Every finding on record at Treasure Isle Care Center

Based on observations interview and record review, the facility failed to their Quality Assurance Performance Improvement policy and demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area as evidenced by repeated deficient practices for F550-Resident Rights/Exercise of Rights and F761- Labeling of Drugs and Biologicals, F689 Free of Accident Hazards/Supervision/Devices, F880 Infection Prevention and Control and F867 QAPI/QAA Improvement Activities. The findings included: Review of the facility's survey history revealed, during a recertification survey with exit dated 07/24/2024 deficient practice was identified for F550-Resident Rights/Exercise of Rights and F761- Labeling of Drugs and Biologicals, F689 Free of Accident Hazards/Supervision/Devices, F880 Infection Prevention and Control and F867 QAPI/QAA Improvement Activities. During this survey with exit date of 10/02/2025, the facility was cited for F550-Resident Rights/Exercise of Rights and F761- Labeling of Drugs and Biologicals, F689 Free of Accident Hazards/Supervision/Devices, F880 Infection Prevention and Control and F867 QAPI/QAA Improvement Activities.On 10/02/2025 at 4:37 PM a Quality Assurance and Performance Improvement (QAPI) overview was conducted with the Nursing Home Administrator, (NHA) the Travelling Nursing Home Administrator and the Director of Nursing (DON).The NHA revealed the meeting are held on the last Thursday of each month. The committee member include the Medical Director, NHA, Corporate representatives, DON, ADON, Admissions, Department Heads. The committee is always focusing on prior tags with ongoing systems in place to maintain compliance and identifying any areas for improvement.

Based on observations, interviews and record review the facility failed to ensure infection control standards were followed as evidenced by nebulizer mask noted uncovered, dirty call light on Resident#15's bed, nebulizer machine on the floor, Resident #5's indwelling urinary catheter drainage bag inside a trash. There were 160 residents residing in the facility at the time of the survey During observation on 09/29/2025 at 09:25 AM, a respiratory mask as noted at Resident # 120's bedside observed without a storage bag. Photographic evidence attached. On 09/30/2025 11:21 AM Resident seated in wheelchair at doorway, alert and watching TV with no distress observed. Liquid within reach. Nebulizer mask not visible at bedside. On 10/01/2025 10:58 AM Resident sleeping in wheelchair near doorway, no distress observed. Liquid at bedside, privacy curtain in place. Empty urinal noted at bedside. Nebulizer mask not visible. Review of the medical records for Resident #120 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to Hypoxic Ischemic Encephalopathy, Unspecified. Review of Resident #120's Physician's Orders Sheet for September 2025 revealed an order dated 09/25/2025 for Levalbuterol HCl Inhalation Nebulization Solution 1.25 MG/3ML (Levalbuterol HCl) 1.25 mg inhale orally via nebulizer every 8 hours as needed for Shortness of Breath. Record review of Resident #120's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score is 10 indicating some cognitive impairment. Section GG for Functional Abilities documented no impairment for upper body extremities and impairment on both sides for lower extremities, independent for eating, partial assistance for toileting and sit to lying, showering, upper and lower body dressing. Section J for Health Conditions documented the resident receives scheduled pain medication regimen. Section O for Special Treatments, Procedures, and Programs documented the resident did not receive the influenza, pneumococcal or covid19 vaccine. Record review of Resident #120's Care Plans revealed the resident has Oxygen Therapy related to (r/t) shortness of breath (SOB), Chronic obstructive pulmonary disease (COPD). Interventions include - Administer Oxygen as ordered. Give medications as ordered by physician. Monitor/document side effects and effectiveness. Promote lung expansion and improve air exchange by positioning with proper body alignment. Interview on 10/02/2025 at 04:28 PM with Staff D, LPN stated After the nebulizer treatment is finished, the device should be placed in a bag and changed weekly or as needed. It should not be left lying uncovered on the dresser. The resident receives nebulizer treatments every 12 hours and as needed. Staff receive infection control training monthly, provided by the ADON. Record Review of the facility policy and procedure titled Infection Prevention and Control Program October 2021 indicate: The Infection Prevention and Control Program is comprehensive program that addresses detection, prevention and control of infections and communicable diseases among residents, visitors, volunteers, those individuals providing services under contractual agreement and personnel. d. Identify and correct problems relating to infection control and prevention practices. 1) On 9/29/25 at 10:23 AM An observation was made of a nebulizer machine on the floor in a resident's room in Section 3 (photo evidence). On 9/29/25 at 10:27 AM Staff A, Registered Nurse (RN) Unit manager was notified about the identified concern. The unit manager picked up the nebulizer machine, placed it in a plastic bag and removed it from the room. On 9/29/25 at 11:07 AM Staff B, Licensed Practical Nurse (LPN) was interviewed about the identified concern and stated, I did round this morning and I didn't notice the nebulizer machine on the floor, or I would have picked it up. 2) On 9/29/25 at 11:10 AM An observation was made of a dirty call light on the bed of a Resident#15 (photo evidence). On 9/29/25 at 11:15 AM Staff A, RN Unit manager was notified and stated, It looks like milk. I will clean it. On 9/29/25 at 11:20 AM Staff C, LPN was interviewed about the identified concern and stated, I did not notice the call light was dirty. 3) On 10/01/25 at 1:30pm an observation was made of Resident #5's indwelling urinary catheter drainage bag inside a trash can next to bed (photo evidence). On 10/01/25 at 1:35 pm Staff A, RN unit manager was notified stated, Earlier in the around 12:30 PM the catheter was properly placed on the side of the bed. Staff A, RN unit manager entered room with surveyor and observed the drainage bag inside the trash can while still connected to resident. and stated, I don't know why it's in the garbage and I will change it. Record review of a quarterly minimum data set reference dated 9/10/25 revealed Resident#5 had a Brief interview of mental status score of 12 indicated moderate cognitive impairment, required substantial/maximal assistance for toileting hygiene and had an indwelling catheter. Record review of a care plan started on 9/10/25 revealed Resident #5 had an indwelling Catheter with interventions that included: observe/document/report to doctor for signs and symptoms of Urinary tract infection. Record review of a September 2025 physicians' order sheet for Resident#5 revealed an order for Suprapubic Catheter: Suprapubic catheter to drainage bag for Neurogenic Bladder. Suprapubic catheter size # 14 French with 10 Cubic centimeter (cc) Balloon. Observe every shift.

Based on observation, interview, and record review, the facility did not ensure one resident (Resident #159) out of eight sampled residents was treated with respect and dignity as evidenced by Resident #159 was observed wearing his shirt inside out. 2) During lunch, Resident #159 did not receive his lunch tray in a timely manner while his roommate had already received lunch and finished eating. 3) Facility staff identified residents requiring assistance with meals as feeders.The findings include. Observation on 09/30/2025 at 9:15 AM, revealed Resident #159 awake in bed, wearing a blue shirt inside out. At 10:20 AM on the same day, Resident #159 seated in a wheelchair, still wearing the shirt inside out. At 11:47 AM Resident #159 noted in the hallway, seated in a wheelchair, with the shirt still inside out.On 09/30/2025 at 12:30 PM, Resident #159 was observed in his room seated in a wheelchair still wearing his shirt inside out waiting to be served lunch while his roommate was already served.On 09/30/2025, at 12:30 PM, Resident #159 was still wearing his shirt inside out while he sat in his room waiting to be served lunch. His roommate had already been served and finished eating. At 12:42 PM, the surveyor asked why Resident #159 had not received his meal tray; the Unit Manager then revealed the tray was on the cart and instructed the staff to take the tray to the resident.09/30/2025 at 12:59 Staff F, Registered Nurse (RN) took the meal tray to Resident #159's room and assisted the resident with eating with his meal.Record review of Resident #159's clinical records showed that the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #159 clinical diagnoses, include Dysphagia, Oropharyngeal Phase Epilepsy (unspecified, not intractable, without status epilepticus), malignant neoplasm of the brain, and chronic respiratory failure with hypoxia. The Quarterly Minimum Data Set (MDS), submitted on 08/25/2025, revealed a Brief Interview for Mental Status Score of 15 out of 15, indicating Resident #159 is cognitively intact. The MDS further indicated that Resident #159 requires assistance from staff for activities of daily living.Review of the facility's Policy and Procedure- Topic titled Residents Rights effective date August 2025 indicate: The facility strives to ensure that each resident has a dignified existence.Interview on 09/30/2025 at 1:01 PM, the Assistant Director of Nursing (ADON) stated: This resident requires assistance with feeding, and we try to serve all the residents who eat independently first. Residents needing assistance are fed afterward or in between, depending on how many nurses or Certified Nursing Assistants are available. The ADON acknowledged the identified concerns.On 10/02/2025 at 11:20 AM, the ADON was apprised of the identified concerns with Resident # 159 wearing his shirt inside out, the ADON revealed the resident requires assistance to dress himself and the CNAs should be checking the residents' clothing.On 10/02/2025 at 11:42 AM, the Director of Nursing (DON) was notified of the identified dignity concerns. The DON revealed the nurses and CNAs are supposed to observe and check the residents' clothing and ensure the residents' clothing is properly worn. Staff are aware that residents requiring assistance with meals should not be identified as feeders.On 10/02/2025 at 11:44 AM, Staff F, a Licensed Practical Nurse (LPN), stated: During rounds, if I notice a resident's shirt is on incorrectly, I go back to the room and change the shirt or assist the resident if they can change it on their own.On 10/02/2025 at 11:52 AM, Staff R, a Certified Nursing Assistant, revealed, I am responsible for ensuring the residents wear their clothes properly. When we pass out meal trays, we should serve everyone at the same time, including those in their rooms. [Resident #159] requires assistance with meals, and on Monday, the lady working left the tray on the cart and should have waited before serving the roommate. The surveyor asked Staff R, CNA, about the facility's policy and terminology for residents that are dependent on staff during mealtime. Staff R, CNA, admitted she had made a mistake and clarified the correct terminology: Resident requires assistance with meals.

Based on observation, record review, and interview, the facility failed to provide an advance directive for one (Resident #151) out of seven residents sampled; as evidence by: Resident #151 did not have an advance directive care plan or acknowledgement form in his chart. There were 160 residents residing in the facility at the time of the survey.During observation and record review on 09/30/2025 1:51 PM the residents advance directives was not located in the electronic chart.On 10/02/2025 03:00 PM, an advance directive care plan was unable to be located electronically.On 10/02/2025 03:20 PM, the facility's Social Services Director presents an advanced directive acknowledgement form with the signature of the resident, dated 10/01/2025. Review of the medical records for Resident #151 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to Cerebral infarction due to embolism of left posterior cerebral artery.Review of Resident #151's Physician's Orders Sheet for August 2025 revealed an order dated 08/13/2025 for Full Resuscitation.Record review of Resident #151 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score is 15 indicating functional cognitive abilities. Section GG for Functional Abilities documented impairment on one side for upper and lower extremities, set up assistance for eating, substantial assistance for toileting and sit to lying, partial assistance for showering, upper and lower body dressing. Record review of Resident #151's Care Plans revealed no care plan for advance directives was done upon admission. Interview on 10/02/2025 at 02:42 PM the Social Services Director stated I have only been working here for five months. Advance directive paperwork should be completed at the time of intake. This includes obtaining documentation such as power of attorney, a living will, and the resident's code status (Do Not Resuscitate or Full Code). Advance directives are admission documents that should be signed upon admission by the resident or their representative. If they are not signed at that time, I have to follow up to obtain the signature. The admissions department is responsible for ensuring these documents are completed. I have discussed with the MDS nurse the importance of including advanced directives in care plans, and each resident should have an advanced directive care plan. At this time, I am unsure of the exact timeframe required to have advance directives signed. Care plan meetings are conducted twice a weekRecord Review of the facility policy and procedure titled Advanced Medical Directives August 2025 indicate: At the time of admission, Admissions shall furnish residents, family members, and / or the resident representatives) with information regarding Advanced Medical Directives.The resident and / or resident representative shall be asked to provide Social Services with a copy of the resident's current Advanced Medical Directives. Social Services will place the Advanced Medical Directives in the resident's medical record and ensure that the presence, or absence, of Advanced Medical Directives is documented in the resident record.Completion of an Advanced Medical Directive is not a requirement for admission or continued stay in the facility. After admission to the facility, the Director of Social Services will assist in providing further guidance and / or information on Health Care Advanced Directives as required or requested.1. Verify that information about Advanced Medical Directives was provided to the resident and / or family / resident representative at the time of admission.

Based on interview and record review the facility failed to provide appropriate notices for one (Resident #175) out of three residents reviewed for beneficiary notices. The resident received the notice after they were discharged from the facility. There were 160 residents residing in the facility at the time of this survey.The findings included:Record review of the Beneficiary Notice Initiative Notice of Medicare Non-Coverage (NOMNC) Policy and Procedure effective May 2012 documented: 4) When to Deliver the NOMNC: A. Must give an advance, completed copy of the Notice of Medicare Non-Coverage (NOMNC to Medicare beneficiaries/Medicare Advantage enrollees receiving covered skilled services no later than two days before the termination of services.Review of the Demographic Face Sheet for Resident #175 documented the resident was admitted on [DATE] with a diagnosis of diabetes mellitus, hypertension, epilepsy, anxiety disorder, bipolar disorder and hyperlipidemia. The resident was discharged from the facility on 8/19/2025 to an assisted living facility (ALF).Review of the Beneficiary Notification Review for Resident #175 documented the Medicare Part A Skilled Services Start date was 8/07/25 and the last covered day of Part A service was 9/17/25. The Notice of Medicare Non-Coverage (NOMNC CMS Form 10123) was provided on 9/17/25 and a verbal consent was received from the resident on 9/17/2025. The resident was discharged from the facility on 8/19/25.Review of the Minimum Data Set (MDS) admission Assessment for Resident #175 dated 8/18/2025 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 11 out of 15 indicating cognitive impairment and the resident required partial to moderate assistance for ADLs (Activities Daily Living).Review of the Physician's Order Sheet (POS) for August 2025 for Resident #175 documented the resident was discharged to an ALF on 8/19/2025.On 10/02/25 at 2:38 PM, interview with the Social Services Director. She stated, The resident had several discharges. I would need to check on them. She refused to acknowledge that the form was filled out after the resident was discharged on 8/19/25.

Based on record reviews and interviews facility failed to submit a [NAME] II Preadmission Screening and Resident Review (PASRR) for a one (Resident #121) out of one sampled resident with a serious mental disorder as evidenced by a record review of a Level I PASRR indicating a Level II to be completed and no Level II was done. There were 161 residents residing in the facility at the time of survey.The findings included: On 9/29/25 at 10:42 AM Resident#121 observed seated in a wheelchair near bed. No apparent distress noted.Record review of a demographic sheet for Resident #121 revealed an admission date of - 6/26/23 with diagnosis that included: Bipolar disorder, Anxiety and Major depressive disorder.Record review of an Annual Minimum Data Set reference dated 7/3/25 revealed Residet#121 was not considered by the state level II Preadmission Screening and Resident Review (PASRR) process to have serious mental illness and/or intellectual disability or a related condition, had diagnosis that included: Anxiety disorder, Depression, Bipolar Disorder, was taking Antipsychotic and Antidepressant medication and received 0 minutes of Psychological Therapy in the last 7 days- 0.Record review of Care Plan started on 8/19/25 revealed Resident #121 was receiving psychotropic medications, had a goal to have minimal side effects and interventions included: Psychological services per order and as needed (PRN). Record review of Resident#121's physician's order sheet revealed orders dated 8/19/25 for Effexor Oral Capsule Extended Release 24 Hour 150 milligram (MG) directions: Give one capsule by mouth one time a day for Depression and 9/6/25 Abilify Oral Tablet 10 MG directions: Give one tablet by mouth at bedtime related to bipolar disorder.Record review of the medical record revealed Resident #121 was evaluated by a psychiatrist on 9/16/25. Record review of a Policy titled, PASRR - Requirements for Completion effective August 2025 revealed Pre-admission Screening & Resident Review (PASRR) Preadmission screening will be conducted prior to admission as the PASRR process is a federally mandated pre-admission screening program (see 42 CFR S 483.100) required to be performed on all individuals prior to admission to a Nursing Home. The screening is reviewed by Admissions for suspicion of serious mental illness and intellectual disability to ensure appropriate placement in the least restrictive environment and to identify the need to provide applicants with needed specialized services. PASRR screening applies to all new admissions into a Medicaid certified nursing facility and includes private pay, Medicare, and Medicaid admissions regardless of payer source. This screening is typically done by discharge planners & hospital staff as a step in the discharge process. It is separate from a medical needs assessment, which most often occurs after a person applies for Medicaid, and is a required step to qualify for Medicaid long-term care assistance.

