Every finding on record at The Springs of Camden

Based on observation, record review, interview, and facility policy review, the facility failed to ensure foods stored in the dry storage area were covered and sealed; expired food items were promptly removed / discarded, on or before the expiration or use by date; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment; and the ice machine was maintained in a clean sanitary condition for one of one meal observed. The findings are: On [DATE] at 10:09 AM, the following observations were made on a shelf above the food preparation counter: a. An opened bag of grits, the bag was not sealed. b. An open box of salt, the box was not covered. On [DATE] at 10:12 AM, this surveyor observed a box of baking soda, on a shelf in the storage room, that had an expiration date of [DATE]. On [DATE] at 10:35 AM, Dietary [NAME] (DC) #6 turned the water on and washed her hands. After washing her hands, she turned off the faucet with her hands, contaminating her clean hands. Without washing her hands again, she removed 20 slices of bread from a bread bag and broke the bread into pieces into the blender. She then added warm milk to be pureed and served to the residents on pureed diets for lunch meal. During an observation on [DATE] at 10:40 AM, the ice machine panel in the kitchen, where ice formed before dropping into the ice collector, had a wet yellowish residue on it. The areas were pointed out to the Maintenance Supervisor, with the Dietary Manager present. During an interview, the Maintenance Supervisor was asked if the residue build up could be wiped off, how often he cleaned the ice machine, and who used the ice from the machine. The Dietary Manager used tissue papers and wiped the wet residue off. The wet residue easily transferred to the tissue, and she (Dietary Manager) stated the area had a dirty, rusty color from the water. The Dietary Manager stated the Certified Nursing Assistants (CNAs) used the ice machine for the water pitchers in the residents' rooms, for the beverages served to the residents, and the kitchen staff used it to fill beverages served to the residents at mealtimes. The Maintenance Supervisor stated that he cleaned the ice machine at the end of each month, and it currently had dirty yellowish residue on it. On [DATE] at 10:58 AM, this surveyor observed a box that contained 14 strawberry banana yogurts on a shelf in the refrigerator, with an expiration date of [DATE]. The DM stated the yogurts had expired. She then removed the box of yogurts from the refrigerator and threw them away. On [DATE] at 11:33 AM, DC #6 removed bags of chicken tenders from the freezer and placed them on the counter by the deep fryer. DC #6 opened a bag of chicken tenders, contaminating her hands. Without washing her hands, she removed chicken tenders from the bag and placed them in a deep fryer to be cooked and served to the residents during the lunch meal. On [DATE] at 11:40 AM, DC #6 washed her hands and then turned off the faucet with her clean hands. DC #6 picked up a clean blade and attached it to the base of the blender. She then placed eight chicken tenders into the blender to grind and be served to the residents on mechanical soft diets for the lunch meal. This surveyor asked DC #6 what she should have done after she touched dirty objects, or before she handled clean equipment, and she stated she should have washed her hands. A review of facility policy titled, Quick Resources Tool, QRT Handwashing, initiated [DATE], provided by the Administrator on [DATE], indicated hands should be washed before starting to work with food and equipment and as often as needed, during food preparation and when changing tasks. A review of facility policy titled, Quick Resources Tool, QRT Safe storage of Food initiated [DATE], provided by the Administrator on [DATE], indicated, all foods will be stored wrapped or in covered containers, and arranged in a manner to prevent cross contamination . A review of facility policy titled, Ice machine and ice storage chests, initiated [DATE], provided by the Administrator on [DATE], indicated to flush and clean the ice machine and dispenser after lengthy water disruptions.

Based on interview, record review, and policy review, the facility failed to ensure that interest was paid on a resident trust account. This failed practice affected one (Resident #3) of three sampled residents, for whom the facility maintained trust accounts, per a list provided by the Business Office Manager (BOM) on 05/07/2025. The findings are: A review of Resident Statement Landscape, for Resident #3 on 01/03/2025, revealed a balance of $2,025.36, prior to the withdrawal on 01/28/2025. A review of Trial Balance dated 05/07/2025, provided by the Business Office Manager (BOM) on 05/07/2025, revealed a balance for Resident #3 of $1,141.17. A review of Resident Statement Landscape , for Resident #3 provided by the BOM on 05/07/2025, revealed that on 01/28/2025, a withdrawal was made in the amount of $1,025.00 for personal needs. During an interview on 05/08/2025 at 12:13 PM, the Business Office Manager (BOM) was asked how much money she withdrew from Resident #3 ' s account? The BOM indicated $1,025.00 was withdrawn from Resident #3 ' s account on 01/28/2025. The BOM indicated she had spoken with Resident #3 ' s Power of Attorney (POA) and asked them to come pick up the money and go spend it on Resident #3. The BOM was unable to provide proof that she had tried to contact the family after she withdrew the money. The BOM said the reason she withdrew the money was to make sure Resident #3 would be under the $2,000 limit and not lose [pronoun] Medicaid funding. Resident #3 ' s money ($1,025.00) sat in the safe at the nursing home from 01/28/2025 until 05/08/2025. The BOM was asked what amount must be deposited in an interest-bearing account for a resident on Medicaid? The BOM indicated $40.00. This surveyor then asked who had access to the safe that had Resident #3 ' s money ($1,025.00). The BOM indicated the Social Services Director and herself. The BOM indicated she did not know if the Administrator was aware that Resident #3 ' s money was in the safe. During an attempt to interview Resident #3 ' s POA, the phone number provided by the facility was found to not be a working number. During an interview on 05/08/2025 at 12:20 PM, the BOM was asked if the money ($1,025.00) out of Resident #3 account, that was in the safe, had been drawing interest since it had been withdrawn from the bank on 01/28/2025. The BOM indicated no. This surveyor asked the BOM what she should have done with the money once the POA did not pick the money up at the facility, in a timely manner? The BOM said she should have deposited it back into Resident #3 account at the bank. During an interview on 05/08/2025 at 12:25 PM, the BOM was asked, when the last quarterly statement for Resident #3 was sent out, if the $1,025.00 was included on Resident #3 balance. The BOM indicated no, because it was in the safe. During an interview on 05/08/2025 at 12:41 PM, the Administrator was asked if he knew about Resident #3 ' s money ($1,025.00) in the safe. The Administrator said, yes and no. The Administrator indicated that he had become aware of the situation, and it was getting deposited back into Resident #3 ' s bank account today. The Administrator was asked if the money ($1,025.00) in the safe was drawing interest while it was in the safe? The Administrator indicated no. The Administrator was asked what the resource limit was when the amount in the account reached $200 of the resource limit. The Administrator indicated $2,000. This surveyor asked what amount must be deposited in an interest-bearing account for a resident on Medicaid. The Administrator indicated $50.00. This surveyor then asked who all had access to the safe where Resident #3 ' s money had been kept. The Administrator indicated the BOM, the Social Services Director, and himself (Administrator). A review of Policy titled Accounting and Records of Resident Funds , provided by the Administrator on 05/08/25, indicate, Individual accounting records are made available to the resident through quarterly statements and upon request. Quarterly statements include the following information: The resident ' s balance at the beginning and ending of the statement period; The total of deposits and withdrawals by the resident for the quarter; Interest earned on the resident ' s funds .

Based on record review and interview, it was determined that the facility failed to ensure the comprehensive assessment for the current and previous year accurately reflected the Pre-admission Screening and Resident Review (PASRR) status of one (Resident #4) of two sampled residents reviewed for comprehensive assessments. The findings include: A review of the annual Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 03/13/2025, revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed Resident #4 had active diagnoses, which included: psychotic disorder, anxiety, and depression. According to the MDS, Resident #4 was not considered by the state, level II PASRR process, to have serious mental illness and/or intellectual disability or a related condition. A review of the annual MDS with the ARD of 03/21/2024, revealed Resident #4 had a BIMS score of 15, which indicated the resident was cognitively intact. The MDS revealed Resident #4 had diagnoses, which included: psychotic disorder and depression. According to the MDS, Resident #4 was not considered by the state, level II PASRR process, to have serious mental illness and/or intellectual disability or a related condition. A review of the Care Plan Report, with a revision date of 01/31/2025, revealed Resident #4 was PASRR level II. During an interview on 05/06/2025 at 3:18 PM, the MDS Coordinator stated Resident #4 was considered by the state as PASARR level II process, to have serious mental illness and/or intellectual disability or a related condition. The MDS Coordinator stated that neither the annual MDS with the ARD of 03/13/2025, nor the annual MDS, ARD of 03/21/2024, noted Resident #4 was considered by the state as PASRR level II, which was completed 09/08/2023. The MDS Coordinator stated both comprehensive MDS assessments were inaccurate. During an interview on 05/08/2025 at 1:39 PM, the Director of Nursing (DON) stated the most recent comprehensive MDS, and the comprehensive assessment from the past year, were inaccurate.

Based on observations and interviews, the facility failed to ensure hot foods were served hot and cold foods/beverages were served cold to maintain palatability and encourage adequate nutritional intake for two meals at which food temperatures were checked. The findings are: On 05/05/2025 at 12:12 PM, the first lunch meal tray for the female unit was placed on a shelf inside the food cart, by License Practical Nurse (LPN) #1. The food cart was located by the kitchen door in the dining room. On 05/05/2025 at 12:25 PM, a cart that contained 16 lunch trays was delivered to the [NAME] Hall (Female unit) by Certified Nursing Assistant (CNA) #2. At 12:37 PM, immediately after the last resident was served in the [NAME] Hall (Female Unit) dining room, the temperatures of the food items from the test trays on the cart were checked by CNA #2, with the following results: a) Pudding: 59 degrees Fahrenheit b) Purred vegetables: 113 degrees Fahrenheit c) Pureed chicken tender: 105.2 degrees Fahrenheit d) Ground chicken tender: 98 degrees Fahrenheit e) Cut green beans: 103.8 degrees Fahrenheit During the noon service observation on 05/05/2025 at 12:53 PM, the first food tray was placed on a shelf in the food cart, for the East 1 Hall by LPN #1. On 05/05/2025 at 1:03 PM, a cart that contained 14 lunch trays was delivered to East 1 Hall, by CNA #3. At 1:12 PM, immediately after the last resident was served in their room on East 1 Hall, the temperatures of the food items from the test trays on the cart were checked by CNA #3, with the following results: a) Milk: 44 degrees Fahrenheit b) Chicken tenders: 114 degrees Fahrenheit c) Purred vegetables: 113 degrees Fahrenheit d) Mashed potatoes: 111 degrees Fahrenheit e) Pureed chicken tender: 114 degrees Fahrenheit f) Ground chicken tender: 104 degrees Fahrenheit g) Cut green beans: 107 degrees Fahrenheit On 05/05/2025 at 1:16 PM, the District Dietary Manager (DDM) stated hall-trays food temperatures should be 120 degrees Fahrenheit when they reach the residents. She explained how long the trays sat from the time they been loaded into food cart, until they were delivered to the halls, could affect the temperature. She also explained that if the plates were not heated, it would affect the temperature further. She then felt the plates with her hands and stated the plates were not warm. On 05/06/2025 at 7:34 AM, the first breakfast tray was placed on a shelf, in an unheated food cart by LPN #7, while the door remained open. The food cart stayed open as she continued loading the remaining meal trays. After placing 14 meal trays inside, she closed the food cart door. On 05/06/2025 at 7:43 AM, CNA #4 then delivered the food cart to the [NAME] Hall (Male unit). At 7:52 AM, immediately after the last resident was served in the [NAME] Hall (Male Unit) dining room, the temperatures of the food items from the test trays on the cart were checked by CNA # 4, with the following results: a) Milk: 55.9 degrees Fahrenheit b) Sausage links: 94.8 degrees Fahrenheit c) Pureed sausage: 102.8 degrees Fahrenheit. d) Pureed chicken tender: 105.2 degrees Fahrenheit e) Ground sausage with gravy: 102.2 degrees Fahrenheit f) Scrambled eggs: 107.7 degrees Fahrenheit Immediately following the temperature checks, CNA #4 stated the food should have been reheated. During an observation of the breakfast meal service on 05/06/2025 at 7:44 AM, the first breakfast meal tray for East 1 Hall was placed on a shelf, in an unheated food cart by LPN #7, while the door remained open. The food cart stayed open as she continued loading the remaining meal trays. On 05/06/2025 at 7:53 AM, an unheated food cart, that contained 14 breakfast meals, was delivered to East 1 Hall by CNA #3. On 5/06/2025 at 8:04 AM, immediately after the last resident was served in their room on East 1 Hall, the temperatures of the food items from the test trays on the cart were checked by CNA #3, with the following results: a) Milk: 45 degrees Fahrenheit b) Scrambled eggs: 113 degrees Fahrenheit Immediately following the temperature checks, CNA #3 stated the food should have been reheated. On 05/06/2025 at 8:03 AM, the first breakfast meal tray for East 2 Hall was placed on a shelf, in an unheated food cart by LPN #7, while the door remained open. The food cart stayed open as she continued loading the remaining meal trays. On 05/06/2025 at 8:11 AM, a cart that contained 13 breakfast meals was delivered to East 2 Hall by CNA #5. At 8:19 PM, immediately after the last resident was served in their room on East 2 Hall, the temperatures of the food items from the test trays on the cart were checked by CNA #8, with the following results: a) Milk: 43.7 degrees Fahrenheit b) Pureed sausage: 104.7 degrees Fahrenheit c) Pureed bread and milk: 113.6 degrees Fahrenheit d) Ground sausage with gravy: 102.2 degrees Fahrenheit e) Pureed eggs: 100.4 degrees Fahrenheit Immediately following the temperature checks, CNA #5 stated the food should have been reheated. During an interview on 05/05/2025 at 11:46 AM, Resident #15 stated the soup provided by the facility, as an option on the alternative menu, was always cold. During an interview on 05/05/2025 at 3:10 PM, Resident #1 was asked if the temperatures of their hot foods and cold foods were appropriate. Resident #1 stated the food was usually cold. The resident stated they usually ate in their room. On 05/06/2025 at 10:33 AM, two alert and oriented residents, who were present during the resident group meeting, were asked if the temperatures of the hot foods and cold foods were appropriate. Two of the five residents, who ate meals in their rooms, agreed with the following statements: a) Resident #49 indicated that their breakfast was cold sometimes. b) Resident #66 indicated that sometimes their food was cold. During an interview on 05/06/2025 at 1:44 PM, LPN #7 stated she did not know the food cart should remain closed while loading meal trays, until the Dietary Manager (DM) informed her. She stated that she had not considered that leaving the door open would cause the food temperatures to drop. During an interview with the Dietary Manager on 05/06/2025 at 1:46 PM, she stated the food cart door should be kept closed each time a meal tray was placed inside, to retain the proper temperature.

Based on observation, interview, and record review, the facility failed to ensure that temperatures were monitored in the refrigerators and freezers to prevent cross contamination and food borne illness for residents who received meals from the facility kitchen. This failed practice had the potential to affect 70 residents who receive meals from the facility kitchen The findings are: 1. On 03/11/2024 at 09:23 AM, between the kitchen and pantry (hallway) is a chest freezer, the freezer was checked and did not have a thermometer in place. The freezer held frozen vegetables. 2. On 03/11/2024 at 09:25 AM, Dietary Employee [DE] #3 was asked about the dented cans in the pantry. DE #3 advised that they are putting the dented cans down on the bottom shelf that is marked for dented cans. DE #3 admitted , In the past I have used a can off the dented shelf before when we were out in the pantry, but it has been a while. Surveyor asked DE #3 if she could remember when the last time was, she used a dented can. DE #3 stated I can't remember it had been a while ago. 3. On 03/11/2024 at 09:29 AM, the standup refrigerator/freezer in the pantry was where the kitchen kept milk and mighty shakes. The temperature was 42 degrees Fahrenheit and mighty shakes were in the bottom left tray. a. On 03/11/2024 at 09:30 AM, the freezer part of the refrigerator/freezer did not have a thermometer, so the temperature was not available. The DE #3 stated that they kept vegetables in this freezer. b. On 03/11/2024 at 09:40 AM, the chest freezer in kitchen by the ice machine identified by the dietary cook [DC] as the meat freezer, did not have a thermometer in it, so the temperature was not available. 4. On 03/13/2024 at 10:03 AM, the Surveyor observed the tea maker with tea made in the container uncovered. At 10:53 AM, the tea container lid was still not on the container. When the Surveyor left kitchen at 12:20 PM, the container of tea was still uncovered. 5. a. On 03/14/2024 at 10:35 AM, the Surveyor spoke with Dietary #2 and asked why it is important to have thermometers in the refrigerators and freezers. Dietary #2 stated To make sure that refrigerators and freezers are working properly, and food is safe. b. On 03/14/2024 at 10:36 AM, the Surveyor asked Dietary #2, Are you required to have thermometers in the refrigerators and freezers? Dietary Employee stated, Yes. 6. On 03/14/2024 at 10:38 AM, the Surveyor asked Dietary #2, What are you supposed to do with dented cans? Dietary #2 stated We have a preselected area for dented cans only where they are placed. Dietary #2 was asked if they could use dented cans. Dietary #2 stated No. 7. a. On 03/14/2024 at 1:46 PM, the Surveyor spoke with the Director of Nursing [DON], and asked why it is important to have thermometers in the refrigerators and freezers? The DON stated, To make sure the refrigerator and freezer are at the right temperatures. b. The DON was asked by the Surveyor if it was okay to use a can of food that was dented. The DON stated No, it could be spoiled.

Based on observation, interview, and record review, the facility failed to ensure that each Resident was treated with respect and dignity during meal service, in a manner that promotes maintenance or enhancement of his/her quality of life for 4 (Resident #19 #28, #37, and #64) of 5 sampled residents that required assistance with meal service. The findings are: 1. Resident #19 was unable to answer questions for the Brief Interview of Mental Status (BIMS) according to the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/02/2024. The care plan documented that Resident #19 required set-up assistance with meals/eating, verbal cues, and staff assistance at times of confusion. Resident #28 scored 06 (0-7 indicates severe cognitive impairment) on a BIMS according to the Quarterly MDS with ARD of 01/31/2024. The care plan documented Resident #28 required extensive assistance with meal /eating. Resident #37 scored 02 on a BIMS according to the Significant Change MDS with Assessment Reference Date of ARD 01/22/2024. The care plan documented that Resident #37 was independent with eating. Resident #64 was unable to answer questions for the BIMS according to the Quarterly MDS with ARD of 12/19/2023. The care plan documented that Resident #64 required set-up assistance with meals/eating. On 03/11/2024 at 12:35 PM, the Surveyor observed Certified Nursing Assistant (CNA) #1 standing while assisting Resident #64 with meal service. On 03/11/2024 at 12:40 PM, the Surveyor observed Licensed Practical Nurse (LPN) #2 standing while attempting to assist Resident #19 who declined the attempt. On 03/11/24 at 12:41 PM, the Surveyor observed LPN #1 standing while assisting Resident #37 with meal service. On 03/11/2024 at 12:57 PM, the Surveyor observed Resident #28 lying in bed with head of bed elevated. The bed was in the lowest position. The Surveyor observed CNA #2 standing while assisting Resident #28 with meal service. On 03/11/2024 at 12:45 PM, the Surveyor asked LPN #2, When staff are assisting Residents with meal service how should they position themselves? LPN #2 stated, Usually sitting. The Surveyor asked LPN #2, Why usually? LPN #2 said To be more formal. On 03/11/2024 at 12:50 PM, the Surveyor asked CNA #1, When staff are assisting Residents with meal service, how should they position themselves? CNA #1 stated, Eye level. On 03/11/2024 at 01:20 PM, the Surveyor asked CNA #2, When staff are assisting Residents with meal service, how should they position themselves? CNA #2 stated, Eye level, I was a little above eye level. On 03/12/2024 at 03:15 PM, the Surveyor was provided a policy titled Resident Rights that documented Federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity.

Based on observation, interview, and record review, the facility failed to ensure medications were not stored at the bedside and on top of the medication carts to prevent the potential of misappropriation of resident property. This failed practice had the potential to affect 4 (Residents #15, #17, #27, #177) sampled residents and had the potential to affect 15 residents that ambulate and/or self-propel on East Hall. The findings are: 1. Resident #177 had diagnoses of Schizophrenia, Major depressive disorder, and post-polio syndrome. The Admission Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 03/05/2024 documented a Brief Interview for Mental Status (BIMS) score of 11 (8-12 indicates moderate cognitive impairment). a. On 03/11/2024 at 10:30 AM, the Surveyor observed a bottle of Bicalutamide (a treatment for prostate cancer) sitting at bedside. The Surveyor asked Resident #177 if he/she takes this medication or does nursing give it to him/her. Resident #177 reported taking one every morning, and that it was obtained from [named] healthcare. b. On 03/11/2024 at 02:13 PM, the Surveyor observed a bottle of Bicalutamide sitting on the right-hand side of Resident #177's bedside table. c. On 03/11/2024 at 02:16 PM, the Surveyor asked Registered Nurse [RN] #1 to accompany the Surveyor to Resident #177's room. The Surveyor asked if any of the residents have self-administration rights and RN #1 said, No, I don't think anyone here has self-administration rights. RN #1 asked Resident #177 where he/she got the medication sitting at the bedside table. Resident #177 told RN #1 that he/she got it from [named] healthcare. RN #1 told Resident #177 that she was going to have to confiscate the bottle of medication from the bedside table and check with the doctor. The Surveyor asked what procedure staff use when residents bring medication into the facility. RN #1 told the Surveyor that they usually look and if the resident has an order for it, it was kept on the cart. RN #1 confirmed that residents need approval for self-administration rights, and to her knowledge nobody has administration rights here. d. On 03/12/2024 at 02:41 PM, the Surveyor asked the Administrator [Admin] if they have any residents that self-administer medications. The Administrator told the Surveyor they do not have anyone that self-administers medication, and that he will get a policy for the Surveyors. 2. Resident #10 had diagnoses of Chronic obstructive pulmonary disease, Dementia, and bipolar disorder. The Admission MDS with an ARD of 09/04/2023 indicated a BIMS score of 12 (8-12 indicates moderate cognitive impairment). a. On 03/12/2024 at 08:16 AM, The Surveyor went to Room East 19 and observed a plastic glass and two small administration cups sitting on Resident #10's breakfast tray. The Surveyor was asking Resident #10 what was on his/her tray when Licensed Practical Nurse [LPN] #1 came into the room. The Surveyor asked LPN #1 if she could identify the medication left on Resident #10's food tray. b. On 03/12/2024 at 08:17 AM, LPN #1 told the Surveyor that the large plastic cup is named a nutritional supplement used to promote wound healing], the orange medicine is [named a nutritional supplement for increased protein needs in wound healing] and the clear medication is lactulose (A medication used to treat constipation). The Surveyor asked if Resident #10 had self-administration rights, and if it was part of their policy to leave medications at the bedside. LPN #1 told the Surveyor Resident #10 did not have self-administration rights, and they are not supposed to leave medications at the bedside. LPN #1 told the Surveyor a CNA was across the hall and asked her for a frozen pack. LPN #1 said she would normally pick up the medication and lock it in the medication cart. The Surveyor asked why staff are not to leave medication at the bedside. LPN #1 told the Surveyor that someone else could take it, or the resident could spill the medication. 3. On 03/12/2024 at 09:24 AM, the Surveyor was accompanying RN #1 down East Hall and RN #1 told the Surveyor that there were no syringes on the cart. RN #1 picked up a small medication cup of pills, locked the medication cup in the cart, and walked down East Hall leaving the Surveyor with the cart. The Surveyor observed 2 medications cards with Prednisone 20 mg and hydrochlorothiazide 12.5 mg tablets laying on the cart. a. On 03/12/2024 at 09:26 AM, RN #1 returned to the medication cart on East Hall and said, Well, I left those medication cards out on my cart. The Surveyor asked Registered Nurse [RN] #1 why staff is expected to put away all medications before leaving their cart. RN #1 told the Surveyor that someone else could come by and take the medications. RN #1 told the Surveyor that nursing is not supposed to leave medications out on the carts unsupervised. b. On 03/12/2024 at 02:57 PM, the Director of Nursing [DON] was asked if their policy allows for medication to be left at resident ' s bedside, and on medication carts unsupervised. The DON told the Surveyor that medications are not to be left at the bedside, or on medication carts unattended. The Surveyor asked why staff was encouraged to not leave medications unattended and the DON said, Its safety for the residents. The Surveyor asked if nursing has been in-serviced on not storing medications at the bedside or unattended, and the DON said, Yes, we do in-service. d. On 03/12/2024 at 03:15 PM, the DON provided a policy titled Self-Administration of Medication documenting .Policy Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation . Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party . e. On 03/13/2024 at 08:59 AM, the DON asked for nursing medication in-service documentation. An in-service related to medications being left at the bedside were not received.

Based on observation, record review, and interview the facility failed to ensure meals were served at a palatable, attractive, and safe appetizing temperature to one 1 Resident #15 of 7 Sampled Residents that eat from the kitchen on East Hall. The findings are: a. On 03/11/24 at 11:11 AM, Resident #15 complained that food is always abnormally cold from the kitchen. Resident #15 said the turnip greens from the kitchen last night tasted straight from the refrigerator. b. On 03/13/24 at 01:20 PM, Dietary #1 provided trays from East Hall. The Surveyor asked Dietary #1 if the temperatures were acceptable to serve to residents. Dietary #1 said the meat should be about 130 degrees, and she expected the cauliflower to be warmer than 116 degrees. The food temperatures were as follows: Pork loin 99.3 degrees Cauliflower 116 degrees Mashed potatoes 136 degrees c. On 03/14/24 at 10:33 AM, the Dietary #2 said the the meat and cauliflower should be about 120 degrees. Dietary #2 said hot hold food at 135 degrees. The Surveyor asked for a policy on food temperatures during service. d. 03/14/24 10:48 AM, Dietary #2 provided a policy titled QRT Food Palatability documenting, . Standard: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature . Guidelines . Proper (safe and appetizing) temperature Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns. Dietary #2 provided a policy titled Meal Distribution documenting, . Standard: Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. Guidelines: . 2. All food items will be transported promptly for appropriate temperature maintenance . 4. The nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents/patients . 6. Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of-service dining.

48977 Based on observation, record review, and interview the facility failed to ensure Droplet Precautions were followed and appropriate PPE was worn in COVID isolation rooms preventing the potential risk for spread of infection and cross contamination affecting all 74 residents in the facility. The facility failed to ensure food and beverages were not used on the plywood table in the laundry room to prevent cross contamination with the potential to affect 67 residents who wash their clothing at the facility, and the facility failed to follow their Legionella Water Management Programing policy by ensuring interventions were in place to prevent the spread of waterborne pathogens, and monitoring effectiveness. This failed practice had the potential to affect all 74 residents. The findings are: 1.a. On 03/11/24 02:10 PM, the Surveyor was walking down East Hall and observed the door was open to room [ROOM NUMBER]-B, and the housekeeping cart was resting outside the door. The Surveyor observed Housekeeping #1 wearing prescription eyeglasses, gloves and a surgical mask holding up a full red bag of garbage. The housekeeper placed the garbage down on the floor and stepped outside the door to room [ROOM NUMBER] and confirmed the red bag was garbage from a COVID room. The Surveyor asked Housekeeper #1 what procedure he followed putting on personal protection equipment (PPE) for a room on droplet precautions. Housekeeper #1said it was okay, and he just wears a surgical mask, and it is sturdy. The other mask fogs up my glasses. The Surveyor asked if the droplet policy allows for prescription glasses, as well as face shield or eye protection. Housekeeper #1 said not sure. Housekeeper #1 looked at the droplet precaution sign on the door and Surveyor read the sign. Housekeeper #1 stated This is the first time I ever heard this. The Surveyor asked Housekeeper #1 why staff were expected to follow PPE protocol. Housekeeper #1 said, I could catch something. 2. a. On 03/12/2024 at 09:50 AM, the Surveyor accompanied Registered Nurse [RN] #1 to room East 10 to observed feeding tube care. RN #1 was observed putting on gloves, and gown and entering the room. RN #1 had on a surgical mask prior to entering the room. On exiting room [ROOM NUMBER] the Surveyor asked RN #1 what procedure staff follow when putting on PPE. RN #1 said, I am not sure . gloves, gown, and mask. RN #1 pointed to the droplet precaution sign on the door, and told the Surveyor it said gloves, gown, N95 mask, and eye protection. The Surveyor asked if their policy allows them to use a surgical mask in place of an N95 mask, and if eye protection is optional. RN #1 said she did not know. The Surveyor observed RN #1 look through the PPE hanging on the door outside room [ROOM NUMBER]-A. RN #1 was looking through the PPE and said, I do not think we have it. I do not see face protection or eye shields in here. b. On 03/12/24 at 03:03 PM, the Surveyor interviewed the Director of Nursing [DON] and asked if staff are expected to wear face or eye protection in droplet precaution rooms, and if a surgical mask substitutes for an N95 mask. The DON said in some isolation rooms staff can wear surgical masks, but COVID rooms must wear a N95 mask, and face protection or eye shields should be worn. The Surveyor asked if personal eyeglasses substitute for eye protection. The DON said there has been some debate on that, but we still say to wear face shields. The Surveyor asked if staff including nursing, Certified Nursing Assistant [CNA], housekeeping have been in-service on isolation rooms and the DON said they have been in-serviced c. On 03/12/2024 at 03:15 PM, The DON provided a policy titled Isolation-Categories of Transmission-Based Precautions documenting .Policy Interpretation and Implementation .When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. A. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. B. Signs and notifications comply with the resident's right to confidentiality or privacy . Droplet precautions . masks will be worn when entering the room. Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions . Any individuals who enter the room of a resident placed on airborne precautions must wear approved respiratory protection . d. On 03/12/2024 at 08:59 AM, The DON was asked for the in-service on isolation. Isolation in-service was not provided. 3. On 03/12/24 at 01:32 PM, the Surveyor reviewed a binder titled Legionella. The binder had 2 pages titled Legionella Surveillance Monitor with check next to areas of the facility. The pages in the binder stated at the bottom All HVAC drain pans are checked for standing water, all empty rooms are checked, and toilets flushed and Please report any suspicious looking water that has been standing to the Administrator or DON. a. On 03/12/24 at 01:50 PM, the Surveyor asked the Maintenance staff will you provide me with any legionella material you have? Maintenance staff (while in the administrator's office) voiced that he had given the binder to Life Safety. The Surveyor asked the Maintenance staff is that all you have on legionella? The Regional Consultant voiced to Administrator give her that diagram of the water source we have. b. On 03/12/24 at 02:09 PM, the Surveyor asked the administrator what measures do you have in place to prevent the growth and/or spread of legionella? The Administrator voiced, we are flushing the water, monitoring for any standing water and if we suspect anything we get the city to test. The Surveyor asked the Administrator can you provide me with any testing that the city has done? The Administrator stated, We have not suspected anything. c. On 03/14/24 at 03:35 PM, the Surveyor asked the Administrator how do you know if the interventions you have in place are effective? The Administrator stated, We don't have any legionella in the building. The Surveyor asked the Administrator how do you know there is not any legionella in the facility? The Administrator stated, No signs or symptoms. 4. On 03/12/24 at 02:30 PM, During a tour of the laundry room The Surveyor observed a plate, 2 cups, a tablet, a cell phone, and a clip board, a table made of plywood. a. On 03/12/24 at 02:40 PM, the Surveyor asked Housekeeping #2 is it standard practice to have personal items, food containers, and drink cups on the folding table? Housekeeping #2 stated, No we just finished eating. The Surveyor asked Housekeeping #2 how you sanitize the table. Housekeeping #2 stated, I don't know. On 03/12/24 03:02 PM, the Surveyor asked DON should there be any personal items on the folding table? Regional Consultant stated, no infection control issue. The Surveyor asked DON how do you sanitize plywood? Regional Consultant voiced, you can't it's porous. 03/12/24 01:10 PM, the Surveyor was provided a policy titled Legionella Water Management Program that documented The water management program includes the following elements: a an interdisciplinary water management team; b. a detailed description and diagram of the water system in the facility, including the following: 1. Receiving; 2. Cold water distribution, 3. Heating; 4. Hot water distribution, 5. waste. a. specific measures used to control the introduction and/or spread of legionella (e.g, temperature, disinfectants); b. the control limits or parameters that are acceptable and that are monitored; c. A diagram of where control measures are applied; d. a system to monitor control limits and the effectiveness of control measures; e. A plan for when control limits are not met and/or control measures are not effective; and f. Documentation of the program.

