left knee scrap [scrape] noted . j. A Progress Note by LPN #2 on 9/30/2021 at 12:50 (P.M.) documented, .Type: Nsg [Nursing] - General Note notified [Hospital] ER for status of ct results and informed by [Hospital Staff] ct of head, spine, facial were done with clear results and would fax results to nh and resident was ready to be picked up to return to nh, informed [DON] . k. A Progress Note by LPN #2 on 9/30/2021 at 13:05 [1:05 P.M.] documented, .Type: Nsg - General Note informed by [DON] resident would not be coming back to nh, will brief oncoming shift . l. A Witness Statement dated 09/28/21 by Certified Nursing Assistant (CNA) #1 documented, .I was refilling the resident's water cup and she got up out of bed and fell hitting her mouth on the bedside table, I alerted the nurse, and she came to resident room and assessed her. m. On 10/07/2021 at 9:29 a.m., Hospice Nurse #1 was asked, Did you know [Resident #2] prior to her being admitted to the facility? Hospice Nurse #1 stated, Yes, I was her Hospice Case Manager. [Resident #2] was admitted with hospice services on 8/19/21. Hospice Nurse #1 was asked, Did you see [Resident #2] after her fall on 9/28/2021? Hospice Nurse #1 stated, Yes, I came to the facility on [DATE] to do a face-to-face follow-up. I would've seen [Resident #2] last because she was COVID-19 positive. It was probably around 3:00 p.m., [Resident #2] did have a change in condition. She was very confused and didn't know who I was that day. She was shaky, like tremors. She did not have that before. She had bilateral orbital bruising and her lip was busted both on the inside of her lip and on the outside. They told me they were doing neuro checks. I did not see a nurse the whole time I was there. She was hypotensive. I do not think her symptoms were related to COVID. Hospice Nurse #1 was asked, Did you call the [Hospice Physician]? Hospice Nurse #1 stated, I wasn't able to get ahold of the [Hospice Physician] right away because he was working on the COVID unit in the hospital. I did notify the family and [Hospice Nurse #2], who was on call. I assessed her and seen [sic] what was going on. [Hospice Physician] did call back a couple hours later and gave verbal orders to send [Resident #2] to the emergency room to be evaluated. The family, [POA] also wanted her sent to the hospital. n. On 10/07/2021 at 12:48 p.m., CNA #1 was asked to describe Resident #2's fall on 9/28/2021. CNA #1 stated, I was filling up her water pitcher; I turned to go in there, and she had fallen. [Resident #2] was trying to go to the bathroom. I turned around and she fell . She hit her face on the bedside table. She had went down on the floor. I'm assuming that she had hit her face on the bedside leg. I'm assuming the metal bar. She had turned on her back when I got there. We didn't start neuro checks until the next day. The nurse did come in and assess [Resident #2]. [LPN #1] did call the family and Hospice and the [DON] and [ADON]. We cleaned up her lip and got the bleeding to stop . I know it was a big deal. The [DON] overrode and said we are not sending out. I know the ambulance was already there. [DON] was giving all kinds of excuses for not sending [Resident #2] out. I know it was a big ordeal. [Resident #2] did not complain of pain. She wasn't complaining at all. The next morning, she did have two black eyes and her lip was split a little bit. She did say her stomach was hurting. That morning [9/29/2021] [Hospice Nurse #1] got there. [Resident #2's] head and stomach were the main concerns. That evening [Hospice Nurse #2] came in. [Hospice Nurse #2] said that has never happened before, where the [DON] refused to send a resident to the hospital. o. On 10/7/2021 at 1:25 p.m., LPN #1was asked, Can you describe the events on 9/28/2021 when [Resident #2] fell in the facility? LPN #1 stated, The aide was filling up her water pitcher and turned around and watched her fall. [Resident #2] hit her mouth on the bedside table. The aide told me that she witnessed the fall. She hollered at me and I came down there. [Resident #2] was bleeding from her lip. We did her vital signs, nothing was abnormal. I took some wound cleanser. There was a gash, more on the inside than out. I used gauze and normal saline. It did quit bleeding. She probably needed stitches. I alerted the [DON], [ADON], [Nurse Practitioner] and [POA]. LPN #1 was asked, Did the resident complain of any pain? LPN #1 stated, [Resident #2] did not have any facial grimacing. Hospice didn't order any pain medications. LPN #1 was asked, Did you start neurological checks? LPN #1 stated, No, we didn't. It was a witnessed fall, and she didn't hit her head. I worked the next day and [Resident #2] did have some bruising to both corners of her eyes. Her nose was not bruised. [Hospice Nurse #2] asked why we were not doing neuro checks. They did start neurological checks the next day. [Hospice Nurse #2] said that you are supposed to do neuro checks anytime someone has an injury above the neck. LPN #1 was asked, How did [Resident #2] do throughout the night? LPN #1 stated, She was awake off and on throughout the night. I left at 10:15 p.m. p. On 10/7/2021 at 1:43 p.m., Hospice Nurse #2 was asked to describe the events that occurred after Resident #2's fall on 9/28/2021. Hospice Nurse #2 stated, I got a call around 9:30ish. The nurse called me. It was the first time I got a call. [LPN #1] told me she tried to get out of bed and hit her lip on the bedside table. [LPN #1] did not say anything about a fall. If it was a fall it is our protocol to come and do a face-to-face assessment. I asked [LPN #1] if I could come and assess [Resident #2]. [LPN #1] told me that she had went to sleep and didn't want to be bothered. On [9/29/2021] around 6:00 p.m., the [POA] called me and said she wanted [Resident #2] evaluated in the emergency room . She said that [Resident #2] was acting strange, according to the report she had gotten from [Hospice Nurse #1]. I tried to call the nursing home, but no one answers there. I finally got ahold of [LPN #2], who agreed that [Resident #2] might have some problems. When I got there, EMS [emergency medical services] was right behind me. I told the [DON] that the resident had a fall the other night and that Hospice and the family wanted her evaluated in the emergency room . I told [DON] that Hospice would pay for the emergency room visit. The [DON] said, No, we don't send them out. [DON] had three to four different reasons. [DON] told me that she doesn't care what the Hospice Doctor says we are not sending her out the door tonight. I called the family, and they were already waiting at the [Hospital]. I went back and assessed [Resident #2]. Her grips were uneven, and her pupils were dilated. She had two black raccoon eyes and a big sore on her top lip that was very swollen. [Resident #2] could not answer my questions or follow my directions. She had a tremor to her left arm. A CNA was back there. I did not get her name and she didn't have a badge on. She kind of told me what had happened. She told me it was a witnessed fall, but the nurse told me she didn't fall. The CNA first told me that she witnessed the fall, then she was telling she heard the resident fall. I don't know what was going on around there. Thank God she did not have a brain bleed. I have never had a facility tell me I couldn't have a patient evaluated at the emergency room . q. On 10/7/2021 at 2:08 p.m., LPN #2 was asked, Did [Resident #2] have a change in condition on 9/29/2021 after her fall on 9/28/2021? LPN #2 stated, [LPN #1] mentioned that [Resident #2] had fallen and had a laceration. When I saw her, she was resting in bed, I did not see any bleeding. She did have bruising to both of her eyes. I was instructed to start neuro checks. This was per the nursing consultant on the computer. [DON] had mentioned earlier that we had to do them. I happened to see on the computer. I don't know who the nursing consultant was. I didn't really notice a change in condition. I was kind of short of time. [Resident #2] was on the Covid Unit. I did take her her meds and she took them with no problems. She wasn't complaining of any pain. She could answer simple questions like yes or no. She was eating and drinking. I know the Hospice Nurse had a conversation with one of our nurses. I don't know their names. I know they wanted to send [Resident #2] out to be evaluated. I know the DON said that we are not going to send out. The next morning [Resident #2's] family came to the nursing home, and the DON said we were going to send [Resident #2] out. r. On 10/7/2021 at 11:41 a.m., Resident #2's POA was asked, Did the facility notify you of [Resident #2's] fall on 9/28/2021 and did you want [Resident #2] transferred to the hospital on 9/29/2021? The POA stated, Yes, they called me on [9/28/2021]; the nurse told me [Resident #2] had fallen but that she was OK and that she just had a busted lip. They didn't tell me that both eyes were black and that she had a big chunk missing from her lip. I'm sure they didn't even look . The next day I called, and I called. You can't get anyone to answer the phone over there. I did talk to the nurse in the a.m., and they told me she was fine. [Hospice Nurse #1] did call me that afternoon. She told me she was going to get the Doctor to write an order to send to the hospital. She told me that [Resident #2's] face was black and that she wasn't acting right. She told me that an ambulance was going to pick her up. [Hospice Nurse #2] called me forty-five minutes later and told me that the facility refused to let her go. A male nurse called me from there and asked me what my complaint was. I told him I wanted [Resident #2] evaluated in the emergency room . All he could say was 'Hmmm'. I guess the DON came in there and said there was no reason to send her out. I don't care what kind of order you got, that is what the DON said. I told her one way or another she is coming out of there. We want her taken to the house. In the emergency room , she didn't have a brain bleed. They didn't even draw any blood in the emergency room . They said we just can't keep her here. All the CT scans were negative . s. On 10/7/2021 at 3:51 p.m., the ADON was asked, Why did the DON not want the resident transferred to the emergency room ? The ADON stated, I called her on [9/29/2021] and told her that Hospice and the family wanted her transferred to the emergency room to be evaluated. They wanted to do a CT scan. I told her [Resident #2] had a POLST [Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [DON] told me that she was going to call the [Nurse Consultant]. [DON] chose not to call the Administrator. We do not know what was said. [DON] did say not to transfer [Resident #2] to the hospital on 9/29/2021, but she changed her mind after the family showed up on [9/30/2021]. t. On 10/6/2021 at 3:39 p.m., the Administrator was asked why the DON did not want to send the resident to the emergency roiagnom on [9/29/2021]? The Administrator stated, The staff said that [Resident #2] had a split lip, but they did not see a change in condition on her. They did do a body audit. The DON did call the Nurse Consultant. If no change in condition, don't send her. That is what I was told. I was not included in the conversation. The family called Hospice. If the family wants to send her out, then it is okay . The Hospice Doctor did give an order. [DON] contacted the Nurse Consultant. I don't know what they talked about. The Administrator was asked, Did the DON provide an explanation to you regarding why she was not wanting to send [Resident #2] to the hospital to be evaluated, even after the family requested and the Hospice Physician provided a written order? The Administrator stated, No. 2. The facility removed the Immediate Jeopardy and corrected the failed practice on 10/04/2021, prior to the survey, as evidenced by the following: a. The Nursing Progress Note dated 9/29/2021 at 12:00 P.M. documented neuro checks were initiated for the resident on 9/29/21. b. On 10/6/2021 at 3:39 p.m., the Administrator stated, I fired the DON for this. She maybe worked here a month and a half. She was only the DON for two weeks . The ADON stated the DON was terminated on 10/4/21. c. An Inservice sheet dated 10/4/21 at 10:00 a.m. documented the Interim DON and Assistant Director of Nursing (ADON) were in-serviced regarding, Insure [ensure] all Doctors orders are carried out in a timely manner. Notify Admin [Administrator] if any issues with sending resident out to ER [emergency room ] / Notify all parties involved. Per documentation provided by the Administrator on 10/7/21, verbal instructions were also provided to all Licensed Nursing Staff by the ADON and Administrator regarding following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . d. An Inservice Education Report dated 10/7/21 at 4:10 p.m. documented, All Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If there are any questions, please feel free to ask Administration.

Complaint # (AR 908) was substantiated (all or in part) in these findings: Based on record review and interview, the facility failed to ensure their abuse and neglect policy and procedures were implemented to prevent resident-to-resident altercations, care plans were updated with interventions to prevent aggressive behaviors, staff were trained on how to monitor and supervise residents with aggressive behaviors, one-on-one monitoring was consistently provided when necessary, and efforts were made to determine and address causative factors for the aggressive behaviors to prevent further physical attacks of other residents for 1 (Resident #15) of 3 (Residents #10, 11, and 15) case mix residents who had history of aggressive behaviors toward other residents. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #13, who was intentionally sought out and attacked by Resident #15 on 2 different occasions, and had the potential to affect 22 residents who had a history of [REDACTED]. The Administrator was notified of the Immediate Jeopardy on 1/10/18 at 8:00 p.m. The findings are 1. The Abuse, Neglect and Exploitation policy received from the Administrator on 1/10/17, documented, Policy: Each Resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medial symptoms. Residents must not be subject to abuse by anyone including, but not limited to: facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family member, legal guardians, friends or other individuals . 2. Abuse, means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Willful, means individual deliberately, not that the individual must have intended to, inflict injury or harm . 5. Prevention of Abuse, Neglect, Exploitation. The facility will consider utilization of the following tips for prevention of abuse, neglect and exploitation of residents . 2. Observe residents behavior and their reaction to other residents, roommates, tablemate's. Place resident in accommodations and environment that keep then calm . J. Provide instructions to staff on care needs of residents . l. Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident's room, residents with self-injurious behaviors, residents with communication disorders and those that require heavy nursing care and/or are totally dependent on staff . 8. Resident Protection after alleged Abuse, Neglect and Exploitation - The facility will make efforts to protect all residents after alleged abuse, neglect and/or exploration. a. Temporary (less than 24 hour) separation from other residents if a resident's behavior poses a threat of abuse or violence. b. Temporary or permanent room or roommate change, where incompatibility creates the potential for abuse .e. Temporary one on one supervision of a resident .j. Increased supervision of staff and/or residents. k. Protection of staff and/or resident from retaliation. 9. Response and Reporting of Abuse, Neglect and Explication- . a. Respond to the needs of the resident and protect them from further incident (document). b. Notify the Director of Nursing and Administrator (document). c. Initiate an investigation immediately. d. Notify the attending physician, resident's family/legal representative and Medical Director. e. Obtain witness statements, following appropriate policies. Suspend the accused employee pending completion of the investigation. Remove the employee from resident care areas immediately . i. Document actions taken in steps above in the medical record . The Administrator should follow up with government agencies during business hours, to confirm the report was received and to report the results of the investigation when final, as required by state agencies. 2. Resident #15 had was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Medicare 30 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/17 documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS); had behavioral symptoms directed towards others on 4 to 6 of the past 7 days, was independent with supervision of 1 person for bed mobility, transfers, ambulation in room and corridor, and dressing, required limited assistance of one person for toilet use and personal hygiene; extensive assistance of 1 person with bathing; had limited range of motion of upper and lower extremity on one side; was 58 inches tall, and weighed 201 pounds. a. The Care Plan documented, Focus, The resident has impaired cognitive function/dementia or impaired thought processes r/t (related to) Alzheimer's, Dementia impaired decision making. Date initiated 12/11/17. Interventions Administer medications as ordered. Ask yes/no questions in order to determine the resident's needs. Cue, orient and supervise as needed. Discuss concerns about confusion, disease process, NH (Nursing Home) placement with resident/family/caregivers. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. b. The resident's documented Incident and Accident Reports were as follows: 1) The Incident/Accident Report dated 1/6/17 at 12:21 a.m. documented, Incident Location; Dining Room, Person preparing report, (Licensed Practical Nurse (LPN) #2). Incident Description, Called to 300 Hall (Secure Unit) for Resident to Resident contact, (Resident #15) attacked (Resident #13) hit him in the back, no injuries noted at this time. Immediate action. Assessed Resident for injuries and kept them apart. Mental Status, oriented to person. Mobility-Ambulatory without assistance. Witness, (Certified Nursing Assistant (CNA)#1). There was no documentation of any follow-up to the incident. 2) The Incident/Accident Report dated 1/6/17 at 11:00 a.m. documented, (Resident #15), Incident Location; Dining Room, Person Preparing Report (LPN #3). Incident Description, Nursing Description: Resident noted to have hit another resident on his head .Immediate Action Taken Description: Redirected Resident to his room, continue one/one r/t (related to) safety. Resident taken to Hospital: No. Injuries observed , no injuries noted. Mental Status: Oriented to Person . There was no documentation of any follow-up to the incident. The one/one monitoring documentation for Resident #15 indicated one/one supervision was provided from 6:30 a.m. through 12:00 p.m.; however, an entry at 11:00 a.m. documented, He (Resident #15) came out of his room and went to the dining room and was hitting (Resident #13) in the head, and we made him go back to his room. c. The Progress Notes documented the following: 1/6/17 at 12:15 a.m. documented by LPN #2, Resident had a Resident to Resident contact. No injuries was noted at this time. Neuro's (neurological checks) are being done on (Resident #15) because Resident stated he was hit in the head. Neuro's were WNL (within normal limits). 1/6/17 2:30 (2:30 a.m.) Resident continuous on I&A (Incident and Accident) x (times) 2. New one tonight at 0015 (12:15 a.m.) Resident to Resident contact again. Resident went in dining room and hit another Resident. Residents both in bed resting with eyes closed. Will continue to monitor. 1/6/17 at 6:28 (6:28 a.m.) Situation: Resident to Resident contact. (Resident #15) attacked (Resident #13). (Resident #13) hit him (Resident #15) back. Background; He (Resident #15) has had other R (Resident) to (Resident) contact. Recommendation: Get (Resident #15) some med (medication). 1/6/17 at 11:00 a.m. Note text; Resident noted to have hit another resident on his head, dr (Dining Room) area. 0 (No) injuries noted, redirected resident to his room. One/one r/t safety. (Family member called) will brief oncoming shift. d. On 1/10/17 at 12:58 p.m., LPN #2 stated that she had been employed for approximately 1 year and worked the 11:00 p.m. - 7:00 a.m. (11-7) shift. The LPN was asked if she had received training for dealing with residents with aggressive behaviors. The LPN stated she had not had any training at this facility, but had training at a previous nursing home and a hospital. The LPN also stated, .make sure we separate the residents and get their minds on something else. The LPN was asked, When staff need help on the secure unit, how do they get help? The LPN stated, They open the door and holler, and if the call light is on for over a minute or two, I will go back. If a resident is up, we try to check with them more often. The LPN was asked to explain what happened with Resident #15 on 1/6/17. The LPN stated. (Resident #15) had gotten up and walked down the hall. (Resident #13) was in the second dining room and (Resident #15) attacked (Resident #13). Hit the resident in the head and (Resident #13) stated that he hit (Resident #15) back. (Resident #13) has a dirty mouth and (Resident #15) doesn't like bad mouth and (Resident #13) talking dirty. (Resident #15) gets really agitated and doesn't like other residents calling staff names. (Resident #15) is not very verbal, he doesn't talk a lot. (Resident #13) runs his mouth a lot. The LPN was asked, What did you do after the first incident? The LPN stated, I separated them and I checked them over. I talked to (Resident #13); he complained of his neck hurting and then he wanted to go out to smoke, I told him no. They were kept in their rooms. (Resident #13) kept coming out and mouthing. The LPN was asked, What did the resident say? The LPN stated, Called me a lying sack of (expletive) because he wasn't allowed to go smoke. The LPN was asked if residents were allowed to smoke at night. The LPN stated, No, due to we don't have enough staff, and they can't take them out to smoke. I am allergic to cigarette smoke, so I can't take them. We usually have 4 or 5 CNAs (Certified Nursing Assistants), here lately will have 5 or 6 due to the aggressive residents. The LPN was asked, How many (staff) are on the men's unit? The LPN stated, One CNA, and one CNA on the women's unit and then 3 to cover the other halls. (The facility had a census of 91 - the 100, 200 hall, 300 Hall Men's Secure Unit, 400 Hall, the front of 500 Hall, back of 500 hall Women's Secure Unit and the 600 Hall). The LPN stated, We put in the immediate ones (interventions). I don't know who puts in the other interventions. The LPN was asked, What did you do when there was a one on one altercation with (Resident #15) and (Resident #13), the first incident on 1/6/17? The LPN stated, The residents were placed in their room and I checked on them. There was no other issues. e. On 1/9/17 at 4:30 p.m., the Director of Nurses (DON) was asked about the issue with resident to resident altercations in the facility. The DON stated, There has been an issue with repeated resident to resident altercation. There was an incident involving (Resident #15). There was a resident to resident altercation with (Resident #18) on 1/3/17. (Resident #15) hit (Resident #18), his roommate, in the head with the control for the recliner. The residents were separated and (Resident #18) was moved to another room. The DON was asked if this incident was investigated to try to determine causative factors. The DON stated, No. The DON was asked, regarding the incident when (Resident #15) hit/attacked (Resident #13) on 1/6/17, when was the one on one initiated and who performed the one on one with (Resident #15) on 1/6/17 after the first incident occurred? The DON stated CNA #3. The DON was asked, The CNA was to be one on one with (Resident #15), and that left 1 CNA to care for the other residents on the hall? The DON stated, Yes. The DON was asked how many staff members were required for the men's secure unit on the day shift and stated, Two. The DON stated the CNA went to talk to the other CNA and (Resident #15) went to the dining room looking for (Resident #13) and attacked him again and hit Resident #13 in the head. The DON was asked, (Resident #15) was seeking out (Resident #13)? The DON stated, Yes. The DON was asked, This was a willful act and the resident was intentionally seeking out (Resident #13)? The DON stated, Yes. The DON was asked to explain what it meant to do one on one with a resident. The DON stated, They are to remain in the room with the resident and go everywhere the resident goes. The DON was asked if the staff member was to leave the resident alone when on one on one. The DON stated, No. The DON was asked, regarding the one on one observation, have the staff been informed on how to conducted one on one monitoring, and is there documentation of the one on one? The DON stated, Yes. The DON was asked when the resident was placed on one on one. The DON stated on the 11:00 p.m. - 7:00 a.m. (11-7) shift. The DON was asked who was sitting with the resident on one on one. The DON stated she was not sure. The DON was asked how many staff were on the 300 hall secure unit at night. The DON stated there was 1 staff person on each secure unit at night. The DON was informed that, based on interviews with staff, Resident #15 was in bed and monitored, but was not placed on one on one. The DON stated, I thought he had been placed on one on one. The DON was asked how staff on the secure unit could contact other staff for assistance when needed and The DON stated, They stick their head out the door and holler. The DON was asked if she had investigated the incident. The DON stated the resident was sent to a geriatric psychiatric facility. The DON was asked if she had investigated the incident for the causative factors related to the 2 incidents and stated, No. The DON was asked if there was a plan in place to address the resident's behaviors when the resident returns from the geri-psych facility. The DON stated, No, not at this time. The DON was asked if any education was provided for the staff related to residents with a [DIAGNOSES REDACTED]. The DON stated, No. 3. The Immediate Jeopardy was removed and the scope/severity reduced to H on 1/11/18 at 3:37 p.m., when the facility implemented the following Plan of Removal: 1. A. On 1/10/2018 at 2030 (8:30 p.m.), Administrator/designee started in-service with all staff on care of residents with dementia and behaviors, including direct care staff on using techniques for redirection to minimize aggressive behavior, ensuring all staff currently working on the floor are immediately in-serviced and that all staff scheduled are inserviced prior to starting tour of duty on the floor including those on leave or vacation. All new staff will also be in-serviced prior to placement on the floor. B. On 1/10/18 at 2030, Administrator/designee purchased, in-serviced, and issued walkie talkies to staff on secure unit to ensure a process for staff to obtain help when needed in secure unit, ensuring all staff currently working on the floor are immediately in-serviced and that all staff scheduled are in-serviced prior to starting tour of duty on the floor including those on leave or vacation. All new staff will also be in-serviced prior to placement of the floor. On 1/6/18 Resident #15's physician was notified and an order was received to send patient to geriatric psychiatric hospital and currently remains in hospital. Upon return to facility patient will be monitored for aggression and aggression care planned and implemented as needed for 1:1 monitoring, Psychiatric consult, and psychiatric evaluation at hospital. On 1/10/18 at 2100 (9:00 p.m.) MDS/Care Plan coordinator immediately reviewed 27 resident care plans with 19 residents having [DIAGNOSES REDACTED]. On 1/10/18 at 2100 (9:00 p.m.) Administrator/designee began in-service with all nurses and direct care staff on care planning and following the care plan of all residents with cognitive limitation and aggressive behavior including those admitted or readmitted from geriatric psychiatric unit to ensure the interventions for dementia and aggressive residents address the residents cognitive limitation and aggressive behavior, ensuring all nurses and direct care staff currently working on the floor are immediately in-serviced and that all nurses and direct care staff scheduled are in-serviced prior to starting tour duty on the floor including those on leave or vacation. All new nurses and direct care staff will also be in-serviced prior to placement of the floor. D. On 1/10/18 at 2030, Administrator/designee immediately began in-service to ensure all aggressive residents placed on one-on-one is implemented, ensuring all staff currently working on the floor are immediately in-serviced and that all staff scheduled are in-serviced prior to starting tour of duty on the floor including those on leave or vacation. All new staff will also be in-inserviced prior to placement on the floor. E. On 1/10/18 at 2030, Administrator began in-service to ensure residents with aggression towards other residents are supervised, ensuring all supervising nursing staff currently working on the floor are immediately in-serviced and that all supervising nursing staff scheduled are in-serviced prior to starting tour of duty on the floor including those on leave or vacation. All new supervising nursing staff will also be in-serviced prior to placement on the floor. F. On 1/10/18 at 2030, Administrator began in-service to ensure one-on-one is provided with additional staff, ensuring all supervising nursing staff currently working on the floor are immediately in-serviced and that all supervising nursing staff scheduled are in-serviced prior to starting tour of duty on the floor including those on leave or vacation. All new supervising nursing staff will also be in-serviced prior to placement on the floor. 2. A. DON/designee will monitor staff knowledge of care of residents with dementia and behavior using monitoring log by asking 2 questions regarding in-service to all unit staff daily for 5 days then three staff members from each unit three times weekly x (times) 4 weeks then monthly, making corrections as needed and reporting negative findings to Administrator. B. DON/designee will monitor presence and proper use of walkie talkies to staff on secure unit ensuring a process for staff to obtain help when needed in secure unit using monitoring log and monitoring all unit staff daily for 5 days then three staff members on secure unit weekly until compliance is achieved, making corrections as needed and reporting negative findings to Administrator. C. DON/designee will review the care plans of all residents with cognitive limitation and aggressive behavior including those admitted or readmitted from geriatric psychiatric unit to ensure the care plan addresses their cognitive limitation and aggressive behavior using a monitoring log 5 times for one week then 3 times weekly until compliance is achieved, making corrections as needed and reporting negative findings to the Administrator. D. DON/designee will visually monitor implementation of one-on-one for all aggressive residents placed one-on-one using a monitoring log daily until compliance is achieved, making corrections as needed and reporting negative findings to the Administrator. E. DON/designee will visually monitor using monitoring log to ensure residents with aggression towards other residents are supervised daily x 5 then three times a week x 4 then weekly, making corrections as needed and reporting negative findings to the Administrator. F. DON/designee will visually monitor using monitoring log to ensure one-on-one is provided with additional staff daily x 5 then three times a week x 4 then weekly, making corrections as needed and reporting negative findings to the Administrator. 3. DON/designee will present finding to QAPI (Quality Assurance and Performance Improvement) committee monthly for additional recommendations.

