Every finding on record at The Springs of Greers Ferry

Based on observation, interview, and facility policy review, the facility failed to ensure kitchen ceiling tiles were cleaned to provide a sanitary environment for food preparation; and the ice machine on the 400 Hall was maintained in a clean and sanitary condition to prevent food and beverage contamination in 1 of 1 kitchen; expired food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; leftover food items were used in a manner to maintain food quality; and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 82 residents who received meals from the kitchen (total census:82), as documented on a list provided by the Dietary Manager on [DATE]. The findings are: 1. On [DATE] at 10:34 AM, the following observations were made in the kitchen: a. The ceiling air vent slats between the steamtable and stove had dust on them. The ceiling tiles by the vent hood were peeling paint, exposing the cement. The area exposed had black stains on it. b. The ceiling tiles in the kitchen had dust on them. c. The ceiling air vent panels between the 2 door refrigerator had rust on them. d. The ceiling air vent panels around the food preparation counter and the stove had rust on them. 2. On [DATE] at 10:35 AM, the deep fryer was covered in greasy food particles. The Dietary Manager was asked when they clean the deep fryer. She stated, Every week. They used it on Friday, and it should have been cleaned. 3. On [DATE] at 10:36 AM, Dietary [NAME] (DC) #1 was wearing gloves on her hands when she picked up a bag of bread from the counter and untied it, contaminating the gloves. Without washing her hands and changing gloves, DC #1 used her contaminated gloved hand to remove slices of bread and place them on the pan liner on the counter. She then removed the lid from a container of peanut butter and a bottle of grape jelly that were on the counter and spread the peanut butter and jelly on the bread to be served to the residents who requested a peanut butter and jelly sandwich with their lunch. 4. On [DATE] at 10:54 AM, the following observations were made on a shelf in the refrigerator in the kitchen: a. Four packages of boiled eggs in an open box had an expiration date of [DATE]. b. A 15 pound box of bacon, the manufacturer's specification on the box indicated, Use by/freeze by [DATE]. There was no date indicated on the box when it was pulled out of the freezer or opened. The Dietary Manager stated they pulled it out over the weekend to be used on Monday, so it will be easy to pull apart. We have the received date on it, but no opened date. c. There were 2 opened bottles of lemon juice, the manufacturer's specification on the bottles indicated, Use by [DATE]. c. There were 2 opened bottles of lemon juice, the manufacturer's specification on the bottles indicated, Use by [DATE]. d. A zip top bag containing leftover sausages. Dietary [NAME] (DA) #1 was asked what the sausages were for. DC #1 stated, We used them the next day for the mechanical soft diets. 5. On [DATE] at 10:54 AM, the following observations were made on a shelf in the refrigerator in the kitchen: 6. On [DATE] at 11:42 AM, DC #1 removed 2 cartons of 2% milk from the milk refrigerator in the storage room and emptied them into a bowl, contaminating her hands. Without washing her hands, DC #1 picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets for noon meal. DC #1 was interviewed on what she should have done after touching dirty objects and before handling clean equipment, DC #1 stated, I should have washed my hands. 7. On [DATE] at 12:40 PM, the following observations were made on a shelf in the kitchen storage room freezer: a. An opened box of pizza. The box was not covered or sealed. b. An opened box of chicken fried steak. The box was not covered or sealed. 9. On [DATE] at 1:20 PM, Dietary Aide (DA) #2 turned on the hand washing sink and washed her hands. Using her bare hands to turn off the faucet, contaminating her hands, before drying her hands with tissue paper. She removed a bottle of grape jelly from the refrigerator and placed it on the counter, removed a bag of bread from the bread rack in the kitchen storage room and placed it on the counter. Without washing her hands, she removed gloves from the glove box and placed them on her hands, contaminating the gloves. She used her contaminated gloved hand to remove slices of bread from the bread bag and placed them on the pan liner on the counter. She removed the lid from a bottle of grape jelly and the lid from a container of peanut butter and spread them on the bread to be served to the residents who requested peanut butter with their lunch. DA #2 was asked what she should have done after touching dirty objects and before handling food items. DA #2 stated, I should have washed my hands. 10. On [DATE] at 1:49 PM, the ice machine on the 400 Hall had wet grayish residue collected on the corners and around the area where ice touched before dropping into the ice collector. It was pointed out to the Dietary Manager and asked if the residue build up could be wiped off. She used tissue paper and wiped it off. The wet grayish residue easily transferred to the tissue. The Dietary Manager was asked who used the ice from the ice machine and how often they cleaned it. She stated that it was cleaned weekly, and they use it in the kitchen to fill beverages served to the residents at mealtimes. 11. A facility policy titled, Food & Nutrition Services Handwashing, initiated [DATE], indicated hand washing should be done before starting to work with food, utensils, or equipment and as often as needed during food preparation and when changing tasks.

Based on record review, observations, and interviews, the facility failed to ensure infection control measures, including hand hygiene were implemented during tracheostomy care for 1 (Resident #9) of 1 sampled resident to prevent potential infection and or the spread of infections. The findings are: 1. Review of a facility policy provided by the Director of Nursing (DON) titled, Suctioning the Lower Airway (Endotracheal or Tracheostomy Tube) with a revision date of October 2010, stated that the nurse should apply sterile gloves and observe sterile technique while suctioning. A review of an Admission Record indicated the facility admitted Resident #9 with a diagnosis of quadriplegia with abnormalities of breathing with a tracheostomy. On 08/13/24 at 2:04 PM, Licensed Practical Nurse (LPN) #9 was observed performing tracheostomy care on Resident #9. While performing care she washed her hands, gloved and put on her gown. Resident was on Enhanced Barrier Precautions. Before suctioning, LPN #9 started out with a sterile field, with her sterile hand she removed the resident's outer cap to the trach and placed it onto the sterile field contaminating the sterile field. With her contaminated hand, she picked up the suction catheter and inserted it into the resident's airway. After she completed suctioning, she used the same hand to replace the cap and touched the inner cannula of the trach. On 08/13/2024 at 2:25 PM, during an interview Licensed Practical Nurse (LPN) #9 stated she should not have laid the cap on the sterile field because it contaminated the sterile field, and she should have changed gloves after removing the outer cap. On 08/14/24 at 3:10 PM, during an interview the Director of Nursing (DON) stated LPN #9 should have not laid the cap on the sterile field because it contaminated the sterile field, and she should have changed gloves after removing the outer cap.

Based on observation, record review, and interview the facility failed to ensure dignity was maintained during lunch service in the dining room as evidenced by staff members not sitting with residents to help them with lunch for two sampled residents, (Resident #45 and Resident #70). These are our findings: 1. A review of the Order Summary revealed Resident #45 had diagnoses of dementia and stroke with weakness on the right dominant side. A review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/08/2024 revealed Resident #45 was given the Staff Assessment for Mental Status (SAMS) which indicated a memory problem for long term and short-term memory. A review of the Care Plan revealed Resident #45 required supervision with eating and required set-up assistance only with eating. 2. A review of the Order Summary revealed Resident #70 had a diagnosis Alzheimer's disease. A review of the Quarterly MDS with an ARD of 07/14/2024 revealed Resident #70 was given the SAMS, which indicated a memory problem for long term and short-term memory. A review of the Care Plan revealed Resident #70 required supervision with set-up assistance with meals/eating. On 08/12/2024 at 1:40 PM, the Surveyor observed Resident #45 and Resident #70 being set up with their lunch meal by Certified Nursing Assistant (CNA) #5 and CNA #6. On 08/12/2024 at 1:42 PM, the Surveyor observed CNA #5 standing next to Resident #70 encouraging the resident to eat lunch. CNA #5 proceeded to bend over and feed Resident #70 a couple bites of scalloped potatoes. CNA #6 was standing next to Resident #45 and was offering the resident verbal encouragement to eat lunch. CNA #6 proceeded to bend over and help Resident #45 with holding their fork. On 08/12/2024 at 1:45 PM, the Surveyor observed CNA #5 and CNA #6 still standing next to Resident #70 and Resident #45. CNA #5 was helping Resident #70 with lunch by offering bites of food. CNA #6 was still offering verbal encouragement to Resident #45. On 08/12/2024 at 1:50 PM, during an interview, CNA #5 and CNA #6 stated that when feeding a resident, you are to sit down next to them. CNA #5 stated that is to keep them from feeling intimidated by the staff members. CNA #6 asked what to do if there are no chairs available to sit next to residents during lunch. CNA #5 stated they should have gone to find chairs instead of standing next to the residents while they ate lunch. On 08/15/2024 at 8:36 AM, during an interview, the Director of Nursing (DON) stated when feeding residents, you sit down next to them to make sure a homelike environment is established. The DON stated that you would not stand over a resident as it is intimidating and not homelike. A review of the facility policy Resident Rights revealed, .Employes shall treat all residents with kindness, respect, and dignity .

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 8 residents who received regular diets from 1 of 1 kitchen according to a list provided by the Dietary Manager on 8/12/24. The findings are: 1. On 8/12/24, a facility noon meal menu indicated all residents were to receive 3 ounces of ham. Residents on pureed diets were to receive 1/2 cup of pureed scalloped potatoes. 2. A facility titled recipe for baked ham initiated on 4/25/2024 indicated for 85 residents, the serving size 3 ounces. For 85 residents use a 22 1/8 pound ham, slice ham into 4 ounce slices, place the ham in a roasting pan, single stacked, add water, and cover the pan with foil. Serve: 3 ounces meat. 3. On 8/12/24 at 12:07 PM, Dietary [NAME] (DC) #1 used a #8 scoop (equivalent to 1/2 cup) to place 6 servings of scalloped potatoes into a blender and pureed, instead of total of 10 servings since 2 residents were to receive pureed doubled portions. 4. On 8/12/24 at 12:16 AM, DC #1 placed 10 small servings of sliced ham into a blender, added its juice and pureed. She poured it into a pan and placed it on the steam table. 5. On 8/12/24 at 1:53 PM, all residents were served small portions of sliced ham. 6. On 8/12/24 at1:55 PM, the Dietary Manager was informed about the portion of ham served to the residents for the noon meal and she asked for the meat to be weighed. She did, and stated, It weighed 1.5 ounces and that wasn't enough. 7. On 8/13/24 at 10:31 AM, DC #1 was asked how many pounds of ham she had prepared for the lunch meal and if she looked at the recipe to see how much to prepare for the noon meal on 8/12/2024. DC #1 confirmed, she made a 10 pound ham and did not look at the recipe. 8. On 8/13/24 at 1:30 PM, during a meeting of the Resident Council, Resident #41 reported that during the last year the portion sizes of meal items were noticeably smaller. The other 3 (Residents #53, #20, and #16) members present verbalized agreement with the assessment that the food portions served were remarkably smaller.

Based on observation, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 8 residents who received pureed diets. The findings are. 1. On 8/12/24 at 12:16 AM, Dietary [NAME] (DC) #1 placed 10 servings of sliced ham into a blender, added its juice and pureed. She poured it into a pan. And placed it on the steam table. The consistency was thick. 2. On 8/12/24 at 12:07 PM, DC #1 used a #8 scoop (equivalent to 1/2 cup) to place 6 servings of scalloped potatoes into a blender and pureed, the consistency was runny. 3. On 8/12/24 at 1:23 PM, DC #1, who prepared the noon meal, was asked to describe the consistency of the pureed ham and pureed scalloped potatoes served to the residents on pureed diets. DC #1 stated the pureed scalloped potatoes were thin and she should have pureed the ham longer to get the right consistency. 4. On 8/13/24 at 7:35 AM, during the breakfast meal service, the following food items were served to the residents on pureed diets: a. Pureed bread. The appearance was too thick. b. The pureed grits were runny. 5. On 8/13/24 at 7:36 AM, Certified Nursing Assistant (CNA) #3 was assisting residents in the dining room with their breakfast meal. She was asked to describe the consistency of the pureed bread and pureed grits served to the residents who required pureed diets. She stated, Pureed bread was thick and pureed grits was thin. 6. On 8/13/24 at 7:40 AM, Dietary [NAME] (DC) #1, who was still serving the breakfast meal was asked to describe the appearance of the pureed bread and pureed grits served to the residents who required pureed diets. DC #1 stated, Pureed bread was thick and pureed grits were thin. 7. A facility policy titled, Pureed Diet no initiated date, provided by the Dietary Manager on 8/13/2024 indicated under how to check the texture is to make sure food is smooth with no lumps; there is no separate thin liquid; food should sit in a pile on the fork; food holds its shape on the spoon; and food is not sticky. A pureed diet is recommended to ensure residents who have problems with swallowing difficulty do not choke.

Based on observation, record review, and interview, the facility failed to ensure the menu card was followed to accommodate one (Resident #61) sampled resident. The findings are: A review of the Order Summary, revealed Resident #61 had diagnoses of dementia, underweight, abnormal weight loss, anorexia, and malnutrition. A review of the Order Summary, revealed Resident #61 had an order for regular enhanced food, mechanical soft texture, thin consistency, with snacks three times a day in between meals, ice cream twice a day, high calorie juice every morning, and enhanced pudding three times a day with meals. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/2024, revealed Resident #61 scored an 11 (moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). On 08/12/2024 at 1:20 PM, the Surveyor observed Resident #61's lunch tray being set up. Chocolate ice cream, peach yogurt, and dessert were in bowls sitting on the tray around the plate that contained ground ham, cauliflower, scalloped potatoes and a slice of bread. Resident #61 immediately began to eat the container of chocolate ice cream. Resident #61 then ate the peach yogurt, and afterwards ate the dessert that was in a separate bowl. Resident #61 tried a couple bites of ground ham, cauliflower and the scalloped potatoes that were on the plate, only to grimace. Resident #61 did not touch the plate again except to pick up the bread to eat it. On 08/12/2024 at 1:50 PM, during an interview, Certified Nursing Assistant (CNA) #7 confirmed Resident #61's lunch card stated to put food in bowls. CNA #7 stated it could help the Resident #61 eat more of their lunch by picking up a bowl instead. On 08/15/2024 at 9:26 AM, during an interview, the Speech Therapist stated they had been working at the facility for a month. Then stated that the bowls were incorporated for the resident either by the previous speech therapist or nursing. The Speech Therapist stated that typically nursing or therapy would add it to make it easier for the resident to eat and hold it close to them so they will eat more. The Speech Therapist stated sometimes the resident does and sometimes the resident does not get all food in bowls at meals. On 08/15/2024 at 09:33 AM, during an interview, the Administrator stated it is important to follow menu orders on a lunch card as the doctor, or therapy has ordered it for the resident, so they will eat and get nutrition. On 08/15/2024 at 09:41 AM, during an interview, the Dietary Manager stated the process to ensure menu cards are followed is that we have somebody that is certified at the window, or I (the Dietary will watch the trays as they go out. The person at the window is supposed to follow what the menu card says. The Dietary Manager stated for Resident #61 that it is a nursing suggestion, from the staff that work on the secure unit regularly, to put the food in bowls so they will eat more at meals, as of right now the resident does not have good intake, they eat like a bird all day. A review of the facility policy titled, Accommodation of Needs stated, .Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being .

Based on observation, record review, and interview, the facility failed to ensure foods stored in the freezer and refrigerator were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; and expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; dietary staff washed their hands and changed gloves before handling food items to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 67 residents who received meals from the Kitchen (Total Census: 67), according to the list provided by the Dietary Supervisor on [DATE] a PM. The findings are: 1. On [DATE] at 9:16 AM, the following observations were made in the refrigerator in the kitchen. a. An opened box of bacon was not covered or sealed. b. An opened box of sausage was not covered or sealed. 2. On [DATE] at 9:18 AM, the following observations made in the freezer in the kitchen. a. An opened box of dinner rolls was not covered or sealed. b. An opened box of loose pancakes was not covered or sealed. 3. On [DATE] at 9:36 AM, 20 cartons of chocolate milk inside a milk crate in the freezer had an expiration date of [DATE]. 4. On [DATE] at 9:52 AM, the ceiling tile above the steam table had black stains at the edges of the area where paint was chipped and paint peeling exposing the board. There were black stains on the air vents of the vent hood. 5. On [DATE] at 9:57 AM, Dietary Employee (DE) #1 opened the refrigerator and removed a bulk of lettuce and tomatoes from the refrigerator and placed them in a colander inside the food preparation sink. He wore gloves on his hands when he turned on the food preparation sink faucet and rinsed the lettuce and tomatoes. After rinsing the lettuce and tomatoes, he turned off the sink faucet with his gloved hand, removed colander that contained lettuce and tomatoes from the sink and placed it on the counter. He removed the gloves from his hands and threw them away. Without washing his hands, he removed gloves from the glove box and placed them on his hands, contaminating the gloves. He removed the lettuce from the colander and placed it on the cutting board. He cut the lettuce and placed it into a pan. He then used the same gloved hand to spread the lettuce out in the pan. At 10:05 AM, he cut the tomatoes and placed them into a pan. At 10:40 AM, DE #1 placed the pans that contained the lettuce and tomatoes on a shelf in the refrigerator to be served to the residents for lunch. 6. On [DATE] at 10:21 AM, DE #2 placed a pan of cake on the counter. Without washing her hands, she placed gloves on her hands, contaminating the gloves. Without changing the gloves and washing her hands. She picked up slices of cake and placed them in individual bowls to be served to the residents for lunch. 7. On [DATE] at 10:25 AM, DE #1 wore mittens on his hands when he removed a pan of hamburger patties from the oven and placed it on the counter. He removed mittens from his hands and placed them on the counter. Without washing his hands, he picked up a pan from under the counter and placed it on the steam table with his fingers inside the pan. At 10:27 AM, he transferred hamburger patties into the pan and placed it on the steam table to be served to the residents for lunch. 8. On [DATE] at 10:30 AM, DE #1 wore mittens on his hands when he removed a pan that contained hamburger patties from the oven and placed it on the counter. He removed the mittens and placed them on the counter. He used a tong to transfer hamburger patties into a pan on the steam table. At 10:33 AM, he placed gloves on his hands, contaminating the gloves. He picked up two onions and placed them on the cutting board. He removed the skins from the onions and without rinsing the onions, he sliced the onions and placed them in a pan. He covered the pan with plastic wrap. At 10:40 AM, DE #1 placed it on a shelf in the refrigerator to be served to the residents for lunch. 9. On [DATE] at 10:49 AM, DE #2 moved a box of plastic wrap on the counter. Without washing her hands, she attached a clean blade to the base of the blender and placed 5 servings of cake in the blender and pureed. 10. On [DATE] at 11:02 AM, DE #1 wore gloves on his hands. He used scissors to open a bag that contained tater tots, contaminating the gloves in the process. He poured the tarter tots into a deep fryer basket and placed it in the oil to fry. After the tater tots were done, he picked up deep fryer basket that contained the tater tots from the oil and placed it on the hook attached to the deep fryer to drain. Without changing gloves and washing his hands, he picked up the basket of tarter tots and used his contaminated gloved hand to push the tater tots inside the basket into a pan to be served to the residents for lunch. At 11:07 AM, without washing his hands, he placed new gloves on his hands, contaminating the gloves. He unzipped a bag that contained slices of cheese and used his contaminated gloved hands to remove slices of cheese and place them in a pan. He covered the pan with plastic wrap and placed it on a shelf in the refrigerator to be served to the residents for lunch. 11. On [DATE] at 11:28 AM, DE #1 turned on the food preparation sink faucet and obtained water into a pot and placed it on the stove and turned on the stove. He removed a can of diced tomatoes from a rack in the Storage Room and placed it on the counter. At 11:32 AM, without washing his hands, he placed gloves on his hands, contaminating the gloves. He picked up a container of beef base from the spice rack and opened it. He removed a teaspoon full of beef base from the container with a plastic spoon, used his contaminated gloved hand to push it down into the pot of water on the stove to be used in pureeing hamburger patties to be served to the residents on pureed diets. At 11:34 AM, he removed the gloves from his hands and threw them away. Without washing his hands, he removed gloves from the glove box and placed them on his hands, contaminating the gloves. He picked up a clean blade and attached it to the base of the blender to be used in grounding meat items to be served to the residents on mechanical soft diets. At 1:12 PM, the Surveyor asked DE #1 what he should have done after touching dirty objects and before handling clean equipment and food items. He stated, I should have washed my hands. 12. The facility policy on Hand Washing, provided by the Dietary Supervisor on [DATE] at 10:23 AM documented, .Wash your hands as often as possible. It is important to wash your hands: Before starting to work with food, utensils, or equipment. Before putting on gloves . After handling soiled utensils and equipment . As often as needed during food preparation and when changing tasks.

Based on observation, record review and interview, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely. This failed practice had the potential to affect 67 residents who resided in the facility according to the Census and Conditions of Residents provided by the Administrator on 07/03/23. The findings are: 1. On 07/03/23 the Payroll Based Journal Staffing Data Report - CASPER Report for January 1 to March 31, 2023, provided by the Centers for Medicare and Medicaid Services (CMS) revealed One Star Staffing Rating was Triggered (Triggered = Star Staffing Rating Equals 1) and an Excessively Low Weekend Staffing was Triggered (Triggered = Submitted Weekend Staffing data is excessively low). 2. Resident #25 had a diagnosis of Quadriplegia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/23 documented the resident was cognitively intact and required extensive physical assistance of two plus persons for bed mobility and dressing, extensive physical assistance of one person for personal hygiene and was totally dependent on staff of on one to two plus persons for transfers and toilet use. a. On 07/04/23 at 8:52 AM, the Surveyor asked Resident #25, Does the facility have enough staff to care for the residents? He said, No, if they are on another hall and helping someone, they cannot come help us. The weekends are worse. They call in and don't show up, sometimes there are just two aides to take care of everybody. b. 07/05/23 11:51 AM, the Care Plan with a revision date of 01/12/23 documented, . I have ADL [activities of daily living] self-care performance deficits AEB [as evidence by] need for extensive to total dependence of 1-2 staff form [for] most ADLs r/t [related to] quadriplegia . 3. Resident #59 had a diagnosis of Hemiplegia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/23 documented the resident was cognitively intact and required extensive physical assistance of one person for bed mobility, transfers, dressing toilet use and personal hygiene. a. On 07/04/23 at 9:43 AM, Resident #59 said they do not have enough help on the weekends. A minute turns into 30 minutes and then into an hour. b. On 07/05/23 at 12:51 PM, the Care Plan documented, .I have ADL self-care performance deficits AEB need for extensive assistance of 1-2 staff for ADLs r/t recent stroke with hemiplegia/hemiparesis to left nondominant side . 4. On 07/04/23 at 9:10 AM, Licensed Practical Nurse (LPN) #1 stated she does not work nights but is aware that nights, both weekend and weekdays, are typically hard to staff. To her knowledge, there are always two nurses in the facility until 11:00 PM, then often one until the day shift comes in. Sometimes the day shift nurse would come in early to help out in the mornings. She thinks they try to have two to three Certified Nursing Assistances (CNAs) in the building on night shift. Sometimes in the mornings there are resident complaints about being left in urine or feces too long. It's more common than it should be, but not every day, and not the same resident. Management has started a referral program for CNA new hires, and she was aware of one new nurse currently in orientation who was hired for nights. 5. On 07/04/23 at 9:22 AM, CNA #1 stated she was not aware of any short staffing currently, but there was a shortage in April that has been corrected. Management started a Referral Program for CNAs and word of mouth to bring in more qualified staff and she believes it is helping. The typical number of staff per shift is six to ten, including nurses and was not aware of any residents who are being left in urine or feces for extended periods of time. 6. On 07/04/23 at 9:34 AM, the Director of Nursing (DON) stated she feels there are no current short staffing issues. Typical staff count is eight to ten for the 6A-6P (6:00 AM-6:00 PM) shift and four to five for the 6P-6A (6:00 PM-6:00 AM), this includes two nurses and four CNAs. She does not feel like any resident is constantly being left in urine or feces for extended periods of time, but if some are occasionally left longer than desirable, it would usually be during the night or after an activity. 7. On 07/04/23 at 10:08 AM, the January through June 2023 Resident Grievance Log provided by the Administrator documented, .1/27/2023 Resident was not showered . call light response time . 02/22/2023 not enough help during 2nd shifts . 02/24/2023 answering call light . 3/10/2023 Call lights not answered timely . 3/13/2023 Wants assistance with shower . 4/5/2023 Wants hair washed . 5/10/23 .having issues getting call lights answered timely . 5/11/23 Resident states she was left on toilet . 5/30/23 .Requested shower . 6/01/2023 Family concerned about resident not being toileted frequently enough . 6/1/23 Resident wants a shower . 6/16/2023 Wants a shower . 6/16/2023 Frequency of showers, shaving . 6/18/2023 Answering call light in a timely manner . 6/21/2023 Answering call light in a timely manner . 6/23/2023 Needs toenails trimmed . 6/27/2023 Call light response . 8. On 07/05/23 at 9:23 AM, the Nursing Staff Log provided by the DON documented, 2/18/23 .census of 64 . 3rd shift 6p-6A 3 unlicensed staff . 2/23/23 3rd shift 2 unlicensed staff . 2/25/23 3rd shift 2 unlicensed staff . 3/1/23 3rd shift 2 unlicensed staff . 3/2/23 3rd shift 2 unlicensed staff . 3/5/23 3rd shift 2 unlicensed staff . 3/13/23 3rd shift 2 unlicensed staff . 3/14/23 3rd shift 2 unlicensed staff . 3/17/23 3rd shift 2 unlicensed staff . 3/18/23 3rd shift 2 unlicensed staff . 4/4/23 3rd shift 2 unlicensed staff . 4/8/23 3rd shift 2 unlicensed staff . 4/14/23 3rd shift 2 unlicensed staff . 5/18/23 3rd shift 2 unlicensed staff . 5/20/23 3rd shift 2 unlicensed staff . 5/21/23 3rd shift 2 unlicensed staff . 5/22/23 3rd shift 2 unlicensed staff . 5/23/23 3rd shift 2 unlicensed staff . 5/26/23 3rd shift 2 unlicensed staff . 5/28/23 3rd shift 2 unlicensed staff . 9. On 07/05/23 at 9:28 AM, the Surveyor asked the DON, Do you have enough staff to meet the needs of the residents? She said, I am going to be honest with you. We had 25 staff members leave after I started. The Surveyor asked, Are the residents getting showers, nail care and shaved as they should? She said, Most of them. The Surveyor asked, The residents are complaining they do not have enough staff on weekends, and they have to wait a long time for call lights to be answered, is that true? She said, They have two nurses on 6p to 6a. There are always two nurses, either myself or the ADON [Assistant Director of Nursing], who works on night shift and two aides. We are working on the call ins. 10. 07/05/23 10:09 AM, during a Resident Council meeting with 4 residents, the Surveyor asked, Do you get the help you need without having to wait a long time? The residents said, Except for the weekends. You are lucky if you see anybody. It takes over 30 minutes to get a call light answered and by that time it is too late. 48388

Based on observation, record review, and interview, the facility failed to ensure facial hair was removed regularly to maintain good grooming for 1 (Resident #63) of 20 (Residents #1, #6, #7, #10, #11, #25, #30, #31, #33, #39, #40, #47, #49, #55, #59, #60, #63, #64, #66 and #67) sampled residents who were dependent on staff for shaving and failed to ensure fingernails were regularly trimmed when needed to maintain good grooming for 2 (Residents #11 and #63) of 30 (Residents #1, #6, #7, #10, #11, #12, #18, #22, #25, #26, #30, #31, #32, #33, #36, #38, #39, #40, #47, #49, #55, #58, #59, #60, #61, #63, #64, #66, #67 and #321) sampled residents who were dependent on staff for nail care. The findings are: 1. Resident #11 had a diagnosis of Quadriplegia and Parkinson's Disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date of 04/19/23 documented the resident was totally dependent on two plus persons for personal hygiene and bathing. a. On 07/03/23 at 10:22 AM, Resident #11 was lying in bed with sharp and jagged fingernails on both hands. The Surveyor asked Resident #11 if his fingernails needed to be trimmed and filed. He said, Yes, I can't do it. b. On 07/03/23 at 3:06 PM, Resident #11 was lying in bed with sharp and jagged fingernails on both hands. c. On 07/03/23 at 2:35 PM, the Care Plan documented, .I am total dependence of 1-2 staff with all my ADL's [Activities of Daily Living] due to my quadriplegia and immobility . Date Initiated: 03/05/2018 Revision on: 01/20/2021 . Nail Care: I am total dependence on 1 staff for nail care. Please clean, trim and file nails on bath days and PRN [as needed]. Date Initiated: 04/23/2020 Revision on: 04/12/2022 . d. On 07/04/23 at 10:06 AM, Restorative Aide (RA) #1 was in Resident #11's room doing stretches with the resident's left arm and hand. The resident was lying in bed and continued to have sharp and jagged fingernails on both hands. The Surveyor asked RA #1 if Resident #11 ever refused care. She said, No. e. On 07/04/23 at 1:11 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 if Resident #11 had sharp jagged fingernails. She said, Yes. The Surveyor asked what could happen with fingernails that are jagged and sharp. She said, They could get a skin tear. 2. Resident #63 had a diagnosis of Type II Diabetes Mellitus. The Admission MDS with an ARD of 04/05/23 documented the resident required extensive physical assistance of one person with personal hygiene and was totally dependent on two plus persons for bathing. a. On 07/03/23 at 10:49 AM, Resident #63 was lying in the bed. He had facial whiskers approximately 1/2 inch long and his fingernails were approximately 3/4 inch long, thick, and jagged. b. On 07/03/23 at 2:19 PM, Resident #63 was up in a shower chair by the Nurses Station. The resident was not clean shaven, and his fingernails were approximately 3/4 inch long, thick, and jagged. c. On 07/04/23 at 9:03 AM, Resident #63 was lying in bed, his fingernails were approximately 3/4 inch long, thick, and jagged. The resident was clean shaven, and his chin was very red. d. The Care Plan documented, I have an ADL self-care performance deficit r/t [related to] weakness. Date Initiated: 03/30/2023 Revision on: 04/05/2023 . Nail Care: Check nail length and trim and clean as necessary. Date Initiated: 04/05/2023 . Personal Hygiene: The resident requires extensive assistance with personal hygiene . e. On 07/04/23 at 1:11 PM, the Surveyor asked LPN #1 if Resident #63 had sharp jagged fingernails. She said, Yes. The Surveyor asked what could happen with fingernails that are jagged and sharp. She said, They could get a skin tear. His right first fingernail is cracked. The Surveyor asked if he prefers to be clean shaven. She said, Yes. 3. On 07/04/23 at 3:49 PM, the Administrator provided the following policies: a. A policy titled, Fingernails/Toenails Care, documented, Purpose The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Reporting 1. Notify the supervisor if the resident refuses the care . b. A policy titled, Shaving the Resident, documented, .Purpose The purpose of this procedure is to promote cleanliness and to provide skin care . Documentation The following information should be recorded in the resident's medical record: l. The date and time that the procedure was performed .

