Every finding on record at Valley Springs Rehabilitation and Health Center

49866 Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 2 (Residents #27, #236,) of 26 sample mix residents reviewed for care plan. The findings are: 1. Review of Resident #27's Admission Record with a date of 4/3/2024 noted the resident had a diagnosis of dementia. Review of Resident #27's Care Plan, with a date of 4/3/2024 did not note dementia care or medications with black box warnings. Review of Resident #27's Admission Nursing Evaluation dated 6/19/2024 noted Diagnosis: 10. Neurological: Non-Alzheimer's dementia. B. Diagnosis MDS list: Non-Alzheimer's dementia. Review of Resident #27's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/2024 noted a score of 3 (00-07 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), and the resident had a diagnosis of non-Alzheimer's dementia. It also noted the resident was currently taking insulin, antipsychotic, anticoagulant, diuretic and had diagnoses of heart failure, hypertension, diabetes mellitus, anxiety, depression, psychotic disorder (other than schizophrenia), and hypothyroidism. Review of Resident #27's Medication Administration Record (MAR) dated January 2025 did not note an area to document resident ' s targeted behaviors and expressions of distress. During an interview with the Assistant Director of Nursing (ADON) on 1/24/2025 at 10:10 AM, she confirmed Resident #27 had a diagnosis of dementia, the MDS with an ARD of 12/28/2024 noted the resident with non-Alzheimer's dementia and she confirmed that Resident #27 was not care planned for dementia that would target behaviors and expressions of distress. During an interview with the MDS Coordinator on 1/24/2025 at 10:36 AM, she confirmed Resident #27 had a diagnosis of dementia, the MDS with an ARD of 12/28/2024 noted the resident with non-Alzheimer's dementia and she confirmed that Resident #27 was not care planned for dementia that would target behaviors and expressions of distress. 2. During an interview with Resident #236 on 1/21/25 at 11:50 AM, the resident revealed two toenails were missing. The great toe and one next to it had nails ripped out prior to admission. The resident ' s right foot was observed with a dressing in place. This surveyor observed Resident #236 with an oxygen concentrator in the room running at five (5) liters per minute (LPM). A breathing device used to treat sleep apnea (Bilevel Positive Airway Pressure (Bi-pap) was also observed in the resident ' s room. Review of Resident #236's Care plan dated 1/7/2025 did not note wounds to toes on the right foot. Resident #236 also had altered respiratory status with difficulty breathing related to diagnosis. Used oxygen and continuous positive airway pressure (CPAP) see medical doctor (MD) orders. Review of Resident #236's Admission Nursing Evaluation dated 1/7/2025 noted right toes 1st and 2nd toenail. Admission nursing evaluation also noted 8. Review of Systems A. Respiratory: 5. Does the resident have, need or use any of the following? a. Oxygen c. CPAP. 5c. CPAP/ BiPAP/ Trilogy specify (order, frequency, settings, when to apply/ remove and any pertinent information) see chart. Review of Resident #236's Admission Record dated 1/7/2025 noted the resident was admitted with diagnoses of acute respiratory failure with low oxygen (hypoxia), chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. Review of the Medicare 5- Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/9/2025 noted in Section O0110. Special Treatments, Procedures, and Programs G2. Bi-pap No; G3. Review of Resident #236's Order Summary Report dated 1/22/2025 noted clean right 1st and 2nd toes with wound cleanser, pat dry, apply triple antibiotic ointment (TAO) cover with non-adherent pad, hold in place with 4x4 gauze and [name brand dressing] Monday, Wednesday, Friday and as needed every day and as needed if soiled/missing, and BiPAP settings: fi02 40%, IPAP 10, EPAP 5, Rate 12. There were no directions on the order to monitor settings or frequency of use. During an interview with Resident #236 on 1/23/25 at 9:50 AM, the resident confirmed wearing the bi-pap every night. The resident verified staff did not monitor the bi-pap settings. During an interview with the Assistant Director of Nursing (ADON) on 1/24/2025 at 10:10 AM, she confirmed Resident #236 was admitted to the facility with two missing toenails on the right foot and confirmed the resident was not care planned for the missing toenails and wound care. She also confirmed the resident wore a bi-pap nightly and confirmed it was not noted on the care plan in order for staff to know how to properly care for residents. During an interview with the Minimum Data Set (MDS) Coordinator on 1/24/2025 at 10:36 AM, she confirmed Resident #236 was admitted to the facility with two missing toenails on the right foot and confirmed the resident was not care planned for missing toenail and wound care. She also confirmed the resident was not care planned for bi-pap use. Review of facility policy titled, Nursing Services Policy, noted residents will be assessed and individual plans of care will be developed to determine the nursing staff required to provide nursing and related services to attain or maintain the highest practical level of physical, mental and psychosocial well-being. A policy for care plans was requested from the Administrator and on 01/23/25 at 02:51 PM the Administrator stated no policy for care plans

Based on observation, interview, record review, and facility document review, it was determined that the facility failed to ensure resident ' s physician orders for a breathing device (bipap) had instructions for monitoring and frequency of use for 1 (Resident #236) of 1 sample mix residents with orders for bi-pap machine and to ensure fall assessments were completed for 1 (Resident #6) of 1 sample mix resident reviewed for fall assessments. The finding are: 1. During an observation on 1/21/25 at 11:56 AM, this surveyor observed Resident #236 with an oxygen concentrator in the room running at five (5) liters per minute (LPM). A breathing device used to treat sleep apnea (Bilevel Positive Airway Pressure (Bi-pap)) was also observed in the resident ' s room. Review of Resident #236's Admission Record dated 1/7/2025 noted the resident was admitted with diagnoses of acute respiratory failure with low oxygen (hypoxia), chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. Review of the Admission Nursing Evaluation dated 1/7/2024 noted 8. Review of Systems A. Respiratory: 5. Does the resident have, need or use any of the following? a. Oxygen c. CPAP. 5c. CPAP/ BiPAP/ Trilogy specify (order, frequency, settings, when to apply/ remove and any pertinent information) see chart. Review of Resident #236's Care plan dated 1/8/2025 noted the resident had altered respiratory status with difficulty breathing related to diagnosis. Used oxygen and continuous positive airway pressure (CPAP) see medical doctor (MD) orders. Review of the Medicare 5- Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/9/2025 noted in Section O0110. Special Treatments, Procedures, and Programs G2. Bi-pap No. Review of the Order Summary Report dated 1/22/2025 noted BiPAP settings: fi02 40%, IPAP 10, EPAP 5, Rate 12. There were no directions on the order to monitor settings or frequency of use. Review of Resident #236's Medication Administration Record (MAR) dated January 2025 did not have an area to document CPAP/ BiPAP use. During an interview with Resident #236 on 1/23/25 at 9:50 AM, Resident #236 confirmed wearing the bi-pap every night. The resident verified staff did not monitor the bi-pap settings. During an interview with the Assistant Director of Nursing (ADON) on 1/24/2025 at 10:10 AM, she confirmed Resident #236 wore a bi-pap nightly and confirmed the order summary report did not note directions for monitoring or frequency of use. During an interview with the MDS Coordinator on 1/24/2025, she confirmed the Medicare 5-day MDS did not note the resident had a bi-pap and that the order summary report did not note direction for monitoring or frequency of use. 2. On 01/21/2025 at 1:03pm, Resident #6 was observed sitting in a recliner in the bedroom with some facial bruising around the eyes and across the bridge of the nose. On the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/10/2025, the resident had a score of 00 on a Brief Interview for Mental Status (BIMS), (0-7 indicates severely impaired). Resident #6 was unable to answer questions regarding the bruising. During a record review, a progress note dated 1/14/2025 indicated the resident had a fall in the bedroom and the resident's face hit the walker. The nurse was notified along with the physician, and family representative. A record review was done of the resident's medical chart and the last fall risk assessment unscheduled documented was on 8/07/2024. The last quarterly fall risk assessment was dated 12/26/2024, which indicated that resident #6 did not have a fall risk assessment since the fall on 1/14/2025. In an interview with the interim Director of Nursing (DON) on 01/24/2025 at 9:57am, the DON confirmed that nursing documents in the facility's electronic medical charts of resident's falls and a fall risk assessment should be done immediately following a fall. In an interview with Assistant Director of Nursing (ADON) on 01/24/2025 at 10:07am, the ADON was asked who completed fall risk assessments. The ADON stated they are done quarterly and after a fall. The ADON confirmed resident #6's fall that happened on 1/14/2025 was just overlooked because the DON was the responsible person for monitoring the falls and was no longer an employee at the facility. The incident most likely fell through the cracks between the DON and the interim DON. A policy and procedure was requested on quality of care and accuracy of assessments. The ADON confirmed that the facility did not have a policy or procedure for quality of care or accuracy of assessments.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure food stored in the freezer was covered or sealed; manufacturer's instructions were followed; 1of 2 ice machines on B-Hall was maintained in clean and sanitary condition; the kitchen floor and door frames were maintained in good repair and were free of chips, paint peeling, stains and rust; baseboards were secured and were maintained in clean sanitary conditions; and dietary staff washed their hands before handling clean equipment or food items for 2 of 2 meals observed. The findings are: 1. On 1/21/2025 at 10:33am during the initial tour of the kitchen, Dietary [NAME] (DC) #1 was asked to pull out the grease trap under the stove top. DC #1 pulled the slide out drawer beneath the stove top and the aluminum foil covering the top was covered in a 16-inch by 6-inch area of charred food particles and spillage. DC #1 was asked how often the grease traps were cleaned. DC #1 said that the grease traps were checked and cleaned once per week. DC #1 confirmed that the grease traps were dirty. 2. On 1/22/25 at 2:18 PM, an opened box of steak fingers was on a shelf in the walk-in freezer. The box was not covered or sealed. 3. On 1/22/25 at 2:21 PM, a box of hamburger buns was on a shelf in the storage room. The manufacturer's specifications on the box indicated it should be kept frozen at 0 degrees Fahrenheit or below. There were also 4 bags of hamburger buns, with 12 buns in each bag. DC #1 was interviewed and asked if the box of hamburger buns should have been stored in the storage room. She stated she did not have space in the freezer to store it but was not aware hamburger buns needed to be frozen. 4. On 1/22/25 at 2:50 PM, a container of cottage cheese was on a shelf in the refrigerator. The lid was cracked, exposing cottage cheese. 5. On 1/22/25 at 2:53 PM, DC #1 opened the cabinet, grabbed containers of spices, and checked their expiration dates, contaminating her hands without washing her hands. She used her contaminated hands to pick up loose filters which were intended for use when brewing coffee and handed them to Dietary Aide (DA) #2 to store them in a bag for later use. The Dietary Manager was interviewed and was asked what she should have done after touching dirty objects and before handling clean equipment she confirmed her mistake, stating she should have washed her hands and disposed of the coffee filters since they were touched with contaminated hands. 6. On 1/22/25 at 3:03 PM, DA #2 lifted the trash can lid and threw away tissue papers, contaminating his hands. Without washing his hands DA #2 placed gloves on his hands contaminating the gloves in process. DA #2 then used his contaminated gloved hands to pick up glasses that contained beverages to be served to the residents for lunch and placed them on the trays. DA #2 was interviewed and was asked what he should have done after touching dirty objects and before handling clean equipment. He stated he should have washed his hands. 7. On 1/22/25 at 3:12 PM, an opened box of egg rolls was on a shelf in the freezer. The box was not covered or sealed, exposing egg rolls to freezer burn. The bottom of the freezer had dried brown stains smeared on it. 8. On 1/22/25 at 3:31 PM, the following observations were made in the kitchen areas: a. The bottom of the deep fryer had an accumulation of grease buildup on it. DC #3 was interviewed and asked how often she cleaned the bottom of the deep fryer. She stated she cleaned it 2 times a week. DC #3 was asked if the area looked like it had been cleaned 2 times a week and she stated it had not been cleaned. b. The floor between the oven and the deep fryer had an accumulation of caked on grease buildup with loose food crumbs on it. c. The grease trap under the grill had an accumulation of black greasy residue and mixture of greasy food particles settled on the walls of it. DC #1 was interviewed and was asked how often she cleaned the grease tray and stated the kitchen staff cleaned it every night. DC #1 was asked if the grease trap looked like it had been cleaned every night. She confirmed it had not been cleaned. d. The floors and the edges of the food preparation counter had accumulations of loose food crumbs and grease. e. Three of three trays on the counter by the steam table where clean plates were placed face down had loose food crumbs on them. f. The bottom of the food preparation counter where the cutting board and pans were kept had loose food crumbs on it. g. The bottom of the steam table where plate covers were kept had loose food crumbs on it. h. A cart by the steam table where food trays were kept had loose food particles on it. i. The floor throughout the kitchen had black stains. 9. On 1/22/25 at 4:49 PM, DC #3 used a tissue to wipe off spilled food from the food preparation counter, contaminating her hands. Afterward, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents for supper. DC #3 was interviewed and was asked what she should have done after touching dirty objects and before handling clean equipment. She stated she had contaminated the blade, and she should have washed her hands before touching the blade. 10. On 1/22/25 at 5:15 PM, DC #3 picked up a spray bottle and placed it on the counter, contaminating her hands. Without washing her hands, DC #3 picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents for supper. 11. On 1/23/25 at 9:34 AM, the area in the ice machine panel located in the dining room on B-hall (Unit) where ice forms before dropping into the ice collector had wet black and brownish colors on it. DC #1 was asked if she could wipe the area. The black and brownish residue easily transferred to the tissue. DC #1 was interviewed and was asked to describe what was observed, who used the ice from the ice machine, and how often she cleaned it. She confirmed the area was dirty and had black and brown residue on it, the maintenance man cleaned it once a month, and the CNAs [Certified Nursing Assistants] used it to fill beverages served to the residents who reside on B-Hall at mealtimes and for the water pitchers in the residents' rooms on B-Hall. 12. On1/23/25 at 9:45 AM, the Maintenance Director was interviewed and was asked how often he cleaned the ice machine. He stated he cleaned it once a month, and stated it was old and dirty. 13. On 1/23/25 at 12:37 PM, DA #4 opened the refrigerator, removed a bag of fresh lettuce, and placed it on the counter. DA #4 then opened the bag, removed one lettuce head, and placed it on the cutting board, without rinsing the lettuce. DA #4 sliced the lettuce and placed the pieces in a bowl. DA #4 then removed a fresh tomato from a box in the refrigerator and placed it on the cutting board, without rinsing it. DA #4 sliced the tomato and placed the pieces on top of the lettuce, creating a tossed salad. DA #4 covered the bowl with a plastic lid and placed it on the counter. Then DA #4 picked up the bowl of tossed salad to send it out with a meal tray to the resident who requested it with their lunch meal. DA #4 was interviewed and asked what she should have done before processing fresh tomato and fresh lettuce for use. She confirmed she should have rinsed them, then removed it and prepared a new one after rinsing the lettuce and tomato. 14. A review of facility policy titled, Handwashing and Glove Usage in Food service, initiated 2016, provided by the DC #1 on 1/23/2025 indicated, food handlers should wash their hands before starting work, after touching dirty dishes or clothing and after touching anything else such as dirty equipment. 15. On 01/21/2025 at 12:35pm, Certified Nursing Assistant (CNA) #6 passed out residents ' food trays and did not sanitize in between each resident. CNA #6 passed the food tray to a resident, assisted them setting up their plate, and then went and got another food tray for another resident. 16. On 01/23/25 12:52pm, CNA #6 was observed passing meal trays to residents. CNA #6 did not wash or sanitize hands between each resident's food tray. CNA #6 picked up a cellphone that was lying on the kitchen counter and touched the screen a few times with the right index finger then laid it back down on the counter. CNA #6 picked up another resident's food tray and took it to a resident's room. CNA #6 returned to the kitchen and picked up another food tray and took it to a resident sitting at the table. 17. On 1/23/2025 at 12:59pm, CNA #6 was asked what should be done between passing food trays to residents. CNA #6 confirmed that hands should be sanitized or washed between each food tray to prevent spreading infection. CNA #6 was asked what should be done after touching a cellphone and before passing another food tray. CNA #6 confirmed that hands should be washed or sanitized because it was part of infection control. CNA #6 confirmed that she did not wash her hands like she should have. 18. On 01/23/2025 at 1:05pm, Licensed Practical Nurse (LPN) #8 was asked what was important to do when passing resident's food trays. LPN #8 stated that hands should be sanitized between each one. LPN #8 confirmed that proper hand hygiene while passing resident's food trays out was part of the facility's infection control and that is something the facility taught its staff. On 01/23/2025 the facility's policy on hand washing and staff in-services were provided. Section G on in-service dated 10/04/2024 indicates that staff should sanitize hands before and after assisting residents with meals.

Based on observation, interview, facility document review, and facility policy review, it was determined that the facility failed to ensure staff maintained hand hygiene during meal service while on the secured unit to prevent cross contamination and to ensure an indwelling catheter was kept out of a resident ' s trash can and was kept off of the floor for 1 (Resident #79) of 2 (Resident #79, #82) sample mix residents with indwelling catheters. The findings are: During an observation of Resident #79 on 1/21/25 at 2:23 PM, this surveyor observed the resident lying in bed on their left side. An indwelling catheter tube draining yellow urine was observed sitting in the resident ' s trash can. Review of Resident #79's Care Plan dated 1/5/2025 noted the resident required partial to moderate assistance with toileting hygiene and helper does all the effort. Resident #27 had an indwelling catheter related to enlarged prostate. Review of Resident #79's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/12/2025 noted the resident had neurogenic bladder. Section H0100. Appliances A. Indwelling catheter yes. During an observation of Resident #79 on 1/21/25 at 2:27 PM, this surveyor observed Resident #79 sitting in a wheelchair self-propelling down the hallway with indwelling catheter collection bag underneath the wheelchair dragging on the floor. During an interview with Resident #79 on 1/22/25 at 9:28 AM, this surveyor asked the resident why they had an indwelling catheter. The resident stated it helped them with going to the bathroom. This surveyor observed the indwelling catheter bag underneath the wheelchair touching the floor. Review of Resident #79's Order Summary Report dated 1/23/2025 noted enhanced barrier precautions every shift, foley: may replace foley drainage bag as needed (PRN) for blockage/build up. May replace leg band prn related to neuromuscular dysfunction of bladder. During an interview with Certified Nursing Assistant (CNA) #9 on 1/24/2025 at 10:07AM, she confirmed Resident #79's indwelling catheter bag was dragging the floor underneath the wheelchair and was an infection control concern. During an interview with the Assistant Director of Nursing (ADON) at the resident's room on 1/24/2025 at 10:10 AM, she confirmed Resident #79 had an indwelling catheter and that it should not be placed in the resident ' s trash can or dragged on the ground underneath the wheelchair. The ADON confirmed it was an infection control issue and could cause contamination. On 01/21/2025 at 12:35pm, Certified Nursing Assistant (CNA) #6 passed out residents ' food trays and did not sanitize hands in between each resident ' s tray. CNA #6 passed the food tray to a resident, assisted them setting up their plate, and then went and got another food tray for another resident. On 01/23/25 at 12:52pm, CNA #6 was observed passing meal trays to residents. CNA #6 did not wash or sanitize hands between each resident's food tray. CNA #6 picked up a cellphone that was lying on the kitchen counter and touched the screen a few times with the right index finger then laid it back down on the counter. CNA #6 picked up another resident's food tray and took it to a resident's room. CNA #6 returned to the kitchen and picked up another food tray and took it to a resident sitting at the table. On 1/23/2025 at 12:59pm, CNA #6 was asked what should be done between passing food trays to residents. CNA #6 confirmed that hands should be sanitized or washed between each food tray to prevent spreading infection. CNA #6 was asked what should be done after touching a cellphone and before passing another food tray. CNA #6 confirmed that hands should be washed or sanitized because it is part of infection control. CNA #6 confirmed that she did not wash her hands like she should have. On 01/23/2025 at 1:05pm, Licensed Practical Nurse #8 (LPN) was asked what was important to do when passing residents ' food trays. LPN #8 stated that hands should be sanitized between each one. LPN #8 confirmed that proper hand hygiene while passing residents ' food trays was part of the facility's infection control and that was something the facility taught its staff. On 01/23/2025 the facility's policy on hand washing and staff in-services were provided. Section G on in-service dated 10/04/2024 indicates that staff should sanitize hands before and after assisting residents with meals.

Based on observation, interviews, record review, and facility document review, it was determined that the facility failed to ensure a comprehensive assessment accurately reflected a resident ' s status and needs for 1 (Resident #236) of 1 sample mix residents reviewed for comprehensive care plan development. The findings are: During an observation on 1/21/25 at 11:56 AM, this surveyor observed Resident #236 with an oxygen concentrator in the room running at five (5) liters per minute (LPM). A breathing device used to treat sleep apnea (Bilevel Positive Airway Pressure (Bipap)) was also observed in the resident ' s room. Review of Resident #236's Admission Record dated 1/7/2025 noted the resident was admitted with diagnoses of acute respiratory failure with low oxygen (hypoxia), chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. Review of the admission Nursing Evaluation, dated 1/7/2024, noted 8. Review of Systems A. Respiratory: 5. Does the resident have, need or use any of the following? a. Oxygen c. CPAP. 5c. CPAP/ BiPAP/ Trilogy specify (order, frequency, settings, when to apply/ remove and any pertinent information) see chart. Review of Resident #236's Care plan dated 1/8/2025 noted the resident had altered respiratory status with difficulty breathing related to diagnoses. Used oxygen and continuous positive airway pressure (CPAP) see medical doctor (MD) orders. Review of the Medicare 5- Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/9/2025 noted in Section O0110. Special Treatments, Procedures, and Programs G2. Bi-pap No; G3. Review of the Order Summary Report dated 1/22/2025 noted BiPAP settings: fi02 40%, IPAP 10, EPAP 5, Rate 12. There were no directions on the order to monitor settings or frequency of use. Review of Resident #236's Medication Administration Record (MAR) dated January 2025 did not have an area to document CPAP/ BiPAP use. During an interview with Resident #236 on 1/23/25 at 9:50 AM, Resident #236 confirmed wearing the bi-pap every night. The resident verified staff did not monitor bi-pap settings. During an interview with the Assistant Director of Nursing (ADON) on 1/24/2025 at 10:10 AM, she confirmed Resident #236 wore a bi-pap nightly and she confirmed the comprehensive assessment for Resident #236 was inaccurate as it did not document the resident had a bi-pap. During an interview with the MDS Coordinator on 1/24/2025, she confirmed the Medicare 5-day MDS did not note the resident had a bi-pap.

Based on interviews, record review, facility document review, it was determined that the facility failed to complete a Preadmission Screening and Resident Review (PASRR) for 1 (Resident #24) of 2 sample residents reviewed for PASRR, to ensure the resident received the needed care and services in the most appropriate setting. The findings are: On 01/23/2025 at 2:53 PM, the Administrator stated the facility did not have a policy for PASRR and goes by the Centers for Medicare and Medicaid Services (CMS) policy. Review of Resident #24's Division of Medical Services (DMS) 787 dated 1/22/2019 noted in Section II the resident had diagnoses of psychosis and dysthymia (depressive disorders). The DMS 787 also documented the resident had a diagnosis of dementia in answer to Section II question number 7. This DMS-787 was accompanied by a letter from [State Designated Professional Associates] that requested further information before it could be processed. Review of Resident #24's DMS-780 dated 6/30/2022 noted the Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition- (DSM-IV) was utilized to substantiate the following diagnosis of Dementia (including Alzheimer's, cognitive disorder, alcohol/drug and other related disorders). The diagnosis was made on the basis of a history or physical findings that lead to the Dementia diagnosis: diagnosis prior to admission 5/1/2014. Section II B. note the resident has a diagnosis of psychosis, panic, or anxiety disorder, and major depression. Question related to section B referencing mental illness as the primary diagnosis and mental illness prior to onset of dementia were left unanswered. Review of Resident #24's Arkansas Department of Health and Human Services Evaluation of Medical Need Criteria (DHHS-703) dated 05/01/2014 noted the resident, under Mental Status section clear checked. Part III, under RN/Counselor comments read in part, Resident had a history of delusions, and behaviors. A review of Resident 24 ' s admission records indicated the facility admitted Resident # 24 with diagnoses that included unspecified psychosis, psychotic disturbance, mood disturbance, anxiety, dementia, and major depressive disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/24/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 14 (13-15 indicated cognitively intact). Section I diagnoses indicated the following, Non-Alzheimer's Dementia, depression, psychotic disorder, and other depressive disorders. Review of Resident #24's electronic chart revealed no PASRR II, or exemption located on electronic chart. On 01/22/2025 at 3:00 PM, PASRR documentation for Resident #24 was requested. On 01/22/2025 at 3:17 PM the Social Services Director (SSD) confirmed that there had not been a preadmission screening accepted by [State Designated Professional Associates]. The SSD reported that after a phone conversation with [State Designated Professional Associates] on this date, there was no confirmed submission of the 787 form due to revision requests that were not received. The SSD stated that instructions were received by the facility consultant to submit a current PASRR. The SSD was asked if the PASRR prescreening should have been completed prior to admission and stated, Yes. On 1/24/2025 at 10:00 AM, during an interview with the MDS Care Plan Coordinator (CPC)/Interim Director of Nursing (DON). The MDS/CPC was asked how long have they been the MDS coordinator. The MDS/CPC stated about 6 years. The MDS/CPC was asked if they were currently acting DON and stated yes, interim DON, RN supervisor type thing. The MDS/CPC was asked who was responsible for completing PASRR screenings and stated the SSD is responsible for those and most are done prior to admission. The MDS/CPC stated she was familiar with Resident #24 and stated the PASRR should have been done prior to admission, the letter should be included in either the paper chart or electronic record.

Based on observation, record review, interview, and facility document review, it was determined that the facility failed to ensure fall mats were maintained in good condition for 1 (Resident #82) of 1 sample mix resident whose fall mats were observed. During an observation of Resident #82 on 1/21/25 11:11 AM, this surveyor observed the resident lying in bed on their back at a forty-five (45) degree angle. A fall mat was present on one side of the bed. One side of the bed was against the wall, with a fall mat approximately 6-8 inches away from the other side of the bed. The fall mat was observed to have rips/tears on it. Review of Resident #82's Care plan dated 1/3/2024 noted the resident was at risk for falls related to impaired safety awareness. The resident was documented as having falls on: 8/29/2024 fall- Intervention on 8/29/2024 noted dysem (non-slip material) to wheelchair 9/03/2024 fall- Intervention on 9/03/2024 noted fall mat 9/12/2024 fall- Intervention on 9/12/2024 noted medication review 9/25/2024 fall- Intervention on 9/25/2024 staff instructed resident not to be left without visual supervision while up in wheelchair During an interview with Certified Nursing Assistant (CNA) #9 in Resident #82's room on 1/24/2025 at 10:07 AM, she confirmed the fall mat was 6-8 inches from the bed and it had rips/ tears. CNA #9 confirmed the fall mat had not been properly maintained and should not have rips/ tears and should be placed by the edge of the resident ' s bed. During an interview with the Assistant Director of Nursing in Resident #82's room on 1/24/2025 at 10:10 AM, she confirmed Resident #82 had rips/ tears on the fall mat and that the fall mat was too far away from the resident ' s bed and should be placed near the edge of the bed. The ADON confirmed the fall mat needed to be replaced. Review of facility policy titled, Accident Hazards Prevention noted resident environment will be free from accident hazards as is possible. The frailty of some residents increases their vulnerability to hazards in the resident environment and can result in life-threatening injuries. It is important that all staff understand the facility's responsibility, as well as their own, to ensure the safest environment possible for residents. An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents. Encourage the use of data to identify potential hazards, risks, and solutions related to specific safety issues that arise; Directs resources to address safety concerns; and Demonstrates a commitment to safety at all levels. Resident Assessment. Resident/ Elders will receive adequate supervision and assistance devices to prevent accidents.

Based on record review, interview, facility document review, and facility policy review, it was determined the facility failed to ensure necessary care and services were provided related to dementia care, as evidenced by failure to ensure residents were assessed prior to admission to a closed unit to determine if placement on the unit was appropriate for the resident and failure to ensure sufficient staff with training in care of residents with dementia and behaviors were available to provide care to the residents who resided on the closed unit in accordance with the comprehensive assessments and plans of care for 1 (Resident #27) of 7 (Residents #1, #2, #4, #6, #12, #19, and #27 ) case mix residents who had behaviors and resided on the closed unit. The findings are: Review of Resident #27's Admission Record with a date of 4/3/3034 noted the resident had a diagnosis of dementia. Review of Resident #27's Care Plan, with a date of 4/3/2024 did not note dementia care. Review of Resident #27's Admission Nursing Evaluation dated 6/19/2024 noted Diagnosis: 10. Neurological: Non- Alzheimer's dementia. B. Diagnosis MDS list: ak. Non-Alzheimer's dementia. Review of Resident #27's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/2024 noted Resident #27 had a score of 3 (00-07 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), and the resident had a diagnosis of non-Alzheimer's dementia. Review of Resident #27's Medication Administration Record (MAR) dated January 2025 did not contain an area to document resident targeted behaviors and expressions of distress. During an interview with the Assistant Director of Nursing (ADON) on 1/24/2025 at 10:10 AM, she confirmed Resident #27 had a diagnosis of dementia, the MDS with an ARD of 12/28/2024 noted the resident with non-Alzheimer's dementia and she confirmed that Resident #27 was not care planned for dementia that would target behaviors and expressions of distress. During an interview with the MDS Coordinator on 1/24/2025 at 10:36 AM, she confirmed Resident #27 had a diagnosis of dementia, the MDS with an ARD of 12/28/2024 noted the resident with non-Alzheimer's dementia and she confirmed that Resident #27 was not care planned for dementia that would target behaviors and expressions of distress.