Complaint # (AR 908) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure comprehensive, resident-centered care plans were promptly developed after admission and re-admission to include interventions that addressed cognitive impairment with aggressive behaviors that could result in harm to self or others, in order to minimize the potential for resident injuries and enable residents to attain the highest practicable level of physical, mental, and psychosocial well-being for 4 (Residents #10, #11, 13, and #15) of 5 (Residents #2, #9, #10, #11, and #15) case mix residents who had a [DIAGNOSES REDACTED]. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Residents #13, #15, #17, #18, and #19) who were physically assaulted by Residents #10, #11, #13, and #15 and had the potential to cause more than minimal harm This failed practice had the potential to affect 26 residents who had a [DIAGNOSES REDACTED]. The Administrator was informed of the Immediate Jeopardy condition on [DATE] at 8:00 p.m. The findings are: The findings are: 1. The facility's written Behavior Management Program, received from the Administrator on [DATE], documented, Preface, This facility promotes and supports a resident centered approach to care. The purpose of this policy is to define and set expectations regarding mood and behavioral health services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, there an individualized approach to care is essential . RAI (Resident Assessment Instrument) Process . The RAI process (MDS (Minimum Data Set), CAAs (Care Area Assessments) and Care Planning) will be completed by the Interdisciplinary Team to determine person-centered care plan goals and approaches based upon the comprehensive assessment. b. Based upon the assessment findings, the interdisciplinary team will complete a comprehensive Person-centered Care Plan including specific mood and behavior interventions and approaches as applicable. c. Recognition and Management of Dementia a. The facility will assess and determine individualized behavioral care plan interventions for individuals with dementia. b. Behavioral interventions are individualized approaches (including direct care and activities) that are provided as part of a supportive physical and psychosocial environment and are directed toward understanding, preventing, relieving and/or accommodating a residents distress or loss of abilities. 5. Mood and Behavior Tracking a. Mood and Behavior tracking documentation will be completed by front line staff, based upon comprehensive assessment outcomes, to identify any mood and behavior patterns, intervention attempted and outcome of approaches. b. Mood and behavior tracking will be reviewed by the interdisciplinary team on a quarterly basis or more often as needed to determine trends and effectiveness of care plan interventions (see Behavior Tracking Policy and Procedure). c. Mood and behavior tracking will be reviewed by the Charge Nurse per facility policy to determine trends and effectiveness of Care Plan interventions . 9. Emergent Changes, a. If a resident displays behaviors or mood changes that are a potential danger to the safety, health and welfare of themselves or others, the interdisciplinary team will assess the resident's current status and in conjunction with the discharge policy, make appropriate intervention or placement decisions . 2. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Medicare 5 Day Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] documented the resident scored 2 (,[DATE] indicates severely impaired in cognitive skills) on the Brief Interview for Mental Status (BIMS); had physical behavioral symptoms directed toward others that had occurred for 1 to 3 days and verbal behaviors symptoms directed towards others that had occurred on 4 to 6 of the last 7 days; required supervision with bed mobility, transfers, ambulation in room and corridor; required limited assistance of 1 person for dressing, and personal hygiene; and that bathing did not occur in the look back period of 7 days. a. The Resident Incident and Accident Reports for aggressive behaviors with this resident documented the following: 1) [DATE] at 12:45 p.m., Resident noted to have hit another resident (Resident #15) in facial area in hallway. Immediate Action Taken, Resident was redirected to safer environment one-on-one watch. There was no documentation in the resident's clinical record that the incident was investigated for causative factors or interventions were developed related to this incident. 2) [DATE] at 6:05 a.m., Aide reported seeing (Resident #11) attacked. (Resident #14) was backing up away from (Resident #11) and (Resident #11) was moving towards him and he tripped over piano bench and fell . (Resident #11) steadied himself on the back of a chair and then picked up the chair and started hitting (Resident #14) with the chair causing skin tear to (Resident #14's) ankle. (Resident #11) fell from swinging chair. (Resident #11) cont.(continued) to cuss at staff and residents, hitting staff aide that is one on one with him. Trying to attack this Nurse. Calling residents (expletives and racial epithets). Resident also tried to attack another resident in the dining room but aide stopped him . Immediate Action Taken, Resident is one on one at this time. Resident was taken to the hospital. There was no documentation regarding a follow-up investigation for this incident. b. Nurses Notes documented the following: 1) On [DATE]: the Resident was standing in hallway at this time holding wheelchair leg rest and threatening to hit the teenagers with it. The Aide tried telling resident there were no teenagers here, and the Nurse talked to the resident, will monitor. 2) On [DATE]: the resident had verbal behaviors of yelling and cussing, with racial slurs, at (other) resident. The resident was redirected. 3) On [DATE]: resident had verbal behaviors of yelling and screaming at staff, medicated with PRN (as needed) [MEDICATION NAME]. 4) On [DATE]: the resident was in hallway threatening trying to hit at CNA (Certified Nursing Assistant), using foul language at CNAs, kicking door entrance, wanted to leave. Resident was taken out to smoke and redirected. [MEDICATION NAME] had been administered earlier. 5) On [DATE]: the resident was very argumentative, yelling using foul language at staff when redirected, refused to take am (morning) meds (medications). Physician was notified and meds were taken to resident's room and resident threw the meds on the floor. The Physician was notified. Order to send resident to (geriatric psychiatric facility). Resident was readmitted to the facility on [DATE]. There was no documentation related to implementation of interventions related to aggressive verbal behaviors. 6) On [DATE]: resident yells at other residents at times with redirection. 7) On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]: Observed for behaviors yells at other residents at times, redirect as needed. 8) On [DATE]: resident was going into other resident's room and cursing at them and threatening them if they don't stop yelling he will shut them up. Resident was redirected. The redirection was ineffective and a stop and watch was filled out for the Physician. 9) On [DATE]: the resident was yelling out that he will make them stop yelling so he can get some rest. 10) On [DATE]: Resident was having increased confusion this shift with aggressive behaviors. Attempted to assault staff. Resident was beating on door of unit demanding to smoke. 11) On [DATE]: the resident was in hallway in w/c (wheelchair) got up and noted to hit another resident (Resident #15) in facial area, resident redirected to safer area. Resident using foul language at staff. Resident was sent to (geriatric psychiatric (geri-psych) facility) and was readmitted to the facility on [DATE] with no documentation of further interventions or plans to address the resident's aggressive behaviors. 12) On [DATE]: the Resident had an incident of verbal behaviors, yelled /cussed at other residents. There were no Nurses Notes related to the incident referenced on the Incident Report dated [DATE]. The resident was sent to Geri-Psych at that time and had not been readmitted to the facility at the time of the survey. c. The Progress Notes documented by the Advanced Practice Nurse (APN) on [DATE] documented, Resident was sent to emergency room for evaluation and treatment on [DATE] secondary to aggressive behaviors along with throwing his television . This incident was not documented in the Nurses Notes. d. The Resident's Comprehensive Care Plan dated as revised [DATE] documented, I have behaviors as evidenced by hitting another resident when he was in the bathroom when I wanted to use it. I also wander at times, an elopement risk and I curse a lot. Goal, I verbalize understanding of need to control physically aggressive behavior through the review date. Revision date ([DATE]). Interventions, Administer medications as ordered. Monitor/document for side effects and effectiveness. Assess and anticipate residents needs, food, thirst, toileting needs, comfort level, body positioning, pain etc. Give the resident as many choices as possible about care and activities, Monitor/document/report PRN any s/sx (signs/symptoms) of resident posing danger to self or others. Psychiatric/Psychogeriatric consult as indicated. When the resident becomes agitated, intervene before agitation escalates, Guide away from source of distress, Encourage calmly in conversation, If response is aggressive, staff to walk away and approach later. There was no documentation of any further interventions to address the additional incidents of aggressive behaviors that occurred on [DATE] and [DATE]. 3. Resident #15 had was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Medicare 30 day MDS with an ARD of [DATE] documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS); had behavioral symptoms directed towards others on 4 to 6 of the past 7 days, was independent with supervision of 1 person for bed mobility, transfers, ambulation in room and corridor, and dressing, required limited assistance of one person for toilet use and personal hygiene; extensive assistance of 1 person with bathing; had limited range of motion of the upper and lower extremity on one side; was 58 inches tall; and weighed 201 pounds. a. Incident and Accident Reports for this resident documented the following:: 1) The Incident/Accident Report dated [DATE] at 12:21 a.m. documented, Incident Location; Dining Room, Person preparing report, Licensed Practical Nurse (LPN) #2. Incident Description, Called to 300 Hall (Secure Unit) for Resident to Resident contact, (Resident #15) attacked (Resident #13) hit him in the back, no injuries noted at this time. Immediate action. Assessed Resident for injuries and kept them apart. Mental Status, oriented to person. Mobility-Ambulatory without assistance. Witness, (Certified Nursing Assistant (CNA))#1. There was no documentation of any follow-up to the incident. 2) The Incident/Accident Report dated [DATE] at 11:00 a.m. documented, (Resident #15), Incident Location; Dining Room, Person Preparing Report (Licensed Practical Nurse (LPN) #3). Incident Description, Nursing Description: Resident noted to have hit another resident on his head .Immediate Action Taken Description: Redirected Resident to his room, continue one/one r/t (related to) safety. Resident taken to Hospital: No. Injuries observed , no injuries noted. Mental Status: Oriented to Person . There was no documentation of any follow-up to the incident. The documentation of 1:1 monitoring for Resident #15 documented one/one from 6:30 a.m. through 12:00 p.m. There was documentation at 11:00 a.m. He (Resident #15) came out of his room and went to the dining room and was hitting (Resident #13) in the head and we made him go back to his room. b. The Progress Notes documented the following: [DATE] at 12:15 a.m. documented by LPN #2, Resident had a Resident to Resident contact. No injuries was noted at this time. Neuro's (neurological checks) are being done on (Resident #15) because Resident stated he was hit in the head. Neuro's were WNL (within normal limits). [DATE] 2:30 (2:30 a.m.) Resident continuous on I&A (Incident and Accident) x (times) 2. New one tonight at 0015 (12:15 a.m.) Resident to Resident contact again. Resident went in dining room and hit another Resident. Residents both in bed resting with eyes closed. Will continue to monitor. [DATE] at 6:28 (6:28 a.m.) Situation: Resident to Resident contact. (Resident #15) attacked (Resident #13). (Resident #13) hit him (Resident #15) back. Background; He (Resident #15) has had other R (Resident) to (Resident) contact. Recommendation: Get (Resident #15) some med (medication). [DATE] at 11:00 a.m. Note text; Resident noted to have hit another resident on his head, dr (Dining Room) area. 0 (No) injuries noted, redirected resident to his room. One/one r/t safety. (Family member called) will brief oncoming shift. c. On [DATE] at 12:58 p.m., LPN #2 stated that she had been employed for approximately 1 year and worked the night shift., 11:00 p.m. - 7:00 a.m. (,[DATE]) shift. The LPN was asked regarding training for dealing with residents with aggressive behaviors. The LPN stated she had not had any training at this facility, but had training at a previous nursing home and a hospital. The LPN stated, Make sure we separate the residents and get their minds on something else. The LPN was asked when staff need help on the secure unit how do they get help. The LPN stated, They open the door and holler and if the call light is on for over a minute or two I will go back. If a resident is up we try to check with them more often. The LPN was asked how long had the phone not been functioning. She stated, I have no idea, I don't know if it has ever worked. The LPN was asked to explain what happened with Resident #15 on [DATE]. The LPN stated. (Resident #15) had gotten up and walked down the hall. (Resident #13) was in the second dining room and (Resident #15) attacked (Resident #13). Hit the resident in the head and (Resident #13) stated that he hit (Resident #15) back. (Resident #13) has a dirty mouth and (Resident #15) doesn't like bad mouth and (Resident #13) talking dirty. (Resident #15) gets really agitated and doesn't like other residents calling staff names. (Resident #15) is not very verbal he doesn't talk a lot. (Resident #13) runs his mouth a lot. The LPN was asked, What did you do after the first incident? The LPN stated, I separated them and I checked them over. I talked to (Resident #13) he complained of neck hurting and then he wanted to go out to smoke, I told him no. They were kept in their rooms. (Resident #13) kept coming out and mouthing. The LPN was asked, What did the resident say? The LPN stated, Called me a lying sack of[***]because he wasn't allowed to go smoke. The LPN was asked if at night were the residents allowed not allowed to smoke. The LPN stated, No, due to we don't have enough staff and they can't take then out to smoke. I am allergic to cigarette smoke so I can't take them. We usually have 4 or 5 CNA's, here lately will have 5 or 6 due to the aggressive residents. The LPN was asked, How many (staff) are on the men's unit? The LPN stated, One CNA and one CNA on the women's and 3 to cover the other halls. (The facility census 91, there 100, 200 hall, 300 Hall Men's Secure Unit 400 Hall, the front of 500 Hall, back of 500 hall Women's Secure Unit and the 600 Hall). The LPN stated, We put in the immediate ones (interventions). I don't know who puts in the other interventions. The LPN was asked, What did you do when there was a one on one altercation with (Resident #15) and (Resident #13) on the first incident on [DATE] . The LPN stated, The residents were placed in their room and I checked on them. There were no other issues. d. The Comprehensive Care Plan documented, Focus, The Resident has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's, Dementia impaired decision making Date initiated [DATE]. Goal, The resident will maintain current level of cognitive function through the review date. Interventions, Administer medications as ordered. Ask yes/no questions in order to determine the resident's needs. Cue, orient and supervise as needed. Discuss concerns about confusion, disease process, NH (Nursing Home) placement with resident/family/caregivers. Keep the Resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. The Comprehensive Care Plan did not address the resident's aggressive behaviors as documented above and the Care Plan was not updated with the continued episodes of aggressive behaviors as documented above. 4. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS with an ARD of [DATE] documented the resident scored 7 ,[DATE] indicates severely impaired) on the BIMS, was independent with transfers and ambulation, had physical behavioral symptoms towards other that had occurred in the past 1 to 3 days and verbal behavioral symptoms towards other that had occurred in the past 4 to 6 days. a. The Resident's Incident Reports documented: 1) [DATE] at 10:50 a.m. Incident Description, Resident noted to have punched another male resident (Resident #18) in his room, Resident was going to use the restroom when it was already occupied. The Resident stated that he was slapped in the face, so he punched the other resident . Immediate Action Taken, Removed resident to safer environment. The report did not document an investigation regarding this incident or interventions related to this incident. 2) [DATE] at 3:43 a.m. Incident Description, was called back to 300 Hall because of Resident to Resident contact, Resident said that (Resident #15) attacked him and he fought back. He first said that his neck hurt on his L (left) side. But when I went to look at this he asked if he asked if he could go smoke and told him no. Then he stated, that he was ok and that I was a lying sack of s***. Then Resident stormed to his room. The Immediate Action Taken, Assessed as much as Resident would let me and kept the Residents apart. There was no documentation that this incident was investigated regarding the causative factors. 3) [DATE] at 11:00 a.m. Incident Description, Resident noted to be sitting in dr (Dining Room) area, another Resident (Resident #15) hit this resident on the head area. Stated he hit me on my head. Immediate Action Taken, Neuro check q (every) shift other resident from this resident r/t (retaining to) safety. There was no documentation regarding an investigation regarding this incident. 4. On [DATE] at 4:30 p.m., the Director of Nursing (DON) was asked about the issues with resident to resident altercations in the facility. The DON stated, There has been an issue with repeated resident to resident altercation. There was an incident involving (Resident #15), the resident to resident altercation with (Resident #18) on [DATE]. (Resident #15) hit (Resident #18), his roommate in the head with control for the recliner. The residents were separated and (Resident #18) was moved to another room. The DON was asked if this incident was investigated to determine the causative factors. The DON stated, No. The DON was asked regarding the incident with Resident #15 who hit/attacked Resident #13 on [DATE] when was the one on one initiated and who performed the one on one with (Resident #15) on [DATE] that night of the incident had occurred? There was documentation in the resident's medical record for the one on one starting at 6:30 a.m. The DON stated CNA #3. The DON was asked if CNA #3 was scheduled for the day shift on the 300 Hall. The DON stated, Yes. The DON was asked if CNA #3 was to be one on one with Resident #15 did that leave 1 CNA to care for the residents on the hall. The DON stated, Yes. The DON was asked how many staff member were required for the men's secure unit on the day shift. The DON stated, 2. The DON was asked if the CNA was pulled to perform the one on one and this left one CNA to care for the other residents. The DON stated. Yes. The DON stated that the CNA went to talk to the other CNA and Resident #15 went to the dining room looking for Resident #13 and attacked him again. Hitting the resident in the head. The DON was asked, This was an willful act and the resident was intentionally seeking out (Resident #13)? The DON stated, Yes. The DON was asked, regarding the one on one for the resident, can you explain how one on one is conducted. The DON stated, They are to remain in the room with the resident and go everywhere the resident goes. The DON was asked if the staff members were to leave the resident alone when on one on one. The DON stated, No. The DON was asked if the staff had been instructed on how to perform one-on-one monitoring and if there was documentation. The DON stated, Yes. The DON was asked when the resident was placed on one on one. The DON stated on the ,[DATE] shift. The DON was asked who was sitting with the resident on one on one. The DON stated that she was not sure. The DON was asked how many staff were on the 300 hall secure unit at night. The DON stated there was 1 staff on each unit. The DON was informed that in an interview with the staff, that Resident #15 was in bed and monitored, but the resident was not placed on one on one. The DON stated, I thought he had been placed on one on one. The DON was asked regarding the communication that the staff had on the secure unit when they needed to contact someone for help. The DON stated, They stick their head out the door and holler. The Surveyor stated, according to observations on the unit, that there was a phone on the secure unit on the morning of [DATE], but the phone was not working. At that time, the CNA #4 reported that the phone had not been functioning for some time. LPN #2 stated they had been employed for approximately one year and was not aware of the phone working. The DON did not respond. The DON was asked if she had investigated the incident. The DON stated the resident was sent to a geriatric psychiatric facility. The DON was asked if she had investigated the incident for the causative factors that lead up the 2 incidents of resident to resident altercation. The DON stated, No. The DON was asked if there was a plan in place to address the resident's behaviors when the resident returns from the geri-psych facility. The DON stated, No, not at this time. The DON was asked if any education was provided for the staff related to residents with a [DIAGNOSES REDACTED]. The DON stated, No. The DON was asked who was responsible for updating the resident's comprehensive care plan and the DON stated that any nurse could update the care plan. The DON was asked if the residents with behaviors have had their care plans updated to address interventions for the aggressive behaviors or plans put in place when the residents were readmitted to the facility due to behaviors. The DON stated, No. The DON was asked if the residents' care plans were individualized to address the resident centered care for the residents' behaviors for these residents that exhibited aggressive behaviors. The DON stated, No. 5. Resident #10 had [DIAGNOSES REDACTED]. The Discharge MDS with an ARD of [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making per a SAMS and had behavioral symptoms of Physical behavioral symptoms directed toward others (e.g. (for example), hitting, kicking, pushing, scratching, grabbing .), and verbal behavioral symptoms directed towards others that had occurred with a frequency in 1 to 3 days. a. The Care Plan dated [DATE] was reviewed and there was no documentation that addressed the resident's [DIAGNOSES REDACTED]. There was no documentation the care plan was discussed with the resident's responsible party when it was initiated on [DATE]. b. A Nursing Progress Note dated [DATE] at 7:00 p.m., written by Registered Nurse (RN) #2, documented, resident was cussing another resident and hit him on the head. Residents were separated and this resident was placed on one-on-one monitoring. mother called and notified, dr (doctor) called . monitoring for behaviors . A Progress Note dated [DATE] at 2:03 a.m. documented, .I & A R/T (related to) hitting another resident . c. An incident report dated [DATE] at 11:32 p.m. documented, .Incident Location: Dining Room . Incident Description: Nursing Description: CNA reported to this nurse that this resident hit another resident in the head . Immediate Action Taken: Description: separated both of the residents the resident went to this room and was being monitored by CNAs on the hall . There was no documentation of an investigation to determine the causative factors for the incident nor any recommendation for any interventions to prevent recurrence. d. A Nursing Progress Note dated [DATE] at 12:00 p.m. documented, resident has increased behaviors this shift. pacing the hallways, cussing towards other residents, making threats to residents and staff, saying he was 'going to break her (expletive) nose.' resident talks to himself, flailing arms around showing anxious body language. cont (continues) to strip clothes off throughout shift, throwing and pushing furniture around. cont with ,[DATE] with staff member at this time. e. A Nursing Progress Note dated [DATE] at 9:55 p.m. documented, resident cont having increased behaviors this shift. Threatening and cussing towards staff and other residents. Resident threw food and silverware at staff this shift. Remains ,[DATE] with staff member. Call (APN), orders given to transfer to (geri-psych hospital). Resident transferred via ems (emergency medical services) left facility at 2100 (9:00 p.m.) . f. The hospital History and Physical dated [DATE] documented, .Impression: 1. Dementia with behavior disorder . A hospital Progress Note dated [DATE] documented, .the patient was pacing the hallways in his nursing home, swearing at staff and residents and threatening other residents . He has been agitated. He refused to leave his room. Poor eye contact. He has continued to be talking to the air and responding to internal stimuli. He engages in conversations with no one. He is smiling and laughing.He taps very hard on the glass around the nurse's station. Apparently the patient swung at the tech (technician) and began chasing the techs.Mood: Irritable and agitated . Assessment: Major neurocognitive disorder with behavioral disturbance . Hx (history) Unspecified [MEDICAL CONDITION] not due to a substance or not physiological condition Hx of Dementia and other diseases classified elsewhere but with behavior disturbance Hx of [MEDICAL CONDITION], unspecified Rule out Delusional disorder Rule out [MEDICAL CONDITION] Rule out Unspecified [MEDICAL CONDITION] . Progress Note dated [DATE] Nursing Report: . He gets easily agitated and will attempt to strike staff when irritable . g. A Nursing Progress Note dated [DATE] at 2:35 p.m. documented, Note Text: resident readmitted to (facility) 300 secured unit, arrived to nh via nh van with staff X 2, alert . up ad lib (as desired) ambulates at intervals, .observed for behaviors, . refused vs (vital signs) this shift . There was no documentation in the resident's care plan that indicated the need to monitor the resident for aggressive behaviors nor interventions that should be implemented if aggressive behaviors occurred. h. A Nursing Progress Note dated [DATE] at 10:15 a.m., written by Registered Nurse (RN) #2, documented, resident was refusing care was kicking hitting CNAs this nurse told CNAs to back off and let resident calm down. Resident does not redirect. i. A Nursing Progress Note dated [DATE] at 1:00 p.m., written by RN #2 documented, resident had sit down on roommate's arm while roommate was sleeping in roommate's bed. j. An Incident Report dated [DATE] at 10:21 p.m. documented, .CNAs walk in resident's room and seen this resident sitting on another resident's arm while the other resident was sleeping in his bed.Notes [DATE] (documented) On [DATE], the resident was found sitting on top of another resident. The resident has inappropriate behaviors that he does not know how to control. Resident was placed one on one until he was sent to (geripsych hospital). k. On [DATE] at 1:38 p.m., the MDS Coordinator was asked who had done the entry assessment for the resident and the MDS Coordinator stated, I did. The MDS Coordinator was asked where the information was obtained about the resident and the MDS Coordinator stated, From the resident chart. The MDS Coordinator was referred to the MDS assessment and was asked if the resident had behaviors and the MDS Coordinator stated, Yes. The MDS Coordinator was asked when the resident had been readmitted and the MDS Coordinator stated, On ,[DATE] (18). The MDS Coordinator was asked who had developed the resident's care plan and the MDS Coordinator stated, He would have only had a temporary (plan) that the nurse who admitted him would have done. The MDS Coordinator was shown the resident's care plan and was asked if this was the temporary care plan and the MDS Coordinator stated, Yes. The MDS Coordinator was asked who updated the care plan when the resident was readmitted and the MDS Coordinator stated, Anyone can update. The MDS Coordinator was asked when the resident was readmitted if the care plan addressed the resident's aggression and the MDS Coordinator stated, He should have had an update on readmit when he came back. l. On [DATE] at 2:05 p.m., the ADON was asked if had done the care plan when the resident returned to facility on [DATE] and the ADON stated, I wasn't here . probably from admission. The ADON was asked if care plans were to be specific and individualized to the resident and the ADON stated, They're suppose to be. The ADON was shown the resident's care plan for review and was asked if the care plan addressed the resident's behaviors. The ADON stated, It addresses ADLs (activities of daily living), transfers, pain medication. The ADON was asked when the resident was readmitted was it a geri-psychiatric facility and the ADON stated, I don't know the hospital exactly but it was a psych facility. The ADON was asked if the resident had to be transferred to a psych facility when he was admitted in ,[DATE] and the ADON stated, Yes. m. On [DATE] at 2:52 p.m., the DON was asked when the resident was admitted in ,[DATE] if it was to the secured unit and the DON stated, Yes. The DON was asked what the reason was when the resident was sent out in ,[DATE] and the DON stated, If I'm not mistaken he was having some aggression.