Based on observation and interview, the facility failed to ensure 2 of 2 clothes dryers remained free of lint build-up to decrease the potential for fire and loss of laundry services for 1 of 1 laundry room. This failed practice had the potential to affect all 67 residents due to the potential for the interruption of laundry services and the potential for fire due to the proximity of the laundry room according to the Resident Census and Conditions of Residents form dated 07/03/23. The findings are: 1. On 07/04/23 at 2:00 PM, during the Infection Control tour of the Laundry Department with the Environmental Director (ED), the following observations were made: a. There were 3 electric dryers in the clean area of the laundry room on the 400 Hall. Dryer #2 did not work and was not in use. The ED opened the bottom drawer to Dryer #1. The Surveyor observed lint hanging off the lint filter approximately 1/4 inch thick. The Surveyor asked her to look on top of the lint trap around the electrical wiring. The Surveyor then asked, What do you see there? She said, Lint. The Surveyor asked, What can happen with that around the wiring? She said, A fire hazard. I was told we are not supposed to touch that. Maintenance is supposed to clean that monthly. She then opened the lint trap for Dryer #3. The Surveyor asked her to look on top of the lint trap around the electrical wiring. The Surveyor asked, What do you see there? She said, Lint. The Surveyor asked, How often do you clean the lint off of the filters? She said, Every 2 hours. b. On 07/04/23 at 2:46 PM, the ED presented the Surveyor with a copy of the Dryer Lint Clean Schedule that documented, .July 2023 . 4 . 6 [6:00] am, 8 [8:00] am, 10 [10:00] am, 12 [12:00] pm, and 2 [2:00] pm ., and was initialed as being completed. A copy of the Quarterly Dryer Maintenance schedule documented, .6/3/23 . Remove all Lint/Dirt From Top to Bottom of Motors . A copy of the Manufacture Guidelines documented, . Clean any lint from the lint compartment and screen daily to maintain proper airflow and avoid overheating . Remove lint and debris from inside the exhaust duct monthly to maintain proper airflow and avoid overheating . c. On 07/04/23 at 3:20 PM, the Surveyor asked the Administrator, Should there be lint around the wiring in the dryers? She said, No. The Surveyor asked, Why? She said, It could be a fire hazard.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 4 residents who received pureed diets and 12 residents who received mechanical soft diets (total census: 67) according to a list provided by the Dietary Supervisor on 07/03/23. The findings are: 1. On 07/03/23, the menu for the lunch meal showed residents who received mechanical soft diets were to receive a #10 scoop (3 ounces) of ground cheeseburger and residents who received pureed diets were to receive a #6 scoop (6 ounces) of pureed cheeseburger on bun, #12 scoop (1/3 cup) of pureed soft cooked vegetables and and a #12 scoop of pureed peas in place of a relish plate. a. On 07/03/23 at 11:38 AM, Dietary Employee (DE) #1 placed 7 servings of hamburger patties into a blender, added a small beef broth and ground. At 11:41 AM, he poured the ground hamburger patties into a pan and placed it on the steam table to be served to 12 residents who required mechanical soft diets. At 12:55 PM, he used a #10 scoop to serve half of a portion of ground hamburger meat to the residents on mechanical soft diets, instead of a full serving of #10 scoop as specified on the menu. b. On 07/03/23 at 11:47 AM, DE #1 placed 7 servings of hamburger patties into a blender, added beef broth and pureed. At 11:52 AM, he poured the pureed beef patties into a pan and placed them on the steam table. At 1:01 PM, he used a #10 scoop to serve half of a portion of pureed hamburger patties to the residents on pureed diets, instead of full serving of #10 scoop as specified on the menu. There were no buns and cheese included in the pureed meat served to the residents on pureed diets for lunch. The menu specified for each resident on a pureed diet to receive a #6 scoop of pureed cheeseburger. c. On 07/03/23 at 12:00 PM, DE #1 used a 4 ounce spoon to place 4 servings of cauliflower into a blender and puree. At 12:04 PM, he poured the pureed cauliflower into a pan and placed it on the steam table. At 1:01 PM, he used a #8 scoop (1/2 cup) and gave 1/2 half scoop to each resident, which is equivalent to 1/4 cup to be served to 4 residents on pureed diets. The menu specified a #12 scoop (1/3) cup of pureed soft, cooked vegetables each. The menu also specified for the residents on pureed diets to receive a #12 scoop of pureed peas, in place of a relish plate. There were no pureed peas prepared and served to the residents on pureed diets. d. On 07/03/23 at 1:12 PM, the Surveyor asked DE #1 the reason the residents on pureed diets did not receive bread and peas. He stated, I gave them cauliflower and mashed potatoes. He was informed that the menu for the pureed diets called for cauliflower and peas. The Surveyor asked if he looked at the menu before preparing the lunch meal. He stated, I looked at the other menu. The Surveyor asked how many residents were on mechanical soft diets. He stated, We have 13 residents. The Surveyor asked how many servings of hamburger patties he prepared for the residents on mechanical soft diets. He stated, I did 7 servings. The Surveyor asked if 7 servings would be enough for 13 residents. He stated, I should have used 13 hamburger patties, instead of 7 servings. The Surveyor asked what scoop sizes he used to serve puree food items and ground meat. He stated, I used a #10 scoop to serve pureed meat and ground meat. A #8 scoop to served pureed cauliflower and mashed potatoes. The portions were small. The portions were not to the rims of the scoops.

Based on record review and interview, the facility failed to develop and implement procedures to ensure the resident's medical record included documentation the resident either received the pneumococcal and influenza vaccine(s) or did not receive the vaccine(s) due to medical contraindications, previous vaccination, or refusal for 2 (Residents #64 and #67) of 5 (Residents #1, #36, #64, #66 and #67) sampled residents. The findings are: 1. Resident #64 had diagnoses of Diabetes Mellitus, Acute Upper Respiratory Infection, and Muscle Weakness (Generalized). The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/05/23 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). The section of the MDS regarding if the resident was up to date on the Pneumococcal Vaccine or had received Influenza Vaccine contained no documentation. a. On 07/05/23 at 3:28 PM, Resident #64's medical record documented the resident received a Pneumococcal Vaccination on 04/10/22 and did not contain documentation the resident received or refused the Influenza Vaccination. 2. Resident #67 had diagnoses of Sepsis due to Streptococcus Pneumoniae and Pneumonia. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/20/23 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). The section of the MDS regarding if the resident was up to date on the Pneumococcal Vaccine or had received Influenza Vaccine contained no documentation. a. On 07/05/23 at 3:34 PM, Resident #67's medical record did not contain documentation the resident received or refused the Pneumococcal or Influenza Vaccinations. 3. On 07/05/23 at 4:05 PM, the Director of Nursing (DON) stated the facility currently does not have a system in place to document resident immunizations in their records. 4. On 07/05/23 at 4:12 PM, the facility policy titled Vaccination of Residents documented, .3. All new residents shall be assessed for current vaccination status upon admission.5. If vaccines are refused, the refusal shall be documented in the resident's medical record. 6. If the resident receives a vaccine, at least the following information shall be documented in the resident's medical record: a. Site of administration; b. Date of administration; c. Lot number of the vaccine; d. Expiration date; e. Name of person administering the vaccine .

Based on observation, record review, and interview, the facility failed to ensure an indwelling urinary catheter drainage bag was concealed in a privacy bag when visible from open door to room and when in common areas to promote dignity and maintain privacy for 1 (Resident # 63) of 5 (Residents #11, #25, #36, #55, and #63) sampled residents who had an indwelling urinary catheter. This failed practice had the potential to affect 6 residents who had indwelling urinary catheters as documented on list provided by the Director of Nursing (DON) on 07/04/23 at 2:40 PM. The findings are: 1. Resident #63 had a diagnosis of Type II Diabetes Mellitus and Urine Retention. a. On 07/04/23 at 9:18 AM, the Surveyor observed Resident #63 lying in the bed. The catheter bag was hanging on the side of the bed, not in a privacy bag. There was approximately 450 cc (cubic centimeters) of yellow urine in the bag. The resident's door was open to the hallway. b. On 07/04/23 at 1:10 PM, the Surveyor observed Resident #63 lying in bed. The catheter bag was hanging on the side of the bed, not in a privacy bag. The resident's door was open to the hallway. c. On 07/04/23 at 1:31 PM, the Care Plan does not address keeping the catheter bag in a privacy bag. d. On 07/04/23 at 1:38 PM, the Surveyor asked the Director of Nursing (DON), Should the resident's catheter bag be in a privacy bag? She said, Yes. The Surveyor asked, Why? She said, Because of dignity. e. The facility policy titled, Catheter Care, Urinary, provided by the DON on 07/04/23 at 2:40 PM, did not address providing a privacy bag.

Based on record review and interview, the facility failed to develop and implement a Chronic Viral Hepatitis C plan of care for 1 (Resident #47) of 2 (Residents #18 and #47) sampled residents who had a diagnosis of Chronic Viral Hepatitis C as documented on a list provided by the Administrator on 07/05/23 at 3:40 PM. The findings are: 1. Resident #47 had a diagnosis of Chronic Viral Hepatitis C. a. A review of Resident #47's medical records documented he was diagnosed with Chronic Viral Hepatitis C on 11/23/22. b. The Care Plan with an initiated date of 07/15/21 and a revision date of 06/06/23 did not address interventions and care related to Chronic Viral Hepatitis C. c. On 07/05/23 at 1:05 PM, during an interview with the MDS Coordinator she was unable to find a Care Plan section that addressed this resident's diagnosis of Chronic Viral Hepatitis C. The MDS Coordinator stated, It must not have ever been carried over [from the MDS]. d. The facility policy titled, Care Plans, Comprehensive Person Centered, provided by the Administrator on 07/05/23 at 3:55 PM documented, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .

Based on observation, interview, and record review, the facility failed to ensure cleaning chemicals, [named] cloth wipes, and perineal cleaning items were contained on 300 Hall (secure unit); failed to ensure normal saline was contained when not in use; and failed to ensure staff used gait belts and two staff for 1 (Resident #1) of 4 (#1, #2, #3, #4) sampled residents who required two staff for transfers. The findings are: 1. On 05/30/23 at 9:11 a.m., observations were made in the Secure Unit (300 Hall) Dining Room. The cabinets above and below the sink had metal latches that contained no locks. The cabinet above the sink contained [named] perineal cleansers. The top cabinet to the right of the sink contained a container of [named] Germicidal Wipes. The cabinet below the sink contained a spray bottle with a yellow liquid disinfecting spray. The cabinets and hazardous materials were not locked. a. On 05/30/23 at 9:13 a.m., the Surveyor asked Certified Nursing Assistant (CNA) #1, When do you put locks on the cabinets doors? CNA #1 replied, I haven't seen any locks on those doors since I've been here. 2. On 05/30/23 at 10:38 a.m., a bottle of 0.9 % [percent] Sodium Chloride (normal saline) was on the treatment cart in the hallway of 300 Hall. There was no staff present. a. On 05/30/23 at 10:41 a.m., the Surveyor asked Registered Nurse (RN) #1, Why should normal saline not be left out and not contained? RN #1 replied, So the residents won't get into it. b. On 05/30/23 at 10:43 a.m., RN #1 pushed the treatment cart to the Nurse's Station and walked away, leaving the bottle of normal saline on top of the treatment cart. There was no staff present. c. On 05/30/23 at 10:45 a.m., the Surveyor asked RN #1, What is the normal saline used for? RN #1 replied, I use normal saline for wounds, and I did not put it in the drawer. 3. Resident #1 had a diagnosis of Hemiplegia, Hemiparesis, Multiple Sclerosis, and Abnormality of gait and mobility. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/17/23 documented the resident scored 15 (13-15 cognitively intact) on the Brief Interview for Mental Status (BIMS), required extensive assist of two staff for bed mobility, transfers, walk in room, walk in corridor, and toilet use. a. The Care Plan with a revision date of 01/13/23 documented, .I have ADL (Activities of Daily Living) self-care performance deficits .transfers .resident requires extensive assistance of 2 staff with transfers . b. The Fall assessment dated [DATE] documented, .Resident's score is a 13 which indicates that he is a high risk for falls at this time . c. On 05/30/23 at 9:44 a.m., the Surveyor asked Resident #1, Tell me about the fall you had recently. Resident #1 stated, I did fall when they didn't use a gait belt on May 12, 2023, the x-ray didn't show anything. The CNA was putting me to bed from my wheelchair, the fall mat was under the bed and my foot hit the fall mat when I went to pivot and we both went down, I landed on my left side. The CNA hit the floor with the right knee, and they didn't use a gait belt. d. On 05/30/23 at 2:56 p.m., the Surveyor asked Resident #1, How many assistants were transferring you when you had your fall on 05/12/23? Resident #1 replied, 1 CNA. The Surveyor asked, Did they use a gait belt during the transfer? Resident #1 replied, No. 4. On 05/30/23 at 3:08 p.m., the Surveyor asked CNA #2, How many staff does it take to transfer Resident #1? CNA #2 replied, 2 person assist. The Surveyor asked, When are gait belts used? CNA #2 replied, Anytime you transfer someone. The Surveyor asked Why are gait belts utilized? CNA #2 replied, To prevent hurting the resident and make it easy on the resident. The Surveyor asked, Where is normal saline stored when not in use and why? CNA #2 replied, In the Medication Room or the treatment cart. The Surveyor asked, Where are peri-care products stored when not in use? CNA #2 replied, In the closet on 400/500 Hall or the Supply Closet. The Surveyor asked, Where are [named wipes] stored when not in use? CNA #2 replied, Locked up. The Surveyor asked, Where are cleaning supplies/sprays stored when not in use? CNA #2 replied, Behind locked doors. The Surveyor asked, Who is responsible for ensuring these items are not left out? CNA #2 replied, Everyone. 5. On 05/30/23 at 3:20 p.m., the Surveyor asked Licensed Practical Nurse (LPN) #1, When are gait belts used? LPN #1 replied, Whenever you transfer somebody. The Surveyor asked, Why are gait belts utilized? LPN #1 replied, So you can hold onto them and not get under the residents' arms. The Surveyor asked, Where is normal saline stored when not in use and why? LPN #1 replied, In the Medication Room because residents could get a hold of it. The Surveyor asked, Where are peri-care products stored when not in use? LPN #1 replied, In a locked room on the hall and because we don't want a resident to get a hold of it. The Surveyor asked, Where are [named wipes] stored when not in use? LPN #1 replied, Locked up because that's got stuff you don't want residents to get a hold of. The Surveyor asked Where are cleaning supplies/sprays stored when not in use? LPN #1 replied, Locked up so residents don't get a hold of it. The Surveyor asked, Who is responsible for ensuring these items are not left out? LPN #1 replied, Everybody. 6. On 05/30/23 at 4:13 p.m., the Surveyor asked the Director of Nursing (DON), How many staff does it take to transfer Resident #1? The DON replied, I thought Resident #1 was a one person assist. The Surveyor asked, When are gait belts used? The DON replied, Only transferring anyone who needs assistance. The Surveyor asked, Why are gait belts utilized? The DON replied, To keep residents from having I and A's (incidents and accidents) and for safety. The Surveyor asked, Who was the CNA performing the transfer on Resident #1 on 05/12/23? The DON replied, CNA #3. The Surveyor asked, Was CNA #3 using a gait belt during the transfer of Resident #1 on 05/12/23? The DON replied, No. The Surveyor asked, Where is normal saline stored when not in use and why? The DON replied, Locked up, so residents don't get them. The Surveyor asked, Where are peri-care products stored when not in use? The DON replied, Locked up so the residents don't get it. The Surveyor asked the DON, Where are [named] wipes stored when not in use? The DON replied, Locked up so no residents get it. The Surveyor asked Where are cleaning supplies/sprays stored when not in use? The DON replied, Locked up, away from residents. The Surveyor asked, Who is responsible for ensuring these items are not left out? The DON replied, All staff. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines related to the concerns found during this survey? The DON replied, I expect them to use a gait belt and follow policy and procedures. 7. On 05/30/23 at 4:43 p.m., The Surveyor asked the Administrator, How many staff does it take to transfer Resident #1? The Administrator replied, I'd have to look. The Surveyor asked, When are gait belts used? The Administrator replied, When they are called for by their Plan of Care. The Surveyor asked, Why are gait belts utilized? The Administrator replied, For safety and proper transfers. The Surveyor asked, Who was the CNA's performing the transfer on Resident #1 on 05/12/23? The Administrator replied, CNA #3. The Surveyor asked, was CNA #3 using a gait belt during the transfer of Resident #1 on 05/12/23? The Administrator replied, I don't know. The Surveyor asked, Where is normal saline stored when not in use and why? The Administrator replied, Locked up out of reach of residents because it's a safety concern. The Surveyor asked, Where are peri-care products stored when not in use and why? The Administrator replied, Locked up so residents don't get it. The Surveyor asked, Where are [named] wipes stored when not in use and why? The Administrator replied, Locked up so residents don't get it. The Surveyor asked, Where are cleaning supplies/sprays stored when not in use? The Administrator replied, Locked up. The Surveyor asked, Who is responsible for ensuring these items are not left out? The Administrator replied, Everyone. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and the CMS guidelines related to the concerns found during this survey? The Administrator replied, We expect them to follow them. 8. The facility policy titled, Hazardous Areas, Devices and Equipment, provided by the Administrator on 05/30/23 at 3:36 p.m. documented, .all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible .a hazard is defined as anything in the environment that has the potential to cause injury or illness .examples of environmental hazards include, but not limited to the following .access to toxic chemicals .disabled locks, latches, or alarms . 9. The facility policy titled, Storage of Medications, provided by the Administrator on 05/30/23 at 3:36 p.m. documented, .the facility stores all drugs and biologicals in a safe, secure, and orderly manner .drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls .the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use . 10. The Safety Data Sheet (SDS) titled, Peri fresh, provided by the Administrator on 05/30/23 at 4:06 p.m. documented, .irritating if placed in eyes, or if ingested .flush eyes with water for 15 minutes .if ingested drink large amounts of water .call physician . 11. The Safety Data Sheet titled, Super Sani-Cloth Germicidal Wipe, provided by the Administrator on 05/30/23 at 4:06 p.m. documented, .causes serious eye irritation .wear protective gloves/protective clothing/eye protection/face protection .store locked up .may be harmful if swallowed .may be harmful if inhaled .

Based on observation, interview, and record review, the facility failed to ensure the residents were treated with dignity and respect as evidenced by failure to provide the residents with privacy, failure to ensure residents of the opposite sex did not share or have access to the same bathroom and failure to ensure residents did not expose themselves to other residents while using the shared bathroom for 2 (Residents #1 and #2) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents. The findings are: 1. Resident #1 had diagnoses of Schizophrenia, Muscle Wasting and Atrophy, and Post-Traumatic Stress Disorder. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/10/23 documented the resident scored 5 (0-7 severe impairment) on the Brief Interview for Mental Status (BIMS), required extensive assist of two persons for bed mobility, and had impairments on both sides to upper extremities, and was admitted to [named] room. a. Review of Resident #1 Care Plan for limited physical mobility initiated on 12/2/22, last revised on 4/6/23 revealed the resident is unable to ambulate. b. Review of Resident #1 Care Plan for history of trauma that affects the resident negatively initiated on 3/10/23 revealed the resident is triggered by being in a room with the door closed and being touched without consent. c. On 05/23/23 at 8:58 a.m., Resident #1 was lying in her bed. The Surveyor asked, When did the facility move you to this room? Resident #1 replied, Last week I got moved. The Surveyor asked, Did a male resident expose himself when you were on the 500 Hall? Resident #1 replied, Resident #2 did use the bathroom, and the door came open when using the bathroom. I can't walk, so I was lying in bed. The Surveyor asked, How many times did that happen? Resident #1 replied, One time that I remember. 2. Resident #2 had diagnoses of Hypertension, Emphysema, and Chronic Obstructive Pulmonary Disease. The Admission MDS with an ARD of 04/26/23 revealed that Resident #2 was admitted to the facility on [DATE] to [named] room, documented a score of 14 a BIMS. a. On 05/22/23 at 5:47 a.m., the Surveyor asked the Nursing Assistant (NA) #1, Did Resident #1 and Resident #2 share a bathroom on 500 Hall? NA #1 replied, The residents' rooms were next to each other, but Resident #1 is a [named electric] lift. The Surveyor asked, When did Resident #1 switch halls? NA #1 replied, About a month ago. b. On 05/22/23 at 10:45 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #2, Why should residents of the opposite sex, not married, not have access to the same bathroom? LPN #2 replied, It's dignity. c. On 05/22/23 at 10:52 a.m., the Surveyor asked Certified Nursing Assistant (CNA) #1, Why should residents of the opposite sex, not married, not have access to the same bathroom? CNA #1 replied, A dignity thing. d. On 05/22/23 at 4:03 p.m., a telephone interview was conducted with LPN #1. The Surveyor asked LPN #1 to elaborate on the situation regarding Resident #1 and Resident #2 having an adjoining bathroom. LPN #1 replied, Resident #1 is bed bound, and was lying in bed, and Resident #2 was in the bathroom using the bathroom, and the door opened, Resident #2 exposed self to Resident #1 while Resident #1 was in the bed. The Surveyor asked, Was this reported to anyone? LPN #1 replied, I mentioned it to the DON and to the Corporate Nurse Manager. The Surveyor asked, When was Resident #1 moved to a different room? LPN #1 replied, Just in the past 2 weeks. e. On 05/23/23 at 11:44 a.m., the Surveyor asked the Social Services Director (SSD), Who is responsible for assigning residents rooms when they admit? The SSD replied, The team, the Administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), when Resident #1 came in, Resident #1 was placed on 500 Hall for skilled, for therapy. The Surveyor asked, Why was Resident #1 and Resident #2 assigned a room with an adjoining bathroom? The SSD replied, I think the justification was because Resident #1 didn't use the bathroom, but Resident #2 could. The Surveyor asked, When was Resident #1 moved from 500 Hall to 100 Hall? The SSD replied, Last week. The Surveyor asked, Why was Resident #1 moved to 100 Hall? The SSD replied, Resident #1 is going long term care, and we use 500 Hall for skilled. The Surveyor asked, Why should female and male residents not have adjoining bathrooms? The SSD replied, Because male and female are different sexes. The Surveyor asked, How are residents dignity/rights protected if Resident #1 and Resident #2 are sharing an adjoining bathroom? The SSD replied, The justification was Resident #1 didn't use the bathroom, but Resident #2 did have access to Resident #1's room. f. On 05/23/23 at 12:24 p.m., the Surveyor asked the DON, Who is responsible for assigning residents rooms when they admit? The DON replied, The interdisciplinary team (IDT). The Surveyor asked, Why was Resident #1 and Resident #2 assigned a room with an adjoining bathroom? The DON replied, Because Resident #1 doesn't toilet. The Surveyor asked, When was Resident #1 moved from 500 Hall to 100 Hall? The DON replied, Last week or in the last 2 weeks. The Surveyor asked, Why was Resident #1 moved to 100 Hall? The DON replied, Resident #1 was moved to 600 Hall because of long term care, then from 600 Hall to 100 Hall because of complaints about the roommate. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines? The DON replied, We expect them to follow all policies and procedures. g. On 05/23/23 at 12:25 p.m., the Surveyor asked the Administrator, Who is responsible for assigning residents rooms when they admit? The Administrator replied, IDT. The Surveyor asked, Why was Resident #1 and Resident #2 assigned a room with an adjoining bathroom? The Administrator replied, Because Resident #1 didn't utilize the bathroom. The Surveyor asked, When was Resident #1 moved from 500 Hall to 100 Hall? The Administrator replied, From 500 Hall to 600 Hall and then to 100 Hall on 05/16/23. The Surveyor asked, How are residents dignity/rights protected if Resident #1 and Resident #2 are sharing an adjoining bathroom? The Administrator replied, Ensure the doors are properly closed. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedures and the CMS guidelines? The Administrator replied, We expect them to follow all policies and procedures.

Based on observation, interview, and record review, the facility failed to ensure the environment was free of safety hazards by failing to repair a broken grab bar in the bathroom for 1 (Resident #3) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents. The findings are: 1. Resident #3 had diagnoses repeated falls, Alzheimer's Disease, and Dementia. The return anticipated MDS with an ARD of 05/13/23 reveled the resident scored 3 (severely impaired) on the Staff Assessment for Mental Status (SAMS), required extensive assist for bed mobility, dressing, toilet use, and personal hygiene; had an impairment to one side to the lower extremity. a. The Progress Note dated 05/13/23 documented, Nsg (nursing) I and A (incident and accident) note .nurse called to resident room where resident was laying in floor in front of toilet .grab bar in bathroom was not connected to wall .staff in-serviced on resident not using restroom until bar in bathroom is fixed by maintenance .placed order in maintenance log .alerted staff for residents to not use restroom until grab bars were fixed . b. On 05/22/23 at 5:41 a.m., a grab bar in Resident #3's bathroom was pulled away from the wall with screws sticking out at 6 inches. There was a sign on the bathroom door in that read, Out of order. c. On 05/23/23 at 11:19 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #2, What do you do if something needs to be fixed? LPN #2 replied, We tell Maintenance, we don't write it down. d. On 05/23/23 at 11:22 a.m., the Surveyor asked Maintenance Staff, What do you do if something needs to be fixed? Maintenance Staff replied, Write it in the Maintenance Book. The Surveyor asked, When was Resident #3's grab bar in the bathroom fixed? Maintenance Staff replied, May 14th, I went in after you left yesterday and it had come out, I fixed it again. The Surveyor asked, Who is responsible for ensuring the facility is free of hazards? Maintenance Staff replied, Me, all staff. e. On 05/23/23 at 12:30 p.m., the Surveyor asked the Director of Nursing (DON), What do you do if something needs to be fixed? The DON replied, Tell Maintenance. The Surveyor asked the DON, Who is responsible for ensuring the facility is free of hazards? The DON replied, Everyone. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines? The DON replied, We expect them to follow all policies and procedures. f. On 05/23/23 at 12:31 p.m., the Surveyor asked the Administrator, What do you do if something needs to be fixed? The Administrator replied, Notify Maintenance, verbally and with the book. The Surveyor asked, Who is responsible for ensuring the facility is free of hazards? The Administrator replied, Everyone. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedures and the CMS guidelines?' The Administrator replied, We expect them to follow all policies and procedures.

Based on observation, interview, and record review, the facility failed to provide pain medication for 1 (Resident #1) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents; failed to provide a physician ordered lotion for 1 (Resident #2) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents, and failed to provide wound treatment for 1 (Resident #3) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents The findings are: 1. Resident #1 had diagnoses of Schizophrenia, Muscle Wasting and Atrophy, and Post-Traumatic Stress Disorder. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/10/23 documented the resident scored 5 (0-7 severe impairment) on the Brief Interview for Mental Status (BIMS), had pain or hurting in the last five days, experienced pain almost constantly, and rated pain at a 10 on a numeric rating scale - with 10 being the worst. a. The Progress Note dated 03/03/23 at 1800 documented, .1730 - - arrived via fac (facility) van with staff CNA [Certified Nursing Assistant] . b. The Progress Note dated 03/03/23 at 1924 documented, .When this nurse entered resident's room, resident glared at this nurse. Resident stated: Someone is about to get hurt if I don't get a [Expletive] pain pill. This nurse apologized, but this nurse was advised by pharmacy via telephone that they will be here on 10 pm run with medications, including pain medication. When this nurse asked resident if I could look at her belly, resident stated You can leave me alone! I don't play well with others. This nurse then advised to resident that we had some paperwork that needed to be signed, and resident refused. Why should I do anything for you? This nurse left resident's room . There is no documentation that the nurse notified the physician. There is no documentation that the resident was administered pain medication. c. The Progress Note dated 03/04/23 at 1200 AM documented, .Resident's medications arrived from pharmacy at 2345pm. Resident received a Percocet 5/325mg at 0000 am per resident request . d. The Physician Order with a start date of 03/04/23 documented, .Percocet oral tablet 5-325 mg [milligram] [Oxycodone w/(with) Acetaminophen] Give 1 tablet by mouth every 6 hours needed . e. The Care Plan with a revision date of 04/06/23 documented, .I have potential for pain r/t surgical wound on abdomen, neuropathy, ovarian cyst, and bilat (bilateral) shoulder muscle wasting .administer analgesia Percocet as per orders . anticipate the resident's need for pain relief and respond to complaint(s) of pain .notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain . f. The Narcotic Medication Book page 116 documented, .Oxycodone/APAP 5/325 mg received 12 tablets from the Pharmacy on 03/03/23 at 2345 .Oxycodone/APAP 5/325 mg 1 tablet was administered to Resident #1 on 03/04/23 at 0000 . g. On 05/23/23 at 8:58 a.m., Resident #1 was lying in her bed. The Surveyor asked, Have you ever had to wait for your pain medication? Resident #1 replied, Yes, that's happened multiple times. The Surveyor asked, Do you remember when you first admitted to facility and the nurse told you your medication would be delivered from the pharmacy later? Resident #1 replied, Yes, I had to wait for hours, it was hurting so bad, me and that nurse got into it, she doesn't work here anymore. The Surveyor asked, Did the nurse call the doctor and get you something else for pain? Resident #1 replied, I don't know. The Surveyor asked, Did the nurse give you anything else for pain? Resident #1 replied, No. h. On 05/23/23 at 10:38 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #2, What do you do if a resident complains of pain and the pain medication hasn't been delivered from the pharmacy? LPN #2 replied, Ask the nurse practitioner if she'll sign a script to pull from the E-kit [emergency kit]. The Surveyor asked, Does the facility have an E-kit and is it utilized? LPN #2 replied, Yes we do, but we must contact the nurse practitioner if it's narcotics. The Surveyor asked, Why wasn't the E-kit utilized on 03/03/23 when Resident #1 admitted from the hospital and complained of pain? LPN #2 replied, I wasn't here, I don't know. The Surveyor asked, Who is responsible for obtaining residents medications, especially pain medications when they ask for them? LPN #2 replied, The nurses. The Surveyor asked, Why should residents' medications be available as ordered? LPN #2 replied, They obviously need it, and if they are in pain, so we treat it immediately. i. On 05/23/23 at 12:08 p.m., the Surveyor asked the Director of Nursing (DON), What do you do if a resident complains of pain and the pain medication hasn't been delivered from the pharmacy? The DON replied, Pull from the E-kit. The Surveyor asked, Does the facility have an E-kit and is it utilized? The DON replied, Yes. The Surveyor asked, Why wasn't the E-kit utilized on 03/03/23 when Resident #1 admitted from the hospital and complained of pain? The DON replied, I wasn't here then. The Surveyor asked, Was the Physician notified on 03/03/23 when Resident #1 complained of pain for a one-time order for pain medications because the pain medications weren't here? The DON replied, I was not here. The Surveyor asked, Who is responsible for obtaining residents medications, especially pain medications when they ask for them? The DON replied, The nurses. The Surveyor asked, Why should residents' medications be available as ordered? The DON replied, Because it's for their needs, as needed. 2. Resident #2 had diagnoses of Hypertension, Emphysema, and Chronic Obstructive Pulmonary Disease. The Admission MDS with an ARD of 04/26/23 had a score of 14(13-15 indicates cognitively intact) on a BIMS. a. The Care Plan with a revision date of 04/24/23 documented, .I am at risk for impaired skin integrity . assist resident to keep skin clean and dry . b. The Progress Note dated 05/11/23 at 14:56 documented, .physician rounded this am, new order for [named] lotion at HS (hour of sleep) on feet . There is no physician order and no documentation this treatment was started nor administered. c. Resident #2's May 2023 Medication Administration Record (MAR) and the Treatment Administration Record (TAR) did not document the administration of [named] lotion to feet at HS. The progress notes did not document the administration of [named] lotion to feet at HS. 3. Resident #3 had diagnoses of repeated falls, Alzheimer's Disease, and Dementia. The return anticipated MDS with an ARD of 05/13/23 reveled the resident scored 3 (severely impaired) on the Staff Assessment for Mental Status (SAMS), a. On 05/22/23 at 5:38 am, Resident #3 was sitting in his wheelchair in the Dining Room. The [NAMED] dressing on his left forearm had peeling edges and a date of 05/17/23. b. On 05/22/23 at 5:41 a.m., the Surveyor asked Nursing Assistant (NA) #1, What happened to Resident #3's arm? NA #1 replied, Resident # 3 had a fall and broke a hip about a week ago. c. On 05/23/23 at 6:39 a.m., a review of Resident #3's Physician Orders did not document an order for dressing change to the left forearm. A review of the May 2023 Medication Administration Record (MAR) and the Treatment Administration Record (TAR) did not document an order or administration of a treatment to Resident #3's left forearm, and a review of Resident #3's Progress Notes did not document any treatment administration or refusal of treatment to Resident #3's left forearm. d. On 05/23/23 at 9:13 a.m., the Surveyor asked Registered Nurse (RN) #1, Who is responsible for wound/treatment care? RN #1 replied, Licensed Practical Nurse (LPN) #3. The Surveyor asked, Did you apply a dressing to Resident #3 today? RN #1 replied, Yes. The Surveyor asked, What kind of wound is on Resident #3's left forearm? RN #1 replied, I don't know. The Surveyor asked, When was an order obtained for Resident #3's dressing on the left forearm? RN #1 replied, I don't know. The Surveyor asked, Why wasn't the dressing to Resident #3's left forearm changed since 05/17/23? RN #1 replied, I don't know, if it comes up on my TAR, I do the dressing. The Surveyor asked, Why should wounds and treatments be assessed and changed (dressing), performed on a consistent basis? RN #1 replied, To monitor wounds to see if they are healing. e. On 05/23/23 at 9:18 a.m., the Surveyor asked LPN #3, Who is responsible for wound and treatment care? LPN #3 replied, I am. The Surveyor asked, What kind of wound is on Resident #3's left forearm? LPN #3 replied, Skin tear. The Surveyor asked, When was an order obtained for Resident #3's dressing on the left forearm? LPN #3 replied, Resident #3 did that when Resident #3 broke a hip, Resident #3 should have had an order. The Surveyor asked LPN #3, Why was an order not obtained for Resident #3 dressing to the left forearm? LPN #3 replied, We have standing orders and the nurses know. The Surveyor asked LPN #3, Why should wounds and treatments be assessed and changed (dressing), performed on a consistent basis? LPN #3 replied, To ensure no infection and to ensure its heeling. The Surveyor asked LPN #3, Were you here yesterday doing dressing changes? LPN #3 replied, I was sick yesterday, LPN #4 did wounds yesterday, and if no one is available, nurses are responsible for their own. f. On 05/23/23 at 9:36 a.m., the Surveyor asked LPN #4, Who is responsible for wound and treatment care? LPN #4 replied, LPN #3. The Surveyor asked, What kind of wound is on Resident #3's left forearm? LPN #4 replied, Skin tear. The Surveyor asked, Where are the wound/treatment orders located? LPN #4 replied, On the MAR and TAR. The Surveyor asked, Why should wounds and treatments be assessed and changed (dressing), performed on a consistent basis? LPN #4 replied, For healing purposes. The Surveyor asked, Why wasn't the dressing to Resident #3's left forearm not changed since 05/17/23? LPN #4 replied, I don't know, we document refused and it shows in progress notes. g. On 05/23/23 at 12:08 p.m., the Surveyor asked the DON, Who is responsible for wound and treatment care? The DON replied, All the nurses and the treatment nurse during the week. The Surveyor asked, Why should wounds and treatments be assessed and changed (dressing), performed on a consistent basis? The DON replied, To heal. The Surveyor asked, Why wasn't the dressing to Resident #3 left forearm not changed since 05/17/23? The DON replied, I don't know. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines? The DON replied, We expect them to follow all policies and procedures. h. On 05/23/23 at 12:25 p.m., the Surveyor asked the Administrator, What are your expectations from your staff regarding following the facilities policy and procedures and the CMS guidelines? The Administrator replied, We expect them to follow all policies and procedures. i. The facility policy titled, Wound Care, was provided by the Administrator on 05/23/23 at 11:28 a.m. documented, .the purpose of this procedure is to provide guidelines for the care of wounds to promote healing .verify that there is a Physician's Order for this procedure .review the care plan .notify the supervisor if the resident refuses the wound care .report other information in accordance with facility policy and professional standards of practice .