Based on observation, interview, and record review, the facility failed to ensure food stored in the refrigerator and freezer was covered or sealed to prevent potential contamination or freezer burn; kitchen floors were clean; and facial hair was covered. This failed practice had the potential to affect 92 residents who received meal trays from the kitchen. The findings are: On 12/17/23 at 10:58 AM, in the freezer there were 6 pork fritters in an open bag with no date on it; 5 pancakes in a bag not sealed that was dated 11/29/23; 4 hamburger patties in a bag not dated; in the refrigerator there was a pan of liquid eggs in a pan covered in foiled that had use for Saturday written on the foil; 42 cups of pudding in the refrigerator uncovered; and the kitchen floors had food crumbs and dirt under the counters. On 12/20/23 at 10:55 AM, Dietary Staff #1 was observed in the kitchen with no hairnet over his beard. On 12/20/23 at 3:41 PM, the Surveyor asked the Dietary Manager, Should the male staff wear a hair net over their beard? She stated, Yes, and Dietary Employee #1 did not have his on when you were in there, but he has on one now. She was asked, Can you tell me why the staff had liquid eggs in a foil pan on Sunday? She stated, I don't know why she pre-prepped the eggs. She was asked, Should all food in the freezer be sealed and dated? She stated, Yes. On 12/21/23 at 9:23 AM, the Administrator was asked, How often are the floors in the kitchen deep cleaned? She stated, The floor tech goes in there every 45 days. It needs to be replaced.

Based on observation, interview, and record review, the facility failed to ensure meals were served at the same time for all residents sitting at the same table for 2 (Residents #18 and #40) of 2 sampled residents to promote dignity and respect. The findings are: On 12/17/2023 at 12:07 PM, the dining staff began serving the residents seated in the dining room. 1. Resident #40 was seated at a table with two other residents. The other residents at the table received their meals and began eating. The other residents eating in the dining room began to finish their meals and leave the room. At 12:27 PM, the Housekeeping Supervisor approached Resident #40 and asked which meal they would like. At 12:28 PM, the Housekeeping Supervisor brought a tray to the table for Resident #40. 2. Resident #18 was seated at a table with two other residents. Resident #18 did not receive a meal tray when the other residents at the table were served. The other residents eating in the dining room began to finish their meals and leave the room. Resident #18 was observed looking at the other residents eating and shaking her head. At 12:35 PM, Nurse Consultant #1 was asked if Resident #18 had a tray coming. Nurse Consultant #1 stated, Oh [Resident #18] doesn't have one? and asked the kitchen staff to provide a tray. At 12:37 PM, Resident #18 received a tray. On 12/20/2023 at 05:05 PM, the Dietary Supervisor confirmed that all the residents seated together at a table should be served at the same time to preserve the dignity of the residents dining. On 12/21/2023 at 08:40 AM, the Administrator confirmed that all the residents seated together at a table should be served at the same time to preserve the dignity of the residents dining. A facility policy titled, Resident Rights and Responsibilities documented, The nursing facility protects and promotes the rights of each Resident/Elder admitted in order to provide a dignified existence . The nursing facility will protect and promote the rights of each Resident/Elder .

Based on observation and interviews, the facility failed to ensure the State Ombudsman's contact information was visible and made available to all 96 residents residing in the facility. The findings are: On 12/19/23 at 03:32 PM, during Resident Council the Surveyor asked, Do you know where the ombudsman's contact information is located? All 4 of the resident council members present confirmed they did not know where the ombudsman's information was located or how to contact them. On 12/19/23 at 03:44 PM, the Surveyor asked the Director of Nursing (DON), Can you show me where the Ombudsman information is located? The DON stated, We just got a new Ombudsman, and confirmed the information was not readily available to the residents. On 12/19/23 at 03:47, Nurse Consultant #2 confirmed the previous ombudsman removed their posters about 2 months ago and the new ombudsman's poster had not been placed in the facility. A facility policy titled, Resident Rights and Responsibilities, provided by the Administrator on 12/21/23 at 8:00 a.m. showed, .The names, addresses, and telephone numbers of the .State Ombudsman program . are posted prominently in the nursing facility .

Based on observation, interview, and policy review, the facility failed to ensure pest control devices were removed from 1 of 1 dining room after the devices became saturated with insects. The findings are: On 12/17/2023 at 12:11 PM, two 12 inch long green adhesive fly traps were observed hanging from the ceiling in the dining room. One trap was hung above the D Hall exit and one above the rolling door window to the kitchen. Both traps were saturated with flies. On 12/17/2023 at 04:44 PM, the same adhesive fly traps remained hanging in the dining room. On 12/18/2023 at 08:35 AM, the same adhesive fly traps remained hanging in the dining room. On 12/19/2023 at 03:05 PM, the same adhesive fly traps remained hanging in the dining room. On 12/20/2023 at 12:15 PM, the same adhesive fly traps remained hanging in the dining room. A resident was sitting directly below one of the adhesive traps eating a meal. On 12/21/2023 at 08:27 AM, the Housekeeping Supervisor stated, Yes, we had flies really bad in the summer, we put those up to get rid of them. The Housekeeping Supervisor confirmed that the traps were unsanitary. On 12/21/2023 at 08:35 AM, the Administrator confirmed that the fly traps hanging in the dining hall were unsanitary. A policy titled, Housekeeping and Maintenance documented, .All rooms and every part of the building (exterior and interior) will be kept clean, orderly, and free of offensive orders. Bath and toilet facilities and food areas will be clean and sanitary at all times .

Based on observation, record review and interview, the facility failed to ensure the environment was as free of accidents and hazards as possible, as evidenced by failure to ensure a bottle of after shave was removed from a bedside table and a razor and a can of shaving cream were removed from a shared bathroom for 1 (Resident #3) of 6 (Residents #3, #41, #59, #61, #72, and #85) sampled residents on the B Hall who needed assistance with shaving as documented on a list provided by Nurse Consultant #2 on 12/19/23 at 2:39 PM and failed to ensure a medication cup was discarded after the morning medication administration to prevent the potential for injury and/or accidents for 6 residents who ambulated independently on the male Secure Unit as documented on a list provided by the Director of Nursing (DON) on 12/21/23 at 10:00 AM. The findings are: 1. Resident #3 had diagnoses of Dementia and Personal History of Traumatic Brain Injury. a. A Care Plan initiated 10/05/23 documented, .Problem .[Resident #3] has potential and hx [history] to be verbally aggressive r/t [related to] Poor impulse control. I will curse, scream and yell and threaten to be physical abusive. I will raise my fists and shake at staff and other residents . b. On 12/17/23 at 12:06 PM, a plastic 4 ounce (oz) bottle of after shave was on Resident #3's bedside table. A blue razor, and a can of shaving cream was on the bathroom sink in the shared bathroom. c. On 12/17/23 at 2:11 PM, a plastic 4 oz bottle of after shave was on Resident #3's bedside table. Resident #3 was asked if the staff shaves him. He stated, I can shave myself sometimes, but the staff has to watch me. d. On 12/17/23 at 2:19 PM, there was a blue razor and a can of shaving cream on the bathroom sink. e. On 12/17/23 at 4:01 PM, there was a blue razor and a can of shaving cream on the bathroom sink. f. On 12/18/23 at 9:05 AM, Resident #3 was resting quietly in bed awake. There was a 4 oz plastic bottle of aftershave on the bedside table. Resident #3's roommate was sitting in the recliner, awake. There was a blue razor and a can of shaving cream on the sink in the bathroom. g. On 12/18/23 at 2:24 PM, there was a 4 oz plastic bottle of after shave on Resident #3's bedside table. A blue razor, and a can of shaving cream were on the sink in the bathroom. h. On 12/20/23 at 9:25 AM, there was a plastic 4 oz bottle of aftershave on Resident #3's bedside table. The door to the resident's room was open. i. On 12/20/23 at 3:01 PM, during an interview, Certified Nursing Assistant (CNA) #1 confirmed the CNAs were responsible for shaving the residents and disposing of the razors; residents could cut themselves or someone if they picked up a disposable razor and that a wandering resident who picked up the bottle of after shave could drink or spill it. j. On 12/21/23 at 12:50 PM, the DON confirmed that no items used to shave residents should be left on the bedside table or in the bathrooms, because it could cause harm to a resident who has cognitive issues and/or wanders. 37634 2. On 12/18/23 at 8:35 AM, Resident #61 was sitting at the dining room table with Resident #85. Licensed Practical Nurse (LPN) #3 administered Resident #61 his medication crushed in pudding and left the medication cup on the table and walked around the corner to her medication cart. On 12/18/23 at 08:39 AM, the Surveyor asked CNA #1 if she could remove the spoon from the medication cup on the table. She removed the spoon from the cup, and pieces of medication were observed in the pudding. On 12/18/23 at 8:40 AM, the Surveyor asked LPN #3, Can you tell me why you left the medication cup on the table after you administered [Resident #61] his medication? She stated, Did I leave it, I'm sorry. On 12/21/23 at 9:18 AM, the DON was asked, What should the nurse do with a medication cup after administering medications crushed in pudding? She stated, Dispose of it in her trash. She was asked, Why is it important that the nurse not leave the medication cup on the table? She stated, Because there could still be medications in the cup. On 12/21/23 a form titled: Inservice Re-education Report dated 11/15/2023 was received from the DON. The form documented, .Do not leave meds [medications] at bedside or dining room table, failure to comply with this will result in immediate termination .

Based on observation, record review and interview, the facility failed to ensure nutritional interventions were implemented after a significant weight loss occurred to minimize the potential for further weight loss for 1 (Resident #85) of 5 (Residents #26, #41, #72, #74 and #85) sampled residents who had experienced a weight loss of 5 percent (%) or more as documented on a list provided by the Assistant Director of Nursing (ADON) on 12/21/23 at 9:57 AM. The findings are: 1. Resident #85 had diagnoses of Nutritional Deficiency, Moderate Intellectual Disabilities and Down Syndrome a. The Physician Orders documented, .[Nutritional Shake] with meals related to Nutritional Deficiency . order date 04/12/23 . Weekly Weights . start date 12/06/2023 . b. A Care Plan initiated 04/12/23 documented, .Problem . I have potential for nutritional deficits related to Dx [diagnosis], cognition . revision date: 04/26/23 . Approaches . Obtain food preferences, likes / dislikes. Date Initiated: 04/12/2023 . Uses divided plate Date Initiated: 09/01/2023 . The Care Plan did not address Resident #85's weight loss of greater than 5%. c. On 12/19/23 at 9:54 AM, a Weight Summary in the electronic medical record (EMR) documented, .12/4/2023 . 108.8 Lbs [pounds] . On 11/02/2023 Resident #85 weighed 120.0 lbs. d. On 12/19/23 at 8:30 AM, Resident #85 was sitting at the table in the main dining room with his breakfast tray in front of him. There was a small glass of clear liquid, an 8 ounce (oz) carton of chocolate milk, and a small cup of a red liquid on the table by his breakfast, but no [Nutritional Shake] was there. e. On 12/20/23 at 8:32 AM, Resident #85 was sitting at the table in the dining room and Certified Nursing Assistant (CNA) #1 was assisting him with his breakfast. Resident #85 was holding an 8 oz carton of chocolate milk. There was also a small glass of orange liquid, and a cup of clear liquid sitting on the table by Resident #85 but there was no [Nutritional Shake] observed on his meal tray or in front of him. At 8:40 AM, Resident #85's breakfast and liquids were cleared from the table and placed on the food cart. f. On 12/20/23 at 12:17 PM, during an interview the Dietary Manager confirmed dietary does not place [Nutritional Shake] on the residents' trays and the nurses are responsible for this. She also stated dietary does send out mighty shakes if residents are to have a house supplement. g. On 12/20/23 at 3:05 PM, Licensed Practical Nurse (LPN) #1 was asked, Do you have [Nutritional Shake] back here? She stated, We do med pass [Nutritional Supplement] to substitute for the [Nutritional Shake]. When it says house supplement that is provided by the kitchen at mealtimes and that's either the health shake or I don't know if it comes out of the kitchen in a cup. She was asked, Do you have an order to substitute the [Nutritional Shake] with [Nutritional Supplement]? She stated, I don't know if it's on the order or not. She was asked, How did you determine to substitute [Nutritional Shake] with [Nutritional Supplement]? She stated, That would just be my nursing judgement. I know they are both high calorie and high protein. [Resident #85] is the only resident that has an order for [Nutritional Shake]. h. On 12/20/23 at 3:27 PM, Resident #85 was propelled in a wheelchair to Therapy by LPN #2 and the Director of Nursing (DON) also followed. They both assisted Resident #85 onto the standing scale for a weight, and the scale showed 108.4 lbs. i. On 12/21/23 at 9:00 AM, the December 2023 Medication Administration Record (MAR) for 12/01/23 at 08:00 AM through 12/19/23 at 12:00 PM documented, .Ensure with meals related to NUTRITIONAL DEFICIENCY, UNSPECIFIED . LPN #1 documented the number 2 (2 = Drug Refused per Chart Code) on 12/1 at 0800. LPN #1 documented a check (check = Administered per Follow Up Codes) for the following dates she was on duty: 12/2 to 12/4, 12/6, 12/9 to12/13, and 12/15 to 12/19. j. On 12/21/23 at 12:49 PM, during an interview the DON confirmed that interventions that are put in place for residents with weight loss should be carried out as ordered. She also confirmed that a nurse should not alter a provider's order without notifying him/her.

Based on observation and interview, the facility failed to ensure the blinds in room [ROOM NUMBER] on the A Hall were in good condition. The findings are: On 12/19/23 at 8:48 AM, the blinds in room [ROOM NUMBER] on the A Hall were missing 9 slats on the left side of the blind. On 12/19/23 at 8:48 AM, the Surveyor asked the Maintenance Supervisor How does the blind look in room [ROOM NUMBER]? He stated, Like crap, it looks like a cat been fighting with it. He was asked, Can you tell me why it hasn't been replaced? He stated, No one has told me about it. On 12/21/23 at 8:16 AM, the blinds in room [ROOM NUMBER] on the A Hall were missing 9 slats on the left side of the blind. Visitors can see through the window when they come to the front entrance.

Based on observation, interview, and record review, the facility failed to ensure training, assessments, and physician orders were implemented to prevent wheelchair harness injury for 1 (Resident #1) of 1 sampled resident whose neck was caught on the chest harness causing a small red area on his [NAME] apple. The Administrator was notified of the Past IJ (Immediate Jeopardy) on 09/22/22 at 9:36 AM, and the facility failed to ensure scissors were not in the possession of 1 (Resident #51) of 5 (Residents #51, #33, #78, #8 and #39) sampled residents who resided on the Secure Unit to ensure the safety of the residents who were ambulatory and resided on the Secure Unit. These failed practice had the potential to affect 0 residents as no residents at this time had a wheelchair with a harness and/or seatbelt as documented on a list provided by the Administrator on 09/22/22 and 14 residents who resided on the Secure Unit as documented on a list provided by the Administrator on 09/19/22. The findings are: 1.Resident #1 had diagnoses of Intellectual Disabilities, [NAME] Syndrome and [CONDITION(S)]. The Quarterly Minimum Data Set (MDS) with an ARD (Assessment Reference Date) of 9/6/22 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and required extensive physical assistance of two plus persons with bed mobility, transfers and dressing and one person physical assistance with personal hygiene, used a wheelchair and did not use a trunk restraint when in the chair or the bed. a. The Comprehensive Care Plan with a revision date of 6/23/22 documented, .I use specialty chair designed by therapy for safety for torso support from contractures. It includes use of safety belts as support measure for positioning. My position will be maintained while I'm up in chair thru [through] next review . Up in chair as needed with safety belts as directed by therapy to maintain positioning R/T [related to] contractures . b. The Nurses Note dated 8/14/22 at 1:00 PM documented .Note Text: Heard [Certified Nursing Assistant (CNA) #6] scream from resident's room for help. This nurse was 1 room away ran to room found CNA pulling resident up. Resident went from resting position to upright position causing resident to slide down in wheelchair, catching neck on chest harness causing a small red area on [NAME] apple. Resident immediately pulled into resting position. No loss of consciousness noted . c. On 9/21/22 at 11:19 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2, Can you tell me what happened on 8/14/22 with [Resident #1]? She stated, I remember this. Then she read her note in the electronic chart and stated, I was giving lunch time meds. I peaked in on him and walked pills over to [a resident] across the hall from him. I heard [CNA #6] scream and I went into his [Resident #1's] room, and he had slid forward in his wheelchair and the harness was at his throat. We immediately jerked him up and put him to bed. We were not sure if the wheelchair had gone down or if he had slid. They are trying to find out what happened. We haven't used that wheelchair anymore. The Surveyor asked LPN #2, When you say harness, can you tell me about this? LPN #2 stated, The wheelchair has straps to keep him in the wheelchair that goes over him. He has involuntary movement. He has a mind of a six-month-old. d. On 9/21/22 at 1:05 PM, the Surveyor asked the Director of Nursing (DON) to describe the incident that happened with Resident #1 on 8/14/22. The DON stated, I was on call, and they called me. He was in his chair and slid. The straps got around his neck. It is a chest harness. It goes over him and hooks to the back of the chair. [CNA #6] saw him and called out for [LPN #2] and his neck did get red, but it did not bruise. We have not used that chair since. I was not sure if the staff had not fastened it right, if he slid down, or if it was because the night staff had taken it apart and the night before to clean it like they did each week. He tends to go forward, and the harness prevents him from going forward . He was admitted with that chair. The Surveyor asked the DON to provide the Risk vs. Benefits education, Assessments, and the Physician's order for the harness. e. On 9/21/22 at 2:16 PM, the DON stated, I could not find a physician's order for the harness, and I couldn't find anything regarding the risk verses benefits education, and I could not find any In-services on the harness before the incident . I did one the day after it happened . f. On 9/21/22 at 2:59 PM, the Surveyor asked the DON for the therapy notes since the care plan mentioned therapy directing and designing the chair. She stated, No, that was at [Facility] where he came from. I looked and I could not find any documentation. g. On 9/22/22 at 8:11 AM, the Surveyor asked the DON, Could I see [Resident #1's] wheelchair? The DON went to the facility's therapy room and pointed to a wheelchair in the corner of the room. The DON stated, The aides were removing the foam arm guards, and the harness, because he slobbers, the seat cushion, and the patted footrest to clean. The Surveyor asked the DON for the Manufacture's guide or instructions. She stated she would look for them. h. On 9/22/22 at 8:41 AM, the Surveyor asked the DON, I wanted to confirm that you said the Restraint Assessment for [Resident #1's] use of the harness was not done? She stated, No, it wasn't i. On 9/22/22 at 9:36 AM, the Administrator was notified the Past IJ (Immediate Jeopardy) was being called due to [Resident #1's] incident with the harness, and that a Plan of Removal would not be required since the wheelchair in question was taken out of service at the time of the incident. The Administrator was asked for a list of residents that currently have a seat belt or a harness. The Administrator stated, Ok, Thank you. j. The typed statement provided by the Administrator on 9/22/22 at 10:15 AM documented, There are no other residents in this building that have a therapeutic harness device or seat belt. The pool was not expanded at this time. k. On 9/22/22 at 3:35 PM, the Surveyor asked the DON, What is the potential negative outcome for [Resident #1's] neck catching on the chest harness? The DON stated, Choking to death, Asphyxiation. l. On 9/23/22 at 10:22 AM, the Surveyor asked the DON, Who is responsible for ensuring the physician has written orders for the harness? The DON stated, Medical Records. The Surveyor asked the DON, Who is ultimately responsible for ensuring there was an order for [Resident #1's] harness? The DON stated, Myself. m. The Manufacturer's Instructions for the chair provided by the Administrator on 9/23/22 at 10:28 AM did not address the harness. 2. Resident #51 had diagnoses of Abnormalities of Plasma Proteins and Dementia. The Quarterly MDS with an ARD of 7/21/22 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was independent with bed mobility and walking. a. The Comprehensive Care Plan with a revision date of 7/29/22 documented, .My safety will be maintained . I receive antiplatelet medication related for blood clot prevention . secured unit . b. On 9/19/22 at 11:35 AM, CNA #4 and this surveyor entered Resident #51's room and observed a pair of scissors lying on the resident's bed. The Surveyor asked CNA #4, Should he have scissors? She stated, I've never heard that he couldn't. The Surveyor asked, What do you normally do when you find something like this in their room? She stated, I would go get the nurse. c. On 9/19/22 at 11:41 AM, the Surveyor asked LPN #1 to follow the surveyor to Resident #51's room. She was informed the resident had scissors. CNA #4 asked Resident #51 where the scissors were, and he told her they were in his drawer. CNA #4 raised the plastic container in the bedside drawer and found the scissors. The Surveyor asked LPN #1, Are scissors supposed to be in [Resident #51's] room? She stated, No they are not. The Surveyor asked, Who is responsible for ensuring the resident's do not have sharp objects? She stated, The Social Service Director will go through and do an inventory of their items when they are admitted . I am not sure how he got a hold of them. The Surveyor asked, What is a potential negative outcome of him having scissors? She stated, Somebody could get hurt. d. On 9/20/22 at 2:50 PM, the Surveyor asked the DON if she was aware of Resident #51 having the scissors yesterday. She stated that she was aware of us finding the scissors and is still unsure of how he got them. They had moved him to another room, and they did not find anything else in his belongings that he was not supposed to have. The Surveyor asked the DON, What is a potential negative outcome of him having scissors? She stated, He could have hurt himself, one of the staff or even another resident. 3. The Facility policy titled, Safety Policy Statement, provided by the Administrator on 9/23/22 at 10:47 AM documented, Every attempt will be made to reduce the possibility of accident occurrence .Employees must understand their personal responsibility for the prevention of injuries .

Based on observation, record review, and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; and 2 of 2 ice machines and 1 of 2 ice scoop holders were maintained in a clean condition to prevent the potential contamination of residents' food or beverages. These failed practices had the potential to affect 77 residents who received meals from the kitchen, (Total Census: 79), as documented on a list provided by the Dietary Manager on 9/22/2022. The findings are: 1. On 09/19/22 at 11:42 AM, during the initial tour of the kitchen with the Dietary Manager (DM), the following food items were in the walk freezer in ziplock bags with only one date on the bag. The date on the bag did not specify if it was an opened date, leftover date, or a received date: a. Bread rolls. b. Brownies. c. Chocolate cupcakes. d. Tortillas. e. Chicken tenders. f. Chicken thighs. g. The Surveyor asked the DM what the one date on ziplock bags represented. The DM stated, Typically it is the date that we received them and re-bagged them. The Surveyor asked, What about the cupcakes that were baked and then frozen? The DM stated, Then it would be the date they were frozen as leftovers after we baked them. The Surveyor asked, If a box of biscuits was received 1/1/22, but not opened until 6/1/22, what date would be on the bag? The DM stated, Just 6/1/22. The Surveyor asked, How would a new employee know what the one date represented? She stated, I see what you are saying. I guess I figured I would just tell them. 2. An opened bag of beef steaks was in the walk-in freezer. The bag was not sealed. The Dietary Supervisor stated, Oh we missed one. 3. On 9/19/2022 at 12:04 PM, the following food items were in a chest freezer in Ziplock bags with only one date on the bag. The date on the bag did not specify if it was an opened date, leftover date, or a received date: a. Potato wedges. b. Fish fillets. c. Chicken patties. d. The DM stated, We will stay late today and get two dates with labels on everything. 4. On 9/19/2022 at 12:18 PM, on the B Hall unit kitchen, there was a ziplock bag of chocolate cookies in a cabinet with no date, label, or name. The DM asked, What if that is a residents? The Surveyor asked, What does your policy for food brought in from families state, should you still know how long they have been in the cabinet or refrigerator? The DM stated, Oh, like the other cookies in the cabinet. (referring to an opened box of cookies that was in a Zip lock bag with received and opened dates on it.) 5. On 9/21/22 at 11:17 AM, Dietary Employee (DE) #1 walked into the kitchen with gloves on her hands. She did not remove her gloves and wash her hands before she picked up utensils by the tips, placed them in individual napkins and wrapped them for the residents to use in eating their lunch meal. The Surveyor immediately asked DE #1, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have removed the gloves and washed my hands. 6. On 9/21/22 at 11:23 AM, DE #2 removed slices of bread from a bag and placed them in the saucepan on the stove. She removed slices of cheese from a bag and placed them on top of the bread in the saucepan on the stove. She picked up a brush from a pot on the stove that contained melted butter and brushed the bread, contaminating her hands. She used her contaminated hand to flip the grilled cheese sandwiches to be served to the residents. The Surveyor immediately asked DE #2, What should you have done after touching dirty objects and before handling food items? She stated, I should have washed my hands. 7. On 9/21/22 at 11:52 AM, the ice scoop holder on the wall by the ice machine had a wet black residue settled at the bottom of it. The ice scoop was resting directly on the black residue at the bottom of the scoop holder. The Surveyor asked the DM to wipe the residue off the bottom of the ice scoop holder. She did, and the wet, black residue easily transferred to the tissue. The Surveyor asked her to describe the contents at the bottom of the scoop holder. She stated, There's black residue. 8. On 09/21/22 11:53 AM, the ice machine in the kitchen had a wet black residue across the panel and on the interior surfaces of it. The Surveyor asked the DM to wipe the residue off the interior surfaces of the ice machine. She did, and the wet, black residue easily transferred to the tissue. The Surveyor asked her to describe the contents within the interior surfaces of the ice machine. She stated, There's black residue. The Surveyor asked, Who uses the ice from the ice machine and how often do you clean ice machine? She stated, CNAs [Certified Nursing Assistants] use it for the water pitchers in the residents' rooms and we use it to fill beverages served to the residents at meals. We wipe it off every morning. We did not clean that area. 9. On 9/21/22 12:17 PM, the side corner of the ice machine panel in the unit, had a wet red brownish residue on it. The Surveyor asked the Maintenance Man to wipe the residue off the corner of ice machine. He did, and the wet, red brownish residue easily transferred to the tissue. The Surveyor asked the DM to describe the contents within the side corner of the ice machine panel. She stated, There's red brownish residue. The Surveyor asked, Who uses the ice from the ice machine and how often do you clean ice machine? She stated, CNAs use it for the water pitchers in the residents' rooms. We clean it weekly. 10. On 9/21/22 at 4:01 PM, DE #2 picked up deep fryer baskets that contained french fries from the deep fryer and set them on the hooks attached to the deep fryer. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to serve to the residents on pureed diets. When she was ready to place fries into the blender, she was immediately stopped and was asked what she should have done after touching dirty objects and before handling clean objects or food items. She stated, I should have washed my hands. 11. On 9/21/22 at 4:32 PM, DE #3 removed fresh tomatoes from their original box. Without rinsing the tomatoes, she placed them on the cutting board, contaminating the cutting board. She cut the tomatoes on the cutting board. DE #3 was immediately stopped when she was ready to place the tomatoes on top of the lettuce to be served to the residents. The Surveyor asked DE #3, what should she have done with the tomatoes before cutting them. She stated, I forgot to rinse them. 12. The facility policy titled, Food Brought Into Resident's Rooms from Outside Sources, provided by the Administrator on 09/19/22 at 11:20 AM documented .2. Foods or beverages brought in from the outside will be labeled with the resident's name, room number and dated with the current date the item(s) was brought to the facility for storage .3. Staff will monitor resident's room, unit, pantry, and refrigeration units for food and beverage disposal for proper labeling, dating, and monitoring for use by dates to discard when applicable . 13. The facility policy titled, Hand Washing and Glove usage in Food Service, provided by the DM on 9/22/2022 at 9:44 AM documented, .When Food Handlers must wash their hands . After leaving and returning to the kitchen/prep area. After touching anything else as dirty equipment work surfaces or cloths .

