Every finding on record at Uptown Rehabilitation Center

Based on observation, record review, and interviews, the facility failed to ensure the environment was free of accident hazards for 2 (R #9 and #25) of 4 (R #5, #6, #9, and #25) residents, when the facility staff failed to:Ensure the residents' bed wheels were locked while the beds were in use to prevent falls.This deficient practice is likely to result in residents getting injured in avoidable accidents and putting residents at risk of serious injury and harm.The findings are: R #9: A. Record review of R #9's face sheet revealed an admission date of 05/28/25 with the following diagnoses: Muscle weakness and unsteadiness on feet.impaired gait (deviation from normal walking) and mobility issues.Chronic pain.Third degree burns (severe, full thickness burns that destroy all layers of the skin and underlying tissues, requiring immediate medical attention) with skin graft (a surgical procedure in which healthy skin is taken from one part of the body and transplanted to cover an area of damaged or missing skin).Right foot drop (cannot lift the front part of the foot due to weakness or paralysis of the muscles). B. Record review of R #9's nursing progress notes, dated 06/19/26, revealed at 12:09 PM a Certified Nursing Assistant (CNA) was notified that R #9 was on the floor. When the nurse entered R #9's room, R #9 was sitting on the floor next to her bed. The room was dark, R #9's walker was pushed to the left side, the bed wheels were unlocked, and the bed had shifted from its normal position. C. Record review of R #9's nursing progress notes, dated 06/25/26, revealed at 3:15 am, R #9 reported she fell while getting out of bed to reach her wheelchair to go to the bathroom. D. On 06/25/26 at 1:00 pm, during an observation, R #9 was leaving the bathroom and returning to her bed. R #9's bed wheels were unlocked, and she needed assistance to lock the wheels so she could safely get into bed. E. On 06/25/26 at 1:03 pm, during an interview, R #9 stated there had been a few times when she went to sit back down on the bed and the bed slid because the wheels were unlocked, which resulted in her falling. R #9 stated her bed wheels seemed to be unlocked frequently, and she did not know who was unlocking her bed. F. On 06/25/26 at 1:15 pm, during an interview, CNA #6 stated there was no reason for CNAs to unlock the brakes on residents' beds. She stated housekeeping staff will unlock the beds at times to clean underneath them, but the wheels should be locked afterward. R #25: G. On 06/26/26 at 8:15 am, during an observation, R #25 was lying in bed asleep with the bed wheels unlocked. H. On 06/26/26 at 8:25 am, during an interview, Registered Nurse (RN) #8 stated R #25's bed wheels should be locked, especially when the resident is lying in the bed. RN #8 stated unlocked bed wheels could contribute to resident falls. She stated both CNAs and housekeepers will unlock and move beds as needed, but they should lock the wheel brakes when they finish moving the bed. I. On 06/29/26 at 3:30 pm, during an interview, the Director of Nursing (DON) stated R #9's last fall on 06/25/26 occurred because the bed wheels were not locked. The DON stated the bed wheels for R #9 and R #25 should be locked at all times when the beds are in use.

Based on record review and interviews, the facility failed to ensure 1 (R #16) of 1 (R #16) resident received necessary behavioral health care to meet their needs, when staff failed to refer them for behavioral health services after they experienced depression symptoms and voiced self harm statements. This deficient practice is likely to result in worsening behaviors and failure to receive the behavioral or mental health care needed to improve mood and reduce depression and anxiety. The findings are: A. Record review of R #16's face sheet revealed an admission date of 03/11/25 with the following diagnoses:Major depressive disorder (is a common and serious mental illness that affects your mood and interest in life).Parkinson's disease (is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves).Macular degeneration (causes reversible vision loss).Alzheimer's disease (is a type of dementia that affects memory, thinking and behavior).Anxiety disorder (persistent and excessive distress that affects daily life). B. Record review of R #16's care plan, dated 02/15/26, revealed R #16 experienced distressed, fluctuating mood symptoms related to sadness, depression, changes in relationships, and personal loss. Facility staff are to refer R #16 to behavioral health as needed. C. Record review of R #16's change in condition (CIC; new, different, or worsening sign, symptom, or behavior in a resident that deviates from their established baseline or expected pattern of health and function) progress note, dated 04/20/26, revealed R #16 was seen by Certified Nursing Assistant (CNA) crying in his room stating that he wants to die because he has no friends. R #16 then left his room and stated he wanted to die because he had no friends, could not leave the facility, and felt like it was a prison. The provider was notified. D. Record review of R #16's electronic health record (EHR), dated 06/29/26, revealed R #16 was not referred to behavioral health services for talk-therapy after the statement he made on 04/20/26. The EHR did not contain physician orders or communication indicating R #16 should be referred to a behavioral health services provider for talk-therapy. E. On 06/29/26 at 1:00 pm, during an interview, Director of Nursing (DON) stated she was not aware of R #16's statements made on 04/20/26. The DON stated the facility prescribed R #16 antidepressant medication in response to his depression and suicidal (self-harm) statements, but talk-therapy was not requested and should have been, since it was an approved service. F. On 06/29/26 at 1:53 pm, during an interview, the out-of-facility Nurse Practitioner (NP) #3 stated R #16 was seen by an out of facility provider on 04/21/26, and his medications for depression and anxiety were increased slightly. She stated the message she received from the facility on 04/20/26 did not indicate that R #16 was feeling suicidal and only reported increased loneliness and anxiety. She stated if a resident voices being suicidal, an assessment is completed to determine the severity of those thoughts, and a referral for behavioral health services would be made if suicidal ideation is reported. NP #3 stated a behavioral health talk therapy referral should have been made for R #16 after his statements on 04/20/26, but this did not occur.

Based on record review and interviews, the facility failed to provide quality care that meets professional standards for 2 (R #2 and #4) of 2 (R #2 and #4) residents, when staff failed to: Obtain and review physician ordered laboratory testing (controlled testing performed on biological, environmental, or other health related samples to support diagnosis, monitoring, prevention, and research of diseases and health conditions) within a timeframe that meets professional standards for R #2 and R #4.This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are:A. Record review of the facility's laboratory (controlled testing is performed on biological, environmental, or other health-related samples to support diagnosis, monitoring, prevention, and research of diseases and health conditions) policy, revised on [DATE], revealed the following: Diagnostic tests (medical procedures that provide objective insights into your body's condition, helping diagnose, monitor, and prevent diseases), including laboratory tests, will be performed as ordered, staff are responsible for notifying the diagnostic service to arrange for testing, and staff are responsible for obtaining the diagnostic test report. All diagnostic test results are reported to the patient's medical provider, and staff are responsible for notifying the physician/advanced practice provider (APP) of diagnostic test results.Critical laboratory values (laboratory test results that fall outside normal reference ranges to such an extent that they indicate an immediate, life-threatening condition requiring prompt clinical intervention) are to be reported immediately, and staff are to document the date and time of physician/APP notification and the provider's response in the medical record. R #2: B. Record reveal of R#2's face sheet revealed an admission date of [DATE] and the following diagnoses: Sepsis (a serious condition in which the body responds improperly to an infection).Morbid (severe) obesity (severely overweight) with alveolar hypoventilation (a condition where the body does not exchange enough carbon dioxide and oxygen in the lungs' air sacs (alveoli), leading to insufficient respiratory function to maintain normal blood carbon dioxide levels). Chronic pain.Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).Chronic embolism (blood clot) and thrombosis (the formation of a blood clot (thrombus) that blocks a blood vessel, either a vein or an artery) of the left femoral vein (vein located in the femur). C. Record review of R #2's care plan, revised on [DATE], revealed R #2 is at risk of sepsis. D. Record review of R #2's physician orders, dated [DATE], revealed orders for staff to obtain laboratory results for a comprehensive metabolic panel (CMP; a blood test that measures 14 substances to assess liver and kidney function, blood sugar, electrolytes, and overall metabolic health), a complete blood count (CBC; a blood test that measures red blood cells, white blood cells, hemoglobin, hematocrit, and platelets to assess overall health and detect medical conditions), c-reactive protein (CRP; blood test measures inflammation in the body and helps assess infection, autoimmune conditions, and cardiovascular risk), a hemoglobin A1C (HgbA1c; blood test to screen, diagnose, or monitor diabetes), and an erythrocyte sedimentation rate (ESR; blood test measures how quickly red blood cells settle in a test tube, indicating the presence of inflammation in the body). E. Record review of R #2's laboratory results, dated [DATE], revealed the following:R #2's laboratory specimens were not collected until [DATE], three days after the order was placed, and the results were reported to the facility on [DATE] and [DATE]. Nurse Practitioner (NP) #2 reviewed the laboratory results on [DATE], and R #2's results were abnormal. F. Record review of R #2's nursing progress notes, dated [DATE], revealed the following: NP #1 reviewed R #2's laboratory results, including the CMP, CRP, CBC, A1C, and ESR. NP #1 documented the abnormal laboratory results along with the physician's response to monitor R #2.R #2 was found unresponsive during a routine morning blood glucose (sugar) check. Cardiopulmonary resuscitation (CPR; an emergency procedure combining chest compressions with artificial ventilation) was initiated, and Emergency Medical Services (EMS) was called. Facility nursing staff continued CPR until EMS arrived, and R #2 was pronounced deceased at 7:10 AM. G. On [DATE] at 9:54 AM, during an interview, Registered Nurse (RN) #2 stated she was not aware laboratory tests had been ordered for R #2 or of any concerns for possible sepsis. RN #2 stated she had not received report regarding pending laboratory tests or instructions to monitor the resident for signs or symptoms of sepsis. RN #2 stated if she had been informed of concerns for possible sepsis or pending laboratory testing, she would have followed up and monitored the resident accordingly. H. On [DATE] at 1:15 PM, during an interview, Licensed Practical Nurse (LPN) #1 stated she worked on [DATE] and was unaware laboratory tests had been ordered for R #2 or of any pending laboratory orders. LPN #1 stated she had cared for R #2 during her recent shifts and had not received report regarding pending laboratory tests or instructions to monitor for possible sepsis. LPN #1 stated on [DATE] she found R #2 unresponsive, initiated CPR, and assisted with the emergency response until EMS arrived. I. On [DATE] at 10:27 AM, during an interview, Certified Nursing Assistant (CNA) #1 stated she was not informed laboratory tests had been ordered for R #2 and she was not instructed to monitor the resident for changes in condition related to the pending laboratory tests. R #4: J. Record review of R #4's face sheet revealed an admission date of [DATE] and the following diagnoses: Acute Kidney Failure. Chronic Kidney Disease. Acute Respiratory Failure with Hypoxia (a condition in which the body's tissues are deprived of adequate oxygen, potentially affecting the whole body or specific regions).Chronic Obstructive Pulmonary Disease (COPD; lung disease).Type 2 Diabetes Mellitus (DM2; a disease in which the body cannot make or properly use insulin).Hypertension (high blood pressure). Atrial Fibrillation (A-Fib; irregular heart rhythm). Peripheral Vascular Disease (PVD; poor circulation).Unstageable (a wound that has full thickness tissue loss but is covered with slough (dead tissue) or eschar (dark scab or falling away of dead skin) so that the true depth of the wound cannot be determined) Pressure Ulcer. K. Record review of R #4's physician orders, dated [DATE], revealed an order to obtain laboratory results for potassium, magnesium, a CBC, CMP, and CRP. L. Record review of R #4's laboratory results, dated [DATE], revealed R #4's laboratory specimens were collected on [DATE], and the results were reported to the facility on [DATE], indicating abnormal laboratory findings. M. Record review of R #4's nursing progress notes, dated [DATE], revealed R #4 was transferred to the hospital due to peripheral edema (swelling of the legs, ankles, and feet caused by excess fluid buildup), altered mental status, and hypotension (low blood pressure) in the presence of acute kidney injury. N. On [DATE] at 1:52 PM, during an interview, RN #1 stated if a resident is suspected of having sepsis, an altered mental status, or meets sepsis criteria, the nurse should immediately notify the provider. RN #1 stated the provider should evaluate the resident and order laboratory tests as indicated. RN #1 stated once laboratory orders are entered, the nurse is responsible for confirming the orders, ensuring the orders are transmitted to the laboratory, and arranging specimen collection. RN #1 stated laboratory turnaround time is typically four hours, and in her opinion, if a resident is suspected of being septic, laboratory testing should be obtained immediately rather than waiting until the next day. O. On [DATE] at 10:19 AM, during an interview, the Medical Director (MD) stated residents suspected of having sepsis should be closely monitored while awaiting laboratory results, including frequent assessments for changes in mental status, vital signs, and other signs of clinical deterioration. The MD stated residents would typically be assessed approximately every two hours. The MD stated laboratory tests ordered to evaluate suspected sepsis should be obtained the same day they are ordered or by the following morning. The MD stated laboratory testing should not take three days and should be completed the afternoon it is ordered or by the following morning. The MD stated R #2 and R #4's laboratory tests should have been completed sooner rather than after multiple days.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 (R #4) of 1 (R #4) resident, when:The facility staff did not ensure a physician's order was accurate for administering Lactated Ringer solution (LR; an intravenous fluid used to replace lost fluids and electrolytes and help correct acid base imbalances), and the LR solution was not administered as expected in accordance with professional standards of practice.If ordered intravenous fluids are not administered as intended, residents may receive substandard care and treatment, placing them at risk for preventable harm. The findings are: A. Record review of the facility's intravenous fluid and drug administration policy, dated 10/2024, revealed the following:A licensed independent practitioner's order is required for all IV infusions. The nurse shall assess the appropriateness of the prescribed therapy, including the resident's condition, dose, route, and rate of the ordered solution or medication. The nurse shall monitor the resident for therapeutic response, recognize adverse reactions, implement nursing interventions as indicated, and provide ongoing monitoring.Prior to IV infusion, the nurse shall verify IV catheter patency (catheter being open, unobstructed, and functioning correctly, allowing fluids and medications to flow freely into the bloodstream without resistance) and flush (a medical procedure involving the injection of a sterile saline solution into an IV line) the IV catheter as ordered. B. Record review of R #4's face sheet revealed an admission date of 05/03/2026 and the following diagnoses: Acute Kidney Failure (a sudden loss of kidney function).Chronic Kidney Disease (CKD; impaired kidney function).Acute Respiratory Failure with Hypoxia (a condition in which the lungs suddenly cannot get enough oxygen into the blood). C. Record review of R #4's physician orders dated 05/20/2026 revealed the following:Active order for Lactated Ringer's Solution 250 mL (milliliters) IV every 30 minutes as needed for acute kidney injury and monitor for fluid volume overload. Check blood pressure and heart rate 30 minutes after each bolus (is a single, concentrated dose of medication or fluid administered rapidly into a vein for immediate therapeutic effect).Bolus may be repeated up to three times as directed by the provider and notify the provider if there was no response after the third bolus. D. Record review of R #4's Treatment Administration Record (TAR), dated 05/20/2026 through 05/31/2026, revealed R #4 was not administered a Lactated Ringer bolus as needed per physician orders during this timeframe. E. Record review of R #4's facility transfer form, dated 05/31/2026, revealed R #4 was transferred to the emergency room (ER) due to peripheral edema (swelling of the legs, ankles, and feet caused by excess fluid buildup), altered mental status, and hypotension (low blood pressure) in the presence of acute kidney injury. R #4's blood pressure (normal range 90/60 mmHg to 120/80 mmHg) was 94/68 mmHg before transfer to the hospital. F. On 06/29/2026 at 8:05 AM, during an interview, Nurse Practitioner (NP) #1 stated she ordered intravenous hydration with Lactated Ringer's solution for R #4, and a peripherally inserted central catheter (PICC line; a thin, flexible catheter inserted into a peripheral vein and guided to a large central vein near the heart to deliver medications, fluids, or nutrition over an extended period) was placed to administer the IV fluids. NP #1 stated the order was to administer one Lactated Ringer bolus, then reassess the resident's vital signs, laboratory results, clinical response, and monitor for fluid volume overload before determining whether additional boluses were needed. NP #1 stated the order allowed up to three boluses but was not intended for all three to be administered consecutively due to the resident's impaired kidney function. NP #1 stated R #4's Lactated Ringer IV administration should have been a scheduled treatment rather than ordered as needed, and the PICC line was placed to administer the ordered solution. G. On 06/29/2026 at 10:19 AM, during an interview, the Medical Director (MD) stated when a resident is borderline septic with hypotension and tachycardia (fast heart rate), he may order one liter of Lactated Ringer's solution to be administered rapidly. The MD stated failure to administer ordered intravenous fluids could contribute to a resident requiring a more rapid transfer to the hospital. The MD stated R #4's IV fluid orders should include clear instructions regarding the rate and timing of administration and emphasized the importance of communication between providers and nursing staff.