Based on observation, interview and record review the facility failed to ensure staff performed incontinent care on 3 (R #1, R #2, R #3) of 3 (R #1, R #2, R #3) sampled residents who were dependent on staff for incontinent care, to prevent skin breakdown and possible infections; the facility also failed to ensure resident's call lights were in reach for 1 (R #1) of 3 ( R #1, R #2, R #3) sampled residents who was dependent on staff for activities of daily living (ADL's); these failed practices had the potential to affect 37 residents who were dependent on staff for incontinent care and 37 residents who were able to use a call light according to the lists provided by the Administrator on 12/20/2022 at 1:02 p.m. The findings are: 1. Resident (R #1) had diagnoses of Urinary Tract Infection, Hemiplegia, Hemiparesis, and Sepsis. The 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/2022 documented the resident scored 14 (13-15 Cognitively Intact) on the Brief Interview for Mental Status (BIMS), required extensive assist for bed mobility, dressing, toilet use, and personal hygiene, was total dependent on staff for transfers, and was always incontinent of bladder and had a colostomy. a. On 12/19/2022 at 7:04 a.m., R #1 was in room lying in bed the call light was on the nightstand approximately four feet out of reach. R #1 stated, my colostomy bag needs to be changed and I'm wet and need to be changed. I didn't have my call light all night long. The Surveyor asked R#1, can you reach your call light? R #1 stated, there's no way I can reach it, and no one came in at all last night. b. On 12/19/2022 at 7:12 a.m., R #1's colostomy bag is was inflated with feces. c. On 12/19/2022 at 7:13 a.m., R #1 stated to Certified Nursing Assistant (CNA) #2, I have not been changed all night and my colostomy bag wasn't emptied all night. d. On 12/19/2022 at 7:18 a.m., CNA #1 and CNA #2 removed R #1 pants. R #1's brief, draw sheet, and mattress were soaked in urine. The Surveyor asked CNA #1 and CNA #2, should R #1's brief, sheet, and mattress be soaked and wet. CNA #1 and CNA #2 both replied, no. The Surveyor asked CNA #1 and CNA #2, who is responsible for ensuring residents are clean and dry? CNA #1 and CNA #2 both stated, we are. e. On 12/19/2022 at 6:28 a.m., the Surveyor asked CNA #3, what kind of condition were the residents found in this morning? CNA #3 stated, some were wet. 2. R #2 had diagnosis of overactive bladder, transient ischemic attack (TIA), and muscle weakness. The Quarterly MDS with an ARD of 11/3/2022 documented the resident scored 8 (8-12 moderately impaired) on the BIMS, required extensive assist for bed mobility, dressing, toilet use, and personal hygiene, and was frequently incontinent of bladder. a. On 12/19/2022 at 6:31 a.m., R #2 was sitting in room in a wheelchair and stated, there wasn't anybody here, I was wet. The Surveyor asked R #2, were you wet last night? R #2 stated, yes I was because no one showed up, and I felt like I was alone, and I felt wet because I was. b. On 12/19/2022 at 6:36 a.m., the Surveyor asked CNA #4, have you come in and found your residents soaked and wet? CNA #4 stated, yes, sometimes, yes here recently. 3. R #3 had diagnoses of heart failure, dementia, and respiratory failure. The Quarterly MDS with an ARD of 9/21/2022 documented the resident scored 13 on the BIMS, required extensive assist for bed mobility, dressing, toilet use, and personal hygiene, and was totally dependent on staff for transfers, and was always incontinent of bowel and bladder. a. On 12/19/2022 at 6:52 a.m., R #3 was in room lying in bed. There was a strong urine odor coming from the room. b. On 12/19/2022 at 6:56 a.m., Licensed Practical Nurse (LPN) #1 checked R #3's brief. R#3's brief was soaked with urine. The draw sheet under R #3 was wet down to the mattress. The Surveyor asked LPN #1, who is responsible for ensuring residents are dry? LPN #1 stated, CNA's. The Surveyor asked LPN #1, how often do they do rounds? LPN #1 stated, every two hours. 4. On 12/20/2022 at 10:17 a.m., the Surveyor asked CNA #5, why should residents have call lights in reach? CNA #5 stated, to get help when needed. The Surveyor asked CNA #5, who is responsible for ensuring residents have call lights? CNA #5 stated, everyone. The Surveyor asked CNA #5, who is responsible for ensuring residents are clean and dry at all times/at night? CNA #5 stated, CNA's. The Surveyor asked CNA #5, how often is incontinent care provided to residents? CNA #5 stated, every two hours and as needed (PRN). The Surveyor asked CNA #5, have staff been trained on providing incontinent care to residents, and how often? CNA #5 stated, yes, at least five or six times. 5. On 12/20/2022 at 12:28 p.m., the Surveyor asked the Director of Nursing (DON), why should residents not be left in urine-soaked briefs and bedding? The DON stated, skin breakdown, dignity issues, potential for infection. The Surveyor asked the DON, why should residents have call lights in reach? The DON stated, so they can call when they need assistance. The Surveyor asked the DON, who is responsible for ensuring residents have call lights. The DON stated, all of us. The Surveyor asked the DON, who is responsible for ensuring residents are clean and dry at all times/at night? The DON stated, CNA's and nurses, direct care staff. The Surveyor asked the DON, have staff been trained on providing incontinent care to residents? The DON stated, yes. The Surveyor asked the DON, how often is incontinent care provided to residents? The DON stated, every two hours and PRN. The Surveyor asked the DON, what are your expectations from your staff regarding following the facility policies and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines. The DON stated, the expectation is they follow the guidelines and the policy and procedures. 6. On 12/20/2022 at 1:02 p.m., the Surveyor asked the Administrator, why should residents not be left in urine-soaked briefs and bedding? The Administrator stated, infection issues. The Surveyor asked the Administrator, why should residents have call lights in reach? The Administrator stated, to have a way to notify staff. The Surveyor asked the Administrator, who is responsible for ensuring residents have call lights? The Administrator stated, CNA's, nurses, everybody. The Surveyor asked the Administrator, who is responsible for ensuring residents are clean and dry at all times/at night? The Administrator stated, CNA's and nurses. The Surveyor asked the Administrator, have staff been trained on providing incontinent care to residents? The Administrator stated, yes. The Surveyor asked the Administrator, how often is incontinent care provided to residents? The Administrator stated, PRN and every two hours. The Surveyor asked the Administrator, what are your expectations from your staff regarding following the facility policies and procedures and the CMS guidelines? The Administrator stated, expect them to follow policy and procedures and the guidelines. 7. A policy provided by the Administrator on 12/19/2022 at 12:44 p.m. via email, documented, Activities of Daily Living (ADLs), Supporting .Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . 8. A policy provide by the Administrator on 12/19/2022 at 12:44 p.m., via email, documented, .Answering the Call Light .the purpose of this procedure is to ensure timely responses to the resident's requests and needs .when the resident is in bed or confined to a chair .be sure the call light is within easy reach of the resident .

Based on observation, record review and interview, the facility failed to ensure a safe, clean, comfortable, homelike environment as evidenced by failure to ensure shower room floor and walls were free of black/pinkish substances; and failed to ensure meal trays were disposed of in a timely manner to prevent the possibility of sickness and/or infection. These failed practices had the potential to affect all residents who received showers and all residents who received meal trays according to a list provided by the Administrator on 12/20/2022 at 1:02 p.m. The findings are: 1. During a tour of the facility on 12/19/2022 the Surveyor observed the following: a. At 7:27 a.m., the shower room on Hall 500 had a pinkish/black substance in the tile cracks of the walls and floor. b. On 12/19/2022 at 7:30 a.m., the shower room on Hall 600 had a pinkish/blackish substance in the tile cracks of the walls and floor. 2. The Surveyor interviewed the following staff regarding the shower rooms: a.On 12/19/22 at 06:38 a.m., The Surveyor asked CNA #4, have you seen any mold in this building? CNA #4 stated, check the bathrooms/shower rooms. b. On 12/19/2022 at 7:30 a.m., the Surveyor asked Housekeeper (HK) #1, what is that pink and black substance in the cracks of the walls and floor. HK #1 stated, I can't say exactly what that is. The Surveyor asked HK #1, how often are shower rooms cleaned? HK #1 stated, I do them as scheduled, at least once a day. The Surveyor asked HK #1, what do you use on the shower walls/floor tiles? HK #1 stated, we use this Peroxide Multi Surface Cleaner Disinfectant. c. On 12/20/22 at 10:17 a.m., the Surveyor asked CNA #5, who is responsible for ensuring there is no pink/black substance in the tile cracks of the floors/walls of the shower rooms? CNA #5 stated, housekeeping; and CNA's, we do sanitize the chairs, I do the floors and whatever was used after resident's showers. The Surveyor asked CNA #5, have staff been trained on cleaning shower rooms? CNA #5 stated, as far as sanitizing goes. d. On 12/20/2022 at 10:44 a.m., The Surveyor asked HKS #2, who is responsible for ensuring there is no pink/black substance in the tile cracks of the walls/floors of the shower rooms. HKS #2 stated, housekeeping and maintenance. The Surveyor asked HKS #2, how often are shower rooms cleaned? HKS #2 stated, shower rooms are cleaned twice a day. The Surveyor asked HKS #2, tell me how the shower rooms are cleaned? HKS #2 stated, spray the room down with peroxide cleaner, take the mats up, spray and clean them off, and mop floors and exit. The Surveyor asked HKS #2, have staff been trained on cleaning shower rooms? HKS #2 stated, yes. The Surveyor asked HKS #2, what are your expectations from your staff regarding following the facilities policy and procedures and following the Centers for Medicare and Medicaid Services (CMS) guidelines? HKS #2 stated, I expect them to follow them to the fullest extent with no short cuts, done the right way all the time. e. On 12/20/2022 at 12:28 p.m., the Surveyor asked the Director of Nursing (DON), who is responsible for ensuring there is no pink/black substance in the tile cracks of the walls/floors of the shower rooms? The DON stated, housekeeping and the CNAs disinfect between the residents. The Surveyor asked the DON, how often are shower rooms cleaned? The DON stated, two times a day, disinfecting in between showers. f. On 12/20/22 at t1:02 p.m., the Surveyor asked the Administrator, who is responsible for ensuring there is no pink/black substance in the tile cracks of the walls/floors of the shower rooms? The Administrator stated, housekeeping. The Surveyor asked the Administrator, how often are shower rooms cleaned? The Administrator stated, housekeeping cleans them two times a day and CNAs disinfect between residents. The Surveyor asked the Administrator, have staff been trained on cleaning shower rooms. The Administrator stated, yes. The Surveyor asked the Administrator, what are your expectations from your staff regarding following the facilities policy and procedures and following the CMS guidelines? The Administrator stated, I expect them to follow policy and procedures and the guidelines. 3. A policy provided by the Administrator on 12/19/2022 at 12:44 p.m., via email, documented .Homelike environment .Residents are provided with a safe, clean, comfortable, and homelike environment .The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting .These characteristics include .clean, sanitary, and orderly environment . 4. During a tour of the facility on 12/19/22, the Surveyor observed the following: a. At 6:17 a.m., a meal tray top was on the outside of [named] room. b. At 6:19 a.m., Licensed Practical Nurse (LPN) #2 was standing inside [named] room with the door open. A meal tray with food was on the bedside table over the bed. c. At 6:25 a.m., a used tray with food was in [named] room on the bedside table. d. At 6:59 a.m., a used tray with food was on the bedside table in [named] rooms. 5. The Surveyor interviewed the following staff regarding used meal trays: a.On 12/19/22 at 6:19 a.m., the Surveyor asked LPN #2, what is that tray of food in resident's room on the bedside table. LPN #2 stated, that's a supper tray. The Surveyor asked LPN #2, why is it still in his room? LPN #2 stated, I don't know. The Surveyor asked LPN #2, who is supposed to pick them up? LPN #2 stated, the Certified Nursing Assistants (CNAs). A picture was taken. b. On 12/19/2022 at 6:38 a.m., the Surveyor asked CNA #4, have you found meal trays from the meals before? CNA #4 stated, yes. c. On 12/20/2022 at 10:17 a.m., the Surveyor asked CNA #5, when should residents meal trays be picked up? CNA #5 stated, when they are finished-within a couple of hours. The Surveyor asked CNA #5, why should meal trays not be left in the residents' rooms? CNA #5 stated, because they wouldn't/food be any good anymore. The Surveyor asked CNA #5, who is responsible for ensuring residents meal trays are picked up? CNA #5 stated, anyone, but usually the CNA's. The Surveyor asked CNA #5, where should meal trays be taken after a resident is finished with the meal tray? CNA #5 stated, back to the dining room. The Surveyor asked CNA #5, have staff been trained on picking up meal trays? CNA #5 stated, yes. d. On 12/20/2022 at 10:44 a.m., the Surveyor asked Housekeeping Supervisor (HKS) #2, when should residents meal trays be picked up. HKS #2 stated, when they are done eating. The Surveyor asked HKS #2, why should meal trays not be left in the residents' rooms? HKS #2 stated, it causes bugs, and they could get something that makes them sick. The Surveyor asked HKS #2, who is responsible for ensuring residents meal trays are picked up? HKS #2 stated, the CNAs. The Surveyor asked HKS #2, where should meal trays be taken after a resident is finished with the meal tray? HKS #2 stated, to the hall cart, then back to dietary. The Surveyor asked HKS #2, have staff been trained on picking up meal trays? HKS #2 stated, yes. e. On 12/20/2022 at 12:28 p.m., the Surveyor asked the Director of Nursing (DON), when should residents meal trays be picked up? The DON stated, when they are finished with their meal. The Surveyor asked the DON, why should meal trays not be left in the residents' rooms? The DON stated, pest control, the food is only good for a certain time. The Surveyor asked the DON, who is responsible for ensuring residents meal trays are picked up? The DON stated, direct care staff. The Surveyor asked the DON, where should meal trays be taken after a resident is finished with the meal tray? The DON stated, put on the tray cart and take to the dining room. The Surveyor asked the DON, have staff been trained on picking up meal trays? The DON stated, yes. The DON stated, yes. The Surveyor asked the DON, what are your expectations from your staff regarding following the facilities policy and procedures and following the CMS guidelines? The DON stated, the expectation is they follow the guidelines and the policy and procedures. f. On 12/20/2022 at 1:02 p.m., the Surveyor asked the Administrator, when should residents meal trays be picked up? The Administrator stated, when done eating. The Surveyor asked the Administrator, why should meal trays not be left in the residents' rooms? The Administrator stated, to make sure they aren't eating bad food. The Surveyor asked the Administrator, who is responsible for ensuring residents meal trays are picked up? The Administrator stated, CNA's. The Surveyor asked the Administrator, where should meal trays be taken after a resident is finished with the meal tray? The Administrator stated, to the dining room. The Surveyor asked the Administrator, have staff been trained on picking up meal trays? The Administrator stated, yes. The Surveyor asked the Administrator, what are your expectations from your staff regarding following the facilities policy and procedures and following the CMS guidelines? The Administrator stated, I expect them to follow policy and procedures and the guidelines. 6. A policy provided by the Administrator on 12/19/2022 at 12:44 p.m., via email, documented, .Assisting the resident with In-Room Meals .the purpose of this procedure is to provide appropriate assistance for residents who choose to receive meals in their rooms remove the tray when the resident has finished his or her meal .

Based on record review and interview, the facility failed to ensure a fall intervention was in place to prevent falls for 1 (Resident #1) of 1 sample mix resident who required a Bolster mattress to prevent falls. This failed practice resulted in past non-compliance at harm level for Resident #1 who did not have a Bolster mattress on the bed and fell on to the floor receiving a laceration to the head and had the potential to affect 11 residents who required a Bolster Mattress according to a list provided by the Administrator on 08/12/2020 and updated on 08/17/2020. The findings are: Resident #1 had a [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 04/23/2020 documented the resident scored 11 (08-12 indicates moderately impaired) per a Brief Interview for Mental Status and required total assistance of 2 for bed mobility, transfer, dressing, and toilet use. a. A Care Plan with a revision date of 10/23/2019 documented, . Bolster mattress applied to bed. 09/12/2019 Date Initiated: 09/13/2019 . b. The Incident and Accident (I & A) report dated 05/30/2020 documented, (Resident #1) was found face down on the floor beside the bed. Blood noted under head. (Resident #1) stated, I was reaching for my Dr. Pepper and slid out of bed. (Resident #1) was sent to the ER (emergency room ) . After resident left facility bolster mattress from previous room was placed on resident's bed in her new room. Staff re-educated to ensure that all fall interventions move with resident when changing rooms . c. The hospital records dated 05/30/2020 documented, .The accident occurred less than 1 hour ago. The fall occurred from a bed. She fell from a height of 3 to 5 ft. She landed on a hard floor. The point of impact was the head. Pain scale: unable to say due to the patient's advanced dementia. She was not ambulatory at the scene.The symptoms are aggravated by activity . Lac (laceration) Repair . The procedure was performed in an emergent situation . Location details scalp . Laceration length 2 cm (centimeters) . Skin closure staples . Number of sutures 4 . Dressing antibiotic ointment and pressure dressing . d. On 08/11/2020 at 10:21 a.m., the Director of Nursing (DON) was asked, What interventions were in place for (Resident #1) regarding falls? The DON replied, She couldn't ambulate, she was a lift. We reclined the wheelchair or (Resident #1) will be in bed. After 05/30/2020, we applied Bolster mattress to bed and prior to that she had had no falls since 2019. e. On 08/12/2020 at 08:17 a.m., the DON was asked, Did you do an in-service on 05/30/2020 regarding fall interventions after (Resident #1) fell . The DON replied, Yes. f. On 08/12/2020 at 09:49 a.m., an Inservice Education Report provided by the Administrator documented, Date: 05/30/2020 .When a resident is moved from one room to another, staff must make certain that ALL safety interventions move with the resident. This is necessary to continue to prevent harm and to provide quality care. After moving the resident, please recheck the room and the care plan to ensure all safety precautions are put into place . g. A Falls Management policy documented, . A risk reduction Falls, and Injuries Program will be used to assess residents/patients to determine fall risk factors. The interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence .

A recertification survey was conducted from 7/22/19 to 7/26/19, after which the survey team exited the facility. On 7/29/19, a surveyor returned to the facility to investigate a facility-reported incident regarding elopement. Complaint # (AR 287) was substantiated, all or in part, with these findings. A. Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to prevent elopement, as evidenced by failure to ensure staff provided frequent visual monitoring of a resident during periods of active exit-seeking behaviors; failure to ensure inspections of the exit doors / alarms on the secure unit were consistently and thoroughly conducted / monitored and documented to ensure they were maintained in proper working order to prevent elopement and potential injury of residents; failure to ensure the door / gate on 1 of 1 Secure Unit Courtyard was secured or equipped with alarms; failure to ensure the perimeter fence surrounding the courtyard where the Secure Unit was located was maintained in intact condition with functional alarms; and failure to ensure all staff responsible for care and monitoring of residents at risk for elopement were aware of the frequency at which the residents' whereabouts should be observed and the protocol to follow when an alarm system / gate was malfunctioning to prevent elopement and potential injury for 1 (Resident #43) of 3 (Residents #43, #16, and #61) sampled residents who resided on the all-male Secure Unit on 200 Hall and were at risk for elopement. This failed practice resulted in immediate jeopardy (removed), which caused or could have caused serious harm, injury, or death for Resident #43, who eloped and was found in a wooded area approximately 75 feet behind the facility, and had the potential to cause more than minimal harm to 8 residents who were at risk for elopement and resided on the All Male Secure Unit / 200 Hall, as documented on the Midnight Census Report dated 7/30/19 provided by the Administrator. The Administrator was notified of the removed Immediate Jeopardy condition on 7/31/19 at 4:38 p.m. The findings are: 1. The facility Special Care Unit Criteria and Consent form, provided by the Administrator on 7/31/19, documented, .in our Special Care Unit for their safety and security due to .[DIAGNOSES REDACTED]. habitually wanders or would wander out of building . would profit by structured environment . significant behavior problem that seriously disrupts others . high elopement risk . 2. Resident #43 was admitted to the facility on [DATE] in the custody of Adult Protective Services (APS) and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 6/19/19 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required supervision or set up assistance with bed mobility, transfer, dressing, and eating; was independent with setup assistance with toilet use; required extensive one person assistance with personal hygiene; required a cane / crutch for mobility; received an Antipsychotic, Antianxiety, and Antidepressant medication 7 out of the last 7 days; and exhibited no rejection of care, wandering behaviors. a. The Plan of Care dated as initiated 2/5/18 documented, .I have Hx (history) of elopement . I am physically and verbally aggressive with others . I yell and curse others . I refuse to eat at times because I am in a nursing home . I will urinate on paper towels and then throw the paper towels on the floor . Provide a safe secure environment on the gated community . Exit seeking behaviors/elopement . b. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762, documented, .Date and Time of Incident (if known) . 7/29/19 . Time . (BLANK) . Time of Discovery .7/29/19 . Time . 0530 (5:30 a.m.) AM . Registered Nurse (RN #1), Charge Nurse noticed (Resident #43) missing from his room when she presented for medication administration at 0530 (5:30 a.m.) on 7/29/19 . After searching the secured unit where (Resident #43) resides, she made all available staff aware of needed search for resident and she called (Local) Police Dept (Department) . She also notified the Director of Nursing who notified the Administrator immediately . (Maintenance Manager) was notified of needed help in searching and he arrived at the facility at 0554 (5:54 a.m.). (Maintenance Manager) located the resident in a wooded area, approximately 75 feet from the facility yard, behind the nursing facility . (Resident #43) had his shirt off and was using it as a pillow . He was lying on the ground . (Resident #43) did not appear in any distress, denied pain, and was able to get up and walk back into the facility with the Maintenance Director. (Resident #43) stated he exited the facility through the courtyard door on the 200 Hall and then exited out a gate in the courtyard. He had broken the existing lock mechanism on the gate. (Resident #43) resides on a Secured Unit and does not wear a Wanderguard alarm. The door where he exited does not have an alarm on it as it opens into the courtyard with the locked fence / gate. (Resident #43) refused to allow an immediate head-to-toe body audit by the nursing staff. On 7/30/19, during his scheduled bathing time, the nurse was able to perform a head-to-toe body audit and no injuries were noted. On the morning of 7/29/19, the Weather Channel predicted the low temperature to be 69 degrees Fahrenheit. The actual temperature in Heber Springs on this morning was low-mid 70s. There was no precipitation at the time . c. An OLTC Witness Statement form dated 7/29/19 documented, .Witness Full Name . (Certified Nursing Assistant (CNA) #1) . At 4:15 a.m., me and (CNA #2) went down Hall 2 to answer a call light. When we got down there, (Resident #43) was in the hallway, because another resident was yelling. (Resident #43) went into his room and that was the last time I seen (saw) him . d. A written form dated 7/29/19 and signed by the Regional Maintenance Manager documented, .I (Regional Maintenance Manager) was asked to come up and repair a courtyard gate. Mag (Magnetic) Lock was off, and I had to re-secure it and wire it back up. Mag Lock was working and locking properly . Everything is working properly . This form was signed by the Regional Maintenance Manager. e. The Daily Staffing Log for the Night Shift (11:00 p.m. to 7:00 a.m.) on 7/28/19 documented the facility had 1 Registered Nurse, 1 Licensed Practical Nurse, and 2 Certified Nursing Assistants working for the entire facility that night, for a census of 59 residents. f. A Body Audit dated 7/29/19 at 1:34 p.m. documented, .Resident has numerous excoriation wounds to bilateral shoulders, upper and lower arms, elbows, chest, abdomen, back, BLE (bilateral lower extremities), feet, and bilateral Achille's tendons etc. (et cetera) with blood noted from being in briar patch (thorns) in the woods. Resident had on old, torn up house shoes that were backless . g. On 7/31/19 at 1:07 p.m., CNA #2 was asked if Resident #43 had attempted to get out of the facility prior to 7/29/19. CNA #2 stated, He is always trying to get out. Earlier in the week, he broke the gate. Maintenance was the one that fixed it. A week earlier, (Resident #43) broke the lock on the gate. I was told in report earlier in the week. CNA #2 was asked if the residents are supervised when going out in the courtyard. CNA #2 stated, Only when they have smoke breaks. They can go out into the courtyard anytime they want. The courtyard is fenced in, and the only way you can get out is if you unlock the gate. It has a keypad on the fence, and you have to punch in a code. CNA #2 was asked how Resident #43 got out of the facility. CNA #2 stated, I don't know. h. On 7/31/19 at 1:16 p.m., Registered Nurse (RN) #1 was asked if Resident #43 had attempted to get out of the facility prior to 7/29/19. RN #1 stated, He constantly wants to leave. During every med (medication) pass with him, he always tells me that he wants to get out of here and that he can't stand this place. It's documented that he has eloped before. RN #1 was asked how he got out of the facility. RN #1 stated, I don't know for sure. A few days before it happened, I knew the gate was broken or wouldn't lock. It was broken for some time. It was my understanding that they were waiting for parts. That is what I was told. The 2 to 10 (2:00 p.m. to 10:00 p.m.) shift was made known (aware) that the gate lock was broken. The CNAs were instructed to lock the courtyard door from the outside, and then go back in through the hall door. This particular night (night of 7/28/19), that wasn't occurring. The last smoke break is at 8:00 p.m. They were not locking the courtyard door. I just figured the gate had been fixed. I had heard rumors that (Resident #43) had broken the gate. i. On 7/31/19 at 1:25 p.m., CNA #1 was asked if Resident #43 had attempted to get out of the facility prior to 7/29/19. CNA #1 stated, A couple of years ago, he did get out. I'm not sure. I wasn't working that day. I never witnessed him trying to get out. He would talk about it. CNA #1 was asked if she knew that the gate lock was broken on 7/28/19. CNA #1 stated, Not until after the Maintenance Man came in that a.m. (morning of 7/29/19). I didn't hear anything about the lock being broken. I didn't know anything about locking the courtyard door and going through the hallway door. j. On 7/31/19 at 1:38 p.m., CNA #3 was asked if Resident #43 had attempted to get out of the facility prior to 7/29/19. CNA #3 stated, (Resident #43) has always been an elopement risk. He has gotten out before. About a year and a half ago. They had moved him to the open hall, and he went out the back door on 600 Hall. The Maintenance Manager found him both times. CNA #3 was asked if she knew the gate lock was broken on 7/28/19. CNA #3 stated, That gate had been fixed earlier in the week. It messed up on Tuesday (7/23/19), and (Maintenance Manager) repaired it. The safety lady from the state was here. It wouldn't lock. They walked out there. It broke on Tuesday (7/23/19), but it got repaired that day. It got broken again on Friday (7/26/19). On Friday is when I think (Resident #43) broke it. I wasn't on the hall. CNA #3 was asked if she was told by the Maintenance Manager that the gate lock was broken on 7/26/19, and what instructions she was given related to the broken gate lock. CNA #3 stated, He did talk to me. He told me he had to order a new part for the gate and to leave the courtyard locked after supervised smoke breaks. You have to let the residents back in and lock the courtyard door from the outside. The courtyard door does not alarm. Then you have to go back in from the side door. It has a keypad, and you just punch in the code. I did not work the weekend. I did tell the next shift. I can't remember who I talked to. k. On 7/31/19 at 1:49 p.m., CNA #4 was asked if she was aware the gate lock was broken on 7/26/19, and if she worked on the weekend (7/27/19 and 7/28/19). CNA #4 stated, I was unaware. I do work on 200 Hall, and I worked on Saturday (7/27/19). I didn't know anything about the wooden gate lock being broken. I always thought it was locked. Nothing was said about the gate being broke. I never heard anything about staff having to use the side, exit door to open the courtyard door. I never seen (saw) (Resident #43) messing with the gate lock. l. On 7/31/19 at 2:47 p.m., Resident #43 was asked if he had a plan regarding leaving the facility and where he wanted to go. Resident #43 stated, I want to be at work again. I build houses and plan to get some of my property back. I could find a place to live. I don't know why I am in APS (Adult Protective Services) custody. I did get out. I was going home to western (Name of Town). I have been planning it for a few days. I will take the 5th (Amendment). I'm [AGE] years old. I need to be at home working. I eloped at (Name of other Long Term Care facility). I had tested the gate a few times by pushing on it. I seen (saw) two screws sticking out through the boards about 1/8 of an inch. I just pushed on the gate and it came right open. I'm getting my escape routes planned out. m. On 7/31/19 at 5:07 p.m., the Maintenance Manager was asked how many times he repaired the lock on the wooden gate, what caused the damage to the lock, and who he reported this to. The Maintenance Manager stated, It was broken on Friday (7/26/19). The electro-magnetic lock part of the magnetic part. It was found lying on the ground. It was broken off the fence. I witnessed (Resident #43) pushing on the gate. It was probably 10:00 a.m. to 11:00 a.m. I was going down the 200 Hall and saw him out in the courtyard rattling the gate. He was out on the patio by himself. I headed out the courtyard door and I saw (Resident #43) swinging the door open about three feet, and then he closed the door back like it wasn't broke. I took him inside and told the CNA that the gate was broken. I told her to lock the deadbolt on the courtyard door so the residents couldn't get into the courtyard. I believe it was (CNA #4). I told her I would do whatever I needed to fix it, but that the residents needed to be 100 percent escorted. I went back into the building and told the Administrator, who no longer works here, and (CNA #3). I told them to inform the CNAs to keep the courtyard door locked. That they would have to lock the door from the outside and go through the side entrance to lock and unlock the courtyard door. I don't know where the key to the deadbolt is. The deadbolt is removed now, and it doesn't have a lock on either side. I replaced it with closet passage handles. The lock mechanism is attached to the outside of the wooden gate. (Resident #43) was pushing the screws out. He kept pushing them out. I did secure the bracket to the fence with two 2 by 4's. I did put some screws in it. We talked about putting lag bolts (heavy, sturdy bolts) in, but we fixed it with screws. I told (CNA #3) and the previous Administrator that the residents needed to be supervised when out in the courtyard until I got it fixed. I did fix the door before that. I believe it was on Tuesday (7/23/19). I think it was from (Resident #43). I reinforced the bracket with the two 2 by 4's. The magnets were pushed too far away so it wouldn't lock. On Friday (7/26/19), he (Resident #43) pushed the gate enough that he pulled the screws out holding the electro-magnetic plate. He actually cut the wires he pushed so hard. No electricity, so the magnets wouldn't connect. The big electro-magnetic box was on the ground on the exterior side of the fence . n. On 7/31/19 at 5:20 p.m., the Director of Nursing (DON) was asked if she was aware that the gate lock was broken or not working on Friday (7/26/19). The DON stated, I was not here on Friday. I didn't hear anything about it 'til on Monday (7/29/19). The previous Administrator told me that the Maintenance Manager did mention to her about something being broken on the gate, but she believed it was being fixed right then. I was told that Maintenance had seen that it had been broken on Friday (7/26/19) and had ordered parts to fix it. I don't know about any instructions. The DON was asked when Resident #43's previous elopement took place. The DON stated, On 2/2/18 . The DON was asked if the courtyard door had an audible alarm, and if it was always left unlocked and stated, It does not alarm when opened. It has never been locked, that I know of. They were supposed to have it locked when the gate lock was broken. The courtyard is enclosed by a wooden fence and gate. The residents are supervised when smoking. We have 8 residents on 200 Hall, which is our only secure unit. The DON was asked if the windows had audible alarms and if they used a Wanderguard system. The DON stated, The windows will only open approximately 6 inches. We do not have any Wanderguard system. The DON was asked when the last in-service was completed regarding elopement policies and procedures, prior to Resident #43's elopement on 7/29/19. The DON stated, It was in (YEAR) . We have a new policy now. o. The facility removed the Immediate Jeopardy and corrected the failed practices related to resident supervision on 7/29/19 prior to the surveyor's re-entry, as evidenced by the following (however, there were current failed practices related to accident hazards at the time of the survey - refer to Paragraph B below): 1.) The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 7/29/19 documented, .Upon discovery, the incident was reported to OLTC (the Office of Long Term Care) via DMS (Division of Medical Services) (form) 7734. An all-staff in-service on Abuse / Neglect was initiated on 7/29/19. The resident was placed on 1:1 (one-on-one) monitoring and is still on 1:1 monitoring as the facility works with his guardian at APS to find alternative, more appropriate placement, as the resident has expressed his desire to no longer live at this facility. The Maintenance Department secured the locking mechanism on the gate that leads out of the courtyard and replaced the doorknob on the door entering the courtyard. While these maintenance tasks were being performed a staff member was assigned to sit at the door to ensure no further elopement attempts were made & (and) to prevent an injury of a resident . Adult Protective Services is his court appointed guardian & (and) a meeting with her and the facility's upper management has been arranged to discuss this matter in great detail. A follow-up neuro (neurological) consult has also been scheduled to obtain a more recent assessment of (Resident #43's) cognitive abilities / deficits. The facility has identified, and is following up on, the elopement risk and determining what will best suit this resident, as well as provide a safe environment for his wellbeing . 2.) A Training Sign-in Sheet dated 7/29/19 documented, .Training Description Abuse & (and) Neglect (Elopement) . Please read & (and) understand the attached A/N (Abuse and Neglect) policy . This facility training form was signed by 38 facility employees. 3.) A typed facility educational form dated 7/29/19 and provided with the above Training Sign-in sheet documented, .If a resident is missing from the facility, all staff present will search for resident. If resident is not located within 15 minutes, the Administrator / DON (Director of Nursing) will be notified and local police dept (Department) will be notified. The residents remaining in the facility will be monitored while the remaining staff begin to search the surrounding courtyards, parking lot, & (and) nearby grounds. It is imperative that all available staff assist in the search to ensure the resident is located quickly. Family / responsible party will be notified, as well as the attending physician. A body audit will be performed by the nurse upon re-entry to the facility. VS (vital signs) will be checked. Abuse / Neglect protocol will be initiated with the DMS (Division of Medical Services) (form) 7734. Witness statements will be obtained from all staff present. Investigation will begin immediately to identify issues and prevent recurrence . 4.) A 24 Hour One-on-One Supervision Watch form dated 7/29/19 documented Resident #43 was placed on one-on-one (1:1) supervision on 7/29/19 at 5:30 a.m. and remained on this level of supervision as of 7/31/19. 5.) A Gate / Fence Check-Off form provided by the Maintenance Manager on 7/31/19 at 5:07 p.m., documented the Gate / Fence was being checked daily, to be continued for two weeks, then bi-weekly for two weeks, then monthly by the Maintenance Manager. 6.) On 7/31/19 at 1:30 p.m., the Secure Unit was observed with the DON present. The windows did open approximately 6 inches and would not open any further due to screws placed in the window brackets. The courtyard was enclosed with a double-sided wooden fence that had a locked gate with keypads on both sides of the wooden fence. The gate lock was in working condition and did not have any apparent concerns. The wooden fence was aged, but appeared stable and had no missing or significantly cracked wooden boards. The 200 Hall did have a hall entry or exit door at the end of the hallway. The door would alarm when pushing on the handle. The alarm continued to sound until it was manually reset at the keypad on the adjacent wall on both sides of the door. The 200 Hall had double doors that had a key pad on both sides of the door. The door was locked and required a code to be entered on the key pad to enter or exit the Secure Unit from the Main Hallway. The double door had an audible alarm that sounded when pressure was applied to the door. 7.) On 7/31/19 at 5:07 p.m., the Maintenance Manager stated, The gate lock did get repaired on Monday (7/29/19). B. Based on observation, record review, and interview, the facility failed to ensure the resident environment was as free of accident hazards as possible, as evidenced by failure to ensure potentially hazardous chemicals were stored in secure location and not left in a resident's room on 1 (100 Hall) of 6 Halls, to prevent potential access or ingestion by cognitively impaired, self-mobile residents. This failed practice had the potential to cause more than minimal harm to 19 residents who were cognitively impaired and independently mobile, according to a list provided by the Director of Nursing (DON) on 7/25/19 at 10:20 a.m. The findings are: 1. On 7/22/19 at 2:05 p.m., containers of hand sanitizer, peri wash, peri wipes, and barrier cream were sitting on a bedside table in the room shared by Residents #28 and #41 on the 100 Hall. A container of deodorant was sitting on the television stand in the residents' room. 2. On 7/24/19 at 3:00 p.m., the Administrator provided the Material Safety Data Sheets (MSDS) for the above products, as follows: a. The Material Safety Data Sheet (MSDS) for the No Rinse Peri Wash documented, .May cause temporary eye irritation . Promptly wash eyes with plenty of water while lifting the eye lids . Rinse mouth thoroughly if ingested . b. The MSDS for the Peri Wipes documented, .Inhalation . seek fresh air . Eye contact . Flush with water . Ingestion . Wash out mouth thoroughly and drink 1 to 2 glasses of water in small sips . c. The MSDS for the deodorant documented, .Eye . (MONTH) cause mild, transient irritation . thoroughly rinsing for 15 to 20 minutes of the affected eye with water is recommended . Skin . Not expected to be irritating . Inhalation . Not expected to be irritating to the respiratory system . Ingestion . (MONTH) be harmful if swallowed in large quantities . Accidental ingestion of undiluted product may cause mild gastrointestinal irritation with nausea, vomiting, and diarrhea . Accidental ingestion of product may necessitate medical attention . In case of accidental ingestion dilute with fluids (water or milk) and treat symptomatically . Do not induce vomiting . d. The MSDS for the hand sanitizer documented, .Eyes . Flush with water . Skin . Flush with water . Ingestion . Do not induce vomiting unless directed to do so by medical personnel . If potentially dangerous quantities of this material have been swallowed, call a physician immediately . e. The MSDS for the Barrier Cream documented, .Eyes . Wash splashes from eyes with water . Ingestion . If small amount wash out mouth with water and drink clean water. If amount is large give plenty of water to drink . Do not induce vomiting and seek medical advice . 3. On 7/22/19 at 2:07 p.m., Certified Nursing Assistant (CNA) #1 was asked, Can you tell me about both of the residents that reside in Room (Number)? CNA #1 stated, Yes, ma'am. Both (residents) are confused at times. CNA #1 was asked, Can you look around in the room and tell me if you see anything that should not be in the room? CNA #1 stated, Those peri wipes, peri wash, barrier cream and hand sanitizer shouldn't be laying out within reach. Actually, the hand sanitizer shouldn't be in the room, period. That deodorant shouldn't be laying on the television stand. It should be put away. CNA #1 was asked what could happen if one of the confused residents accessed the items and stated, They could have possibly drunk the hand sanitizer. 4. On 7/23/19 at 8:57 a.m., the Director of Nursing (DON) was asked, Should peri wash, peri wipes, barrier cream, hand sanitizer, and deodorant be laying on the bedside table or television stand in a resident's room? She stated, No. It should not be laying out in the room. It should have been put away. She was asked what could happen if a confused resident accessed the items and stated, It could be misused or ingested.