Complaint (AR 908) substantiated, all or in part, in these findings. A. Based on record review and interview, the facility failed to ensure resident to resident altercations were investigated, causative factors were identified, and interventions implemented to prevent further resident-to-resident altercations and aggressive behaviors for 4 of 4 (Resident #10, 11, 13, and 15) case mix residents who exhibited aggressive behaviors and for 5 of 5 (Residents #13, #15, #17, #18, and #19) case mix residents who were assaulted by other residents who had aggressive behaviors. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Residents #13, #15, #17, #18, and #19) who were physically assaulted by Residents #10, #11, #13, and #15 and had the potential to cause more than minimal harm to 13 residents who resided on the 300 Hall secure unit, as documented on a list provided by the Administrator [DATE]; and 10 residents who were involved in Resident to Resident altercations as documented on a list provided by Registered Nurse (RN Consultant) #1 on [DATE]. The Administrator was informed of the Immediate Jeopardy condition on [DATE] at 8:00 p.m. The findings are: 1. Resident #11 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Medicare 5 Day Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] documented the resident scored 2 (,[DATE] indicates severely impaired) on the Brief Interview for Mental Status (BIMS), had physical behavioral symptoms directed toward others that had occurred for 1 to 3 days and verbal behaviors symptoms directed towards others that had occurred over the 4 to 6 days, required supervision with bed mobility, transfers, ambulation in room and corridor, required limited assistance of 1 person for dressing, and personal hygiene. a. The Incident and Accident documented as follows: 1) [DATE] at 12:45 p.m. Resident noted to have hit another resident (Resident #15) in facial area in hallway. Immediate Action Taken, Resident was redirected to safer environment one-on-one watch. There was no documentation that the incident was investigated for causative factors and no documentation related to intervention implemented to prevent further incidents. 2) [DATE] at 6:05 a.m. Aide reported seeing (Resident #11) attacked (Resident #14) was backing up away from (Resident #11) and (Resident #11) was moving towards him and he tripped over piano bench and fell . (Resident #11) had steadied himself on the back of a chair and then picked up the chair and started hitting (Resident #14) with the chair causing skin tear to (Resident #14) ankle. (Resident #11) fell from swinging chair. (Resident #11) cont.(continued) to cuss at staff and residents, hitting staff aide that is one on one with him. Trying to attack this Nurse. Calling residents (expletives). Resident also tried to attack another resident in the dining room but aide stopped him . Immediate Action Taken, Resident is one on one at this time. Resident was taken to the hospital. There was no documentation regarding follow-up investigation for this incident. b. Nurses and Progress Notes documented: 1) On [DATE] the resident was standing in hallway at this time holding wheelchair leg rest and threatening to hit the teenagers with it. The Aide tried telling resident there were no teenagers here and the Nurse talked to the resident, will monitor. 2) On [DATE] the resident had verbal behaviors of yelling and cussing with racial slurs at resident, the resident was redirected. 3) On [DATE] resident had verbal behaviors of yelling and screaming at staff, medicated with PRN (as needed) [MEDICATION NAME]. 4) On [DATE] the resident was in hallway threatening trying to hit at CNA using foul language at CNA's kicking door entrance wanted to leave. Resident was taken out to smoke and redirected. [MEDICATION NAME] had been administered earlier. 5) On [DATE] the resident was very argumentative, yelling using foul language at staff when redirected, refused to take am (morning) meds (medications). Physician was notified and meds were taken to resident's room and resident threw the meds on the floor. The Physician was notified. Order to send resident to (geri-psych facility). Resident was readmitted to the facility on [DATE]. There was no documentation related to implementation of interventions related to aggressive verbal behaviors. The hospital discharge instructions dated [DATE] documented, .Indicators/Treatment Plan . ,[DATE] (24 hours/7 days) Care Nursing Home Psy. (psychiatric) Med (medication) Management . 6) The Progress Notes documented by the APN, on [DATE] documented, Resident was sent to emergency room for evaluation and treatment on [DATE] secondary to aggressive behaviors along with throwing his television . This incident wasn't documented in the Nurses Notes. 7) On [DATE] Resident yells at other residents at times with redirection. 8) On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] observed for behaviors yells at other residents at times, redirect as needed. 9) On [DATE] the resident was going into other resident's room and cursing at them and threatening them if they don't stop yelling he will shut them up. Resident was redirected. The redirection was ineffective and a stop and watch was filled out for the Physician. 10) On [DATE] the resident was yelling out that he will make them stop yelling so he can get some rest. 11) On [DATE] Resident was having increased confusion this shift with aggressive behaviors. Attempted to assault staff. Resident was beating on door of unit demanding to smoke. 12) On [DATE] the resident was in hallway in w/c (wheelchair) got up and noted to hit another resident (Resident #15) in facial area, resident redirected to safer area. Resident using foul language at staff. Resident was sent to Geri-Psych and was readmitted to the facility on [DATE] at 9:51 a.m. according to the facility Progress Notes. 13) On [DATE] the resident had incident of verbal behaviors yelled /cussed at residents. c. There were no Nurses Notes related to the incident that had occurred on [DATE] the Resident was sent to Geri-Psych and has not been readmitted to the facility at this time. There was no Incident Reports related to the resident verbal behaviors during the past month. d. On [DATE] at 6:24 p.m., the Incidents and Accidents Reports and Nurses Notes for Resident #11 were reviewed with the DON. The resident had 23 incidents of aggressive behavior including an incident of throwing a television and had been sent to a geri-psych facility on [DATE]. The DON was asked if there was a plan put in place to address the causative factors for these incidents. The DON stated, Not that I'm aware of. Nurses Notes documented verbal aggressive behaviors, the Incidents Report on [DATE] documented aggressive behaviors, and there was a resident-to-resident altercation, then the resident was admitted to geri-psych for the second time on [DATE]. The DON was asked if a plan was put in place to address the resident's aggressive behaviors at the time of readmission. The DON stated, No. The DON was asked due to the aggressive behavior, could this have affected the safety of the other residents and the DON stated, Yes. The DON stated, (Resident #11) was moved off the unit. when? The DON was asked for what reason. The DON stated to reduce the commotions and less stimulation. The DON was asked if there was any training or instruction to the staff when Resident #11 was moved off the secure unit. The DON stated, No. The DON was asked if there was an investigation into the causative factors regarding the incident on [DATE], when Resident #11 had aggressive behavior towards Resident #14 and tried to attack another resident. The DON stated, there was no investigation done. The DON was asked if she had reviewed the Nurses Notes to ensure appropriate follow-up was provided after incidents of resident-to-resident aggressions and stated, No. The DON was asked who was responsible for ensuring follow-up was provided and documented after incidents and stated, I'm not for sure. 3. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS with an ARD of [DATE] documented the resident scored a 7 (,[DATE] indicates severely impaired in cognitive skills) on the BIMS; had behavioral symptoms of physical behaviors directed towards others, verbal behavioral symptoms directed towards, and wandering behaviors have occurred in the past 4 to 6 days; and was independent with transfers, ambulation in room, and supervision with ambulation in corridor. a. The Incident & Accident Reports documented: 1) [DATE] at 10:50 a.m., Incident Description, Resident noted to have punched another male resident in his room, Resident was going to use the restroom when it was already occupied. Resident stated he was slapped in the face so he punched the other resident (Resident #13) . Action Taken, Removed resident to safer environment. There was no documentation that the incident was investigated or intervention was implemented. 2) [DATE] at 3:43 a.m., Incident Description, Was called to back of 300 Hall because of Resident to Resident contact, Resident said that (Resident #13) attacked him and he fought back. He first said that his neck hurt on his left side, but when I went to look at this he asked if he could go smoke and told him no, then stated that he was ok and I was a lying bag of (expletive). Resident then stormed off. Immediate Action Taken, Assessed as much as Resident would let me and kept the Residents apart. There was no documentation regarding a follow up or interventionism implemented regarding this incident. 3) [DATE] at 11:00 a.m., Incident Description, Resident noted to be sitting in dr (dining room) area another resident (Resident #13) hit this resident on head area. Immediate Action Taken, Neuro check q shift, redirected other resident r/t safety. There was no documentation that the incident was investigated for the causative factors or interventions implemented regarding this incident. 4. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS with an ARD of [DATE] documented the resident scored 7 ,[DATE] indicates severely impaired) on the BIMS, was independent with transfers and ambulation, had physical behavioral symptoms towards other that had occurred in the past 1 to 3 days and verbal behavioral symptoms towards other that had occurred in the past 4 to 6 days. a. The Resident's Incident Reports documented: 1) [DATE] at 10:50 a.m. Incident Description, Resident noted to have punched another male resident (Resident #18) in his room, Resident was going to use the restroom when it was already occupied. The Resident stated that he was slapped in the face, so he punched the other resident . Immediate Action Taken, Removed resident to safer environment. The report did not document an investigation regarding this incident or interventions related to this incident. 2) [DATE] at 3:43 a.m. Incident Description, was called back to 300 Hall because of Resident to Resident contact, Resident said that (Resident #15) attacked him and he fought back. He first said that his neck hurt on his L (left) side. But when I went to look at this he asked if he asked if he could go smoke and told him no. Then he stated, that he was ok and that I was a lying sack of s***. Then Resident stormed to his room. The Immediate Action Taken, Assessed as much as Resident would let me and kept the Residents apart. There was no documentation that this incident was investigated regarding the causative factors. 3) [DATE] at 11:00 a.m. Incident Description, Resident noted to be sitting in dr (Dining Room) area, another Resident (Resident #15) hit this resident on the head area. Stated he hit me on my head. Immediate Action Taken, Neuro check q (every) shift other resident from this resident r/t (retaining to) safety. There was no documentation regarding an investigation regarding this incident. 5. Resident #10 had [DIAGNOSES REDACTED]. The Discharge MDS with an ARD of [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and had physical behavioral symptoms directed toward others (e.g. (for example), hitting, kicking, pushing, scratching, grabbing .), and verbal behavioral symptoms directed towards others that had occurred in with a frequency in 1 to 3 days. a. The Care Plan dated [DATE] was reviewed and there was no documentation that addressed the resident's [DIAGNOSES REDACTED]. b. A Progress Note dated [DATE] at 7:00 p.m., written by Registered Nurse (RN) #2, documented, resident was cussing another resident and hit him on the head. residents were separated and this resident was placed on one-on-one monitoring. mother called and notified, dr (doctor) called . monitoring for behaviors . 1) An incident report dated [DATE] at 11:32 p.m. documented, .Incident Location: Dining Room . Incident Description: Nursing Description: cna (Certified Nursing Assistant) reported to this nurse that this resident hit another resident (Resident #17) in the head . Immediate Action Taken: Description: separated both of the residents the resident went to this room and was being monitoring by cnas on the hall . There was no documentation an investigation to determine the causative factor for the incident nor recommended interventions. There was no documentation of one on one monitoring by direct care staff. 2) A Progress Note dated [DATE] at 2:03 a.m. documented, .I & A (Incident and Accident) R/T (related to) hitting another resident . c. A Progress Note dated [DATE] at 12:00 p.m. documented, resident has increased behaviors this shift. pacing the hallways, cussing towards other residents, making threats to residents and staff, saying he was 'going to break her (expletive) nose.' resident talks to himself, flailing arms around showing anxious body language. cont (continues) to strip clothes off throughout shift, throwing and pushing furniture around. cont with ,[DATE] with staff member at this time. d. A Progress Note dated [DATE] at 9:55 p.m. documented, resident cont having increased behaviors this shift. threatening and cussing towards staff and other residents. resident threw food and silverware at staff this shift. remains ,[DATE] with staff member. call (Advance Practice Nurse (APN)), orders given to transfer to (geriatric psychiatric (geri-psych) hospital). resident transferred via ems (emergency medical services) left facility at 2100 (9:00 p.m.) . e. A hospital History and Physical dated [DATE] documented, .Impression: 1. Dementia with behavior disorder . A hospital Progress Note dated [DATE] documented, .the patient was pacing the hallways in his nursing home, swearing at staff and residents and threatening other residents . He has been agitated. He refused to leave his room. Poor eye contact. He has continued to be talking to the air and responding to internal stimuli. He engages in conversations with no one. He is smiling and laughing.He taps very hard on the glass around the nurse's station. Apparently the patient swung at the tech (technician) and began chasing the techs.Mood: Irritable and agitated . Assessment: Major neurocognitive disorder with behavioral disturbance . Hx (history) Unspecified [MEDICAL CONDITION] not due to a substance or not physiological condition Hx of Dementia and other diseases classified elsewhere but with behavior disturbance Hx of [MEDICAL CONDITION], unspecified Rule out Delusional disorder Rule out [MEDICAL CONDITION] Rule out Unspecified [MEDICAL CONDITION] . Progress Note dated [DATE] Nursing Report: . He gets easily agitated and will attempt to strike staff when irritable.He attempted to knock over a table . Progress Note dated [DATE] .Nursing Report: At times the patient will be observed laughing and talking himself. He seen wandering around the hallways and can be easily agitated. He received [MEDICATION NAME] 2 mg (milligrams) at 1100 (11:00 a.m.) yesterday for escalating behavior problems. He was in hallway yelling and screaming stating 'I can kill you.' Staff has some difficulty with patient's ADLs (activities of daily living) as he can be resistant.A Progress Note dated [DATE] .Nursing Report: .He was noted to have been agitated and physically aggressive when awakened for medications. He spat out the water when offered. Frequently uses profanity to verbalize himself . A Progress Note dated [DATE] . The patient was considerably agitated this morning with no inciting trigger. He began flipping over tables in the dining room. Staff was called to hold the patient for [MEDICATION NAME] 2 mg. He began exhibiting additional agitated behavior attempting to swing at staff members . He was unable to be redirected.A Progress Note [DATE] MD (Medical Doctor) notes the patient has been aggressive, fights, and response to internal stimulation. He is seen grabbing things on the unit. Conversing with visual hallucinations.Per nursing, the patient has been agitated, anxious, and difficult to redirect. He fidgets with things in the hallways. He attempts to pick things up on the floor when there is nothing present. He notes to be leaning on the glass doors and bumping his forehead. He attempted to take the fire extinguisher. He screams, profanities and yells when no one is there . Progress Note dated [DATE] . Patient continues to exhibit rapidly impulsive behavior. They noted that he suddenly got out of his chair yesterday, walked across the dining room and hit the refrigerator with his fist. He began becoming aggressive with the tech that was one on one with him, grabbing her arms and squeezing and twisting . He continued to be wandering around the hallways hallucinating and picking things up from the floor that are not present. He sporadically aggressive with staff members . Progress Note [DATE] .Patient continues to be wandering around the hallways carrying on a conversation with himself.He exhibited threatening behaviors toward staff members, getting agitated and unable to redirect him . He threatened to kill staff members . will become agitated without much provocation . Patient was kicking, punching, cursing . Progress Note [DATE] . Continues to exhibit aggressive and wandering behavior around the unit requiring one on one observation to provide safe environment. Patient at times will exhibit agitation wanting to hit people. He walked by a door seeing his reflection and stated that he was going to kill that person . The Discharge Summary dated [DATE] documented, .He is improved by time of discharge . He is consistently cooperative with care and free of aggressive/combative behavior and threats . There was no documentation of any intervention to prevent further aggressive behaviors. f. A nursing Progress Note dated [DATE] at 2:35 p.m. documented, resident readmitted to (facility) 300 secured unit, arrived to nh (nursing home) via nh van with staff x (times) 2, . ambulates at intervals, responds to verbal commands, . observed for behaviors, . wanders at intervals . refused vs (vital signs) this shift . g. A nursing Progress Note dated [DATE] at 10:15 a.m. written by RN #2, documented, resident was refusing care was kicking hitting cnas this nurse told cnas to back off and let resident calm down. resident does not redirect. h. A nursing Progress Note dated [DATE] at 1:00 p.m. written by RN #2 documented, resident had sit down on roommates arm while roommate was sleeping in roommates bed. An incident report dated [DATE] at 10:21 p.m. documented, .cnas walk in residents room and seen this resident sitting on another residents (Resident #19) arm while the other resident was sleeping in his bed.Notes [DATE] On [DATE], the resident was found sitting on top of another resident. The resident has inappropriate behaviors that he does not know how to control. resident was placed one on one until he was sent to (geri-psych hospital). i. A nursing Progress Note dated [DATE] at 10:56 p.m. documented, received orders from (Physician ) to send resident to (geri-psych hospital) resident left facility at 215 pm. (2:15 p.m.), was transported by our facility 2 cnas and van. j. On [DATE] at 3:35 p.m., RN #2 was asked if the resident was still in the facility and the RN stated, No. The RN was asked when the resident had left the facility and the RN stated, Around 2:15 p.m. ([DATE]) . k. On [DATE] at 10:17 a.m., the DON was asked which resident it was who Resident #10 had hit on the incident on [DATE] and the DON stated, (Resident #19) The DON was asked about the incident and why the resident had been sent out of the facility. The DON stated, He was sitting on top of another resident and had straddled him and had his hands on his (Resident #19) chest. The DON was asked who the other resident was and the DON stated, (Resident #19 name). The DON was asked if the resident had thrown something and the DON stated, Yes, towel rack. The DON was asked if the resident had resisted care when the CNA staff were in the room with the resident and the DON stated, I think he was. They were cleaning him, (CNA #7 and CNA #8 ). l. On [DATE] at 10:50 a.m., CNA #7 was asked if the resident had resisted care on [DATE] and the CNA stated, He had used the bathroom on self, bowel, we got him in the bathroom half way he started hitting us, cussing us, he tore the metal piece off the wall and started using it as a weapon threw it. He was hitting us with it, me and (CNA #8). I called for help, I used my phone, personal phone only way to call for help, (CNA/RNA (Restorative Nursing Assistant #2) and (RN #2) the nurse, (RN #2) came back. They helped us come out of bathroom. Tried to open door (door to adjoining room) and couldn't and he (Resident #10) was standing between us and the door. They got him from behind up underneath the arms, backwards. He just walked backwards. The CNA was asked if the staff members touched the resident and the CNA stated, They were touching. They were on each side and they were walking him. (RNA #2), myself, (CNA #8) got him into the bed. The CNA was asked why they had gotten the resident to bed and the CNA stated, To try to get him cleaned up, he still had poop all over him. So we attempted to get him clean. CNA #7 was asked if it was 3 staff members who had tried to clean the resident and the CNA stated, 3 of us. So the nurse left, I'll return in a moment. I need to report. The CNA was asked if the nurse was in the room when they tried to get the resident in the bed and the CNA stated, Yes. In the bed wasn't the problem, it was cleaning him that was the problem. He wouldn't let us clean him so we stepped back from the situation to see if he would calm down. So we left the room, we continued our rounds, to see if he would calm down, we just left him be. The CNA was asked what time this had occurred and how long they had been out of the room and stated, I don't remember exact time but it was before lunch. The CNA was asked if they had returned to the room and stated, We did about 15 minutes later; we had to go to (Resident #19) to change him. The CNA was asked where Resident #10 was and stated, In his bed; he had done covered himself up and looked to be asleep, so we thought he might have calmed down, so we attempted to clean him again. The CNA was asked what occurred next and the CNA stated, (CNA #8) went to the linen cart and I went to get cleaning supplies and when we came back, (Resident #10) was on top of (Resident #19). He was straddling him, he had his arms holding him down, he was facing him. CNA #7 was asked what staff was to do when a resident had an aggressive behavior and stated, We were told to leave the resident, to back off, that's what they tell us here. The CNA was asked who had given these instructions and the CNA stated, Our Administrator, DON (Director of Nursing), ADON (Assistant DON). The CNA was asked if the resident was having any behavior when they had first attempted to provide care on [DATE] and the CNA stated, Yes, he started cussing at us. He told us no the first 2 times, the third time we were able to get his shirt off. It was when the pants came off is when he got upset. We asked him, he told us no, so we ran the water to make sure the water was warm in the bathroom sink, then we asked again, he told us no, so we just got out soaps and stuff ready and he told us if you (expletive) have to. He let us take the shirt off. The CNA was then asked if the first time that the resident had said No did they leave the room and the CNA stated, No we just turned our backs. The CNA was asked if they remained in the bathroom with the resident and the CNA stated, Yes. The CNA was asked if they remained in the bathroom with the resident the second time that the resident refused care and the CNA stated, We still turned our back. The CNA was asked if the resident had resisted when the pants were taken off and the CNA stated, He resisted when the pants came off. By that time we were trying to get out of the bathroom. I was by the sink and she (CNA #8) was by the toilet. The CNA was asked why, when the resident had said no on the first attempt to provide care, the CNAs remained and stated, That's just where we stayed. The CNA was asked if that seemed to further agitate the resident and stated, Yes. The CNA was asked how long she had worked on the secured unit and the CNA stated, 3 months. The CNA was asked what special training she had to work on the secured unit and the CNA stated, When I worked for (another facility name) I had to take special training to work their unit. The CNA was asked what training consisted of and the CNA stated, It just showed us what to do in situations. The CNA was asked if they were instructed to leave the resident and the CNA stated, They told us to leave the scene as soon as the resident is safe. Leave the scene, report, re-eval (reevaluate) what to do, how to approach the situation. The CNA was asked if she had followed those instructions and stated, I didn't. m. On [DATE] at 7:09 p.m., RN #2 was asked what occurred on [DATE] when there was an incident with the resident and stated, I was on the hall and (CNA/RNA #2) came and got me and (CNA #7 and CNA #8) were in the bathroom. You could tell he (Resident #10) was mad and he wasn't going to listen to them and he was trying to grab at them, so me and (CNA/RNA) told them to back off, they did. They were in the bathroom, he was on the toilet. I didn't know at the time what happened. They were trying to get him out and that's what I saw. The RN was asked if she had instructed the staff to stop care and stated, Yes. The RN was asked what happened then and stated, First thing I said was 'y'all back off', me and (CNA/RNA) put gloves on, and we were going to redirect him and (CNA/RNA) talked to him and she talks real soft and we were able to redirect.I asked the girls (CNA #7 and 8) to clean up the bathroom and I asked them to come back and check and make sure he was still calm. The RN was asked if she had gone back and checked the resident and stated, I went and told (DON) he was refusing care and what he was doing . The RN was asked if a resident was resisting care, what was to be done and stated, Stop. The RN was asked what was done after the incident to address the behavior and stated, I heard we were sending him out to (geri-psychiatric hospital) and he was on one on one. 6. Resident #17 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a SAMS and had no behavioral symptoms identified that put others at significant risk for physical injury. a. An incident report dated [DATE] at 11:49 p.m. documented, .Incident Description Nursing Description: cnas on hall reported to this nurse that this resident got hit on the head by another resident (Resident #10) Description: no response . There was no additional documentation that indicated there had been an investigation to the cause of the incident. As of [DATE] and there was no documentation in the nursing progress notes that indicated that the resident had aggressive behaviors towards other residents. There was no documentation there was follow up to assess the resident after another resident had hit the resident during an incident on [DATE]. 7. Resident #19 had [DIAGNOSES REDACTED]. The resident was admitted on [DATE], had an unplanned discharge to the hospital on [DATE], returned to the facility from an acute care hospital on [DATE], and had an initial MDS assessment pending. a. An incident report dated [DATE] documented, .Incident Location: Resident's Room . Nursing Description: cnas reported that another resident (Resident #10) was sitting on his left arm while resident was sleeping in his bed. resident kept on sleeping . Notes [DATE] (documented) On [DATE], the staff found another resident sitting on top of this resident. The resident shown no sign of pain such as facial grimacing or redness noted to any body part . The other resident was removed from on top of this resident and the two residents were separated. b. The nursing progress notes were reviewed from the dates of [DATE] thru [DATE] and there was no documentation of any resident to resident incident. 8. On [DATE] at 4:40 p.m., the Director of Nursing (DON) was asked if the staff who worked on the secured unit had specific training to work with residents with behaviors and the DON stated, No. The DON was asked if the staff members had training in how to manage the care of residents with dementia and the DON stated, Not since I've been here. The DON was asked how they ensured the CNA and licensed nursing staff knew how to care for residents with dementia with behaviors. The DON stated, I guess I can't answer that, I can't ensure that. The DON was asked if all staff who worked on the secure unit with residents with dementia and residents with behaviors should be knowledgeable in working with residents who have these [DIAGNOSES REDACTED]. On [DATE] at 6:24 p.m., the DON was asked due to the issues with the frequent incidents of resident-to-resident altercations, has the facility had any additional training regarding dealing with aggressive behaviors. The DON stated, No, I'm working on that, (performance improvement consultant group) has been contacted. The DON was asked if she had called AIPP. The DON stated, No, I haven't followed up on this. The DON was asked can you explain the staffing on the secure unit. The DON stated, on days and evening there are 2 CNA'S and on nights there is 1 CNA. The DON was asked if that was adequate staffing considering the aggressive behaviors of some the residents on the secure unit to ensure the safety of the other residents and staff. The DON stated that was the staffing we have at this time. 9. On [DATE] at 4:40 p.m., the Director of Nursing (DON) was asked how the staff were to obtain help when there was an incident or problem on the secure unit. The DON stated, One of them will come out here and grab help. The DON was asked how this was acc (TRUNCATED)