Based on record review and interviews, the facility failed to ensure a resident did not receive unnecessary pain management medications for 1 (R #6) of 1 (R #6) resident. This deficient practice is likely to lead to unwanted drug effects and poor patient outcomes. The findings are: A. Record review of R #6's face sheet revealed an admission date of 05/12/26 and a discharge date of 05/29/26, with the following diagnoses:Acute osteomyelitis (infection in the bone) of the right ankle.Fracture of shaft of left clavicle (left shoulder fracture). B. Record review of R #6's care plan, dated 05/13/26, revealed R #6 is at risk for substance use (refers to the consumption of alcohol, tobacco, prescription medications, or illicit drugs, which may lead to negative physical, mental, or social consequences) related to a history of addiction. C. Record review of R #6's hospital medication summary, dated 05/12/26, revealed R #6 was to receive the following medications upon discharge from the hospital: Buprenorphine-naloxone (suboxone; a combination medication used to treat opioid/narcotic addiction) 4 milligram (MG), one sublingual film (a thin, dissolvable strip of medication placed under the tongue to allow rapid absorption directly into the bloodstream) every 4 hours.Lidocaine topical (used to relieve localized nerve pain by numbing the affected area), two patches every 12 hours for pain. Methocarbamol (muscle relaxant used to relieve pain and discomfort from acute musculoskeletal conditions) 750 mg, three times per day. D. Record review of R #6's physician orders revealed the following:Dated 05/13/26, Buprenorphine HCl-naloxone, sublingual Film 4 mg. Give one film sublingually four times a day for opioid use disorder (OUD). This medication was discontinued on 05/18/26. Dated 05/14/26, Oxycodone HCl (used to manage pain severe enough to require an opioid pain medicine when other pain medicines do not treat pain well enough or are not tolerated) extended release (ER) tablet 12-hour abuse-deterrent 10 mg. Give one tablet by mouth every 12 hours for moderate to severe pain for 14 days. This medication was discontinued on 05/27/26.Dated 05/18/26, Buprenorphine HCl-naloxone, sublingual Film 4 mg. Give one film sublingually four times a day for opioid use disorder (OUD). This medication was discontinued on 05/25/26. Dated 05/25/26, Buprenorphine HCl-naloxone, sublingual Film 4 mg. Give one film sublingually every four hours for pain for three days. Dated 05/27/26, Oxycodone HCl ER tablet 12-hour abuse-deterrent 10 mg. Give one tablet by mouth every 12 hours for moderate to severe pain. Do not exceed two tablets within 24 hours. E. On 06/24/26 at 12:05 pm, during an interview, the Director of Nursing (DON) stated the suboxone prescriptions are reviewed by Physician #1, who oversees a methadone (a long-acting opioid medication that is used to reduce withdrawal symptoms in people addicted to heroin or other narcotic drugs) clinic. The DON stated methadone is given only in the clinic and Suboxone is delivered to the facility and administered to residents as ordered. The DON stated she has questioned why some residents are being given Suboxone and oxycodone together, as in R #6's case, because Suboxone can block the intended effects of oxycodone. F. On 06/29/26 at 10:00 am, during an interview, the Medical Director (MD) stated he works closely with Physician #1 and is highly involved in the care of residents in the facility, but he does not prescribe Suboxone or oxycodone. The MD stated residents who take Suboxone would need high amounts of oxycodone to receive pain relief. He stated a dose of 20 to 30 milligrams of oxycodone would be needed to override the Suboxone's effects, and a 10 milligram dose would provide only a placebo effect (a phenomenon where a person experiences real improvement in health or symptoms after receiving a treatment that has no therapeutic effect, driven by their expectations or beliefs). The MD stated even if oxycodone does not provide adequate pain control, it will calm their [resident's] mind.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 (R #1) of 1 (R #1) resident reviewed, when: The facility failed to ensure R #1 received a newly prescribed antibiotic, after staff were aware of the new antibiotic orders.If the facility fails to obtain and administer a prescribed antibiotic for a resident with an active infection, then residents are likely to experience a worsening infection, disease progression, and avoidable complications. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: Osteomyelitis, right ankle and foot (inflammation of bone and bone marrow),Cellulitis of the lower right limb (deep inflammation of the tissues just under the skin; caused by infection). R #1 was discharged from the facility on 10/14/2025. B. Record review of R #1's Physician Assistant (PA) progress note, dated 10/13/2025, revealed R #1 was prescribed a new antibiotic (doxycycline) by podiatry (the treatment of the feet and their ailments) on 10/09/2025; however, the prescription was sent to an out of facility pharmacy and was not obtained or initiated by the facility. The note further revealed the facility nursing staff were aware of the prescription and informed R #1 the prescription had been sent to an out of facility pharmacy. The PA documented a discussion with R #1 regarding the need to obtain the medication and stated the medication could be delivered later that day or the following day. The PA progress note also revealed R #1 expressed concern regarding lack of antibiotic treatment and requested immediate medical attention, including requesting emergency services due to her need for antibiotics. C. Record review of R #1's October 2025 Medication Administration Record (MAR) revealed R #1 did not receive the prescribed doxycycline antibiotic between 10/09/2025 and 10/14/2025. D. Record review of R #1's Discharge Transition Plan, dated 10/14/2025, revealed R #1's medication list did not include doxycycline antibiotic therapy, and R #1 was discharged from the facility without documented access to the prescribed medication, indicating the facility failed to ensure continuation of treatment for an active infection. E. On 03/19/2026 at 1:03 p.m., during an interview, R #1 stated her foot remained swollen with pus pockets [localized collection of infected fluid], which caused severe pain. She stated she informed the facility nursing staff that she needed the antibiotic prescribed after her podiatry appointment, but she did not receive the antibiotic medication prior to discharge. F. On 03/23/2026 at 11:00 a.m., during an interview, the Director of Nursing (DON) confirmed R #1 did not receive doxycycline antibiotic therapy between 10/09/2025 and 10/14/2025 due to the facility not obtaining the prescribed medication from the out of facility pharmacy. The DON stated the facility was aware of R #1's doxycycline antibiotic order, but the antibiotic was never ordered by the facility.

Based on record review, observation, and interviews, the facility failed to maintain an effective pest control program (measures to eradicate and contain common household pests) so that the facility is free of pests and rodents. This deficient practice is likely to affect all 120 residents listed on the resident census list provided by the Administrator (ADM) on 07/29/25 and are likely lead to airborne illnesses, emotional distress, and may deteriorate quality of life in residents.The findings are:A. Record review of the facility's Infection Control Practices policy, dated 01/08/24, revealed the following:- All tasks will be documented in the TELS (a building management platform that helps maintenance staff with facility maintenance, life safety code inspection and testing, and asset management) Preventive Maintenance program.- The facility will provide a pest free environment by contracting a pest control vendor for appropriate services on a periodic basis whether weekly, monthly, or as needed. B. Record review of the facility's monthly resident council minutes revealed the following:- On 06/19/25, noted complaints to administration stating the residents are seeing big roaches alive and coming up from the drains. There were also noted concerns of mice being spotted at night in the backyard.- On 07/17/25, noted reports of mice in residents' room and requests for more fly traps in the kitchen. There were also noted reports of cockroaches in a resident's peanut butter and jelly sandwich, cockroach in the food tray on 100 hall, and flies on cottage cheese cups. C. Record review of the facility's grievance form, dated 07/02/25, revealed R #7 witness a cockroach in the food cart on 100 hall, it was crawling around and on the food trays. D. Record review of the [Name of Exterminators Corporation] Invoices revealed the following:- On 05/27/25, a contractor sprayed inside of common areas and all interior parts of the building. Invoice noted few roaches noted at the end of the halls by exit doors. A contractor requested respray since he is still seeing roaches in the building. Invoice noted the targeted pest were ants and roaches.- On 06/27/25, a contractor sprayed inside of common areas and all interior parts of the building. Invoice noted kitchen was good and clean, but a few roaches were still noted in the kitchen. Invoice noted plastic wall covering needed to be replaced due to it separating from the wall and roaches are nesting behind the paneling. Invoice noted the targeted pest were ants and roaches.- On 07/25/25, a contractor sprayed inside of common areas and all interior parts of the building. Invoice noted kitchen was good and clean, but a few roaches were still noted in the kitchen. Invoice noted the targeted pest were ants and roaches. E. Record review of the facility's TELS work orders revealed the following:- On 05/23/25, spiders reported in the residents' rooms.- On 06/13/25, cockroaches reported on multiple walls and on food trays.- On 07/14/25, mice reported in resident room. F. On 07/29/25 at 8:18 am, observation revealed three small insects characterized by one pair of wings and a pair of halteres (modified hind wings used for balance) flying and landing on top serving plates, serving side up, in the kitchen. G. On 07/30/25 at 2:54 pm, observation revealed a brown oval-shaped bug with two long antennae and six legs upside down and was still moving in the facility's conference room. H. On 07/29/25 at 8:49 am, during an interview, Kitchen Account Manager (KAM) stated her expectation is for the pest contractor to go and spay the kitchen for pest control when insects are seen in the kitchen. KAM stated when kitchen staff see flies they just shoosh them away and sanitize the area the flies were. She stated serving plates should be stored upside down, serving side down, but it is hard to do so as they are not steady to keep the plates upside down. I. On 07/29/25 at 1:06 pm, during an interview, R #8 stated she has seen roaches and spiders in her room and bathroom. J. On 07/29/25 at 1:23 pm, during an interview, R #7 stated she was given a peanut butter and jelly sandwich for lunch and when she took a bite, she noticed the taste was off. She stated she opened her sandwich and realized there was a cockroach in her sandwich that she had just taken a bit off. R #7 stated she told the Unit Manager (UM) about the incident the day it happened. R #7 stated she tried talking to the KAM the day of the incident but got denied and instead was offered meal alternatives from other kitchen staff. She stated she refused meal alternatives as she was disgusted by the food at that time. R #7 stated she witnessed a roach inside the food cart that had unserved food trays in 100 hall as well. She stated two Certified Nursing Assistants were screaming when they were at the food cart, that caught her attention and got closer to realize there was a roach inside the food cart. K. On 07/29/25 at 2:13 pm, during an interview, Unit Manager (UM) stated a resident did notify her of a roach being in the resident's lunch and resident had taken a bite of the sandwich with the roach inside of it. UM stated she has seen a roach before in the food carts and notified the Administrator (ADM) and Director Of Nursing (DON) at that time. She stated another resident had a mouse inside their room and witnessed a hole in the wall. UM stated Maintenance Director (MD) was notified of the mice issued. She stated her expectation is for the facility to provide a pest free environment for the staff and the residents. L. On 07/30/25 at 9:22 am, during an interview, the Maintenance Director (MD) stated a licensed pest contractor does monthly sprays inside and outside the facility as well as setting up traps for pests. MD stated he still gets complaints about pests in the facility from residents and staff. He stated a mouse was trapped and killed in a resident's room recently and the kitchen staff has also complained about roaches in the kitchen. MD stated if a work order was submitted in TELS system he would make sure to do a fast follow up and resolve the issue reported. He stated staff and administration frequently text him or verbally notify him about the pest issues instead of entering a TELS work order for each instance. He stated any roach complaints he will call the licensed pest contractor or notify the ADM. [No supporting documents provided to show additional licensed pest contractor sprays of the building] He stated there is a work order submitted for the kitchen to help with the pest control being handled by the property manager, there has been no resolution on that order. He stated staff have not been educated to use TELS to submit a work order for reporting pest control issues. M. On 07/30/25 at 2:11 pm, during an interview, ADM stated she has received complaints from staff and residents regarding cockroaches and mice in the facility and in the resident rooms. She stated staff reported to her that a roach was seen outside the food cart not inside of it. ADM stated she had one report of a mouse inside a resident's room, and she notified maintenance to go set up traps. She stated a mouse was caught and killed because of the traps placed in the resident's room.

Based on observation and interview, the facility failed to prepare and serve food under sanitary conditions when dietary staff failed to wear hairnets while in the kitchen. This deficient practice is likely to affect all 120 residents listed on the resident census list provided by the Administrator (ADM) on 07/29/25 and are likely lead to foodborne illnesses in residents if food is not being prepared and safe food handling practices are not adhered to.The findings are:A. On 07/29/25 at 8:04 am, observation revealed [NAME] prepared and served food in the kitchen and did not wear a hair net.B. On 07/29/25 at 8:30 am, observation revealed Kitchen Account Manager (KAM) walked in the kitchen and did not wear a hair net.C. On 07/29/25 at 8:19 am, during an interview with the Cook, she confirmed she was not wearing a hairnet when preparing and serving resident meals. She stated she should be wearing a hairnet while working in the kitchen.D. On 07/29/25 at 8:39 am, during an interview with the KAM, she stated all kitchen staff including herself should be wearing hair nets when entering and working in the kitchen.E. On 07/30/25 at 2:11 pm, during an interview with the ADM, stated all staff, not just kitchen staff, should wear a hair net when entering the kitchen and going past the marked yellow line. She stated kitchen staff should be wearing hair nets at all time while working in the kitchen.

Based on interview and record review, the facility failed to follow physician orders when staff did not enter an order for a nebulizer (device that turns liquid medication into a fine mist, allowing it to be inhaled directly into the lungs) treatment into the medical record for 1 (R #15) of 1 (R #15) resident. This deficient practice could likely result in a resident not receiving the treatment as ordered by the physician which could cause the resident's respiratory status to be compromised. The findings are: A. Record review of R #15's face sheet revealed an admission date of 05/26/24 with the following diagnoses: -Chronic Obstructive Pulmonary Disorder (COPD; lung disease). -Type II diabetes (DM2; a disease in which the body cannot make or properly use insulin). -Hodgkin lymphoma (type of cancer that affects the lymphatic system) -Asthma (chronic lung disease). -Cardiomegaly (a medical condition in which the heart becomes enlarged). B. Record review of R #15's encounter notes, dated 05/17/25 at 1:00 am and written by telehealth provider after hours, revealed R #15 experienced hypoxia (a condition where tissues are deprived of adequate oxygen supply). The assessment and plan for exacerbation COPD: Give albuterol (aerosol medication that helps with breathing difficulties) nebulizer treatment now and attempt to decreases oxygen to 3 liters per minute (LPM) after nebulizer treatment. Notify provider if shortness of breath worsens, patient appears to be in distress or if oxygen saturation decreases. C. Record review of R #15's change in condition notes, dated 05/17/25 at 1:06 pm, revealed R #15 experienced shortness of breath and his oxygen saturation was at 85 percent (%). The provider recommended to give a nebulizer treatment and decrease oxygen from 5 LPM to 2 LPM for COPD and anxiety. D. Record review of R #15's encounter notes made by telehealth providers after hours, dated 05/17/25 at 9:00 pm, indicated R #15 experienced an episode of COPD exacerbation and anxiety attack and was treated for both. R #15 experienced new onset confusion, and the patient was seen grabbing at things that were not there. R #15's oxygen was 92%, and the resident was currently on 5 LPM by nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs). The resident denied shortness of breath. RN reported the daughter was present in the room and requested transportation to hospital for further work up. The resident's oxygen (O2) was 92% on 5 LPM per nasal cannula. The provider sent R #15 out to the hospital. E. Record review of R #15's physician's orders, dated 05/17/25, revealed staff did not enter the albuterol nebulizer treatment order into the medical record. F. Record review of R #15's progress notes, dated 05/17/25, revealed staff did not document R #15 received the nebulizer treatment. G. Record review of R #15's nursing progress notes revealed the following: - Dated 05/18/25 at 6:13 am, R #15 had a quiet night but had one episode of panic attack and yelling that he wants to be released. The resident's oxygen saturation remained low on 2 LPM ranging between 79% to 88%. - Dated 05/18/25 at 1:41 pm, R #15 expressed being ready to go (die) and was experiencing delirium by grasping at things in the air and asked staff to take the animals out of his room and to kill the birds on his bed. Oxygen level 1 to 4 LPM was 88-89%, increased to 5 LPM. The resident's oxygen saturation went up to 92%. - Dated 05/18/25 at 2:29 pm, R #15 was transferred to the hospital. H. On 07/30/25 at 10:51 am, during an interview with the Market Resource Clinician (MRC) and the Director of Nursing (DON), the MRC stated she saw where the nebulizer treatment was the plan for R #15 on two different occasions on 05/17/25 by two different after-hours providers. The MRC stated she did not see either of the nebulizer treatments in the physician orders, and it was not clear if R #15 received the nebulizer treatments.The MRC stated since there was not a lot of documentation in the resident's record, and it was not clear what happened. The MRC did not know if the resident's oxygen LPM was raised from 2 LPM when R #15's oxygen saturation was between 77 to 88%. The MRC stated the nurses might have give R #15 the treatment without putting the order in for it. She stated that was not what should happen, but it could have. I. On 07/30/25 at 2:04 pm, during an interview with the Administrator, she stated it was expected for staff to put orders for any treatment or medication into the residents' medical record. The Administrator stated there had been some issues with the on-call provider in the past. She stated the on-call providers have not always communicated the orders verbally, and they just put them into their encounter note. The Administrator stated the nurse would be unaware of the order if that occurred.

Based on observations and interviews, the facility failed to secure medications and make them inaccessible to unauthorized staff for one medication cart on the 300 hall, creating a risk of unauthorized staff or residents taking a medication not prescribed to them. This deficient practice had the potential to affect all 25 residents residing on 300 hall as identified by the Resident Census provided by the Administrator on 07/29/25.A. On 07/29/25 at 1:05 pm, an observation was made of Nurse #9 walking away from the medication cart without locking it. Nurse #9 was observed to walk into a resident's room. Other (unidentified resident and staff members) were also present on the hall.B. On 07/29/25 at 1:08 pm, an observation was made of the Unit Manager (UM) #2 walking down the hall. UM stopped at the medication cart and locked it. She was observed telling Nurse #9 he needed to lock the medication cart every time he walks away from it. C. On 07/29/25 at 1:08 pm, during an interview with the UM #2 she stated the expectation is to lock the medication cart every time a nurse walks away from it. UM #2 stated Nurse #9 was new and he is still being trained. D. On 07/30/25 at 2:04 pm, during an interview with the Administrator, she confirmed the cart should not have been left unattended.

Based on record review and interview, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following physician orders for 1 (R #15) of 1 (R #15) resident reviewed for diabetic medications. Failure to follow physician orders is likely to cause residents to not receive the care and treatment they require. The findings are: A. Record review of R #15 face sheet revealed an admission date of 05/26/24. R #15 had a diagnosis of: -Chronic Obstructive Pulmonary Disorder (COPD; lung disease). -Type II diabetes (DM2, a disease in which the body cannot make or properly use insulin). -Hodgkin lymphoma (type of cancer that affects the lymphatic system) -Asthma (chronic lung disease). -Cardiomegaly (a medical condition in which the heart becomes enlarged). B. Record review of R #15's physician orders revealed the following orders: -Insulin Glargine Subcutaneous (fat layer between skin and muscle) Solution Pen-injector 100 UNIT/milliliter. Inject 18 unit subcutaneously one time a day for Diabetes Mellitus type 2. Decrease 20 units to 18 units start date 05/08/25. -Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML. Inject 29 unit subcutaneously one time a day for DM2. Increase AM from 20 units to 25 units to 27 units to 29 units start date 03/23/25. -Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML. Inject 29 unit subcutaneously one time a day for DM2. Start date 03/24/25. -Hypoglycemia (blood sugar is too low) Protocol (fast acting carbohydrates released into the system) Observe Sign /Symptoms of hypoglycemia as needed If blood glucose is less than 70 mg/dl or ordered low parameter follow Hypoglycemia protocol start date 05/27/24 -Glucagon (peptide hormone) Emergency Kit 1 MG Glucagon Inject 1 mg intramuscularly (into the muscle) as needed for blood glucose (BG) less than 70. Not arousable conscious or able to swallow Hold all diabetic meds until provider authorizes resumption, remain with patient and keep in bed/chair for safety. Repeat blood glucose in 15 min. Start date 05/27/24 C. Record review of R #15's care plan, dated 05/27/24, revealed the following: - Problem: Diabetes. - Focus: R #2 should be free of all signs and symptoms of hyper/hypoglycemia (low blood sugar, normal blood sugar measurement is 70 to 99 mg/dL), - Intervention: Monitor for signs and symptoms of hyper/hypoglycemia and report abnormal findings to physician. D. Record review of R #15's blood glucose readings, dated 05/01/25 through 05/18/25 revealed staff documented the following: - On 05/18/25 at 6:23 am, R #15's blood glucose measured 67.0 mg/dL. - On 05/17/25 at 9:26 am, R #15's blood glucose measured 61.0 mg/dL. - On 05/11/25 at 8:51 am, R #15's blood glucose measured 62.0 mg/dL. -On 05/07/25 at 7:32 am, R #15's blood glucose measured 50.0 mg/dL. -On 05/04/25 at 6:30 am, R #15's blood glucose measured 67.0 mg/dL. E. Record review of R #15's medication administration record (MAR), dated 05/01/25 through 05/18/25, revealed staff did not administer the Insta-Glucose as ordered by the physician when R #15's blood glucose measured below 70. F. On 07/30/25 at 1:30 pm, during an interview with the Director of Nursing (DON), she stated R #15 had an order for Insta-Glucose if his blood sugar measured below 70 mg/dL. She stated she expected staff to administer the Insta-Glucose gel if R #2's blood sugar dropped below 70. G. On 07/30/25 at 2:04 pm, during an interview with the Administrator, she stated her expectation would be that nurses follow the orders. If his blood sugar falls below 70, nurses should give the insta glucose. H. On 07/30/25 at 10:20 am, during an interview with Nurse #9, she stated if a resident's blood sugar was below 70, then she would assess the resident and give them sugar like a cookie or candy or juice. She stated if the sugar did not work, then she would give the insta glucose. I. On 07/30/25 at 10:30 am, during an interview with Nurse #10, she stated if a diabetic resident had a blood sugar below 70, then you should follow the physician's order. She stated staff should check to see if the residents were alert and conscious and then give them insta glucose. Nurse #10 stated staff should not give juice first, and nurses should always follow the physician order. Nurse #10 stated if the resident refused the glucose gel, then she would give orange juice or milk.