Based on observation, record review and interview, the facility failed to ensure individualized activity care plans were developed and implemented for 9 (Residents #9, #31, #19, #20, #30, #38, #43, #54 and #61) of 9 sampled residents who were cognitively impaired and resided on the facility's 2 secure units, and failed to ensure planned activities that were appropriate for the residents' functional and cognitive abilities were consistently provided for the 26 cognitively impaired residents who resided on 2 of 2 secure units in the facility, to maintain socialization and quality of life and minimize behavioral symptoms for those residents to the extent possible. These failed practices resulted in a pattern of psychosocial harm to Residents #9, #19, and #61, who resided on the 2 secure units, were not provided with a regular program of activities and experienced boredom, decreased quality of life and / or exacerbation of their behavioral symptoms; and had the potential to cause more than minimal harm to the other 23 residents (for a total of 26 residents) who resided on the 2 secure units, as documented on a list provided by the Administrator on 10/1/18 at 2:28 p.m. The facility also failed to ensure staff were aware of each resident's preferred activities and that participation in group activities, one on one activities, and self-directed activities was consistently documented to facilitate the ability to accurately evaluate residents' interest and participation in the activity program for 14 (Residents #2, #9, #18, #19, #20, #29, #30, #31 #38, #43, #49, #54, #56, and #61) of 14 sampled residents whose activity documentation was reviewed. This failed practice had the potential to affect all 63 residents who resided in the facility, as documented on the Resident Census and Conditions of Residents form dated 9/24/18. The findings are: 1. Resident #9 resided on the male secured unit and had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/9/18 documented the resident scored 13 (13-15 indicates cognitively intact) on a brief interview for mental status (BIMS); exhibited verbal behavioral symptoms directed toward others daily with impact on resident that significantly interfered with the resident's care and that significantly interfered with the resident's participation in activities or social interactions and impact on others that significantly intruded on the privacy or activity of others and significantly disrupted care or living environment; had behaviors or other symptoms that had deteriorated since prior assessment; had activity preferences of books, newspapers, magazines to read, listening to music, being around animals such as pets, keeping up with the news, doing things with groups of people, doing favorite activities and going outside, which were very important to the resident; and religious services or practices, which were somewhat important. a. The (MONTH) (YEAR) Activity Log for this resident documented no group activity participation, no one on one activity participation, and no self-directed activity participation. b. A Behavior Note dated 8/1/18 documented, .Describe Behavior: still angry cursing, pacing hall, yelling at staff & (and) other residents . Complaining about 'Drug dealing, lying, stealing murdering people even get a chance to go before a judge; this ain't right'. Will continue to observe . episodes of anger, confusion, verbally abusive, repetitive & causing confusion. Called (Physician #1) reported situation. New order to administer 1mg/ml [MEDICATION NAME] at 6:30 pm in left deltoid. Non-pharmacological interventions: attempted to talk with him, resident angry cursing & repetitive over CNA (Certified Nursing Assistant) on her phone while smoking them at 330pm to her female girlfriend. He will not talk . Gave 1st dose in left deltoid at 6:30 pm. Resident said, 'I'm so nervous I need something now & rolled up his sleeve'. This nurse said it will be about 10 min (minutes) I have to go sign out the medication. He said 'ok I'll be in my room, so no one steals anything else'. Outcome: at 8:00 pm still anxious . c. A Nurse's Note dated 8/3/18 documented, .Resident continues with behaviors this shift of stating 'I HAVE GOT TO GET OUT OF THE CRAZY PLACE. Somebody keeps going into my room and stealing my stuff. I had a cell phone and someone stole it and no one is doing anything about it.' I told the resident that it has been reported but resident still complains about it. After receiving his HS meds (medication) resident slammed the door to his room and went to bed . d. A Nurse's Note dated 8/14/18 documented, .He continues to go outside and smoke on supervised smoke breaks. He is day 12 of increase in [MEDICATION NAME] and [MEDICATION NAME] and continues with his behaviors of cursing at staff and beating on the exit doors. He states, 'I'm going to get out of this place one way or the other. They don't have any right holding me against my will. I hate this place' . e. A Nurse's Note dated 8/19/18 documented, .Resident was hitting the main unit doors to 300 secured unit at approx. 2030 (8:30 p.m.) screaming he wanted his medication. I explained to him we would get it to him as soon as we could, but at the moment we were busy with another resident. He turned around and cursed off. Same type of behavior most days shift . f. A Behavior Note dated 8/20/18 documented, .Yelling screaming cursing and stated, 'I wanting to go to hospital and wanted out of this damn place so I can go to my own doctor.' Non- pharmacological interventions: spoke with resident but he would not calm down administered 4 IBU ([MEDICATION NAME]) 200 mg to equal 800 mg r/t (related to) swelling and pain to scrotum. I asked if he wanted ice and he stated, 'Hell no, I want out of this damn place.' Effect: Resident eventually went back to his room. PRN medication: IBU 200 mg give 4 tabs to equal 800mg . g. A Re-Admission Summary dated 8/29/18 documented, .readmitted from hospital: behavior health unit under the care and services of . (Physician) . h. The (MONTH) (YEAR) Activity Log documented the resident refused group activity participation on 2 occasions (8/8/18 and 8/9/18). No other group activity opportunities were documented, and there was no documentation of one on one activity participation or self-directed activity participation. i. A Nurse's Note dated 9/15/18 documented, .Resident exhibiting increased behaviors r/t banging on the inside door for attention. When I went back to the unit, resident yelled at me and said he wanted more coffee. I explained to him that the kitchen was preparing lunch trays for all the resident and that at the time they don't have any made. They said they would make some as soon as they could. Resident said 'that's (expletive)'. He also said 'we pay for it we should be able to get some'. I said 'I can't help the unit drank all of it before kitchen had more made'. Resident was not happy but did settle down. When coffee was done it was taken to unit and they got their coffee . j. The Comprehensive Care Plan revised on 9/18/18 did not address activity needs. k. A Nurse's Note dated 9/19/18 documented, .Resident up ambulating with steady gait on 300 unit, respirations even and unlabored with no s/s of distress noted. Resident has increased behaviors this day r/t arguing with CNAs. Awaiting MD (Medical Doctor) response to recent labs (laboratory results). Resident goes out on designated smoke times, usually . argue with CNAs to go early. He thinks they should be able to smoke when they want to . l. A Physician's Progress Note dated 9/26/18 documented, .Patient up in hallway requesting to go home needs to get back to work. Staff reports patient constantly request to go home, but has not had aggressive behavior recently. Will continue to monitor and treat accordingly, exam stable . m. The (MONTH) (YEAR) Activity Log documented, .group activity participation on 9/4/18 going outside . 9/12/18 Refreshment Social . 9/17-19/18 going outside . 9/26/18 Bingo . Self-Directed Activity Participation . T.V. on 9/5-7/18, 9/9-14/18, 9/17-21/18, and 9/24-26/18 . A total of 6 structured or group activities were documented for the month of (MONTH) (YEAR), with the remainder of the activities being self-directed. The resident's previously documented activity preferences of books, newspapers, magazines to read, listening to music, being around animals such as pets, and keeping up with the news were not documented at any time during the month of (MONTH) (YEAR), and his preferred activity of going outside was documented on 4 occasions throughout the month. n. On 9/24/18 at 11:25 a.m., the resident was pacing on the 200 hall male secure unit corridor and stated, I need out of here. I got a public intox (intoxication charge) two years ago, and I have served my time. I need out of here. This place is crazy. I pay $1,040 per month. I need to go back to work. I want out, and if you can't get me out, I will escape again. I've done it before, and I will do it again. That's not a threat, that's a promise. The resident was walking up and down the hallway from the exit door to secure door that led into the other parts of the facility. 2. Resident #61 resided on the male secure unit had [DIAGNOSES REDACTED]. The Significant Change MDS with an ARD of 5/22/18 documented the resident scored 0 (0-6 indicates severe cognitive impairment) on a BIMS and had activity preferences of being around animals such as pets, keeping up with the news, doing favorite activities, being outside for fresh air, and participating in religious services or practices that were very important to the resident, and rated having books, newspaper and magazines to read, listening to music and doing things with groups of people as somewhat important. a. The Comprehensive Care Plan revised on 8/22/18 did not address the resident's activity needs. b. The (MONTH) (YEAR) Activity Log documented no group, one-on-one or self-directed activity participation. c. The July, (MONTH) and (MONTH) (YEAR) MARs documented, .Behaviors - Monitor for the following: Itching, picking at skin, relentlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, [MEDICAL CONDITION], aggression, refusing care every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and document findings in a progress note . There was no documentation for 7/3/18 and all remaining dates for (MONTH) through (MONTH) documented a check mark, with no documentation as to what the check marks indicated. d. The (MONTH) (YEAR) Activity Log documented one Group Activity Participation on 8/14/18 - Crafts. There was no documentation of one-on-one or self-directed activity participation. e. A Nurse's Note dated 8/23/18 documented, .Resident woke up around midnight and came to the kitchen with the CNA on the hall. The CNA asked me to come to the 300 hall because this resident was exhibiting negative behaviors towards the CNA. When I got back there, resident was standing in kitchen and kept trying to get in (CNA's) face. I asked (CNA) to please sit down and then resident was talking to me sweetly and telling me that he didn't want anything to do with him, pointing at (CNA). I began talking to him and asked him if he was ready to go back to bed. I said let me show you to your room. He followed me and when he got in his room I told him good night and shut the door. Resident stayed in room for a while then later around 4 am came out of room and sat in kitchen talking with CNA. Resident's behavior was much better . f. A Nurse's Note dated 8/26/18 documented, .Resident very aggressive towards CNA was called to the room by them resident in shirt only continued to try and hit this nurse. Was able to assist resident to bathroom where he did void. Tried to help resident get dressed but he continued to try and hit monitored resident while he put pull-ups on. Tried to get resident to come to dining room for lunch he continued to be agitated let resident remain in bed at this time. Non-pharmacological interventions: Bathroom, Rest . Effect: Resident went back to sleep, lunch offered later, no more behavior noted. Will cont (continue) to monitor . g. A Nurse's Note dated 8/31/18 documented, .Aggressive angry threatening the staff with his walking cane. As he started up with the cane, the other CNA was able to get hold of it before he could swing the cane. He then went running out his room door down the hall pushing & (and) throwing everything out of his way. This nurse stepped between the first CNA & resident attempting to redirect with his noon medications. Didn't want meds, wanted to kill me, grabbed my throat then clothes, I continued to talk calm slow asking what was wrong did he want lunch how could I help; he finally let go & walked to dining room to sit down in a chair where a glass of tea was poured. Non-pharmacological interventions: Talking, redirection . Effect: effective PRN (as needed) medication: none, Outcome: good, reported to MD to send to Geri Psych for eval (evaluation) & treatment . Informed Dr . of aggressive behavior. Med changes, received new orders to send to Geri Psych for eval & treatment. Called (geri-psych facility) faxed info they requested for 72 hour hold about 4:30 pm. called (ambulance service) to send form for emrg (emergency) transport, received & returned also made copy for EMS (Emergency Medical Service) team upon arrival. Called daughter to inform of behaviors and of transfer to (hospital) (Ambulance service) arrived at 7:24 pm. resident secured on gurney transfer papers and report handed over. Called report to . ER (emergency room ) . h. The (MONTH) (YEAR) Activity Log documented, .group activity participation on 9/12/18 Refreshment Social . Self Directed Activity Participation . 9/14/18 TV . 9/19-21/18 TV .9/24/18 TV . 9/26/18 TV . There was no documentation the resident's preferred activities of being around animals, being outside for fresh air, and participating in religious services or practices were provided. 3. Resident #19 resided on the female secured unit and had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 4/13/18 documented the resident scored 0 (0-7 indicates severe cognitive impairment) on a BIMS, had inattention and disorganized thinking behaviors continuously present, had physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others daily, had an overall presence of behavioral symptoms that had an impact that significantly interfered with the resident's participation in activities or social interactions and had an impact on others that significantly intruded on the privacy or activity of others and significantly disrupted care or living environment, had wandering behaviors daily, had activity preferences of listening to music, being around animals such as pets, participating in favorite activities, spending time outdoors, and participating in religious activities or practices per a staff assessment for daily and activity preferences, required extensive physical assistance from one staff member for bed mobility, required limited physical assistance from one staff member for transfers, walking in room and corridor, and received antipsychotic and antidepressant medications on 7 of the past 7 days. a. A physician's orders [REDACTED].[MEDICATION NAME] Oxalate ([MEDICATION NAME]) Tablet 20 MG (milligram) Give 1 tablet by mouth one time a day for Depression . b. The Comprehensive Care Plan revised on 7/9/18 documented, .I am at risk for social isolation due to . I have difficulty understanding others and making myself understood . I will be able to interact with my peers, family and staff through my next review date . I can best understand simple, direct communication . Please invite me to activities and assist me to getting to them . c. The (MONTH) (YEAR) Activity Log had no documentation of group, one-on-one or self-directed activity participation. d. The (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Record (MAR) documented, .Behaviors - Monitor for the following: Itching, picking at skin, relentlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, [MEDICAL CONDITION], aggression, refusing care every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and document findings in a progress note . The section for 7/3/18 was blank, and all remaining dates in July, (MONTH) and (MONTH) documented only a check mark, with no indication on the form as to what the check marks indicated. e. A Nurse's Note dated 7/17/18 documented, .Resident is day 6 of [MEDICATION NAME] 0.25 mg at hs (bedtime) changed to QOD. (every other day). Resident does get loud and excited at times. Other than that, no negative behaviors noted . f. A physician's orders [REDACTED].[MEDICATION NAME] Tablet 0.5 MG ([MEDICATION NAME]) Give 1 tablet by mouth at bedtime for Anxiety related to Anxiety Disorder, Unspecified . g. The (MONTH) (YEAR) Activity Log had no documentation of group, one-on-one or self-directed activity participation. h. A physician's orders [REDACTED].[MEDICATION NAME] Tablet 0.25 MG ([MEDICATION NAME]) Give 1 tablet by mouth at bedtime every other day related to Unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition . i. The (MONTH) (YEAR) Activity Log documented, .Group Activity Participation . 9/12/18 Refreshment Social . There was no documentation of one-on-one or self-directed activity participation, and the 9/12/18 activity was the only group activity documented for this resident. There was no documentation the resident's preferred activities of listening to music, being around animals such as pets, spending time outdoors, and participating in religious activities or practices were provided to the resident at any time during the month of (MONTH) (YEAR). j. A list provided by the Administrator on 10/1/18 at 2:28 p.m. documented the resident transferred to a geriatric-psychiatric (geri-psych) hospital on [DATE]. 4. Resident #31 resided on the male secure unit and had [DIAGNOSES REDACTED]. Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbance, Other Specified Depressive Episodes, Generalized Anxiety Disorder, Anxiety Disorder, and Dementia with Lewy Bodies. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/21/18 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), had behaviors of inattention continuously, had no other behaviors documented, preferred listening to music, doing favorite activities, spending time outdoors, and participating in religious services or practices per a Staff Assessment for Activity Preference, was totally dependent on one person for locomotion off the unit, required extensive physical assistance of 2-plus people for bed mobility and transfers, received antianxiety medication on 1 of the past 7 days and antidepressant medications on 7 of the past 7 days, and received hospice care. a. The (MONTH) (YEAR) and the (MONTH) (YEAR) Activity Logs had no documentation of any activities for this resident. b. The (MONTH) (YEAR) Activity Log documented a Refreshment Social on 9/12/18. As of 9/27/18, this was the only activity documented for the resident for the month of (MONTH) (YEAR). There was no documentation the resident's preferred activities of listening to music, spending time outdoors, and participating in religious services or practices were provided for the resident at any time during the month of (MONTH) (YEAR). 5. Resident #20 resided on the male secured unit and had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 10/3/18 documented the resident scored 6 (0-6 indicates severe cognitive impairment) on a BIMS and had activity preferences of having books, newspapers, magazines to read, listening to music, being around animals such as pets, keeping up with the news, doing things with groups of people, doing favorite activities, and going outside that were very important to the resident, and participating in religious services and activities that were somewhat important, per an interview for daily and activity preferences. a. The Comprehensive Care Plan revised on 7/12/18 did not address the resident's activity needs. b. The (MONTH) (YEAR) Activity log had no documentation of any activities that were provided for the resident. c. The (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) MARs documented, .Behaviors - Monitor for the following: Itching, picking at skin, relentlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, [MEDICAL CONDITION], aggression, refusing care every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and document findings in a progress note . The section for 7/3/18 had no documentation, and all remaining dates throughout July, (MONTH) and (MONTH) (YEAR) documented a check mark, with no documentation as to what the check marks indicated. d. The (MONTH) (YEAR) Activity Log documented, .Group Activity Participation . 8/8/18 Refreshment Social . 8/14/18 Crafts . There was no documentation of one-on-one or self-directed activity participation, and the 2 group activities documented above were the only group activities documented for the month of (MONTH) (YEAR). e. The (MONTH) (YEAR) Activity Log documented, .Group Activity Participation . 9/4/18 Gardening/Outdoor . 9/12/18 Refreshment Social . 9/24-25/18 Resident Refused . There were multiple entries of going outside on the evening shift, and multiple entries of watching TV as a self-directed activity. There was no documentation the resident's preferred activities of having books, newspapers, and magazines to read, listening to music, being around animals such as pets, and keeping up with the news were provided for the resident. 6. Resident #30 resided on the male secured unit and had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 2/1/18 documented the resident scored 3 (0-6 indicates severe cognitive impairment) on a BIMS and had activity preferences of listening to music, participating in favorite activities and going outside for fresh air that were very important, and having books, newspapers, and magazines to read, participating in religious practices and doing things with groups of people that were somewhat important. a. The Comprehensive Care Plan revised on 5/1/18 did not address the resident's activity needs. b. The (MONTH) (YEAR) Activity Log documented no group activity participation, one-on-one or self-directed activity participation. c. The (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) MAR documented, .Behaviors - Monitor for the following: Itching, picking at skin, relentlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, [MEDICAL CONDITION], aggression, refusing care every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and document findings in a progress note . There was no documentation for 7/3/18, and all other dates throughout (MONTH) and (MONTH) documented a check mark, with no documentation as to what the check marks indicated. d. A Nurse's Note dated 7/22/18 documented, .Day 3 of order for ABT (antibiotic) [MEDICATION NAME] Capsule 300mg PO BID (two times daily) x (times) 10 days r/t (related to) UTI (urinary tract infection) with no adverse reactions noted. Resting in bed with eyes closed at this time with no s/s of pain or distress voiced and respirations even and unlabored. Still wanders into other resident's rooms and is confused as to where the restroom is and urinates on the floor or in the trash can . e. A Social Note dated 7/23/18 documented, .resides on 300 hall community. (Resident #30)'s adaptive needs are supervision when up ambulating, set up for meals, he wears glasses . Elder's known distress is wandering in and out of other elders' rooms. Elder talks plainly when he speaks but very quietly. Social will continue to visit . f. A Nurse's Note dated 7/23/18 documented, .Day 4 of [MEDICATION NAME] for UTI. No apparent adverse reaction noted. Fluids encouraged and offered frequently. Wanders in the hall and in and out of other rooms. Is easily redirected as needed. No s/s of distress or discomfort. Emotional support provided . g. The (MONTH) (YEAR) Activity Log documented one Group Activity Participation on 8/14/18 at 11:46 a.m. - Crafts. There was no documentation of one-on-one or self-directed activities, and only one group activity documented for the month. h. A Nurse's Note dated 8/5/18 documented, .Resident confused most of the time . Resident wanders the unit and is usually fiddling with whatever is in front of him. He is easily redirected. No negative behaviors noted this shift . i. A physician's orders [REDACTED].[MEDICATION NAME] Tablet 100 MG ([MEDICATION NAME] HCl ([MEDICATION NAME])) Give 1 tablet by mouth one time a day related to Major [MEDICAL CONDITION], Recurrent, Unspecified . j. A physician's orders [REDACTED].[MEDICATION NAME] Tablet 0.5 MG ([MEDICATION NAME]) give 1 tablet by mouth at bedtime . k. A Social Note dated 9/28/18 documented, .Elder participates in some group activity and some one on one activities such as going outside, building things out of logs, making toy cars and racing them, and helping and watching do puzzles. Elder enjoys going outside and planting things and just digging in the dirt. He independently walks and is usually able to make his needs and wants known. Elder wears glasses and sometimes forgets where he puts them . l. The (MONTH) (YEAR) Activity Log documented, .group activity participation on 9/12/18 Refreshment Social . 9/24/18 Resident Refused . 9/26/18 Bingo . No other group activities were documented as offered or attended. There were multiple dates of going outside under one-on-one activity participation and multiple dates of watching TV as self-directed activity participation. 7. Resident #38 resided on the female secured unit and had [DIAGNOSES REDACTED]. The MDS with an ARD of 2/15/18 documented the resident scored 4 (0-6 indicates severe impairment) on a Brief Interview for Mental Status (BIMS) and had activity preferences of listening to music, going outside for fresh air, participating in favorite activities and participating in religious services that were very important, being around animal such as pets and doing activities with groups of people that were somewhat important, and having books, newspapers, and magazines to read and keeping up with the news that were not very important to the resident. a. The Comprehensive Care Plan revised on 6/7/18 did not address the resident's activity needs. b. The (MONTH) (YEAR) MAR had no documentation of behaviors. c. The (MONTH) (YEAR) Activity Log documented, .Group Activity Participation . 7/16/18 Church Service . 7/23/18 Church Service . No other group activities were documented, and there was no documentation of one-on-one or self-directed activity participation for the month of (MONTH) (YEAR). d. The (MONTH) (YEAR) Activity log documented, .Group Activity Participation . 8/2/18 Bingo . 8/8/18 Refreshment Social . 8/9/18 Bingo . 8/14/18 Crafts . 8/20/18 Church Service . 8/24/18 Crafts . There was no documentation of one-on-one or self-directed activity participation for (MONTH) (YEAR), and a total of 6 group activities for the entire month. e. The (MONTH) (YEAR) MAR had no documentation of behaviors. f. The (MONTH) (YEAR) Activity log documented, .Group Activity Participation . 9/4/18 Exercise . 9/10/18 Church Service . 9/12/18 Refreshment Social . 9/14/18 Women's Group . 9/17/18 Church Service . 9/24/18 Church Service . 9/25/18 Bingo . There was no documentation regarding any one-on-one or self-directed activity participation. g. The (MONTH) (YEAR) MAR had no documentation of behaviors. h. On 9/24/18 at 11:16 AM, the resident was sitting in a wheelchair in the secure unit dining room with a blanket. 8. Resident #43 resided on the female secure unit and had [DIAGNOSES REDACTED]. The MDS with an ARD of 2/28/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, had no documented behaviors and had activity preferences of listening to music, going outside, participating in favorite activities, and participating in religious services and practices that were very important to the resident, having books, newspapers and magazines to read, being around animals such as pets, doing things with groups of people that were somewhat important and keeping up with news was rated as not very important to the resident. a. The Comprehensive Care Plan revised on 7/23/18 had no documentation of activities. b. The (MONTH) (YEAR) Activity Log documented group activity participation on 7/2/18 Crafts, and no one-on-one or self-directed activities were documented. c. The (MONTH) (YEAR) MAR and Nurses' Notes had no documentation of behaviors. d. The (MONTH) (YEAR) Activity Log documented Group Activity Participation on 8/19/18 Reading and 8/31/18 Reading. There was no documentation of one-on-one activity participation and one self-directed activity on 8/14/18 - Visitors. No other activities were documented for the month of (MONTH) (YEAR). e. The (MONTH) (YEAR) MAR and Nurses' Notes had no documentation of behaviors. f. A Social Note dated 8/13/18 documented, . Elder resides on 200 hall community. Elder sometimes goes home on the weekends with her husband. Elder participates in group activities such as arts and crafts. Elder reads on her own in her room. SUD (Secured Unit Director) will continue to visit and encourage elder to participate in group activities of her choosing . g. A Physician's Progress Note dated 8/29/18 documented, .Patient up on side of bed shows no signs of discomfort or distress at this time. Patient currently doing well with [MEDICATION NAME], decreased crying as well as diabetic [MEDICAL CONDITION] will continue current treatment, exam stable . h. The (MONTH) (YEAR) Activity Log documented, .group activity participation on 9/22/18 Music Group . 9/26/18 Other see activity note . 9/27/18 Relig (TRUNCATED)