Based on observations, record review and interviews, the facility failed to ensure proper positioning to prevent choking and aspiration for one (Resident #108) out of three sampled residents observed during dining; as evidenced by Resident #108 who has a diagnosis of Dysphagia Oropharyngeal Phase (difficulty swallowing) was noted in bed lying flat eating his lunch meal increasing the risk of food or liquid entering his airway leading to complications that include but not limited to aspiration pneumonia. The findings include: Observation on 09/30/2025 at 12:36 PM revealed Resident #108 lying flat in bed eating in his lunch meal.On 09/30/2025 at 12:37 PM Staff I, Certified Nursing Assistant, entered the room and the surveyor asked about Resident #108's position while eating his meal. Staff I, C N A reported the meal tray and set up was done by another staff and stated: This resident is a [requires assistants with eating], and we usually feed him. He like when [Staff P] feeds him. Staff I, CN A attempted to assist the resident without positioning the resident appropriately and the surveyor intervened. Staff I, CNA stated she will ask Staff P, CNA to assist the resident.On 09/30/2025 at 12:40 PM, the Assistant Director of Nursing (ADON) was shown Resident #108 lying flat in bed eating. The ADON stated, The resident should be elevated to prevent aspiration.On 09/30/2025 at 12:41 PM, during the observation and interview with the ADON the Unit Manager entered the room and stated: He always refuses to sit up.On 09/30/2025 at 12:42PM revealed Staff P, Certified Nursing Assistant, entered the room and assisted Resident #108 with his meal, the resident was noted compliant.Review of Resident # 108's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to: Dysphagia oropharyngeal, and dementia related to other diseases, focusing on unspecified severity and the absence of behavioral, psychotic, mood disturbances, and anxiety and cognitive communication deficit .There isn't information on Resident #108's Dietary Order Summary for September 2025 in the entities.The Dietary Order Summary for Resident #108 in September 2025 noted an active order dated 03/28/2025, specifying a no added salt diet with regular texture and thin consistency fortified foods.Review of Quarterly Minimum Data Set (MDS) submitted 09/29/2025 revealed Resident # 108 is cognitively intact; functional abilities documented for eating the resident requires setting up for meals and clean-up assistance required.The Sections for Behavior related to Rejection of Care - Presence and Frequency noted: Behavior not exhibitedOther Health Conditions noted: Shortness of breath or trouble breathing when lying flat-Checked (Yes)On 09/30/2025 at 2:01PM, Staff I, CNA revealed, He like to lay flat to eat but I should make sure I position him up in the bed to eat.Review of the policy and procedure provided indicate:Policy Topic: Free of Accidents and Hazards Supervision/ Devices indicate the facility shall ensure patient centered care and services are provided to residents in accordance with each resident's preferences and goals and in accordance with professional standards of practice that meet each resident's physical mental and psychosocial needs.Procedure: 1. The facility shall ensure that: b. Each resident receives supervision and assistance to prevent accidents to the extent possible

Based on observation records reviewed and interviews, the facility's staff failed to ensure a safe environment free of potential accidents and hazards for two out of three sampled residents, as evidenced by observation a knife in Resident #15's room on the windowsill and Resident #21 in possession of cigarettes. This deficiency increases the risk of negative outcomes that could affect all occupants in the facility. The findings include. Observation on 09/29/2025 at 9:40 AM, Resident #21 noted seated in an electric wheelchair in his room, with cigarettes visible in an open accessory bag (photographic evidence). Certified Nursing Assistant (CNA) Staff Q revealed that the resident goes out on pass and returns with the cigarettes. At 10:30 AM, the Assistant Director of Nursing (ADON) was shown the cigarettes in the open accessory attached to the right side of the wheelchair. The ADON immediately acknowledged the concern and informed the resident that he is not allowed to have cigarettes in his possession. The facility admitted Resident #21 on 06/07/2025 with clinical diagnoses including but not limited to Paraplegia unspecified, Neuromuscular Dysfunction of Bladder, Polyneuropathy, and type 2 Diabetes. The Nursing Home Administrator (NHA) revealed during an interview at 4:12 PM that law enforcement was called, and the resident refused to sign the behavioral note. Staff confiscated the cigarettes and implemented a 1:1 monitoring. The resident will remain on 1:1 monitoring, and nurses will be vigilant when he goes out on pass. Staff reminded all smokers and the assigned staff that cigarettes must be kept in the smoking cart and locked. The resident signed a compliance agreement upon admission and was educated and reminded of the consequences for noncompliance. He refused to sign the behavioral notes, and a Psych consult was done on 09/30/25. Resident #21's Smoking Care Plan indicates that he is a current smoker. The plan includes measures to ensure the resident remains safe while smoking, informs of the Facility Smoking Policy, designated smoking areas and times, the need to turn off oxygen, and the use of ash trays and smoking aprons. Smoking materials are kept by facility staff, and smoking is supervised as indicated. The Quarterly Minimum Data Set (MDS) submitted on 09/27/2025 shows Resident #21 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating cognitive intactness. He is dependent on staff for activities of daily living, according to the functional status section. The facility's policy and procedure effective August 2024 titled Smoking/Tobacco Use: 4. Staff should label smoking/tobacco materials with the resident's name and maintain them in a secure location. Residents may not keep combustible smoking materials in their room. Residents are not allowed to retain lighters, matches, cigarettes, e-cigarettes, ignitable tobacco products, or other smoking materials in their personal possession. 5. Staff will inform the resident, family, or visitors of the designated smoking/tobacco use area and times. 6. Staff will maintain cigarette/tobacco counts for each smoker. They will add cigarettes/tobacco brought into the facility to individualized inventory sheets and reconcile throughout the day as cigarettes are consumed and reconcile at the end of each day. If counts do not reconcile, the employee smoking attendant will notify the supervisor. Observation on 9/29/2025 at 11:10 AM in Resident #15's room a knife was noted on the windowsill. Staff A, Registered Nurse (RN), unit manager, was notified about identified concern and removed knife. Staff was interviewed about facility protocol and stated and stated, The knife should not be there. On 9/29/2025 at 11:15 AM Staff B, Licensed Practical Nurse (LPN) was interviewed and stated, I did not see the knife when I did rounds. Record review of a demographic sheet revealed Resident#15 was admitted on [DATE] with diagnosis that included: Sequelae of cerebral infarction, Heart failure and gastronomy status. Record review revealed the Annual Minimum Data set (MDS) reference dated 9/6/25 revealed Resident#15 Brief Interview of Mental Status score was undetermined and was dependent for eating. Record review of a Anticoagulation care plan initiated on 9/6/25 revealed Resident#15 had on anticoagulant/antiplatelet therapy medication) related to History of Stroke, had a goal to Will be free from discomfort or adverse reactions related to use through the review date and the interventions included: Provide safe environment: Assist with transfers/ mobility as needed, protect extremities from trauma to lessen the possibility of bleeding/ injury. Record review of a June 2025 physician's order sheet revealed Resident#15 had an order for Aspirin 81 Oral Tablet Chewable Directions: Give one tablet via Tube one time a day for cardiovascular disease, monitor for signs and symptoms (S/S) of bleeding during each nursing shift. Notify prescriber if resident experiences any of the following: S/S of dark/discolored urine, black tarry stools, nosebleed, vomiting. Review of the facility's Policy and Procedure effective September 2025 indicate: TOPIC-Free of Accident Hazards/Supervision/Devices POLICY- The facility shall ensure that patient-centered care and services are provided to residents in accordance with each resident's preferences and goals, and in accordance with professional standards of practice that meet each resident's physical, mental, and psychosocial needs. PROCEDURE 1. The facility shall ensure that: a. The resident environment remains free of accident hazards to the extent possible. b. Each resident receives supervision and assistance to prevent accidents to the extent possible.

Based on observations, records reviewed and interviews, the facility staff did not properly position an indwelling urinary tubing to facilitate the flow of urine for one (Resident #21) out of two sampled residents with an indwelling urinary catheter. As evidenced by; Resident #21's indwelling catheter tubing was positioned above the bladder and kinked. This improper practice prevented urine from freely flowing and increasing the risk for catheter-associated urinary tract infections and other serious medical issues. At the time of this survey, eleven residents with indwelling urinary catheters resided in the facility.The findings include. On 09/29/2025 at 9:32 AM, staff completed Resident #21's morning care, the indwelling catheter tubing was noted coiled on the bed. At 9:38 AM, Certified Nursing Assistants (CNAs) Staff Q and M used a mechanical lift to transfer Resident #21 from the bed to an electric wheelchair, positioning the indwelling catheter's tubing curled between the resident's legs.Record review revealed the facility admitted Resident #21 on 06/07/2025 with clinical diagnoses including but not limited to Paraplegia unspecified, Neuromuscular Dysfunction of Bladder, Polyneuropathy, and type 2 Diabetes.Review of the Physician Order Summary for September 2025 included an active order dated 06/07/2025 for Urinary Catheter care daily and PRN (as needed) for preventative measures. An active order dated 06/18/2025 required urinary catheter to drainage bag for DX (Diagnosis) Neurogenic Bladder, with a Urinary Catheter size #20 FR with balloon, and observation every shift.On 09/29/2025 at 9:42 AM when asked about the policy for catheter's tubing position, Staff M, CNA, stated that it was acceptable if the bag remained below the bladder. Observation on 09/29/2025 at 10:20 AM, Resident #21 was seated in a reclined electric wheelchair watching television in the activities/dining area. The indwelling urinary catheter tubing was noted curled and kinked; the urine appeared cloudy and was not flowing freely.On 09/29/2025 at 10:30 AM, the surveyor showed the Assistant Director of Nursing (ADON) and the Unit Manager that Resident #21's indwelling catheter tubing was curled and kinked. Both the Unit Manager and the ADON acknowledged the concern and noted that they would change the drainage bag.Review of the Urinary Catheter Care Plan for Resident #21 began on 9/7/2025 and aimed for completion on 9/15/2025. The plan included providing catheter care daily and as needed, educating the resident and family about catheterization and minimizing complications, observing for signs and symptoms of discomfort during urination and frequency, documenting pain or discomfort due to the catheter, keeping the catheter tubing free of kinks, and ensuring the drainage bag stayed below the level of the bladder.Review of the Quarterly Minimum Data Set (MDS) submitted 09/27/2025, Resident #21 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating cognitive intactness. The functional status section revealed the resident is dependent on staff for activities of daily living. The Bladder and Bowel section noted the use of an indwelling catheter and frequent bowel incontinence, with no current toileting program in place to manage the resident's bowel continence.On 10/01/2025 Staff G, Licensed Practical Nurse (LPN) revealed the catheter tubing should not be kept straight to allow drainage and prevent backflow.On 10/01/2025 at 2:05 PM, Staff I, CNA revealed the catheter bag should be below the bed and the tubing straight. Review of the facility's Policy and Procedure effective September 2025 Topic titledQuality of Care indicate:POLICY:It is the policy of the facility to ensure that each resident receives the necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance with State and Federal Regulations.PROCEDURE:1. The facility shall ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident's right to refuse treatment and within the limits of recognized pathology and the normal aging process.2. Quality of care and services shall be provided to the resident in accordance with professional standards of care to the extent possible, including but not limited to:a.) assistive devices,e.) incontinence care and management,h.) activities of daily living,

Based on observations, interviews, and record reviews, the facility failed to ensure their medication error rate were 5% or lower as evidenced by an error rate of 64.29 % out of 28 opportunities. There were 160 residents residing in the facility at the time of survey.The findings included:On 09/30/25 at 10:27 AM, a medication observation was completed with Staff F, RN on the Section 4 medication cart #1 for Resident #108. Staff F, RN revealed Resident #108 takes medicine by mouth in a whole form. Staff F, RN performed hand hygiene and verified each medication according to the physician's order and placed the following medications into a cup:1. Amlodipine 5 mg, po, 1 tab, once a day2. Lisinopril 10 mg, 1 tab, daily, po3. Procardia 90 mg xl, po, once daily, 1 tab4. Metformin 500 mg, po, 1 tab, twice a day 5 Multivitamin, 1 tab, po, once a day6. Lactulose 30 ml, liquid, po, twice a day7. Juven 1 packet, powder mix in 240 ml water, po, twice a dayThe nurse locks the cart and screen, performs hand hygiene, and dons gloves and gown.Vital signs: BP 120/62, HR 105.The nurse disinfects the blood pressure cuff with wipes and administers prescribed medications. The resident refuses lactulose and Juven, which are poured down the sink, and related trash is discarded. The bedside table is cleaned.The nurse then removes Personal Protective Equipment (PPE), completes hand hygiene, and signs off on medication administration.On 10/01/25 at 10:22 AM a medication observation was completed with Staff G, LPN on the Section 4 medication cart #1 for Resident #80. Staff G, LPN revealed Resident #80 takes medicine by mouth in a whole form. Staff G, LPN performed hand hygiene and verified each medication according to the physician's order and placed the following medications into a cup:Propranolol 10 mg, 1 tab, po, every 8 hours prn 2. Risperdal 2 mg, po, every morning and at bedtime 3. Artificial tears 1 %, 1 drop, 1 drop in both eyes 4. Divalproex 250 mg, po, 1 tab, twice a day 5. Duloxetine 20 mg, 1 cap, po, once a day 6. Gabapentin 600 mg, po, 3 times a day, 1 tab7. Methocarbamol 750 mg, 1 tab, po 3 times a day 8. Sertraline 25 mg, po, 1 tab, once a day 9. Meclizine 12.5 mg, 1 tab, po, once a day 10. Percocet 5-325 mg, po, 1 tab, every 4 hours as neededThe nurse signs the narcotic book after administering as needed narcotics, then locks the cart and screen. After knocking on the door, the nurse applies gloves and administers oral medications. Eye drops are instilled in both eyes, followed by wiping with tissue. Hand hygiene is performed, and the eye drops are returned to storage. The nurse signs off on medication administration in the computer. On 10/01/25 at 10:41 AM a medication observation was completed with Staff G, LPN on the Section 4 medication cart #1 for Resident #48. Staff G, LPN revealed Resident #48 takes medicine by mouth in a whole form. Staff G, LPN performed hand hygiene and verified each medication according to the physician's order and placed the following medications into a cup:Ibuprofen 800 mg, 1 tab, po, every 8 hours prn 2. Finasteride 5 mg, po, 1 tab, once a day 3. Gabapentin 300 mg, one tab, po, 3 times a day Vital signs: 101/53, HR:76 The nurse locks the cart and screen, obtains the resident's vital signs, and ensures privacy. Medications are administered, with blood pressure medication held due to low blood pressure. The blood pressure machine is disinfected, and the unadministered medication is discarded in the pill buster. Hand hygiene is performed. A note is written to the physician, and medications are signed off in the computer.On 09/30/2025 at 3:25 PM a narcotic count for Section 5 cart with Staff E, RN revealed no loose pills or expired medications observed in the medication cart. Staff E, RN documented signing off on ClonazePAM Oral Tablet 0.5 mg (Clonazepam), a controlled substance, for administration of 1 tablet by mouth once daily for anxiety. The medication was signed at 3:10 PM, though it was scheduled for 9:00 AM, for Resident #49. When questioned, the nurse stated her pen had run out earlier and she forgot to obtain a new one to complete the signature.Record review of a policy titled, Medication Administration, 09/18 stated 1. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. Medications should not be given at mealtimes or in the dining room unless specifically ordered with meal.Interview on 10/02/2025 at 06:26 PM with Director of Nursing (DON) stated Nurses are required to sign the narcotic book immediately upon administration of medications and should not wait hours after giving the medication. A medication is considered late if it is administered more than one hour past the scheduled time. The acceptable time frame for giving medications is within one hour before or after the scheduled time. Penalties for late administration may include verbal or written warnings. Medication tracking is performed by checking every other day and conducting a weekly review on Thursdays, which includes reviewing the Electronic Medication Administration Record (EMAR) and narcotic books. Nurses receive education on medication storage, and the medication pass annually and as needed, provided by the Assistant Director of Nursing (ADON), unit manager, or myself.

Based on observations, record reviews, interviews, the facility failed to ensure medications and biologicals are stored in accordance with professional standards in keep the unit one medication storage room and three medications: as evidence by twelve expired Nutritional Supplement in the medication storage room on unit one and expired insulin on medication cart three. There were 160 residents that resided in the facility at the time of survey.The findings include: On 09/29/2025 at 02:45 PM, the medication storage room in unit 1 was observed with the Assistant Director of Nursing (ADON). It was revealed that the medication log was signed for daytime on 09/29/25. Twelve Nutritional Supplement feedings were found to be expired, with an expiration date of 05/01/2025 (photo evidence available). Termite and rodent droppings were observed in the cabinets. Interview with the Director of Nursing on 10/02/2025 at 06:26 PM stated Expired medications should never be present in the medication carts or medication storage rooms. On 9/29/25 at 3:50 PM, during a medication storage check on the Station 3, back medication cart with Staff C, Licensed Practical Nurse (LPN), an observation was made of an expired bottle of insulin labeled open date 8/30/25 and expiration date 9/28/25 and an unopened bottle of insulin (photo evidence). On 9/29/25 at 4:05 pm Staff C, Licensed Practical Nurse (LPN) was interviewed about the facility's protocol for medication storage and stated: When the insulin is unopened it is kept in the fridge and any expired insulin bottles are discarded. Interview on 10/01/25 at 10:48 AM, Staff A, Registered Nurse (RN) unit manager, about the identified concern. The Unit manager stated, I check the med carts and treatment carts in section 3 once a week on Fridays. I educate the nurses to check all meds for expiration dates. Record review of The Facility's policy titled, Medication Storage 9/18 4.1 STORAGE OF MEDICATION POLICY revealed Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observations, records reviewed and interviews, the facility failed to ensure privacy of confidential information on three (units three, four and five) out of five nursing stations as evidenced by an unattended unlocked computer screen with information visible and information was on top of a treatment cart. The findings included: Observation on 7/23/25 at 6:50 AM of the unit three nursing station revealed an unattended unlocked computer screen with visible resident information. (Photographic evidence). The surveyor notified Staff C, Licensed Practical Nurse (LPN) who was on the unit away from the computer at the time of observation. Staff C, LPN was asked about the facility's protocol for protecting resident information and stated: When I am away from the computer the screen should be turned off to protect residents' information. On 7/23/25 at 6:55 AM an observation on unit four nursing station revealed a document with Resident information was left on top of a treatment cart in the hallway unattended. (Photographic evidence). The surveyor notified Staff D, LPN and asked about the facility's protocol for protecting residents' information; Staff D, LPN stated: All information is to be kept private, and I don't know who left that on top of the cart. On 7/23/25 at 7:01 AM an observation on unit five nursing station revealed an unattended unlocked computer screen with visible resident formation. (Photographic evidence). The surveyor notified Staff E, LPN and asked was asked about the facility's protocol for protecting resident information and stated, I left it open because I was helping a resident. The screen should be off for privacy. Record review of a policy titled: Health Information Management: Privacy effective date: January 2013 revised dates: July 2016; August 2017; April 2018; May 2018; May 2020 indicate: It is the policy of the Facility that compliance with the Privacy Rule is maintained to assure that individual's health information is properly protected while allowing the flow of personal and health information needed to promote the highest quality of health care and to protect the public's health and well-being. The Facility will protect individually identifiable health information held or transmitted, in any form or media whether electronic, paper, or oral.

