Every finding on record at The Villa at Texarkana

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #1) reviewed for infection control practices. The facility failed to ensure CNA A performed hand hygiene and changed her gloves during Resident #1's incontinent care on 06/29/26. This failure could place residents and staff at risk for cross contamination and the spread of infection. The findings included: Record review of the face sheet, dated 06/22/26, reflected Resident #1 was an [AGE] year-old male who admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia (a decline in mental ability severe enough to interfere with daily life) without behaviors. Record review of the admission MDS assessment, dated 06/22/26, reflected Resident #1 had clear speech, was rarely/never understood by others, and was rarely/never able to understand others. Resident #1 had a BIMS score of 3, which indicated severe cognitive impairment. Resident #1 usually required substantial/maximum assistance with toileting hygiene and was always incontinent of urine. Record review of the comprehensive care plan, dated 06/24/26, reflected Resident #1 required maximum assistance with ADL care and was incontinent of his bowel and bladder. The interventions included: provide incontinent care every two hours as needed. During an observation on 06/29/26 beginning at 1:31 p.m., CNA A and CNA B provided incontinent care to Resident #1. CNA A removed Resident #1's brief, wiped his front peri area with wet wipes, turned him on his right side, wiped his back peri area with wet wipes, applied barrier cream, and placed a clean brief under Resident #1 without changing her gloves or performing hand hygiene. During an interview on 06/29/26 at 3:36 p.m., CNA A stated she normally changed gloves and performed hand hygiene after each individual wipe during incontinent care. CNA A stated she should have changed gloves and performed hand hygiene when going from the front to the back and after applying the barrier cream. CNA A stated she believed she did those things when performing peri care on Resident #1. She stated it was important to change gloves and perform hand hygiene during incontinent care to prevent cross contamination. During an interview on 06/29/26 at 3:50 p.m., CNA B stated during incontinent care on Resident #1 she noticed CNA A did not change her gloves or perform hand hygiene at the appropriate times. She stated she was unsure if she was allowed to tell her when the state was observing. CNA B stated it was important to change gloves and perform hand hygiene during incontinent care to prevent the spread of infection or urinary tract infections. During an interview on 06/30/26 at 12:53 p.m., the DON stated she was also the infection control preventionist. She stated she expected the nursing staff to ensure gloves were changed and hand hygiene was performed during incontinent care when going from the front to the back or moving from clean to dirty. The DON stated the nursing staff was responsible for monitoring to ensure gloves were changed and hand hygiene was performed during incontinent care. She stated it was important to prevent infections or cross contamination. During an interview on 06/30/26 at 1:11 p.m., the Administrator stated she expected the nursing staff to practice safe infection control practices during incontinent care. She stated everyone was responsible for monitoring to ensure infection control practices were followed. She stated it was important to ensure infection control practices were followed during incontinent care to prevent the spread of infection, to ensure patient safety, and maintain quality of care. Record review of the Perineal Care policy, dated October 2010, did not address changing gloves or performing hand hygiene. No additional policies were provided by the facility.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for kitchen sanitation. The facility did not ensure:1. The flour scoop was kept out of the storage container on 03/09/2026, 03/10/2026, and 03/11/2026.2. The deep fryer and stove were free of caked on grease. These failures could place residents at risk for cross contamination and food-borne illness.The findings included: During an initial tour observation in the kitchen on 03/09/2026 beginning at 9:00 a.m., it was revealed that the flour scoop was left inside the flour container. The deep fryer was located beside the stove with a small gap between them. There was solidified grease on the floor between the stove and the deep fryer, that was caked up around the legs of the deep fryer. The whole side of the stove had caked on yellowish-brown grease. The back of the deep fryer had thick layers of caked on grease that were yellowish-brown. The fryer baskets were hanging on the back of the fryer. The caked on grease was darker around the bolts of the deep fryer. During an observation in the kitchen on 03/10/2026 beginning at 10:00 a.m., it was revealed that the flour scoop was left inside the flour container. There was solidified grease on the floor between the stove and the deep fryer, that was caked up around the legs of the deep fryer. The whole side of the stove had caked on yellowish-brown grease. The back of the deep fryer had thick layers of caked on grease that were yellowish-brown. The fryer baskets were hanging on the back of the fryer. The caked on grease was darker around the bolts of the deep fryer. During an observation and interview on 03/11/2026 beginning at 10:18 a.m., [NAME] B opened the flour container to remove the scoop that had been left. The scoop was a quarter pitcher and the handle was laying on top of the flour. [NAME] B stated everyone was responsible for monitoring to ensure the scoops were not left in the storage containers. [NAME] B was unsure why the scoop was left in the flour storage container. [NAME] B stated the deep fryer had the caked on grease that would not come off. [NAME] B stated the deep fryer was cleaned twice weekly and as needed. [NAME] B stated the cooks were responsible for cleaning the deep fryer. [NAME] B stated the Dietary Manager had tried to clean the caked on grease on the stove and deep fryer, but it would not come off. [NAME] B stated it was important to ensure scoops were not left in the storage container and the deep fryer was cleaned to prevent cross-contamination and ensure the kitchen and equipment were sanitary. She stated it could have made residents sick. During an observation and interview on 03/11/2026 beginning at 10:23 a.m., the Dietary Manager stated she expected the dietary staff to ensure the scoops were not left in the storage containers. The Dietary Manager stated the cooks were responsible for monitoring to ensure the scoops were not left in the storage containers. She stated it was important to ensure the scoops were not left in the storage container to prevent cross contamination. She stated the deep fryer and stove was cleaned once per week. She stated she had tried to clean the stove and deep fryer with several cleaning products but the caked on grease would not come off. The Dietary Manager scraped the side of the stove with her fingernail and yellow debris was noted on her fingernail. The Dietary Manager stated it was important to ensure the equipment was cleaned and sanitary to prevent food-borne illness to the residents. During an interview on 03/11/2026 beginning at 1:07 p.m., the Administrator stated she expected the dietary staff to maintain sanitary conditions in the kitchen. She stated she expected scoops to be stored outside the storage container and equipment to be kept clean and sanitary. She stated the Dietary Manager was responsible for monitoring to ensure the dietary staff maintained a sanitary kitchen. She stated it was important to ensure kitchen sanitation to promote safe food handling. Record review of the Policy for Monitoring Kitchen Cleanliness and Sanitation, undated, reflected Everyone will be assigned a cleaning job in the kitchen. They will be responsible for keeping said equipment clean for the entire month. Record review of the Cleaning the Deep Fryer policy, undated, reflected The deep fryer in the kitchen is to be cleaned weekly, or more often depending on the condition of the grease, at the Dietary Manager's discretion. Record review of the Food Storage policy, undated, reflected .8. Label and date all storage containers or bins. Keep free of scoops. Record review of the 2022 Food Code by the Food and Drug Administration reflected During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored. (B) In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon. Equipment Food-contact SURFACES and UTENSILS shall be clean to sight and touch. The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 1 memory care unit consisting of 14 residents reviewed for activities. The facility failed to provide meaningful activities for dementia residents on the memory care unit. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.Findings included: Record review of the March 2026 Group Activities Calendar posted in the memory care unit dining area revealed the following activities: 03/09/2026 03/10/2026 03/11/202610 a.m.-Exercise 10 a.m.-Dancing 10 a.m.-Sit to Fit1 p.m.- Bean Bag Toss 1 p.m.- Match Up 1 p.m.- Tic Tac Toe2 p.m.- Memory Lane 2 p.m.-Name that Tune 2 p.m.-Nail Care3 p.m.-[NAME] Toss 3 p.m.- Art Shop 3 p.m.-Match Up During an observation on 03/09/2026 at 10:06 a.m., there were 6 residents sitting in the sitting/dining area of the memory care unit. The television was on with no sound. The nurse was monitoring the residents. No CNA or activity personnel were present. No exercise or other activity was taking place. During an observation on 03/09/2026 at 12:55 p.m.-1:25 p.m., the dining and sitting area nor hallways had any memory care/dementia focused activities. The television was on in dining area with no sound. No bean bag toss was taking place. No meaningful activity was offered to the residents. Five residents were in the sitting/dining area. During an observation on 03/09/2026 at 2:01 p.m.-2:30 p.m., several (6) residents were in the sitting area/dining area. No meaningful activities were offered to the residents. Television was on with no sound. Two residents sitting with head on table. Two residents were wandering up and down hallway. During an observation on 03/10/2026 at 9:49 a.m.-10:15 a.m., several (5) residents were in the sitting area/dining area with no meaningful activities offered to residents. No dancing and no music was present during this time. Television was on and nurse was sitting at table with 2 residents. The nurse was looking through a magazine and watching TV, not engaging with any residents. During an observation on 03/10/2026 at 2:48 p.m.- 3:18 p.m., several (6) residents were in the sitting area and dining area with no meaningful activities offered to residents. No arts and crafts were being performed with the residents. During an interview on 03/10/2026 at 3:20 p.m., the Memory Care Activity Assistant stated she was pulled to the floor on 200 hall to work because someone called in. She stated in her absence the nurse should be doing the scheduled activities with the residents. She stated she had not been following the activities calendar because the residents that were on memory care now were unable to participate in several of the activities. She stated she had not spoken to the activities director about making changes to the calendar to correct the calendar with more appropriate activities. She stated instead she had been letting them watch TV and do their own thing, like snack and nap when they wanted. She stated the importance of activities on the unit was to exercise the residents' bodies and minds and keep boredom down. She stated engaged residents were less likely to fall, have behaviors and become depressed. During an interview on 03/11/2026 at 10:00 a.m., the DON said staff received annual training on dementia centered care. She stated all staff should be providing person centered care to the memory care residents. She stated the facility interviewed the residents' families to get input on activities that interested their family members before admission. She stated the facility had some activities available for the residents, but she understood the activities on the calendar needed to be followed. She stated trying to find activities that all the residents would be interested in, it be safe, and not be an infection control risk could be challenging. She said not providing residents individualized, structured activities had the potential for increased behaviors and falls. She stated the AD was out on leave. During an interview on 03/11/2026 at 11:00 a.m., the Administrator said it was the IDTs responsibility to provide the residents on the secured unit dementia centered care. She stated the facility should be following the calendar and using the residents' care plans to find activities to meet their needs. She stated the activities should be at their level and staff should be assisting with activities. She stated the secured unit needed structured activities, things to keep them busy. She stated when residents were not provided with activities throughout the day, they could have increased behaviors and falls. Record review of a facility's Dementia policy dated 11/2021 indicated .direct care staff will support the resident in initiating and completing activities.therapeutic and recreational activities will be supervised and supported throughout the day as needed.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained free from accident hazards for 1 of 20 residents (Resident #84) reviewed for accident hazards.The facility failed to keep prohibited items, chemical insecticide (targeting roaches), out of Resident #84's room.This failure could place residents at risk for injury, harm, and impairment or death.Findings included: Record review of Resident #84's face sheet, dated 11/21/25, indicated he was a [AGE] year-old male, re-admitted to the facility on [DATE] and originally admitted on [DATE]. His diagnoses included Major Depressive Disorder (a common, serious mental health condition characterized by persistent sadness, loss of interest, and fatigue lasting at least two weeks, significantly impairing daily life), Cerebral Infarction (a type of ischemic stroke caused by a blockage in a blood vessel, leading to brain tissue death due to lack of oxygen and nutrient), and Pneumonia (an infection causing inflammation in one or both lungs' air sacs, resulting in cough, fever, chills, and breathing difficulties). Record review of Resident #84's Annual MDS assessment, dated 12/16/25, indicated he had a BIMS score of 15, which indicated intact cognition. Record review of Resident #84's care plan indicated that a problem initiated on 2/21/2019 showed that Resident #84 had a problem with depression and anxiety related to decreased cognition that required monitoring by staff. During an interview and observation on 3/9/26 at 9:27 a.m. it was observed that Resident # 84 had a spray bottle of chemical insect killer in his room. He said that if he saw a bug he would spray and kill them. He said that he got bug spray from his family. He said that he had had it for a while and no staff told him he couldn't have it. During an interview on 3/11/26 at 10:27 a.m. with CMA A she said that residents should not have bottles of chemical bug spray in their rooms. She said that residents could misuse the spray or a resident who was confused could enter the room and poison themselves. During an interview on 3/11/26 at 10:38 a.m. the Director of Nursing said that residents should not have chemical bug spray in their rooms. She said that residents could potentially poison themselves if they misused a chemical, especially poison. She said that there are a number of items that residents cannot have in their room and chemical poisons was one of them. During an interview on 3/11/26 at 10:50 a.m. with the Administrator she said that residents should not have chemical bug spray in their room. She said that Resident #84's family brought the chemicals into the room. She said they contract pest control and residents should not have pest control products in their room. She said that residents could poison themselves if they misused chemical bug spray. Record review of a facility policy titled, Safety and Supervision of Residents dated July 2017 indicated that the purpose of this policy was to, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Our facility-oriented approach to safety addresses risks for groups of residents.Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; reviews of safety and incident/ accident data; and a facility-wide commitment to safety at all levels of the organization.Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.

Based on interview and record review the facility failed to ensure an accurate MDS assessment was completed for 1 of 16 residents reviewed for MDS accuracy. (Resident #8) The facility failed to accurately code Resident #8's psychotropic medication use. This failure could place residents at risk of receiving unneeded care and services.Findings included: Record review of an undated face sheet revealed Resident #8 was an [AGE] year-old female, admitted on [DATE] with the diagnoses of Alzheimer's disease (a progressive, incurable neurodegenerative disorder and the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive difficulties), and diabetes type II (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar). Record review of a quarterly MDS assessment dated [DATE] for Resident #8 revealed a BIMS score of 03, which indicated severe cognitive impairment. The MDS also revealed Resident #8 required partial assistance (helper does less than half the work) with bed mobility, transfer, and toileting. The MDS revealed Resident #8 took antipsychotic medications daily. Record review of the consolidated physician orders for December 2025 revealed no orders for antipsychotic medications for Resident #8. Record review of the MAR dated December 2025 revealed no antipsychotic medications were administered for Resident #8. During an interview on 03/11/2026 at 10:00 a.m., the MDS Coordinator revealed Resident #8 should not have been coded as receiving daily antipsychotic medications. The MDS Coordinator stated Resident #8 had no order for antipsychotic medications in December 2025 and this must have been a miscoding. The MDS Coordinator stated miscoding the MDS can lead to wrong information reported on the Quality Measures and potentially wrong information being care planned for the resident which could confuse the staff caring for the residents. During an interview on 03/11/2026 at 11:15 a.m., the DON stated it was the responsibility of the MDS Coordinator to ensure accurate MDSs were produced and transmitted to CMS. The DON stated there was currently no system check in place to audit the MDS accuracy but ultimately the DON or Regional Nurse signed the MDS for completion and the MDS nurses signed it for accuracy. During an interview on 03/11/2026 at 12:00 p.m., the Administrator stated it was the responsibility of the MDS Coordinator to produce accurate MDSs and care plans. The Administrator stated accuracy is important for revenue as well as to ensure the facility was reporting the correct information to CMS on the quality measures. During a record review of the facility's undated Minimum Data Set Policy for MDS assessment Data Accuracy, revealed the purpose of the MDS policy was to ensure each resident received an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. The assessment should accurately reflect the resident's status.

Based on interview and record review the facility failed to complete the quarterly MDS assessment not less frequently than every 3 months for 1 of 16 (Resident #62) residents reviewed for MDS completion. The facility failed to complete the quarterly MDS assessment for Resident #62, within 92 calendar days of the previous annual assessment dated [DATE]. These failures could place residents at risk of not receiving services to provide quality care.The findings included: 1. Record review of a face sheet dated 03/09/2026 indicated Resident #62 was a [AGE] year-old male that admitted on [DATE] with diagnoses of dementia (a progressive decline in mental ability-including memory, thinking, and behavior-that interferes with daily life and is not a normal part of aging), benign prostatic hypertrophy (a common, noncancerous condition in men over 50 where the prostate gland enlarges, pressing on the urethra and causing urinary issues like weak stream, frequency, and urgency), and hypertension (high blood pressure). Record review on 03/09/2026 of MDS data for Resident #62 revealed the following:08/06/2025- Quarterly MDS Completed11/06/2025- Annual MDS Completed Record review of the 11/06/2025 Annual MDS assessment revealed Resident #62 had a BIMS score of 01, which indicated severe cognitive impairment. He required supervision with ADL assistance for safety. During an interview on 03/11/2026 at 9:00 a.m., the MDS Coordinator stated it was her responsibility to ensure all MDS assessments were completed and transmitted timely. She stated Resident #62 was due for a quarterly MDS on 02/06/2026 and she overlooked transmitting it. She stated she was unsure how she overlooked it because she had a paper backup system in place to ensure scheduling stayed on time for MDS assessments, and the system they used to input the data tracked the due date. The MDS Coordinator stated quarterly assessments were due every 92 days, except when an annual was completed. She stated the annual assessment took the place of the quarterly assessment. The MDS Coordinator stated the only thing being late with a MDS could affect was billing. She stated there was no negative impact on the residents from a late MDS. During an interview on 03/11/2026 at 9:21 a.m., the DON said the MDS Coordinator was responsible for completing and transmitting the all MDSs in a timely manner. She said she expected the MDS assessments to be completed and transmitted in the appropriate timeframe. She said MDSs not being completed and transmitted in the appropriate timeframe would not negatively affect resident's care. During an interview on 03/11/2026 at 11:01 a.m., the Administrator said the MDS Coordinator was responsible for completing MDS assessments and transmitting them in a timely manner. She said she did not feel like there could be a negative outcome for the assessments not being completed timely or being transmitted timely. Record review of a Quarterly Assessments facility policy last updated 02/2025 indicated, .Quarterly assessments are conducted to assist in updating person-centered care plans.Quarterly MDS assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual.The quarterly MDS assessment is a quarterly assessment due every 92 days.

Based on interview and record review, the facility failed to complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 1 of 22 residents (Resident #47) reviewed for comprehensive MDS assessment timing. The facility failed to complete Resident #47's annual comprehensive MDS assessment within 366 days of the previous comprehensive MDS assessment. This failure could place residents at risk of not having their needs met. The findings included: Record review the face sheet, dated 03/10/2026, revealed Resident #47 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of dementia (memory loss). Record review of Resident #47's annual MDS assessment reflected an ARD date of 01/28/2025. The next comprehensive MDS assessment should have been scheduled on or before 01/28/2026. Record review of Resident #47's annual MDS assessment reflected an ARD date of 02/27/2026, which indicated the comprehensive MDS assessment was completed 30 days late. Record review of the MDS final validation report, dated 03/04/2026, reflected Resident #47's annual MDS assessment was completed late. During an interview on 03/11/2026 at 9:00 a.m., the MDS Coordinator stated it was her responsibility to ensure all MDS assessments were completed and transmitted timely. She stated Resident #47 was due for an annual assessment and she failed to transmit it timely. She stated she was unsure how she overlooked it because she had a paper backup system in place to ensure scheduling stayed on time for MDS assessments, and the system they used to input the data tracked the due date. The MDS Coordinator stated annual assessments were due every 366 days, except when a significant change was completed. She stated the significant change assessment took the place of the annual assessment. The MDS Coordinator stated the only thing being late with an MDS could affect was billing. She stated there was no negative impact on the residents from a late MDS. During an interview on 03/11/2026 beginning at 1:07 p.m., the Administrator stated she expected MDS assessments to have been completed within the required timeframes. She stated the regional MDS nurse was responsible for monitoring to ensure MDS assessments were completed timely. She stated it was important to ensure MDS assessments were completed timely to ensure residents received the care and services they required. Record review of a Comprehensive Assessments facility policy last updated 02/2025 indicated, .Comprehensive assessments are conducted to assist in developing person-centered care plans.Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. Record review of the RAI Manual, dated October 2025, reflected Annual (comprehensive) assessments should have been completed no later than ARD of previous comprehensive assessment + 366 calendar days.

Based on observation, interview, and record review, the facility failed to attempt to use alternatives prior to installing a side or bed rail, obtain informed consent prior to installation, ensure correct installation, use and maintenance of bedrails for 1 of 23 residents (Resident #30) reviewed for bedrails . 1. The facility failed to ensure informed consent for the use of Resident #30's bed rails were obtained prior to installation. 2. The facility failed to obtain a bed rail assessment to assess the risk of entrapment for Resident #30's bed rails. These failures could place residents at risk of entrapment or injury. Findings included: Record review of Resident #30's face sheet, dated 12/11/24, indicated he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included anxiety disorder (mental health conditions that cause uncontrollable and excessive feelings of fear or anxiety that can interfere with daily life), and myopathy (disease that affects the muscles and causes them to malfunction). Record review of Resident #30's quarterly MDS assessment, dated 09/16/24, indicated he has a BIMS score of 13, which indicated intact cognition. He was able to make himself understood and he was able to understand others. He required substantial assistance with rolling left and right and sit to stand. He was completely dependent on staff for assistance for lying to sitting on side of bed, and chair/bed to chair transfers. Record review of Resident #30's physician's orders, dated 12/11/24, did not indicate an order for bed rails. Record review of Resident #30's care plan, last revised on 10/24/24, indicated a focus of resident is at risk for falls. This focus included a statement of: Assist rail to resident left side of bed. another focus indicated on the care plan was resident is at risk for pressure ulcers/skin breakdown. This focus included a statement of: 2 half rails for positioning. During an observation and interview on 12/09/24 at 09:50 AM, Resident #30 was in his room lying in his bed. His bed had rails that were greater than one-quarter the length of his mattress. He said he used them to help move around in the bed. He said he had not had any issues with them. During an interview on 12/10/24 at 12:52 PM, LVN E said she was responsible for care plans in the facility. She said that the bed rails were added to Resident #30's bed because he had a fall. She said they were for the resident to use to turn and assist for bed mobility. During an observation on 12/10/24 at 1:00PM, Resident #30 was lying in his bed in his room. Corporate Nurse F was present and had a tape measure to measure the bed rails and mattress of Resident #30's bed. His mattress measured approximately 79 inches long and the bed rails were approximately 30.5 inches long. During an interview on 12/10/24 at 01:05PM, the Administrator said they considered the rails on Resident #30's bed to be for mobility and for turn assist. She said they are not intended to keep him from falling or keep him in the bed. she said they did not do any informed consent or bed rail assessments. She said they did not do the assessments and informed consent because they did not consider the rails to be restraints. During an interview on 12/11/24 at 12:47 PM, the DON said Resident #30 should have had the informed consent, assessments, and all the requirements completed for bed rails. She said they will change the rails to the proper turn assist rails. She said the risk to Resident #30 was there could be potential skin breakdown by the rails being too long. Record review of the facility's policy, Proper Use of Side Rails, last revised December 2016, stated: .The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids . .General Guidelines . .2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan . . 9, Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks .

Based on observations, interviews, and record reviews the facility failed to ensure the hand hygiene procedures were followed by staff involved in direct resident contact for 1 of 5 residents (Resident #59) reviewed for infection control. The facility failed to ensure Staffing Coordinator M performed appropriate hand washing after incontinent care was performed for Resident #59. This failure could result an increase the infections, cross contamination and decrease quality of life. Record review of face sheet date 12/10/2024 indicated Resident #59 was a [AGE] year old male initially admitted to the facility on [DATE] with a diagnoses which included unspecified dementia (a general term for dementia that doesn't have a specific diagnosis), anoxic brain damage (cerebral hypoxia occurs when the brain doesn't receive enough oxygen) and a personal history of urinary tract infections. Record review of a quarterly MDS dated [DATE] revealed Resident #59 had a BIMS score of 12 and the resident was usually understood and usually understood others. The MDS indicated Resident #59 was dependent with toileting hygiene and required moderate assistance with personal hygiene. Record review of Resident #59 care plan dated 02/21/2024 indicated Resident #59 was incontinent of bowel and bladder, due to diagnosis of neuromuscular dysfunction of bladder (a condition where the nerves controlling bladder function are damaged, leading to impaired bladder muscle activity and resulting in difficulty emptying the bladder or incontinence) and anoxic brain damage. Record review of Staffing Coordinator M Proficiency checkoffs dated 09/16/2024 revealed Handwashing, and Perineal care was satisfactory. During an observation of incontinent care performed on 12/10/24 at 1:50 PM by Staffing Coordinator M on Resident #59. Staffing Coordinator M did not wash her hands after she performed incontinent care on Resident #59 before she applied a clean brief and placed covers over the resident. During an interview on 12/11/24 at 9:33 A.M., CNA I said after incontinent care was performed the CNA should wash their hands or sanitize, then applied clean gloves before a clean brief was placed on a resident and prior to covering the resident. She said improper hygiene could made the resident at risk for infections such as urinary tract infections. During an interview on 12/11/24 at 9:38 A.M., CNA A said after she performed incontinent care she would wash or sanitize her hands then apply clean gloves, then apply a clean brief and apply the covers over the resident. She said she always washed her hands before and after incontinent care. She said the negative effects of improper hand hygiene was it could spread germs. During an interview on 12/11/24 at 9:44 A.M., RN B said after peri care staff should wash their hands before applying a clean brief and applying covers over the resident. He said improper hand hygiene could cause infections. During an interview on 12/11/24 at 9:51 A.M., ADON J said after peri care the aide should wash their hands and applied clean gloves before a clean brief and the covers were applied to the resident. She said negative effect of improper hygiene could cause infections and potentially cause other resident to get infections as well. During an interview on 12/11/24 at 10:09 A.M., LVN O said after peri care was performed peri care the aide should have washed their hands or sanitize their hands then apply clean gloves. She said after the clean gloves were applied the aide could have applied a clean brief and the resident's covers. She said a negative effect of improper hand hygiene was cross contamination. During an interview on 12/11/24 at 10:25 A.M., CNA L said she took her dirty gloves off and wash my hands before she touched anything after incontinent care. She said then she would have applied clean gloves then apply a clean brief and covered the resident. She said a negative effect of improper hygiene was infection. During an interview on 12/11/24 at 10:30 A.M., Staffing Coordinator M said she should had washed her hands and changed her gloves before she grabbed the clean brief and pulled his covers over Resident #59. She said improper hand hygiene could cause cross contamination. During an interview on 12/11/24 at 10:38 A.M., Restorative Aide K said after incontinent, or peri care the aide should most definitely wash their hands apply clean gloves before a clean brief and resident covers were placed on a resident. She said staff could transfer bacteria on the sheets and to the resident. During an interview on 12/11/24 at 1:48 P.M., the DON said she expected the staff to wash their hands and change gloves after incontinent care or peri care was performed. She said after staff had washed their hands and apply clean gloves, then a clean brief and replaced resident covers for the resident should have been done. She said improper hand hygiene can cause cross contamination. During an interview on 12/12/24 at 2:07 P.M., the ADM said she expected staff to perform proper hand hygiene during incontinent or peri care with residents. She said some of the risks with improper hand hygiene are infections and it could affect the resident's quality of life. Record review of the facility Infection Control Policy, undated indicated all employees are required to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Record review of the facility policy Perineal Care revised 10/2010 indicated remove gloves and discard into designed container. Wash and dry your hands thoroughly. Reposition the bed covers. Make resident comfortable. Record review of the facility policy Handwashing/ Hand Hygiene revised 08/2015 indicated all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread on infections to other personnel, residents, and visitors.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 14 residents (Resident #66, Resident #72) reviewed for adequate supervision. The facility failed to ensure that Resident #66 and Resident #72 did not have cigarette lighters in their room and in their personal possession. This failure could place residents at risk for injury, harm, and impairment or death. Findings included: 1. Record review of the face sheet 06/26/24 indicated Resident #66 was [AGE] years old and was admitted on [DATE] with diagnoses including Addisonian Crisis (Adrenal crisis, is a life-threatening medical emergency that requires immediate treatment), Hypoglycemia (occurs when your blood sugar level drops too low), Type 2 Diabetes (a condition that occurs when the body doesn't use insulin properly, leading to high blood sugar levels). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #66 was understood and understood others. The MDS indicated a BIMS score of 13 indicating Resident #66 was cognitively intact. The MDS indicated Resident #66 required use a walker to ambulate and supervision for some ADLs. Record review of Resident #66's Care Plan dated 7/23/24, revealed a problem initiation on 7/23/2024 that Resident #66 was a smoker. Indicated that Resident #66 would keep his smoking materials at the nurse's station. During interview and observation on 12/09/24 at 10:17 a.m., Resident #66 had a lighter on his bedside table. Surveyor asked if Resident #66's lighter worked as it was a type of metal collectable lighters. Resident #66 opened the top of the metal light struck the [NAME] which produced a fire. He said that he keeps his lighter on his bedside table so he can go out and smoke whenever he wants. No cigarettes were observed in the room. 2. Record review of the face sheet 01/31/24 indicated Resident #72 was [AGE] years old and was admitted on [DATE] with diagnoses including Muscle Weakness (occurs when your muscles are unable to contract properly, resulting in reduced strength), Abnormalities of Gait and Mobility (deviations from a normal walking pattern, including issues like limping, shuffling feet, dragging toes, difficulty with coordination, short steps, or an unsteady gait), Schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #72 was understood and understood others. The MDS indicated a BIMS score of 15 indicating Resident #72 was cognitively intact. The MDS indicated Resident #72 required use a walker to ambulate and supervision for some ADLs. Record review of Resident #72's Care Plan dated 1/09/23, revealed a problem initiation on 2/20/2024 that Resident #72 was non-compliant with facility smoking policies. Indicated that staff were to Instruct resident about the facility policy on smoking: locations, times, safety concerns. During an interview and observation on 12/09/24 at 9:56 a.m., Resident #72 was observed to have two plastic lighters in his room on his walker in plain sight. He said that he always kept his lighters with him. Resident #72 began getting agitated that the surveyor was asking about his lighters and walked out of the room. During an interview on 12/09/24 at 10:24 a.m., RN B said that Residents are not allows to keep their smoking materials on them or in their room. He said that they residents could start a fire if they are able to keep them. He said he would go confiscate the lighters. He said that it is the responsibility of any staff to confiscate lighters. During an interview on 12/11/24 at 12:44 p.m., the Director of Nurses said it was the policy of the facility that residents cannot keep their lighters with them. She said that their policy says to take the lighters from residents. She said that residents could cause a fire if they have use of their lighters unsupervised . During an interview on 12/11/24 at 12:47 p.m., the Administrator said their policy does not allow a resident to keep their lighters in their room. She said that residents cannot have smoking materials with them. She said that residents could start a fire in the facility if they have their lighters and are unsupervised. Record review of an undated facility policy and titled, Smoking and Vaping Policy Indicated that, Policy: Smoking and/ or vaping is not allowed anywhere WITHIN this facility (by residents and/or staff). It is the policy of this facility to establish and maintain resident smoking and vaping policies. Smoking is not allowed in resident's rooms or inside the facility Materials are not to be carried by residents or allowed in resident rooms. They must be kept in the smoking box or stored in the Administrators office until use is needed.