Complaint # (AR 740) was substantiated (all or in part) with these findings: Based on record review and interview, the facility's Nursing Administration failed to monitor the facility's fall prevention program and promptly identify and address ongoing deficient practices to prevent serious potential injuries related to falls, as evidenced by failure to ensure falls were consistently evaluated for causative factors and effective fall prevention interventions were developed, consistently implemented and evaluated for effectiveness to reduce the potential for injuries due to falls for 3 (Residents #1, #3 and #6) of 7 (Residents #1, #2, #3, #5, #6, #7 and #9) case mix residents who had a history of [REDACTED].#1, who experienced a fall that resulted in in a [MEDICAL CONDITION], continued to experience additional falls, and subsequently sustained a fracture to the other hip, and had the potential to cause more than minimal harm to 26 residents who had a history of [REDACTED]. 1. The Job Description for the Director of Nursing, provided by the Administrator on 7/25/18, documented, .Care Plan and Assessment Functions .Ensure that all personnel involved in providing care to the resident is aware of the care plan and that care plans are used in administering daily care to the resident .Review nurses notes to determine if the care plan is being followed . Review and revise care plans and assessments a necessary, but at least quarterly . 2. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/7/18 documented the resident scored 0 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance of two persons for transfers, ambulation and locomotion and had one fall since admission with injury. a. A Fall Risk assessment dated [DATE] documented, .Score: 14 . If the total score is 12 or greater, then the resident is considered to be at high risk for falls . b. An Incident Note dated 5/7/18 at 3:51 a.m. documented, .At 3:10 a.m. the resident stood up from a chair in the dining room with his cane and when he took a step he fell sideways to the floor and landed on his R (right) hip and elbow .Body audit performed with no bruising noted to areas however resident stated that he could not bear weight to R (right) leg r/t (related/to) pain .Resident was assisted to w/c (wheelchair) with 2 staff. Neuro (neurological) checks performed and WNL (within normal limits) along with ROM (range of motion) to all extremities with pain voiced to hip. VS (vital signs) taken. X-ray to obtain X-ray of R hip. Was assisted to bed with no problems noted . Dr. (name) notified and DON (Director of Nursing) notified at 3:30 a.m. 1.) A Progress Note dated 5/7/18 at 3:33 p.m. documented, .VS: (vital signs) Temp 97.7 Pulse 69, Resp (respiration) 20, B/P (blood pressure)156/71. Resident fell in dining room at 3:30 a.m. (Mobile X-ray Service) came and x-rayed resident's right hip and received results and it showed Femoral Neck Fracture. Notified Dr. (Name). New order to send him to (Hospital) ER. Notified (Transport Service) and they transported him and left facility at 12:20 p.m. Resident's son, (Name) was going to meet him there . 2.) A physician's orders [REDACTED].Mobile X-ray to be obtained to R (right) hip r/t (related/to) fall and complaint of pain to area. Cannot bear weight to R leg. One time only for fall with pain to R hip . 3.) A physician's orders [REDACTED].Send resident to (Hospital Name) via (transport service) r/t (related to) fractured right hip . 4.) A Radiology Report dated 5/7/18 documented, .Reason for study: Pain in Right hip .Impression .Femoral neck fracture . 5.) A hospital History and Physical dated 5/7/18 documented, .Chief Complaint: Pain right hip .R (right) Hip Slightly comminuted [MEDICAL CONDITION] femoral neck with impaction and Varus deformity. [MEDICAL CONDITION] changes are noted .Impression: Right femoral neck fracture . 6.) A facility Nursing Narrative Summary dated 5/10/18 documented, .He has a 14cm (centimeter) incision to right hip, edges well approximated with steri strips intact with dressing intact. Dressing can be changed daily if needed. If it stays dry and no drainage noted, dressing can be removed. Follow up with (Name of Physician) as needed. He is transferred with sit to stand with max assist (assistance) x (times) 2 . c. An Incident Report dated 6/3/18 at 8:55 a.m. documented, .Staff reported resident on floor, when coming from outside with another resident, resident was scooting to the door on his buttocks that leads outside, w/c (wheelchair) behind resident in hallway, resident clean and dry, non-skid socks on, denies pain. When asking resident what happened, resident states 'can you help me' .No injuries observed . There was no documentation of any further effort to determine the causative factors of this fall. d. A Fall Risk assessment dated [DATE] documented, .Score: 19 .Category: High Risk Fall . e. A Care Plan dated 6/8/18 documented, .I am at risk for falls due to 1) Dx (diagnosis) of depression, dementia, and anxiety. 2) I take [MEDICAL CONDITION] medications. 3) Frequently incontinent of bowel and bladder. 4) I need help with toileting. 5) Cognitive and communication deficits. 6) Unsafe behaviors .Ensure pathways are free from clutter .I crawl around on the floor, please supervise me for my safety .I use a wheelchair for mobility .Please administer my medications as ordered .Please ensure that I am wearing non-skid shoes or socks when out of bed . Please observe me for changes in my condition that may warrant increase in supervision and notify my doctor/nurse .Resident to have mattress on floor to rest/sleep on to prevent falls out of bed and no items in room (dressers, tables, recliner, chairs, etc. (et cetera) curtains to be tied up to help prevent resident pulling up items. 6/13/18 Mattress on floor discontinued, on regular mattress . f. An Incident Report dated 6/27/18 at 4:30 p.m. documented, .This nurse was walking down the hallway and another resident told me that this resident was up. I went into resident's room and he was sitting down on his buttocks on the floor in his bathroom in front of the toilet .No injuries observed . There was no documentation of any further effort to determine the causative factors of this fall. The report did not address whether the care planned non-skid socks or shoes were in place at the time of the fall. On 7/24/18 at 4:23 p.m., the Director of Nursing was asked if any interventions had been initiated for the fall for (Resident #1) for the falls on 5/7/18, 6/3/18 and 6/27/18.? She stated, No there were not interventions, put in place. g. A Nursing Note dated 7/9/18 at 1:30 a.m. documented, .6p-6a (evening night) shift: CNAs (Certified Nurse Assistants) report to nurse that resident is complaining that is left hip is hurting during incontinent care. Resident is lying in bed, noted a small discoloration to left hip area. Resident can move his legs and can sit on the side of the bed by himself. Obtained order from PCP (Primary Care Physician) for X-ray of left hip due to pain. (Mobile X-ray service) notified . 1.) A physician's orders [REDACTED].(Mobile X-ray service) to do Left Hip X-ray due to resident . 2.) A Radiology Results Report dated 7/9/18 documented, .Reason: Pain in Left Hip . Impression . 1. Femoral Neck fracture . 3.) A physician's orders [REDACTED].Send to (Hospital Name)ER. Femoral Neck fracture of Left hip . h. A Hospital Discharge Summary dated 7/13/18 documented, .Final Diagnoses: [REDACTED]. i. On 7/24/18 at 4:23 p.m., the Director of Nursing (DON) was asked if she could locate any documentation of fall prevention interventions that were planned in response to the resident's falls on 5/7/18, 6/3/18 and 6/27/18. She stated, No. The DON was asked if any new interventions were put in place when Resident #1 was crawling on the floor? She stated, The resident was care planned to crawl; his mattress was placed on the floor. The MDS Coordinator might have more information; she will be here tomorrow. j. On 7/25/18 at 8:15 a.m., the Administrator was asked if she could locate any documentation of interventions that were planned in response to the resident's falls on 5/7/18, 6/3/18 and 6/27/18. She stated she was unable to locate any further information regarding fall prevent interventions for this resident. k. On 7/25/18 at 10:14 a.m., the MDS Coordinator was asked if she could locate any documentation of interventions that were planned in response to the resident's falls on 5/7/18, 6/3/18 and 6/27/18. She stated, I am familiar with (Resident #1); he was one of the more challenging residents. The only interventions that I am aware of is what is on the Care Plan. Interventions should be a team decision. Immediately after a fall occurs, there should be an immediate intervention developed by the nurse on duty that is investigating the fall. In my opinion, there should be a fall committee that meets and discusses the falls. There was a fall committee until about a month ago, a group that used to include housekeeping and therapy. The therapist lost a son, so she was out of pocket; the DON did not direct the falls meetings, and it fell apart. I was a part of the meeting; I would pull the I and As (Incident/Accident Reports) for the meetings and review them. After this, it fell apart. If there was an intervention in the progress notes, then I would put it on the care plan, but there was not any discussions held as far as I know in regards to long term interventions. I did not do an intervention for the fall in the dining room for (Resident #1); I do not remember a team fall meeting. When the resident was transferred to the hospital and returned back to the facility, I did not put any intervention in place. I did a change of condition MDS, and I updated the care plan, but I did not put a fall intervention in place. I did not formulate any other interventions for when the resident crawled off the mattress. There is no intervention for the fall on 6/3/18 or 6/27/18, when the resident was found on the bathroom floor. I am the only person that updates the care plan with fall interventions. Interventions would not be documented anywhere else. I put interventions in the kiosk for the CNAs (Certified Nurse Assistants) to have knowledge of them. I update the kiosk with the interventions when I know them. l. On 7/25/18 at 10:59 a.m., CNA #1was asked about the incidents with Resident #1. The CNA stated, I have worked with (Resident #1). I heard that there was a second fall. I was there during the day after the first fall (5/7/18) on the night shift. Resident may have slightly complained of pain, then he would ask for something to eat. It would be brief. Sometimes when I laid him down, he would briefly complain of pain. Resident would usually ask for several things in concession; it was difficult to determine if he was in pain. A couple of times, I told the nurse, just to be on the safe side. I was not here when the actual fall happened. I was here when the resident's mattress was on the floor; the resident was always restless, would crawl out into the hallway. When this happened, I would grab his wheelchair and get someone to help me get him into the chair. I would offer a drink or some food. There was no other padding around the mattress. There was a mattress, pillow, blankets and belongings in the closet. Everything else was removed from the resident's room. Resident would wander into other resident's rooms. If a resident falls, I know about the interventions. I go to the nurse and ask them. The kiosk is updated with the interventions, but if not, I ask the nurse. m. On 7/25/18 at 11:14 a.m., Licensed Practical Nurse (LPN) #1 was asked about the incidents with Resident #1. The LPN stated, I did not witness the resident's falls. I remember the DON and the CNA telling me that the resident was up in the dining room and saw him fall. I got the x-ray that morning when I came on duty. We got the x-ray results. I sent the results to the doctor and called him and received an order to transfer the resident to the hospital. The mattress was on the bed at that time. Resident did not seem to be in pain. I can't really remember the details of what happened. CNAs did not mention anything about resident being in pain. Before going to the hospital, the resident was walking; he was confused. On return from the hospital after surgery, I don't know what happened, but he was not himself. Resident was really confused. He was up and down and was everywhere. Resident was crawling on floor, scooting on floor. The resident's mattress was put on the floor at that time. Resident continued to crawl off the mattress, would crawl out into the hallway. Sometimes we would get the resident up and put him into his wheelchair. I was off Thursday through Sunday prior to the resident being sent out with the second fracture. On Monday morning when I returned to work, the Nurse on duty told me that an x-ray had been ordered due to pain during peri-care . The X-ray was taken on my shift. When I received the report, I called the Doctor with results. The Doctor wanted to get him in with a doctor in town. He was not available, so we sent him to (City) . The LPN was asked who initiated new interventions after a fall and stated, We (nurses) are the ones that initiates the interventions after a fall. We in-service the staff or tell them verbally of any new interventions . n. On 7/26/18 at 9:24 a.m., LPN #2 was asked about the development of interventions after a resident falls and stated, .It depends on the situation as to what interventions to put in place after a resident falls. We have to check residents more frequently if they are confused and falling. The interventions are included in the I/A. When I complete the I/A, we have to come up with an intervention. It is difficult at times, to think of a different intervention to use each time a resident falls. The MDS Coordinator will look at and review the I/A reports on the interventions to see if they are appropriate. We tell the aides what interventions are put into place . o. The facility's Fall Protocol, provided by the Administrator on 7/25/18 at 5:55 p.m., documented, .Purpose .4. To prepare a plan of care to reduce the potential for injury related to falls .Procedure .Note: All residents will be assessed for fall risk using the Fall Risk Assessment upon admission, readmission, quarterly, significant change in status and at the time of the fall. Those residents that are to be determined high risk will have Care Plan indicated . Any time a resident is found on the floor . If a resident rolls off the bed or mattress that is close to the floor this is considered a fall . Charge Nurse Duties .4. Complete the Event Report . 5. Complete fall investigation report front page . 6. Implement intervention to prevent further injury . 7. In-Service staff on new intervention as needed . MDS duties . 2. Update the Care Plan with new interventions . Director of Nursing or Designee Duties . 1. Complete fall investigation follow up (back page) .2. Review fall risk assessment for completion .3. Review fall investigation follow-up and fall risk during standard of care/fall risk meeting . 5. Review intervention for appropriate intervention change as needed . General Documentation's Guidelines .5. Immediate intervention . General Resident Care Plan Documentation Guidelines . 2. List new intervention developed for each fall with date of implementation . 3. List new intervention on CNA care plan . p. On 7/26/18 at 10:02 a.m., 1 year as, the DON was asked who was responsible for implementing interventions after a fall and stated, The nurse on the floor after a resident falls is responsible for implementing an intervention; she should chart it on the incident report. We have fall meetings every other week, we meet with therapy and discuss the falls. The incident reports are reviewed within 72 hours, by myself (sic). Myself (sic) and the MDS Coordinator review the incident reports for appropriate interventions. If the intervention is not appropriate the care plan will be updated with an appropriate intervention. The MDS Coordinator updates the care plan. The interventions are verbalized to the staff by the nurse completing the incident report and by the nurse if the intervention is changed. It is also added to the kiosk. q. On 7/26/18 at 8:45 a.m., the MDS Co-Coordinator was asked about the facility's protocols for conducting fall risk assessments and stated, Fall assessments are completed by the assistant MDS Coordinator; she does the quarterly falls assessments, annual and change of condition. The nurses are to complete them after each fall. I do not review the fall assessments after the nurses complete them. I'm not sure if anyone reviews them. Nursing, I think, should increase staffing for more eyes on (the residents). I have a care plan in place for all residents that are at high risk for falls. 3. Resident #3 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 6/21/18 documented the resident scored 7 (0-7 indicates severely impaired) on a BIMS, was totally dependent on two persons for transfers, had an indwelling urinary catheter and was incontinent of bowel and had two or more falls since admission to the facility. a. An Incident Report dated 4/10/18 at 4:00 a.m. documented, .Resident reported he rolled out of bed. Resident was lying on Rt (right) side. No injury noted at this time . There was no documentation of efforts to determine the causative factors of this fall and there was no documentation of an intervention that was initiated after this fall occurred. b. A Fall Risk assessment dated [DATE] documented, .Score: 9 .If total score is 12 or greater, then the resident is considered to be at high risk for falls . c. A Care Plan dated 5/19/18 documented, .I am at risk for falls with injury and other injury due to: 1. Dx (diagnosis) [MEDICAL CONDITIONS], Depression, Chronic Hep ([MEDICAL CONDITION]) C. 2. Antidepressant use . Ensure when rounding that I am positioned in the middle of the bed .Give me verbal cues/reminders when I cannot remember . d. On 7/25/18 at 8:15 a.m., the Administrator was asked if she had found any interventions that were initiated between the fall on 4/10/18 and 5/19/18 (Care Plan date). She stated she was not able to locate further information of interventions for falls for Resident #3. e. On 7/26/18 at 10:02 a.m., the Director of Nursing (DON) was asked about interventions that were initiated after Resident #3's fall on 4/10/18. She stated, I have not been able to find any other interventions or documentation related to the falls on (Resident #1 or #3). 4. Resident #6 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/27/18 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a BIMS, required limited assistance of 1 person for transfers, bed mobility, and locomotion and has had 2 or more fall since admission with an injury and 2 or more falls since admission without an injury. a. An Incident Report dated 2/12/18 at 3:15 p.m. documented, Aide heard noise in resident's room upon entering room noted that resident was laying (sic) on the floor on right side in a fetal position with head laying (sic) on his shoe by the foot of the bed. Resident stated, 'I thought I had to go to the bathroom and slipped on the floor, I hit my head and right elbow on the floor and I want to go to the VA (Veterans Administration) hospital'. b. The Care Plan with a revision date of 6/28/18 documented, I require limited to extensive assistance with all ADLs (activities of daily living), I am at risk for falls with injury and impaired hygiene .I have a cognition deficit due to dx (diagnosis) of Dementia . c. On 7/26/18 at 8:45 a.m., the Registered Nurse Minimum Data Set Coordinator was asked if the intervention to increase one-to-one social visits was an appropriate intervention to address a fall that occurred at 3:00 a.m. and stated, No. The MDS Coordinator was asked if any other interventions were initiated after the resident's fall on 2/12/18. The MDS Coordinator stated, There are no post fall investigations that I am aware of. If that intervention was inappropriate, the DON (Director of Nursing) would have changed it when it was reviewed. To my knowledge, there was no other intervention put into place. 5. The Immediate Jeopardy was removed on 7/25/18 at 6:11 p.m., and the scope and severity was reduced to H, when the facility implemented the following Plan of Removal: 1. On 7/25/18 an outside Nurse Consultant will train Administrator and DON/designee on fall program and appropriate interventions. 2. By 7/25/18 the DON/designee will review all Incident and Accident forms for the last 3 months to ensure appropriate interventions are Care Planned and in place. 3. On 7/25/18 the facility identified 24 residents at High Fall Risk, and the IDT (Interdisciplinary Team) is assessing them to assure appropriate interventions are in place. 4. Starting 7/25/18 nurses will be in-serviced as they report to work on starting falls investigation and implementation of interventions. 5. Starting 7/26/18 all Incident and Accident (I/A) will be reviewed by the Interdisciplinary Team for appropriate interventions during morning stand up meeting. 6. Starting 7/26/18 during daily rounds the DON/designee will review interventions are in place for all new care planned interventions related to I/A. 7. Starting 7/26/18 Interdisciplinary team will meet weekly to audit new I/A forms to ensure Care Plans are up to date and interventions are in place. Any negative findings will be reported to the QA (Quality Assurance) Committee for review and recommendations.

Complaint # (AR 740) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure falls were consistently evaluated for causative factors and effective fall prevention interventions were developed, consistently implemented and evaluated for effectiveness to reduce the potential for injuries due to falls for 3 (Residents #1, #3 and #6) of 7 (Residents #1, #2, #3, #5, #6, #7 and #9) case mix residents who had a history of [REDACTED].#1, who experienced a fall that resulted in in a [MEDICAL CONDITION], continued to experience additional falls, and subsequently sustained a fracture to the other hip, and had the potential to cause more than minimal harm to 26 residents who had a history of [REDACTED]. 1. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/7/18 documented the resident scored 0 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance of two persons for transfers, ambulation and locomotion and had one fall since admission with injury. a. A Fall Risk assessment dated [DATE] documented, .Score: 14 . If the total score is 12 or greater, then the resident is considered to be at high risk for falls . b. An Incident Note dated 5/7/18 at 3:51 a.m. documented, .At 3:10 a.m. the resident stood up from a chair in the dining room with his cane and when he took a step he fell sideways to the floor and landed on his R (right) hip and elbow . Body audit performed with no bruising noted to areas however resident stated that he could not bear weight to R (right) leg r/t (related/to) pain .Resident was assisted to w/c (wheelchair) with 2 staff. Neuro (neurological) checks performed and WNL (within normal limits) along with ROM (range of motion) to all extremities with pain voiced to hip. VS (vital signs) taken. X-ray to obtain X-ray of R hip. Was assisted to bed with no problems noted . Dr. (name) notified and DON (Director of Nursing) notified at 3:30 a.m. 1.) A Progress Note dated 5/7/18 at 3:33 p.m. documented, .VS: (vital signs) Temp 97.7 Pulse 69, Resp (respiration) 20, B/P (blood pressure) 156/71. Resident fell in dining room at 3:30 a.m. (Mobile X-ray Service) came and x-rayed resident's right hip and received results and it showed Femoral Neck Fracture. Notified Dr. (Name). New order to send him to (Hospital) ER. Notified (Transport Service) and they transported him and left facility at 12:20 p.m. Resident's son, (Name) was going to meet him there . 2.) A physician's orders [REDACTED]. Mobile X-ray to be obtained to R (right) hip r/t (related/to) fall and complaint of pain to area. Cannot bear weight to R leg. One time only for fall with pain to R hip . 3.) A physician's orders [REDACTED].Send resident to (Hospital Name) via (transport service) r/t (related to) fractured right hip . 4.) A Radiology Report dated 5/7/18 documented, . Reason for study: Pain in Right hip .Impression .Femoral neck fracture . 5.) A hospital History and Physical dated 5/7/18 documented, .Chief Complaint: Pain right hip . R (right) Hip Slightly comminuted [MEDICAL CONDITION] femoral neck with impaction and Varus deformity. [MEDICAL CONDITION] changes are noted. Impression: Right femoral neck fracture . 6.) A facility Nursing Narrative Summary dated 5/10/18 documented, .He has a 14cm (centimeter) incision to right hip, edges well approximated with steri strips intact with dressing intact. Dressing can be changed daily if needed. If it stays dry and no drainage noted, dressing can be removed. Follow up with (Name of Physician) as needed. He is transferred with sit to stand with max assist (assistance) x (times) 2 . There was no documentation found in the Care Plan or Nurses Notes to indicate interventions had been identified. c. An Incident Report dated 6/3/18 at 8:55 a.m. documented, .Staff reported resident on floor, when coming from outside with another resident, resident was scooting to the door on his buttocks that leads outside, w/c (wheelchair) behind resident in hallway, resident clean and dry, non-skid socks on, denies pain. When asking resident what happened, resident states 'can you help me' .No injuries observed . There was no documentation of any further effort to determine the causative factors of this fall. d. A Fall Risk assessment dated [DATE] documented, .Score: 19 .Category: High Risk Fall . e. A Care Plan dated 6/8/18 documented, . I am at risk for falls due to 1) Dx (diagnosis) of depression, dementia, and anxiety. 2) I take [MEDICAL CONDITION] medications. 3) Frequently incontinent of bowel and bladder. 4) I need help with toileting. 5) Cognitive and communication deficits. 6) Unsafe behaviors . Ensure pathways are free from clutter .I crawl around on the floor, please supervise me for my safety .I use a wheelchair for mobility .Please administer my medications as ordered .Please ensure that I am wearing non-skid shoes or socks when out of bed . Please observe me for changes in my condition that may warrant increase in supervision and notify my doctor/nurse .Resident to have mattress on floor to rest/sleep on to prevent falls out of bed and no items in room (dressers, tables, recliner, chairs, etc. (et cetera) curtains to be tied up to help prevent resident pulling up items. 6/13/18 Mattress on floor discontinued, on regular mattress . f. An Incident Report dated 6/27/18 at 4:30 p.m. documented, .This nurse was walking down the hallway and another resident told me that this resident was up. I went into resident's room and he was sitting down on his buttocks on the floor in his bathroom in front of the toilet . No injuries observed . There was no documentation of any further effort to determine the causative factors of this fall. The report did not address whether the care planned non-skid socks or shoes were in place at the time of the fall. On 7/24/18 at 4:23 p.m., the Director of Nursing was asked if any interventions had been initiated for the fall for (Resident #1) for the falls on 5/7/18, 6/3/18 and 6/27/18.? She stated, No there were not interventions, put in place. g. A Nursing Note dated 7/9/18 at 1:30 a.m. documented, .6p-6a (evening night) shift: CNAs (Certified Nurse Assistants) report to nurse that resident is complaining that is left hip is hurting during incontinent care. Resident is lying in bed, noted a small discoloration to left hip area. Resident can move his legs and can sit on the side of the bed by himself. Obtained order from PCP (Primary Care Physician) for X-ray of left hip due to pain. (Mobile X-ray service) notified . A Nursing Note dated 7/9/18 at 8:01 p.m. documented, . Resident was up in wheelchair this morning and kept trying to get up from his chair. The nurse from previous shift received order to X-ray resident's left hip r/t pain and was noted that there was a red discoloration to his left hip area. X-ray was done today and results showed: There is a moderately displaced and angulated acute appearing fracture involving the subcapital femoral neck region. No hip dislocation is seen. There is mild height loss of the L5 vertebral body, this is age indeterminate. Impression: Femoral neck fracture. Faxed results to (Physician Name) and notified MD (Medical Doctor) via telephone. Received order to send out to (Hospital) ER (emergency room ). Jeff, son was notified of this. Resident was (transported by) North Star at 3:30 pm. Called in report to (Registered Nurse) at (Hospital) ER. 1.) A physician's orders [REDACTED]. (Mobile X-ray service) to do Left Hip X-ray due to resident . 2.) A Radiology Results Report dated 7/9/18 documented, .Reason: Pain in Left Hip . Impression . 1. Femoral Neck fracture . 3.) A physician's orders [REDACTED].Send to (Hospital Name)ER. Femoral Neck fracture of Left hip . h. A Hospital Discharge Summary dated 7/13/18 documented, . Final Diagnoses: [REDACTED]. i. On 7/24/18 at 4:23 p.m., the Director of Nursing (DON) was asked if she could locate any documentation of fall prevention interventions that were planned in response to the resident's falls on 5/7/18, 6/3/18 and 6/27/18. She stated, No. The DON was asked if any new interventions were put in place when Resident #1 was crawling on the floor? She stated, The resident was care planned to crawl; his mattress was placed on the floor. The MDS Coordinator might have more information; she will be here tomorrow. j. On 7/25/18 at 8:15 a.m., the Administrator was asked if she could locate any documentation of interventions that were planned in response to the resident's falls on 5/7/18, 6/3/18 and 6/27/18. She stated she was unable to locate any further information regarding fall prevent interventions for this resident. k. On 7/25/18 at 10:14 a.m., the MDS Coordinator was asked if she could locate any documentation of interventions that were planned in response to the resident's falls on 5/7/18, 6/3/18 and 6/27/18. She stated, I am familiar with (Resident #1); he was one of the more challenging residents. The only interventions that I am aware of is what is on the Care Plan. Interventions should be a team decision. Immediately after a fall occurs, there should be an immediate intervention developed by the nurse on duty that is investigating the fall. In my opinion, there should be a fall committee that meets and discusses the falls. There was a fall committee until about a month ago, a group that used to include housekeeping and therapy. The therapist lost a son, so she was out of pocket; the DON did not direct the falls meetings, and it fell apart. I was a part of the meeting; I would pull the I and As (Incident/Accident Reports) for the meetings and review them. After this, it fell apart. If there was an intervention in the progress notes, then I would put it on the care plan, but there was not any discussions held as far as I know in regards to long term interventions. I did not do an intervention for the fall in the dining room for (Resident #1); I do not remember a team fall meeting. When the resident was transferred to the hospital and returned back to the facility, I did not put any intervention in place. I did a change of condition MDS, and I updated the care plan, but I did not put a fall intervention in place. I did not formulate any other interventions for when the resident crawled off the mattress. There is no intervention for the fall on 6/3/18 or 6/27/18, when the resident was found on the bathroom floor. I am the only person that updates the care plan with fall interventions. Interventions would not be documented anywhere else. I put interventions in the kiosk for the CNAs (Certified Nurse Assistants) to have knowledge of them. I update the kiosk with the interventions when I know them. l. On 7/25/18 at 10:59 a.m., CNA #1was asked about the incidents with Resident #1. The CNA stated, I have worked with (Resident #1). I heard that there was a second fall. I was there during the day after the first fall (5/7/18) on the night shift. Resident may have slightly complained of pain, then he would ask for something to eat. It would be brief. Sometimes when I laid him down, he would briefly complain of pain. Resident would usually ask for several things in concession; it was difficult to determine if he was in pain. A couple of times, I told the nurse, just to be on the safe side. I was not here when the actual fall happened. I was here when the resident's mattress was on the floor; the resident was always restless, would crawl out into the hallway. When this happened, I would grab his wheelchair and get someone to help me get him into the chair. I would offer a drink or some food. There was no other padding around the mattress. There was a mattress, pillow, blankets and belongings in the closet. Everything else was removed from the resident's room. Resident would wander into other resident's rooms. If a resident falls, I know about the interventions. I go to the nurse and ask them. The kiosk is updated with the interventions, but if not, I ask the nurse. m. On 7/25/18 at 11:14 a.m., Licensed Practical Nurse (LPN) #1 was asked about the incidents with Resident #1. The LPN stated, I did not witness the resident's falls. I remember the DON and the CNA telling me that the resident was up in the dining room and saw him fall. I got the x-ray that morning when I came on duty. We got the x-ray results. I sent the results to the doctor and called him and received an order to transfer the resident to the hospital. The mattress was on the bed at that time. Resident did not seem to be in pain. I can't really remember the details of what happened. CNAs did not mention anything about resident being in pain. Before going to the hospital, the resident was walking; he was confused. On return from the hospital after surgery, I don't know what happened, but he was not himself. Resident was really confused. He was up and down and was everywhere. Resident was crawling on floor, scooting on floor. The resident's mattress was put on the floor at that time. Resident continued to crawl off the mattress, would crawl out into the hallway. Sometimes we would get the resident up and put him into his wheelchair. I was off Thursday through Sunday prior to the resident being sent out with the second fracture. On Monday morning when I returned to work, the Nurse on duty told me that an x-ray had been ordered due to pain during peri-care . The X-ray was taken on my shift. When I received the report, I called the Doctor with results. The Doctor wanted to get him in with a doctor in town. He was not available, so we sent him to (City) . The LPN was asked who initiated new interventions after a fall and stated, We (nurses) are the ones that initiates the interventions after a fall. We in-service the staff or tell them verbally of any new interventions . n. On 7/26/18 at 9:24 a.m., LPN #2 was asked about the development of interventions after a resident falls and stated, .It depends on the situation as to what interventions to put in place after a resident falls. We have to check residents more frequently if they are confused and falling. The interventions are included in the I/A. When I complete the I/A, we have to come up with an intervention. It is difficult at times, to think of a different intervention to use each time a resident falls. The MDS Coordinator will look at and review the I/A reports on the interventions to see if they are appropriate. We tell the aides what interventions are put into place . o. The facility's Fall Protocol, provided by the Administrator on 7/25/18 at 5:55 p.m., documented, .Purpose .4. To prepare a plan of care to reduce the potential for injury related to falls .Procedure .Note: All residents will be assessed for fall risk using the Fall Risk Assessment upon admission, readmission, quarterly, significant change in status and at the time of the fall. Those residents that are to be determined high risk will have Care Plan indicated . Any time a resident is found on the floor . If a resident rolls off the bed or mattress that is close to the floor this is considered a fall . Charge Nurse Duties .4. Complete the Event Report . 5. Complete fall investigation report front page . 6. Implement intervention to prevent further injury . 7. In-Service staff on new intervention as needed . MDS duties . 2. Update the Care Plan with new interventions . Director of Nursing or Designee Duties . 1. Complete fall investigation follow up (back page) .2. Review fall risk assessment for completion .3. Review fall investigation follow-up and fall risk during standard of care/fall risk meeting . 5. Review intervention for appropriate intervention change as needed . General Documentation's Guidelines .5. Immediate intervention . General Resident Care Plan Documentation Guidelines . 2. List new intervention developed for each fall with date of implementation . 3. List new intervention on CNA care plan . p. On 7/26/18 at 10:02 a.m., the DON was asked who was responsible for implementing interventions after a fall and stated, The nurse on the floor after a resident falls is responsible for implementing an intervention; she should chart it on the incident report. We have fall meetings every other week, we meet with therapy and discuss the falls. The incident reports are reviewed within 72 hours, by myself (sic). Myself (sic) and the MDS Coordinator review the incident reports for appropriate interventions. If the intervention is not appropriate the care plan will be updated with an appropriate intervention. The MDS Coordinator updates the care plan. The interventions are verbalized to the staff by the nurse completing the incident report and by the nurse if the intervention is changed. It is also added to the kiosk. q. On 7/26/18 at 8:45 a.m., the MDS Co-Coordinator was asked about the facility's protocols for conducting fall risk assessments and stated, Fall assessments are completed by the assistant MDS Coordinator; she does the quarterly falls assessments, annual and change of condition. The nurses are to complete them after each fall. I do not review the fall assessments after the nurses complete them. I'm not sure if anyone reviews them. Nursing, I think, should increase staffing for more eyes on (the residents). I have a care plan in place for all residents that are at high risk for falls. 2. Resident #3 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 6/21/18 documented the resident scored 7 (0-7 indicates severely impaired) on a BIMS, was totally dependent on two persons for transfers, had an indwelling urinary catheter and was incontinent of bowel and had two or more falls since admission to the facility. a. An Incident Report dated 4/10/18 at 4:00 a.m. documented, .Resident reported he rolled out of bed. Resident was lying on Rt (right) side. No injury noted at this time . There was no documentation of efforts to determine the causative factors of this fall and there was no documentation of an intervention that was initiated after this fall occurred. b. A Fall Risk assessment dated [DATE] documented, .Score: 9 .If total score is 12 or greater, then the resident is considered to be at high risk for falls . c. A Care Plan dated 5/19/18 documented, .I am at risk for falls with injury and other injury due to: 1. Dx (diagnosis) [MEDICAL CONDITIONS], Depression, Chronic Hep ([MEDICAL CONDITION]) C. 2. Antidepressant use . Ensure when rounding that I am positioned in the middle of the bed .Give me verbal cues/reminders when I cannot remember . d. On 7/25/18 at 8:15 a.m., the Administrator was asked if she had found any interventions that were initiated between the fall on 4/10/18 and 5/19/18 (Care Plan date). She stated she was not able to locate further information of interventions for falls for Resident #3. e. On 7/26/18 at 10:02 a.m., the Director of Nursing (DON) was asked about interventions that were initiated after Resident #3's fall on 4/10/18. She stated, I have not been able to find any other interventions or documentation related to the falls on (Resident #1 or #3). 3. Resident #6 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/27/18 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a BIMS, required limited assistance of 1 person for transfers, bed mobility, and locomotion and has had 2 or more fall since admission with an injury and 2 or more falls since admission without an injury. a. An Incident Report dated 2/12/18 at 3:15 p.m. documented, Aide heard noise in resident's room upon entering room noted that resident was laying (sic) on the floor on right side in a fetal position with head laying (sic) on his shoe by the foot of the bed. Resident stated, 'I thought I had to go to the bathroom and slipped on the floor, I hit my head and right elbow on the floor and I want to go to the VA (Veterans Administration) hospital'. b. The Care Plan with a revision date of 6/28/18 documented, I require limited to extensive assistance with all ADLs (activities of daily living), I am at risk for falls with injury and impaired hygiene . c. On 7/26/18 at 8:45 a.m., the Registered Nurse Minimum Data Set Coordinator was asked if the intervention to increase one-to-one social visits was an appropriate intervention to address a fall that occurred at 3:00 a.m. and stated, No. The MDS Coordinator was asked if any other interventions were initiated after the resident's fall on 2/12/18. The MDS Coordinator stated, There are no post fall investigations that I am aware of. If that intervention was inappropriate, the DON (Director of Nursing) would have changed it when it was reviewed. To my knowledge, there was no other intervention put into place. 4. The Immediate Jeopardy was removed on 7/25/18 at 6:11 p.m., and the scope and severity was reduced to H, when the facility implemented the following Plan of Removal: 1. On 7/25/18 an outside Nurse Consultant will train Administrator and DON/designee on fall program and appropriate interventions. 2. By 7/25/18 the DON/designee will review all Incident and Accident forms for the last 3 months to ensure appropriate interventions are Care Planned and in place. 3. On 7/25/18 the facility identified 24 residents at High Fall Risk, and the IDT (Interdisciplinary Team) is assessing them to assure appropriate interventions are in place. 4. Starting 7/25/18 nurses will be in-serviced as they report to work on starting falls investigation and implementation of interventions. 5. Starting 7/26/18 all Incident and Accident (I/A) will be reviewed by the Interdisciplinary Team for appropriate interventions during morning stand up meeting. 6. Starting 7/26/18 during daily rounds the DON/designee will review interventions are in place for all new care planned interventions related to I/A. 7. Starting 7/26/18 Interdisciplinary team will meet weekly to audit new I/A forms to ensure Care Plans are up to date and interventions are in place. Any negative findings will be reported to the QA (Quality Assurance) Committee for review and recommendations.