Based on observation and interviews, the facility failed to close or lock the computer screen on the medication cart making personal information inaccessible to unauthorized staff and other residents for 1 (R #18) of 1 (R #18). This deficient practice could cause other to view sensitive, private, medical information. The findings are: A. On 07/29/25 at 1:05 pm, an observation was made of Nurse #9 walking away from the medication cart without locking the computer screen. Nurse #9 was observed to walk into a resident's room. Other (unidentified resident and staff members) were also present on the hall. The computer screen was open with medical information for an unidentified resident up on the screen. B. On 07/29/25 at 1:08 pm, an observation was made of the Unit Manager (UM) #2 walking down the hall. UM stopped at the medication cart and closed the screen to the computer. She was observed telling Nurse #9, he needed to close or lock the screen on the medication cart every time he walks away from it. C. On 07/29/25 at 1:08 pm, during an interview with the UM #2 she stated the expectation is to close or lock the computer screen on the medication cart every time a nurse walks away from it. UM #2 stated Nurse #9 was new and he is still being trained. D. On 07/30/25 at 2:04 pm, during an interview with the Administrator, she confirmed the computer screen should not have been open with resident medical information for others to see it.

Based on observation, record review, and interview, the facility failed to ensure the nutritional needs and preferences were met for all 118 residents listed on the facility census provided by the Administrator on 04/28/25 when staff failed to: 1. Serve the food items listed on the menu. 2. Provide residents with the opportunity to select their choice from the menu or alternate menu in advance of meal service. If the facility is not providing meal as listed on the menu or offering residents the option to select their choice of meal in advance of meal service, then residents are likely to experience frustration, depression, weight loss, and feel unimportant. The findings are: A. Record review of posted lunch menu for 04/30/25 revealed the following:- Main menu item was sausage pizza with marinated cucumber salad. - Alternate menu item was crispy breaded chicken, corn with fresh herbs, and a dinner roll with margarine. - Dessert was a peanut butter cookie. B. On 04/30/25 at 12:24 pm, an observation of the lunch meal service revealed staff served R #19 a cubed pork with peppers sandwich instead of the pizza on the menu. C. On 04/30/256 at 12:25 pm during an interview, R #19 stated, I am tired of this shit. They (facility staff) constantly serve me stuff that is not on the menu. She stated she was often served meals that were not a complete meal or something that was not on the menu. R #19 stated she was tired of being served the wrong food. She stated that she reported the many issues with the food service to everyone she could from the Certified Nurse Aides (CNAs) to the dietary staff and nothing changes. D. On 04/30/25 at 12:29 pm during an interview, the Corporate Chef (CC) stated he did not know why R #19 was served a cubed pork with peppers sub sandwich instead of the pizza on the menu. He stated maybe it was because R #19 had a dairy allergy, and there is cheese on pizza. CC stated he did not know why she was served something that was not on the menu for today or the alternate menu. E. On 05/01/25 at 10:48 am during an interview, R #19 stated staff served her two pieces of toast on a plate with nothing else. She stated her roommate received eggs but did not like them. She stated her roommate gave her the eggs. R #19 stated she was tired of it. F. On 05/02/25 at 10:29 am during an interview, the Dietary Manager (DM), she stated staff did not ask residents in advance what they preferred from the daily menu. She stated there was a book with resident room numbers, what their meal preferences were, and which staff member the resident told about their preferences. The DM stated the facility chose what meals to substitute, and the residents did not know in advance what the substitution would be. She stated it was not their usual process to have residents select their meals in advance. The DM stated if a resident did not like what was served, then they can send it back to the kitchen and request something off the alternate menu. She further stated that the residents were aware they could order something off the alternate menu if they preferred.

Based on observation and interview, the facility failed to ensure all garbage and refuse containers had lids or were covered when not in use. This deficient practice could likely affect all 118 residents identified on the resident census list provided by the Administrator on 04/28/25. This deficient practice could likely result in the unintentional sheltering and feeding of pests. The findings are: A. On 04/28/25 at 9:23 am during an observation, the kitchen the garbage dumpster, located outside the back entrance of the kitchen, was full of garbage, uncovered, and not in use. B. On 05/02/25 at 10:01 am during an observation, the outside dumpster contained garbage, uncovered, and not in use. C. On 05/02/25 at 10:08 am during an interview, the Maintenance Director (MD) stated staff place all facility garbage, to include the kitchen trash, in the dumpster located outside the back entrance to the kitchen. D. On 05/02/25 at 10:29 A.M., during an interview, the Dietary Manager (DM) stated all garbage containers should be closed or covered. She stated it was the kitchen staff's responsibility to make sure the garbage cans covered and the dumpsters were closed. She she stated an open dumpster could welcome animals to get into the dumpster.

Based on interviews and record reviews, the facility failed to provide complete documentation of an infection surveillance plan (ISP, a system for tracking and monitoring infections) for identifying, tracking, monitoring, and reporting of infections, communicable diseases (an illness that can spread from one person to another), and outbreaks (the occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time) among residents and staff. This failed practice has the potential to affect all 118 residents in the facility. This deficient practice is likely to lead to a higher risk of patient harm, difficulty identifying and addressing outbreaks, and difficulty tracking the effectiveness of infection prevention measures (basic practices to stop the spread of germs). The findings are: A. Record review of the facility's Infection Prevention and Control Program (IPCP) documentation, undated, revealed it did not include the following: - A procedure on how staff monitored residents to identify possible infections and communicable diseases. - Early detection and management of a potentially infectious, symptomatic residents that required laboratory testing and the implementation of appropriate transmission-based precautions (TBP, used to prevent the spread of infectious agents from individuals who are suspected to be infected. Includes contact precautions, droplet precautions, and airborne precautions. Examples are wearing gloves, face masks, and gowns or using disposable equipment) and personal protective equipment (PPE, protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) and tracking this information in an infectious disease log. - Evidence-based surveillance (making decisions about care, education, or management by using the best available research evidence, along with own expertise and the unique circumstances of the individual or situation) to define infections and the use of a data collection tool (instruments used to gather, organize, and store data from various sources). - Ongoing analysis of surveillance data and documentation of follow-up activity in response. B. On 04/30/25 at 12:20 pm, during an interview, the facility's Administrator stated the facility implemented infection surveillance. The Administrator did not provide any additional information regarding th facility's IPCP. C. On 04/30/25 at 1:27 pm, during an interview, the Interim Director of Nursing (IDON) stated she started her position a few weeks ago. She stated the previous Director of Nursing (DON), who was responsible for the IPCP at the facility, did not give her any documents on the facility's efforts on infection surveillance. D. On 04/30/25 at 2:00 pm, during an interview, the Infection Control Preventionist (ICP), stated she started her position 3 weeks ago. She stated the previous DON was responsible for the facility's IPCP but did not give her in any documents regarding the facility's efforts to implement an infection surveillance. She stated she was not aware of what documantation the previous DON should have given her, because she was new to the ICP position. E. On 05/02/25 at 9:44 am, during an interview, the facility's Medical Director (MD) stated he was not aware of his responsibility in implementing and maintaining a proper infection surveillance plan. The MD stated the facility contacted him if they needed to, but the facility did not contact him on a constant basis, like meetings or to coordinate and monitor infections.

Based on record review and interview, the facility failed to ensure staff implemented a comprehensive Antibiotic Stewardship Program (ASP, a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This failed practice has the potential to affect all 118 residents in the facility. Residents identified on the matrix provided by the Administrator on 04/30/25. This deficient practice could likely result in the inappropriate use of antibiotics and lead to resistance of Multi-Drug Resistant Organisms (MDRO; a germ that is resistant to many antibiotics). The findings are: A. Record review of the facility's Antibiotic Stewardship policy, dated 12/16/24, revealed the purpose of the policy was to reduce inappropriate antibiotic use and prevent the development of antibiotic-resistant organisms. B. Record review of the facility's Infection Prevention and Control Program (IPCP), revealed the facility did not have a proper and adequate ASP that included: 1. Written antibiotic use protocols on antibiotic prescribing, including the documentation of the indication, dosage, and duration of use of antibiotics. 2. Protocols to review clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and identify what infection assessment tools are used for one or more infections. 3. A process for a periodic review of antibiotic use by prescribing practitioners to determine whether an infection or communicable disease has been documented and whether an appropriate antibiotic has been prescribed for the recommended length of time. 4. Protocols to optimize the treatment of infections by ensuring that residents who require antibiotics are prescribed the appropriate antibiotic. 5. A system for the provision of feedback reports on antibiotic use, antibiotic resistance (the ability of microorganisms, such as bacteria, to withstand the effects of antibiotics that were designed to kill or inhibit their growth) patterns based on laboratory data, and prescribing practices for the prescribing practitioner. C. On 04/30/25 at 1:27 pm during an interview, the facility's Administrator, the Interim Director of Nursing (IDON) and the Infection Preventionist (IP) stated they did not have ongoing monitoring documentation for antibiotic usage patterns or evidence to show an annual review of the Antibiotic Stewardship Program was completed. They stated the previous Director of Nursing (DON) handled the Infection Prevention and Control Program (IPCP) but did not give them any documents to support the facility's efforts toward implementing an ASP. D. On 05/02/25 at 9:44 am, during an interview, the Medical Director (MD) stated he was not aware of his responsibility in implementing and maintaining a proper and adequate ASP. He stated the facility contacted him if they needed to, but the facility did not contact him on a constant basis, like meetings or to coordinate and monitor antibiotics use in the facility. E. On 05/02/25 at 1:30 pm, during an interview, the facility's Consultant Pharmacist (CP) stated he conducted medication regimen reviews (MMRs, a comprehensive assessment of a patient's current and past medications, aimed at identifying and resolving potential drug-related problems) monthly. He stated he expected the facility to implement an ASP, and he could be part of implementing the program.

Based on observation, record review, and interviews, the facility failed to maintain a clean, safe, and comfortable environment for residents when staff failed to: 1) Repair damaged and broken blinds in resident rooms #103, #109, #206, #305, #309, and #311. 2) Repair broken wall tiles in resident bathrooms in rooms #103, #106, and #107. 3) Paint over unpainted drywall in resident rooms #101, #102, #103, #107, #302, #303, and #305. 4) Clean dust from ceiling fans above the dining room eating area. 5) Replace stained tablecloths in the dining room. 6) Ensure the cleanliness of vending machines in the common area. 7) Maintain the conference room in a clean, uncluttered, and hazard-free condition. Failure to maintain the building in a clean and comfortable manner is likely to result in unsafe conditions and prevent residents from enjoying everyday activities. These deficient practices could likely result in residents feeling frustrated, embarrassed, and unimportant. The findings are: Broken Blinds A. On 04/28/25 at 10:00 A.M., during an observation, resident rooms #103, #109, #206, #305, #309, and #311 had broken blinds. B. On 05/02/25 at 2:00 P.M., during an interview, the Maintenance Director (MD) stated he was aware of some of the broken blinds in resident rooms. He stated he only checked a few rooms for maintenance issues because of time constraints. He said staff were expected to submit work orders when they noticed broken blinds. He stated he did not routinely inspect resident rooms for damaged fixtures, such as blinds. Resident Shower Rooms C. On 04/28/25 at 10:00 A.M., during an observation, the following resident rooms had missing wall tiles in the showers: - room [ROOM NUMBER] was missing 11 wall tiles. - room [ROOM NUMBER] was missing six wall tiles. - room [ROOM NUMBER] was missing eight wall tiles. D. On 05/02/25 at 2:00 P.M., during an interview, the MD stated he was not aware of the broken tiles in the bathrooms of Rooms #103, #106, and #107. He stated he only had time to check a few rooms each week for general maintenance issues but could not provide a schedule or system for those checks. He said staff were expected to submit work orders for any needed repairs, including broken tiles. He stated he did not routinely enter resident rooms to inspect for damage unless staff submitted a work order. Unpainted Walls E. On 04/29/25 at 8:32 A.M., during an observation of the 100 and 300 units, seven resident rooms (#101, #102, #103, #107, #302, #303, and #305) had areas of unpainted drywall mud on the walls. The unpainted drywall mud was not painted to match the surrounding wall surfaces and gave the appearance of incomplete repair work. F. On 05/02/24 at 2:15 P.M., during an interview, the MD stated he did not get to the unfinished and unpainted room walls, because he was busy. Dining Room G. On 04/30/25 at 12:41 P.M., during an observation of the dining area, three ceiling fans located above the residents' eating area had visible dust buildup on the fan blades. H. On 05/02/25 at 3:02 P.M., during an interview, the Housekeeping Staff (HS) stated she expected staff to clean the ceiling fans in the dining area monthly. She stated she could not recall when staff last cleaned the fans. She stated dust from the fans could fall onto residents and their food if staff did not clean the fans regularly. Tablecloths in Dining Room I. On 04/29/25 at 10:36 A.M., during an observation of the dining room, the tablecloths on the tables had a strong odor and were stained with cup rings and other stains. J. On 05/02/25 at 3:00 P.M., during an interview,the HS stated she asked for new tablecloths for the dining room, but she did not receive them yet. She stated she expected the tablecloths to be odor free and without stains. Vending Machine K. On 04/30/25 at 12:43 P.M., during an observation, the dining area contained two vending machines. Further observation revealed the tops of the vending machines were dusty. Several used white Styrofoam cups and eight smashed soda cans sat on top of the dusty vending machines. L. On 04/30/25 at 3:02 P.M., during an interview, the HS stated she did not realize the tops of the vending machines were dirty. She stated the housekeeping team did not have a routine system in place to check or clean the tops of the vending machines. She stated her Supervisor expected staff to maintain all visible and non-visible surfaces in a clean condition, but the tops of the vending machines were not part of the daily or weekly cleaning checklist. Conference Room M. On 04/28/25 at 10:41 am, during an observation, the sink in the conference room had a container under the sink drain. Further observation revealed the container was full to the top with black water which had a strong odor. N. On 04/28/25 at 10:42 am during an interview, the Administrator (ADM) confirmed the container of black water with a strong odor was located under the sink in the conference room. The ADM stated the conference room was utilized for resident Care Plan meetings, and residents and family members attended the Care Plan meetings in the room. The ADM stated the standing water with an odor was not acceptable. 50752

Based on observation, record review, and interview, the facility failed to ensure staff revised the care plans for 2 (R #7 and R #24) of 2 (R #7 and R #24) residents reviewed. Staff failed to update the care plans to reflect each resident's current needs regarding the use of appropriate utensils during mealtime. Appropriate utensils refer to those assessed as safe and suitable for the resident based on their physical and mental condition (e.g., plastic utensils instead of metal for residents with a history of self-harm). If care plans are not updated to reflect residents' current needs, then staff may provide inappropriate items or assistance, which could result in unmet care needs and safety risks. The findings are: R #7 A. Record review of R #7's face sheet revealed an admitted [DATE] with the following diagnoses: - Unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), -Muscle weakness (reduction in the power exerted by muscles.) B. Record review of R #7's Care Plan, dated 03/04/25, revealed the resident to use plastic utensils for eating. C. On 04/29/25 at 12:55 P.M., during an observation, R #7 sat in the dining room with staff and ate his lunch. R #7 ate lunch with a metal fork. D. On 05/02/25 at 10:00 A.M., during an interview, the Administrator stated R #7 had a history of suicidal thoughts but had not exhibited such thoughts for several years. She stated she was confident the facility could manage any concerns related to his mental health. She explained R #7 was currently permitted to use metal forks and spoons. She stated care plan meetings were held quarterly (every 90 days), but staff did not update R #7's care plan. She stated it was her expectation that staff review and update each resident ' s care plan at least every quarter. E. On 05/02/25 at 10:40 A.M., during an interview, the Director of Nursing (DON) stated staff did not revise R #7's care plan and remove that the resident had to use plastic utensils. She stated it was her expectation for staff to review and update resident care plans quarterly. R #24 F. Record review of R #24's face sheet revealed an admitted [DATE] with a diagnosis of dementia. G. On 04/29/25 at 12:25 P.M., during an observation, R #24 ate his lunch alone in the dining room while staff served meals to the other residents. R #24 ate his pureed lunch with a regular-sized teaspoon. R #24 coughed and cleared his throat. Staff told the resident to take a drink, and R #24 continued to eat. H. Record review of R #24's Care Plan, dated 04/30/25, revealed staff were directed to do the following: - Provide a small spoon for meals. - Provide assistance during meals. - Encourage small sips and bites and cue as needed. - Encourage resident to chew and swallow each bite. - Encourage resident to alternate liquids and solids. - Encourage resident to perform double swallows. - Encourage small sips and bites and cue as needed. - Monitor for sign and symptoms of aspiration (sucking food into the airway.) I. On 05/02/25 at 9:55 A.M., during an interview, the Speech-Language Pathologist (SLP) stated R #24 was on a pureed diet (a texture modified diet that requires no chewing), because he choked on the chewable food. She stated she did not receive any new updates about his choking issues since the resident switched to pureed foods. She stated the resident managed well with the pureed diet and did not need constant staff supervision while in the dining room. She stated staff should have updated the resident's care plan when R #24 switched to pureed food to state the resident could use a regular size spoon. She stated she did not recall when the puree diet was changed. She stated she did not have anything to do with resident care plans. J. On 05/02/25 at 10:00 A.M., during an interview with the Administrator, she stated R #24 could have a regular sized spoon since he switched to a pureed diet. She stated they reviewed R #24's nourishment care area in the resident's care plan, but they missed the spoon section. She stated the spoon was listed under activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating.) She stated it was her expectation for staff to review and update all resident care plans quarterly. K. On 05/02/25 at 10:40 A.M., during an interview, the DON stated staff did not revise R #24's care plan was for the use of a regular spoon while eating. She stated it was her expectation for staff to review and update all resident care plans quarterly.