Based on record review and interviews facility failed to protect one (Resident #1) out of three sampled residents' right to be free from abuse and neglect, as evidenced by a staff member witnessed Resident #1 being physically abused (slapped on the buttocks) during hygiene. The findings included:On 7/14/25 a federal report of allegation of abuse was received. The facility reported an incident of Staff B, Licensed Practical Nurse witnessing Staff A, Certified Nursing Assistant (CNA) slap Resident #1 on the buttocks during hygiene care. The facility suspended the alleged perpetrator, investigated and notified the required government authorities, physician and family member of Resident #1. The facility concluded that the incident was verified. On 7/23/25 at 7:30 AM Resident #1 in bed, eyes closed, no apparent distress; at 1:00 PM Resident#1 observed in a recliner in room speaking incoherently. Record review of a demographic sheet revealed Resident #1 was admitted on [DATE] with diagnosis that included: Cerebral infarction, Cognitive communication deficit and Alzheimer's disease. Record review of a Quarterly Minimum data Set reference dated 4/15/25 revealed Resident#1 had Brief Interview of Mental Status score of 00, indicating severe cognitive impairment, was dependent for all hygiene care, speech unclear, and rarely/ never understood or understands. Record review of revealed Resident #1 had a care plan for Activities of daily living Self Care Performance Deficit initiated on 6/19/23 and revised on 12/05/24 with interventions that included: Converse with resident while providing care, explain tasks to be performed including what resident will do and what staff will do, provide assistance as needed to perform ADL functions. Record review of the electronic health record revealed a nursing note dated 7/14/25 at 1:25 PM written by Staff B, Registered Nurse revealed: I saw the CNA hit [Resident #1] with open right hand very hard to the resident on the right gluteus. I made noise because I was in shock and the CNA did not expect me behind her and she turn around told me Do not talk with her finger too. she left the room. Nurse in charge was reported immediately. Responsible party reported. MD (Medical Doctor) aware. Interview on 7/23/25 at 4:37 PM. the Director of Nursing (DON) stated: On 7/14/25 around 10:00 AM, I was in the morning clinical meeting and I was notified by [Staff B, RN] that she witnessed [Staff A, CNA] slap [Resident #1]. I immediately went to the room, removed the [Staff A] CNA from the room. At that time, [Staff A, CNA] was interviewed and revealed she slapped [Resident #1] on the right buttocks because the resident would not stop crying and she had other stresses and didn't know what came over her. [Staff A, CNA] was suspended pending investigation. A skin and pain evaluation for [Resident #1] and the family was notified. We also interviewed residents and staff and completed a full house in-service on Abuse and Neglect. Our conclusion was that no other residents were harmed, and no other staff witnessed any incidents. The incident was verified. [Staff A, CNA] received a disciplinary write up due to not accepting the assignment because she said she arrived first and should be able to keep her assignment State community-based agency department police were notified. The incident was verified due to the nurses and CNA statements. I followed up with the family to let them know the process. The nurses completed a full skin check for all the residents that the CNA may have come in contact with. The CNA is currently suspended and has not returned for active duty. Record review of a Policy titled, Topic: Abuse Prevention Program Effective: 2012 Change Date(s): December 2016; May 2019; January 2020; August 2020; January 2021; March 2021; March 2022; August 2022; November 2024 POLICY: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events.

Based on observations, records reviewed and interviews, the facility failed to properly secure medications on two (Units 1 and 5 out of five Nursing Units as evidenced by an unattended unlocked medication cart on Unit one and medication left on top of an unattended medication cart on Unit five. There were 162 residents residing in the facility at the time of the survey The findings included: On 7/23/25 at 6:58 am An observation was made on Nursing unit 1 of an unlocked unattended medication cart on (photographic evidence). The Surveyor notified Staff F, supervisor Registered Nurse (RN) who was in the hallway away from cart. The surveyor asked Staff F, supervisor Registered Nurse (RN) about the facility's protocol for storing medication and Staff F, RN replied, The cart should be locked when I am not in front of it. On 7/23/25 at an observation was made on Nursing Unit five unattended medication cart on top of the medication cart (photographic evidence). The Surveyor notified Staff E, Licensed Practical Nurse (LPN) and asked about the facility's protocol for storing medication and Staff E, Licensed Practical Nurse (LPN) stated, Medications should be inside the medication cart but I got nervous. Record review of a policy tiled Medication storage 2007 revealed Policy: Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observations records reviewed and interview , used the facility failed to implement infection prevention and control practices; as evidence by several observations revealed residents' rooms were cluttered, had open food items, spoiled food items, linen observed on floor, dirty bathroom and showers, urinal on floor with urine seen from hallway, soiled gauze pads observed on resident's nightstand, used syringe, suction tubing and disposable gown on top of residents' wardrobe, staff failure to wear Personal Protective Equipment (PPE), drainage bag for indwelling catheter on floor, empty food container in residents' room swarmed with flies, soiled floors and trash on floors, increasing the potential for the contracting and spreading of diseases. The findings include. On 03/03/2025 starting at 7:10 AM, during observational tour of the facility; infection prevention and control concerns identified included but not limited to several residents' rooms were noted unorganized, cluttered, dirty bathrooms, soiled floors, dirty bathrooms, linen on floors and open food items in residents' rooms. (Photographic Evidence) Observation on 03/03/2025 at 7:35 AM, in the room that resident numbers 6,7 and 8 reside revealed open food items, empty food container swarmed with flies, open milk, rotten mango with flies, open crackers, box on the floor with open cookies, urinals on the floor and dirty bathroom. (Photographic Evidence) On 03/03/2025 at 11:47 AM, Resident #7 was not in the room, open milk containers, an unwrapped sandwich, empty food container with flies and other items were observed on the over bed table. (Photographic Evidence). On 03/03/2025 at 7:38 AM the floor in Room # 21 was noted soiled with brown stains and trash on the floor. On 03/03/2025 at 11:46 AM, a urinal with urine in room [ROOM NUMBER] was visible from the hallway. (Photographic Evidence) On 03/03/2025 at 11:47 AM the floor in room [ROOM NUMBER] was still soiled and had trash on the floor. (Photographic Evidence) On 03/03/2025 at 11:39 AM, linen was observed on the floor visible from hallway. Observation on 03/03/2025 at 8:18 AM, uncovered linen noted on a chair falling to the floor that was soiled and had trash. Observation on 03/03/2025 at 11:56 AM, the floor was still soiled and had trash.(Photographic evidence) Resident #9 On 03/03/2025 at 7:45 AM, Resident # 9 was observed in bed awake and alert, with Tracheostomy in place and feeding infusing via Gastronomy Tube (G-Tube). There were soiled gauze pads on the resident's bedside table and an open packet of unused gauze pads. There were flies in the room and on the gauze pads. (Photographic Evidence) Observation on 03/03/25 at 8:18 AM, Resident # 9 was awake in bed and waved when greeted, the soiled gauze pads and the open packet of unused gauze pads were still on the bedside table; and flies were noted in the room. (Photographic Evidence) Observation on 03/03/2025 at 12:10 PM, the soiled gauze pads had flies and open packet with the unused gauze pads were on Resident #9's bedside table. (Photographic Evidence) Observation on 03/04/2025 at 7:57 AM, Resident # 9 was awake in bed. The soiled gauze pads had flies and an open packet of gauze pads from the day prior were still on the bedside table. (Photographic Evidence) Review of Resident # 9's clinical records documented the resident was readmitted to the facility on [DATE]. Clinical diagnoses include but not limited to Acute and Chronic Respiratory Failure with Hypoxia. Review of Resident # 9's 14-day Admission assessment dated [DATE], revealed the resident requires Tracheostomy care. Nutritional Approach indicate the resident requires use of a feeding tube and therapeutic diet. Resident #10 On 03/03/2025 at 7:46 AM Resident # 10 was asleep in bed, the drainage bag for the indwelling catheter was observed on the floor. On 03/03/2025 at 12:10 PM, Resident #10 who is under Enhanced Barrier Precautions (EBP) was being provided hygiene care by Certified Nursing Assistants (CNAs) Staff N, and Staff O; both CNAs were only wearing gloves but no gown as is required. Observation on 03/04/2025 at 7:58 AM, Resident #10 was asleep in bed, the drainage bag for the indwelling catheter was on the floor in a grocery bag. (Photographic Evidence) Review of Resident #10's clinical records revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include but not limited to Paraplegia, Bacteriuria, Seizure Disorder and Unspecified psychosis not due to a substance or known physiological condition. Resident #10's Care Plan indicate the resident requires Enhanced Barrier Precautions related to presence of a chronic wound and/or indwelling medical devices. Resident uses a Urinary catheter with risk for infection and/or complications: If rejection of care is noted, discuss with resident preferences for time or routine changes in daily activities and honor if within reasonableness. Interview on 03/04/2025 at 8:32 AM with Staff O, CNA, regarding the required PPE that should be worn when providing care for residents such as Resident # 10 who is under EBP due to an indwelling catheter. Staff N, CNA acknowledged she was only wearing gloves and stated: I should wear gloves and gown when giving care for residents on Enhanced Barrier Precaution at all times. Interview on 03/04/2025 at 8:09 AM, Staff D, Registered Nurse (RN was shown the identified concerns that included the soiled gauze pads and the open packet with unused gauze pads left on Resident # 9's bedside table that had been there since the day prior. Staff D, RN was shown the grocery bag with Resident # 10's catheter bag on the floor, the used syringe, the suction tubing and the yellow gown on the top of the residents' wardrobe. Staff D, RN acknowledged the concerns. Interview on 03/04/2025 at 08:11 AM with CNAs Staff L and Staff P regarding the urinal on the floor the day prior, they revealed it should not have been there because of privacy and infection control. On 03/04/2025 at 8:40 AM Staff J, Licensed Practical Nurse (LPN) was shown pictures of some identified infection concerns, She stated: The linen should never be on the floor and the rooms should be cleaned by housekeeping, when the resident food items are done the staff must toss it out and the milk must not be left to get warm because the resident can become sick, we try to encourage the residents to keep the rooms clutter free but they go out and bring more an that is a safety problem and infection control problem. Interview on 03/04/2025 at 9:22 AM the Infection Control Preventionist was informed of the that infection control concerns identified. She indicated that staff gets confused with what Personal Protective Equipment they should wear when providing direct care for residents on Enhance Barrier Precaution. When asked about some of the other identified concern related to specific residents using a resident centered approach, she was adamant that the residents are not compliant, are aggressive and will not cooperate. The Administrator joined the meeting and was apprised of the identified infection control and prevention that increased risk for pests and diseases. On 03/04/2025 at 9:57 AM the Environmental Services Director revealed the floors are cleaned daily and as needed. Review of the facility's Policy and Procedure topic titled: Infection Prevention and Control Program effective October 2021 indicate: The Infection Prevention and Control Program is a comprehensive program that addresses detection, prevention and control of infections and communicable diseases among residents, visitors, volunteers, those individuals providing services under contractual agreement and personnel. The Infection Prevention and Control Program . The goals of the Infection Prevention and Control Program are to: a. Provision of a safe sanitary, and comfortable environment b. Decrease the risk of infection and communicable diseases development and transmission to residents, volunteers, visitors, individuals providing services under a contractual arrangement and personnel. c. Monitor for occurrence of infections and communicable diseases and implement appropriate prevention measures to reduce occurrences d. Identify and correct problems relating to infection control and prevention practices. The facility's Policy For Enhance Barrier Precautions with effective April 2024 Indicate: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission .that employ targeted gown and glove use during high contact resident activities .EBP is indicated for residents with any of the following . 2. Wounds and/ or indwelling medical devices even if the resident is not known to be infected or colonized with a multi-drug-resistant organism.

Based on observations, records reviewed and interviews the facility failed to ensure residents residing in the facility had a safe clean and clutter free environment; as evidenced by observations of several residents that included but not limited to: Resident #6, Resident #7, Resident #8, Resident #11 and Resident #12 call lights were not within the residents reach in the event immediate assistance is needed. (photographic evidence). 2)The facility failed to ensure residents' rooms were organized in a manner that provided a pest free and safe environment. 3} The facility failed to ensure emergency exits were clear and unobstructed. (photographic evidence) The findings include: On 03/03/2025 during multiple observations conducted between the hours 7:29 AM to 8:32 AM revealed call lights were out of reach for several residents that included but not limited to Resident # 4, Resident #6, Resident # 7, Resident # 8, Resident #11 and Resident # 12. Observations on 03/03/2025 at 11:54 AM revealed call lights remained out of reach for several residents. Observations on 03/04/2025 at 7:40 AM revealed call lights were out of reach for Resident # 4, Resident #6, Resident # 7, Resident # 8, Resident #11, Resident # 12 and several other residents. Record review of the facility's policy and Procedure; Topic titled Physical Environment effective August 2024 -Item 5. Indicates: ensure an applicable working system is in place and within reach for the resident to summon assistance, including, but not limited to: Typical call light with cord, Manual call bell and Specialty call bell as needed. Interview on 03/03/2025 at 7:34 AM Staff E, Certified Nursing Assistant (CNA) stated: the call light must be near the resident to call for help. Interview on 03/03/2025 at 11:40 AM Staff K, CNA stated: I put the call lights on the bed rail or on the patient lap so they can call for help. I don't do it for all of them because some of them don't use it. Interview on 03/04/2024 at 7:45 AM with Staff B, Licensed Practical Nurse (LPN). She stated: The call lights must be within reach for the resident and staff also family, I make rounds at start of shift to check, but sometimes the resident don't want the call light, and remove the call light and we have to keep explaining why they need it. Staff B was asked if she documented when a resident does not want the call light within reach, she stated, no. On 03/03/2025 at 7:22 AM revealed Fire Exit Door #3 was obstructed by two wheelchairs and two recliners. Observation on 03/03/2025 at 8:05 AM revealed Fire Exit Door #17 was blocked with a soiled linen bin and a clean linen bin. (photographic evidence) Observations on 03/03/2025 at 8:18 AM revealed Resident #4 in bed awake covered with a white blanket that was torn and shredded at that time the resident revealed she was cold. During a second observation on 03/03/2025 at 11:56 AM Resident #4 was awake in bed covered with the torn white blanket. On 03/03/2025 at 8:19 AM observation revealed floor in room [ROOM NUMBER] soiled , red stains on floor, cup cover on floor. Observation on 03/03/2025 at 11:54 AM floor in room [ROOM NUMBER] soiled and cup cover and straw observed on floor. On 03/03/2025 at 11:57 AM Staff K, CNA was asked about the torn blanket. Staff K revealed the resident was cold and there were no additional blankets available. Observations on 03/03/2025 and on 03/04/2025 room [ROOM NUMBER] was noted cluttered, floor soiled and open food items and rotted fruit swarmed with flies. On 03/03/2025 and on 03/04/2025 flies were observed in Room numbers 106, 107, 108 and 109. On 03/04/2025 at 8:15 AM Staff D, Registered Nurse (RN) was asked about the flies observed in rooms 106 to 109. Staff D acknowledged the concerns with the flies and revealed pest control services comes on a regular basis. Staff D revealed the emergency exit should not be blocked and she ensure the staff keep the area clear. Interview on 03/04/2025 at 9:57 AM with the Environmental Services Director regarding the identified concerns and the photographs shown. She revealed it is hard for the staff to remove the soiled linen without blocking the emergency door. When asked about the clean linen and the soiled linen bins located in the same area blocking the door, she stated the clean and soiled linen should not be close to each other should not be blocking the exit door and can be avoided if only the soiled bin was being emptied. When asked about the cleaning of the floors and residents rooms she revealed the rooms and floors are cleaned daily and garbage pans emptied as needed. On 03/04/2025 at 10:26 AM during the environmental tour with Maintenance Staff. He acknowledged the facility has a problem with flies and he revealed the facility has the zappers in the hallways and in the area (section 5) there are more zappers and pest control comes to the facility weekly. Facility policy and procedure titled Physical Environment effective August 2024 Policy: A safe, clean, comfortable, and home-life environment is provided for each resident, allowing the use of personal belongings to the greatest extent possible.areas are provided to enable staff to provide residents with needed services. Procedure: 1. Encourage residents to bring their individual possessions within the limits of the safety of the resident and others. 2. Maintain sufficient space and equipment in dining, health services, recreation, and program areas. Remove unnecessary clutter. 4. Assure resident care equipment is clean, properly stored, and identified. Topic: Pest/Insect Control: Policy- The facility strives to protect the residents, staff and visitors from insects and other pests by controlling infestation through contracts with outside pest control agencies. Each facility will contract with a pest control agency . Evaluate effectiveness of services and contact pest control agency if additional services are needed.