Based on interview and record review, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 2 of 5 residents (Resident #8 and Resident #18) reviewed for unnecessary medications. 1. The facility failed to ensure Resident #8 had an appropriate rationale for declining a GDR for her Zyprexa medication (an antipsychotic medication used to treat bipolar disorder). 2. The facility failed to ensure Resident #18 had an appropriate diagnosis for her prescribed Trileptal (it can treat epileptic seizures). This failure could put residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: 1. Record review of Resident #8's face sheet, dated [DATE], indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (a decline in mental ability that affects thinking, memory, and behavior, and interferes with daily life), cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked), bipolar disorder (a serious mental illness that causes extreme shifts in mood, energy, thinking, behavior, and sleep), and anxiety disorder (mental health conditions that cause uncontrollable and excessive feelings of fear or anxiety that can interfere with daily life). Record review of Resident #8's annual MDS assessment, dated [DATE], indicated she had a BIMS score of 6, which indicated severe cognitive impairment. The MDS indicated that she received antipsychotic medication during her assessment window. Record review of Resident #8's physician's orders, dated [DATE], indicated this order: *Zyprexa Tablet 2.5 mg Give 1 tablet by mouth at bedtime related to bipolar disorder. The start date was [DATE]. Record review of Resident #8's consultant pharmacist / physician communication dated [DATE], indicated the consultant pharmacist communicated to the physician that the olanzapine (Zyprexa) medication was due for a GDR and recommended a change in the order to every other night for 14 days and then trial discontinue. The note further indicated If resident failed previous dose reduction attempt or is clinically contraindicated, please document clinical rationale below. The physician / prescriber response stated: hospice care. During an interview on [DATE] at 12:47 PM, the DON said she expected the provider to provide an appropriate rationale for their decision regarding GDR's. She said the risk to the resident was that she could be potentially receiving unnecessary psychotropic medications. During an interview on [DATE] at 01:10 PM, the Administrator said she expected the GDR to be justified. She said the risk to the resident was that it was possible that the resident could be on an unnecessary medication for longer than necessary. 2. Record review of Resident #18's face sheet dated [DATE] indicated an 83-years-old female admitted to the facility on [DATE]. Resident #18 had diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) major depression disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #18's MDS assessment dated [DATE] indicated Resident #18 was usually understood and usually understood others. Resident #18's BIMS score was a 6. Resident #18 required moderate assistance with toileting and personal hygiene. Resident #18 MDS indicated she had major depression and anxiety disorder, unspecified. Record review of Resident #18's care plan dated [DATE] indicated has impaired cognition diagnosis of Alzheimer's disease, anxiety. Resident #18 has inattention and disorganized thinking at times. Resident has delusional thoughts at times, such as she believes she is babysitting kids and waiting for her family member (who is deceased ) to pick her up. Record review of Resident #18's Medication Summary Report dated [DATE] ordered and [DATE] started indicated Trileptal Oral Tablet 150 MG (Oxcarbazepine) Give 1 tablet by mouth three times a day related to anxiety disorder, unspecified. During an interview on [DATE] at 9:44 A.M., RN B said ADON J was responsible for putting the medications in the system and making sure the medications match the diagnosis. He said a negative effect on the medication could not be ineffective if monitoring for the wrong diagnosis. During an interview on [DATE] at 9:51 A.M., ADON J said the nurses were responsible to make sure the medications match the proper diagnosis. She said the doctor was responsible to ensure the medication match the diagnosis when he signed the orders. She said when the nurse gets the orders, they should make sure the orders match the diagnosis. She said the ADON's put the orders in and make sure the orders match the diagnosis. She said a negative effect of a medication with the wrong diagnosis could cause a different effect in the resident and staff would monitor for whatever the medication was used for. During an interview on [DATE] at 10:09 A.M., LVN O said she wrote the orders on admission, but the ADON usually put in the orders in the system with the diagnosis. She said but if the ADON was busy or had not put the orders in the charge nurse would do it. She said a negative effect of a medication not having the correct diagnosis was a medication could not a positive outcome for a resident if staff monitored the resident for the incorrect diagnosis. During an interview on [DATE] at 1:48 P.M., the DON said on admission ADON J normally did the admissions, but if she was not here one of the other ADON's put the orders and diagnosis in the system. She said expected the nurses to make sure the medications were with the correct diagnosis. She said negative effect of not having the correct diagnosis with the medication would be not checking the correct parameters for that medication. During an interview on [DATE] at 2:07 P.M., the ADM said she expected the nurses to put the correct diagnosis with the appropriate medications. She said a negative effect of not having the correct diagnosis with the appropriate medication could cause medication errors and effect quality of care. She said the facility had corrected the issue with the medication. Record review of the facility policy Medication Therapy revised ,d+[DATE] indicated Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. Medication use shall be consistent with an individual's condition, prognosis, values, wishes and responses to such treatment. Record review of the facility's undated policy, Behavior and Psychoactive Management Program, stated: .Tapering and Gradual Dose Reduction (GDR) . .3. After the first year, GDR or tapering should be attempted once a year. 4. GDR or tapering may be considered clinically contraindicated if the resident's targeted symptoms worsened or returned during the reduction. If this occurs the physician must document the clinical rationale why further GDR attempts should not be done (further attempts may cause impairment of resident function, increase distressed behavior(s), cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder 48958

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 12 resident personal refrigerators reviewed for food safety (Resident #75). The facility failed to ensure the refrigerator for Resident #75 did not contain expired bologna and milk. This failure could place resident at risk for food borne illnesses. Findings include: 1. Record review of Resident #75's face sheet dated [DATE] indicated Resident #75 was [AGE] years old male and was admitted on [DATE] with diagnoses including Edema (a condition where fluid builds up in the body's tissues, causing swelling), Muscle Weakness (occurs when your muscles are unable to contract properly, resulting in reduced strength), and Cerebral Infarction (a serious condition that occurs when blood flow to the brain is blocked, resulting in brain tissue death). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #75 was understood and understood others. The MDS indicated a BIMS score of 12 indicating Resident #75 had mildly impaired cognition. The MDS indicated Resident #75 required supervision for some ADLs. Record review of Resident #75's care plan dated [DATE] revealed that Resident #75 required assistance with his activities of daily living. During an observation and interview on [DATE] at 10:24 a.m ., Resident #75's personal refrigerator had expired bologna (13th [DATE]) and milk ([DATE]th 2024) He said that he will eat whatever is in his refrigerator. He said he does not look for expiration dates before eating food. He said he doesn't throw any of the food away. He said staff come every few months and cleans his refrigerator out. During an interview on [DATE] at 08:36 a.m., CNA A said that housekeeping and any staff that enters a resident room and saw that there was expired food in their refrigerator should throw that food away. She said that residents could be placed at risk of illness if they ate expired meat or expired milk. During an interview on [DATE] at 12:44 p.m. the Director of Nursing said housekeeping was responsible for ensuring that residents personal refrigerators were cleaned out and expired foods thrown away . She said non-clinical staff should also double check that housekeeping was removing expired items and cleaning. She said that residents could be placed at risk of foodborne illness eating expired meat and milk. During an interview on [DATE] at 12:55 p.m. the Administrator said resident's personal refrigerators should be cleaned out by any staff that recognizes there was spoiled food in their refrigerators. She said that it was primarily the responsibility of housekeeping. She said that residents would be put at risk for foodborne illness. Record review of a facility policy revised July of 2014 titled, Food Receiving and Storage. Policy indicated, Foods shall be received and stored in a manner that complies with safe food handling practices Food items and snacks kept on the nursing units must be maintained as indicated. All food items to be kept below 41 F must be placed in the refrigerator located at the nurses' station and labeled with a use by date. All foods belonging to residents must be labeled with the resident's name, the item and the use by date.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 23 residents reviewed for environment. (Resident #57 and Resident #72) 1. The facility failed to repair an electrical outlet in the room of Resident #57 a timely manner. 2. The facility failed to provide a functioning bed light pull string for Resident #72. These failures placed residents at risk of injury of, living in an uncomfortable environment and a decrease in quality of life and self-worth. Findings included: 1. Record review of the face sheet 12/10/24 indicated Resident #57 was [AGE] years old and was admitted on [DATE] with diagnoses including heart failure, dementia, and weakness. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #57 was sometimes understood and sometimes understood others. The MDS indicated a BIMS score of 07 indicating Resident #57 was severely cognitively impaired. The MDS indicated Resident #72 was dependent on staff for ADLs. During an observation and interview on 12/09/24 at 10:04 a.m., near the head of the bed of Resident #57's bed was a red electrical outlet hanging out of the wall. The outlet was secured to the wall by metal brackets. The screw in the top bracket was completely out of the wall. The top part of the outlet was approximately 1 inch away from the wall exposing the entire length of the screw, the electrical conduit (a tube that protects and routes electrical wiring in a building or structure), and three holes in the wall. There were three electrical cords plugged into the outlet. Family Member A (family member of Resident #57) said the outlet had been hanging off the wall forever. During an observation and interview on 12/10/24 at 8:12 a.m., Resident #57 was in bed. Approximately 3 feet away from Resident #57 was a red electrical outlet hanging out of the wall. The outlet was secured to the wall by metal brackets. The screw in the top bracket was completely out of the wall. The top part of the outlet was approximately 1 inch away from the wall exposing the entire length of the screw, the electrical conduit (a tube that protects and routes electrical wiring in a building or structure), and three holes in the wall. There were two electrical cords plugged into the outlet. Resident #57 said she did not know how long the outlet had been pulled away from the wall. During an interview on 12/10/24 at 8:24 a.m., Family Member B (family member of Resident #57) said the outlet had been that way for several months. Family Member B said it had concerned them. Family Member B said there had been attempts made in the past to reattach the outlet to the wall, but it never stayed attached very long. During an interview on 12/10/24 at 9:47 a.m., RN B said he had not noticed the outlet in Resident 57's room. He said all maintenance issues were entered into the maintenance log that was kept at the nurses' station. He said the log was then checked by Maintenance Director so the appropriate repairs could be made. During an interview on 12/11/24 at 7:57 a.m., the Maintenance Director said maintenance issues were supposed to be put in service order books at each nurses' station. He said he had a huge problem with staff not doing this. He said staff just stop maintenance staff in the hall and verbally tell them. He said the outlet had been repaired several times. He said staff raising the head of the bed kept pulling the outlet out of the wall. He said he just found out on 12/10/24 that it was pulled out from the wall again. He said the wall itself and the outlet needed to be repaired and the power would have to be shut off in that room. He said this has been an ongoing issue for approximately 3 weeks. He said the box was originally` anchored to the wall but not anchored to a stud. He said now it was temporarily secured to the wall until the dry wall could be replaced. During an interview on 12/11/24 at 8:11 a.m., CNA C said the outlet beside Resident #57's bed had been hanging out of the wall for months. She said she had verbally reported the outlet being out of the wall to maintenance when it was first pulled from the wall. She said, It's been a good minute. During an interview on 12/11/24 at 8:15 a.m., CNA D said the outlet in Resident 57's room had been pulled out from the wall for months. She said when the bed was raised up it would hand on the outlet. She said she had reported to maintenance herself. She said she reported it to them verbally. She said she did not know if there had been previous attempts by maintenance to repair the outlet. During an interview on 12/11/24 at 9:07 a.m., the DON said she would have expected for the outlet to have been repaired in a timely and appropriate manner. She said the outlet hanging out of the wall could be a fire hazard. During an interview on 12/11/24 at 1:50 p.m., the Administrator said staff should put maintenance request on the log at each nurse's station. She said anything concerning electrical should be repaired immediately. She said would have expected the outlet to have been appropriately prepared and in a timely manner. She said an outlet not being repaired could potentially be a fire hazard or could fall and hit the resident. Record review of an In-service Training Report dated 09/03/24 for All Staff and was titled Maintenance Logs indicated, All staff are required to complete a maintenance request when they observe repairs that are needed. Use the log books that are located at the nurse station. Do no assume the dept is aware. I would rather the request be made over and over other than not at all. The In-Service was conducted by the Administrator. Record review of a Maintenance Repair Log that was in a binder at the nurses' station for Resident #57's hall did not indicate a repair request for the outlet in Resident #57's room . 2. Record review of the face sheet 01/31/24 indicated Resident #72 was [AGE] years old and was admitted on [DATE] with diagnoses including Muscle Weakness (occurs when your muscles are unable to contract properly, resulting in reduced strength), Abnormalities of Gait and Mobility (deviations from a normal walking pattern, including issues like limping, shuffling feet, dragging toes, difficulty with coordination, short steps, or an unsteady gait), Schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #72 was understood and understood others. The MDS indicated a BIMS score of 15 indicating Resident #72 was cognitively intact. The MDS indicated Resident #72 required use a walker to ambulate and supervision for some ADLs. During an interview and observation on 12/09/24 at 09:56 a.m., Resident # 72 said is that his only complaint was he wanted his light pull cord fixed. He said he tied his call light button cord to his light switch cord so he could turn his light on. He said he doesn't know if he has asked for it to be fixed. He said that he would prefer for the light above his bed to have a pull cord that was not torn off. It was observed that Resident #72's light above his bed had a frayed and torn pull cord. The cord turns the light on above his bed. It was approximately 75% torn off. Resident #72 said had tied his call light cord to the torn light pull string so he could reach it from his bed, so he didn't have to stand up. During an interview on 12/11/24 at 09:42 a.m., the Maintenance Director said he did not know that resident #72 had a broken pull cord for his light. He said if he had known he would fix it as that was a simple problem. He said that he had issues with staff reporting in their maintenance log broken items that need fixed. He said that residents lived in the facility as their home and should have a comfortable and homelike environment. Record review of facility Maintenance Log revealed that there was no report for Resident #72's light pull cord being frayed and torn. During an interview on 12/11/24 at 12:52 p.m., the Administrator said the Maintenance Director was responsible for maintaining the building including bed light pull cords. She said that the Maintenance Director is required to do rounds in the facility and identify issues such as this. She said that this issue when found by staff should be reported in the maintenance log. She said that rigging up a self-fix so that Resident #72 could turn his light on was a quality-of-life issue that should be addressed immediately. Record review of a facility policy revision date of May 2017 and titled, Quality of Life - Homelike Environment Indicated that, Residents are provided with a safe clean comfortable and homelike environment and encouraged to use their personal belongings to the extent possible Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. The lighting design emphasizes sufficient general lighting in resident-use areas task lighting as needed. Record review of a facility policy revision date of December 2009 and titled, Maintenance Service Indicated that, Maintenance service shall be provided to all areas of the building, grounds, and equipment The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines Maintaining lighting levels that are comfortable, and assuring that exit lights are in good working order Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned 45643

Based on interview and record review the facility failed to ensure that resident assessments accurately reflected the resident's status for 1 (Resident #20) of 12 residents reviewed for accuracy of resident assessments. The facility failed to ensure that Resident #20's MDS quarterly assessment accurately reflected the resident had 5 injections of insulin and had no UTI (urinary tract infection). This failure put residents at risk for not receiving care and services needed. Findings included: Record review of Resident #20's face sheet dated 12/09/2024 revealed she was a 77-years-old female, admitted to the facility on [DATE]. She had diagnoses of depression, obesity, glaucoma (a group of eye diseases that can lead to damage of the optic nerve) Record review of the quarterly MDS assessment dated [DATE] indicated Resident #20 had a BIMS of 15, which indicated no cognitive impairment. The MDS also revealed Resident #20 received injections of insulin for 5 days in the prior 7 days. The MDS was not coded for UTI. Record review of the consolidated orders dated 11/2024 indicated Resident #20 was started on Rocephin 1 gram intramuscularly daily on 11/15/2024. There were no orders for insulin. Record review of Resident #20's MAR dated 11/2024 indicated Resident #20 received injections 11/15/2024 daily through 11/24/2024 of antibiotic medication. The MAR had no orders for insulin. Record review of a urinalysis for Resident #20 indicated she had a UTI with 3 separate organisms cultured on 11/15/2024. During an interview on 12/11/2024 at 10:20 a.m., the MDS Coordinator stated she made a mistake by claiming 5 days of injections of insulin for Resident #20. She stated most people that got injections received insulin and it was just an oversight. She stated she had not claimed UTI because she felt it did not meet criteria for a UTI. She stated Resident #20 only had one day of symptoms. She stated this failure would not affect the resident in a negative. During an interview on 12/11/2024 at 2:00 p.m., the DON stated the MDS was important to be coded accurately because it was what was care planned about the resident and that was how the staff knew the individual needs of each resident. She stated Resident #20 was positive for a UTI in November 2024 because she complained of burning and itching with urination and tested positive for multiple bacteria. She stated that UTI should have been claimed as a diagnosis on the MDS. She stated not coding that or the antibiotics was not an accurate reflection of the resident because she was someone with frequent UTI's. During an interview on 12/11/2024 at 2:15 p.m., the ADM stated she expected the MDS to be coded accurately so the staff new the correct way to care for each resident individually. She stated it was an oversight on the part of the MDS nurse and it was corrected before the interview. She stated the facility followed the RAI manual for their policy on accuracy of the MDS. Review of an undated facility Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy indicated, The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident .According to CMS's RAI Version 3.0 manual; the MDS is a core set of screening, clinical, and functional status elements .which forms the foundation of a comprehensive assessment for all residents of nursing homes .the items of the MDS standardize communication about resident problems and conditions with nursing homes, between nursing homes, and outside agencies .Federal regulations .require that .the assessment accurately reflects the resident's status .

Based on observations, record reviews, and interviews, the facility failed to protect and promote the rights of the resident in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 18 residents (Resident #63, Resident #53) reviewed for resident rights. The facility failed to protect and value Resident # 63's rights when the facility failed to allow Resident #63 call the police to report a potential crime. The facility failed to protect and promote the rights of Resident #53 by not knocking on the door prior to entering the resident's room. This failure could place residents at risk for decreased quality of life, increased anxiety, decreased privacy, and increased stress. Findings included: Record review of Resident #63's face sheet dated 10/24/22 indicated he was [AGE] years old and admitted to the facility on [DATE] with diagnoses including Muscle Wasting and Atrophy (the loss of muscle mass and strength, often caused by disuse, injury, malnutrition, or neurological conditions, resulting in a decrease in muscle size and function), Delusional Disorders (a mental illness that involves having fixed false beliefs, or delusions, that are not based in reality), Hypertensive Heart Disease (a group of heart problems that develop due to long-term high blood pressure). Record review of Resident #63's quarterly MDS dated [DATE] indicated he was understood and understood others. The MDS indicated a BIMS score of 13 which indicated Resident #63 was cognitively intact. The MDS indicated Resident #63 did not reject care. Record review of Resident #63's care plan dated 5/10/24 shows that Resident #63 has a history of being verbally aggressive at times. Shows that Resident #63 has a potential for side effects regarding his psychotropic medications. During an interview on 12/10/24 at 11:00 a.m. Ombudsman A said she remembered the incident with Resident #63 and Resident #13 . She said that she does not know what to believe with the incident because both residents changed their story so much. She said that Resident #63 did complain to her after describing his side of the story that he wanted to call the police. She said the day she spoke to Resident #63 she also spoke to RN G who she educated that he needed to assist Resident #63 in calling the police. She said she educated the RN on duty as it was the weekend, and he was in charge. She said that she also educated him as Resident #63 said he was not able to call the police the day the incident occurred because he was told that only the Administrator was able to call the police. During an interview on 12/10/24 at 12:40 p.m., Resident #63 said he was not afraid of Resident #13. He said he still leaves his room and goes to all his activities and eats in the dining room, but he will ignore Resident #13. He said he does not remember exactly what happened the day of the incident. He said he wants to call the police and has not been given the opportunity to do so. During an interview on 12/10/24 at 2:55 p.m., RN G said he was working as the charge nurse on the day the incident occurred between Resident #13 and Resident #63. He said that he did hear something going on, but he did not see it. He said that he was told Resident #13 and Resident #63 got into an altercation after Resident #63 ran over the foot of Resident #13 on accident. He said he was told that Resident #13 either tripped and fell on to Resident #63 or Resident #13 slapped Resident #63 . He said he wasn't sure what was true. He said he wasn't sure if he spoke to Ombudsman A and B about the incident and calling the police. During an interview on 12/10/24 at 3:12 p.m., Resident #13 said that she remembers the incident with Resident #63. She said she was shocked when Resident #63 ran over her foot. She said that she slapped Resident #63 in response. She said she felt really bad about it and wished she did not do that. She said she did not slap him hard and that she barely touched him. She said that she was happy Resident #63 was ok and she would never slap anyone again. She said this was the first time she every slapped anyone. She said now she has a sitter with her day and night watching her. She said that she regrets what happened and wants to stay clear of Resident #63 in the future. She said she feels safe at the facility and is not afraid of Resident #63. During an interview on 12/11/24 at 9:13 a.m., with Ombudsman B she said she spoke with RN G with Ombudsman A and they called him into a room and interviewed him alone. She said he was the RN on duty at the time and he said he did not witness the incident. She said he assessed Resident #13's foot and she was unharmed, and it was determined that Resident #63 did not run over Resident #13's foot. She said they asked RN G if he called the police and he said he did not. They said they educated RN G that he was required to call the police if a resident asked to, and Resident #63 had requested to call the police. She said that they educated RN G that they must allow a resident to use the phone if they requested to. During an interview on 12/11/24 at 12:44 p.m. the Director of Nurses said residents have the right to call outside the building to police or anyone else if they request to. She said that residents should be allowed to call the police to make a report whether their story is true or not as it is their right. During an interview on 12/11/24 at 12:55 p.m., the Administrator said residents have the right to call the police if they so desire to do so. She said that if a resident comes to a staff and asks to use the phone to call the police the staff should direct the resident to a phone. 2. Record review of an undated face sheet revealed Resident #53 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of anxiety, Diabetes Mellitus Type II (prolonged high levels of glucose in the blood), and dementia (a group of symptoms affecting the memory). Record review of an annual MDS assessment dated [DATE] revealed Resident #53 had a BIMS of 05 which indicated a severe cognitive impairment. Resident #53 was dependent for ADLs such as toileting, transfer, and bathing. During a record review on 12/10/2024 at 10:10 a.m. of the facility Inservice binder, no Inservice was noted on knocking before entering a resident's room. During an observation on 12/10/2024 at 8:20 a.m. CMA H entered Resident #53's room without knocking and Resident #53 was exposed during incontinent care. Resident #53 was facing the wall and the door was closed within 15 seconds. Resident #53 was not aware she was exposed to the hallway, medication aide, and surveyor. During an interview on 12/11/2024 at 9:45 a.m., Resident #53's family member stated he had been a witness to the CNA and Medication Aides not knocking on the door several times. She stated luckily, she had never witnessed any unclothed residents as she walked by rooms. She stated Resident #53 was a private person and would not like knowing she was exposed to the hallway and staff members. During an interview on 12/11/2024 at 10:00 a.m., CMA H stated she was aware she was supposed to knock on the resident's door prior to entering. She stated she accidentally forgot to knock before entering but quickly corrected herself once she saw Resident #53 was exposed. She stated it was not her intention to cause any embarrassment to Resident #53. During an interview on 12/11/2024 at 11:00 a.m., the DON stated it was the resident's right to live in home that was as close to the home they lived in prior to coming to the facility. She stated that was why knocking before entering was important. She stated no one that worked there would enter someone's home without knocking first and it was the same concept at the nursing facility. During an interview on 12/11/2024 at 2:00 p.m., the ADM stated she expected all staff to knock and provide care with dignity and respect for the elders of the community. She stated no one enters the staff's home without knocking and she wanted the staff to understand the correlation. She stated not knocking can make the resident feel less important and as if their privacy was unimportant to the facility. Review of the facility 's policy titled Resident Rights with a revised date of December 2016 indicated, Employees shall treat all residents with kindness, respect, and dignity Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation exercise his or her rights as a resident of the facility and as a resident or citizen of the United States communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter. 45643

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure all food items were labeled and dated. The facility failed to ensure a clean ice machine. These failures could place residents at risk of foodborne illness and food contamination. Findings include: During an observation on [DATE] at 8:53 a.m., there were 14 bags of a light brown triangle shaped food item in the pantry with no date or label. During an observation on [DATE] at 8:54 a.m., in the walk-in freezer there was 1 bag of round beige colored unknown food items on the floor with no label. There was 1 bag of square light brown unknown food items with no date or label. There were 2 bags round beige colored food item no date or label. There was 1 plastic bag of unknown frozen small round off white food items with no date or label. During an observation on [DATE] at 8:56 a.m., in the walk-in cooler there were 6 bags of a yellow liquid with no label. There was 1 gallon of orange juice with a best by date of [DATE]. There were 2 bags of whipped topping with no date. There were 2 bags of green leafy vegetables with no label. During an observation on [DATE] at 9:00 a.m., there was a sign hanging on the refrigerator in the kitchen, Nothing goes in here without an in and out date and label. Dietary Supervisor. During an observation on [DATE] at 9:01 a.m., the dishwasher testing strips had an expiration date of [DATE]. During an observation on [DATE] at 9:03 a.m., in the ice machine there was a black substance, that flaked off when touched, in the seams of the metal pieces in the top of the ice machine over the ice. During an interview on [DATE] at 8:55 a.m., the Dietary Manager said all kitchen staff were responsible for dating and labeling foods. She said everything was supposed to be first in and first out. She said as the food items were put away all foods should be dated and labeled. She said undated food could be expired or old. She said food that was too old could cause illness. She said the dishwasher testing strips expired before she became the dietary manager. She said she was not aware she was responsible for cleaning the ice machine. She thought maintenance was responsible. During an interview on [DATE] at 9:20 a.m., the Maintenance Supervisor said he said he was responsible for cleaning the ice machine. He said he cleaned the ice machine once every 6 months. He said he did check the ice machine once a month. He said he did not have an ice machine check list. He said the cleaning of the ice machine was not documented. He said he thought he had last cleaned the ice machine in August or September when repairs were done on the machine. It said the previous Dietary Manager did clean the ice machine at times. During an interview on [DATE] at 10:46 a.m., the Administrator said the dietary department was responsible for dating and labeling food items. She said anytime any food item was opened or removed from a box it should be dated and labeled. She said all foods received from a vendor should be dated. She said out of date foods could make a resident ill. She said the dietary department and maintenance were both responsible for keeping the ice machine clean. She said the ice machine not being kept clean could cause resident to receive contaminated/dirty ice. Review of a Sanitization facility policy dated [DATE] indicated, .The food service area shall be maintained in a clean and sanitary manner .all utensils, counters, shelves and equipment shall be kept clean .Ice machines and ice storage containers will be drained, cleaned and sanitized . Review of a Food Receiving and Storage facility policy dated [DATE] indicated, .Foods shall be received and stored in a manner that complies with safe food handling practices .Dry foods that are stored in bins will be removed from original packaging, labeled and dated. Such food will be rotated using a first in - first out system .All food stored in the refrigerator or freezer will be covered, labeled and dated .