Based on record review, observation, and interview, the facility failed to ensure a safe environment free of the potential for accidents and hazards for all residents when staff failed to: - Ensure accurate smoking supervision assessments were completed for R #7; - Ensure residents did not have lighters in their rooms; - Ensure staff did not store personal belongings in resident rooms; - Prevent unsecured bleach cleaning wipes from being left in resident bathrooms. This deficient practice placed residents at risk for burns, fire-related injuries, chemical exposure, and ingestion of unsafe substances. The findings are: R #7 A. Record review of facility's Smoking Safety policy, dated 04/10/24, revealed all smoking supplies (to include tobacco, matches, lighters, and lighter fluid) must be labeled with the resident's name, room number, and bed number; maintained by staff; and stored in a suitable cabinet at the nurses station. Lighters are not permitted in resident rooms due to fire risk, especially when oxygen is in use. B. Record review of R #7's face sheet revealed an admitted [DATE], with the following diagnoses: -Unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). -Muscle weakness. C. Record review of R #7's smoking assessments revealed the following: conflicting documentation regarding the resident's need for supervision: - Dated 01/02/25, R #7 had dementia and required supervised smoking. - Dated 04/04/25, R #7 had dementia and could to smoke independently (without supervision.) D. On 05/02/25 at 1:18 P.M., during an interview with the Director of Nursing (DON), she stated R #7 had dementia, and staff were expected to supervise the resident while he smoked. She stated smoking assessments were completed quarterly. She stated she expected staff to assess residents with dementia appropriately and to monitor them during smoking activities. She stated it was hazardous for a resident with dementia to smoke unsupervised. The DON stated it was her responsibility to ensure smoking assessments were completed accurately. Lighter in Rooms E. Record review of the facility's Smoking Policy, dated 04/10/24, revealed smoking supplies (to include tobacco, matches, lighters, and lighter fluid) will be maintained by staff and stored in a suitable cabinet at the nursing station. F. On 04/29/25 at 1:33 P.M., during an observation of a resident room in the 200 unit, a resident sat on his bed and held a green lighter in his hand. G. On 04/29/25 at 2:30 P.M., during an interview, the Administrator stated lighters were not permitted in resident rooms due to the risk of fire. She stated staff were expected to retrieve lighters for residents from the nurses' station and ensure residents returned them promptly after smoking. She stated nursing staff were responsible to ensure residents did not retain lighters in their possession. The Administrator also stated staff routinely swept the halls to check for lighters, but she did not specify the frequency of these checks. H. On 05/01/25 at 11:23 A.M., during an observation of the 100 hall, a blue lighter sat on a resident's bedside table in an occupied room. I. On 05/01/25 at 12:05 P.M., during an interview, Unit Manager (UM) #1 stated staff attempted to confiscate lighters from all residents but sometimes residents refused. She stated staff documented when residents refused and attempted to retrieve the lighter later. She stated lighters posed multiple hazards, to include burns, risk of fire, and increased danger due to oxygen use in the building. She stated she confiscated three lighters from different residents earlier that day. J. On 05/01/25 at 1:10 P.M., during an interview, the Director of Nursing (DON) stated she was not aware staff found lighters in residents' rooms. She stated residents were not supposed to retain lighters. She stated some residents used oxygen in the facility and that increased the danger of fire. She stated lighters in resident rooms violated facility policy and posed a serious risk. Staff belonging in resident room K. On 05/01/25 at 3:00 P.M., during an observation of a resident's room, the room was furnished for two residents, but only one resident lived in the room. Further observation revealed a staff purse, a duffle bag, and a grey sweater in the unoccupied closet. L. On 05/01/25 at 3:45 P.M., during an interview, UM #1 stated staff personal belonging should not be in the resident rooms. She stated many hazards could happen if the resident got into the staff's belongings M. On 05/02/25 at 10:30 A.M., during an interview, the Administrator stated staff was expected to store personal items in the staff break room. She stated staff were never permitted to leave belongings in residents' rooms. She stated residents could access and take items that did not belong to them, including food or drinks that were not part of their dietary plan. Bleach Wipes N. On 05/01/25 at 10:23 A.M., during an observation of resident room [ROOM NUMBER], a container of bleach wipes sat on the bathroom sink. Further observation revealed the container of bleach wipes did not have a top, and the wipes in the container were exposed. O. On 05/02/25 at 2:14 P.M., during an interview, Certified Nursing Assistant (CNA) #12 stated bleach wipes should not be left in resident bathrooms. She stated she did not know the potential hazards of leaving the wipes accessible. P. On 05/02/25 at 2:30 P.M., during an interview, UM #1 stated staff should not leave wipes in any resident bathroom. She stated the resident could mistake the bleach wipes for personal wipes and misuse them.

Based on observations, interviews and record review, the facility failed to ensure Nurses and Certified Medication Aides (CMAs) dated opened insulin (a medication prescribed to help the body turn food into energy and manages blood sugar levels) pens and discarded them within 28 days of the opening date for 5 (R #5, R #27, R #47, R #71, R #82) of 5 (R #5, R #27, R #47, R #71, R #82) residents reviewed. This deficient practice is likely to result in all five residents receiving medications that are less effective or expired. The findings are: A. Record review of the facility's Medication Storage Policy, dated [DATE], revealed the following: - Note the date on the label for insulin vials and pens when first used. - The policy did not address discarding insulin pens within 28 days of opening. B. Record review of the manufacturer's instructions for Insulin Glargine multiple dose vial, dated 2022, revealed staff were instructed to throw away all opened vials after 28 days of use, even if there was insulin left in the pen. C. Record review of the manufacturer's instructions for Insulin Lispro multiple dose vial, dated 2023, revealed staff were instructed to throw away all opened vials after 28 days of use, even if there was insulin left in the pen. D. Record review of the manufacturer's instructions for Insulin Aspart multiple dose vial, dated 2023, revealed staff were instructed to throw away all opened vials after 28 days of use, even if there was insulin left in the pen. E. On [DATE] at 10:04 am, observation of the 100 Hall medication cart revealed the following: - Insulin Lispro (a short-acting insulin),100 units/milliliter (ml) multiple-dose pen was opened and dated [DATE]. The insulin pen belonged to R #5. - Insulin Lispro ml multiple-dose pen was opened and dated [DATE]. The insulin pen belonged to R #27. - Insulin Lispro 100 units/ml multiple-dose pen was opened and dated [DATE]. The insulin pen belonged to R #47. - Insulin Glargine (a long-acting insulin),100 units/ ml multiple-dose pen was opened and dated [DATE]. The insulin pen belonged to R #71. - Insulin Lispro 100 units/ ml multiple-dose pen was opened and dated [DATE]. The insulin pen belonged to R #71. - Insulin Aspart (a short-acting insulin),100 units/ ml multiple-dose pen was opened and dated [DATE]. The insulin pen belonged to R #82. F. Record review of R #5's Physician Orders, revealed an order for Insulin Lispro. Start date [DATE], stop date [DATE]. G. Record review of R #27's Physician Orders, revealed R #27 had an order for Insulin Lispro. Start date [DATE], stop date [DATE]. H. Record review of R #47's Physician Orders, revealed R #47 had an order for Insulin Lispro. Start date [DATE], stop date [DATE]. I. Record review of R #71's Physician Orders, revealed R #71 had the following orders: - Insulin Glargine. Start date [DATE], stop date [DATE]. - Insulin Lispro. Start date [DATE], stop date [DATE]. J. Record review of R #82's Physician Orders, dated [DATE], revealed R #82 had an active order to receive Insulin Aspart. K. On [DATE] at 2:06 pm, during an interview, Nurse #2 stated he should have discarded the opened insulin pens within 28 days of the opening date. L. On [DATE] at 2:45 pm, during an interview, 100 Hall Unit Manager (UM) #2 stated staff must date the opened insulin pens and discard them within 28 days of the opening date. She stated she expected Nurses and CMAs to check the insulin pens for labeleing when they start thier shifts and discard them after 28 days. M. On [DATE] at 12:56 pm, during an interview, the Director of Nursing (DON) stated staff must date the opened insulin pens and discard them within 28 days of the opening date. She stated Nurses and CMAs are trained on insulin pen labeling. She stated she expected Nurses and CMAs to label the insulin pens when they first open them and discard them after 28 days, even if there was still insulin inside them. N. On [DATE] at 10:20 pm, during an interview, the facility's Consultant Pharmacist (CP) #1 stated she expected Nurses and CMAs to date the opened insulin pens and discard them within 28 days of the opening date. He stated after 28 days of opening insulin pens they are considered expired.

Based on resident and staff interviews, record review, and review of the facility policy, the facility failed to protect the right of one of one resident reviewed for abuse (Resident (R) 51) to be free from physical abuse by R111. R51 suffered two events of physical abuse by R111 when R111 was not adequately supervised following the first event of abuse. The second event resulted in R51 being hospitalized for a fractured arm and a [CONDITION(S)] requiring stitches. Immediate action to ensure staff provided adequate supervision and/or monitoring to any resident threatening the health and safety of themselves or others was required to prevent recurrence of the situation. The facility's Administrator and Director of Nursing (DON) were informed on 11/16/21 at 6:30 PM that Immediate Jeopardy existed related to the failure to ensure R51 was free from abuse by R111 and the failure to prevent a recurrence of the abuse with adequate supervision of R111. The Immediate Jeopardy began on 10/28/22, the date of both incidents of physical abuse by R111 towards R51. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 11/17/22 at 2:20 PM. The survey team validated implementation of the removal plan through observations, staff interviews, and review of audit records and facility training records. The Immediate Jeopardy was removed on 11/17/22 at 3:52 PM. After removal of the Immediate Jeopardy, the deficiency remained at a G scope and severity for isolated actual harm. Findings include: 1. Review of R51's undated Admission Record, located in the Profile tab of the Electronic Medical Record (EMR), revealed R51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R51's quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/27/22, revealed R51 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. R51 occasionally exhibited verbal behavioral symptoms directed toward others. Review of R51's 10/29/22 General Note, found in the Progress Notes tab of the EMR, revealed, Resident returned from hospital at 2015 [8:15 PM] on 10/28/22. Back with humerus [upper arm] fracture treated with immobilization sling on the left arm. Noted with sutures on the right-side head frontal area, open to air. Continued review of R51's 10/28/22 and 10/29/22 Progress Notes revealed no documentation regarding the incident leading to the hospitalization , humerus fracture, and stitches to the head. 2. Review of R111's undated Admission Record, located in the Profile tab of the EMR, revealed R111 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R111's Significant Change of Condition MDS assessment, with an ARD of 09/16/22, located in the MDS tab of the EMR, revealed R111 had a BIMS score of five of 15, indicating severe cognitive impairment. He did not exhibit any mood or behavioral symptoms and had no change in behavioral status. R111 was able to ambulate using a walker with supervision only. He received an antipsychotic medication twice during the seven-day lookback period. Review of R111's Progress Notes, under the Progress Notes tab of the EMR, from his admission on 08/12/22 to 10/23/22, revealed no documentation of behavioral or mood symptoms. The 10/24/22 notes under the Progress Notes tab revealed the first documented episodes of behavioral symptoms: -Review of R111's 10/24/22, 10:53 AM General Note revealed, Resident has been very aggressive and combative all morning. He has been threatening to physically hit [his roommate] and other residents. When I tried to talk to him to de-escalate the situation by walking him back to his room. He forcefully grabbed my arm and pushed me away. -Review of a 10/24/22, 2:38 PM General Note indicated, Resident was seen by NP [Nurse Practitioner]. New order for [MEDICATION(S)] [an antipsychotic medication], 5 mg [milligrams] BID [twice daily]. Consent obtained. -Review of R111's 10/24/22, 6:37 PM General Note revealed, Resident is noticed with aggressive behaviors throughout the day. Spending most of the time in the toilet, making roommate upset, arguing with staff, etc. Hard to redirect many times. -Review of R111's 10/24/2022 11:33 PM General Note revealed, Resd [resident] continues to cross over to his roommate's side and digging on his belongings, getting into his closet and peeing on his roommate's trash can. Resd was advised to stop the aggression and he was directed out of his roommate's belongings. Resd became so aggressive with the staff and threatens [sic] to hit the CNA's [certified nurse aides]. This behavior has continued since yesterday 10/23/22 and regardless of the redirection the Resd continues to cross over to his roommate's side and digging on his staff [sic]. Review of R111's comprehensive Care Plan, located in the Care Plan tab of the EMR, revealed the facility revised the resident's Care Plan on 10/25/22 to address his new behavioral symptoms: -Review of R111's 10/25/22 behavior Care Plan revealed, [R111] yells at roommate even if roommate is not there, constantly goes in bathroom and flushes toilet, yells at residents in activities, going through roommates [sic] belongings, urinating in trash can and on roommates [sic] items, grabbing others due to [CONDITION(S)]. The documented goal was, [R111] will not harm others daily. The interventions included: Administer medications as ordered, . firmly but gently redirect, . monitor and document behaviors, . psych [psychiatric] eval [evaluation] as ordered and PRN [as needed], . [and] seek input from family on normal behaviors for resident and current status. -Review of R111's second 10/25/22 behavior Care Plan revealed Resident/patient exhibit [sic] physical behaviors related to: Cognitive Loss/Dementia, Poor impulse control, and [Psychiatric Disorder(s):] [CONDITION(S)]. The documented goal was, Resident/Patient will not harm others daily. Interventions included: Evaluate need for Psych/Behavioral Health consult, . Encourage resident/patient to seek staff support for distressed mood, . Explain all care, including procedures (one step at a time) and the reason for performing the care before initiating, . Remove resident/patient from environment if needed. Gently guide the resident from the environment while speaking in a calm reassuring voice, . If resident/patient becomes combative or resistive, postpone care/activity and allow time for him/her to regain composure, . Provide a calm, quiet, well-lit environment, . Social Service visits to provide support, as needed and/or requested resident/patient, . Divert resident/patient by giving alternative objects or activities, . [and] Listen to resident and try to calm. Review of R111's 10/25/22 Social Service Note, found in the Progress Notes tab of the EMR, revealed, the Social Services Director (SSD) had contacted two behavioral health facilities to seek alternate placement for R111, but he was denied at both. The note documented the Ombudsman was informed of the situation. Continued review of R111's Progress Notes, under the Progress Notes tab of the EMR, revealed R111's behavioral symptoms continued from 10/26/22 through 10/28/22: -Review of a 10/26/22 4:15 AM General Note revealed, Resident trespassing to roommate bedside . Rummaging through roommates [sic] trash cans upsetting the roommates. Pacing in the room, attempting to fix TV on the wall, rearranging the closet, moving bed sides [sic] table, and w/c [wheelchair]. Resident becomes aggressive when redirected. Roommate reports resident slams the door throughout the night causing disturbance. Roommates reports [sic] unable to sleep due to resident noisy behaviors and disruptions. Roommate . became upset reporting we cannot sleep throughout the night, saying 'I cannot take this, something needs to be done'. Monitoring continues. -Review of a 10/26/22, 8:46 AM General Note revealed, Roommates are complaining that the patient . was up all night and was making a lot of noise. They say they were unable to sleep and that [R111] was seen going through trash cans. -Review of a 10/26/22, 10:26 AM Nursing Documentation Note revealed, . patient has been very agitated, new orders for medications were given, patient will continue to be monitored . Mental Health/Behavior reviewed. Physical behaviors, directed towards others occurs daily or almost daily. Verbal behaviors, directed towards others occurs daily or almost daily. Other behaviors, NOT directed towards others occurs daily or almost daily. Rejection of care occurs daily or almost daily. Wandering occurs daily or almost daily and poses significant risk and/or is intruding on others. Pt. [patient] is experiencing agitation/restlessness. Pt. is experiencing anxiety about surroundings. Pt. is experiencing hallucinations. Pt. is experiencing delusions. Patient has had several issues all noted. Exhibits behavior: [CONDITION(S)] (e.g. Restless Walking Patterns). Additional mental health/behavior comments: not sleeping and disturbing his roommates. -Review of a 10/27/22, 3:55 AM General Late Entry Note revealed, At the beginning of the shift, Resident was going through the food cart. Thereafter notices eating other co-resident left-over food. Redirected back to his room. Resident reported to have been trespassing to co- roommates. Noisy banging the wheelchair against the walker. Rubbing the telephone around the codes. Resident when sleeping snoring too loud, causing roommates to be awake. Roommate . reported kept waking up going to the bathroom due to the noises made by the roommate . Roommate . concern of the resident. Resident monitoring continues. Resident took medication as ordered. -Review of a 10/27/22 6:16 PM General Note revealed, Patient going thru [sic] all the trash, he also pulled the fire alarm, Maintenance was here and was able to reset it. -Review of a 10/27/22 11:00 PM Nursing Documentation Note revealed, Resident pulled the fire alarm at the beginning of the shift. He took a box of Keurig coffee, he said 'I got it from the doctors [sic] office.' Resident's roommate bed-A, said he felt intimidated by resident, because resident had a pen in his hand, and he didn't know what resident was going to do with the pen. Resident was reassured. [R111] is with eyes closed resting, at present, will continue to monitor . Physical behaviors, directed towards others occurs daily or almost daily. Verbal behaviors, directed towards others occurs daily or almost daily. Other behaviors, NOT directed towards others occurs daily or almost daily. Rejection of care occurs daily or almost daily. Pt. [patient] is experiencing restless [sic]. Getting into co-residents belongings. And when attempting to redirect, he will get angry. -Review of a 10/28/22, 10:07 AM General Note revealed, Resident had a physical altercation with his roommate (R51), 911 was called. Brother . was called to notify with no answer, voicemail was left. -Review of a 10/28/22, 11:10 AM (late entry) Social Service Note documented, Social services director [SSD] was walking to 200 hundred hall and saw [R111] sitting down on his wheelchair at the nurses station. SSD heard [R111] saying, 'I will get him, I will get him.' SSD approached [R111] and asked him who was he talking about. [R111] pointed down the 200 hall. [R111] went outside to the patio with a CNA, and the Activities Director. Unit Manager was notified. -Review of 10/28/22, 11:06 AM Social Service Note revealed the SSD called R111's responsible party to inform that R111 had pushed a resident, and the police was [sic] coming to talk to him. The note further documented R111 was escorted by the police to a behavioral health hospital. Though R111's behaviors escalated from 10/24/22 through 10/28/22, there were no new interventions added to his Care Plan after the initial creation of the 10/25/22 behavioral Care Plans. Review of the facility's 10/28/22 Health Facility Incident Report, provided on paper in the investigation packet by the Administrator, revealed at 10:45 AM, [R51's] roommate [R111] came out of the bathroom and began hitting [R51], knocking him to the ground. [CONDITION(S)], and arm immobile. Review of an undated and untitled, handwritten witness statement, provided on paper in the investigation packet by the Administrator, revealed Licensed Practical Nurse (LPN) 1 documented, [R51] came out [of his room] and told me that [R111] had pushed him. I reported it and asked [R51] to stay calm. I was at the front office when a CNA came and told me that the two had gotten in a fight in the room. I ran as fast as I could. I found [R51] on the floor and [R111] was leaving the room. I asked one of the CNA's [sic] to get [R111] out of the room. [R51] had blood coming from the side of his head. Review of a 10/28/22 untitled and handwritten witness statement, provided on paper in the investigation packet by the Administrator, revealed CNA5 documented CNA4 asked if I could go into [R111 and R51's room] with her because [R111 and R51] were arguing. As we are [sic] walking to the room, we heard a loud crash so we ran in to find R5]1 on the floor face down and [R111] standing over him. We immediately removed [R111] from the room . When the nurse arrived I stepped out of the room with [R111] and he said, 'I've killed before, and I'll kill him next.' [R111] then continued to say things along the lines of, 'I'll [expletive] kill him; [expletive] him; I'll kill him the next time I see him. Review of a 10/28/22 typed, untitled witness statement, provided on paper in the investigation packet by the Administrator, Unit Manager (UM) 1 documented, During morning meeting [LPN1] came in and stated [R111] had shoved [R51]. [UM1] went down the hall to assess the situation. [CNA4] came into meeting and stated that [R51] was bleeding. Upon my arrival to resident's room [R51] laying on floor on his right side. Blood coming from right forehead. Complaints of left arm pain. I asked resident what had happened and he stated 'that mother [expletive] hit me, I was checking on [roommate] and he bum rushed me when he came out of the bathroom. l think my arm is broken; I can't move my hand. Administrator called, and then I immediately called 911 to have them remove [R111]. [LPN1] had already called 911 for [R51]. I assessed [R51] again to check his head, 1-inch-long gash to right side of forehead. I also cut clothing away from residents [sic] arm to visualize skin. Swelling present to left upper arm, painful to touch. I went to speak with [R111] about the altercation. [R111] was outside with Activities Director. I asked what happened, resident muttering incoherent words then asked, 'Did I kill him? Cause if I see him I'm going to [expletive] kill him again.' Resident then again started to talk non-coherently. Resident left with [Activities Director]. Police arrived at 1006. I spoke with the officers regarding the situation. [R51] was interviewed by police . Police asked me to take them to [R111]. [R111] inside of activities room with [Activities Director]. An immediate discharge was given to the resident to sign, and police interviewed [R111]. [R111] again stated to the police that he was going to 'Kill him' again. Police stated he would be charged with Assault and Battery and taken to [a hospital] for psych clearance. Review of the investigation packet provided by the Administrator revealed no witness statement from CNA4 was included. Review of the 11/07/22 Complaint Narrative Investigation Report (5 Day), provided on paper in the investigation packet by the Administrator, revealed, On 10/28/2022 [LPN1] walked on unit [sic] walked into morning meeting stating that [R111] shoved [R51]. Unit Manager and Director of Nursing went down to unit to assess the situation. Upon arrival resident, [R51] was noted laying on the floor on his right side, blood coming from forehead and pain in left arm. [R51] was assessed, resident had 1-inch-long gash to right side of forehead. It was also noted that swelling was present to left upper arm and painful to touch. Facility actions: Residents were immediately separated, [Name of City] Police notified . as well and 911 called for [R51]. [R111] was taken outside with the Activities Director. Director of Nursing interviewed both residents. [R51] stated, 'that mother [expletive] hit me, I was checking on my roommate and he bum rushed me when he came out of the bathroom. I think my arm is broken; I can't move my hand.' During interview with [R111], resident was muttering incoherent words then asked, 'Did I kill him? Cause if I see him I'm going to [expletive] kill him again.' Resident then started to talk non-coherently again. Police arrived to facility and met with [R111] and stated to DON that he would be charged with Assault and Battery and taken to [a behavioral health hospital] for psych clearance. [R51] was taken to the emergency room for further evaluation. A chart review was completed on [R111]. Resident has a BIMS score of 5 and diagnosis [sic] of: [CONDITION(S)] disorder [CONDITION(S)] type, chronic diastolic heart failure, and severe protein calorie malnutrition. Per review of resident's medication, resident [sic] 10 mg [MEDICATION(S)] was discontinued on 10/26 and [MEDICATION(S)] [an antipsychotic medication] 2 mg, [MEDICATION(S)] [an antipsychotic medication] 25 mg, and [MEDICATION(S)] 5 mg were started on 10/26. Resident was also on [MEDICATION(S)] [a mood stabilizing medication] l000 mg twice daily since admission . but gradual dose reduction of the [MEDICATION(S)] was started on 08/30 and was [decreased] to 750 [mg] twice daily. Resident was also on 25 mg [MEDICATION(S)] [an antipsychotic medication] twice a day on admission and [reduced] on 09/6/2022 to 12.5[mg] twice a day for 5 days then discontinued. It was noted on 10/27 that resident was going through roommate's trash and food cart. A chart review was completed on [R51]. Resident has a BIMS score of 13 [intact cognition] and diagnosis [sic] of: follicular [CONDITION(S)] grade III, opioid dependence, other stimulant abuse, and drug induced pancytopenia [a deficiency of all three cellular components of the blood]. The facility acted accordingly, and abuse, neglect or exploitation could not be substantiated . Conclusion: [R51] was transferred out to hospital and readmitted with humerus fracture and staples to right side of head. Fracture was treated with hospitalization . CT scan completed resulting with slight micro motion artifact [Misregistration artifacts, which appear as blurring, streaking, or shading, are caused by patient movement during a CT scan]. [R111] was issued a discharge notice from facility and [R51] did place charged [sic] on [R111] for assault and battery. In an interview on 11/16/22 at 3:00 PM, LPN1 stated when R51 first reported he had been pushed by R111, R51 had not been physically harmed and was upright. LPN1 told R51 to remain calm and stay in his room, as she had noticed R111 had gone outside to the courtyard area to smoke. LPN1 stated she then left the unit to inform the DON and UM1 of the allegation, who were in the morning interdisciplinary team meeting. LPN1 stated that a little bit later, she was told by a CNA that R51 was on the floor. LPN1 stated R111 was not witnessed pushing R51 either time it happened. LPN1 stated she felt R111's actions were willful, and he mentioned to other staff that he was going to kill R51. In an interview on 11/16/22 at 3:20 PM, CNA4 stated she heard R51 and R111 were fighting. She went to the room with CNA5 and found R51 lying injured on the floor, with R111 rummaging through his closet. CNA4 asked CNA5 to escort R111 out of the room to a quiet location. CNA4 stated she was not aware of interventions to deal with R111's behaviors at that time because he had just recently been moved to her hall. She stated he had to move rooms because of arguments with his first roommate. In an interview on 11/16/22 at 3:31 PM, UM1 stated she was alerted during the morning meeting that there was an altercation between R51 and R111. She immediately left the meeting and went to the room, where she saw R51 on the floor with a CNA near him. The UM1 stated interventions implemented for behaviors prior to the incident included inviting to activities and redirecting with things to keep him busy. She stated there was no formal supervision or monitoring of R111, but he was frequently out of his room. In a concurrent interview with the DON and Administrator on 11/17/22 at 4:00 PM, the Administrator stated the R111 began exhibiting problem behaviors when he had arguments with his first roommate and was moved to another room. She stated behavioral interventions included referrals to psychiatry and medication adjustments, attempts to place at alternate behavioral units, and redirection. The Administrator stated R111 was out of his room most of the time socializing with staff and wandering the halls, but there were no interventions to ensure he was not aggressive with other residents while he was wandering. The Administrator stated she was not in the facility on 10/28/22. The DON stated on 10/28/22, there were two incidents of R111 pushing R51. The DON stated first, R51 alleged R111 pushed him, and LPN1 made sure the residents were separated and left the floor to report to administration during the morning meeting. The DON confirmed [R111] was able to return to his room and physically assault R51 causing injury; R111 was not supervised or monitored during that interval after the first allegation was made. The Administrator and DON both stated R111 should have been provided close monitoring and supervision after the first allegation was made to LPN1 in order to prevent R111 from being able to assault R51 again. The Administrator stated it was substantiated through her investigation that R111 had physically abused R51, causing injury. She stated the report documented abuse was unsubstantiated in error. The Administrator and DON confirmed R111 had physically abused R51 twice. The Administrator stated she had not done any training on abuse with staff since the incident. Review of the facility's 05/01/22 Abuse Prohibition policy revealed, Training . will be provided to all employees -- through orientation, Code of Conduct training, and a minimum of annually - and will include: . The Abuse Prohibition policy; . Appropriate interventions to deal with aggressive and/or catastrophic reactions of patients; . Dementia management and patient abuse prevention; and . Understanding behavioral symptoms of patients that may increase the risk of abuse and neglect and how to respond. Actions to prevent abuse . will include: . intervening in situations in which abuse . is more likely to occur. If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. The Center will provide adequate supervision when the risk of patient-to-patient altercation is suspected. The Center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. The Center should seek alternative placement for the patient exhibiting the abusive behavior, if warranted.