Complaint # (AR 908) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure there was sufficient and competent staff that were trained to provide the necessary services to assure resident safety and well-being of each resident for 4 of 4 Resident #10, 11, 13, and 15) case mix residents who exhibited aggressive behaviors and protection were put in place to prevent further resident-to-resident altercations toward 5 of 5 (Residents #13, #15, #17, #18, and #19) case mix residents who were assaulted by another resident who had aggressive behaviors. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Residents #13, #15, #17, #18, and #19) who were physically assaulted by Residents #10, #11, #13, and #15 and had the potential to cause more than minimal harm to 13 residents who resided on the 300 Hall secure unit as documented on a list provided on by the Administrator [DATE] and 10 residents who were involved in Resident to Resident altercations as documented on a list provided by the Registered Nurse (RN Consultant) #1 on [DATE]. The facility was informed of the Immediate Jeopardy condition on [DATE] at 8:00 p.m. The findings are: 1. The Facility Operation Management for Behavioral Health Services was received from the Administrator on [DATE] documented, Policy It is the policy of this facility that al resident receive care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning. Policy Explanation and Compliance Guidelines 1. The facility will ensure that each resident receives the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial will-being, in accordance with the comprehensive assessment and plan of care . 3. The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. 2. The Operation Management for Training Requirement received from the Administrator on [DATE] documented, Policy, It is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement and volunteers consistent with their expected roles. 3. Resident #10 had [DIAGNOSES REDACTED]. The Discharge MDS with an ARD of [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and had physical behavioral symptoms directed toward others (e.g. (for example), hitting, kicking, pushing, scratching, grabbing .), and verbal behavioral symptoms directed towards others that had occurred in with a frequency in 1 to 3 days. a. A Progress Note dated [DATE] at 7:00 p.m., written by Registered Nurse (RN) #2, documented, resident was cussing another resident and hit him on the head. residents were separated and this resident was placed on one-on-one monitoring. mother called and notified, dr (doctor) called . monitoring for behaviors . 1) An incident report dated [DATE] at 11:32 p.m. documented, .Incident Location: Dining Room . Incident Description: Nursing Description: cna (Certified Nursing Assistant) reported to this nurse that this resident hit another resident (Resident #17) in the head . Immediate Action Taken: Description: separated both of the residents the resident went to this room and was being monitoring by cnas on the hall . There was no documentation an investigation to determine the causative factor for the incident nor recommended interventions. There was no documentation of one on one monitoring by direct care staff. 2) A Progress Note dated [DATE] at 2:03 a.m. documented, .I & A (Incident and Accident) R/T (related to) hitting another resident . b. A Progress Note dated [DATE] at 12:00 p.m. documented, resident has increased behaviors this shift. pacing the hallways, cussing towards other residents, making threats to residents and staff, saying he was 'going to break her f****** nose.' resident talks to himself, flailing arms around showing anxious body language. cont (continues) to strip clothes off throughout shift, throwing and pushing furniture around. cont with ,[DATE] with staff member at this time. c. A Progress Note dated [DATE] at 9:55 p.m. documented, resident cont having increased behaviors this shift. threatening and cussing towards staff and other residents. resident threw food and silverware at staff this shift. remains ,[DATE] with staff member. call (Advance Practice Nurse (APN)), orders given to transfer to (geriatric psychiatric (geri-psych) hospital). resident transferred via ems (emergency medical services) left facility at 2100 (9:00 p.m.) . d. A hospital History and Physical dated [DATE] documented, .Impression: 1. Dementia with behavior disorder . A hospital Progress Note dated [DATE] documented, .the patient was pacing the hallways in his nursing home, swearing at staff and residents and threatening other residents . He has been agitated. He refused to leave his room. Poor eye contact. He has continued to be talking to the air and responding to internal stimuli. He engages in conversations with no one. He is smiling and laughing.He taps very hard on the glass around the nurse's station. Apparently the patient swung at the tech (technician) and began chasing the techs.Mood: Irritable and agitated . Assessment: Major neurocognitive disorder with behavioral disturbance . Hx (history) Unspecified [MEDICAL CONDITION] not due to a substance or not physiological condition Hx of Dementia and other diseases classified elsewhere but with behavior disturbance Hx of [MEDICAL CONDITION], unspecified Rule out Delusional disorder Rule out [MEDICAL CONDITION] Rule out Unspecified [MEDICAL CONDITION] . Progress Note dated [DATE] Nursing Report: . He gets easily agitated and will attempt to strike staff when irritable.He attempted to knock over a table . Progress Note dated [DATE] .Nursing Report: At times the patient will be observed laughing and talking himself. He seen wandering around the hallways and can be easily agitated. He received [MEDICATION NAME] 2 mg (milligrams) at 1100 (11:00 a.m.) yesterday for escalating behavior problems. He was in hallway yelling and screaming stating 'I can kill you.' Staff has some difficulty with patient's ADLs (activities of daily living) as he can be resistant.A Progress Note dated [DATE] .Nursing Report: .He was noted to have been agitated and physically aggressive when awakened for medications. He spat out the water when offered. Frequently uses profanity to verbalize himself . A Progress Note dated [DATE] . The patient was considerably agitated this morning with no inciting trigger. He began flipping over tables in the dining room. Staff was called to hold the patient for [MEDICATION NAME] 2 mg. He began exhibiting additional agitated behavior attempting to swing at staff members . He was unable to be redirected.A Progress Note [DATE] MD (Medical Doctor) notes the patient has been aggressive, fights, and response to internal stimulation. He is seen grabbing things on the unit. Conversing with visual hallucinations.Per nursing, the patient has been agitated, anxious, and difficult to redirect. He fidgets with things in the hallways. He attempts to pick things up on the floor when there is nothing present. He notes to be leaning on the glass doors and bumping his forehead. He attempted to take the fire extinguisher. He screams, profanities and yells when no one is there . Progress Note dated [DATE] . Patient continues to exhibit rapidly impulsive behavior. They noted that he suddenly got out of his chair yesterday, walked across the dining room and hit the refrigerator with his fist. He began becoming aggressive with the tech that was one on one with him, grabbing her arms and squeezing and twisting . He continued to be wandering around the hallways hallucinating and picking things up from the floor that are not present. He sporadically aggressive with staff members . Progress Note [DATE] .Patient continues to be wandering around the hallways carrying on a conversation with himself.He exhibited threatening behaviors toward staff members, getting agitated and unable to redirect him . He threatened to kill staff members . will become agitated without much provocation . Patient was kicking, punching, cursing . Progress Note [DATE] . Continues to exhibit aggressive and wandering behavior around the unit requiring one on one observation to provide safe environment. Patient at times will exhibit agitation wanting to hit people. He walked by a door seeing his reflection and stated that he was going to kill that person . The Discharge Summary dated [DATE] documented, .He is improved by time of discharge . He is consistently cooperative with care and free of aggressive/combative behavior and threats . There was no documentation of any intervention to prevent further aggressive behaviors. e. A nursing Progress Note dated [DATE] at 2:35 p.m. documented, resident readmitted to (facility) 300 secured unit, arrived to nh (nursing home) via nh van with staff x (times) 2, . ambulates at intervals, responds to verbal commands, . observed for behaviors, . wanders at intervals . refused vs (vital signs) this shift . f. The Care Plan dated [DATE] was reviewed and there was no documentation that addressed the resident's [DIAGNOSES REDACTED]. g. A nursing Progress Note dated [DATE] at 10:15 a.m. written by RN #2, documented, resident was refusing care was kicking hitting cnas thus nurse told cnas to back off and let resident calm down. resident does not redirect. h. A nursing Progress Note dated [DATE] at 1:00 p.m. written by RN #2 documented, resident had sit down on roommates arm while roommate was sleeping in roommates bed. An incident report dated [DATE] at 10:21 p.m. documented, .cnas walk in residents room and seen this resident sitting on another residents (Resident #19) arm while the other resident was sleeping in his bed.Notes [DATE] On [DATE], the resident was found sitting on top of another resident. The resident has inappropriate behaviors that he does not know how to control. resident was placed one on one until he was sent to (geri-psych hospital). i. A nursing Progress Note dated [DATE] at 10:56 p.m. documented, received orders from (Physician ) to send resident to (geri-psych hospital) resident left facility at 215 pm. (2:15 p.m.), was transported by our facility 2 cnas and van. j. On [DATE] at 10:17 a.m., the DON was asked who was the resident that Resident #10 had hit on the incident on [DATE] and the DON stated, (Resident #19) The DON was asked about the incident and why the resident had been sent out of the facility. The DON stated, He was sitting on top of another resident and had straddled him and had his hands on his (Resident #19) chest. The DON was asked who the other resident was and the DON stated, (Resident #19 name). The DON was asked if the resident had thrown something and the DON stated, Yes, towel rack. The DON was asked if the resident had resisted care when the CNA staff were in the room with the resident and the DON stated, I think he was. They were cleaning him, (CNA #7 and CNA #8). k. On [DATE] at 10:50 a.m., CNA #7 was asked if the resident had resisted care on [DATE] and the CNA stated, He had used the bathroom on self, bowel, we got him in the bathroom half way he started hitting us, cussing us, he tore the metal piece off the wall and started using it as a weapon threw it. He was hitting us with it, me and (CNA #8). I called for help, I used my phone, personal phone only way to call for help, (CNA/RNA (Restorative Nursing Assistant #2) and (RN #2) the nurse, (RN #2) came back. They helped us come out of bathroom. Tried to open door (door to adjoining room) and couldn't and he (Resident #10) was standing between us and the door. They got him from behind up underneath the arms, backwards. He just walked backwards. The CNA was asked if the staff members touched the resident and the CNA stated, They were touching. They were on each side and they were walking him. (RNA #2), myself, (CNA #8) got him into the bed. The CNA was asked why they had gotten the resident to bed and the CNA stated, To try to get him cleaned up, he still had poop all over him. So we attempted to get him clean. CNA #7 was asked if it was 3 staff members who had tried to clean the resident and the CNA stated, 3 of us. So the nurse left, I'll return in a moment. I need to report. The CNA was asked if the nurse was in the room when they tried to get the resident in the bed and the CNA stated, Yes. In the bed wasn't the problem, it was cleaning him that was the problem. He wouldn't let us clean him so we stepped back from the situation to see if he would calm down. So we left the room so we continued our rounds, to see if he would calm down, we just left him be. The CNA was asked what time this had occurred and how long out of room and the CNA stated, I don't remember exact time but it was before lunch. The CNA was asked if they had returned back into the room and the CNA stated, We did about 15 minutes later we go had to (Resident #19) to change him. The CNA was asked where Resident #10 was and the CNA stated, In his bed he had done covered himself up and looked to be asleep so we thought he might have calmed down so we attempted to clean him again. The CNA was asked what occurred next and the CNA stated, (CNA #8) went to the linen cart and I went to get cleaning supplies and when we came back. (Resident #10) was on top of (Resident #19). He was straddling him, he had his arms holding him down, he was facing him. CNA #7 was asked what staff was to do when a resident had an aggressive behavior and the CNA stated, We were told to leave the resident, to back off, that's what they tell us here. The CNA was asked who had given these instructions and the CNA stated, Our Administrator, DON (Director of Nursing), ADON (Assistant DON). The CNA was asked if the resident was having any behavior when they had first attempted to provide care on [DATE] and the CNA stated, Yes, he started cussing at us. He told us no the first 2 times, the third time we were able to get his shirt off. It was when the pants came off is when he got upset. We asked him, he told us no, so we ran the water to make sure the water was warm in the bathroom sink, then we asked again, he told us no, so we just got out soaps and stuff ready and he told us if you F****** have to. He let us take the shirt off. The CNA was then asked if the first time that the resident had said No did they leave the room and the CNA stated, No we just turned our backs. The CNA was asked if they remained in the bathroom with the resident and the CNA stated, Yes. The CNA was asked if they remained in the bathroom with the resident the second time that the resident refused care and the CNA stated, We still turned our back. The CNA was asked if the resident had resisted when the pants were taken off and the CNA stated, He resisted when the pants came off. By that time we were trying to get out of the bathroom. I was by the sink and she (CNA #8) was by the toilet. The CNA was asked why when the resident had said no on the first attempt to provide care why they remained and the CNA stated, That's just where we stayed. The CNA was asked how long she had worked on the secured unit and the CNA stated, 3 months. The CNA was asked what special training she had to work on the secured unit and the CNA stated, When I worked for (another facility name) I had to take special training to work their unit. The CNA was asked what training consisted of and the CNA stated, It just showed us what to do in situations. The CNA was asked if they were instructed to leave the resident and the CNA stated, They told us to leave the scene as soon as the resident is safe. Leave the scene, report, reeval (reevaluate) what to do how to approach the situation. The CNA was asked if she had followed those instructions and the CNA stated, I didn't. l. On [DATE] at 2:52 p.m., the DON was asked when the resident was admitted [DATE] was it to the secured unit and the DON stated, Yes. The DON was asked why the resident had been sent out of he facility on [DATE] and the DON stated, If I'm not mistaken he was having some aggression. The DON was asked who that other resident was and the DON stated, I can't remember. The DON was asked if the resident was readmitted from a geripsych unit on [DATE] and the DON stated, Yes. The DON was asked if she was aware that the resident had behaviors and the DON stated, The behaviors aggression and sexually inappropriate. The DON was asked what nursing staff was to do when a resident was aggressive and the DON stated, What I tell them to do is leave them alone and let them calm down. The DON was asked how long staff should wait before care was attempted again and the DON stated, I usually tell them about ,[DATE] minutes. The DON was asked if a resident said No should staff still provide care and the DON stated, If they say no I would say no, stop and see if someone else can do it. m. On [DATE] at 7:09 p.m., RN #2 was asked what had occurred on [DATE] when there was an incident with the resident and the RN stated, I was on the hall and (CNA/RNA #2) came and got me and girls were (CNA #7 and CNA #8) were in bathroom, he (Resident #10). You could tell he was mad and he wasn't going to listen to them and he was trying to grab at them, so me and (CNA/RNA) told them to back off, they did. They were in the bathroom, he was on the toilet. I didn't know at the time what happened. They were trying to get him out and that's what I saw. The RN was asked if she had instructed the staff to stop care and the RN stated, Yes. The RN was asked what had occurred and the RN stated, First thing I said was ya'll back off, me and (CNA/RNA) put gloves on and we were going to redirect him and (CNA/RNA) talked to him and she talks real soft and we were able to redirect.I asked the girls (CNA #7 and 8) to clean up the bathroom and I asked them to come back and check and make sure he was still calm. The RN was asked if she had gone back and checked the resident and the RN stated, I went and told (DON) he was refusing care and what he was doing . The RN was asked if a resident was resisting care what was to be done and the RN stated, Stop. The RN was asked what was done then about the resident's behavior and the RN stated, I heard we were sending him out to (geri-psychiatric hospital) and he was on one on one. 4. Resident #11 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Medicare 5 Day Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] documented the resident scored 2 (,[DATE] indicates severely impaired) on the Brief Interview for Mental Status (BIMS), had physical behavioral symptoms directed toward others that had occurred for 1 to 3 days and verbal behaviors symptoms directed towards others that had occurred over the 4 to 6 days, required supervision with bed mobility, transfers, ambulation in room and corridor, required limited assistance of 1 person for dressing, and personal hygiene. a. The Incident and Accident documented as follows: 1) [DATE] at 12:45 p.m. Resident noted to have hit another resident (Resident #15) in facial area in hallway. Immediate Action Taken, Resident was redirected to safer environment one-on-one watch. There was no documentation that the incident was investigated for causative factors and no documentation related to intervention implemented to prevent further incidents. 2) [DATE] at 6:05 a.m. Aide reported seeing (Resident #11) attacked (Resident #14) was backing up away from (Resident #11) and (Resident #11) was moving towards him and he tripped over piano bench and fell . (Resident #11) had steadied himself on the back of a chair and then picked up the chair and started hitting (Resident #14) with the chair causing skin tear to (Resident #14) ankle. (Resident #11) fell from swinging chair. (Resident #11) cont.(continued) to cuss at staff and residents, hitting staff aide that is one on one with him. Trying to attack this Nurse. Calling residents f*** n*****, b*****. Resident also tried to attack another resident in the dining room but aide stopped him . Immediate Action Taken, Resident is one on one at this time. Resident was taken to the hospital. There was no documentation regarding follow-up investigation for this incident. b. Nurses and Progress Notes documented: 1) On [DATE] the resident was standing in hallway at this time holding wheelchair leg rest and threatening to hit the teenagers with it. The Aide tried telling resident there were no teenagers here and the Nurse talked to the resident, will monitor. 2) On [DATE] the resident had verbal behaviors of yelling and cussing with racial slurs at resident, the resident was redirected. 3) On [DATE] resident had verbal behaviors of yelling and screaming at staff, medicated with PRN (as needed) [MEDICATION NAME]. 4) On [DATE] the resident was in hallway threatening trying to hit at CNA using foul language at CNA's kicking door entrance wanted to leave. Resident was taken out to smoke and redirected. [MEDICATION NAME] had been administered earlier. 5) On [DATE] the resident was very argumentative, yelling using foul language at staff when redirected, refused to take am (morning) meds (medications). Physician was notified and meds were taken to resident's room and resident threw the meds on the floor. The Physician was notified. Order to send resident to (geri-psych facility). Resident was readmitted to the facility on [DATE]. There was no documentation related to implementation of interventions related to aggressive verbal behaviors. The hospital discharge instructions dated [DATE] documented, .Indicators/Treatment Plan . ,[DATE] (24 hours/7 days) Care Nursing Home Psy. (psychiatric) Med (medication) Management . 6) The Progress Notes documented by the APN, on [DATE] documented, Resident was sent to emergency room for evaluation and treatment on [DATE] secondary to aggressive behaviors along with throwing his television . This incident wasn't documented in the Nurses Notes. 7) On [DATE] Resident yells at other residents at times with redirection. 8) On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] observed for behaviors yells at other residents at times, redirect as needed. 9) On [DATE] the resident was going into other residents room and cursing at them and threatening them if they don't stop yelling he will shut them up. Resident was redirected. The redirection was ineffective and a stop and watch was filled out for the Physician. 10) On [DATE] the resident was yelling out that he will make them stop yelling so he can get some rest. 11) On [DATE] Resident was having increased confusion this shift with aggressive behaviors. Attempted to assault staff. Resident was beating on door of unit demanding to smoke. 12) On [DATE] the resident was in hallway in w/c (wheelchair) got up and noted to hit another resident (Resident #15) in facial area, resident redirected to safer area. Resident using foul language at staff. Resident was sent to Geri-Psych and was readmitted to the facility on [DATE] at 9:51 a.m. according to the facility Progress Notes. 13) On [DATE] the resident had incident of verbal behaviors yelled /cussed at residents. c. There were no Nurses Notes related to the incident that had occurred on [DATE] the Resident was sent to Geri-Psych and has not been readmitted to the facility at this time. There was no Incident Reports related to the resident verbal behaviors during the past month. d. The Progress Notes documented by the APN, on [DATE] documented, Resident was sent to emergency room for evaluation and treatment on [DATE] secondary to aggressive behaviors along with throwing his television . 5. Resident #15 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Admission MDS with an ARD of [DATE] documented the resident scored a 7 (,[DATE] indicates severely impaired in cognitive skills) on the BIMS; had behavioral symptoms of physical behaviors directed towards others, verbal behavioral symptoms directed towards, and wandering behaviors have occurred in the past 4 to 6 days; and was independent with transfers, ambulation in room, and supervision with ambulation in corridor. a. The Comprehensive Care Plan documented, Focus - The Resident has impaired cognitive function/dementia or impaired thought processes r/t (related to) Alzheimer's, Dementia impaired decision making. Date initiated [DATE] . Interventions - Administer medications as ordered. Ask yes/no questions in order to determine the resident's needs. Cue, orient and supervise as needed. Discuss concerns about confusion, disease process. NH (Nursing Home) placement with resident/family/caregivers. Keep the Resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. b. The Incident & Accident Reports documented: 1) [DATE] at 10:50 a.m., The Incident Description, Resident noted to have punched another male resident in his room, Resident was going to use the restroom when it was already occupied. Resident stated he was slapped in the face so he punched the other resident (Resident #13) . Action Taken, Removed resident to safer environment. There was no documentation that the incident was investigated or intervention was implemented. 