Based on observation, interview, and record review, the facility failed to protect the privacy of 1 (Resident #38) sampled resident by leaving medication cards face up and unattended on the medication cart on East Hall. This failed practice had the potential to affect all 74 residents that are receiving medication in the facility. The findings are: Resident #38 had diagnoses of Cerebral infarctions, Dysphagia (difficulty with swallowing), and Chronic respiratory failure with Hypoxia (decreased level of oxygen in blood). The Modified Medicare Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 02.16.2024 documented a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact) in non-verbal resident. Resident #38 is dependent for tube feeding, bed mobility, transfers, toileting, bathing, dressing and personal hygiene. a. On 03/12/2024 at 09:24 AM, the Surveyor observed 2 medication cards with prednisone 20 mg (milligram), and hydrochlorothiazide 12.5 mg tablets laying on the East Hall medication cart, facing up, with Resident #38's name clearly visible. b. On 03/12/2024 at 09:26 AM, Registered Nurse [RN] #1 returned to the cart and said, Well, I left those medication cards out on my cart. The Surveyor asked RN #1 why staff are expected to put away all medications before leaving their cart. RN #1 said someone could come by and get the medications, and it also leaves patient information visible on the cart, and it is Health Insurance Portability Accountability Act [HIPAA]. The Surveyor asked RN #1 why staff are expected to protect resident information. RN #1 said patient information could be used to spread rumors, figure out someone's diagnosis, or someone could tell a family member what they saw. c. On 03/12/2024 at 03:00 PM, the Surveyor asked the Director of Nursing [DON] why it is important to protect resident information, and the DON said, It is a HIPAA violation. The Surveyor asked what concerns they would have if someone saw a resident ' s information. The DON said they can do anything with that information. d. On 03/12/2024 at 03:15 PM, the DON provided a policy titled Resident Rights documenting, .Policy Interpretation and Implementation .privacy and confidentiality . The Surveyor requested in-service documentation. e. On 03/13/2024 at 10:35 AM, the DON provided an in-service (02/22/24) titled Staff Inservice Education documenting, .Privacy a big concern during med pass-knock before entering, close door and pull curtain for meds (injections, updrafts, blood sugar etc .

Based on interview and record review, the facility failed to conduct meetings about resident care planning and/or notified family representatives of any such meeting for 1 (Resident #28) sampled resident. The findings are: Resident #28 had diagnoses of Neurocognitive disorder with Parkinsonism. Resident #28 scored 06 (0-7 indicates severe cognitive impairment) on a Brief Interview of Mental Status according to the Quarterly Minimum Data Set with Assessment Reference Date of 01/31/2024. Resident #28's spouse was the responsible party, power of attorney for care and finances. On 03/11/2024 at 01:30 PM, the Surveyor asked Resident #28's spouse, Are you invited to attend the care plan meetings for Resident #28? The Resident #28's spouse stated, I don't know what that is I have never been to one of those meeting. On 03/12/2024 at 03:20 PM, the Surveyor asked the Social Worker, Who does the care plan meetings? The Social Worker voiced, I do. The Surveyor asked the Social Worker, How do you notify family and/ resident the facility is planning a meeting? The Social Worker voiced, I call them. The Surveyor asked the Social Worker, How do you document the notification and/or meeting? The Social Worker voiced that she puts in a note. The Surveyor asked the Social Worker to pull up Resident #28 and provide documentation that a care plan meeting was conducted, and the Resident ' s spouse was notified. The Social Worker stated, I don't have anything I probably didn't make one for [him/her] (reference documentation). The Surveyor asked the Social Worker, What about when Resident #28 was admitted , was there a meeting? The Social Worker voiced, I don't have one for [him/her] (referencing documentation). On 03/12/2024 at 03:33 PM, the Surveyor asked the Director of Nursing (DON), How often does the facility conduct care plan meetings? The DON stated, Quarterly, on admission, and as needed. The Surveyor asked the DON to provide documentation showing that Resident #28 had a care plan meeting on admission and/or quarterly. The Social Worker in the presence of DON voiced that the Resident had not had a care plan meeting. On 03/13/2024 at 10:35 AM, a policy titled Care Plan, Comprehensive Person-Centered documented, The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Each resident's comprehensive person-centered care plan will be consistent with the resident's right to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process; b. identify individuals or roles to be included; c. request meetings; d. request revisions to the plan of care; e. participate in establishing the expected goals and outcomes of care; f. participate in determining the type, amount, frequency, and duration of care; g. receive the service and/or items included in the plan of care; and h. see the plan and sign it after significant changes are made.

Based on observation, interview, and record review, the facility failed to ensure a mechanical lift was maintained in a safe, operational condition to prevent possible injury for 1 (Resident #22) sampled resident with the potential to affect 17 residents on East Hall requiring mechanical lift assistance. The findings are: a. On 03/11/2024 at 10:45 AM, the Surveyor observed a mechanical lift machine resting on the left side of East Hall. The Surveyor observed a missing clip on the front of the hanger bar. b. On 03/11/2024 at 01:10 PM, the Surveyor observed Certified Nursing Assistant (CNA) # 3 come out of room [ROOM NUMBER]. The Surveyor observed the mechanical lift being pulled away from room [ROOM NUMBER] A ' s ' bed through the door opening. CNA #3 confirmed she just transferred Resident #22 to his/her bed. The Surveyor asked what procedure is used for connecting the lift pad to the hanger bar. CNA #3 said she connects the lift pad to the hooks and pointed to the hanger bar. The Surveyor asked how the lift pad was connected to the front hanger bar with a missing clip. CNA said they used the outer hooks on the front and back, and they were just really careful and made sure the lift pad stayed on the front outer hook with the missing clip. The Surveyor asked if CNA #3 what the metal clip for, and CNA #3 said it helps make sure the lift pad stays on the hook. The Surveyor asked what concerns CNA #3 had about using the lift machine without a clip. CNA #3 said the lift could have leaned to the side and fallen over. c. On 03/11/2024 at 01:17 PM, the Director of Nursing [DON] was asked to accompany the Surveyor to East Hall and pointed out the lift machine outside room [ROOM NUMBER]. The Surveyor asked what the process staff is are expected to follow when the lift is missing a clip. The DON said staff should notify maintenance, administration, or the DON when equipment is not working. The Surveyor asked why the DON would want to be notified and was told so they can make sure the pads are fixed, and in proper working condition. The Surveyor asked if there are any concerns when using a mechanical lift without clips. The DON said the clips ensure the lift pad is in place, and the lift pad could come off without the clip. d. On 03/12/2024 at 02:30 PM, the DON provided a user manual titled [named] 600 REPEL-1 documenting .Using the Sling Warning .Be sure to check the sling attachments each time the sling is removed and replaced, to ensure that it is properly attached before the patient is removed from a stationary object (bed, chair, or commode) . Transferring the Patient Warning . When elevated a few inches off the surface of the stationary object (wheelchair, commode, or bed) and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hanger bar. If any attachments are not properly in place, lower the patient back onto the stationary object (wheelchair, commode, or bed) and correct this problem . Performance Maintenance Warning . After the first year of use, the hooks of the hangar bar and the mounting brackets of the boom should be inspected every three months to determine the extent of wear. If these parts become worn, replacement must be made .

Based on observation, interview, and record review, the facility failed to ensure proper incontinence care was provided to 1 (Resident #64) of 4 sampled residents dependent on staff for incontinence care on Co-ed [NAME] Hall. This failed practice had the potential affect 9 Residents dependents on staff for incontinence care and cause skin breakdown, poor hygiene, and/or infection. The findings are: Resident #64 had diagnoses of Alzheimer's disease and Dementia with other behavior disturbances. Resident #64 was unable to answer questions for the Brief Interview of Mental Status according to the Quarterly Minimum Data Set with Assessment Reference Date of 12/19/2023 and was always incontinent of bowel and bladder. On 03/11/24 at 01:50 PM, the Surveyor observed Certified Nursing Assistant #1 and #2 place Resident #64 on a dry incontinence pad. After incontinence care was complete, CNA #1 and #2 rolled Resident from left to right to remove incontinence brief and pad. When Resident #64 was rolled onto his left side the Surveyor observed a wet circular spot on the incontinence pad that had been dry initially. CNA #1 and #2 placed a clean incontinence brief on Resident #64 without repeating the process for urinary incontinence care. On 03/11/24 at 02:30 PM, the Surveyor asked CNA #1 and #2, Is there something you should have done prior to placing a clean incontinence brief on Resident #64 due to the wet incontinence pad? CNA #2 said, We should have performed care again and change the pad. On 03/12/2024 at 03:02 PM, the Surveyor asked the Director of Nursing (DON), If a Resident is incontinent of urine while staff are performing incontinent care, what should they do? The DON stated, They should start over, get a cloth. On 03/13/2024 at 03:15 PM, the Surveyor was provided a policy titled Perineal Care documented that The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.

Based on observation and interview the facility failed to ensure that food was prepared under sanitary conditions; that food and equipment was stored in a manner that did not promote foodborne illness; and resident trays were free of chips and cracks. The failed practice had the potential to effect 64 residents who received their meals from one of one kitchen according to a list provided by the Administrator on 1/12/23 10:10 AM. The findings are: a. On 1/09/23 at 5:13 PM, there was a black substance that outlined the circumference of the door on the stainless-steel front of the freezer where the rubber seal closures met the back of the unit. Multiple boxes of food had water from the condenser frozen on top of them. Areas of rust were on the shelves of the freezer. b. On 1/09/23 at 5:14 PM, the deep fryer was uncovered. The front of the appliance was covered in a greasy substance with food particles adhered to it. The top of the unit and the area surrounding the fat well was covered in a light brown substance that was shiny and contained food particles. The floor under and around the deep dryer and range was discolored with irregular areas that were black in color. c. On 1/09/23 at 5:16 PM, the walls surrounding the corner worktable were covered in food that was splattered and dried. The area extended approximately 4 feet above the worktable on two walls. d. On 1/09/23 at 5:21 PM, a one-gallon pitcher of lemonade which was 1/3 full was on the shelf in the refrigerator. The lid was turned so that the liquid was open to air and contaminants. e. On 1/09/23 at 5:23 PM, a one-gallon pitcher of sweet tea had the lid turned so that the tea was open to air and contaminates. A second one-gallon pitcher which was one half full had the lid turned so that the tea is open to air and contaminates. f. On 1/09/23 at 5:24 PM, the wall behind the freezer, refrigerator and the door to the dining room was covered in large particles of dust and debris. The particles extended over the door and the length of the wall behind the refrigerator and freezer. g. On 1/09/23 at 5:35 PM, the chest freezer which contained vegetables did not have a thermometer located on the inside. h. On 1/09/23 at 5:37 PM, a large stack of hinged, Styrofoam trays was located on top of the freezer. The original packaging was opened and the trays were exposed to air, contaminants and potential pests. i. On 1/10/23 at 10:40 AM, multiple trays were being utilized for the lunch meal. Several trays had multiple cracks and chips in the tray coating which covered the entire metal tray. On the corner and sides of the trays were areas in which the metal tray form was visible creating a sharp area which posed a potential hazard to residents or anyone handling the tray. j. On 1/10/23 at 12:20 PM, the Surveyor asked the Dietary Manager, how many trays are available for serving? She reported, that trays in question are used to serve the residents who elect to eat in their rooms, as the trays are designed to fit in the insulated cart. The Dietary Manager reported that at present she has 46 trays in the kitchen, however she feels there are multiple trays that have not been washed or returned to the kitchen from the breakfast meal. The Dietary Manager found 6 of the 46 trays were cracked, chipped or broken. k. On 1/12/23 at 1:00 PM, the Administrator provided a policy and procedure entitled, Sanitization. Number 2 stated, All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. l. On 1/13/23 at 8:30 AM, the Surveyor asked the Dietary Manager if the kitchen utilized a cleaning schedule. She stated, we were, but we are still short (staffing). The Surveyor asked, how often is the deep fryer cleaned? She stated, usually once per week.

Based on observation and interview the facility failed to ensure that the kitchen freezer operated in a manner that was safe and minimized the possibility of food cross contamination which could result in food borne illness. The failed practice had the potential to affect the 64 residents who obtain their meals from 1 of 1 Kitchen according to a list provided by the Administrator on 1/12/23 at 10:10 AM. The findings are: a. On 1/9/23 at 5:13 PM, a 2-door freezer had rivulets of water streaming down from the condenser that was located at the top of the unit. The Dietary Manager stated, we are getting a new company on Wednesday, so I hope they will fix that. The Surveyor asked the Dietary Manager if the Maintenance Department was aware of the problem. She stated, yes, we have had this problem for about 6 months. b. On 1/10/23 at 1:00 PM, the Maintenance Worker was in the Administrator's office. The Surveyor asked if they were aware of the problems with the freezer in the kitchen. The Administrator reported that the facility had had the freezer worked on multiple times. c. On 1/12/23 at 8:55 AM, a review of the monthly Dietary Department evaluations completed by the Registered Dietitian identified the following: 7/26/22 - .Ice buildup in the meat freezer (this is an ongoing issue) 8/24/22 - .Some ice buildup in big silver freezer noted - mostly in bottom/floor noted this visit . 9/28/22 - .Some ice buildup in the big silver freezer noted - mostly in bottom/floor noted this visit . 10/28/22 - .Some ice buildup in the big silver freezer noted - mostly in bottom/floor noted this visit . 12/20/22 - .Ice buildup in big silver freezer . d. On 1/13/23 at 9:15 AM, the Administrator provided invoices for service calls related to the freezer. They were as follows: 9/16/22 - Checked reach in cooler, found the condenser coil stopped up with grease and dirt, removed the coil and cleaned it. 10/31/22 - Checked ice machine, replaced water filter and adjusted float. No service was provided for the freezer. 11/30/22 - Checked reach in freezer, found the breaker had tripped, could not find any shorts. 12/15/22 - Checked reach in cooler, found and replaced door gasket on middle door. 1/4/23 - Checked cooler, worked on the door gasket on middle door, found the right door leaking at bottom left corner. e. On 1/13/23 at 9:30 AM, the Surveyor asked the Administrator if he realized that only one invoice spoke directly of the freezer. He stated, I know they say cooler, but I promise you the freezer is the only thing we have had problems with.

Based on interview and record review, the facility failed to ensure the Minimum Data Sets (MDS) were accurately encoded for oxygen for 1 (Resident #41) of 2 (Resident #41 and R #71) sample selected residents with Physician Orders for Oxygen; and failed to ensure MDS were accurately encoded for Anticoagulants (AC) for 2 (Resident #1 and #55) of 3 (Resident #1, #11, and #55) sample selected residents with Physician Orders (PO) for Plavix. The findings are: 1. Resident #41 had a diagnosis of Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries, Peripheral Vascular disease, and chronic kidney disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/22 documented a Brief Interview of Mental Status (BIMS) score of 14 (13-15 indicates cognitively intact). a.On 01/10/23 at 02:05 PM, a review of R #41's Care Plan (CP), PO, and MDS showed oxygen usage. The Annual MDS dated [DATE] did not show oxygen usage. b. On 01/10/23 at 03:26 PM, the Surveyor asked the MDS Coordinator to pull up R #41's Annual MDS dated [DATE] and look at section O. The Surveyor asked the MDS Coordinator to pull up the documentation she used to determine what she marked in this section for oxygen. The MDS Coordinator stated she did not mark oxygen because R #41 [named] did not use oxygen in the 7-day look back period. The Surveyor asked the MDS Coordinator how she determined that information. The MDS Coordinator pulled up R #41's Medication Administration Records (MAR) and stated I use the MAR. The Surveyor asked if all 7 days were marked that R #41 used oxygen. The MDS Coordinator stated that they were marked but it is also based on his O2 [oxygen] saturation. The MDS Coordinator pulled up R #41's vitals in the electronic records and stated all but one of his O2 stats are with Oxygen via Nasal Cannula. I will complete a modification to his MDS. 2. Resident #1 had diagnoses of Diffuse traumatic brain injury, bipolar disorder, and Cognitive communication deficit. The Significant Change and Modification of Significant Change Minimum Data Set (MDS) with Assessment Reference Dates (ARD) of 11/17/22 documented a Brief Interview of Mental Status (BIMS) score of 3 (0-7 indicates severe cognitive impairment). a. On 01/09/23 at 11:21 PM, a review of R #1's electronic record showed no active, discontinued, or completed AC (anti-coagulants) medications. b. On 01/10/23 at 03:32 PM, The Surveyor asked the MDS Coordinator to pull up R #1's Significant Change and Modification of Significant Change both dated 11/17/22 and look at section N. The Surveyor stated this was regarding an AC too. The MDS Coordinator pulled up R #1's records and stated, Yup, same story with this one. I will get both modifications completed. 3. Resident #55 had diagnoses of Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, End stage renal disease, and Diabetes mellitus due to underlying condition with diabetic neuropathy. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/22 documented a Brief Interview of Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact). a. On 01/10/23 at 12:04 PM, a review of R #55's electronic record showed no active, discontinued, or completed AC medications. b. On 01/10/23 at 03:32 PM, the Surveyor asked the MDS Coordinator to pull up R #55's Quarterly MDS dated [DATE] and look at section N. The Surveyor then asked the MDS Coordinator if Anticoagulant (AC) was marked. The MDS Coordinator stated, Yes ma'am it is, for 7 days. The Surveyor asked what she used to determine the AC. The MDS Coordinator stated, Probably Plavix. They've talked to me about that before. I will have to modify that MDS. There were discrepancies on how I was trained between the last company and this company. The Surveyor asked what the Resident Assessment Instrument (RAI) manual stated. The MDS Coordinator stated, not to mark it. The Surveyor asked why. The MDS Coordinator stated, Because it is an Antiplatelet and not an Anticoagulant. 4. On 01/12/23 at 09:08 AM, the Surveyor received from the Consultant #2 the policy for Certifying Accuracy of the Resident Assessment which documented .Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment . and the policy for Resident Assessments which documented .10. All members of the care team, including licensed and unlicensed staff members, are asked to participate in the resident assessment process .

Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) care was provided to 1 (Resident #41) of 5 (Resident #3, R #20, R #35, R #36, and R #41) sample selected residents who were dependent on staff for ADL care as documented on the list provided by Consultant #1 on 1/12/23. The findings are: 1. Resident #41 had a diagnosis of Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries, Peripheral Vascular disease, and chronic kidney disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/22 documented a Brief Interview of Mental Status (BIMS) score of 14 (13-15 indicates cognitively intact) and documented R #41 required total assistance of 1 person for transfers, extensive assistance of 1 person for toileting and eating, and limited assistance of 1 person for bed mobility. a. On 01/09/23 at 05:43 PM, during initial rounds, the Surveyor asked R #41 if he was receiving his showers or bed baths. R #41 shrugged his shoulders. The Surveyor asked if he was getting his hands, hair, and nails cleaned. R #41 showed the Surveyor his right hand and his nails were clean. R #41 then took his pointer finger of his right hand and ran his nail under his contracted fingers of his left hand. R #41's nail produced a thick 1/4-inch mass of yellow/brown and white matter. R #41 responded with what sounded like no. The Surveyor asked if the staff cleaned under his contracture and R #41 shook his head side to side no. The Surveyor asked if he liked his beard. R #41 again shook his head side to side. The Surveyor asked if staff shaved it for him. R #41 shook his head side to side. The Surveyor asked if he wanted the 1/2-inch-long beard shaved off. R #41 nodded his head up and down. The Surveyor noted R #41's lips were dry and peeling. The Surveyor asked if his lips were dry, and he nodded up and down. b. On 01/10/23 at 09:20 AM, the Surveyor asked R #41 if he had a shower this morning. He shook his head from side to side and took his finger from his right hand and scraped under his left contracture hand and yellowish matter was removed. R #41 rubbed his beard with his hands and shook his head from side to side. The Surveyor asked, no shave this morning? R #41 shook head from side to side and shrugged. R #41's lips were dry and peeling. c. On 01/10/23 at 03:38 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2 if the facility had shower assistants. LPN #2 stated, the Certified Nursing Assistants (CNA)s provide the showers on the 7-3 shift and the 3-11 shift does them if the 7-3 CNAs do not get them done. The Surveyor asked to speak to the CNA on the East Hall. d. On 01/10/23 at 03:45 PM, the Surveyor asked CNA #5 if she provided showers or bed baths for the residents on the East Hall. CNA #5 stated, yes ma'am. The Surveyor asked if shaving and cleaning contractured hands was part of the showering process. CNA #5 stated, yes ma'am. I do all that in the shower room before I come out. The Surveyor asked when the last time she provided a shower or bed bath for R #41. CNA #5 stated Ummm, on Sunday. It was a bed bath. The Surveyor asked if CNA #5 shaved R #41 and cleaned under his contractured hand. CNA #5 stated, no, I did a quick bed bath and didn't shave him because we were too busy. e. On 01/10/23 at 03:51 PM, the Surveyor asked Consultant #1 if shaving was part of the showering process. Consultant #1 stated, yes ma'am. The Surveyor asked Consultant #1 was cleaning under a contractured hand part of the showering process. Consultant #1 stated, yes ma'am. The Surveyor asked if being too busy was a reason to do a quick bed bath, not shave a resident and not clean under contractured fingers. Consultant #1 stated, no, you take the time to clean them well and shave them if needed. Consultant #1 provided a printout of ADL bathing tasks for Resident #41 for the last 14 days which documented five sponge baths on 1/9/23, 1/6/23, 1/4/23, 1/2/23, 12/30/22, and 12/28/22. f. On 01/12/23 at 08:27 AM, the Surveyor walked down the East Hall and R #41 waved the Surveyor to his room. R #41 had a wide smile on his face and rubbed his cheeks with his right hand. The Surveyor stated, you got a shave. R #41 smiled even bigger and pointed to his left hand and gave the Surveyor a thumbs up. The Surveyor asked, they cleaned the inside of your hand too? R #41 nodded his head up and down, smiling wide. g. On 1/13/23 at 09:53 AM, the Administrator provided the Activities of Daily Living policy which documented, .Residents who are unable to carry out activities of daily living independently will receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene . and .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .

Based on observation, interview, and record review, the facility failed to ensure catheter bags were maintained in a manner to minimize the risk of contamination for 1 (Resident #50) of 4 (Resident #11, R #20, R #40, and R #50) sample selected residents with catheters and failed to ensure catheter care and catheter output was completed and documented per Physicians Orders for 1 (Resident #40) of 4 (Resident #11, R #20, R #40, and R #50) sample selected residents with catheters as documented on the list of residents with catheters provided by Consultant #2 at 9:08 AM on 1/12/23. The findings are: 1. Resident #50 had diagnoses of NEUROMUSCULAR DYSFUNCTION OF BLADDER and Diabetes Mellitus, Type II. On the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/22 the resident received a score of 11 (8-12 Moderately impaired) on the Brief Interview of Mental Status (BIMS). The resident required Extensive Assistance for bed mobility, transfers, locomotion on and of the unit, dressing, toileting, and personal hygiene. Resident was totally dependent for bathing and independent for eating. a. On 01/09/23 at 06:31 PM, Resident #50 was lying in bed watching TV [television]. The Resident's catheter was in a privacy bag on the floor. b. On 01/10/23 at 08:32 AM, Resident #50 was lying in bed watching TV. The Resident's catheter bag was hanging on the right side of the bed and was touching the floor. This Surveyor asked Certified Nursing Assistant (CNA) #3 if the catheter bag should be on the floor. She stated no. CNA #3 went into the room and placed it back on the side of the bed elevating the bag above the floor. c. On 01/11/23 at 10:33 AM, the Surveyor asked CNA #3, why should the catheter bag not be on the floor? CNA #3 said, because you could trip, fall, which could pull on it and pull it out. The Surveyor asked, what other reasons are there for not placing the catheter bag on the floor? CNA #3 said, for sanitary reasons, could get dirty, could get floor dirty, cause an infection. d. On 01/12/23 at 10:53 AM, the Surveyor asked CNA #4, when you enter a resident's room, and they have a catheter what should you look for? CNA #4 said, if it is in a privacy bag and that it is not tight and pulling. The Surveyor asked, where do you store the catheter bag? CNA #4 said, on the back of the wheelchair. CNA #4 pointed to the area behind the wheelchair which would position the catheter bag lower than the bladder. e. On 01/12/23 at 10:55 AM, the Surveyor asked Licensed Practical Nurse (LPN) #3, when you enter a resident's room and know they have a catheter, what do you look for? LPN #3 said, I look on the floor to see if the catheter has fallen, then I look to see if the catheter is below the bladder and attached to the bed frame. The Surveyor asked LPN #3, why do you do this? LPN #3 said, for infection control. f. On 01/12/23 at 11:10 AM, the surveyor asked the Assistant Director of Nursing (ADON), if you had a resident with a catheter what would you look for upon entrance in their room? The ADON said, I would look to see if the catheter was in a privacy bag, if the tubing was kinked, if the urine is draining, is there is any sediment, and if the catheter bag is touching the floor. The Surveyor asked the ADON, why do you do these things? The ADON said, to protect resident from infection. 2. Resident #40 had diagnoses of Hemiplegia and Hemiparesis following cerebral infarction, Type II Diabetes Mellitus, and Cognitive Communication Deficit. On the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/20/22 the resident received a score of 4 (0-7 indicated severe impairment) on the Brief Interview for Mental Status (BIMS). The MDS documented the resident required limited assistance for bed mobility, transfer, and extensive assistance for toileting. a.A review of Progress Notes dated 1/6/2023 at 09:36 a.m. showed, Orders - Administration Note Text: Cranberry Capsule Give 450 mg [milligrams] by mouth one time a day for UTI [Urinary Tract Infection] prevention awaiting clarification and 12/11/2022 New order received per [named] Advanced Practical Nurse (APN) to repeat UA [urinalysis] C and S to ensure previous ABT [antibiotic] Macrobid was effective for UTI . b. The Physician Orders (PO) for 1/7/23 documented, .1/7/23 Cranberry Capsule Give 1000 mcg [micrograms] by mouth one time a day for UTI prevention . and .12/14/2022 Augmentin 875mg BID [2 times a day] PO x 10 days for UTI . c. On 01/11/23 at 08:05 AM, a review of R #40's January 2023 Treatment Administration Record (TAR) showed no documentation of Foley catheter care every shift and PRN [as needed] on 1/1/23 day shift, 1/1/23 night shift, 1/3/23 night shift, 1/7/23 night shift, 1/8/23 night shift, and 1/10/23 day shift. d. Review of R #40's January 2023 Medication Administration Record (MAR) showed no documentation for Foley Catheter output documented on 1/4/23 evening shift and 1/8/23 evening shift. e. On 01/11/23 at 09:19 AM, a review of Antibiotic Stewardship with the Assistant Director of Nursing/Infection Control and Preventionist (ADON/ICP) and the December 2022 log showed 8 residents in close proximity on the East Hall had Urinary Tract Infections. The ADON/ICP stated she had educated staff on peri care and foley cath [catheter] care. The ADON/ICP mentioned sometimes a resident is prone to UTIs, such as R #40 [named]. f. On 01/11/23 at 03:08 PM, the Surveyor asked the ADON/ICP what blanks meant on MARs and TARs. The ADON/ICP stated, That the task was not documented. The Surveyor asked the ADON/ICP what it meant when a task or service of care was not documented. The ADON/ICP stated, It means you can't prove you did it. The Surveyor asked the ADON/ICP to pull up R #40's MAR and TAR for her catheter care and output. The ADON/ICP reviewed R #40's MAR and TAR and stated Yes, there are blanks. The Surveyor asked if those should have been completed each shift. The ADON/ICP stated, Yes. The Surveyor asked what possible negative outcomes could occur if catheter care and catheter output were not completed. The ADON/ICP stated, That it was not cleaned, and it could cause an infection. 3. On 1/12/23 at 09:08 AM, Consultant #2 provide a policy and procedure entitled, Catheter Care, Urinary which documented, .Input/Output records 2. Maintain an accurate record of the resident's daily output, per facility policy and procedure ., .Infection Control records 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. Do not clean the periurethral area with Antiseptics to prevent catheter associated UTIs while the catheter is in place. Routine hygiene (e.g., cleansing of the metal surface during daily bathing or showering) is appropriate . and .Infection Control #2 b. Be sure the catheter tubing and drainage bag are kept off the floor . 46723

Based on observation, interview, and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee put forth good faith attempts to correct, monitor, and reassess its own quality deficiencies for proper respiratory care for residents who were on Oxygen Therapy, and for Activities of Daily Living (ADL) Care for residents who were dependent on staff's physical assistance for ADL tasks. This failed practice had the potential to affect (how many residents?) The findings are: 1. On 01/09/23 at 08:20 PM, the Administrator provided the Facility assessment dated [DATE]. (All the rest of this was not pertinent) 2. On 01/09/23 at 08:20 PM, the Administrator provided a QAPI Plan dated 2023 which documented .Guiding Principle #2: The Outcome of QAPI in our organization is to improve the quality of care and the quality of life for our residents . and .the team will thoughtfully and thoroughly consider the progress made in the last year toward achieving the designated QAPI goals and current status of measurement in meeting and sustaining the performance indicators. 3. On 01/10/23 at 11:33 AM, the Administrator provided a list of the members of the QA Committee. 4. On 01/10/23 at 11:40 AM, the Surveyor asked about Facility Assessment's date. The Administrator stated, It should be 1/10/2023. The Administrator corrected the dated and initialed the document. The Surveyor asked if it was just completed today. The Administrator stated, No, well, yes. Showed two care areas with a pattern of deficiencies: a. F677 was cited on the 2018, 2019, 2020, and 2021 annual surveys. b. F695 was cited on the 2020 and 2021 annual surveys. 6. On 01/13/23 at 09:38 AM, the Surveyor asked the Administrator how often QAA meetings were held. The Administrator stated, QAA meetings are held monthly. The Surveyor asked, what members were required to attend? The Administrator stated, Ummm, well, me [Administrator], the DON (Director of Nursing), all the Dept [Department] heads, the ADON (Assistant Director of Nursing), Dietary, Maintenance, the Housekeeping Supervisor, the Treatment Nurse, and the Medical Director. I think that is all. The Surveyor asked the Administrator, are you aware of the pattern areas of deficiencies the facility had from 2018 to 2021? The Administrator stated, Ummm, no ma'am. I am not aware of any patterns. The Surveyor asked, how long do you track a deficiency listed on the 2567 after it is received? The Administrator stated, until compliance is met. The Surveyor asked, do you check on it again at any point after compliance is met? The Administrator stated, only if we see an issue. The Surveyor asked, how do you track the progress of compliance? The Administrator stated, we do the QAA meetings and meet regularly on our PIPs (Performance Improvement Projects).