Based on observations, records review and interviews, the facility failed to provide adequate respiratory care and services for two residents, (Resident #4 and Resident # 5) as evidenced by failure to ensure oxygen was being administered at the correct flow rate ordered. (Photographic evidence) The findings include. On 03/03/2025 at 8:16 AM Resident # 4 was observed in bed awake with oxygen at a flow rate of 4 Liters Per Minute (LPM) via nasal cannula. Review of Resident #4's clinical records revealed the resident was initially admitted [DATE] and readmitted to the facility on [DATE]. Clinical diagnoses include Chronic Obstructive Pulmonary Disease with Exacerbation, Acute Respiratory Failure with Hypoxia and Shortness Of Breath (SOB). Review of the Physicians orders for March 2025 revealed the resident should be receiving oxygen at 2 LPM PRN (as needed) for SOB. Observation on 03/03/2025 at 12:01 PM, Resident # 4 was awake in bed with oxygen at a flow rate of 4 LPM. On 03/03/2025 at 8:17 AM, Resident # 5 was observed in bed asleep with oxygen at a flow rate of 3 Liters Per Minute (LPM) via nasal cannula. Review of Resident # 5's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include Interstitial Pulmonary Diseases and Acute Respiratory Failure with Hypoxia. Review of the Physicians orders for March 2025 revealed the resident should be receiving oxygen at 2 LPM continuously. Observation on 03/03/2025 at 12:00 PM, Resident # 5 was in bed with oxygen at a flow rate of 3 LPM. During an interview on 03/03/2025 at 12:05 PM, Staff G, Registered Nurse (RN) was asked to verify the oxygen flow rate orders for Resident # 4 and Resident#5. Staff G, RN revealed Resident# 4's order is for oxygen at 2 LPM PRN and Resident # 5's order is for oxygen at 2 LPM continuously. When Staff G, RN, was shown the flow rate settings on each concentrator she acknowledged the rates were incorrect for both residents and stated, I did not check at the start of my shift. Review of the facility's Policy and Procedures documented: Topic Oxygen Therapy. Effective November 2023. Policy indicate: Oxygen is provided to residents based on physician's orders to supplement oxygen as needed per disease process. Procedure: indicates: Item 1. Verify physician order. Item 7. Apply device to the resident with appropriate liter flow.

Based on interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F880 Infection Prevention & Control. These deficient practices have the potential to affect 168 residents residing in the facility at the time of the survey. The findings included: Record review of Quality Assessment and Assurance (QA & A) Compliance policy and procedure (effective date July 2022). The purpose of the committees is to review and analyze facility related data, evaluate improvement plans effectiveness and direct appropriate actions for the facility response. Systems failures and/or in-depth analysis of processes are addressed through development of a QAPI. QAPI requires a systematic review of data, identification of the root cause(s) of the systems failure and implementation of corrective actions. Review of the facility's survey history revealed, during a recertification survey with exit dated June 13, 2024, F880 Infection Prevention & Control was cited. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 12/31/24, 01/30/25 and 02/27/25: documented the facility had a QAA Committee meeting monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON) and other department heads. Interview with the Administrator on 03/04/2025 at 11:15 AM. He revealed the QAPI (Quality Assurance and Performance Improvement) meetings are held on the last Thursday of each month or as needed. He stated that QAPI committee members are Administrator, Director of Nursing, Assistant Director of Nursing, Infection Preventionist, Risk Manager, Staff Development Coordinator, Clinical Reimbursement Director, Program Manager, Maintenance Director, Housekeeping/Laundry Supervisor, Social Services Director, Activity Director, Food Service Manager, Business Office Manager, Admissions Coordinator, Medical Records, Pharmacy, Registered Dietitian and Unit Managers. He stated, The purpose of the QAPI committee is to make sure that we are doing everything in our power so that to ensure quality care and the systems are remaining function and to identify anything we can improve where we failed. Where we identify failures, we will implement a plan to correct and follow-up biweekly.

Based on observations, record review and interview, the facility failed to ensure safety for all residents the residents in the facility as evidence by a knife was observed in one (Resident #46) out of eight residents sampled. Staff failed to intervene in a timely manner during an argument between two residents (Resident #128 and Resident #170) that enabled Resident #170 to strike Resident #128, which led to Resident #170 being arrested by local law enforcement. The facility's incidents by incident types report from January 2023 to June 10, 2024 revealed there were six alleged abuse incidents and nine incidents of resident-to-resident altercation. There were 136 residents residing in the facility at the time of this survey. 1) During initial observation on 6/10/2024 at 9:15 AM in the room shared between Resident #115, Resident # 46, Resident # 130 and Resident #138, it was noted upon entrance that a small white pill was on the floor (photo taken). observation of Resident # 46's top drawer that was noted open showed a long knife in the drawer with a blade approximately four inches long (photo taken). Resident # 46 was not in the room but her three roommates were. The survey's Team Coordinator (TC) was immediately notified. The Director of Nursing (DON) and the Administrator (NHA) were informed of the findings by the team and an observation was made with the DON and the NHA who acknowledged the knife in the resident's drawer. The DON and NHA were informed of the seriousness of any resident possessing a knife in the facility. The DON and NHA immediately had staff check all the resident's rooms and drawers for any prohibited items. The knife was immediately removed from the room. The pill on the floor was also removed and disposed of by the DON and NHA. Record review of Resident #46s clinical records revealed an initial admission of 12/17/2010 and most recent readmitted [DATE]. Diagnoses include but not limited to Type 2 Diabetes Mellitus, Anxiety Disorder and Insomnia. Review of Resident #46's Annual Minimum Data Set (MDS) dated [DATE] section C for Cognitive Pattern documented a Brief Interview of Mental status of 13 out of 15 this suggests the Resident's cognition is intact. Section D for mood document rarely for social isolation Section E for Behaviors showed no behavioral symptoms. On 06/10/2024 at 9:45 AM the DON called an emergency Resident Council meeting. In attendance at the meeting were the Assistant NHA, DON, NHA, Resident Counsel President, Activities Director and 15 residents. The DON asked if anyone had knives in their belongings and if knives are allowed, the residents responded no. One resident commented that a knife can be used to harm another person and verbalized understanding why no knives are allowed. The Residents Counsel President (Resident #46) then revealed she has a knife in her room to cut mangoes and she knew knives are not allowed. There were residents engaging in conversation and made statements such as: Why do I need a knife when I have these (showing his fist). The DON again announced that knives and sharp objects are not allowed. The meeting was adjourned at 10:21 AM. On 06/10/2024 at 10:25 AM the Resident #46 approached the surveyor and revealed I feel bad about what I did. Resident #46 stated I will be fasting until 11:00 AM tomorrow (10/11/2024) and I am going to church the following day (10/12/2024) and you can speak with me after. Interview On 06/13/2024 at 9:04 AM, Resident #46 revealed: I took the knife from my sister's house on Sunday to peel my mangoes. I know I should not have the knife and they (DON and NHA) told me because of me they are getting a tag. I feel bad about it. I was not going to hurt anybody with it. When my son comes next week he can get it. My son said mom, you know you should not have a knife. my family is mad with me too and I feel bad. Resident # 46 then asked: Do you know where the knife is, who took it, where did they put it? Resident #46 was asked why she is asking where the knife is and who has it. Resident #46 stated: I need it for when my son comes next week, so he can get it. Resident # 46 was informed that when her son comes for it the facility's staff will speak with him and give the knife to him to take home. Resident #46 has three roommates that reported they had no concerns and get along with each other. Resident #115 was admitted to the facility on [DATE] and is bedbound. Clinical diagnoses include Hemiplegia and Hemiparesis and Major Depressive Disorder., according to the quarterly MDS dated [DATE] in section C for cognitive Pattern indicates a Brief Interview of Mental Status (BIMS) score of 13 out of 15 this suggests the resident's cognition is intact. Resident # 138 was admitted to the facility on [DATE], Resident #138 is ambulatory and also uses a wheelchair to get around. Clinical diagnoses include unspecified Mood Affective Disorder. Review of the quarterly MDS dated [DATE] indicates a BIMS score of 15 out of 15 this suggests Resident #138 cognition is intact. Resident #130 was initially admitted to the facility on ,d+[DATE] 2023 and readmitted on [DATE], Resident #130 is ambulatory. The clinical diagnoses include but not limited to Conduct Disorder unspecified, Bipolar disorder, Major Depressive and Anxiety disorder. Review of the quarterly MDS dated [DATE] in Section C for Cognitive Pattern the resident has a BIMS score of 14 out of 15 to indicate Resident #130 cognition is intact. On 06/12/2024 at 9:15 AM during an interview with the DON and NHA; the DON reported that the staff did a sweep and looked at all residents draws and rooms for any sharp items that are not allowed. The DON stated: I don't think she would use the knife inappropriately she is alert and oriented and has no history both past and present of harming anyone. She is a hoarder; her side of the room is cluttered. We check back and forth we check her draw, and it is now locked she was educated, and she has been given a food peeler and she is in agreement and area to keep locked. her room mates are alert, and oriented [Resident #115] is non ambulatory and has history of checking to see who is entering the room. The concierge will be checking their assigned area each day for the block assigned if residents refuse to have drawers checked based on policy if resident refuse we can call law enforcement. The NHA and DON were informed that the food peeler is a sharp object. They both revealed other option will be considered such as informing the resident to ask staff to peel her mangoes. The DON and NHA were asked if they understood that the knife found could be used by anyone to inflict harm both accidentally and intentionally. The DON stated: As far as harm goes, no harm was done. Possibility of harm, no because this resident would not cause any harm. When the resident went out on pass Sunday she took it back and based on residents' rights it is dignity and residents rights to search them when the return from pass. We are going to develop something for safety, we spoke to the sister, and she stated that the resident took the knife back to the facility to peel mangoes. During the resident Council meeting with about 15 residents and concierge we told the other residents not to take anything that can cause harm and when the sweep was done we found nothing. The DON and NHA were asked what if another resident, staff or visitor had found or knew about the knife. The DON stated: The other residents in room would not allow any other resident to pass. The NHA and DON were reminded that the drawer was open, and the knife was visible when they checked the room with the surveyor and only one resident (Resident #115) was in the room. The DON stated no harm was done and the possibility exist for any resident or staff. The DON and NHA were asked how the facility could have prevented this situation, based on the fact that three out of four residents residing in the room is capable of using a knife; and the possibility exist because Resident # 115 was in the room, and she is not ambulatory to stop anyone from harming her; also, a staff member could have gone in the room and harm themselves while checking the drawer. The DON and NHA agreed and reported that the possibility existed for the residents, any staff member and anyone visiting the facility could have been harmed if the knife somehow got into the hands of anyone with bad intentions. The resident who had the knife may be alert and oriented, but it cannot be predicted that the resident would never do any harm with the knife but at the same time the resident could harm herself either intentionally or accidentally. When asked what the facility did and will do to prevent this incident from reoccurring? The NHA stated: The system in place would violate the resident's rights to check the residents' drawers. The resident took the knife in on Sunday night, she knew that she should not bring the knife and no sharp objects. The DON and NHA revealed the facility has a sign posted indicating NO GUNS ALLOWED and nothing indicating no knives, so moving forward the sign will be updated to include knives and sharp objects. The DON and NHA revealed the admission records had nothing indicating that no knives are allowed in personal items or in possession of any resident. Also, the facility's policy did not indicate that knives are not allowed. The NHA and DON indicated that the policy will be revised. The DON and NHA acknowledged that this is a major Safety issue. 2) Observation and interview on 06/13/2024 at 9:22 AM Resident #128 was alert and oriented with no sign of distress. Resident # 128 agreed to be interviewed. When asked about the incident on 04/17/2024, Resident #128 reported Resident #170 picked on him before, but he ignored him. It was dinner time went to sit with some women, he told me to move from the table, I did not move from the table, he punched me in the face and busted my lip. Review of Resident # 128's clinical records revealed, Resident # 128 was admitted to the facility on [DATE]; clinical diagnoses include but not limited to cerebral infarction, dysphagia, type 2 diabetes mellitus, schizophrenia, bipolar disorder, current episode manic severe with psychotic features. Review of Resident #128's Quarterly Minimum Data Set (MDS) dated [DATE] Section C for Cognitive Pattern, Brief Interview of Mental Status (BIMS) documented a score of 15 out of 15 indicating the resident is cognitively intact. Section D for Moods and Section E for Behaviors did not indicate the resident having any moods and behaviors. Review of Resident #170's clinical records documented an admitted [DATE] with an initial admitted [DATE]. Clinical diagnoses include but not limited to type 2 diabetes mellitus, Post Traumatic Stress Disorder (PTSD) and Paranoid Schizophrenia. Resident # 170 was discharged from the facility on 04/17/2024. Review of Resident #170's quarterly MDS dated [DATE] Section C for Cognitive Pattern BIMS documented a BIMS score of 15 out of 15 indicating the resident is cognitively intact. Section D for Moods and Section E for Behaviors did not indicate the resident had any moods or behaviors. Record review revealed both residents did not have any change in medications. Record review of the Nursing Home Federal Report revealed that on 04/17/2024 at 5:55 PM Resident #128 reported an allegation of abuse to Registered Nurse (RN) Staff K, who then reported this to the Director of Nursing (DON). The DON immediately reported to the Nursing Home Administrator (NHA) at 6:30 PM. The NHA reported the incident. The incident was reported but did not reach the criteria to be accepted for further investigation. The reported documented: [Resident #128] reported that [Resident # 170] told him to move from the table and then hit him on the face after he refused to leave the dining room table where he was sitting. [Resident #128] sustained a skin tear to the upper lip. With no pain concerns. He remains at his usual behavioral baseline participating in usual activities with no distress. Further review revealed Resident #170 was arrested by law enforcement due to aggressive behavior. Case number provided. Steps were taken to ensure residents are protected and included emotional support provided confirming [Resident #128] felt safe. Skin and pain assessment completed with no concerns. The resident's Physician was notified, and orders were received for facial x-ray and neuro checks. The resident's responsible party was notified. Review of interviews of others that may have knowledge of the alleged incident documented indicated that three Certified Nursing Assistants, one Licensed Practical Nurse and one Registered Nurse and the supervisor confirmed the incident and interviews with four residents indicated one resident was sitting at the table and witnessed the incident and other resident heard loud voices. On 04/17/2024 Certified Nursing Assistant [] confirmed that while passing trays for dinner, she heard the residents arguing and immediately assisted in separating the two individuals. On 06/12/2024 at 11:20 AM the report was reviewed with the Administrator regarding the incident. Several Attempts to interview staff that witnessed the incident by phone with no success. Review of the facility's policies and procedures with most recent change date August 2022 document: the facility has implemented processes which strive to reduce the risk of abuse, neglect exploitation, mistreatment and misappropriation of resident's property. These policies guide the identification, management and reporting of suspected or alleged, abuse, neglect, mistreatment and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events.

Based on observations interview and record review, the facility failed to their Quality Assurance Performance Improvement policy and demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F550-Resident Rights/Exercise of Rights and F725 Sufficient Nursing Staff. The findings included: Review of the facility's survey history revealed, during a recertification survey with exit dated January 12, 2023 the facility was cited F550-Resident Rights/Exercise of Rights based on staff failure to ensure dignity during dining and F725 Sufficient Nursing Staff. During this survey with exit date of June 13, 2024, the facility was cited F550-Resident Rights/Exercise of Rights related to staff standing while feeding a resident (Resident #131) and observation of two residents (Resident #27 and Resident #473) wearing hospital type gowns in dining area and F725 Sufficient Nursing Staff. On 6/13/2024 at 3:02 PM Quality Assurance and Performance Improvement (QAPI) overview was conducted with the NHA, DON and Assistant NHA. It was reported that the last meeting was held on 5/21/2024. The DON reported the meetings are held monthly and all department heads attends the meetings. For concerns with dignity the DON reported education is ongoing. Anything that occurs we educate the staff. For staffing concerns the NHA and DON reported the facility does not use Agency staff. The DON revealed: On weekends we add the unit manager but from Monday to Friday a unit manager on each unit. On the weekends we only have one supervisor because during the weekend we have more nurses. The NHA, Assistant NHA and DON were informed that there are concerns with the facility's Quality Assurance and Performance Improvement based on the identified concerns.