Based on interview and record review, the facility failed to ensure an Advanced Directive was available in the medical record for 2 (Residents #58 and #282) of 2 sampled residents whose records were reviewed for an Advanced Directive. This failed practice had the potential to effect 79 residents at the facility per the Resident Census and Conditions of Residents received from the Director of Nursing (DON) on [DATE]. The findings are: 1. Resident #58 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] documented the resident scored 2 (,d+[DATE] indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. The Acknowledgment of Advance Directive/Medical Treatment Decisions Receipt dated [DATE] documented, .I have chosen to formulate and issue the attached Advanced Directive/DNR instruction . b. On [DATE] at 1:35 PM, the Surveyor asked the Social Service Director (SSD) for a copy of Resident #58's Advanced Directive. The SSD stated she would have to look for it. The SSD searched the electronic records and opened a Durable Power of Attorney (POA) form and stated that was the advanced directive. The Surveyor pointed to the POA document under 5. Restrictions on Agent's Powers; letter f. and asked the SSD to read it. The SSD read out loud, My agent cannot execute on my behalf an Advanced Directive for Health Care, Living Will or other document. and then SSD stated Oh goodness. I'm sorry. I did not see that. 2. Resident #282 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an ARD of [DATE] documented the resident scored 9 (,d+[DATE] indicates moderately cognitively impaired) on a BIMS. a. The Acknowledgment of Advance Directive/Medical Treatment Decisions Receipt dated [DATE] documented, .I do not currently have an Advance Directive and have requested information/assistance in formulating an Advance Directive . b. On [DATE] at 01:35 PM, the Surveyor asked the SSD for a copy of the documentation for the Advanced Directive education provided to Resident #282. The SSD stated the information and education was given during the admission process. The Surveyor asked where that was documented. The SSD stated it was not, but she could make the entry. The SSD showed the surveyor the packet that was given for education when requested. The Surveyor asked where it was documented that the Resident or Representative received the information and education. The SSD stated, I'm sorry. I didn't document it. 3. On [DATE] at 1:50 PM, the Surveyor asked the SSD, What could be the outcome of Advanced Directive information not being property documented? The SSD stated, If something happens to a resident, my coworkers would not know the resident's wishes, and they might not be followed, which I know could be really bad. 8. The Advance Directives policy provided by the Administrator on [DATE] at 11:44 AM documented, . Upon admission to the Facility, the Resident/Elder or his/her legal representative shall be asked whether he/she has executed any Advance Directives . If the Resident/Elder has an Advance Directive, a copy should be kept in the Resident/Elder's medical records . 2. Advance Directive/Medical Treatment Decisions Form . i. Present the Resident/Elder or legal representative with the Advance Directive/Medical Treatment Decisions Form . ii. Determine whether the Resident/Elder has an existing Advance Directive . iii. Remember: the Resident DNR/CPR [Do Not Resuscitate/Cardiopulmonary Resuscitation] Instruction and EMS/DNR physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment were coded accurately to ensure residents received adequate care for 3 (Residents #33, #48 and #66) of 18 (Residents #1, #8, #17, #19, #26, #30, #31, #33, #37, #45, #48, #51, #56, #58, #66, #76, #78, and #282) sampled residents whose MDS was reviewed. The findings are: 1. Resident #33 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an Assessment Reference Date (ARD) of 7/23/22 documented the resident scored 00 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS), had delusions and wandering behavior had occurred 1 to 3 days and did not use a wander/elopement alarm. a. The Physicians Order dated 05/20/19 documented, .Wander Guard to Right Ankle . b. The Care Plan with a revision date of 5/7/21 documented, .I am an elopement risk/wanderer due to Impaired safety awareness R/T [related to] my Dx [diagnosis] .Resident resides on special care unit R/T Dx. and benefits from a smaller environment . WANDER ALERT: on right ankle. Check placement daily. Date Initiated: 01/06/2020 . d. The Wandering Risk Scale dated 7/28/22 documented, .9.0 - at risk. a. On 9/21/22 at 4:29 PM Resident #33 had a wander guard on her right ankle. The Surveyor asked Certified Nursing Assistant (CNA) #6, Does [Resident #33] have exit seeking behaviors? She stated, Yes, she will go down to the double doors and feel for a crack or someway out. She checks doors and she will push on that back door too. She has the alarm on her right ankle . e. On 9/23/22 at 10:12 AM, the Surveyor asked the MDS Coordinator, What is the last accepted MDS ARD for [Resident #33]? She stated, 7/23/22 it was a Quarterly. The Surveyor asked, Did you code her as wearing an alarm? She looked at her computer screen and stated, I will have to do a correction on that because that was an error, she has an ankle bracelet. 2.Resident #48 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS with and ARD of 07/29/22 documented the resident scored 8 (8-12 indicates moderately cognitively impaired) on a BIMS and did not receive [CONDITION(S)]. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 9/23/22 at 10:12 AM, the Surveyor asked the MDS Coordinator, Who is responsible for completing the MDSs? She stated, I am. The Surveyor asked, Who is responsible for submitting the Care Plans and updating them? She stated, I do. The Surveyor asked the MDS Coordinator, What is the last accepted MDS ARD for [Resident #48]? She stated, 7/29/22, it was a quarterly The Surveyor asked, Did you code him as receiving [CONDITION(S)]? She looked at her computer screen and stated, I should have. I did that wrong. I will have to a correction on that. It should have been on there. 3. Resident #66 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Comprehensive Plan of Care with an initiated date of 11/16/21 documented, .I and/or my family have elected Hospice Services . r/t Alzheimer's Disease Late Onset . c. On 09/23/22 at 10:12 AM, the Surveyor asked MDS Coordinator to look at the quarterly MDS dated [DATE] Section O and if Hospice services was coded correctly. She stated, No, I will have to do a correction on that. 4. On 9/23/22 at 10:26 AM, the Surveyor asked the Administrator for a policy on coding the MDS and she stated, We use the RAI [Resident Assessment Instrument] manual as our policy.

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) evaluation process was completed in accordance with the State PASRR process to ensure the resident received appropriate care and services for 4 (Residents #8, #31, #51 and #78) of 4 sampled residents who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Resident #8 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #31 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Resident #51 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with ARD of 7/21/22 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a BIMS and received an antidepressant for 7 days of the 7 day look back period. 4. Resident #78 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change MDS with ARD of 9/6/22 documented the resident scored 1 (0-7 indicates severely cognitively impaired) on a BIMS and received an antidepressant for 7 days of the 7 day look back period. 5. On 09/20/22 at 1:35 PM, the Surveyor asked the Social Service Director (SSD) for a copy of Resident #8's, Resident #31's, Resident #51's and Resident #78's PASRRs. The SSD stated she would need to check for them. 6. On 09/20/22 at 3:10 PM, the SSD informed the Surveyor that she had emailed [State Designated Professional Associates] to check on the PASRRs requested because she could not find them. 7. On 09/21/22 at 10:37 AM, the Surveyor asked the Administrator if Medical Records or any other employee would know where PASRRs were. The Administrator stated, [SSD name] would be the only one to ask. I believe she contacted [State Designated Professional Associates] to get copies. 8. The email from [State Designated Professional Associates] provided by the SSD on 09/21/22 at 11:50 AM, documented: a.[Resident #8] .NON PASRR on 8/23/19 . If you need something in writing from us, you will have to submit a new app [application] . b.[Resident #31] .Not in our system at all . c.[Resident #51] .Not in our system at all . d.[Resident #78] .NON PASRR on 8/23/19 . If you need something in writing from us, you will have to submit a new app . 9. On 09/22/22 at 1:50 PM, the Surveyor asked the SSD, What could be the outcome of a PASRR not being completed or saved and properly documented in a resident's file? The SSD stated, My understanding is if a PASRR is not done it means that a resident has not met the criteria to be here. The Surveyor asked, What information does the PASRR give the facility? The SSD stated, I do not know. I just know it tells us if the person can be here or not.

Based on observation, record review and interview, the facility Administration and Nursing Administration failed to ensure: Necessary care and services were provided to Residents #3, #34, #35, #36, #37, #38, #39, and #40 to prevent the potential for the spread of parasites and to prevent re-infestation of bed bugs. The facility failed to ensure appropriate pest elimination techniques were followed for washing and cleaning to ensure pest were eliminated and to ensure appropriate monitoring was provided to ensure pest were eliminated and prevent complications related to continued infestation of bed bugs for 8 of 8 (Residents #3, #34, #35, #36, #37, #38, #39, and #40) case-mix residents who were observed by staff to have bed bugs on bedding. The facility failed to ensure staff conducted complete body audits on all residents to ensure all residents who were affected by the bed bug infestation were identified and received treatment. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious ham, injury or death to Residents #3, #34, #35, #36, #37, #38, #39, and #40 due to the infestation of beg bugs and had the potential to cause more than minimal harm to 59 residents who resided on C, D, E and F halls as identified by a Census List provided by the Assistant Director of Nurses on [DATE]. The Administrator was informed of the immediate jeopardy on [DATE] at 2:22 p.m. Residents who had a [DIAGNOSES REDACTED].#7, #12, #16, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30) of 13 case mix residents who resided on the locked unit. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death for 13 (Residents #7, #12, #16, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30) residents who resided on the locked unit according to the census list provided by the Assistant Director of Nurses (ADON) on [DATE]. The Administrator was informed of the Immediate Jeopardy on [DATE] at 2:09 p.m. The findings are: The Job Description and Performance Standards for the Administrator provided by Human Resources on [DATE] at 2:20 p.m. documented, The purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents' needs in compliance with federal, state and local requirements .Authority is delegated to the individual in this position to: Develop, maintain and implement operational policies and procedures to meet residents' needs in compliance with federal, state and local requirements. Determine the personnel requirements of the facility and hire or arrange for sufficient staff to implement the facility policies and procedures. Develop a monitoring system to assure compliance with federal, state and local requirements . The Job Description and Performance Standards for the Director of Nursing Services provided by Human Resources on [DATE] at 2:20 p.m. documented, The purpose of this position is to provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department .Authority is delegated to the individual in this position to: Assess resident needs and interview, hire and terminate adequate nursing personnel. Set resident care standards in accordance with accepted current standards of care to provide high quality care to residents. Develop and implement policies and procedures for nursing care of residents. Supervise and manage all aspects of the nursing department. Assess, direct and supervise residents' care needs. Cooperate with administration to assure efficient, cost-effective operation of the facility . A. Findings related to the facility Administration and Director of Nursing failures to provide necessary care and services to residents to prevent the potential for the spread of parasites and to prevent re-infestation of bed bugs: 1. On [DATE] at 4:36 p.m. during clinical record review, the following information was found in the Nurses Notes of resident (Residents #3, #34, #35, #36, #37, #38, #39, #40) records: a. Resident #40 1) A Nurses Note dated [DATE] at 10:22 p.m. documented, Bed bugs found in resident's bed and clothing and on person. Sheets and clothing bagged up and sent to laundry. New mattress placed on bed. (Physician) notified and N.O. (new order) received to apply [MEDICATION NAME] cream all over in AM (morning) and repeat in one week. (Family members) notified. 2) A Nurses Note dated [DATE] at 12:48 p.m. documented, [MEDICATION NAME] washed off Res. (resident) per Rx (prescription) via shower within 8 - 14 hours following [MEDICATION NAME] application. 3) A Nurses Note dated [DATE] at 6:17 a.m. documented, Staff was doing 2 AM rounds when they found a live bed bug crawling on resident's pillow case placed at resident's back. On call (physician) notified. Resident was showered, hair and body negative for bed bugs. No bites observed on resident during body audit. Belongings in resident's room bagged up and left in room for housekeeping to pick up for laundry. Addendum: Resident moved to room (number) on F Hall. b. Resident #39 1) A Nurses Note dated [DATE] at 2:25 p.m documented, Bed bugs found in Res. (resident) rm. (room) All belongings bagged and cleaned. (Physician) notified and N.O. (new order) received - [MEDICATION NAME] 5% cream. Apply from the head down and then remove by washing in 8 - 14 hrs. (hours) Repeat in one week. POA (Power of Attorney) notified. 2) A Nurses Note dated [DATE] at 12:47 p.m. documented, [MEDICATION NAME] washed off Res (resident) per RX (prescription) via shower within 8 -14 hours following [MEDICATION NAME] application. c. Resident #35 A Nurses Note dated [DATE] at 2:33 p.m. documented, Bed bugs found in Res. (resident) rm. (room) All belongings bagged and cleaned. (Physician) notified. POA (Power of Attorney) notified. d. Resident #34 1) A Nurses Note dated [DATE] at 2:34 p.m. documented, Bed bugs found in Res. (resident) rm. (room) All belongings bagged and cleaned. (Physician) notified. POA (Power of Attorney) notified. 2) A list provided by the Director of Nurses (DON) on [DATE] at 11:30 a.m., documented the resident had been moved into a room with Resident #32 on [DATE]. e. Resident #36 1) A Nurses Note dated [DATE] at 2:35 p.m. documented, Bed bugs found in Res. (resident) rm. (room). All belongings bagged and cleaned. (Physician) notified and N.O. (new order) received to apply [MEDICATION NAME] 5% cream. Apply from the head down and then remove by washing in 8 - 14 hrs. (hours). Repeat in one week. POA (Power of Attorney) notified. 2) A Nurses Note dated [DATE] at 12:47 p.m. documented: [MEDICATION NAME] washed off Res. (resident) per Rx (prescription) via shower within 8 - 14 hours following [MEDICATION NAME] application. 3) A Nurses Note dated [DATE] at 6:12 a.m. documented, Staff was doing 2 AM rounds when they found a live bed bug crawling on resident's pillow case placed at resident's back. On call (physician) notified. Resident was showered, hair and body negative for bed bugs. No bites observed on resident during body audit. Belongings in resident's room bagged up and left in room for housekeeping to pick up for laundry. Addendum: Resident moved to room (number) on F Hall. A list provided by the DON on [DATE] at 11:30 a.m. documented the resident was moved to a room on F hall where another resident resided. f. Resident #37 A Nurses Note dated [DATE] at 12:47 p.m. documented: [MEDICATION NAME] washed off Res (resident) per RX (prescription) via shower within 8 -14 hours following [MEDICATION NAME] application. g. Resident #38 1) A Nurses Note dated [DATE] at 2:36 p.m. documented, Bed bugs found in Res. (resident) rm (room) All belongings bagged and cleaned. (Physician) notified and N.O. (new order) received - [MEDICATION NAME] 5% cream. Apply from the head down and then remove by washing in 8 - 14 hrs. (hours) Repeat in one week. POA (Power of Attorney) notified. 2) A Nurses Note dated [DATE] at 8:39 p.m. documented, Post ABT (antibiotic) with no ASE (adverse side effects) noted at this time. Temporarily on F Hall d/t (due to) bed bug decontamination of primary rm . 3) A Nurses Note dated [DATE] at 12:45 p.m. documented, [MEDICATION NAME] washed off Res (resident) per RX (prescription) via shower within 8 -14 hours following [MEDICATION NAME] application. h. Resident #3 1) A Nurse Note dated [DATE] at 8:29 p.m. documented, Bed bugs found in Res rm. Res, belongings cleaned and/or bagged to rid of infest. (infestation) Res temporarily on F hall at this time. N.O. received per (physician): [MEDICATION NAME] cream applied from head down and then to be washed 8 - 14 hrs later. To be repeated in one week. 2) A Nurse Note dated [DATE] at 12:47 p.m. documented, [MEDICATION NAME] washed off Res per RX via shower within 8 - 14 hours following [MEDICATION NAME] application. 3. On [DATE] at 10:35 a.m. bags filled with unidentified items were on the ground outside the door of the laundry near the Biohazard closet: 9 red plastic Biohazard bags, 13 yellow plastic Biohazard bags, 3 black plastic bags and 3 white plastic bags. The bags were lying directly on the ground, located next to the fence for the Generator. The Floor Technician and Housekeeper #1 were asked what items were in the bags. Housekeeper #1 stated, The stuff in the bags is resident's belongings. Housekeeper #1 was asked, How long has it been here? Housekeeper #1 stated, Two weeks. Housekeeper #1 was asked, Why are the resident's belongings outside in plastic bags? Housekeeper #1 stated, Bed bugs. The bugs have to have extreme heat for 14 days to kill the bugs. The stuff was put in the plastic bags, put outside in the 90 degree plus heat will kill them (bed bugs). At 10:40 a.m., the Housekeeping Supervisor came around the corner of the laundry where the bags were located on the ground. The Housekeeping Supervisor was asked to explain the bags on the ground. The Housekeeping Supervisor stated, The first initial 14 days is over. The CNAs (Certified Nurses Assistants) brought the items (resident belongings) outside, pest control sprayed inside (the rooms) and after 14 days had elapsed, we had another bed bug (in the same room) noted, so the process started over (on Friday [DATE]). The Housekeeping Supervisor was asked, Is this stuff (the bags of resident items) considered Biohazard? The Housekeeping Supervisor stated, Yes, the clothing belongs to the residents and (the items) can't go back inside until they are free of bed bugs. The Housekeeping Supervisor was asked, What rooms were affected? The Housekeeping Supervisor stated, Resident rooms (Residents #38 and Resident #3), (Resident #39 and Resident #35) and (Resident #34 and #37). The Housekeeping Supervisor was asked, What is the process for bed bugs? The Housekeeping Supervisor stated, Our company has a policy and procedure on bed bugs and that is what we followed. The Housekeeping Supervisor was asked, Where are you at (with the procedure) now? The Housekeeping Supervisor stated, There was only one live bug found (on [DATE]) and the procedure started over on Friday. The Housekeeping Supervisor was asked, How did the resident's belongings get outside in plastic bags on the ground? the Housekeeping Supervisor stated, The CNA's brought the bags out here. We (Laundry) just wash it and hand it back out to the residents. The Housekeeping Supervisor was asked, Will the Biohazard company come and pick up the Biohazard bags that are outside on the ground? The Housekeeping Supervisor stated, That's all items that need to be cleaned/washed and returned to the residents. The Housekeeping Supervisor was asked, Is all of the bags resident belongings? The Housekeeping Supervisor stated, Yes, it is all resident belongings (that need to be returned). The Housekeeping Supervisor was asked, Is that appropriate storage of Biohazard items and resident belongings? The Housekeeping Supervisor stated, No, it is not. At 10:55 a.m., the Administrator was asked about the resident belongings in the Biohazard bags placed on the ground outside of laundry. The Administrator stated, We had bed bugs. We got the pest control involved, and the pest control company told us to put the items outside in plastic bags for ,[DATE] days. The combination of the plastic bag and 90 degree plus heat would effectively kill the bed bugs. I did verbal education with the (weekend) RN. This occurred on the weekend and the CNAs put the resident's belongings in red (biohazard) bags. I don't know why they used red biohazard bags other than the fact that it was bed bugs. I was not happy about them (CNAs) using red bags for personal belongings. The (CNAs) should not have used red bags. The resident's belongings should not have been put in red bags, it was resident's personal belongings. We were waiting the 14 days and then they (items) could be washed and returned, if they were items from the original rooms (on [DATE]). The first outbreak was Friday, 2 weeks ago ([DATE]). Anything in a biohazard bag that has been outside for 14 days could be returned now. The Administrator was asked, Are these (bags) items that have been sprayed? The Administrator stated; No personals (personal clothing) were sprayed. The items went into the plastic bags and the heat from the bags and the 90 degree days would have effectively killed the bugs. 4. On [DATE] at 9:15 a.m., the Administrator was asked, What halls were affected by the bed bugs? The Administrator stated; D Hall was the only hall affected by the bed bugs. The Administrator was asked, How did you identify that only D Hall was affected (by the bed bugs)? The Administrator stated, We noticed the first room at dinnertime (supper) on Friday or Saturday (not sure of the exact day), the weekend RN (Registered Nurse) phoned me and stated we had another room affected, then the CNAs checked all the rooms and there were other rooms affected on D Hall. There were no bugs on any other halls. A facility wide check was done by the CNAs on the hall. That is when the CNAs used the biohazard bags to bag up the resident's belongings. The Administrator was asked, What did you do with the resident's that were affected? The Administrator stated, All (affected) were moved to F Hall. The Administrator was asked, Were these residents moved into rooms with other residents? The Administrator stated, I'm not sure. I know we had empty rooms on F Hall, but possibly (put resident's affected in rooms with non affected residents). The Administrator was asked, Did the pest control company spray on Friday ([DATE]) when staff went to return the resident's belonging and identified another bed bug? The Administrator stated, Yes, (pest control representative) did 2 applications. The Administrator was asked, Why did you only spray 4 of the 7 rooms on D Hall? Why was the whole hall not sprayed? The Administrator stated, We only sprayed the 4 rooms that were affected. That's the only rooms we found bugs in. The Administrator was asked, Where are the resident's belongings from Friday ([DATE]) when the live bed bug was found? The Administrator stated, I'm hoping they (belongings) are in storage. 5. An invoice [DATE] from the pest control company provided by the Administrator on [DATE] at 2:25 p.m. documented resident rooms #28, 29, 30 and 32 were treated for [REDACTED]. The pest control contract provided by the Administrator on [DATE] at 5:25 p.m. documented, Service Agreement: . This agreement shall be in effect from February 2014 and stay in effect until said party notifies (Name of Company). Basic Service; (Company) will provide on a regular monthly service, which includes treating for cockroaches, mice, fleas, ticks, c[DIAGNOSES REDACTED], ants, silverfish, firebrats, millipedes, ground beetles, scorpions, clover mites, box elder bugs, spiders and carpenter bees. All trouble calls will be answered promptly at no additional charge. Date started; [DATE]. There was no documentation regarding bed bugs in the agreement. As of the exit conference on [DATE] at 7:45 p.m., the Administrator had provided no further documentation of pest treatment by the pest control company 6. On [DATE] at 9:24 a.m., Licensed Practical Nurse (LPN) #1 was asked, When did the resident's belongings get returned? LPN #1 stated, All the items (belongings) for residents were brought back in (inside the building) by (name of Social Director) yesterday. At 9:27 a.m., the Social Director was asked, When and why did you bring the residents' items (belongings) back inside the building? The Social Director stated, Yesterday ([DATE]) and this morning ([DATE]). Housekeeping stated the time had expired (for the items to remain outside in the heat) and the Administrator told me I could bring the stuff (resident belongings) back inside (the building). Those were the items that could not be laundered, such as wreaths and knick-knacks that could not be run through the heat of the dryer. We (CNA and Social Director) used a disinfectant spray (Virex II 256) and sprayed the items down and wiped them off before we took them back inside for the residents. The Social Director was asked, Is the spray something that can be used to exterminate bed bugs? The Social Director stated, (The housekeeping Supervisor) would know if the spray can be used for extermination of the bed bugs. I was just using it for disinfectant to clean the residents' items that had been outside for 2 weeks. The Social Director was asked, Is (Virex II 256) spray an appropriate extermination product (for bed bugs)? The Social Director stated, I don't know. The Social Director was asked, Who decided what treatment would be used (for the bed bugs)? The Social Director stated, I would assume it was (the Maintenance Director) and the Administrator. At 9:30 a.m., the Housekeeping Supervisor provided a bottle of Virex II 256 spray that had been used to clean the resident's belongings that could not withstand the heat of the commercial dryer. The Material Safety Data Sheet for Virex II 256 documented uses for bacteria, viruses, veterinary viruses, fungi and yeast. There were no pest or pest control references listed. The product was listed as a disinfectant. At 10:30 a.m., the pest control representative was asked, What is the first step of the process for the bed bugs? He stated, Call us. We come in and do an inspection of the room to identify if it actually is a bed bug. If they do have them, then all the laundry has to be taken and done, all items go through the laundry, the shelves have to be wiped down with a spray to eliminate the bugs, the baseboards and the cracks/crevices all have to be sprayed to eliminate the bugs. All items, anything that can be laundered, such as clothes, linens animals, anything cloth has to be run through the dryers. It is an intense treatment, everything is sprayed. The electrical plates are taken off the wall and sprayed behind, the drawers are sprayed and any personal hard items must be wiped down to eliminate the bugs. He was asked, Can plastic bags placed outside kill the bugs? He stated, Plastic bags can kill the bed bugs. We inspect the items, treat the items and place them in the plastic bags. The bags are not an effective treatment for [REDACTED].? He stated, The first treatment was done on [DATE]. But people can be bit and not realize they are bitten for up to 14 days. He was asked, Were the bags outside treated? He stated, No, that was out there when I got here, the rooms were empty. I sprayed the rooms. He was asked, What rooms did you treat? He stated, room [ROOM NUMBER], 29, 30 and 32. He was asked, Was there any follow-up treatments? He stated, I was only called back to treat room [ROOM NUMBER], the room of the original infestation. Now, room [ROOM NUMBER] was reported to me today, when I got here. He was asked, Were there bugs found in any other rooms? He stated, No, bed bugs were only found in room [ROOM NUMBER]. Rooms 28, 29 and 30 were treated for [REDACTED].? He stated, Spraying and high heat for sustained time will kill the bedbugs. Warmer temperatures (not high heat) exacerbate the multiplication (of the bugs). He also stated, I am waiting on the Housekeeping Supervisor, I have to train her on what to look for and where to look (in identifying an infestation). 7. The facility's Bed Bug Protocol received from the Administrator on [DATE] at 11:05 a.m. documented: .(Bed Bug) bites result in itchy skin reactions and scratching bed bug bites can lead to secondary skin infections. Bed bug infestations may result in psychological distress, disruption of sleep and agitation. Responding to a Bed Bug Incident: If bed bugs are reported or suspected, do the following: 1. Get specimens if possible for professional identification. 2. Arrange for an inspection as soon as possible by a (Pest control company name) representative. 3. Do not move patient to another room until after (pest control company name) has evaluated the situation. 4. Medical equipment, personal items and beds should not be removed from the room until they have been treated. 5. Cooperate fully with the recommendations made by your (pest control company name) representative to prepare rooms for inspection and treatment. Treatment Instructions: 1. Be sure (residents) do not take any personal items out of the rooms. 2. Remove clothing, linens and materials designated for disposal from the infested room in sealed plastic bags to prevent moving bugs to other areas. 3. Wash all linens, curtains, clothing, stuffed animals, etc. in hot water and dry on high heat. Observe washing and drying instructions from manufacturer. Heat is the important part. Do not air dry items. Be Proactive: Implement a bed bug awareness and education program for each of the following sectors: Doctors, nurses, aides and other health or social care providers. Environmental services (housekeeping) and maintenance staff. Admissions and other support staff. Directors and Administrators. Family members of patients/residents in long-term care such as nursing homes or assisted living. All staff should be alert for evidence of bed bugs: Environmental services should do routine inspections for bed bugs as part of daily service to patient rooms. Care givers should listen for reports of bites by patients and visitors, and look for possible bed bug bites on patients. NOTE: (Name of pest control company) can provide an education program for your facility - free of charge. 8. On [DATE] at 11:30 a.m. the Administrator provided a list of room moves in which residents from D Hall were moved to designated rooms on F Hall. The form identified two residents from the D Hall bed bug infestation were moved into rooms on the F and C Hals with other residents on [DATE]. The resident in room [ROOM NUMBER] A on the D Hall was moved to room [ROOM NUMBER] B on the F Hall Room with a resident who was in the A bed. The resident in room [ROOM NUMBER] A on the D Hall was moved to room [ROOM NUMBER] A on the C Hall Room with a resident who was in the B Bed. Moving these resident at this time put the resident who resided in the room in jeopardy of being infested by bed bugs. At 11:30 a.m., the Administrator provided CNA Bath Checklists (body audits) for the list of Resident's who had been moved. Resident #34 had a CNA Bath Checklist dated [DATE] at 3:30 a.m. that contained no documentation of rash or bug bites. Resident #36 had a CNA Bath Checklist dated [DATE] (with no time) that contained no documentation of rash or bites. As of [DATE] at the exit conference on [DATE] at 7:45 p.m. with the facility, the Administrator had provided no further documentation of completed body audits for the other residents involved (Resident #s 35, 37, 38, 39, and 40). 9. On [DATE] at 1:02 p.m. CNA #13 was asked, Can you tell me about the bed bugs. CNA #13 stated, I was one of them (here when the bugs were found). We were getting ready for dinner, got Resident #40 stuff (belongings) all off the bed and floor. I saw the bugs. I told LPN #1 and the Administrator. The Administrator came (to the room) and looked, said to put hair nets on, booties, yellow isolation gowns and gloves and throw everything away. We (CNAs) got everything out and replaced the bed. Bugs were on the furniture and cabinets. There were no bugs on the roommate, only on Resident #40. We gave Resident #40 a shower, (the resident) had bugs on (the residents) hair and body. The next day, staff moved all residents on D Hall, there were only 3 rooms left, all the residents stuff (personal belongings) were bagged (up), washed all the clothes. I was also on (duty) when the residents' personal belongings were brought back in. CNA #13 was asked, Did you receive any training related to bed bugs? CNA #13 stated, No, just saw the bugs. I thought bed bugs were smaller than that. The Administrator told me they were bed bugs. At 1:45 p.m., CNA #1 was asked, Did you see the bed bugs? CNA #1 stated, I didn't see the bugs myself. CNA #1 was asked, Have you had any training in how to identify bed bugs or what to look for? CNA #1 stated, I had no training on what to look for or what they look like. CNA #1 was asked, Can you describe what happened (with the bed bugs)? CNA #1 stated, On Saturday ([DATE]) I was one of the CNAs that bagged up the resident's belongings. (I) didn't do anything to the belongings, (I) put them in 2 bags, double bagged like we do for Biohazard linens and put the bags in the hall. When I went home at 11:00 p.m. that night, the bags were still in the hall, or in one of the rooms, I can't remember, but I know some of the bags were still in the hall. CNA #1 was asked, Have you had any training since that day ([DATE]) on what to look for or how to identify bed bugs? CNA #1 stated, No, I have not. At 1:55 p.m., CNA #14 was asked, Can you tell me about the bed bugs? CNA #14 stated, I'm not sure of the date, but it started during the night. I came in and saw all the residents on D Hall, everybody (all the Residents) was showered and had cream on (the skin) them. The residents were all in gowns. The wheelchair was disinfected, all the (residents) stuff (personal belongings) was bagged and taken out. CNA #14 was asked, What about the laundry? CNA #14 stated, I don't know. I was told to bag all of it and put it on a cart. We used Dial soap on all of the residents and most (of the residents) were moved to F Hall. One (resident) was moved to C Hall. CNA #14 was asked, Did you see the bugs? CNA #14 stated, Yes, I saw the bugs. There were a couple of bugs on (Resident #39). CNA #14 was asked, Can you describe the bugs? CNA #14 stated, They (bugs) are little tiny black bugs, I saw a couple of them, I got them out and flushed them down the drain. I scrubbed the resident's hair really good. CNA #14 was asked, Did you receive any training regarding bed bugs? CNA #14 stated, They (facility) told us to double glove and not get them (the bugs) on our uniform and everything as we go. 10. The Bed Bug Infestation Protocol provided by DON on [DATE] at 11:55 a.m. documented: Managing a bed bug infestation is a difficult task that requires a removal or treatment of [REDACTED]. Treatment Procedures: (Bullet) Infested and infestation-prone bedding and garments will need to be bagged and laundered (120 degrees Fahrenheit minimum) since these items cannot be treated with insecticides. (Bullet) . clothes dryer set at medium heat for ,[DATE] minutes. While dry cleaning procedures also kill bed bugs, there is risk of infesting the establishment when buggy items are de-bagged, tagged and sorted. (Bullet) Items which cannot be put in a washer or dryer can sometimes be de-infested by wrapping in plastic and placing them outdoors in a hot, sunny location, closed vehicle, etc. for at least a day. Monitoring with a thermometer is prudent .(Bullet) . Bed bugs and especially the eggs can be difficult to dislodge.(Bullet) At times it may be necessary to throw out infested items, especially beds and upholstered furniture. (Bullet) . Professionals treat using a variety of low-odor sprays, dusts and aerosols. Application entails treating all areas where the bugs are discovered or tend to crawl or hide. This may take hours of effort and follow-up visits are usually required. (Bullet) Eliminating bed bugs from beds can be challenging. If there are holes or tears in the fabric, the bugs and eggs may be inside, as well as outside. (Bullet) . Encasements will not, however, keep bed bugs from crawling onto a bed and biting a sleeping person. A copy of the Joint Statement on Bed Bug Control in the United States from the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Environmental Protection Agency (EPA) provided by DON on [DATE] at 11:55 a.m. documented, The CDC and the EPA developed this document to highlight emerging public health issues associated with bed bugs in communities throughout the U.S. Impact of Bed Bugs on Public Health: Bed bugs cause a variety of negative physical health, mental health and economic consequences. Many people have a mild to severe allergic reaction to the bites with effects ranging from no reaction to a small bite mark to, in rare cases [MEDICATION NAME] (severe, whole-body reaction. These bites can also lead to secondary infections such as impetigo, ecthyma, and lymphanigitis. Bed bugs may also affect the mental health of people living in infested homes. Reported effects include anxiety, [MEDICAL CONDITION] and systemic reactions. Bed Bug Biology: Bed bugs can travel over 100 feet in one night, but they tend to live within 8 feet of where people sleep. Bed bugs are usually transported from place to place as people travel. Bed bugs travel in seams and folds of luggage, overnight bags, folded clothing, bedding, furniture, and anywhere else they can hide. One of the easiest ways to identify a bed bug infestation is by bite marks that appear on the face, neck, arms, hands and any other body parts. However, these bite marks may take as long as 14 days to develop in some people . When bed bugs bite, they inject an anesthetic and an anticoagulant that prevents a person from feeling the bite. A comprehensive Integrated Pest Management program to control bed bugs may include a number of methods such as: using monitoring devices, removing clutter where bed bugs can hide, applying heat treatment, vacuuming, sealing cracks and crevices to remove hiding places, using non-chemical pesticides and judicious use of effective chemical pesticides . How are bed bugs treated and prevented? . The best way to treat a bite is to avoid scratching the area and apply antiseptic creams or lotions and take an [MEDICATION NAME]. Bed bug infestations are commonly treated by insecticide spraying. Finally, to rid a dwelling of bed bugs for good, every possible hiding place must be cleaned or treated. In a home, that means all clothing, bedding, linens, and other washable fabrics must be laundered, usually repeatedly. Every crevice and seam of mattresses and upholstered furniture must be inspected and treated. Cracks in walls must be sealed, loose wallpaper reattached or removed, and carpets treated and vacuumed. Dresser drawers have to be emptied and cleaned, and all clutter must be removed to limit hiding places for stray bed bugs . 11. On [DATE] at 9:47 a.m. Laundry employee #1 was asked, Do you remember the red and yellow bags of resident's belongings and linen from the bed bug incident? Laundry employee #1 stated, I do. Laundry Employee #1 was asked, What process did you do with those items (in laundry)? Laundry Employee #1 stated, They were washed and dried and put back into resident's rooms and closets. Laundry Employee #1 was asked, Did you do anything different with