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment 2 of 4 shower rooms reviewed for environment. (Shower # 1 and Shower # 4) The facility failed to clean and repair tiles in the facility shower room [ROOM NUMBER] and 4. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: During an interview on 11/14/23 at 3:30 p.m. with Resident # 82, she stated the showers in the shower rooms were bothering her. She said that there was mold growing on the tiles and the caulking was coming apart. She said that there were tiles that were broken and coming off the wall. She said the main reason why she was bothered by the showers was, there was mold or mildew on the tiles, in the broken tiles, and in the caulking on the floor and walls. She said that she wants the showers cleaned, the caulking restored, and the tiles replaced. During an observation on 11/14/23 at 5:05 p.m. shower rooms 1, 2, 3 and 4 were inspected. Shower room [ROOM NUMBER] and 4 had broken tiles, caulking that was missing between the floor tile and the wall tile, and caulking that had worn down and needed replacement. It was observed that both showers 1 and 4 had broken tiles on the wall where it met the floor. It was observed a black substance on the caulking, shower tile grout lines, tiles, and behind the broken tiles. Caulk lines where the floor met the wall was no longer white but was now black in color presumably from mildew and mold. During an interview on 11/15/23 at 10:20 a.m. with the Maintenance Supervisor, he stated he has a maintenance order book that he keeps at the nurse ' s station. He stated all facility staff had access to this book and were supposed to report damage to the building or any items that need fixed. He stated it was not written in the facility maintenance log that shower rooms [ROOM NUMBERS] needed repair to the tile and caulking. He stated it had not been reported to him that the caulking in the shower rooms needed repair and that it had turned black. He stated that the picture the surveyor showed him shows that there was mildew or mold in the shower room. He stated that over time the caulking wore down and would need to be replaced. He said the caulking has to be cut out in order for it to be replaced. He stated that it was also not reported to him that the shower tiles had started to detach from the walls and needed repair. He stated that he has already worked on the shower rooms [ROOM NUMBERS] and they were in good condition. He stated he will replace the caulking in shower rooms [ROOM NUMBERS] as well as replace the tile. He stated he has the tile that goes in the shower rooms, but he has not yet replaced them. During an interview on 11/15/23 at 11:14 a.m. with the Administrator, she stated she expects staff keep the showers clean and free from mold or mildew. She stated she expects the Maintenance Supervisor to keep the shower room in good working condition which includes intact tile and caulking in the appropriate areas. She stated she wants residents to feel that they live in a clean and comfortable homelike environment and that includes the shower rooms. During an interview on 11/15/23 at 11:23 a.m. with the Director of Nursing, she stated that she expects her staff to keep the shower rooms clean and working. She stated mold or mildew could pose a risk to residents in the form of infections. Record review of the Maintenance Work Log dated from January 1, 2023 to Novemer 2023 revealed maintenance services. The Maintenance Work History Report did not reveal shower room work on the tile or the caulking. Review of a Quality of Life - Homelike Environment facility policy dated May 2017 indicated, Residents are provided with a safe, clean, comfortable, homelike environment .staff shall provide person-centered care that emphasizes the residents ' comfort, independence, and personal needs and preferences .the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include clean, sanitary, and orderly environment . pleasant neutral scents.

Based on observation, interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 21 residents (Residents #37, #78), reviewed for care plans. The facility failed to revise and update Resident #37's comprehensive care plan with new enteral feeding orders. The facility failed to revise and update Resident #78's comprehensive care plan for hospice services. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: 1. Record review of the undated face sheet indicated Resident #37 was a [AGE] year-old female that was admitted on [DATE]. Record review of the physician's orders dated 11/13/23 indicated Resident #37 had diagnoses that included: Major depression (persistently depressed mood or loss if interest in activities causing significant impairment in daily life), Diabetes Mellitus type 2 (a chronic condition that affects the way the body processes sugar), Gastro-Esophageal Reflux Disease (stomach content persistently and regularly flows up into the esophagus), Dysphagia (difficulty or discomfort in swallowing), and dementia (impairment of at least 2 brain functions, such as memory loss and judgement). The physician's orders indicated: 5/24/23 Glucerna 1.5 cal, 240 ml bolus (a single dose given all at once) three times a day for feeding. Flush with 60 ml water before and after bolus. Record review of the quarterly MDS dated [DATE] indicated Resident #37 had no speech, rarely understood others, and was rarely understood by others. She had short and long-term memory problems with inattention, disorganized thinking, and an altered level of consciousness that was continuously present. The MDS indicated she had a feeding tube. Record review of the care plan dated 6/1/23 indicated: Resident #37 gets Glucerna 1.5 cal. Give 75 ml/hr via peg tube at night with 25cc/hr water flush. The care plan indicated she required a peg tube due to dysphagia and had impaired cognition. Record review on 11/14/23 at 11:30 AM, of Resident #37's care plan indicated she still received continuous feedings. The care plan did not indicate she was changed to bolus feedings on 5/24/23. Record review of the MAR for Resident #37 dated 10/1/23-10/31/23 indicated: Glucerna 1.5 cal 240 ml bolus three times a day for feeding. Flush with 60 ml water before and after bolus. The start date was 5/24/23. Record review of the MAR for 11/1/23-11/30/23 indicated: Glucerna 1.5 cal 240 ml bolus three times a day for feeding. Flush with 60 ml water before and after bolus. The start date was 5/24/23. 2. Record review of a face sheet dated 11/13/23 revealed Resident #78 was [AGE] years old and was admitted on [DATE] and was initially admitted on [DATE] with diagnoses including Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), muscle weakness, and stroke. Record review of a handwritten physician's order dated 09/05/23 indicated Resident #78 was admitted to hospice care with a diagnosis of vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). Record review of the most recent MDS dated [DATE] indicated Resident #78 was receiving hospice care while a resident in the facility. Record review of a care plan last revised on 11/06/23 did not indicate Resident #78 was receiving hospice care. During an interview on 11/14/23 at 12:20 PM, the Regional Nurse said Resident #37's care plan had not been updated to indicate she was currently on bolus feedings. She said Resident #37 was receiving the correct feedings ordered by the physician. During an interview on 11/14/23 at 2:43 PM, the Regional Nurse looked at the care plan for Resident #37 and said she understood it had not been changed to bolus feedings (on 5/24/23) and still indicated a continuous feeding. The Regional Nurse and this surveyor compared the care plan to the physician's orders. She said the care plan did not reflect the current care of the resident. She said the care plan should have been updated with Resident #37's new orders for bolus feedings. During an interview on 11/14/23 at 3:36 PM, RN C said care plans should be updated and accurate because they were the blueprint on how to care for the resident. He said Resident #37 used to be a continuous feeding at night, but he knew the order changed to bolus feedings, so he would not make a mistake even if the care plan was incorrect. He said the care plan should still be accurate. He said the person responsible for making sure the care plans were accurate was the CPC. During an interview on 11/14/23 at 3:40 PM, LVN B said the care plans for residents should always be updated and accurate because that was how their care was dictated. She said if the care plans were wrong, they should be updated as soon as possible. LVN B said the CPC was responsible for making sure the care plans were correct and up to date. She said ultimately all nurses were responsible for making sure the care plans were correct. During an interview on 11/14/23 at 3:44 p.m., a family member of Resident #78 said the resident was receiving hospice care. The family member said hospice was working on providing Resident #78 with a low floor bed. During an interview on 11/14/23 at 3:45 PM, ADON A said the care plans being accurate was very important because that was how they knew how to take care of the resident. She said the person responsible for making sure the care plan was accurate was the CPC. During an interview on 11/14/23 at 4:31 PM, the DON said the care plan for Resident #37 should have been correct and updated so they administered her feeding correctly. She said it was on the MAR correctly, so she believed that the feeding was being given correctly. She said the CPC was responsible for accuracy of the care plans and keeping them updated. She said the ADM had been checking the care plans since October of 2023, but she did not know if she had looked at that Resident #37's. She said moving forward from right now they will be bringing care plans to the morning meeting to go over them and make sure they were correct. She said beginning right now she would be checking all care plans for revisions and accuracy. She said the problem with the care plans being wrong was that the staff may not know to do the right things for the resident. During an observation on 11/14/23 at 4:45 PM, Resident #37 was lying in her bed. Her eyes were open. The head of her bed was up approximately 35 degrees. She did not acknowledge this surveyor or respond to verbal stimulation. During an interview on 11/14/23 04:57 PM, the DON said the Comprehensive Care Plan policy was the only one they had. She said they did not have a policy regarding updating or revising care plans. During a phone interview on 11/14/23 at 5:44 PM, the CPC said Resident #78's care plan should have been updated to show he was on hospice care. She said Resident #37's care plan should have been updated to show she got bolus feedings through her peg tube and no longer got continuous feedings at night. She said it was important for the care plans to be correct because nurses looked at them to see how to care for a resident. She said she was responsible for making sure the care plans were correct. She said she had started checking care plans for accuracy recently, in the last 10 days or so. The CPC said no one was checking her care plans for accuracy but the ADM, DON, and ADON's were going to start checking them for accuracy during the care plan meetings. During an interview on 11/15/23 at 8:10 AM, the DON said the process for updating changes on a care plan was they would take the triplicate for the new orders into the stand-up meeting and go over the new orders at that time. She said they would give the copy to the CPC. The DON said she could not provide the triplicates or the notes from the stand-up meeting because they had been shredded. She said she did not know how Resident 78's hospice order, or Resident #37's feeding change was missed. During an interview on 11/15/23 08:15 AM, RN F said she had worked at the facility for 3 months and always worked PRN. She said Resident #37 had always gotten bolus feedings since she had worked. She said the physician's orders indicated she got bolus feedings. She said it was important for the care plan to be accurate to know how to properly care for the patient. She said she went by a resident's orders and double checked it on the MAR for accuracy. She said the MAR and physician's orders both indicated bolus feedings for Resident #37. During an interview on 11/15/23 08:52 AM, the Regional Nurse provided the updated care plan for Resident #37 that indicated: Resident #37 requires Glucerna 1.5 calorie, 240 ml bolus three times a day for feeding. Flush with 60 ml water before and after bolus. The care plan revision was dated 11/14/23. During an interview on 11/15/23 09:22 AM, the MDS nurse said she did not do anything regarding care plans. She said care plans were the responsibility of the CPC. During an interview on 11/15/23 09:39 AM, the ADM said the new process for care plans as of 10/24/23 was to discuss any changes at the morning meetings with the ADON's, DON, and herself. She said the DON and ADON's were currently auditing care plans, but they had not gotten to Resident #37 or Resident #78's care plan yet. She said the new process was to compare the consolidated physician's orders with the care plans to make sure nothing was missed, and the care plan was correct. The ADM said the CPC was responsible for making sure the care plan was accurate but ultimately, as the ADM she was responsible. Review of a Care Plans, Comprehensive Person-Centered facility policy dated December 2016 indicated, .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 .the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .The comprehensive, person-centered care plan will .Describe the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being .Incorporate identified problem areas .Assessments of residents are on-going and care plans are revised as information about the residents and the resident's condition change . 35295

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 2 of 21 residents reviewed for ADLs. (Resident #3 and Resident #72) The facility failed to remove facial hair from female Resident #3. The facility failed to shave facial hair for male Resident #72. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: 1. Record review of Resident #3's Admission Record dated 03/15/23 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Physical Debility (General debility is a state of general weakness or feebleness that may be a result or an outcome of one or more medical conditions), Muscle Wasting and Atrophy (Muscular atrophy is the decrease in size and wasting of muscle tissue), and Anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). Record review of Resident #3 ' s Quarterly MDS dated [DATE] revealed a BIMS with a score of 5, which indicated resident #3 has severely impaired cognition. The MDS also revealed, Resident #3, required limited assistance with personal hygiene. Resident #3 required one-person physical assistance with personal hygiene, including shaving. Record review of Resident #3's Care Plan dated 6/21/23, revealed a problem initiation on 3/31/23 resident requires assistance with ADL care related to diagnosis of Dementia. Resident #3 ' s care plan did not show that she refused care. During an observation and interview on 11/13/23 at 10:16 a.m. Resident #3 was observed lying in her bed. She presented with 10 to 15 chin hairs and mustache hairs that were approximately one inch long. She stated that she does not remember the last time she was shaved. She stated that she does not shave herself. She stated that she would prefer to be shaved and not have any facial hair. During an interview and observation on 11/14/23 at 8:30 a.m. Resident # 3 was observed with facial hair. During an interview on 1/15/23 at 9:31 a.m. RN F, she stated the CNAs were responsible to shave residents. She stated CNAs can shave a resident when they give the resident a bath. She stated dependent residents were not able to shave themselves on their own, they require assistance. She stated that she thinks that it was reasonable for a female to want to be clean shaven. She stated that the resident however will need to allow the staff to shave them without refusing. During an interview on 11/15/23 at 09:44 a.m. CNA G stated the CNAs and nurses were responsible for ADLs for dependent residents. She stated some residents refuse ADL care. She stated that if a resident refuses ADL care staff can encourage residents so that care can be provided. CNA G stated the names of resident ' s that refuse care. Resident #3 was not included. CNA G worked on Resident #3 ' s hall. During an interview on 11/15/23 at 11:14 a.m. with the Administrator, she stated residents who were dependent for ADLs should have their facial hair shaved by staff. She stated it was staff ' s responsibility to ensure that residents who were dependent for ADLs were groomed. She stated unless a resident refuses staff should ensure residents were groomed properly and according to their care plan. She stated resident ' s care plans should reflect if they refuse care. During an interview on 11/15/23 at 11:23 a.m. with the DON, she . She stated it was the responsibility of CNAs to shave residents that were/are dependent for care. She stated nurses should ensure that the CNAs were/are completing these tasks and they too are overseen by the ADONs. She stated it was reasonable that a female resident would not want facial hair. 2. Record review of a face sheet dated 11/15/23 revealed Resident #72 was a [AGE] year-old male and was admitted on [DATE] with diagnoses including muscle weakness, high blood pressure, and Parkinson ' s Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Record review of the most recent MDS dated [DATE] indicated Resident #72 was understood and understood others. The MDS indicated a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #72 was totally dependent on staff for personal hygiene. Record review of a care plan last revised on 09/06/23 did not indicated Resident #72 ' s need for assistance with personal hygiene or shaving. Record review on nurse ' s notes from 11/01/23 to 11/15/23 did not indicate Resident #72 had refused care. Record review of CNA-ADL Tracking Form dated 11/2023 indicated Resident #72 had received total assistance with personal hygiene on 11/01/23 - 11/14/23. During an observation and interview on 11/13/23 at 10:09 a.m., Resident #72 was in bed. The resident had unkept facial hair extending down onto his neck. He said staff did not shave him as often as he would like. He said he prefers a goatee and to clean shaven around the goatee. During an observation on 11/14/23 at 10:06 a.m., Resident #72 was in bed. The hospice CNA and a facility CNA were assisting Resident #72 with dressing. The resident had unkept facial hair extending down onto his neck. During an observation and interview on 11/15/23 at 8:06 a.m., Resident #72 said that staff never shave him. He said staff do not offer to shave him. He said he got a bath on 11/14/23 and still was not shaved. The resident had unkept facial hair extending down onto his neck. Resident #72 said to the surveyor, I thought you weren ' t going to come back to see about this. During an interview on 11/15/23 at 9:07 a.m., CNA K said male residents were supposed to be shaved on shower days. She said Resident #72 was very picky about who shaved him. She said he would let her shave him. She said staff should offer for him to be shaved on his bath days. She said his bath days were Tuesdays, Thursdays, and Saturdays. During an interview on 11/15/23 at 9:14 a.m., LPN L said staff should offer to shave male resident on their bath days and as needed. During an interview on 11/15/23 at 10:19 a.m., the DON said she would have expected Resident #72 to have been shaved on his bath days and as needed. She said the hospice aide usually shaved him and she was not sure why he had not been shaved. She said not being shaved could be a dignity thing. During an interview on 11/15/23 at 10:46 a.m., the Administrator said she would have expected Resident #72 to have been shaved. She said hospice was responsible for his baths. She said staff should have offered to shave him and shave him anytime he asked. She said she had visited with him, and he had asked to be shaved. She said Resident #72 not being shaved could make him uncomfortable. She said the beauty shop also provided shaves to the resident. Review of a Quality of Life, Activities of Daily Living (ADLs)/Maintain Abilities facility policy dated 11/28/2017 indicated, .To appropriately address resident and facility practices that would affect the resident ' s ability to attain and maintain his/her practicable well-being .The facility must provide the necessary care and services, based on the comprehensive assessment of a resident and consistent with the resident ' s needs and choices, to ensure that a resident ' s abilities in activities of daily living do not diminish unless circumstances of the individual ' s clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The facility must provide care and services, in accordance with the previous paragraph, for the following activities of daily living .Hygiene .grooming . 45643

Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 2 residents (Resident #24 and #55) reviewed for respiratory care and services. The facility failed to ensure Resident #24's oxygen concentrator was set at 2 LPM, as ordered by the physician. The facility failed to change the filters on oxygen concentrator machines that were in use for Resident #55. This failure could place residents at risk for developing respiratory complications. Findings included: 1. Record review of Resident #24's face sheet, dated 11/14/23, indicated she was a [AGE] year-old female, admitted to the facility 09/13/23. Her diagnoses included polycythemia vera (a rare blood disorder in which there is an increase in all blood cells, particularly red blood cells), and asthma (a disease in which the airways clog and narrow, making it hard to breathe). Record review of Resident #24's admission MDS assessment , dated 09/20/23, indicated she had a BIMS score of 15, which indicated intact cognition. She was able to make herself understood and she was able to understand others. She did not exhibit behavior of rejection of care. Record review of Resident #24's undated physician's orders indicated she had an order for oxygen via nasal cannula 2 L as needed. The start date was 09/28/23. Record review of Resident #24's undated care plan indicated a focus of resident requires the use of oxygen as needed. The focus was last revised on 10/25/23. Interventions included oxygen as ordered. During an observation on 11/14/23 at 04:20 PM, Resident #24 was in her room lying in her bed. She had oxygen in place via nasal cannula. The oxygen concentrator at her bedside was set to 3.5 LPM. During an observation on 11/15/23 at 08:07 AM, Resident #24 was in her room lying in her bed. She had oxygen in place via nasal cannula. The oxygen concentrator at her bedside was set to 3.5 LPM. During an interview on 11/15/23 at 09:25 AM, LVN H said she was assigned to Resident #24 on 11/15/23. She said Resident #24 had an order for oxygen as needed. She said the order indicated Resident #24's oxygen concentrator should have been set at 2 LPM. She said the concentrator should not have been set at 3.5 LPM. She said the oxygen concentrator should be set to the ordered rate. She said the resident could suffer CO2 overload and decreased respiratory drive. She said no one was responsible for ensuring the oxygen concentrators were set at the ordered rate other than the nurse. During an observation on 11/15/23 at 09:33 AM, Resident #24 was lying in bed in her room. She had oxygen in place via nasal cannula. The concentrator at her bedside was set at 3.5 LPM. During an interview on 11/15/23 at 9:52 AM, ADON J said she expected Resident #24's oxygen concentrator to be set at the ordered rate. She said if Resident #24's oxygen was set too high she could overexert herself and suffer complications. She said the nurse was responsible for ensuring the oxygen rate was set correctly throughout their shift. She said the ADONs and charge nurses were responsible for ensuring the oxygen rate was set correctly. She said all licensed personnel were responsible for ensuring the oxygen rate was set correctly. During an interview on 11/15/23 at 09:55AM, the DON said she expected Resident #24's oxygen to be set at the ordered rate. She said Resident #24 could become dependent on the higher dose of oxygen. She said the nurse was responsible for ensuring the oxygen was set at the ordered rate. She said the ADONs were also responsible for checking the oxygen was set at the ordered rate. During an interview on 11/15/23 at 09:57 AM, the Administrator said she expected Resident #24 to be given the ordered dose of oxygen. She said she expected the nurses to keep an eye on the oxygen rate. She said the resident could suffer a negative effect if the rate was set at the wrong rate. 45643 2. Record review of an undated face sheet revealed Resident #55 was an [AGE] year-old, female, and admitted on [DATE] with diagnoses including Chronic Obtrusive Pulmonary Disease (a common lung disease causing restricted airflow and breathing problems), Palpitations (feelings or sensations that your heart is pounding or racing), Dyspnea (difficult or labored breathing). Record review of the Quarterly MDS dated [DATE] revealed Resident #55 had a BIMS score of 7, which indicated Resident # 55 has severely impaired cognition. Resident #55 was coded as receiving oxygen therapy. Resident #55 required limited assistance with ADLs. Record review of Resident #55 ' s care plan revised on 2/10/21 shows that she receives oxygen as ordered for PRN shortness of breath. Care plan stated that staff are to, Ensure oxygen concentrator is clean and in good working order. During an observation and interview on 11/13/23 at 10:16 a.m. Resident #55 ' s oxygen concentrator external filter was obstructed with dust and debris. Resident #55 stated she used the oxygen concentrator. She stated she did not remember the last time someone cleaned the machine nor the filter on the machine. Resident #55 was observed with the nasal cannula attached to the concentrator on her bed indicating that she uses the device. During an observation on 11/15/23 at 9:00 a.m. Resident #55 ' s oxygen concentrator external filter had yet to be cleaned or replaced. The filter was obstructed with dirt and debris. During an interview on 11/15/23 at 9:31 a.m. with RN F, she stated that the night shift nurses were responsible to change out the oxygen concentrator filters but she wasn ' t sure. She stated she does not look at the concentrator filters. During an interview on 11/15/23 at 9:44 a.m. with CNA G, she stated that it was not her responsibility or that of CNAs to clean or change the filters on oxygen concentrators. She stated she knows what the filter looks like and its location. She stated she was able to report if a filter was dirty to a nurse. During an interview on 11/15/23 at 11:14 a.m. with the Administrator, she stated. She stated it wasis the nurse ' s responsibility to ensure that oxygen concentrator filters wereare cleaned and replaced when needed. She stated that there should not be a buildup of dust on the external filters. She stated that a resident could become ill if the filters wereare not kept clean and free from dust and particles. During an interview on 11/15/23 at 11:23 a.m. with the Director of Nursing, she stated it was the nurse ' s responsibility to ensure that the external filter for the oxygen concentrator was free from dust and debris. She stated that residents were placed at risk for respiratory issues, and it could cause the machine to not work properly. She stated it was the facility ' s policy to ensure that respiratory equipment was in a good and working order. Record review of facility policy titled Oxygen Administration revised in October of 2010 revealed that, The purpose of this procedure is to provide guidelines for safe oxygen administration Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol Review the resident's care plan to assess for any special needs of the resident Assemble the equipment and supplies as needed.

Based on interview and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 1 resident reviewed for accidents and supervision. (Resident #2) The facility failed to provide appropriate supervision for Resident #2 to prevent falls with and without injury. This failure places residents at risk for serious injury related to falls. Findings included: 1. Record review of an undated face sheet indicated Resident #2 was a [AGE] year-old male and admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) and repeated falls. Record review of the MDS dated [DATE] indicated Resident #2 was sometimes understood but understood others. A BIMS score of 99 indicated Resident #2 was severely cognitively impaired. The MDS indicated Resident #2 required extensive assist of 2 staff for bed mobility and transfer and he was dependent for toileting. Resident #2 was coded as always being incontinent of bowel and bladder. Resident #2 had 2 or more falls with no injury coded. Record review of incident reports for Resident #2 revealed the following: 09/07/2023- Resident #2 had a fall in his room on the secured unit at 7:15 a.m., all meds were on hold-intervention was urinalysis. 09/08/2023- Resident #2 had a fall in his room on the secured unit at 12:30 a.m., aides heard a big bang and found resident on the floor in room with a broken lamp on the floor beside him.- intervention turn and reposition bars added to bed. 09/13/2023- Resident #2 had a fall in his room on the secured unit at 2:11 a.m., nurse was out of unit on 200 hall, CNA H was on break in her car, CNA I was providing care to another resident when she heard a thud. Intervention CNAs working the unit at night could not leave the building for breaks. 09/30/2023-Resident #2 had a fall on the floor in unit at 3:35 p.m., fall mats in place- No intervention further intervention. 10/05/2023- Resident #2 had a fall in his new room on 400 hall at 8:30 p.m., slipped off bed onto floor. No Intervention further intervention. 10/07/2023- Resident #2 brought to nurses' station so staff could watch him. Resident #2 was noted to be on the floor by a nurse from another station that was passing by at 7:30 a.m.- Intervention was high back wheelchair. 10/10/2023-Resident #2 was found on the floor in room- Intervention- Inservice staff about working with agitated, impulsive residents and how to provide incontinent care to them. 10/13/2023-Resident #2 fell in his room and was found on the fall mat. No intervention. 10/16/2023- Resident #2 fell at 7:36 a.m. at the nurse's station. No witness. Laceration to eye requiring sutures. Noted on the floor by a nurse from another hall.- Sent to ER. 10/16/2023- Resident #2 fell at 11:45 a.m., at the nurse's station while 3 nurses sat at the station. Resident landed on his right arm. 10/17/2023- Resident #2 fell in room at 6:27 a.m., slipped off bed onto right knee and scooted on buttock across room. Intervention was frequent monitoring. No documentation of frequent monitoring was located. 10/20/2023- Resident #2 found sitting on floor in room. Resident had a skin tear to his right hand and complained of pain. Xray done and a fracture of indeterminate age was found to his ulnar bone. During on observation on 10/18/2023 at 2:00 p.m., Resident #2 was up in his wheelchair in his room alone. Resident #2's room was noted to have fall mats on the floor on the right side of bed and foam wrapped around the transfer bar on his bed. Resident #2 remained in room alone for 15 minutes until CNA came to assist him to bed. Resident #2 was noted to have a large area of bruising to his left eye deep purple in color. Resident #2 had a laceration to his brow bone on the left side. During an interview on 10/19/2023 at 10:02 a.m., CNA H stated she was working with Resident #2 on the night of 09/13/2023 when he fell . CNA H stated she went on her lunch break and when out to her car to talk on her cell phone. CNA H stated Resident #2 was up in his wheelchair in his room when she left CNA I alone on the unit while she went to break. CNA H explained the nurse for the secured unit was also the nurse for the 200 hall at night time and they stayed out on 200 hall unless they needed them to come back there for something. CNA H stated the nurse came outside and beat on her car hood and signaled for her to come back in the facility. CNA H stated the nurse informed her Resident #2 had fallen and she needed to come in from her break to assist the other aide in getting him up off the floor. CNA H stated Resident #2 had fallen over in the wheelchair because it was on its side when she arrived at the room. CNA H stated Resident #2 was not injured from the fall. CNA H stated the next day there was an in-service that said the staff on night shift had to stay in the building during break. CNA H stated with the nurse on 200 hall there was no way to keep an eye on all the residents if you are assisting another resident and no one else is on the hall. During and observation on 10/19/2023 at 11:35 a.m., Resident #2 was sitting in a wheelchair at the nurse's station. No nurses or CNAs were noted to be at the station at the time. Resident #2 was unattended outside of nursesnurse's station for 10 minutes prior to the nurse returning to the nurses station. During an interview on 10/19/2023 at 2:15 p.m., CNA I stated she recalled Resident #2 falling on 09/13/2023 because she was on the unit alone and she had opened the unit door and hollered for the nurse to come check on him. CNA I stated she was giving care to another resident when she heard Resident #2 fall. CNA I stated she had to finish the care she was doing before she could go see what occurred in Resident #2's room. CNA I stated Resident #2 has tipped his wheelchair over and was lying on his side on the floor. CNA I stated he had not appeared to be injured but she went and got the nurse to check him to make sure. CNA I stated there was no way to watch all the residents when they were caring for any resident that took 2 people to care for or if one of them was on break. CNA I stated they did their best and they had not had too many instances where they were left alone and something happened. During an interview on 10/22/2023 at 10:00 a.m., LVN J stated she was the nurse that found Resident #2 on the floor in the 400 hallway on 10/07/2023. LVN J stated she was told by other nurses that Resident #2's family wanted him to be looked after more closely and the staff was to put him at the nurse's station when they got him up. LVN J said it was right after 7:00 a.m., when she was walking toward the nurse's station, she saw him down on the floor. She stated his wheelchair was few feet behind him and it appeared he had gotten up and took a few steps and fell . LVN J stated the CNAs were getting people ready for breakfast and his nurse was in a resident's room. There was no one at the nurse's station to keep an eye on him at that time of day. LVN J stated Resident #2 had to have constant eyes on him unless he was asleep. During an interview on 10/22/2023 at 11:00 a.m., CNA F stated she had assisted Resident #2 many times with getting out of bed and bathing. CNA F stated on 10/16/2023 around 7:15 a.m., she was working on 300 because an aide called in and when she rounded the corner at the nurse's station, she found Resident #2 on the floor lying in a large puddle of blood. CNA F stated she looked for his nurse briefly and could not find her, so she notified the nurse working the 300 hall. CNA F stated LVN K came and assessed the resident and sent him to the hospital. CNA F stated Resident #2 did not need to be left at the nurse's station when no one was around to watch the resident. CNA F stated he was safer in his room if he was unattended because he had padded furniture and fall mats there. During an observation on 10/22/2023 at 11:30 a.m., Resident #2 was sitting at the nurse's station in a wheelchair. Resident #2 had a splint/cast noted to his right arm at this time. No staff was at the nurse's station or in sight of Resident #2 for 20 minutes. The 300-hall nurse and 400- hall nurse that share the nurse's station were checking blood sugars on the hall and the 1 CNA was on break and 1 was providing care to another resident during this time. During an interview on 10/22/2023 at 1:10 p.m., LVN K stated she was the nurse that sent Resident #2 out on 10/16/2023 at 7:40 a.m. LVN K stated she was not the nurse assigned to care for and monitor Resident #2 on 10/16/2023. LVN K stated she was familiar with Resident #2 because he had several falls prior to 10/16/2023 and his family was very vocal at the facility. LVN K stated she could not locate his nurse (RN L) after assessing him, so she continued with the process and sent him to the ER to be evaluated. LVN K stated she was unaware of the reason Resident #2 was left at the nurse's station unattended and his nurse was not in the building to ask who was supposed to be monitoring him. LVN K stated he returned around 2 hours later with some sutures to his eyebrow. LVN K stated later on 10/16/2023 at around 11:00 a.m., Resident #2 was at the nurses' station when he returned from the ER, and he fell again at the nurse's station. LVN K stated she and two other nurses were sitting at the nurses' station with their heads down and did not see what happened that made him fall. Record review of the timesheet for RN L for 10/16/2023, showed she was clocked out from 7:12 a.m. to 7:42 a.m. During an interview on 10/22/2023 at 1:25 p.m., RN L stated she was assigned to the care of Resident #2 as his charge nurse on 10/16/2023. RN L stated she was not available during his first fall at 7:15 or 7:30 a.m., but she was sitting across from him at the nurse's station when he fell for the second time that day just a few hours later. RN L stated Resident #2 moved quickly when he decided to get up. RN L stated she and the other nurse behind the nurse's station had their heads down and she did not know he had fallen until she heard him hit the floor. During an interview on 10/23/2023 at 10:00 a.m., Resident #2's family stated they attempted to hire a sitter to come in at night and sit with Resident #2 until he became tired and was ready to go to bed in attempt to decrease his agitation and decrease his falls. Resident #2's family stated the approach of some of the staff to a man with dementia was what caused him to become upset and restless. Resident #2's family stated he did not do well with lots of noise or people grabbing him by the clothes to do care. Resident #2's family stated she made all this clear to the facility when he had an episode of being combative and injured his hand. Resident #2's family stated after a week and a half of the sitter coming into the building and helping Resident #2, the Administrator stated she could no longer come be the sitter for Resident #2 because she was employed by the facility prn. Resident #2's family stated the Administrator refused to provide extra supervision for Resident #2 stating this is not a facility that provides 24 hours a day sitters. During an interview on 10/23/2023 at 11:45 a.m., the Administrator stated she did tell the family she could not use the CNA as the sitter for Resident #2 because in the facility handbook it stated no gifts could be received for care given for residents of the facility. The Administrator stated it was the facilities responsibility to come up with interventions for falls and to continue to update the interventions when they do not work to prevent accidents and injuries. The Administrator stated it was ultimately the facilities responsibility to provide adequate supervision to keep all the residents safe. Record review of a policy dated July 2017 titled Safety and Supervision of Residents revealed that the facility strived to make resident safety and supervision and assistance to prevent accidents facility wide priorities. The individualized, resident-centered approach to safety .1. Our individualized resident-centered approach to safety addresses safety and accident hazards for individual residents.4. Implementing interventions to reduce accident risks and hazards shall include the following .communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training, as necessary; ensuring the interventions are implemented; and documenting interventions.