Based on observation, record review, interviews, and policy review, the facility failed to ensure that one resident (R) R21 was properly transferred with a two-person assist instead of a one-person assist, which resulted in causing harm to R21. R21 sustained a fractured left tibia during a transfer. In addition, the facility failed to ensure that four residents (R11, R37, R54 and R262) were properly supervised from keeping smoking materials (lighters) on their person and smoking in undesignated area. Findings include: Review of facility provided policy titled Safe Resident Handling/Transfer Equipment revised 10/01/21 indicated Staff may use safe resident handling equipment, such as lifts or repositioning equipment, for patients/residents when needed. Patients will be assessed to determine the correct equipment to use. Staff will be trained in the use of each type of equipment. Slide boards are an approved method of transfer. Due to the variety of lifts used in centers, manufacturer's instructions will be used. If manufacturer's instructions are not available in the center, contact Risk Management for assistance. Two trained persons are required to operate a total lift or sit to stand lift, regardless if manufacturer instructions state only one person is needed. No one under the age of 18 may operate a mechanical lift. The total lift will be used as the primary intervention for dependent lifting, transferring, and repositioning. The total lift is used for those patients who are dependent non-weight bearing or have inconsistent weight bearing. In addition, the total lift will be used to lift patients/residents off of the floor, unless contraindicated. The divided leg sling is used with the total lift for the majority of patients. 1. Review of the facility provided Face Sheet for R21, indicated that R21 was admitted to the facility on [DATE] with a diagnosis that includes polyneuropathy, diabetes, anxiety, and [CONDITION(S)] disease of nervous system. Review of facility provided Lift Transfer Reposition dated 10/03/22 revealed that R21 was a total lift requiring a medium size sling with divided legs. Review of R21's Annual Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 10/05/22 located in the Electronic Medical Record (EMR) under the MDS tab indicated that R21 was a two-person assist for transfers and had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, meaning that R21 was cognitively intact. Review of R21's Progress Note (facility provided) dated 11/01/22 revealed that R21 complained of her left knee hurting causing her to have difficulty turning in bed for personal care. R21 said that she noticed pain starting after her shower on 10/29/22. The Progress Note further revealed an x-ray was ordered. Review of the Complaint Narrative Investigation Report-5 day (facility provided) dated 11/02/22 revealed that On 11/01/22 R21 reported to the nurse that her left knee was hurting and was causing difficulty turning in bed for personal care. R21 stated she noticed the pain after her shower on 10/29/22. The results of R21's left knee x-ray dated 11/02/22 revealed an anterior lateral tibia fracture with depression, mild soft tissue swelling and joint space narrowing and effusion. The Director of Nursing (DON) interviewed Certified Nursing Assistant (CNA) 3, who had assisted R21 with her shower. CNA3 stated that she transferred R21 into shower chair and R21 stated that she hit her knee. The CNA3 stated that she did not think she hit R21's knee on anything. CNA3 stated she did let the nurse know of R21's complaint. R21 was sent out to the hospital for further evaluation on 11/02/22 after the x-ray results were received. R21 returned the same day wearing a splint on the left leg. The investigation further revealed R21 is a two-person physical assist with all Activities of Daily Living (ADL's). Staff will be educated on safe resident handling, transfers and use of mechanical lifts. Review of conclusion indicated After review of chart and interview with the staff member it was found that R21 was not transferred correctly. R21 is a two person assist and CNA3 transferred resident by herself potentially transferring R21 incorrectly. The facility acted accordingly, and abuse, neglect, or exploitation could not be substantiated. Review of R21's Physician Orders for November 2022 (facility provided) which indicated that R21 needed a mechanical lift with a two person assist under direct supervision of the nurse, starting 11/02/22. Review of CNA3's personnel file (facility provided) indicated that CNA3 was hired on 01/21/14. Review of Disciplinary Action Record dated 03/18/14 indicated Written recommended action from date of infraction (03/14/14). Transferred a resident who you knew was a two person assist, without assistance. As a result of this, the resident had a fall. If it is found you to perform an unsafe transfer again stronger discipline will be taken up to and including termination of employment. This was signed by the supervisor, witness, and CNA3. During R21's interview on 11/14/22 at 10:00 AM, she stated during her shower on 10/29/22 CNA3 picked her up by herself without using a lift. R21 confirmed that she told CNA3 not to pick her up, saying that she might fall. R21 confirmed that she went to the hospital on Tuesday or Wednesday following the incident because she was complaining of pain. The facility ordered a portal x-ray, which showed a fractured tibia. During further interview, R21 confirmed that she had told the other CNAs and nurses what had happened. Interview with the Administrator on 11/16/22 at 2:45 PM, confirmed that R21 was a two person assist and that CNA3 confessed that she transferred R21 by herself, without using another staff member. She said that she educated CNA3, after the incident, about using two person transfers, not transferring by herself, and going by the Kardex not only for R21, but for all residents. The Administrator was aware of CNA3's past written disciplinary action about an unsafe transfer, which resulted in another resident's fall, prior to this management taking over the facility. Interview with CNA3 on 11/17/22 at 6:09 PM, she confirmed that the transfer for R21 happened on 10/29/22. She said that at 12:53 AM she went into R21's room and told R21, that it was just her that would be doing the transfers and confirmed that R21 had no objection. CNA3 revealed she put the gait belt around R21 and sat R21 into a sitting position on the side of the bed and moved her over to the shower chair. CNA3 denied that R21 had a fall and/or hitting something during the transfer. She confirmed that she was the only person that transferred her that night. Said that she showered R21, washed her hair and brushed her teeth, then transferred R21 back to her bed. After the shower and getting into bed, R21 complained of some knee pain, which CNA3 informed the nurse. CNA3 confirmed that after this incident, she was re-trained for transfers and confirmed that she gets annual training for transfers, including how to use the Hoyer lift and the sit to stand lift, indicating that she had this training prior to this incident. 2. Review of R54's Face Sheet (facility provided) revealed that R54 was admitted to the facility on [DATE] with a diagnosis including Chronic Obstructive Pulmonary Disease ([CONDITION(S)]), history of tobacco use, and [CONDITION(S)]. Review of R54's Quarterly MDS with ARD of 08/18/22 located in the EMR under the MDS tab indicated that R54 had a BIMS score of 13 out of 15, indicating that R54 was cognitively intact. Review of R54's Smoking Assessment (facility provided) dated 10/18/22 revealed Resident had no dementia; resident did not use oxygen; resident had no poor memory; resident could demonstrate the location of the designated smoking area; resident had no history of sharing/selling cigarette or smoking materials; no history of fire setting or arson; and no history of unsafe smoking habits. Continued review indicated that the Resident can safety hold a cigarette/e-cigarette device; resident has the ability to light a cigarette/ignite an e-cigarette device; resident can properly dispose of ashes or butts or turn-off/dispose of e-cigarette device; resident can smoke safety using a smoking apron; and resident is cognitively and physically safely manage/store/secure smoking materials including e-cigarette devices. Further review indicated that the resident can independently smoke, and residents are not allowed to keep lighters, lighter fluid or matches at the bedside, and e-cigarette charging must occur at the nurses station. During tour of the facility on 11/14/22 between 10:00 AM and 11:05 AM revealed one cigarette and lighter was observed on R54's overbed table. R54 was alert, yet confused; however, was able to confirm that he smokes. There were no burn holes observed in his clothing. At 3:15 PM, there was one cigarette and lighter observed on R54's overbed table (to the right of his bed). R54 was up and walking around his room. During observation on 11/15/22 at 3:30 PM, R54 lying in his bed, alert and orientated, no cigarettes and lighter noted on his bedtable; however, R54 said that his lighter was in his pocket, confirming that he had smoked earlier. During observation on 11/16/22 at 8:50 AM, R54 was sitting on the corner of his bed, reading a book, alert and oriented. R54 said that he did not have any more cigarettes but confirmed that his lighter was in his pocket. Interview with Licensed Practical Nurse (LPN) 3 on 11/16/22 at 5:05 PM confirmed that smoking residents are always supervised by facility staff, and that residents are not allowed to share cigarettes, and/or have lighters. He said that he was unaware of R54 having a lighter. Said that R54 does not have his own cigarettes, that R54 tends to pick up butts from the ground due to his history of being homeless. At 5:10 PM, LPN 3 approached R54, who was sitting in the day area watching television, and R54 handed the lighter, out of his pocket to the Activity Director. 3. Review of the undated Admission Record located in the Profile tab of the EMR, revealed R262 was admitted to the facility on [DATE]. Review of the Smoking Evaluation dated 11/01/22, located in the Assessment tab of the EMR revealed R262 did not have dementia, could demonstrate the location of the designated smoking area and the resident could properly dispose of ashes or butts. R262 may smoke independently per the smoking evaluation. The evaluation indicated residents are not allowed to keep lighters, lighter fluid or matches at the bedside. During an interview on 11/14/22 at 10:02 AM R262 stated she smokes outside of the front lobby door, and she keeps her own cigarettes and lighter. On 11/15/22 at 1:51 PM R262 said she was able to smoke out in front of the lobby today and someone helped her get there. She stated that she has her own cigarettes and lighter. On 11/15/22 at 4:08 PM approximately 12 cigarette butts sere observed on the ground right outside the front entrance, and one cigarette butt was found immediately outside the front door. There was no smoking safety receptacle in the area for proper disposal of cigarettes. In an interview on 11/15/22 at 4:08 PM, Receptionist 1 stated there are a handful of patients that smoke outside in the front including R262. The reception desk is located in the lobby near the front doors. On 11/16/22 at 8:30 AM approximately six cigarette butts were seen outside the front lobby door near the garbage can. Cigarette ash was on the garbage can lid in multiple places. In an interview on 11/16/22 at 8:56 AM, Receptionist 2 confirmed seeing a resident smoke outside yesterday. Receptionist 2 said she told the Director of Nursing (DON). She said they should smoke in the designated area at the patio area. During an interview on 11/16/22 at 5:08 PM, Unit Manager (UM) 2 said the nurses are supposed to keep all cigarettes and lighters at the nurse's station. He stated currently there is not a cigarette container at the station and no cigarettes or lighters were being kept at the nursing station. The UM stated he was aware that R262 and other residents are smoking in an undesignated area outside the lobby doors. 4. Review of the undated Admission Record located in the Profile tab of the EMR revealed R11 was admitted to the facility on [DATE]. R11's diagnosis included cerebral infarction disrupted blood flow to the brain), traumatic brain injury, [CONDITION(S)], diabetes, and symptoms and signs involving cognitive functions and awareness (impaired thought process). Review of the Smoking Evaluation dated 03/11/22 located in the Assessment tab of the EMR revealed R11 did not have dementia, could demonstrate the location of the designated smoking area and the resident could properly dispose of ashes or butts. R11 smoking evaluation indicates, Focus: Patient may smoke independently per smoking assessment; resident noted to dig cigarette butts out of trash, off ground and ashtrays; she does not accept redirection when educated on risk of infection if smoking butts left by others. The evaluation indicated residents are not allowed to keep lighters, lighter fluid or matches at the bedside. On 11/17/22 at 9:29 AM R11 was observed wheeling herself down the 100 hall to her room with her cigarettes and a lighter in her lap. On 11/17/22 at 2:33 PM the Maintenance Director (MD) confirmed seeing the cigarette butts on the ground outside the front of the lobby doors. The MD said it looks like cigarette ash is on the garbage can, and there is not a non-combustible ashtray. He stated this could be a fire hazard. During an interview on 11/17/22 at 4:25 PM, the DON stated there is one long term resident that smokes outside the front door and the rest that smoke there are from the 400 hall. She said that residents can have cigarettes but not the lighter in their possession for safety reasons. The facility's October 2022 Smoking policy documented, Smoking will only be allowed in designated areas .Ash trays made of non-combustible materials .shall be provided in all designated smoking areas as well as at all entrances . Smoking supplies (including but not limited to tobacco, matches, lighters, lighter fluid .) will be .maintained by staff, and stored in a suitable cabinet kept at the nursing station .Patients will not be allowed to maintain their own lighter, lighter fluid or matches. 5. Review of R37's Face Sheet located in the EMR under the Profile tab, revealed an admitted [DATE] and included the following diagnoses of chronic obstructive pulmonary disease, chronic [CONDITION(S)], asthma, major depressive disorder, nicotine dependence, cerebral infarction, and anxiety disorder. Review of R37's MDS with an ARD of 09/15/22 located in the EMR and under the MDS tab indicated that R37 had a BIMS score of 14 out of 15, indicating the resident is cognitively intact. During an interview on 11/14/22 at 2:06 PM, R37 stated that she keeps her own smoking materials in her room. During a subsequent interview on 11/16/22 at 5:30 PM, R37 showed the backpack that she keeps her smoking materials in, which included cigarettes and a lighter, and did not contain any means of locking it. During an interview on 11/16/22 at 5:07 PM with CNA7, indicated that four residents on her hall smoke. CNA7 stated that two of the four residents keep their smoking materials on them or in their rooms. During an interview on 11/16/22 at 5:30 PM with the Activities Director (AD), she stated that residents do keep their smoking materials with them in their rooms. When asked what the facility's smoking policy indicated, she read the policy and replied No, that's not the policy for them to keep them. During an interview on 11/17/22 at 1:53 PM with the Administrator, she stated that smoking is an on-going facility issue, particularly with residents keeping lighters/matches. The Administrator confirmed that residents can keep their cigarettes but are not supposed to keep their lighters/matches. She stated staff are always taking them from the residents and completing rooms searches, but it continues to be an issue. Review of the facility's policy titled, Smoking dated 10/24/22 indicated, Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, batteries, refill cartridges, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nurses station. The policy also indicated, If the patient is cognitively and physically able to secure smoking materials (excluding matches and lighters), the Center may allow them to maintain their own tobacco or electronic cigarette products in a locked compartment.