2) [DATE] at 3:43 a.m., Incident Description, Was called to back of 300 Hall because of Resident to Resident contact, Resident said that (Resident #13) attacked him and he fought back. He first said that his neck hurt on his left side, but when I went to look at this he asked if he could go smoke and told him no, then stated that he was ok and I was a lying bag of s***. Resident then stormed off. Immediate Action Taken, Assessed as much as Resident would let me and kept the Residents apart. There was no documentation regarding a follow up or interventionism implemented regarding this incident. 3) [DATE] at 11:00 a.m., Incident Description, Resident noted to be sitting in dr (dining room) area another resident (Resident #13) hit this resident on head area. Immediate Action Taken, Neuro check q shift, redirected other resident r/t safety. There was no documentation that the incident was investigated for the causative factors or interventions implemented regarding this incident. b. The Residents one/one documentation for Resident #15 documented one/one from 6:30 a.m. through 12:00 p.m. There was documentation at 11:00 a.m. He (Resident #15) came out of his room and went to the dining room and was hitting (Resident #13) in the head and we made him go back to his room. c. The following Progress Notes documented: 1) [DATE] at 12:15 a.m. signed by LPN #2 documented, Resident had a Resident to Resident contact. No injuries was noted at this time. Neuro's are being done on (Resident #15) because Resident stated he was hit in the head. Neuro's were WNL (with in normal limits). 2) [DATE] at 2:30 a.m., Resident continuous on I&A (Incident and Accident) x (times) 2 New one tonight at 0015 (12:15 a.m.) Resident to Resident contact again. Resident went in dining room and hit another Resident . Residents both in bed resting with eyes closed. Will continue to monitor. 3) [DATE] at 6:28 a.m., Situation: Resident to Resident contact. (Resident #15) attacked (Resident #13). (Resident #13) hit him (Resident #15) back. Background; He (Resident #15) has had other R (Resident) to R contact. Recommendation; Get (Resident #15) some med (Medication). 4) [DATE] at 11:00 a.m. Note text; Resident noted to have hit another resident on his head, dr (Dining Room) area. 0 (No) injuries noted, redirected resident to his room. One/one r/t safety. (Family member called) will brief oncoming shift. d. On [DATE] at 12:58 p.m., LPN #2 stated she had been employed for approximately 1 year and worked the night shift. 11:00 p.m. - 7:00 a.m. (,[DATE]) shift. The LPN was asked regarding any training to deal with residents' with aggressive behaviors. The LPN stated she had not had any training at this facility, but had some training at a previous nursing home and a hospital. The LPN stated, .Make sure we separate the residents and get their minds on something else. The LPN was asked to explain what happened with (Resident #15) on [DATE]. The LPN stated. (Resident #15) had gotten up and walked down the hall. (Resident #13) was in the second dining room and (Resident #15) attacked (Resident #13) in the head and (Resident #13) stated that he hit (Resident #15) back. (Resident #13) has a dirty mouth and (Resident #15) doesn't like bad mouth and other (Resident #13) talking dirty. (Resident #15) gets really agitated and doesn't like other residents calling staff names. (Resident #15) is not very verbal he doesn't talk a lot. (Resident #13) runs his mouth a lot. The LPN was asked, What did you do after the first incident? The LPN stated, I separated them and I checked them over. I talked to (Resident #13) he complained of neck hurting and then he went to his room, he kept coming out and mouthing. The LPN was asked, What did the resident say? The LPN stated, Called me a lying sack of[***]because he wasn't allowed to go smoke, they are not allowed to go smoke, due to we don't have enough staff and they can't take then out to smoke and I am allergic to cigarette smoke so I can't take them. Staffing, we usually have 4 or 5 CNA's, here lately we have 5 or 6 due to the aggressive residents.' The LPN was asked how many staff were on the men's unit, one CNA and one CNA on the women's and 3 to cover the other halls. The LPN was asked, Have you had any other issue with aggressive behaviors? The LPN stated, Yes, with (Resident #11), he was put out on the hall and had Resident to Resident altercation and was sent out to Geri-Psych and isn't supposed to be readmitted . The LPN was asked who puts interventions on the Incident and Accident forms. The LPN stated that we put in the immediate ones (Interventions) I don't know who puts in the interventions. The LPN was asked, What did you do when there was a one-on-one altercation with (Resident #15) and (Resident #13). The LPN stated, The residents were placed in their room and I checked on them. There was no other issues. The LPN was asked if the resident was placed on one-on-one. The LPN stated, No, he had gone to bed and was monitored. The LPN was asked how many CNA's were on the 300 Hall, the Men's Secure Unit that night. The LPN stated, We only have one CNA on the hall at night. e. On [DATE] at 4:30 p.m., the DON was asked when the one-on-one was initiated and who performed the one-on-one starting at 6:30 a.m. after the incident where Resident #15 hit/attacked Resident #13 on [DATE]. The DON stated CNA #3. The DON was asked if CNA #3 was scheduled for the 300 Hall, men's secure unit. The DON stated, Yes. The CNA was to be one-on-one with Resident #15 and tha (TRUNCATED)

Complaint # (AR 908) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure specific, person-centered interventions to address aggressive behaviors were developed and implemented to prevent further incidents of resident-to-resident assault for 4 of 4 (Resident #10, 11, 13, and 15) case mix residents were had [DIAGNOSES REDACTED]. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Residents #13, #15, #17, #18, and #19) who were physically assaulted by Residents #10, #11, #13, and #15 and had the potential to cause more than minimal harm to 13 residents who resided on the 300 Hall secure unit, as documented on a list provided by the Administrator [DATE]; and 10 residents who were involved in Resident to Resident altercations as documented on a list provided by Registered Nurse (RN Consultant) #1 on [DATE]. The Administrator was informed of the Immediate Jeopardy condition on [DATE] at 8:00 p.m. The findings are: 1. The Facility Policy and Procedure for Behavior Management Program received from the Administrator on [DATE]. Preface: This facility promotes and supports a resident centered approach to care. The purpose of this policy is to define and set expectations regarding mood and behavioral health services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, where an individualized approach to care is essential . RAI (Resident Assessment Instrument) Process a. The RAI processes (MDS (Minimum Data set), CAA's (Care Area Assessment) and Care Planning) will be completed by the Interdisciplinary Team to determine person-centered care plan goals and approaches based upon the comprehensive assessment. b. Based upon the assessment findings, the interdisciplinary team will complete a comprehensive Person-centered Care Plan including specific mood and behavior interventions and approaches as applicable. c. Recognition and Management of Dementia a. The facility will assess and determine individualized behavioral care plan interventions for individuals with dementia. b. Behavioral interventions are individualized approaches (including direct care and activities) that are provided as part of a supportive physical and psychosocial environment and are directed toward understanding, preventing, relieving and/or accommodating a resident's distress or loss of abilities. 5. Mood and Behavior Tracking a. Mood and Behavior tracking documentation will be completed by front line staff, based upon comprehensive assessment outcomes, to identify any mood and behavior patterns, intervention attempted and outcome of approaches. b. Mood and behavior tracking will be reviewed by the interdisciplinary team on a quarterly basis or more often as needed to determine trends and effectiveness of care plan interventions (see Behavior Tracking Policy and Procedure). c. Mood and behavior tracking will be reviewed by the Charge Nurse per facility policy to determine trends and effectiveness of Care Plan interventions . 9. Emergent Changes: a. If a resident displays behaviors or mood changes that are a potential danger to the safety, health and welfare of themselves or others, the interdisciplinary team will assess the resident's current status and in conjunction with the discharge policy, make appropriate intervention or placement decisions. 2. Resident #11 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Medicare 5 Day Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] documented the resident scored 2 (,[DATE] indicates severely impaired) on the Brief Interview for Mental Status (BIMS), had physical behavioral symptoms directed toward others that had occurred for 1 to 3 days and verbal behaviors symptoms directed towards others that had occurred over the 4 to 6 days, required supervision with bed mobility, transfers, ambulation in room and corridor, required limited assistance of 1 person for dressing, and personal hygiene. a. The Incident and Accident documented as follows: 1) [DATE] at 12:45 p.m. Resident noted to have hit another resident (Resident #15) in facial area in hallway. Immediate Action Taken, Resident was redirected to safer environment one-on-one watch. There was no documentation that the incident was investigated for causative factors and no documentation related to intervention implemented to prevent further incidents. 2) [DATE] at 6:05 a.m. Aide reported seeing (Resident #11) attacked (Resident #14) was backing up away from (Resident #11) and (Resident #11) was moving towards him and he tripped over piano bench and fell . (Resident #11) had steadied himself on the back of a chair and then picked up the chair and started hitting (Resident #14) with the chair causing skin tear to (Resident #14) ankle. (Resident #11) fell from swinging chair. (Resident #11) cont.(continued) to cuss at staff and residents, hitting staff aide that is one-on-one with him. Trying to attack this Nurse. Calling residents (expletive). Resident also tried to attack another resident in the dining room but aide stopped him . Immediate Action Taken, Resident is one-on-one at this time. Resident was taken to the hospital. There was no documentation regarding follow-up investigation for this incident. b. Nurses Notes documented: 1) On [DATE] the resident was standing in hallway at this time holding wheelchair leg rest and threatening to hit the teenagers with it. The Aide tried telling resident there were no teenagers here and the Nurse talked to the resident, will monitor. 2) On [DATE] the resident had verbal behaviors of yelling and cussing with racial slurs at resident, the resident was redirected. 3) On [DATE] resident had verbal behaviors of yelling and screaming at staff, medicated with PRN (as needed) [MEDICATION NAME]. 4) On [DATE] the resident was in hallway threatening trying to hit at CNA using foul language at CNA's kicking door entrance wanted to leave. Resident was taken out to smoke and redirected. [MEDICATION NAME] had been administered earlier. 5) On [DATE] the resident was very argumentative, yelling using foul language at staff when redirected, refused to take am (morning) meds (medications). Physician was notified and meds were taken to resident's room and resident threw the meds on the floor. The Physician was notified. Order to send resident to (geri-psych facility). Resident was readmitted to the facility on [DATE]. There was no documentation related to implementation of interventions related to aggressive verbal behaviors. The hospital discharge instructions dated [DATE] documented, .Indicators/Treatment Plan . ,[DATE] (24 hours/7 days) Care Nursing Home Psy. (psychiatric) Med (medication) Management . 6) The Progress Notes documented by the APN, on [DATE] documented, Resident was sent to emergency room for evaluation and treatment on [DATE] secondary to aggressive behaviors along with throwing his television . This incident wasn't documented in the Nurses Notes. 7) On [DATE] Resident yells at other residents at times with redirection. 8) On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] observed for behaviors yells at other residents at times, redirect as needed. 9) On [DATE] the resident was going into other residents room and cursing at them and threatening them if they don't stop yelling he will shut them up. Resident was redirected. The redirection was ineffective and a stop and watch was filled out for the Physician. 10) On [DATE] the resident was yelling out that he will make them stop yelling so he can get some rest. 11) On [DATE] Resident was having increased confusion this shift with aggressive behaviors. Attempted to assault staff. Resident was beating on door of unit demanding to smoke. 11) On [DATE] the resident was in hallway in w/c (wheelchair) got up and noted to hit another resident (Resident #15) in facial area, resident redirected to safer area. Resident using foul language at staff. Resident was sent to Geri-Psych and was readmitted to the facility on [DATE] at 9:51 a.m. according to the facility Progress Notes. 12) On [DATE] the resident had incident of verbal behaviors yelled /cussed at residents. c. There were no Nurses Notes related to the incident that had occurred on [DATE] the Resident was sent to Geri-Psych and has not been readmitted to the facility at this time. There was no Incident Reports related to the resident verbal behaviors during the past month. d. On [DATE] at 6:24 p.m., the Incidents and Accidents Reports and Nurses Notes for Resident #11 were reviewed with the DON. The resident was had 23 incidents of aggressive behavior including an incident of throwing a television and had been sent to a geri-psyche facility on [DATE]. The DON was asked if there was a plan put in place to address the causative factors for these incidents. The DON stated, Not that I'm aware of. Nurses Notes documented verbal aggressive behaviors, the Incidents Report on [DATE] documented aggressive behaviors, and there was a resident-to-resident altercation, then the resident was admitted to geri-psych for the second time on [DATE]. The DON was asked if there a plan was put in place to address the resident's aggressive behaviors at the time readmission. The DON stated, No. The DON was asked due to the aggressive behavior, could this have affected the safety of the other residents and the DON stated, Yes. The DON stated, (Resident #11) was moved off the unit. The DON was asked for what reason. The DON stated to reduce the commotions and less stimulation. The DON was asked if there was any training or instruction to the staff when Resident #11 was moved off the secure unit. The DON stated, No. The DON was asked if there was an investigation into the causative factors regarding the incident on [DATE], when Resident #11 had aggressive behavior towards Resident #14 and tried to attack another resident, then was sent to a geri-psych facility and has not returned to this facility at this time. The DON stated, there was no investigation done. 3. Resident #15 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Admission MDS with an ARD of [DATE] documented the resident scored a 7 (,[DATE] indicates severely impaired in cognitive skills) on the BIMS; had behavioral symptoms of physical behaviors directed towards others, verbal behavioral symptoms directed towards, and wandering behaviors have occurred in the past 4 to 6 days; and was independent with transfers, ambulation in room, and supervision with ambulation in corridor. a. The Incident & Accident Reports documented: 1) [DATE] at 10:50 a.m., The Incident Description, Resident noted to have punched another male resident in his room, Resident was going to use the restroom when it was already occupied. Resident stated he was slapped in the face so he punched the other resident (Resident #13) . Action Taken, Removed resident to safer environment. There was no documentation that the incident was investigated or intervention was implemented. 2) [DATE] at 3:43 a.m., Incident Description, Was called to back of 300 Hall because of Resident to Resident contact, Resident said that (Resident #13) attacked him and he fought back. He first said that his neck hurt on his left side, but when I went to look at this he asked if he could go smoke and told him no, then stated that he was ok and I was a lying bag of s***. Resident then stormed off. Immediate Action Taken, Assessed as much as Resident would let me and kept the Residents apart. There was no documentation regarding a follow up or interventionism implemented regarding this incident. 3) [DATE] at 11:00 a.m., Incident Description, Resident noted to be sitting in dr (dining room) area another resident (Resident #14) hit this resident on head area. Immediate Action Taken, Neuro check q shift, redirected other resident r/t safety. There was no documentation that the incident was investigated for the causative factors or interventions implemented regarding this incident. 4. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS with an ARD of [DATE] documented the resident scored 7 ,[DATE] indicates severely impaired) on the BIMS, was independent with transfers and ambulation, had physical behavioral symptoms towards other that had occurred in the past 1 to 3 days and verbal behavioral symptoms towards other that had occurred in the past 4 to 6 days. a. The Residents incident Reports documented: 1) [DATE] at 10:50 a.m. Incident Description, Resident noted to have punched another male resident (Resident #18) in his room, Resident was going to use the restroom when it was already occupied. The Resident stated that he was slapped in the face, so he punched the other resident . Immediate Action Taken, Removed resident to safer environment. The report did not document an investigation regarding this incident or interventions related to this incident. 2) [DATE] at 3:43 a.m. Incident Description, was called back to 300 Hall because of Resident to Resident contact, Resident said that (Resident #15) attacked him and he fought back. He first said that his neck hurt on his L (left) side. But when I went to look at this he asked if he asked if he could go smoke and told him no. Then he stated, that he was ok and that I was a lying sack of s***. Then Resident stormed to his room. The Immediate Action Taken, Assessed as much as Resident would let me and kept the Residents apart. There was no documentation that this incident was investigated regarding the causative factors. 3) [DATE] at 11:00 a.m. Incident Description, Resident noted to be sitting in dr (Dining Room) area, another Resident (Resident #15) hit this resident on the head area. Stated he hit me on my head. Immediate Action Taken, Neuro check q (every) shift other resident from this resident r/t (retaining to) safety. There was no documentation regarding an investigation regarding this incident. 5. Resident #10 had [DIAGNOSES REDACTED]. The Discharge MDS with an ARD of [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and had physical behavioral symptoms directed toward others (e.g. (for example), hitting, kicking, pushing, scratching, grabbing .), and verbal behavioral symptoms directed towards others that had occurred in with a frequency in 1 to 3 days. a. A Progress Note dated [DATE] at 7:00 p.m., written by Registered Nurse (RN) #2, documented, resident was cussing another resident and hit him on the head. residents were separated and this resident was placed on one-on-one monitoring. mother called and notified, dr (doctor) called . monitoring for behaviors . 1) An incident report dated [DATE] at 11:32 p.m. documented, .Incident Location: Dining Room . Incident Description: Nursing Description: cna (Certified Nursing Assistant) reported to this nurse that this resident hit another resident (Resident #17) in the head . Immediate Action Taken: Description: separated both of the residents the resident went to this room and was being monitoring by cnas on the hall . There was no documentation an investigation to determine the causative factor for the incident nor recommended interventions. There was no documentation of one-on-one monitoring by direct care staff. 2) A Progress Note dated [DATE] at 2:03 a.m. documented, .I & A (Incident and Accident) R/T (related to) hitting another resident . b. A Progress Note dated [DATE] at 12:00 p.m. documented, resident has increased behaviors this shift. pacing the hallways, cussing towards other residents, making threats to residents and staff, saying he was 'going to break her f****** nose.' resident talks to himself, flailing arms around showing anxious body language. cont (continues) to strip clothes off throughout shift, throwing and pushing furniture around. cont with ,[DATE] with staff member at this time. c. A Progress Note dated [DATE] at 9:55 p.m. documented, resident cont having increased behaviors this shift. threatening and cussing towards staff and other residents. resident threw food and silverware at staff this shift. remains ,[DATE] with staff member. call (Advance Practice Nurse (APN)), orders given to transfer to (geriatric psychiatric (geri-psych) hospital). resident transferred via ems (emergency medical services) left facility at 2100 (9:00 p.m.) . d. A hospital History and Physical dated [DATE] documented, .Impression: 1. Dementia with behavior disorder . A hospital Progress Note dated [DATE] documented, .the patient was pacing the hallways in his nursing home, soaring ??? at staff and residents and threatening other residents . He has been agitated. He refused to leave his room. Poor eye contact. He has continued to be talking to the air and responding to internal stimuli. He engages in conversations with no one. He is smiling and laughing.He taps very hard on the glass around the nurse's station. Apparently the patient swung at the tech (technician) and began chasing the techs.Mood: Irritable and agitated . Assessment: Major neurocognitive disorder with behavioral disturbance . Hx (history) Unspecified [MEDICAL CONDITION] not due to a substance or not physiological condition Hx of Dementia and other diseases classified elsewhere but with behavior disturbance Hx of [MEDICAL CONDITION], unspecified Rule out Delusional disorder Rule out [MEDICAL CONDITION] Rule out Unspecified [MEDICAL CONDITION] . Progress Note dated [DATE] Nursing Report: . He gets easily agitated and will attempt to strike staff when irritable.He attempted to knock over a table . Progress Note dated [DATE] .Nursing Report: At times the patient will be observed laughing and talking to himself. He seen wandering around the hallways and can be easily agitated. He received [MEDICATION NAME] 2 mg (milligrams) at 1100 (11:00 a.m.) yesterday for escalating behavior problems. He was in hallway yelling and screaming stating 'I can kill you.' Staff has some difficulty with patient's ADLs (activities of daily living) as he can be resistant.A Progress Note dated [DATE] .Nursing Report: .He was noted to have been agitated and physically aggressive when awakened for medications. He spat out the water when offered. Frequently uses profanity to verbalize himself . A Progress Note dated [DATE] . The patient was considerably agitated this morning with no inciting trigger. He began flipping over tables in the dining room. Staff was called to hold the patient for [MEDICATION NAME] 2 mg. He began exhibiting additional agitated behavior attempting to swing at staff members . He was unable to be redirected.A Progress Note [DATE] MD (Medical Doctor) notes the patient has been aggressive, fights, and response to internal stimulation. He is seen grabbing things on the unit. Conversing with visual hallucinations.Per nursing, the patient has been agitated, anxious, and difficult to redirect. He fidgets with things in the hallways. He attempts to pick things up on the floor when there is nothing present. He notes to be leaning on the glass doors and bumping his forehead. He attempted to take the fire extinguisher. He screams, profanities and yells when no one is there . Progress Note dated [DATE] . Patient continues to exhibit rapidly impulsive behavior. They noted that he suddenly got out of his chair yesterday, walked across the dining room and hit the refrigerator with his fist. He began becoming aggressive with the tech that was one-on-one with him, grabbing her arms and squeezing and twisting . He continued to be wandering around the hallways hallucinating and picking things up from the floor that are not present. He sporadically aggressive with staff members . Progress Note [DATE] .Patient continues to be wandering around the hallways carrying on a conversation with himself.He exhibited threatening behaviors toward staff members, getting agitated and unable to redirect him . He threatened to kill staff members . will become agitated without much provocation . Patient was kicking, punching, cursing . Progress Note [DATE] . Continues to exhibit aggressive and wandering behavior around the unit requiring one-on-one observation to provide safe environment. Patient at times will exhibit agitation wanting to hit people. He walked by a door seeing his reflection and stated that he was going to kill that person . The Discharge Summary dated [DATE] documented, .He is improved by time of discharge . He is consistently cooperative with care and free of aggressive/combative behavior and threats . There was no documentation of any intervention to prevent further aggressive behaviors. e. A nursing Progress Note dated [DATE] at 2:35 p.m. documented, resident readmitted to (facility) 300 secured unit, arrived to nh (nursing home) via nh van with staff x (times) 2, . ambulates at intervals, responds to verbal commands, . observed for behaviors, . wanders at intervals . refused vs (vital signs) this shift . f. The Care Plan dated [DATE] was reviewed and there was no documentation that addressed the resident's [DIAGNOSES REDACTED]. g. A nursing Progress Note dated [DATE] at 10:15 a.m. written by RN #2, documented, resident was refusing care was kicking hitting cnas thus nurse told cnas to back off and let resident calm down. resident does not redirect. h. A nursing Progress Note dated [DATE] at 1:00 p.m. written by RN #2 documented, resident had sit down on roommates arm while roommate was sleeping in roommate's bed. An incident report dated [DATE] at 10:21 p.m. documented, .cnas walk in residents room and seen this resident sitting on another residents (Resident #19) arm while the other resident was sleeping in his bed.Notes [DATE] On [DATE], the resident was found sitting on top of another resident. The resident has inappropriate behaviors that he does not know how to control. resident was placed one-on-one until he was sent to (geri-psych hospital). i. A nursing Progress Note dated [DATE] at 10:56 p.m. documented, received orders from (Physician ) to send resident to (geri-psych hospital) resident left facility at 215 pm. (2:15 p.m.), was transported by our facility 2 cnas and van. j. On [DATE] at 3:35 p.m., RN #2 was asked if the resident was