Based on interview and record review the facility failed to immediately consult the physician when there was a significant change in the resident's physical and mental status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 6 Residents (Resident #19) whose records were reviewed for change in condition. The facility failed to consult a physician or NP of Resident #19's signs and symptoms of extrapyramidal side effects (side effects of antipsychotic medicines. EPS can cause movement and muscle control problems throughout your body) after her return from a behavioral hospital. An Immediate Jeopardy (IJ) situation was identified on 09/15/2022 at 7:40 PM. While the IJ was removed on 09/16/2022 at 5:00 PM, the facility remained out of compliance at a scope of isolated with a severity of actual harm, due to the facility's need evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not having their physician consulted of changes in condition timely, resulting in a delay in medical intervention, decline in health, possible worsening, or irreversible symptoms. Findings included: Record review of the face sheet dated 08/30/22 revealed Resident #19 was [AGE] years old, female, and admitted on [DATE] and readmitted on [DATE] with diagnoses including [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the admission MDS dated [DATE] revealed Resident #19 was sometimes understood and sometimes understood others. The MDS revealed Resident #19 had a BIMS of 01 which indicated severe cognitive impairment. The MDS revealed Resident # 19 had evidence of inattention and disorganized thinking. The MDS revealed Resident #19 hallucinated, physical, verbal, and other behavioral symptoms directed towards others. The MDS revealed Resident #19 rejected care and wandered. The MDS revealed Resident #19 required limited assistance for dressing, toilet use, personal hygiene, and bathing but independent for transfers, walking, and eating. The MDS revealed Resident #19 had active diagnoses of Alzheimer's, Non-Alzheimer's dementia, anxiety, [CONDITION(S)], and depression. The MDS revealed Resident #19 received antianxiety (reduces anxiety) and antidepressant (used to treat major depressive disorder). Record review of the significant change MDS due to being placed on hospice dated 08/02/22 revealed Resident #19 was sometimes understood and sometimes understood others. The MDS revealed Resident #19 had a BIMS of 01 which indicated severe cognitive impairment. The MDS revealed Resident # 19 had evidence of inattention and disorganized thinking. The MDS revealed Resident #19 hallucinated, physical, verbal, and other behavioral symptoms directed towards others. The MDS revealed Resident #19 rejected care and wandered. The MDS revealed Resident #19 required extensive assistance for dressing, toilet use, personal hygiene, and bathing but independent for transfers, walk in room, and eating. The MDS revealed Resident #19 had active diagnoses of Alzheimer's, Non-Alzheimer's dementia, [CONDITION(S)], mood affective disorder (as mood disorders, are mental disorders that primarily affect a person's emotional state) and depression. The MDS revealed Resident #19 received antipsychotic and antidepressant. The MDS revealed Resident #19 received antipsychotic on a routine basis, gradual reduction had not been attempted. Record review of the undated care plan revealed Resident #19 required moderate assistance for ADL care and cues related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan revealed Resident #19 had episodes of physically and verbally abusive to staff and resident at times with difficult redirect, pace the hallways and go in and out of other residents' room at times, refuses care at times, impulsive related to diagnoses of Alzheimer's and dementia initiated on 06/27/22 and revised on 08/03/22. Interventions initiated on 06/27/22, included approach in calm manner, be firm, not forceful, redirect, medication as ordered, and monitor/document behaviors. The care plan revealed Resident #19 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's and dementia, initiated, and revised on 06/27/22. The care plan revealed Resident #19 had potential for side effects related to [CONDITION(S)] medication, initiated on 06/27/22. Interventions initiated on 06/27/22, included give medication as ordered and monitor for effectiveness, notify MD of any note side effects, or change in behavior, and set up psychological evaluation as needed. Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the progress note dated 06/23/22 revealed resident being very aggressive with staff and other residents .started pulling on another resident who told her to stop .we attempted to redirect her .pushed nurse head .started yelling Record review of the behavioral hospital paperwork written by NP Y dated 07/01/22 revealed admitted [DATE] .history of Alzheimer's dementia .behavioral disturbance and yelling, hitting, and throwing things at staff members and other residents .nursing home staff states that nothing makes symptoms any better or worse .tangential thoughts and loose speech .requires gerichair off and on due to pacing and difficult to redirect .will charge at staff .ongoing confusion .anxious with cognitive impairments/changes in evolving routine/environment .behaviors .mood instability .emotional instability .within normal limits muscle strength and tone, slow ambulation for gait and station, fair eye contact, restless/fidgety, confused, orientation to person only, and fluent speech . Record review of the behavioral hospital paperwork written by MD Z dated 07/11/22 revealed .pleasant but continuously disoriented and confused .unsteady gait .no aggression noted . Record review of the behavioral hospital discharge paperwork dated 07/19/22 revealed Resident #19 discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharge medication list revealed [MEDICATION(S)] ([MEDICATION(S)]) 500mg three times a day, [MEDICATION(S)] ([MEDICATION(S)]) 1mg oral daily, and [MEDICATION(S)] 2mg oral once at bedtime with no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the behavioral/intervention monthly flow record dated 07/22 revealed Resident #19 monitored behavior was hitting and kicking at staff and resident, psychoactive drug/dose: [MEDICATION(S)] 500 mg, Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the behavioral/intervention monthly flow record dated 07/22 revealed Resident #19 monitored behavior was hitting and kicking at staff and resident, psychoactive drug/dose: [MEDICATION(S)] 1mg and 2mg, Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a physician's notes dated 08/16/22 revealed MD W stated .this patient was seen in my office having had a significant change in her condition .she went from an open unit with long hallways to a closed Alzheimer's dementia unit .she did not do well with the transition .she was psychiatrically hospitalized .while hospitalized placed on [MEDICATION(S)] .[MEDICATION(S)] .the family member has become quite concerned since her return back .family member reports the patient is no longer walking .speech is garbled and nonsensical .no eye contact slumped posture noted . shuffling of gait noted .poor balance .cogwheeling of both upper extremities .clonus of the right hand .affect anxious but flattened .no violence towards the examiner .this patient symptoms are consistent with pseudo parkinsonism of [MEDICATION(S)] .this will be discontinued .obtain [MEDICATION(S)] level today .repeat urinalysis for urinary tract infection .if return of aggression, [MEDICATION(S)] 25 milligrams may be used twice daily .continue [MEDICATION(S)] .posture: rigid .eye contact: avoidant .activity: slowed .affect: flat .mood/affect: no significant change .thought process/functioning: notable change .behavior/functioning: notable change .medical condition: notable change .behavioral health Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #19's progress notes 07/19/22-08/30/22 did not revealed documentation of EPS sign and symptoms or notification of change in condition to MD W, MD X, NP E, or NP X. During an observation on 08/29/22 at 10:55 a.m., Resident #19 wandered up and down the secured unit hallway. Resident #19's posture was slightly stooped with a shuffling gait. Resident #19 had mumbled speech with occasionally understood words and did not make eye contact. During an observation on 08/30/22 at 8:39 a.m., Resident #19 wandered up and down the secured unit hallway. Resident #19's posture was slightly stooped with a shuffling gait. Resident #19 had mumbled speech with occasionally understood words and did not make eye contact. During a phone interview on 08/30/22 at 9:04 a.m., the family members of Resident #19 said they felt Resident #19 was over medicated. They said before her admission to the facility, she was at an assisted living and only taking an antidepressant and something to help her sleep. They said within days of being admitted , they were getting phone calls of Resident #19 wandering and displaying aggressive behaviors. The family members said they felt the change in facilities and the [MEDICATION(S)] of the secured unit increased Resident #19's behaviors. They said Resident #19 was sent to a local behavioral hospital on 06/24/22, and during admission, lab results showed she had a urinary tract infection. They said UTIs could make any elderly person act out of character. The family members said when Resident #19 returned to the facility from the behavioral hospital, she was unrecognizable. They said she was stooped over when she walked, barely could feed herself, and drowsy. The family members said they had been pushing the facility to wean Resident #19 off some or lower the dosage of some medications. During an observation on 08/30/22 at 1:51 p.m., Resident #19 was asleep in her bed. During an observation on 08/30/22 at 3:07 p.m., Resident #19 was asleep in her bed. During an observation on 08/30/22 at 5:16 p.m., Resident #19 was asleep in her bed. During an interview on 08/31/22 at 3:12 p.m., the DON said she had been in the position for about 3 weeks but was the ADON for 6 years. She said Resident #19 did return to the facility with [MEDICATION(S)] and [MEDICATION(S)]. She said Resident #19 posture had significantly improved over the last month. She said she returned from the behavioral hospital with a stooped posture. On 08/31/22 at 4:58 p.m., call placed to NP E and left voice message. NP E did not return call prior to exit. During an interview on 09/02/22 at 9:40 a.m., the pharmacy consultant said any medication was appropriate for use if it controlled the behaviors the resident was exhibiting even if they did not have the correct diagnosis. The PC said she did not know Resident #19 had a [CONDITION(S)] when she went to the behavioral hospital which could have caused some of the extreme behaviors. She said she only went by the hospital paperwork which showed the extreme behaviors which a mood stabilizer would be appropriate to treat. The pharmacy consultant said she did not know Resident #19 came back from the facility with [CONDITION(S)] med side effects like stooped walking and drowsiness, which could have indicated she did not have the right diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she could see why it would have been important for Resident #19 to have been seen by her primary doctor or psychiatrist to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 09/15/22 at 6:14 p.m., Resident #19 was wandering the secured unit with one house slipper on her foot. Resident #19 had bruises noted to her face. Resident #19 responded to the Administrator when she addressed her but did not make eye contact with a flat affect. Resident #19 had improved but rigid posture and shuffled gait. During an interview on 09/15/22 at 6:40 p.m., MD W said he has been providing medical management since 05/05/ 2020 to Resident #19 and was currently overseeing her care at the facility. He said the facility, nor the behavioral hospital notified him of Resident #19 admission in June and he should have been notified of her admission and discharge. He said learned of the psychiatric hospitalization from a family member after Resident #19 returned and the family member wanted to make an appointment. MD W said he did not know Resident #19 had urinary tract infection during her admission to the behavioral hospital. He said he expected the facility to inform him of important issues such as extrapyramidal symptoms (an inability to sit still, involuntary muscle contraction, tremors, stiff muscles, and involuntary facial movements; the symptoms of EPS are debilitating, interfering with social functioning and communication, motor tasks, and activities of daily living. This is often associated with poor quality of life and abandonment of therapy), falls, and behaviors since he does not round at the facility. He was never notified of signs or symptoms of EPS. He said Resident #19 had severe EPS when he assessed her on 08/16/22 and 09/14/22 she still had them but not as frequently. He said he discontinued [MEDICATION(S)] on 08/16/22 due to Resident #19's EPS and scheduled a follow up visit on 09/14/22 to ensure the facility followed his orders. During an interview on 09/15/22 at 7:35 p.m., the Administrator said during the admission process Resident #19's family member preferred she continue using MD W as her primary care physician. She said the facility allowed MD W to continue overseeing Resident #19's care to appease the family. The ADM and ADON were notified on 09/15/22 at 7:40 p.m., an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided with the IJ template on 9/15/2022 at 8:09 p.m. The following plan of removal was submitted by the facility and was accepted on 9/16/2022 at 12:00 p.m.: 1. All nursing staff have been in serviced on 09/16/22 by DON the following: - Interventions documentation on behavioral monitoring record - Identify Extrapyramidal symptoms - Notifying Physicians when a resident has a significant change - Use of medication/documented justification from MD or NP for 14 days PRN [CONDITION(S)] meds - Assessing behaviors clinically (i.e., [CONDITION(S)], oxygen levels, sugar level, and type of possible infections) 2. All new nurses will be in serviced in orientation regarding facility policy and practice regarding [CONDITION(S)] medications. 3. All residents were screened on 09/16/22 by DON and ADON for any EPS. 4. All admissions and readmissions will be reviewed for accurate diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. A Physician has been contacted to review [CONDITION(S)] PRN medications on residents on Resident #19 and #77 immediately. 6. The DON and designee will follow up and continuously monitor to ensure compliance. Monitoring of the POR included: Record review of the in-service on 09/16/2022 at 2:30 p.m., provided to all nurses addressed intervention documentation on behavioral monitoring record, identifying extrapyramidal symptoms, notifying physician when a resident has a significant change, use of medication/justification for 14-day [CONDITION(S)] meds, and behaviors clinical versus mental. Content of summary of training session: 1. Documentation is required on each shift for any/all non-pharma logical interventions prior to administering PRN medication or any medication listed for [CONDITION(S)] use on the behavioral monitoring record for each medication on each resident. 2. see attached EPS signs and symptoms. 3. MD must be notified with any resident change of condition and documented in the chart (i.e., behavior change, physical change, mental change) mental and physical decline must be reported to MD or NP. 4. All PRN [CONDITION(S)] medications will only be ordered on a 14 day use and documentation should be provided by MD or NP prior to 14 days use of medication. 5. Behavior management must be approached from a clinical viewpoint prior to administering PRN [CONDITION(S)]. Record review of the educational handout on 09/16/22 at 2:30 p.m., provided to all nurses addressed, How do I recognize extrapyramidal symptoms? Record review of the example of a behavioral monitoring flowsheet on 09/16/22 at 2:30 p.m., provided to all nurses addressed how to properly fill out and document on the flowsheet for [CONDITION(S)] medications. Record Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] 1. The licensed nursing staff should not first give a prn [CONDITION(S)] medication when a resident became increasingly agitated. 2. Signs and symptoms of extrapyramidal effects included shuffled/unsteady gait, stooped over poor posture, and tremors. 3. An inability to sit still, involuntary muscle contraction, tremors, stiff muscles, and involuntary facial movement were symptoms of extrapyramidal effects. 4. After giving a PRN medication the nurse should reassess and document its effectiveness. 5. Notify the MD, NP, or supervisor if a resident is showing signs of EPS. 6. After a resident received a PRN medication, the nurse should document on the behavioral monitoring sheet and prn sheet. 7. Offering snacks and activities or walk away and provide safe space if necessary were good options of redirection for residents prior to admin prn [CONDITION(S)] medications. Interviews conducted on 09/16/22 at (2:39 p.m., LVN M who worked 6am-2pm shift) (2:56 p.m., RN N who worked 6am-2pm shift) (3:07 p.m., LVN C who worked 6am-2pm shift) (3:24 p.m., LVN O who worked 2pm-10pm shift) (3:36 p.m., LVN P who worked 2pm-10pm shift) (3:48 p.m., LVN S who worked 2pm-10pm shift) (3:53 p.m., LVN T who worked 10pm-2am shift) (3:55 p.m., LVN U who worked 10pm-2am shift) (4:20 p.m., LVN V who worked 10pm-2am shift) (4:33 p.m., DON) (4:41 p.m., RN Z (ADON)) revealed they had received education on alternative non-pharmalogical intervention to use before giving prn medication such as activities and snacks, side effects of [CONDITION(S)] medications, proper documentation of prn administration which should include reason and effectiveness, interventions used and consider mental versus clinical behaviors when there is a change in condition, when and who to notify for change of condition and recognizing EPS side effects such as stooped posture, shuffling feet, and tremors. During an interview on 09/16/22 at 3:07 p.m., LVN C said she took care of Resident #19 after her admission to the facility and since her return from the behavioral hospital. She said Resident #19 had a change of condition related to her shuffled gait and stooped posture. LVN C said she did not report or document the changes because NP X made rounds and should have seen the changes. She said she did not notify a MD either. Record review of a resident roster dated 09/16/22 revealed the DON and ADON assessed all residents for any EPS. Record review of a facility notifying the physician of significant change in status policy dated 03/11/13 revealed .the nurse will notify the physician immediately with significant change in status .the nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .if the resident remains in the facility and a significant change has occurred, update the care plan accordingly . The Administrator was informed the Immediate Jeopardy was removed on 09/16/2022 at 5:00 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. On 09/19/22 at 1:40 p.m., called NP E and left message to return phone at her earliest convenience. NP E did not return phone call prior to exit. On 09/19/22 at 3:49 p.m., called NP X and unable to leave message due to full mailbox. On 09/19/22 at 4:57 p.m., called MD X and left message to return phone when he was available. MD X did not return phone call prior to exit.