Based on record review, interview, and observation the facility failed to provide adequate supervision for 2 (R #s 1 and 24) of 12 (R #s 1, 2, 3, 4, 5, 6, 7, 8, 14, 19, 24 and 25) residents reviewed for accident hazards. This deficient practice likely resulted in: 1. R #1's death, by staff not monitoring/watching the resident more closely when staff had been aware of his behavior. 2. R #24 smoking in his room If staff are not monitoring and watching residents more closely, than avoidable accidents, causing harm or death to residents will continue to occur. The findings are: Findings related to R #1: [NAME] Record review of the Nutritional assessment dated [DATE], indicated that R #1 was on a regular, liberalized diet and the diet texture was Dysphagia puree (food blended smooth with no lumps or particles). B. Record review of R #1's facesheet indicated that resident was admitted to the facility on [DATE] had a [DIAGNOSES REDACTED]. C. Record review of the menu for Saturday ([DATE]) revealed that hot dog on a bun was served. D. Record review of a nursing progress note dated [DATE] indicated that at 1:30 PM, R #1 was noticed to be choking walking from the kitchen very frantic. A dinner roll was in his mouth not chewed well. This resident is on a pureed diet and not to have whole foods. (Name of nurse) started the [MEDICATION NAME] maneuver (a first aid procedure used to treat upper airway obstructions (or choking)) without success. Resident loss (sic) consciousness we helped him to the floor. 911 was called and dispatched. (Name of nurse) and myself (Name of nurse) started Cardiac [MEDICAL CONDITION] Resuscitation(CPR) with oxygen delivery and suction, trading chest compression's with other certified employees. After roughly 15 minutes (Name of) Ambulance and Fire department took over. (Name of Physician's Assistant (PA)) on call and called and notified of the 911 call. 2:28 PM CPR was stopped and Resident was moved into a private room and POA (Power of Attorney) (Name of POA) was called and notified. (Name of), RN (Registered Nurse) Unit director was called and notified she came to and pronounced. 3:00 (PM) OMI (Office of the Medical Investigator) notified they are to be picking up the body. E. On [DATE] at 9:29 am, during an interview with Unit Manager (UM), she stated that she became aware of the situation at 2:13 pm when she received a phone call from RN #1, Emergency Medical Services (EMS) was still working on R #1. F. On [DATE] at 9:44 am, during an interview with the Center Nurse Executive (CNE), she stated that she received a call about R #1. She was given information on what was currently happening. She was informed by staff that he R #1 had chocked on a hot dog (with bun) and staff and EMS were unable to save him. She stated that she immediately began looking into how R #1 had eaten a hot dog, since he was a puree diet only. The CNE stated that what she discovered was that the lunch plates were still on the dining room trays in the dining room, the doors to the dining room were always open on that side of the dining room. She stated that R #1 had wandered back into the dining room and ate a hot dog off of another residents plate that had not been picked up. He began to choke and walked towards the nursing station grabbing his throat like he couldn't breathe. Staff tried to clear his throat and did get some of the food out. RN #1 began the [MEDICATION NAME] on R #1 but after around three thrusts R #1 passed out. They lowered him to the floor and began CPR and suctioning. Emergency Medical Services (EMS) was called and when they finally arrived they took over. They were able to clear his airway and intubate (insert a tube into a person or a body part, especially the trachea for ventilation) him, but they were not able to save him and R #1 passed away. [NAME] On [DATE] at 10:41 am, during an interview with Certified Nurse Aide (CNA) #2, she stated that her involvement had to do with assisting in doing compressions and was in the dining room when R #1 wondered in and ate the hot dog. She stated that even though she was in the dining room, she did not see him at all. She stated that she was talking to Kitchen Aide #2. CNA #2 also stated that after she spoke with Kitchen Aide #2, she went out towards the long term care unit. That is when she saw that CPR was being given. She went over and offered help and started to do the compressions, while another staff was giving the breaths. CNA #2 stated that she did not work much with R #1 but she did know who he was and what diet he was on. She stated that she had seen him before eating off of other residents plates. She stated that it was known that this was a behavior for him and other staff members knew too. H. On [DATE] at 1:37 pm, it was observed in the dining room that plates and trays were still being cleared from the tables from the lunch meal at noon. I. On [DATE] at 1:50 pm, during an interview with Kitchen Aide #1, she stated that she was aware of R #1 and she was aware of his diet. She knew that he was not supposed to have anything other than puree food. She stated that she did bust him several times in the dining room taking food off of others plates after the meal was over. She stated that she would tell the nurse or a CNA about his behavior. She stated that she was surprised that no one saw him (R #1) that day because there were a few people still in the dining room. She stated that he really needed more supervision. [NAME] On [DATE] at 1:57 pm, during an interview with Kitchen Aide #2, he stated that he has not been here (working at the facility) that long but he is aware of R #1 and his diet. He stated that he was talking with a CNA in the dining room but did not see him come back into the dining room. He stated that R #1 was known for putting his hands-on other residents food. He stated that he probably needed more supervision. K. On [DATE] at 2:08 pm, during an interview with the Restorative Aide, she stated that she had been working with R #1 about 8 months. He ate pretty well and he did need assistance. He was a little shaky and at times would scoop too much food for one bite. She stated that she was not in the dining room when R #1 came back in (on [DATE]). She stated that there were two staff members assisting other residents with eating and that was all. She stated that she had seen him grab other residents food (in the past). Staff were all aware of this behavior and what diet he was on and also that he wandered frequently. Staff were aware of the behavior so that was the intervention for him; that staff keep their eye out for him. The only thing that likely would have prevented this from happening would have been a one on one (one staff supervision for one resident) situation. L. On [DATE] at 2:35 pm, during an interview with CNA #1, she stated that she was caring for R #1 that day. She stated that they had gotten him cleaned up and changed after lunch (on [DATE]) and he took off because he did not like to stay in his room. It was at shift change and so she was doing her rounds. She heard a staff member say something to the resident. So, she went to go see what was going on. She stated that she saw that he had bread his mouth. They called the nurse down and tried to clear his mouth out. He was panicking and kicking and moving around. The nurse came over and tried to do the [MEDICATION NAME] on him. He got like three thrusts in and than R #1 passed out. CPR was done for around 15 minutes before the Emergency Medical Technicians (EMTs) showed up and took over. They were not able to get him back. CNA #1 stated that lunch had been done for about one hour and she remembers that it was 2:00 pm because it was shift change, people were coming in for their shift. She stated that when the doors were shut to the dining room, she did not see R #1 try to go in. He would try to get to other peoples' plates. Someone would assist him with eating. If he came back in (to the dining room) they would remove him again. M. On [DATE] at 3:19 pm during an interview with RN #1, he stated that he was getting ready to assist another resident when his attention was drawn over to the nurses station. He heard a staff member ask R #1 to take something out of his mouth. So he rushed over to help. He tried to get the food out but wasn't able to, they only got some of it out. He stated that he started the [MEDICATION NAME] maneuver on R #1 and got three thrusts on him before he passed out, and they lowered him to the ground and started CPR. He stated that 911 had been called and it took them 15 minutes to arrive. N. On [DATE] at 11:07 am, during an interview with the CNE, she stated that she was aware of his behavior of grabbing food. She stated that their interventions previously were to just monitor him, keep an eye on him. She stated that looking back on this situation now, if they had been closing the dining room doors before now, that might have prevented his death. She stated that he really didn't open and go through doors (that were closed). She stated that they have implemented cleaning off the trays/plates in the dining room right away, right after dining. Not waiting until all of the room trays are in before focusing on the dining room. She stated that they stopped having hot dogs on the menu and they have also identified others who had similarities to R #1. Residents who are mobile, who have puree or mechanical soft diet, residents who also wander and have Dementia. She stated that no resident in the building meets that criteria but they have identified those residents who have a potential for this. O. On [DATE] at 1:10 pm, during observations of the dining room, it was observed that there were residents in the dining room being assisted. Hot dogs were being served at lunch even though the Center Executive Director (CED) had asked for hot dogs to be taken off the menu permanently. At 1:22 pm management in the dining room began to clear the tables of plates and trays because there was no one available to clear the dining room. P. On [DATE] at 1:36 pm, during an interview with the Corporate Executive Director (CED), he stated that it was communicated last week to the corporate dietary manager about no longer serving hot dogs, or having them on the menu. He stated that he was told by Corporate Dietary Manger that it wouldn't be a problem to remove them. He agreed that some of the interventions that they had put into place (immediately clearing plates after a resident finishes eating and no longer serving hot dogs) did not happen today ([DATE]) and they needed to work on it. Q. Record review of the facility follow up report (undated) revealed Resident in late stages of dementia, which caused wandering/elopement risk, and communication had become difficult; resident had command of very few words. Resident BIMS (Brief Interview for Mental Status) 00 (scores between 0 and 7 indicate severe cognitive impact) led to impulsivity and inability to make safe choices .Facility was in the process of providing/reinforcing BLS (Basic Life Support) certifications for all direct care staff. BLS Instructor (contractor) as well as Practice Development Specialist (Genesis trainer) were contacted to expedite this training asap. Staff attendance and successful passing of competency is required on or before [DATE] or staff will be removed from schedule until complete. Agency competencies are being reviewed to insure current BLS certification. All regular agency staff will be required to attend facility-specific competency on or before [DATE]. Any new agency staff will be required to attend competency evaluation prior to their first shifts in the building. Administrator discussed table bussing with dietary manager. Policy had been to wait until no more than 5% of residents were still in the dining room. Administrator and dietary manager agreed to start table bussing sooner, and moving that task in front of collecting hall tray carts. At admission, IDT (interdisciplinary team) will evaluate incoming patients for choking risk including the factors of altered texture diet, cognition deficits and able to be mobile on their own. These individuals will be added to the KARDEX (paper-based record keeping) instructions for monitoring post meals. Ongoing audit initiated to ensure staff compliance with safety plan for residents who are on altered textured diets. Ad hoc (when necessary) QAPI (Quality Assurance Performance Improvement) emergency meeting held [DATE]. Audit to be completed daily x 4 weeks then 3x weekly for 4 weeks, then weekly for 2 months. Audits will be presented to QAPI committee for tracking, trending, and further recommendations monthly for 3 months. Conclusion: Facility verifies incident occurred. In talking with family post incident, resident had a long time love of hot dogs, which is what he grabbed off the table. Due to his extreme dementia, resident was unable to consciously understand that he shouldn't have tried to eat it. Resident's cognitive function had declined to the point where his ability to remember to chew and swallow food had been impacted Based on record review and interview, non-compliance at Immediate Jeopardy occurred on [DATE] for R #1. The immediate Jeopardy was removed when R #1 died and no other residents were identified to be at risk with similar behaviors of grabbing food from other residents trays. The scope and severity is reduced to level 2, E. Findings related to R #24: R. Record review of a nursing progress note dated [DATE], indicated that R #24 had been caught smoking in his room. S. On [DATE] at 11:45 am, an observation was made of a cigarette butt on the floor in R #24's room. T. On [DATE] at 11:45 am, during an interview with R #24, he stated that he had not been smoking in his room and did not know how that cigarette butt got there. U. On [DATE] at 11:21 am, observations were made of R #24's room and of his room mates. No one in the room used oxygen. V. On [DATE] at 11:32 am, during an interview with Center Nurse Executive (CNE), she stated that she had not been made aware of the smoking incident with R #2 smoking in his room.

Based on record review and interview, the facility failed to notify the physician and responsible party when there was a change in condition for 1 (R# 208) of 1 (R# 208) residents reviewed for Notification of Change. If physicians and responsible parties are not informed when residents have a significant change in condition, they may be unable to make decisions regarding teatment, advocate on behalf of the resident and this may result in a delay in treatment. The findings are: A. Record review of the Nursing assessment dated [DATE] indicated that R #208 was admitted to the facility for post-surgery rehabilitation. B. Review of a Physician order [REDACTED]. Clean chest incision with VASHE (a wound cleanser), pat dry, apply thin layer of [MEDICATION NAME] (antibiotic ointment) and cover with prevail (a type of wound dressing). Change QD (daily) and PRN (as needed). Check placement QS (each shift). C. Record review of Progress Notes indicated the following: 1. 10/02/16 at 7:43 am: Remains on IV (intravenous) antibiotic for infection to RLE (right lower extremity) graft site infection. No adverse reactions noted. Dressing to site is clean, dry and intact. Dressing to chest and abdomen is clean, dry and intact. IV antibiotics as ordered. 2. 10/03/16 at 1:09 pm: Sternal (breast/chest bone) incision with staples. Incision is red and there is moderate yellow drainage. JP sites (surgical drainage) have copious amounts of purulent (discharging pus, a sign of infection) drainage. D. Record review of R #208's medical record revealed no documentation to indicate that R #208's physician or Responsible Party were notified of the change in condition regarding the sternal incision. E. On 10/18/16 at 8:46 am, during interview with the Director of Nursing (DON), she verified that the nurse caring for R #208 noted the purulent drainage from the chest incision site. She stated that the nurse did not notify the resident's physician or responsible party as R #208 had a follow up appointment with her surgeon the following morning and the nurse decided to monitor R #208 on her own. The DON stated that she has since educated the nursing staff that they need to notify the physician and responsible parties immediately of any change in condition involving a resident so that decisions can be made regarding treatment changes if necessary.

Based on record review and interview, the facility failed to ensure that medical treatment was provided in a timely manner for 1 (R #206) of 4 (R #16, 141, 206, and 207) residents reviewed for falls when R #206 was not sent out for an x-ray for over 4 hours after injury to her ankle was discovered by staff. The injury was first reported to nursing staff at 6:00am and R #206 was sent out to (Name of Adult Day Care Program) via transport van at approximately 10:00am where she was assessed and an x-ray revealed a fractured ankle. This deficient practice likely resulted in harm when R #206 experienced unnecessary pain after fracturing her ankle and had to wait at least 4 hours for medical treatment. The findings are: A. Record review of R #206's Admission Nursing assessment dated [DATE] revealed: Reason for Admission is for respite (care that provides caregivers a temporary rest from caregiving). R #206 arrived via private car and was ambulating without impairment. B. Record review of R #206's progress note dated 08/15/16 at 4:08 am revealed: RES (resident) with no c/o (complaint of) pain. C. Record review of R #206's Pain Assessment Medication Sheet dated August 2016 revealed: a pain assessment was completed on all three shifts during her stay at the facility. On 08/15/16, R #206's pain level was documented as 0 - no pain. D. Record review of R #206's Medication Administration Record [REDACTED]. R #206 was asked for a pain level and answered 10 out of 10 (very severe, horrible pain). E. Record review of R #206's progress note dated 08/15/16 at 8:42 am revealed: Right ankle is swollen/painful, resident is guarding lower extremity (referring to either hip, knee, ankle or foot). Discoloration noted from lower lateral (outside) shin to ankle . ROM (range of motion) to right lower leg is limited, resident will not flex or extend foot. Call to (name of R #206's daughter) and she is aware of fall. Call to adult day care (ADC) program R #206 belongs to. Nurse (name of ADC nurse) just called back and states 'let me get in touch with MD (medical doctor) to see what they want to do.' Tylenol administered for pain, will continue to monitor. F. On 10/17/16 at 3:33 pm, during interview, Licensed Practical Nurse (LPN) #3 confirmed she was the admitting and discharging nurse for R #206 during her last respite stay at the facility. She stated, I was in report (daily nursing meeting at change of shift) and the CNA (Certified Nurse Aid) said (name of R #206) cannot walk. She was stable, was breathing, and did not have an airway obstruction so we finished report. After report, (name of R #206) was lying down and I asked her 'What's wrong? Show me what hurts.' She pulled up her right pant leg and showed me. There was some redness, I think. I think there was swelling. She couldn't bare any weight at all. She didn't have range of motion. She tried but couldn't because it hurt too much. When asked if LPN #3 suspected R #206's ankle was broken she stated, Yeah I thought she had a fracture or something really wrong with it. When asked why she did not send R #206 out to the Emergency Department (ED) LPN #3 stated, With (Name of Adult Day Care Program) clients you never really decide that (to send a resident out to the ED) on your own unless it's a life or death situation. G. On 10/17/16 at 4:56 pm, during interview, CNA #6 was asked if she knew what happened with R #206 on 08/15/16 and stated she (CNA #6) noticed R #206 was in pain so CNA #6 alerted LPN #3. She stated, The nurses were in report so it had to be at 6:00 am. CNA #6 confirmed this was the time when staff first noticed R #206's injured ankle. H. On 10/17/16 at 10:27 am, during interview, the receptionist confirmed witnessing R #206 being picked up by the (Name of Adult Day Care Program) transportation service on 08/15/16 around 10:00am. She was asked to explain what (Name of Adult Day Care Program) was and stated, It's a daytime program. The residents live with us here over the weekend, (Name of Adult Day Care Program) picks them up weekdays. (Name of R #206) goes there (Name of Adult Day Care Program) and the daughter picks her up from the day program. She was asked about the events on 08/15/16 and stated, The CNA brought her (R #206) up here and parked her in front of me. I asked why she only had one shoe and they said it was because her foot was swollen and her shoe was in her suitcase. (Name of Adult Day Care Program) called to say they were picking her (R #206) up, which was normal, and I told them her foot was swollen. The driver showed up and said they couldn't take her with the 4-wheel walker but the driver had a portable wheelchair in the van. They had to put her in the wheelchair. They picked her up and transferred her over. She said 'ouch, ouch, ouch', they loaded her in the wheelchair, and put her in the truck. I. Record review of facility's Complaint Narrative Investigation Report (no date) revealed: (Name of R #206's doctor) arrived at the facility on 08/16/16 at 10:00am . (Per (name of R #206's doctor), xrays revealed two fractures to RLE (right lower extremity) . Recordings of video camera showed resident (R #206) to ambulate to and from dining room on 08/14/16 without assist using her rollator/4-wheeled walker. The recordings displayed no visible difficulty by resident in ambulating. Resident returned to room at 6:08 pm on 08/14/16 and it did not appear that resident left her room until she was taken to the front lobby by her CNA while sitting on her rollator at approximately 10:00 am on 08/15/16. J. On 10/17/16 at 2:20 pm during interview, the Director of Nursing (DON) confirmed that the facility allowed (Name of Adult Day Care Program) to take R #206 with the understanding that (Name of Adult Day Care Program) would assess her ankle. DON stated the facility will not send a resident who belongs to (Name of Adult Day Care Program) to the Emergency Department unless it's a 911 situation.