Based on interview and record review, the facility failed to ensure all staff were fully vaccinated, had an approved or pending medical or religious exemption, or a temporary delay per the Center for Disease Control (CDC) per the Centers for Medicare and Medicaid Services (CMS) COVID-19 Health Care Staff Vaccination Regulations Quality, Safety and Oversight on 01/14/22 (QSO). The findings are: 1. On 01/09/23 at 08:03 PM, the Administrator provided the Assistant Director of Nursing/Infection Control & and Preventionist's (ADON/ICP) [named] Infection Prevention Certificate dated 11/28/20. 2. On 01/09/23 at 08:27 PM, the Minimum Data Set (MDS) Coordinator provided a list for the last 4 weeks that contained the names of 5 Covid-19 positive residents and 5 Covid-19 positive staff. 3. On 01/10/23 at 09:00 AM, the ADON/ICP provided the COVID-19 staff Matrix. 4. On 01/10/23 at 10:00 AM, the Surveyor asked the ADON/ICP to review the Matrix as there were 20 staff listed in the column titled Not vaccinated without exemption/delay. 5. On 01/10/23 at 03:50 PM, the Administrator provided an updated COVID-19 Matrix. 6. On 01/11/23 at 09:19 AM, a review of the staff COVID-19 Vaccination Matrix showed three staff marked as partially vaccinated. The Surveyor asked the ADON/ICP, are the 3 staff marked as partially vaccinated new hires? The ADON/ICP stated, No, they are PRN [as needed]. The Surveyor asked, do they have exemptions? The ADON/ICP stated, no. The Surveyor asked, have they worked since their 2nd [second] vaccination was due? The ADON/ICP stated, Yes, they all have. Two are PRN. [named] is my HR (Human Resource) Employee, so she definitely has. 7. On 01/11/23 at 10:01 AM, the Surveyor asked Consultant #1, if an employee is not a new hire, is partially vaccinated, and does not have an exemption, should they continue to work? Consultant #2 stated, No, we have to be regulatory compliant. Consultant #1 stated, ADON/ICP [named] is getting with HR to check documentation on exemptions. 8. On 01/11/23 at 11:05 AM, the ADON/ICP provided documentation of a COVID-19 vaccination religious exemption for the HR employee dated 12/8/22. Her first COVID-19 vaccination was 11/23/21. The ADON/ICP stated, we do not have an exemption for either Certified Nursing Assistant #1 or #2. (CNA). The ADON/ICP handed the Surveyor a paper which documented CNA #1's first COVID-19 vaccination was on 3/9/22, her hire date was 3/30/22, she went to PRN status on 12/26/22. CNA #2's 1st [first] COVID-19 vaccination was 7/26/21, her hire date was 12/1/20 and she went to PRN status on 8/10/22. 9. On 01/11/23 at 11:20 AM, the Surveyor requested payroll documentation for CNA #1 and CNA #2 from Consultant #1. 10. On 01/11/23 at 11:45 AM, Consultant #1 provided payroll documentation which documented CNA #1 worked in the facility until pay period ending 12/21/22 and CNA #2 worked in the facility until pay period ending 10/26/22. CNA #1 had worked 2,745.45 hours and CNA #2 had worked 1,280.56 hours since the facility changed ownership in April 2022. 11. On 01/13/23 at 08:56 AM, the Surveyor requested payroll documentation for the HR staff for 12/25/21 to 12/7/22. This was the time the HR staff was not fully vaccinated and did not have an approved exemption. 12. On 01/13/23 at 09:26 AM, the HR Employee stated she must have written the wrong date on the exemption form provided earlier in the week. The HR Employee handed the Surveyor a new exemption form, with wet ink, dated 12/8/21, with a different statement at the bottom for the basis of the request. HR's payroll documentation was not provided for the time period requested. 13. On 01/09/23 at 06:34 PM, the ADON/ICP provided the F888 Vaccine Policy and Contingency Plan which documented, .In accordance with the rulings and mandates from Center for Medicare and Medicaid Services (CMS) related to the COVID-19 vaccine, all eligible employees will be required to be fully vaccinated or request an exemption based on recognized medical conditions or religious beliefs, observances, or practices. The facility will offer reasonable accommodations based on recognized medical conditions or religious beliefs, observances, or practices that exempt the employee from complying with the mandate . and .Phase 2: All eligible staff must have received the necessary shots to be fully vaccinated - either two doses of [named pharmaceutical companies] or one dose of [named pharmaceutical company] - by March 14th, 2022 . and Any employee hired after Phase 1 who are eligible for the vaccine, will be required to have their first dose administered prior to providing any care, treatment, or other services . 14. On 01/09/23 at 07:54 PM, the ADON/ICP provided the policy for Coronavirus Disease (COVID-19)- Infection Prevention and Control Measures which documented, .The infection prevention and control measures that are implemented to address the SARS-CoV2 pandemic are incorporated into the facility infection prevention and control plan. These measures include: .d. Vaccinations . 15. On 01/09/23 at 08:43 PM, the (ADON/ICP) Provided the policy for Monitoring Compliance with Infection Control which documented, .The infection preventionist or designee monitors the compliance and effectiveness of our infection prevention and control policies and practices . and .The infection preventionist conducts compliance surveillance at least quarterly or at a frequency determined by the Infection Prevention and Control Committee. (IPCC) or the Quality Assurance and Performance Improvement (QAPI) committee . 16. On 01/09/23 at 08:43 PM, the ADON/ICP provided the policy for Coronavirus Disease (COVID-19)-Testing Staff which documented, .Fully vaccinated refers to the CDC definition. The current definition can be found at Interim Public Health Recommendations for Fully Vaccinated People (CDC) ., . Unvaccinated refers to the person who does not fit the definition of fully vaccinated, including people whose vaccination status is not known ., and Facility Staff includes employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in the facility's nurse assistant training programs or from affiliated academic institutions .

Based on observation, record review, and interview the facility failed to ensure the appropriate lift pad was used when transferring with the mechanical lift to prevent the potential for accidents or injury for 1 (Resident #50) of 7 (Residents #21, #33 #39, #42, #43, #50, and #55) sampled residents who were transferred with a mechanical lift. This failed practice resulted in past noncompliance at the level of immediate jeopardy which caused or could have caused harm, serious harm, or death to Resident #50 who was lifted with the wrong size lift sling and sustained a laceration to the resident's right ear lobe and had the potential to affect 14 residents who were transferred with a mechanical lift according to the list provided by the Director of Nursing (DON) on 5/17/19. The Administrator was notified of the past noncompliance at the level of Immediate Jeopardy on 5/16/19 at 1:56 p.m. The findings are: 1. Resident #50 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/7/19 documented the resident was severely impaired in cognitive skills for daily decision making per a staff assessment for mental status, was totally dependent on the assistance of two plus people for transfer, and bed mobility and had functional limitation in range of motion in upper and lower extremities on both sides. a. A Visual/Bedside Kardex Report dated on admission 9/12/2013 documented, Transferring-Require full body lift (Reliant 600) with (2) staff assistance for transfers. Use large lift strap. b. A Transfer Evaluation dated 4/20/19 documented, Resident is dependent on staff X (times) 2 with transfers using full body lift (Reliant 600). c. Nurses notes dated 5/11/19 documented, At 9 am (9:00 a.m.) I was called into (Room number) where I observed a very large laceration on resident's right ear lobe. Dry pressure dressing applied and PA (Physician Assistant) notified with new orders to send to ER (emergency room ). Ambulance notified to transport, Responsible party and DON and Administrator notified. Report called to ER and at 9:30 am ambulance here and transported to ER. CNA's (Certified Nursing Assistants) reported that during transfer with lift pad resident was leaning to the right. Lift pad had metal bar that caused laceration to right ear lobe. Nursing Note dated 5/11/2019 at 11:30 a.m., documented, Note Text: Resident returned to the facility from ER in stable condition. Family at bedside. Bandage in place to right ear without drainage. ER nurse called and stated resident had 11 stitches to right ear. Respirations are even and unlabored on room air. B/P (blood pressure) 115/78 T (temperature) 98 P (pulse) 76 R (respirations) 18. d. An Incident/Accident Report dated 5/11/19 documented, Resident obtained a very large laceration to right ear during transfer with lift pad. Action taken: Resident injury assessed and dry pressure dressing applied. MD (Medical Doctor) notified and resident sent to ER. Contact #1 notified, DON and Administrator. Lift pad had a metal bar and it cut resident's ear. e. On 05/15/19 at 11:24 a.m., the resident was sitting in a geri chair in her room with her feet up. Licensed Practical Nurse (LPN) #1 provided wound care to right ear. The LPN removed the old dressing dated 5/14/19. There was a small amount of yellowish drainage, the sutures were intact, and the nurse stated there were no signs/symptoms of infection, no excessive redness, or swelling noted. f. On 5/15/19 at 1:46 p.m., the resident was transferred from her geri chair to the bed by Certified Nursing Assistant (CNA) #1. The harness was correctly hooked on all sides and locked in place. The harnesses for the lift pad stayed intact throughout transfer. g. On 5/15/19 at 2:28 p.m., CNA #1 was asked, Tell me what happened to cause the incident to the resident's ear. She stated, We used the Marissa Lift and as the other (CNA #2) had a hold of her, and we had to lean over the opposite way that she lean because her neck is contracted, and she has to be straight in the geri chair. So, there is a middle bar on the lift that you have to push down so that it will cause the resident to sit up completely. So I had to push the bar down so once we put her in the chair we saw the blood, we did not see her right ear actually strike anything during the transfer, but there was blood on the bar of the lift so we figure that this is what struck her right ear. She was asked, Was the lift pad too big for her? She stated, No it was kinda snug. She was asked, So, would you say it was too small? She stated, Yes, it was too small. She was asked, How do you know what size lift pad to use for a resident? She stated, There is really no size chart, we pretty much look and guess. She was asked, What happened after you noticed the injury? She stated, One of us went and got the nurse. She was asked, What did the facility do after the incident? She stated, They sent her to the hospital and the other CNA (#2) and I got written up and suspended for 3 days, they immediately sent us home that Saturday. She was asked, Did you receive any education/in-service afterwards? She stated, Yes, we were in-serviced on using the lift. She was asked, Did you have to return the demonstration? She stated, Yes. She was asked, Have you ever had any other injuries in using the lift? She stated, No, this is my first time in 16 yrs. She was asked, Do you think the lift pad being the wrong size caused the incident? She stated, That's a possibility. h. On 5/15/19 at 2:43 p.m., CNA #2 was asked about the transfer incident with Resident #50 and she stated, While the other (CNA #1) was transferring her from the bed to the geri chair, we were using the Marissa body lift and I was holding her from behind because of the way her upper body is, and (CNA #1) was directing her on the lift the part that you push to direct them toward the chair. While holding the bar that keeps them in a sitting position, and the resident leans toward the left and I was holding her toward the right side to prevent her from hitting her head on the bar on that side. Where the lift pad is, her ear got caught on the side of the lift strap, it was in the harness and the harness was locked and I saw when we got her into the chair the blood on the lift pad. She was asked, Was the lift pad appropriate size? She stated, No ma'am. She was asked, Was it too big or too small? She stated, Too small. She was asked, How do you know what size lift pad to use for a resident? She stated, For each resident in their Kardex on the KIOSK (electronic medical record system) have the size or color that they are to use and hers did not have either on there. Hers just said to use a body lift on her. She was asked, Had you transferred her before? She stated, Yes. She was asked, What size lift pad did you use? She stated, The same size or one that was bigger. She was asked, Did you have any other accidents? She stated, No, this was my first time, I've been a CNA for [AGE] years and this was my first incident using a lift. She was asked, What happened after you saw the blood? She stated, The other (CNA #1) went and got the nurse, and she looked at her ear and we suggested to her that we use the other lift, it doesn't have the bar in the middle like the first lift and we didn't have another size lift pad to put her back in the bed. She was asked, What happened to you all after the incident? She stated, We were written up and suspended that day, for 3 days from Saturday around 11 until yesterday morning. She was asked, Did they reeducate? She stated, Yes, when I returned on yesterday morning, I had to do retraining using lift with return demonstration. i. On 5/16/19 at 8:37 a.m., Licensed Practical Nurse (LPN #2) was asked about the incident with the lift on 5/11/19. She stated, I think it happened the way the CNA's said it happened because they were so up front about it. One of them came and got me and I went in and assessed her. She (resident) leans over to one side and can't move or anything. I have no reason to not to believe what the CNA's said happened. She was asked, Do you know if she had been assessed for the proper lift size of lift sling/pad? She stated, There is a certain size you are to use on a resident. She was asked, Do you think they used the correct size sling on this resident? She stated, They did say that they used the wrong size sling. They have all been trained on what size to use on each resident and lift. She was asked, What happened after the incident? She stated, I wrote them up, and suspended them until it was investigated. The resident was sent out to the hospital and returned with sutures. At 8:45 a.m., the Director of Nursing (DON) was asked if the resident had ever been assessed for the proper size lift and which lift to use? She stated, Yes, we do transfer evaluations quarterly. She was asked, Has the resident ever been assessed for the size of sling and type of lift to use? She stated, Yes. She was asked, Where do the CNA's find the information for what type and size sling and lift they need to use with a resident? She stated, It would be on the Kiosk. When asked, Can you show me where it is on the Kiosk? She stated, Yes. We went to the Kiosk and this resident does have the information listed for lift pad size, Full Body Mechanical lift (Reliant 600) with (2) staff assistance for transfers. Use large pad. When asked what the in-service covered? She stated, Abuse/Neglect, Using correct pad and correct Lift. We did check offs with return demonstration. Do you have the check off sheets? She stated, Yes. At 9:00 a.m., the MDS Coordinator was asked about the information in the Kiosk and stated, I do the transfer evaluations quarterly. The information in kiosk stays on there and is updated as needed. 2. The facility removed the Immediate Jeopardy and corrected the failed practices from 5/11/19 prior to the survey, as evidenced by the following: a. Both CNA's were suspended for 3 days on 5/11/19. b. An in-service sheet dated 5/13/19 and titled, Mechanical Lift Transfers and Check-offs, documented each CNA was re-trained and completed a return demonstration of a mechanical lift transfer. c. The facility's monitoring sheets documented ongoing monitoring of mechanical lift transfer was to be conducted weekly for 4 weeks, then every 2 weeks for a period of 4 weeks, then monthly thereafter.

Complaint # (AR 876) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure protective measures were immediately and consistently implemented after discovery of a fracture of unknown origin to prevent potential exacerbation of the injury and failed to ensure a complete and thorough investigation was conducted to rule out possible abuse or neglect for 1 (Resident #5) of 1 case mix resident who sustained a fracture of unknown origin. These failed practices resulted in immediate jeopardy, which caused or could have caused serious harm or further injury to Resident #5, who sustained a fracture of unknown origin and did not receive the necessary precautions to avoid further injury. According to a list provided by the Administrator on 9/6/18, there were no other residents in the facility who had sustained a fracture of unknown origin. The Administrator was informed of the immediate jeopardy condition on 8/31/18 at 3:40 p.m. The findings are: Resident #5 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/26/18 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, required extensive assistance for transfer, walked with limited assistance, was not steady with balance and only able to stabilize with staff assistance, and had 1 fall with major injury. a. The Care Plan dated 6/18/18 documented, .I have an ADL (activity of daily living) self-care performance deficit r/t (related to) dementia. I have limited physical mobility r/t dementia. I will get up w/o (without) asking for help . Transfers: Resident requires extensive assistance with transfers . I am at risk for falls r/t dementia; poor safety awareness; high fall risk . Goal: I will not sustain serious injury through the review date.Approaches/Tasks Educate the .caregivers about safety reminders and what to do if a fall occurs . b. An Incident Report dated 6/21/18 at 7:15 a.m. documented, .Incident Location: Hallway, Person Preparing Report: LPN (Licensed Practical Nurse) #1 Incident Description Nursing Description: Resident unable to give. This nurse notified that resident in floor in hallway. Resident laying (sic) on left side, laceration to rt (right) brow area with blood. Ambulance called at time. Pressure dressing applied. Resident awake and alert. Pupils (times) 2 equal and round reacts to light. Grips strong. Resident stated pain to rt eye. Transferred to ER (emergency room ) via ambulance. Immediate Action Taken Description: Neuro (neurological) check performed immediately, pressure dressing applied to wound. Sent to ER, daughter, wife, (Physician #1) MD (Medical Doctor), DON (Director of Nursing) all notified.Injuries Observed at Time of Incident Injury Type Abrasion Injury Location 37) Right knee (front) Injury Type Laceration Injury Location 64) Other .Notes: Laceration to rt brow area. 3 sutures in place . Notes: sutures intact to right brow area. No s/sx (signs/symptoms) of infection noted. No delayed injuries noted. Therapy to screen and wing mattress placed on bed . c. An emergency room Physician Documentation Record dated 6/21/18 from Hospital #1 documented, .Arrival Date: 06/21/2018 Time: 07:39 . 08:10 Details of fall: The patient fell from an upright position, while walking . Onset: The symptoms/episode began/occurred just prior to arrival. Associated injuries: The patient sustained injury to the head, laceration, 1.5 cms (centimeters), of the right eye. Associated signs and symptoms: Loss of consciousness: the patient experienced no loss of consciousness.ROS (review of systems) 08:11 .extremity: Negative for acute changes.Musculoskeletal/extremity: Extremities: all appear grossly normal, with no appreciated pain with palpation, no acute changes . d. The Nursing Progress Notes dated 6/21/18 at 11:34 a.m. and written by RN #1 documented, Incident Note Nature/Description of Incident: This nurse notified that resident in floor in hallway. Resident laying (sic) on left side, laceration to rt brow area with blood. Ambulance called at time. Pressure dressing applied. Resident awake and alert. Pupils (times) 2 equal and round reacts to light. Grips strong. Resident stated pain to rt eye. Transferred to ER via ambulance. Description of Injuries: Laceration to rt brow, abrasion rt knees Immediate Actions Taken: Neuro (neurological) check immediately, pressure dressing applied, transferred ER. Medical Profession Notified (Who/When): (Physician #1) Resident Representative Notified (Who/When): Wife, DON, (and) Daughter. e The Nursing Progress Note dated 6/21/18 at 11:38 a.m. and signed by LPN #3 documented, Note Text: Resident up in his w/c (wheelchair) to the dining room for his meal. Resident continues to strike out at staff and attempts to bite staff. He is grabbing staff hands and arms, scratching staff. Bandage intact above right eye brow. Neuro check in process and is within normal limits . There was no documentation to indicate the resident was in pain while up in the wheelchair. f. The Nursing Progress Note dated 6/22/18 at 2:26 a.m. and signed by LPN #2 documented, Note Text: Resident behavior still hasn't changed . neuros intact denies any pain at this time. incont (incontinent) of b/b (bowel and bladder) prn (as needed) pericare (perineal care). Resident is combative toward staff . There was no documentation to indicate the resident experienced pain with movement or when incontinent care was performed. g. The Nursing Progress Note dated 6/22/18 at 10:53 a.m., and signed by RN #1 documented, Note Text: Resident up in wc (wheelchair) in dining room at this time. No s/s (signs and symptoms) of distress. Incontinent of B/B, 2 (times) assist to bathroom. Peri care done by staff. Will attempt to hit, scratch staff during care. Will answer yes or no questions. Attempts to walk without assistance. Gait weak and unsteady. Dressing to rt brow is CDI (clean, dry and intact) from incident on 6/21/18. Neuro check normal. Denies pain at this time. There was no documentation to indicate the resident exhibited pain with incontinent care nor while he was up in the wheelchair. h. The Nursing Progress Note dated 6/22/18 at 11:38 p.m. and signed by LPN #3 documented, bandage above right eye intact. No c/o (complaint of) pain voiced . i. The Nursing Progress Note dated 6/23/18 at 2:59 a.m. and signed by LPN #4 documented, Note Text: Resident lying in bed awake and alert to person. Bandage above right eye in place and intact. No s/s pain/discomfort noted at this time. Resident remains on q (every) shift neuro checks at this time . There was no documentation to indicate the resident was in pain. j. The Nursing Progress Note dated 6/25/18 at 4:18 p.m., and signed by RN #1 documented, While obtaining UA (urinalysis) resident yelling 'ow' and grimacing while moving legs. (Physician #1) notified. New order for bilateral hip x-ray. This note, dated 4 days after the 6/21/18 fall, was the first reference in the clinical record to the resident experiencing any pain with movement of his legs. k. A mobile Radiology Results Report dated 6/25/18 documented, Radiology: 06/25/18 20:56 (8:56 p.m.) . Procedure: Hips bilat (bilaterally) w (with) or w/o (without) pelvis 2 V (views) Interpretation: Reason for Study: .Pain in unspecified hip . FINDINGS: Mildly displaced [MEDICATION NAME] fracture through the right femoral neck. The right femoral head remains appropriately seated within the acetabulum. There is superior migration of the right femoral shaft. Mild left hip [MEDICAL CONDITION] changes. Imaged pelvic ring appears intact without evidence of disruption or cortical step-off. Unremarkable appearance of the sacroiliac joints and pubic symphysis.IMPRESSION: 1. Mildly displaced [MEDICATION NAME] right femoral neck fracture. l. A Nursing Note dated 6/26/18 at 4:56 a.m. and signed by LPN #1 documented, Mobile fax came through for x ray of the right hip. Impression: Mildly displaced [MEDICATION NAME] right neck fracture. MD and family will be notified and oncoming nurse will be aware of this report. m. A Nursing Note dated 6/26/18 at 6:55 a.m. and signed by LPN #1, documented, Faxed results to MD and DON is aware about the x-ray and UA with culture in the refrigerator. n. A Nursing Progress Note dated 6/26/18 at 8:22 a.m. and signed by RN #1 documented, Resident sent to (Hospital #1) ER per (Physician #1) and transferred to (Hospital #2) per family request. o. An Emergency Department Record dated 6/26/18 at 9:01 a.m., written by the Emergency Department Physician for Hospital #1, documented, Physician Documentation . 09:35 (a.m.) presents to ER with complaints of Hip Pain . The patient or guardian reports decreased range of motion, deformity. The complaints affect the right hip. Onset: The symptoms/episode began/occurred yesterday. Modifying factors: the symptoms are aggravated by any movement. Unable to obtain . due to baseline dementia. Pt (patient) sent in from the NH (nursing home) for right [MEDICAL CONDITION]. He fell 5 days ago and was seen here in the ER. I was the physician that evaluated him but he did not have any hip deformity or pain. Yesterday the NH noted he had hip pain and ordered an x ray that showed a right [MEDICAL CONDITION] . Exam: In obvious pain . Head/face: Noted is a laceration(s) of the healing right eyebrow laceration with sutures in place.Musculoskeletal/extremity: Extremities: noted in the right hip: right hip shortened and rotated . Differential Diagnosis: [REDACTED]. Disposition: .Emergent. Disposition Summary: 06/26/18 10:42 (a.m.) Transfer Ordered Transfer Location: (Hospital #2) Reason: Higher level of care . Problem: new .Preliminary [DIAGNOSES REDACTED]. p. Hospital #1 Nurses Notes dated 6/26/18 at 9:03 a.m. documented, .Presenting complaint: Nursing home nurse states that patient had a fall on Thursday (6/21/18) and was sent to the ER. Then yesterday while obtaining a urine specimen patient was hollering out in pain when legs were moved. They then obtained an x-ray and found a right [MEDICAL CONDITION]. Report is in nursing home paperwork. Patient has also running fever since Saturday and urine specimen looked really bad .09:03 (a.m.) Transition of care: patient was received from another setting of care (long-term care facility) (facility name). 09:03 Method of Arrival: WC (wheelchair) . Triage Assessment: 09:38 . Pain: Complains of pain in low back area and right hip Pain currently is 8 out of 10 on a pain scale.Patient was seen on Thursday (6/21/18) in ER for fall. Patient was not exhibiting any pain, moaning, or hollering when moving lower extremities on Thursday like he is today . Screening: .Injuries sustained: On Thursday the patient complained of head pain and laceration to forehead. Today he is complaining of hip and back pain . Outcome: 11:36 a.m. Transferred Receiving Facility . XR (x-ray) Pelvis . Procedure: Pelvis 2 views. Indication: Fall, now presenting with decreased range of motion. Findings: There is a fracture through the femoral neck with foreshortened appearance. There is no dislocation of the femoral head. The left hip is intact . Impression: Right femoral neck fracture . q. An ambulance service run form titled, Prehospital Care Report and dated 6/26/18 documented, .At Scene: 06/26/18 11:36 (a.m.) .Narrative: .EMS (Emergency Medical Services) Unit . dispatched to (Hospital #1) ER to transport a patient with a right femur fracture to (Hospital #2) .Patient total lift to stretcher . r. A Hospital #2 Discharge Summary dated 7/2/18 documented, History of Present Illness: .was admitted due to a right femoral neck fracture .[DIAGNOSES REDACTED]. Femoral neck fracture. 2. Systemic [MEDICAL CONDITION] response syndrome . He was transferred from an outlying ER due to a right femoral neck fracture. (Physician #2) with orthopedics was consulted. He underwent right hemiarthroplasty on (MONTH) 27, (YEAR), due to his high-risk for fall and inability to follow commands and severe behavioral disturbance . s. An Orthopedic Consultation dated 6/26/18 documented, .Chief Complaint: Right hip pain. History of Present Illness: The patient is a nursing home patient with severe dementia, who was evaluated at (local hospital) this morning and diagnosed right femoral neck fracture. It is displaced on x-rays here, required hemiarthroplasty, plan on doing this for him tomorrow .the right lower extremity, which is externally rotated and shortened somewhat .Impression: Right femoral neck fracture . t. On 8/30/18 at 5:20 p.m., RN #1 was asked when the resident was transferred to the hospital, and how the resident was transported, by gurney or via wheelchair, after the fracture was identified on 6/26/18 and stated, Immediately. I do remember it was by our van. I don't remember a gurney. I do remember a wheelchair . I do remember he was in the wheelchair. The RN was asked how the resident was transferred to the wheelchair that day and stated, With 2-person assist with a gait belt; me and (Transport Certified Nursing Assistant (CNA)). The RN was asked why, if staff were aware of the fracture, the resident was manually transferred from bed and placed in a wheelchair. The RN stated, You'll have to ask (Director of Nursing (DON)); I normally ask her how to transport. The RN was asked, if a resident has a [MEDICAL CONDITION], should they be transported in a wheelchair? The RN stated, No. u. On 8/30/18 at 5:40 p.m., the DON was asked what was done when the fracture was identified and stated, We talked with (Administrator) about it, and we all associated it with the fall he had. The DON was asked if the fracture was investigated and stated, Yes. Talked to staff. The DON was asked if this had been documented and to whom she had spoken. The DON stated, Verbally. I don't remember who. The DON was asked what should be done when a fracture was identified and whether an Incident and Accident Report was done. The DON stated, We associated it was with the other fall. The DON was asked how it was associated that the fracture was related to the fall on 6/21/18. The DON stated, We just verbally asked everyone if he had (another) fall, and everyone said 'no'. v. On 8/30/18 at 5:55 p.m., the Administrator was asked if an incident report was completed when the resident's fracture was discovered and stated, I don't think we did one. She (nurse) moved his legs and he yelled. We assumed it was from when he fell on the 21st (6/21/18). The Administrator was asked if the fracture was considered an injury of unknown origin and stated, He had fallen and it was on that hip. I remember asking him when he fell (on 6/21/18) did he hurt. She (nurse) said he yelled out when she got the UA (on 6/25/18). w. On 8/31/18 at 11:32 a.m., the DON was asked, when a resident sustains a [MEDICAL CONDITION], should the resident be transported by van? The DON stated, No. The DON was asked if RN #1 was instructed to transport the resident by wheelchair in the facility van after the fracture was identified. The DON stated, No, I don't recall. The DON was asked if an investigation was completed to try to determine the cause of the fracture and stated, I talked to (Administrator) about it, and we associated it with the fall he had the week before. I asked around, like verbally. The DON was asked if the interviews were documented and stated, No. The DON was asked if she recalled which staff were interviewed regarding the fracture and stated, No I don't. x. On 8/31/18 at 12:30 p.m., the Administrator was asked, when there is an injury of unknown origin, what is to be done? She stated, An investigation. The Administrator was asked if an investigation was completed when the resident's fracture was identified and stated, No. The Administrator was asked if there should have been an investigation and stated, Yes. The Administrator was asked if a resident should be transported by wheelchair in the facility van after a [MEDICAL CONDITION] was identified. The Administrator stated, No I talked to her (nurse), and he was already up in the wheelchair. y. The immediate jeopardy was removed on 8/31/18 at 7:10 p.m. and the scope/severity reduced to D, when the facility implemented the following Plan of Removal: 1.) On 8/31/18 at 5:00 p.m. Administrator/Designee immediately in-serviced all Nursing and C.N.A. (Certified Nursing Assistant) staff currently working on 3-11 (3:00 p.m. to 11:00 p.m.) shift on protective measures to be put in place when a resident has a suspected fracture or we are awaiting results of an x-ray for a suspected fracture to include if a resident has a suspected fracture that we will not move the affected limb unless necessary for the care of the resident, resident will not be transported by facility van with a fracture or suspected fracture, resident will not be transferred with gait belt if resident has a fracture or suspected fracture, resident will be assessed for shift for additional injury or pain Q (every) shift x (times) 72 hours. The remaining nursing and C.N.A. staff will be in-serviced prior to working their next scheduled shift. Employees on vacation or leave will be in-serviced prior to their return to work. All new hires will be in-serviced prior to working a shift. 2.) On 8/31/18 at 5:00 p.m. Administrator/Designee immediately in-serviced all Nursing and C.N.A. staff currently working on 3-11 shift on supervision and monitoring of residents to prevent accidents and appropriate observation, monitoring and follow up after an accident has occurred to include follow up documentation for monitoring and assessment for pain Q shift x 72 hours post incident. The remaining nursing and C.N.A. staff will be in-serviced prior to working their next scheduled shift. Employees on vacation or leave will be in-serviced prior to their return to work. All new hires will be in-serviced prior to working a shift. 3.) On 8/31/18 at 5:00 p.m. DON and Administrative nursing staff immediately audited residents with I & As (Incidents and Accidents) who had a fracture since 6/21/18 to ensure proper measures were put in place to protect the resident from further injury. 4.) DON/Designee will review I & As and nurses notes 5 x weekly x 8 weeks to ensure there are no injuries of unknown origin. 5.) DON/Designee will review I & As and nurses notes 5 x weekly x 8 weeks to ensure proper assessment, monitoring, and follow up after an I & A has occurred.