Based on observation, interview and record review, the facility failed to ensure that resident prn orders for [CONDITION(S)] drugs are limited to 14 days, and if prescribing practitioner believed it is appropriate for PRN order to be extended beyond 14 days, then document rationale in resident's medical record for 2 of 6 residents review for unnecessary medications (Resident #19 and Resident #77). 1. The facility failed to monitor and recognize serious side effects of a newly prescribed antipsychotic medication for Resident #19 resulting in the resident developing extrapyramidal symptoms (serious side effects that develop after taking antipsychotic medication), decreased activity of daily living capabilities and a decreased quality of life. 2. The facility failed to ensure after Resident #19 returned from a behavioral hospital admission, her diagnoses and behaviors were appropriate for continual use of [MEDICATION(S)] Sprinkles and [MEDICATION(S)]. 3. The facility failed to use and document other interventions used before administering prn [CONDITION(S)] medication per facility's policy for Resident #19 and Resident #77. 4. The facility failed to limit Resident #19 and Resident #77 [CONDITION(S)] prn medications to 14 days and the prescribing practitioner did not provide rationale for extended use. An Immediate Jeopardy (IJ) situation was identified on 09/15/2022 at 7:40 PM. While the IJ was removed on 09/16/2022 at 5:00 PM, the facility remained out of compliance at a scope of isolated with the severity of actual harm, due to the facility's need evaluate the effectiveness of the corrective systems. These failures could place residents at risk for possible [CONDITION(S)] medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: 1. Record review of the face sheet dated 08/30/22 revealed Resident #19 was [AGE] years old, female, and admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, dementia without and with behavioral disturbance, depression, and anxiety. Record review of the admission MDS dated [DATE] revealed Resident #19 was sometimes understood and sometimes understood others. The MDS revealed Resident #19 had a BIMS of 01 which indicated severe cognitive impairment. The MDS revealed Resident # 19 had evidence of inattention and disorganized thinking. The MDS revealed Resident #19 hallucinated, physical, verbal, and other behavioral symptoms directed towards others. The MDS revealed Resident #19 rejected care and wandered. The MDS revealed Resident #19 required limited assistance for dressing, toilet use, personal hygiene, and bathing but independent for transfers, walking, and eating. The MDS revealed Resident #19 had active diagnoses of Alzheimer's, Non-Alzheimer's dementia, anxiety, [CONDITION(S)], and depression. The MDS revealed Resident #19 received antianxiety (reduces anxiety) and antidepressant (used to treat major depressive disorder). Record review of the significant change MDS due to being placed on hospice dated 08/02/22 revealed Resident #19 was sometimes understood and sometimes understood others. The MDS revealed Resident #19 had a BIMS of 01 which indicated severe cognitive impairment. The MDS revealed Resident # 19 had evidence of inattention and disorganized thinking. The MDS revealed Resident #19 hallucinated, physical, verbal, and other behavioral symptoms directed towards others. The MDS revealed Resident #19 rejected care and wandered. The MDS revealed Resident #19 required extensive assistance for dressing, toilet use, personal hygiene, and bathing but independent for transfers, walk in room, and eating. The MDS revealed Resident #19 had active diagnoses of Alzheimer's, Non-Alzheimer's dementia, [CONDITION(S)], mood affective disorder (as mood disorders, are mental disorders that primarily affect a person's emotional state) and depression. The MDS revealed Resident #19 received antipsychotic and antidepressant. The MDS revealed Resident #19 received antipsychotic on a routine basis, gradual dose reduction had not been attempted. Record review of the undated care plan revealed Resident #19 required moderate assistance for ADL care and cues related to diagnosis of Alzheimer's initiated and revised on 06/27/22. The care plan revealed Resident #19 had episodes of physically and verbally abusive to staff and resident at times with difficult redirect, pace the hallways and go in and out of other residents' room at times, refuses care at times, impulsive related to diagnoses of Alzheimer's and dementia initiated on 06/27/22 and revised on 08/03/22. Interventions initiated on 06/27/22, included approach in calm manner, be firm, not forceful, redirect, medication as ordered, and monitor/document behaviors. The care plan revealed Resident #19 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's and dementia, initiated, and revised on 06/27/22. The care plan revealed Resident #19 had potential for side effects related to [CONDITION(S)] medication, initiated on 06/27/22. Interventions initiated on 06/27/22, included give medication as ordered and monitor for effectiveness, notify MD of any note side effects, or change in behavior, and set up psychological evaluation as needed. Record review of the consolidated physician order dated 05/31/22 revealed Resident #19 was ordered on 05/31/22 [MEDICATION(S)] (is used to treat anxiety and panic disorders) tablet 0.25mg, 1 tablet by mouth as needed for anxiety for 14 days three times a day, as needed. Record review of a handwritten medication record dated 05/31/22 revealed Resident #19 was prescribed [MEDICATION(S)] ([MEDICATION(S)]) 0.5mg PO TID PRN x 30 days with a started date of 06/09/22 related to diagnosis of anxiety but no rationale for 30 days. The MAR revealed Resident #19 received 1 dose on 06/12/22, 06/13/22, 06/15/22, 06/16/22, 06/21/22, 06/23/22 and 06/24/22. Resident #19 received 2 doses on 06/14/22, 06/18/22, 06/19/22, 06/20/22, 06/22/22, and 06/23/22. Resident #19 received 3 doses on 06/17/22. Record review of the PRN sheet dated 05/31/22 revealed documentation of reason (anxiety) and effectiveness (effective) for doses given on 06/03/22, 06/14/22, 06/18/22, 06/19/22, 06/20/22, 06/24/22 at 7:00 a.m. completed by LVN C and dose on 06/07/22 at 8:00 a.m. completed by LVN D. Record review of the medication administration record dated 06/01/22-06/30/22 revealed Resident #19 was prescribed [MEDICATION(S)] (is used to treat anxiety and panic disorders) tablet 0.25mg, 1 tablet by mouth as needed for anxiety for 14 days three times a day, as needed with start date of 05/31/22 and discontinued dated of 06/09/22. The MAR revealed Resident #19 received 2 doses during 06/01/22-06/08/22 except received 3 doses on 06/06/22. Record review of the consolidated physician order dated 06/27/22 revealed Resident #19 was ordered [MEDICATION(S)] ([MEDICATION(S)]) 0.5mg PO TID PRN for anxiety for 30 days with start date of 06/09/22. Record review of the behavioral/intervention monthly flow record dated 06/2022 revealed for Resident #19 monitoring for [MEDICATION(S)] with documentation of increased anxiety and heart rate behaviors with intervention of activity, redirect and one on one were on day shift for 06/03/22 by LVN C, 06/04/22 by LVN C, 06/05/22 by LVN C, 06/08/22 by LVN C, and 06/09/22. The behavioral intervention monthly flow record had no other days of documentation for alternative interventions attempted prior to administration of PRN [CONDITION(S)] medication. Record review of the consolidated physician orders dated 07/28/22 revealed Resident #19 had orders for [MEDICATION(S)] Sprinkles Capsule (to treat [CONDITION(S)] disorders, mental/mood conditions (such as manic phase of [CONDITION(S)] disorder), and to prevent migraine headaches) 125 MG (500 MG) by mouth three times a day for mood stabilizer ordered on 07/19/22. The consolidated physician orders revealed Resident #19 had orders for [MEDICATION(S)] (antipsychotic; is a medication that works in the brain to treat [CONDITION(S)]) tablet 1MG 1 tablet by mouth a day and [MEDICATION(S)] 2MG, 1 tablet by mouth at bedtime for aggressive behaviors ordered on 07/19/22. Record review of the MAR dated 07/01-07/31/22 revealed on 07/19/22 Resident #19 was given [MEDICATION(S)] tablet 1MG between 07/22/22-07/31/22, [MEDICATION(S)] 2MG was given 07/19/22-07/31/22 and [MEDICATION(S)] Sprinkles Capsule 125 MG (500 MG) was given between 07/19/22-07/31/22. Record review of the MAR dated 08/01/22-08/31/22 revealed Resident #19 on 08/01/22-08/17/22 was given [MEDICATION(S)] tablet 1MG and [MEDICATION(S)] 2MG on 08/01/22-08/16/22, [MEDICATION(S)] Sprinkles Capsule 500 MG given on 08/01/22 - 08/15/22 and was modified 08/15/22 to twice a day. Record review of the progress note dated 06/23/22 revealed resident being very aggressive with staff and other residents .started pulling on another resident who told her to stop .we attempted to redirect her .pushed nurse head .started yelling Record review of the behavioral hospital paperwork written by NP Y dated 07/01/22 revealed admitted [DATE] .history of Alzheimer's dementia .behavioral disturbance and yelling, hitting, and throwing things at staff members and other residents (reason for admission to behavioral hospital) .nursing home staff states that nothing makes symptoms any better or worse .tangential thoughts and loose speech .requires gerichair off and on due to pacing and difficult to redirect .will charge at staff .ongoing confusion .anxious with cognitive impairments/changes in evolving routine/environment .behaviors .mood instability .emotional instability .within normal limits muscle strength and tone, slow ambulation for gait and station, fair eye contact, restless/fidgety, confused, orientation to person only, and fluent speech . Record review of the behavioral hospital paperwork written by MD Z dated 07/11/22 revealed .pleasant but continuously disoriented and confused .unsteady gait .no aggression noted . Record review of the behavioral hospital discharge paperwork dated 07/19/22 revealed Resident #19 discharge diagnosis of acute Alzheimer's dementia with behavioral disturbance. The discharge medication list revealed [MEDICATION(S)] ([MEDICATION(S)]) 500mg three times a day, [MEDICATION(S)] ([MEDICATION(S)]) 1mg oral daily, and [MEDICATION(S)] 2mg oral once at bedtime with no diagnosis or indication of use noted. The behavioral hospital paperwork revealed Resident #19 had a urinary tract infection upon admission and was treated with antibiotics. Record review of the behavioral/intervention monthly flow record dated 07/22 revealed Resident #19 monitored behavior was hitting and kicking at staff and resident, psychoactive drug/dose: [MEDICATION(S)] 500 mg, Diagnosis: Mood Stabilizer. No behaviors or side effects noted. Record review of the behavioral/intervention monthly flow record dated 07/22 revealed Resident #19 monitored behavior was hitting and kicking at staff and resident, psychoactive drug/dose: [MEDICATION(S)] 1mg and 2mg, Diagnosis: Aggressive behaviors. One evening shift on 07/21/22, LVN AA noted two episodes of behaviors with intervention of redirect, 1 on 1, give food and fluids. Record review of a physician's notes dated 08/16/22 revealed MD W stated .this patient was seen in my office having had a significant change in her condition .she went from an open unit with long hallways to a closed Alzheimer's dementia unit .she did not do well with the transition .she was psychiatrically hospitalized .while hospitalized placed on [MEDICATION(S)] .[MEDICATION(S)] .the family member has become quite concerned since her return back .family member reports the patient is no longer walking .speech is garbled and nonsensical .no eye contact slumped posture noted . shuffling of gait noted .poor balance .cogwheeling of both upper extremities .clonus of the right hand .affect anxious but flattened .no violence towards the examiner .this patient symptoms are consistent with pseudo parkinsonism of [MEDICATION(S)] .this will be discontinued .obtain [MEDICATION(S)] level today .repeat urinalysis for urinary tract infection .if return of aggression, [MEDICATION(S)] 25 milligrams may be used twice daily .continue [MEDICATION(S)] .posture: rigid .eye contact: avoidant .activity: slowed .affect: flat .mood/affect: no significant change .thought process/functioning: notable change .behavior/functioning: notable change .medical condition: notable change .behavioral health diagnosis: neuroleptic induced parkinsonism .follow up in 1 month . During an observation on 08/29/22 at 10:55 a.m., Resident #19 wandered up and down the secured unit hallway. Resident #19 posture was slightly stooped with a shuffling gait. Resident #19 had mumbled speech with occasionally understood words and did not make eye contact. During an observation on 08/30/22 at 8:39 a.m., Resident #19 wandered up and down the secured unit hallway. Resident #19 posture was slightly stooped with a shuffling gait. Resident #19 had mumbled speech with occasionally understood words and did not make eye contact. During a phone interview on 08/30/22 at 9:04 a.m., the family members of Resident #19 said they felt Resident #19 was over medicated. They said before her admission to the facility, she was at an assisted living and only taking an antidepressant and something to help her sleep. They said within days of being admitted , they were getting phone calls of Resident #19 wandering and displaying aggressive behaviors. The family members said they felt the change in facilities and the [MEDICATION(S)] of the secured unit increased Resident #19's behaviors. They said Resident #19 was sent to a local behavioral hospital on 06/24/22, and during admission, lab results showed she had a urinary tract infection. They said UTIs could make any elderly person act out of character. The family members said when Resident #19 returned to the facility from the behavioral hospital, she was unrecognizable. They said she was stooped over when she walked, barely could feed herself, and drowsy. The family members said they had been pushing the facility to wean Resident #19 off some or lower the dosage of some medications. During an observation on 08/30/22 at 1:51 p.m., Resident #19 was asleep in her bed. During an observation on 08/30/22 at 3:07 p.m., Resident #19 was asleep in her bed. During an observation on 08/30/22 at 5:16 p.m., Resident #19 was asleep in her bed. During an interview on 08/31/22 at 3:12 p.m., the DON said she had been in the position for about 3 weeks but was the ADON for 6 years. She said the ADON's monitor medications and appropriate diagnoses from admissions, MDs/NPs should be writing new medications orders with appropriate diagnoses, and the MDS coordinator puts in the diagnosis's codes. She said Resident #19 did return to the facility with [MEDICATION(S)] and [MEDICATION(S)]. She said she did not know why the MDS nurse added mood affective disorder on the MDS diagnoses, but it was not showing on the face sheet. She said Resident #19 posture had significantly improved over the last month. She said she returned from the behavioral hospital with a stooped posture During an interview on 08/31/22 at 4:00 p.m., the MDS nurse said she was responsible for diagnoses from hospital admissions. She said she added the mood affective disorder to the MDS because the [MEDICATION(S)] use on the MAR said mood stabilizer. During an interview on 08/31/22 at 04:36 p.m., the Regional DON and the DON said Resident #19's diagnosis of mood instability description came from the behavioral hospital paperwork. When this surveyor questioned on the clarification needed to place mood disorder or mood stabilizer diagnosis on the medication [MEDICATION(S)] and aggressive behavior for [MEDICATION(S)], they stated the physician, or rather NP E signed off on the medication order summary on 07/19/22 after the resident's hospitalization . They said NP E verified Resident #19 had correct diagnosis for [MEDICATION(S)] and [MEDICATION(S)]. They said the physician/NP would have expected the diagnosis to be from the hospital paperwork, and we did not know we had to let them know mood stabilizer or aggressive behavior was incorrect diagnoses since Resident #19 did not have a history in her medical diagnosis of mood disorder, only Dementia and Alzheimer's. The DON said for [MEDICATION(S)] usage, the facility always used mood instability as the use of or diagnosis reason, and no one had ever said it was wrong. When asked if the pharmacist had ever recommended on the monthly medication reviews about clarifying diagnosis for psychotropics they stated, no. They said they were unaware the facility needed to ask for diagnosis clarification from physicians. On 08/31/22 at 4:58 p.m., called placed to NP E and left voice message. During an interview on 09/02/22 at 9:40 a.m., the pharmacy consultant said any medication was appropriate for use if it controlled the behaviors the resident was exhibiting even if they did not have the correct diagnosis. The PC said she did not know Resident #19 had a [CONDITION(S)] when she went to the behavioral hospital which could have caused some of the extreme behaviors. She said she only went by the hospital paperwork which showed the extreme behaviors which a mood stabilizer would be appropriate to treat. She said she did not know Resident #19 came back from the facility with [CONDITION(S)] med side effects like stooped walking and drowsiness, which could have indicated she did not have the right diagnosis to be prescribed [MEDICATION(S)] and [MEDICATION(S)]. She said she did not know why the MDS nurse changed her diagnosis to mood affective disorder since she was on a mood stabilizer because normally indication of use was what they normally used. She said she could see why it would have been important for Resident #19 to have been seen by her primary doctor or psychiatrist to diagnosis her with an appropriate diagnosis before continuing [MEDICATION(S)] and [MEDICATION(S)] after returning from the behavioral hospital. Record review of a physician order dated 09/4/22 written by LVN T revealed Resident #19 had a fall involving the head and body. Record review of a hospice order dated 09/7/22 revealed Resident #19 experienced over sedation and increased fall risk with new orders to discontinue [MEDICATION(S)] 125 mg 4 tabs BID to 125 mg 2 tabs BID. During an observation on 09/15/22 at 6:14 p.m., Resident #19 was wandering the secured unit with one house slipper on her foot. Resident #19 had bruises noted to her face. Resident #19 responded to the Administrator when she addressed her but did not make eye contact with a flat affect. Resident #19 had improved but rigid posture and shuffled gait. During an interview on 09/15/22 at 6:40 p.m., MD W said he has been providing medical management since 05/05/ 2020 to Resident #19 and was currently overseeing her care at the facility. He said the facility, nor the behavioral hospital notified him of Resident #19 admission in June and he should have been notified of her admission and discharge. He said learned of the psychiatric hospitalization from a family member after Resident #19 returned and the family member wanted to make an appointment. MD W said he did not know Resident #19 had urinary tract infection during her admission to the behavioral hospital. He said he expected the facility to inform him of important issues such as extrapyramidal symptoms (an inability to sit still, involuntary muscle contraction, tremors, stiff muscles, and involuntary facial movements; the symptoms of EPS are debilitating, interfering with social functioning and communication, motor tasks, and activities of daily living. This is often associated with poor quality of life and abandonment of therapy), falls, and behaviors since he does not round at the facility. He was never notified of signs or symptoms of EPS. He said Resident #19 had severe EPS when he assessed her on 08/16/22 and 09/14/22 she still had them but not as frequently. He said he discontinued [MEDICATION(S)] on 08/16/22 due to Resident #19's EPS and scheduled a follow up visit on 09/14/22 to ensure the facility followed his orders. 2. Record review of the face sheet dated 08/30/22 revealed Resident #77 was [AGE] years old, female, and admitted on [DATE] with readmitted [DATE] with diagnoses including dementia with behavioral disturbance, [CONDITION(S)] disorder, anxiety, major depressive disorder, and [CONDITION(S)]. Record review of the MDS dated [DATE] revealed Resident #77 was understood and usually understood others. The MDS revealed Resident #77 had a BIMS on 03 which indicated severe cognitive impairment and required extensive assistance for transfer, dressing, toilet use, personal hygiene, and bathing but independent for eating. The MDS revealed Resident #77 received antianxiety and antidepressant. The MDS revealed no issues were found during drug regimen review. Record review of the undated care plan revealed Resident #77 had history of anxiety/agitation/irritability which required monitoring per staff initiated on 04/27/22. Interventions included administer meds as ordered, check resident frequently to assess needs, monitor behaviors and medication for effectiveness, redirect, reorient, and reassure as needed. Record review of the consolidated physician order dated 07/28/22 revealed Resident #77 was ordered on 06/20/22 [MEDICATION(S)] tablet 1MG, 1 tablet by mouth as needed for anxiety for 60 days BID PRN. Record review of the MAR dated 06/01/22-06/30/22 revealed Resident #77 was prescribed [MEDICATION(S)] tablet 1MG, 1 tablet by mouth as needed for anxiety for 60 days BID PRN with started dated of 04/14/22. Resident #77 received doses on 06/01/22 given by LVN D, 06/03/22 (2 doses), 06/06/22, 06/07/22, 06/11/22 given by LVN D and 06/12/22. Record review of an undated handwritten medication record revealed on 06/20/22, Resident #77 was prescribed [MEDICATION(S)] 1mg PO BID PRN x 60 days for diagnosis of anxiety. Resident #77 received doses on 06/20/22 given by LVN C, 06/21/22 given by LVN D, 06/23/22 given by LVN D, 06/24/22 given by LVN C, 06/25/22, 06/26/22 (2 doses), 06/28/22 (2 doses), and 06/29/22. Record review of the PRN sheet dated 05/30/22 revealed documentation of reason and effectiveness for dose given on 06/03/22 (crying/anxiety; effective) by LVN C, 06/06/22 (verbal/agitation; effective), 06/19/22 (anxiety; effective) by LVN C, 06/22/22 (anxiety; effective) by LVN D, 06/24/22 (anxiety; effective) by LVN C. Record review of the behavioral/intervention monthly flow record dated 06/2022 revealed Resident #77 had monitoring for [MEDICATION(S)] 1MG/Diagnosis of anxiety. The flow record had no documentation of striking out, hitting staff and other resident behaviors to monitor. The behavioral intervention monthly flow had no documentation of alternative interventions attempted prior to administration of PRN [CONDITION(S)] medication. During an interview on 08/31/22 at 2:43 p.m., LVN C said she worked the secured unit once-twice a week. She said she knew Resident #19 and Resident #77. She said she could not remember prn medication administration for June 2022. She said to give prn [CONDITION(S)] medications, the facility required nurses to document behaviors, interventions such as redirect, snacks, activities, taking them outside, and effectiveness. She said NPs and physicians ordered prn medications 14-60 days. During an interview on 08/31/22 at 3:12 p.m., the DON said she had been in the position for about 3 weeks but was the ADON for 6 years. She said the pharmacy consultant recently told the facility PRN [CONDITION(S)] medication could be longer than 14 days. She said she did not know where the PC received her information from. She said she did not know the prescribing practitioner had to provide a rationale for prn medication longer than 14 days. She said prn medication should be given after all other interventions were attempted. She said the behaviors and interventions and the effectiveness of the interventions needed to be charted. She said it was important to have documentation to provide to physicians and NPs for continuation, modification, or discontinuation of medications. She said LVN D was no longer employed by the facility to ask about prn administration. During an interview on 08/31/22 at 04:36 p.m., the Regional DON and the DON said they did not know to ask for a reasoning on PRN psychotropics that were longer than 14 days. They said the pharmacist had not found issues on the monthly medication reviews with prn [CONDITION(S)] being more than 14 days. On 08/31/22 at 4:58 p.m., a call was placed to NP E to ask about Resident #19 and Resident #77's prn orders but was unable to reach her and left voice message. During an interview on 08/31/22 at 5:00 p.m., the Administrator said she did not know the physician had to provide documentation or rationale for prn [CONDITION(S)] use greater than 14 days. She said the facility would have to come up with a system to figure out the best way to accomplish this. She said the residents on the secured unit normally needed their prn for more than 14 days. During an interview on 09/02/22 at 9:40 a.m., the pharmacy consultant said her understanding of prn usage was it could be longer than 14 days if there was an indication of use. She said she did not know there had to be a documented rationale for longer usage. She said she understood if a resident did not have a standing order for [MEDICATION(S)] or [MEDICATION(S)], then having it prn x 14 days was important to monitor in case the resident needed it scheduled or other medications adjusted. The ADM and ADON were notified on 09/15/22 at 7:40 p.m., an Immediate Jeopardy situation was identified due to the above failures. The administrator was provided with the IJ template on 9/15/2022 at 8:09 p.m. The following plan of removal was submitted by the facility and was accepted on 9/16/2022 at 12:00 p.m.: 1. All nursing staff have been in serviced on 09/16/22 by DON the following: - Interventions documentation on behavioral monitoring record - Identify Extrapyramidal symptoms - Notifying Physicians when a resident has a significant change - Use of medication/documented justification from MD or NP for 14 days PRN [CONDITION(S)] meds - Assessing behaviors clinically (ie. [CONDITION(S)], oxygen levels, sugar level, and type of possible infections) 2. All new nurses will be in serviced in orientation regarding facility policy and practice regarding [CONDITION(S)] medications. 3. All residents were screened on 09/16/22 by DON and ADON for any EPS. 4. All admissions and readmissions will be reviewed for accurate DX relevant to [CONDITION(S)] medications by DON. 5. A Physician has been contacted to review [CONDITION(S)] PRN medications on residents on resident #19 and #77 immediately. 6. The DON and designee will follow up and continuously monitor to ensure compliance. Monitoring of the POR included: Record review of the in-service on 09/16/2022 at 2:30 p.m., provided to all nurses addressed intervention documentation on behavioral monitoring record, identifying extrapyramidal symptoms, use of medication/justification for 14-day [CONDITION(S)] meds, and behaviors clinical versus mental. Content of summary of training session: 1. Documentation is required on each shift for any/all non-pharma logical interventions prior to administering PRN medication or any medication listed for [CONDITION(S)] use on the behavioral monitoring record for each medication on each resident. 2. see attached EPS signs and symptoms. 3. All PRN [CONDITION(S)] medications will only be ordered on a 14 day use and documentation should be provided by MD or NP prior to 14 days use of medication. 4. Behavior management must be approached from a clinical viewpoint prior to administering PRN [CONDITION(S)]. Record review of the educational handout on 09/16/22 at 2:30 p.m., provided to all nurses addressed, How do I recognize extrapyramidal symptoms? Record review of the example of a behavioral monitoring flowsheet on 09/16/22 at 2:30 p.m., provided to all nurses addressed how to properly fill out and document on the flowsheet for [CONDITION(S)] medications. Record review of the post test on 09/16/22 at 2:30 p.m., revealed: 1. The licensed nursing staff should not first give a prn [CONDITION(S)] medication when a resident became increasingly agitated. 2. Signs and symptoms of extrapyramidal effects included shuffled/unsteady gait, stooped over poor posture, and tremors. 3. An inability to sit still, involuntary muscle contraction, tremors, stiff muscles, and involuntary facial movement were symptoms of extrapyramidal effects. 4. After giving a PRN medication the nurse should reassess and document its effectiveness. 5. After a resident received a PRN medication, the nurse should document on the behavioral monitoring sheet and prn sheet. 6. Offering snacks and activities or walk away and provide safe space if necessary were good options of redirection for residents prior to admin prn [CONDITION(S)] medications. Interviews conducted on 09/16/22 at (2:39 p.m., LVN M) (2:56 p.m., RN N) (3:07 p.m., LVN C) (3:24 p.m., LVN O) (3:36 p.m., LVN P) (3:48 p.m., LVN S) (3:53 p.m., LVN T) (3:55 p.m., LVN U) (4:20 p.m., LVN V) (4:33 p.m., DON) (4:41 p.m., RN Z) revealed they had received education on alternative non-pharmalogical intervention to use before giving prn medication such as activities and snacks, side effects of [CONDITION(S)] medications, proper documentation of prn administration which should include reason and effectiveness, interventions used and consider mental versus clinical behaviors when there is a change in condition, and recognizing EPS side effects such as stooped posture, shuffling feet, and tremors. RN N said he worked on the secured unit a handful of times but did know Resident #19's stooped posture had recently improved since her return from the behavioral hospital. During an interview on 09/16/22 at 3:07 p.m., LVN C said she took care of Resident #19 after her admission to the facility and since her return from the behavioral hospital. She said Resident #19 had a change of condition related to her shuffled gait and stooped posture. LVN C said she did not report or document the changes because NP X made rounds and should have seen the changes. She said she did not notify a MD either. Record review of a resident roster dated 09/16/22 revealed the DON and ADON assessed all residents for any EPS. Record review of an undated and unlabeled facility policy revealed .resident must be assessed to ensure that the behavior, agitation, etc. is not due to pain, needing to toilet, or other unmet need .always treat any agitation, aggressive behaviors, etc. as pain first .do the PAINAD and administer PRN pain meds BEFORE administering [MEDICATION(S)], or other psychoactive drug .document all efforts in the nurse's notes AND on the behavior monitoring sheets .document the prn medication on the PRN flow sheet and document whether or not the interventions are/were effective .document that you tried non-medication interventions prior to administering a prn anti-anxiety drugs .no order for prn anti-anxiety medications can be more than 14 days . The Administrator was informed the Immediate Jeopardy was removed on 09/16/2022 at 5:00 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. On 09/19/22 at 1:40 p.m., called NP E and left message to return phone at her earliest convenience. NP E did not return phone call prior to exit. On 09/19/22 at 3:49 p.m., called NP X and unable to leave message due to full mailbox. On 09/19/22 at 4:57 p.m., called MD X and left message to return phone when he was available. MD X did not return phone call prior to exit.

Based on observation, interview and record review the facility failed to ensure residents were free from abuse for 1 or 7 residents reviewed for abuse. (Resident #1) RN A physically assaulted Resident #1 during incontinent care. Resulting in Resident #1 sustaining skin tears to both arms requiring medical attention. Resident #1 was fearful of additional harm after the altercation. This was determined to be past non-compliance with actual harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk for abuse. Findings included: A face sheet dated 03/25/21 and consolidated physician orders [REDACTED].#1 was an [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. MDS dated [DATE] indicated Resident #1 had moderately impaired cognition, was short tempered, easily annoyed more than half the time and rejected care daily. Physical behavioral symptoms included sexually inappropriate behavior toward others, hitting, kicking, pushing, scratching and grabbing. Total assistance was required in dressing, toileting and personal hygiene. A care plan dated 02/22/21, indicated Resident #1 had cognitive issues related to [MEDICAL CONDITION]. Staff were to allow him to assist with ADL's as much as possible and make independent decisions as able. He had a history of [REDACTED]. Staff were to give him time to respond when providing care due to [DIAGNOSES REDACTED]. A skin assessment dated [DATE] for Resident #1 completed by RN B showed multiple skin tears to the right outer forearm, multiple skin tears to the left inner forearm and discoloration and redness to the inside of the upper left arm at the bottom of the bicep. During an observation and interview on 04/05/21 at 1:00 p.m. Resident #1 was lying on his bed. There was a cloth sleeve on Resident #1's right arm that extended from his wrist to his upper arm. RN C pulled the sleeve down to show a gaze bandage dated 04/04/21 on the right outer forearm. The bandage was removed by RN C, to show three dime-sized scabbed-over wounds to the right outer forearm. There was no sleeve or bandage on Resident #1's left arm. There were two larger scabbed-over wounds to the left inner forearm. RN C said the wounds were from the incident with RN A and had scabbed-over and were healing. There was no redness or swelling observed. A Provider Investigation Report dated 03/28/21 showed the administrator reported RN A was suspended pending the results of alleged abuse of Resident #1. RN A was terminated due to failing to follow facility policy and procedures in dealing with agitated residents. During a telephone interview on 04/01/21 at 12:28 p.m. RN A said she was the charge nurse for the secure unit on 03/28/21 from 6 a.m. to 2 p.m. RN A said she around 1:30 p.m. she was assisting CNA A to change Resident #1. RN A said when they turned Resident #1 over on his side to clean him, Resident # grabbed her crotch and would not let go. RN A said she grabbed his arms and had to force him to release her. RN A said after she was able to make Resident #1 let go, he continued to hit at her with both arms. She said she noticed blood dripping on the bed and floor. RN A said the blood was coming from Resident #1's arms. RN A said she was not sure if her fingernails caused the skin tears to Resident #1's arms, because it all happened so fast and she was in pain and wanted him to let go of her. RN A said she felt bad for what happened, but she had to make Resident #1 to let go of her crotch. RN A said she wiped some blood with a sheet. RN A said CNA A went to get the RN Supervisor and she went to the nurses' station to call the administrator. RN A said it was the end of her shift, she completed an incident report, was in-serviced on dealing with agitated residents and abuse and was told she was suspending pending an investigation into the incident. RN A said she was informed by the administrator she was being terminated due to failing to follow facility policy. RN A said she was aware of the policy on dealing with agitated residents and had been trained on abuse prohibition. During an interview on 04/05/21 at 11:10 a.m. CNA A said she was working in the secure unit on 03/28/21 on the 6:00 a.m. to 2:00 p.m. shift. CNA A said around 1:30 p.m. RN A was assisting her to change Resident #1. CNA said RN A was being rough with Resident #1 and it was causing him to become agitated. CNA A said Resident #1 normally holds to the side of the bed to feel secure. RN A became agitated at Resident #1 and the two of them were swinging their arms at each other. CNA A said she yelled out to RN A by name to Stop!. CNA A said RN A and Resident #1 kept swinging at each other. CNA said rather than letting Resident #1 grab the side of the bed, RN A was trying to hold his arms down and would not allow him to grab the side of the bed. CNA said she observed blood dripping from Resident #1's arms on to the sheet and on the floor. CNA A said she again called RN A by name and to Stop!. She said she went to get the RN Supervisor and RN A followed her out the door. CNA A said she found RN supervisor and told him to come check on Resident #1 because there was blood everywhere. CNA A said RN Supervisor assess Resident #1 and treated his wounds. CNA A said she assisted RN Supervisor to conduct a body assessment of Resident #1. CNA A said she saw scratches on both arms that appeared to be caused by fingernails. CNA said Resident #1 was visibly upset and kept repeating Please don't hurt me, please don't. CNA A said RN A retuned to the room while RN supervisor was treating the skin tears and said, He was grabbing my crotch and I had to do what I had to do to get him to stop. CNA A said she never saw Resident #1 grab RN A's crotch. CNA said she saw both RN A and Resident #1 swinging at each other. CNA A said she did not see RN A punch Resident #1, but she saw RN A swinging and grabbing at Resident #1's arms. CNA A said she tried to get RN A to stop, but RN A just continued to swing and grab Resident #1's arms. CNA A said she felt the actions of RN A were abusive. CNA A said the whole incident could have been avoided if RN A would have just stopped and given Resident #1 some time to calm down. During an interview on 04/01/21 at 12:45 p.m. the RN B said he was working as the RN supervisor on 03/28/21 during 6:00 a.m. to 2:00 p.m. shift. RN B said just before the end of the shift, CNA A told him Resident #1 had a skin tear on his arms and needed attention. RN B said Resident #1 had skin tears on both arms and they were consistent with the size of fingernails. RN B said RN A was distraught and told him Resident #1 had grabbed her crotch and the skin tears happened when RN A grabbed Resident #1's arms to get him to let go. RN B said RN A should have stopped care when Resident #1 became agitated and gave him time to clam down. RN B said Resident #1 was visibly upset after the incident and kept repeating, Please don't hurt me. RN B said RN A was suspended on 03/28/21 pending investigation and terminated the next day. RN B said RN A should not have provoked Resident #1 nor fought with him. RN B said all staff have be trained if a resident is resistant to care to stop and give the resident time to calm down and try again later. Facility abuse policy dated 04/05/16 The Villa at Texarkana, Abuse and Neglect prohibition program, Definitions: .Abuse: The commission of any act which causes harm or significant distress to a resident. Physical Abuse includes the hitting or hurting by physical means of any resident . Each resident has the right to be free from abuse, corporal punishment or involuntary seclusion. Residents will not be subject to abuse by anyone, including, but not limited to, facility staff . An undated Facility policy provided by the administrator on 04/01/21 Pain, Self-Determination and Refusing Care .Nurses and Nurse Aides: Anytime a resident is combative (biting, hitting), cursing or displaying any other signs or symptoms which could be related to pain or discomfort, the CNA or nurse MUST stop what he or she is doing immediately, (for example, stop doing peri care, repositioning, treating a wound, etc.) ensure the resident is safe and covered appropriately, and go for assistance from the charge nurse or DON. The surveyor determined the facility was in non-compliance on 03/28/21 through 04/01/21 and took the following actions to correct the non-compliance: During an interview on 04/05/21 at 2:30 p.m. the administrator said she was the abuse prohibition coordinator and a plan of correction to ensure all resident were safe from abuse and neglect was initiated on 03/28/21. Administrator said Inservice training started immediately on caring for agitated residents, resident rights and abuse prohibition. Administrator said RN A was immediately suspended on 03/28/21 and left the facility after completing an incident report and giving a statement concerning the incident. Administrator said RN A was terminated on 03/29/21 due to failure to follow facility policy and procedures. Administrator said resident safety rounds were conducted and all residents reported feeling safe. Administrator said the incident was reported to the state within two hours and the final report was submitted on 04/01/21. Administrator said the incident was discussed in weekly QA meeting on 04/02/21. Administrator said the next QAPI (Quality Assurance and Performance Improvement) meeting for is scheduled for 04/16/21 and resident satisfaction will continue to be monitored by the abuse prohibition coordinator, department heads and the QAPI team. During an interview on 04/05/21 at 2:30 p.m. Regional nurse said the QAPI meets monthly. Regional nurse said the QAPI is scheduled to meet on April 16, 2021 and the incident will be discussed at the next scheduled meeting. Regional nurse said any new staff or staff working PRN (as needed) will receive training before allowed to work the floor. Employee training records showed RN A received in-service training rights and Resident Abuse on multiple occasions prior to the incident on 03/28/21. Records showed RN A received training on Resident Rights and Resident Abuse on 03/28/21 after the incident. The training was conducted by the abuse prohibition coordinator. Employee training records showed all staff had completed training on Resident Rights, Dealing with Agitated Residents and Resident Abuse by 03/30/21. QA meeting notes dated 04/02/21 showed the reportable incident involving RN A and Resident #1 was discussed at the weekly quality assurance committee meeting which included all department heads. The QA committee will continue to monitor. During interviews with RN C, CNA A, MA A and RA A on 04/05/21 at 1:00 p.m., 11:10 p.m., 3:35 p.m. and 3:45 p.m. said they received in-service training on 03/28/21 and 03/29/21 on dealing with agitated residents, abuse and neglect prohibition and resident rights. They were able to identify and describe the types of abuse and what to do when a resident becomes combative or resistant to care.