still in the facility and the RN stated, No. The RN was asked when the resident had left the facility and the RN stated, Around 2:15 p.m. ([DATE]) . k. On [DATE] at 10:17 a.m., the DON was asked who was the resident that Resident #10 had hit on the incident on [DATE] and the DON stated, (Resident #19) The DON was asked about the incident and why the resident had been sent out of the facility. The DON stated, He was sitting on top of another resident and had straddled him and had his hands on his (Resident #19) chest. The DON was asked who the other resident was and the DON stated, (Resident #19 name). The DON was asked if the resident had thrown something and the DON stated, Yes, towel rack. The DON was asked if the resident had resisted care when the CNA staff were in the room with the resident and the DON stated, I think he was. They were cleaning him, (CNA #7 and CNA #8). l. On [DATE] at 10:50 a.m., CNA #7 was asked if the resident had resisted care on [DATE] and the CNA stated, He had used the bathroom on self, bowel, we got him in the bathroom half way he started hitting us, cussing us, he tore the metal piece off the wall and started using it as a weapon threw it. He was hitting us with it, me and (CNA #8). I called for help, I used my phone, personal phone only way to call for help, (CNA/RNA (Restorative Nursing Assistant #2) and (RN #2) the nurse, (RN #2) came back. They helped us come out of bathroom. Tried to open door (door to adjoining room) and couldn't and he (Resident #10) was standing between us and the door. They got him from behind up underneath the arms, backwards. He just walked backwards. The CNA was asked if the staff members touched the resident and the CNA stated, They were touching. They were on each side and they were walking him. (RNA #2), myself, (CNA #8) got him into the bed. The CNA was asked why they had gotten the resident to bed and the CNA stated, To try to get him cleaned up, he still had poop all over him. So we attempted to get him clean. CNA #7 was asked if it was 3 staff members who had tried to clean the resident and the CNA stated, 3 of us. So the nurse left, I'll return in a moment. I need to report. The CNA was asked if the nurse was in the room when they tried to get the resident in the bed and the CNA stated, Yes. In the bed wasn't the problem, it was cleaning him that was the problem. He wouldn't let us clean him so we stepped back from the situation to see if he would calm down. So we left the room so we continued our rounds, to see if he would calm down, we just left him be. The CNA was asked what time this had occurred and how long out of room and the CNA stated, I don't remember exact time but it was before lunch. The CNA was asked if they had returned back into the room and the CNA stated, We did about 15 minutes later we go had to (Resident #19) to change him. The CNA was asked where Resident #10 was and the CNA stated, In his bed he had done covered himself up and looked to be asleep so we thought he might have calmed down so we attempted to clean him again. The CNA was asked what occurred next and the CNA stated, (CNA #8) went to the linen cart and I went to get cleaning supplies and when we came back. (Resident #10) was on top of (Resident #19). He was straddling him, he had his arms holding him down, he was facing him. CNA #7 was asked what staff was to do when a resident had an aggressive behavior and the CNA stated, We were told to leave the resident, to back off, that's what they tell us here. The CNA was asked who had given these instructions and the CNA stated, Our Administrator, DON (Director of Nursing), ADON (Assistant DON). The CNA was asked if the resident was having any behavior when they had first attempted to provide care on [DATE] and the CNA stated, Yes, he started cussing at us. He told us no the first 2 times, the third time we were able to get his shirt off. It was when the pants came off is when he got upset. We asked him, he told us no, so we ran the water to make sure the water was warm in the bathroom sink, then we asked again, he told us no, so we just got out soaps and stuff ready and he told us if you F****** have to. He let us take the shirt off. The CNA was then asked if the first time that the resident had said No did they leave the room and the CNA stated, No we just turned our backs. The CNA was asked if they remained in the bathroom with the resident and the CNA stated, Yes. The CNA was asked if they remained in the bathroom with the resident the second time that the resident refused care and the CNA stated, We still turned our back. The CNA was asked if the resident had resisted when the pants were taken off and the CNA stated, He resisted when the pants came off. By that time we were trying to get out of the bathroom. I was by the sink and she (CNA #8) was by the toilet. The CNA was asked why when the resident had said no on the first attempt to provide care why they remained and the CNA stated, That's just where we stayed. The CNA was asked how long she had worked on the secured unit and the CNA stated, 3 months. The CNA was asked what special training she had to work on the secured unit and the CNA stated, When I worked for (another facility name) I had to take special training to work their unit. The CNA was asked what training consisted of and the CNA stated, It just showed us what to do in situations. The CNA was asked if they were instructed to leave the resident and the CNA stated, They told us to leave the scene as soon as the resident is safe. Leave the scene, report, reeval (reevaluate) what to do how to approach the situation. The CNA was asked if she had followed those instructions and the CNA stated, I didn't. m. On [DATE] at 2:52 p.m., the DON was asked when the resident was admitted [DATE] was it to the secure unit and the DON stated, Yes. The DON was asked why the resident had been sent out of the facility on [DATE] and the DON stated, If I'm not mistaken he was having some aggression. The DON was asked who that other resident was and the DON stated, I can't remember. The DON was asked if the resident was readmitted from a geri-psych unit on [DATE] and the DON stated, Yes. The DON was asked if she was aware that the resident had behaviors and the DON stated, The behaviors aggression and sexually inappropriate. The DON was asked what nursing staff was to do when a resident was aggressive and the DON stated, What I tell them to do is leave them alone and let them calm down. The DON was asked how long staff should wait before care was attempted again and the DON stated, I usually tell them about ,[DATE] minutes. The DON was asked if a resident said No should staff still provide care and the DON stated, If they say no I would say no, stop and see if someone else can do it. n. On [DATE] at 7:09 p.m., RN #2 was asked what had occurred on [DATE] when there was an incident with the resident and the RN stated, I was on the hall and (CNA/RNA #2) came and got me and girls were (CNA #7 and CNA #8) were in bathroom, he (Resident #10). You could tell he was mad and he wasn't going to listen to them and he was trying to grab at them, so me and (CNA/RNA) told them to back off, they did. They were in the bathroom, he was on the toilet. I didn't know at the time what happened. They were trying to get him out and that's what I saw. The RN was asked if she had instructed the staff to stop care and the RN stated, Yes. The RN was asked what had occurred and the RN stated, First thing I said was ya'll back off, me and (CNA/RNA) put gloves on and we were going to redirect him and (CNA/RNA) talked to him and she talks real soft and we were able to redirect.I asked the girls (CNA #7 and 8) to clean up the bathroom and I asked them to come back and check and make sure he was still calm. The RN was asked if she had gone back and checked the resident and the RN stated, I went and told (DON) he was refusing care and what he was doing . The RN was asked if a resident was resisting care what was to be done and the RN stated, Stop. The RN was asked what was done then about the resident's behavior and the RN stated, I heard we were sending him out to (geri-psychiatric hospital) and he was on one-on-one. 6. On [DATE] at 4:30 p.m., the Director of Nurses (DON) was asked regarding the issue with resident to resident altercations in the facility. The DON stated, There has been an issue with repeated resident to resident altercation. There was an incident involving (Resident #15). There was a resident to resident altercation with (Resident #18) on [DATE]. (Resident #15) hit (Resident #18), his roommate in the head with control for the recliner. The residents were separated and (Resident #18) was moved to another room. The DON was asked if this incident was investigated following the incident to determine the causative factors. The DON stated, No. The DON was asked regarding the incident when Resident #15 hit/attacked Resident #1 (TRUNCATED)

Complaint # (AR 908) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure administration and nursing administration promptly acted to correct failures regarding the provision of adequate supervision for residents with a history of aggressive behaviors toward other residents. Administration failed to investigate resident to resident altercations, attempt to identify the causative factors, and ensure that effective interventions were developed and adequate trained staff were available to consistently carry out planned interventions to prevent further resident-to-resident altercations and aggressive behaviors for 4 of 4 (Resident #10, 11, 13, and 15) case mix residents who exhibited aggressive behaviors and for 5 of 5 (Residents #13, #15, #17, #18, and #19) case mix residents who were assaulted by another resident who had aggressive behaviors. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Residents #13, #15, #17, #18, and #19) who were physically assaulted by Residents #10, #11, #13, and #15 and had the potential to cause more than minimal harm to 13 residents who resided on the 300 Hall secure unit as documented on a list provided on by the Administrator [DATE] and 10 residents who were involved in Resident to Resident altercations as documented on a list provided by the Registered Nurse (RN Consultant) #1 on [DATE]. The facility was informed of the Immediate Jeopardy condition on [DATE] at 8:00 p.m. The findings are: 1. The Job Description for the CEO (Chief Executive Officer (Administrator)) received from the Assistant Business Office Manager (ABOM) on [DATE] documented, Summary, The CEO is responsible for the day to day operations and direction of the facility, and ensures that the facility complies with all policies and procedures set forth by the company, as well as those required by regulatory agencies. Also ensures that expectations of the corporation and our customers are met or exceeded on a continual basis. Essential Job duties and responsibilities: 1. Ensure that the facility complies with all policies and procedures set forth by the company, regulatory agencies and other appropriate bodies. Carries out al policies established by the company and advises on the formulation of these policies. Develops and submits to the company a plan of organization for the conduct of facility operations and recommends changes when necessary. 2. Direct the financial management of the facility through budgeting review and implementation reviews related reports and sets standard for performance. Cooperates with the controller to ensure that all services are appropriately charged, bills are generated and monies are collected in a timely manner. Present the Company monthly reports reflecting the professional service and financial activities of the facility and such special reports as may be required by the Company. 3. Ensure quality care and excellent communication with patients, families and staff . 4. Demonstrate effective management/leadership skills. Direct staff members effectively and clearly communicate to them individual and facility expectations. Improves the skills and knowledge of staff members to help them realize their full potential . 5. Manages Human Resources issues within areas responsibility . Maintain effective and appropriate staffing levels as evidenced by ongoing budgetary analysis. Prepares and conducts effective and timely employee performance appraisals. Utilizes the performance management disciplinary process effectively and appropriately. Ensures facility specific orientation to all new employees and ensures ongoing educational training as required by the Company policy and to meet the facility's needs in collaboration with Human Resources, actively recruits, selects and retains employees for facility vacancies . 2. The Job Description for the Director of Nursing received from the ABOM on [DATE] documented, The Director of Nursing (DON) is responsible for overall management of the Nursing Department and coordination of other disciplines to provide quality care to all patients/residents . She/he also monitors the outcomes of nursing service activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agency standards, policies and procedures . monitoring the effective use of budgeted resources (personnel .) . Essential Job Duties and Responsibilities 1. Ensures that nursing interventions meet the personal, physical and cognitive needs of each patient/resident as well as maximize his/her self care capacities, identity, independence, choice and opportunity for social interaction 7. Maintains adequate staffing ratios and levels of preparation to meet the needs of patients/residents . 10. Incorporates nursing philosophy, standard and objectives into the evaluation process for staff and nursing services and ensures . are an integral part of the orientation and education of nursing service personnel . 3. Resident #11 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Medicare 5 Day Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] documented the resident scored 2 (,[DATE] indicates severely impaired) on the Brief Interview for Mental Status (BIMS), had physical behavioral symptoms directed toward others that had occurred for 1 to 3 days and verbal behaviors symptoms directed towards others that had occurred over the 4 to 6 days, required supervision with bed mobility, transfers, ambulation in room and corridor, required limited assistance of 1 person for dressing, and personal hygiene. a. The Incident and Accident documented as follows: 1) [DATE] at 12:45 p.m. Resident noted to have hit another resident (Resident #15) in facial area in hallway. Immediate Action Taken, Resident was redirected to safer environment one-on-one watch. There was no documentation that the incident was investigated for causative factors and no documentation related to intervention implemented to prevent further incidents. 2) [DATE] at 6:05 a.m. Aide reported seeing (Resident #11) attacked (Resident #14) was backing up away from (Resident #11) and (Resident #11) was moving towards him and he tripped over piano bench and fell . (Resident #11) had steadied himself on the back of a chair and then picked up the chair and started hitting (Resident #14) with the chair causing skin tear to (Resident #14) ankle. (Resident #11) fell from swinging chair. (Resident #11) cont.(continued) to cuss at staff and residents, hitting staff aide that is one on one with him. Trying to attack this Nurse. Calling residents f*** n*****, b*****. Resident also tried to attack another resident in the dining room but aide stopped him . Immediate Action Taken, Resident is one on one at this time. Resident was taken to the hospital. There was no documentation regarding follow-up investigation for this incident. b. Nurses Notes documented: 1) On [DATE] the resident was standing in hallway at this time holding wheelchair leg rest and threatening to hit the teenagers with it. The Aide tried telling resident there were no teenagers here and the Nurse talked to the resident, will monitor. 2) On [DATE] the resident had verbal behaviors of yelling and cussing with racial slurs at resident, the resident was redirected. 3) On [DATE] resident had verbal behaviors of yelling and screaming at staff, medicated with PRN (as needed) [MEDICATION NAME]. 4) On [DATE] the resident was in hallway threatening trying to hit at CNA using foul language at CNA's kicking door entrance wanted to leave. Resident was taken out to smoke and redirected. [MEDICATION NAME] had been administered earlier. 5) On [DATE] the resident was very argumentative, yelling using foul language at staff when redirected, refused to take am (morning) meds (medications). Physician was notified and meds were taken to resident's room and resident threw the meds on the floor. The Physician was notified. Order to send resident to (geri-psych facility). Resident was readmitted to the facility on [DATE]. There was no documentation related to implementation of interventions related to aggressive verbal behaviors. The hospital discharge instructions dated [DATE] documented, .Indicators/Treatment Plan . ,[DATE] (24 hours/7 days) Care Nursing Home Psy. (psychiatric) Med (medication) Management . 6) The Progress Notes documented by the APN, on [DATE] documented, Resident was sent to emergency room for evaluation and treatment on [DATE] secondary to aggressive behaviors along with throwing his television . This incident wasn't documented in the Nurses Notes. 7) On [DATE] Resident yells at other residents at times with redirection. 8) On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] observed for behaviors yells at other residents at times, redirect as needed. 9) On [DATE] the resident was going into other residents room and cursing at them and threatening them if they don't stop yelling he will shut them up. Resident was redirected. The redirection was ineffective and a stop and watch was filled out for the Physician. 10) On [DATE] the resident was yelling out that he will make them stop yelling so he can get some rest. 11) On [DATE] Resident was having increased confusion this shift with aggressive behaviors. Attempted to assault staff. Resident was beating on door of unit demanding to smoke. 12) On [DATE] the resident was in hallway in w/c (wheelchair) got up and noted to hit another resident (Resident #15) in facial area, resident redirected to safer area. Resident using foul language at staff. Resident was sent to Geri-Psych and was readmitted to the facility on [DATE] at 9:51 a.m. according to the facility Progress Notes. 13) On [DATE] the resident had incident of verbal behaviors yelled /cussed at residents. c. There were no Nurses Notes related to the incident that had occurred on [DATE] the Resident was sent to Geri-Psych and has not been readmitted to the facility at this time. There was no Incident Reports related to the resident verbal behaviors during the past month. d. On [DATE] at 6:24 p.m., the Incidents and Accidents Reports and Nurses Notes for Resident #11 were reviewed with the DON. The resident was had 23 incidents of aggressive behavior including an incident of throwing a television and had been sent to a geri-psyche facility on [DATE]. The DON was asked if there was a plan put in place to address the causative factors for these incidents. The DON stated, Not that I'm aware of. Nurses Notes documented verbal aggressive behaviors, the Incidents Report on [DATE] documented aggressive behaviors, and there was a resident-to-resident altercation, then the resident was admitted to geri-psych for the second time on [DATE]. The DON was asked if there a plan was put in place to address the resident's aggressive behaviors at the time readmission. The DON stated, No. The DON was asked due to the aggressive behavior, could this have affected the safety of the other residents and the DON stated, Yes. The DON stated, (Resident #11) was moved off the unit. The DON was asked for what reason. The DON stated to reduce the commotions and less stimulation. The DON was asked if there was any training or instruction to the staff when Resident #11 was moved off the secure unit. The DON stated, No. The DON was asked if there was an investigation into the causative factors regarding the incident on [DATE], when Resident #11 had aggressive behavior towards Resident #14 and tried to attack another resident, then was sent to a geri-psych facility and has not returned to this facility at this time. The DON stated, there was no investigation done. 4. Resident #15 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Admission MDS with an ARD of [DATE] documented the resident scored a 7 (,[DATE] indicates severely impaired in cognitive skills) on the BIMS; had behavioral symptoms of physical behaviors directed towards others, verbal behavioral symptoms directed towards, and wandering behaviors have occurred in the past 4 to 6 days; and was independent with transfers, ambulation in room, and supervision with ambulation in corridor. a. The Incident & Accident Reports documented: 1) [DATE] at 10:50 a.m., The Incident Description, Resident noted to have punched another male resident in his room, Resident was going to use the restroom when it was already occupied. Resident stated he was slapped in the face so he punched the other resident (Resident #13) . Action Taken, Removed resident to safer environment. There was no documentation that the incident was investigated or intervention was implemented. 2) [DATE] at 3:43 a.m., Incident Description, Was called to back of 300 Hall because of Resident to Resident contact, Resident said that (Resident #13) attacked him and he fought back. He first said that his neck hurt on his left side, but when I went to look at this he asked if he could go smoke and told him no, then stated that he was ok and I was a lying bag of s***. Resident then stormed off. Immediate Action Taken, Assessed as much as Resident would let me and kept the Residents apart. There was no documentation regarding a follow up or interventionism implemented regarding this incident. 3) [DATE] at 11:00 a.m. , Incident Description, Resident noted to be sitting in dr (dining room) area another resident (Resident #14) hit this resident on head area. Immediate Action Taken, Neuro check q shift, redirected other resident r/t safety. There was no documentation that the incident was investigated for the causative factors or interventions implemented regarding this incident. 5. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS with an ARD of [DATE] documented the resident scored 7 ,[DATE] indicates severely impaired) on the BIMS, was independent with transfers and ambulation, had physical behavioral symptoms towards other that had occurred in the past 1 to 3 days and verbal behavioral symptoms towards other that had occurred in the past 4 to 6 days. a. The Residents incident Reports documented: 1) [DATE] at 10:50 a.m. Incident Description, Resident noted to have punched another male resident (Resident #18) in his room, Resident was going to use the restroom when it was already occupied. The Resident stated that he was slapped in the face, so he punched the other resident . Immediate Action Taken, Removed resident to safer environment. The report did not document an investigation regarding this incident or interventions related to this incident. 2) [DATE] at 3:43 a.m. Incident Description, was called back to 300 Hall because of Resident to Resident contact, Resident said that (Resident #15) attacked him and he fought back. He first said that his neck hurt on his L (left) side. But when I went to look at this he asked if he asked if he could go smoke and told him no. Then he stated, that he was ok and that I was a lying sack of s***. Then Resident stormed to his room. The Immediate Action Taken, Assessed as much as Resident would let me and kept the Residents apart. There was no documentation that this incident was investigated regarding the causative factors. 3) [DATE] at 11:00 a.m. Incident Description, Resident noted to be sitting in dr (Dining Room) area, another Resident (Resident #15) hit this resident on the head area. Stated he hit me on my head. Immediate Action Taken, Neuro check q (every) shift other resident from this resident r/t (retaining to) safety. There was no documentation regarding an investigation regarding this incident. 6. Resident #10 had [DIAGNOSES REDACTED]. The Discharge MDS with an ARD of [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and had physical behavioral symptoms directed toward others (e.g. (for example), hitting, kicking, pushing, scratching, grabbing .), and verbal behavioral symptoms directed towards others that had occurred in with a frequency in 1 to 3 days. a. A Progress Note dated [DATE] at 7:00 p.m., written by Registered Nurse (RN) #2, documented, resident was cussing another resident and hit him on the head. residents were separated and this resident was placed on one-on-one monitoring. mother called and notified, dr (doctor) called . monitoring for behaviors . 1) An incident report dated [DATE] at 11:32 p.m. documented, .Incident Location: Dining Room . Incident Description: Nursing Description: cna (Certified Nursing Assistant) reported to this nurse that this resident hit another resident (Resident #17) in the head . Immediate Action Taken: Description: separated both of the residents the resident went to this room and was being monitoring by cnas on the hall . There was no documentation an investigation to determine the causative factor for the incident nor recommended interventions. There was no documentation of one on one monitoring by direct care staff. 