Complaint # (AR 876) was substantiated (all or in part) with these findings: A. Based on record review and interview, the facility failed to ensure adequate supervision was provided to prevent further potential injury after Resident #5 was diagnosed with [REDACTED].#5) of 1 case mix resident who sustained a [MEDICAL CONDITION] in the past 3 months. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #5, who sustained a (mildly displaced) [MEDICAL CONDITION] and was subsequently subjected to a weight-bearing, gait-belt transfer and transported to the emergency room in the facility van. According to a list provided by the Administrator on 9/6/18, no other residents sustained [MEDICAL CONDITION] in the past 3 months. The Administrator was informed of the Immediate Jeopardy condition on 8/31/18 at 3:40 p.m. The findings are: Resident #5 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/26/18 documented the resident was severely impaired in cognitive skills for daily decision making per the Staff Assessment for Mental Status, required extensive assistance for transfer, walked with limited assistance, was not steady with balance and only able to stabilize with staff assistance, and had 1 fall with major injury. a. The Care Plan dated 6/18/18 documented, .I have an ADL (activity of daily living) self-care performance deficit r/t (related to) dementia. I have limited physical mobility r/t dementia. I will get up w/o (without) asking for help .Transfers: Resident requires extensive assistance with transfers . I am at risk for falls r/t dementia; poor safety awareness; high fall risk . Goal: I will not sustain serious injury through the review date.Approaches/Tasks Educate the .caregivers about safety reminders and what to do if a fall occurs . b. The Nursing Progress Note dated 6/25/18 at 4:18 p.m. and signed by Registered Nurse (RN) #1 documented, While obtaining UA (urinalysis) resident yelling 'ow' and grimacing while moving legs. (Physician #1) notified. New order for bilateral hip x-ray. c. A mobile Radiology Results Report dated 6/25/18 documented, Radiology: 06/25/18 20:56 (8:56 p.m.) . Procedure: Hips bilat (bilaterally) w (with) or w/o (without) pelvis 2 V (views) Interpretation: Reason for Study: .Pain in unspecified hip . FINDINGS: Mildly displaced [MEDICATION NAME] fracture through the right femoral neck. The right femoral head remains appropriately seated within the acetabulum. There is superior migration of the right femoral shaft. Mild left hip [MEDICAL CONDITION] changes. Imaged pelvic ring appears intact without evidence of disruption or cortical step-off. Unremarkable appearance of the sacroiliac joints and pubic symphysis.IMPRESSION: 1. Mildly displaced [MEDICATION NAME] right femoral neck fracture. d. A Nursing Note written by LPN #1, dated 6/26/18 at 4:56 a.m. documented, Mobile fax came through for x-ray of the right hip. Impression: Mildly displaced [MEDICATION NAME] right neck fracture. MD and family will be notified and oncoming nurse will be aware of this report. e. A Nursing Note dated 6/26/18 at 6:55 a.m. and written by Licensed Practical Nurse (LPN) #1 documented, Faxed results to MD and DON (Director of Nursing) is aware about the x-ray and UA with culture in the refrigerator. f. A Nursing Progress Note dated 6/26/18 at 8:22 a.m. and written by RN #1 and documented, Resident sent to (Hospital #1) ER (emergency room ) per (Physician #1) and transferred to (Hospital #2) per family request. g. An Emergency Department Record dated 6/26/18 at 9:01 a.m., written by the Emergency Department Physician for Hospital #1, documented, Physician Documentation . 09:35 (a.m.) presents to ER with complaints of Hip Pain . The patient or guardian reports decreased range of motion, deformity. The complaints affect the right hip. Onset: The symptoms/episode began/occurred yesterday. Modifying factors: the symptoms are aggravated by any movement . Pt (patient) sent in from the NH (nursing home) for right [MEDICAL CONDITION] . Exam: In obvious pain . Musculoskeletal/extremity: Extremities: noted in the right hip: right hip shortened and rotated . Differential Diagnosis: [REDACTED]. Disposition: .Emergent. Disposition Summary: 06/26/18 10:42 (a.m.) Transfer Ordered. Transfer Location: (Hospital #2) Reason: Higher level of care . Problem: new . Preliminary [DIAGNOSES REDACTED]. h. A Hospital #1-based ambulance service run form entitled Prehospital Care Report dated 6/26/18 documented, .At Scene: 06/26/18 11:36 (a.m.) .Narrative: .EMS (Emergency Medical Services) Unit . dispatched to (Hospital #1) ER to transport a patient with a right femur fracture to (Hospital #2).Patient total lift to stretcher . i. A Hospital #2 Discharge Summary dated 7/2/18 documented, History of Present Illness: .was admitted due to a right femoral neck fracture . (Physician #2) with orthopedics was consulted. He underwent right hemiarthroplasty on (MONTH) 27, (YEAR), due to his high-risk for fall and inability to follow commands and severe behavioral disturbance . j. A Hospital #2 Orthopedic Consultation dated 6/26/18 documented, .Orthopedic Consultation. Chief Complaint: Right hip pain. History of Present Illness: The patient is a nursing home patient with severe dementia, who was evaluated at (local hospital) this morning and diagnosed right femoral neck fracture. It is displaced on x-rays here, required hemiarthroplasty, plan on doing this for him tomorrow.the right lower extremity, which is externally rotated and shortened somewhat.Impression: Right femoral neck fracture . k. On 8/30/18 at 4:25 p.m., RN #1 was asked what done on 6/25/18 when an attempt was made to obtain a urine specimen for UA. The RN stated, Immediately called the doctor. That afternoon. The RN was asked if she was still in the facility when the x-ray was performed. The RN stated, Yes because I assisted the tech. The RN was asked what time the resident initially yelled out in pain and stated, That afternoon, I don't know, about 2 (2:00 p.m.). We were trying to get him to lay (sic) down to get the UA. The RN was asked if there were any problems obtaining the urine specimen and stated, A little combative. He became agitated. The RN was asked what was done and stated, Had some help to hold his hands. The RN was asked who assisted and stated, I don't remember. The RN was asked if the resident's legs were held and stated, That would have been me. He brought his leg up, he yelled. I wasn't holding him, but when he moved his leg apart, he yelled. The RN was asked if the resident was still in the building the next day and stated, Yes. The RN was asked when she was initially made aware the resident had a fracture and stated, I found out from the night shift; nurse gave report. l. On 8/30/18 at 5:20 p.m., RN #1 was asked when the resident was transferred to the hospital and how the transfer was accomplished, by wheelchair or gurney. The RN stated, Immediately. I do remember it was by our van . I do remember he was in the wheelchair. The RN was asked how the resident was transferred to the wheelchair and stated, With 2 person assist with a gait belt; me and (Transport Certified Nursing Assistant (CNA)). The RN was asked why, since staff were aware of the [MEDICAL CONDITION], the resident was placed in a wheelchair and stated, You'll have to ask (Director of Nursing (DON)); I normally ask her how to transport. The RN was asked, if a resident has a [MEDICAL CONDITION], should they be transported in a wheelchair? The RN stated, No. m. On 8/31/18 at 11:15 a.m., Hospital #1's Medical Records Clerk was interviewed and confirmed no ambulance was sent to the facility on [DATE] to transport the resident from the facility to Hospital #1. n. On 8/31/18 at 11:32 a.m., the DON was asked, when a resident sustains a [MEDICAL CONDITION], should the resident be transported by van? The DON stated, No. The DON was asked if she had instructed RN #1 to transport the resident by wheelchair in the facility van on 6/26/18. The DON stated, No, I don't recall. o. On 8/31/18 at 12:30 p.m., the Administrator was asked if a resident with a [MEDICAL CONDITION] should be transported by wheelchair in the facility van and stated, No I talked to her (nurse), and he was already up in the wheelchair. The Administrator did not indicate awareness of the gait belt transfer after the fracture was identified, as described by RN #1. p. The immediate jeopardy was removed on 8/31/18 at 7:10 p.m. and the scope/severity reduced to E, when the facility implemented the following Plan of Removal: 1.) On 8/31/18 at 5:00 p.m. Administrator/Designee immediately in-serviced all Nursing and C.N.A. (Certified Nursing Assistant) staff currently working on 3-11 (3:00 p.m. to 11:00 p.m.) shift on protective measures to be put in place when a resident has a suspected fracture or we are awaiting results of an x-ray for a suspected fracture to include if a resident has a suspected fracture that we will not move the affected limb unless necessary for the care of the resident, resident will not be transported by facility van with a fracture or suspected fracture, resident will not be transferred with gait belt if resident has a fracture or suspected fracture, resident will be assessed for shift for additional injury or pain Q (every) shift x (times) 72 hours. The remaining nursing and C.N.A. staff will be in-serviced prior to working their next scheduled shift. Employees on vacation or leave will be in-serviced prior to their return to work. All new hires will be in-serviced prior to working a shift. 2.) On 8/31/18 at 5:00 p.m. Administrator/Designee immediately in-serviced all Nursing and C.N.A. staff currently working on 3-11 shift on supervision and monitoring of residents to prevent accidents and appropriate observation, monitoring and follow up after an accident has occurred to include follow up documentation for monitoring and assessment for pain Q shift x 72 hours post incident. The remaining nursing and C.N.A. staff will be in-serviced prior to working their next scheduled shift. Employees on vacation or leave will be in-serviced prior to their return to work. All new hires will be in-serviced prior to working a shift. 3.) On 8/31/18 at 5:00 p.m. DON and Administrative nursing staff immediately audited residents with I & As (Incident and Accidents) who had a fracture since 6/21/18 to ensure proper measures were put in place to protect the resident from further injury. 4.) DON/Designee will review I & As and nurses notes 5 x weekly x 8 weeks to ensure there are no injuries of unknown origin. 5.) DON/Designee will review I & As and nurses notes 5 x weekly x 8 weeks to ensure proper assessment, monitoring, and follow up after an I & A has occurred. B. Based on observation, record review and interview, the facility failed to ensure resident falls and incidents were investigated to attempt to identify and address causative factors and failed to ensure interventions were consistently implemented to minimize the potential for further falls or injuries for 1 (Resident #10) of 2 (Residents #3 and #10) case mix residents who had a history of [REDACTED].#6 and #10) of 3 (Residents #5, #6 and #10) case mix residents whose incidents / injuries were investigated by the surveyor; and failed to utilize geri-sleeves were consistently applied, as ordered, to prevent further potential skin tears for 1 (Resident #6) of 1 case mix resident who had geri-sleeves ordered. These failed practices had the potential to affect 30 residents who had incidents / accidents, including falls, in the past 3 months, as documented on lists provided by the Director of Nursing (DON) on 9/20/18; and 1 resident who had an order for [REDACTED]. 1. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/3/18 documented the resident scored 9 (8 to 12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance for toileting, had bowel and bladder incontinence and had no documented skin conditions. a. The Care Plan dated 5/2/18 documented, .At previous facility, I had an actual fall with serious injury, fracture my right hip r/t (related to) Poor Balance, Poor communication / comprehension, Psychoactive drug use. Unsteady gait .I have a history of falls . 5/31/18 skin tear in performing therapy I am at risk for skin impairment r/t immobility . Approaches/Tasks Geri-sleeves . b. An Incident Report documented, .Skin Concern Date: 8/20/2018 10:23 a.m.Person Preparing Report: (Registered Nurse (RN) #1) Incident Description Nursing Description: reported to this nurse that resident has skin tear to left little finger knuckle .Unable to verbalize how it happened. Staff asked to be mindful of location of extremities during pt (patient) care .Injury Type Skin Tear Injury Location Left Finger . Notes: Staff asked to be mindful of location of extremities during patient care . There was no documentation the skin tear was evaluated to attempt to determine its cause. c. The Physician order [REDACTED].Steri-strips in place on left pinky finger . Directions every day shift for skin tear . d. A Physician order [REDACTED].Description: Geri Sleeves on while up in WC (wheelchair) Order Summary: Geri Sleeves on while up in WC every shift for skin integrity . e. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. There were initials for each shift on 8/30/18 and 8/31/18. f. The (MONTH) (YEAR) MAR indicated [REDACTED]. Nurses' initials were documented to indicate the Geri-sleeves were in place each shift, as ordered, through 9/5/18. g. On 9/4/18 at 11:40 a.m., the DON was asked if the skin tear on 8/20/18 was investigated for causative factors and stated, No. h. On 9/4/18 at 3:00 p.m., the resident was sitting in a wheelchair in the dining/day room and had a short-sleeved shirt on. There were no geri-sleeves in place to protect the resident's forearms and hands. The DON was asked if the resident had geri-sleeves on. The DON stated, Not right now. At 3:04 p.m., Licensed Practical Nurse (LPN) #6 entered the dining/day room and stated, Took them off at lunch 'cause they were nasty and I forgot to put them back on. i. On 9/4/18 at 3:15 p.m., LPN #6 was asked if the resident was to have geri-sleeves on and stated, She is, but we took them off at lunch, because they were nasty and I forgot to put them back on. The LPN was asked who had removed the geri-sleeves at lunch and stated, I did. LPN #1 was asked if there was an order for [REDACTED]. The LPN stated, Yes I believe so. j. On 9/6/18 at 1:50 p.m., CNA #1 was asked if she had reported a skin tear to the nurse that the resident had and the CNA stated, Yes. The CNA was asked what had happened and the CNA stated, I had just walked up to her at the table and I noticed the blood on the table and the skin tear was already there. The CNA was asked if the resident was to wear geri-sleeves and the CNA stated, I believe so. 2. Resident #10 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/22/18 documented the resident scored 12 (8-12 indicates moderate impairment) on the BIMS, did not walk in room or corridor, required extensive staff assistance with transfer, and had 2 falls with no injury. a. The Care Plan initiated on 3/31/18 and revised on 7/27/18 documented, I had an actual fall with no injury, r/t (related to) Poor Balance, Poor communication/comprehension, Unsteady gait . Approaches/Tasks .7/18 had gripper socks on . For no apparent acute injury, determine and address causative factors of the fall. Date initiated 03/31/2018 . Gripper socks applied . Date Initiated: 04/18/2018 . gripper socks applied . Date Initiated: 07/12/2018 . The resident's care plan documented gripper socks as the planned intervention for 3 separate incidents. b. An Office of Long Term Care Incident and Accident form, Division of Medical Services (DMS) form 7734 dated 3/31/18 at 2:48 p.m. and written by LPN #2 documented, .Incident Location: Resident Room . Incident Description Nursing Description: Heard resident screaming help down the hall, witnessed sitting on floor beside bed, noticed resident did not have on any 'no slip' socks, and resident was soiled. Resident stated that he was trying to get in bed and slipped. Immediate Action Taken Description: .no slip socks were put on resident feet . Notes: gripper socks applied to resident's feet . The incident report indicated that gripper socks were applied to the resident's feet as an intervention for fall prevention. c. An Incident Report dated 4/18/18 at 7:10 p.m., written by LPN #3, documented, .Incident Description . found on the floor beside his bed with his w/c near him, he had on black house shoes but shoes was not on properly he had his heels on the back of his shoes and his w/c was not locked. States he was transferring to bed . Immediate Action Taken Description: gripper socks applied to feet . Notes: .gripper socks applied to feet . The incident report indicated that the resident had on house shoes that were not properly applied and there were no gripper socks. The form listed gripper socks were applied to the resident's feet. d. An Incident Report dated 7/18/18 at 7:50 p.m., written by LPN #3, documented, .Incident Description . summoned to resident room by staff when entering room resident is on his knees beside his bed. He is holding to the side rail for support. He had regular socks on his feet .states my foot slipped when trying to get in bed . Immediate Action Taken Description: gripper socks applied to feet . The incident form indicated the resident had regular socks on and the immediate intervention taken was application of gripper socks. e. On 9/6/18 at 11:40 a.m., the Director of Nursing (DON) was asked if Resident #10 should have had gripper socks on when the resident fell on [DATE] and stated, Yes. The DON was asked if the gripper socks, initially placed on Resident #10 on 3/31/18, should have been in place when the resident fell on [DATE] and 7/18/18. The DON stated, He should have. The DON was asked if there had been any additional recommendations or interventions for Resident #10 for the 7/18/18 fall and stated, No. The DON was asked if interventions should be added when a resident had continued falls and stated, Yes. The DON was asked if incidents should be reviewed for causative factors and stated, Yes. The DON was asked if she was responsible for reviewing Incident Reports and stated, Yes. 3. The facility's written procedure titled, Event Investigation, provided by the DON on 8/30/18 at 7:45 p.m., documented, .Purpose 1. To investigate the cause of all marks, discolorations, skin breaks and injuries which have not been witnessed. 2. To identify any injuries after a resident sustains an accident or incident . INVESTIGATION PR[NAME]EDURE . Interview the resident to determine cause of any conditions identified. 4. Interview any witnesses to determine cause of any conditions identified . 14. Attempt to determine the cause of any conditions identified. 15. Implement preventive measures as appropriate. General Documentation Guidelines 1. Compete Event Investigation Report . a. Document an exact description of incident/accident and the surrounding circumstances . c. The written report will be reviewed by the DON or another facility RN and a follow-up written within 24 hours of the incident/accident . Document all information in the nurse's notes including a full description of the incident/accident, vital signs, and all measures taken .

Complaint # (AR 876) was substantiated (all or in part) with these findings: Based on record review and interview, the facility's Administration and Nursing Administration failed to ensure staff were aware of necessary protective measures and that those protective measures were immediately implemented after discovery of a fracture of unknown origin to prevent potential exacerbation of the injury for 1 (Resident #5), and failed to ensure complete and thorough investigations were consistently conducted after incidents / accidents / injuries, to rule out possible abuse or neglect and identify causative factors for 2 (Residents #5 and #10) of 3 (Residents #5, #6 and #10) case mix residents whose incidents / accidents / injuries were investigated by the surveyor. These failed practices resulted in immediate jeopardy, which caused or could have caused serious harm or further injury to Resident #5, who sustained a fracture of unknown origin and did not receive the necessary precautions to avoid further injury. According to a list provided by the Administrator on 9/6/18, there were no other residents in the facility who had sustained a fracture of unknown origin; the failed practice regarding failure to investigate incidents had the potential to cause more than minimal harm to 30 residents who experienced incidents / accidents in the past 3 months, as documented on lists provided by the Director of Nursing (DON) on 9/20/18. The Administrator was informed of the immediate jeopardy condition on 8/31/18 at 3:40 p.m. The findings are: 1. The Administrator's job description, received from the Administrator on 8/31/18 at 12:45 p.m., documented, .Purpose of Your Job Description. The primary purpose of your job position is to direct the day to day functions of the facility in accordance with current Federal, State, and local standards, guidelines, and regulations that govern the Long Term Care Facility to assure that the highest degree of quality care can be provided to our residents at all times. Delegation of Authority as the Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Major Duties and Responsibilities: Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities. Develop and maintain written policies and procedures that govern the operation of the facility. Develop and maintain written job descriptions and performance evaluations for each staff position. Assist department directors in the development and use of departmental policies and procedures, and establish a rapport in and between departments so that each can see the importance of team work. Interpret the facility's policies and procedures to employee, residents, family members, visitors, government agencies, etc. as necessary. Review the facility's policies and procedures periodically, at least annually, and make changes as necessary to assure continued compliance with current regulations. Assure that all employees, residents, visitors, and the general public follow established policies and procedures . 2. The Director of Nursing Services job description, received from the Administrator on 8/31/18 at 12:45 p.m., documented, The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Services Department in accordance with current Federal, State, and local standards, guidelines, and regulations that govern our facility, as may be directed by the Administrator and Medical Director, to ensure that the highest degree of quality care is maintained at all times. Delegation of Authority as the Director of Nursing Services, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. In the absence of the Medical Director, you are charged with carrying out the resident care policies established by this facility.Major Duties and Responsibilities Plan, develop, organize, implement, evaluate, and direct the Nursing Services Department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long term care facility. Develop, maintain, and periodically update written policies and procedures that govern the day to day functions of the nursing service department. Develop, maintain, and periodically update the Nursing Service Procedure Manual. Develop methods for coordination of nursing services with other resident services to ensure the continuity of the residents' total regimen of care.Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. (et cetera) as necessary .Make written or oral reports/recommendations to the Administrator, as necessary/required concerning the operation of the Nursing Services Department .Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided and that they reflect the resident's response to the care .Ensure that nursing service personnel follow established departmental policies and procedures . 3. On 9/4/18 at 5:30 p.m., the Administrator was asked who was responsible for overseeing investigations of injuries of unknown origin and reporting. The Administrator stated, Me. 4. Resident #5 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/26/18 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, required extensive assistance for transfer, walked with limited assistance, was not steady with balance and only able to stabilize with staff assistance, and had 1 fall with major injury. a. The Care Plan dated 6/18/18 documented, .I have an ADL (activity of daily living) self-care performance deficit r/t (related to) dementia. I have limited physical mobility r/t dementia. I will get up w/o (without) asking for help . Transfers: Resident requires extensive assistance with transfers . I am at risk for falls r/t dementia; poor safety awareness; high fall risk . Goal: I will not sustain serious injury through the review date .Approaches/Tasks Educate the .caregivers about safety reminders and what to do if a fall occurs . b. An Incident Report dated 6/21/18 at 7:15 a.m. documented, .Incident Location: Hallway, Person Preparing Report: LPN (Licensed Practical Nurse) #1 Incident Description Nursing Description: Resident unable to give. This nurse notified that resident in floor in hallway. Resident laying (sic) on left side, laceration to rt (right) brow area with blood. Ambulance called at time. Pressure dressing applied. Resident awake and alert. Pupils (times) 2 equal and round reacts to light. Grips strong. Resident stated pain to rt eye. Transferred to ER (emergency room ) via ambulance. Immediate Action Taken Description: Neuro (neurological) check performed immediately, pressure dressing applied to wound. Sent to ER, daughter, wife, (Physician #1) MD (Medical Doctor), DON (Director of Nursing) all notified.Injuries Observed at Time of Incident Injury Type Abrasion Injury Location 37) Right knee (front) Injury Type Laceration Injury Location 64) Other .Notes: Laceration to rt brow area. 3 sutures in place . Notes: sutures intact to right brow area. No s/sx (signs/symptoms) of infection noted. No delayed injuries noted. Therapy to screen and wing mattress placed on bed . c. An emergency room Physician Documentation Record dated 6/21/18 from Hospital #1 documented, .Arrival Date: 06/21/2018 Time: 07:39 . 08:10 Details of fall: The patient fell from an upright position, while walking . Onset: The symptoms/episode began/occurred just prior to arrival. Associated injuries: The patient sustained injury to the head, laceration, 1.5 cms (centimeters), of the right eye. Associated signs and symptoms: Loss of consciousness: the patient experienced no loss of consciousness.ROS (review of systems) 08:11 .extremity: Negative for acute changes.Musculoskeletal/extremity: Extremities: all appear grossly normal, with no appreciated pain with palpation, no acute changes . d. The Nursing Progress Notes dated 6/21/18 at 11:34 a.m. and written by RN #1 documented, Incident Note Nature/Description of Incident: This nurse notified that resident in floor in hallway. Resident laying (sic) on left side, laceration to rt brow area with blood. Ambulance called at time. Pressure dressing applied. Resident awake and alert. Pupils (times) 2 equal and round reacts to light. Grips strong. Resident stated pain to rt eye. Transferred to ER via ambulance. Description of Injuries: Laceration to rt brow, abrasion rt knees Immediate Actions Taken: Neuro (neurological) check immediately, pressure dressing applied, transferred ER. Medical Profession Notified (Who/When): (Physician #1) Resident Representative Notified (Who/When): Wife, DON, (and) Daughter. e. The Nursing Progress Note dated 6/21/18 at 11:38 a.m., and signed by LPN #3 documented, Note Text: Resident up in his w/c (wheelchair) to the dining room for his meal. Resident continues to strike out at staff and attempts to bite staff. He is grabbing staff hands and arms, scratching staff. Bandage intact above right eye brow. Neuro check in process and is within normal limits . There was no documentation to indicate the resident was in pain while up in the wheelchair. f. The Nursing Progress Note dated 6/22/18 at 2:26 a.m. and signed by LPN #2 documented, Note Text: Resident behavior still hasn't changed . neuros intact denies any pain at this time. incont (incontinent) of b/b (bowel and bladder) prn (as needed) pericare (perineal care). Resident is combative toward staff . There was no documentation to indicate the resident experienced pain with movement or when incontinent care was performed. g. The Nursing Progress Note dated 6/22/18 at 10:53 a.m., and signed by RN #1 documented, Note Text: Resident up in wc (wheelchair) in dining room at this time. No s/s (signs and symptoms) of distress. Incontinent of B/B, 2 (times) assist to bathroom. Peri care done by staff. Will attempt to hit, scratch staff during care. Will answer yes or no questions. Attempts to walk without assistance. Gait weak and unsteady. Dressing to rt brow is CDI (clean, dry and intact) from incident on 6/21/18. Neuro check normal. Denies pain at this time. There was no documentation to indicate the resident exhibited pain with incontinent care nor while he was up in the wheelchair. h. The Nursing Progress Note dated 6/22/18 at 11:38 p.m., and signed by LPN #3 documented, bandage above right eye intact. No c/o (complaint of) pain voiced . i. The Nursing Progress Note dated 6/23/18 at 2:59 a.m., and signed by LPN #4 documented, Note Text: Resident lying in bed awake and alert to person. Bandage above right eye in place and intact. No s/s pain/discomfort noted at this time. Resident remains on q (every) shift neuro checks at this time . There was no documentation to indicate the resident was in pain. j. The Nursing Progress Note dated 6/25/18 at 4:18 p.m., and signed by RN #1 documented, While obtaining UA (urinalysis) resident yelling 'ow' and grimacing while moving legs. (Physician #1) notified. New order for bilateral hip x-ray. This note, dated 4 days after the 6/21/18 fall, was the first reference in the clinical record to the resident experiencing any pain with movement of his legs. k. A mobile Radiology Results Report dated 6/25/18 documented, Radiology: 06/25/18 20:56 (8:56 p.m.) . Procedure: Hips bilat (bilaterally) w (with) or w/o (without) pelvis 2 V (views) Interpretation: Reason for Study: .Pain in unspecified hip . FINDINGS: Mildly displaced [MEDICATION NAME] fracture through the right femoral neck. The right femoral head remains appropriately seated within the acetabulum. There is superior migration of the right femoral shaft. Mild left hip [MEDICAL CONDITION] changes. Imaged pelvic ring appears intact without evidence of disruption or cortical step-off. Unremarkable appearance of the sacroiliac joints and pubic symphysis.IMPRESSION: 1. Mildly displaced [MEDICATION NAME] right femoral neck fracture. l. A Nursing Note dated 6/26/18 at 4:56 a.m. and signed by LPN #1 documented, Mobile fax came through for x ray of the right hip. Impression: Mildly displaced [MEDICATION NAME] right neck fracture. MD and family will be notified and oncoming nurse will be aware of this report. m. A Nursing Note dated 6/26/18 at 6:55 a.m. and signed by LPN #1, documented, Faxed results to MD and DON is aware about the x-ray and UA with culture in the refrigerator. n. A Nursing Progress Note dated 6/26/18 at 8:22 a.m., and signed by RN #1 and documented, Resident sent to (Hospital #1) ER per (Physician #1) and transferred to (Hospital #2) per family request. o. An Emergency Department Record dated 6/26/18 at 9:01 a.m., written by the Emergency Department Physician for Hospital #1, documented, Physician Documentation . 09:35 (a.m.) presents to ER with complaints of Hip Pain . The patient or guardian reports decreased range of motion, deformity. The complaints affect the right hip. Onset: The symptoms/episode began/occurred yesterday. Modifying factors: the symptoms are aggravated by any movement. Unable to obtain . due to baseline dementia. Pt (patient) sent in from the NH (nursing home) for right [MEDICAL CONDITION]. He fell 5 days ago and was seen here in the ER. I was the physician that evaluated him but he did not have any hip deformity or pain. Yesterday the NH noted he had hip pain and ordered an x ray that showed a right [MEDICAL CONDITION] . Exam: In obvious pain . Head/face: Noted is a laceration(s) of the healing right eyebrow laceration with sutures in place.Musculoskeletal/extremity: Extremities: noted in the right hip: right hip shortened and rotated . Differential Diagnosis: [REDACTED]. Disposition: .Emergent. Disposition Summary: 06/26/18 10:42 (a.m.) Transfer Ordered Transfer Location: (Hospital #2) Reason: Higher level of care . Problem: new .Preliminary [DIAGNOSES REDACTED]. p. Hospital #1 Nurses Notes dated 6/26/18 at 9:03 a.m. documented, .Presenting complaint: Nursing home nurse states that patient had a fall on Thursday (6/21/18) and was sent to the ER. Then yesterday while obtaining a urine specimen patient was hollering out in pain when legs were moved. They then obtained an x-ray and found a right [MEDICAL CONDITION]. Report is in nursing home paperwork. Patient has also running fever since Saturday and urine specimen looked really bad .09:03 (a.m.) Transition of care: patient was received from another setting of care (long-term care facility) (facility name). 09:03 Method of Arrival: WC (wheelchair) . Triage Assessment: 09:38 . Pain: Complains of pain in low back area and right hip Pain currently is 8 out of 10 on a pain scale.Patient was seen on Thursday (6/21/18) in ER for fall. Patient was not exhibiting any pain, moaning, or hollering when moving lower extremities on Thursday like he is today . Screening: .Injuries sustained: On Thursday the patient complained of head pain and laceration to forehead. Today he is complaining of hip and back pain . Outcome: 11:36 a.m. Transferred Receiving Facility . XR (x-ray) Pelvis . Procedure: Pelvis 2 views. Indication: Fall, now presenting with decreased range of motion. Findings: There is a fracture through the femoral neck with foreshortened appearance. There is no dislocation of the femoral head. The left hip is intact . Impression: Right femoral neck fracture . q. An ambulance service run form titled, Prehospital Care Report and dated 6/26/18 documented, .At Scene: 06/26/18 11:36 (a.m.) .Narrative: .EMS (Emergency Medical Services) Unit . dispatched to (Hospital #1) ER to transport a patient with a right femur fracture to (Hospital #2) .Patient total lift to stretcher . r. A Hospital #2 Discharge Summary dated 7/2/18 documented, History of Present Illness: .was admitted due to a right femoral neck fracture .[DIAGNOSES REDACTED]. Femoral neck fracture. 2. Systemic [MEDICAL CONDITION] response syndrome . He was transferred from an outlying ER due to a right femoral neck fracture. (Physician #2) with orthopedics was consulted. He underwent right hemiarthroplasty on (MONTH) 27, (YEAR), due to his high-risk for fall and inability to follow commands and severe behavioral disturbance . s. An Orthopedic Consultation dated 6/26/18 documented, .Chief Complaint: Right hip pain. History of Present Illness: The patient is a nursing home patient with severe dementia, who was evaluated at (local hospital) this morning and diagnosed right femoral neck fracture. It is displaced on x-rays here, required hemiarthroplasty, plan on doing this for him tomorrow .the right lower extremity, which is externally rotated and shortened somewhat .Impression: Right femoral neck fracture . t. On 8/30/18 at 5:20 p.m., RN #1 was asked when the resident was transferred to the hospital, and how the resident was transported, by gurney or via wheelchair, after the fracture was identified on 6/26/18 and stated, Immediately. I do remember it was by our van. I don't remember a gurney. I do remember a wheelchair . I do remember he was in the wheelchair. The RN was asked how the resident was transferred to the wheelchair that day and stated, With 2-person assist with a gait belt; me and (Transport Certified Nursing Assistant (CNA)). The RN was asked why, if staff were aware of the fracture, the resident was manually transferred from bed and placed in a wheelchair. The RN stated, You'll have to ask (Director of Nursing (DON)); I normally ask her how to transport. The RN was asked, if a resident has a [MEDICAL CONDITION], should they be transported in a wheelchair? The RN stated, No. u. On 8/30/18 at 5:40 p.m., the DON was asked what was done when the fracture was identified and stated, We talked with (Administrator) about it, and we all associated it with the fall he had. The DON was asked if the fracture was investigated and stated, Yes. Talked to staff. The DON was asked if this had been documented and to whom she had spoken. The DON stated, Verbally. I don't remember who. The DON was asked what should be done when a fracture was identified and whether an Incident and Accident Report was done. The DON stated, We associated it was with the other fall. The DON was asked how it was associated that the fracture was related to the fall on 6/21/18. The DON stated, We just verbally asked everyone if he had (another) fall, and everyone said 'no'. v. On 8/30/18 at 5:55 p.m., the Administrator was asked if an incident report was completed when the resident's fracture was discovered and stated, I don't think we did one. She (nurse) moved his legs and he yelled. We assumed it was from when he fell on the 21st (6/21/18). The Administrator was asked if the fracture was considered an injury of unknown origin and stated, He had fallen and it was on that hip. I remember asking him when he fell (on 6/21/18) did he hurt. She (nurse) said he yelled out when she got the UA (on 6/25/18). w. On 8/31/18 at 11:32 a.m., the DON was asked, when a resident sustains a [MEDICAL CONDITION], should the resident be transported by van? The DON stated, No. The DON was asked if RN #1 was instructed to transport the resident by wheelchair in the facility van after the fracture was identified. The DON stated, No, I don't recall. The DON was asked if an investigation was completed to try to determine the cause of the fracture and stated, I talked to (Administrator) about it, and we associated it with the fall he had the week before. I asked around, like verbally. The DON was asked if the interviews were documented and stated, No. The DON was asked if she recalled which staff were interviewed regarding the fracture and stated, No I don't. x. On 8/31/18 at 12:30 p.m., the Administrator was asked when there was an injury of unknown origin what was to be done. The Administrator stated, An investigation. The Administrator was asked if there had been an investigation when it was found that the resident had sustained a fracture and stated, No. The Administrator was asked if there should have been an investigation and stated, Yes. The Administrator was asked who was responsible for initiating an investigation when there is a fracture and the origin is unknown. The Administrator stated the Administrator, DON or Assistant DON (ADON) and the nurse who discovered, then interview other staff, .then CNAs and residents, sometimes. The Administrator was asked who was responsible for overseeing the investigation. The Administrator stated, The Administrator, DON and ADON. The Administrator was asked if a resident should be transported by wheelchair in the van when there was a [MEDICAL CONDITION] sustained and the Administrator stated, No I talked to her (nurse) and he was already up in wheelchair. 5. Resident #10 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/22/18 documented the resident scored 12 (8-12 indicates moderate impairment) on the BIMS, did not walk in room or corridor, required extensive staff assistance with transfer, and had 2 falls with no injury. a. The Care Plan initiated on 3/31/18 and revised on 7/27/18 documented, I had an actual fall with no injury, r/t (related to) Poor Balance, Poor communication/comprehension, Unsteady gait . Approaches/Tasks .7/18 had gripper socks on . For no apparent acute injury, determine and address causative factors of the fall. Date initiated 03/31/2018 . Gripper socks applied . Date Initiated: 04/18/2018 . gripper socks applied . Date Initiated: 07/12/2018 . The resident's care plan documented gripper socks as the planned intervention for 3 separate incidents. b. An Office of Long Term Care Incident and Accident form, Division of Medical Services (DMS) form 7734 dated 3/31/18 at 2:48 p.m. and written by LPN #2 documented, .Incident Location: Resident Room . Incident Description Nursing Description: Heard resident screaming help down the hall, witnessed sitting on floor beside bed, noticed resident did not have on any 'no slip' socks, and resident was soiled. Resident stated that he was trying to get in bed and slipped. Immediate Action Taken Description: .no slip socks were put on resident feet . Notes: gripper socks applied to resident's feet . The incident report indicated that gripper socks were applied to the resident's feet as an intervention for fall prevention. c. An Incident Report dated 4/18/18 at 7:10 p.m., written by LPN #3, documented, .Incident Description . found on the floor beside his bed with his w/c near him, he had on black house shoes but shoes was not on properly he had his heels on the back of his shoes and his w/c was not locked. States he was transferring to bed . Immediate Action Taken Description: gripper socks applied to feet . Notes: .gripper socks applied to feet . The incident report indicated that the resident had on house shoes that were not properly applied and there were no gripper socks. The form listed gripper socks were applied to the resident's feet. d. An Incident Report dated 7/18/18 at 7:50 p.m., written by LPN #3, documented, .Incident Description . summoned to resident room by staff when entering room resident is on his knees beside his bed. He is holding to the side rail for support. He had regular socks on his feet .states my foot slipped when trying to get in bed . Immediate Action Taken Description: gripper socks applied to feet . The incident form indicated the resident had regular socks on and the immediate intervention taken was application of gripper socks. e. On 9/6/18 at 11:40 a.m., the Director of Nursing (DON) was asked if Resident #10 should have had gripper socks on when the resident fell on [DATE] and stated, Yes. The DON was asked if the gripper socks, initially placed on Resident #10 on 3/31/18, should have been in place when the resident fell on [DATE] and 7/18/18. The DON stated, He should have. The DON was asked if there had been any additional recommendations or interventions for Resident #10 for the 7/18/18 fall and stated, No. The DON was asked if interventions should be added when a resident had continued falls and stated, Yes. The DON was asked if incidents should be reviewed for causative factors and stated, Yes. The DON was asked if she was responsible for reviewing Incident Reports and stated, Yes. 6. The facility's written procedure titled, Event Investigation, provided by the DON on 8/30/18 at 7:45 p.m., documented, .Purpose 1. To investigate the cause of all marks, discolorations, skin breaks and injuries which have not been witnessed. 2. To identify any injuries after a resident sustains an accident or incident . INVESTIGATION PR[NAME]EDURE . Interview the resident to determine cause of any conditions identified. 4. Interview any witnesses to determine cause of any conditions identified . 14. Attempt to determine the cause of any conditions identified. 15. Implement preventive measures as appropriate. General Documentation Guidelines 1. Compete Event Investigation Report . a. Document an exact description of incident/accident and the surrounding circumstances . c. The written report will be reviewed by the DON or another facility RN and a follow-up written within 24 hours of the incident/accident . Document all information in the nurse's notes including a full description of the incident/accident, vital signs, and all measures taken . 7. The immediate jeopardy to Resident #5 was removed on 8/31/18 at 7:10 p.m. and the scope/severity reduced to E, when the facility implemented the following Plan of Removal: 1.) On 8/31/18 at 5:00 p.m. Administrator/Designee immediately in-serviced all Nursing and C.N.A. (Certified Nursing Assistant) staff currently working on 3-11 (3:00 p.m. to 11:00 p.m.) shift on protective measures to be put in place when a resident has a suspected fracture or we are awaiting results of an x-ray for a suspected fracture to include if a resident has a suspected fracture that we will not move the affected limb unless necessary for the care of the resident, resident will not be transported by facility van with a fracture or suspected fracture, resident will not be transferred with gait belt if resident has a fracture or suspected fracture, resident will be assessed for shift for additional injury or pain Q (every) shift x (times) 72 hours. The remaining nursing and C.N.A. staff will be in-serviced prior to working their next scheduled shift. Employees on vacation or leave will be in-serviced prior to their return to work. All new hires will be in-serviced prior to working a shift. 2.) On 8/31/18 at 5:00 p.m. Administrator/Designee immediately in-serviced all Nursing and C.N.A. staff currently working on 3-11 shift on supervision and monitoring of residents to prevent accidents and appropriate observation, monitoring and follow up after an accident has occurred to include follow up documentation for monitoring and assessment for pain Q shift x 72 hours post incident. The remaining nursing and C.N.A. staff will be in-serviced prior to working their next scheduled shift. Employees on vacation or leave will be in-serviced prior to their return to work. All new hires will be in-serviced prior to working a shift. 3.) On 8/31/18 at 5:00 p.m. DON and Administrative nursing staff immediately audited residents with I & As (Incidents and Accidents) who had a fracture since 6/21/18 to ensure proper measures were put in place to protect the resident from further injury. 4.) DON/Designee will review I & As and nurses notes 5 x weekly x 8 weeks to ensure there are no injuries of unknown origin. 5.) DON/Designee will review I & As and nurses notes 5 x weekly x 8 weeks to ensure proper assessment, monitoring, and follow up after an I & A has occurred.