Based on observation, record review and interview, the facility failed to ensure necessary care and services were provided to Residents #3, #34, #35, #36, #37, #38, #39, and #40 to prevent the potential for the spread of parasites and to prevent re-infestation of bed bugs. The facility failed to ensure appropriate pest elimination techniques were followed for washing and cleaning to ensure pest were eliminated and to ensure appropriate monitoring was provided to ensure pest were eliminated and prevent complications related to continued infestation of bed bugs for 8 of 8 (Residents #3, #34, #35, #36, #37, #38, #39, and #40) case-mix residents who were observed by staff to have bed bugs on bedding. The facility failed to ensure staff conducted complete body audits on all residents to ensure all residents who were affected by the bed bug infestation were identified and received treatment. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious ham, injury or death to Residents #3, #34, #35, #36, #37, #38, #39, and #40 due to the infestation of beg bugs and had the potential to cause more than minimal harm to 59 residents who resided on C, D, E and F halls as identified by a Census List provided by the Assistant Director of Nurses on [DATE]. The Administrator was informed of the immediate jeopardy [DATE] at 2:22 p.m. The findings are: 1. On [DATE] at 4:36 p.m. during clinical record review, the following information was found in the Nurses Notes of resident (Residents #3, #34, #35, #36, #37, #38, #39, #40) records: a. Resident #40 1) A Nurses Note dated [DATE] at 10:22 p.m. documented, Bed bugs found in resident's bed and clothing and on person. Sheets and clothing bagged up and sent to laundry. New mattress placed on bed. (Physician) notified and N.O. (new order) received to apply [MEDICATION NAME] cream all over in AM (morning) and repeat in one week. (Family members) notified. 2) A Nurses Note dated [DATE] at 12:48 p.m. documented, [MEDICATION NAME] washed off Res. (resident) per Rx (prescription) via shower within 8 - 14 hours following [MEDICATION NAME] application. 3) A Nurses Note dated [DATE] at 6:17 a.m. documented, Staff was doing 2 AM rounds when they found a live bed bug crawling on resident's pillow case placed at resident's back. On call (physician) notified. Resident was showered, hair and body negative for bed bugs. No bites observed on resident during body audit. Belongings in resident's room bagged up and left in room for housekeeping to pick up for laundry. Addendum: Resident moved to room (number) on F Hall. b. Resident #39 1) A Nurses Note dated [DATE] at 2:25 p.m. documented, Bed bugs found in Res. (resident) rm. (room) All belongings bagged and cleaned. (Physician) notified and N.O. (new order) received - [MEDICATION NAME] 5% cream. Apply from the head down and then remove by washing in 8 - 14 hrs. (hours) Repeat in one week. POA (Power of Attorney) notified. 2) A Nurses Note dated [DATE] at 12:47 p.m. documented, [MEDICATION NAME] washed off Res (resident) per RX (prescription) via shower within 8 -14 hours following [MEDICATION NAME] application. c. Resident #35 A Nurses Note dated [DATE] at 2:33 p.m. documented, Bed bugs found in Res. (resident) rm. (room) All belongings bagged and cleaned. (Physician) notified. POA (Power of Attorney) notified. d. Resident #34 1) A Nurses Note dated [DATE] at 2:34 p.m. documented, Bed bugs found in Res. (resident) rm. (room) All belongings bagged and cleaned. (Physician) notified. POA (Power of Attorney) notified. 2) A list provided by the Director of Nurses (DON) on [DATE] at 11:30 a.m., documented the resident had been moved into a room with Resident #32 on [DATE]. e. Resident #36 1) A Nurses Note dated [DATE] at 2:35 p.m. documented, Bed bugs found in Res. (resident) rm. (room). All belongings bagged and cleaned. (Physician) notified and N.O. (new order) received to apply [MEDICATION NAME] 5% cream. Apply from the head down and then remove by washing in 8 - 14 hrs. (hours). Repeat in one week. POA (Power of Attorney) notified. 2) A Nurses Note dated [DATE] at 12:47 p.m. documented: [MEDICATION NAME] washed off Res. (resident) per Rx (prescription) via shower within 8 - 14 hours following [MEDICATION NAME] application. 3) A Nurses Note dated [DATE] at 6:12 a.m. documented, Staff was doing 2 AM rounds when they found a live bed bug crawling on resident's pillow case placed at resident's back. On call (physician) notified. Resident was showered, hair and body negative for bed bugs. No bites observed on resident during body audit. Belongings in resident's room bagged up and left in room for housekeeping to pick up for laundry. Addendum: Resident moved to room (number) on F Hall. A list provided by the DON on [DATE] at 11:30 a.m. documented the resident was moved to a room on F hall where another resident resided. f. Resident #37 A Nurses Note dated [DATE] at 12:47 p.m. documented: [MEDICATION NAME] washed off Res (resident) per RX (prescription) via shower within 8 -14 hours following [MEDICATION NAME] application. g. Resident #38 1) A Nurses Note dated [DATE] at 2:36 p.m. documented, Bed bugs found in Res. (resident) rm (room) All belongings bagged and cleaned. (Physician) notified and N.O. (new order) received - [MEDICATION NAME] 5% cream. Apply from the head down and then remove by washing in 8 - 14 hrs. (hours) Repeat in one week. POA (Power of Attorney) notified. 2) A Nurses Note dated [DATE] at 8:39 p.m. documented, Post ABT (antibiotic) with no ASE (adverse side effects) noted at this time. Temporarily on F Hall d/t (due to) bed bug decontamination of primary rm . 3) A Nurses Note dated [DATE] at 12:45 p.m. documented, [MEDICATION NAME] washed off Res (resident) per RX (prescription) via shower within 8 -14 hours following [MEDICATION NAME] application. h. Resident #3 1) A Nurse Note dated [DATE] at 8:29 p.m. documented, Bed bugs found in Res rm. Res, belongings cleaned and/or bagged to rid of infest. (infestation) Res temporarily on F hall at this time. N.O. received per (physician): [MEDICATION NAME] cream applied from head down and then to be washed 8 - 14 hrs later. To be repeated in one week. 2) A Nurse Note dated [DATE] at 12:47 p.m. documented, [MEDICATION NAME] washed off Res per RX via shower within 8 - 14 hours following [MEDICATION NAME] application. 2. On [DATE] at 10:35 a.m. bags filled with unidentified items were on the ground outside the door of the laundry near the Biohazard closet: 9 red plastic Biohazard bags, 13 yellow plastic Biohazard bags, 3 black plastic bags and 3 white plastic bags. The bags were lying directly on the ground, located next to the fence for the Generator. The Floor Technician and Housekeeper #1 were asked what items were in the bags. Housekeeper #1 stated, The stuff in the bags is resident's belongings. Housekeeper #1 was asked, How long has it been here? Housekeeper #1 stated, Two weeks. Housekeeper #1 was asked, Why are the resident's belongings outside in plastic bags? Housekeeper #1 stated, Bed bugs. The bugs have to have extreme heat for 14 days to kill the bugs. The stuff was put in the plastic bags, put outside in the 90 degree plus heat will kill them (bed bugs). 3. On [DATE] at 10:40 a.m., the Housekeeping Supervisor came around the corner of the laundry where the bags were located on the ground. The Housekeeping Supervisor was asked to explain the bags on the ground. The Housekeeping Supervisor stated, The first initial 14 days is over. The CNAs (Certified Nurses Assistants) brought the items (resident belongings) outside, pest control sprayed inside (the rooms) and after 14 days had elapsed, we had another bed bug (in the same room) noted, so the process started over (on Friday [DATE]). The Housekeeping Supervisor was asked, Is this stuff (the bags of resident items) considered Biohazard? The Housekeeping Supervisor stated, Yes, the clothing belongs to the residents and (the items) can't go back inside until they are free of bed bugs. The Housekeeping Supervisor was asked, What rooms were affected? The Housekeeping Supervisor stated, Resident rooms (Residents #38 and Resident #3), (Resident #39 and Resident #35) and (Resident #34 and #37). The Housekeeping Supervisor was asked, What is the process for bed bugs? The Housekeeping Supervisor stated, Our company has a policy and procedure on bed bugs and that is what we followed. The Housekeeping Supervisor was asked, Where are you at (with the procedure) now? The Housekeeping Supervisor stated, There was only one live bug found (on [DATE]) and the procedure started over on Friday. The Housekeeping Supervisor was asked, How did the resident's belongings get outside in plastic bags on the ground? the Housekeeping Supervisor stated, The CNA's brought the bags out here. We (Laundry) just wash it and hand it back out to the residents. The Housekeeping Supervisor was asked, Will the Biohazard company come and pick up the Biohazard bags that are outside on the ground? The Housekeeping Supervisor stated, That's all items that need to be cleaned/washed and returned to the residents. The Housekeeping Supervisor was asked, Is all of the bags resident belongings? The Housekeeping Supervisor stated, Yes, it is all resident belongings (that need to be returned). The Housekeeping Supervisor was asked, Is that appropriate storage of Biohazard items and resident belongings? The Housekeeping Supervisor stated, No, it is not. 4. On [DATE] at 10:55 a.m., the Administrator was asked about the resident belongings in the Biohazard bags placed on the ground outside of laundry. The Administrator stated, We had bed bugs. We got the pest control involved, and the pest control company told us to put the items outside in plastic bags for ,[DATE] days. The combination of the plastic bag and 90 degree plus heat would effectively kill the bed bugs. I did verbal education with the (weekend) RN. This occurred on the weekend and the CNAs put the resident's belongings in red (biohazard) bags. I don't know why they used red biohazard bags other than the fact that it was bed bugs. I was not happy about them (CNAs) using red bags for personal belongings. The (CNAs) should not have used red bags. The resident's belongings should not have been put in red bags, it was resident's personal belongings. We were waiting the 14 days and then they (items) could be washed and returned, if they were items from the original rooms (on [DATE]). The first outbreak was Friday, 2 weeks ago ([DATE]). Anything in a biohazard bag that has been outside for 14 days could be returned now. The Administrator was asked, Are these (bags) items that have been sprayed? The Administrator stated; No personals (personal clothing) were sprayed. The items went into the plastic bags and the heat from the bags and the 90 degree days would have effectively killed the bugs. 5. On [DATE] at 9:15 a.m., the Administrator was asked, What halls were affected by the bed bugs? The Administrator stated; D Hall was the only hall affected by the bed bugs. The Administrator was asked, How did you identify that only D Hall was affected (by the bed bugs)? The Administrator stated, We noticed the first room at dinnertime (supper) on Friday or Saturday (not sure of the exact day), the weekend RN (Registered Nurse) phoned me and stated we had another room affected, then the CNAs checked all the rooms and there were other rooms affected on D Hall. There were no bugs on any other halls. A facility wide check was done by the CNAs on the hall. That is when the CNAs used the biohazard bags to bag up the resident's belongings. The Administrator was asked, What did you do with the resident's that were affected? The Administrator stated, All (affected) were moved to F Hall. The Administrator was asked, Were these residents moved into rooms with other residents? The Administrator stated, I'm not sure. I know we had empty rooms on F Hall, but possibly (put resident's affected in rooms with non affected residents). The Administrator was asked, Did the pest control company spray on Friday ([DATE]) when staff went to return the resident's belonging and identified another bed bug? The Administrator stated, Yes, (pest control representative) did 2 applications. The Administrator was asked, Why did you only spray 4 of the 7 rooms on D Hall? Why was the whole hall not sprayed? The Administrator stated, We only sprayed the 4 rooms that were affected. That's the only rooms we found bugs in. The Administrator was asked, Where are the resident's belongings from Friday ([DATE]) when the live bed bug was found? The Administrator stated, I'm hoping they (belongings) are in storage. 6. An invoice [DATE] from the pest control company provided by the Administrator on [DATE] at 2:25 p.m. documented resident rooms #28, 29, 30 and 32 were treated for [REDACTED]. The pest control contract provided by the Administrator on [DATE] at 5:25 p.m. documented, Service Agreement: . This agreement shall be in effect from February 2014 and stay in effect until said party notifies (Name of Company). Basic Service; (Company) will provide on a regular monthly service, which includes treating for cockroaches, mice, fleas, ticks, c[DIAGNOSES REDACTED], ants, silverfish, firebrats, millipedes, ground beetles, scorpions, clover mites, box elder bugs, spiders and carpenter bees. All trouble calls will be answered promptly at no additional charge. Date started; [DATE]. There was no documentation regarding bed bugs in the agreement. As of the exit conference on [DATE] at 7:45 p.m., the Administrator had provided no further documentation of pest treatment by the pest control company 7. On [DATE] at 9:24 a.m., Licensed Practical Nurse (LPN) #1 was asked, When did the resident's belongings get returned? LPN #1 stated, All the items (belongings) for residents were brought back in (inside the building) by (name of Social Director) yesterday. 8. On [DATE] at 9:27 a.m., the Social Director was asked, When and why did you bring the residents' items (belongings) back inside the building? The Social Director stated, Yesterday ([DATE]) and this morning ([DATE]). Housekeeping stated the time had expired (for the items to remain outside in the heat) and the Administrator told me I could bring the stuff (resident belongings) back inside (the building). Those were the items that could not be laundered, such as wreaths and knick-knacks that could not be run through the heat of the dryer. We (CNA and Social Director) used a disinfectant spray (Virex II 256) and sprayed the items down and wiped them off before we took them back inside for the residents. The Social Director was asked, Is the spray something that can be used to exterminate bed bugs? The Social Director stated, (The housekeeping Supervisor) would know if the spray can be used for extermination of the bed bugs. I was just using it for disinfectant to clean the residents' items that had been outside for 2 weeks. The Social Director was asked, Is (Virex II 256) spray an appropriate extermination product (for bed bugs)? The Social Director stated, I don't know. The Social Director was asked, Who decided what treatment would be used (for the bed bugs)? The Social Director stated, I would assume it was (the Maintenance Director) and the Administrator. 9. On [DATE] at 9:30 a.m., the Housekeeping Supervisor provided a bottle of Virex II 256 spray that had been used to clean the resident's belongings that could not withstand the heat of the commercial dryer. The Material Safety Data Sheet for Virex II 256 documented uses for bacteria, viruses, veterinary viruses, fungi and yeast. There were no pest or pest control references listed. The product was listed as a disinfectant. 10. On [DATE] at 10:30 a.m., the pest control representative was asked, What is the first step of the process for the bed bugs? He stated, Call us. We come in and do an inspection of the room to identify if it actually is a bed bug. If they do have them, then all the laundry has to be taken and done, all items go through the laundry, the shelves have to be wiped down with a spray to eliminate the bugs, the baseboards and the cracks/crevices all have to be sprayed to eliminate the bugs. All items, anything that can be laundered, such as clothes, linens animals, anything cloth has to be run through the dryers. It is an intense treatment, everything is sprayed. The electrical plates are taken off the wall and sprayed behind, the drawers are sprayed and any personal hard items must be wiped down to eliminate the bugs. He was asked, Can plastic bags placed outside kill the bugs? He stated, Plastic bags can kill the bed bugs. We inspect the items, treat the items and place them in the plastic bags. The bags are not an effective treatment for [REDACTED].? He stated, The first treatment was done on [DATE]. But people can be bit and not realize they are bitten for up to 14 days. He was asked, Were the bags outside treated? He stated, No, that was out there when I got here, the rooms were empty. I sprayed the rooms. He was asked, What rooms did you treat? He stated, room [ROOM NUMBER], 29, 30 and 32. He was asked, Was there any follow-up treatments? He stated, I was only called back to treat room [ROOM NUMBER], the room of the original infestation. Now, room [ROOM NUMBER] was reported to me today, when I got here. He was asked, Were there bugs found in any other rooms? He stated, No, bed bugs were only found in room [ROOM NUMBER]. Rooms 28, 29 and 30 were treated for [REDACTED].? He stated, Spraying and high heat for sustained time will kill the bedbugs. Warmer temperatures (not high heat) exacerbate the multiplication (of the bugs). He also stated, I am waiting on the Housekeeping Supervisor, I have to train her on what to look for and where to look (in identifying an infestation). 11. The facility's Bed Bug Protocol received from the Administrator on [DATE] at 11:05 a.m. documented: .(Bed Bug) bites result in itchy skin reactions and scratching bed bug bites can lead to secondary skin infections. Bed bug infestations may result in psychological distress, disruption of sleep and agitation. Responding to a Bed Bug Incident: If bed bugs are reported or suspected, do the following: 1. Get specimens if possible for professional identification. 2. Arrange for an inspection as soon as possible by a (Pest control company name) representative. 3. Do not move patient to another room until after (pest control company name) has evaluated the situation. 4. Medical equipment, personal items and beds should not be removed from the room until they have been treated. 5. Cooperate fully with the recommendations made by your (pest control company name) representative to prepare rooms for inspection and treatment. Treatment Instructions: 1. Be sure (residents) do not take any personal items out of the rooms . 2. Remove clothing, linens and materials designated for disposal from the infested room in sealed plastic bags to prevent moving bugs to other areas. 3. Wash all linens, curtains, clothing, stuffed animals, etc. in hot water and dry on high heat. Observe washing and drying instructions from manufacturer. Heat is the important part. Do not air dry items. Be Proactive: Implement a bed bug awareness and education program for each of the following sectors: Doctors, nurses, aides and other health or social care providers. Environmental services (housekeeping) and maintenance staff. Admissions and other support staff. Directors and Administrators. Family members of patients/residents in long-term care such as nursing homes or assisted living. All staff should be alert for evidence of bed bugs: Environmental services should do routine inspections for bed bugs as part of daily service to patient rooms. Care givers should listen for reports of bites by patients and visitors, and look for possible bed bug bites on patients. NOTE: (Name of pest control company) can provide an education program for your facility - free of charge. 12. On [DATE] at 11:30 a.m. the Administrator provided a list of room moves in which residents from D Hall were moved to designated rooms on F Hall. The form identified two residents from the D Hall bed bug infestation were moved into rooms on the F and C Hals with other residents on [DATE]. The resident in room [ROOM NUMBER] A on the D Hall was moved to room [ROOM NUMBER] B on the F Hall Room with a resident who was in the A bed. The resident in room [ROOM NUMBER] A on the D Hall was moved to room [ROOM NUMBER] A on the C Hall Room with a resident who was in the B Bed. Moving these residents at this time put the resident who resided in the room in jeopardy of being infested by bed bugs. 13. On [DATE] at 11:30 a.m., the Administrator provided CNA Bath Checklists (body audits) for the list of Resident's who had been moved. Resident #34 had a CNA Bath Checklist dated [DATE] at 3:30 a.m. that contained no documentation of rash or bug bites. Resident #36 had a CNA Bath Checklist dated [DATE] (with no time) that contained no documentation of rash or bites. As of [DATE] at the exit conference on [DATE] at 7:45 p.m. with the facility, the Administrator had provided no further documentation of completed body audits for the other residents involved (Resident #s 35, 37, 38, 39, and 40). 14. On [DATE] at 1:02 p.m. CNA #13 was asked, Can you tell me about the bed bugs. CNA #13 stated, I was one of them (here when the bugs were found). We were getting ready for dinner, got Resident #40 stuff (belongings) all off the bed and floor. I saw the bugs. I told LPN #1 and the Administrator. The Administrator came (to the room) and looked, said to put hair nets on, booties, yellow isolation gowns and gloves and throw everything away. We (CNAs) got everything out and replaced the bed. Bugs were on the furniture and cabinets. There were no bugs on the roommate, only on Resident #40. We gave Resident #40 a shower, (the resident) had bugs on (the residents) hair and body. The next day, staff moved all residents on D Hall, there were only 3 rooms left, all the residents stuff (personal belongings) were bagged (up), washed all the clothes. I was also on (duty) when the residents' personal belongings were brought back in. CNA #13 was asked, Did you receive any training related to bed bugs? CNA #13 stated, No, just saw the bugs. I thought bed bugs were smaller than that. The Administrator told me they were bed bugs. 15. On [DATE] at 1:45 p.m., CNA #1 was asked, Did you see the bed bugs? CNA #1 stated, I didn't see the bugs myself. CNA #1 was asked, Have you had any training in how to identify bed bugs or what to look for? CNA #1 stated, I had no training on what to look for or what they look like. CNA #1 was asked, Can you describe what happened (with the bed bugs)? CNA #1 stated, On Saturday ([DATE]) I was one of the CNAs that bagged up the resident's belongings. (I) didn't do anything to the belongings, (I) put them in 2 bags, double bagged like we do for Biohazard linens and put the bags in the hall. When I went home at 11:00 p.m. that night, the bags were still in the hall, or in one of the rooms, I can't remember, but I know some of the bags were still in the hall. CNA #1 was asked, Have you had any training since that day ([DATE]) on what to look for or how to identify bed bugs? CNA #1 stated, No, I have not. 16. On [DATE] at 1:55 p.m., CNA #14 was asked, Can you tell me about the bed bugs? CNA #14 stated, I'm not sure of the date, but it started during the night. I came in and saw all the residents on D Hall, everybody (all the Residents) was showered and had cream on (the skin) them. The residents were all in gowns. The wheelchair was disinfected, all the (residents) stuff (personal belongings) was bagged and taken out. CNA #14 was asked, What about the laundry? CNA #14 stated, I don't know. I was told to bag all of it and put it on a cart. We used Dial soap on all of the residents and most (of the residents) were moved to F Hall. One (resident) was moved to C Hall. CNA #14 was asked, Did you see the bugs? CNA #14 stated, Yes, I saw the bugs. There were a couple of bugs on (Resident #39). CNA #14 was asked, Can you describe the bugs? CNA #14 stated, They (bugs) are little tiny black bugs, I saw a couple of them, I got them out and flushed them down the drain. I scrubbed the resident's hair really good. CNA #14 was asked, Did you receive any training regarding bed bugs? CNA #14 stated, They (facility) told us to double glove and not get them (the bugs) on our uniform and everything as we go. 17. The Bed Bug Infestation Protocol provided by DON on [DATE] at 11:55 a.m. documented: Managing a bed bug infestation is a difficult task that requires a removal or treatment of [REDACTED]. Treatment Procedures: (Bullet) Infested and infestation-prone bedding and garments will need to be bagged and laundered (120 degrees Fahrenheit minimum) since these items cannot be treated with insecticides. (Bullet) . clothes dryer set at medium heat for ,[DATE] minutes. While dry cleaning procedures also kill bed bugs, there is risk of infesting the establishment when buggy items are de-bagged, tagged and sorted. (Bullet) Items which cannot be put in a washer or dryer can sometimes be de-infested by wrapping in plastic and placing them outdoors in a hot, sunny location, closed vehicle, etc. for at least a day. Monitoring with a thermometer is prudent .(Bullet) . Bed bugs and especially the eggs can be difficult to dislodge.(Bullet) At times it may be necessary to throw out infested items, especially beds and upholstered furniture. (Bullet) . Professionals treat using a variety of low-odor sprays, dusts and aerosols. Application entails treating all areas where the bugs are discovered or tend to crawl or hide. This may take hours of effort and follow-up visits are usually required. (Bullet) Eliminating bed bugs from beds can be challenging. If there are holes or tears in the fabric, the bugs and eggs may be inside, as well as outside . (Bullet) . Encasements will not, however, keep bed bugs from crawling onto a bed and biting a sleeping person. 18. A copy of the Joint Statement on Bed Bug Control in the United States from the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Environmental Protection Agency (EPA) provided by DON on [DATE] at 11:55 a.m. documented, The CDC and the EPA developed this document to highlight emerging public health issues associated with bed bugs in communities throughout the U.S. Impact of Bed Bugs on Public Health: Bed bugs cause a variety of negative physical health, mental health and economic consequences. Many people have a mild to severe allergic reaction to the bites with effects ranging from no reaction to a small bite mark to, in rare cases [MEDICATION NAME] (severe, whole-body reaction. These bites can also lead to secondary infections such as impetigo, ecthyma, and lymphanigitis. Bed bugs may also affect the mental health of people living in infested homes. Reported effects include anxiety, [MEDICAL CONDITION] and systemic reactions . Bed Bug Biology: Bed bugs can travel over 100 feet in one night, but they tend to live within 8 feet of where people sleep. Bed bugs are usually transported from place to place as people travel. Bed bugs travel in seams and folds of luggage, overnight bags, folded clothing, bedding, furniture, and anywhere else they can hide. One of the easiest ways to identify a bed bug infestation is by bite marks that appear on the face, neck, arms, hands and any other body parts. However, these bite marks may take as long as 14 days to develop in some people . When bed bugs bite, they inject an anesthetic and an anticoagulant that prevents a person from feeling the bite. A comprehensive Integrated Pest Management program to control bed bugs may include a number of methods such as: using monitoring devices, removing clutter where bed bugs can hide, applying heat treatment, vacuuming, sealing cracks and crevices to remove hiding places, using non-chemical pesticides and judicious use of effective chemical pesticides . How are bed bugs treated and prevented? . The best way to treat a bite is to avoid scratching the area and apply antiseptic creams or lotions and take an [MEDICATION NAME]. Bed bug infestations are commonly treated by insecticide spraying. Finally, to rid a dwelling of bed bugs for good, every possible hiding place must be cleaned or treated. In a home, that means all clothing, bedding, linens, and other washable fabrics must be laundered, usually repeatedly. Every crevice and seam of mattresses and upholstered furniture must be inspected and treated. Cracks in walls must be sealed, loose wallpaper reattached or removed, and carpets treated and vacuumed. Dresser drawers have to be emptied and cleaned, and all clutter must be removed to limit hiding places for stray bed bugs. 19. On [DATE] at 9:47 a.m. Laundry employee #1 was asked, Do you remember the red and yellow bags of resident's belongings and linen from the bed bug incident? Laundry employee #1 stated, I do. Laundry Employee #1 was asked, What process did you do with those items (in laundry)? Laundry Employee #1 stated, They were washed and dried and put back into resident's rooms and closets. Laundry Employee #1 was asked, Did you do anything different with those items? Laundry Employee #1 stated, No, we used the same wash settings for all the resident's clothes and personals (personal clothing). Laundry Employee #1 was asked, Were there any other chemicals used on these items? Laundry Employee #1 stated, No, just the chemicals that are programmed into the machine. We didn't spray them or anything like that, we just took them out of the plastic bags, put them into the washer and punched the chemical button, then put them into the dryer. After that, they would be folded and put back into the resident's rooms. 20. On [DATE] at 10:45 a.m., CNA #2 was asked, What day did the bed bug incident occur? CNA #2 stated, (I) can't remember the exact day, it was a few weeks ago on Saturday ([DATE]). The evening before, (staff) had found a bug on Resident #40. (The resident) was taken out of (resident's) room, showered, had a treatment cream applied and was placed back into (resident's) room. We have a weekend supervisor. I did my best to avoid the area. I did not want the bugs (on me). CNA #2 was asked, Did anyone check the roommate (for bed bugs)? CNA #2 stated, I don't know. One of the other girls (CNAs) moved the bedside table and could see the bugs. The weekend supervisor and 2 other CNAs went into the room and were taking everything out, bagging it up, and took and tied (the bags) in knots. I said we needed to check everybody else. They checked (Resident #38), check the bed, and the resident told staff (resident's) son had bugs at home. CNA #2 was asked, Did anyone check that out (son)? CNA #2 stated, I don't know. I avoided the hall as much as I could but I did see that they (weekend supervisor) moved (Resident #40) to an empty room on F Hall and the room was sealed, the door knob was removed (to keep everyone out). (Resident #3) was (Resident #40) roommate. (Resident #37) and (Resident #34) were moved too and the rooms were sealed. I was not involved in the room searches. Pest control came and treated those resident rooms. Staff took all the clothes out to laundry on Saturday ([DATE]) and put them in the barrel until they could be washed. The furniture and knick knacks went to biohazard bags outside. Those bags were still out there on Monday ([DATE]) and have been there for 2 weeks. I went home (that evening), stripped on the porch and put all my laundry into the washer and dryer. I took precautions just in case (I h