Based on observation, record review and interview, the facility failed to ensure Residents #1 received necessary treatment and services to promote healing and prevent new sores from developing. The facility failed to thoroughly assess/reassess and document severely excoriated skin to the perineal and buttock area to ensure prompt identification of deterioration or failure to heal; failed to consult the physician for treatment changes when the skin was not healing; failed to consistently administer prescribed wound treatment; and failure to thoroughly cleanse all soiled areas during incontinent care for 1 (Resident #1) of 3 (Residents #1, 6 and 8 ) case-mix residents who had pressure ulcers or were at risk for pressure ulcers. The failed practice resulted in a pattern of actual harm to Resident #1 who developed an unidentified unstageable pressure sore to the scrotum along with multiple Stage II sores to the scrotum, buttocks and coccyx, and had the potential to affect 4 residents who had pressure sores and 23 residents who received preventive skin care as identified by the Resident Census and Conditions of Residents form dated 6/3/13. The facility also failed to ensure heels were floated while in bed in accordance with the plan of care to prevent potential pressure ulcer development for 1 of 1 (Resident #7) case mix residents who had physician orders [REDACTED]. This failed practice had the potential to cause more than minimal harm for 2 residents who had physician orders [REDACTED]. The findings are: 1. Resident # 1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/13 documented the resident scored 7 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance from staff for personal hygiene, bathing and toilet use, had an indwelling catheter, was occasionally incontinent of bowel, had a Stage 2 pressure ulcer that developed on 3/8/2013 that had worsened and had other skin problems: [MEDICAL CONDITION] not ulcers, rashes, cuts. a. The Plan of Care updated on 3/6/13 documented, "Problem: I am at risk for pressure ulcers and impaired skin integrity. Approaches: ...I need daily observation of skin with routine care. I need full skin evaluation weekly by a nurse. ... Please administer my treatments as ordered." The handwritten entries on the Plan of Care documented, "3/30/13: Apply [MEDICATION NAME] to buttocks q (every) time turned or cleaned. 4/30/13: Apply [MEDICATION NAME] topical aerosol to excoriated areas in buttocks." b. The Braden Risk Score dated 3/13/13 documented a score of 13. c. A physician's orders [REDACTED]." As of 6/6/13at 12:30 p.m., there was no documentation on the Departmental Notes dated 4/30/13 of an assessment of excoriation to the buttocks and no Wound Assessment Report found in the clinical record documenting the excoriated areas mentioned in the physician's orders [REDACTED]. d. The April 2013 (and May 2013) Electronic Record Wound Assessment Reports documented the resident had a Stage 2 Pressure sore on the left buttock identified on 3/8/13. The reports documented the following dates and measurements: 1) 4/5/13 the wound measurements (left buttock) were 3.00 cm (centimeters) long, 1.00 cm wide and 0.10 cm deep. 2) 4/12/13 the Stage 2 Pressure sore to the left buttock measured 0.50 cm long, 0.30 cm wide, and 0.10 cm deep and had improved. 3) 5/3/13 the Stage 2 Pressure sore to the left buttock measured 0.50 cm long, 0.30 cm wide, and 0.10 cm deep and had improved. There were no more measurements documented in the Electronic Record past these dates. 4) 5/28/13 the Stage 2 Pressure sore to the left buttock was documented as resolved. e. The May 2013 Treatment Administration Record (TAR) documented the [MEDICATION NAME] Topical Aerosol treatment to excoriated areas on buttocks was initiated on 5/1/13 on the 2-10 (2:00 p.m. to 10:00 p.m.) shift. The medication was scheduled twice a day on the 6-2 (6:00 a.m. to 2:00 p.m.) shift and the 2-10 shift. f. The May 2013 Medication Administration Record (MAR) documented the resident received a [MEDICATION NAME] 5-325 tablet daily from 5/1/13 through 5/18/13 and on 5/31/13 for complaints of pain from his bottom that was rated a 7 or 8 on a pain scale of 1-10. The narrative Pain Rating and Follow Up form documented that the resident received a [MEDICATION NAME] 5-325 tablet for pain on 5/19/13, 5/21/13, 5/22/13, 5/25/13 and 5/27/13 for complaints of pain from her bottom. g. The May 2013 Departmental Notes documented the following regarding the excoriation to the buttocks and reports of pain : 1) The 5/1/13 and 5/2/13 Notes contained no documentation of any assessment of the resident's buttocks or perineal area. The entry dated 5/2/13 at 11:22 a.m. documented, "Resident req (requested) pain tab (tablet) for pain stated bottom hurting and after repositioned cont (continued) to hurt about (8) (Pain Level 8 of 10) so 7:00 a.m. pain tab given ..." 2) The Departmental Note dated 5/3/13 at 3:34 a.m. documented, "... Resident is Day 1 of new treatment order of [MEDICATION NAME] to buttocks with no signs or symptoms of adverse reaction noted. Area to buttocks is very red at this time. This nurse applied [MEDICATION NAME] to residents buttocks this shift ..." The Departmental Note dated 5/3/13 at 9:35 a.m. documented, "Resident req pain tab for pain stated bottom hurting and after repositioned cont to hurt about (8) so 7:40 a.m. pain tab given ..." 3) The Departmental Note dated 5/4/13 at 2:48 a.m. documented, "... Resident continues with new treatment order for topical aerosol to excoriated area on buttocks ..." There was no documentation of the condition of the excoriated area, or whether the excoriation was improved or worsened. 4) The Departmental Note dated 5/5/13 at 2:32 a.m. documented, "...Resident continues with Day 2 of new treatment to excoriated buttocks. Continues with redness to area and scrotum. Denied pain to area at time of treatment ..." There was no documentation that the Physician was notified that the excoriation had now spread to the scrotum. There was no documentation of how much of the buttock area or how much of the scrotum area was excoriated. The Departmental Note dated 5/5/13 at 2:47 p.m. documented, "This is day 3 for the addition of [MEDICATION NAME] spray to resident's sacral area. (Resident #1) is tolerating this treatment change well without adverse reactions." 5) The Departmental Note dated 5/6/2013 at 10:00 a.m. documented, "Resident in bed this a.m. and stated bottom was hurting a little when ask if he needed pain tab stated might help rated pain at 7 and pain tab given at 7:30 a.m ..." 6) The Departmental Notes dated 5/10/13 at 3:31 a.m. documented, "... Area to buttocks is very red at this time. This nurse applied [MEDICATION NAME] to residents buttocks this shift. Hall aides are aware of the need to keep resident off of buttocks and not to use pad under resident. This nurse performed increased rounds on resident this shift to make sure he is being rotated properly..." There was no documentation that the Physician was notified of the continued redness to the buttocks. 7) The Departmental Notes dated 5/13/13, 5/14/14, 5/25/13, 5/26/13, and 5/27/13 documented that the Resident was medicated with a pain tablet for complaints of pain in the bottom. There was no documentation of any assessment of the condition of the Resident's bottom until the Wound Assessment Report dated 5/28/13. 8) A Wound Assessment Report dated 5/28/13 documented, "Wound Type: Irritation/Excoriation. Wound Location: Perineal area. Wound Status: blank. Date Wound Identified: 5/6/13. Cause: Moisture. Measurements: Blank. Describe skin irritation/excoriation, Red, severe irritation. Date Physician Notified: 5/6/13." The Wound Assessment Report documented that the excoriation was identified on 5/6/13 and that the Physician was notified 5/6/13, but there was no assessment documented in the electronic record for 5/6/13. Note: Order for [MEDICATION NAME] Spray to excoriated areas received 4/30/13. h. The June 2013 MAR and Departmental Notes documented that the Resident received [MEDICATION NAME] 5-325 daily from June 1 through June 4 , 2013 for complaints of pain from his bottom and back that was rated 7 to 8 on a pain scale of 1-10. The June 2013 TAR documented that the [MEDICATION NAME] Spray was scheduled to be administered at 8:00 a.m. and 8:00 p.m. daily. The 8:00 a.m. dose was documented on 6/1/13, but the 8:00 p.m. dose was circled as not given. The 8:00 a.m. dose on 6/2/13 was blank. The 8:00 p.m. dose on 6/2/13 was circled as not given. The 8:00 a.m. dose on 6/3/13 was circled as not given. The 8:00 p.m. dose on 6/3/13 was documented as given. A total of 4 doses of [MEDICATION NAME] was not administered to the resident between 6/1/13 and 6/3/13. On 6/5/13 at 3:25 p.m., the Treatment Nurse was asked, "Who does the [MEDICATION NAME] spray on the Resident?" The Treatment Nurse stated, "I do the day shift and the evening shift is done by the nurse." The Treatment Nurse was asked, "If it's (TAR entry) circled, does it mean it wasn't done?" The Treatment Nurse stated, "Yes." The Treatment Nurse was asked why the treatment wasn't done 6/1/13 at 8:00 p.m., 6/2/13 at 8:00 a.m. and 8:00 p.m. and 6/3/13 at 8:00 a.m.. The Treatment Nurse stated, "We were out of [MEDICATION NAME] those days." On 6/6/13 at 4:05 p.m., the Treatment Nurse was asked, "What was done to treat the wound when the [MEDICATION NAME] ran out?" The Treatment Nurse stated, "I don't know." The Treatment Nurse was asked, "Was the doctor notified for any treatment orders until the [MEDICATION NAME] was filled?" The Treatment Nurse stated, "I don't know." i. The Wound Assessment Report dated 6/4/13 documented, "Wound Type: Irritation/Excoriation. Wound Location: Perineal area. Wound Status: Improved. Date Wound Identified: 5/6/13. Cause: Moisture. Measurements: Blank. Describe skin irritation/excoriation, Red, severe irritation. Date Physician Notified: 5/6/13." There was no documentation of the excoriation to the scrotum, and no documentation of any open areas or sores to the scrotum, buttocks or coccyx. The Wound Healing Progress Report documented, "Type of Wound/Location: Irritation/Excoriation Perineal Area. Measurement of Wound Discovery / Date Identified: 0.00 X 0.00 5/06/13. 5/28/13: 0.00 x 0.00. 6/4/13 0.00 x 0.00." There were no measurements of the areas affected by the excoriation. j. On 6/4/13 at 5:40 p.m., Certified Nurse's Aide (CNA) #1 and CNA #2 entered the resident's room to perform incontinent care. CNA #1 took an incontinent wipe and cleaned the resident's penis and top part of the scrotum, but did not clean the bottom part of the scrotum. When the resident's legs were parted to push the brief down between the legs, a large black sore was noted on the scrotum that measured approximately 1.5 inches long and 0.5 inch wide with another open area below the black sore that measured approximately 1.5 inches long and 1/4 inches wide. CNA #1 was asked, "What is that (pointing to the black sore on the scrotum)?" CNA #1 stated, "I don't know. The nurse puts something on it." The resident was turned to the left side and the entire buttock, rectal, perineal and upper thigh area was extremely red with open areas in the folds of the upper thighs where the buttocks and thighs meet. There was serous weeping from the dark red excoriated flesh. Feces was packed into the rectal inner buttock area and extended to the scrotum. CNA #1 cleaned the rectal area and buttock area, but did not wash the scrotum. CNA #1 then took a tube off the over-bed table and squeezed a creamy substance into the gloved hand and applied it to the resident's buttock area. CNA #1 was asked, "What is that?" CNA #1 stated, "Remedy with antifungal cream. The Treatment Nurse also puts cream on the resident." There was no order for the application of antifungal cream to the resident's buttocks. k. On 6/5/13 at 12:00 p.m., the Treatment Nurse (LPN #4) was asked, "You documented an assessment of the Resident on 6/4/13, and did you notice any [MEDICAL CONDITION] to the scrotum?" The Treatment Nurse stated, "No." The Treatment Nurse was asked, "Were there any open areas to the buttock?" The Treatment Nurse stated, "No." The Director of Nursing (DON) and the Treatment Nurse were taken to the resident's room to assess the resident's excoriation. The resident was in the bed with no brief on the bottom and no incontinent pad underneath. There was feces in the bed and packed between the buttocks and pressed against the scrotum. The black sore was on the scrotum and the open area that had been viewed during care on 6/4/13. There was an additional open area on the scrotum, as well as new open areas on the buttocks and coccyx. The Treatment Nurse was asked, "What would you call that on the wound (pointing to black sore on scrotum)?" The Treatment Nurse stated, "Eschar." The Treatment Nurse was asked, "Is that (wound) stageable?" The Treatment Nurse stated, "No." The Treatment Nurse was asked, "What treatment has been used on the resident?" The Treatment Nurse stated, "[MEDICATION NAME] spray." The Treatment Nurse was asked, "When the [MEDICATION NAME] was not healing the resident, was the Physician notified?" The Treatment Nurse stated, "The Nurse Consultant didn't want us to call the doctor. She wanted to give the [MEDICATION NAME] a chance to work. He's had open areas on the buttocks before. It has looked worse than this." The Treatment Nurse was asked, "Has a wound clinic ever been considered because of the difficulty to heal?" The Treatment Nurse stated, "The Nurse Consultant does not want us to use the wound clinic." The Treatment Nurse was asked, "Has the doctor been made aware of the condition of the resident's scrotum?" The Treatment Nurse stated, "No." On 6/5/13 at 12:45 p.m. the Treatment Nurse was asked, "What are the CNAs supposed to do if they see a [MEDICAL CONDITION] or sore during care?" The Treatment Nurse stated, "They document on a sheet and tell the charge nurse. They document it in the computer kiosk under skin conditions." The Treatment Nurse was asked, "What are the charge nurses supposed to do?" The Treatment Nurse stated, "Call the doctor." The Skin Check (CNA- Smart Charting) from the kiosk documentation performed by the CNAs dated 6/4/13 at 3:58 a.m., 11:31 a.m., and 10:09 p.m. documented, "No new findings." l. The wound measurements written on a piece of notebook paper provided by the Treatment Nurse on 6/5/13 at 12:50 p.m. documented, "Scrotum: 2.00 (cm) x 1.50 cm x eschar. 3.00 x 0.50 x 0.10 open. 2.00 x 0.50 x 0.10 open. Buttocks: 1.00 x 0.50 x 0.10 open. Rt. (Right) Buttock. 1.50 x 0.50 x 0.10 open Rt. Buttock." On 6/6/13 at 11:30 a.m., the Director of Nursing (DON) approached the Surveyor with two yellow sticky notes and stated, "These are the wound measurements we took yesterday (6/5/13) afternoon. We called the doctor and have orders." The first sticky note documented, "(Resident #1) 6/5/13. Scrotum. 2cm x 2.5 cm black. 2 cm x 0.1 cm. 3.5 cm x 0.1 cm. 3cm x 0.4 cm. Coccyx R (Right) side. 0.4 cm x 1 cm. 0.4 cm x 3.6 cm. 1.8 cm x 0.5 cm. 4.5 cm x 0.3 cm. " The second sticky note documented, "(Resident #1) 6/5/13. Coccyx L (left) side. 5.5 cm x 0.7 cm. " A physician's orders [REDACTED]. Honey Gel to darkened area of scrotum two times a day topically. Low air loss mattress. [MEDICATION NAME] powder topically every shift and with each incontinent episode to groin. [MEDICATION NAME] spray to buttocks and coccyx every shift and with every incontinent episode topically." m. A Physicians Progress noted dated 6/6/13 documented, "Excoriated coccyx, scrotum, inner thigh bilat. (bilaterally). Open area on scrotum (with) eschar white + (and) black. Multiple open areas in excoriated area. Will refer to Wd (Wound) Clinic. Continue current tx (treatment) until wd clinic appt (appointment)." n. The facility policy titled, "Quality Assurance Skin Assessment" received from the Treatment Nurse on 6/5/13 documented, "Procedure: 1. Observations of a resident's skin are made upon each time the resident is provided personal care by the CNAs and licensed nurses. Any skin conditions observed throughout the day are reported immediately to the charge who will complete an assessment, and notify the physician as needed. 2. In addition to daily observations of the resident's skin by the nursing staff; A Licensed Nurse will be assigned to complete an assessment of every resident's skin at least weekly. 3. Document on the appropriate Skin Condition Monitoring Report/Pressure Sore Report, an assessment of those areas identified as requiring treatment or monitoring. Utilize a separate sheet for each identified area. 4. Notify the resident's physician as appropriate." 2. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 5/2/13 documented the resident scored 0 (0-7 indicates severe impairment) on a BIMS, was totally dependent on staff for bed mobility and transfers, was at risk for pressure ulcers and had no pressure ulcers. a. The Risk History Report dated 5/2/13 documented a Braden Risk Score of 10. A score of 12 or less indicates high risk for pressure ulcer development." b. A Physician order [REDACTED]." c. The "Care Plan" dated 3/19/13 documented, "Problem... At risk for skin breakdown and skin impairment... Float heels at all times while in bed." d. On 6/4/13 at 9:30 a.m., 2:45 p.m., 5:15 p.m. and 6:05 p.m. the resident was lying in bed with his heels laying directly on the mattress not offloaded. e. On 6/6/13 at 8:20 a.m., Certified Nursing Assistant (CNA) #5 was asked if the resident's feet were supposed to be floated. CNA #5 stated, "I don't know if it is his feet or his knees that are supposed to be off loaded." CNA #5 was asked what dose floating heels mean. CNA #5 stated, "To keep their feet up so they don't touch the mattress."

Based on observation, interview and record review, Nursing Administration failed to ensure that necessary care and services were provided to promote healing and prevent the development of additional pressure sores as evidenced by the facility's failure to ensure thorough assessment/reassessment and documentation of severely excoriated skin to the perineal and buttock area to ensure prompt identification of deterioration or failure to heal; failure to consult the physician for treatment changes when the skin was not healing; failure to consistently administer prescribed wound treatment; and failure to thoroughly cleanse all soiled areas during incontinent care for 1 (Resident #1) of 3 (Residents #1, 6 and 8 ) case-mix residents who had pressure ulcers or were at risk for pressure ulcers. The failed practice resulted in a pattern of actual harm to Resident #1 who developed an unidentified unstageable pressure sore to the scrotum along with multiple Stage II sores to the scrotum, buttocks and coccyx, and had the potential to affect 4 residents in facility with pressure sores and 23 residents receiving preventive skin care as identified by the Resident Census and Conditions of Residents form dated 6/3/13. The findings are: 1. The Job description for the Director of Nursing provided by the Administrator on 6/6/13 documented, "Duties: ... 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. ...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." The facility policy titled, "Quality Assurance Skin Assessment" provided by the Treatment Nurse on 6/5/13 documented, "Procedure: 1. Observations of a resident's skin are made upon each time the resident is provided personal care by the CNAs and licensed nurses. Any skin conditions observed throughout the day are reported immediately to the charge who will complete an assessment, and notify the physician as needed. 2. In addition to daily observations of the resident's skin by the nursing staff; A Licensed Nurse will be assigned to complete an assessment of every resident's skin at least weekly. 3. Document on the appropriate Skin Condition Monitoring Report/Pressure Sore Report, an assessment of those areas identified as requiring treatment or monitoring. Utilize a separate sheet for each identified area. 4. Notify the resident's physician as appropriate." 2. Resident # 1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/13 documented the resident scored 7 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance from staff for personal hygiene, bathing and toilet use, had an indwelling catheter, was occasionally incontinent of bowel, had a Stage 2 pressure ulcer that developed on 3/8/2013 that had worsened and had other skin problems: [MEDICAL CONDITION] not ulcers, rashes, cuts. a. The Plan of Care updated on 3/6/13 documented, "Problem: I am at risk for pressure ulcers and impaired skin integrity. Approaches: ...I need daily observation of skin with routine care. I need full skin evaluation weekly by a nurse. ... Please administer my treatments as ordered." The handwritten entries on the Plan of Care documented, "3/30/13: Apply [MEDICATION NAME] to buttocks q (every) time turned or cleaned. 4/30/13: Apply [MEDICATION NAME] topical aerosol to excoriated areas in buttocks." b. The Braden Risk Score dated 3/13/13 documented a score of 13. The facility's Policy titled Risk Assessment for Pressure Sores received from the Treatment Nurse on 6/5/13 at 2:25 p.m. documented. "All residents will have a Risk Assessment for Pressure Ulcers on admission/readmission, with a significant change in condition quarterly and annually. ...Procedure: 1. Obtain the Braden Scale for Predicting Pressure Sore Risk. c. A physician's orders [REDACTED]." As of6/6/13 at 12:30 p.m., there was no documentation on the Departmental Notes dated 4/30/13 of an assessment of excoriation to the buttocks and no Wound Assessment Report found in the clinical record documenting the excoriated areas mentioned in the physician's orders [REDACTED]. d. The April 2013 and May 2013 Electronic Record Wound Assessment Reports documented the resident had a Stage 2 Pressure sore on the left buttock identified on 3/8/13. The reports documented the following dates and measurements: 1) 4/5/13 the wound measurements (left buttock) were 3.00 cm (centimeters) long, 1.00 cm wide and 0.10 cm deep. 2) 4/12/13 the Stage 2 Pressure sore to the left buttock measured 0.50 cm long, 0.30 cm wide, and 0.10 cm deep and had improved. 3 5/3/13 the Stage 2 Pressure sore to the left buttock measured 0.50 cm long, 0.30 cm wide, and 0.10 cm deep and had improved. The report documented the "Date Wound Resolved 5/28/13. There were no more measurements reports of the Electronic Record past these dates. e. The May 2013 Treatment Administration Record (TAR) documented the [MEDICATION NAME] Topical Aerosol treatment to excoriated areas on buttocks was initiated on 5/1/13 on the 2-10 (2:00 p.m. to 10:00 p.m.) shift. The medication was scheduled twice a day on the 6-2 (6:00 a.m. to 2:00 p.m.) shift and the 2-10 shift. f. The May 2013 Medication Administration Record (MAR) documented the resident received a [MEDICATION NAME] 5-325 tablet daily from 5/1/13 through 5/18/13 and on 5/31/13 for complaints of pain from his bottom that was rated a 7 or 8 on a pain scale of 1-10. The narrative Pain Rating and Follow Up form documented that the resident received a [MEDICATION NAME] 5-325 tablet for pain on 5/19/13, 5/21/13, 5/22/13, 5/25/13 and 5/27/13 for complaints of pain from her bottom. g. The May 2013 Departmental Notes documented the following regarding the excoriation to the buttocks and reports of pain : 1) The 5/1/13 and 5/2/13 Notes contained no documentation of any assessment of the resident's buttocks or perineal area. The entry dated 5/2/13 at 11:22 a.m. documented, "Resident req (requested) pain tab (tablet) for pain stated bottom hurting and after repositioned cont (continued) to hurt about (8) (Pain Level 8 of 10) so 7:00 a.m. pain tab given ..." 2) The Departmental Note dated 5/3/13 at 3:34 a.m. documented, "... Resident is Day 1 of new treatment order of [MEDICATION NAME] to buttocks with no signs or symptoms of adverse reaction noted. Area to buttocks is very red at this time. This nurse applied [MEDICATION NAME] to residents buttocks this shift ..." The Departmental Note dated 5/3/13 at 9:35 a.m. documented, "Resident req pain tab for pain stated bottom hurting and after repositioned cont to hurt about (8) so 7:40 a.m. pain tab given ..." 3) The Departmental Note dated 5/4/13 at 2:48 a.m. documented, "... Resident continues with new treatment order for topical aerosol to excoriated area on buttocks ..." There was no documentation of the condition of the excoriated area, or whether the excoriation was improved or worsened. 4) The Departmental Note dated 5/5/13 at 2:32 a.m. documented, "...Resident continues with Day 2 of new treatment to excoriated buttocks. Continues with redness to area and scrotum. Denied pain to area at time of treatment ..." There was no documentation that the Physician was notified that the excoriation had now spread to the scrotum. There was no documentation of how much of the buttock area or how much of the scrotum area was excoriated. The Departmental Note dated 5/5/13 at 2:47 p.m. documented, "This is day 3 for the addition of [MEDICATION NAME] spray to resident's sacral area. (Resident #1) is tolerating this treatment change well without adverse reactions." 5) The Departmental Note dated 5/6/2013 at 10:00 a.m. documented, "Resident in bed this a.m. and stated bottom was hurting a little when ask if he needed pain tab stated might help rated pain at 7 and pain tab given at 7:30 a.m ..." 6) The Departmental Notes dated 5/10/13 at 3:31 a.m. documented, "... Area to buttocks is very red at this time. This nurse applied [MEDICATION NAME] to residents buttocks this shift. Hall aides are aware of the need to keep resident off of buttocks and not to use pad under resident. This nurse performed increased rounds on resident this shift to make sure he is being rotated properly..." There was no documentation that the Physician was notified of the continued redness to the buttocks. 7) The Departmental Notes dated 5/13/13, 5/14/14, 5/25/13, 5/26/13, and 5/27/13 documented that the Resident was medicated with a pain tablet for complaints of pain in the bottom. There was no documentation of any assessment of the condition of the Resident's bottom until the Wound Assessment Report dated 5/28/13. 8) A Wound Assessment Report dated 5/28/13 documented, "Wound Type: Irritation/Excoriation. Wound Location: Perineal area. Wound Status: blank. Date Wound Identified: 5/6/13. Cause: Moisture. Measurements: Blank. Describe skin irritation/excoriation, Red, severe irritation. Date Physician Notified: 5/6/13." The Wound Assessment Report documented that the excoriation was identified on 5/6/13 and that the Physician was notified 5/6/13, but there was no assessment documented in the electronic record for 5/6/13. Note: Order for [MEDICATION NAME] Spray to excoriated areas received 4/30/13. h. The June 2013 MAR and Departmental Notes documented that the Resident received [MEDICATION NAME] 5-325 daily from June 1 through June 4 , 2013 for complaints of pain from his bottom and back that was rated 7 to 8 on a pain scale of 1-10. The June 2013 TAR documented that the [MEDICATION NAME] Spray was scheduled to be administered at 8:00 a.m. and 8:00 p.m. daily. The 8:00 a.m. dose was documented on 6/1/13, but the 8:00 p.m. dose was circled as not given. The 8:00 a.m. dose on 6/2/13 was blank. The 8:00 p.m. dose on 6/2/13 was circled as not given. The 8:00 a.m. dose on 6/3/13 was circled as not given. The 8:00 p.m. dose on 6/3/13 was documented as given. A total of 4 doses of [MEDICATION NAME] was not administered to the resident between 6/1/13 and 6/3/13. On 6/5/13 at 3:25 p.m., the Treatment Nurse was asked, "Who does the [MEDICATION NAME] spray on the Resident?" The Treatment Nurse stated, "I do the day shift and the evening shift is done by the nurse." The Treatment Nurse was asked, "If it's (TAR entry) circled, does it mean it wasn't done?" The Treatment Nurse stated, "Yes." The Treatment Nurse was asked why the treatment wasn't done 6/1/13 at 8:00 p.m., 6/2/13 at 8:00 a.m. and 8:00 p.m. and 6/3/13 at 8:00 a.m.. The Treatment Nurse stated, "We were out of [MEDICATION NAME] those days." On 6/6/13 at 4:05 p.m., the Treatment Nurse was asked, "What was done to treat the wound when the [MEDICATION NAME] ran out?" The Treatment Nurse stated, "I don't know." The Treatment Nurse was asked, "Was the doctor notified for any treatment orders until the [MEDICATION NAME] was filled?" The Treatment Nurse stated, "I don't know." i. The Wound Assessment Report dated 6/4/13 documented, "Wound Type: Irritation/Excoriation. Wound Location: Perineal area. Wound Status: Improved. Date Wound Identified: 5/6/13. Cause: Moisture. Measurements: Blank. Describe skin irritation/excoriation, Red, severe irritation. Date Physician Notified: 5/6/13." There was no documentation of the excoriation to the scrotum, and no documentation of any open areas or sores to the scrotum, buttocks or coccyx. The Wound Healing Progress Report documented, "Type of Wound/Location: Irritation/Excoriation Perineal Area. Measurement of Wound Discovery / Date Identified: 0.00 X 0.00 5/06/13. 5/28/13: 0.00 x 0.00. 6/4/13 0.00 x 0.00." There were no measurements of the areas affected by the excoriation. j. On 6/4/13 at 5:40 p.m., Certified Nurse's Aide (CNA) #1 and CNA #2 entered the resident's room to perform incontinent care. CNA #1 took an incontinent wipe and cleaned the resident's penis and top part of the scrotum, but did not clean the bottom part of the scrotum. When the resident's legs were parted to push the brief down between the legs, a large black sore was noted on the scrotum that measured approximately 1.5 inches long and 0.5 inch wide with another open area below the black sore that measured approximately 1.5 inches long and 1/4 inches wide. CNA #1 was asked, "What is that (pointing to the black sore on the scrotum)?" CNA #1 stated, "I don't know. The nurse puts something on it." The resident was turned to the left side and the entire buttock, rectal, perineal and upper thigh area was extremely red with open areas in the folds of the upper thighs where the buttocks and thighs meet. There was serous weeping from the dark red excoriated flesh. Feces was packed into the rectal inner buttock area and extended to the scrotum. CNA #1 cleaned the rectal area and buttock area, but did not wash the scrotum. CNA #1 then took a tube off the over-bed table and squeezed a creamy substance into the gloved hand and applied it to the resident's buttock area. CNA #1 was asked, "What is that?" CNA #1 stated, "Remedy with antifungal cream. The Treatment Nurse also puts cream on the resident." There was no order for the application of antifungal cream to the resident's buttocks. k. On 6/5/13 at 12:00 p.m., the Treatment Nurse (LPN #4) was asked, "You documented an assessment of the Resident on 6/4/13, and did you notice any [MEDICAL CONDITION] to the scrotum?" The Treatment Nurse stated, "No." The Treatment Nurse was asked, "Were there any open areas to the buttock?" The Treatment Nurse stated, "No." The Director of Nursing (DON) and the Treatment Nurse were taken to the resident's room to assess the resident's excoriation. The resident was in the bed with no brief on the bottom and no incontinent pad underneath. There was feces in the bed and packed between the buttocks and pressed against the scrotum. The black sore was on the scrotum and the open area that had been viewed during care on 6/4/13. There was an additional open area on the scrotum, as well as new open areas on the buttocks and coccyx. The Treatment Nurse was asked, "What would you call that on the wound (pointing to black sore on scrotum)?" The Treatment Nurse stated, "Eschar." The Treatment Nurse was asked, "Is that (wound) stageable?" The Treatment Nurse stated, "No." The Treatment Nurse was asked, "What treatment has been used on the resident?" The Treatment Nurse stated, "[MEDICATION NAME] spray." The Treatment Nurse was asked, "When the [MEDICATION NAME] was not healing the resident, was the Physician notified?" The Treatment Nurse stated, "The Nurse Consultant didn't want us to call the doctor. She wanted to give the [MEDICATION NAME] a chance to work. He's had open areas on the buttocks before. It has looked worse than this." The Treatment Nurse was asked, "Has a wound clinic ever been considered because of the difficulty to heal?" The Treatment Nurse stated, "The Nurse Consultant does not want us to use the wound clinic." The Treatment Nurse was asked, "Has the doctor been made aware of the condition of the resident's scrotum?" The Treatment Nurse stated, "No." On 6/5/13 at 12:45 p.m. the Treatment Nurse was asked, "What are the CNAs supposed to do if they see a [MEDICAL CONDITION] or sore during care?" The Treatment Nurse stated, "They document on a sheet and tell the charge nurse. They document it in the computer kiosk under skin conditions." The Treatment Nurse was asked, "What are the charge nurses supposed to do?" The Treatment Nurse stated, "Call the doctor." The Skin Check (CNA- Smart Charting) from the kiosk documentation performed by the CNAs dated 6/4/13 at 3:58 a.m., 11:31 a.m., and 10:09 p.m. documented, "No new findings." l. The wound measurements written on a piece of notebook paper provided by the Treatment Nurse on 6/5/13 at 12:50 p.m. documented, "Scrotum: 2.00 (cm) x 1.50 cm x eschar. 3.00 x 0.50 x 0.10 open. 2.00 x 0.50 x 0.10 open. Buttocks: 1.00 x 0.50 x 0.10 open. Rt. (Right) Buttock. 1.50 x 0.50 x 0.10 open Rt. Buttock." On 6/6/13 at 11:30 a.m., the Director of Nursing (DON) approached the Surveyor with two yellow sticky notes and stated, "These are the wound measurements we took yesterday (6/5/13) afternoon. We called the doctor and have orders." The first sticky note documented, "(Resident #1) 6/5/13. Scrotum. 2cm x 2.5 cm black. 2 cm x 0.1 cm. 3.5 cm x 0.1 cm. 3cm x 0.4 cm. Coccyx R (Right) side. 0.4 cm x 1 cm. 0.4 cm x 3.6 cm. 1.8 cm x 0.5 cm. 4.5 cm x 0.3 cm. " The second sticky note documented, "(Resident #1) 6/5/13. Coccyx L (left) side. 5.5 cm x 0.7 cm. " A physician's orders [REDACTED]. Honey Gel to darkened area of scrotum two times a day topically. Low air loss mattress. [MEDICATION NAME] powder topically every shift and with each incontinent episode to groin. [MEDICATION NAME] spray to buttocks and coccyx every shift and with every incontinent episode topically." m. A Physicians Progress noted dated 6/6/13 documented, "Excoriated coccyx, scrotum, inner thigh bilat. (bilaterally). Open area on scrotum (with) eschar white + (and) black. Multiple open areas in excoriated area. Will refer to Wd (Wound) Clinic. Continue current tx (treatment) until wd clinic appt (appointment)."