Based on observation, record reviews and interviews, the facility failed to provide care, services and supervision to prevent resident to resident abuse related to two (resident #2, and resident #5) out of five residents sampled. This deficient practice enabled resident #4 to strike resident #2 on 11/12/20 and resident #5 on 3/16/21 causing injury to both residents. There were 166 residents residing in the facility at the time of the survey. On March 26, 2021, it was determined the findings of the survey posed immediate jeopardy to the health and safety of the residents admitted to the facility. The facility's Administrator, Director of Nursing and Regional Nurse Consultant were notified of the immediate Jeopardy on March 26, 2021 at 2:00 PM. The findings included: Record review of the facility's policy titled, Abuse Prevention Program with the revision date on 01/2020, the policy documented: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of resident's property. These policies guide the identification, management and reporting of suspected or alleged, abuse, neglect, mistreatment and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Review of the facility's policy titled, Behavior Management Program Overview with the effective date of 02/2021, the policy documented: The facility promotes the utilization of a behavior management program based on individual resident needs. Procedure: 4) Identify and implement interventions based on identified triggers and possible causes of behaviors; 7) Identify individual specific behavior symptom goals and interventions; 8) Communicate resident centered interventions to staff; 9) Monitor the frequency of the behavior(s) and the effectiveness of the interventions. Review of the Face Sheet for Resident #2 documented, the resident was admitted to the facility on [DATE]. Clinical [DIAGNOSES REDACTED]. Review of Resident's #2 Behavioral care plan dated 6/19/18 documented the resident exhibits the following behavior: wandering; Goal: Control/Minimize Outburst; Interventions/Tasks: Observe for changes in behavior and report to physician namely (ie.); [MEDICAL CONDITION], nervousness, loss of interest, decreased ability to concentrate, repetitive movements. Review of the event/post event progress notes for Resident #2 revealed the following: Dated 11/12/20 time stamped 18:00-Staff member reported that resident get struck in the mouth by another resident and noted with a loose tooth in front upper jaw. Staff member redirected resident back to her unit. Head to toe assessment done, no other visible injuries noted. During assessment, observed resident's loose tooth came out with scant of blood in resident mouth. Mouth care provided, Ice pack applied to resident mouth and 2 Tylenol 325mg(milligrams) given as ordered for pain. Vital signs taken. MD(Medical Doctor) made aware of resident's status, order received for dental consult. Record review of Resident #2s dental consult revealed, a dental consult was completed on 11/23/20, an annual screening was completed and the comments included, there were no signs of infection or swelling, the soft tissues were within normal limits(WNL), the resident was confused, the resident was not cooperating during the examination, the resident was not a candidate for p/ds Fab(a dental procedure) and no follow up was needed. Review of the physician's orders [REDACTED].#2 for November 2020 documented the resident did not receive any [MEDICAL CONDITION] medications and received Tylenol 325 milligrams (mg) tablets, 2 tablets orally for pain on 11/12/20. Review of the facility's Wanderers List documented three residents were known as wanderers in the facility. Resident #2 was on the wanderers list. The facility's Wandering policy and procedure and Supervision policy and procedure documentation were requested several times and never received from the facility's administrative staff. Review of the Face Sheet for Resident #4 documented, the resident was admitted to the facility on [DATE]. Clinical [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) dated 9/01/20 documented resident #4 had a BIMS Summary Score of 9 out of 15 indicating moderate impairment and noted that the resident was confused but was able to make needs known and can follow simple commands. No behaviors were noted. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] for Resident #4 indicated the residents Brief Interview for Mental Status (BIMS) Summary Score was 7 out of 15 indicating moderate impairment and noted that the resident was confused, but was able to make needs known and can follow simple commands. No behaviors were noted. Review of the MDS Significant Change dated 3/01/21 for Resident #4 indicated the residents Brief Interview for Mental Status (BIMS) Summary Score 7 out of 15 indicating moderate impairment and noted that the resident was confused, but was able to make needs known and can follow simple commands. No behaviors were noted. Review of Resident's #4 Behavioral care plan dated 11/13/20 documented the resident exhibits the following behaviors: becoming physically aggressive with staff and physically aggressive with others/peers wandering; Goals: Control/Minimize Outburst, Will not harm other residents, Will not harm themselves, Will not harm staff; Interventions/Tasks: Observe for changes in behavior and report to physician namely (ie.) (such as); [MEDICAL CONDITION], nervousness, loss of interest, decreased ability to concentrate, repetitive movements. Review of the physician's orders [REDACTED].#4 for November 2020 documented, the resident was receiving antipsychotic medications and [MEDICAL CONDITION] disorder medications. The medications were: [MEDICATION NAME] 100mg tablet, 100mg tablet oral at night (HS) for [MEDICAL CONDITION], start date was 8/26/20; [MEDICATION NAME] 50mg tablet, 50mg tablet oral twice a day (BID) for [MEDICAL CONDITION], start date was 9/30/20, end date was 11/13/20; [MEDICATION NAME] DR (Delayed Release) 250mg tablet 250mg tablet oral BID for paranoid [MEDICAL CONDITION] and [MEDICATION NAME] 200mg tablet 200mg tablet oral BID for [MEDICAL CONDITION], start date 11/13/20. The [MEDICATION NAME] was increased to 200mg after the 11/12/20 resident to resident abuse incident. Review of the POS [REDACTED]. The order was written on 3/16/21. Review of the pharmaceutical associated behavior logs for Resident #4 documented the following: November 2020: 11/3/20-Morning shift, mood changes, 11/06/20-Night shift, mood changes, 11/22/20- Morning and evening shift, mood changes, 11/26/20-Morning and evening, mood changes, 11/29/20 -Morning shift, mood changes; December 2020: Mood Changes: On 12/06/20 in the morning, 12/7/20 in the evening, 12/13/20 morning and evening, 12/19/20 evening shift, Agitation and anger: on 12/20/20 in the morning, 12/20/20 in the evening, agitation, 12/27/20 morning shift-anger and agitation, 12/29/20- agitation on the morning shift; January 2021: 01/01/21 evening shift-anger and agitation, 01/17/21-anger and agitation-evening and night, 01/21/21-anger and agitation; February 2021: 02/06/21-Evening and Night shift-anger and agitation, 02/07/21-anger and agitation, 02/21/21-anger and agitation, 02/23/21 evening shift-paranoia and anxiety, 02/24/21-agitation and paranoia, 02/26/21-agitation and paranoia during night shift; March 2021: 03/02/2021-Evening shift-anxiety and mood changes, 03/03/2021-Evening shift anxiety and mood changes, 03/09/2021-Evening shift anxiety and mood changes, 03/11/21-Evening shift anxiety and mood changes. The behavior logs for 03/16/2021 (day of the incident) had no behaviors documented and noted that the medication was effective. Further review of the behavior log in conjunction with the medications prescribed revealed, no documentation on the behavior logs related to the first reported resident to resident abuse incident on 11/12/20. Documentation after the first incident when the medication ([MEDICATION NAME]) was increased revealed incidents indicating the medication and interventions were ineffective. Review of the Behavior Progress Note for Resident #4 revealed the following: Dated 11/12/20, time stamped 16:33-Staff reported that resident had an episode of aggressive behavior during which he struck another resident. When asked, resident stated that the other resident was about to enter his room and he hit her. Resident instructed to call staff for assistance and should not be combative and to always call staff for assistance. Resident verbalizes understanding. Resident placed on one on one supervision. MD made aware. Psych consult ordered and carried out. Review of the General Progress Note for Resident #4 documented the following: Dated 11/12/20, time stamped 20:40-Resident lying in bed quietly in stable condition with staff at bedside for one on one supervision. Safety measures maintained. Bed in lowest position. Call light within reach. Review of the Psychological Consult for Resident #4 revealed the following: Dated 11/13/20-Resident denies suicidal and homicidal ideations; Diagnosis: [REDACTED]. Review of the Event/Post Event Progress Note for Resident #4 documented the following: Dated 3/16/21, time stamped 15:24-During rounds resident reported to staff that he struck his roommate. Resident stated to staff that he struck his roommate. Resident was removed from room and placed in dining room near nursing station for close observation and monitoring. MD was notified, new order given to transfer resident to local hospital for further evaluation. Diagnosis: [REDACTED]. Review of the Face Sheet for Resident #5 revealed, the resident was admitted to the facility on [DATE]. Clinical [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#5 for March 2021 revealed, the resident received nutrition and all medications via a feeding tube. Record review of the Event/Post Event Progress Notes for Resident #5 documented the following: Dated 3/16/21, time stamped 10:58-The following event has occurred: Resident to Resident Altercation; The resident is cognitively impaired and evaluation of facial expression indicates there is a little pain; Dated 3/16/21, stamped 16:40-Resident is calm. The following interventions are in place to assist in the prevention of another altercation: Separation of residents. Room changed. Educating the resident on acceptable behaviors. Upon evaluation for redness, bruising or pain, the following is noted: swollen nose and redness; Dated 3/17/21, time stamped 19:24-Resident nose swollen and is currently on [MEDICATION NAME] antibiotic and Dated 3/18/21, time stamped 00:42-Resident in bed resting in no distress. Upon evaluation for redness, bruising, or pain, the following is noted: discoloration noted on resident nose. Review of the X-Ray Results dated 3/16/21 for Resident #5 documented the following: Facial Bones, Less than 3 views (Lat(Lateral), AP(Anterior-front; Posterior-back), Waters(X-ray view with the chin raised and placed on the x-ray cassette) or Caldwell(X-ray view with the nose and forehead against the x-ray cassette); Impression: Nondisplaced fracture of indeterminate age anterior nasal bone. Review of the Telephone Orders for Resident #5 documented the following: Dated 3/16/21, time stamped 10:33-Stat Facial bone X-ray STAT for Swelling; Dated 3/16/21, time stamped 16:18-[MEDICATION NAME] tablet 875-125mg give 1 tablet via PE[DEVICE] two times a day for sinusitis for 7 days; Dated 3/16/21, time stamped 16:20-Tylenol tablet 325mg give 2 tablet via PE[DEVICE] every 6 hours for pain for 1 week and Dated 3/16/21, time stamped 16:22-Ice pack to nose for 15 minutes three times a day for [MEDICATION NAME] for 4 days. On 3/24/21 at 9:31 AM, the Director of Nursing (DON)/Risk Manager stated, On 11/12/20 at 5:35 pm, it was reported she was walking in the hallway when she was struck by a resident in front of his room. The resident(Resident #4) reported she entered his room, he told her to leave and she did not respond so he struck her at which time she turned around and left. When she was assessed she had one tooth that was very loose and the loose tooth came out and there was a small amount of blood to the upper lip. The aggressor(Resident #4) was put on one to one supervision to make sure he and others were safe. The attending physician was called and gave orders for a psych eval. The psych doctor was called, he came here and saw the resident and he did adjustments to the aggressor's medications. He did not recommend to send the resident(Resident #4) out. The resident(Resident #2) received an order for [REDACTED].#2) is a wanderer and has a care plan for wandering. She walks around. The resident(Residnet #2) had a BIMS (Brief Interview for Mental Status) score of 99 and she is confused. The resident(Resident #2) is not on any psych medications. Subsequent interview with the Director of Nursing (DON)/Risk Manager on 3/24/21 at 10:05 AM stated, On 3/16/21 at 10:50 pm, during rounds the resident(Resident #4) reported to the nurse that he struck his roommate because he was grinding his teeth and disturbing his sleep. The aggressor is alert and oriented times two. The victim is non-verbal, not alert and has total dependence. The attending physician and psychiatrist later gave orders to transfer the aggressor to the hospital for a behavioral evaluation. On 3/24/21 at 11:06 AM, Staff A Licensed Practical Nurse (LPN) stated, During rounds, resident(Resident #4) had told me he struck the roommate because he was grinding teeth and making noise. I walked over to the resident to assess him and noticed swelling on his face. I removed the aggressor from the room and placed him by the nurses' station to keep a close eye on him. The doctor was called for the resident(Resident #5) and the order was given to get an x-ray done. The x-ray results came back and I relayed the results to the doctor and she told me she was on her way to the facility. For the aggressor, the MD (Medical Doctor) was called so that we could transfer him out to a local hospital for evaluation. I know his psych medications were adjusted at one time. I have heard he had behavioral issues with other staff but never with me. Interview with the Regional Nurse Consultant on 3/24/21 at 11:57 AM about resident #4 it was stated, The resident was immediately placed on 1:1 (one to one) on 11/12/20. He had a psych consult done the next day and had a medication adjustment from [MEDICATION NAME] 50mg BID and increased to 200mg BID. Further documentation showed that the medication was effective. During a subsequent interview on 3/24/21 at 11:59 AM, the Regional Nurse Consultant stated about resident #2, She was assessed immediately and provided Tylenol right away and it was effective. She did not have any other pain or discomfort. She had a dental consult on 11/23/20. No signs or infections or swelling. During an interview on 3/24/21 at 12:27 PM, the Psychiatrist stated, I have been coming here for a long time, since 1990. In November 2020, he got into a confrontation with another resident in his room. He felt threatened. He was not suicidal, not homicidal. He was fine, that is why I didn't send him to the hospital. He was not agitated and he felt he was provoked. He would have been sent right back, if I sent him out to the hospital at that time. The only thing you can do is separate them and observe them. In order to go into the psych unit, you have to meet the criteria. I adjusted his medication and increased the [MEDICATION NAME] to 200mg BID. The March 2021, incident he had to be sent out for evaluation because he was not provoked. He had a [DIAGNOSES REDACTED]. During an interview on 3/24/21 at 1:03 PM via telephone, the Attending Physician stated, I remember he had an argument with another resident in November and hit the resident. They called me and I gave an order for [REDACTED]. During an interview on 3/24/21 at 1:18 PM via telephone, Staff C-Certified Nursing Assistant (CNA) was contacted. After attempting to contact the staff member, a voice message with the call back number was left. A second attempt was made to contact Staff C on 3/25/21 at 2:15 PM via telephone, Staff C stated, I work on the 3-11 shift. I did not see anything with both residents. That happened on the 11-7 shift. Staff C had been listed as a witness to the 11/12/20 abuse incident.