A. Based on observation, record review and interview, the facility failed to ensure residents who had a [DIAGNOSES REDACTED].#7, #12, #16, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30) of 13 case mix residents who resided on the locked unit. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death for 13 (Residents #7, #12, #16, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30) residents who resided on the locked unit according to the census list provided by the Assistant Director of Nurses (ADON) on 8/24/15. The Administrator was informed of the Immediate Jeopardy on 8/27/15 at 2:09 p.m. The findings are: 1. The Alzheimer's Care Advanced Alzheimer Care Units Admission Criteria/Discharge Criteria for B-hall received from the Alzheimer Unit Director on 8/27/15 at 12:32 p.m. documented the following: Resident must have a primary [DIAGNOSES REDACTED]. The resident must not exhibit behaviors that may result in injury to self or others. Physical abuse, combativeness, continual yelling or screaming that disrupts programming and escalates others, or self-destructive behavior will result in discharge from the unit . At any time, should the resident's medical condition be so acute as to require skilled care for aggressive curative (rather than palliative) treatment, the resident may be transferred into the skilled unit for care . Residents should be mobile, either by independent or assisted ambulation. Use of walkers, gerichairs, canes or 1 person assist for ambulation is permissible . 2. The August 2015 Activity Calendar for the B Hall received from the Alzheimer Unit Director (AUD) on 8/25/15 at 2:38 p.m. documented the following activities for 8/24/15: 9:00 a.m. Current Events 10:00 a.m. Exercise 2:00 p.m. Music 4:00 p.m. Arts and Crafts 7:00 p.m. Pretty Nails On 8/24/15 observations made for B Unit were as follows: a. At 10:12 a.m., there were 3 residents in the day room with the television on. They were not actively watching the television. There were 2 residents in wheelchairs in the hall and 2 residents in the doorway of the day room. None of the residents were actively watching the television program that was currently airing. There were 3 residents in the dining room. The television was the only activity at this time on the unit. There was no activity of Exercise being provided at this time. The residents were moving about in wheelchairs and verbalizing loudly. b. At 10:15 a.m., Resident #24 was in a wheelchair with a tray and wore a back brace. The resident was sitting near the day room but not included in the group near the television. c. At 11:00 a.m., a movie was playing on the television in the day room. Four residents were in the day room but not actively watching the movie, which was a comedy. Two residents were in the dining room, one with coffee. A housekeeper was the only staff present at this time in the area. d. At 12:30 p.m., residents were gathered in the dining room for the noon meal. Resident #28 was at a table and was calling out loudly and repetitively. e. At 3:30 p.m., there was no activity provided. Residents were moving about in wheelchairs and verbalizing loudly. Resident #29 was agitated and repeatedly stated he wanted out. Certified Nurse Assistant (CNA) #4 was in the hallway. CNA #4 stated, He gets worse as the day goes on. Sundowners. He'll be better when his family comes in. CNA #4 did not go to the resident or try to calm him in any way. 3. The August 2015 Activity Calendar for the B Hall received from the Alzheimer Unit Director (AUD) on 8/25/15 at 2:38 p.m. documented the following activities for 8/25/15: 9:00 a.m. Current Events 10:00 a.m. Exercise 2:00 p.m. Music 4:00 p.m. Let's Paint 7:00 p.m. Healing Touch On 8/25/15 observations made for B Unit were as follows: a. At 8:46 a.m., the television was on in the day room. There were 4 residents in the area that were not watching the television. Resident #22 had a yellow substance food spill on her top and lap. Multiple crumbs covered the wheelchair foot pedal cover. b. At 9:02 a.m., Resident #22 remained in the day area with the food spills on her clothing. Music was playing on the television. Four other residents were in the day room. Resident #26 ambulated out of the day room and down the hall. Resident #7 sat in a reclined wheelchair in the day area and three flies landed on the resident and crawled on her clothing. No active listening/participation in the music was observed. No staff was present to assist or encourage residents with the music activity. c. At 9:12 a.m., CNA #4, CNA #5 and the Alzheimer's Unit Director (AUD) were in the room of Resident #28 related to a fall leaving no staff to monitor the residents in the day room/dining room/hallway. d. At 9: 20 a.m., no staff was present in the day room or dining room areas to monitor the residents. e. At 9:32 a.m., there was no activity provided. The music program on the television was no longer playing. Resident #22 remained with the same food spills on her clothing. f. At 9:35 a.m., Resident #29 was at the locked door yelling, President of the United States! Help! They won't let me go where I want to go! No staff was present. g. At 9:41 a.m., the facility cosmetologist was present. Four residents were near the locked door. Resident #12 sat at a dining room table and Resident #24 sat in the dining room near Resident #12. The residents in the day area/hall were verbalizing loudly. h. At 9:43 a.m., the AUD entered the hall. The cosmetologist stated that Resident #29 liked to play the piano. The AUD left the unit and returned with a keyboard and placed it on a dining room table. The Housekeeping Supervisor was talking with Resident #25. A few residents were assisted to the dining room and Resident #29 played the keyboard briefly and then moved away. Resident #26 ambulated into the hall and then the dining room. She had multiple food spills on her pants from the upper left front side down the left side to the knee. i. At 9:49 a.m., the AUD provided fluids/cool aid to some of the residents present in the dining room and the adjoining hall and day room. CNA #4 removed Resident #24 from the area to her room. There was an odor of feces coming from the resident. j. At 9:53 a.m., the cosmetologist attempted to get Resident #25 to drink the red cool aid. Resident #25 was crying out for her children and threw the fluids at the cosmetologist and cried out, My children! Take me home to my children! The AUD came to Resident #25 and attempted to calm the resident. The AUD or other staff did not offer fluids to all the residents present. Resident #7 was in the day room and facing the television that was not turned on. Resident #29 was at the locked door kicking it with his feet. Many of the residents were loudly verbalizing, yelling and many were moving about. k. At 9:56 a.m., the cosmetologist performed nail care for Resident #27 in the dining room. Resident #25 stated, I want to go home. Resident #25 attempted to get out of the exit door. CNA #4 came to the resident and talked softly to her. Licensed Practical Nurse (LPN) #4 arrived at 10:00 a.m. Resident #25 stated, I want help to get out of this place! LPN #4 talked softly to the resident about her family. The resident was crying and calling out her daughter's name. Resident #24 was returned to the day area from her room by CNA #5, the wheelchair tray was in place. Her name was written in large black print letters across the back shoulder area of the clothing she was wearing. There was a hole in the left sleeve cuff and a smaller hole on the right cuff. l. At 10:07 a.m., CNA #5 talked to Resident #25 who calmed briefly and when the CNA told the resident of need to change pants (from the cool aid spill), the resident stated, No. CNA #5 stated, You're wet. Resident #25 stated, They'll dry. CNA #5 obtained a moistened paper towel to wash her face. m. At 10:10 a.m., CNA #5 asked Resident #22 if she wanted to go to the bathroom. CNA #5 then left the resident to move a shower chair. CNA #4 took the resident to her room. n. At 11:17 a.m., Resident #22 continued with the same shirt with food spills. Music was playing in the day room. CNA #5 was asked, What do you do when not giving care. CNA #5 stated, I give care. Talk to them. TV, radio. It gets a little loud some days. My partner (CNA #4) is at lunch now. CNA #5 did not have assistance on the unit. o. At 2:17 p.m., there was no activity provided on the unit. Multiple residents were moving about in wheelchairs. Resident #27 rolled her wheelchair into the day room over Resident #21's right foot/toe, who was sitting in a chair on the left just inside the door. Resident #21 cried out in pain. Resident #27 stated loudly, What're you hollering for? CNA #4 came from the dining room to check on the resident. CNA #4 went out of the hall to inform the nurse. Resident #26 continued with the same pants on with spills/stains. LPN #3 assessed Resident #21 where the resident sat in the day room. The multiple residents in the area were vocally loud. p. At 2:32 p.m., the AUD was asked for a copy of the activity calendar for the units. There was no calendar posted on the B unit. The AUD stated, I can get you a copy from the A hall. When asked about the B hall calendar, the AUD stated, It's not posted but I can get you a copy. When asked who does activities on the units, the AUD stated, Aides. When asked if any one person was assigned, the AUD stated, No. I'm back and forth. q. At 4:21 p.m., Resident #26 continued with the same pants with food spills/stains. 4. The August 2015 Activity Calendar for 8/26/15 received from the Alzheimer Unit Director (AUD) on 8/25/15 at 2:38 p.m. documented the following: 9:00 a.m. Current Events 10:00 a.m. Exercise 2:00 p.m. Music 4:00 p.m. Craft corner 7:00 p.m. Pretty nails On 8/26/15 observations made for B Unit were as follows: a. At 8:08 a.m., CNA #5 was feeding Resident #12. LPN #4 was at a medication cart parked between the dining room and day room. CNA #6 was serving drinks to residents in the dining room. Resident #16 was in the day room lying on the couch. The television was on. He was not watching the television. b. At 8:10 a.m., Resident #27 requested coffee. CNA #6 asked if she wanted water or cool aid. Resident #27 stated, I want coffee. CNA #6 stated, We ran out of coffee. We will get more when we take the cart back. Resident #27 was given an 8 ounce cup of water. c. At 8:35 a.m., Resident #22 was in a wheelchair with milk-like food spills on her top and lap and a piece of bread measuring approximately 3 inches long and one inch wide. At 8:38 a.m., CNA #6 removed the piece of bread from the resident's lap. The television was on in the day room. Three residents were in the day room. One was watching the news/weather on the television by standing in front of the television. CNA #6 stated that Resident #27 had already had 2 cups of coffee this morning. The nurse said not to give too much. It makes her blood pressure go up. After I gave her the water she didn't ask anymore. d. On 8/26/15 at 8:42 a.m., CNA #5 was asked how many staff were on the B hall and stated, Only me and another aide. At this time both CNAs were in Resident #7's room to do a 2 person gait belt transfer, there was no staff on the hall to monitor the other residents. CNA #5 stated, She (AUD) wants us to do activities. I can't do it all with what I've got to do. It was bad yesterday, noisy. When I got home, I just blew up. e. At 9:26 a.m., multiple residents sat in the day room and near the day room door. The AUD entered the hall and asked Resident #28 if she liked sports. Resident #28 said she did not, very loudly and continued to talk loudly. The AUD then asked Resident #29 if he liked sports - baseball and began talking to the resident. Resident #22 continued to sit in a wheelchair near the day room with the same milky food spills on her shirt and lap. 5. On 8/27/15 observations made for B Unit were as follows: a. At 12:35 p.m., Resident #30 sat in the dining room at a table with head down and not eating. CNA #4 attempted to wake the resident one time by shaking the resident ' s shoulder and speaking to the resident. The resident's shirt was pulled up exposing the right side of the abdomen and around to the back. Without any further interaction with the resident, CNA #4 then continued to serve other residents food. b. At 12:36 p.m., the AUD entered the unit, gave the surveyor a copied form of the Initial Activity Assessment (undated) for Resident #7 and left the unit immediately. c. At 12:38 p.m., Resident #24 was sucking and biting on her shirt by lifting the shirt and tearing pieces of cloth off with her teeth and spitting it out. She rolled the pieces in her left hand. This was not observed by the 2 CNAs who were serving lunch. Resident #24 pulled up her top exposing her breasts and bit the material 2 times, still not observed by the staff. d. At 12:40 p.m., a family member of another resident assisted Resident #22 with a juice spill at the table. The CNAs continued to serve lunch. e. At 12:42 p.m., Resident #26 ambulated from the day room to the dining room. She had a large wet area covering her entire buttock area. She stated, It got wet and pulled at the pants. CNA #5 took the resident to her room with a bag of peri-care supplies, leaving one CNA in the dining room. f. At 12:44 p.m., the AUD was present on the unit. She placed a clothing protector on Resident #24 and began to feed the resident. g. At 12:46 p.m., Resident #30 began to eat without assistance. The resident's shirt was still pulled up exposing parts of the resident's abdomen, right side and back. h. On 8/27/15 at 12:50 p.m., a supply closet located to the left of the television in the day room had the key in the door knob. The door was not locked and opened easily. The supply closet contained activity supplies and personal hygiene products. It also contained 2 bottles of nail polish and one safety razor in an open box on the top right shelf. A shelf along the back of the wall contained a box approximately 3/4 full of wooden manicure sticks, eleven safety razors and a one quart spray bottle almost full of cleaner with bleach. CNA #6 was assisting residents in the dining room. CNA #5 had taken Resident #26 to her room to change her clothing. No other staff was present. i. At 12:55 p.m., Resident #29 cried out, I need to go bad! He sat in a wheelchair in the hall. A family member pushed the resident in the wheelchair to his room and stated, Wait til (CNA #4) gets back. The resident stated, Hurry up. I'm going to mess my pants. j. At 12:57 p.m., the AUD brought a sit to stand mechanical lift to the unit. She instructed CNA #4 to get Resident #29 up and the AUD left the unit. With CNA #4 in a resident's room and the AUD absent from the unit, CNA #5 was the only staff left on the hall. There was one family member present. LPN #1 was present and feeding a resident in the dining room. k. At 1:00 p.m., the AUD brought the sling for the sit to stand lift to Resident #29's room. l. At 1:50 p.m., the majority of the residents who resided on the unit were in the day room/hall. There was no activity provided. There was no nursing staff on the hall. The 2 CNAs assigned to the hall were in Resident #28's room assisting the resident. A housekeeper was mopping the dining room floor. Resident #26 ambulated into the dining room and walked on the wet floor in socks. The housekeeper stopped mopping. The housekeeper and the surveyor assisted the resident from the dining room area. 6. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/16/15 documented the resident scored 0 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), sometimes made self-understood, was inattentive, had disorganized thinking and psychomotor retardation, had minimal depression, required extensive assistance for bed mobility, transfer, locomotion, dressing, eating, toilet use, personal hygiene and bathing and was always incontinent of bladder and bowel. a. The Care Plan dated 3/11/15 documented, Problem .I have a life long history of depression .Approaches .1:1 visits with me. Allow me opportunities to make choices regarding my schedule. Observe me for changes in my mood status. Evaluate for environmental changes to enhance my mood. Allow me to select seating at activities and in dining room .Monitor me for suicidal ideation .Visit with me and discuss my interests, past social patterns in community. Record/monitor me for patterns of target behaviors. Provide opportunities for me for increased socialization with others on my unit and during mealtimes. Provide opportunities for me to correspond with others outside of facility via writing letters, sending emails, or making telephone calls. Problem .I am at risks for falls .Approaches .Assist with ADLs (activities of daily living) as needed but encourage resident to do as much for self as possible and allow them plenty of time without feeling rushed .Set up hygiene supplies and encourage Resident to do as much as possible for self but always assist as needed . Problem .I wander into unsafe situations .Approaches .Place me in area where frequent observation is possible. Alert staff to my wandering behavior. Provide diversional activities for me .If I wander away from unit, instruct staff to stay with me, converse and gently persuade me to walk back to designated area with them. Note which exits I favor for elopement from facility. Alert staff working near those areas. Monitor and document my behavior . b. The Closet Care Plan dated 3/18/15 documented, Restraints: lap belt, pressure alarm, bolster mattress .bed mobility: assist of 1 or 2 .splints (right) hip fx (fracture), ambulation/mobility: assist of 1 or 2 gait belt .Toileting: incontinent, briefs .shower .low bed .toilet Q (every) 4 (hours) at night . c. Documentation in the area of Behavior Observations on the August 2015 ADL Sheet included one check mark on 8/4/15 at 10:30 p.m. All other dates and shift were either blank or had a zero documented. 8/24/15 through 8/29/15 documented, O for each shift. d. A monthly summary Nurses Note dated 8/5/15 documented, .admitted to this facility in December 2010 . Transfers with 2 person gait belt staff assisting into wheelchair and is pushed about by staff. 1 person extensive assistance needed with ADLs (Activities of Daily Living) such as dressing, bathing, oral care, and incontinent care. Showers and shampoos given 3 X's weekly .Oral care provided after each meal, HS (bedtime), and PRN (as needed) .Alert and oriented to name only with short and long term memory loss noted due to Alzheimers. Pleasant and cooperative with staff and others. No s/s (signs/symptoms) of depression noted at present .Incontinent of bowel and bladder and is checked often with good pericare provided PRN .feeds self with tray set up . e. On 8/24/15 at 6:35 a.m., the resident was in a low to the floor, high-backed wheelchair in the dining room. CNA #7 stated, this was an Alzheimer's unit for end-stage moderate to severe. f. On 8/26/15 at 8:42 a.m., CNA #5 and CNA #6 pushed the resident in the wheelchair to her room. CNA #6 stated, We call the wheelchair a low rider. CNA #5 gathered supplies and returned to the resident ' s room at 8:45 a.m. with a shower chair. CNA #5 pushed the resident from the B hall to the F hall shower room. CNA #5 stated, Can't use B hall (shower). When the CNA sprayed water on the resident in the shower, Resident #7 cried out, Its wet! Its wet! Get off! The CNA talked calmly to the resident and decided not to wash the resident's hair. The CNA stated the resident normally did not act like that in the shower. 7. Resident #12 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 6/23/15 documented the resident scored 0 (0 - 7 indicates severe impairment) on the BIMS, was inattentive, had disorganized thinking and altered level of consciousness, required supervision only for eating, required extensive assistance in bed mobility, transfer, locomotion, dressing, toileting and personal hygiene, was totally dependent for bathing and was always incontinent of bladder and bowel. a. The Care Plan dated 7/14/14 documented, Problem/Need .I need max (maximum) assistance with my ADL's .I need you to assist me with my ADLs but continue to encourage me to be independent as much as possible .I need you to set up my hygiene supplies and encourage me to do as much as possible for myself but always assist as needed .I need assistance with meals; encourage me to try to feed myself and document how much I eat. I must be fed by staff, take your time please and record how much I eat. I require the use of a mechanical lift and 2 staff for all transfers .Problem/Need .Activities: Resident participates in group programming of interest with reminders and encouragement at times .Approaches .Offer opportunities for success and praise as often as possible. Encourage resident to socialize with other resident and staff. Give resident verbal reminders of activity before commencement of activity and assist as needed. Offer activity programs directed toward specific interests of resident. Engage resident in group activities of interest and capabilities such as music, spiritual, exercise, social functions, cooking, folding, trivia, bingo, word games, etc .Problem/Need .I wander into unsafe situations .Approaches .Provide diversional activities for me . b. The Closet Care Plan (undated) documented, Bed mobility assist of 1 .Ambulation/mobility .assist of 1, wheelchair, lift to chair, Eating .cueing, set-up, Toileting .incontinent, briefs .toilet every 2 hours, fed at meals . c. The August 2015 CNA ADL sheet documented, Behavior observations. All shifts documented a zero or were blank except 8/16/15 at 10:30 p.m. documented, N. There was no legend on the form that documented what N meant. d. On 8/24/15 at 10:00 a.m., CNA #8 and CNA #9 entered the resident room to transfer the resident using a sit to stand mechanical lift. The sit to stand lift base where a resident would stand was covered in crumbs and debris. While the CNAs were in the resident ' s room, there was no staff present on the hall monitoring the other residents. 8. Resident #23 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 6/23/15 documented the resident had a BIMS score of 0 (0 - 7 indicates severe impairment), required extensive assistance for ADLs and was mobile in a wheelchair. a. The Care Plan dated 10/13/14 documented, Problem/Need .I am at risk for bleeding secondary to the use of anticoagulant therapy .Approaches .Observe me for s/s of bleeding and report to MD (medical doctor). (Bleeding gums, Hematuria, joint pain, swelling, epistaxis, increased bruising, abdominal pain, tarry stools . Problem/need .I have poor safety awareness .Approaches .Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician . Problem/need .I wander into unsafe situations .Approaches .Place me in area where frequent observation is possible. Alert staff to my wandering behavior. Provide diversional activities for me. Approach me positively and in calm, accepting manner . b. On 8/29/15 at 9:55 a.m., a review of the resident Incident and Accident Report for June, July and August 2015 documented the following: 1) A Resident Incident Report dated 7/28/15 at 4:30 p.m. documented, CNA (name) came to this nurse and stated that while resident was agitated she witnessed her grab another resident's left wrist. No injury. Immediate Actions Taken: Resident's were already separated. Assessed for injuries. (Physician) and family notified. 2) A Resident Incident Report dated 8/17/15 at 12;30 a.m. documented, CNA (name) notified this nurse that she discovered a skin tear with a red ring measuring approximately 2 cm (centimeters) x (by) 2 cm around the wound. Skin tear to left forearm measuring approximately 1 cm x 0.25 cm with red ring measuring approximately 2 cm x 2 cm surrounding it. Wound site is cool to the touch with no c/o (complaint of) pain voiced. Immediate Actions Taken: Wound site cleaned and patted dry 3) A Resident Incident Report dated 8/18/15 at 2:16 p.m. documented, This resident sitting in hallway in w/c (wheelchair) Another resident pushed Hoyer lift into this resident. (Injuries) none. Immediate Actions Taken: Assessed resident for injury, removed Hoyer lift from hall 9. Resident #28 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 8/4/15 documented the resident scored 0 (0 - 7 indicates severely impaired) on the BIMS, was inattentive, had delirium and an altered level of consciousness, was totally dependent for ADLs, was always incontinent of bladder and bowel and used a wheelchair. a. The Care Plan dated 12/19/13 documented, Problem/need .I display socially inappropriate/disruptive behavior .Approaches .Monitor and document my behavior. Do not argue with me. Praise me for demonstrating desired behavior. Administer my behavior medications as ordered by physician. Talk with me in calm voice when my behavior is disruptive. Remove me from public area when behavior is disruptive and unacceptable Problem/need .I am at risk for falls .Approaches .12/2/14 I require a Marissa lift (with) 2 staff assist for all transfers . Problem/need .I wander into unsafe situations .Approaches .Place me in area where frequent observation is possible. Alert staff to my wandering behavior. Provide diversional activities for me. Approach me positively and in calm, accepting manner . b. On 8/29/15 at 10:23 a.m., a review of the resident Incident and Accident Report for June, July and August 2015 documented the following: 1) A Resident Incident Report dated 6/26/15 at 10:42 a.m. documented, Reported by (name) Resident found to have small abrasion to LLE (left lower extremity) 3 cm abrasion to LLE Immediate Actions Taken: First aid to LLE. Immediate Post-incident action: Resident to wear long pants while up in wheelchair to prevent scraping of skin. 2) A Resident Incident Report dated 7/21/15 at 3:00 p.m. documented, CNA came to this nurse and stated resident was in the floor beside her bed and her left arm was caught in the bed rail. No injuries. Immediate actions taken: Assessed for injuries. CNAs lifted resident from floor (with) lift and placed in wheelchair. Neuro check initiated. (Physician), Supervisor, and family notified. Immediate Post-Incident Action: An alarm will be clipped on her gown while she is in bed. 3) A Resident Incident Report Dated 8/25/15 at 9:15 a.m. documented, CNAs were transferring resident with Hoyer had resident in lift. Lift malfunctioned lowering to floor. No injuries noted. Immediate Actions taken: Resident immediately assessed for injury then returned to bed. Notified (Physician) and (name) responsible party notified. Lift was removed by maintenance and repaired. Immediate Post-Incident Action: Maintenance notified. Lift removed from use and repaired. Staff then re-educated on use of the lift. 10. Resident #29 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 8/19/15 documented the resident scored 0 (0 -7 indicates severe impairment) on the BIMS, had disorganized thinking, required extensive assistance in ADLs, used a wheelchair, and was frequently incontinent of bladder and bowel. a. The Care Plan undated documented, Problem onset date: 8/25/15 I require extensive assist x 1 staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing and require extensive assist x 1 staff locomotion . Approaches .Please assist me to specific areas when I am up in my w/c such as activities, therapy, dining room, and my room . b. On 8/29/15 at 10:27 a.m., a review of the resident Incident and Accident Report for June, July and August 2015 documented the following: An Incident Report dated 8/12/15 at 8:00 p.m. documented, Resident in room was reaching to grab something off low bed in room when he slid out of wheelchair onto hands and knees. No s/s (signs/symptoms) of injuries noted at this x. ROM (range of motion) WNL (within normal limits) to all extremities for this resident. Immediate Actions taken: Assessed for injuries no s/s of injuries noted at this (was documented). Assisted back into wheelchair x 2 staff then prepared and assisted into bed. Immediate Post-Incident Action: Low bed removed from resident's room. 11. Resident #22 had [DIAGNOSES REDACTED]. The 5 day admission MDS with an ARD of 6/17/15 documented the resident scored 0 (0 - 7 indicates severely impaired) on the BIMS, had inattention and disorganized thinking, had delusions, required extensive assistance for ADLs, used a wheelchair, and was frequently incontinent of bladder and bowel. a. The undated Care Plan documented, Problem Onset: 8/25/2015 I have a skin tear/laceration .Approaches .I need a mechanical lift to avoid further skin tears . Problem onset 8/25/2015 I am experiencing the presence of pain in my fractured finger .Approaches: Administer my pain medication as ordered. Assist me with diversional activities. Assist me to change positions slowly as needed. Observe for worsening of my pain symptoms such as: discomfort, soreness, tightness, stiffness, fatigue, sleeplessness, stress, anxiety and report to physician. Dressing as ordered to hand . Problem Onset 08/25/15 I require extensive assist (assistance) x 2 staff with bed mobility, transfers, dressing, toileting, personal hygiene and bathing and required extensive assist x 1 staff with locomotion .Approaches .Please assist me to specific areas when I am up in w/c such as activities, therapy, dining room and my room . b. On 8/29/15 at 10:13 a.m., a review of the resident Incident and Accident Report for June, July and August 2015 documented the following: 1) An Incident Report dated 6/6/15 at 8:00 p.m. documented, Resident sitting in a hall dining room when she stood self up out of dining room chair took one step, lost balance, and fell to knees. No s/s of injuries noted at this x but resident is complaining of right knee pain. Placed call to (physician) with new order received: on-site imaging to do X-ray of right knee due to fall. Immediate actions taken: Assessed resident for injuries found zero s/s of injuries noted at this x. Checked ROM with resident complaining when this nurse touched right knee, assisted into chair x 2 staff, called (physician) and X-ray order. Immediate Post-Incident Action: Resident to be assisted to the restroom Q (every) 2 hours and PRN and before and after meals. Interventions: CNA instructed to keep resident in view, do not leave alone in the w/c room. A Final Radiology Report dated 6/7/15 documented, Right hip pain post fall .Findings: Non-displaced intertrochanteric fracture prox