This is a new deficiency. Based on observation, record review and interview, the facility's Nursing Administration failed to ensure that choking hazards were not accessible to a resident who placed inedible items in his mouth, reports were made to supervisory personnel when choking hazards were identified, investigations were conducted after incidents of resident placing foreign objects in his mouth, and interventions were planned and implemented in attempts to prevent further incidents of choking hazards for 1 (Resident #1) of 3 (Residents #1, #8 and #9) case mix residents who were identified with a history of placing foreign objects in their mouths. The failed practice resulted in Immediate Jeopardy which was likely to cause serious injury, harm or death for Resident #1, who had a history of [REDACTED]. The facility was informed of the Immediate Jeopardy on 5/19/11 at 6:05 p.m. The failed practice had the potential to affect 7 residents who were identified with a history of placing foreign objects in their mouths according to a list provided by the Director of Nursing (DON) on 5/20/11 at 12:42 p.m. The findings are: 1. The job description for the Director of Nursing Services documented, "Reports to: Chief Executive Officer (Administrator), ...General Purpose: To lead and direct, and manage the overall operations of the nursing department in accordance with standards of practice ...Nursing Dept. (Department) Management Duties: . . . 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, ...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 . . . environment," and, ...Compliance Duties: Must adhere to the facility policies which include documentation and reporting responsibilities." 2. The "Incident Documentation and Investigation" policy and procedure documented, a. "Policy: It is the intent of the facility that all incidents involving resident care will be investigated and documented on the Incident Documentation and Investigation Tool (I&A reports) to enable the facility to evaluate the care given to residents, to assist in prevention of incidents, and evaluate intervention given in the event of an incident. An "incident" is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident." 3. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/15/11 documented the resident scored 0 (0-7 indicates severely impaired) on a Brief Interview for Mental Status, had short and long term memory problems had wandering behavior daily, required supervision for locomotion in room/corridor and on/off unit, was steady at all times for all balance tests, and had no functional limitation in range of motion for the upper and lower extremities. a. A "Notice of Room Change" form dated 1/20/11 documented the resident had been moved to the 300 Hall secured unit. The facility's Admission Criteria form for the secured unit documented, "Resident may have a primary [DIAGNOSES REDACTED]. . ." b. Nurse's Notes were printed from a computer medical record dated between 1/25/11 through 5/19/11. with the following findings: 4/26/11 at 7:37 p.m. - "He wanders without purpose throughout the unit and is near constant care for redirection from others rooms and properties." 4/28/11 at 6:28 p.m. - "Behavior of touching every item he passes continues . . . and is near constant care for the staff." 5/1/11 at 8:11 p.m. - "Near constant care to keep him from others' rooms and properties." 5/2/11 at 11:29 a.m. - "Resident is ambulatory to unit and paces the floor without purpose." 5/3/11 at 11:04 p.m. - "He is near constant care for the staff, wanders without purpose every waking moment. Repeated attempts for activity are grossly unsuccessful." 5/5/11 at 9:53 p.m. - "Repetitive behaviors of wandering into others rooms." 5/6/11 at 9:10 p.m. - "Wandering without purpose and into anything within sight. He is near constant care for his safety, to deep from others rooms and property . . ." Nurse's Notes dated 5/7/11 at 3:47 p.m. (a Saturday), and signed by Licensed Practical Nurse (LPN) #5, documented, "At the onset of the shift (approximately 2:00 p.m.) resident is ambulating in the hallway and CNA (Certified Nursing Assistant) observes him chewing on something, no food items had been given. Upon inspection of his mouth it was found to be plastic cap off of soda bottle from the trash can . . . counseling is done with resident but no observed understanding is noted . . . Continued negative behaviors are wandering in & (and) out of others rooms, unplugging call lights from wall sockets, taking others property. Near constant care & guarding for staff, total care for all needs." There was no documentation that Licensed Practical Nurse (LPN) #5 had notified the Director of Nursing (DON) or the resident's physician about the inedible bottle cap found in the resident's mouth. The Nurse's Notes dated 5/8/11 (3), 5/9/11 (4), 5/10/11 (1) and 5/15/11 (1) that were documented since the incident on 5/7/11 did not document reference to the bottle cap found in the resident's mouth or other similar incidents of placing inedible objects in his mouth. c. On 5/18/11 at 3:07 p.m., the resident was ambulating without assist in and out of the secured unit's dayroom and kitchen/dining room. d. On 5/19/11 at 8:35 a.m., the resident was ambulating at the far end of the hall, near his assigned room. An unattended housekeeping cart was against the wall just before the resident's room doorway. There was no staff in the immediate area (LPN #2 was in and out of the dayroom passing medications and CNA #1 and Nurse Aide Trainee (TNA) #1 was on the unit, in and out of rooms/dayroom.) Housekeeper #1 was in a room across the hall from the cart and did not have line-of-sight to the cart. The resident took a disposable glove from a glove box located on top of the housekeeping cart, held it to his face, then placed it partially on his right hand. The resident then walked into the dayroom and stood next to LPN #2, who did not look at the resident. At approximately 8:38 a.m., the resident then walked to the kitchen/dining room on the unit (the door was open) and stood next to an open window. LPN #2 entered the dining room and closed the window, but did not remove the glove from the resident's hand. At 8:42 a.m., the resident then returned to the housekeeping cart that remained unattended and removed a washcloth from a large stack on top of the cart. The resident walked up and down the 300 Hall wearing the glove and carrying the washcloth in his right hand. At 8:46 a.m., TNA #1 assisted the resident out of another resident's room and took the glove and washcloth from him, after a period of 11 minutes since he took the glove from the housekeeping cart without staff intervention. e. On 5/19/11 at 9:06 a.m., the resident was sitting in a rocking chair in the unit's dayroom while TNA #1 read to residents. f. On 5/19/11 at 10:31 a.m., CNA #1 was asked if she had been made aware of the resident's history of putting a foreign object in his mouth. CNA #1 denied she had been told that and stated, "He tries to get other people's food " off of trays. g. On 5/19/11 at 10:32 a.m., the resident was in the unit's open kitchen/dining room without staff in attendance. The resident was standing at the far end of the room where cabinets and drawers were located. At 10:33 a.m., CNA #1 and TNA #1 entered the kitchen and directed the resident from the room. An inspection was done of contents of drawers/cabinets at that time. The cabinets contained plastic medication cups, styrofoam cups, an open kleenex box, paper towels, straws in paper wraps, packets of artificial sweetener in a gallon-sized plastic storage bag (sealed). One of the drawers contained an open gallon-sized ziploc plastic storage bag with other storage bags in it. h. On 5/19/11 at 10:35 a.m., TNA #1 stated she had worked in the facility and on 300 Hall unit (day shifts) for one month. She was asked if she had been made aware of the resident's history of putting a foreign object in his mouth. TNA #1 stated, "No, but I have seen him try to put jelly packets in mouth, but we're there to stop him." i. On 5/19/11 at 2:13 p.m., LPN #2, who had worked the day shift on 300 Hall secured unit and another hall, was asked if she was aware of the incident documented on 5/7/11 (soda pop bottle cap in mouth). LPN #2 stated, "I think I remember reading something about that. I usually work other halls." LPN #2 was asked if she was aware of any new instructions for care of the resident and she stated, "None that I'm aware of, he pretty much needs constant supervision." During this interview, LPN #2 was charting in the unit medication room, where a small desk and the residents' charts were kept and was located in the far left corner of the unit's kitchen/dining room. The resident was in the kitchen by the cabinets and sink. At 2:15 p.m., LPN #3 entered the unit and told CNA #2 (scheduled to work the evening shift), "I'm here to help you, I don't know the people." The resident ambulated out of the kitchen with a plastic glass in his hand while CNA #2 was giving resident by resident report to LPN #3 (who was assigned to work as second nursing assistant on 300 Hall unit for the evening shift) and CNA #2 stated, "He will pick up everything," as she took the glass from the resident. j. On 5/19/11 at 2:30 p.m., an interview was conducted with CNA #2 about the resident's behaviors. CNA #2 stated, "He never sits down, can't get him to," "Constantly going, like that cup I took out of his hand, he got under sink," He gets things off the nurses' cart, he grabs things and keeps going." CNA #2 was asked if she had knowledge of items the resident may have put in his mouth, and she stated, "bottle cap, quart-size ziploc bag. I didn't see ziploc bag, have been told, plastic flower. I've taken real flowers, jelly packets (out of his mouth)." CNA #2 was asked when she was told about the ziploc bag and she stated, "2 weeks ago." CNA #2 was asked if she had ever witnessed the resident rummaging in the unit kitchen, and she stated, "Yes, that's why we (evening shift) try to keep the door closed." CNA #2 was asked if she had been given any new instructions for care / supervision of the resident and she stated, "No, (LPN #5-evening shift nurse for 300 hall) and I have discussed, we try to give him gum, he won't put things in his mouth as much." k. On 5/19/11 at 2:35 p.m., LPN #5 stated she had worked on 300 Hall as a CNA for two years, and as a nurse for the past 4 years. LPN #5 was read the Nurse's Note from 5/7/11 about the bottle cap in the resident's mouth and she stated, "told by CNA. He puts everything (in mouth). Within past 2-3 weeks we've been trying to put gum in his mouth." LPN #5 was asked what items she was aware of that the resident had placed in his mouth and she stated, "I have seen real flowers, stems and flowers, artificial flower, eats paper napkins, shreds at table, heard (about) jelly packet." LPN #5 stated, "I'm the one who found ziploc bag in mouth, I came onto the floor at 2:00 p.m., saw him chewing on something . . . finally opened mouth, balled up storage bag. When I got it out, it was a quart-size ziploc bag." LPN #5 was asked if she had discussed this incident with the DON or Assistant Director of Nursing (ADON) and she stated, "No, it's just another thing I had to take out of his mouth," asked if she had filled out an Incident Report and LPN #5 stated, "No." LPN #5 was asked why the incident was not reported and she stated, "If I filled out a report, I'd be filling one out every hour." LPN #5 was asked if she felt the incidents with items in the resident's mouth had lessened with use of gum and she stated, "Oh, yes." l. On 5/19/11 at 3:05 p.m., the Acute Care Unit (ACU) Director (who stated she had held that position for [AGE] years) stated that 300 Hall was, "not an Alzheimer's unit, (it's) a locked unit." She was asked how she became aware of residents' incidents on the 300 Hall unit and she stated, "Nurses call if (residents) go to hospital, altercation, skin tear, fall." The ACU Director was asked about her knowledge of this resident's behaviors in the last 2 months, and she stated, "(resident) likes to push residents, doesn't talk, child-like." She stated the resident, "(Has) curiosity, we had him on 200 Hall (the licensed Alzheimer's Unit in the facility), he would walk constantly, may pick up a pen, moved container in ice machine over, almost like a child. Picks flowers, puts in mouth. I've given him gum." The ACU Director was asked if she was involved in the care planning process for residents who lived on the 300 Hall and she stated, "Yes." She was asked how recently had she been made aware of the resident putting flowers in his mouth and she stated, "On Mother's Day (5/8/11, a Sunday)." The ACU Director was asked if the resident was found by staff with a foreign object in his mouth, would she expect to be notified and she stated, "Yes." Asked if an I&A report would be filled out and she stated, "Yes." m. On 5/19/11 at 3:51 p.m., the DON and ACU Director were asked to provide all I&A reports for this resident since 4/1/11. On 5/19/11 at 5:15 p.m., the ACU Director provided a computerized print-out of one incident dated 4/13/11 for a bruise of unknown origin and stated, "That's all he's got." n. On 5/19/11 at 3:55 p.m., an interview was conducted with the DON and the Administrator was present in the room. The DON was informed of the stated and documented history of this resident having inedible items in his mouth. The DON was asked, "Were you aware he puts things in mouth?" and she stated, "I read nurse's note just one time about bottle cap." The DON was asked, "What did you do about it?" and she stated, "Nothing." The DON was asked if she had spoken to staff about the resident ' s behavior, and she stated she had spoken to LPN #5 about where the bottle cap came from. The DON denied she had been informed about the other incidents of inedible items found in the resident's mouth. The DON was asked if, after she read the nurse's note dated 5/7/11, if the 300 Hall unit was assessed for any other accident hazards and she stated, "We'd have to remove everything back there." DON was asked if there was any discussion with staff about increased supervision and she stated, "No, we had increased (to) 2 CNAs (an action planned for the evening shift specifically for the 300 Hall in a Plan of Correction with an alleged compliance date of 4/29/11)." The Administrator was asked if he had been informed by any staff member about the residents behavior or about the bottle cap, that was documented in nurses notes, and he shook his head right to left (indicating 'no'). o. On 5/19/11 at 5:20 p.m., CNA #5 was asked if she had worked on the unit with this resident and she stated she didn't usually work on that hall but, "I did work there last week and pulled a flower stem out of his mouth." CNA #5 was asked if she told the nurse and she stated, "Yes," but did not remember who the nurse was on duty that day. 4. On 5/19/11 at 10:00 p.m., the Immediate Jeopardy was removed and the severity/scope lowered to an, "E," after the facility began implementation of their Plan of Removal as follows: a. "All cognitively impaired residents with the ability to ambulate via wheelchair or walking and (who had) the use of at least one arm were assessed that could be at risk of a choking related incident by placing foreign objects in their mouth . . . Of those assessed, there are 7 residents identified that place foreign objects in their mouth (paper products at meals)." b. Resident #1 was placed on 1:1 monitoring, his physician was notified and an order received to send the resident out for evaluation on 5/20/11 at 7:00 a.m. Upon his return, Resident #1 was care planned for line of sight monitoring while awake, the unit dining room door closed and locked when not in use, no paper products on meal tray and to offer gum, food and drink every hour between meals and in times of increased agitation or activity. Food and drink items were to be kept in the dining room refrigerator. c. The Housekeeping Supervisor was in-serviced by the DON on 5/19/11 at 5:30 p.m. to have housekeepers on 300 Hall unit take cart into room while cleaning and never leave cart unattended. d. The ACU Director was in-serviced by the DON on 5/19/11 at 7:30 p.m. that the dining room door on 300 Hall unit was to be shut and locked during non-use hours at all times. e. All facility staff received training that began on 5/19/11 at 6:30 p.m. for the care of Resident #1, upon his return to the facility and the other residents identified at risk would no longer have any type of paper products on meal trays. f. Training was also provided that if a resident was observed putting foreign objects in their mouth, they were to remove the object and report to nurse immediately. The nurse was complete an incident report and notify the DON, resident's physician and family. Interventions were to be put in place immediately and if paper products on meal trays, the dietary department notified to remove paper products from trays and keep that resident within view of staff while awake. "All employees, licensed and unlicensed, will receive the above training prior to working on floor. This will be ongoing training. Newly hired employees or employees returning from leave will also receive the same training." g. An LPN monitored every hour that 1:1 was being done as planned for Resident #1 and documented it on a Continuous Monitoring Tool. The Administrator/designee checked that all monitoring was documented and done as planned every 12 hours. Any identified failures of staff to follow instruction would be documented, immediate retraining performed, and the Administrator and DON notified. Repeated failures would be addressed with disciplinary actions up to and including termination.