The facility failed to keep residents free from physical and verbal abuse for 1 (R #152) of 1 (R #152). On 09/25/14 at 12:58 pm, R #152 rolled her wheelchair into the office doorway where PA #1 was working on his charting. R #152 began saying, "I want to go home!" repeatedly. PA #1 at this time grabbed the resident's wheelchair with both hands and pushed R #152 backwards into the hallway. As he pushed R #152's wheelchair, he was yelling loudly and in an abusive tone at R #152, "I am unavailable. I have no time for you!" As PA #1 walked off, PA #1 kept saying in the same demeanor "I am unavailable!" PA #1 did not look for help for R #152. PA #1 returned and again said in an abusive demeanor, "I have no time for you!" repeatedly to R #152. No staff tried to stop or remove PA #1 from coming back to the resident. Staff did not make the Acting Manager (AM) fully aware of the situation. PA #1 was not removed from the facility immediately after the incident. This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at the facility on 09/25/14 at 3:10 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included: 1. The Physician's Assistant (PA #1), was removed from the center and will be suspended from service until further notice and a full investigation has been completed. 2. The 6 patients/residents that were seen by PA#1 on 09/25/14 will be interviewed on 09/25/14 regarding any interactions they have experienced or observed with other patients/residents that were perceived by the patients as abusive. 3. Other current patients/residents who are identified via admission nursing assessment and/or MDS (Minimum Data Set) with a BIMS (Brief Interview for Mental Status) score of 13 or above as being able to understand and be understood will be interviewed by 10/01/14. 4. Current staff on duty will be interviewed regarding any interactions they have observed between patients/residents or staff will be reported immediately to HFLC (Health Facility Licensing and Certification) and thoroughly investigated per policy and procedure. 5. Current staff on duty will be in-serviced and documented on In-Service sign-in sheets on identification and immediate reporting of any abuse of neglect of patients/residents on 09/25/14. Other staff will be in-serviced prior to their next scheduled shift. Based on the Plan of Removal and observation, the IJ was lifted on 09/25/14 at 5:10 pm. This resulted in the scope and severity being reduced from a scope and severity of J to Level 2, Scope G. Based on observations, record review and interview, the facility failed to ensure that residents were free from abuse for 2 (R #87 and #152) of 2 (R #87 and #152). This deficient practice resulted to 1) prevent R #152 from being physically and verbally abused and 2) failed to prevent R #87 from being verbally abused. The findings are: Resident #152 A. On 09/25/14 at 12:58 pm, observation of the 400 Hall revealed R #152 rolled her wheelchair into the office doorway on 400 Hall where PA #1 was charting documents in resident's medical records. R #152 stated, "I want to go home!" repeatedly. PA #1, who was now in the doorway, used both hands to push R #152's wheelchair backwards into the hallway. As PA #1 pushed R #152's wheelchair PA #1 was yelling loudly and in an abusive tone at R #152, "I am unavailable. I have no time for you!" After pushing R #152's wheelchair out of the way, PA #1 walked off angrily around the corner to the dining room. In the same demeanor PA #1 kept saying, "I am unavailable!" while walking away. PA #1 did not look for help for R #152. The Director of Social Services, upon hearing the commotion, came up to R #152 to try and calm R #152 down and check on R #152. An observation at the nurses' station revealed there was one med tech, two nurses, and the Director of Nursing, (DON) all watched what had happened. No other staff came to check on R #152. B. On 09/25/14 at 1:04 pm, observation of the 400 Hall revealed PA #1 turned the corner from the dining hall onto the 400 hall. R #152 was still in the 400 hall trying to be calmed down by the Director of Social Services. PA #1 again stated in an abusive demeanor, "I have no time for you!" repeatedly to R #152, while walking past R #152 to the office where PA #1 was charting. No staff tried to stop or remove PA #1 from coming back and yelling at the resident. C. On 09/25/14 at 1:01 pm, observation of the 400 Hall and interview with PA #1, PA #1 walked over and stated to the surveyors in the same abusive demeanor, "Just so you know R #152 hit me in the leg with R #152's wheelchair! R #152 has been abusive to me in the past!" D. On 09/25/14 at 1:04 pm, an interview was conducted with PA #1. PA #1 stated, "I have a lot of patience for everything! But when it comes to that I have no patience! I have no patience for abuse!" E. On 09/25/14 at 1:31 pm, R #152 was interviewed. R #152 was asked about what happened with PA #1. R #152 stated, "I want to go back home with my dog.". The resident was crying and stated, "I told (Name of PA #1) I wanted to go home and (name of PA#1) shoved me away. (Name of PA #1) said he's unavailable! (Name of PA #1) said he has no time! (Name of PA #1) shouldn't have shoved me! (Name of PA #1) has no right to shove me! No one has a right to shove me! I am pissed! (Name of PA #1) never has time! (Name of PA #1) always says I has no time! Why won't (name of PA #1) let me go home? I am in my 50's and I am in a nursing home! Welcome to my nightmare!" F. On 09/25/14 at 1:40 pm, observation of the 400 hall revealed PA #1 was seeing residents on the 400 hall. G. On 09/25/14 at 1:57 pm, an interview was conducted with the Facility Manager (FM). The FM stated, "PA #1 told me in passing that the R #152 had hit him with her wheel chair. The Director Social Services calmed her down. We have contacted the Medical Doctor (MD) to see if the MD could come and see her, but R #152 is calm now. R #152 is eating in the dining room." H. On 09/25/14 at 2:10 pm, observation of the 400 hall revealed that PA #1 was looking over medical records in PA #1's office. Resident #87 I. On 09/23/14 at 8:09 am, R #87 was interviewed. The resident was asked if they had been abused by staff a resident or by anyone. R #87 stated, "Yes, Certified Nursing Assistants (CNA) CNA #1 and CNA #2 have. CNA #1 tells me to get up and go do it yourself." R #87 was asked when does this happen the resident stated, "I ask if I can have a cocoa (beverage with chocolate) and (name of CNA #1) says get up and go and do it yourself, I have other residents." R #87 was asked can you tell me about CNA #2 R #87 stated, "(name of CNA #2) is just rude. If I ask her for anything she tells me, what do you want now? Yesterday, (09/22/14) I told (name of CNA #2) that I needed my pain medication and it took an hour before (name of CNA #2) told anyone. It was too close to regular time so I had to wait longer." R #87 was asked if she had told anyone about CNAs #1 and #2 she stated, "Yes, I have told (name of LPN #1). (Name of LPN #1) knows that it is hard for me to write with my nerves. So I did not fill out a formal grievance report." J. On 09/26/14 at 11:50 am, LPN #1 was interviewed. LPN #1 was asked if they had been made aware of any issues that R #87 had with CNA #1 and CNA #2. The LPN stated, "Yes, they have not brought (name of R #87) food or drinks sometimes; R #87 told me that she thinks they believe she is more capable of doing things then she is. I talked to CNA #1 and told them that R #87 is a resident. We have to respect the residents. You have to answer R #87's light, and assist R #87 with all needs. They said they tried to encourage R #87 to do more on the resident's own." When asked if the incident had reported to administration, LPN #1 stated, "I did not report this issue because I did not take it in a way that would suggest abuse." K. Review of the grievance log revealed no evidence of incident report concerning R #87, CNA #1 and CNA #2. L. Record Review of the facility's Abuse Prevention Policy effective date 08/31/07 revealed the following: 1. "It is the policy of this center to do all within its control (sic) maintain the resident's right to be free from verbal, sexual, physical, and mental abuse ... through the implementation of seven components." a. "Training of employees on incident management system within 30 days of employment and annually ... At a minimum training would include: an overview of potential abuse ... Staff legal responsibility to report their knowledge related to allegations ... including how to complete incident management report form ... specific instructions on how to respond (appropriate interventions) to deal with aggressive and/or catastrophic reactions of residents, abuse ... How to recognize signs of burnout, frustration and stress that may lead to abuse ... The importance of protecting residents from potentially abusive situations ..." b. "Prevention ... Education of staff related to the need to communicate any concerns that they observe or that have been reported to them ... Educating residents, families, and staff to the fact that reports may be verbal or written ... Supervision of staff to identify inappropriate behaviors, such as ... rough handling ... All staff will be trained to report any such observations to the appropriate department head or charge nurse who will then report to the administrator." c. "Reporting ... All staff will be trained to report incidents immediately to the administrator ... to include ... abuse... Alleged violations and substantiated incidents will be reported to the state agency immediately."

The facility failed to implement their abuse policies and procedures for 1 (R #152) of 1 (R #152). On 09/25/14 at 12:58 pm, R #152 rolled her wheelchair into the office doorway where PA #1 was working on his charting. R #152 began saying, "I want to go home! " repeatedly. PA #1 at this time grabbed the resident's wheelchair with both hands and pushed R #152 backwards into the hallway. As he pushed R #152's wheelchair, he was yelling loudly and in an abusive tone at R #152, "I am unavailable. I have no time for you!" As PA #1 walked off angrily he kept saying in the same demeanor, "I am unavailable!" down the hallway and entered the dining room. PA #1 did not look for help for R #152. PA #1 returned and again he was saying in an abusive demeanor, "I have no time for you!" repeatedly to R #152, (who was still in the 400 hall trying to be calmed down), while walking back to the office. No staff tried to stop or remove PA #1 from coming back to the resident. Staff did not make the administrator fully aware of the situation. PA #1 was not removed from the facility immediately after the incident. This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at the facility on 09/25/14 at 3:10 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included: 1. The Physician's Assistant (PA #1), was removed from the center and will be suspended from service until further notice and a full investigation has been completed. 2. The 6 patients/residents that were seen by PA#1 on 09/25/14 will be interviewed on 09/25/14 regarding any interactions they have experienced or observed with other patients/residents that were perceived by the patients as abusive. 3. Other current patients/residents who are identified via admission nursing assessment and/or MDS (Minimum Data Set) with a BIMS (Brief Interview for Mental Status) score of 13 or above as being able to understand and be understood will be interviewed by 10/01/14. 4. Current staff on duty will be interviewed regarding any interactions they have observed between patients/residents or staff will be reported immediately to HFLC (Health Facility Licensing and Certification) and thoroughly investigated per policy and procedure. 5. Current staff on duty will be in-serviced and documented on In-Service sign-in sheets on identification and immediate reporting of any abuse of neglect of patients/residents on 09/25/14. Other staff will be in-serviced prior to their next scheduled shift. Based on the Plan of Removal and observation, the IJ was lifted on 09/25/14 at 5:10 pm. This resulted in the scope and severity being reduced from a scope and severity of J to Level 2, Scope G. Based on observation, record review and interview, the facility failed to implement their abuse policies and procedures for 2 (R #87 and #152) of 2 (R #87 and #152). This deficient practice likely resulted to 1) prevent R #152 from being physically and verbally abused and 2) failed to prevent R #87 from being verbally abused. The findings are: A. Record Review of the facility's Abuse Prevention Policy effective date 08/31/07 revealed the following: 1. "It is the policy of this center to do all within its control (sic) maintain the resident's right to be free from verbal, sexual, physical, and mental abuse ... through the implementation of seven components." a. "Training of employees on incident management system within 30 days of employment and annually ... At a minimum training would include: an overview of potential abuse ... Staff legal responsibility to report their knowledge related to allegations ... including how to complete incident management report form ... specific instructions on how to respond (appropriate interventions) to deal with aggressive and/or catastrophic reactions of residents, abuse ... How to recognize signs of burnout, frustration and stress that may lead to abuse ... The importance of protecting residents from potentially abusive situations ..." b. "Prevention ... Education of staff related to the need to communicate any concerns that they observe or that have been reported to them ... Educating residents, families, and staff to the fact that reports may be verbal or written ... Supervision of staff to identify inappropriate behaviors, such as ... rough handling ... All staff will be trained to report any such observations to the appropriate department head or charge nurse who will then report to the administrator." c. "Reporting ... All staff will be trained to report incidents immediately to the administrator ... to include ... abuse... Alleged violations and substantiated incidents will be reported to the state agency immediately." Resident #152 B. On 09/25/14 at 12:58 pm, observation of the 400 Hall revealed R #152 rolled her wheelchair into the office doorway on 400 Hall where PA #1 was charting documents in resident's medical records. R #152 stated, "I want to go home!" repeatedly. PA #1, who was now in the doorway, used both hands to push R #152's wheelchair backwards into the hallway. As he pushed R #152's wheelchair PA #1 was yelling loudly and in an abusive tone at R #152, "I am unavailable. I have no time for you!" After pushing R #152's wheelchair out of the way, PA #1 walked off angrily around the corner to the dining room. In the same demeanor PA #1 kept saying, "I am unavailable!" while walking away. PA #1 did not look for help for R #152. The Director of Social Services, upon hearing the commotion, came up to R #152 to try and calm her down and check on her. At the nurses' station there was one med tech, two nurses, and the Director of Nursing (DON) all watched what had happened. No other staff came to check on R #152. C. On 09/25/14 at 1:04 pm, observation of the 400 Hall revealed PA #1 turned the corner from the dining hall onto the 400 hall. R #152 was still in the 400 hall trying to be calmed down by the Director of Social Services. PA #1 again said an abusive demeanor, "I have no time for you!" repeatedly to R #152, while walking past R #152 to the office where PA #1 was charting. No staff tried to stop or remove PA #1 from coming back and yelling at the resident. D. On 09/25/14 at 1:01 pm, observation of the 400 Hall and interview with PA #1, PA #1 walked over and stated to the surveyors in the same abusive demeanor, "Just so you know (name of R #152) hit me in the leg with R #152's wheelchair! (Name of R #152) has been abusive to me in the past!" E. On 09/25/14 at 1:04 pm, PA #1 approached the surveyors and stated loudly and in an abusive manor, "I have a lot of patience for everything! But when it comes to that I have no patience! I have no patience for abuse!" F. On 09/25/14 at 1:31 pm, R #152 was interviewed. R #152 was asked what happened with PA #1. R #152 stated, "I want to go back home with my dog." As the resident was crying she also stated, "I told him (PA #1) I wanted to go home and (name of PA #1) shoved me away. (Name of PA #1) said they were not unavailable! (Name of PA #1) He said they had no time! (Name of PA #1) shouldn't have shoved me! (Name of PA #1) has no right to shove me! No one has a right to shove me! I am pissed! (Name of PA #1) never has time! (Name of PA #1) always says I have no time! Why won't (name of PA #1) let me go home? I am in my 50's and I am in a nursing home! Welcome to my nightmare!" G. On 09/25/14 at 1:40 pm, observation of the 400 hall revealed PA #1 was seeing residents on the 400 hall. H. On 09/25/14 at 1:57 pm, the Acting Manager (AM) was interviewed. The AM was asked if they knew about the incident that had occurred between PA #1 and R #152. The AM stated, "(Name PA #1) told me in passing that the R #152 had hit PA #1 with her wheel chair. The Director Social Services calmed R #152 down. We have contacted R #152's Medical Doctor (MD) to see if they could come see the resident, but (name of R #152) is calm now. (Name of R #152) is eating in the dining room." I. On 09/25/14 at 2:10 pm, observation of the 400 hall revealed that PA #1 was looking over charts in his office. Resident #87 J. On 09/23/14 at 8:09 am, R #87 was interviewed. The resident was asked if they had been abused by staff, a resident, or by anyone. R #87 stated, "Yes Certified Nursing Assistants (CNA) CNA #1 and CNA #2 have. CNA #1 tells me to get up and go do it yourself." R #87 was asked when does this happen the resident stated, "I ask if I can have a cocoa (beverage with chocolate) and (name of CNA #1) says get up and go and do it yourself, I have other residents." R #87 was asked can you tell me about CNA #2 R #87 stated, "(name of CNA #2) is just rude. If I ask her for anything (name of CNA #2) tells me, what do you want now? Yesterday, (09/22/14) I told (name of CNA #2) that I needed my pain medication and it took an hour before (name of CNA #2) told anyone. It was too close to regular time so I had to wait longer." R #87 was asked if she had told anyone about CNAs #1 and #2 she stated "Yes I have told (name of LPN #1). (Name of LPN #1) knows that it is hard for me to write with my nerves. So I did not fill out a formal grievance report." K. On 09/26/14 at 11:50 am, LPN #1 was interviewed. LPN #1 was asked if they had been made aware of any issues that R #87 had with CNA #1 and CNA #2. The LPN stated, "Yes, they have not brought (name of R #87) food or drinks sometimes; (name of R #87) told me that she thinks they believe she is more capable of doing things then she is. I talked to (name of CNA #1) and told them that (name of R #87) is a resident. We have to respect the residents. You have to answer (name of R #87)'s light, and assist (name of R #87) with all needs. They said they tried to encourage (name of R #87) to do more on the resident's own." When asked if the incident had been reported to administration, LPN #1 stated, "I did not report this issue because I did not take it in a way that would suggest abuse." L. Review of the grievance log revealed no evidence of incident report concerning R #87, CNA #1 and CNA #2.