Based on observation, record review and interview, the facility failed to ensure sufficient qualified nursing staff were available on a daily basis to meet residents' needs as evidenced by failure to ensure that staff were deployed so that all residents in the main dining room were assisted with meals to ensure the nutritional needs of the residents were being for 1 (Resident #13) of 4 (Resident #s 4, 8, 12, and 13) case mix residents who needed assistance to eat. The facility failed to ensure staff was deployed on the B hall secure unit so that activities were provided to enhance the residents lives and adequate supervision was provided to prevent potential injuries and accidents for 13 (Residents #7, #12, #16, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30) of 13 case mix residents who resided on the locked unit. The failure to ensure adequate staff on B Hall to supervise residents to prevent accidents resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death for 13 (Residents #7, #12, #16, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30) residents who resided on the locked unit according to the census list provided by the Assistant Director of Nurses (ADON) on 8/24/15. The Administrator was informed of the Immediate Jeopardy on 8/27/15 at 2:09 p.m. The failure to ensure staff was deployed to assist residents to eat in the main dining room had the potential to cause more than minimal harm for 66 residents who required assistance with meals as identified by a list provided by the Administrator on 8/29/15. The findings are: 1. Resident #13 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/4/15 documented the resident scored 4 (0 - 7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), required limited assistance of one person for assistance with eating, had a weight of 84 pounds and received a mechanically altered diet. a. A physician order [REDACTED]. b. The undated Care Plan documented, Problem Onset: 05/28/2015 I am at nutritional risk and below my ideal body weight . Goal . Promote my nutritional intake necessary to maintain or improve current weight . Approaches . Staff to assist me with tray set-up and observe for needed assistance during meal prn (as needed) . Problem . I am at risk for pressure ulcers . Encourage my good nutritional intake . Problem . I need mod to max (moderate to maximum) assistance with my activities of daily living . Approaches . I can usually feed myself at meals; monitor and assist me as needed . c. The facility's Weight Change Comparison for May - July 2015 provided by the Social Director on 8/28/15 at 3:26 p.m., documented the following weights: 1) 5/5/15 - 83.8 2) 5/28/15 - 76.2 3) 6/8/15 - 80 4) 7/7/15 - 83 On 8/25/15 at 11:30 a.m., the resident's electronic clinical record documented the August, 2015 weight of 81. d. On 8/24/15 at 12:35 p.m., the resident sat at a table in the main dining room and was served her meal. Resident #42 sat on the resident's left and Resident #43 sat on the resident's right. At 1:14 p.m., the resident sat with a spoon in her right hand. She had made no attempt to eat. She laid the spoon down at 1:15 p.m. The Activity Director assisted and fed Resident #42. When Resident #42 completed her meal, the Activity Director then assisted Resident #43. At 1:20 p.m., the Activity Director offered Resident #43 a magazine as she sat at the dining room table. The Activity Director did not speak to Resident #13. She asked Resident #43 if she was done eating. At 1:21 p.m., Resident #13 lifted a cup of lemon-aid and drank a sip. At 1:22 p.m., the Activity Director continued to sit with Resident #43 and offered her ice cream. At 1:29 p.m., Certified Nurse Assistant (CNA) #22 stopped by the table and asked Resident #13, Are you not eating? Let me get a chair. CNA #22 gave the resident a bite of potatoes. Resident #13 stated, It's dry and cold. CNA #22 stated, I'll get fresh warm potatoes with butter. At 1:35 p.m., a bowel of buttered mashed potatoes was brought to the resident. CNA #22 fed the resident a bite of potatoes. CNA #22 asked if that was better. Resident #13 shook head to indicate yes. Pureed roll, green beans, ham, dessert and potatoes with gravy were on the resident's tray with a red napkin. At 1:42 p.m., CNA #22 was told by CNA #2 to go to the hall. CNA #22 left the dining room. CNA #13 immediately came to the resident and said, Are you done? She removed the resident's clothing protector and pushed the resident from the dining room. The resident ate 4 bites of the potatoes during the time she was being assisted with the meal by CNA #22. On 8/28/15 at 2:36 p.m., Dietary Employee #2 was asked what the red napkin on resident's tray was for. Dietary Employee #2 stated, Red napkin means fortified foods on trays. e. On 8/24/15 at 5:40 p.m., the resident sat at the dining room table with her supper meal and slowly fed herself. At 6:20 p.m., the Activity Director came to the resident to assist her to eat. The August 2015 Activity Calendar for the B Hall received from the Alzheimer Unit Director (AUD) on 8/25/15 at 2:38 p.m. documented the following activities for 8/24/15: 9:00 a.m. Current Events 10:00 a.m. Exercise 2:00 p.m. Music 4:00 p.m. Arts and Crafts 7:00 p.m. Pretty Nails 2. On 8/24/15 observations made for B Unit were as follows: a. At 10:12 a.m., there were 3 residents in the day room with the television on. They were not actively watching the television. There were 2 residents in wheelchairs in the hall and 2 residents in the doorway of the day room. None of the residents were actively watching the television program that was currently airing. There were 3 residents in the dining room. The television was the only activity at this time on the unit. There was no activity of Exercise being provided at this time. The residents were moving about in wheelchairs and verbalizing loudly. b. At 10:15 a.m., Resident #24 was in a wheelchair with a tray and wore a back brace. The resident was sitting near the day room but not included in the group near the television. c. At 11:00 a.m., a movie was playing on the television in the day room. Four residents were in the day room but not actively watching the movie, which was a comedy. Two residents were in the dining room, one with coffee. A housekeeper was the only staff present at this time in the area. d. At 12:30 p.m., residents were gathered in the dining room for the noon meal. Resident #28 was at a table and was calling out loudly and repetitively. e. At 3:30 p.m., there was no activity provided. Residents were moving about in wheelchairs and verbalizing loudly. Resident #29 was agitated and repeatedly stated he wanted out. Certified Nurse Assistant (CNA) #4 was in the hallway. CNA #4 stated, He gets worse as the day goes on. Sundowners. He'll be better when his family comes in. CNA #4 did not go to the resident or try to calm him in any way. 3. The August 2015 Activity Calendar for the B Hall received from the Alzheimer Unit Director (AUD) on 8/25/15 at 2:38 p.m. documented the following activities for 8/25/15: 9:00 a.m. Current Events 10:00 a.m. Exercise 2:00 p.m. Music 4:00 p.m. Let's Paint 7:00 p.m. Healing Touch On 8/25/15 observations made for B Unit were as follows: a. At 8:46 a.m., the television was on in the day room. There were 4 residents in the area that were not watching the television. Resident #22 had a yellow substance food spill on her top and lap. Multiple crumbs covered the wheelchair foot pedal cover. b. At 9:02 a.m., Resident #22 remained in the day area with the food spills on her clothing. Music was playing on the television. Four other residents were in the day room. Resident #26 ambulated out of the day room and down the hall. Resident #7 sat in a reclined wheelchair in the day area and three flies landed on the resident and crawled on her clothing. No active listening/participation in the music was observed. No staff was present to assist or encourage residents with the music activity. c. At 9:12 a.m., CNA #4, CNA #5 and the Alzheimer's Unit Director (AUD) were in the room of Resident #28 related to a fall leaving no staff to monitor the residents in the day room/dining room/hallway. d. At 9: 20 a.m., no staff was present in the day room or dining room areas to monitor the residents. e. At 9:32 a.m., there was no activity provided. The music program on the television was no longer playing. Resident #22 remained with the same food spills on her clothing. f. At 9:35 a.m., Resident #29 was at the locked door yelling, President of the United States! Help! They won't let me go where I want to go! No staff was present. g. At 9:41 a.m., the facility cosmetologist was present. Four residents were near the locked door. Resident #12 sat at a dining room table and Resident #24 sat in the dining room near Resident #12. The residents in the day area/hall were verbalizing loudly. h. At 9:43 a.m., the AUD entered the hall. The cosmetologist stated that Resident #29 liked to play the piano. The AUD left the unit and returned with a keyboard and placed it on a dining room table. The Housekeeping Supervisor was talking with Resident #25. A few residents were assisted to the dining room and Resident #29 played the keyboard briefly and then moved away. Resident #26 ambulated into the hall and then the dining room. She had multiple food spills on her pants from the upper left front side down the left side to the knee. i. At 9:49 a.m., the AUD provided fluids/cool aid to some of the residents present in the dining room and the adjoining hall and day room. CNA #4 removed Resident #24 from the area to her room. There was an odor of feces coming from the resident. j. At 9:53 a.m., the cosmetologist attempted to get Resident #25 to drink the red cool aid. Resident #25 was crying out for her children and threw the fluids at the cosmetologist and cried out, My children! Take me home to my children! The AUD came to Resident #25 and attempted to calm the resident. The AUD or other staff did not offer fluids to all the residents present. Resident #7 was in the day room and facing the television that was not turned on. Resident #29 was at the locked door kicking it with his feet. Many of the residents were loudly verbalizing, yelling and many were moving about. k. At 9:56 a.m., the cosmetologist performed nail care for Resident #27 in the dining room. Resident #25 stated, I want to go home. Resident #25 attempted to get out of the exit door. CNA #4 came to the resident and talked softly to her. Licensed Practical Nurse (LPN) #4 arrived at 10:00 a.m. Resident #25 stated, I want help to get out of this place! LPN #4 talked softly to the resident about her family. The resident was crying and calling out her daughter's name. Resident #24 was returned to the day area from her room by CNA #5, the wheelchair tray was in place. Her name was written in large black print letters across the back shoulder area of the clothing she was wearing. There was a hole in the left sleeve cuff and a smaller hole on the right cuff. l. At 10:07 a.m., CNA #5 talked to Resident #25 who calmed briefly and when the CNA told the resident of need to change pants (from the cool aid spill), the resident stated, No. CNA #5 stated, You're wet. Resident #25 stated, They'll dry. CNA #5 obtained a moistened paper towel to wash her face. m. At 10:10 a.m., CNA #5 asked Resident #22 if she wanted to go to the bathroom. CNA #5 then left the resident to move a shower chair. CNA #4 took the resident to her room. n. At 11:17 a.m., Resident #22 continued with the same shirt with food spills. Music was playing in the day room. CNA #5 was asked, What do you do when not giving care. CNA #5 stated, I give care. Talk to them. TV, radio. It gets a little loud some days. My partner (CNA #4) is at lunch now. CNA #5 did not have assistance on the unit. o. At 2:17 p.m., there was no activity provided on the unit. Multiple residents were moving about in wheelchairs. Resident #27 rolled her wheelchair into the day room over Resident #21's right foot/toe, who was sitting in a chair on the left just inside the door. Resident #21 cried out in pain. Resident #27 stated loudly, What're you hollering for? CNA #4 came from the dining room to check on the resident. CNA #4 went out of the hall to inform the nurse. Resident #26 continued with the same pants on with spills/stains. LPN #3 assessed Resident #21 where the resident sat in the day room. The multiple residents in the area were vocally loud. p. At 2:32 p.m., the AUD was asked for a copy of the activity calendar for the units. There was no calendar posted on the B unit. The AUD stated, I can get you a copy from the A hall. When asked about the B hall calendar, the AUD stated, It's not posted but I can get you a copy. When asked who does activities on the units, the AUD stated, Aides. When asked if any one person was assigned, the AUD stated, No. I'm back and forth. q. At 4:21 p.m., Resident #26 continued with the same pants with food spills/stains. 4. The August 2015 Activity Calendar for 8/26/15 received from the Alzheimer Unit Director (AUD) on 8/25/15 at 2:38 p.m. documented the following: 9:00 a.m. Current Events 10:00 a.m. Exercise 2:00 p.m. Music 4:00 p.m. Craft corner 7:00 p.m. Pretty nails On 8/26/15 observations made for B Unit were as follows: a. At 8:08 a.m., CNA #5 was feeding Resident #12. LPN #4 was at a medication cart parked between the dining room and day room. CNA #6 was serving drinks to residents in the dining room. Resident #16 was in the day room lying on the couch. The television was on. He was not watching the television. b. At 8:10 a.m., Resident #27 requested coffee. CNA #6 asked if she wanted water or cool aid. Resident #27 stated, I want coffee. CNA #6 stated, We ran out of coffee. We will get more when we take the cart back. Resident #27 was given an 8 ounce cup of water. c. At 8:35 a.m., Resident #22 was in a wheelchair with milk-like food spills on her top and lap and a piece of bread measuring approximately 3 inches long and one inch wide. At 8:38 a.m., CNA #6 removed the piece of bread from the resident's lap. The television was on in the day room. Three residents were in the day room. One was watching the news/weather on the television by standing in front of the television. CNA #6 stated that Resident #27 had already had 2 cups of coffee this morning. The nurse said not to give too much. It makes her blood pressure go up. After I gave her the water she didn't ask anymore. d. On 8/26/15 at 8:42 a.m., CNA #5 was asked how many staff were on the B hall and stated, Only me and another aide. At this time both CNAs were in Resident #7's room to do a 2 person gait belt transfer, there was no staff on the hall to monitor the other residents. CNA #5 stated, She (AUD) wants us to do activities. I can't do it all with what I've got to do. It was bad yesterday, noisy. When I got home, I just blew up. e. At 9:26 a.m., multiple residents sat in the day room and near the day room door. The AUD entered the hall and asked Resident #28 if she liked sports. Resident #28 said she did not, very loudly and continued to talk loudly. The AUD then asked Resident #29 if he liked sports - baseball and began talking to the resident. Resident #22 continued to sit in a wheelchair near the day room with the same milky food spills on her shirt and lap. On 8/27/15 observations made for B Unit were as follows: a. At 12:35 p.m., Resident #30 sat in the dining room at a table with head down and not eating. CNA #4 attempted to wake the resident one time by shaking the resident's shoulder and speaking to the resident. The resident's shirt was pulled up exposing the right side of the abdomen and around to the back. Without any further interaction with the resident, CNA #4 then continued to serve other residents food. b. At 12:36 p.m., the AUD entered the unit, gave the surveyor a copied form of the Initial Activity Assessment (undated) for Resident #7 and left the unit immediately. c. At 12:38 p.m., Resident #24 was sucking and biting on her shirt by lifting the shirt and tearing pieces of cloth off with her teeth and spitting it out. She rolled the pieces in her left hand. This was not observed by the 2 CNAs who were serving lunch. Resident #24 pulled up her top exposing her breasts and bit the material 2 times, still not observed by the staff. d. At 12:40 p.m., a family member of another resident assisted Resident #22 with a juice spill at the table. The CNAs continued to serve lunch. e. At 12:42 p.m., Resident #26 ambulated from the day room to the dining room. She had a large wet area covering her entire buttock area. She stated, It got wet and pulled at the pants. CNA #5 took the resident to her room with a bag of peri-care supplies, leaving one CNA in the dining room. f. At 12:44 p.m., the AUD was present on the unit. She placed a clothing protector on Resident #24 and began to feed the resident. g. At 12:46 p.m., Resident #30 began to eat without assistance. The resident's shirt was still pulled up exposing parts of the resident's abdomen, right side and back. h. On 8/27/15 at 12:50 p.m., a supply closet located to the left of the television in the day room had the key in the door knob. The door was not locked and opened easily. The supply closet contained activity supplies and personal hygiene products. It also contained 2 bottles of nail polish and one safety razor in an open box on the top right shelf. A shelf along the back of the wall contained a box approximately 3/4 full of wooden manicure sticks, eleven safety razors and a one quart spray bottle almost full of cleaner with bleach. CNA #6 was assisting residents in the dining room. CNA #5 had taken Resident #26 to her room to change her clothing. No other staff was present. i. At 12:55 p.m., Resident #29 cried out, I need to go bad! He sat in a wheelchair in the hall. A family member pushed the resident in the wheelchair to his room and stated, Wait til (CNA #4) gets back. The resident stated, Hurry up. I'm going to mess my pants. j. At 12:57 p.m., the AUD brought a sit to stand mechanical lift to the unit. She instructed CNA #4 to get Resident #29 up and the AUD left the unit. With CNA #4 in a resident's room and the AUD absent from the unit, CNA #5 was the only staff left on the hall. There was one family member present. LPN #1 was present and feeding a resident in the dining room. k. At 1:00 p.m., the AUD brought the sling for the sit to stand lift to Resident #29's room. l. At 1:50 p.m., the majority of the residents who resided on the unit were in the day room/hall. There was no activity provided. There was no nursing staff on the hall. The 2 CNAs assigned to the hall were in Resident #28's room assisting the resident. A housekeeper was mopping the dining room floor. Resident #26 ambulated into the dining room and walked on the wet floor in socks. The housekeeper stopped mopping. The housekeeper and the surveyor assisted the resident from the dining room area. 5. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/16/15 documented the resident scored 0 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), sometimes made self-understood, was inattentive, had disorganized thinking and psychomotor [MEDICAL CONDITION], had minimal depression, required extensive assistance for bed mobility, transfer, locomotion, dressing, eating, toilet use, personal hygiene and bathing and was always incontinent of bladder and bowel. a. The Care Plan dated 3/11/15 documented, Problem . I have a life long history of depression . Approaches . 1:1 visits with me. Allow me opportunities to make choices regarding my schedule. Observe me for changes in my mood status. Evaluate for environmental changes to enhance my mood. Allow me to select seating at activities and in dining room . Monitor me for suicidal ideation . Visit with me and discuss my interests, past social patterns in community. Record/monitor me for patterns of target behaviors. Provide opportunities for me for increased socialization with others on my unit and during mealtimes. Provide opportunities for me to correspond with others outside of facility via writing letters, sending emails, or making telephone calls. Problem . I am at risks for falls . Approaches . Assist with ADLs (activities of daily living) as needed but encourage resident to do as much for self as possible and allow them plenty of time without feeling rushed . Set up hygiene supplies and encourage Resident to do as much as possible for self but always assist as needed . Problem . I wander into unsafe situations . Approaches . Place me in area where frequent observation is possible. Alert staff to my wandering behavior. Provide diversional activities for me . If I wander away from unit, instruct staff to stay with me, converse and gently persuade me to walk back to designated area with them. Note which exits I favor for elopement from facility. Alert staff working near those areas. Monitor and document my behavior . b. The Closet Care Plan dated 3/18/15 documented, Restraints: lap belt, pressure alarm, bolster mattress . bed mobility: assist of 1 or 2 . splints (right) hip fx (fracture), ambulation/mobility: assist of 1 or 2 gait belt . Toileting: incontinent, briefs . shower . low bed . toilet Q (every) 4 (hours) at night . c. Documentation in the area of Behavior Observations on the August 2015 ADL Sheet included one check mark on 8/4/15 at 10:30 p.m. All other dates and shift were either blank or had a zero documented. 8/24/15 through 8/29/15 documented, O for each shift. d. A monthly summary Nurses Note dated 8/5/15 documented, . admitted to this facility in December 2010 . Transfers with 2 person gait belt staff assisting into wheelchair and is pushed about by staff. 1 person extensive assistance needed with ADLs (Activities of Daily Living) such as dressing, bathing, oral care, and incontinent care. Showers and shampoos given 3 X's weekly . Oral care provided after each meal, HS (bedtime), and PRN (as needed) . Alert and oriented to name only with short and long term memory loss noted due to Alzheimers. Pleasant and cooperative with staff and others. No s/s (signs/symptoms) of depression noted at present . Incontinent of bowel and bladder and is checked often with good pericare provided PRN . feeds self with tray set up . e. On 8/24/15 at 6:35 a.m., the resident was in a low to the floor, high-backed wheelchair in the dining room. CNA #7 stated, this was an Alzheimer's unit for end-stage moderate to severe. f. On 8/26/15 at 8:42 a.m., CNA #5 and CNA #6 pushed the resident in the wheelchair to her room. CNA #6 stated, We call the wheelchair a low rider. CNA #5 gathered supplies and returned to the resident's room at 8:45 a.m. with a shower chair. CNA #5 pushed the resident from the B hall to the F hall shower room. CNA #5 stated, Can't use B hall (shower). When the CNA sprayed water on the resident in the shower, Resident #7 cried out, Its wet! Its wet! Get off! The CNA talked calmly to the resident and decided not to wash the resident's hair. The CNA stated the resident normally did not act like that in the shower. 6. Resident #12 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 6/23/15 documented the resident scored 0 (0 - 7 indicates severe impairment) on the BIMS, was inattentive, had disorganized thinking and altered level of consciousness, required supervision only for eating, required extensive assistance in bed mobility, transfer, locomotion, dressing, toileting and personal hygiene, was totally dependent for bathing and was always incontinent of bladder and bowel. a. The Care Plan dated 7/14/14 documented, Problem/Need . I need max (maximum) assistance with my ADL's . I need you to assist me with my ADLs but continue to encourage me to be independent as much as possible . I need you to set up my hygiene supplies and encourage me to do as much as possible for myself but always assist as needed . I need assistance with meals; encourage me to try to feed myself and document how much I eat. I must be fed by staff, take your time please and record how much I eat. I require the use of a mechanical lift and 2 staff for all transfers . Problem/Need . Activities: Resident participates in group programming of interest with reminders and encouragement at times . Approaches . Offer opportunities for success and praise as often as possible. Encourage resident to socialize with other resident and staff. Give resident verbal reminders of activity before commencement of activity and assist as needed. Offer activity programs directed toward specific interests of resident. Engage resident in group activities of interest and capabilities such as music, spiritual, exercise, social functions, cooking, folding, trivia, bingo, word games, etc . Problem/Need . I wander into unsafe situations . Approaches . Provide diversional activities for me . b. The Closet Care Plan (undated) documented, Bed mobility assist of 1 . Ambulation/mobility . assist of 1, wheelchair, lift to chair, Eating . cueing, set-up, Toileting . incontinent, briefs . toilet every 2 hours, fed at meals . c. The August 2015 CNA ADL sheet documented, Behavior observations. All shifts documented a zero or were blank except 8/16/15 at 10:30 p.m. documented, N. There was no legend on the form that documented what N meant. d. On 8/24/15 at 10:00 a.m., CNA #8 and CNA #9 entered the resident room to transfer the resident using a sit to stand mechanical lift. The sit to stand lift base where a resident would stand was covered in crumbs and debris. While the CNAs were in the resident's room, there was no staff present on the hall monitoring the other residents. 7. Resident #23 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 6/23/15 documented the resident had a BIMS score of 0 (0 - 7 indicates severe impairment), required extensive assistance for ADLs and was mobile in a wheelchair. a. The Care Plan dated 10/13/14 documented, Problem/Need . I am at risk for bleeding secondary to the use of anticoagulant therapy . Approaches . Observe me for s/s of bleeding and report to MD (medical doctor). (Bleeding gums, Hematuria, joint pain, swelling, epistaxis, increased bruising, abdominal pain, tarry stools . Problem/need . I have poor safety awareness . Approaches . Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician . Problem/need . I wander into unsafe situations . Approaches . Place me in area where frequent observation is possible. Alert staff to my wandering behavior. Provide diversional activities for me. Approach me positively and in calm, accepting manner . b. On 8/29/15 at 9:55 a.m., a review of the resident Incident and Accident Report for June, July and August 2015 documented the following: 1) A Resident Incident Report dated 7/28/15 at 4:30 p.m. documented, CNA (name) came to this nurse and stated that while resident was agitated she witnessed her grab another resident's left wrist. No injury. Immediate Actions Taken: Resident's were already separated. Assessed for injuries. (Physician) and family notified. 2) A Resident Incident Report dated 8/17/15 at 12;30 a.m. documented, CNA (name) notified this nurse that she discovered a skin tear with a red ring measuring approximately 2 cm (centimeters) x (by) 2 cm around the wound. Skin tear to left forearm measuring approximately 1 cm x 0.25 cm with red ring measuring approximately 2 cm x 2 cm surrounding it. Wound site is cool to the touch with no c/o (complaint of) pain voiced. Immediate Actions Taken: Wound site cleaned and patted dry 3) A Resident Incident Report dated 8/18/15 at 2:16 p.m. documented, This resident sitting in hallway in w/c (wheelchair) Another resident pushed Hoyer lift into this resident. (Injuries) none. Immediate Actions Taken: Assessed resident for injury, removed Hoyer lift from hall 8. Resident #28 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 8/4/15 documented the resident scored 0 (0 - 7 indicates severely impaired) on the BIMS, was inattentive, had [MEDICAL CONDITION] and an altered level of consciousness, was totally dependent for ADLs, was always incontinent of bladder and bowel and used a wheelchair. a. The Care Plan dated 12/19/13 documented, Problem/need . I display socially inappropriate/disruptive behavior . Approaches . Monitor and document my behavior. Do not argue with me. Praise me for demonstrating desired behavior. Administer my behavior medications as ordered by physician. Talk with me in calm voice when my behavior is disruptive. Remove me from public area when behavior is disruptive and unacceptable . Problem/need . I am at risk for falls . Approaches . 12/2/14 I require a Marissa lift (with) 2 staff assist for all transfers . Problem/need . I wander into unsafe situations . Approaches . Place me in area where frequent observation is possible. Alert staff to my wandering behavior. Provide diversional activities for me. Approach me positively and in calm, accepting manner . b. On 8/29/15 at 10:23 a.m., a review of the resident Incident and Accident Report for June, July and August 2015 documented the following: 1) A Resident Incident Report dated 6/26/15 at 10:42 a.m. documented, Reported by (name) Resident found to have small abrasion to LLE (left lower extremity) 3 cm abrasion to LLE Immediate Actions Taken: First aid to LLE. Immediate Post-incident action: Resident to wear long pants while up in wheelchair to prevent scraping of skin. 2) A Resident Incident Report dated 7/21/15 at 3:00 p.m. documented, CNA came to this nurse and stated resident was in the floor beside her bed and her left arm was caught in the bed rail. No injuries. Immediate actions taken: Assessed for injuries. CNAs lifted resident from floor (with) lift and placed in wheelchair. Neuro check initiated. (Physician), Supervisor, and family notified. Immediate Post-Incident Action: An alarm will be clipped on her gown while she is in bed. 3) A Resident Incident Report Dated 8/25/15 at 9:15 a.m. documented, CNAs were transferring resident with Hoyer had resident in lift. Lift malfunctioned lowering to floor. No injuries noted. Immediate Actions taken: Resident immediately assessed for injury then returned to bed. Notified (Physician) and (name) responsible party notified. Lift was removed by maintenance and repaired. Immediate Post-Incident Action: Maintenance notified. Lift removed from use and repaired. Staff than re-educated on use of the lift. 9. Resident #29 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 8/19/15 documented the resident scored 0 (0 -7 indicates severe impairment) on the BIMS, had disorganized thinking, required extensive assistance in ADLs, used a wheelchair, and was frequently incontinent of bladder and bowel. a. The Care Plan undated documented, Problem onset date: 8/25/15 I require extensive assist x 1 staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing and require extensive assist x 1 staff locomotion . Approaches . Please assist me to specific areas when I am up in my w/c such as activitie