Complaint # (AR 476) substantiated, all or in part, in these findings: Based on record review and interview, the facility failed to ensure immediate consultation with physician and Adult Protective Services regarding frequent agitated, aggressive, and/or intrusive behaviors that increased risk of being injured or injuring others due to his behaviors for 1 (Resident #7) of 4 (Resident #7, #12, #13 and #14 ) case mix residents who were was admitted to the Certified Alzheimer Care Unit in the past 6 months. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious injury, harm or possible death for Resident #8 who sustained an orbital and maxillary fracture and had the potential to affect 19 residents who resided on the Certified Alzheimer's Unit as of 7/21/15. The Immediate Jeopardy was removed by the facility on 7/21/15 at 7:00 a.m. and the scope/severity reduced to H when the facility identified the issue and initiated corrective action however the facility did not correct the underlying deficient practice at the time of the survey. The facility was informed of the Immediate Jeopardy removed on 7/24/15 at 5:15 p.m. The findings are: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The History and Physical Report from the geri-psych unit dated 3/13/15 documented, .admitted : 03/13/2015 .He apparently was in a psych unit in Little Rock and he was aggressive and/or taking food from other people's trays? Concern was expressed that he might be harmed on an acute unit and was sent to Geri unit. At this facility, he has been noted to lay on other people beds and take their clothing. Any other history is absolutely unavailable to this physician at this time . The Discharge Summary dated 4/6/15 documented, Principle Diagnosis: [REDACTED]. Hospital Course: Patient was admitted to our unit and continued to evidence confusion, intrusiveness, and ease of agitation as well as a tendency to not take his medication despite prompting . Despite increasing doses of [MEDICATION NAME] the patient remained, he is easily agitated and intrusive and difficult to redirect and eventually began to have tolerability issues with the [MEDICATION NAME] in terms of side effects . The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 7/13/15 documented the resident scored 3 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS); had a mood score of 0; had wandering behaviors that occurred daily; required limited assistance of 1 person for bed mobility, transfers, ambulation in room or corridor and personal hygiene; was occasionally incontinent of bowel and bladder; had no pain; was 75 inches (6 foot 2 1/2 inches) in height; and received Antipsychotic, Antidepressant and Antianxiety medication 7 of the past 7 days. The responsible party was APS (Adult Protective Service) worker #1. a. Departmental Notes dated 4/7/15 at 1:12 a.m. documented, On 4/6/15 10 p.m. Resident admitted to (facility name) secured Alzheimer's Unit LTC (long term care) bed . He is ambulatory independently in corridors with slow and steady gait. b. Departmental Notes from 4/7/15-4/30/15 (23 days) documented the resident had 11 episodes of increased agitation, aggression, and/or intrusiveness that required PRN (as needed) medication. The Departmental Notes did not document consultation with physician and APS regarding resident increased risk of being injured or injuring others due to his behaviors: 1) Departmental Notes dated 4/7/15 at 1:47 p.m. documented, Resident pacing and going to exit doors. Resident entering other residents' rooms and disturbing them and their visitors. Resident redirected and diverted with activities and food and drinks. Diversions [MEDICATION NAME] only a few minutes . pacing and exit seeking. [MEDICATION NAME] 5 mg (milligrams) IM (intramuscular) given. 2) Departmental Notes dated 4/9/15 at 2:17 a.m. documented, On 4/8/15 at 3:00 p.m.Resident is becoming verbally aggressive with staff and other residents. He states, 'If you say anything else I will hold you in contempt of court and you will be put in jail for no less than 9 days.' He points at a female resident states 'Sit down and don't say a word or I will put you in jail.' Resident medicated with [MEDICATION NAME] 5 mg IM. At 7:15 p.m. awake wandering around in dining room takes a soda from a female resident she asks him to put it down and he uses profanity. 3) Departmental Notes dated 4/10/15 at 12:26 a.m. documented, On 4/9/15 . at 6:00 p.m. resident is up wandering around the dining room and telling female resident to sit down and do not say anything. Attempts to redirect resident to his seat and he states ' Stop talking ' staff let resident wander with close supervision until he seated himself at table . 6:30 p.m. [MEDICATION NAME] 5 mg IM right deltoid. Departmental Notes dated 4/10/15 at 3:06 p.m. documented, .New orders received from (Physician) derease (decrease) Trazadone to 150 mg at hs (hour of sleep), dc (discontinue) [MEDICATION NAME], give [MEDICATION NAME] 25 mg. q (every) a.m. and 50 mg at hs. APS (Adult Protective Services) notified . 4) Departmental Notes dated 4/11/15 at 1:01 a.m. documented, On 4/10/15 . at 4:45 p.m. Resident went to stand over female resident seated in her w/c (wheelchair) and asks her 'Why did you get my chair' resident daughter remains present and states, 'No that her w/c.' resident turns to resident daughter and states, You are a lie. Staff redirects across the hall for privacy [MEDICATION NAME] 5 mg IM for increased agitation/aggressiveness. 7:30 p.m. Resident is in a female room and refuses to leave room. He was redirected by staff after 15 minutes spent with redirection . 5) Departmental Notes dated 4/13/15 at 10:28 p.m. at 7:30 p.m. documented, .resident pushed the west exit door open to the courtyard causing the alarm to sound. Resident redirected . [MEDICATION NAME] 5 mg IM. 6) Departmental Notes dated 4/19/15 at 10:44 p.m. documented, Resident up pacing hallway . verbally abusive to residents and staff. Administered [MEDICATION NAME] 2 mg IM in left hip at 2130 (9:30 p.m.) . 7) Departmental Notes dated 4/20/15 at 12:39 p.m. documented, Resident observed pacing in hallways and other resident's rooms picking up various objects and putting them in his pocket. Resident got hold of housekeepers cart and started pushing it down the hallway staff x (times) 3 attempted to get cart away from him and he became combative, hitting at staff and saying we had better get away from him. Eventually walked away from cart continue to pick up and pocket other resident belongings becoming more agitated and verbally and physically aggressive. 1200 [MEDICATION NAME] 1 mg IM given x 3 staff with much difficulty. 8) Departmental Notes dated 4/23/15 at 4:14 p.m. documented, 4/22/15 at 8:30 p.m. Resident turned to water on in the sink in his bathroom placed a trash can in the sink causing the water to fill the sink overflowing the bathroom and room (number) bedroom which then flowed out into the corridor. He is wandering into other residents room removing their walkers, trash cans, and other items . he then was served alternate meal . He refused to eat became verbally aggressive with staff. He was medicated with [MEDICATION NAME] 5 mg IM right deltoid. Departmental Notes dated 4/23/15 at 2:54 p.m. documented, Resident followed staff out of exit door this morning, agitated and slightly combative when staff attempted to redirect him back . (Physician) notified, new order received for [MEDICATION NAME] 1 mg po (by mouth) q (every) 4 hrs (hours) prn agitation . Departmental Notes at 3:34 p.m. documented the physician would be at facility on 4/30/15 and make medication adjustments. 9) Departmental Notes dated 4/26/15 at 1:39 p.m. at 11:00 a.m. documented, Resident became agitated and started to ambulate in hallway by eye wash station. Hit window with his right hand knocking out a pane of plexi-glass. No injury. Resident medicated with [MEDICATION NAME] 1 mg IM r (right) arm for agitation. 10) Departmental Notes dated 4/29/15 at 12:37 p.m. documented, 12:34 p.m. R (Resident) pacing the hallway back and forth. Agitstion (agitation) noted to be increased at this time. R refuses to go into dining room and eat, stating 'there's bad people in there.' [MEDICATION NAME] 1 mg given po at this time . 11) Departmental Notes dated 4/30/15 at 2:18 a.m. documented, 1:00 a.m. Resident up pacing back and forth in hallways not easily redirected increase agitation when redirecting resident. [MEDICATION NAME] ([MEDICATION NAME]) 2 mg/ml [MEDICATION NAME] inject 0.5 ml (1 mg) IM given . c. Departmental Notes and the May 2015 Medication Administration Record [REDACTED]. The Departmental Notes and physician progress notes [REDACTED]. 1) Departmental Notes dated 5/2/15 at 10:59 p.m. documented, At 10:00 a.m. resident pacing back and forth in hallway, very anger, balling fist and trying to hit staff and residents. [MEDICATION NAME] 2 mg administered. At 1700 (5:00 p.m.) Resident pacing back and forth in hallway, very anger (angry) balling fist and trying to hit staff and residents. [MEDICATION NAME] 2 mg administer(ed) . 2) Departmental Notes dated 5/2/15 at 10:59 p.m. documented, .at 1700 (5:00 p.m.) resident pacing back and forth in hallway, very anger (angry), balling fist and trying to hit staff and residents. [MEDICATION NAME] 2 mg administer(ed) . 3) The back of the May 2015 MAR indicated [REDACTED].o. for increased agitation on 5/4/15 at 6:15 p.m. 4) The back of the May 2015 MAR indicated [REDACTED].o. for increased agitation on 5/5/15 at 1030. 5) Departmental Notes dated 5/6/15 at 3:54 a.m. documented, 2:45 p.m. Resident up wandering hallways not easily redirected easily agitated. [MEDICATION NAME] 1 mg 1 tab po given . 6) Departmental Notes dated 5/7/15 at 6:28 a.m. documented, 5:30 a.m. Resident is up attempting to wander throughout halls. Not easily redirected . Increased agitation [MEDICATION NAME] 1 mg po given. 7) Departmental Notes dated 5/7/15 at 1:02 p.m. documented, 0915 (9:15 a.m.) R is noted to have extreme agitation at this time. Housekeeper state he will not leave things on her cart alone. R (Resident) noted trying to move the doghouse on the unit as another R was leaning on it as he does daily. R noncompliant with redirection. [MEDICATION NAME] 2 mg/ml [MEDICATION NAME] inject 0.5 ml (1 mg) IM given at this time for agitation . Departmental Notes dated 5/7/15 at 1:16 p.m., 1100 (11:00 a.m.)-R is noted across the hall from his room in another R room without pants or brief on. R in other resident's bathroom running the water to the point of almost overflowing. R taken back to his room . 8) Departmental Notes dated 5/8/15 at 12:08 a.m. documented, Resident up wandering up and down hallways. Inattention fidgeting with door knobs trying to open doors. Moving the dog house trying to pick it up. Not easily redirected increase in agitation [MEDICATION NAME] 1 mg 1 tablet given po . 9) Departmental Notes dated 5/8/15 at 6:02 a.m. documented, Resident wandering in dining room getting into drawers and anything that is on the counter. Resident will not put on clothing and not easily redirected to his room. Increased agitation when trying to dress him or redirect. [MEDICATION NAME] 1 mg 1 tab po given 10) Departmental Notes Addendum dated 5/8/15 at 11:59 a.m. documented, Resident in and out of resident's rooms going in bathrooms and turning water on not easily redirected. Resident noted to be incontinent of bowel, when staff approached him for toileting and peri-care he's very resistive and became slightly combative. Male staff arrived and peri-care given per 3 staff. 12:30(p.m.) [MEDICATION NAME] 1 mg po given. 11) The back of the May 2015 MAR indicated [REDACTED].o. for increased agitation at 7:00 p.m. on 5/8/15. 12) Departmental Notes dated 5/8/15 at 4:44 a.m. documented, 11:30 (p.m.) Resident up wandering halls with diaper on head and no pants. Not easily redirected increase in agitation when trying to get resident go back to room. [MEDICATION NAME] 1 mg 1 tablet given po . 13) Departmental Notes dated 5/9/15 at 6:05 a.m. documented, Residnet (resident) taking clothes off and on in room. Resident as (has) clothing all over room. Has diaper on head and shirt on wrong way. Resident urinating outside door. Not easily redirected. [MEDICATION NAME] 1 mg po given . 14) The back of the May 2015 MAR indicated [REDACTED].o. for increased agitation at 7:00 p.m. on 5/12/15. 15) Departmental Notes dated 5/13/15 documented, 7 p.m. Resident is up wandering from table to table in the dining room, turning on the water at the sink, becoming loud with staff and other residents. He is redirected with fluids and food but continues with behavior escalation. He is medicated with [MEDICATION NAME] 1 mg 2 po . 16) The back of the May 2015 MAR indicated [REDACTED].o. for increased agitation on 5/16/15 at 1940 (7:40 p. m.). 17) The back of the May 2015 MAR indicated [REDACTED].o. for increased agitation on 5/17/15 at 1610 (4:10 p.m.). 18) Departmental Notes dated 5/21/15 at 4:04 p.m. documented, 1000 (10 a.m.) Resident observed standing at window in kitchen looking out at parking lot, he said he see his car out there and needs to go get it, he attempted to open window, multiple attempts per staff to divert him away from window before he complied, then he became severely agitated with staff and verbally aggressive. At 10:30 a.m. attempted to give [MEDICATION NAME] 0.5 ml 1 mg IM per assist x 3 staff, resident became extremely agitated and resistive and unable to give complete dose . Lorezpam 1 mg po given and taken without incident . 19) Departmental Notes dated 5/21/15 at 11:42 p.m. documented, .7:00 p.m. He is medicated with [MEDICATION NAME] 1 mg 1 po for increased agitation when staff attempts to assist with changing of his clothes. 20) Departmental Notes dated 5/22/15 at 6:43 a.m. documented, 1:10 a.m. gave bruse (?) 0.5mg im (IM) for being vety (very) aggitated (agitated) and trying to take things in other resident froom (room). The May 2015 Medication Administration Record [REDACTED]. 21) Departmental Notes dated 5/22/15 at 11:18 a.m. documented, 1045 Resident observed at window in dining room pulling up on window and trying to open it, not easily diverted. Resident left dining room and began pacing in hallways and pounding on door and window of Nursing Station. Lorezepan 1 mg po given . 22) Departmental Notes dated 5/25/15 at 1:46 p.m. documented, Since out of bed this morning resident has been pacing, going in other residents rooms and getting their belongings, he became agitated with staff when redirected. Lorezepam 1 mg po given at 11:30 a.m 23) Departmental Notes dated 5/25/15 at 11:35 p.m. documented, 6:40 p.m. Resident up and pacing in the corridors. He has behavior of wandering in other residents rooms. Resident in (room [ROOM NUMBER]) states he doesn't want this resident (Resident #7) back in his room. ADON (Assistant Director of Nurses) was notified of the resident in (room [ROOM NUMBER]) concerns of this resident coming into his room. At 7:00 p.m. Resident has wandered into room [ROOM NUMBER] when redirecting him he became agitated states, 'Just leave me alone' , staff gave resident sandwich and sweet tea and medicated him with [MEDICATION NAME] 1 mg po. Staff remains in room [ROOM NUMBER] with resident (#7) until he agrees to go to his room . Departmental Notes dated 5/27/15 at 3:44 p.m. documented, Resident pacing hallways and going into other residents rooms pilfering in closets and drawers. Attempts to redirect with activities/food/fluids. Resident becomes increasingly agitated towards staff. Call placed to (Physician) with new orders received to increase [MEDICATION NAME] to 50 mg in am and 100 mg hs. (APS) notified of new orders . Departmental Notes dated 5/28/15 at 4:34 p.m. documented, (Physician) here to examine resident with no new orders received. physician progress notes [REDACTED].He was transferred to psych facility for APS related issue. He was aggressively taking food from other patient's trays. Because of his aggressive behavior, it was felt that there might be some issues with him being placed in acute care unit, so he was admitted to the Geriatric Unit at this facility. It had been reported that he was found on occasion on other peoples' beds removing their clothes. Beyond that, I can't get much else .Plan: He seems to have done better with the dose reduction on the medications he came in here taking. At this point we'll sit tight and see how he responds with the switch from [MEDICATION NAME] to [MEDICATION NAME] bid (twice daily) . 24) Departmental Notes dated 5/31/15 at 4:10 p.m. documented, At 4:15 p.m. administered [MEDICATION NAME] 2 mg IM right hip for agiation (agitation). d. Departmental Notes and the June 2015 Medication Administration Record [REDACTED]. The Departmental Notes did not document consultation with physician and APS regarding resident increased risk of being injured or injuring others due to his behaviors: 1) Departmental Notes dated 6/1/15 4:10 p.m. documented, At 1430 (2:30 p.m.) Resident went in eyewash room, had BM (bowel movement) smeared it on cabinets and is clothing. He refused to change his clothes or allow staff to assist him, he became verbally and physically threatening. [MEDICATION NAME] 1 mg IM given. 2) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/5/15 at 9:30 a.m. 3) The back of the June 2015 MAR indicated [REDACTED]. 4) The back of the June 2015 MAR indicated [REDACTED]. 5) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/16/15 at 4:30 p.m. 6) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/17/15 at 10:45 a.m. 7) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/19/15 at 4:30 p.m. 8) The back of the June 2015 MAR indicated [REDACTED]. 9) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/23/15 at 10:45 a.m. 10) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/23/15 at 3:30 p.m. 11) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/26/15 at 9:30 a.m. 12) Departmental Notes dated 6/26/15 11:52 p.m. documented, 4:20 p.m. Resident was walking pass staff he caught her left arm holding tightly around her left wrist, verbal cueing from staff to resident to released staff arm then redirected to dining room for food and fluid. Resident continues to be verbal aggressive to staff and other residents. He is medicated with [MEDICATION NAME] 1 mg po. 13) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/27/15 at 11:40 a.m. e. Departmental Notes and the July 2015 Medication Administration Record [REDACTED]. The Departmental Notes did not document consultation with physician and APS regarding resident increased risk of being injured or injuring others due to his behaviors: 1) The back of the July 2015 MAR indicated [REDACTED].o. for increased agitation on 7/01/15 at 3:00 a.m. 2) Departmental Notes dated 7/2/15 10:32 a.m. documented, 10:30 a.m. [MEDICATION NAME] 1 mg po given, resident observed over past hour pacing in hallways, going in male residents room and bothering them. Resident talking non-stop in manic like mode with speech becoming threatening towards some staff. All attempts to divert his attention with activities snacks, 1-1 have been futile . 3) The back of the July 2015 MAR indicated [REDACTED].o. for increased agitation on 7/4/15 at 9:15 a.m. 4) The back of the July 2015 MAR indicated [REDACTED].o. for increased agitation on 7/5/15 at 9:00 a.m. 5) The back of the July 2015 MAR indicated [REDACTED].o. for increased agitation on 7/8/15 at 11:30 a.m. 6) Departmental Notes dated 7/16/15 at 3:19 p.m. documented, 10:45 a.m. Resident woke up this morning in agitated mood, pacing with angry of tone of voice when staff cues him for redirections and to dining room for breakfast. Resident made attempt to hit staff but did not make contact. [MEDICATION NAME] 1 mg po given . f. Departmental Notes dated 7/21/15 at 7:30 a.m. documented, 6:30 a.m. Resident came to Nurse at Nurse's station stated, ' Someone attacked me. ' this nurse followed resident to room and found (Resident #8) sitting on bed with blood coming from nose and hematoma with quarter sized swelling to right eye. This (Resident #8) could not state what happened. Resident (Resident #7) stated, ' She attacked me. ' I asked did resident hit her, he (Resident #7) stated, ' I kicked her in the face. ' When asked Resident did this resident (Resident #8) hit him he stated, No. This Nurse separated the resident into Nurses Station. Resident (Resident #7) denies any pain 0 on pain scale 1-10. Full ROM (range of motion) in UE (upper extremities) and LE (lower extremities) No noted blood on resident. Resident was given [MEDICATION NAME] 2 mg/ml 0.5 ml (IM) given to right gluteus medius . Called on call MD . notified of incident . 6:55 a.m. Attempted to notify (APS worker #1) and only answering machine. A Continuous Monitoring 1:1 form dated 7/21/15 documented the facility began continuous 1 on 1 monitoring of resident at 6:30 a.m. which continued until discharge. Resident #8, a [AGE] year old female, had [DIAGNOSES REDACTED]. Departmental Notes date 7/21/15 at 11:24 a.m. documented, Discharge dx (diagnosis) from ER facial fracture. Right orbital and right maxillary fracture . g. Departmental Notes dated 7/23/15 at 3:14 p.m. and signed Alzheimer ' s Care Unit Director (ACUD) documented, At approximately 1:30 p.m. this Nurse took over the 1:1 continuous monitoring to relieve CNA for lunch. (Resident #7) was ambulating up and down hallway. Resident went into the room of two female residents and I had difficulty redirecting him to leave the room. He was exhibiting sternness and reverting to cop lingo when speaking to me. I attempted to hold open the door he was trying to shut and he grabbed my wrist stating. ' I will murder you and they will find you hanging in the trees. ' Once redirected and back into hallway, resident became increasingly agitated and inconsolable. He opened the door to another resident ' s room, entered and I was unable to redirect him out of the room. (Resident #7) reached down to grab a shoe belonging to the resident of the room he entered and the two resident became verbally aggressive towards one another and I had to call for help to redirect (Resident #7). The (Name) ADON and (Name) DON entered the room. The (DON) was able to get (Resident #7) attention and walk him out the room. (Resident #7) became increasingly agitated, would not take the oral [MEDICATION NAME] 1 mg that the LPN was offering. (Resident #7) became increasingly verbally threatening to staff and several staff members stated they were scared of him at this point. He was not able to be redirected and I sought guidance from the DON and ADON. I was told to call ambulance and send him to ER. The ER was contacted and the ambulance was dispatched to the facility. It took several staff members to get (Resident #7) to calm down and get onto the stretcher. (Resident #7) was given [MEDICATION NAME] 1 mg IM in right deltoid muscle. Phone (APS Worker #1) and left message. ER call and stated they were sending (Resident#7) back to the facility. I spoke with (APS Worker #1) and will seek placement at geri-psych. facility with her approval of facility Departmental Notes dated 7/23/15 documented the resident was transferred out of facility at 7:00 p.m. h. On 7/24/15 licensed nurses were interviewed: At 9:40 a.m., Licensed Practical Nurse (LPN) #5 was asked if she worked on the Certified Alzheimer Unit. The LPN stated, Yes for 3 1/2 years. The LPN was asked what was Resident #7 behaviors. The LPN stated, He would wander in and out of other residents' rooms, he had trouble finding the bathroom. He had behaviors, but I was able to control him better than other people. He got agitated, he would pace, pilfer and pick up things. The LPN was asked if Resident #7 ' s behaviors got to a point that he had to have medications. The LPN stated, Yes, there were periods that he would have to be medicated. Then all of a sudden his behaviors escalated, they had been random. The LPN was asked if she had talked to anyone. The LPN stated the CNAs reported to her his behaviors. The LPN was asked if she had reported to anyone else regarding the increased episodes of the resident ' s behaviors. The LPN stated, Yes, I spoke with then Alzheimer Care Unit Director. The LPN was asked what was the criteria for giving residents the PRN (as needed) medications. The LPN stated, We try redirection, activities, food, 1-to-1 with him before we give the medications. The LPN was asked, Did you call the physician when the resident received PRN medication for several days and the resident's behaviors of agitation had increased and was the responsible party notified. The LPN stated, No. At 10:55 a.m., LPN #4 was asked if she worked on the Certified Alzheimer Unit. The LPN stated for 1 year. The LPN was asked what was Resident #7's behaviors. The LPN stated, At times he can become verbally abusive and you have to redirect him. The LPN was asked what kind of behaviors did he exhibit. The LPN stated, Verbal threats that he was going to do something to you. Sometimes he would calm down and sometimes he required medication to calm him down. The LPN was asked what kind of threats did the resident make, did the resident threaten to hit. The LPN was shown documentation that she documented on 5/2/15. The LPN stated, Yes he did ball up his fist and threaten to hit staff and residents. The LPN was asked if she had reported this incident to anyone. The LPN stated, I can't remember. The LPN was asked if she had called the Physician or the responsible party regarding the increased behaviors. The LPN stated, I can't remember. The LPN was asked, Do you feel that the resident ' s aggressive behaviors should have been reported? The LPN stated, I probably called the Supervisor on call. The LPN was asked where this was documented. The LPN stated, It's not documented. The LPN was asked if the other residents were at risk. The LPN stated, Not at that time, we redirected him and gave him medication. The LPN was asked should a resident be admitted to the Certified Alzheimer Unit with a Psychiatric Diagnosis. The LPN stated, No. The LPN was asked why. The LPN stated, No, that would be a potential danger. At 1:35 p.m., LPN #2 was asked if she worked on the Certified Alzheimer Unit. The LPN stated, Yes on the 11-7 shift. The LPN was asked if there were any issues related to behaviors or aggressive residents on the Alzheimer Unit. The LPN stated, Yes with (Resident #7) that was the only issue. He was doing fine, then he had periods of agitation and not easily redirected. The LPN was asked what the resident's behaviors were. The LPN stated, He knocked out a window, no major problems until the other day. The LPN was asked what happened. The LPN stated, I was at the Nursing station, (Resident #7) came to the Nursing Station and stated that somebody had attacked him. I followed him back to his room and I saw (Resident #8) sitting on the bed with blood all over her. I got (Resident #7) out of the room. I got (Resident #8) out of the room, I got her sent to the ER (emergency room ). When (Resident #7) came to the Nursing Station he was not showing any signs or symptoms of aggression. I asked (Resident #7) what happened. (Resident #7) stated ' I kicked her in the face ' . The LPN was asked when did this happen. The LPN stated, It occurred at about 6:30 a.m. on 7/21/15. The LPN was asked if there had been any aggressive behaviors problems. The LPN stated no resident to resident contact, but he had aggressive behavior that wasn't easily redirected. The LPN stated, I was at the Nursing Station. The LPN was asked if she could see down the hall. The LPN stated, Not the front hall where (Resident #7 and #8) were located. The LPN was asked if (Resident #8) had any behaviors. The LPN stated, She generally didn't wander, once in a blue moon did she get up at night. The LPN was asked if Resident #7 had any behaviors at night. The LPN stated, He did wander at night, he had started sleeping, but that morning he was getting up. i. On 7/23/15 at 7:00 p.m., the Director of Nursing (DON) was asked, after reviewing the documentation regarding Resident #7, if this resident was appropriate for the Certified Alzheimer's Unit. The DON stated, I was not aware of his history. I didn't read the documentation at that time of admission. The DON was asked if she was aware of the resident's aggressive behaviors that were documented in the resident ' s clinical record. The DON stated, I was aware of his pacing and going in other resident rooms. I was not aware of his aggressive behaviors towards staff and other residents. The DON was shown the documentation on 5/2/15 that the resident had balled up his fist and was threatening the staff and other residents. The DON stated, I was not aware. The DON was asked if the resident's increased incidents of aggressive behaviors were reported to her. The DON stated, No. The DON was asked if a resident was having increased episodes of aggressive behaviors shouldn't this be reported to the Physician and responsible party. The DON stated, Yes. The DON was asked if the increased episodes of aggressive behaviors would put the other residents on the Alzheimer's unit at risk. The DON stated, Yes. j. On 7/24/15 at 2:15 p.m., the Alzheimer Care Unit Director (ACUD) was asked if the staff reported any aggressive behaviors or increased behaviors regarding Resident #7. The ACUD stated, No. The ACUD was asked if a resident had increased behaviors that required to be medicated who should they report to. The