Based on observation, interview and record review the facility failed to follow written policy to ensure residents were free from abuse for 1 or 7 residents reviewed for abuse. (Resident #1) RN A physically assaulted Resident #1 during incontinent care. Resulting in Resident #1 sustaining skin tears to both arms requiring medical attention. Resident #1 was fearful of additional harm after the altercation. This was determined to be past non-compliance with actual harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk for abuse. Findings included: Facility abuse policy dated 04/05/16 The Villa at Texarkana, Abuse and Neglect prohibition program, Definitions: .Abuse: The commission of any act which causes harm or significant distress to a resident. Physical Abuse includes the hitting or hurting by physical means of any resident . Each resident has the right to be free from abuse, corporal punishment or involuntary seclusion. Residents will not be subject to abuse by anyone, including, but not limited to, facility staff . An undated Facility policy provided by the administrator on 04/01/21 Pain, Self-Determination and Refusing Care .Nurses and Nurse Aides: Anytime a resident is combative (biting, hitting), cursing or displaying any other signs or symptoms which could be related to pain or discomfort, the CNA or nurse MUST stop what he or she is doing immediately, (for example, stop doing peri care, repositioning, treating a wound, etc.) ensure the resident is safe and covered appropriately, and go for assistance from the charge nurse or DON. A face sheet dated 03/25/21 and consolidated physician orders [REDACTED].#1 was an [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. MDS dated [DATE] indicated Resident #1 had moderately impaired cognition, was short tempered, easily annoyed more than half the time and rejected care daily. Physical behavioral symptoms included sexually inappropriate behavior toward others, hitting, kicking, pushing, scratching and grabbing. Total assistance was required in dressing, toileting and personal hygiene. A care plan dated 02/22/21, indicated Resident #1 had cognitive issues related to [MEDICAL CONDITION]. Staff were to allow him to assist with ADL's as much as possible and make independent decisions as able. He had a history of [REDACTED]. Staff were to give him time to respond when providing care due to [DIAGNOSES REDACTED]. A skin assessment dated [DATE] for Resident #1 showed multiple skin tears to the right outer forearm, multiple skin tears to the left inner forearm and discoloration and redness to the inside of the upper left arm at the bottom of the bicep. During an observation and interview on 04/05/21 at 1:00 p.m. Resident #1 was lying on his bed. There was a cloth sleeve on Resident #1's right arm that extended from his wrist to his upper arm. RN C pulled the sleeve down to show a gaze bandage dated 04/04/21 on the right outer forearm. The bandage was removed by RN C, to show three dime-sized scabbed-over wounds to the right outer forearm. There was no sleeve or bandage on Resident #1's left arm. There were two larger scabbed-over wounds to the left inner forearm. RN C said the wounds were from the incident with RN A and had scabbed-over and were healing. There was no redness or swelling observed. A Provider Investigation Report dated 03/28/21 showed the administrator reported RN A was suspended pending the results of alleged abuse of Resident #1. RN A was terminated on 03/29/21 due to failing to follow facility policy and procedures in dealing with agitated residents. During a telephone interview on 04/01/21 at 12:28 p.m. RN A said she was the charge nurse for the secure unit on 03/28/21 from 6 a.m. to 2 p.m. RN A said she around 1:30 p.m. she was assisting CNA A to change Resident #1. RN A said when they turned Resident #1 over on his side to clean him, Resident # grabbed her crotch and would not let go. RN A said she grabbed his arms and had to force him to release her. RN A said after she was able to make Resident #1 let go, he continued to hit at her with both arms. She said she noticed blood dripping on the bed and floor. RN A said the blood was coming from Resident #1's arms. RN A said she was not sure if her fingernails caused the skin tears to Resident #1's arms, because it all happened so fast and she was in pain and wanted him to let go of her. RN A said she felt bad for what happened, but she had to make Resident #1 to let go of her crotch. RN A said she wiped some blood with a sheet. RN A said CNA A went to get the RN Supervisor and she went to the nurses' station to call the administrator. RN A said it was the end of her shift, she completed an incident report, was in-serviced on dealing with agitated residents and abuse and was told she was suspending pending an investigation into the incident. RN A said she was informed by the administrator she was being terminated due to failing to follow facility policy. RN A said she was aware of the policy on dealing with agitated residents and had been trained on abuse prohibition. During an interview on 04/05/21 at 11:10 a.m. CNA A said she was working in the secure unit on 03/28/21 on the 6:00 a.m. to 2:00 p.m. shift. CNA A said around 1:30 p.m. RN A was assisting her to change Resident #1. CNA said RN A was being rough with Resident #1 and it was causing him to become agitated. CNA A said Resident #1 normally holds to the side of the bed to feel secure. RN A became agitated at Resident #1 and the two of them were swinging their arms at each other. CNA A said she yelled out to RN A by name to Stop!. CNA A said RA A and Resident #1 kept swinging at each other. CNA said rather than letting Resident #1 grab the side of the bed, RN A was trying to hold his arms down and would not allow him to grab the side of the bed. CNA said she observed blood dripping from Resident #1's arms on to the sheet and on the floor. CNA A said she again called RN A by name and to Stop!. She said she went to get the RN Supervisor and RN A followed her out the door. CNA A said she found RN supervisor and told him to come check on Resident #1 because there was blood everywhere. CNA A said RN Supervisor assess Resident #1 and treated his wounds. CNA A said she assisted RN Supervisor to conduct a body assessment of Resident #1. CNA A said she saw scratches on both arms that appeared to be caused by fingernails. CNA said Resident #1 was visibly upset and kept repeating Please don't hurt me, please don't. CNA A said RN A retuned to the room while RN supervisor was treating the skin tears and said, He was grabbing my crotch and I had to do what I had to do to get him to stop. CNA A said she never saw Resident #1 grab RN A's crotch. CNA said she saw both RN A and Resident #1 swinging at each other. CNA A said she did not see RN A punch Resident #1, but she saw RN A swinging and grabbing at Resident #1's arms. CNA A said she tried to get RN A to stop, but RN A just continued to swing and grab Resident #1's arms. CNA A said she felt the actions of RN A were abusive. CNA A said the whole incident could have been avoided if RN A would have just stopped and given Resident #1 some time to calm down. During an interview on 04/01/21 at 12:45 p.m. the RN B said he was working as the RN supervisor on 03/28/21 during 6:00 a.m. to 2:00 p.m. shift. RN B said just before the end of the shift, CNA A told him Resident #1 had a skin tear on his arms and needed attention. RN B said Resident #1 had skin tears on both arms and they were consistent with the size of fingernails. RN B said RN A was distraught and told him Resident #1 had grabbed her crotch and the skin tears happened when RN A grabbed Resident #1's arms to get him to let go. RN B said RN A should have stopped care when Resident #1 became agitated and gave him time to calm down. RN B said Resident #1 was visibly upset after the incident and kept repeating, Please don't hurt me. RN B said RN A was suspended on 03/28/21 pending investigation and terminated the next day. RN B said RN A should not have provoked Resident #1 nor fought with him. RN B said all staff have be trained if a resident is resistant to care to stop and give the resident time to calm down and try again later. The surveyor determined the facility was in non-compliance on 03/28/21 through 04/01/21 and took the following actions to correct the non-compliance: During an interview on 04/05/21 at 2:30 p.m. the administrator said she was the abuse prohibition coordinator and a plan of correction to ensure all resident were safe from abuse and neglect was initiated on 03/28/21. Administrator said Inservice training started immediately on caring for agitated residents, resident rights and abuse prohibition. Administrator said RN A was immediately suspended on 03/28/21 and left the facility after completing an incident report and giving a statement concerning the incident. Administrator said RN A was terminated on 03/29/21 due to failure to follow facility policy and procedures. Administrator said resident safety rounds were conducted and all residents reported feeling safe. Administrator said the incident was reported to the state within two hours and the final report was submitted on 04/01/21. Administrator said the incident was discussed in weekly QA meeting on 04/02/21. Administrator said the next QAPI (Quality Assurance and Performance Improvement) meeting for is scheduled for 04/16/21 and resident satisfaction will continue to be monitored by the abuse prohibition coordinator, department heads and the QAPI team. During an interview on 04/05/21 at 2:30 p.m. Regional nurse said the QAPI meets monthly. Regional nurse said the QAPI is scheduled to meet on April 16, 2021 and the incident will be discussed at the next scheduled meeting. Regional nurse said any new staff or staff working PRN (as needed) will receive training before allowed to work the floor. Employee training records showed RN A received in-service training rights and Resident Abuse on multiple occasions prior to the incident on 03/28/21. Records showed RN A received training on Resident Rights and Resident Abuse on 03/28/21 after the incident. The training was conducted by the abuse prohibition coordinator. Employee training records showed all staff had completed training on Resident Rights, Dealing with Agitated Residents and Resident Abuse by 03/30/21. QA meeting notes dated 04/02/21 showed the reportable incident involving RN A and Resident #1 was discussed at the weekly quality assurance committee meeting which included all department heads. The QA committee will continue to monitor. During interviews with RN C, CNA A, MA A and RA A on 04/05/21 at 1:00 p.m., 11:10 p.m., 3:35 p.m. and 3:45 p.m. said they received in-service training on 03/28/21 and 03/29/21 on dealing with agitated residents, abuse and neglect prohibition and resident rights. They were able to identify and describe the types of abuse and what to do when a resident becomes combative or resistant to care.

Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistance was provided to prevent accidents for 1 of 3 residents reviewed for accidents. (Resident #1) The facility did not supervise Resident #1 at mealtime and she suffered a burn to her left thigh from hot soup. This was determined to be past non-compliance due to the facility having implemented actions to correct the non-compliance prior to the beginning of the survey. This failure could place residents who require assistance with meals at risk for injuries. Findings included: Consolidated physician orders [REDACTED].#1 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #1 sometimes understood others and was sometimes understood and required limited assistance of one staff with eating. The MDS indicated Resident #1 had an active [DIAGNOSES REDACTED]. A care plan revised on 1/14/19 indicated Resident #1 required assistance with ADLs. The care plan indicated staff were to set up meals and cue the resident verbally and physically as needed to complete the meal. The care plan indicated Resident #1 had impaired cognition, was impulsive, and staff would monitor environmental factors and monitor her safety. An incident report dated 8/11/19 indicated Resident #1 spilled hot soup on her upper left thigh during meal time. The report indicated she sustained a burn and received first aid in the facility. The report indicated confusion and disorientation were noted as contributing factors. A nursing note dated 8/11/19 indicated Resident #1 spilled hot soup in her lap causing a 9 cm by 6.5 cm dark pink area. The note indicated notifications were made to physician, administration, and the responsible party. Physician orders [REDACTED]. An acute care plan for skin dated 8/11/19 indicated Resident #1 had a blister related to a burn from hot liquids. An acute care plan for hot liquids/burns dated 8/12/19 indicated Resident #1 was at risk [MEDICAL CONDITION] staff would encourage Resident #1 to eat in the dining room. The care plan indicated staff would not leave the meal tray in the room unattended. Physician orders [REDACTED]. Physician orders [REDACTED]. Apply [MEDICATION NAME] and cover with dressing daily and as needed until resolved. A skin assessment dated [DATE] indicated Resident #1 had a 9 cm x 8 cm wound to the left thigh. During an interview on 8/20/19 at 2:05 p.m., CNA D said she delivered Resident #1's meal tray on 8/11/19. She said she could not find the over the bed table, so she placed Resident #1's tray on the nightstand beside the bed. CNA D said she did not think Resident #1 could reach the tray. CNA D said she left the room and went to the dining room to tell CNA C about the over the bed table. CNA D said Resident #1 was sitting upright in bed and was awake when she left the room. CNA D said Resident #1 was confused but had good and bad days. CNA D said Resident #1 received assistance with her meals whether she was in bed or in the dining room. During an interview on 8/20/19 at 1:09 p.m., CNA C said she was working the hall with CNA D when Resident #1 burned herself. CNA C said CNA D delivered Resident #1's meal tray that evening. CNA C said CNA D came to the dining room and told her she could not find Resident #1's over the bed table so she had placed Resident #1's meal tray on the nightstand. CNA C said she went to Resident #1's room and saw Resident #1 leaned over the bed, pulling the tray toward her. She said the hot soup spilled on Resident #1's left upper leg. She said the resident had a reddened area on her leg from the burn. CNA C said she reported the burn to the nurse and the ADON. CNA C said Resident #1 could feed herself, but she needed assistance. She said Resident #1 was confused and would push away from the table and wander away before she had eaten. CNA C said Resident #1 needed redirection frequently and normally ate in the dining room at the assisted table. She said Resident #1 was emotional that evening, so they left her in the bed for her meal. During an interview on 8/20/19 at 12:36 p.m. CNA A said Resident #1 was confused and could not complete her ADLs without assistance. CNA A said Resident #1 required assistance with feeding. She said Resident #1 could feed herself, but she did not have the best controlled movement. CNA A said Resident #1 normally went to the dining room for meals and sat at the assisted table. During an interview on 8/20/19 at 12:57 p.m., LVN B said Resident #1 was alert and oriented to herself only and was dependent on staff for ADLs. LVN B said Resident #1 received assistance with feeding. LVN B said Resident #1 could feed herself but she dropped food. During an interview on 8/20/19 at 1:29 p.m., CNA [NAME] said Resident #1 was alert but confused. He said Resident #1 required assistance during meals and had to be re-directed during meals because she would leave while eating. CNA [NAME] said Resident #1 had to be cued to eat and had to be physically fed as needed. During an interview on 8/20/19 at 2:24 p.m., the DON said she looked at the burn on Resident #1's thigh on Monday (8/12/19). She said it was a blister at that time and measured 9 cm x 7 cm. She said the physician was notified and ordered monitoring at that time until the blister ruptured. The DON said the blister ruptured on Tuesday (8/13/19) and they began treatments. The DON said Resident #1 had a habit of grabbing things and picking at stuff. The DON said Resident #1 required assistance with meals. She said the facility conducted in-services with all departments following the incident. She said the dietary manager would conduct random temperature checks on hot liquids leaving the kitchen and staff were to bring Resident #1 to the dining room for all meals unless she refused. She said staff were in-serviced on food temperatures and serving hot liquids and were instructed not to leave trays unattended in resident rooms. The facility took the following actions to correct the non-compliance: *An in-service dated 8/12/19 for the nursing department indicated Resident #1 was to be in the dining room for all meals unless she refused, and staff were not to leave trays unattended in resident rooms. *An in-service dated 8/12/19 for dietary indicated the dietary supervisor would complete random temperature checks on hot food and liquids leaving the kitchen, kitchen staff were to be cautious with hot liquids, feel the bottom of containers holding hot liquids, and not heat food in the microwave. *An in-service dated 8/13/19 for all departments indicated staff were to be cautious with hot liquids, feel the bottoms of containers holding hot liquids prior to serving, never microwave trays and notify the dietary department if meals were found to be cold. During an interview on 8/20/19 at 12:15 pm CNA G said since Resident #1's burn incident, they had to make sure to take Resident #1 to the dining room for all meals unless she refused to do so. During an interview on 8/20/19 at 1:09 p.m., CNA C said they had to make sure Resident #1 was up for all meals. She had to eat in the dining room unless she refused. CNA C said they could not leave Resident #1's meal tray in her room unattended. During an interview on 8/20/19 at 2:05 p.m., CNA D said Resident #1 normally ate meals in the dining room. She said they had to make sure she went to the dining room unless she refused and wanted to eat in her room. CNA D said they could not leave Resident #1's meal tray in her room. She said they had to be ready to assist her with her meal when they took the tray in the room.

Based on observation, interview, and record review, the administrator and maintenance supervisor failed to effectively utilize resources to develop a plan of evacuation and train staff in emergency evacuation procedures for 1 of 1 resident reviewed for emergency evacuation (Resident #12) and failed to have detailed written plans and procedures to meet all potential emergencies and disasters. 1.The administrator did not develop a plan of evacuation for Resident #12 (a bariatric resident) and the maintenance supervisor did not train staff how to evacuate Resident #12. 2. The administrator did not develop a written policy for evacuation and safety for residents during emergency situations. 3. The maintenance supervisor did not train the staff on emergency evacuation procedures for bariatric residents. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on 5/21/13. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place Resident #12 at risk for serious injury or death in the event of an emergency evacuation and could place some other residents at risk for injuries during an emergency. Findings included: 1. Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #12's cognition was moderately impaired, required extensive assistance with bed mobility, total dependence with activities of daily living (ADLs) and that transfers or locomotion on or off the unit had not occurred during this assessment period. Resident #12's nursing care plan dated 03/13/13 indicated the following: "Problem: The resident is generally bedfast-is not transferred, will sit on side of bed occasionally. Goal: Resident will be safe within environment. Approach: Requires extra large bed due to [MEDICAL CONDITION]. Problem: Resident is extremely obese and requires significant assistance during an evacuation. Goal: Resident would be kept safe as possible during bad weather or fire. Approach: Would require the use of several strong people to aid in resident evacuation due to resident being severely obese weighing over 400 pounds; and in case of tornado the resident would be eased to the floor on a flat sheet with as many to assist as needed to assure her safety and pulled into the hallway away from any glass." During an interview on 5/20/13 at 2:30 p.m. CNA O said she would roll Resident #12 out in her bed. CNA O then looked at the resident's bed and said, "That bed wouldn't fit out that door. I don't know how we would evacuate her." CNA O said she had received no training regarding how to evacuate Resident #12 in an emergency. During an interview on 5/20/13 at 2:45 p.m. CNA P said she had been working at the facility off and on for 7 years. CNA P said there was usually an extra wide wheel chair located on Hall 400 and a hoyer lift kept on either Hall 300 or Hall 400, but the hoyer lift would not hold Resident #12. CNA P said, "I guess we would have to put a blanket under Resident #12 and have enough staff to pull her out." CNA P said she had never received any training on how to evacuate Resident #12. CNA P said she knew about using the blanket from working at other facilities. During an interview on 5/20/13 at 2:55 p.m. CNA Q said she worked at the facility for a little over a year on the hall where Resident #12 resided. CNA Q said she had received no training on evacuating a resident on a bariatric bed at the facility. During an interview on 5/20/13 at 3:00 p.m. RNA R said he had worked at the facility for 3 years and had not received any training on how to get Resident #12 out of the building in case of an emergency. The facility did not have a bariatric lift or a bariatric wheel chair. During an interview on 5/20/13 at 4:05 p.m. the Medical Director said the facility needed a bariatric lift and wheel chair to be able to evacuate Resident #12 in case of fire. During an interview on 5/20/13 at 4:30 p.m. the administrator said the facility did not have a hoyer lift or wheel chair that could accommodate Resident #12's weight. She said in order to evacuate Resident #12, staff would have to do a "dead man's drag" to get her out of the building. It had been several years ago when the facility had the fire department come out and demonstrate how to do the dead man's drag and she was not sure if current staff had been trained on how to do this procedure to evacuate Resident #12. The administrator said it would take 8 to 9 staff to do a dead man drag in order to evacuate Resident #12, as it took 6 pretty good sized men to raise/lower a stretcher with the resident on it. During an interview 5/20/13 at 4:52 p.m. the DON said it would take about 8 staff to assist Resident #12 to evacuate in case of emergency. She denied giving in-services to staff regarding evacuation of Resident #12 and said the maintenance man did fire drills and would be the person that would provide training and in-services regarding evacuation of the facility in an emergency. The DON said in order to evacuate Resident #12 the resident's mattress would be pushed to the door of her room and the sheet would be used to pull the resident the rest of the way out the door. She said the facility had never actually practiced doing this before. Resident #12 would be the last resident evacuated from the building. The DON did not know when the last disaster in-service was done. During an interview on 5/23/13 at 12:37 p.m. the maintenance supervisor said he was responsible for the disaster manual. He said he was unaware of the need to train staff annually on emergency preparedness. He said he had not provided any training regarding the dead man drag in evacuating Resident #12. The disaster plan dated 4/17/13 did not contain any procedures for evacuating residents who required Bariatric equipment. The administrator and DON were notified on 5/20/13 at 5:40 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted on 5/20/13 at 8:50 p.m. and included: "I. A MegaMover to be placed on Resident #12's bed to remain there at all times. The MegaMover has the strength to move an individual that weighs in excess of 700 pounds. II. All staff to be in-serviced on the use of the MegaMover prior to start of their shifts. III. An additional 10 MegaMovers were ordered and kept in Resident #12 ' s closet to change out as they become soiled. IV. Resident to be evacuated through the exit at the end of 200 Hall and how she is to be transported to the evacuation site; and V. Tells how many staff it would take to evacuate Resident #12 with the MegaMover and who is to assist with getting the resident on the facility ' s van. VI. The facility would be contacting the family with a list of facilities that specialized in bariatric patients and would assist them in moving Resident #12 to a facility of their choice. VII. All in-services would be completed by 10:00 a.m. on 5/24/13." The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by interviews with 17 CNAs over all shifts. These staff indicated the facility had provided in-services on how to use the MegaMover in evacuating Resident #12, how many staff it would take to utilize this piece of equipment, who was to assist with the transporting of the resident and where she was to be transferred during evacuation. On 5/21/13 at 11:25 a.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non-Immediate Jeopardy The disaster manual dated 4/17/13 provided by the administrator: -was not updated annually by the emergency preparedness coordinator (EPC); -did not describe the resident population; -did not include how to notify DADS for self-reporting incidents; -did not document the name and contact information for the local emergency management coordinator (EMC), as identified by the office of the local mayor or county judge; -did not include procedures for notifying the local EMC of the execution of the plan; -did not identify the EPC, or the alternate EPC; -did not address how the EPC will be notified of an emergency or who the EPC will notify in an emergency situation, or when the notifications will occur; -did not identify the primary mode of communication or the alternate mode of communication; -did not include procedures for maintaining a current list of telephone numbers for residents responsible parties, or pre-arranged receiving facilities, or facility staff telephone numbers; -did not include arrangement for a sufficient number of vehicles to safely evacuate all residents; -did not identify the types of services used by residents; -did not have maps that showed the destinations and routes; -did not include a 24 hour phone number for the shelter contract for the local church; -did not include a facility to evacuate to in another town; -did not inform staff where to meet outside the building during an evacuation; -did not include a section for each core function of emergency management based on a facility ' s decision to either shelter in place or evacuate during an emergency; and -did not include arrangements for the families of staff. -did not include a plan that coordinated a staffing response to an emergency situation; -did not include procedures to maintain communication with facility staff involved in an emergency situation; -did not include procedures to maintain communication with the driver of a vehicle transporting residents, medication, records, food, water, equipment, or supplies during an evacuation; -did not include procedures to ensure and account for residents and facility staff present in the building have been evacuated; -did not include procedures to account for residents absent from the facility at the time of the evacuation; -did not include procedures to release resident information in an emergency situation to promote continuity of a resident's care; -did not include procedures to contact the local emergency management coordinator to find out if it is safe to return to the geographical area after the evacuation; -did not include procedures to notify DADS Regulatory Services regional office for the area by telephone immediately after the EPC makes a decision to evacuate and when returned; -did not include procedures for safely transporting residents, facility staff involved in an evacuation; and -did not train facility staff at least annually on their responsibilities for the emergency plan. During an interview on 5/23/13 at 11:55 a.m. the administrator said the maintenance supervisor was the EPC. She said she did not know who the new EMC was. She said she did not have another out-of-town facility to evacuate to. She said she had a list of employees in a glass case in the hallway, but it did not have contact numbers with it. She said she thought the disaster manual was up-to-date. During an interview on 5/23/13 at 12:37 p.m. the maintenance supervisor said he was responsible for the disaster manual. He said he was unaware he needed a 24 hour contact number for the local church. He said he was unaware of the need to train staff annually on emergency preparedness. He said the emergency preparedness manual did not include sheltering in place arrangements. The CMS 672 dated 5/20/13 indicated a census of 92 with one bariatric resident. The CMS 672 dated 5/20/13 indicated a facility census of 91 residents.with 1 bariatric resident.

Based on interview and record review the facility failed to ensure training for emergency procedures for evacuation for 1 of 1 resident (Resident #12) in the facility that utilized a bariatric bed (specialty heavy-duty beds that are wider than average and can support the excess weight of bariatric/morbidly obese individuals) was provided for 4 of 4 employees interviewed for emergency evacuation procedures. (CNAs O, P, Q and RNA R) This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on 5/21/13. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place Resident #12 at risk for serious injury or death in the event of an emergency evacuation. These failures could place the census of 92 residents at risk of injury in the event of a fire or emergency evacuation. Findings Included: 1. Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #12's cognition was moderately impaired, required extensive assistance with bed mobility, total dependence with activities of daily living (ADLs) and that transfers or locomotion on or off the unit had not occurred during this assessment period. Resident #12's nursing care plan dated 03/13/13 indicated the following: "Problem: The resident is generally bedfast-is not transferred, will sit on side of bed occasionally. Goal: Resident will be safe within environment. Approach: Requires extra large bed due to [MEDICAL CONDITION]. Problem: Resident is extremely obese and requires significant assistance during an evacuation. Goal: Resident would be kept safe as possible during bad weather or fire. Approach: Would require the use of several strong people to aid in resident evacuation due to resident being severely obese weighing over 400 pounds; and in case of tornado the resident would be eased to the floor on a flat sheet with as many to assist as needed to assure her safety and pulled into the hallway away from any glass." During an interview on 5/20/13 at 2:30 p.m. CNA O said she would roll Resident #12 out in her bed. CNA O then looked at the resident's bed and said, "That bed wouldn't fit out that door. I don't know how we would evacuate her." CNA O said she had received no training regarding how to evacuate Resident #12 in an emergency. During an interview on 5/20/13 at 2:45 p.m. CNA P said she had been working at the facility off and on for 7 years. CNA P said there was usually an extra wide wheel chair located on Hall 400 and a hoyer lift kept on either Hall 300 or Hall 400, but the hoyer lift would not hold Resident #12. CNA P said, "I guess we would have to put a blanket under Resident #12 and have enough staff to pull her out." CNA P said she had never received any training on how to evacuate Resident #12. CNA P said she knew about using the blanket from working at other facilities. During an interview on 5/20/13 at 2:55 p.m. CNA Q said she worked at the facility for a little over a year on the hall where Resident #12 resided. CNA Q said she had received no training on evacuating a resident on a bariatric bed at the facility. During an interview on 5/20/13 at 3:00 p.m. RNA R said he had worked at the facility for 3 years and had not received any training on how to get Resident #12 out of the building in case of an emergency. The facility did not have a bariatric lift or a bariatric wheel chair. During an interview on 5/20/13 at 4:05 p.m. the Medical Director said the facility needed a bariatric lift and wheel chair to be able to evacuate Resident #12 in case of fire. During an interview on 5/20/13 at 4:30 p.m. the administrator said the facility did not have a hoyer lift or wheel chair that could accommodate Resident #12's weight. She said in order to evacuate Resident #12, staff would have to do a "dead man's drag" to get her out of the building. It had been several years ago when the facility had the fire department come out and demonstrate how to do the dead man's drag and she was not sure if current staff had been trained on how to do this procedure to evacuate Resident #12. The administrator said it would take 8 to 9 staff to do a dead man drag in order to evacuate Resident #12, as it took 6 pretty good sized men to raise/lower a stretcher with the resident on it. During an interview 5/20/13 at 4:52 p.m. the DON said it would take about 8 staff to assist Resident #12 to evacuate in case of emergency. She denied giving in-services to staff regarding evacuation of Resident #12 and said the maintenance man did fire drills and would be the person that would provide training and in-services regarding evacuation of the facility in an emergency. The DON said in order to evacuate Resident #12 the resident's mattress would be pushed to the door of her room and the sheet would be used to pull the resident the rest of the way out the door. She said the facility had never actually practiced doing this before. Resident #12 would be the last resident evacuated from the building. The DON did not know when the last disaster in-service was done. During an interview on 5/23/13 at 12:37 p.m. the maintenance supervisor said he was responsible for the disaster manual. He said he was unaware of the need to train staff annually on emergency preparedness. He said he had not provided any training regarding the dead man drag in evacuating Resident #12. The disaster plan dated 4/17/13 did not contain any procedures for evacuating residents who required Bariatric equipment. The administrator and DON were notified on 5/20/13 at 5:40 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted on 5/20/13 at 8:50 p.m. and included: "I. A MegaMover to be placed on Resident #12's bed to remain there at all times. The MegaMover has the strength to move an individual that weighs in excess of 700 pounds. II. All staff to be in-serviced on the use of the MegaMover prior to start of their shifts. III. An additional 10 MegaMovers were ordered and kept in Resident #12 ' s closet to change out as they become soiled. IV. Resident to be evacuated through the exit at the end of 200 Hall and how she is to be transported to the evacuation site; and V. Tells how many staff it would take to evacuate Resident #12 with the MegaMover and who is to assist with getting the resident on the facility ' s van. VI. The facility would be contacting the family with a list of facilities that specialized in bariatric patients and would assist them in moving Resident #12 to a facility of their choice. VII. All in-services would be completed by 10:00 a.m. on 5/24/13." The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by interviews with 17 CNAs over all shifts. These staff indicated the facility had provided in-services on how to use the MegaMover in evacuating Resident #12, how many staff it would take to utilize this piece of equipment, who was to assist with the transporting of the resident and where she was to be transferred during evacuation. On 5/21/13 at 11:25 a.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 5/20/13 indicated a facility census of 91 residents and 1 bariatric resident.