Based on observation, record review and interview, the facility failed to ensure an effective pest control program was in place to prevent the possible spread of parasites and re-infestation of bed bugs. The facility failed to ensure appropriate pest elimination techniques were followed for washing and cleaning to ensure pest were eliminated and to ensure appropriate monitoring was provided to ensure pest were eliminated and prevent complications related to continued infestation of bed bugs for 8 of 8 (Residents #3, #34, #35, #36, #37, #38, #39, and #40) case-mix residents who were observed by staff to have bed bugs on bedding. The facility failed to ensure staff conducted complete body audits on all residents to ensure all residents who were affected by the bed bug infestation were identified and received treatment. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious ham, injury or death to Residents #3, #34, #35, #36, #37, #38, #39, and #40 due to the infestation of beg bugs and had the potential to cause more than minimal harm to 59 residents who resided on C, D, E and F halls as identified by a Census List provided by the Assistant Director of Nurses on 8/24/15. The Administrator was informed of the immediate jeopardy 8/26/15 at 2:22 p.m. The findings are: 1. On 8/25/15 at 4:36 p.m. during clinical record review, the following information was found in the Nurses Notes of resident (Residents #3, #34, #35, #36, #37, #38, #39, #40) records: a. Resident #40 1) A Nurses Note dated 8/7/15 at 10:22 p.m. documented, Bed bugs found in resident's bed and clothing and on person. Sheets and clothing bagged up and sent to laundry. New mattress placed on bed. (Physician) notified and N.O. (new order) received to apply [MEDICATION NAME] cream all over in AM (morning) and repeat in one week. (Family members) notified. 2) A Nurses Note dated 8/9/15 at 12:48 p.m. documented, [MEDICATION NAME] washed off Res. (resident) per Rx (prescription) via shower within 8 - 14 hours following [MEDICATION NAME] application. 3) A Nurses Note dated 8/17/15 at 6:17 a.m. documented, Staff was doing 2 AM rounds when they found a live bed bug crawling on resident's pillow case placed at resident's back. On call (physician) notified. Resident was showered, hair and body negative for bed bugs. No bites observed on resident during body audit. Belongings in resident's room bagged up and left in room for housekeeping to pick up for laundry. Addendum: Resident moved to room (number) on F Hall. b. Resident #39 1) A Nurses Note dated 8/8/15 at 2:25 p.m. documented, Bed bugs found in Res. (resident) rm. (room) All belongings bagged and cleaned. (Physician) notified and N.O. (new order) received - [MEDICATION NAME] 5% cream. Apply from the head down and then remove by washing in 8 - 14 hrs. (hours) Repeat in one week. POA (Power of Attorney) notified. 2) A Nurses Note dated 8/9/15 at 12:47 p.m. documented, [MEDICATION NAME] washed off Res (resident) per RX (prescription) via shower within 8 -14 hours following [MEDICATION NAME] application. c. Resident #35 A Nurses Note dated 8/8/15 at 2:33 p.m. documented, Bed bugs found in Res. (resident) rm. (room) All belongings bagged and cleaned. (Physician) notified. POA (Power of Attorney) notified. d. Resident #34 1) A Nurses Note dated 8/8/15 at 2:34 p.m. documented, Bed bugs found in Res. (resident) rm. (room) All belongings bagged and cleaned. (Physician) notified. POA (Power of Attorney) notified. 2) A list provided by the Director of Nurses (DON) on 8/26/15 at 11:30 a.m., documented the resident had been moved into a room with Resident #32 on 8/8/15. e. Resident #36 1) A Nurses Note dated 8/8/15 at 2:35 p.m. documented, Bed bugs found in Res. (resident) rm. (room). All belongings bagged and cleaned. (Physician) notified and N.O. (new order) received to apply [MEDICATION NAME] 5% cream. Apply from the head down and then remove by washing in 8 - 14 hrs. (hours). Repeat in one week. POA (Power of Attorney) notified. 2) A Nurses Note dated 8/9/15 at 12:47 p.m. documented: [MEDICATION NAME] washed off Res. (resident) per Rx (prescription) via shower within 8 - 14 hours following [MEDICATION NAME] application. 3) A Nurses Note dated 8/17/15 at 6:12 a.m. documented, Staff was doing 2 AM rounds when they found a live bed bug crawling on resident's pillow case placed at resident's back. On call (physician) notified. Resident was showered, hair and body negative for bed bugs. No bites observed on resident during body audit. Belongings in resident's room bagged up and left in room for housekeeping to pick up for laundry. Addendum: Resident moved to room (number) on F Hall. A list provided by the DON on 8/26/15 at 11:30 a.m. documented the resident was moved to a room on F hall where another resident resided. f. Resident #37 A Nurses Note dated 8/9/15 at 12:47 p.m. documented: [MEDICATION NAME] washed off Res (resident) per RX (prescription) via shower within 8 -14 hours following [MEDICATION NAME] application. g. Resident #38 1) A Nurses Note dated 8/9/15 at 2:36 p.m. documented, Bed bugs found in Res. (resident) rm (room) All belongings bagged and cleaned. (Physician) notified and N.O. (new order) received - [MEDICATION NAME] 5% cream. Apply from the head down and then remove by washing in 8 - 14 hrs. (hours) Repeat in one week. POA (Power of Attorney) notified. 2) A Nurses Note dated 8/8/15 at 8:39 p.m. documented, Post ABT (antibiotic) with no ASE (adverse side effects) noted at this time. Temporarily on F Hall d/t (due to) bed bug decontamination of primary rm . 3) A Nurses Note dated 8/9/15 at 12:45 p.m. documented, [MEDICATION NAME] washed off Res (resident) per RX (prescription) via shower within 8 -14 hours following [MEDICATION NAME] application. h. Resident #3 1) A Nurse Note dated 8/8/15 at 8:29 p.m. documented, Bed bugs found in Res rm. Res, belongings cleaned and/or bagged to rid of infest. (infestation) Res temporarily on F hall at this time. N.O. (New Order) received per (physician): [MEDICATION NAME] cream applied from head down and then to be washed 8 - 14 hrs later. To be repeated in one week. 2) A Nurse Note dated 8/9/15 at 12:47 p.m. documented, [MEDICATION NAME] washed off Res per RX via shower within 8 - 14 hours following [MEDICATION NAME] application. 2. On 8/24/15 at 10:35 a.m. bags filled with unidentified items were on the ground outside the door of the laundry near the Biohazard closet: 9 red plastic Biohazard bags, 13 yellow plastic Biohazard bags, 3 black plastic bags and 3 white plastic bags. The bags were lying directly on the ground, located next to the fence for the Generator. The Floor Technician and Housekeeper #1 were asked what items were in the bags. Housekeeper #1 stated, The stuff in the bags is resident's belongings. Housekeeper #1 was asked, How long has it been here? Housekeeper #1 stated, Two weeks. Housekeeper #1 was asked, Why are the resident's belongings outside in plastic bags? Housekeeper #1 stated, Bed bugs. The bugs have to have extreme heat for 14 days to kill the bugs. The stuff was put in the plastic bags, put outside in the 90 degree plus heat will kill them (bed bugs). 3. On 8/24/15 at 10:40 a.m., the Housekeeping Supervisor came around the corner of the laundry where the bags were located on the ground. The Housekeeping Supervisor was asked to explain the bags on the ground. The Housekeeping Supervisor stated, The first initial 14 days is over. The CNAs (Certified Nurses Assistants) brought the items (resident belongings) outside, pest control sprayed inside (the rooms) and after 14 days had elapsed, we had another bed bug (in the same room) noted, so the process started over (on Friday 8/21/15). The Housekeeping Supervisor was asked, Is this stuff (the bags of resident items) considered Biohazard? The Housekeeping Supervisor stated, Yes, the clothing belongs to the residents and (the items) can't go back inside until they are free of bed bugs. The Housekeeping Supervisor was asked, What rooms were affected? The Housekeeping Supervisor stated, Resident rooms (Residents #38 and Resident #3), (Resident #39 and Resident #35) and (Resident #34 and #37). The Housekeeping Supervisor was asked, What is the process for bed bugs? The Housekeeping Supervisor stated, Our company has a policy and procedure on bed bugs and that is what we followed. The Housekeeping Supervisor was asked, Where are you at (with the procedure) now? The Housekeeping Supervisor stated, There was only one live bug found (on 8/21/15) and the procedure started over on Friday. The Housekeeping Supervisor was asked, How did the resident's belongings get outside in plastic bags on the ground? the Housekeeping Supervisor stated, The CNA's brought the bags out here. We (Laundry) just wash it and hand it back out to the residents. The Housekeeping Supervisor was asked, Will the Biohazard company come and pick up the Biohazard bags that are outside on the ground? The Housekeeping Supervisor stated, That's all items that need to be cleaned/washed and returned to the residents. The Housekeeping Supervisor was asked, Is all of the bags resident belongings? The Housekeeping Supervisor stated, Yes, it is all resident belongings (that need to be returned). The Housekeeping Supervisor was asked, Is that appropriate storage of Biohazard items and resident belongings? The Housekeeping Supervisor stated, No, it is not. 4. On 8/24/15 at 10:55 a.m., the Administrator was asked about the resident belongings in the Biohazard bags placed on the ground outside of laundry. The Administrator stated, We had bed bugs. We got the pest control involved, and the pest control company told us to put the items outside in plastic bags for 10-14 days. The combination of the plastic bag and 90 degree plus heat would effectively kill the bed bugs. I did verbal education with the (weekend) RN. This occurred on the weekend and the CNAs put the resident's belongings in red (biohazard) bags. I don't know why they used red biohazard bags other than the fact that it was bed bugs. I was not happy about them (CNAs) using red bags for personal belongings. The (CNAs) should not have used red bags. The resident's belongings should not have been put in red bags, it was resident's personal belongings. We were waiting the 14 days and then they (items) could be washed and returned, if they were items from the original rooms (on 8/7/15). The first outbreak was Friday, 2 weeks ago (8/7/15). Anything in a biohazard bag that has been outside for 14 days could be returned now. The Administrator was asked, Are these (bags) items that have been sprayed? The Administrator stated; No personals (personal clothing) were sprayed. The items went into the plastic bags and the heat from the bags and the 90 degree days would have effectively killed the bugs. 5. On 8/26/15 at 9:15 a.m., the Administrator was asked, What halls were affected by the bed bugs? The Administrator stated; D Hall was the only hall affected by the bed bugs. The Administrator was asked, How did you identify that only D Hall was affected (by the bed bugs)? The Administrator stated, We noticed the first room at dinnertime (supper) on Friday or Saturday (not sure of the exact day), the weekend RN (Registered Nurse) phoned me and stated we had another room affected, then the CNAs checked all the rooms and there were other rooms affected on D Hall. There were no bugs on any other halls. A facility wide check was done by the CNAs on the hall. That is when the CNAs used the biohazard bags to bag up the resident's belongings. The Administrator was asked, What did you do with the resident's that were affected? The Administrator stated, All (affected) were moved to F Hall. The Administrator was asked, Were these residents moved into rooms with other residents? The Administrator stated, I'm not sure. I know we had empty rooms on F Hall, but possibly (put resident's affected in rooms with non affected residents). The Administrator was asked, Did the pest control company spray on Friday (8/14/15) when staff went to return the resident's belonging and identified another bed bug? The Administrator stated, Yes, (pest control representative) did 2 applications. The Administrator was asked, Why did you only spray 4 of the 7 rooms on D Hall? Why was the whole hall not sprayed? The Administrator stated, We only sprayed the 4 rooms that were affected. That's the only rooms we found bugs in. The Administrator was asked, Where are the resident's belongings from Friday (8/21/15) when the live bed bug was found? The Administrator stated, I'm hoping they (belongings) are in storage. 6. An invoice 8/10/15 from the pest control company provided by the Administrator on 8/25/15 at 2:25 p.m. documented resident rooms #28, 29, 30 and 32 were treated for [REDACTED]. The pest control contract provided by the Administrator on 8/26/15 at 5:25 p.m. documented, Service Agreement: .This agreement shall be in effect from February 2014 and stay in effect until said party notifies (Name of Company). Basic Service; (Company) will provide on a regular monthly service, which includes treating for cockroaches, mice, fleas, ticks, c[DIAGNOSES REDACTED], ants, silverfish, firebrats, millipedes, ground beetles, scorpions, clover mites, box elder bugs, spiders and carpenter bees. All trouble calls will be answered promptly at no additional charge. Date started; November 2009. There was no documentation regarding bed bugs in the agreement. As of the exit conference on 8/29/15 at 7:45 p.m., the Administrator had provided no further documentation of pest treatment by the pest control company 7. On 8/26/15 at 9:24 a.m., Licensed Practical Nurse (LPN) #1 was asked, When did the resident's belongings get returned? LPN #1 stated, All the items (belongings) for residents were brought back in (inside the building) by (name of Social Director) yesterday. 8. On 8/26/15 at 9:27 a.m., the Social Director was asked, When and why did you bring the residents' items (belongings) back inside the building? The Social Director stated, Yesterday (8/25/15) and this morning (8/26/15). Housekeeping stated the time had expired (for the items to remain outside in the heat) and the Administrator told me I could bring the stuff (resident belongings) back inside (the building). Those were the items that could not be laundered, such as wreaths and knick-knacks that could not be run through the heat of the dryer. We (CNA and Social Director) used a disinfectant spray (Virex II 256) and sprayed the items down and wiped them off before we took them back inside for the residents. The Social Director was asked, Is the spray something that can be used to exterminate bed bugs? The Social Director stated, (The housekeeping Supervisor) would know if the spray can be used for extermination of the bed bugs. I was just using it for disinfectant to clean the residents' items that had been outside for 2 weeks. The Social Director was asked, Is (Virex II 256) spray an appropriate extermination product (for bed bugs)? The Social Director stated, I don't know. The Social Director was asked, Who decided what treatment would be used (for the bed bugs)? The Social Director stated, I would assume it was (the Maintenance Director) and the Administrator. 9. On 8/26/15 at 9:30 a.m., the Housekeeping Supervisor provided a bottle of Virex II 256 spray that had been used to clean the resident's belongings that could not withstand the heat of the commercial dryer. The Material Safety Data Sheet for Virex II 256 documented uses for bacteria, viruses, veterinary viruses, fungi and yeast. There were no pest or pest control references listed. The product was listed as a disinfectant. 10. On 8/26/15 at 10:30 a.m., the pest control representative was asked, What is the first step of the process for the bed bugs? He stated, Call us. We come in and do an inspection of the room to identify if it actually is a bed bug. If they do have them, then all the laundry has to be taken and done, all items go through the laundry, the shelves have to be wiped down with a spray to eliminate the bugs, the baseboards and the cracks/crevices all have to be sprayed to eliminate the bugs. All items, anything that can be laundered, such as clothes, linens animals, anything cloth has to be run through the dryers. It is an intense treatment, everything is sprayed. The electrical plates are taken off the wall and sprayed behind, the drawers are sprayed and any personal hard items must be wiped down to eliminate the bugs. He was asked, Can plastic bags placed outside kill the bugs? He stated, Plastic bags can kill the bed bugs. We inspect the items, treat the items and place them in the plastic bags. The bags are not an effective treatment for [REDACTED].? He stated, The first treatment was done on 8/10/15. But people can be bit and not realize they are bitten for up to 14 days. He was asked, Were the bags outside treated? He stated, No, that was out there when I got here, the rooms were empty. I sprayed the rooms. He was asked, What rooms did you treat? He stated, Room 28, 29, 30 and 32. He was asked, Was there any follow-up treatments? He stated, I was only called back to treat room 32, the room of the original infestation. Now, room 45 was reported to me today, when I got here. He was asked, Were there bugs found in any other rooms? He stated, No, bed bugs were only found in room 32. Rooms 28, 29 and 30 were treated for [REDACTED].? He stated, Spraying and high heat for sustained time will kill the bedbugs. Warmer temperatures (not high heat) exacerbate the multiplication (of the bugs). He also stated, I am waiting on the Housekeeping Supervisor, I have to train her on what to look for and where to look (in identifying an infestation). 11. The facility's Bed Bug Protocol received from the Administrator on 8/26/15 at 11:05 a.m. documented: .(Bed Bug) bites result in itchy skin reactions and scratching bed bug bites can lead to secondary skin infections. Bed bug infestations may result in psychological distress, disruption of sleep and agitation. Responding to a Bed Bug Incident: If bed bugs are reported or suspected, do the following: 1. Get specimens if possible for professional identification. 2. Arrange for an inspection as soon as possible by a (Pest control company name) representative. 3. Do not move patient to another room until after (pest control company name) has evaluated the situation. 4. Medical equipment, personal items and beds should not be removed from the room until they have been treated. 5. Cooperate fully with the recommendations made by your (pest control company name) representative to prepare rooms for inspection and treatment. Treatment Instructions: 1. Be sure (residents) do not take any personal items out of the rooms. 2. Remove clothing, linens and materials designated for disposal from the infested room in sealed plastic bags to prevent moving bugs to other areas. 3. Wash all linens, curtains, clothing, stuffed animals, etc. in hot water and dry on high heat. Observe washing and drying instructions from manufacturer. Heat is the important part. Do not air dry items. Be Proactive: Implement a bed bug awareness and education program for each of the following sectors: Doctors, nurses, aides and other health or social care providers. Environmental services (housekeeping) and maintenance staff. Admissions and other support staff. Directors and Administrators. Family members of patients/residents in long-term care such as nursing homes or assisted living. All staff should be alert for evidence of bed bugs: Environmental services should do routine inspections for bed bugs as part of daily service to patient rooms. Care givers should listen for reports of bites by patients and visitors, and look for possible bed bug bites on patients. NOTE: (Name of pest control company) can provide an education program for your facility - free of charge. 12. On 8/26/15 at 11:30 a.m. the Administrator provided a list of room moves in which residents from D Hall were moved to designated rooms on F Hall. The form identified two residents from the D Hall bed bug infestation were moved into rooms on the F and C Hals with other residents on 8/8/14. The resident in Room 29 A on the D Hall was moved to room 53 B on the F Hall Room with a resident who was in the A bed. The resident in room 30 A on the D Hall was moved to room 20 A on the C Hall Room with a resident who was in the B Bed. Moving these resident at this time put the resident who resided in the room in jeopardy of being infested by bed bugs. 13. On 8/26/15 at 11:30 a.m., the Administrator provided CNA Bath Checklists (body audits) for the list of Resident's who had been moved. Resident #34 had a CNA Bath Checklist dated 8/8/15 at 3:30 a.m. that contained no documentation of rash or bug bites. Resident #36 had a CNA Bath Checklist dated 8/8/15 (with no time) that contained no documentation of rash or bites. As of 8/29/15 at the exit conference on 8/29/15 at 7:45 p.m. with the facility, the Administrator had provided no further documentation of completed body audits for the other residents involved (Resident #s 35, 37, 38, 39, and 40). 14. On 8/26/15 at 1:02 p.m. CNA #13 was asked, Can you tell me about the bed bugs. CNA #13 stated, I was one of them (here when the bugs were found). We were getting ready for dinner, got Resident #40 stuff (belongings) all off the bed and floor. I saw the bugs. I told LPN #1 and the Administrator. The Administrator came (to the room) and looked, said to put hair nets on, booties, yellow isolation gowns and gloves and throw everything away. We (CNAs) got everything out and replaced the bed. Bugs were on the furniture and cabinets. There were no bugs on the roommate, only on Resident #40. We gave Resident #40 a shower, (the resident) had bugs on (the residents) hair and body. The next day, staff moved all residents on D Hall, there were only 3 rooms left, all the residents stuff (personal belongings) were bagged (up), washed all the clothes. I was also on (duty) when the residents' personal belongings were brought back in. CNA #13 was asked, Did you receive any training related to bed bugs? CNA #13 stated, No, just saw the bugs. I thought bed bugs were smaller than that. The Administrator told me they were bed bugs. 15. On 8/26/15 at 1:45 p.m., CNA #1 was asked, Did you see the bed bugs? CNA #1 stated, I didn't see the bugs myself. CNA #1 was asked, Have you had any training in how to identify bed bugs or what to look for? CNA #1 stated, I had no training on what to look for or what they look like. CNA #1 was asked, Can you describe what happened (with the bed bugs)? CNA #1 stated, On Saturday (8/8/15) I was one of the CNAs that bagged up the resident's belongings. (I) didn't do anything to the belongings, (I) put them in 2 bags, double bagged like we do for Biohazard linens and put the bags in the hall. When I went home at 11:00 p.m. that night, the bags were still in the hall, or in one of the rooms, I can't remember, but I know some of the bags were still in the hall. CNA #1 was asked, Have you had any training since that day (8/8/15) on what to look for or how to identify bed bugs? CNA #1 stated, No, I have not. 16. On 8/26/15 at 1:55 p.m., CNA #14 was asked, Can you tell me about the bed bugs? CNA #14 stated, I'm not sure of the date, but it started during the night. I came in and saw all the residents on D Hall, everybody (all the Residents) was showered and had cream on (the skin) them. The residents were all in gowns. The wheelchair was disinfected, all the (residents) stuff (personal belongings) was bagged and taken out. CNA #14 was asked, What about the laundry? CNA #14 stated, I don't know. I was told to bag all of it and put it on a cart. We used Dial soap on all of the residents and most (of the residents) were moved to F Hall. One (resident) was moved to C Hall. CNA #14 was asked, Did you see the bugs? CNA #14 stated, Yes, I saw the bugs. There were a couple of bugs on (Resident #39). CNA #14 was asked, Can you describe the bugs? CNA #14 stated, They (bugs) are little tiny black bugs, I saw a couple of them, I got them out and flushed them down the drain. I scrubbed the resident's hair really good. CNA #14 was asked, Did you receive any training regarding bed bugs? CNA #14 stated, They (facility) told us to double glove and not get them (the bugs) on our uniform and everything as we go. 17. The Bed Bug Infestation Protocol provided by DON on 8/26/15 at 11:55 a.m. documented: Managing a bed bug infestation is a difficult task that requires a removal or treatment of [REDACTED]. Treatment Procedures: (Bullet) Infested and infestation-prone bedding and garments will need to be bagged and laundered (120 degrees Fahrenheit minimum) since these items cannot be treated with insecticides. (Bullet) . clothes dryer set at medium heat for 10-20 minutes. While dry cleaning procedures also kill bed bugs, there is risk of infesting the establishment when buggy items are de-bagged, tagged and sorted. (Bullet) Items which cannot be put in a washer or dryer can sometimes be de-infested by wrapping in plastic and placing them outdoors in a hot, sunny location, closed vehicle, etc. for at least a day. Monitoring with a thermometer is prudent .(Bullet) . Bed bugs and especially the eggs can be difficult to dislodge.(Bullet) At times it may be necessary to throw out infested items, especially beds and upholstered furniture. (Bullet) . Professionals treat using a variety of low-odor sprays, dusts and aerosols. Application entails treating all areas where the bugs are discovered or tend to crawl or hide. This may take hours of effort and follow-up visits are usually required. (Bullet) Eliminating bed bugs from beds can be challenging. If there are holes or tears in the fabric, the bugs and eggs may be inside, as well as outside. (Bullet) . Encasements will not, however, keep bed bugs from crawling onto a bed and biting a sleeping person. 17. A copy of the Joint Statement on Bed Bug Control in the United States from the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Environmental Protection Agency (EPA) provided by DON on 8/26/15 at 11:55 a.m. documented, The CDC and the EPA developed this document to highlight emerging public health issues associated with bed bugs in communities throughout the U.S. Impact of Bed Bugs on Public Health: Bed bugs cause a variety of negative physical health, mental health and economic consequences. Many people have a mild to severe allergic reaction to the bites with effects ranging from no reaction to a small bite mark to, in rare cases [MEDICATION NAME] (severe, whole-body reaction. These bites can also lead to secondary infections such as impetigo, ecthyma, and lymphanigitis. Bed bugs may also affect the mental health of people living in infested homes. Reported effects include anxiety, [MEDICAL CONDITION] and systemic reactions. Bed Bug Biology: Bed bugs can travel over 100 feet in one night, but they tend to live within 8 feet of where people sleep. Bed bugs are usually transported from place to place as people travel. Bed bugs travel in seams and folds of luggage, overnight bags, folded clothing, bedding, furniture, and anywhere else they can hide. One of the easiest ways to identify a bed bug infestation is by bite marks that appear on the face, neck, arms, hands and any other body parts. However, these bite marks may take as long as 14 days to develop in some people . When bed bugs bite, they inject an anesthetic and an anticoagulant that prevents a person from feeling the bite. A comprehensive Integrated Pest Management program to control bed bugs may include a number of methods such as: using monitoring devices, removing clutter where bed bugs can hide, applying heat treatment, vacuuming, sealing cracks and crevices to remove hiding places, using non-chemical pesticides and judicious use of effective chemical pesticides. How are bed bugs treated and prevented? . The best way to treat a bite is to avoid scratching the area and apply antiseptic creams or lotions and take an [MEDICATION NAME]. Bed bug infestations are commonly treated by insecticide spraying. Finally, to rid a dwelling of bed bugs for good, every possible hiding place must be cleaned or treated. In a home, that means all clothing, bedding, linens, and other washable fabrics must be laundered, usually repeatedly. Every crevice and seam of mattresses and upholstered furniture must be inspected and treated. Cracks in walls must be sealed, loose wallpaper reattached or removed, and carpets treated and vacuumed. Dresser drawers have to be emptied and cleaned, and all clutter must be removed to limit hiding places for stray bed bugs. 18. On 8/28/15 at 9:47 a.m. Laundry Employee #1 was asked, Do you remember the red and yellow bags of resident's belongings and linen from the bed bug incident? Laundry employee #1 stated, I do. Laundry Employee #1 was asked, What process did you do with those items (in laundry)? Laundry Employee #1 stated, They were washed and dried and put back into resident's rooms and closets. Laundry Employee #1 was asked, Did you do anything different with those items? Laundry Employee #1 stated, No, we used the same wash settings for all the resident's clothes and personals (personal clothing). Laundry Employee #1 was asked, Were there any other chemicals used on these items? Laundry Employee #1 stated, No, just the chemicals that are programmed into the machine. We didn't spray them or anything like that, we just took them out of the plastic bags, put them into the washer and punched the chemical button, then put them into the dryer. After that, they would be folded and put back into the resident's rooms. 19. On 8/28/15 at 10:45 a.m., CNA #2 was asked, What day did the bed bug incident occur? CNA #2 stated, (I) can't remember the exact day, it was a few weeks ago on Saturday (8/8/15). The evening before, (staff) had found a bug on Resident #40. (The resident) was taken out of (resident's) room, showered, had a treatment cream applied and was placed back into (resident's) room. We have a weekend supervisor. I did my best to avoid the area. I did not want the bugs (on me). CNA #2 was asked, Did anyone check the roommate (for bed bugs)? CNA #2 stated, I don't know. One of the other girls (CNAs) moved the bedside table and could see the bugs. The weekend supervisor and 2 other CNAs went into the room and were taking everything out, bagging it up, and took and tied (the bags) in knots. I said we needed to check everybody else. They checked (Resident #38), check the bed, and the resident told staff (resident's) son had bugs at home. CNA #2 was asked, Did anyone check that out (son)? CNA #2 stated, I don't know. I avoided the hall as much as I could but I did see that they (weekend supervisor) moved (Resident #40) to an empty room on F Hall and the room was sealed, the door knob was removed (to keep everyone out). (Resident #3) was (Resident #40) roommate. (Resident #37) and (Resident #34) were moved too and the rooms were sealed. I was not involved in the room searches. Pest control came and treated those resident rooms. Staff took all the clothes out to laundry on Saturday (8/8/15) and put them in the barrel until they could be washed. The furniture and knick knacks went to biohazard bags outside. Those bags were still out there on Monday (8/24/15) and have been there for 2 weeks. I went home (that evening), stripped on the porch and put all my laundry into the washer and dryer. I took precautions just in case (I had taken bugs home). I didn't have any bites on me. 20. On 8/28/15 at 11:02 a.m., CNA #2 provided a copy of a pest control invoice. The facility's pest control company had done a home visit on 8/27/15 and checked the house for bed bugs. No bed bugs found. CNA #2 was asked, What prompted the home visit from the pest control comp