Complaint # (AR 476) substantiated, all or in part, in these findings: Based on observation, record review and interview, the facility failed to fully operationalize written policies and procedures related to the certified Alzheimer Care Unit to prevent neglect as evidenced by the facilities failures to ensure adequate pre-screening for appropriateness of placement prior to admission, to ensure risk factors due to behaviors were identified with interventions promptly developed and consistently implemented and assessed for effectiveness; to ensure physician, Adult Protective Services (resident guardian), and facility management involved in developing interventions to ensure safety of resident as well as the other residents that was in close contact; to ensure sufficient staffing to monitor resident to prevent resident injury for 1 (Resident #7) of 4 (Resident #7, #12, #13 and #14 ) case mix residents who were admitted to the Certified Alzheimer Care Unit in the past 6 months. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious injury, harm or possible death for Resident #8 who sustained an orbital and maxillary fracture and had the potential to affect 19 residents that resided on the Certified Alzheimer's Unit as of 7/21/15. The Immediate Jeopardy was removed by the facility on 7/21/15 at 7:00 a.m. and the scope/severity reduced to H when the facility identified the issue and initiated corrective action however the facility did not correct the underlying deficient practice at the time of the survey. The facility was informed of the Immediate Jeopardy removed on 7/24/15 at 5:15 p.m. The findings are: 1. On 7/27/15 at 11:30 a.m., the Administrator provided the Admission/Discharge Criteria for the Alzheimer Care Unit. The criteria was documented as follows: I. The primary [DIAGNOSES REDACTED]. established. II. The cognitive loss is not a result of head injury, mental illness or mental [MEDICAL CONDITION]. (Persons with [MEDICAL CONDITION], mental illness and mental [MEDICAL CONDITION] have different needs). Look for age appropriateness as well as former lifestyle. III. The resident must not be harmful to self (self-injurious) or other residents . This is to certify that (Facility Name) Alzheimer Special Care Unit capacity is 40 beds is hereby recognized in compliance with the Office of Long Term Care's rules and regulation for Alzheimer's Special Care Units and is authorized to advertise or otherwise hold itself out as offering a specialized unit for the residents with Alzheimer's or related dementia. 2. The Department of Human Services Division of Human Services Regulation Memo-Promulgation of Alzheimer's Special Care Unit Regulation for Nursing Homes documented, The Office of Long Term Care has promulgated regulations for Alzheimer's Special Care Units (ASCU'S) For Nursing Homes. The regulations became effective October 1, 2003. A copy of the regulations is attached to this memorandum. Definitions . Alzheimer's Special Care Unit. A separate and distinct unit within a Long Term Care Facility that segregates and provides a special program for residents with a [DIAGNOSES REDACTED]. Direct Care Staff. An individual who is an employee of the facility or who is an employee of temporary agency assigned to work in the facility and who has received or will receive in accordance with this regulation specialized; training regarding Alzheimer's or related Dementia and is responsible for providing direct, hands-on care or services to resident in the ASCU. 3. The ACU (Alzheimer Care Unit) Book containing policies, procedures, and other documentation for the specialized Alzheimer unit was received from the Alzheimer Care Unit Director (ACUD) on 7/25/15 at 5:55 p.m. The ACUD was asked if this was the policy and procedures that were put in place when the ACU unit was approved by Department of Human Services as an accredited Alzheimer's Care Unit. The ACUD stated that she was hired approximately 3 weeks ago and was still in training. The ACUD stated, The Beacon book was their advertising, but also had policies. The Policy and Procedures were reviewed for the Admission Policy documented .2. The assessment process begins prior to admission with the inquiry and pre-admission screening . 9. The initial assessment for pre-admission/admission should . Ascertain the validity of the [DIAGNOSES REDACTED]. Even with a [DIAGNOSES REDACTED]. Assess the social needs, preferences, behaviors and medical needs of the individual to maintain a balance of social needs and personalities among the existing participants in the program. The Policy and Procedures in the Alzheimer's Care Unit book documented, Department Dedicated Alzheimer's Care Unit Subject: Staffing Policy documented, There will be sufficient consistent and qualified staff dedicated to carry out the mission policies and the care plan of the dementia care services. Department Heads, All facility department heads retain accountability for assessing planning and documenting the delivery of services on the unit as well as clinical oversight including, acting as a resource to the unit. Evaluating referral regarding nutritional, medical, social, and recreational needs when a resident experiences a significant change or evidences a need that cannot be met through unit staff intervention. Provide clinical oversight on the unit . Resident with cognitive impairment require a more constant staff presence for the implementation of the structured daily plan for each resident in their assignment. Consistent assignments are the basis of the primary care aide system in which CNA (Certified Nursing Assistant) leads his/her assigned residents through successful activities of daily living, meals and recreation. Each unit will have established staff to resident ratio . . Staffing Ratio ------ primary caregivers case load should not exceed. Day/shift staffing ration 1 BACS (Beverly Alzheimer's Care Specialist) to 8 residents. Evening Shift staffing ratio 1 BACS to 10 residents and Night Shift staffing ratio of 1 BACS to 10 residents. 4. The Beacon Place Program Binder Admission Criteria received from the Alzheimer Care Unit Director (ACUD) on 7/23/15 documented, Policy Skilled Nursing Facilities that have a secure or Memory Care model will provide specialized services to meet the needs of individuals with [DIAGNOSES REDACTED]. [AGE] years of age moderate to severe Dementia. Benefit from a secure environment with or without behaviors Procedure Clinical team will evaluate incoming residents to verify a [DIAGNOSES REDACTED]. Team will utilize the following admission criteria in addition to the current admissions guidelines to determine if the resident is appropriate for the community. If a prospective resident has a [DIAGNOSES REDACTED]. admitting [DIAGNOSES REDACTED]. Dementia Alzheimer Type Frontal Temporal Dementia [MEDICAL CONDITION] [MEDICAL CONDITION] related Dementia [DIAGNOSES REDACTED] Dementia's secondary to [MEDICAL CONDITION]. Basic Admission Criteria: 65 and younger (younger individuals will be considered on a case by case basis) Experiencing symptoms related to dementia that are unmanageable in current community setting benefit from secure therapeutic environment. 5. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The History and Physical Report from the geri-psych unit dated 3/13/15 documented, .admitted : 03/13/2015 .He apparently was in a psych unit in Little Rock and he was aggressive and /or taking food from other people's trays? Concern was expressed that he might be harmed on an acute unit and was sent to Geri unit. At this facility, he has been noted to lay on other people beds and take their clothing. Any other history is absolutely unavailable to this physician at this time . The Discharge Summary dated 4/6/15 documented, Principle Diagnosis: [REDACTED]. Hospital Course: Patient was admitted to our unit and continued to evidence confusion, intrusiveness, and ease of agitation as well as a tendency to not take his medication despite prompting .Despite increasing doses of [MEDICATION NAME] the patient remained, he is easily agitated and intrusive and difficult to redirect and eventually began to have tolerability issues with the [MEDICATION NAME] in terms of side effects . The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 7/13/15 documented the resident scored 3 (a score of 0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS); had a mood score of 0; had wandering behaviors that occurred daily; required limited assistance of 1 person for bed mobility, transfers, ambulation in room or corridor and personal hygiene; was occasionally incontinent of bowel and bladder; had no pain; was 75 inches (6 foot 2 1/2 inches) in height; and received Antipsychotic, Antidepressant and Antianxiety medication 7 of the past 7 days. The responsible party was APS (Adult Protective Service) worker #1. a. Departmental Notes dated 4/7/15 at 1:12 a.m. documented, On 4/6/15 10 p.m. Resident admitted to (facility name) secured Alzheimer's Unit LTC (long term care) bed .He is ambulatory independently in corridors with slow and steady gait. b. Departmental Notes from 4/7/15-4/30/15 (23 days) documented the resident had 11 episodes of increased agitation, aggression, and/or intrusiveness that required PRN medication. The Departmental Notes did not document consultation with physician, APS, or facility management regarding resident increased risk of being injured or injuring others due to his behaviors: 1) Departmental Notes dated 4/7/15 at 1:47 p.m. documented, Resident pacing and going to exit doors. Resident entering other residents rooms and disturbing them and their visitors. Resident redirected and diverted with activities and food and drinks. Diversions [MEDICATION NAME] only a few minutes . pacing and exit seeking. [MEDICATION NAME] 5 mg (milligrams) IM (intramuscular) given. 2) Departmental Notes dated 4/9/15 at 2:17 a.m. documented, On 4/8/15 at 3:00 p.m.Resident is becoming verbally aggressive with staff and other residents. He states, 'If you say anything else I will hold you in contempt of court and you will be put in jail for no less than 9 days.' He points at a female resident states 'Sit down and don't say a word or I will put you in jail.' Resident medicated with [MEDICATION NAME] 5 mg IM. At 7:15 p.m. awake wandering around in dining room takes a soda from a female resident she asks him to put it down and he uses profanity. 3) Departmental Notes dated 4/10/15 at 12:26 a.m. documented, On 4/9/15 . at 6:00 p.m. resident is up wandering around the dining room and telling female resident to sit down and do not say anything. Attempts to redirect resident to his seat and he states 'Stop talking' staff let resident wander with close supervision until he seated himself at table . 6:30 p.m.[MEDICATION NAME] 5 mg IM right deltoid. Departmental Notes dated 4/10/15 at 3:06 p.m. documented, .New orders received from (Physician) derease (decrease) Trazadone to 150 mg at hs (hour of sleep), dc (discontinue) [MEDICATION NAME], give [MEDICATION NAME] 25 mg. q (every) a.m. and 50 mg at hs. APS (Adult Protective Services) notified . 4) Departmental Notes dated 4/11/15 at 1:01 a.m. documented, On 4/10/15 . at 4:45 p.m. Resident went to stand over female resident seated in her w/c (wheelchair) and asks her 'Why did you get my chair' resident daughter remains present and states, 'No that her w/c.' resident turns to resident daughter and states, You are a lie. Staff redirects across the hall for privacy [MEDICATION NAME] 5 mg IM for increased agitation/aggressiveness. 7:30 p.m. Resident is in a female room and refuses to leave room. He was redirected by staff after 15 minutes spent with redirection . 5) Departmental Notes dated 4/13/15 at 10:28 p.m. at 7:30 p.m. documented, .resident pushed the west exit door open to the courtyard causing the alarm to sound. Resident redirected .[MEDICATION NAME] 5 mg IM. 6) Departmental Notes dated 4/19/15 at 10:44 p.m. documented, Resident up pacing hallway . verbally abusive to residents and staff. Administered [MEDICATION NAME] 2 mg IM in left hip at 2130 (930 p.m.) . 7) Departmental Notes dated 4/20/15 at 12:39 p.m. documented, Resident observed pacing in hallways and other resident's rooms picking up various objects and putting them in his pocket. Resident got hold of housekeepers cart and started pushing it down the hallway staff x 3 attempted to get cart away from him and he became combative, hitting at staff and saying we had better get away from him. Eventually walked away from cart continue to pick up and pocket other resident belongings becoming more agitated and verbally and physically aggressive. 1200 [MEDICATION NAME] 1 mg IM given x 3 staff with much difficulty. 8) Departmental Notes dated 4/23/15 at 4:14 p.m. documented, 4/22/15 at 8:30 p.m. Resident turned to water on in the sink in his bathroom placed a trash can in the sink causing the water to fill the sink overflowing the bathroom and room (number) bedroom which then flowed out into the corridor. He is wandering into other residents room removing their walkers, trash cans, and other items he then was served alternate meal .He refused to eat became verbally aggressive with staff. He was medicated with [MEDICATION NAME] 5 mg IM right deltoid. Departmental Notes dated 4/23/15 at 2:54 p.m. documented, Resident followed staff out of exit door this morning, agitated and slightly combative when staff attempted to redirect him back . (Physician) notified, new order received for [MEDICATION NAME] 1 mg po (by mouth) q (every) 4 hrs (hours) prn agitation . Departmental Notes at 3:34 p.m. documented the physician would be at facility on 4/30/15 and make medication adjustments. 9) Departmental Notes dated 4/26/15 at 1:39 p.m. at 11:00 a.m. documented, Resident became agitated and started to ambulate in hallway by eye wash station. Hit window with his right hand knocking out a pane of plexi-glass. No injury. Resident medicated with [MEDICATION NAME] 1 mg IM r (right) arm for agitation. 10) Departmental Notes dated 4/29/15 at 12:37 p.m. documented, 12:34 p.m. R (Resident) pacing the hallway back and forth. Agitstion (agitation) noted to be increased at this time. R refuses to go into dining room and eat, stating ' there ' s bad people in there.' [MEDICATION NAME] 1 mg given po at this time . 11) Departmental Notes dated 4/30/15 at 2:18 a.m. documented, 1:00 a.m. Resident up pacing back and forth in hallways not easily redirected increase agitation when redirecting resident. [MEDICATION NAME] ([MEDICATION NAME]) 2 mg/ml [MEDICATION NAME] inject 0.5 ml (1 mg) IM given c. Departmental Notes and the May 2015 Medication Administration Record [REDACTED]. The Departmental Notes did not document consultation with physician, APS, or facility management regarding resident increased risk of being injured or injuring others due to his behaviors 1) Departmental Notes dated 5/2/15 at 10:59 p.m. documented, At 10:00 a.m. resident pacing back and forth in hallway, very anger, balling fist and trying to hit staff and residents. [MEDICATION NAME] 2 mg administered. At 1700 (5:00 p.m.) Resident pacing back and forth in hallway, very anger (angry) balling fist and trying to hit staff and residents. [MEDICATION NAME] 2 mg administer(ed) . 2) Departmental Notes dated 5/2/15 at 10:59 p.m. documented, .at 1700 (5:00 p.m.) resident pacing back and forth in hallway, very anger (angry), balling fist and trying to hit staff and residents. [MEDICATION NAME] 2 mg administer(ed) . 3) The back of the May 2015 MAR indicated [REDACTED].o. for increased agitation on 5/4/15 at 6:15 p.m. 4) The back of the May 2015 MAR indicated [REDACTED].o. for increased agitation on 5/5/15 at 1030. 5) Departmental Notes dated 5/6/15 at 3:54 a.m. documented, 2:45 p.m. Resident up wandering hallways not easily redirected easily agitated. [MEDICATION NAME] 1 mg 1 tab po given . 6) Departmental Notes dated 5/7/15 at 6:28 a.m. documented, 5:30 a.m. Resident is up attempting to wander throughout halls. Not easily redirected . Increased agitation [MEDICATION NAME] 1 mg po given. 7) Departmental Notes dated 5/7/15 at 1:02 p.m. documented, 0915 R is noted to have extreme agitation at this time. Housekeeper state he will not leave things on her cart alone. R (Resident) noted trying to move the doghouse on the unit as another R was leaning on it as he does daily. R noncompliant with redirection. [MEDICATION NAME] 2 mg/ml [MEDICATION NAME] inject 0.5 ml (1 mg) IM given at this time for agitation . Departmental Notes dated 5/7/15 at 1:16 p.m., 1100-R is noted across the hall from his room in another R room without pants or brief on. R in other residents bathroom running the water to the point of almost overflowing. R taken back to his room . 8) Departmental Notes dated 5/8/15 at 12:08 a.m. documented, Resident up wandering up and down hallways. Inattention fidgeting with door knobs trying to open doors. Moving the dog house trying to pick it up. Not easily redirected increase in agitation [MEDICATION NAME] 1 mg 1 tablet given po . 9) Departmental Notes dated 5/8/15 at 6:02 a.m. documented, Resident wandering in dining room getting into drawers and anything that is on the counter. Resident will not put on clothing and not easily redirected to his room. Increased agitation when trying to dress him or redirect. [MEDICATION NAME] 1 mg 1 tab po given 10) Departmental Notes Addendum dated 5/8/15 at 11:59 a.m. documented, Resident in and out of resident's rooms going in bathrooms and turning water on not easily redirected. Resident noted to be incontinent of bowel, when staff approached him for toileting and peri-care he's very resistive and became slightly combative. Male staff arrived and peri-care given per 3 staff. 12:30 [MEDICATION NAME] 1 mg po given. 11) The back of the May 2015 MAR indicated [REDACTED].o. for increased agitation at 7:00 p.m. on 5/8/15. 12) Departmental Notes dated 5/8/15 at 4:44 a.m. documented, 11:30 (p.m.) Resident up wandering halls with diaper on head and no pants. Not easily redirected increase in agitation when trying to get resident go back to room. [MEDICATION NAME] 1 mg 1 tablet given po . 13) Departmental Notes dated 5/9/15 at 6:05 a.m. documented, Residnet (resident) taking clothes off and on in room. Resident as (has) clothing all over room. Has diaper on head and shirt on wrong way. Resident urinating outside door. Not easily redirected. [MEDICATION NAME] 1 mg po given . 14) The back of the May 2015 MAR indicated [REDACTED].o. for increased agitation at 7:00 p.m. on 5/12/15. 15) Departmental Notes dated 5/13/15 documented, 7 p.m. Resident is up wandering from table to table in the dining room, turning on the water at the sink, becoming loud with staff and other residents. He is redirected with fluids and food but continues with behavior escalation. He is medicated with [MEDICATION NAME] 1 mg 2 po . 16) The back of the May 2015 MAR indicated [REDACTED].o. for increased agitation on 5/16/15 at 1940 (7:40 p. m.). 17) The back of the May 2015 MAR indicated [REDACTED].o. for increased agitation on 5/17/15 at 1610 (4:10 p.m.). 18) Departmental Notes dated 5/21/15 at 4:04 p.m. documented, 1000 (10 a.m.) Resident observed standing at window in kitchen looking out at parking lot, he said he see his car out there and needs to go get it, he attempted to open window, multiple attempts per staff to divert him away from window before he complied, then he became severely agitated with staff and verbally aggressive. At 10:30 a.m. attempted to give [MEDICATION NAME] 0.5 ml 1 mg IM per assist x 3 staff, resident became extremely agitated and resistive and unable to give complete dose . [MEDICATION NAME] 1 mg po given and taken without incident . 19) Departmental Notes dated 5/21/15 at 11:42 p.m. documented, .7:00 p.m. He is medicated with [MEDICATION NAME] 1 mg 1 po for increased agitation when staff attempts to assist with changing of his clothes. 20) Departmental Notes dated 5/22/15 at 6:43 a.m. documented, 1:10 a.m. gave bruse (?) 0.5mg im (IM)for being vety (very) aggitated (agitated) and trying to take things in other resident froom (room). The May 2015 Medication Administration Record [REDACTED]. 21) Departmental Notes dated 5/22/15 at 11:18 a.m. documented, 1045 Resident observed at window in dining room pulling up on window and trying to open it, not easily diverted. Resident left dining room and began pacing in hallways and pounding on door and window of Nursing Station. Lorezepan 1 mg po given . 22) Departmental Notes dated 5/25/15 at 1:46 p.m. documented, Since out of bed this morning resident has been pacing, going in other residents rooms and getting their belongings, he became agitated with staff when redirected. Lorezepam 1 mg po given at 11:30 a.m. 23) Departmental Notes dated 5/25/15 at 11:35 p.m. documented, 6:40 p.m. Resident up and pacing in the corridors. He has behavior of wandering in other residents rooms. Resident in (room [ROOM NUMBER]) states he doesn't want this resident (Resident #7) back in his room. ADON (Assistant Director of Nurses) was notified of the resident in (room [ROOM NUMBER]) concerns of this resident coming into his room. At 7:00 p.m. Resident has wandered into room [ROOM NUMBER] when redirecting him he became agitated states, ' Just leave me alone ' , staff gave resident sandwich and sweet tea and medicated him with [MEDICATION NAME] 1 mg po. Staff remains in room [ROOM NUMBER] with resident (#7) until he agrees to go to his room . Departmental Notes dated 5/27/15 at 3:44 p.m. documented, Resident pacing hallways and going into other residents rooms pilfering in closets and drawers. Attempts to redirect with activities/food/fluids. Resident becomes increasingly agitated towards staff. Call placed to (Physician) with new orders received to increase [MEDICATION NAME] to 50 mg in am and 100 mg hs. (APS) notified of new orders . Departmental Notes dated 5/28/15 at 4:34 p.m. documented, (Physician) here to examine resident with no new orders received. physician progress notes [REDACTED].He was transferred to psych facility for APS related issue. He was aggressively taking food from other patient's trays. Because of his aggressive behavior, it was felt that there might be some issues with him being placed in acute care unit, so he was admitted to the Geriatric Unit at this facility. It had been reported that he was found on occasion on other peoples' beds removing their clothes. Beyond that, I can't get much else .Plan: He seems to have done better with the dose reduction on the medications he came in here taking. At this point we 'll sit tight and see how he responds with the switch from [MEDICATION NAME] to [MEDICATION NAME] bid (twice daily) . 24) Departmental Notes dated 5/31/15 at 4:10 p.m. documented, At 4:15 p.m. administered [MEDICATION NAME] 2 mg IM right hip for agiation (agitation). d. Departmental Notes and the June 2015 Medication Administration Record [REDACTED]. The Departmental Notes did not document consultation with physician, APS, or facility management regarding resident increased risk of being injured or injuring others due to his behaviors: 1) Departmental Notes dated 6/1/15 4:10 p.m. documented, At 1430 (2:30 p.m.) Resident went in eyewash room, had BM (bowel movement) smeared it on cabinets and is clothing. He refused to change his clothes or allow staff to assist him, he became verbally and physically threatening. [MEDICATION NAME] 1 mg IM given. 2) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/5/15 at 9:30 a.m. 3) The back of the June 2015 MAR indicated [REDACTED]. 4) The back of the June 2015 MAR indicated [REDACTED]. 5) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/16/15 at 4:30 p.m. 6) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/17/15 at 10:45 a.m. 7) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/19/15 at 4:30 p.m. 8) The back of the June 2015 MAR indicated [REDACTED]. 9) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/23/15 at 10:45 a.m. 10) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/23/15 at 3:30 p.m. 11) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/26/15 at 9:30 a.m. 12) Departmental Notes dated 6/26/15 11:52 p.m. documented, 4:20 p.m. Resident was walking pass staff he caught her left arm holding tightly around her left wrist, verbal cueing from staff to resident to released staff arm then redirected to dining room for food and fluid. Resident continues to be verbal aggressive to staff and other residents. He is medicated with [MEDICATION NAME] 1 mg po. 13) The back of the June 2015 MAR indicated [REDACTED].o. for increased agitation on 6/27/15 at 11:40 a.m. e. Departmental Notes and the July 2015 Medication Administration Record [REDACTED]. The Departmental Notes did not document consultation with physician, APS, facility management regarding resident increased risk of being injured or injuring others due to his behaviors: 1) The back of the July 2015 MAR indicated [REDACTED].o. for increased agitation on 7/01/15 at 3:00 a.m. 2) Departmental Notes dated 7/2/15 10:32 a.m. documented, 10:30 a.m. [MEDICATION NAME] 1 mg po given, resident observed over past hour pacing in hallways, going in male residents room and bothering them. Resident talking non-stop in manic like mode with speech becoming threatening towards some staff. All attempts to divert his attention with activities snacks, 1-1 have been futile . 3) The back of the July 2015 MAR indicated [REDACTED].o. for increased agitation on 7/4/15 at 9:15 a.m. 4) The back of the July 2015 MAR indicated [REDACTED].o. for increased agitation on 7/5/15 at 9:00 a.m. 5) The back of the July 2015 MAR indicated [REDACTED].o. for increased agitation on 7/8/15 at 11:30 a.m. 6) Departmental Notes dated 7/16/15 at 3:19 p.m. documented, 10:45 a.m. Resident woke up this morning in agitated mood, pacing with angry of tone of voice when staff cues him for redirections and to dining room for breakfast. Resident made attempt to hit staff but did not make contact. [MEDICATION NAME] 1 mg po given . f. The Resident's Comprehensive Care Plan with review date of 7/14/15 cpoc (continue plan of care) documented: Problem Onset 04/14/15 . I display verbally aggressive behaviors. Goal .I will decrease my episodes of verbally aggressive behaviors by 50%. Approaches . Activities staff to visit with me and provide diversion activities. Observe and document my behaviors A handwritten note dated 4/26/15 documented, Broke window out on secured unit, with no injuries. Secured windows. Nursing staff in-serviced to administer p.m. (as needed) med before behaviors becomes escalated. Problem Onset 04/14/15 .Resident has Mood & (and)/or Behavior concerns - Has orders for [MEDICAL CONDITION] medication(s). Goal .-Resident will remain free of injury/adverse effects related to [MEDICAL CONDITION] medication(s) for the next 30 days . Approach .Monitor for Behaviors and intervene as needed . Remove to a private areas when behaviors are disrupting to others . A handwritten note dated 4/10/15 documented, (increased) verbal aggression towards staff/residents .D/C (discontinue) [MEDICATION NAME] 10 mg hs (decrease) [MEDICATION NAME] 150 mg hs [MEDICATION NAME] 25 mg am (and) 50 mg pm The care plan did not address resident's risk of being injured or injuring others due to his intrusive and aggressive behaviors. The care plan had no new interventions after 4/26/15 for mood/behaviors. g. Departmental Notes dated 7/21/15 at 7:30 a.m. documented, 6:30 a.m. Resident came to Nurse at Nurse's station stated, 'Someone attacked me.' this nurse followed resident to room and found (Resident #8) sitting on bed with blood coming from nose and hematoma with quarter sized swelling to right eye. This (Resident #8) could not state what happened. Resident (Resident #7) stated, 'She attacked me.' I asked did resident hit her, he (Resident #7) stated, 'I kicked her in the face.' When asked Resident did this resident (Resident #8) hit him he stated, No. This Nurse separated the resident into Nurses Station. Resident (Resident #7) denies any pain 0 on pain scale 1-10. Full ROM (range of motion) in UE (upper extremities) and LE (lower extremities) No noted blood on resident. Resident was given [MEDICATION NAME] 2 mg/ml 0.5 ml (IM) given to right gluteus medius . Called on call MD .notified of incident .6:55 a.m. Attempted to notify (APS worker #1) and only answering machine. A Continuous Monitoring 1:1 form dated 7/21/15 documented the facility began continuous 1 on 1 monitoring of resident at 6:30 a.m. which continued until discharge. Resident #8, a [AGE] year old female, had [DIAGNOSES REDACTED]. Departmental Notes date 7/21/15 at 11:24 a.m. documented, Discharge dx (diagnosis) from ER facial fracture. Right orbital and right maxillary fracture . On 7/21/15 at 11:28 a.m. during initial rounds of the facility, the resident's right eye was swollen shut and there was extensive dark purple bruising, and bruising to the left cheek area. There was dried blood on both nares and a trickle of bright red blood from the