Based on record reviews and interviews, the facility failed to implement their abuse policy to address resident to resident abuse as evidenced by staff failure to provide care and services including adequate supervision to prevent infliction of harm and injury to vulnerable residents for two (resident #2, resident #5) out of five residents sampled. This deficient practice enabled resident #4 to strike resident #2 on 11/12/20 and resident #5 on 3/16/21 causing injury to both residents. There were 166 residents residing in the facility at the time of the survey. On March 26, 2021, it was determined the findings of the survey posed immediate jeopardy to the health and safety of the residents admitted to the facility. The facility's Administrator, Director of Nursing and Regional Nurse Consultant were notified of the immediate Jeopardy on March 26, 2021 at 2:00 PM. The findings included: Record review of the facility's policy titled, Abuse Prevention Program with the revision date on 01/2020, the policy documented: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of resident's property. These policies guide the identification, management and reporting of suspected or alleged, abuse, neglect, mistreatment and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Review of the Face Sheet for Resident #2 documented, the resident was admitted to the facility on [DATE]. Clinical [DIAGNOSES REDACTED]. Review of Resident's #2 Behavioral care plan dated 6/19/18 documented the resident exhibits the following behavior: wandering; Goal: Control/Minimize Outburst; Interventions/Tasks: Observe for changes in behavior and report to physician namely (ie.); [MEDICAL CONDITION], nervousness, loss of interest, decreased ability to concentrate, repetitive movements. Review of the event/post event progress notes for Resident #2 documented the following: Dated 11/12/20 time stamped 18:00-Staff member reported that resident get struck in the mouth by another resident and noted with a loose tooth in front upper jaw. Staff member redirected resident back to her unit. Head to toe assessment done, no other visible injuries noted. During assessment, observed resident's loose tooth came out with scant of blood in resident mouth. Mouth care provided, Ice pack applied to resident mouth and 2 Tylenol 325mg(milligrams) given as ordered for pain. Vital signs taken. MD made aware of resident's status, order received for dental consult. Record review of Resident #2s dental consult revealed, a dental consult was completed on 11/23/20, an annual screening was completed and the comments included, there were no signs of infection or swelling, the soft tissues were within normal limits(WNL), the resident was confused, the resident was not cooperating during the examination, the resident was not a candidate for p/ds Fab(a dental procedure) and no follow up was needed. Review of the physician's orders [REDACTED].#2 for November 2020 documented, the resident did not receive any [MEDICAL CONDITION] medications and received Tylenol 325 milligrams (mg) tablets 2 tablets oral for pain on 11/12/20. Review of the facility's Wanderers List documented three residents were known as wanderers in the facility. Resident #2 was on the wanderers list. The Wandering policy and procedure and Supervision policy and procedure documentation were requested several times and never received from the facility's administrative staff. Review of the Face Sheet for Resident #4 documented, the resident was admitted to the facility on [DATE]. Clinical [DIAGNOSES REDACTED]. Review of Resident's #4 Behavioral care plan dated 11/13/20 documented the resident exhibits the following behaviors: becoming physically aggressive with staff and physically aggressive with others/peers wandering; Goals: Control/Minimize Outburst, Will not harm other residents, Will not harm themselves, Will not harm staff; Interventions/Tasks: Observe for changes in behavior and report to physician ie. (such as); [MEDICAL CONDITION], nervousness, loss of interest, decreased ability to concentrate, repetitive movements. Review of the physician's orders [REDACTED].#4 for November 2020 documented the resident was receiving antipsychotic medications and [MEDICAL CONDITION] disorder medications. Medications were: [MEDICATION NAME] 100mg tablet 100mg tablet oral at night (HS) for [MEDICAL CONDITION], start date was 8/26/20; [MEDICATION NAME] 50mg tablet 50mg tablet oral twice a day (BID) for [MEDICAL CONDITION], start date was 9/30/20, end date was 11/13/20; [MEDICATION NAME] DR (Delayed Release) 250mg tablet 250mg tablet oral BID for paranoid [MEDICAL CONDITION] and [MEDICATION NAME] 200mg tablet 200mg tablet oral BID for [MEDICAL CONDITION], start date 11/13/20. The [MEDICATION NAME] was increased to 200mg after the 11/12/20 abuse incident. Review of the POS [REDACTED]. The order was written on 3/16/21. Review of the pharmaceutical associated behavior logs for Resident #4 documented the following: November 2020: 11/3/20-Morning shift mood changes, 11/06/20-Night shift mood changes, 11/22/20- Morning and evening shift mood changes, 11/26/20-Morning and evening mood changes, 11/29/20 -Morning shift mood changes; December 2020: Mood Changes: On 12/06/20 in the morning, 12/7/20 in the evening, 12/13/20 morning and evening, 12/19/20 evening shift, Agitation and anger: 12/20/20 in the morning, 12/20/20 in the evening agitation, 12/27/20 morning shift-anger and agitation, 12/29/20- agitation on the morning shift; January 2021: 01/01/21 evening shift-anger and agitation, 01/17/21-anger and agitation-evening and night, 01/21/21-anger and agitation; February 2021: 02/06/21-Evening and Night shift-anger and agitation, 02/07/21-anger and agitation, 02/21/21-anger and agitation, 02/23/21 evening shift-paranoia and anxiety, 02/24/21-agitation and paranoia, 02/26/21-agitation and paranoia during night shift; March 2021: 03/02/2021-Evening shift-anxiety and mood changes, 03/03/2021-Evening shift anxiety and mood changes, 03/09/2021-Evening shift anxiety and mood changes, 03/11/21-Evening shift anxiety and mood changes. The behavior logs for 03/16/2021 (day of the incident) had no behaviors documented and noted that the medication was effective. Further review of the behavior log in conjunction with the medications prescribed revealed no documentation on the behavior logs related to the first reported incident on 11/12/20. Documentation after the first incident when the medication ([MEDICATION NAME]) was increased revealed, incidents indicating the medication and interventions were ineffective. Review of the Behavior Progress Note for Resident #4 documented the following: Dated 11/12/20, time stamped 16:33-Staff reported that resident had an episode of aggressive behavior during which he struck another resident. When asked, resident stated that the other resident was about to enter his room and he hit her. Resident instructed to call staff for assistance and should not be combative and to always call staff for assistance. Resident verbalizes understanding. Resident placed on one on one supervision. MD (Medical Doctor) made aware. Psych consult ordered and carried out. Review of the General Progress Note for Resident #4 documented the following: Dated 11/12/20, time stamped 20:40-Resident lying in bed quietly in stable condition with staff at bedside for one on one supervision. Safety measures maintained. Bed in lowest position. Call light within reach. Review of the Psychological Consult for Resident #4 documented the following: Dated 11/13/20-Resident denies suicidal and homicidal ideations; Diagnosis: [REDACTED]. Review of the Event/Post Event Progress Note for Resident #4 documented the following: Dated 3/16/21, time stamped 15:24-During round resident reported to staff that he struck his roommate. Resident stated to staff that he struck his roommate. Resident was removed from room and placed in dining room near nursing station for close observation and monitoring. MD was notified, new order given to transfer resident to local hospital for further evaluation. Diagnosis: [REDACTED]. Review of the Face Sheet for Resident #5 documented, the resident was admitted to the facility on [DATE]. Clinical [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#5 for March 2021 documented the resident was receiving nutrition and all medications via a feeding tube. Review of the Event/Post Event Progress Notes for Resident #5 documented the following: Dated 3/16/21, time stamped 10:58-The following event has occurred: Resident to Resident Altercation; The resident is cognitively impaired and evaluation of facial expression indicates there is a little pain; Dated 3/16/21, stamped 16:40-Resident is calm. The following interventions are in place to assist in the prevention of another altercation: Separation of residents. Room changed. Educating the resident on acceptable behaviors. Upon evaluation for redness, bruising or pain, the following is noted: swollen nose and redness; Dated 3/17/21, time stamped 19:24-Resident nose swollen and is currently on [MEDICATION NAME] antibiotic and Dated 3/18/21, time stamped 00:42-Resident in bed resting in no distress. Upon evaluation for redness, bruising, or pain, the following is noted: discoloration noted on resident nose. Review of the Telephone Orders for Resident #5 documented the following: Dated 3/16/21, time stamped 10:33-Stat Facial bone X-ray STAT for Swelling; Dated 3/16/21, time stamped 16:18-[MEDICATION NAME] tablet 875-125mg give 1 tablet via PE[DEVICE] two times a day for sinusitis for 7 days; Dated 3/16/21, time stamped 16:20-Tylenol tablet 325mg give 2 tablet via PE[DEVICE] every 6 hours for pain for 1 week and Dated 3/16/21, time stamped 16:22-Ice pack to nose for 15 minutes three times a day for [MEDICATION NAME] for 4 days. Review of the X-Ray Results dated 3/16/21 for Resident #5 documented the following: Facial Bones, Less than 3 views (Lat(Lateral), AP(Anterior-front; Posterior-back), Waters(X-ray view with the chin raised and placed on the x-ray cassette) or Caldwell(X-ray view with the nose and forehead against the x-ray cassette); Impression: Nondisplaced fracture of indeterminate age anterior nasal bone. On 3/24/21 at 9:31 AM, the Director of Nursing (DON)/Risk Manager stated, On 11/12/20 at 5:35 pm, it was reported she was walking in the hallway when she was struck by a resident in front of his room. The resident(Resident #4) reported she entered his room, he told her to leave and she did not respond so he struck her at which time she turned around and left. When she was assessed she had one tooth that was very loose and the loose tooth came out and there was a small amount of blood to the upper lip. The aggressor(Resident #4) was put on one to one supervision to make sure he and others were safe. The attending physician was called and gave orders for a psych eval. The psych doctor was called, he came here and saw the resident and he did adjustments to the aggressor's medications. He did not recommend to send the resident(Resident #4) out. The resident(Resident #2) received an order for [REDACTED].#2) is a wanderer and has a care plan for wandering. She walks around. The resident(Residnet #2) had a BIMS (Brief Interview for Mental Status) score of 99 and she is confused. The resident(Resident #2) is not on any psych medications. Subsequent interview with the Director of Nursing (DON)/Risk Manager on 3/24/21 at 10:05 AM stated, On 3/16/21 at 10:50 pm, during rounds the resident(Resident #4) reported to the nurse that he struck his roommate because he was grinding his teeth and disturbing his sleep. The aggressor is alert and oriented times two. The victim is non-verbal, not alert and has total dependence. The attending physician and psychiatrist later gave orders to transfer the aggressor to the hospital for a behavioral evaluation. On 3/24/21 at 11:06 AM, Staff A Licensed Practical Nurse (LPN) stated, During rounds, resident(Resident #4) had told me he struck the roommate because he was grinding teeth and making noise. I walked over to the resident to assess him and noticed swelling on his face. I removed the aggressor from the room and placed him by the nurses' station to keep a close eye on him. The doctor was called for the resident(Resident #5) and the order was given to get an x-ray done. The x-ray results came back and I relayed the results to the doctor and she told me she was on her way to the facility. For the aggressor, the MD (Medical Doctor) was called so that we could transfer him out to a local hospital for evaluation. I know his psych medications were adjusted at one time. I have heard he had behavioral issues with other staff but never with me. Interview with the Regional Nurse Consultant on 3/24/21 at 11:57 AM stated, The resident(Resident #4) was immediately placed on 1:1 (one to one) on 11/12/20. He had a psych consult done the next day and had medication adjustment from [MEDICATION NAME] 50mg BID and increased to 200mg BID. Further documentation showed that the medication was effective. Subsequent interview on 3/24/21 at 11:59 AM, the Regional Nurse Consultant stated about resident #2, She was assessed immediately and provided Tylenol right away and it was effective. She did not have any other pain or discomfort. She had a dental consult on 11/23/20. No signs or infections or swelling. On 3/24/21 at 12:27 PM, the Psychiatrist stated about Resident #4, I have been coming here for a long time, since 1990. In November 2020, he got into a confrontation with another resident in his room. He felt threatened. He was not suicidal, not homicidal. He was fine that is why I didn't send him to the hospital. He was not agitated and he felt he was provoked. He would have been sent right back, if I sent him out to the hospital at that time. The only thing you can do is separate them and observe them. In order to go into the psych unit, you have to meet the criteria. I adjusted his medication and increased the [MEDICATION NAME] to 200mg BID. The March 2021, incident he had to be sent out for evaluation because he was not provoked. He had a [DIAGNOSES REDACTED]. On 3/24/21 at 1:03 PM via telephone, the Attending Physician stated, I remember he had an argument with another resident in November and hit the resident. They called me and I gave an order for [REDACTED]. On 3/24/21 at 1:18 PM via telephone, Staff C-Certified Nursing Assistant (CNA) was contacted. Attempted to contact the staff member, voice message with call back number left. A second attempt was made to contact Staff C on 3/25/21 at 2:15 PM via telephone stated, I work on the 3-11 shift. I did not see anything with both residents. That happened on the 11-7 shift. Staff C had been listed as a witness to the 11/12/20 abuse incident.

Based on observation, interviews and record review, the facility failed to provide adequate supervision to ensure the safety of vulnerable residents as evidenced by resident to resident abuse resulting in the injury of two (resident #2, resident #5) out of five residents sampled. This deficient practice enabled resident #4 to strike resident #2 on 11/12/20 and resident #5 on 3/16/21 causing injury to both residents. There were 166 residents residing in the facility at the time of the survey. On March 26, 2021, it was determined the findings of the survey posed immediate jeopardy to the health and safety of the residents admitted to the facility. The facility's Administrator, Director of Nursing and Regional Nurse Consultant were notified of the immediate Jeopardy on March 26, 2021 at 2:00 PM. The findings included: Record review of the Face Sheet for Resident #2 documented, the resident was admitted to the facility on [DATE]. Clinical [DIAGNOSES REDACTED]. Review of the facility's Wanderers List documented three residents were known as wanderers in the facility. Resident #2 was on the wanderers list. The facility's Wandering policy and procedure and Supervision policy and procedure documentation were requested several times and never received from the facility's administrative staff. Review of the Brief Interview for Mental Status (BIMS) dated 10/30/20 documented resident #2 had a BIMS Summary Score of 99 indicating cognitive impairment and noted that the resident was confused. Review of Resident's #2 Behavioral care plan dated 6/19/18 documented the resident exhibits the following behavior: wandering; Goal: Control/Minimize Outburst; Interventions/Tasks: Observe for changes in behavior and report to physician namely (ie.); [MEDICAL CONDITION], nervousness, loss of interest, decreased ability to concentrate, repetitive movements. Review of the event/post event progress notes for Resident #2 revealed the following: Dated 11/12/20 time stamped 18:00-Staff member reported that resident get struck in the mouth by another resident and noted with a loose tooth in front upper jaw. Staff member redirected resident back to her unit. Head to toe assessment done, no other visible injuries noted. During assessment, observed resident's loose tooth came out with scant of blood in resident mouth. Mouth care provided, Ice pack applied to resident mouth and 2 Tylenol 325mg(milligrams) given as ordered for pain. Vital signs taken. MD(Medical Doctor) made aware of resident's status, order received for dental consult. Record review of Resident #2s dental consult revealed, a dental consult was completed on 11/23/20, an annual screening was completed and the comments included, there were no signs of infection or swelling, the soft tissues were within normal limits(WNL), the resident was confused, the resident was not cooperating during the examination, the resident was not a candidate for p/ds Fab(a dental procedure) and no follow up was needed. Review of the physician's orders [REDACTED].#2 for November 2020 documented the resident did not receive any [MEDICAL CONDITION] medications and received Tylenol 325 milligrams (mg) tablets, 2 tablets orally for pain on 11/12/20. Review of the Face Sheet for Resident #4 documented, the resident was admitted to the facility on [DATE]. Clinical [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) dated 9/01/20 documented resident #4 had a BIMS Summary Score of 9 out of 15 indicating moderate impairment and noted that the resident was confused but was able to make needs known and can follow simple commands. No behaviors were noted. Review of Resident's #4 Behavioral care plan dated 11/13/20 documented the resident exhibits the following behaviors: becoming physically aggressive with staff and physically aggressive with others/peers wandering; Goals: Control/Minimize Outburst, Will not harm other residents, Will not harm themselves, Will not harm staff; Interventions/Tasks: Observe for changes in behavior and report to physician ie. (such as); [MEDICAL CONDITION], nervousness, loss of interest, decreased ability to concentrate, repetitive movements. Review of the physician's orders [REDACTED].#4 for November 2020 documented the resident was receiving antipsychotic medications and [MEDICAL CONDITION] disorder medications. Medications were: [MEDICATION NAME] 100mg tablet 100mg tablet oral at night (HS) for [MEDICAL CONDITION], start date was 8/26/20; [MEDICATION NAME] 50mg tablet 50mg tablet oral twice a day (BID) for [MEDICAL CONDITION], start date was 9/30/20, end date was 11/13/20; [MEDICATION NAME] DR (Delayed Release) 250mg tablet 250mg tablet oral BID for paranoid [MEDICAL CONDITION] and [MEDICATION NAME] 200mg tablet 200mg tablet oral BID for [MEDICAL CONDITION], start date 11/13/20. The [MEDICATION NAME] was increased to 200mg after the 11/12/20 abuse incident. Review of the POS [REDACTED]. The order was written on 3/16/21. Review of the pharmaceutical associated behavior logs for Resident #4 documented the following: November 2020: 11/3/20-Morning shift mood changes, 11/06/20-Night shift mood changes, 11/22/20- Morning and evening shift mood changes, 11/26/20-Morning and evening mood changes, 11/29/20 -Morning shift mood changes; December 2020: Mood Changes: On 12/06/20 in the morning, 12/7/20 in the evening, 12/13/20 morning and evening, 12/19/20 evening shift, Agitation and anger: 12/20/20 in the morning, 12/20/20 in the evening agitation, 12/27/20 morning shift-anger and agitation, 12/29/20- agitation on the morning shift; January 2021: 01/01/21 evening shift-anger and agitation, 01/17/21-anger and agitation-evening and night, 01/21/21-anger and agitation; February 2021: 02/06/21-Evening and Night shift-anger and agitation, 02/07/21-anger and agitation, 02/21/21-anger and agitation, 02/23/21 evening shift-paranoia and anxiety, 02/24/21-agitation and paranoia, 02/26/21-agitation and paranoia during night shift; March 2021: 03/02/2021-Evening shift-anxiety and mood changes, 03/03/2021-Evening shift anxiety and mood changes, 03/09/2021-Evening shift anxiety and mood changes, 03/11/21-Evening shift anxiety and mood changes. The behavior logs for 03/16/2021 (day of the incident) had no behaviors documented and noted that the medication was effective. Further review of the behavior log in conjunction with the medications prescribed revealed no documentation on the behavior logs related to the first reported incident on 11/12/20. Documentation after the first incident when the medication ([MEDICATION NAME]) was increased revealed incidents indicating the medication and interventions were ineffective. Review of the Behavior Progress Note for Resident #4 documented the following: Dated 11/12/20, time stamped 16:33-Staff reported that resident had an episode of aggressive behavior during which he struck another resident. When asked, resident stated that the other resident was about to enter his room and he hit her. Resident instructed to call staff for assistance and should not be combative and to always call staff for assistance. Resident verbalizes understanding. Resident placed on one on one supervision. MD made aware. Psych consult ordered and carried out. Review of the General Progress Note for Resident #4 documented the following: Dated 11/12/20, time stamped 20:40-Resident lying in bed quietly in stable condition with staff at bedside for one on one supervision. Safety measures maintained. Bed in lowest position. Call light within reach. Review of the Psychological Consult for Resident #4 documented the following: Dated 11/13/20-Resident denies suicidal and homicidal ideations; Diagnosis: [REDACTED]. Review of the Event/Post Event Progress Note for Resident #4 documented the following: Dated 3/16/21, time stamped 15:24-During round resident reported to staff that he struck his roommate. Resident stated to staff that he struck his roommate. Resident was removed from room and placed in dining room near nursing station for close observation and monitoring. MD was notified, new order given to transfer resident to local hospital for further evaluation. Diagnosis: [REDACTED]. Review of the Face Sheet for Resident #5 documented, the resident was admitted to the facility on [DATE]. Clinical [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) dated 3/03/21 documented resident #5 had a BIMS Summary Score was not scored indicating severe cognitive impairment and noted that the resident was confused. Review of the physician's orders [REDACTED].#5 for March 2021 documented the resident was received nutrition and all medications via a feeding tube. Review of the Event/Post Event Progress Notes for Resident #5 documented the following: Dated 3/16/21, time stamped 10:58-The following event has occurred: Resident to Resident Altercation; The resident is cognitively impaired and evaluation of facial expression indicates there is a little pain; Dated 3/16/21, stamped 16:40-Resident is calm. The following interventions are in place to assist in the prevention of another altercation: Separation of residents. Room changed. Educating the resident on acceptable behaviors. Upon evaluation for redness, bruising or pain, the following is noted: swollen nose and redness; Dated 3/17/21, time stamped 19:24-Resident nose swollen and is currently on [MEDICATION NAME] antibiotic and Dated 3/18/21, time stamped 00:42-Resident in bed resting in no distress. Upon evaluation for redness, bruising, or pain, the following is noted: discoloration noted on resident nose. Review of the Telephone Orders for Resident #5 documented the following: Dated 3/16/21, time stamped 10:33-Stat Facial bone X-ray STAT for Swelling; Dated 3/16/21, time stamped 16:18-[MEDICATION NAME] tablet 875-125mg give 1 tablet via PE[DEVICE] two times a day for sinusitis for 7 days; Dated 3/16/21, time stamped 16:20-Tylenol tablet 325mg give 2 tablet via PE[DEVICE] every 6 hours for pain for 1 week and Dated 3/16/21, time stamped 16:22-Ice pack to nose for 15 minutes three times a day for [MEDICATION NAME] for 4 days. Review of the X-Ray Results dated 3/16/21 for Resident #5 documented the following: Facial Bones, Less than 3 views (Lat(Lateral), AP(Anterior-front; Posterior-back), Waters(X-ray view with the chin raised and placed on the x-ray cassette) or Caldwell(X-ray view with the nose and forehead against the x-ray cassette); Impression: Nondisplaced fracture of indeterminate age anterior nasal bone. On 3/24/21 at 9:31 AM, the Director of Nursing (DON)/Risk Manager stated, On 11/12/20 at 5:35 pm, it was reported she was walking in the hallway when she was struck by a resident in front of his room. The resident(Resident #4) reported she entered his room, he told her to leave and she did not respond so he struck her at which time she turned around and left. When she was assessed she had one tooth that was very loose and the loose tooth came out and there was a small amount of blood to the upper lip. The aggressor(Resident #4) was put on one to one supervision to make sure he and others were safe. The attending physician was called and gave orders for a psych eval. The psych doctor was called, he came here and saw the resident and he did adjustments to the aggressor's medications. He did not recommend to send the resident(Resident #4) out. The resident(Resident #2) received an order for [REDACTED].#2) is a wanderer and has a care plan for wandering. She walks around. The resident(Residnet #2) had a BIMS (Brief Interview for Mental Status) score of 99 and she is confused. The resident(Resident #2) is not on any psych medications. Subsequent interview with the Director of Nursing (DON)/Risk Manager on 3/24/21 at 10:05 AM stated, On 3/16/21 at 10:50 pm, during rounds the resident(Resident #4) reported to the nurse that he struck his roommate because he was grinding his teeth and disturbing his sleep. The aggressor is alert and oriented times two. The victim is non-verbal, not alert and has total dependence. The attending physician and psychiatrist later gave orders to transfer the aggressor to the hospital for a behavioral evaluation. On 3/24/21 at 11:06 AM, Staff A Licensed Practical Nurse (LPN) stated, During rounds, resident(Resident #4) had told me he struck the roommate because he was grinding teeth and making noise. I walked over to the resident to assess him and noticed swelling on his face. I removed the aggressor from the room and placed him by the nurses' station to keep a close eye on him. The doctor was called for the resident(Resident #5) and the order was given to get an x-ray done. The x-ray results came back and I relayed the results to the doctor and she told me she was on her way to the facility. For the aggressor, the MD (Medical Doctor) was called so that we could transfer him out to a local hospital for evaluation. I know his psych medications were adjusted at one time. I have heard he had behavioral issues with other staff but never with me. On 3/24/21 at 11:59 AM, the Regional Nurse Consultant stated, She(Resident #2) was assessed immediately and provided Tylenol right away and it was effective. She did not have any other pain or discomfort. She had a dental consult on 11/23/20. No signs or infections or swelling. Patient is not a candidate for d/s fab. Subsequent interview with the Regional Nurse Consultant on 3/24/21 at 11:57 AM stated, The resident(Resident #4) was immediately placed on 1:1 (one to one) on 11/12/20. He had a psych consult done the next day and had medication adjustment from [MEDICATION NAME] 50mg BID and increased to 200mg BID. Further documentation showed that the medication was effective. On 3/24/21 at 12:27 PM, the Psychiatrist stated about Resident #4, I have been coming here for a long time, since 1990. In November 2020, he got into a confrontation with another resident in his room. He felt threatened. He was not suicidal, not homicidal. He was fine that is why I didn't send him to the hospital. He was not agitated and he felt he was provoked. He would have been sent right back, if I sent him out to the hospital at that time. The only thing you can do is separate them and observe them. In order to go into the psych unit, you have to meet the criteria. I adjusted his medication and increased the [MEDICATION NAME] to 200mg BID. The March 2021, incident he had to be sent out for evaluation because he was not provoked. He had a [DIAGNOSES REDACTED]. On 3/24/21 at 1:03 PM via telephone, the Attending Physician stated about Resident #4, I remember he had an argument with another resident in November and hit the resident. They called me and I gave an order for [REDACTED]. On 3/24/21 at 1:18 PM via telephone, Staff C-Certified Nursing Assistant (CNA) was contacted. Attempted to contact the staff member, voice message with call back number left. A second attempt was made to contact Staff C on 3/25/21 at 2:15 PM via telephone stated, I work on the 3-11 shift. I did not see anything with both residents. That happened on the 11-7 shift. Staff C was listed as a witness to the 11/12/20 abuse incident.