This is a re-written deficiency. A. Based on observation, record review and interview, the facility failed to ensure that choking hazards were not accessible to a resident who placed inedible items in his mouth, reports were made to supervisory personnel when choking hazards were identified, investigations were conducted after incidents of resident placing foreign objects in his mouth, and interventions were planned and implemented in attempts to prevent further incidents of choking hazards for 1 (Resident #1) of 3 (Residents #1, #8 and #9) case mix residents who were identified with a history of placing foreign objects in their mouths. The failed practice resulted in Immediate Jeopardy which was likely to cause serious injury, harm or death for Resident #1, who had a history of [REDACTED]. The facility was informed of the Immediate Jeopardy on 5/19/11 at 6:05 p.m. The failed practice had the potential to affect 7 residents who were identified with a history of placing foreign objects in their mouths according to a list provided by the Director of Nursing (DON) on 5/20/11 at 12:42 p.m. The findings are: 1. The facility's policy and procedure titled "Incident Documentation and Investigation" documented, "Policy: It is the intent of the facility that all incidents involving resident care will be investigated and documented on the Incident Documentation and Investigation Tool (I&A reports) to enable the facility to evaluate the care given to residents, to assist in prevention of incidents, and evaluate intervention given in the event of an incident. An "incident" is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. ... Procedure: a. The Charge Nurse at the time of the resident care incident is responsible for conducting an investigation of the circumstances surrounding the incident, and for notifying the Director of Nursing and / or CEO (Chief Executive Officer) . . . b. The Charge Nurse at the time of the incident is responsible to complete the Incident Documentation and Investigation Tool, ...c. The Charge Nurse at the time of the incident is responsible for documenting the incident in the resident's medical record ... ... Notifications and documentation in the Resident's Medical Record: a. The Charge Nurse shall put the resident on the 24 Hour Report, documenting the incident, and notify the Director of Nursing for follow through as needed, ...c. The Charge Nurse is also required to document the incident in the Nurse's Notes section of the resident's medical record ...The Nurse's Notes should contain the following documentation: 1. Clear, objective facts of what occurred; 2. A thorough assessment of the resident's condition at the time of the incident ...5. Any contacts made or attempted with the resident's physician . . . or any other health care professional or person involved with the resident's care." 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/15/11 documented the resident scored 0 (0-7 indicates severely impaired) on a Brief Interview for Mental Status, had short and long term memory problems had wandering behavior daily, required supervision for locomotion in room/corridor and on/off unit, was steady at all times for all balance tests, and had no functional limitation in range of motion for the upper and lower extremities. a. A "Notice of Room Change" form dated 1/20/11 documented the resident had been moved to the 300 Hall secured unit. The facility's Admission Criteria form for the secured unit documented, "Resident may have a primary [DIAGNOSES REDACTED]. . ." b. Nurse's Notes were printed from a computer medical record dated between 1/25/11 through 5/19/11. with the following findings: 4/26/11 at 7:37 p.m. - "He wanders without purpose throughout the unit and is near constant care for redirection from others rooms and properties." 4/28/11 at 6:28 p.m. - "Behavior of touching every item he passes continues . . . and is near constant care for the staff." 5/1/11 at 8:11 p.m. - "Near constant care to keep him from others' rooms and properties." 5/2/11 at 11:29 a.m. - "Resident is ambulatory to unit and paces the floor without purpose." 5/3/11 at 11:04 p.m. - "He is near constant care for the staff, wanders without purpose every waking moment. Repeated attempts for activity are grossly unsuccessful." 5/5/11 at 9:53 p.m. - "Repetitive behaviors of wandering into others rooms." 5/6/11 at 9:10 p.m. - "Wandering without purpose and into anything within sight. He is near constant care for his safety, to deep from others rooms and property . . ." Nurse's Notes dated 5/7/11 at 3:47 p.m. (a Saturday), and signed by Licensed Practical Nurse (LPN) #5, documented, "At the onset of the shift (approximately 2:00 p.m.) resident is ambulating in the hallway and CNA (Certified Nursing Assistant) observes him chewing on something, no food items had been given. Upon inspection of his mouth it was found to be plastic cap off of soda bottle from the trash can . . . counseling is done with resident but no observed understanding is noted . . . Continued negative behaviors are wandering in & (and) out of others rooms, unplugging call lights from wall sockets, taking others property. Near constant care & guarding for staff, total care for all needs." There was no documentation that Licensed Practical Nurse (LPN) #5 had notified the Director of Nursing (DON) or the resident's physician about the inedible bottle cap found in the resident's mouth. The Nurse's Notes dated 5/8/11 (3), 5/9/11 (4), 5/10/11 (1) and 5/15/11 (1) that were documented since the incident on 5/7/11 did not document reference to the bottle cap found in the resident's mouth or other similar incidents of placing inedible objects in his mouth. c. On 5/18/11 at 3:07 p.m., the resident was ambulating without assist in and out of the secured unit's dayroom and kitchen/dining room. d. On 5/19/11 at 8:35 a.m., the resident was ambulating at the far end of the hall, near his assigned room. An unattended housekeeping cart was against the wall just before the resident's room doorway. There was no staff in the immediate area (LPN #2 was in and out of the dayroom passing medications and CNA #1 and Nurse Aide Trainee (TNA) #1 was on the unit, in and out of rooms/dayroom.) Housekeeper #1 was in a room across the hall from the cart and did not have line-of-sight to the cart. The resident took a disposable glove from a glove box located on top of the housekeeping cart, held it to his face, then placed it partially on his right hand. The resident then walked into the dayroom and stood next to LPN #2, who did not look at the resident. At approximately 8:38 a.m., the resident then walked to the kitchen/dining room on the unit (the door was open) and stood next to an open window. LPN #2 entered the dining room and closed the window, but did not remove the glove from the resident's hand. At 8:42 a.m., the resident then returned to the housekeeping cart that remained unattended and removed a washcloth from a large stack on top of the cart. The resident walked up and down the 300 Hall wearing the glove and carrying the washcloth in his right hand. At 8:46 a.m., TNA #1 assisted the resident out of another resident's room and took the glove and washcloth from him, after a period of 11 minutes since he took the glove from the housekeeping cart without staff intervention. e. On 5/19/11 at 9:06 a.m., the resident was sitting in a rocking chair in the unit's dayroom while TNA #1 read to residents. f. On 5/19/11 at 10:31 a.m., CNA #1 was asked if she had been made aware of the resident's history of putting a foreign object in his mouth. CNA #1 denied she had been told that and stated, "He tries to get other people's food " off of trays. g. On 5/19/11 at 10:32 a.m., the resident was in the unit's open kitchen/dining room without staff in attendance. The resident was standing at the far end of the room where cabinets and drawers were located. At 10:33 a.m., CNA #1 and TNA #1 entered the kitchen and directed the resident from the room. An inspection was done of contents of drawers/cabinets at that time. The cabinets contained plastic medication cups, styrofoam cups, an open kleenex box, paper towels, straws in paper wraps, packets of artificial sweetener in a gallon-sized plastic storage bag (sealed). One of the drawers contained an open gallon-sized ziploc plastic storage bag with other storage bags in it. h. On 5/19/11 at 10:35 a.m., TNA #1 stated she had worked in the facility and on 300 Hall unit (day shifts) for one month. She was asked if she had been made aware of the resident's history of putting a foreign object in his mouth. TNA #1 stated, "No, but I have seen him try to put jelly packets in mouth, but we're there to stop him." i. On 5/19/11 at 2:13 p.m., LPN #2, who had worked the day shift on 300 Hall secured unit and another hall, was asked if she was aware of the incident documented on 5/7/11 (soda pop bottle cap in mouth). LPN #2 stated, "I think I remember reading something about that. I usually work other halls." LPN #2 was asked if she was aware of any new instructions for care of the resident and she stated, "None that I'm aware of, he pretty much needs constant supervision." During this interview, LPN #2 was charting in the unit medication room, where a small desk and the residents' charts were kept and was located in the far left corner of the unit's kitchen/dining room. The resident was in the kitchen by the cabinets and sink. At 2:15 p.m., LPN #3 entered the unit and told CNA #2 (scheduled to work the evening shift), "I'm here to help you, I don't know the people." The resident ambulated out of the kitchen with a plastic glass in his hand while CNA #2 was giving resident by resident report to LPN #3 (who was assigned to work as second nursing assistant on 300 Hall unit for the evening shift) and CNA #2 stated, "He will pick up everything," as she took the glass from the resident. j. On 5/19/11 at 2:30 p.m., an interview was conducted with CNA #2 about the resident's behaviors. CNA #2 stated, "He never sits down, can't get him to," "Constantly going, like that cup I took out of his hand, he got under sink," He gets things off the nurses' cart, he grabs things and keeps going." CNA #2 was asked if she had knowledge of items the resident may have put in his mouth, and she stated, "bottle cap, quart-size ziploc bag. I didn't see ziploc bag, have been told, plastic flower. I've taken real flowers, jelly packets (out of his mouth)." CNA #2 was asked when she was told about the ziploc bag and she stated, "2 weeks ago." CNA #2 was asked if she had ever witnessed the resident rummaging in the unit kitchen, and she stated, "Yes, that's why we (evening shift) try to keep the door closed." CNA #2 was asked if she had been given any new instructions for care / supervision of the resident and she stated, "No, (LPN #5-evening shift nurse for 300 hall) and I have discussed, we try to give him gum, he won't put things in his mouth as much." k. On 5/19/11 at 2:35 p.m., LPN #5 stated she had worked on 300 Hall as a CNA for two years, and as a nurse for the past 4 years. LPN #5 was read the Nurse's Note from 5/7/11 about the bottle cap in the resident's mouth and she stated, "told by CNA. He puts everything (in mouth). Within past 2-3 weeks we've been trying to put gum in his mouth." LPN #5 was asked what items she was aware of that the resident had placed in his mouth and she stated, "I have seen real flowers, stems and flowers, artificial flower, eats paper napkins, shreds at table, heard (about) jelly packet." LPN #5 stated, "I'm the one who found ziploc bag in mouth, I came onto the floor at 2:00 p.m., saw him chewing on something . . . finally opened mouth, balled up storage bag. When I got it out, it was a quart-size ziploc bag." LPN #5 was asked if she had discussed this incident with the DON or Assistant Director of Nursing (ADON) and she stated, "No, it's just another thing I had to take out of his mouth," asked if she had filled out an Incident Report and LPN #5 stated, "No." LPN #5 was asked why the incident was not reported and she stated, "If I filled out a report, I'd be filling one out every hour." LPN #5 was asked if she felt the incidents with items in the resident's mouth had lessened with use of gum and she stated, "Oh, yes." l. On 5/19/11 at 3:05 p.m., the Acute Care Unit (ACU) Director (who stated she had held that position for [AGE] years) stated that 300 Hall was, "not an Alzheimer's unit, (it's) a locked unit." She was asked how she became aware of residents' incidents on the 300 Hall unit and she stated, "Nurses call if (residents) go to hospital, altercation, skin tear, fall." The ACU Director was asked about her knowledge of this resident's behaviors in the last 2 months, and she stated, "(resident) likes to push residents, doesn't talk, child-like." She stated the resident, "(Has) curiosity, we had him on 200 Hall (the licensed Alzheimer's Unit in the facility), he would walk constantly, may pick up a pen, moved container in ice machine over, almost like a child. Picks flowers, puts in mouth. I've given him gum." The ACU Director was asked if she was involved in the care planning process for residents who lived on the 300 Hall and she stated, "Yes." She was asked how recently had she been made aware of the resident putting flowers in his mouth and she stated, "On Mother's Day (5/8/11, a Sunday)." The ACU Director was asked if the resident was found by staff with a foreign object in his mouth, would she expect to be notified and she stated, "Yes." Asked if an I&A report would be filled out and she stated, "Yes." m. On 5/19/11 at 3:51 p.m., the DON and ACU Director were asked to provide all I&A reports for this resident since 4/1/11. On 5/19/11 at 5:15 p.m., the ACU Director provided a computerized print-out of one incident dated 4/13/11 for a bruise of unknown origin and stated, "That's all he's got." n. On 5/19/11 at 3:55 p.m., an interview was conducted with the DON and the Administrator was present in the room. The DON was informed of the stated and documented history of this resident having inedible items in his mouth. The DON was asked, "Were you aware he puts things in mouth?" and she stated, "I read nurse's note just one time about bottle cap." The DON was asked, "What did you do about it?" and she stated, "Nothing." The DON was asked if she had spoken to staff about the resident ' s behavior, and she stated she had spoken to LPN #5 about where the bottle cap came from. The DON denied she had been informed about the other incidents of inedible items found in the resident's mouth. The DON was asked if, after she read the nurse's note dated 5/7/11, if the 300 Hall unit was assessed for any other accident hazards and she stated, "We'd have to remove everything back there." DON was asked if there was any discussion with staff about increased supervision and she stated, "No, we had increased (to) 2 CNAs (an action planned for the evening shift specifically for the 300 Hall in a Plan of Correction with an alleged compliance date of 4/29/11)." The Administrator was asked if he had been informed by any staff member about the residents behavior or about the bottle cap, that was documented in nurses notes, and he shook his head right to left (indicating 'no'). o. On 5/19/11 at 5:20 p.m., CNA #5 was asked if she had worked on the unit with this resident and she stated she didn't usually work on that hall but, "I did work there last week and pulled a flower stem out of his mouth." CNA #5 was asked if she told the nurse and she stated, "Yes," but did not remember who the nurse was on duty that day. 3. On 5/19/11 at 10:00 p.m., the Immediate Jeopardy was removed and the severity/scope lowered to an, "E," after the facility began implementation of their Plan of Removal as follows: a. "All cognitively impaired residents with the ability to ambulate via wheelchair or walking and (who had) the use of at least one arm were assessed that could be at risk of a choking related incident by placing foreign objects in their mouth . . . Of those assessed, there are 7 residents identified that place foreign objects in their mouth (paper products at meals)." b. Resident #1 was placed on 1:1 monitoring, his physician was notified and an order received to send the resident out for evaluation on 5/20/11 at 7:00 a.m. Upon his return, Resident #1 was care planned for line of sight monitoring while awake, the unit dining room door closed and locked when not in use, no paper products on meal tray and to offer gum, food and drink every hour between meals and in times of increased agitation or activity. Food and drink items were to be kept in the dining room refrigerator. c. The Housekeeping Supervisor was in-serviced by the DON on 5/19/11 at 5:30 p.m. to have housekeepers on 300 Hall unit take cart into room while cleaning and never leave cart unattended. d. The ACU Director was in-serviced by the DON on 5/19/11 at 7:30 p.m. that the dining room door on 300 Hall unit was to be shut and locked during non-use hours at all times. e. All facility staff received training that began on 5/19/11 at 6:30 p.m. for the care of Resident #1, upon his return to the facility and the other residents identified at risk would no longer have any type of paper products on meal trays. f. Training was also provided that if a resident was observed putting foreign objects in their mouth, they were to remove the object and report to nurse immediately. The nurse was complete an incident report and notify the DON, resident's physician and family. Interventions were to be put in place immediately and if paper products on meal trays, the dietary department notified to remove paper products from trays and keep that resident within view of staff while awake. "All employees, licensed and unlicensed, will receive the above training prior to working on floor. This will be ongoing training. Newly hired employees or employees returning from leave will also receive the same training." g. An LPN monitored every hour that 1:1 was being done as planned for Resident #1 and documented it on a Continuous Monitoring Tool. The Administrator/designee checked that all monitoring was documented and done as planned every 12 hours. Any identified failures of staff to follow instruction would be documented, immediate retraining performed, and the Administrator and DON notified. Repeated failures would be addressed with disciplinary actions up to and including termination. B. Based on observation, record review and interview, the facility failed to ensure restraints were applied according to manufacturer's instructions to reduce the potential for injury for 1 (Resident #8) of 5 (Residents #2, #3, #8, #9 and #10) case mix residents who used physical restraint devices. The facility also failed to ensure interventions planned for prevention of falls were consistently implemented to decrease the potential for injury for 3 (Residents #3, #12 and #13) of 8 (Residents #3 and #7 through #13) case mix residents who used safety alarms or fall mats. The failed practices had the potential to affect 8 residents who used physical restraint devices as documented on a list provided by the Director of Nursing (DON) on 5/18/11 at 6:00 p.m. and 20 residents who were at risk for falls and used safety alarms or fall mats as documented by DON on 5/21/11 at 12:12 p.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/22/11 documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status, required extensive assistance of two staff members for bed mobility and transfers, was not steady and only able to stabilize with human assistance for moving from seated to standing position, walking and turning around while walking and surface-to-surface transfers, had no functional limitations in range of motion (ROM) for the upper or lower extremities, and had 2 or more falls since the prior assessment. a. The Care Plan dated 7/16/10 documented, "Risk for falls r/t (related to) unsteady gait and progression in his dementia, resident has tunnel vision, ... Approaches ...CNA in-serviced on alarms being on, alarm turned on ...bolster mattress upon arrival, frequent checks until mattress arrives." The Care Plan was printed from computerized medical records on 5/20/11 at 11:35 a.m. and did not document revisions after the initial Care Plan date. b. A Physicians order dated 11/10/10, "Pressure alarm to be placed under resident, at all times while in bed." The order was on the May 2011 Physicians Orders sheet. c. A Resident Incident Report (I&A) dated 4/6/11 at 11:50 p.m., documented, "Called to resident room and he was in floor laying back, noted blood on his right knee, and in floor. Resident stated that he climbed over the top and landed here. Noted several abrasions right upper back of arm bruised, right lower arm area about 4-5 inches, right side of his back with abrasions left lower leg abrasion, left arm at elbow had abrasion. All ROM within normal limits. ...Immediate Post-Incident Action ...We will place fall mat by bed . . ." There was no documentation in the I&A or in Nurses' Notes dated 4/6/11 for the same incident of an alarm in place in the resident's bed. d. An I&A report dated 5/15/11 at 7:32 p.m., documented, "Resident was found in floor by (LPN #4) . . . Abrasion to back 4 inches long. Scratch on left thigh 4 inches long, red mark on forearms bilaterally. ...Immediate Post-Incident Action ...Alarm was not present on resident as care planned. ...Immediate Actions Taken ...Immediate first aid. ...Narrative of Investigation ...New Interventions: . . . Bolster mattress ordered and to be placed on bed upon arrival. Frequent check on resident while in bed until mattress arrives." e. On 5/18/11 at 5:04 p.m., the Assistant DON (ADON) stated the resident did not use alarms. Between the dates of 5/18/11 at 5:04 p.m. and 5/19/11 at 10:42 a.m., all observations were of the resident up in his wheelchair. On 5/19/11 at 10:43 a.m., an attempt was made to locate an alarm for the resident's bed. The covers on the bed were smooth to touch and no alarm box for a pressure alarm could be located on the bed frame. There were anti-skid strips by the foot of the bed and a 1/4 siderail placed at the midpoint of the resident's mattress, which was a geomat pressure relief mattress without raised edges (a bolster mattress has raised edges on all sides to inhibit movement from the bed). f. On 5/21/11 at 8:24 a.m., the ADON was asked to accompany the surveyor to the resident's bed and locate a pressure alarm. The ADON was unable to locate an alarm in the bed or room. The ADON asked CNA #3 if she knew anything about the alarm, and CNA #3 stated, "I've never seen one." On 5/21/11 at 9:46 a.m., with the ADON present, CNA #4 (who stated she had worked the hall where the resident lived for approximately 6 months) was asked if she had ever seen a pressure alarm on the resident's bed and she stated, "no." The ADON was asked where the resident's fall mat was located, and the ADON asked CNA #4, "where would (resident's) mat be?" CNA #4 stated, "I've never seen one." g. On 5/21/11 at 9:12 a.m., the DON was asked to provide the purchase orders for the resident's pressure alarm and bolster mattress. On 5/21/11 at 10:27 a.m. the DON provided copies of the purchase orders that documented as follows: An order dated 5/18/11 at 5:09 p.m. for a bed sensor alarm and another order dated 5/19/11 at 8:50 a.m. for a bolster mattress. 2. Resident #12 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 14-day Medicare MDS with an ARD of 4/19/11 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required supervision for locomotion in room, corridor and on unit, had hallucinations and delusions, did not have steady balance but was able to stabilize without human assistance for all balance tests, had no falls since admission and had no functional limitations in range of motion in upper or lower extremities. a. The Care Plan dated 4/6/11 documented a problem for potential injury associated with unsteady gait and an approach, "bed and chair alarm in place and checked for proper functioning every shift." The May 2011 Physician order [REDACTED]. b. The CNA Care Plan received from the DON on 5/20/11 at 12:02 p.m. did not address alarm use for this resident. c. On 5/19/11 at 10:40 a.m., the resident was sitting in an upright recliner in his room and had his eyes closed. An alarm box was on an overbed table approximately 2 feet from the resident and was not attached to the resident. On 5/19/11 at 12:21 p.m. and 1:54 p.m., the resident was in a wheelchair without an alarm in place. The alarm box remained on the resident's overbed table at both of those times. 3. Resident #13 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/14/11 documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status and was incontinent of bowel and bladder. a. The physician's orders [REDACTED]." b. On 5/18/11 at 3:07 p.m., the resident was in a wheelchair in the day room of the secure unit with no alarm in place. c. On 5/19/11 at 9:32 a.m., the resident was in a wheelchair in the day room of the secure unit with no alarm in place. d. On 5/20/11 at 11:20 a.m., the resident was in a wheelchair in the day room of the secure unit with no alarm in place. 4. On 5/21/11 at 11:49 a.m., the DON was asked where alarm use was documented in residents' clinical records. The DON stated that nurses and CNAs, "do not document alarm use." The DON was asked if alarms were possibly signed off on ADL records, Medication Administration Records, or Treatment Records, and she stated, "No." 5. Resident #8 had [DIAGNOSES REDACTED]. The MDS with an ARD of 2/19/11 documented the resident scored 3 (0-6 indicates severe impairment) on a Brief Interview for Mental Status, balance was unsteady and had one fall since admission. a. The Care Plan dated 4/26/11 documented, "Resident has a self releasing w/c (wheelchair) belt d/t (due to) impaired cognition resulting in poor safety awareness. Resident uses w/c related to parkinson's progression. " b. The Nurse's Note dated 4/26/11 and timed 1:03 p.m. documented, "At 0610 (6:10 a.m.) CNA (Certified Nurse's Assistant) reported found on floor on hands and knees. No s/s (signs and symptoms) of pain discomfort or injury noted. Family and MD (Medical Doctor) aware. NO (new order) d/c (discontinue) lap buddy and body alarm. Apply Velcro w/c belt to decrease the risk of falls..." c. On 5/18/11 at 3:07 p.m., the resident was in a wheelchair in the day room with a 6 inch wide band of foam around the lower chest/upper abdomen area extending around the back of the wheelchair above the arm rests and secured behind the upper back of the wheelchair with velcro. The foam belt was not secured to the wheelchair by the grommet. d. On 5/19/11 at 8:45 a.m., the resident was in his room sitting on the side of the roommate's bed. The 6 inch wide foam was on the wheelchair and a clip body alarm was on the wheelchair in the room. Training Nurse's Aide (TNA) #1 was asked to come to the room. TNA #1 stated, "He got up and took off without us." e. On 5/19/11 at 11:40 a.m. and 12:15 p.m., the resident was in the wheelchair in the dining room with the 6 inch foam belt under the arm rests of the wheelchair and fastened behind the back of the chair with Velcro. The foam belt was not secured to the wheelchair by the grommet. f. On 5/20/11 at 10:50 a.m., the resident was in the wheelchair in the day room with the 6 inch foam belt around the lower chest and upper abdomen extending over the top of the arm rests of the wheelchair, and secured to the back of the wheelchair with Velcro. The foam belt was not secured to the chair by the grommet. g. On 5/20/11 at 11:20 a.m, the resident was in the wheelchair in the day room with the 6 inch foam belt around the chest and upper abdomen extending over the top of the arms of the wheelchair and secured behind the back of the wheelchair with Velcro. Licensed Practical Nurse (LPN) #1 was asked, "Is that how that restraint is supposed to be applied?' LPN #1 stated, "Yes, it goes around and fastens in the back." LPN #1 was asked, "You were told to put it above the arm rests?" LPN #1 stated, "They never told us either way." h. On 5/20/11 at 2:30 p.m., the Assistant Director of Nursing (ADON) provided instructions for the application of the foam belt restraint. The instructions for the "Versatile Wheelchair Belt documented, "Belt attaches to the back of the wheelchair through the grommet on the back rest... b. For Velcro release in back. i. Remove one screw from the left side of the chair back. ii. Align grommet with screw hole. iii. Replace screw tightly. iv. Wrap strap around back of the wheelchair and then around the front of the body. v. Secure Velcro in back." A picture of the wheelchair belt provided by the ADON showed the belt low on the lap and below the arm rests of the wheelchair. The ADON was asked, "Was that how the restraint was applied?" The ADON stated, "No. In fact I worked hard to get these instructions. These weren't in the package."

Based on observation, record review and interview, the facility failed to ensure adequate staff was available on the 300 Hall secure unit during the evening shift to closely monitor and help prevent resident-to-resident altercations and falls for 1 (Resident #9) of 1 case mix resident who resided on the 300 Hall secure unit, exhibited aggressive behaviors toward other residents and had a history of [REDACTED].#9) of 17 (Residents #1-9 and 12-19) case mix residents who were at risk for falls. The failed practices were likely to affect 12 residents who resided on the 300 Hall and 10 residents with a history of falls, as documented on the Roster Matrix provided by the Administrator on 3/28/11. The facility failed to ensure planned interventions to prevent further skin tears were consistently implemented and that interventions were appropriate for the resident's cognitive status for 1 (Resident #4) of 3 (Residents #1, #4 and #9) case mix residents with a history of skin tears. These failed practices had the potential to affect 17 residents with skin tears, as per a list provided by the Director of Nurses on 3/31/11 at3:15 p.m. The facility failed to ensure doors on 4 (Halls 100, 200, 300 and 400) of 6 halls were free of rough, jagged edges to reduce the risk of skin tears or other injuries. The failed practice had the potential to affect 10 residents who were independently ambulatory as identified by the Resident Census and Conditions of Residents form dated 3/28/11. The findings are: 1. Resident #9 had a [DIAGNOSES REDACTED]., exhibited wandering behaviors on 1-3 of the past 7 days, had 2 or more falls without injury since the prior assessment, had hallucinations and delusions and exhibited the following Behavioral Symptoms: 1) Physical behavioral symptoms directed toward others (e.g. (for example), hitting, kicking, pushing, scratching, grabbing, abusing others) and 2) Verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others). The Care Area Assessment (CAA) Summary for this MDS was not completed as of 3/29/11. No care area triggers, care planning decisions or location and dates of CAA further assessment information was documented. a. The Plan of Care developed on 6/25/10 and updated 1/27/11 did not address any problems with delirium or behaviors. 1.) An Incident Report dated 10/02/10 at 4:30 p.m. documented an incident occurred in the hall way: "Another resident was trying to get into her old room and another resident was pushing this resident (Resident #9) in his wheelchair and run into other resident. The other resident told this resident to get off of her and then this resident punched the other resident in the eye. While the CNA was trying to get them separated, this resident hit her again in the face." The immediate actions taken documented, "Separated Residents, assessed resident. VS (vital signs). One on one monitoring." 2.) An Incident Report dated 10/02/10 at 4:40 p.m. (10 minutes after the previous incident) documented an incident occurred in the dining room. "CNA (Certified Nurse Assistant) reported this resident (Resident #9) and other resident were sitting in dining room. The other resident grabbed onto the edge of the table and this resident did not like it, so this resident hit other resident. Another resident tried to get in on it as well but CNA got them separated before anything else happened." The immediate action taken documented, "One on one monitoring and Nurse instructed to give PRN (as needed) medication when resident is agitated." The Staffing Log dated 10/2/10 documented one CNA was assigned to the 300 Hall secure unit on the evening shift and one LPN was assigned as charge nurse for both the 300 and 200 Hall. Departmental Notes dated 10/3/10 at 10:46 a.m. documented, "Resident has had no behaviors toward others today he remains on 1 on 1 till this after evening..." An addendum note dated 10/3/10 at 9:02 p.m. documented, "Received orders from (physician) to have a UA (urinalysis) on resident due to his behaviors..." 3.) An Incident Report dated 10/04/10 at 3:35 p.m. documented an incident occurred in the hallway. "Another resident approaches this resident (Resident #9) and aggressively takes off his ball cap, he grabs his hat back and begins striking the other with the hat and strikes the other man with his other fist on the left upper arm ...Residents separated... assessed for BRP (bathroom privileges) need (resident is clean and dry)... PRN Ativan given. MD (Medical Doctor) and family notified." A physician order [REDACTED]." There were no further documented altercations with other residents until 2/12/11. 4.) An Incident Report dated 2/12/11 at 4:00 p.m. documented an incident occurred in the Activity Room on the secure unit. "...this resident was coming into the day room... he reached out to pull himself forward and grabbed other resident's left arm. Other resident told him to let go and tried to push his hand off and this resident started swinging at her but did not make contact." New interventions documented, "Residents separated. This resident placed 1:1 (on one-to-one supervision)." The Daily Staffing Log dated 2/12/11 documented one CNA was assigned to the 300 Hall and one LPN was assigned as charge nurse for both the 100 and 300 Hall. A Continuous Monitoring Sheet dated 2/12/11 documented the resident was monitored hourly from 4:00 p.m. to 5:00 a.m. Departmental Notes dated 2/13/11 at 8:11 a.m. documented, "...Resident was one-to-one monitoring last evening r/t (related to) episode..." An Immediate Plan of Care dated 2/14/11 documented, "Altercation (with) another resident... Interventions: Plan to keep resident monitor + (and) give more activities to help keep busy + keep occupied..." No further altercations with other residents were documented until 3/27/11. 5.) An Incident Report dated 3/27/11 at 5:15 p.m. documented an incident occurred in the dining room. "Resident takes food item off of resident seated next to him, at the dining room table at the supper meal. When the other man grabs it back, this resident picks up spoon and strikes him on the back of the left hand." The immediate actions documented, "Separated the residents, PRN medication for combative behaviors and continuous monitoring." The New interventions documented, "MD and family notified. Resident moved to another location to finish meal service. PRN Ativan given. Residents kept in separate location on unit for the rest of the evening." The Daily Staffing Log dated 3/27/11 documented one CNA was assigned to the 300 Hall and one LPN served as charge nurse over the 100 and 300 Halls. Departmental Notes dated 3/27/11 at 10:00 p.m. described the above incident and documented, "...This nurse witnessed the event and called to CNA whose back was turned but in the same room... Residents are kept in separate locations and continuous monitoring is done... fax to (physician) to notify of incident..." 6.) On 3/28/11 at 3:50 p.m., during initial tour, the resident was propelling himself down the hallway on closed unit." 7.) On 3/30/11 at 2:01 p.m., the Director of Nurses and the Alzheimer's Director were interviewed and asked the following questions: "Who monitors care on the secured wings?" The Alzheimer's Director stated, "The Aides, Nurses and myself go around and check." "Do you track/trend incidents and the time of day they occur?" The Director of Nurses (DON) stated, "Yes." "Do you know when (Resident #9's) incidents occurred?" The DON stated, "Yes, on the second shift." "How many staff persons do you have on the 300 hall?" The DON stated, "Usually 1, if it's a good day, maybe 2." "How do you provide one-on-one monitoring as documented in the interventions?" The DON stated, "I don't know. I ask them the same thing, when the incidents occurred on the same day." 8.) On 3/30/11 at 3:20 p.m., CNA #3, who stated that she had worked at the facility for 1.5 years, was asked if she was the only CNA assigned to the 300 Hall at this time and stated, "Yes". When asked, "Do you always work this hall (300 Hall)?" She stated, "Yes." When asked about how one-to-one monitoring was provided, the CNA stated, "Have someone come in or from another hall". b. The Care Plan dated 6/15/10 documented, "At risk for falls r/t (related to) falls. ...Approaches ...Falling Star program. CNA inserviced on replacing lap buddy after meals. Continues lap belt applied. Resident is to be put to bed after meals." 1.) An Incident Report dated 10/06/10 at 5:45 p.m. documented an incident occurred in the living room (day room), "CNA reports responding to sounding seat belt alarm (and) witnessing the resident crawling forward out of his w/c (wheelchair), before being able to reach his location resident is on all fours (hands and knees) in front of his w/c." The New interventions documented, "MD and family notified. PRN Ativan given for anxiety." 2.) A Incident Report dated 10/11/10 at 4:45 p.m. documented an incident occurred in another resident's bathroom, "CNA reported she was moving residents into the dining room for supper, and couldn't find this resident, so she went in other resident's rooms looking for him. She found him in another residents' room lying on his back on the floor by the bathroom. ... Immediate post incident Action: "Keep resident close by and monitor. ...New Interventions: MD and family notified. See if resident can be picked up for therapy services while on hospice." 3.) Nurses notes dated 11/12/2010 at 6:33 p.m. documented, "At 6:15 p.m., CNA responds to resident's w/c seat belt alarm, he is found on floor in unoccupied rooms bathroom. ...CNA at the time of the fall was still attending last full assist feed resident in the dining room and this resident had already finished eating and was self mobile to the unit hallway." 4.) An Incident Report dated 11/20/10 at 12:45 a.m. documented an incident occurred in the hallway on the unit, "Heard noise, turned and found resident in floor with wheelchair up rights (upright). Apparently leaned forward and lost balance and fell on to L (left) shoulder. L knee abrasion noted very small without drainage." New interventions documented, "MD and family notified. Belt reapplied and resident repositioned for comfort. ...11/21/11 Physical Therapy modified wheelchair with calf sling and cushion to prevent feet from going under chair and realign body to prevent improper upper body weight distribution." 5.) An Incident Report dated 12/12/10 at 8:25 p.m. documented an incident occurred in the resident's room, "Resident was found on floor at his bedside, upper torso on the fall mat and legs off of fall mat." The Immediate actions documented, "Pressure alarm added to his personal protection equipment. Wife is in agreement." 6.) An Incident Report dated 1/1/11 at 4:20 p.m. documented an incident occurred on the hallway on the unit, "CNA reports being several feet from the resident in the hallway and seeing him lean very far forward in his w/c to attempt to propel himself forward and she is on her way to attempt to straighten his posture in the w/c, before reaching him, the resident unfastens seatbelt and falls forward from the chair onto the floor. Rolling out of chair onto his right side. ...The Immediate Post - Incident: To attempt to keep resident sitting upright in his w/c, attach personal alarm to resident with sorter string on the pull-box and add Therapy to add positioning to therapy regimen." 7.) An Incident Report dated 1/4/11 at 6:25 p.m. documented an incident occurred in the hallway on the unit, "Found on floor in the hallway of the unit, this nurse, responding to his personal seat belt alarm. He is lying on his left side in front of his w/c ... Abrasion to left knee, circular in shape and 4 cm (centimeters) across, with leading abrasion line superiorly down from the patella; be possible impact point with the floor." Actions documented, "Staff to keep resident within eyesight view of the resident and Positioning device ordered to keep resident upright in chair." 8.) An Incident Report dated 1/10/11 at 6:45 p.m. documented an incident occurred in the hallway on the unit, "CNA reported to this nurse that she was turned around on the end of the hallway and heard this resident say 'help' and she turned around and this resident was on the floor." New interventions documented, "MD and Family notified. Ensure activity apron is in place. Therapy to put on shoulder harness upon arrival." 9.) Physician orders [REDACTED]." 10). A Resident Incident Report dated 2/4/11 at 12:30 p.m. documented an incident occurred in the hallway on the unit, "Called to hall and found resident on floor on his hands and knees. He left dining room and was trying to stand and went down onto floor onto hands and knees. On left knee cm 1x1 abrasion." New interventions documented, "MD and family notified. CNA inserviced on the importance of replacing lap buddy immediately after meals." 11.) An Incident Report dated 2/5/11 at 6:00 p.m. documented an incident occurred in the resident's room, "Resident's w/c alarm went off and I found him on floor on his knees. Red marks on both knees, left knee had steri strips from a previous fall. ...Incident Investigation: ...Resident removed his lap buddy and attempted to transfer himself to bed and fell . ...New interventions documented, "MD and family notified. Resident to be put to bed immediately after evening meal." 12.) An Incident Report dated 2/6/11 at 4:40 p.m. documented an incident occurred in the activity room on the unit, "CNA reported she was in another resident's room and she heard resident say 'oh' and she went to activity room and this resident was lying in the floor in front of his wheelchair. ...Incident Investigation ... Resident removed lap buddy and attempted to stand without assistance ... Resident fell in front of his wheel chair. New interventions documented, "MD and family notified. Wheelchair belt ordered for resident. To be applied upon arrival. Continuous monitoring until it arrives." 13.) An Incident Report dated 2/28/11 at 6:00 p.m. documented an incident occurred in the dining room on the unit, "Res (resident) was in dining rm (room) on secured unit and was trying to remove lap buddy from w/c. Skin tear to left wrist. 1 cm x 1 cm in size." New interventions documented, "MD and family notified. Speak with therapy and order new lap buddy." 14.) A physician's orders [REDACTED]." 15.) On 3/29/11 at 10:58 a.m., the resident was in a rocking recliner in the day room. The personal alarm box was on the seat of the chair, under the resident's right elbow and was not attached to the chair, which could allow the resident to rise from the chair without causing the alarm to sound. 2. Resident #4 had [DIAGNOSES REDACTED]. The Initial MDS with an assessment reference date of 1/27/11 documented the resident scored 2 on a Brief Interview for Mental Status (BIMS) (0-7 indicates severe impairment) and required extensive assistance for bed mobility and transfers. a. The Plan of Care (not dated, other than the print date of 3/29/11 at 5:00 p.m.) documented, "I have a skin tear/laceration ...resident self inflicts scratches to self he pick at arm." The interventions documented, " ...Protect my area from further injury ... I need a mechanical lift to avoid further skin tears." b. An Incident Report dated 1/24/11 at 4:30 p.m. documented, "At 4:30 p.m., CNA notified this nurse to come and look at this resident's left hand. CNA was pushing resident up to dining table for supper and the top of his left hand bumped the edge of the dining room table." New Interventions documented, "MD and family notified. Inservice with CNA to be careful of resident's extremities when pushing resident up to table." c. An Incident Report dated 1/31/11 at 5:00 p.m., documented, " CNA reported that resident was in bed and CNA was going to get him up for supper. When she pulled residents sleeve up she noticed skin tear to upper left foreman. 1.5 cm (centimeter) x 1 cm skin tear to upper left forearm." New interventions documented, "Clip finger nails and keep short, geri-sleeves pulled up." d. An Incident Report dated 2/1/11 at 10:30 a.m., documented," Resident was setting in w/c, rubbing hands together. Resident began picking at L (left) middle finger. 1 cm x 1 cm on top L middle finger." New interventions documented, "MD and family notified. Resident instructed not to pick at fingers." The MDS documented the resident had severely impaired cognitive skills. e. An Incident Report dated 2/1/11 at 6:10 p.m. documented, "Resident attempts to cross his legs, back of tennis shoe scrape left shin and superficial skin tear is result. 2 x 1 superficial." New interventions documented, "MD and family notified. Resident instructed to use care when crossing his legs." f. An Incident Report dated 2/10/11 at 8:00 a.m. documented, "Called to dining room on hall 3 and resident sitting in his wheelchair and noted blood to left hand and after cleaning found skin tear to top of middle finger area steri stripped and talked with therapy about padding for arm cradle on wheelchair." New interventions documented, "MD and family notified. Arm pad for arm cradle applied to wheelchair." g. An Incident Report dated 2/20/11 at 7:50 p.m. documented, "Resident had abrasion on left heel due to rubbing heel against foot board of bed and rubbing along sheets." New interventions documented, "MD and family notified. Resident's heels off loaded while in bed and podus boots applied." h. An Incident Report dated 2/28/11 at 4:00 a.m., documented, "At 4:00 a.m., resident was being transferred to w/c by aide and called this nurse into resident's room to assess a skin tear on bottom of resident's left foot below left great toe that was noticed after resident was in w/c. 2 cm long under L (left) foot below great L toe." New interventions documented, "MD and family notified. CNA instructed to transfer with 2 assist." A Facility - Lift/Mobility Assessment for Residents dated 2/28/11 documented, "Lift required ...Sara Lift." i. An Incident Report dated 3/7/11 at 11:00 a.m. documented, "Resident was rubbing his left shin with his shoe on right foot. 1.4 cm x 0.8 cm abrasion to left shin." New interventions documented, "MD and family notified. Podis boot to both feet." This was the same as the 2/20/11 intervention and no other new interventions were documented at this time. j. An Incident Report dated 3/12/11 at 9:15 p.m. documented, "CNA prepares the resident for change of clothing and getting him ready for bed. Skin tear with dried blood and intact skin flap is observed. Resident had been wearing long sleeved shirt and no blood stains are on clothing exterior. Right elbow 2 cm x 1/2 cm x superficial." New interventions documented, "MD and family notified. Geri sleeves applied to both arms." k. On 3/29/10 at 8:10 a.m., the resident was sitting in a wheelchair in the activity room on the 300 hall. There were no geri sleeves on either arm. At 9:18 a.m. and 9:30 a.m., the resident was in bed. There were no geri sleeves on the resident's arms and no podus boot was on either foot. The heels were directly on the mattress. At 9:40 a.m., the Treatment Nurse provided a treatment to the skin tear on the right elbow. After completing the treatment the Nurse applied a geri sleeve to the right arm. She did not apply one to the left arm and did not check it to make sure there was a geri sleeve on it. At 10:10 a.m., 11:55 a.m., and 2:40 p.m., the resident was in a wheelchair. There was no geri sleeve on the left arm. l. On 3/30/11 at 10:10 a.m., CNA # 4 and LPN #1 transferred the resident to the bed. There was no geri sleeve to the left arm. There was no podus boots applied. At 10:20 a.m., the resident was observed in bed. There was no podus boots applied to his feet. m. On 3/30/11 at 2:01 p.m., the Director of Nurses and the Alzheimer's Director were interviewed and asked, "Who monitors care on the secured wings to ensure podus boots and geri sleeves are applied." The Director stated, "The Aides, Nurses and myself go around and check." The Director of Nurses was asked, "How does your staff know what to do for a resident?" She replied, "It is keyed into the Kiosk." She reviewed the Kiosk then stated, "No geri sleeves on it." 3. On 3/20/11 at 2:20 p.m., the following observations were made during Environmental Rounds: a. The 100 hall entry door had rough jagged edges on the left side of the door. b. The bedroom doors to rooms #100, #103, #104, #105, #106, #107, #108, #109 and #110 had rough and jagged edges. c. The bedroom doors to rooms #204 and 206 had rough and jagged edges. The bedroom door on 207 had a loose plastic on outside of door measuring approximately 1foot long on the side of the door knob. d. The bedroom doors to rooms #305, #307 and #311 had rough and jagged edges. e. Both doors to the Activity Room/Day Room had rough and jagged edges. f. The 400 hall entry door had rough and jagged edges on both sides. g. The bedroom doors to rooms #400 and #402 had rough and jagged edges.