Complaint # (AR 476) substantiated, all or in part. in these findings: A. Based on observation, record review and interview, the facility failed to ensure risk factors due to behaviors were identified with interventions promptly developed and consistently implemented and assessed for effectiveness; to ensure physician, Adult Protective Services (resident guardian), and facility management involved in developing interventions to ensure safety of resident as well as the other residents that were in close contact; to ensure sufficient staffing to monitor resident to prevent resident injury for 1 (Resident #7) of 4 (Resident #7, #12, #13 and #14) case mix residents who were admitted to the Certified Alzheimer Care Unit in the past 6 months. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious injury, harm or possible death for Resident #8 who sustained an orbital and maxillary fracture and had the potential to affect 19 residents that resided on the Certified Alzheimer's Unit as of 7/21/15. The Immediate Jeopardy was removed by the facility on 7/21/15 at 7:00 a.m. and the scope/severity reduced to H when the facility identified the issue and initiated corrective action however the facility did not correct the underlying deficient practice at the time of the survey. The facility was informed of the Immediate Jeopardy removed on 7/24/15 at 5:15 p.m. The findings are: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The History and Physical Report from the geri-psych unit dated 3/13/15 documented, .admitted : 03/13/2015 .He apparently was in a psych unit in Little Rock and he was aggressive and /or taking food from other people's trays? Concern was expressed that he might be harmed on an acute unit and was sent to Geri unit. At this facility, he has been noted to lay on other people beds and take their clothing. Any other history is absolutely unavailable to this physician at this time . The Discharge Summary dated 4/6/15 documented, Principle Diagnosis: [REDACTED]. Hospital Course: Patient was admitted to our unit and continued to evidence confusion, intrusiveness, and ease of agitation as well as a tendency to not take his medication despite prompting . Despite increasing doses of Haldol the patient remained, he is easily agitated and intrusive and difficult to redirect and eventually began to have tolerability issues with the Haldol in terms of side effects . The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 7/13/15 documented the resident scored 3 (a score of 0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS); had a mood score of 0; had wandering behaviors that occurred daily; required limited assistance of 1 person for bed mobility, transfers, ambulation in room or corridor and personal hygiene; was occasionally incontinent of bowel and bladder; had no pain; was 75 inches (6 foot 2 1/2 inches) in height; and received Antipsychotic, Antidepressant and Antianxiety medication 7 of the past 7 days. The responsible party was APS (Adult Protective Service) worker #1. a. Departmental Notes dated 4/7/15 at 1:12 a.m. documented, On 4/6/15 10 p.m. Resident admitted to (facility name) secured Alzheimer's Unit LTC (long term care) bed .He is ambulatory independently in corridors with slow and steady gait. b. Departmental Notes from 4/7/15-4/30/15 (23 days) documented the resident had 11 episodes of increased agitation, aggression, and/or intrusiveness that required PRN (as needed) medication. The Departmental Notes did not document consultation with physician, APS, or facility management regarding resident increased risk of being injured or injuring others due to his behaviors: 1) Departmental Notes dated 4/7/15 at 1:47 p.m. documented, Resident pacing and going to exit doors. Resident entering other residents' rooms and disturbing them and their visitors. Resident redirected and diverted with activities and food and drinks. Diversions lasting only a few minutes . pacing and exit seeking. Haldol 5 mg (milligrams) IM (intramuscular) given. 2) Departmental Notes dated 4/9/15 at 2:17 a.m. documented, On 4/8/15 at 3:00 p.m.Resident is becoming verbally aggressive with staff and other residents. He states, 'If you say anything else I will hold you in contempt of court and you will be put in jail for no less than 9 days.' He points at a female resident states 'Sit down and don't say a word or I will put you in jail.' Resident medicated with Haldol 5 mg IM. At 7:15 p.m. awake wandering around in dining room takes a soda from a female resident she asks him to put it down and he uses profanity. 3) Departmental Notes dated 4/10/15 at 12:26 a.m. documented, On 4/9/15 . at 6:00 p.m. resident is up wandering around the dining room and telling female resident to sit down and do not say anything. Attempts to redirect resident to his seat and he states ' Stop talking' staff let resident wander with close supervision until he seated himself at table . 6:30 p.m.Haldol 5 mg IM right deltoid. Departmental Notes dated 4/10/15 at 3:06 p.m. documented, .New orders received from (Physician) derease (decrease) Trazadone to 150 mg at hs (hour of sleep), dc (discontinue) Zyprexa, give Seroquel 25 mg. q a.m. and 50 mg at hs. APS (Adult Protective Services) notified . 4) Departmental Notes dated 4/11/15 at 1:01 a.m. documented, On 4/10/15 . at 4:45 p.m. Resident went to stand over female resident seated in her w/c (wheelchair) and asks her 'Why did you get my chair' resident daughter remains present and states, 'No that her w/c.' resident turns to resident daughter and states, You are a lie. Staff redirects across the hall for privacy Haldol 5 mg IM for increased agitation/aggressiveness. 7:30 p.m. Resident is in a female room and refuses to leave room. He was redirected by staff after 15 minutes spent with redirection . 5) Departmental Notes dated 4/13/15 at 10:28 p.m. at 7:30 p.m. documented, .resident pushed the west exit door open to the courtyard causing the alarm to sound. Resident redirected .Haldol 5 mg IM. 6) Departmental Notes dated 4/19/15 at 10:44 p.m. documented, Resident up pacing hallway . verbally abusive to residents and staff. Administered Lorazepam 2 mg IM in left hip at 2130 (9:30 p.m.) . 7) Departmental Notes dated 4/20/15 at 12:39 p.m. documented, Resident observed pacing in hallways and other resident's rooms picking up various objects and putting them in his pocket. Resident got hold of housekeepers cart and started pushing it down the hallway staff x 3 attempted to get cart away from him and he became combative, hitting at staff and saying we had better get away from him. Eventually walked away from cart continue to pick up and pocket other resident belongings becoming more agitated and verbally and physically aggressive. 1200 Lorazepam 1 mg IM given x 3 staff with much difficulty. 8) Departmental Notes dated 4/23/15 at 4:14 p.m. documented, 4/22/15 at 8:30 p.m. Resident turned to water on in the sink in his bathroom placed a trash can in the sink causing the water to fill the sink overflowing the bathroom and room (number) bedroom which then flowed out into the corridor. He is wandering into other residents room removing their walkers, trash cans, and other items he then was served alternate meal .He refused to eat became verbally aggressive with staff. He was medicated with Haldol 5 mg IM right deltoid. Departmental Notes dated 4/23/15 at 2:54 p.m. documented, Resident followed staff out of exit door this morning, agitated and slightly combative when staff attempted to redirect him back . (Physician) notified, new order received for Lorazepam 1 mg po (by mouth) q (every) 4 hrs (hours) prn agitation . Departmental Notes at 3:34 p.m. documented the physician would be at facility on 4/30/15 and make medication adjustments. 9) Departmental Notes dated 4/26/15 at 1:39 p.m. at 11:00 a.m. documented, Resident became agitated and started to ambulate in hallway by eye wash station. Hit window with his right hand knocking out a pane of plexi-glass. No injury. Resident medicated with Lorazepam 1 mg IM r (right) arm for agitation. 10) Departmental Notes dated 4/29/15 at 12:37 p.m. documented, 12:34 p.m. R (Resident) pacing the hallway back and forth. Agitstion (agitation) noted to be increased at this time. R refuses to go into dining room and eat, stating 'there's bad people in there.' Lorazepam 1 mg given po at this time . 11) Departmental Notes dated 4/30/15 at 2:18 a.m. documented, 1:00 a.m. Resident up pacing back and forth in hallways not easily redirected increase agitation when redirecting resident. Ativan (Lorazepam) 2 mg/ml carpuject inject 0.5 ml (1 mg) IM given . c. Departmental Notes and the May 2015 Medication Administration Record (MAR) from 5/1/15 - 5/31/15 (31 days) documented the resident had 24 episodes of increased agitation, aggression, and/or intrusiveness that required PRN medication. The Departmental Notes did not document consultation with physician, APS, or facility management regarding resident increased risk of being injured or injuring others due to his behaviors: 1) Departmental Notes dated 5/2/15 at 10:59 p.m. documented, At 10:00 a.m. resident pacing back and forth in hallway, very anger, balling fist and trying to hit staff and residents. Lorazepam 2 mg administered. At 1700 (5:00 p.m.) Resident pacing back and forth in hallway, very anger (angry) balling fist and trying to hit staff and residents. Lorazepam 2 mg administer(ed) . 2) Departmental Notes dated 5/2/15 at 10:59 p.m. documented, .at 1700 (5:00 p.m.) resident pacing back and forth in hallway, very anger (angry), balling fist and trying to hit staff and residents. Lorazepam 2 mg administer(ed) . 3) The back of the May 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 5/4/15 at 6:15 p.m. 4) The back of the May 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 5/5/15 at 1030. 5) Departmental Notes dated 5/6/15 at 3:54 a.m. documented, 2:45 p.m. Resident up wandering hallways not easily redirected easily agitated. Ativan 1 mg 1 tab po given . 6) Departmental Notes dated 5/7/15 at 6:28 a.m. documented, 5:30 a.m. Resident is up attempting to wander throughout halls. Not easily redirected . Increased agitation Ativan 1 mg po given. 7) Departmental Notes dated 5/7/15 at 1:02 p.m. documented, 0915 R is noted to have extreme agitation at this time. Housekeeper state he will not leave things on her cart alone. R (Resident) noted trying to move the doghouse on the unit as another R was leaning on it as he does daily. R noncompliant with redirection. Lorazepam 2 mg/ml carpuject inject 0.5 ml (1 mg) IM given at this time for agitation . Departmental Notes dated 5/7/15 at 1:16 p.m., 1100 (11:00 a.m.)-R is noted across the hall from his room in another R room without pants or brief on. R in other resident's bathroom running the water to the point of almost overflowing. R taken back to his room . 8) Departmental Notes dated 5/8/15 at 12:08 a.m. documented, Resident up wandering up and down hallways. Inattention fidgeting with door knobs trying to open doors. Moving the dog house trying to pick it up. Not easily redirected increase in agitation Ativan 1 mg 1 tablet given po . 9) Departmental Notes dated 5/8/15 at 6:02 a.m. documented, Resident wandering in dining room getting into drawers and anything that is on the counter. Resident will not put on clothing and not easily redirected to his room. Increased agitation when trying to dress him or redirect. Ativan 1 mg 1 tab po given . 10) Departmental Notes Addendum dated 5/8/15 at 11:59 a.m. documented, Resident in and out of resident's rooms going in bathrooms and turning water on not easily redirected. Resident noted to be incontinent of bowel, when staff approached him for toileting and peri-care he's very resistive and became slightly combative. Male staff arrived and peri-care given per 3 staff. 12:30 Ativan 1 mg po given. 11) The back of the May 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation at 7:00 p.m. on 5/8/15. 12) Departmental Notes dated 5/8/15 at 4:44 a.m. documented, 11:30 (p.m.) Resident up wandering halls with diaper on head and no pants. Not easily redirected increase in agitation when trying to get resident go back to room. Ativan 1 mg 1 tablet given po . 13) Departmental Notes dated 5/9/15 at 6:05 a.m. documented, Residnet (resident) taking clothes off and on in room. Resident as (has) clothing all over room. Has diaper on head and shirt on wrong way. Resident urinating outside door. Not easily redirected. Ativan 1 mg po given . 14) The back of the May 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation at 7:00 p.m. on 5/12/15. 15) Departmental Notes dated 5/13/15 documented, 7 p.m. Resident is up wandering from table to table in the dining room, turning on the water at the sink, becoming loud with staff and other residents. He is redirected with fluids and food but continues with behavior escalation. He is medicated with Ativan 1 mg 2 po . 16) The back of the May 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 5/16/15 at 1940 (7:40 p. m.). 17) The back of the May 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 5/17/15 at 1610 (4:10 p.m.). 18) Departmental Notes dated 5/21/15 at 4:04 p.m. documented, 1000 (10 a.m.) Resident observed standing at window in kitchen looking out at parking lot, he said he see his car out there and needs to go get it, he attempted to open window, multiple attempts per staff to divert him away from window before he complied, then he became severely agitated with staff and verbally aggressive. At 10:30 a.m. attempted to give Lorazepam 0.5 ml 1 mg IM per assist x 3 staff, resident became extremely agitated and resistive and unable to give complete dose . Lorezpam 1 mg po given and taken without incident . 19) Departmental Notes dated 5/21/15 at 11:42 p.m. documented, .7:00 p.m. He is medicated with Ativan 1 mg 1 po for increased agitation when staff attempts to assist with changing of his clothes. 20) Departmental Notes dated 5/22/15 at 6:43 a.m. documented, 1:10 a.m. gave bruse (?) 0.5mg im (IM)for being vety (very) aggitated (agitated) and trying to take things in other resident froom (room). The May 2015 Medication Administration Record (MAR) documented Lorazepam 1 mg IM was administered. 21) Departmental Notes dated 5/22/15 at 11:18 a.m. documented, 1045 (10:45 a.m.) Resident observed at window in dining room pulling up on window and trying to open it, not easily diverted. Resident left dining room and began pacing in hallways and pounding on door and window of Nursing Station. Lorezepan 1 mg po given . 22) Departmental Notes dated 5/25/15 at 1:46 p.m. documented, Since out of bed this morning resident has been pacing, going in other residents rooms and getting their belongings, he became agitated with staff when redirected. Lorazepam 1 mg po given at 11:30 a.m. 23) Departmental Notes dated 5/25/15 at 11:35 p.m. documented, 6:40 p.m. Resident up and pacing in the corridors. He has behavior of wandering in other residents rooms. Resident in (room #33) states he doesn't want this resident (Resident #7) back in his room. ADON (Assistant Director of Nurses) was notified of the resident in (room #33) concerns of this resident coming into his room. At 7:00 p.m. Resident has wandered into room #34 when redirecting him he became agitated states, 'Just leave me alone' , staff gave resident sandwich and sweet tea and medicated him with Ativan 1 mg po. Staff remains in room 34 with resident (#7) until he agrees to go to his room . Departmental Notes dated 5/27/15 at 3:44 p.m. documented, Resident pacing hallways and going into other residents rooms pilfering in closets and drawers. Attempts to redirect with activities/food/fluids. Resident becomes increasingly agitated towards staff. Call placed to (Physician) with new orders received to increase Seroquel to 50 mg in am and 100 mg hs. (APS) notified of new orders . Departmental Notes dated 5/28/15 at 4:34 p.m. documented, (Physician) here to examine resident with no new orders received. physician progress notes [REDACTED].He was transferred to psych facility for APS related issue. He was aggressively taking food from other patient's trays. Because of his aggressive behavior, it was felt that there might be some issues with him being placed in acute care unit, so he was admitted to the Geriatric Unit at this facility. It had been reported that he was found on occasion on other peoples' beds removing their clothes. Beyond that, I can't get much else . Plan: He seems to have done better with the dose reduction on the medications he came in here taking. At this point we'll sit tight and see how he responds with the switch from Abilify to Seroquel bid (twice daily) . 24) Departmental Notes dated 5/31/15 at 4:10 p.m. documented, At 4:15 p.m. administered Lorazepam 2 mg IM right hip for agiation (agitation). d. Departmental Notes and the June 2015 Medication Administration Record (MAR) from 6/1/15 - 6/30/15 (30 days) documented the resident had 13 episodes of increased agitation, aggression, and/or intrusiveness that required PRN medication. The Departmental Notes did not document consultation with physician, APS, or facility management regarding resident increased risk of being injured or injuring others due to his behaviors: 1) Departmental Notes dated 6/1/15 4:10 p.m. documented, At 1430 (2:30 p.m.) Resident went in eyewash room, had BM (bowel movement) smeared it on cabinets and is clothing. He refused to change his clothes or allow staff to assist him, he became verbally and physically threatening. Lorazepam 1 mg IM given. 2) The back of the June 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 6/5/15 at 9:30 a.m. 3) The back of the June 2015 MAR documented the resident was administered Lorazepam 1 mg IM for behavior on 6/7/15 at 1830 (6:30 p.m.). 4) The back of the June 2015 MAR documented the resident was administered Lorazepam 1 mg IM for behavior agitation on 6/8/15 at 0400 (4:00 a.m.). 5) The back of the June 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 6/16/15 at 4:30 p.m. 6) The back of the June 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 6/17/15 at 10:45 a.m. 7) The back of the June 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 6/19/15 at 4:30 p.m. 8) The back of the June 2015 MAR documented the resident was administered Lorazepam 1 mg IM for behavior agitation on 6/21/15 at 2202 (10:02 p.m.). 9) The back of the June 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 6/23/15 at 10:45 a.m. 10) The back of the June 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 6/23/15 at 3:30 p.m. 11) The back of the June 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 6/26/15 at 9:30 a.m. 12) Departmental Notes dated 6/26/15 11:52 p.m. documented, 4:20 p.m. Resident was walking pass staff he caught her left arm holding tightly around her left wrist, verbal cueing from staff to resident to released staff arm then redirected to dining room for food and fluid. Resident continues to be verbal aggressive to staff and other residents. He is medicated with Ativan 1 mg po. 13) The back of the June 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 6/27/15 at 11:40 a.m. e. Departmental Notes and the July 2015 Medication Administration Record (MAR) from 7/1/15 - 7/16/15 (16 days) documented the resident had 6 episodes of increased agitation, aggression, and/or intrusiveness that required PRN medication. The Departmental Notes did not document consultation with physician, APS, facility management regarding resident increased risk of being injured or injuring others due to his behaviors: 1) The back of the July 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 7/01/15 at 3:00 a.m. 2) Departmental Notes dated 7/2/15 10:32 a.m. documented, 10:30 a.m. Ativan 1 mg po given, resident observed over past hour pacing in hallways, going in male residents room and bothering them. Resident talking non-stop in manic like mode with speech becoming threatening towards some staff. All attempts to divert his attention with activities snacks, 1-1 have been futile . 3) The back of the July 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 7/4/15 at 9:15 a.m. 4) The back of the July 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 7/5/15 at 9:00 a.m. 5) The back of the July 2015 MAR documented the resident was administered Lorazepam 1 mg p.o. for increased agitation on 7/8/15 at 11:30 a.m. 6) Departmental Notes dated 7/16/15 at 3:19 p.m. documented, 10:45 a.m. Resident woke up this morning in agitated mood, pacing with angry of tone of voice when staff cues him for redirections and to dining room for breakfast. Resident made attempt to hit staff but did not make contact. Ativan 1 mg po given . f. The Resident's Comprehensive Care Plan with review date of 7/14/15 cpoc (continue plan of care) documented: Problem Onset 04/14/15 . I display verbally aggressive behaviors. Goal .I will decrease my episodes of verbally aggressive behaviors by 50%. Approaches . Activities staff to visit with me and provide diversion activities. Observe and document my behaviors . A handwritten note dated 4/26/15 documented, Broke window out on secured unit, with no injuries. Secured windows. Nursing staff in-serviced to administer p.m. (as needed) med before behaviors becomes escalated. Problem Onset 04/14/15 .Resident has Mood & (and)/or Behavior concerns - Has orders for Psychotropic medication(s). Goal .-Resident will remain free of injury/adverse effects related to Psychotropic medication(s) for the next 30 days . Approach .Monitor for Behaviors and intervene as needed .-Remove to a private areas when behaviors are disrupting to others . A handwritten note dated 4/10/15 documented, (increased) verbal aggression towards staff/residents . D/C (discontinue) Zyprexa 10 mg hs (decrease) Trazodone 150 mg hs Seroquel 25 mg am (and) 50 mg pm The care plan did not address resident's risk of being injured or injuring others due to his intrusive and aggressive behaviors. The care plan had no new interventions after 4/26/15 for mood/behaviors. g. Departmental Notes dated 7/21/15 at 7:30 a.m. documented, 6:30 a.m. Resident came to Nurse at Nurse's station stated, 'Someone attacked me.' this nurse followed resident to room and found (Resident #8) sitting on bed with blood coming from nose and hematoma with quarter sized swelling to right eye. This (Resident #8) could not state what happened. Resident (Resident #7) stated, 'She attacked me.' I asked did resident hit her, he (Resident #7) stated, 'I kicked her in the face.' When asked Resident did this resident (Resident #8) hit him he stated, No. This Nurse separated the resident into Nurses Station. Resident (Resident #7) denies any pain 0 on pain scale 1-10. Full ROM (range of motion) in UE (upper extremities) and LE (lower extremities) No noted blood on resident. Resident was given Ativan 2 mg/ml 0.5 ml (IM) given to right gluteus medius .Called on call MD .notified of incident .6:55 a.m. Attempted to notify (APS worker #1) and only answering machine. A Continuous Monitoring 1:1 form dated 7/21/15 documented the facility began continuous 1 on 1 monitoring of resident at 6:30 a.m. which continued until discharge. Resident #8, a [AGE] year old female, had [DIAGNOSES REDACTED]. Departmental Notes date 7/21/15 at 11:24 a.m. documented, Discharge dx (diagnosis) from ER facial fracture. Right orbital and right maxillary fracture . On 7/21/15 at 11:28 a.m. during initial rounds of the facility, the resident ' s right eye was swollen shut and there was extensive dark purple bruising, and bruising to the left cheek area. There was dried blood on both nares and a trickle of bright red blood from the right nare. The OLTC (Office of Long Term Care) Incident and Accident Report (I&A) dated 7/21/15 documented the type of abuse Physical. Steps taken to prevent continued Abuse or neglect during the investigation: An investigation was initiated immediately. Family, Local Law Enforcement and Administrator were notified.(Resident #7) was removed from room taken to Nurse Station for evaluation and placed 1:1 for safety. First Aid was provided to Resident (#8) by Registered Nurse (RN) #1 and (Resident #8) was then immediately transported to Ouachita County Medical Center ER for evaluation. Investigation is ongoing at this time. g. Departmental Notes dated 7/23/15 at 3:14 p.m. and signed Alzheimer's Care Unit Director (ACUD) documented, At approximately 1:30 p.m. this Nurse took over the 1:1 continuous monitoring to relieve CNA for lunch. (Resident #7) was ambulating up and down hallway. Resident went into the room of two female residents and I had difficulty redirecting him to leave the room. He was exhibiting sternness and reverting to cop lingo when speaking to me. I attempted to hold open the door he was trying to shut and he grabbed my wrist stating. 'I will murder you and they will find you hanging in the trees.' Once redirected and back into hallway, resident became increasingly agitated and inconsolable. He opened the door to another resident's room, entered and I was unable to redirect him out of the room. (Resident #7) reached down to grab a shoe belonging to the resident of the room he entered and the two resident became verbally aggressive towards one another and I had to call for help to redirect (Resident #7). The (Name) ADON and (Name) DON entered the room. The (DON) was able to get (Resident #7) attention and walk him out the room. (Resident #7) became increasingly agitated, would not take the oral Ativan 1 mg that the LPN was offering. (Resident #7) became increasingly verbally threatening to staff and several staff members stated they were scared of him at this point. He was not able to be redirected and I sought guidance from the DON and ADON. I was told to call ambulance and send him to ER. The ER was contacted and the ambulance was dispatched to the facility. It took several staff members to get (Resident #7) to calm down and get onto the stretcher. (Resident #7) was given Ativan 1 mg IM in right deltoid muscle. Phone (APS Worker #1) and left message. ER call and stated they were sending (Resident#7) back to the facility. I spoke with (APS Worker #1) and will seek placement at geri-psych. facility with her approval of facility Departmental Notes dated 7/23/15 documented the resident was transferred out of facility at 7:00 p.m. h. On 7/24/15 licensed nurses were interviewed: At 9:40 a.m., Licensed Practical Nurse (LPN) #5 was asked if she worked on the Certified Alzheimer Unit. The LPN stated, Yes for 3 1/2 years. The LPN was asked what was Resident #7 behaviors. The LPN stated, He would wander in and out of other residents rooms, he had trouble finding the bathroom. He had behaviors, but I was able to control him better than other people. He got agitated, he would pace, pilfer and pick up things. The LPN was asked if Resident #7's behaviors got to a point that he had to have medications. The LPN stated, Yes, there were periods that he would have to be medicated. Then all of a sudden his behaviors escalated, they had been random. The LPN was asked if she had talked to anyone. The LPN stated the CNAs reported to her his behaviors. The LPN was asked if she had reported to anyone else regarding the increased episodes of the resident ' s behaviors. The LPN stated, Yes, I spoke with then Alzheimer Care Unit Director. The LPN was asked what was the criteria for giving residents the PRN (as needed) medications. The LPN stated, We try redirection, activities, food, 1 to 1 with him before we give the medications. The LPN was asked, Did you call the physician when the resident received PRN medication for several days and the resident's behaviors of agitation had increased and was the responsible party notified. The LPN stated, No. At 10:55 a.m., LPN #4 was asked if she worked on the Certified Alzheimer Unit. The LPN stated for 1 year. The LPN was asked what Resident #7 ' s behaviors were. The LPN stated, At times he can become verbally abusive and you have to redirect him. The LPN was asked what kind of behaviors the resident exhibited. The LPN stated, Verbal threats that he was going to do something to you. Sometimes he would calm down and sometimes he required medication to calm him down. The LPN was asked what kind of threats did the resident make, did the resident threaten to hit. The LPN was shown documentation that she documented on 5/2/15. The LPN stated, Yes he did ball up his fist and threaten to hit staff and residents. The LPN was asked if she had reported this incident to anyone. The LPN stated, I can't remember. The LPN was asked if she had called the Physician or the responsibility party regarding the increased behaviors. The LPN stated, I can't remember. The LPN was asked, Do you feel that the resident's aggressive behaviors should have been reported? The LPN stated, I probably called the Supervisor on call. The LPN was asked where this was documented. The LPN stated, It's not documented. The LPN was asked if the other residents were at risk. The LPN stated, Not at that time, we redirected him and gave him medication. The LPN was asked should a resident be admitted to the Certified Alzheimer Unit with a Psychiatric Diagnosis. The LPN stated, No. The LPN was asked why. The LPN stated, No, that would be a potential danger. At 1:35 p.m., LPN #2 was asked if she worked on the Certified Alzheimer Unit. The LPN stated, Yes on the 11-7 shift. The LPN was asked if she had training for the Certified Alzheimer Unit. The LPN stated, Yes, by the former ACUD that gave in-services. The LPN was asked if she had been trained on dealing with aggressive resident. The LPN stated, Not at this facility, but elsewhere. The LPN was asked if there were any issues related to behaviors or aggressive residents on the Alzheimer Unit. The LPN stated, Yes with (Resident #7) that was the only issue. He was doing fine, then he had periods of agitation and not easily redirected. The LPN was asked what the resident's behaviors were. The LPN stated, He knocked out a window, no major problems until the other day. The LPN was asked what happened. The LPN stated, I was at the Nursing s