Based on record review, and interview the facility failed to implement their policy to prevent neglect for 1 (R #2) of 1 (R #2) residents that was left alone in the shower room by Certified Nursing Assistant (CNA) #1 and fell out of the shower chair. This deficient practice likely caused the resident to sustain a below the knee fracture. The findings are: A. Review of the facility's "Abuse Prevention" policy dated 08/31/07 indicated "It is the policy of this Center to do all within its control maintain the resident's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntuary seclusion, neglect and misappropriation of property." B. Review of the Health Facilities Licensing and Certification (HFL&C) Incident report dated 11/14/12 indicated, "Certified Nursing Assistant (who was identified as CNA #1) had given resident (referring to R #2) a shower. CNA stepped out of bathroom...to get a blanket just a few feet away...at that time the resident fell off the shower chair onto the floor...During x-ray process, bruise was noted to right knee...x-ray was positive for proximal (nearest the point of attachment) tib/fib (tibia/fibula) (tibia-the inner and larger bone of the leg, fibula-the outer and smaller bone of the leg) fracture." C. Review of the facility "Report of Alleged Incident/Accident" document dated 11/14/12, indicated, "CNA had completed resident's shower in bathroom...left bathroom to get towel/baby powder from room...the instant CNA left bathroom, he heard resident fall to floor...Extent of Injury: pain to right knee, fracture/dislocation..." a. "Witness Statement form" from Staff/CNA #1 indicated, "I left the shower room to grab some towels and baby powder so I could put on resident..." b. "FSI-Fall Scene Investigation Report" dated 11/14/12 indicated, "CNA left resident in shower chair in bathroom to get towel/baby powder from room, resident then fell ." c. "Facility follow up investigation" dated 11/21/12 indicated, "...CNA had completed (name of R #2's) shower in the bathroom, he left the bathroom to get a towel and powder, almost immediately after he left the room he heard the resident fall to the floor..." D. Record review and interviews for R #2 revealed the following: 1. Medical record review indicated: a. "Face Sheet" dated 05/16/12 indicated [DIAGNOSES REDACTED]. b. "Quarterly MDS" (Minimum Data Set) dated 10/10/12 indicated the resident required total dependence (meaning full staff performance) for bathing, personal hygiene, and transferring. It further indicated the resident had an impairment on one side of the lower extremity that interfered with daily functions or placed the resident at risk for injury. c. "Fall Risk Assessments" dated 10/23/12 and 11/15/12 indicated the resident was at a very high risk for falls. d. "SBAR (Situation, Background Assessment Request) Physician Communication and Progress Note" dated 11/14/12 indicated, "...CNA had completed resident's shower in bathroom...left bathroom to get towel/baby powder from room...the instant CNA left bathroom he heard resident fall to floor...right knee X-ray exhibits fracture..." e. "Physician's Telephone Order" dated 11/14/12 indicated, "X-ray to right knee to eval..." f. "Final X-ray report" dated 11/14/12 indicated, "There is an impaction fracture (when one end of a bone is driven into the end of another bone) of the proximal tibia there also appears to be a subtle (very acute)nondisplaced fracture (a break in a bone in which the bone remains aligned) of the proximal fibula. g. "Licensed Nurses Note" dated 11/14/12, indicated, CNA (referring to Staff/CNA #1) had completed resident's shower in bathroom. Left bathroom to get towels/baby powder from room. The instant CNA left bathroom, he heard resident fall to floor...Resident on floor on right side of body." 2. Interviews identified: a. On 04/04/13 at 2:00 pm, during interview, the Administrator stated, "The employee (referring to CNA #1) had just finished showering her (referring to R #2)...He pivoted and had to take one or two steps and reach for a towel that was at the foot of the bed...While he was turned away, she slid off the shower chair...I would think that would constitute, leaving the patient unattended....With our policy, you should never leave the residents unattended." b. On 04/04/13 at 2:25 pm, during interview, the Director of Nursing (DON) stated, "The CNA (referring to CNA #1) made the decision to step out of the bathroom to grab a towel and powder and it happened in a split second...He made the decision to do that...She fell ... She (referring to R #2) was demented and had a history of [REDACTED]." c. On 04/04/13 at 2:45 pm, during interview, Licensed Practical Nurse (LPN) #1 stated, "The CNA (referring to CNA #1) was giving her a shower and she fell from the shower chair...When I went in and checked her out, she was very confused...One of her legs was contracted (drawn together or reduced in size)...He (referring to CNA #1) said he had her in the bathroom and reached to get a towel and then she was on the floor...He turned away, and she slipped out of the shower chair...X-rays of the right knee were done which showed a fracture." d. On 04/05/13 at 8:32 am, during interview, Family Member #1 of R #2 stated, "On 11/14/12, I got a call from the Nursing Home that my mother had fallen...I showed up within forty minutes and she (R #2) was in the dining hall...When I walked in to feed her, I noticed she was wincing and leaning to one side of the wheelchair...she said 'I hurt' she told me she hurt really bad...X-rays were done and come to find out, her leg was broken...Her leg was broken in half on the right side below the knee...she was badly bruised up to her groin area..The issue was, they broke her leg and they were neglectful... When I arrived at the facility, in the hallway, I ran into the CNA that gave her a shower....He told me that he left that bathroom and went over to the end table in her room to get powder to put on her....Her end table (referring to the dresser drawer) is up against the window which is about five to six feet away and not within view of my mom....". e. On 04/05/13 at 9:45 am, during interview, the Assistant Director of Nursing (ADON) stated, "The nurse told me that the CNA stepped out of the shower room to get a blanket...When I talked to him (referring to CNA #1), he said that he left the shower room to get some towels and baby powder...This is what he told me...He said the powder was on edge of the bed...In hindsight, he should have put the supplies he needed in the bathroom...As a general rule the patient is our focus...he knew afterward that he probably should have had all his supplies closer...He made a wrong judgement, and I felt he made a wrong choice in leaving the resident unattended." f. On 04/05/13 at 10:15 am, during interview, CNA #1 stated, "On that day (referring to 11/14/12), I was giving her a shower... After I was done, I went to get the baby powder and towels which were located on her dresser about one to two to three feet away....As I left, I heard a crash...As soon as she fell I called the nurse...I didn't see the fall... The only thing I didn't have was baby powder... So, I had to leave the bathroom to get the baby powder...When I turned around, she was laying in the fetal position...She complained about pain in her leg when she was laying on the floor and when the nurse was talking to her....Now, I know that I should have gathered all my materials before giving her a shower and to never leave anyone unattended in the shower alone...I messed up...I knew all of this before hand...That one day, I just forgot something, which was the powder."

Based on record review and interview, the facility failed to maintain 1 (R #2) of 1 (R #2) residents highest physical well being. Certified Nursing Assistant (CNA) #1 left R #2 unattended while the resident was in a shower chair and the resident fell out of the chair. This deficient practice likely caused the resident to experience pain, sustain a bruise to the right knee and a below the knee fracture. The findings are: A. Review of the Health Facilities Licensing and Certification (HFL&C) Incident report dated 11/14/12 indicated, "Certified Nursing Assistant (who was identified as CNA #1) had given resident (referring to R #2) a shower. CNA stepped out of bathroom...to get a blanket just a few feet away...at that time the resident fell off the shower chair onto the floor...During x-ray process, bruise was noted to right knee...x-ray was positive for proximal (nearest the point of attachment) tib/fib (tibia/fibula) (tibia-the inner and larger bone of the leg, fibula-the outer and smaller bone of the leg) fracture." B. Review of the facility "Report of Alleged Incident/Accident" document dated 11/14/12, indicated, "CNA had completed resident's shower in bathroom...left bathroom to get towel/baby powder from room...the instant CNA left bathroom, he heard resident fall to floor...Extent of Injury: pain to right knee, fracture/dislocation..." a. "Witness Statement form" from Staff/CNA #1 indicated, "I left the shower room to grab some towels and baby powder so I could put on resident..." b. "FSI-Fall Scene Investigation Report" dated 11/14/12 indicated, "CNA left resident in shower chair in bathroom to get towel/baby powder from room, resident then fell ." c. "Facility follow up investigation" dated 11/21/12 indicated, "...CNA had completed (name of R #2's) shower in the bathroom, he left the bathroom to get a towel and powder, almost immediately after he left the room he heard the resident fall to the floor..." C. Record review and interviews for R #2 revealed the following: 1. Medical record review indicated: a. "Face Sheet" dated 05/16/12 indicated [DIAGNOSES REDACTED]. b. "Quarterly MDS" (Minimum Data Set) dated 10/10/12 indicated the resident required total dependence (meaning full staff performance) for bathing, personal hygiene, and transferring. It further indicated the resident had an impairment on one side of the lower extremity that interfered with daily functions or placed the resident at risk for injury. c. "Fall Risk Assessments" dated 10/23/12 and 11/15/12 indicated the resident was at a very high risk for falls. d. "SBAR (Situation, Background Assessment Request) Physician Communication and Progress Note" dated 11/14/12 indicated, "...CNA had completed resident's shower in bathroom...left bathroom to get towel/baby powder from room...the instant CNA left bathroom he heard resident fall to floor...right knee X-ray exhibits fracture..." e. "Physician's Telephone Order" dated 11/14/12 indicated, "X-ray to right knee to eval..." f. "Final X-ray report" dated 11/14/12 indicated, "There is an impaction fracture (when one end of a bone is driven into the end of another bone) of the proximal tibia there also appears to be a subtle (very acute)nondisplaced fracture (a break in a bone in which the bone remains aligned) of the proximal fibula. g. "Licensed Nurses Note" dated 11/14/12, indicated, CNA (referring to Staff/CNA #1) had completed resident's shower in bathroom. Left bathroom to get towels/baby powder from room. The instant CNA left bathroom, he heard resident fall to floor...Resident on floor on right side of body." 2. Interviews identified: a. On 04/04/13 at 2:00 pm, during interview, the Administrator stated, "The employee (referring to CNA #1) had just finished showering her (referring to R #2)...He pivoted and had to take one or two steps and reach for a towel that was at the foot of the bed...While he was turned away, she slid off the shower chair...I would think that would constitute, leaving the patient unattended....With our policy, you should never leave the residents unattended." b. On 04/04/13 at 2:25 pm, during interview, the Director of Nursing (DON) stated, "The CNA (referring to CNA #1) made the decision to step out of the bathroom to grab a towel and powder and it happened in a split second...He made the decision to do that...She fell ... She (referring to R #2) was demented and had a history of [REDACTED]." c. On 04/04/13 at 2:45 pm, during interview, Licensed Practical Nurse (LPN) #1 stated, "The CNA (referring to CNA #1) was giving her a shower and she fell from the shower chair...When I went in and checked her out, she was very confused...One of her legs was contracted (drawn together or reduced in size)...He (referring to CNA #1) said he had her in the bathroom and reached to get a towel and then she was on the floor...He turned away, and she slipped out of the shower chair...X-rays of the right knee were done which showed a fracture." d. On 04/05/13 at 8:32 am, during interview, Family Member #1 of R #2 stated, "On 11/14/12, I got a call from the Nursing Home that my mother had fallen...I showed up within forty minutes and she (R #2) was in the dining hall...When I walked in to feed her, I noticed she was wincing and leaning to one side of the wheelchair...she said 'I hurt' she told me she hurt really bad...X-rays were done and come to find out, her leg was broken...Her leg was broken in half on the right side below the knee...she was badly bruised up to her groin area..The issue was, they broke her leg and they were neglectful... When I arrived at the facility, in the hallway, I ran into the CNA that gave her a shower....He told me that he left that bathroom and went over to the end table in her room to get powder to put on her....Her end table (referring to the dresser drawer) is up against the window which is about five to six feet away and not within view of my mom....". e. On 04/05/13 at 9:45 am, during interview, the Assistant Director of Nursing (ADON) stated, "The nurse told me that the CNA stepped out of the shower room to get a blanket...When I talked to him (referring to CNA #1), he said that he left the shower room to get some towels and baby powder...This is what he told me...He said the powder was on edge of the bed...In hindsight, he should have put the supplies he needed in the bathroom...As a general rule the patient is our focus...he knew afterward that he probably should have had all his supplies closer...He made a wrong judgement, and I felt he made a wrong choice in leaving the resident unattended." f. On 04/05/13 at 10:15 am, during interview, CNA #1 stated, "On that day (referring to 11/14/12), I was giving her a shower... After I was done, I went to get the baby powder and towels which were located on her dresser about one to two to three feet away....As I left, I heard a crash...As soon as she fell I called the nurse...I didn't see the fall... The only thing I didn't have was baby powder... So, I had to leave the bathroom to get the baby powder...When I turned around, she was laying in the fetal position...She complained about pain in her leg when she was laying on the floor and when the nurse was talking to her....Now, I know that I should have gathered all my materials before giving her a shower and to never leave anyone unattended in the shower alone...I messed up...I knew all of this before hand...That one day, I just forgot something, which was the powder."

Based on record review and interview, the facility failed to follow-up on the large number of infections identified in the monthly Resident Infection Control Surveillance Information Log and presented to the QAA (Quality Assessment and Assurance) committee during their quarterly meetings. This failed practice had the potential to affect all 112 residents in the facility (as indicated on the alphabetical list provided by the administrator) by not developing action plans to correct the issue of an inordinate number of infections identified in the monthly infection log. The findings are: A. During record review of the Resident Infection Control Surveillance Information Log the following was revealed: 1. For the month of May 2012 the facility documented sixty total infections. Thirty-five (58%) of those infections were facility acquired. 2. For the month of June 2012 the facility documented forty-eight total infections. Thirty-three (69%) of those infections were facility acquired. 3. For the month of July 2012 the facility documented sixty-nine total infections. Forty-eight (70%) of those infections were facility acquired. 4. For the month of August 2012 the facility documented sixty-seven total infections. Forty-three (64%) of those infections were facility acquired. B. On 09/05/12 at 6:20 pm, during an interview with the DON (Director of Nursing), she stated, "We bring up the subject of infection control in every one of our QA (Quality Assurance) Meetings." She also stated that we haven't identified any infection issues. C. On 09/05/12 at 6:25 pm, during an interview with the Administrator, she stated, "During every QA Meeting we discuss the subject of infection. We did not identify any issue with [MEDICAL CONDITIONS] infections."

The facility failed to ensure that food transport carts used by residents were properly disinfected with a sanitizer that kills Clostridium difficile (C-diff) between meals to prevent the spread of the microorganism which causes infection of the gastro intestinal tract . This failure led to an Immediate Jeopardy (IJ) being identified on 09/05/12 at 5:30 pm. The facility was notified of the IJ at 6:45 pm. The facility took corrective action by providing an acceptable Plan of Removal on 09/05/12 at 8:45 pm and the IJ was lifted. The scope and severity was lowered to an F. The following is the Plan of Removal: 1. All dietary carts were thoroughly cleaned with a 10:1 bleach solution at approximately 4:30 pm. 2. Dietary Cart Cleaning Schedule developed for dietary personnel; staff to initial that all 5 carts have been cleaned with bleach solution following each meal service (breakfast, lunch and dinner). Dietary Aide assigned to cleaning the carts 7 days per week, Cook assigned to validate cleaning 7 days per week, and Dietary Manager to verify compliance 5 days per week. 3. In-service all dietary staff on proper cleaning techniques of carts with bleach solution, staff in Center at this time (evening) have been in-serviced, Dietary Manager to in-service all remaining dietary staff as they report to duty, but prior to working their shift; beginning at 5:00 am tomorrow (09/06/12) until all staff have been in-serviced prior to the beginning of their next shift. 4. Re-educate all employees at all staff meeting on 09/07/12 of isolation protocol and potential for contamination resulting from removal of items from isolation rooms facility Policy and Procedure. 5. In-service Dining Room Monitor on isolation protocols, proper cleaning of carts with bleach solutions to assist in monitoring of compliance. Based on observation, record review and interview, the facility failed to effectively disinfect the food carts used to transport food to the residents. This deficient practice is likely to have caused harm by spreading[DIAGNOSES REDACTED] (Clostridium difficile) bacteria to the 112 residents (identified on the alphabetical list provided by the administrator) residing in the facility. The findings are: A. On 08/29/12 at 6:15 pm, Staff #3, CNA (Certified Nursing Assistant), was observed to remove a dinner tray from Isolation room [ROOM NUMBER]. Resident #242, residing in this room was on contact isolation precautions for[DIAGNOSES REDACTED] a microorganism which causes infection of the gastro intestinal tract. The CNA then placed the contaminated tray into the food cart which was then taken to the kitchen for cleaning and disinfecting. B. On 08/30/12 at 10:15 am during an interview with the Assistant Dietary Manager, she stated, "The food carts get pretty messy. We clean and disinfect them between every meal with a bleach based disinfectant and then once a week we thoroughly clean and disinfect them." C. On 09/05/12 at 3:30 pm, during interview with the Dietary Aide, she stated that they use the sanitizer used in the 3-compartment sink to sanitize the food carts. 1. At 3:35 pm, the Assistant Dietary Manager stated that they use the sanitizer from the 3-compartment sink to sanitize the carts after every meal and then once a week clean the food carts with a bleach based sanitizer. 2. At 3:40 pm, during observation the Enviro Bac 2 bottle indicated that it did not kill[DIAGNOSES REDACTED] bacteria. 3. At 4:00 pm, during interview with the Assistant Dietary Manager and the Dietary Manager they stated that they use Enviro Bac 2 to sanitize the food carts after each meal. D. On 09/05/12 at 5:50 pm during a telephone interview with the Registered Dietician, she stated, "The dietary carts should be cleaned after every meal with a Chlorine (bleach) based sanitizer in order to kill C- Diff. bacteria. We are not doing this at this time. She also stated that in the past we used a bleach solution to clean the carts after every meal. We need to start process again. Another way to prevent the spread of infection would be to use disposable plates and utensils." E. During record review of the Resident Infection Control Surveillance Information Log the following was revealed: 1. For the month of May 2012 the facility documented sixty total infections. Thirty-five (58%) of those infections were facility acquired. Of the facility acquired infections nine were[DIAGNOSES REDACTED]. infections. 2. For the month of June 2012 the facility documented forty-eight total infections. Thirty-three (69%) of those infections were facility acquired. Of the facility acquired infections three were[DIAGNOSES REDACTED]. infections. 3. For the month of July 2012 the facility documented sixty-nine total infections. Forty-eight (70%) of those infections were facility acquired. Of the facility acquired infections six were[DIAGNOSES REDACTED]. infections. 4. For the month of August 2012 the facility documented sixty-seven total infections. Forty-three (64%) of those infections were facility acquired. Of the facility acquired infections five were[DIAGNOSES REDACTED]. infections. Based on observation, record review and interview the facility failed to implement effective infection control procedures to ensure the prevention and transmission of[DIAGNOSES REDACTED] infection. This deficient practice presents a risk of potential harm by cross contamination of[DIAGNOSES REDACTED] bacteria to all 112 residents (as identified on the alphabetical list provided by the administrator on 08/27/12) in the facility. The findings are: A. On 08/29/12 at 8:58 am, during medication administration observation, Staff #5 Certified Medication Aide (CMA), took a multidose bottle of antibiotic into an isolation room (C-diff) to administer Resident #242 medication by mouth via syringe. The syringe was rinsed with water and returned to the bottle attached with rubberband then placed in the medication refrigerator located in the 400 hall medication room. 1. Review of Resident #242's Physicians Telephone Order, dated 08/15/12, indicated [MEDICATION NAME] 125mg (miligrams) by mouth four times a day times 14 days for a [DIAGNOSES REDACTED]. 2. On 08/31/12 at 11:00 am, during interview, the Director of Nursing stated "It is not our standard of practice to take a multi-dose bottle of medication into a resident's room. She (CMA) should have poured the medication, left the bottle on the medication cart, and took the individual dosage to the resident. The bottle of medication should never have entered the resident's room. " B. On 08/30/12 at 7:45 am during observation, Staff #4, CNA, delivered a breakfast tray to Isolation room [ROOM NUMBER] without wearing a protective gown and disposable gloves. 1. According to the Centers For Disease Control guidelines "Anyone planning to enter a room of a resident on contact isolation precautions is required to wear a protective gown and disposable gloves." C. According to the facility's Antibiotic Resistant Microorganism (ARM) policy and procedure effective 04/01/08 indicates under procedures: Prevention and Control of ARM Transmission 1. Standard Precautions including Contact Precautions. b. Protective Barriers: Gloves: put gloves on immediately prior to anticipated contact with blood and other body fluids or when touching surfaces with blood or other body fluids. Remove gloves when the specific task is completed and wash hands. Gowns: Wear gowns when it is anticipated that clothing will become soiled with blood or other body fluids or when in contact with soiled surfaces (such as siderails or bed linens of an infected resident) is anticipated. Remove gowns when the procedure is complete and prior to leaving the resident's room.