Based on observation, interview, and record review, the facility failed to have an effective plan of evacuation for 1 of 1 bariatic resident (Resident #12 ) and failed to have detailed written plans and procedures to meet all potential emergencies and disasters. Immediate Jeopardy 1. The facility did not have a plan of evacuation for Resident #12 (a bariatric resident) and staff did not know how to evacuate Resident #12. Staff did not know how they would evacuate Resident #12 to safety in the event of an emergency. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on 5/21/13. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place Resident #12 at risk for serious injury or death in the event of an emergency evacuation. Non-Immediate Jeaopardy 2. The Disaster Manual did not have detailed plans and procedures and lacked pertinent information. This failure could place the census of 92 residents at risk of injury in the event of a disaster. Findings included: 1. Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #12's cognition was moderately impaired, required extensive assistance with bed mobility, total dependence with activities of daily living (ADLs) and that transfers or locomotion on or off the unit had not occurred during this assessment period. Resident #12's nursing care plan dated 03/13/13 indicated the following: "Problem: The resident is generally bedfast-is not transferred, will sit on side of bed occasionally. Goal: Resident will be safe within environment. Approach: Requires extra large bed due to [MEDICAL CONDITION]. Problem: Resident is extremely obese and requires significant assistance during an evacuation. Goal: Resident would be kept safe as possible during bad weather or fire. Approach: Would require the use of several strong people to aid in resident evacuation due to resident being severely obese weighing over 400 pounds; and in case of tornado the resident would be eased to the floor on a flat sheet with as many to assist as needed to assure her safety and pulled into the hallway away from any glass." During an interview on 5/20/13 at 2:30 p.m. CNA O said she would roll Resident #12 out in her bed. CNA O then looked at the resident's bed and said, "That bed wouldn't fit out that door. I don't know how we would evacuate her." CNA O said she had received no training regarding how to evacuate Resident #12 in an emergency. During an interview on 5/20/13 at 2:45 p.m. CNA P said she had been working at the facility off and on for 7 years. CNA P said there was usually an extra wide wheel chair located on Hall 400 and a hoyer lift kept on either Hall 300 or Hall 400, but the hoyer lift would not hold Resident #12. CNA P said, "I guess we would have to put a blanket under Resident #12 and have enough staff to pull her out." CNA P said she had never received any training on how to evacuate Resident #12. CNA P said she knew about using the blanket from working at other facilities. During an interview on 5/20/13 at 2:55 p.m. CNA Q said she worked at the facility for a little over a year on the hall where Resident #12 resided. CNA Q said she had received no training on evacuating a resident on a bariatric bed at the facility. During an interview on 5/20/13 at 3:00 p.m. RNA R said he had worked at the facility for 3 years and had not received any training on how to get Resident #12 out of the building in case of an emergency. The facility did not have a bariatric lift or a bariatric wheel chair. During an interview on 5/20/13 at 4:05 p.m. the Medical Director said the facility needed a bariatric lift and wheel chair to be able to evacuate Resident #12 in case of fire. During an interview on 5/20/13 at 4:30 p.m. the administrator said the facility did not have a hoyer lift or wheel chair that could accommodate Resident #12's weight. She said in order to evacuate Resident #12, staff would have to do a "dead man's drag" to get her out of the building. It had been several years ago when the facility had the fire department come out and demonstrate how to do the dead man's drag and she was not sure if current staff had been trained on how to do this procedure to evacuate Resident #12. The administrator said it would take 8 to 9 staff to do a dead man drag in order to evacuate Resident #12, as it took 6 pretty good sized men to raise/lower a stretcher with the resident on it. During an interview 5/20/13 at 4:52 p.m. the DON said it would take about 8 staff to assist Resident #12 to evacuate in case of emergency. She denied giving in-services to staff regarding evacuation of Resident #12 and said the maintenance man did fire drills and would be the person that would provide training and in-services regarding evacuation of the facility in an emergency. The DON said in order to evacuate Resident #12 the resident's mattress would be pushed to the door of her room and the sheet would be used to pull the resident the rest of the way out the door. She said the facility had never actually practiced doing this before. Resident #12 would be the last resident evacuated from the building. The DON did not know when the last disaster in-service was done. During an interview on 5/23/13 at 12:37 p.m. the maintenance supervisor said he was responsible for the disaster manual. He said he was unaware of the need to train staff annually on emergency preparedness. He said he had not provided any training regarding the dead man drag in evacuating Resident #12. The disaster plan dated 4/17/13 did not contain any procedures for evacuating residents who required Bariatric equipment. The administrator and DON were notified on 5/20/13 at 5:40 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted on 5/20/13 at 8:50 p.m. and included: "I. A MegaMover to be placed on Resident #12's bed to remain there at all times. The MegaMover has the strength to move an individual that weighs in excess of 700 pounds. II. All staff to be in-serviced on the use of the MegaMover prior to start of their shifts. III. An additional 10 MegaMovers were ordered and kept in Resident #12 ' s closet to change out as they become soiled. IV. Resident to be evacuated through the exit at the end of 200 Hall and how she is to be transported to the evacuation site; and V. Tells how many staff it would take to evacuate Resident #12 with the MegaMover and who is to assist with getting the resident on the facility ' s van. VI. The facility would be contacting the family with a list of facilities that specialized in bariatric patients and would assist them in moving Resident #12 to a facility of their choice. VII. All in-services would be completed by 10:00 a.m. on 5/24/13." The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by interviews with 17 CNAs over all shifts. These staff indicated the facility had provided in-services on how to use the MegaMover in evacuating Resident #12, how many staff it would take to utilize this piece of equipment, who was to assist with the transporting of the resident and where she was to be transferred during evacuation. On 5/21/13 at 11:25 a.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non-Immediate Jeopardy 2. The disaster manual dated 4/17/13 provided by the administrator: -was not updated annually by the emergency preparedness coordinator (EPC); -did not describe the resident population; -did not include how to notify DADS for self-reporting incidents; -did not document the name and contact information for the local emergency management coordinator (EMC), as identified by the office of the local mayor or county judge; -did not include procedures for notifying the local EMC of the execution of the plan; -did not identify the EPC, or the alternate EPC; -did not address how the EPC will be notified of an emergency or who the EPC will notify in an emergency situation, or when the notifications will occur; -did not identify the primary mode of communication or the alternate mode of communication; -did not include procedures for maintaining a current list of telephone numbers for residents responsible parties, or pre-arranged receiving facilities, or facility staff telephone numbers; -did not include arrangement for a sufficient number of vehicles to safely evacuate all residents; -did not identify the types of services used by residents; -did not have maps that showed the destinations and routes; -did not include a 24 hour phone number for the shelter contract for the local church; -did not include a facility to evacuate to in another town; -did not inform staff where to meet outside the building during an evacuation; -did not include a section for each core function of emergency management based on a facility ' s decision to either shelter in place or evacuate during an emergency; and -did not include arrangements for the families of staff. -did not include a plan that coordinated a staffing response to an emergency situation; -did not include procedures to maintain communication with facility staff involved in an emergency situation; -did not include procedures to maintain communication with the driver of a vehicle transporting residents, medication, records, food, water, equipment, or supplies during an evacuation; -did not include procedures to ensure and account for residents and facility staff present in the building have been evacuated; -did not include procedures to account for residents absent from the facility at the time of the evacuation; -did not include procedures to release resident information in an emergency situation to promote continuity of a resident's care; -did not include procedures to contact the local emergency management coordinator to find out if it is safe to return to the geographical area after the evacuation; -did not include procedures to notify DADS Regulatory Services regional office for the area by telephone immediately after the EPC makes a decision to evacuate and when returned; -did not include procedures for safely transporting residents, facility staff involved in an evacuation; and -did not train facility staff at least annually on their responsibilities for the emergency plan. During an interview on 5/23/13 at 11:55 a.m. the administrator said the maintenance supervisor was the EPC. She said she did not know who the new EMC was. She said she did not have another out-of-town facility to evacuate to. She said she had a list of employees in a glass case in the hallway, but it did not have contact numbers with it. She said she thought the disaster manual was up-to-date. During an interview on 5/23/13 at 12:37 p.m. the maintenance supervisor said he was responsible for the disaster manual. He said he was unaware he needed a 24 hour contact number for the local church. He said he was unaware of the need to train staff annually on emergency preparedness. He said the emergency preparedness manual did not include sheltering in place arrangements. The CMS 672 dated 5/20/13 indicated a census of 92 with one bariatric resident.

Based on observation, interview, and record review the facility failed to provide supervision to ensure 7 of 8 residents reviewed for accidents were assessed and interventions were implemented to prevent coffee burns. (Resident #s 9, 5, 15, 23, 24, 25 and 26) Resident #9 was not assessed to determine if she could handle hot liquids without a lid. She spilled hot coffee in her bed and received second degree burns on her right hip and buttocks. Resident #5 spilled coffee on his abdomen and right leg and a treatment was ordered for Silvadene (used to treat burns). Resident #5 was at risk for injury due to periods of motor restlessness, took several psychotropic medications that could produce drowsiness and the resident was not assessed to determine if he could handle hot liquids without a lid. Resident #15 was dependent for all of her ADLs including feeding and was not assessed to determine if she was safe with hot liquids. She spilled coffee on her chest and a treatment was ordered for Silvadene. Resident #24 was weak and having difficulty sitting on the side of bed. The resident was not supervised while drinking coffee. Resident #25 was lying down attempting to feed herself and at risk for spilling her coffee. She was drinking coffee without a lid in her room unsupervised. Resident #26 was weak and having difficulty sitting on the side of bed. The resident was not supervised while drinking coffee. Resident #23 had visible hand tremors. She was drinking coffee without a lid in the dining room. She was not provided supervision while drinking hot liquids. This failure likely contributed to Resident #s 9, 5, and 15's receiving coffee burns and could place 51 residents that drink coffee at risk for burns or injury related to hot coffee. Findings included: 1.) Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #9 had clear comprehension and could express her needs and wants. Her assessment indicated she needed extensive assistance with bed mobility, ADL care and set up help with eating. A care plan updated 3/8/12 indicated Resident #9 was at risk for injury due to her limited balance while sitting related to her above the knee amputation of both legs. An accident/incident report dated 5/5/12 at 2:15 a.m., indicated Resident #9 had 4 quarter sized blisters on her right outer buttocks. Resident #9 said she had spilled hot coffee on herself at supper time and had informed the nurse that worked on the 2-10 shift. The report indicated the treatment provided was Silvadene to right outer buttock twice a day until healed and a Provale cup (cup prevents spilling and smaller sips), while drinking coffee in bed and an insulated mug while up. Resident #9's skin condition report dated 5/8/12 indicated the following: *right inner buttocks - small amount of yellow, color less intense, serosanginous drainage (clear blood tinged drainage); *top right buttocks - small amount of yellow, color less intense, red with serosanginous drainage; and *lower right buttocks - less intense, red serosanginous drainage, yellow center During an observation on 5/8/12 at 10:20 a.m., LVN C provided treatment to Resident #9's wounds. The following open areas were on her right buttocks and upper hip: *right inner buttocks - 3.3 X 2.5 cm, thin yellow slough, no redness surrounding outer wound; *top right buttocks- 6 cm by 10.5 cm, thin yellow slough; *lower right buttocks- 6 cm by 13 cm, thin yellow slough. During an observation on 5/8/12 at 4:30 p.m., Resident #9 was lying in bed. An insulated cup with lid on it was on the over bed table. She said she was given the cup after she spilled her coffee. 2.) Physician orders [REDACTED]. The orders required Resident #5 to receive Effexor two times daily (depression) and Seroquel daily (anti-psychotic). The most recent MDS dated [DATE] indicated Resident #5 usually comprehended most conversations and had some difficulty communicating. His assessment indicated he required extensive assistance with ADLs and supervision with eating. The care plan dated 4/5/12 indicated Resident #5 had impaired functional ability and was at risk of injury due to periods of motor restlessness, he required extensive assistance with his ADLs. Nursing notes dated 2/27/12 at 11:00 a.m., indicated Resident #5 spilled coffee on his abdomen and right leg. The physician assistant was contacted and Silvadene cream was ordered to be applied daily until healed. During an interview on 5/9/12 at 10:20 a.m., LVN C reviewed Resident #5's clinical record and could not find documentation regarding the resident's skin condition after the coffee spill. February and March 2012 treatment records indicated Resident #5 received Silvadene cream to his stomach and right leg from 2/27/12 to 3/6/12 (9 days). During an observation and interview on 5/9/12 at 12:40 p.m., Resident #5 was eating lunch in his room. He said he used a regular coffee cup (no lid). 3.) Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated she required extensive assistance with eating. An updated care plan dated 3/29/12 indicated Resident #15 was dependent on staff for all ADLs and displayed confused behavior. Nursing notes dated 2/19/12 at 7:25 a.m., indicated Resident #15 was in the dining room drinking coffee and spilled coffee on her chest, and her chest was red. A nursing note dated 2/19/12 at 9:15 a.m., indicated a physician order [REDACTED]. A treatment record dated 2/19/12 -3/2/12 indicated by a drawing that Resident #15's chest was reddened across her entire upper chest; no measurements were documented. The treatment record documented her chest as healed on 3/2/12. The treatment record dated February 2012 indicated Resident #15 received Silvadene cream to the reddened area on her chest two times a day from 2/19 -2/29/12 (10 days). 4.) Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #24 was able to express her ideas/ wants and had clear comprehension in understanding. Her assessment indicated she required extensive assistance with transfers, walking, locomotion and personal hygiene. She required set up help with eating. The care plan dated 2/22/12 indicated Resident #24 required minimal assistance with eating and ate in her room with staff monitoring. During an observation on 5/9/12 at 8:30 a.m., Resident #24 was sitting on the side of her bed, holding onto the bed, using chest muscles to breath. She was attempting to feed herself but had difficulty getting food to her mouth. She was drinking coffee from a cup without a lid. Facility staff were not present during her meal. 5.) physician's orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #25 was able to express her ideas/ wants and had clear comprehension in understanding. Her assessment noted she required extensive to total assistance with all ADLs and required set up help with eating. During an observation on 5/9/12 at 8:25 a.m., Resident #25 was seen attempting to feed herself lying down. She was drinking coffee from a cup without a lid. Facility staff were not present during her meal. 6.) Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #26 was able to express her ideas/ wants and had clear comprehension in understanding. Her assessment indicated she was independent with her ADLs and required set up help with eating. The care plan dated 2/16/12 indicated Resident #26 had impaired ADL abilities due to forgetfulness and she was receiving therapy services due to generalized weakness During an observation on 5/9/12 at 8:32 a.m., Resident #26 was eating breakfast in her room. She was wearing oxygen canal and having difficulty breathing and feeding herself. She was drinking coffee from a cup without a lid. 7.) Physician orders [REDACTED]. The care plan dated 3/22/12 noted Resident #23 had impaired cognition for daily decision making and a [DIAGNOSES REDACTED]. During an observation on 5/9/12 at 7:45 a.m., Resident #23 was drinking coffee unsupervised from a cup without a lid. She had visible tremors in her hands as she attempted to drink her coffee. During an interview on 5/9/12 at 2:20 p.m., RN H said Resident #23 had hand tremors since RN H started working at the facility February 2012. During an interview on 5/8/12 at 4:15 p.m., Dietary Aide F said they replenished the coffee every two hours to ensure fresh coffee. She said they put the coffee in pump pots that were accessible to residents in the dining room. During an interview on 5/8/12 at 4:35 p.m., the FSS said he use to get cold coffee complaints, but since he got new pump pots sometimes he was told the coffee was too hot. He said if residents told him the coffee was too hot, they put ice cubes in their coffee. During an interview on 5/9/12 at 12:15 p.m., the DON said she had not assessed nor identified residents who drank coffee for being "at risk" for spilling coffee. She said she had in-serviced staff regarding coffee in the past. A facility in-service dated 9/12/11 indicated staff should not fill coffee cups completely but pour 1/2 to 3/4 full and add ice to cool down. Residents should be supervised in the dining room and if residents are given coffee, staff should stay with them until they finish drinking. The in-service did not address residents who drank coffee in their rooms. The website, firstaid.about.com/od/.../a/07_burn_degrees.htm, accessed 5/9/12, indicated: First-Degree Burns This means a superficial burn. The surface of the skin is damaged, but the epidermis (the outermost is still intact, and therefore able to perform its functions (control temperature and protect from infection or injury). When determining severity, care providers ignore first-degree burns. Second-Degree Burns This means damage that has extended through the epidermis and into the dermis (the second layer of skin). Second-degree burns also are known as partial-thickness burns. In determining the severity of burns, the presence of second degree burns indicates a loss of skin function. Blisters are the first sign of a second-degree burn. As the epidermis is destroyed, it begins to separate from the dermis. Fluid builds beneath it, causing blisters. Eventually, the blisters will spread into one another until the very thin epidermis falls away, exposing the raw dermis underneath. Once the epidermis has separated from the raw dermis, the victim begins to lose fluid, heat, and the ability to block infection. The raw nerve cells of the dermis also mean second degree burns are the most painful. On 5/9/12 at 9:12 a.m., the FSS provided a list of 51 residents who drank coffee.

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures by: * not identifying, prohibiting and preventing further potential abuse by Resident #1 for 2 of 6 residents sampled for abuse (Residents #2 and #3). Resident #1 lived on the secure unit and had a history of [REDACTED]. On 8/26/10 Resident #1 turned over the chair Resident #3 was sitting in and Resident #3 sustained a [MEDICAL CONDITION]. Prior to the [MEDICAL CONDITION], Resident #3 was ambulatory. Resident #3 became dependent on staff for mobility and ambulation. Resident #1 struck Resident #2, her roommate, eleven times in less than two months. An immediate jeopardy was identified on 9/30/10. Although the immediate jeopardy was removed on 10/1/10, the facility remained out of compliance because of the facility's need to monitor and evaluate whether the systems put into place were effective. The non-compliance continued at a pattern of actual harm. These failures placed the 18 residents on the secure unit at risk of injury by Resident #1 from aggressive behavior which created an immediate jeopardy (IJ) situation. Non-Immediate Jeopardy *not thoroughly investigating an injury of unknown origin for 1 of 6 residents sampled for abuse/neglect (Resident #4). On 9/23/10 Resident #4 had a black purplish bruise to her left outer thigh. As of 10/1/10, 7 days later, the facility had not investigated the injury and had not reported the incident to the state agency. This failure could place the facility census of 95 residents at risk of injuries of unknown origin. Findings include: The facility undated Abuse and Neglect policy and procedure documented the following: -definition of physical abuse was: hitting, slapping, pinching, scratching, spitting, holding roughly, jerking, or corporal punishment. -definition of neglect was: lack of care and supervision; unmet need of physical, social, emotional, spiritual and medical. -an individual was to report abuse and neglect immediately -each resident has the right to a dignified existence, and to be free from verbal, sexual, physical, or mental abuse; corporal punishment; and involuntary seclusion, among other right listed in the Federal Register and State Law. -It is the policy of the facility to maintain an environment of zero tolerance of incidents of abuse, neglect, and misappropriation of resident property. -The facility would make every effort to identify, correct and intervene in situations which abuse, neglect and/or misappropriation of resident property is more likely to occur. This included assessing, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with history of aggressive behaviors. -The facility would identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse and to determine the direction of the investigation. -The facility would report all alleged violations and all substantiated incidents to the State agency and to all other agencies as required, and to take all necessary corrective actions depending on the results of the investigation. 1.) On 9/30/10 at 6:17 p.m., Resident #3 was observed lying in bed. Resident #3's left hip was purple in color and had an incision scar. A Facility Unusual Occurrence Incident Report documented that on 8/26/10 at 8:45 a.m., Resident #1 turned Resident #3's chair over and Resident #3 landed on her left side. Resident #1 was removed from the area and was administered medication for agitation. In an interview on 9/30/10 at 1:05 p.m., the DON said Resident #3 was a very thin framed lady and she resided on the secure unit. She said Resident #3 was sitting in a chair "minding her own business" when Resident #1 came over and pushed her chair over. She said Resident #3 sustained a fractured left hip and was now non-ambulatory. She said Resident #1's aggressive behavior was "very unpredictable" and they were trying to find her alternate placement. She said they had talked about placing Resident #1 on one-on-one supervision in the past but it was not financially feasible. A handwritten statement from CNA C dated 8/26/10 documented that she was providing care to another resident when she looked up and saw Resident #1 turn Resident #3's chair over. Interdisciplinary Progress Notes dated 8/26/10 at 4:00 p.m. documented an X-ray of Resident #3's left hip revealed a possible fracture/break. Resident #3 was transferred to the hospital. A hospital history and physical dated 8/26/10 documented that Resident #3 was brought to the emergency room with left hip pain and X-rays confirmed a [MEDICAL CONDITION]. A nursing admission assessment dated [DATE] noted Resident #3 returned to the facility following hip surgery. Resident #3's Plan of Treatment For Outpatient Rehabilitation Physical Therapy dated 9/17/10 documented that she was on the secure unit and walked without any assistive devices prior to her fall on 8/26/10. It also documented that she was ordered physical therapy in order to address her "drastic decline after [MEDICAL CONDITION] with all functional mobility and balance." Resident #3's admission MDS dated [DATE] documented that she was [AGE] years old and walked independently and transferred herself. Resident #3's MDS completed on 9/17/10 (after the 8/26/10 incident) documented that she was nonambulatory and dependent on staff for transfers. Resident #1's September 2010 physician orders [REDACTED]. These orders noted the resident was to receive [MEDICATION NAME] gel every 4 hours as needed for agitation (initiated 6/4/10). An MDS dated [DATE] noted Resident #1 had: -moderately impaired cognitive skills for decision making. -persistent anger with self and others up to five days a week. -persistent mood indicators over the last 7 days that were not easily altered. -wandering, verbally and physically abusive behavioral symptoms, socially inappropriate/disruptive behavioral symptoms, and -resisted care. Resident #1's care plans dated 6/15/10 and 8/10/10 indicated she had episodes of combative behaviors and she would slap and hit other individuals. The approaches/interventions documented the facility would do the following once a combative episode occurred: - Separate from others; isolate no more than 30 minutes. - Leave resident alone for a few minutes. - Explain firmly but gently the behavior was not acceptable. - Reduce distractions and negative environmental stimuli as much as possible (for example: loud noise, multiple conversations, bright lights, and shiny floors.) The care plan did not address preventive measures. The Facility Unusual Occurrence Incident Reports noted the following: *8/4/10 at 9:30 a.m. - Resident #1 slapped Resident #2 on the arm. The residents were separated and re-directed. *8/5/10 at 12:15 p.m. - Resident #2 hit Resident #1 on the arm. Resident #1 slapped Resident #2 in the face. The residents were separated and re-directed. *8/12/10 at 10:00 a.m. - Resident #1 slapped Resident #2 on the forehead. The staff redirected Resident #1 and offered her a snack. *8/12/10 at 11:45 a.m. - Resident #1 slapped an unidentified resident on the right side of the face. Resident #1 was redirected and administered [MEDICATION NAME] gel. The residents were separated. *8/20/10 at 11:40 a.m. - Resident #1 slapped Resident #2 on the face. Resident #1 was administered [MEDICATION NAME] gel. The residents were separated and redirected. *8/20/10 at 1:10 p.m. - Resident #1 slapped Resident #5 on the right cheek. They redirected Resident #1 to her room. *8/23/10 at 11:20 a.m. - Resident #1 slapped Resident #6 on his back. The staff redirected Resident #1 and separated the residents. *8/26/10 at 9:15 a.m. - Resident #1 slapped Resident #2 "very hard, forcefully" Resident #1 was administered [MEDICATION NAME] gel. *9/7/10 at 1:40 p.m. - Resident #1 slapped Resident #2 on the left cheek. The staff redirected Resident #1. *9/11/10 at 12:30 p.m. - Resident #1 hit Resident #2 on her right shoulder. The staff redirected Resident #1 and separated the residents. *9/11/10 at 4:30 p.m. - Resident #1 slapped Resident #2 twice on her cheeks. When the nurse tried to intervene, Resident #1 bit the nurse on the left hand. *9/17/10 at 6:00 a.m. - Resident #1 slapped Resident #2 on the left cheek. The staff redirected Resident #1 and separated the residents. *9/22/10 at 12:30 p.m. - Resident #1 slapped Resident #2 on the right cheek. The staff redirected Resident #1 and separated the residents. Resident #1's Mental Health Progress Notes dated 9/23/10 documented that she continued to have problems with slapping residents and her outbursts could happen at any time. Resident #1 did not seem to have any way of controlling her impulses due to her mental [MEDICAL CONDITION] and cognitive status. Resident #1 was not responding to therapy. In an interview with the SW on 9/30/10 at 1:49 p.m., she said for at least 8 months, Resident #1 and Resident #2 had been roommates. She said as far as she was aware, all the altercations between the two residents had occurred in the dining room on the secure unit. The SW said she started seeking alternate placement for Resident #1 on 8/27/10. She said other facilities would not accept the resident due to her aggressive combative behaviors and elopement risk. The SW said they had a care plan meeting with Resident #1's mother on 8/27/10 and her mother stated she was unable to care for her at home. In an interview with the administrator on 9/30/10 at 3:07 p.m., she said she was aware that Resident #1 had aggressive behaviors and would hit and slap other residents on the secure unit. She said the psychologist visited with Resident #1 every Thursday and the physician had changed the resident's medications. The facility had attempted to place her in a group home but no group home would accept Resident #1 because she was incontinent, had aggressive behaviors and was an elopement risk. The administrator said the resident's mother was unable to care for her at home and the resident did not have any where else to go. The administrator said in the meantime, they were trying to monitor the resident "as much as they could." In an interview with the administrator on 9/30/10 at 3:39 p.m., she said the facility had not placed Resident #1 on one-on-one supervision/monitoring because they were not financially able to pay for it. In an interview with CNA C on 9/30/10 at 11:24 a.m., she said she had worked on the secure unit for about four months. CNA C said Resident #1 would slap other residents, especially her roommate, Resident #2. She said that Resident #2 was hard of hearing and yelled out a lot. Her yelling annoyed Resident #1 because she did not like loud noises. In a telephone interview with RN F on 9/30/10 at 12:15 p.m., she said that on 9/11/10 she witnessed Resident #1 forcefully slap Resident #2 twice in the face. She said she had witnessed Resident #1 slap other residents on the secure unit. RN F said two CNAs and a nurse were scheduled to care for 18 residents on the secure unit at all times. She said all the residents were ambulatory and it was hard to constantly monitor Resident #1 and care for the other residents. In an interview with LPN E on 9/30/10 at 2:05 p.m. she said she had been a charge nurse on the secure unit for the last 4-5 months. She said that Resident #1's aggressive behavior had became worse within the last two months. She said that Resident #1's aggression with slapping and hitting other residents would just "come out of the blue" without any warning signs. In an interview with LPN D on 9/30/10 at 2:18 p.m., she said that she had been working on the secure unit for about three weeks. She said it was hard to intervene and stop Resident #1 from slapping or hitting other residents because her aggressive behaviors were spontaneous. She said Resident #2 and Resident #1 were room mates and Resident #2 did not know when to back off or stay away from Resident #1. LPN D said Resident #1 did not exhibit any warning signs before she became aggressive toward other residents. On 10/1/10 at 11:27 a.m. LPN B stated she had been working on the secure unit with Resident #1 since the end of July 2010 or the first of August 2010. She said that she was on duty on the day when Resident #1 slapped a male resident (Resident #6) and she had to get in between the two residents. The LPN said Resident #6 was angry and agitated when Resident #1 hit him and he was going toward Resident #1 like he was about to hit her. The facility's failure to adequately address Resident #1's aggressive behavior which resulted in injury of another resident created an immediate jeopardy (IJ) situation. The facility's administrator, assistant administrator, and the DON were informed of the immediate jeopardy situation on 9/30/10 at 3:39 p.m. On 9/30/10 at 7:29 p.m. the following "Plan of Removal" was accepted: - Copy of thirty day discharge letter issued to her mother on 9/30/10. Resident #1's mother was issued an intent to discharge letter at approximately 4:45 p.m. on 9/30/10. - Copy of schedule for 24 hour one-on-one staffing for the next seven days with Resident #1, which will continue until her discharge. To correct the situation, we will have one-on-one staffing with Resident #1 around the clock until such time as we can place her somewhere else. These staff members will make hourly documentation entries on Resident #1. The sole purpose of the staff member is to keep (Resident #1) from being aggressive. This staffing began at approximately 3:48 p.m. on 9/30/10 and will continue for the next seven days until resident's discharge. - In-service documentation for staff that will be caring for her. - Initial in-service completed by Assistant Administrator on 9/30/10 at 3:48 p.m. with CNA G and Charge Nurse on Unit, LPN D. - Charge Nurses are is to in-service all incoming one-on-one staff members regarding charting and monitoring for Resident #1. - On October 1, 2010 at 9:00 a.m., resident will be assessed by a Geriatric-Psych Unit for placement. - In an effort to assure the safety of all residents, every resident on the unit will be assessed for behavior. This will be completed by 5:00 p.m. on October 1, 2010. These assessments will be performed by the Social Work Consultant. - All unit staff will be in-serviced at 2:00 p.m. on October 1, 2010 on managing residents with behaviors. This will be performed by the Social Work Consultant. - The current activities schedule for the unit will be reviewed by the psychologist, and additional activities will be added as he deems necessary in an effort to prevent boredom and attempt to lessen aggressive behavior. On 9/30/10 and 1/01/10 the survey team reviewed the facility's implementation of the plan of removal. Interviews were conducted with six staff on 10/1/10 after they were in-serviced on how to manage residents with behaviors. On 9/30/10 at 9:00 p.m. behavior assessments for all eighteen residents on the secure unit were completed and on 10/1/10 copies were provided to the surveyor. Review of these assessments revealed that no other residents on the secure unit were assessed as having aggressive behaviors towards other residents or staff. Administrative staff, licensed nurses, certified nurse aides and the social worker provided accurate information on how to monitor and manage residents with aggressive behaviors. In an observation and interview with CNA G on 9/30/10 at 6:04 p.m., CNA G was on the secure unit, providing one-on-one supervision and monitoring for Resident #1. CNA G was directly beside Resident #1 and whenever the resident got up to ambulate, CNA G remained at her side. CNA G said she was told to make hourly entries regarding the resident's behavior and that she was not supposed to leave the resident's side. CNA G said she started providing one-on-one supervision for Resident #1 at 3:45 p.m. On 10/1/10 at 11:25 a.m., Resident #1 was observed sitting in the dining room on the secure unit and her mother was at her side visiting with her. CNA I was providing one-on-one supervision and monitoring for Resident #1. In an interview with CNA I on 10/1/10 at 11:54 a.m., she said she came to work at 6:00 a.m. and was instructed to constantly monitor and supervise Resident #1. CNA I said that she was told that she was to hourly document what Resident #1's activity. Resident #1's Pre-Screening Behavioral Health Assessment sheet dated 10/1/10 at 9:30 a.m. revealed that an alternate facility had assessed the resident and accepted her for admission. A physician telephone order dated 10/1/10 revealed Resident #1 was to be discharged from the facility. On 10/1/10 at 11:53 a.m., Resident #1 was observed leaving the facility for admission to the alternate facility. The survey team determined that the facility had implemented its plan of removal sufficiently to remove the immediate jeopardy. The administrator, assistant administrator and DON were informed the immediate jeopardy was removed on 10/1/10 at 4:00 p.m. Although the immediate jeopardy was removed on 10/1/10, the facility remained out of compliance at a pattern of actual harm. The deficient practice remained uncorrected due to the need for the facility to in-service and train all staff regarding residents with behavior problems, and to monitor and evaluate whether the systems put in place were effective. A resident roster dated 9/30/10 noted 18 residents lived on the secure unit. Non-Immediate Jeopardy 2.) Resident #4's September 2010 physician order [REDACTED]. Resident #4's MDS dated [DATE] documented that she had modified independent cognitive skills for decision making. Review of the facility Unusual Occurrence Incident Reports dated 9/23/10 noted Resident #4 had a black purplish bruise to her left outer thigh. Resident #4 told staff that a man hit her and caused the bruise. In an interview with the DON/abuse coordinator on 9/30/10 at 1:04 p.m., she said the facility had not initiated an investigation and they had not notified the state agency regarding the injury. She said "I showed it to the administrator today and she told me I should have reported it." The DON said, "I just dropped the ball on this one." On 10/1/10 at 12:44 p.m., Resident #4's skin was observed with CNA J and the resident had a purple bruise to her left outer thigh. In an interview with Resident #4 on 10/1/10 at 12:44 p.m., she said she did not know how she got the bruise. The CMS 672 dated 9/30/10 noted a census of 95 residents. On 10/1/10 the facility was given an opportunity to provide additional information during the exit conference. None was provided.