A. Based on observation, record review and interview the facility failed to ensure residents with cognitive limitations and [DIAGNOSES REDACTED].#1 and #2) of 4 (Residents #1, #2, #7 and #14) case mix residents who smoked. This failed practice resulted in Immediate Jeopardy for Resident #1 that caused or could have caused serious injury, harm, impairment or death for Resident #1 and had the potential to affect 7 facility residents who smoked as documented on a list provided by the Business Manager on 3/14/11 at 6:15 p.m. The facility was informed of the Immediate Jeopardy on 3/14/11 at 6:45 p.m. The findings are: 1. The "Policy Interpretation and Implementation" regarding the facility's Smoking Policy received from the Director of Nursing on 3/14/11 at 6:15 p.m. documented: "1) An admission and quarterly smoking safety assessment will be completed for those residents that smoke. 2) According to the assessment, the resident may require staff supervision, smoking apron, and/or other types of assistance to safely smoke. 3) The resident specific interventions will be noted on the resident's care plan and communicated to the staff as necessary. 4) Any resident and/or family that does not comply with the facility policy will have further training and monitoring and possibly receive a 30 day discharge notice for noncompliance. 5) The residents will be encouraged to smoke no more than 1 - 2 cigarettes at each smoking time as this will allow them to have enough cigarettes to last the entire month. 6) The staff will monitor for noncompliance and report to their supervisors as necessary. 7) Periodic room searches may be necessary in order to remove lighters from the rooms so that all residents will be kept safe. 2. Resident #1 had [DIAGNOSES REDACTED]. a. A "Quarterly Smoking Safety Review" form dated 1/20/10 in the section titled "Interventions" documented the resident smoked safely with minimal supervision and the "Facility storage of fire materials only." An unsigned, undated "Smoking Safety Assessment" documented the resident had modified independence in cognitive skills for decision making; disorganized speech; ability to communicate the need for help if lit material falls on them; and wheelchair was the primary mode of transportation. The assessment documented the question "Is resident able to move without assistance to/from designated smoking area?", no answer was documented; the resident had no visual limitation; the resident had no range of motion limitation. The section titled "Disease/[DIAGNOSES REDACTED]." The section titled "Fire safety" documented, "Lighter/matches have been obtained from outside source." The "History of smoking incidents" section documented none. The section titled "History of smoking incidents " asked the following questions and had boxes to check if any of the following had occurred: "Burned Clothing; History of falling asleep while smoking; Burned furniture; Throws lighted tobacco products in trash can; Smoking in bed; Drops ashes on self; Other;" None of the boxes were checked. The section titled "Interventions" listed interventions of: Independent; Smokes safely with minimal supervision; Smoking apron; Facility storage of tobacco products and fire. Each had a box to be checked if the intervention was to be used. None were checked. The sections titled "Assistive devices " documented, " Resident instructed and understands facility smoking policy; care planned concern. " Nurse signature and Date were left blank. b. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/4/11 documented the resident scored a 9 (moderately impaired Cognitive skills for daily decision making) on the Brief Interview for Mental Status (BIMS), Inattention (Behavior continuously present, does not fluctuate) Psychomotor [MEDICAL CONDITION] (. . . continuous. . . does not fluctuate), the resident required limited assistance for transfer, extensive assistance with ambulation, had impairment in range of motion on one side of upper and lower extremity and was mobile with wheelchair. c. On 3/14/11at 3:10 p.m., the resident was on the patio outside the front door of the facility in a wheelchair, smoking a cigarette. The resident had several burn holes on the front of her fleece jacket. There was no staff or other residents outside. There was no nonflammable, protective covering on the resident to prevent burns. As surveyors entered the building, the resident stubbed her cigarette out on the side of her wheelchair and placed the remainder of the cigarette into her pocket. A packet of cigarettes was visible in the resident ' s pocket. The facility had 2 double glass doors at the entrance and the doors had to be held open by the surveyors in order for the resident to enter the building. A staff member passing in the entry was asked to assist the resident to push her wheelchair in. d. On 3/14/11 at 6:15 p.m., the Social Director stated she did the smoking assessments. She stated at times the resident wanted to keep her own cigarettes but they did not let her. She was asked if the resident was supervised when she smoked. She stated "sometimes." She was asked if she was aware of the resident's [DIAGNOSES REDACTED]." She was asked if knowing of these [DIAGNOSES REDACTED]. She stated, "Yes." She was asked to accompany the surveyor to see the resident. The resident was in the wheelchair in the East hallway still wearing the fleece jacket with the burn holes. The Social Director was asked what she saw. She stated she saw the burn holes. She stated, "I will have to re-do the smoking assessment". The resident was asked about the holes in her jacket. She stated, "Ash blows on it." The Social Director was asked if the facility had any smoking aprons. She stated, "No." The Social Director was told the resident had been observed with cigarettes in her pocket. The resident allowed her to look in the pocket but no cigarettes were found. e. There was no plan of care regarding the resident's smoking until 3/14/11, after the facility was notified of the burn holes in the resident's clothing. f. On 3/18/11 at 3:40 p.m. the Administrator stated, "She (the Resident) has holes in all her clothes, She came in with them. " 3. Resident #2 had [DIAGNOSES REDACTED]. A "Quarterly Smoking Safety Review" form dated 1/20/10 in the section titled "Interventions" documented the resident smoked safely with minimal supervision and the "Facility storage of fire materials only." A Significant Change in Status Minimum Data Set with an ARD of 3/9/11 documented that the resident had a BIMS score of 3 (severely impaired), was non-ambulatory and required extensive assistance to transfer. a. An unsigned, undated "Smoking Safety Assessment" documented the resident was severely impaired in cognitive skills for decision making; mental function varies. Clear speech; able to communicate the need for help if lit material falls on them; Wheelchair primary mode of transportation; no visual limitation; no range of motion limitation. The section for documenting "Disease/[DIAGNOSES REDACTED]. The section titled "Fire safety" documented "Lighter/matches have been obtained from outside source." The "History of smoking incidents" section had boxes to be checked with either a yes or no answers. Neither box was checked. The section titled "Interventions" listed in the smoking safety assessment documented: Independent; Smokes safely with minimal supervision; Smoking apron; Facility storage of tobacco products and fire. None were checked. The sections titled "Assistive devices " documented, " Resident instructed and understands facility smoking policy; care planned concern. " Nurse signature and Date were all blank. c. The plan of care did not address the resident's smoking until 3/14/11 when it was brought to the facility's attention. 4. On 3/14/11 at 7:15 p.m., the Immediate Jeopardy was removed and the scope/severity reduced to "E" when the facility implemented the following plan of removal: a. All residents that smoke will be reassessed 3/14/11 using the smoking safety assessment form. b. All residents that smoke will not be allowed to smoke unattended beginning 3/14/11 at 7:00 p.m. until all assessments are completed. c. All smoking materials will be removed from the resident's rooms and stored at the nurses station. A log will be maintained each time the resident smokes with name of staff assigned to monitor. The log will be monitored daily by the CEO, DON, designee. The residents will have assigned smoking times as follows: 6 a.m., 8 a.m., 10 a.m., 12 noon, 2 p.m., 4 p.m., 6 p.m., 8 p.m. d. All staff will be inserviced regarding the plan of removal beginning 3/14/11 as each employee clocks in for work until all staff are in-serviced. e. All residents who smoke will have their care plan updated as of 3/14/11. B. Based on observation, interview and record review the facility failed to ensure residents were assessed for the most appropriate method of transfer for 2 of 2 case mix residents (Residents #7 and #9) who were transferred by mechanical lift. This failed practice had the potential to affect 18 residents who were transferred by mechanical lift as documented on a list provided by the Director of Nursing on 3/18/11. The findings are: 1. Resident #7 had [DIAGNOSES REDACTED]. A quarterly MDS with an ARD of 2/3/11 documented the resident had unclear speech, sometimes understood verbal content, had highly impaired vision, was unable to complete a BIMS, was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, had Inattention Altered level of consciousness, psychomotor [MEDICAL CONDITION], required extensive assistance of 1 person for transfer, was non-ambulatory, and had impairment in range of motion in upper extremity on 1 side. a. A "Facility - Lift/Mobility assessment for Residents " form, copyrighted by the mechanical lift manufacturer who supplied the facility with its mechanical lifts, documented quarterly assessments were conducted for this resident on 3/22/10 and 5/28/10. The form documented the resident could bear weight on left leg only, was able to follow simple instructions, able to grip with at least one hand or a second staff member is available to assist with transfer, and was able to undergo moderate pressure to the mid to lower back. All 5 questions were answered "Yes." The instructions following these questions documented, "If all 5 questions are answered yes the resident is a candidate for the Sara lift. . .(place an X over Sara in "Lift Required" box below. None of the 4 lift options were marked as the appropriate lift for the resident. The area for number of staff was not completed. Sling size based on the resident's weight was not indicated as required on the assessment form. A diagram of a person standing on a Sara (stand up) lift was circled. The diagram depicted a person standing with knees slightly bent, hips in alignment with the spine, leaning slightly backwards with back straight and grasping the handles of the lift. b. On 3/16/11 at 9:20 p.m. CNA #1 transferred the resident from the wheelchair to the bed using the Sara 3000 lift. The lift sling was placed around the resident's back and attached to the clip attachment points on the handgrips. The resident's feet were placed on the foot support platform and a strap was placed behind the resident's knees and attached to the upright bar of the lift. As the resident was lifted by the strap around her thorax and back, her knees and hips bent approximately 90 degrees and she was transferred in a sitting position, not bearing any weight on her legs. She did not grasp the handgrips with either hand. After providing incontinent care the resident was transferred back to the wheelchair by CNA #1. The resident held the handgrip loosely with one hand and the left foot slipped off the foot support platform. The resident was transferred back to the wheelchair in a sitting position with no weight bearing on her legs. c. A Lift Mobility Assessment for Residents was completed for this resident on 3/16/11. All questions were answered as in the above assessment but "Sara 2000" was circled as the appropriate lift for use on this resident. The MDS coordinator was asked when she completed the assessments dated 3/16/11 and she stated she had just been asked to do the lift assessments. She was questioned about the Sara 2000 lift she stated it was a mistake, the facility did not have a Sara 2000 lift, she meant to document Sara 3000. 2. Resident #9 had [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE] documented the resident was Severely Impaired with Cognitive Skills for Daily decision making and required extensive assistance with ADL's. a. The Care Plan last updated 1/12/11 documented, "At risk for falls due to resident is non ambulatory, dependent on staff for transfers, w/c (wheelchair) is primary mode of locomotion, she wanders with no sense of safety, ..... ambulate and is unable. Approaches. . . Use mechanical lift for transfers. " The care plan did not document the type of lift to use. b. A "Facility - Lift/Mobility Assessment for Residents" form for this resident dated 10/14/09 documented the resident could bear weight but did not document whether the resident could bear weight on one or both legs. The question "Resident able to follow simple instructions?" was not answered; "Resident able to grip with at least one hand or a second staff member is available to assist with transfer" was answered " Yes " ; and "Resident able to undergo moderate pressure to the mid to lower back" was answered "Yes." The instructions documented, "If all 5 (above) questions are answered yes, the resident is a candidate for the Sara lift. . .(place an X over Sara in "Lift Required" box below). " The Sara 2000 lift was circled as the appropriate lift for the resident. The area for number of staff was not completed. Sling size based on the resident's weight was not indicated as required on the assessment form. c. On 3/16/11 at 9:40 a.m., CNA #1 transferred the resident to bed from the w/c using Sara Lift 3000. The CNA positioned the lift in front of the resident's w/c and applied the sling behind the resident's back. He secured one side of the sling to the lift by pulling the sling toward the lift and pulling the resident forward. He secured the other strap on the sling to the lift by pulling the resident forward with the strap of the sling. He turned the lift toward the bed, positioned the legs of the lift under the bed, and did not lock the lift. The resident was lowered onto the bed. The CNA removed the sling from the lift and pushed the lift backwards with his right hand. The CNA provided incontinent care, applied an incontinent brief, pulled on the resident's pants. The CNA pulled the resident's legs forward, lifting the resident with his hand behind her back, sitting her on the edge of the bed. The CNA pulled the lift forward, hitting the resident's feet with the lift platform. The resident slid forward on the edge of the bed with feet stretched outward, leaning backward. The CNA was able to pull the resident back onto the bed and lay the resident down. He stated to the resident, "You almost slipped." As the CNA attempted to raise the resident she stiffened her body. As she sat on the edge of the bed her legs were stretched out with her buttocks on the very edge of the bed, leaning backwards. The CNA pulled the lift to the bed but did not lock the lift. He secured the sling to the lift. He stated, "You almost gave me a [MEDICAL CONDITION]." He raised the resident up in the lift. The lift sling that was placed around the resident's thorax slid upward under her arms with her hands dangling to the sides. The resident did not attempt to hold onto the sling with either hand. The resident's left foot fell off the foot platform, as the resident's knees bent. The CNA turned the lift towards the wheelchair, repositioned the residents foot, repositioned the lift in front of the wheelchair and lowered the resident into the wheelchair. d. The "Facility - Lift/Mobility Assessment for Residents" for this resident dated 3/16/11 documented, "Resident is able to follow simple instructions" with answer as "No." (The October 2010 assessment did not document an answer to this question.) The instructions documented if any of the above questions (included the one above) was answered "no" then the resident was not a candidate for the Sara (standing lift). Based on the answers to the above questions the resident was assessed as requiring a "Marisa (recumbent, sling) lift. "

A. Based on observation, record review and interview, the facility failed to ensure Resident #1 and #2 received adequate supervision and assistance devices to prevent burns. The facility failed to ensure residents who smoked unsupervised were assessed accurately for the ability to do so safely and interventions were developed/ implemented to reduce the risk for burns resulting from unsupervised smoking for 2 (Resident #1 and #2) of 4 (Residents #1, #2, #7, and #14) case mix residents who smoked. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious injury, harm, impairment or death for Resident #1 who had cigarette burns on her clothing and had the potential to affect 7 facility residents who smoked as documented on a list provided by the Business office Manager on 3/14/11. The facility was notified of the Immediate Jeopardy on 3/14/11 at 6:45 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. A "Quarterly Smoking Safety Review" form dated 1/20/10 in the section titled "Interventions" documented the resident smoked safely with minimal supervision and the "Facility storage of fire materials only." The "Smoking Safety Assessment" documented the resident had modified independence in cognitive skills for decision making; disorganized speech; was able to communicate the need for help if lit material fell on her; Wheelchair was the primary mode of transportation; had no visual limitation; and had no range of motion limitation. The section "Disease/[DIAGNOSES REDACTED]." The section titled "Fire safety" documented, "Lighter/matches have been obtained from outside source." The "History of smoking incidents" section documented none. This section asked questions with boxes to check if any of the following had occurred: Burned Clothing; History of falling asleep while smoking; Burned furniture; Throws lighted tobacco products in trash can; Smoking in bed; Drops ashes on self; Other;" None of the boxes were checked. Interventions listed in the smoking safety assessment documented: Independent; Smokes safely with minimal supervision; Smoking apron; Facility storage of tobacco products and fire. None were checked. The document was unsigned and undated. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/4/11 documented a score of 9 (moderately impaired Cognitive skills for daily decision making) on the Brief Interview for Mental Status (BIMS), Inattention (Behavior continuously present, does not fluctuate) Psychomotor Retardation (. . . continuous. . . does not fluctuate), the resident required limited assistance for transfer, extensive assistance with ambulation, had impairment in range of motion on one side of upper and lower extremity and was mobile with wheelchair. a. On 3/14/11at 3:10 p.m., the resident was on the patio outside the front door of the facility in a wheelchair, smoking a cigarette. The resident had several burn holes on the front of her fleece jacket. There was no staff or other residents outside. There was no nonflammable, protective covering on the resident to prevent burns. As surveyors entered the building, the resident stubbed her cigarette out on the side of her wheelchair and placed the remainder of the cigarette into her pocket. A packet of cigarettes was visible in the resident ' s pocket. The facility had 2 double glass doors at the entrance and the doors had to be held open by the surveyors in order for the resident to enter the building. A staff member passing in the entry was asked to assist the resident to push her wheelchair in. b. On 3/14/11 at 6:15 p.m., the Social Director stated she did the smoking assessments. She stated at times the resident wanted to keep her own cigarettes but they did not let her. She was asked if the resident was supervised when she smoked. She stated, "Sometimes." She was asked if she was aware of the resident's [DIAGNOSES REDACTED]." She was asked if knowing of these [DIAGNOSES REDACTED]. She stated "Yes." She was asked to accompany the surveyor to see the resident. The resident was in the wheelchair in the East hallway still wearing the fleece jacket with the burn holes. The Social Director was asked what she saw. She stated she saw the burn holes. She stated, "I will have to re-do the smoking assessment. " The resident was asked about the holes in her jacket. She stated, "Ash blows on it." The Social Director was asked if the facility had any smoking aprons. She stated, "No." 2. Resident #2 had [DIAGNOSES REDACTED]. A "Quarterly Smoking Safety Review" form dated 1/20/10 in the section titled "Interventions" documented the resident smoked safely with minimal supervision and the "Facility storage of fire materials only." A Significant Change in Status Minimum Data Set with an ARD of 3/9/11 documented that the resident had a BIMS score of 3 (severely impaired) was non-ambulatory and required extensive assistance to transfer. a. An unsigned, undated "Smoking Safety Assessment" documented the resident was severely impaired in cognitive skills for decision making; mental function varies. Clear speech; able to communicate the need for help if lit material falls on them; Wheelchair primary mode of transportation; no visual limitation; no range of motion limitation. The section for documenting "Disease/[DIAGNOSES REDACTED]." The section titled "Fire safety" documented "Lighter/matches have been obtained from outside source." The "History of smoking incidents" section had boxes to be checked with either a yes or no answers. Neither box was checked. The section titled "Interventions" listed in the smoking safety assessment documented: Independent; Smokes safely with minimal supervision; Smoking apron; Facility storage of tobacco products and fire. None were checked. The sections titled "Assistive devices; Resident instructed and understands facility smoking policy; care planned concern; Nurse signature and Date were all blank. b. The plan of care did not address the resident's smoking until 3/14/11 when it was brought to the facility's attention. 3. On 3/14/11 at 7:15 p.m., the Immediate Jeopardy was removed and the scope/severity reduced to "E" when the facility implemented the following plan of removal: a. All residents that smoke will be reassessed 3/14/11 using the smoking safety assessment form. b. All residents that smoke will not be allowed to smoke unattended beginning 3/14/11 at 7:00 p.m. until all assessments are completed. c. All smoking materials will be removed from the resident's rooms and stored at the nurses station. A log will be maintained each time the resident smokes with name of staff assigned to monitor. The log will be monitored daily by the CEO, DON, designee. The residents will have assigned smoking times as follows: 6 a.m., 8 a.m., 10 a.m., 12 noon, 2 p.m., 4 p.m., 6 p.m., 8 p.m. d. All staff will be inserviced regarding the plan of removal beginning 3/14/11 as each employee clocks in for work until all staff are in-serviced. e. All residents who smoke will have their care plan updated as of 3/14/11. B. Based on observations, record review and interview, the facility failed to ensure interventions were developed and implemented to prevent the potential for injury during transfer for 1 (Resident #7) of 2 (Residents #7 and #9) case mix residents who were transferred by mechanical lifts. This failed practice had the potential to affect 18 residents who were transferred by mechanical lift as documented on a list provided by the Director of Nursing on 3/18/11. The findings are: 1. The facility Policy for the Stand-Up Lift documented: "The stand-up lift is to assist weight-bearing residents when standing and toileting, and for use as short distance resident transfer aid. " 2. Resident #7 had [DIAGNOSES REDACTED]. A quarterly MDS with an ARD of 2/3/11 documented the resident had severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, had Inattention Altered level of consciousness, psychomotor retardation, required extensive assistance of 1 person for transfer, was non-ambulatory, and had impairment in range of motion in upper extremity on 1 side. a. A "Facility - Lift/Mobility assessment for Residents" form for this resident documented quarterly assessments were conducted on 3/22/10 and 5/28/10. A Sara (Standing) lift diagram was circled on the form. The diagram depicted a person standing with knees slightly bent, hips in alignment with the spine, leaning slightly backwards with back straight and grasping the handles of the lift. b. On 3/16/11 at 9:20 p.m., CNA #1 transferred the resident from the wheelchair to the bed using the Sara 3000 lift. The lift sling was placed around the resident's back and attached to the clip attachment points on the handgrips. The resident's feet were placed on the foot support platform and a strap was placed behind the resident's knees and attached to the upright bar of the lift. The breaks on the lift were not applied while the resident was attached to the lift and raised off the chair. The resident was lifted by the strap around her thorax and back, her knees and hips bent approximately 90 degrees. She was transferred to a sitting position, the resident did not bear any weight on her legs. She did not grasp the handgrips with either hand during the transfer to the bed. After providing incontinent care, CNA #1 grasped the resident under the knees and pulled her lower legs over the side of the bed while with his right arm behind her neck he pulled the resident upright. He placed her feet on the foot support of the lift and the left foot slipped off. The brakes were not applied while the resident was attached to the lift and raised from the bed. The resident held the handgrip loosely with one hand. The resident was transferred with the Sara lift back to the wheelchair to a sitting position, the resident did not bear weight on her legs. 3. Resident #9 had [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE] documented the resident was Severely Impaired with Cognitive Skills for Daily decision making and required extensive assistance with ADL's. a. A "Facility - Lift/Mobility Assessment for Residents" form for this resident dated 10/14/09 documented the resident could bear weight but did not document whether the resident could bear weight on one or both legs. The form documented the following questions/answers: Resident can bear weight on at least one leg? Answer: Yes. Resident able to follow simple instructions? No Answer; Resident is able to grip with at least one hand or a (second) staff member is available to assist with transfer? Answer: Yes; Resident is able to undergo moderate pressure to the mid to lower back? Answer: Yes. Resident weighs less than 350 lbs? (SARA 2000) Answer: Yes The instructions documented, "If the five questions were answered Yes, then the patient is a candidate for the Sara Lift. If any of the four questions were No, then the resident is not a SARA lift candidate, (place an X over Sara in "Lift Required" box below). " The Sara 2000 lift was circled as the appropriate lift for the resident. The area for number of staff was not completed. Sling size based on the resident's weight was not indicated as required on the assessment form. b. The Care Plan last updated 1/12/11, documented, "At risk for falls due to resident is non ambulatory, dependent on staff for transfers, w/c (wheelchair) is primary mode of locomotion, she wanders with no sense of safety, requires self release belt due to attempts to sand and ambulate and is unable. ...Approaches. . . Use mechanical lift for transfers. " The care plan did not document the type of lift to use. c. On 3/16/11 at 9:40 a.m., CNA #1 transferred the resident to bed from the w/c using a Sara Lift 3000. The CNA positioned the lift in front of the resident's w/c and applied the sling behind the resident ' s back. He secured one side of the sling to the lift by pulling the sling toward the lift and pulling the resident forward. He secured the other strap on the sling to the lift by pulling the resident forward with the strap of the sling. He turned the lift toward the bed, positioned the legs of the lift under the bed. He did not lock lift. The Resident was lowered onto the bed, the CNA removed the sling from the lift and pushed the lift backward with his right hand. The CNA provided incontinent care, applied an incontinent brief, pulled on the resident ' s pants and pulled the resident's legs forward, lifting the resident with his hand behind her back, sitting her on the edge of the bed. The CNA pulled the lift forward, hitting the resident's feet with the lift platform. The resident slid forward on the edge of the bed with feet stretched outward, leaning backward. The CNA was able to pull the resident back onto the bed and lay the resident down. He stated to the resident, "You almost slipped." As the CNA attempted to raise the resident she stiffened her body, and as she sat on the edge of the bed her legs were stretched out with her buttocks on the very edge of the bed, leaning backwards. The CNA pulled the lift to the bed but did not lock the lift. He secured the sling to the lift. He stated, "You almost gave me a heart attack." He raised the resident up in the lift. The lift sling that was placed around the resident's thorax slid upward under her arms with her hands dangling to the sides. The resident did not attempt to hold onto sling with either hand. The left foot fell off the foot platform, as the resident's knees bent. The CNA turned the lift toward the wheelchair, repositioned resident ' s foot, repositioned the lift in front of the wheelchair and lowered the resident into the wheelchair. d. The "Facility - Lift/Mobility Assessment for Residents" for this resident dated 3/16/11 documented, "Resident is able to follow simple instructions" with answer as "No." (The October 2010 assessment did not document an answer to this question.) The instructions documented if any of the above questions (included the one above) was answered "no" then the resident was not a candidate for the Sara (standing lift). Based on the answers to the above questions the resident was assessed as requiring a "Marisa (recumbent, sling) lift. " C. Based on observations, the facility failed to ensure that the environment was free of accident hazards as evidenced by doors with splintered and rough edges, loose panel, a gap in the panel on doors and no protruding areas on door paneling's. The findings are: On 3/17/11 at 9:00 a.m., the following was observed: a. The fire doors on the east hall had splintered edges along the inside next to the hinges. b. The panel on the door of room 26 had a gap of 1 inch by 4 inches and the edges were rough. c. The fire doors on the back east hall had rough edges and the panel was loose. There was a 1/4 inch x 1/2 inch rough splintered area 40 1/2 inches from the floor. d. In Room 11, the door had a 1 x 1/2 inch area sticking out from the panel. e. In Room 19, the window glass was too short and had approximately a 1/4 inch gap that was covered with card board. f. A skill circular saw and a reciprocating saw was outside the maintenance building on a cart, unsecured. g. The area outside at the end of West hall had 5 old beds, a commode and a lot of wood piled up. h. The West shower room had a paper towel dispenser lying on the floor with the screws sticking up, the sharps container on the wall was overflowing with razors and unused razors were lying on the counter by the sink.

Based on observation, record review and interview, Nursing Administration failed to ensure a system was in place to develop and implement measures to accurately assess and plan care to reduce the risk [MEDICAL CONDITION] 2 (Residents #1 and 2) of 4 (Residents #1, #2, #7, and #14) case mix residents who smoked. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious injury , harm, impairment or death for Resident #1 who had [MEDICAL CONDITION] her clothing and had the potential to affect 7 facility residents who smoked as documented on a list provided by the Business office Manager on 3/14/11. The facility was notified of the Immediate Jeopardy on 3/14/11 at 6:45 p.m. The findings are: 1. The facility's job description for the Director of Nursing documented, "General Purpose: To lead and direct, and manage the overall operations of the nursing department in accordance with standards of practice, customer needs, government regulations and facility policies, with focus on maintaining excellent care for the residents/patients . . . " Essential job Functions: " Nursing Dept. (Department) Management Duties: Leads the facility nursing staff by interpreting and putting into effect nursing administrative policies as established by the facility. Develops and maintains nursing care objectives and standards of nursing care practices for the facility. Plan, organize and direct effective administration of nursing units and patient care based on the established goals and objectives, standards, policies and procedures. Has the administrative authority, responsibility and accountability for all functions, activities and training of the nursing services department. Develops an environment that allows for creative thinking, problem solving and empowerment in the development of a facility nursing team . . . Oversees regular rounds to monitor delivery of nursing care, cleanliness, appearance and safety of the facility; moral (morale) of the staff; and ensures needs are being addressed . . . " Compliance Management Duties: " . . . Observe, monitor and participate as needed in the day-to-day functions of the nursing department. Conduct daily rounds to assess resident care and assure that residents are provided with a safe, clean and orderly environment." 2. The "Policy Interpretation and Implementation" regarding the facility's Smoking Policy received from the Director of Nursing on 3/14/11 at 6:15 p.m. documented: "1) An admission and quarterly smoking safety assessment will be completed for those residents that smoke. 2) According to the assessment, the resident may require staff supervision, smoking apron, and/or other types of assistance to safely smoke. 3) The resident specific interventions will be noted on the resident's care plan and communicated to the staff as necessary. 4) Any resident and/or family that does not comply with the facility policy will have further training and monitoring and possibly receive a 30 day discharge notice for noncompliance. 5) The residents will be encouraged to smoke no more than 1 - 2 cigarettes at each smoking time as this will allow them to have enough cigarettes to last the entire month. 6) The staff will monitor for noncompliance and report to their supervisors as necessary. 7) Periodic room searches may be necessary in order to remove lighters from the rooms so that all residents will be kept safe. " 3. Resident #1 had [DIAGNOSES REDACTED]. a. A "Quarterly Smoking Safety Review" form dated 1/20/10 in the section titled "Interventions" documented the resident smoked safely with minimal supervision and the "Facility storage of fire materials only". The "Smoking Safety Assessment" documented modified independence in cognitive skills for decision making; Disorganized speech; able to communicate the need for help if lit material falls on them; Wheelchair primary mode of transportation; no visual limitation; no range of motion limitation. The section for documenting "Disease/[DIAGNOSES REDACTED]. The section titled "Fire safety" documented "Lighter/matches have been obtained from outside source". The "History of smoking incidents" section documented none. This section asked questions with boxes to check in any of the following had occurred: Burned Clothing; History of falling asleep while smoking; Burned furniture; Throws lighted tobacco products in trash can; Smoking in bed; Drops ashes on self; Other;" None of the boxes were checked. Interventions listed in the smoking safety assessment documented: Independent; Smokes safely with minimal supervision; Smoking apron; Facility storage of tobacco products and fire. None were checked. The document was unsigned and undated. b. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/4/11 documented a score of 9 (moderately impaired Cognitive skills for daily decision making) on the Brief Interview for Mental Status (BIMS), Inattention (Behavior continuously present, does not fluctuate) Psychomotor [MEDICAL CONDITION] (. . . continuous. . . does not fluctuate), the resident required limited assistance for transfer, extensive assistance with ambulation, had impairment in range of motion on one side of upper and lower extremity and was mobile with wheelchair. c. On 3/14/11at 3:10 p.m., the resident was on the patio outside the front door of the facility in a wheelchair, smoking a cigarette. The resident had several burn holes on the front of her fleece jacket. There was no staff or other residents outside. There was no nonflammable, protective covering on the resident to prevent burns. As surveyors entered the building, the resident stubbed her cigarette out on the side of her wheelchair and placed the remainder of the cigarette into her pocket. A packet of cigarettes was visible in the resident ' s pocket. The facility had 2 double glass doors at the entrance and the doors had to be held open by the surveyors in order for the resident to enter the building. A staff member passing in the entry was asked to assist the resident to push her wheelchair in. d. On 3/14/11 at 6:15 p.m., the Social Director stated she did the smoking assessments. She stated at times the resident wanted to keep her own cigarettes but they did not let her. She was asked if the resident was supervised when she smoked. She stated, "Sometimes." She was asked if she was aware of the resident's [DIAGNOSES REDACTED]." She was asked if knowing of these [DIAGNOSES REDACTED]. She stated "Yes." She was asked to accompany the surveyor to see the resident. The resident was in the wheelchair in the East hallway still wearing the fleece jacket with the burn holes. The Social Director was asked what she saw. She stated she saw the burn holes. She stated, "I will have to re-do the smoking assessment. " The resident was asked about the holes in her jacket. She stated, "Ash blows on it." The Social Director was asked if the facility had any smoking aprons. She stated, "No." e. on 3/18/11 at 3:40 p.m. the Administrator stated the resident had holes in all her clothing. Her clothing had burnholes when she was admitted . 4. Resident #2 had [DIAGNOSES REDACTED]. A "Quarterly Smoking Safety Review" form dated 1/20/10 in the section titled "Interventions" documented the resident smoked safely with minimal supervision and the "Facility storage of fire materials only." A Significant Change in Status Minimum Data Set with an ARD of 3/9/11 documented that the resident had a BIMS score of 3 (severely impaired) was non-ambulatory and required extensive assistance to transfer. a. An unsigned, undated "Smoking Safety Assessment" documented the resident was severely impaired in cognitive skills for decision making; mental function varies. Clear speech; able to communicate the need for help if lit material falls on them; Wheelchair primary mode of transportation; no visual limitation; no range of motion limitation. The section for documenting "Disease/[DIAGNOSES REDACTED]. The section titled "Fire safety" documented "Lighter/matches have been obtained from outside source". The "History of smoking incidents" section had boxes to be checked with either a yes or no answers. Neither box was checked. The section titled "Interventions" listed in the smoking safety assessment documented: Independent; Smokes safely with minimal supervision; Smoking apron; Facility storage of tobacco products and fire. None were checked. The sections titled "Assistive devices; Resident instructed and understands facility smoking policy; care planned concern; Nurse signature and Date were all blank. b. The plan of care did not address the resident's smoking until 3/14/11 when it was brought to the facility's attention. 5. On 3/14/11 at 7:15 p.m., the Immediate Jeopardy was removed and the scope/severity reduced to "E" when the facility implemented the following plan of removal: a. All residents that smoke will be reassessed 3/14/11 using the smoking safety assessment form. b. All residents that smoke will not be allowed to smoke unattended beginning 3/14/11 at 7:00 p.m. until all assessments are completed. c. All smoking materials will be removed from the resident's rooms and stored at the nurses station. A log will be maintained each time the resident smokes with name of staff assigned to monitor. The log will be monitored daily by the CEO, DON, designee. The residents will have assigned smoking times as follows: 6 am., 8 am., 10 a.m., 12 noon, 2 pm., 4 pm., 6 pm., 8 pm. d. All staff will be inserviced regarding the plan of removal beginning 3/14/11 as each employee clocks in for work until all staff are in-serviced. e. All residents who smoke will have their care plan updated as of 3/14/11.