2) A Progress Note dated [DATE] at 2:03 a.m. documented, .I & A (Incident and Accident) R/T (related to) hitting another resident . b. A Progress Note dated [DATE] at 12:00 p.m. documented, resident has increased behaviors this shift. pacing the hallways, cussing towards other residents, making threats to residents and staff, saying he was 'going to break her (expletive) nose.' resident talks to himself, flailing arms around showing anxious body language. cont (continues) to strip clothes off throughout shift, throwing and pushing furniture around. cont with ,[DATE] with staff member at this time. c. A Progress Note dated [DATE] at 9:55 p.m. documented, resident cont having increased behaviors this shift. threatening and cussing towards staff and other residents. resident threw food and silverware at staff this shift. remains ,[DATE] with staff member. call (Advance Practice Nurse (APN)), orders given to transfer to (geriatric psychiatric (geri-psych) hospital). resident transferred via ems (emergency medical services) left facility at 2100 (9:00 p.m.) . d. A hospital History and Physical dated [DATE] documented, .Impression: 1. Dementia with behavior disorder . A hospital Progress Note dated [DATE] documented, .the patient was pacing the hallways in his nursing home, swearing at staff and residents and threatening other residents . He has been agitated. He refused to leave his room. Poor eye contact. He has continued to be talking to the air and responding to internal stimuli. He engages in conversations with no one. He is smiling and laughing.He taps very hard on the glass around the nurse's station. Apparently the patient swung at the tech (technician) and began chasing the techs.Mood: Irritable and agitated . Assessment: Major neurocognitive disorder with behavioral disturbance . Hx (history) Unspecified [MEDICAL CONDITION] not due to a substance or not physiological condition Hx of Dementia and other diseases classified elsewhere but with behavior disturbance Hx of [MEDICAL CONDITION], unspecified Rule out Delusional disorder Rule out [MEDICAL CONDITION] Rule out Unspecified [MEDICAL CONDITION] . Progress Note dated [DATE] Nursing Report: . He gets easily agitated and will attempt to strike staff when irritable.He attempted to knock over a table . Progress Note dated [DATE] .Nursing Report: At times the patient will be observed laughing and talking himself. He seen wandering around the hallways and can be easily agitated. He received [MEDICATION NAME] 2 mg (milligrams) at 1100 (11:00 a.m.) yesterday for escalating behavior problems. He was in hallway yelling and screaming stating 'I can kill you.' Staff has some difficulty with patient's ADLs (activities of daily living) as he can be resistant.A Progress Note dated [DATE] .Nursing Report: .He was noted to have been agitated and physically aggressive when awakened for medications. He spat out the water when offered. Frequently uses profanity to verbalize himself . A Progress Note dated [DATE] . The patient was considerably agitated this morning with no inciting trigger. He began flipping over tables in the dining room. Staff was called to hold the patient for [MEDICATION NAME] 2 mg. He began exhibiting additional agitated behavior attempting to swing at staff members . He was unable to be redirected.A Progress Note [DATE] MD (Medical Doctor) notes the patient has been aggressive, fights, and response to internal stimulation. He is seen grabbing things on the unit. Conversing with visual hallucinations.Per nursing, the patient has been agitated, anxious, and difficult to redirect. He fidgets with things in the hallways. He attempts to pick things up on the floor when there is nothing present. He notes to be leaning on the glass doors and bumping his forehead. He attempted to take the fire extinguisher. He screams, profanities and yells when no one is there . Progress Note dated [DATE] . Patient continues to exhibit rapidly impulsive behavior. They noted that he suddenly got out of his chair yesterday, walked across the dining room and hit the refrigerator with his fist. He began becoming aggressive with the tech that was one on one with him, grabbing her arms and squeezing and twisting . He continued to be wandering around the hallways hallucinating and picking things up from the floor that are not present. He sporadically aggressive with staff members . Progress Note [DATE] .Patient continues to be wandering around the hallways carrying on a conversation with himself.He exhibited threatening behaviors toward staff members, getting agitated and unable to redirect him . He threatened to kill staff members . will become agitated without much provocation . Patient was kicking, punching, cursing . Progress Note [DATE] . Continues to exhibit aggressive and wandering behavior around the unit requiring one on one observation to provide safe environment. Patient at times will exhibit agitation wanting to hit people. He walked by a door seeing his reflection and stated that he was going to kill that person . The Discharge Summary dated [DATE] documented, .He is improved by time of discharge . He is consistently cooperative with care and free of aggressive/combative behavior and threats . There was no documentation of any intervention to prevent further aggressive behaviors. e. A nursing Progress Note dated [DATE] at 2:35 p.m. documented, resident readmitted to (facility) 300 secured unit, arrived to nh (nursing home) via nh van with staff x (times) 2, . ambulates at intervals, responds to verbal commands, . observed for behaviors, . wanders at intervals . refused vs (vital signs) this shift . f. The Care Plan dated [DATE] was reviewed and there was no documentation that addressed the resident's [DIAGNOSES REDACTED]. g. A nursing Progress Note dated [DATE] at 10:15 a.m. written by RN #2, documented, resident was refusing care was kicking hitting cnas thus nurse told cnas to back off and let resident calm down. resident does not redirect. h. A nursing Progress Note dated [DATE] at 1:00 p.m. written by RN #2 documented, resident had sit down on roommates arm while roommate was sleeping in roommate's bed. An incident report dated [DATE] at 10:21 p.m. documented, .cnas walk in residents room and seen this resident sitting on another residents (Resident #19) arm while the other resident was sleeping in his bed.Notes [DATE] On [DATE], the resident was found sitting on top of another resident. The resident has inappropriate behaviors that he does not know how to control. resident was placed one on one until he was sent to (geri-psych hospital). i. A nursing Progress Note dated [DATE] at 10:56 p.m. documented, received orders from (Physician ) to send resident to (geri-psych hospital) resident left facility at 215 pm. (2:15 p.m.), was transported by our facility 2 cnas and van. j. On [DATE] at 3:35 p.m., RN #2 was asked if the resident was still in the facility and the RN stated, No. The RN was asked when the resident had left the facility and the RN stated, Around 2:15 p.m. ([DATE]) . k. On [DATE] at 10:17 a.m., the DON was asked who was the resident that Resident #10 had hit on the incident on [DATE] and the DON stated, (Resident #19) The DON was asked about the incident and why the resident had been sent out of the facility. The DON stated, He was sitting on top of another resident and had straddled him and had his hands on his (Resident #19) chest. The DON was asked who the other resident was and the DON stated, (Resident #19 name). The DON was asked if the resident had thrown something and the DON stated, Yes, towel rack. The DON was asked if the resident had resisted care when the CNA staff were in the room with the resident and the DON stated, I think he was. They were cleaning him, (CNA #7 and CNA #8). l. On [DATE] at 10:50 a.m., CNA #7 was asked if the resident had resisted care on [DATE] and the CNA stated, He had used the bathroom on self, bowel, we got him in the bathroom half way he started hitting us, cussing us, he tore the metal piece off the wall and started using it as a weapon threw it. He was hitting us with it, me and (CNA #8). I called for help, I used my phone, personal phone only way to call for help, (CNA/RNA (Restorative Nursing Assistant #2) and (RN #2) the nurse, (RN #2) came back. They helped us come out of bathroom. Tried to open door (door to adjoining room) and couldn't and he (Resident #10) was standing between us and the door. They got him from behind up underneath the arms, backwards. He just walked backwards. The CNA was asked if the staff members touched the resident and the CNA stated, They were touching. They were on each side and they were walking him. (RNA #2), myself, (CNA #8) got him into the bed. The CNA was asked why they had gotten the resident to bed and the CNA stated, To try to get him cleaned up, he still had poop all over him. So we attempted to get him clean. CNA #7 was asked if it was 3 staff members who had tried to clean the resident and the CNA stated, 3 of us. So the nurse left, I'll return in a moment. I need to report. The CNA was asked if the nurse was in the room when they tried to get the resident in the bed and the CNA stated, Yes. In the bed wasn't the problem, it was cleaning him that was the problem. He wouldn't let us clean him so we stepped back from the situation to see if he would calm down. So we left the room so we continued our rounds, to see if he would calm down, we just left him be. The CNA was asked what time this had occurred and how long out of room and the CNA stated, I don't remember exact time but it was before lunch. The CNA was asked if they had returned back into the room and the CNA stated, We did about 15 minutes later we go had to (Resident #19) to change him. The CNA was asked where Resident #10 was and the CNA stated, In his bed he had done covered himself up and looked to be asleep so we thought he might have calmed down so we attempted to clean him again. The CNA was asked what occurred next and the CNA stated, (CNA #8) went to the linen cart and I went to get cleaning supplies and when we came back. (Resident #10) was on top of (Resident #19). He was straddling him, he had his arms holding him down, he was facing him. CNA #7 was asked what staff was to do when a resident had an aggressive behavior and the CNA stated, We were told to leave the resident, to back off, that's what they tell us here. The CNA was asked who had given these instructions and the CNA stated, Our Administrator, DON (Director of Nursing), ADON (Assistant DON). The CNA was asked if the resident was having any behavior when they had first attempted to provide care on [DATE] and the CNA stated, Yes, he started cussing at us. He told us no the first 2 times, the third time we were able to get his shirt off. It was when the pants came off is when he got upset. We asked him, he told us no, so we ran the water to make sure the water was warm in the bathroom sink, then we asked again, he told us no, so we just got out soaps and stuff ready and he told us if you F****** have to. He let us take the shirt off. The CNA was then asked if the first time that the resident had said No did they leave the room and the CNA stated, No we just turned our backs. The CNA was asked if they remained in the bathroom with the resident and the CNA stated, Yes. The CNA was asked if they remained in the bathroom with the resident the second time that the resident refused care and the CNA stated, We still turned our back. The CNA was asked if the resident had resisted when the pants were taken off and the CNA stated, He resisted when the pants came off. By that time we were trying to get out of the bathroom. I was by the sink and she (CNA #8) was by the toilet. The CNA was asked why when the resident had said no on the first attempt to provide care why they remained and the CNA stated, That's just where we stayed. The CNA was asked how long she had worked on the secured unit and the CNA stated, 3 months. The CNA was asked what special training she had to work on the secured unit and the CNA stated, When I worked for (another facility name) I had to take special training to work their unit. The CNA was asked what training consisted of and the CNA stated, It just showed us what to do in situations. The CNA was asked if they were instructed to leave the resident and the CNA stated, They told us to leave the scene as soon as the resident is safe. Leave the scene, report, reeval (reevaluate) what to do how to approach the situation. The CNA was asked if she had followed those instructions and the CNA stated, I didn't. m. On [DATE] at 2:52 p.m., the DON was asked when the resident was admitted [DATE] was it to the secured unit and the DON stated, Yes. The DON was asked why the resident had been sent out of he facility on [DATE] and the DON stated, If I'm not mistaken he was having some aggression. The DON was asked who that other resident was and the DON stated, I can't remember. The DON was asked if the resident was readmitted from a geripsych unit on [DATE] and the DON stated, Yes. The DON was asked if she was aware that the resident had behaviors and the DON stated, The behaviors aggression and sexually inappropriate. The DON was asked what nursing staff was to do when a resident was aggressive and the DON stated, What I tell them to do is leave them alone and let them calm down. The DON was asked how long staff should wait before care was attempted again and the DON stated, I usually tell them about ,[DATE] minutes. The DON was asked if a resident said No should staff still provide care and the DON stated, If they say no I would say no, stop and see if someone else can do it. n. On [DATE] at 7:09 p.m., RN #2 was asked what had occurred on [DATE] when there was an incident with the resident and the RN stated, I was on the hall and (CNA/RNA #2) came and got me and girls were (CNA #7 and CNA #8) were in bathroom, he (Resident #10). You could tell he was mad and he wasn't going to listen to them and he was trying to grab at them, so me and (CNA/RNA) told them to back off, they did. They were in the bathroom, he was on the toilet. I didn't know at the time what happened. They were trying to get him out and that's what I saw. The RN was asked if she had instructed the staff to stop care and the RN stated, Yes. The RN was asked what had occu (TRUNCATED)

A. Based on record review and interview, the facility failed to ensure necessary care and services were provided to manage [MEDICAL CONDITIONS] in a newly admitted resident, to minimize the potential for [MEDICAL CONDITION] exacerbation, as evidenced by failure to ensure the resident received diuretics at the physician-ordered frequency and that the physician order [REDACTED].#1) case mix resident who was admitted in the past 2 months and had a [DIAGNOSES REDACTED].#18, who experienced an acute [MEDICAL CONDITION] exacerbation and required hospitalization , and had the potential to cause more than minimal harm to 9 residents who had a [DIAGNOSES REDACTED]. Resident #18 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Medicare Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/9/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); required extensive assistance of 2-plus persons with bed mobility and transfers, required limited assistance of 1 person for eating, was incontinent of bowel and bladder, had an active [DIAGNOSES REDACTED]. a. A medication orders list dated and signed by the physician on 6/2/17 documented, [MEDICATION NAME] 20 mg (milligrams) oral 09, 12 (9:00 a.m. and 12:00 p.m.) . [MEDICATION NAME] ([MEDICATION NAME]) 40 mg oral daily . Admit to (Facility Name) . The admission orders [REDACTED] b. An Admission Nursing assessment dated [DATE] at 3:07 p.m. documented the resident was admitted to the facility from the hospital on [DATE] at 2:00 p.m. The sections of the assessment designated for documentation of vital signs, oxygen saturation and weight were all left blank. The respiratory section of the assessment documented the resident had oxygen orders for 3 liters per minute, had clear breath sounds, had labored respirations and that the resident stated he was short of breath at all times. The cardiac section of the assessment documented [MEDICAL CONDITION] was present and that the resident had orders for monitoring of oxygen saturation every shift. c. The Care Plan documented, Problem Onset (not dated): Resident has dx (diagnosis) & (and) / or s/s (signs / symptoms) of respiratory disease / illness (Failure) . The approaches (not dated) documented, Observe for episodes of shortness of breath, cyanosis; administer medications / oxygen as per orders . O2 (oxygen) sats (saturation) as ordered and prn (as needed) . Notify physician of any change in condition noted . Vital signs, O2 sats as needed . An additional Care Plan problem (not dated) documented, Resident has dx of [MEDICAL CONDITION] & / or is on cardiac medications . Approaches . Observe resident for any change in condition and notify physician and family immediately . monitor vital signs; report abnormal results as per physician preference . Weight upon admission, re-weight 2nd day of admission, weekly x 4 weeks then monthly and prn . Typed interventions for Daily weights and Monitor Intake and Output had been crossed out with a pen, with no initials as to who removed the interventions from the Care Plan and no date when they were removed. d. The 2017 Monthly Weights Log, provided by the DON on 7/25/17 at 10:30 a.m. documented the resident's June 2017 weight was 256.8 pounds. The log did not document the specific date upon which this weight was obtained, nor were any additional weights documented in the clinical record for this resident between 6/2/17 and 6/13/17. The Weight Summary sheet for this resident, printed from the electronic record by the Director of Nursing on 7/27/17 at 3:10 p.m., documented the 256.8-pound weight was obtained on 6/6/17, 4 days after the resident's admission to the facility. No other weights were documented at any time between 6/2/17 and 6/13/17. e. Progress Notes dated 6/3/17 at 10:29 a.m. documented Medication Administration notes indicating the facility was awaiting delivery of the resident's [MEDICATION NAME], and other medications from the pharmacy. This was a period of 20 hours after the resident was admitted to the facility. 1.) The June 2017 Medication Administration Record [REDACTED]. 2.) On 7/27/17 at 11:45 a.m., Licensed Practical Nurse (LPN) #1 stated. I put that ([MEDICATION NAME] 20 mg) on the MAR indicated [REDACTED]. The LPN was asked, What do you do if you have a question about a medicine (order)? She stated, Clarify it. The LPN was asked, Why didn't you clarify this order? She stated, I really don't have an answer to that. I put it on the MAR indicated [REDACTED] f. Progress Notes dated 6/4/17 at 2:45 p.m. documented, Resident in bed on O2 at 2 l/m (liters per minute) via nasal cannula. Updrafts as ordered . Resident was in bed all shift. No complaints at this time . g. Progress Notes dated 6/6/17 at 3:32 a.m. documented, Resident c/o (complains of) shortness of breath. SpO2 (oxygen saturation) between 85-97%. Resident elevated in bed. O2 mask applied in place of nasal cannula due to resident being a mouth breather. (Name) APN (Advanced Practice Nurse) notified. New orders obtained for 40 mg IM (intramuscular injection) [MEDICATION NAME], 1 mg IM [MEDICATION NAME] now, obtain BUN (blood urea nitrogen) / Creatinine levels in a.m. (morning). After administration resident pulse ox (oxygen saturation) 94%, heart rate 81. Resident states, 'The medicine is working'. There was no documentation of a complete respiratory assessment, including breath sounds, during this episode. h. Progress Notes dated 6/10/17 at 10:22 p.m. documented, .Res (Resident) c/o SOB (shortness of breath) while laying (sic) in bed. Res currently has on O2 (at) 2 lpm (liters per minute) via nc (nasal cannula) with effective results. No s/s of distress / pain. Resp (respirations) even / unlabored . The cardiopulmonary section of the Skilled Documentation form for this date / time documented the resident's oxygen saturation was 95%. Section VII, item H of the Skilled Documentation form (designated for documentation of the location and degree of [MEDICAL CONDITION] present) did not document the presence of [MEDICAL CONDITION]. i. Progress Notes dated 6/11/17 at 2:46 a.m. documented, .Resident on right side with fan in her face blowing on her, O2 on at 2 liters per n/c. SpO2 97%. No acute distress noted. Resp fast, denies any pain or discomfort . The Skilled Documentation form for this date / time documented the oxygen saturation was 95%; no lung sounds were documented. The vital signs section of the form did not document a respiratory rate. Section VII, item H did not document the presence of [MEDICAL CONDITION] at this time. j. Progress Notes dated 6/11/17 at 1:18 p.m. documented, Resident lays (sic) on right side c/o SOB. SpO2 (blank) on nasal cannula. Venti mask (OxyMask) put on and SpO2 raised to 92%. Continue current plan of care . There was no documentation of what the oxygen saturation was prior to application of the OxyMask and no documentation of an assessment of the resident's breath sounds at this time. The notes did not document the oxygen flow rate that was being administered via the nasal cannula or the mask. The Skilled Documentation form for this date / time documented an oxygen saturation of 96%; however, the date /time of that reading was documented as 6/11/17 at 12:10 (approximately 1 hour prior to this episode of shortness of breath). Section VII, item H of the form did not document the presence of [MEDICAL CONDITION]. k. Progress Notes dated 6/11/17 at 2:09 p.m. documented, Resident has nasal cannula at 3 L/min (liters per minute). Resident has V.S. (vital signs) of T (temperature) 97.0, BP (blood pressure) 160/77, P (pulse)-89, SpO2-81, laying (sic) on right side with fan blowing in her face . fast resp of 22, very shallow . Called (APN) who asked if resident had veti (Venti) mask, said to keep venti-mask on except when eating. The notes did not specify the flow rate at which the oxygen should be administered via the mask, nor the minimum oxygen saturation that would require adjustment of the oxygen flow rate. 1.) On 7/27/17 at 2:40 p.m., Registered Nurse (RN) #3 was asked about the order for a Venti-mask and stated, These are the only masks that our company (facility) uses. They are called OxyMasks. She showed the surveyor an OxyMask, which had a manufacturer's label in the package that documented a flow rate of 2 liters per minute would provide an FiO2 (fraction of inspired oxygen) of 27-32%, and a flow rate of 3 liters per minute would provide an FiO2 of 30 to 60%. 2.) The OxyMask manufacturer's instructions, obtained from the OxyMask website at http://thebetteroxygenmask.com documented, .Adjust the oxygen flow from 1 to 15+ (plus) lpm (liters per minute) to achieve prescribed patient oxygen saturation or oxygen flow rate . Allow patient to stabilize on oxygen flow and assess. Adjust oxygen flow rate as necessary to achieve or maintain prescribed oxygen saturation . Actual FiO2 will vary. Breath rate, depth of breathing and distance of the diffuser from the face will affect performance. Actual flow rate required should be prescribed in conjunction with the use of a pulse oximeter . l. Progress Notes dated 6/11/17 at 11:56 p.m. documented, .resident resting on right side with face in fan with skeleton mask (OxyMask) on 2 liters O2, resident very demanding this shift, resident weak . resp (respirations) are even but heavy . There was no documentation the resident's breath sounds were checked, no documentation of an oxygen saturation or respiratory rate, and the Skilled Documentation form for this date / time documented the oxygen saturation from earlier that day (96% at 12:10 in the afternoon). Section VII, item H of the form documented the presence of 2-plus (2+) [MEDICAL CONDITION] to the resident's ankles and feet. m. Progress Notes dated 6/12/17 at 10:16 a.m. documented, .pt (patient) continues on 2l's (2 liters) O2 continuous via skeleton mask. No c/o pain . no s/s of distress . No breath sounds were documented. Shortness of breath was checked on the Skilled Documentation form for this date / time, and an oxygen saturation of 98% was documented. Section VII, item H of the form documented the presence of 2+ [MEDICAL CONDITION] to the resident's ankles and feet. n. Progress Notes dated 6/13/17 at 12:33 a.m. documented, .Resident reports increased anxiety, restlessness, and requesting medication. Patient was provided with calm environment, reassurance of O2 level, and television for distraction. All attempts noneffective, administered PRN antianxiety med . There was no documentation an assessment was conducted at this time to determine if the resident's increased anxiety may have been related to the resident's cardiopulmonary status. No lung sounds, oxygen saturation, or other assessment information was documented as this time. o. A Progress Notes dated 6/13/17 at 3:23 documented, Resident in skilled bed for systolic [MEDICAL CONDITION] .3:41 p.m. documented, Resident having trouble breathing. PRN [MEDICATION NAME] given, updraft given. Resident just states that she wants to be put on hospice and shot. She had visitors setting (sic) with her and tried to give all of her stuff away. O2 Stat (Sat) was down in the 60s. Tried deep breathing but resident was not very cooperative. Call (APN) received telephone order to send resident to ED (Emergency Department) . p. A Nursing Progress Noted dated 6/13/17 at 3:41 p.m. documented, Resident having trouble breathing. PRN (As Needed) Ativin given, updraft given . O2 Stat (Sat) down in the 60s .Call (Advanced Practice Nurse) received order to send resident to ED (Emergency Department) . q. The Order Summary Report dated as printed on 7/26/17 at 12:51 p.m. documented a physician order [REDACTED]. Additional physician orders [REDACTED]. Pulse ox (oxygen saturation) check every shift and as needed for shortness of breath; if pulse ox less than 92%, place O2 at 3L per NC; if pulse ox less than 90% place O2 and notify MD (Medical Doctor) every 15 minutes as needed . Physician orders [REDACTED]. [MEDICATION NAME] tablet 20 mg. Give 1 tablet by mouth two times a day for [MEDICAL CONDITION] related to unspecified diastolic (congestive) heart failure . These orders were all correctly transcribed to the June 2017 Medication Administration Record, [REDACTED]. (A physician order [REDACTED]. discharge home 6/24/17 with meds .). r. On 7/27/17 at 3:30 p.m., the Administrator and DON were asked to provide documentation of a corrective action plan that included ongoing monitoring to ensure the deficient practices did not recur for other residents admitted with [MEDICAL CONDITION]. The Administrator and DON were unable to provide the requested documentation. s. The immediate jeopardy was removed and the scope / severity reduced to H on 7/28/17 at 11:37 a.m., when the facility implemented the following plan of removal: 1.) All Licensed Nursing staff will be educated prior to beginning their shift on: A. How to conduct a thorough respiratory assessment. B. Weight and respiratory symptoms monitoring and change of condition notification of physician. C. Prevention of medication errors and administration of medication procedures (to include clarification of any orders that are unclear). Beginning 7/27/17 at 8 PM (8:00 p.m.). 2.) All residents with [DIAGNOSES REDACTED]. 3.) All staff will be educated related to signs and symptoms of respiratory disease exacerbation and interact stop and watch to enable accurate and timely reporting of changes in condition. 4.) A medication matchback will be done for all residents matching (current) physician orders [REDACTED]. 5.) All new and returning admission orders [REDACTED]. 6.) DON / Designee will monitor weekly to ensure all residents with [MEDICAL CONDITION] are receiving proper monitoring and assessments, with any signs and symptoms of exacerbation to be reported immediately to the physician. B. Based on observation, record review and interview, the facility failed to ensure necessary care and services were provided for indwelling urinary catheter maintenance, as evidenced by failure to ensure an indwelling urinary catheter was secured to prevent potential trauma to the urinary meatus or bladder for 1 (Resident #5) of 1 case mix resident who had an indwelling urinary catheter. This failed practice had the potential to affect 3 residents who had indwelling urinary catheters, as documented on a list provided by the Director of Nursing (DON) on 7/28/17 at 1:42 p.m. The findings are: Resident #5 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set with an assessment reference date of 6/6/17 documented the resident scored 6 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS), required extensive assistance for bed mobility, transfers and toilet use, had an ostomy, required a wheel chair for mobility, was frequently incontinent of urine and did not have an indwelling urinary catheter. a. A physician's orders [REDACTED]. b. On 7/26/17 at 9:17 a.m., Certified Nursing Assistant (CNA) #5 and CNA #6 provided catheter care to the resident. During the care, the indwelling urinary catheter was not secured in any way to prevent pulling and potential trauma to the urethral meatus. CNA #5 was asked if the resident had a device to secure the indwelling catheter and stated she did not recall the resident ever having a device to secure it. The CNA also stated, I know she needs one. c. On 7/26/17 at 9:50 a.m., the Interim DON was asked if the resident's catheter should be secured and stated, Yes. Usually have a leg strap.