Based on observation, interview, and record review, the facility failed to provide adequate monitoring and supervision, and failed to develop and implement effective intervention strategies for 1 of 4 residents (Resident #1) sampled for aggressive behaviors. Resident #1 lived on the secure unit and had a history of [REDACTED]. On 8/26/10 Resident #1 turned over the chair Resident #3 was sitting in and Resident #3 sustained a fractured hip. Prior to the hip fracture, Resident #3 was ambulatory. Resident #3 became dependent on staff for mobility. Resident #1 struck Resident #2, her roommate, eleven times in less than two months. An immediate jeopardy was identified on 9/30/10. Although the immediate jeopardy was removed on 10/1/10, the facility remained out of compliance because of the facility's need to monitor and evaluate whether the systems put into place were effective. The non-compliance continued at a pattern of actual harm. These failures placed the 18 residents on the secure unit at risk of injury by Resident #1 which created an immediate jeopardy situation. Findings included: On 9/30/10 at 6:17 p.m., Resident #3 was observed lying in bed. Resident #3's left hip was purple in color and had an incision scar. A Facility Unusual Occurrence Incident Report documented that on 8/26/10 at 8:45 a.m., Resident #1 turned Resident #3's chair over and Resident #3 landed on her left side. Resident #1 was removed from the area and was administered medication for agitation. In an interview on 9/30/10 at 1:05 p.m., the DON said Resident #3 was a very thin framed lady and she resided on the secure unit. She said Resident #3 was sitting in a chair "minding her own business" when Resident #1 came over and pushed her chair over. She said Resident #3 sustained a fractured left hip and was now non-ambulatory. She said Resident #1's aggressive behavior was "very unpredictable" and they were trying to find her alternate placement. She said they had talked about placing Resident #1 on one-on-one supervision in the past but it was not financially feasible. A handwritten statement from CNA C dated 8/26/10 documented that she was providing care to another resident when she looked up and saw Resident #1 turn Resident #3's chair over. Interdisciplinary Progress Notes dated 8/26/10 at 4:00 p.m. documented an X-ray of Resident #3's left hip revealed a possible fracture/break. Resident #3 was transferred to the hospital. A hospital history and physical dated 8/26/10 documented that Resident #3 was brought to the emergency room with left hip pain and X-rays confirmed a hip fracture. A nursing admission assessment dated [DATE] noted Resident #3 returned to the facility following hip surgery. Resident #3's Plan of Treatment For Outpatient Rehabilitation Physical Therapy dated 9/17/10 documented that she was on the secure unit and walked without any assistive devices prior to her fall on 8/26/10. It also documented that she was ordered physical therapy in order to address her "drastic decline after hip fracture with all functional mobility and balance." Resident #3's admission MDS dated [DATE] documented that she was [AGE] years old and walked independently and transferred herself. Resident #3's MDS completed on 9/17/10 (after the 8/26/10 incident) documented that she was non-ambulatory and dependent on staff for transfers. Resident #1's September 2010 physician orders [REDACTED]. These orders noted the resident was to receive lorazepam gel every 4 hours as needed for agitation (initiated 6/4/10). An MDS dated [DATE] noted Resident #1 had: -moderately impaired cognitive skills for decision making. -persistent anger with self and others up to five days a week. -persistent mood indicators over the last 7 days that were not easily altered. -wandering, verbally and physically abusive behavioral symptoms, socially inappropriate/disruptive behavioral symptoms, and -resisted care. Resident #1's care plans dated 6/15/10 and 8/10/10 indicated she had episodes of combative behaviors and she would slap and hit other individuals. The approaches/interventions documented the facility would do the following once a combative episode occurred: - Separate from others; isolate no more than 30 minutes. - Leave resident alone for a few minutes. - Explain firmly but gently the behavior was not acceptable. - Reduce distractions and negative environmental stimuli as much as possible (for example: loud noise, multiple conversations, bright lights, and shiny floors.) The care plan did not address preventive measures. The Facility Unusual Occurrence Incident Reports noted the following: *8/4/10 at 9:30 a.m. - Resident #1 slapped Resident #2 on the arm. The residents were separated and re-directed. *8/5/10 at 12:15 p.m. - Resident #2 hit Resident #1 on the arm. Resident #1 slapped Resident #2 in the face. The residents were separated and re-directed. *8/12/10 at 10:00 a.m. - Resident #1 slapped Resident #2 on the forehead. The staff redirected Resident #1 and offered her a snack. *8/12/10 at 11:45 a.m. - Resident #1 slapped an unidentified resident on the right side of the face. Resident #1 was redirected and administered lorazepam gel. The residents were separated. *8/20/10 at 11:40 a.m. - Resident #1 slapped Resident #2 on the face. Resident #1 was administered lorazepam gel. The residents were separated and redirected. *8/20/10 at 1:10 p.m. - Resident #1 slapped Resident #5 on the right cheek. They redirected Resident #1 to her room. *8/23/10 at 11:20 a.m. - Resident #1 slapped Resident #6 on his back. The staff redirected Resident #1 and separated the residents. *8/26/10 at 9:15 a.m. - Resident #1 slapped Resident #2 "very hard, forcefully" Resident #1 was administered lorazepam gel. *9/7/10 at 1:40 p.m. - Resident #1 slapped Resident #2 on the left cheek. The staff redirected Resident #1. *9/11/10 at 12:30 p.m. - Resident #1 hit Resident #2 on her right shoulder. The staff redirected Resident #1 and separated the residents. *9/11/10 at 4:30 p.m. - Resident #1 slapped Resident #2 twice on her cheeks. When the nurse tried to intervene, Resident #1 bit the nurse on the left hand. *9/17/10 at 6:00 a.m. - Resident #1 slapped Resident #2 on the left cheek. The staff redirected Resident #1 and separated the residents. *9/22/10 at 12:30 p.m. - Resident #1 slapped Resident #2 on the right cheek. The staff redirected Resident #1 and separated the residents. Resident #1's Mental Health Progress Notes dated 9/23/10 documented that she continued to have problems with slapping residents and her outbursts could happen at any time. Resident #1 did not seem to have any way of controlling her impulses due to her mental retardation and cognitive status. Resident #1 was not responding to therapy. In an interview with the SW on 9/30/10 at 1:49 p.m., she said for at least 8 months, Resident #1 and Resident #2 had been roommates. She said as far as she was aware, all the altercations between the two residents had occurred in the dining room on the secure unit. The SW said she started seeking alternate placement for Resident #1 on 8/27/10. She said other facilities would not accept the resident due to her aggressive combative behaviors and elopement risk. The SW said they had a care plan meeting with Resident #1's mother on 8/27/10 and her mother stated she was unable to care for her at home. In an interview with the administrator on 9/30/10 at 3:07 p.m., she said she was aware that Resident #1 had aggressive behaviors and would hit and slap other residents on the secure unit. She said the psychologist visited with Resident #1 every Thursday and the physician had changed the resident's medications. The facility had attempted to place her in a group home but no group home would accept Resident #1 because she was incontinent, had aggressive behaviors and was an elopement risk. The administrator said the resident's mother was unable to care for her at home and the resident did not have any where else to go. The administrator said in the meantime, they were trying to monitor the resident "as much as they could." In an interview with the administrator on 9/30/10 at 3:39 p.m., she said the facility had not placed Resident #1 on one-on-one supervision/monitoring because they were not financially able to pay for it. In an interview with CNA C on 9/30/10 at 11:24 a.m., she said she had worked on the secure unit for about four months. CNA C said Resident #1 would slap other residents, especially her roommate, Resident #2. She said that Resident #2 was hard of hearing and yelled out a lot. Her yelling annoyed Resident #1 because she did not like loud noises. In a telephone interview with RN F on 9/30/10 at 12:15 p.m., she said that on 9/11/10 she witnessed Resident #1 forcefully slap Resident #2 twice in the face. She said she had witnessed Resident #1 slap other residents on the secure unit. RN F said two CNAs and a nurse were scheduled to care for 18 residents on the secure unit at all times. She said all the residents were ambulatory and it was hard to constantly monitor Resident #1 and care for the other residents. In an interview with LPN E on 9/30/10 at 2:05 p.m. she said she had been a charge nurse on the secure unit for the last 4-5 months. She said that Resident #1's aggressive behavior had became worse within the last two months. She said that Resident #1's aggression with slapping and hitting other residents would just "come out of the blue" without any warning signs. In an interview with LPN D on 9/30/10 at 2:18 p.m., she said that she had been working on the secure unit for about three weeks. She said it was hard to intervene and stop Resident #1 from slapping or hitting other residents because her aggressive behaviors were spontaneous. She said Resident #2 and Resident #1 were room mates and Resident #2 did not know when to back off or stay away from Resident #1. LPN D said Resident #1 did not exhibit any warning signs before she became aggressive toward other residents. On 10/1/10 at 11:27 a.m. LPN B stated she had been working on the secure unit with Resident #1 since the end of July 2010 or the first of August 2010. She said that she was on duty on the day when Resident #1 slapped a male resident (Resident #6) and she had to get in between the two residents. The LPN said Resident #6 was angry and agitated when Resident #1 hit him and he was going toward Resident #1 like he was about to hit her. The facility's failure to adequately address Resident #1's aggressive behavior which resulted in injury of another resident created an immediate jeopardy (IJ) situation. The facility's administrator, assistant administrator, and the DON were informed of the immediate jeopardy situation on 9/30/10 at 3:39 p.m. On 9/30/10 at 7:29 p.m. the following "Plan of Removal" was accepted: - Copy of thirty day discharge letter issued to her mother on 9/30/10. Resident #1's mother was issued an intent to discharge letter at approximately 4:45 p.m. on 9/30/10. - Copy of schedule for 24 hour one-on-one staffing for the next seven days with Resident #1, which will continue until her discharge. To correct the situation, we will have one-on-one staffing with Resident #1 around the clock until such time as we can place her somewhere else. These staff members will make hourly documentation entries on Resident #1. The sole purpose of the staff member is to keep (Resident #1) from being aggressive. This staffing began at approximately 3:48 p.m. on 9/30/10 and will continue for the next seven days until resident's discharge. - In-service documentation for staff that will be caring for her. - Initial in-service completed by Assistant Administrator on 9/30/10 at 3:48 p.m. with CNA G and Charge Nurse on Unit, LPN D. - Charge Nurses are is to in-service all incoming one-on-one staff members regarding charting and monitoring for Resident #1. - On October 1, 2010 at 9:00 a.m., resident will be assessed by a Geriatric-Psych Unit for placement. - In an effort to assure the safety of all residents, every resident on the unit will be assessed for behavior. This will be completed by 5:00 p.m. on October 1, 2010. These assessments will be performed by the Social Work Consultant. - All unit staff will be in-serviced at 2:00 p.m. on October 1, 2010 on managing residents with behaviors. This will be performed by the Social Work Consultant. - The current activities schedule for the unit will be reviewed by the psychologist, and additional activities will be added as he deems necessary in an effort to prevent boredom and attempt to lessen aggressive behavior. On 9/30/10 and 1/01/10 the survey team reviewed the facility's implementation of the plan of removal. Interviews were conducted with six staff on 10/1/10 after they were in-serviced on how to manage residents with behaviors. On 9/30/10 at 9:00 p.m. behavior assessments for all eighteen residents on the secure unit were completed and on 10/1/10 copies were provided to the surveyor. Review of these assessments revealed that no other residents on the secure unit were assessed as having aggressive behaviors towards other residents or staff. Administrative staff, licensed nurses, certified nurse aides and the social worker provided accurate information on how to monitor and manage residents with aggressive behaviors. In an observation and interview with CNA G on 9/30/10 at 6:04 p.m., CNA G was on the secure unit, providing one-on-one supervision and monitoring for Resident #1. CNA G was directly beside Resident #1 and whenever the resident got up to ambulate, CNA G remained at her side. CNA G said she was told to make hourly entries regarding the resident's behavior and that she was not supposed to leave the resident's side. CNA G said she started providing one-on-one supervision for Resident #1 at 3:45 p.m. On 10/1/10 at 11:25 a.m., Resident #1 was observed sitting in the dining room on the secure unit and her mother was at her side visiting with her. CNA I was providing one-on-one supervision and monitoring for Resident #1. In an interview with CNA I on 10/1/10 at 11:54 a.m., she said she came to work at 6:00 a.m. and was instructed to constantly monitor and supervise Resident #1. CNA I said that she was told that she was to hourly document what Resident #1's activity. Resident #1's Pre-Screening Behavioral Health Assessment sheet dated 10/1/10 at 9:30 a.m. revealed that an alternate facility had assessed the resident and accepted her for admission. A physician telephone order dated 10/1/10 revealed Resident #1 was to be discharged from the facility. On 10/1/10 at 11:53 a.m., Resident #1 was observed leaving the facility for admission to the alternate facility. The survey team determined that the facility had implemented its plan of removal sufficiently to remove the immediate jeopardy. The administrator, assistant administrator and DON were informed the immediate jeopardy was removed on 10/1/10 at 4:00 p.m. Although the immediate jeopardy was removed on 10/1/10, the facility remained out of compliance at a pattern of actual harm. The deficient practice remained uncorrected due to the need for the facility to in-service and train all staff regarding residents with behavior problems, and to monitor and evaluate whether the systems put in place were effective. A resident roster dated 9/30/10 noted 18 residents lived on the secure unit. On 10/1/10 the facility was given an opportunity to provide additional information during the exit conference. None was provided.

Based on observation, interview, and record review, for 2 of 5 residents sampled for abuse (Residents #2 and #3), the facility failed to implement their policies and procedures to identify, prohibit and prevent further potential abuse by Resident #1. Resident #1 lived on the secure unit and had a history of [REDACTED]. On 8/26/10 Resident #1 turned over the chair Resident #3 was sitting in and Resident #3 sustained a [MEDICAL CONDITION]. Prior to the [MEDICAL CONDITION], Resident #3 was ambulatory. Resident #3 became dependent on staff for mobility and ambulation. Resident #1 struck Resident #2, her roommate, eleven times in less than two months. An immediate jeopardy was identified on 9/30/10. Although the immediate jeopardy was removed on 10/1/10, the facility remained out of compliance because of the facility's need to monitor and evaluate whether the systems put into place were effective. The non-compliance continued at a pattern of actual harm. These failures placed the 18 residents on the secure unit at risk of injury by Resident #1 from aggressive behavior which created an immediate jeopardy (IJ) situation. Findings included: On 9/30/10 at 6:17 p.m., Resident #3 was observed lying in bed. Resident #3's left hip was purple in color and had an incision scar. A Facility Unusual Occurrence Incident Report documented that on 8/26/10 at 8:45 a.m., Resident #1 turned Resident #3's chair over and Resident #3 landed on her left side. Resident #1 was removed from the area and was administered medication for agitation. In an interview on 9/30/10 at 1:05 p.m., the DON said Resident #3 was a very thin framed lady and she resided on the secure unit. She said Resident #3 was sitting in a chair "minding her own business" when Resident #1 came over and pushed her chair over. She said Resident #3 sustained a fractured left hip and was now non-ambulatory. She said Resident #1's aggressive behavior was "very unpredictable" and they were trying to find her alternate placement. She said they had talked about placing Resident #1 on one-on-one supervision in the past but it was not financially feasible. A handwritten statement from CNA C dated 8/26/10 documented that she was providing care to another resident when she looked up and saw Resident #1 turn Resident #3's chair over. Interdisciplinary Progress Notes dated 8/26/10 at 4:00 p.m. documented an X-ray of Resident #3's left hip revealed a possible fracture/break. Resident #3 was transferred to the hospital. A hospital history and physical dated 8/26/10 documented that Resident #3 was brought to the emergency room with left hip pain and X-rays confirmed a [MEDICAL CONDITION]. A nursing admission assessment dated [DATE] noted Resident #3 returned to the facility following hip surgery. Resident #3's Plan of Treatment For Outpatient Rehabilitation Physical Therapy dated 9/17/10 documented that she was on the secure unit and walked without any assistive devices prior to her fall on 8/26/10. It also documented that she was ordered physical therapy in order to address her "drastic decline after [MEDICAL CONDITION] with all functional mobility and balance." Resident #3's admission MDS dated [DATE] documented that she was [AGE] years old and walked independently and transferred herself. Resident #3's MDS completed on 9/17/10 (after the 8/26/10 incident) documented that she was nonambulatory and dependent on staff for transfers. Resident #1's September 2010 physician orders [REDACTED]. These orders noted the resident was to receive [MEDICATION NAME] gel every 4 hours as needed for agitation (initiated 6/4/10). An MDS dated [DATE] noted Resident #1 had: -moderately impaired cognitive skills for decision making. -persistent anger with self and others up to five days a week. -persistent mood indicators over the last 7 days that were not easily altered. -wandering, verbally and physically abusive behavioral symptoms, socially inappropriate/disruptive behavioral symptoms, and -resisted care. Resident #1's care plans dated 6/15/10 and 8/10/10 indicated she had episodes of combative behaviors and she would slap and hit other individuals. The approaches/interventions documented the facility would do the following once a combative episode occurred: - Separate from others; isolate no more than 30 minutes. - Leave resident alone for a few minutes. - Explain firmly but gently the behavior was not acceptable. - Reduce distractions and negative environmental stimuli as much as possible (for example: loud noise, multiple conversations, bright lights, and shiny floors.) The care plan did not address preventive measures. The Facility Unusual Occurrence Incident Reports noted the following: *8/4/10 at 9:30 a.m. - Resident #1 slapped Resident #2 on the arm. The residents were separated and re-directed. *8/5/10 at 12:15 p.m. - Resident #2 hit Resident #1 on the arm. Resident #1 slapped Resident #2 in the face. The residents were separated and re-directed. *8/12/10 at 10:00 a.m. - Resident #1 slapped Resident #2 on the forehead. The staff redirected Resident #1 and offered her a snack. *8/12/10 at 11:45 a.m. - Resident #1 slapped an unidentified resident on the right side of the face. Resident #1 was redirected and administered [MEDICATION NAME] gel. The residents were separated. *8/20/10 at 11:40 a.m. - Resident #1 slapped Resident #2 on the face. Resident #1 was administered [MEDICATION NAME] gel. The residents were separated and redirected. *8/20/10 at 1:10 p.m. - Resident #1 slapped Resident #5 on the right cheek. They redirected Resident #1 to her room. *8/23/10 at 11:20 a.m. - Resident #1 slapped Resident #6 on his back. The staff redirected Resident #1 and separated the residents. *8/26/10 at 9:15 a.m. - Resident #1 slapped Resident #2 "very hard, forcefully" Resident #1 was administered [MEDICATION NAME] gel. *9/7/10 at 1:40 p.m. - Resident #1 slapped Resident #2 on the left cheek. The staff redirected Resident #1. *9/11/10 at 12:30 p.m. - Resident #1 hit Resident #2 on her right shoulder. The staff redirected Resident #1 and separated the residents. *9/11/10 at 4:30 p.m. - Resident #1 slapped Resident #2 twice on her cheeks. When the nurse tried to intervene, Resident #1 bit the nurse on the left hand. *9/17/10 at 6:00 a.m. - Resident #1 slapped Resident #2 on the left cheek. The staff redirected Resident #1 and separated the residents. *9/22/10 at 12:30 p.m. - Resident #1 slapped Resident #2 on the right cheek. The staff redirected Resident #1 and separated the residents. Resident #1's Mental Health Progress Notes dated 9/23/10 documented that she continued to have problems with slapping residents and her outbursts could happen at any time. Resident #1 did not seem to have any way of controlling her impulses due to her mental [MEDICAL CONDITION] and cognitive status. Resident #1 was not responding to therapy. In an interview with the SW on 9/30/10 at 1:49 p.m., she said for at least 8 months, Resident #1 and Resident #2 had been roommates. She said as far as she was aware, all the altercations between the two residents had occurred in the dining room on the secure unit. The SW said she started seeking alternate placement for Resident #1 on 8/27/10. She said other facilities would not accept the resident due to her aggressive combative behaviors and elopement risk. The SW said they had a care plan meeting with Resident #1's mother on 8/27/10 and her mother stated she was unable to care for her at home. In an interview with the administrator on 9/30/10 at 3:07 p.m., she said she was aware that Resident #1 had aggressive behaviors and would hit and slap other residents on the secure unit. She said the psychologist visited with Resident #1 every Thursday and the physician had changed the resident's medications. The facility had attempted to place her in a group home but no group home would accept Resident #1 because she was incontinent, had aggressive behaviors and was an elopement risk. The administrator said the resident's mother was unable to care for her at home and the resident did not have any where else to go. The administrator said in the meantime, they were trying to monitor the resident "as much as they could." In an interview with the administrator on 9/30/10 at 3:39 p.m., she said the facility had not placed Resident #1 on one-on-one supervision/monitoring because they were not financially able to pay for it. In an interview with CNA C on 9/30/10 at 11:24 a.m., she said she had worked on the secure unit for about four months. CNA C said Resident #1 would slap other residents, especially her roommate, Resident #2. She said that Resident #2 was hard of hearing and yelled out a lot. Her yelling annoyed Resident #1 because she did not like loud noises. In a telephone interview with RN F on 9/30/10 at 12:15 p.m., she said that on 9/11/10 she witnessed Resident #1 forcefully slap Resident #2 twice in the face. She said she had witnessed Resident #1 slap other residents on the secure unit. RN F said two CNAs and a nurse were scheduled to care for 18 residents on the secure unit at all times. She said all the residents were ambulatory and it was hard to constantly monitor Resident #1 and care for the other residents. In an interview with LPN E on 9/30/10 at 2:05 p.m. she said she had been a charge nurse on the secure unit for the last 4-5 months. She said that Resident #1's aggressive behavior had became worse within the last two months. She said that Resident #1's aggression with slapping and hitting other residents would just "come out of the blue" without any warning signs. In an interview with LPN D on 9/30/10 at 2:18 p.m., she said that she had been working on the secure unit for about three weeks. She said it was hard to intervene and stop Resident #1 from slapping or hitting other residents because her aggressive behaviors were spontaneous. She said Resident #2 and Resident #1 were room mates and Resident #2 did not know when to back off or stay away from Resident #1. LPN D said Resident #1 did not exhibit any warning signs before she became aggressive toward other residents. On 10/1/10 at 11:27 a.m. LPN B stated she had been working on the secure unit with Resident #1 since the end of July 2010 or the first of August 2010. She said that she was on duty on the day when Resident #1 slapped a male resident (Resident #6) and she had to get in between the two residents. The LPN said Resident #6 was angry and agitated when Resident #1 hit him and he was going toward Resident #1 like he was about to hit her. The facility's failure to adequately address Resident #1's aggressive behavior which resulted in injury of another resident created an immediate jeopardy (IJ) situation. The facility's administrator, assistant administrator, and the DON were informed of the immediate jeopardy situation on 9/30/10 at 3:39 p.m. On 9/30/10 at 7:29 p.m. the following "Plan of Removal" was accepted: - Copy of thirty day discharge letter issued to her mother on 9/30/10. Resident #1's mother was issued an intent to discharge letter at approximately 4:45 p.m. on 9/30/10. - Copy of schedule for 24 hour one-on-one staffing for the next seven days with Resident #1, which will continue until her discharge. To correct the situation, we will have one-on-one staffing with Resident #1 around the clock until such time as we can place her somewhere else. These staff members will make hourly documentation entries on Resident #1. The sole purpose of the staff member is to keep (Resident #1) from being aggressive. This staffing began at approximately 3:48 p.m. on 9/30/10 and will continue for the next seven days until resident's discharge. - In-service documentation for staff that will be caring for her. - Initial in-service completed by Assistant Administrator on 9/30/10 at 3:48 p.m. with CNA G and Charge Nurse on Unit, LPN D. - Charge Nurses are is to in-service all incoming one-on-one staff members regarding charting and monitoring for Resident #1. - On October 1, 2010 at 9:00 a.m., resident will be assessed by a Geriatric-Psych Unit for placement. - In an effort to assure the safety of all residents, every resident on the unit will be assessed for behavior. This will be completed by 5:00 p.m. on October 1, 2010. These assessments will be performed by the Social Work Consultant. - All unit staff will be in-serviced at 2:00 p.m. on October 1, 2010 on managing residents with behaviors. This will be performed by the Social Work Consultant. - The current activities schedule for the unit will be reviewed by the psychologist, and additional activities will be added as he deems necessary in an effort to prevent boredom and attempt to lessen aggressive behavior. On 9/30/10 and 1/01/10 the survey team reviewed the facility's implementation of the plan of removal. Interviews were conducted with six staff on 10/1/10 after they were in-serviced on how to manage residents with behaviors. On 9/30/10 at 9:00 p.m. behavior assessments for all eighteen residents on the secure unit were completed and on 10/1/10 copies were provided to the surveyor. Review of these assessments revealed that no other residents on the secure unit were assessed as having aggressive behaviors towards other residents or staff. Administrative staff, licensed nurses, certified nurse aides and the social worker provided accurate information on how to monitor and manage residents with aggressive behaviors. In an observation and interview with CNA G on 9/30/10 at 6:04 p.m., CNA G was on the secure unit, providing one-on-one supervision and monitoring for Resident #1. CNA G was directly beside Resident #1 and whenever the resident got up to ambulate, CNA G remained at her side. CNA G said she was told to make hourly entries regarding the resident's behavior and that she was not supposed to leave the resident's side. CNA G said she started providing one-on-one supervision for Resident #1 at 3:45 p.m. On 10/1/10 at 11:25 a.m., Resident #1 was observed sitting in the dining room on the secure unit and her mother was at her side visiting with her. CNA I was providing one-on-one supervision and monitoring for Resident #1. In an interview with CNA I on 10/1/10 at 11:54 a.m., she said she came to work at 6:00 a.m. and was instructed to constantly monitor and supervise Resident #1. CNA I said that she was told that she was to hourly document what Resident #1's activity. Resident #1's Pre-Screening Behavioral Health Assessment sheet dated 10/1/10 at 9:30 a.m. revealed that an alternate facility had assessed the resident and accepted her for admission. A physician telephone order dated 10/1/10 revealed Resident #1 was to be discharged from the facility. On 10/1/10 at 11:53 a.m., Resident #1 was observed leaving the facility for admission to the alternate facility. The survey team determined that the facility had implemented its plan of removal sufficiently to remove the immediate jeopardy. The administrator, assistant administrator and DON were informed the immediate jeopardy was removed on 10/1/10 at 4:00 p.m. Although the immediate jeopardy was removed on 10/1/10, the facility remained out of compliance at a pattern of actual harm. The deficient practice remained uncorrected due to the need for the facility to in-service and train all staff regarding residents with behavior problems, and to monitor and evaluate whether the systems put in place were effective. A resident roster dated 9/30/10 noted 18 residents lived on the secure unit. The undated facility Abuse and Neglect policy and procedure documented the following: -The definition of physical abuse was: hitting, slapping, pinching, scratching, spitting, holding roughly, jerking, or corporal punishment. -The definition of neglect was lack of care and supervision; unmet need of physical, social, emotional, spiritual and medical. -An individual was to report abuse and neglect immediately. -Each resident has the right to a dignified existence, and to be free from verbal, sexual, physical, or mental abuse; corporal punishment; and involuntary. seclusion, among other rights listed in the Federal Register and State Law. -It is the policy of the facility to maintain an environment of zero tolerance of incidents of abuse, neglect, and misappropriation of resident property. -The facility would make every effort to identify, correct and intervene in situations which abuse, neglect and/or misappropriation of resident property is more likely to occur. This included assessing, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with history of aggressive behaviors. -The facility would identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse and to determine the direction of the investigation. -The facility would report all alleged violations and all substantiated incidents to the State agency and to all other agencies as required, and to take all necessary corrective actions depending on the results of the investigation. On 10/1/10 the facility was given an opportunity to provide additional information during the exit conference. None was provided.