Based on observations, record reviews and interviews, the facility's administration failed to implement and provide services that effectively and efficiently related to ensuring safety measures were in place to prevent resident to resident abuse of two (resident #2, and resident #5) out of five residents sampled. As evidenced by resident to resident abuse resulting in the injury of two residents in two separate incidents by another resident. These system failures enabled resident #4 to strike resident #2 on 11/12/20 and resident #5 on 3/16/21 causing injury to both residents. The facility's administration failed to implement levels of supervision to meet the residents identified needs. There were 166 residents residing in the facility at the time of the survey. On March 26, 2021, it was determined the findings of the survey posed immediate jeopardy to the health and safety of the residents admitted to the facility. The facility's Administrator, Director of Nursing and Regional Nurse Consultant were notified of the immediate Jeopardy on March 26, 2021 at 2:00 PM. The findings included: Record review of the facility's policy titled, Abuse Prevention Program with a revision date on 01/2020, the policy documented: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of resident's property. These policies guide the identification, management and reporting of suspected or alleged, abuse, neglect, mistreatment and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. The facility's Wandering policy and procedure and Supervision policy and procedure documentation were requested several times and never received from the facility's administrative staff. Review of the Job Description for the Nursing Home Administrator (NHA) documented: The Nursing Home Administrator is responsible for maintaining appropriate guidelines and regulations to assure the highest degree of attention and care is provided to all residents. Review of the Job Description for the Director of Nursing documented: The Director of Nursing is responsible for developing, organizing, evaluating and administering patient care programs and services of the Center. Has twenty four (24) hour responsibility for the overall delivery of nursing services and ensures the implementation of all clinical policies and procedures. Review of the Job Description for the Risk Manager documented: The Risk Manager is responsible for planning, organizing and coordinating all aspects of the Clinical Risk Management program within the facility. The Risk Manager collaborates with the NHA, Facility Staff, Physicians, Residents and Families to make available the provision of quality care by the identification of potential and actual problems with subsequent formulation of solutions to alleviate these problems through the facilities internal risk management/quality assurance program. Review of the Face Sheet for Resident #2 documented, the resident was admitted to the facility on [DATE]. Clinical [DIAGNOSES REDACTED]. Review of Resident's #2 Behavioral care plan dated 6/19/18 documented the resident exhibits the following behavior: wandering; Goal: Control/Minimize Outburst; Interventions/Tasks: Observe for changes in behavior and report to physician namely (ie.); [MEDICAL CONDITION], nervousness, loss of interest, decreased ability to concentrate, repetitive movements. Review of the event/post event progress notes for Resident #2 revealed the following: Dated 11/12/20 time stamped 18:00-Staff member reported that resident get struck in the mouth by another resident and noted with a loose tooth in front upper jaw. Staff member redirected resident back to her unit. Head to toe assessment done, no other visible injuries noted. During assessment, observed resident's loose tooth came out with scant of blood in resident mouth. Mouth care provided, Ice pack applied to resident mouth and 2 Tylenol 325mg given as ordered for pain. Vital signs taken. MD(Medical Doctor) made aware of resident's status, order received for dental consult. Review of the facility's Wanderers List documented three residents were known as wanderers in the facility. Resident #2 was on the wanderers list. The facility's Wandering policy and procedure and Supervision policy and procedure documentation were requested several times and never received from the facility's administrative staff. Review of the Face Sheet for Resident #4 documented, the resident was admitted to the facility on [DATE]. Clinical [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) dated 9/01/20 documented resident #4 had a BIMS Summary Score of 9 out of 15 indicating moderate impairment and noted that the resident was confused but was able to make needs known and can follow simple commands. No behaviors were noted. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] for Resident #4 indicated the residents Brief Interview for Mental Status (BIMS) Summary Score was 7 out of 15 indicating moderate impairment and noted that the resident was confused, but was able to make needs known and can follow simple commands. No behaviors were noted. Review of the MDS Significant Change dated 3/01/21 for Resident #4 indicated the residents Brief Interview for Mental Status (BIMS) Summary Score 7 out of 15 indicating moderate impairment and noted that the resident was confused, but was able to make needs known and can follow simple commands. No behaviors were noted. Review of Resident's #4 Behavioral care plan dated 11/13/20 documented the resident exhibits the following behaviors: becoming physically aggressive with staff and physically aggressive with others/peers wandering; Goals: Control/Minimize Outburst, Will not harm other residents, Will not harm themselves, Will not harm staff; Interventions/Tasks: Observe for changes in behavior and report to physician namely (ie.) (such as); [MEDICAL CONDITION], nervousness, loss of interest, decreased ability to concentrate, repetitive movements. Review of the physician's orders [REDACTED].#4 for November 2020 documented, the resident was receiving antipsychotic medications and [MEDICAL CONDITION] disorder medications. The medications were: [MEDICATION NAME] 100mg(milligram) tablet, 100mg tablet oral at night (HS) for [MEDICAL CONDITION], start date was 8/26/20; [MEDICATION NAME] 50mg tablet, 50mg tablet oral twice a day (BID) for [MEDICAL CONDITION], start date was 9/30/20, end date was 11/13/20; [MEDICATION NAME] DR (Delayed Release) 250mg tablet 250mg tablet oral BID for paranoid [MEDICAL CONDITION] and [MEDICATION NAME] 200mg tablet 200mg tablet oral BID for [MEDICAL CONDITION], start date 11/13/20. The [MEDICATION NAME] was increased to 200mg after the 11/12/20 resident to resident abuse incident. Review of the POS [REDACTED]. The order was written on 3/16/21. Review of the pharmaceutical associated behavior logs for Resident #4 documented the following: November 2020: 11/3/20-Morning shift, mood changes, 11/06/20-Night shift, mood changes, 11/22/20- Morning and evening shift, mood changes, 11/26/20-Morning and evening, mood changes, 11/29/20 -Morning shift, mood changes; December 2020: Mood Changes: On 12/06/20 in the morning, 12/7/20 in the evening, 12/13/20 morning and evening, 12/19/20 evening shift, Agitation and anger: on 12/20/20 in the morning, 12/20/20 in the evening, agitation, 12/27/20 morning shift-anger and agitation, 12/29/20- agitation on the morning shift; January 2021: 01/01/21 evening shift-anger and agitation, 01/17/21-anger and agitation-evening and night, 01/21/21-anger and agitation; February 2021: 02/06/21-Evening and Night shift-anger and agitation, 02/07/21-anger and agitation, 02/21/21-anger and agitation, 02/23/21 evening shift-paranoia and anxiety, 02/24/21-agitation and paranoia, 02/26/21-agitation and paranoia during night shift; March 2021: 03/02/2021-Evening shift-anxiety and mood changes, 03/03/2021-Evening shift anxiety and mood changes, 03/09/2021-Evening shift anxiety and mood changes, 03/11/21-Evening shift anxiety and mood changes. The behavior logs for 03/16/2021 (day of the incident) had no behaviors documented and noted that the medication was effective. Further review of the behavior log in conjunction with the medications prescribed revealed, no documentation on the behavior logs related to the first reported resident to resident abuse incident on 11/12/20. Documentation after the first incident when the medication ([MEDICATION NAME]) was increased revealed incidents indicating the medication and interventions were ineffective. Review of the Behavior Progress Note for Resident #4 revealed the following: Dated 11/12/20, time stamped 16:33-Staff reported that resident had an episode of aggressive behavior during which he struck another resident. When asked, resident stated that the other resident was about to enter his room and he hit her. Resident instructed to call staff for assistance and should not be combative and to always call staff for assistance. Resident verbalizes understanding. Resident placed on one on one supervision. MD made aware. Psych consult ordered and carried out. Review of the General Progress Note for Resident #4 documented the following: Dated 11/12/20, time stamped 20:40-Resident lying in bed quietly in stable condition with staff at bedside for one on one supervision. Safety measures maintained. Bed in lowest position. Call light within reach. Review of the Psychological Consult for Resident #4 revealed the following: Dated 11/13/20-Resident denies suicidal and homicidal ideations; Diagnosis: [REDACTED]. Review of the Event/Post Event Progress Note for Resident #4 documented the following: Dated 3/16/21, time stamped 15:24-During rounds resident reported to staff that he struck his roommate. Resident stated to staff that he struck his roommate. Resident was removed from room and placed in dining room near nursing station for close observation and monitoring. MD was notified, new order given to transfer resident to local hospital for further evaluation. Diagnosis: [REDACTED]. Review of the Face Sheet for Resident #5 revealed, the resident was admitted to the facility on [DATE]. Clinical [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#5 for March 2021 revealed, the resident received nutrition and all medications via a feeding tube. Record review of the Event/Post Event Progress Notes for Resident #5 documented the following: Dated 3/16/21, time stamped 10:58-The following event has occurred: Resident to Resident Altercation; The resident is cognitively impaired and evaluation of facial expression indicates there is a little pain; Dated 3/16/21, stamped 16:40-Resident is calm. The following interventions are in place to assist in the prevention of another altercation: Separation of residents. Room changed. Educating the resident on acceptable behaviors. Upon evaluation for redness, bruising or pain, the following is noted: swollen nose and redness; Dated 3/17/21, time stamped 19:24-Resident nose swollen and is currently on [MEDICATION NAME] antibiotic and Dated 3/18/21, time stamped 00:42-Resident in bed resting in no distress. Upon evaluation for redness, bruising, or pain, the following is noted: discoloration noted on resident nose. Review of the X-Ray Results dated 3/16/21 for Resident #5 documented the following: Facial Bones, Less than 3 views (Lat(Lateral), AP(Anterior-front; Posterior-back), Waters(X-ray view with the chin raised and placed on the x-ray cassette) or Caldwell(X-ray view with the nose and forehead against the x-ray cassette); Impression: Nondisplaced fracture of indeterminate age anterior nasal bone. Review of the Telephone Orders for Resident #5 documented the following: Dated 3/16/21, time stamped 10:33-Stat Facial bone X-ray STAT for Swelling; Dated 3/16/21, time stamped 16:18-[MEDICATION NAME] tablet 875-125mg give 1 tablet via PE[DEVICE] two times a day for sinusitis for 7 days; Dated 3/16/21, time stamped 16:20-Tylenol tablet 325mg give 2 tablet via PE[DEVICE] every 6 hours for pain for 1 week and Dated 3/16/21, time stamped 16:22-Ice pack to nose for 15 minutes three times a day for [MEDICATION NAME] for 4 days. On 3/24/21 at 9:31 AM, the Director of Nursing (DON)/Risk Manager stated, On 11/12/20 at 5:35 pm, it was reported she was walking in the hallway when she was struck by a resident in front of his room. The resident(Resident #4) reported she entered his room, he told her to leave and she did not respond so he struck her at which time she turned around and left. When she was assessed she had one tooth that was very loose and the loose tooth came out and there was a small amount of blood to the upper lip. The aggressor(Resident #4) was put on one to one supervision to make sure he and others were safe. The attending physician was called and gave orders for a psych eval. The psych doctor was called, he came here and saw the resident and he did adjustments to the aggressor's medications. He did not recommend to send the resident(Resident #4) out. The resident(Resident #2) received an order for [REDACTED].#2) is a wanderer and has a care plan for wandering. She walks around. The resident(Residnet #2) had a BIMS (Brief Interview for Mental Status) score of 99 and she is confused. The resident(Resident #2) is not on any psych medications. Subsequent interview with the Director of Nursing (DON)/Risk Manager on 3/24/21 at 10:05 AM stated, On 3/16/21 at 10:50 pm, during rounds the resident(Resident #4) reported to the nurse that he struck his roommate because he was grinding his teeth and disturbing his sleep. The aggressor is alert and oriented times two. The victim is non-verbal, not alert and has total dependence. The attending physician and psychiatrist later gave orders to transfer the aggressor to the hospital for a behavioral evaluation. On 3/24/21 at 11:06 AM, Staff A Licensed Practical Nurse (LPN) stated, During rounds, resident(Resident #4) had told me he struck the roommate because he was grinding teeth and making noise. I walked over to the resident to assess him and noticed swelling on his face. I removed the aggressor from the room and placed him by the nurses' station to keep a close eye on him. The doctor was called for the resident(Resident #5) and the order was given to get an x-ray done. The x-ray results came back and I relayed the results to the doctor and she told me she was on her way to the facility. For the aggressor, the MD (Medical Doctor) was called so that we could transfer him out to a local hospital for evaluation. I know his psych medications were adjusted at one time. I have heard he had behavioral issues with other staff but never with me. On 3/24/21 at 11:59 AM, the Regional Nurse Consultant stated, She(Resident #2) was assessed immediately and provided Tylenol right away and it was effective. She did not have any other pain or discomfort. She had a dental consult on 11/23/20. No signs or infections or swelling. Patient is not a candidate for d/s fab. Subsequent interview with the Regional Nurse Consultant on 3/24/21 at 11:57 AM stated, The resident(Resident #4) was immediately placed on 1:1 (one to one) on 11/12/20. He had a psych consult done the next day and had medication adjustment from [MEDICATION NAME] 50mg BID and increased to 200mg BID. Further documentation showed that the medication was effective. On 3/24/21 at 12:27 PM, the Psychiatrist stated about Resident #4, I have been coming here for a long time, since 1990. In November 2020, he got into a confrontation with another resident in his room. He felt threatened. He was not suicidal, not homicidal. He was fine that is why I didn't send him to the hospital. He was not agitated and he felt he was provoked. He would have been sent right back, if I sent him out to the hospital at that time. The only thing you can do is separate them and observe them. In order to go into the psych unit, you have to meet the criteria. I adjusted his medication and increased the [MEDICATION NAME] to 200mg BID. The March 2021, incident he had to be sent out for evaluation because he was not provoked. He had a [DIAGNOSES REDACTED]. On 3/24/21 at 1:03 PM via telephone, the Attending Physician stated about Resident #4, I remember he had an argument with another resident in November and hit the resident. They called me and I gave an order for [REDACTED]. During an interview on 3/24/21 at 1:18 PM via telephone, Staff C-Certified Nursing Assistant (CNA) was contacted. After attempting to contact the staff member, a voice message with the call back number was left. A second attempt was made to contact Staff C on 3/25/21 at 2:15 PM via telephone, staff C stated, I work on the 3-11 shift. I did not see anything with both residents. That happened on the 11-7 shift. Staff C had been listed as a witness to the 11/12/20 abuse incident.

Based on interview and record review, the facility failed to revise the fall care plan after a fall was sustained with major injury for one (R#149) out of one resident reviewed for falls. Findings include: Record review of the Fall and Injury Management Policy and Procedure (no date available) documented the following: Overview-The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Falls and Injuries Program. Data is collected on residents/patients for fall risk factors. The interdisciplinary team works with the resident/patient and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Guidelines: status [REDACTED]. Review of the Demographic Face Sheet for Resident #149 documented the resident was originally admitted on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 Discharge-Return Anticipated Assessment for Resident #149 dated 3/24/18 indicated the residents Brief Interview for Mental Status (BIMS) Summary Score was 14, indicating little to no cognitive impairment, required extensive assistance with two+ persons physical assist for transfer, toilet use and the resident had one fall except a major injury. Review of the Fall Care Plan for Resident #149 documented: Focus: Resident is at risk for falls or fall related injury because of: Cognitive, [MEDICAL CONDITION], Psych Meds. Right [MEDICAL CONDITION]. Does not call for assistance despite encouragement to ask for help. Poor safety awareness (Written 9/01/17). Goal: Will minimize the risk of additional fall and fall r/t injury from a preventable fall through the next review date. Interventions: Frequent rounds to monitor safety; Review for individualize toileting schedule; Educate/remind resident to request for assistance from staff prior to ambulation or transfer; Provide environmental adaptations: Bed in low position. The care plan was not updated and revised with new interventions to assist in preventing falls that could potentially result in fracture. Interview with Staff I, Registered Nurse/MDS on 5/10/18 at 4:27 pm she stated, We initiate a care plan on Admission. We have 72 hours or 14 days until we complete it. If a patient has a fall, it is on the focus on the care plan. The staff put interventions in place to prevent the falls. The fall care plan is supposed to be updated if they have a fall. Review of the Event/Post Event Notes for Resident #149 documented the resident sustained [REDACTED].