Complaint # (AR 064) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure a newly admitted resident with a [DIAGNOSES REDACTED].#18) of 8 (Residents #1, #2, #3, #4, #8, #10 and #18) case mix residents who had physician orders [REDACTED].#18, who received a diuretic medication once daily, instead of twice daily as ordered by the physician, and subsequently experienced an acute [MEDICAL CONDITION] exacerbation and required hospitalization . The failed practice also had the potential to cause more than minimal harm to 47 residents who had physician orders [REDACTED]. 1. Resident #18 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Medicare Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/9/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); required extensive assistance of 2-plus persons with bed mobility and transfers, required limited assistance of 1 person for eating, was incontinent of bowel and bladder, had an active [DIAGNOSES REDACTED]. a. An Admission Nursing assessment dated [DATE] at 3:07 p.m. documented the resident was admitted to the facility from the hospital on [DATE] at 2:00 p.m. b. A medication orders list dated and signed by the physician on 6/2/17 documented, [MEDICATION NAME] 20 mg (milligrams) oral 09, 12 (9:00 a.m. and 12:00 p.m.) . [MEDICATION NAME] ([MEDICATION NAME]) 40 mg oral daily . Admit to (Facility Name) . c. Progress Notes dated 6/3/17 at 10:29 a.m. documented Medication Administration notes indicating the facility was awaiting delivery of the resident's [MEDICATION NAME], and other medications from the pharmacy. This was a period of 20 hours after the resident was admitted to the facility. d. The June 2017 Medication Administration Record [REDACTED]. e. The following Progress Notes were documented during the 11-day timeframe when the resident's [MEDICATION NAME] was being administered only once daily: 1.) Progress Notes dated 6/4/17 at 2:45 p.m. documented, Resident in bed on O2 at 2 l/m (liters per minute) via nasal cannula. Updrafts as ordered . Resident was in bed all shift. No complaints at this time . 2.) Progress Notes dated 6/6/17 at 3:32 a.m. documented, Resident c/o (complains of) shortness of breath. SpO2 (oxygen saturation) between 85-97%. Resident elevated in bed. O2 mask applied in place of nasal cannula due to resident being a mouth breather. (Name) APN (Advanced Practice Nurse) notified. New orders obtained for 40 mg IM (intramuscular injection) [MEDICATION NAME], 1 mg IM [MEDICATION NAME] now, obtain BUN (blood urea nitrogen) / Creatinine levels in a.m. (morning). After administration resident pulse ox (oxygen saturation) 94%, heart rate 81. Resident states, 'The medicine is working'. 3.) Progress Notes dated 6/10/17 at 10:22 p.m. documented, .Res (Resident) c/o SOB (shortness of breath) while laying (sic) in bed. Res currently has on O2 (at) 2 lpm (liters per minute) via nc (nasal cannula) with effective results. No s/s of distress / pain. Resp (respirations) even / unlabored . The cardiopulmonary section of the Skilled Documentation form for this date / time documented the resident's oxygen saturation was 95%. Section VII, item H of the Skilled Documentation form (designated for documentation of the location and degree of [MEDICAL CONDITION] present) did not document the presence of [MEDICAL CONDITION]. 4.) Progress Notes dated 6/11/17 at 2:46 a.m. documented, .Resident on right side with fan in her face blowing on her, O2 on at 2 liters per n/c. SpO2 97%. No acute distress noted. Resp fast, denies any pain or discomfort . The Skilled Documentation form for this date / time documented the oxygen saturation was 95%; Section VII, item H did not document the presence of [MEDICAL CONDITION] at this time. 5.) Progress Notes dated 6/11/17 at 1:18 p.m. documented, Resident lays (sic) on right side c/o SOB. SpO2 (blank) on nasal cannula. Venti mask (OxyMask) put on and SpO2 raised to 92%. Continue current plan of care . The Skilled Documentation form Section VII, item H of the form did not document the presence of [MEDICAL CONDITION]. 6.) Progress Notes dated 6/11/17 at 2:09 p.m. documented, Resident has nasal cannula at 3 L/min (liters per minute). Resident has V.S. (vital signs) of T (temperature) 97.0, BP (blood pressure) 160/77, P (pulse)-89, SpO2-81, laying (sic) on right side with fan blowing in her face . fast resp of 22, very shallow . Called (APN) who asked if resident had veti (Venti) mask, said to keep venti-mask on except when eating. 7.) Progress Notes dated 6/11/17 at 11:56 p.m. documented, .resident resting on right side with face in fan with skeleton mask (OxyMask) on 2 liters O2, resident very demanding this shift, resident weak . resp (respirations) are even but heavy . The Skilled Documentation form, Section VII, item H documented the presence of 2-plus (2+) [MEDICAL CONDITION] to the resident's ankles and feet. 8.) Progress Notes dated 6/12/17 at 10:16 a.m. documented, .pt (patient) continues on 2l's (2 liters) O2 continuous via skeleton mask. No c/o pain . no s/s of distress . Shortness of breath was checked on the Skilled Documentation form for this date / time, and Section VII, item H of the form documented the presence of 2+ [MEDICAL CONDITION] to the resident's ankles and feet. 9.) Progress Notes dated 6/13/17 at 12:33 a.m. documented, .Resident reports increased anxiety, restlessness, and requesting medication. Patient was provided with calm environment, reassurance of O2 level, and television for distraction. All attempts noneffective, administered PRN antianxiety med . 10.) Progress Notes dated 6/13/17 at 3:41 p.m. documented, Resident having trouble breathing. PRN [MEDICATION NAME] given, updraft given. Resident just states that she wants to be put on hospice and shot. She had visitors setting (sic) with her and tried to give all of her stuff away. O2 Stat (Sat) was down in the 60s. Tried deep breathing but resident was not very cooperative. Call (APN) received telephone order to send resident to ED (Emergency Department) . f. A Progress Notes dated 6/13/17 at 3:23 documented, Resident in skilled bed for systolic [MEDICAL CONDITION] .3:41 p.m. documented, Resident having trouble breathing. PRN [MEDICATION NAME] given, updraft given. Resident just states that she wants to be put on hospice and shot. She had visitors setting (sic) with her and tried to give all of her stuff away. O2 Stat (Sat) was down in the 60s. Tried deep breathing but resident was not very cooperative. Call (APN) received telephone order to send resident to ED (Emergency Department) . g. The Order Summary Report dated as printed on 7/26/17 at 12:51 p.m. documented a physician order [REDACTED]. Physician orders [REDACTED].[MEDICATION NAME] tablet 20 mg. Give 1 tablet by mouth two times a day for [MEDICAL CONDITION] related to unspecified diastolic (congestive) heart failure . These orders were correctly transcribed to the June 2017 Medication Administration Record, [REDACTED]. (A physician order [REDACTED]. discharge home 6/24/17 with meds .). h. On 7/27/17 at 11:15 a.m., Licensed Practical Nurse (LPN) #1 provided documentation of an in-service conducted on 6/13/17, instructing her on the proper way to input a physician order. At 11:45 a.m., LPN #1 stated, I put that ([MEDICATION NAME] 20 mg) on the MAR indicated [REDACTED]. The LPN was asked, What do you do if you have a question about a medicine (order)? She stated, Clarify it. The LPN was asked, Why didn't you clarify this order? She stated, I really don't have an answer to that. I put it on the MAR indicated [REDACTED] i. On 7/27/17 at 11:45 a.m., the Administrator was asked for any in-services provided to nursing staff regarding clarification of unclear physician orders. She stated, I do not have any in-services on clarifying orders. j. On 7/27/17 at 12:25 p.m. and 12:30 p.m., Registered Nurses (RNs) #1 and #2 were asked, What would you do if you did not understand an order? Both nurses stated, I would clarify it. k. On 7/27/17 at 12:30 p.m., LPN #2 and the DON were asked, What would you do if you had an order that you did not understand? Both nurses stated, Clarify it. l. On 7/27/17 at 3:30 p.m., the Administrator and DON were asked to provide documentation of a corrective action plan that included ongoing monitoring to ensure the deficient practices did not recur for other residents admitted with [MEDICAL CONDITION]. The Administrator and DON were unable to provide the requested documentation. m. This medication error was significant based on the frequency of the error, the classification of the medication (diuretic) and the condition of the resident. n. The immediate jeopardy was removed and the scope / severity reduced to H on 7/28/17 at 11:37 a.m., when the facility implemented the following plan of removal: 1.) All Licensed Nursing staff will be educated prior to beginning their shift on: A. How to conduct a thorough respiratory assessment. B. Weight and respiratory symptoms monitoring and change of condition notification of physician. C. Prevention of medication errors and administration of medication procedures (to include clarification of any orders that are unclear). Beginning 7/27/17 at 8 PM (8:00 p.m.). 2.) All residents with [DIAGNOSES REDACTED]. 3.) All staff will be educated related to signs and symptoms of respiratory disease exacerbation and interact stop and watch to enable accurate and timely reporting of changes in condition. 4.) A medication matchback will be done for all residents matching (current) physician orders [REDACTED]. 5.) All new and returning admission orders [REDACTED]. 6.) DON / Designee will monitor weekly to ensure all residents with [MEDICAL CONDITION] are receiving proper monitoring and assessments, with any signs and symptoms of exacerbation to be reported immediately to the physician.

Complaint # (AR 698) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure physician-ordered, Registered Dietitian (RD)-recommended and / or care planned nutritional interventions were promptly and consistently implemented to minimize the potential for further weight loss and failed to ensure a Registered Dietitian evaluation of calorie and protein needs was promptly conducted after identification of a significant weight loss, to facilitate the ability to develop effective interventions to prevent further potential weight loss for 1 (Resident #5) of 2 (Residents #2 and 5) case mix residents who experienced unplanned weight loss. The failed practice resulted in a pattern of actual harm for Resident #5, who experienced a severe, unplanned weight loss, did not receive the physician-ordered supplement for a period of 7 days, and subsequently lost additional weight. The failed practice also had the potential to cause more than minimal harm for 6 residents who had unplanned weight loss, as documented on the Resident Census and Conditions of Residents form dated 3/8/17 at 8:22 a.m. The findings are: Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an assessment reference date of 8/31/16 documented the resident had moderately impaired cognitive skills for daily decision making, had poor appetite or overeating, needed extensive assistance of one person for eating, weighed 138 pounds, had a weight loss that was not a physician-prescribed weight-loss regimen, required a mechanically altered diet and had a Stage 2 pressure ulcer present on admit/reentry. Note: The weight of 138 pounds was correct as of the MDS assessment reference date; however, the resident's admission weight was documented as 149.2 pounds (refer to paragraph c. below). a. A Diet Order and Communication form dated 8/24/16 documented the resident was to receive a Regular Mechanical Soft diet, and, .loves banana and pudding. b. A Care Plan with a problem onset date of 8/31/16 documented, I am at nutritional risk as I receive a mechanically altered/therapeutic diet as ordered by my physician . Promote my nutritional intake necessary to maintain or improve current weight, skin, and health status . Please weigh me (every) month, (as needed), or as ordered by my MD (Medical Doctor). Notify MD, DON (Director of Nursing), and DSM (Dietary Services Manager) of any changes in weight of 5% more or less . Interview me and provide my food/beverage of choice per my current orders. Obtain my food preferences and update quarterly and (as needed) . c. An August and September 2016 weight record printed from the clinical record on 3/9/17 at 9:04 a.m. documented the following weights: 8/24/16: 149.2 pounds 8/29/16: 138.0 pounds 9/5/16: 136.00 pounds d. A Diet Order (and) Communication form dated 9/8/16 documented a diet change to pureed diet. e. The September 2016 weight records printed from the clinical record on 3/9/17 at 9:04 a.m. documented the resident's weight on 9/12/16 was 120.0 pounds and on 9/21/17 the residents weight was 118.4. This was a severe weight loss of 20.6% in less than a one-month period from 8/24/16 to 9/21/16. No further weights were documented between 9/21/16 and 9/26/16 when the resident was discharged from the facility. The August and September Meal and Snack intake record printed from the clinical record on 3/8/17 at 3:59 p.m., documented 16 of the 93 opportunities documentation for meal consumption of breakfast, lunch and dinner from 8/25/17 thru 9/25/17. f. The September 2017 Physician order [REDACTED]. f. A Dietary Consultant Review Recommendations report dated 9/13/16 documented, .(Resident #5) .Add 30 (cubic centimeters) cc promod BID (twice daily) . med pass instead. This was a period of 20 days after the initial weight loss of 11.2 pounds in a 5-day period from 8/24/16 to 8/29/16 was identified, and a period of 4 days after the severe 19.6% weight loss in less than one month was documented on 9/12/16. g. A Physician's Progress Note dated 9/14/16 and signed by Registered Nurse Practitioner (RNP) #1 documented, .Staff reports 7 lb (pound) weight loss over the last week (note: the resident's weight loss in the one-week period from 9/5/16 to 9/12/16 was actually 16 pounds, according to the facility's weight records above) . No [MEDICAL CONDITION] . Diagnosis & (and) Assessment: 1. Unintentional weight loss - acute, 7lb weight loss, order given for med-pass 30 cc (by mouth) (twice daily), continue to monitor for any acute changes and/or worsening of condition . h. A Physician's Telephone Order dated 9/15/16 documented, Med Pass 30 cc BID r/t (related to) wt (weight) loss . i. A Departmental Note dated 9/15/16 at 2:57 p.m. documented, IDT (Interdisciplinary Team) meeting held, resident is on PAR r/t (related to) wounds. Resident's wound, Stage 2 to coccyx is closed. Will add med pass 2.0 30cc by mouth twice a day for supplement. Resident's weight this week is 120. Will continue to monitor weights closely at this time . j. A Physician's Progress Note dated 9/22/16 and signed by RNP #1 documented, .Upon assessment, noted unintentional weight loss, declining, weight was 149.2 on August 30 and 118.4 as of today, currently on med pass . Staff reports unintentional weight loss and changes in appetite . Diagnosis & (and) Assessment: 1. Failure to Thrive - acute, hospice consult ordered today per spouse request due to possible home with hospice next week . 2. Unintentional weight loss - acute, continue med pass 30 cc by mouth twice a day, continue to monitor for any acute changes and/or worsening of condition . k. A Dietary Consultant Review Recommendation report dated 9/22/16 documented, .(R#5) recommendation Medpass 2.0 to 90 cc QID (four times a day) . l. A Physician's Telephone Order dated 9/22/16 at 2:50 p.m. (prior to the evening meal time) documented, Med Pass 2.0 give 90 cc QID r/t wt loss . As of 3/8/17 at 4:02 p.m., the September 2016 Medication Administration Record [REDACTED]. The physician order [REDACTED]. m. A Diet Order and Communication form dated 9/23/16 documented the resident was to receive a Regular Mechanical Soft diet. n. A Departmental Note dated 9/26/17 at 1:07 p.m. documented, New Order received to D/C (discharge) home with meds. Resident's wife to pick up resident at this time . o. On 3/9/17 at 9:51 a.m., the Assistant Director of Nursing (ADON) was asked, When residents are first admitted , do you use the hospital weight? The ADON stated, No, we weigh them. The ADON was asked, When did you find out the resident was losing weight? and stated, From 9/15/16 to 9/22/16, we picked up he was losing weight. The ADON was asked, How do you track weight loss? and stated (Dietary Manager) enters the weight and tells us. Then, we talk about it in PAR (Patient Assessment Review). Interventions would be placed on the MAR. The ADON was asked, When someone has weight loss, what is the policy? The ADON stated, Put them on PAR, watch meal consumptions. They should ask likes and dislikes upon admission. (Dietary Manager) does that. The ADON was asked, Can you locate the MAR for (Resident #5) that shows the order dated 9/15/16 for Med Pass 30cc by mouth twice daily? She stated I'll look. At 10:28 a.m., the ADON returned to the surveyor work room and stated This is the only one I can find (referring to the MAR indicated [REDACTED].

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure new interventions were developed and implemented to address repeated falls from a wheelchair, in order to decrease the potential for injury for 1 (Resident #7) of 3 (Residents #1, #6 and #7) case mix residents who fell in the last 90 days. The failed practice resulted in actual harm to Resident #7, who removed his lap buddy, fell from the wheelchair and sustained a fractured hip, and had the potential to cause more than minimal harm to 5 residents who fell in the last 90 days, according to the Incident and Accident (I&A) log provided by the Director of Nursing (DON) on 2/26/14 at 1:00 p.m. The findings are: Resident #7 had a [DIAGNOSES REDACTED]. a. The Resident Plan of Care dated 9/25/13 documented, " ...Problem: I have poor safety awareness and take psychotropic Meds (medications) daily placing me at increased risk for fall... Interventions: ...I prefer wearing tennis shoes, I need a night light on to help me see at night, remind me to ask for assist for all ambulation and refer me to PT (physical therapy) for evaluation." b. An Incident/Accident report dated 1/6/14 at 1:35 a.m. documented, "Aide told this nurse resident was lying on floor, bed alarm sounded, resident climbing over bedroll, fell on to floor, hit head. Skin tear to left elbow." The Investigation follow-up dated 1/6/14 at 2:10 a.m., documented past interventions as bed alarm, floor mats and bedrails, and a new intervention, "beveled mattress". c. An Incident/Accident report dated 1/10/ 14 at 5:20 a.m. documented, "Resident had removed lap-buddy, was in hallway outside lounge area, observed on floor lying semi left side, semi back." The new intervention documented, "Review of meds by MD (Medical Doctor) and wedge cushion." d. An Incident/Accident report dated 1/15/14 at 7:30 p.m. documented, "Resident up in w/c (wheelchair) in lobby. Took lap buddy off several times through shift this nurse was at med room passing med. CNA (Certified Nursing Assistant) call to this nurse, this nurse turned around and resident was on floor. Alarm not sounding and checked and it was not on. Resident scratched side of head." The resident was sent to the local hospital for evaluation. The new intervention documented, "...keep out of site (alarm) and larger lap buddy." e. An Incident/Accident report dated 1/18/14 at 4:10 p.m., documented, "CNA heard bed alarm sounding went into room and called to this nurse. Reported res (resident) on floor this nurse observed resident on floor lying on left side. Rails were up, unsure if hit head sent to ER (emergency room ) to evaluation." Past interventions were documented, "...Bed/chair alarm, low bed, lap buddy", and the new intervention documented, "door open to observe." f. An Incident/Accident Report dated 1/19/14 at 12:15 a.m. documented, "Observed lap buddy on floor, w/c (wheelchair) alarm was blinking but was under w/c cushion. Resident on floor in front of w/c." The new intervention documented, "...Give resident something to hold while up in w/c." g. An Incident/Accident Report dated 1/19/14 at 10:49 a.m. documented, "Resident removed lap buddy and got out of chair without assist. fell in floor in front of w/c..." The new intrervention documented, "... Spoke with spouse about placing resident in secure unit, so he can receive more one-on-one care and be watched closer - refuses." There was no documentation an alternative intervention was developed and implemented after the resident's spouse refused to have the resident transferred to the secure unit. h. An Incident/Accident Report dated 1/26/14 at 7:00 p.m. documented, "Resident up in front lobby removed lap-buddy, stood up alarm sounding and fell in floor before myself and another nurse could reach him. Sent out to ER to evaluate." The investigation follow-up dated 1/26/14 at 10:00 p.m., documented, " ... new interventions ...Cont (continue) alarms & lap buddy, family refuses secure unit for closer supervision." There was no documentation of any new interventions that were developed and implemented to address the resident's repeated removal of the lap buddy, resulting in repeated falls. There was no documentation of any further interventions to attempt to minimize the potential for injury from these repeated falls. i. An Incident/Accident Report dated 1/29/14 at 7:30 p.m. documented, "Resident took off his lap buddy in his wheelchair, chair alarm was sounding, another LPN (Licensed Practical Nurse) caught him as he fell but he still hit his right hip. Did not hit head..." The investigation follow-up dated 1/29/14 at 7:30 p.m., documented, " ...past interventions: w/c (wheelchair alarm, bed alarm, low bed with mat, lap buddy, larger lap buddy, (recommendation) at family care plan meeting to place resident on unit-family refuses ... new interventions: to ER (emergency room ) for eval (evaluation) and tx (treatment) ...(resident) returned to facility with report of no fx (fracture) ...1/30/14 requested x-ray report ...1400 (2:00 p.m.) hosp (hospital) faxed and called stating Fx (fractured) rt (right) hip ...res (resident) sent to hosp (hospital)" j. Nurses Notes dated 2/4/14 at 3:09 a.m., documented," ...Resident is readmit day 2 from hospital with hip fracture ..." k. On 2/26/13 at 2:40 p.m. and 2/27/14 at 1:55 p.m., the resident was lying in bed. The bed was approximately 3 feet above the floor and there was a fall mat at the bedside. l. On 2/27/14 at 1:58 p.m., the Director of Nursing was questioned about the intervention of a low bed. She stated that they did put him in a lower bed, but his wife wanted him to have longer side rails, so they put him back in the higher bed. She was then asked, "What did you do after the spouse refused to move him to the secure wing?" She stated, "We didn't do anything new, we continued with the alarms and the lap buddy." The DON was then asked, "What did you do to prevent injury?" She stated, "Just the alarms and lap buddy." She was then asked "Why does the resident have side rails if he is coming out of bed?" She replied, "There was no issue with him climbing over the side rails and the spouse wanted them for boundaries." She was asked, "When you decided that you could do nothing else to prevent the resident from falling, what did you do to minimize the injury?" She stated, "We didn't do anything new, we continued with the alarms and lap buddy."