Based on observation, interview and record review, the facility failed to prevent a major injury which resulted from a fall. The resident sustained [REDACTED].#149) out of one resident reviewed for falls. This practice has the potential to affect all 166 residents present in the facility at the time of the survey. The Findings include: Record review of the Fall and Injury Management Policy and Procedure (no date available) documented the following: Overview-The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Falls and Injuries Program. Data is collected on residents/patients for fall risk factors. The interdisciplinary team works with the resident/patient and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Guidelines: 1) Evaluate and review risk factors for falls and injuries. status [REDACTED]. Observation of Resident #149 on 5/09/18 at 9:15 am revealed, the Resident was sitting in a wheelchair in the Section 4 dining room, eating breakfast. Multiple observations were made throughout the survey process and attempts were made to interview the resident but the resident would only stare and not answer the questions. Review of the Demographic Face Sheet for Resident #149 documented the resident was originally admitted on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 Discharge-Return Anticipated Assessment for Resident #149 dated 3/24/18 indicated the residents Brief Interview for Mental Status (BIMS) Summary Score was 14, indicating little to no cognitive impairment, required extensive assistance with two+ persons physical assist for transfer, toilet use and the resident had one fall except a major injury. Review of the Admission/Readmission Data Collection form dated 9/01/17 documented Resident #149 had no falls in the last 90 days. Review of the Fall Care Plan for Resident #149 documented: Focus: Resident is at risk for falls or fall related injury because of: Cognitive, [MEDICAL CONDITION], Psych Meds. Right [MEDICAL CONDITION]. Does not call for assistance despite encouragement to ask for help. Poor safety awareness (Written 9/01/17). Goal: Will minimize the risk of additional fall and fall r/t injury from a preventable fall through the next review date. Interventions: Frequent rounds to monitor safety; Review for individualized toileting schedule; Educate/remind resident to request for assistance from staff prior to ambulation or transfer; Provide environmental adaptations: Bed in low position. The care plan was not updated and revised with new interventions to assist in preventing falls that could potentially result in fracture. Review of the Event/Post Event Notes for Resident #149 documented the following: 1) Dated 3/20/18 06:49-At 2 AM, Nursing Assistant informed the nurse that she noted the resident on the floor, upon arrival, resident noted on the floor in a sitting position. Resident stated, I fell on the floor while trying to sit on toilette. Resident is alert and verbally responsive, denied pain at this time, respiration even and non-labor, skin is warm and dry to touch no skin impairment noted, staff transferred the resident back to chair, vital signs as follow BP-142/68, T-97.5, R-18, P-62, Regular O2-98. Call placed to MD spoke with answering service, awaiting response from the doctor and 2) Dated 3/24/18 at 11:23-Resident complaint of right leg tender to touch from scale 1 to 10; VS-135/77, P77, R18, T-97.6. Resident states 9, Tylenol Prn given as ordered after 30 minutes up on assessment. Resident states still in pain from scale 1 to 10 states 10. Call placed, order received for X-ray. X-ray done awaiting for X-ray result. Resident self-responsible party. Review of the Event/Post Event Notes for Resident #149 documented the resident sustained [REDACTED]. Review of the physician's orders [REDACTED].#149 dated (MONTH) (YEAR) documented the resident received [MEDICATION NAME]-[MEDICATION NAME] 5-325mg (milligrams) tab (tablet) 1 tab PO (by mouth) every 4 hours PRN (as needed) for pain, [MEDICATION NAME] 5mg tab 5mg PO HS (night) for [MEDICAL CONDITION], [MEDICATION NAME] 50mg tab 50mg PO BID (twice a day) for scpt ([MEDICAL CONDITION]), Levetiracetam Solution 100mg/ml (milliliters) 5ml PO BID for [MEDICAL CONDITION], [MEDICATION NAME] HCL 100mg tab 100mg PO HS for depression, [MEDICATION NAME] 20mg tab 20mg PO one time a day for depression and PT (Physical Therapy) Clarification: Resident to be seen 6 times per week for 60 days for [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of the Medication Administration Record [REDACTED]. Facility staff were to monitor pain every shift and record pain number on a 0-10 scale every shift for Pain Monitoring: On 3/20/18-Pain level on all three shifts were (0); On 3/21/18-Pain level on two shifts (Day, & Night) were (2); On 3/22/18-Pain level on all shift, one shift (Day) was (2); On 3/23/18-Pain level on all three shifts was (0); On 3/24/18-Pain level on all shifts, one shift (Evening) was (2). Review of the Lab X-rays dated 3/24/18 documented the resident sustained [REDACTED]. The X-ray was conducted four days after the fall occurred. Review of the Physician's Telephone Orders (PTO) for Resident #149 dated 3/24/18 at 16:40 documented to send the resident to a local hospital for Acute [MEDICAL CONDITION]. Review of the Physical Therapy (PT) Screening Form for Resident #149 dated 5/03/18 documented the following: Reason for Screen: Fall; Patient Exhibits the following problems: Transfer To/From Bed/Wheelchair/Chair; Frequent Falls/Hazard of Fall; General Safety Awareness and Patient currently vs. (versus) skilled PT services. Will review safety. Reviewed PT Plan of Care for Resident #149 dated 3/31/18 documented the following: 1) Certification 3/31/18 to 5/29/18; 2) LTC (Long Term Care) resident at this facility who was transferred to local hospital due to complaints of right hip pain following a fall incident while transferring from bed to wheelchair. CT (Computed Tomography) of the hip revealed acute right femoral right neck fracture. Resident to receive skilled services for therapeutic exercise, neuromuscular re-education, gait training for 6 times a week for 60 days. Review of the PT-Therapist Progress Note for Resident #149 dated 4/30/18 documented the patient continues to require skilled PT services to focus on: Therapeutic exercise, Neuromuscular re-education, Gait training and Therapeutic activities. Interview with Staff E a Licensed Practical Nurse on 5/10/18 at 12:00 pm she stated, Resident is alert, oriented x (times) two. Required total dependence for ADLs (Activities of Daily Living). Unfortunately, yes, he has fallen a lot. He will try to get out of bed, to go to the bathroom. Unit Manager advised everyone to offer assistance to the bathroom on each shift. No falls have occurred on my shift. We take him to the bathroom, every 2 hours. He will pull the call light. Interview with Staff F a Registered Nurse on 5/10/18 at 12:10 pm she stated, He had several falls on the 11-7 shift. We oriented him to the call bell. He was told to call us when you want to go the restroom and he doesn't. As soon as they walk out he gets up. He is on the toileting program and has periods of incontinence. I interviewed the nurses and CNA's (certified nursing assistants) on the 11-7 shift and they say he was getting up on his own. The 3/20/18 fall happened on the 11-7 shift. He said he was trying to get up to go the bathroom. We monitor them for 72 hours and if they have any pain. He expressed pain to the hip. The doctor ordered an x-ray and it came back with [MEDICAL CONDITION] and the doctor gave an order to send him out to the hospital because of [MEDICAL CONDITION]. After the fall on 3/20/18, we tried to get him to move to Bed A but, he said, no. We referred him to PT after he had a fall. They assess his safety. Attempted an interview on 5/10/18 at 3:27 pm with contact Staff G, the attending physician and reached the Answering Service. The operator refused to take a message to relay to the physician to return the call. Interview with Staff H a Physical Therapist on 5/10/18 at 3:42 pm he stated, The resident was receiving PT. The goals are range of motion to right hip and right knee extension, standing goal and increase strength to lower extremities. He was sent to the hospital after fall with significant decreased weakness to the lower extremities, decreased balance, decreased coordination, decreased trunk control, decreased safety awareness, range of motion to lower extremities. Usually, once they have a fall they are referred to PT for a screen. He started receiving PT on 3/31/18 and will continue until he reaches max goal. Interview with Staff I a Registered Nurse/MDS on 5/10/18 at 4:27 pm she stated, We initiate a care plan on Admission. We have 72 hours or 14 days until we complete it. If a patient has a fall, it is on the focus on the care plan. The staff put interventions in place to prevent the falls. The fall care plan is supposed to be updated if they have a fall.

Based on record review and interview, the facility failed to ensure each residents drug regimen was free from unnecessary drugs for 2 of 3 sampled residents (resident #2 and resident #4) who had physician orders [REDACTED].#3 for pain and the application of [MEDICATION NAME] to a right knee amputation. This lead to a negative outcome for resident #2. The Findings include: 1) Medical record review revealed that resident #2 was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A) Record review of resident #2's physician orders [REDACTED].= 0 unit; 201.0-250.0 = 2 units; 251.0-300.0 = 4 units; 301.0-350.0 = 6 units; 351.0-400.0 = 8 units, subcutaneously every 6 hours for DM." The order indicated to call the MD for a result greater than 400. Review of resident #2's September 2012 MAR indicated [REDACTED]. B) Review of resident #2's 9/30/12 9:00 AM nurses' note revealed that it indicated that the resident was received in bed in no apparent distress and that all care was rendered, including all due medications via PEG tube. The nurses notes documented the medications were tolerated well. Review of resident #2's 9/30/12 9:30 AM nurses' note revealed that during medication administration of another resident, the nurse noticed that resident #2 was not breathing properly. According to the note, the vital signs were taken and were BP 149/87, pulse 151, respirations 18, oxygen saturation 73, temperature 98.4 degrees, and the blood glucose was high and "unreadable." The physician was notified and wrote an order to send the resident to the hospital. Staff called 911 who came and transported the resident out via stretcher. C) Record review of a Miami-Dade Fire rescue incident report revealed the ambulance was dispatched on 9/30/12 at 9:54 AM and arrived at the facility at 10:00 AM. The report noted the cause as [MEDICAL CONDITION] and the complaint of being lethargic. A comment noted high blood sugar and a low oxygen saturation. There was a description on the report indicating that the BP was 149/82, the pulse was 155, the oxygen saturation was 53 and that resident #2 had a Non re-breather (NRB) mask on that was connected to an empty oxygen bottle. The NRB mask had a deflated reservoir and there was condensation observed in the mask. Emergency personnel replaced the mask with their own and the oxygen saturation went up to 69 within minutes. Upon re-assessment, resident #2's blood sugar was 542 and respirations were 30. D) Record review of documentation from the receiving hospital revealed that resident #2 arrived at the hospital on [DATE] at 10:35 AM. Vital signs taken at the hospital revealed that at 10:36 AM the resident's respirations were 49 and his pulse was 156. E) Record review of resident #2's physician orders [REDACTED]. The order had the parameters to hold the medication for a systolic blood pressure (SBP) of less than 110 and for a diastolic blood pressure (DBP) of less than 70. Record review of resident #2's September 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The [MEDICATION NAME] was being given at 9:00 AM and 5:00 PM. The following discrepancies were noted: On 9/14/12, for the 5:00 PM dose of [MEDICATION NAME], the MAR indicated The MAR indicated x" was not part of the key. Additionally, there were staff initials and a "9." According to the key, "9" meant, "other/see Nurse Notes." Review of the corresponding nurses' note dated 9/14/12 at 17:00 (5:00 PM) revealed "bp (blood pressure) 124/70, no coverage given." Per the physician's parameters, the medication should have been given. F) On 9/24/12, for the 5:00 PM dose of [MEDICATION NAME], the MAR indicated Additionally, there were staff initials and a "9." Review of the corresponding nurses' note dated 9/24/12 at 17:00 revealed "bs 127/76 no coverage given." Per the physician's parameters, the medication should have been given. G) On 9/25/12, for the 5:00 PM dose of [MEDICATION NAME], the MAR indicated Additionally, there were staff initials and a "9." Review of the corresponding nurses' note dated 9/25/12 at 17:00 revealed "bp 112/70 no [MEDICATION NAME] 0.1 mg given." Per the physician's parameters, the medication should have been given. H) On 9/27/12, for the 5:00 PM dose of [MEDICATION NAME], the MAR indicated [REDACTED]. There was a check mark which, according to the key, indicated that the medication was administered. Per the physician's parameters, the medication should have been held as the DBP was less than 70. I) On 9/28/12, for the 5:00 PM dose of [MEDICATION NAME], the MAR indicated Additionally, there were staff initials and a "9." Review of the corresponding nurses' note dated 9/28/12 at 17:00 revealed "BP 126/72 NO [MEDICATION NAME] ADM." Per the physician's parameters, the medication should have been given. J) On 9/29/12, for the 5:00 PM dose of [MEDICATION NAME], the MAR indicated Additionally, there were staff initials and a "9." Review of the corresponding nurses' note dated 9/29/12 at 17:00 revealed "bs 116/78 no [MEDICATION NAME] given." Per the physician's parameters, the medication should have been given. Interview with Licensed Practical Nurse (LPN) #1 on 9/3/12 at 4:54 PM revealed that she stated, after reviewing resident #2's nurses' notes, the September 2012 MAR, and the physician orders, resident #2's [MEDICATION NAME] HCL 0.1 mg should have been held if the systolic blood pressure was less than 110 and if the diastolic blood pressure was less than 70. Interview with the Director of Nursing on 10/3/12 at 4:00 PM revealed that, when asked to explain the discrepancies on resident #2's MAR, she could not, but that she would get the unit Register Nurse (RN). Interview with the physician on 10/5/12 at 2:28 PM revealed that he provided coverage for resident #2's primary care physician (PCP) from 9/18 through 10/8/12. In addition, he stated that he was not notified that resident #2's [MEDICATION NAME] was held on 9/14, 9/24, 9/25, 9/28, and 9/29/2012. K) Record review of resident #2's physician's orders [REDACTED]. Cover with ABD and wrap loosely with kling." Review of resident #2's September 2012 MAR indicated [REDACTED]. From 9/15 through 9/18, the MAR indicated [REDACTED]. Review of the corresponding nurses' note dated 9/15/12 at 17:00 revealed "iodine on hold until available, dressing done." Review of the nurses' note dated 9/16/12 at 17:00 revealed, "hold [MEDICATION NAME] until received." Review of the nurses' note dated 9/17/12 at 17:00 revealed, "[MEDICATION NAME] on hold until received." Review of the nurses' note dated 9/18/12 at 17:00 revealed, "on hold until received." L) Further review of resident #2's physician orders [REDACTED]." Review of resident #2's September 2012 MAR indicated [REDACTED]. However, on 9/21/12, the MAR indicated [REDACTED]. Review of the corresponding nurses' note dated 9/21/12 at 15:00 revealed "[MEDICATION NAME] on hold until received." M) Further review of resident #2's September 2012 MAR indicated [REDACTED]. The second order (dated 9/20/12) was discontinued on 9/27/12. There was no indication that the medication should have been held from 9/15/12 to 9/18/12. Interview with LPN #2 and LPN #3 on 10/3/12 at 6:23 PM revealed that LPN #2 stated, after reviewing resident #2's September 2012 MAR, nurses notes, and physician orders, that [MEDICATION NAME] was on hold until 9/20/12 and had no explanation as to why it was held from 9/15 to 9/18. Interview with the physician on 10/5/12 at 2:28 PM revealed that he covered for resident #2's primary care physician (PCP) from 9/18 through 10/8/12. He stated that he was not notified the [MEDICATION NAME] was not being used for cleaning resident #2's right below the knee stump during the days he covered for resident #2's PCP. N) Record review of resident #2's September 2012 MAR indicated [REDACTED]." The MAR indicated H") from 9/8/12 to 9/12/12. Review of resident #2's nurses' note dated 9/7/12 at 15:00 (3:00 PM) revealed "Tylenol 625 mg administered prior to wound care." Review of resident #2's nurses' note dated 9/7/12 at 22:57 (10:57 PM) revealed "spoke to (name) from pharmacy regarding Tylenol #3 she said prescription is needed call placed to MD (medical doctor) times 2 no respond endorsed to the incoming nurse for am nurse to f/up tomorrow with MD." Review of resident #2's nurses' note dated 9/9/12 at 22:41 (10:41 PM) revealed "Please call for script for Tylenol #3 on Monday." Review of resident #2's nurses' note dated 9/10/12 at 18:23 (6:23 PM) revealed "give 650 mg tabs of Tylenol prior to wound care." Review of resident #2's September 2012 physician orders [REDACTED]. However, the order was a PRN (as needed) order and was not routine. The resident's nurses notes indicated that Tylenol 650 mg was given on 9/10/12 and that Tylenol 650 mg was given on 9/7/12. There was no documentation on the resident's September 2012 MAR indicated [REDACTED]. Interview with the RN on 10/3/12 at 6:00 PM revealed that she, after reviewing resident #2's nurses' notes from 9/7/12, confirmed that Tylenol #3 was not given because a prescription was needed from the physician. The RN also stated, resident #2 got Tylenol 650 mg prior to wound care and that he was not in pain. 2) Medical record review revealed that resident #4 was admitted on [DATE] and re-admitted on [DATE] with a [DIAGNOSES REDACTED]. Record review of resident #4's physician orders [REDACTED]. The order indicated to hold the medication for a SBP of less than 110 and for a DBP of less than 60. Record review of resident #4's August 2012 MAR indicated x." There was no nursing note indicating that the medication was given or that the resident's blood pressure was taken at that time. Interview with LPN #1 on 10/3/12 at 12:57 PM revealed that, after reviewing resident #4's August 2012 MAR, she stated that he did not get his [MEDICATION NAME] HCL 0.1mg on 8/15/12 at 6:00 PM. In addition, she also checked the nurses' note to see if it was documented as to why [MEDICATION NAME] was not given and no nurses notes were documented on 8/15/12.