Based on observation, record review and interview, the facility failed to ensure the Quality Assurance Committee identified, developed and implemented action plans, and monitored and made revisions to the action plans as needed for 13 of 13 (Residents #7, #12, #16, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) case mix residents who resided on the B secure unit and required a higher level of supervision due to their diagnoses. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death for 13 residents (Residents #7, #12, #16, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) who had a [DIAGNOSES REDACTED]. The Administrator was informed of the Immediate Jeopardy on 8/27/15 at 2:09 p.m. The findings are: 1. The Alzheimer's Care Advanced Alzheimer Care Units Admission Criteria/Discharge Criteria for B-hall received from the Alzheimer Unit Director on 8/27/15 at 12:32 p.m. documented the following: Resident must have a primary [DIAGNOSES REDACTED]. The resident must not exhibit behaviors that may result in injury to self or others. Physical abuse, combativeness, continual yelling or screaming that disrupts programming and escalates others, or self-destructive behavior will result in discharge from the unit . At any time, should the resident's medical condition be so acute as to require skilled care for aggressive curative (rather than palliative) treatment, the resident may be transferred into the skilled unit for care . Residents should be mobile, either by independent or assisted ambulation. Use of walkers, gerichairs, canes or 1 person assist for ambulation is permissible . 2. The August 2015 Activity Calendar for the B Hall received from the Alzheimer Unit Director (AUD) on 8/25/15 at 2:38 p.m. documented the following activities for 8/24/15: 9:00 a.m. Current Events 10:00 a.m. Exercise 2:00 p.m. Music 4:00 p.m. Arts and Crafts 7:00 p.m. Pretty Nails On 8/24/15 observations made for B Unit were as follows: a. At 10:12 a.m., there were 3 residents in the day room with the television on. They were not actively watching the television. There were 2 residents in wheelchairs in the hall and 2 residents in the doorway of the day room. None of the residents were actively watching the television program that was currently airing. There were 3 residents in the dining room. The television was the only activity at this time on the unit. There was no activity of Exercise being provided at this time. The residents were moving about in wheelchairs and verbalizing loudly. b. At 10:15 a.m., Resident #24 was in a wheelchair with a tray and wore a back brace. The resident was sitting near the day room, but not included in the group near the television. c. At 11:00 a.m., a movie was playing on the television in the day room. Four residents were in the day room but not actively watching the movie, which was a comedy. Two residents were in the dining room, one with coffee. A housekeeper was the only staff present at this time in the area. d. At 12:30 p.m., residents were gathered in the dining room for the noon meal. Resident #28 was at a table and was calling out loudly and repetitively. e. At 3:30 p.m., there was no activity provided. Residents were moving about in wheelchairs and verbalizing loudly. Resident #29 was agitated and repeatedly stated he wanted out. Certified Nurse Assistant (CNA) #4 was in the hallway. CNA #4 stated, He gets worse as the day goes on. Sundowners. He'll be better when his family comes in. CNA #4 did not go to the resident or try to calm him in any way. 3. The August 2015 Activity Calendar for the B Hall received from the Alzheimer Unit Director (AUD) on 8/25/15 at 2:38 p.m. documented the following activities for 8/25/15: 9:00 a.m. Current Events 10:00 a.m. Exercise 2:00 p.m. Music 4:00 p.m. Let's Paint 7:00 p.m. Healing Touch On 8/25/15 observations made for B Unit were as follows: a. At 8:46 a.m., the television was on in the day room. There were 4 residents in the area that were not watching the television. Resident #22 had a yellow substance food spill on her top and lap. Multiple crumbs covered the wheelchair foot pedal cover. b. At 9:02 a.m., Resident #22 remained in the day area with the food spills on her clothing. Music was playing on the television. Four other residents were in the day room. Resident #26 ambulated out of the day room and down the hall. Resident #7 sat in a reclined wheelchair in the day area and three flies landed on the resident and crawled on her clothing. No active listening / participation in the music was observed. No staff was present to assist or encourage residents with the music activity. c. At 9:12 a.m., CNA #4, CNA #5 and the Alzheimer's Unit Director (AUD) were in the room of Resident #28 related to a fall, leaving no staff to monitor the residents in the day room / dining room / hallway. d. At 9: 20 a.m., no staff was present in the day room or dining room areas to monitor the residents. e. At 9:32 a.m., there was no activity provided. The music program on the television was no longer playing. Resident #22 remained with the same food spills on her clothing. f. At 9:35 a.m., Resident #29 was at the locked door yelling, President of the United States! Help! They won't let me go where I want to go! No staff was present. g. At 9:41 a.m., the facility cosmetologist was present. Four residents were near the locked door. Resident #12 sat at a dining room table and Resident #24 sat in the dining room near Resident #12. The residents in the day area / hall were verbalizing loudly. h. At 9:43 a.m., the AUD entered the hall. The cosmetologist stated that Resident #29 liked to play the piano. The AUD left the unit and returned with a keyboard and placed it on a dining room table. The Housekeeping Supervisor was talking with Resident #25. A few residents were assisted to the dining room and Resident #29 played the keyboard briefly and then moved away. Resident #26 ambulated into the hall and then the dining room. She had multiple food spills on her pants from the upper left front side down the left side to the knee. i. At 9:49 a.m., the AUD provided fluids / cool aid to some of the residents present in the dining room and the adjoining hall and day room. CNA #4 removed Resident #24 from the area to her room. There was an odor of feces coming from the resident. j. At 9:53 a.m., the cosmetologist attempted to get Resident #25 to drink the red cool aid. Resident #25 was crying out for her children and threw the fluids at the cosmetologist and cried out, My children! Take me home to my children! The AUD came to Resident #25 and attempted to calm the resident. The AUD or other staff did not offer fluids to all the residents present. Resident #7 was in the day room and facing the television that was not turned on. Resident #29 was at the locked door kicking it with his feet. Many of the residents were loudly verbalizing, yelling and many were moving about. k. At 9:56 a.m., the cosmetologist performed nail care for Resident #27 in the dining room. Resident #25 stated, I want to go home. Resident #25 attempted to get out of the exit door. CNA #4 came to the resident and talked softly to her. Licensed Practical Nurse (LPN) #4 arrived at 10:00 a.m. Resident #25 stated, I want help to get out of this place! LPN #4 talked softly to the resident about her family. The resident was crying and calling out her daughter's name. Resident #24 was returned to the day area from her room by CNA #5, the wheelchair tray was in place. Her name was written in large black print letters across the back shoulder area of the clothing she was wearing. There was a hole in the left sleeve cuff and a smaller hole on the right cuff. l. At 10:07 a.m., CNA #5 talked to Resident #25 who calmed briefly and when the CNA told the resident of need to change pants (from the cool aid spill), the resident stated, No. CNA #5 stated, You're wet. Resident #25 stated, They'll dry. CNA #5 obtained a moistened paper towel to wash her face. m. At 10:10 a.m., CNA #5 asked Resident #22 if she wanted to go to the bathroom. CNA #5 then left the resident to move a shower chair. CNA #4 took the resident to her room. n. At 11:17 a.m., Resident #22 continued with the same shirt with food spills. Music was playing in the day room. CNA #5 was asked, What do you do when not giving care. CNA #5 stated, I give care. Talk to them. TV, radio. It gets a little loud some days. My partner (CNA #4) is at lunch now. CNA #5 did not have assistance on the unit. o. At 2:17 p.m., there was no activity provided on the unit. Multiple residents were moving about in wheelchairs. Resident #27 rolled her wheelchair into the day room over Resident #21's right foot / toe, who was sitting in a chair on the left just inside the door. Resident #21 cried out in pain. Resident #27 stated loudly, What're you hollering for? CNA #4 came from the dining room to check on the resident. CNA #4 went out of the hall to inform the nurse. Resident #26 continued with the same pants on with spills / stains. LPN #3 assessed Resident #21 where the resident sat in the day room. The multiple residents in the area were vocally loud. p. At 2:32 p.m., the AUD was asked for a copy of the activity calendar for the units. There was no calendar posted on the B unit. The AUD stated, I can get you a copy from the A hall. When asked about the B hall calendar, the AUD stated, It's not posted but I can get you a copy. When asked who does activities on the units, the AUD stated, Aides. When asked if any one person was assigned, the AUD stated, No. I'm back and forth. q. At 4:21 p.m., Resident #26 continued with the same pants with food spills / stains. 4. The August 2015 Activity Calendar for 8/26/15 received from the Alzheimer Unit Director (AUD) on 8/25/15 at 2:38 p.m. documented the following: 9:00 a.m. Current Events 10:00 a.m. Exercise 2:00 p.m. Music 4:00 p.m. Craft corner 7:00 p.m. Pretty nails On 8/26/15 observations made for B Unit were as follows: a. At 8:08 a.m., CNA #5 was feeding Resident #12. LPN #4 was at a medication cart parked between the dining room and day room. CNA #6 was serving drinks to residents in the dining room. Resident #16 was in the day room lying on the couch. The television was on. He was not watching the television. b. At 8:10 a.m., Resident #27 requested coffee. CNA #6 asked if she wanted water or cool aid. Resident #27 stated, I want coffee. CNA #6 stated, We ran out of coffee. We will get more when we take the cart back. Resident #27 was given an 8-ounce cup of water. c. At 8:35 a.m., Resident #22 was in a wheelchair with milk-like food spills on her top and lap and a piece of bread measuring approximately 3 inches long and one inch wide. At 8:38 a.m., CNA #6 removed the piece of bread from the resident's lap. The television was on in the day room. Three residents were in the day room. One was watching the news / weather on the television by standing in front of the television. CNA #6 stated that Resident #27 had already had 2 cups of coffee this morning. The nurse said not to give too much. It makes her blood pressure go up. After I gave her the water she didn't ask anymore. d. On 8/26/15 at 8:42 a.m., CNA #5 was asked how many staff were on the B hall. The CNA stated, Only me and another aide. At this time both CNAs were in Resident #7's room to do a 2 person gait belt transfer, there was no staff on the hall to monitor the other residents. CNA #5 stated, She (AUD) wants us to do activities. I can't do it all with what I've got to do. It was bad yesterday, noisy. When I got home, I just blew up. e. At 9:26 a.m., multiple residents sat in the day room and near the day room door. The AUD entered the hall and asked Resident #28 if she liked sports. Resident #28 said she did not, very loudly and continued to talk loudly. The AUD then asked Resident #29 if he liked sports - baseball and began talking to the resident. Resident #22 continued to sit in a wheelchair near the day room with the same milky food spills on her shirt and lap. 5. On 8/27/15 observations made for B Unit were as follows: a. At 12:35 p.m., Resident #30 sat in the dining room at a table with head down and not eating. CNA #4 attempted to wake the resident one time by shaking the resident's shoulder and speaking to the resident. The resident's shirt was pulled up exposing the right side of the abdomen and around to the back. Without any further interaction with the resident, CNA #4 then continued to serve other residents food. b. At 12:36 p.m., the AUD entered the unit, gave the surveyor a copied form of the Initial Activity Assessment (undated) for Resident #7 and left the unit immediately. c. At 12:38 p.m., Resident #24 was sucking and biting on her shirt by lifting the shirt and tearing pieces of cloth off with her teeth and spitting it out. She rolled the pieces in her left hand. This was not observed by the 2 CNAs who were serving lunch. Resident #24 pulled up her top exposing her breasts and bit the material 2 times, still not observed by the staff. d. At 12:40 p.m., a family member of another resident assisted Resident #22 with a juice spill at the table. The CNAs continued to serve lunch. e. At 12:42 p.m., Resident #26 ambulated from the day room to the dining room. She had a large wet area covering her entire buttock area. She stated, It got wet and pulled at the pants. CNA #5 took the resident to her room with a bag of peri-care supplies, leaving one CNA in the dining room. f. At 12:44 p.m., the AUD was present on the unit. She placed a clothing protector on Resident #24 and began to feed the resident. g. At 12:46 p.m., Resident #30 began to eat without assistance. The resident's shirt was still pulled up, exposing parts of the resident's abdomen, right side and back. h. On 8/27/15 at 12:50 p.m., a supply closet located to the left of the television in the day room had the key in the door knob. The door was not locked and opened easily. The supply closet contained activity supplies and personal hygiene products. It also contained 2 bottles of nail polish and one safety razor in an open box on the top right shelf. A shelf along the back of the wall contained a box approximately 3/4 full of wooden manicure sticks, eleven safety razors and a one quart spray bottle almost full of cleaner with bleach. CNA #6 was assisting residents in the dining room. CNA #5 had taken Resident #26 to her room to change her clothing. No other staff was present. i. At 12:55 p.m., Resident #29 cried out, I need to go bad! He sat in a wheelchair in the hall. A family member pushed the resident in the wheelchair to his room and stated, Wait til (CNA #4) gets back. The resident stated, Hurry up. I'm going to mess my pants. j. At 12:57 p.m., the AUD brought a sit to stand mechanical lift to the unit. She instructed CNA #4 to get Resident #29 up and the AUD left the unit. With CNA #4 in a resident's room and the AUD absent from the unit, CNA #5 was the only staff left on the hall. There was one family member present. LPN #1 was present and feeding a resident in the dining room. k. At 1:00 p.m., the AUD brought the sling for the sit to stand lift to Resident #29's room. l. At 1:50 p.m., the majority of the residents who resided on the unit were in the day room / hall. There was no activity provided. There was no nursing staff on the hall. The 2 CNAs assigned to the hall were in Resident #28's room assisting the resident. A housekeeper was mopping the dining room floor. Resident #26 ambulated into the dining room and walked on the wet floor in socks. The housekeeper stopped mopping. The housekeeper and the surveyor assisted the resident from the dining room area. 6. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/16/15 documented the resident scored 0 (0 - 7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), sometimes made self understood, was inattentive, had disorganized thinking and psychomotor [MEDICAL CONDITION], had minimal depression, required extensive assistance for bed mobility, transfer, locomotion, dressing, eating, toilet use, personal hygiene and bathing and was always incontinent of bladder and bowel. a. The Care Plan dated 3/11/15 documented, Problem . I have a life long history of depression . Approaches . 1:1 visits with me. Allow me opportunities to make choices regarding my schedule. Observe me for changes in my mood status. Evaluate for environmental changes to enhance my mood. Allow me to select seating at activities and in dining room . Monitor me for suicidal ideation . Visit with me and discuss my interests, past social patterns in community. Record / monitor me for patterns of target behaviors. Provide opportunities for me for increased socialization with others on my unit and during mealtimes. Provide opportunities for me to correspond with others outside of facility via writing letters, sending emails, or making telephone calls. Problem . I am at risks for falls . Approaches . Assist with ADLs (activities of daily living) as needed but encourage resident to do as much for self as possible and allow them plenty of time without feeling rushed . Set up hygiene supplies and encourage Resident to do as much as possible for self but always assist as needed . Problem . I wander into unsafe situations . Approaches . Place me in area where frequent observation is possible. Alert staff to my wandering behavior. Provide diversional activities for me . If I wander away from unit, instruct staff to stay with me, converse and gently persuade me to walk back to designated area with them. Note which exits I favor for elopement from facility. Alert staff working near those areas. Monitor and document my behavior . b. The Closet Care Plan dated 3/18/15 documented, Restraints: lap belt, pressure alarm, bolster mattress . bed mobility: assist of 1 or 2 . splints (right) hip fx (fracture), ambulation/mobility: assist of 1 or 2 gait belt . Toileting: incontinent, briefs . shower . low bed . toilet Q (every) 4 (hours) at night . c. Documentation in the area of Behavior Observations on the August 2015 ADL Sheet included one check mark on 8/4/15 at 10:30 p.m. All other dates and shift were either blank or had a zero documented. 8/24/15 through 8/29/15 documented, O for each shift. d. A monthly summary Nurses Note dated 8/5/15 documented, .admitted to this facility in December 2010 . Transfers with 2 person gait belt staff assisting into wheelchair and is pushed about by staff. 1 person extensive assistance needed with ADLs (Activities of Daily Living) such as dressing, bathing, oral care, and incontinent care. Showers and shampoos given 3 (times) weekly . Oral care provided after each meal, HS (bedtime), and PRN (as needed) . Alert and oriented to name only with short and long term memory loss noted due to Alzheimers. Pleasant and cooperative with staff and others. No s/s (signs or symptoms) of depression noted at present . Incontinent of bowel and bladder and is checked often with good pericare provided PRN . feeds self with tray set up . e. On 8/24/15 at 6:35 a.m., the resident was in a low to the floor, high-backed wheelchair in the dining room. CNA #7 stated, this was an Alzheimer's unit for end-stage moderate to severe. f. On 8/26/15 at 8:42 a.m., CNA #5 and CNA #6 pushed the resident in the wheelchair to her room. CNA #6 stated, We call the wheelchair a low rider. CNA #5 gathered supplies and returned to the resident's room at 8:45 a.m. with a shower chair. CNA #5 pushed the resident from the B hall to the F hall shower room. CNA #5 stated, Can't use B hall (shower). When the CNA sprayed water on the resident in the shower, Resident #7 cried out, It's wet! It's wet! Get off! The CNA talked calmly to the resident and decided not to wash the resident's hair. The CNA stated the resident normally did not act like that in the shower. 7. Resident #12 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 6/23/15 documented the resident scored 0 (0 - 7 indicates severe cognitive impairment) on the BIMS, was inattentive, had disorganized thinking and altered level of consciousness, required supervision only for eating, required extensive assistance in bed mobility, transfer, locomotion, dressing, toileting and personal hygiene, was totally dependent for bathing and was always incontinent of bladder and bowel. a. The Care Plan dated 7/14/14 documented, Problem/Need . I need max (maximum) assistance with my ADL's . I need you to assist me with my ADLs but continue to encourage me to be independent as much as possible . I need you to set up my hygiene supplies and encourage me to do as much as possible for myself but always assist as needed . I need assistance with meals; encourage me to try to feed myself and document how much I eat. I must be fed by staff, take your time please and record how much I eat. I require the use of a mechanical lift and 2 staff for all transfers . Problem / Need . Activities: Resident participates in group programming of interest with reminders and encouragement at times . Approaches . Offer opportunities for success and praise as often as possible. Encourage resident to socialize with other resident and staff. Give resident verbal reminders of activity before commencement of activity and assist as needed. Offer activity programs directed toward specific interests of resident. Engage resident in group activities of interest and capabilities such as music, spiritual, exercise, social functions, cooking, folding, trivia, bingo, word games, etc . Problem / Need . I wander into unsafe situations . Approaches . Provide diversional activities for me . b. The Closet Care Plan (undated) documented, Bed mobility assist of 1 . Ambulation/mobility . assist of 1, wheelchair, lift to chair, Eating . cueing, set-up, Toileting . incontinent, briefs . toilet every 2 hours, fed at meals . c. The August 2015 CNA ADL sheet documented, Behavior observations. All shifts documented a zero or were blank except 8/16/15 at 10:30 p.m. documented, N. There was no legend on the form that documented what N meant. d. On 8/24/15 at 10:00 a.m., CNA #8 and CNA #9 entered the resident's room to transfer the resident using a sit to stand mechanical lift. The sit to stand lift base where a resident would stand was covered in crumbs and debris. While the CNAs were in the resident's room, there was no staff present on the hall monitoring the other residents. 8. Resident #23 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 6/23/15 documented the resident had a BIMS score of 0 (0 - 7 indicates severe cognitive impairment), required extensive assistance for ADLs and was mobile in a wheelchair. a. The Care Plan dated 10/13/14 documented, Problem / Need . I am at risk for bleeding secondary to the use of anticoagulant therapy . Approaches . Observe me for s/s of bleeding and report to MD (medical doctor). (Bleeding gums, Hematuria, joint pain, swelling, epistaxis, increased bruising, abdominal pain, tarry stools . Problem / need . I have poor safety awareness . Approaches . Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician . Problem / need . I wander into unsafe situations . Approaches . Place me in area where frequent observation is possible. Alert staff to my wandering behavior. Provide diversional activities for me. Approach me positively and in calm, accepting manner . b. On 8/29/15 at 9:55 a.m., a review of the resident Incident and Accident Report for June, July and August 2015 documented the following: 1) A Resident Incident Report dated 7/28/15 at 4:30 p.m. documented, CNA (name) came to this nurse and stated that while resident was agitated she witnessed her grab another resident's left wrist. No injury. Immediate Actions Taken: Resident's were already separated. Assessed for injuries. (Physician) and family notified. 2) A Resident Incident Report dated 8/17/15 at 12;30 a.m. documented, CNA (name) notified this nurse that she discovered a skin tear with a red ring measuring approximately 2 cm (centimeters) (by) 2 cm around the wound. Skin tear to left forearm measuring approximately 1 cm (by) 0.25 cm with red ring measuring approximately 2 cm (by) 2 cm surrounding it. Wound site is cool to the touch with no c/o (complaint of) pain voiced. Immediate Actions Taken: Wound site cleaned and patted dry . 3) A Resident Incident Report dated 8/18/15 at 2:16 p.m. documented, This resident sitting in hallway in w/c (wheelchair) Another resident pushed Hoyer lift into this resident. (Injuries) none. Immediate Actions Taken: Assessed resident for injury, removed Hoyer lift from hall . 9. Resident #28 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 8/4/15 documented the resident scored 0 (0 - 7 indicates severe cognitive impairment) on the BIMS, was inattentive, had [MEDICAL CONDITION] and an altered level of consciousness, was totally dependent for ADLs, was always incontinent of bladder and bowel and used a wheelchair. a. The Care Plan dated 12/19/13 documented, Problem / need . I display socially inappropriate/disruptive behavior . Approaches . Monitor and document my behavior. Do not argue with me. Praise me for demonstrating desired behavior. Administer my behavior medications as ordered by physician. Talk with me in calm voice when my behavior is disruptive. Remove me from public area when behavior is disruptive and unacceptable Problem / need . I am at risk for falls .Approaches . 12/2/14 I require a Marissa lift (with) 2 staff assist for all transfers . Problem / need . I wander into unsafe situations . Approaches . Place me in area where frequent observation is possible. Alert staff to my wandering behavior. Provide diversional activities for me. Approach me positively and in calm, accepting manner . b. On 8/29/15 at 10:23 a.m., a review of the resident Incident and Accident Report for June, July and August 2015 documented the following: 1) A Resident Incident Report dated 6/26/15 at 10:42 a.m. documented, Reported by (name) Resident found to have small abrasion to LLE (left lower extremity) 3 cm abrasion to LLE Immediate Actions Taken: First aid to LLE . Immediate Post-incident action: Resident to wear long pants while up in wheelchair to prevent scraping of skin. 2) A Resident Incident Report dated 7/21/15 at 3:00 p.m. documented, CNA came to this nurse and stated resident was in the floor beside her bed and her left arm was caught in the bed rail. No injuries. Immediate actions taken: Assessed for injuries. CNAs lifted resident from floor (with) lift and placed in wheelchair. Neuro check initiated. (Physician), Supervisor, and family notified . Immediate Post-Incident Action: An alarm will be clipped on her gown while she is in bed. 3) A Resident Incident Report Dated 8/25/15 at 9:15 a.m. documented, CNAs were transferring resident with Hoyer had resident in lift. Lift malfunctioned lowering to floor. No injuries noted. Immediate Actions taken: Resident immediately assessed for injury then returned to bed. Notified (Physician) and (name) responsible party notified. Lift was removed by maintenance and repaired. Immediate Post-Incident Action: Maintenance notified. Lift removed from use and repaired. Staff than re-educated on use of the lift. 10. Resident #29 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 8/19/15 documented the resident scored 0 (0 -7 indicates severe cognitive impairment) on the BIMS, had disorganized thinking, required extensive assistance in ADLs, used a wheelchair, and was frequently incontinent of bladder and bowel. a. The Care Plan undated documented, Problem onset date: 8/25/15 I require extensive assist (times) 1 staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing and require extensive assist (times) 1 staff locomotion . Approaches . Please assist me to specific areas when I am up in my w/c such as activities, therapy, dining room, and my room . b. On 8/29/15 at 10:27 a.m., a review of the resident Incident and Accident Report for June, July and August 2015 documented the following: An Incident Report dated 8/12/15 at 8:00 p.m. documented, Resident in room was reaching to grab something off low bed in room when he slid out of wheelchair onto hands and knees. No s/s (signs/symptoms) of injuries noted at this (time). ROM (range of motion) WNL (within normal limits) to all extremities for this resident. Immediate Actions taken: Assessed for injuries no s/s of injuries noted at this (was documented). Assisted back into wheelchair (times) 2 staff then prepared and assisted into bed. Immediate Post-Incident Action: Low bed removed from resident's room. 11. Resident #22 had [DIAGNOSES REDACTED]. The 5 day admission MDS with an ARD of 6/17/15 documented the resident scored 0 (0 - 7 indicates severe cognitive impairment) on the BIMS, had inattention and disorganized thinking, had delusions, required extensive assistance for ADLs, used a wheelchair, and was frequently incontinent of bladder and bowel. a. The undated Care Plan documented, Problem Onset: 8/25/2015 I have a skin tear/laceration . Approaches . I need a mechanical lift to avoid further skin tears . Problem onset 8/25/2015 I am experiencing the presence of pain in my fractured finger . Approaches: Administer my pain medication as ordered. Assist me with diversional activities. Assist me to change positions slowly as needed. Observe for worsening of my pain symptoms such as: discomfort, soreness, tightness, stiffness, fatigue, sleeplessness, stress, anxiety and report to physician. Dressing as ordered to hand . Problem Onset 08/25/15 I require extensive assist (assistance) x(times) 2 staff with bed mobility, transfers, dressing, toileting, personal hygiene and bathing and required extensive assist x 1 staff with locomotion . Approaches . Please assist me to specific areas when I am up in w/c such as activities, therapy, dining room and my room . b. On 8/29/15 at 10:13 a.m., a review of the resident Incident and Accident Report for June, July and August 2015 documented the following: 1) An Incident Report dated 6/6/15 at 8:00 p.m. documented, Resident sitting in a hall dining room when she stood self up out of dining room chair took one step, lost balance, and fell to knees. No s/s of injuries noted at this x (time) but resident is complaining of right knee pain. Placed call to (physician) with new order received: on-site imaging to do X-ray of right knee due to fall. Immediate actions taken: Assessed resident for injuries found zero s/s of injuries noted at this x. Checked ROM with resident complaining when this nurse touched right knee, assisted into chair x (times) 2 staff, called (physician) and X-ray order. Immediate Post-Incident Action: Resident to be assisted to the restroom Q (every) 2 hours and PRN and before and after meals. Interventions: CNA instructed to keep resident i

Based on observation, record review and interview, the facility failed to ensure that Resident #11 who had a [MEDICAL CONDITION] received proper treatment and care to prevent complications. The facility failed to ensure licensed staff was informed immediately of a significant change in condition/respiratory distress; to ensure Licensed Staff was competent in providing tracheal suctioning; and to ensure staff responded promptly to the need for suctioning to prevent complications for 1 of 1 (Resident #11) case mix residents who had a [MEDICAL CONDITION]. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death for Resident #11 who had to be hospitalized after a change in respiratory status that required deep suctioning and Licensed staff was not competent when performing tracheal suctioning. There were no other resident who had [MEDICAL CONDITION] within the facility. The facility was notified of the Immediate Jeopardy on 8/24/15 at 8:1 a.m. The findings are: Resident #11 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 7/24/15 documented the resident scored 0 (0 - 7 indicated severely impaired) on a brief interview for mental status, was totally dependent on one-to-two staff members for all Activities of Daily Living (ADL's), was short of breath/trouble breathing while lying flat, received oxygen therapy, suctioning and [MEDICAL CONDITION] care while a resident, and was not offered a pneumococcal vaccine. a. The August 2015 Physician order [REDACTED].PRN (as needed) suction secretions [MEDICAL CONDITION] to excessive secretions . b. The Plan of Care copied on 8/25/15 at 11:00 documented, .Problem Onset: 8/24/2015 I am unable to care for my [MEDICAL CONDITION] and sometimes I have shortness of breath .Approaches: Perform [MEDICAL CONDITION] every shift; Check [MEDICAL CONDITION] daily for redness or drainage; listen to my lung sounds every shift; monitor my vital signs; suction as needed for increased secretions; medications as ordered to decrease secretions;[MEDICAL CONDITION] as ordered .Problem Onset: 8/24/2015 I require oxygen therapy .Approaches: Monitor for changes in my symptoms that may indicate worsening respiratory status and report to physician .Problem: I need total assistance with my activities of daily living (ADLs) .Approaches: I need you to ensure my call light is in reach and please answer it promptly . c. On 8/24/15 at 7:01 a.m., the resident was lying in bed, and gurgling when the Health Facility Surveyor (HFS) entered the resident's room. She immediately summoned CNAs (Certified Nurses Assistant) #17 and #18 to the resident bed. After being summoned, CNA #17 and #18 attended the resident in the other bed and did not summon the nurse. The HFS then summoned the Registered Nurse (RN) Surveyor to the resident's room. At 7:03 a.m., the RN Surveyor entered the resident's room and observed the resident lying in bed with a [MEDICAL CONDITION] cannula in place, gurgling, face beet red, wide eyed and the call light was not within reach. CNA #17 and #18 were still attending to the resident in the other bed. The HFS went to get a nurse and let her know that the resident was in respiratory distress and needed to be suctioned. At 7:05 a.m., Licensed Practical Nurse (LPN) #12 entered the room after telling the HFS that she was not his (Resident #11) nurse as she retrieved gloves from the Housekeeping Closet. She then took the connection tubing that was already connected to the suction machine and placed it directly on the tip and around the [MEDICAL CONDITION] cannula four times. Each time she placed the connection tubing on the tip and around the cannula, she used an already open cup of non-sterile water placing the tip of the tubing in it. She did not use sterile gloves nor did she use a sterile suction tube at this point. LPN #12 was asked if sterile suction tubing was not available to suction down [MEDICAL CONDITION] to remove the thick, greyish green thick secretions still causing him respiratory distress. She stated, Yes, but it's all right here (pointing at the tip of [MEDICAL CONDITION]) can't you see? This surveyor responded that he obviously still needs suctioning down the cannula since he is still in respiratory distress, gurgling, coughing and red faced. She then stated, as she removed sterile gloves and suction tubing, I'm not his nurse; not sure I can do this, or if he will let me. She then donned a pair of sterile gloves, retrieved the suction tubing and attempted to dig at [MEDICAL CONDITION] trying to pull out the cannula when the resident grabbed her hand with his left hand. At this time the Surveyor stopped her and instructed her to get a nurse that knew how to suction him. She left and as she was leaving the room she stated to the other surveyor outside the doorway, I don't know what to do, I'm not his nurse. At 7:12 a.m., LPN #11 entered, washed her hands, donned sterile gloves and put on a sterile suction tubing and thoroughly suctioned Resident #11's [MEDICAL CONDITION] cannula removing copious amount of secretions without incident. d. On 8/24/15 at 7:20 a.m., LPN #13, who provided care for the resident during the 11 - 7 (night shift) on 8/23/15 was asked if she was aware that (Resident #11) was in respiratory distress this morning? She stated, No, but I did have to suction him two times last night due to increase in secretions. He is post day 3 antibiotic therapy for an Upper Respiratory Infection. He was cultured 2 weeks ago. She was then asked if he could use a call light to call for help? She stated, Yes, he can use his left hand to call for help if the call light is in that hand. She was then asked if she was aware that he did not have the call light in his left hand or near his left hand to call for help this morning when he was in respiratory distress? She stated, No, but I check on him every 2 hours and the aides check on him every 2 hours, so he's checked at a minimum every hour because he is like a typical step down unit patient. Needs frequent monitoring. The aides were just in there repositioning him so they must have not put his call light back in his left hand before they left. e. On 8/24/15 at 8:32 a.m., CNA #17 was asked when she went to (Resident #11's) room, why did she go to the other bed? The CNA stated, I didn't catch the name of the resident from the surveyor. She was then asked if (Resident #11) gurgles like that a lot. She stated, He sounds like that all the time. She was then asked if he could use the call light. She stated, Yes. She was asked if she had been trained in recognizing changes in condition. She stated, Yes. She was then asked, What do you do when you notice a change? She stated, Tell the nurse. She was asked how long she had worked here? She stated, Almost a year. f. On 8/24/15 at 12:15 p.m. the Immediate Jeopardy was removed and the scope/severity reduced to G when the following Plan of Removal was put in place: a. The Medical Director was called for an order to have the resident transported to the hospital for assessment. b. An immediate investigation of the incident was started. c. The 11-7 nurse was called to return to the facility to provide her written statement, and also for re-education/training related to [MEDICAL CONDITION] care and airway management. d. An in-service was initiated immediately with all nursing staff regarding [MEDICAL CONDITION] care and airway management, by Director of Program Management, RRT/LRCP (Registered Respiratory Therapist/Licensed Respiratory Care Practitioner). e. No nursing staff will be allowed to return to the floor, until they have completed this retraining. All staff currently not working (vacation, etc) and new hires will be trained prior to being allowed to work on the floor. f. All residents with orders for [MEDICAL CONDITION] care and suctioning were identified per physician orders. Resident was assessed on 8/24/15, at approximately 8:30 a.m. by DON, with no negative findings. Resident was transported to ER (emergency room ) at approximately 10:25 a.m. for evaluation. g. Nursing staff will be checked to determine that the correct [MEDICAL CONDITION] care is being provided, by DON/Designee 3x's per week, times 4 weeks; however, this monitoring process will be ongoing.

A. Based on observation, record review and interview, the facility failed to ensure residents with Dementia who resided on the secured unit were consistently provided with an activities program that was based on assessed preferences, interests and varied to meet the needs of the residents; activities were provided according to a planned activity calendar to alleviate potential boredom, restless behaviors and depression; and participation in activities was consistently documented and evaluated for 13 (Residents #7, #12, #16, #21 through #30) of 13 case mix residents who resided on the Advanced Alzheimer Care Unit (AACU). The failed practice resulted in a pattern of harm for Residents #7, #8, #12, #16, #21 through #30 who had a [DIAGNOSES REDACTED]. The findings are: 1. On 8/25/15 at 2:32 p.m., the AUD (Alzheimer's Unit Director) was asked for a copy of the activity calendar for the units. There was no calendar posted on the B unit. The AUD stated, I can get you a copy from the A hall. When asked about the B hall calendar, the AUD stated, It's not posted but I can get you a copy. When asked who does activities on the units, the AUD stated, Aides. When asked if any one person was assigned, the AUD stated, No. I'm back and forth. 2. The August 2015 Activity Calendar (obtained from the AUD on 8/25/15) for the B Hall documented the following activities for 8/24/15: 9:00 a.m. Current Events 10:00 a.m. Exercise 2:00 p.m. Music 4:00 p.m. Arts and Crafts 7:00 p.m. Pretty Nails On 8/24/15 observations made for B Unit were as follows: a. At 10:12 a.m., there were 3 residents in the day room with the television on. They were not actively watching the television. There were 2 residents in wheelchairs in the hall and 2 residents in the doorway of the day room. None of the residents were actively watching the television program that was currently airing. There were 3 residents in the dining room. The television was the only activity at this time on the unit. There was no activity of Exercise being provided at this time. The residents were moving about in wheelchairs and verbalizing loudly. b. At 10:15 a.m., Resident #24 was in a wheelchair with a tray and wore a back brace. The resident was sitting near the day room but not included in the group near the television. c. At 11:00 a.m., a movie was playing on the television in the day room. Four residents were in the day room but not actively watching the movie, which was a comedy. Two residents were in the dining room, one with coffee. A housekeeper was the only staff present at this time in the area. d. At 3:30 p.m., there was no activity provided. Residents were moving about in wheelchairs and verbalizing loudly. Resident #29 was agitated and repeatedly stated he wanted out. Certified Nurse Assistant (CNA) #4 was in the hallway. CNA #4 stated, He gets worse as the day goes on. Sundowners. He'll be better when his family comes in. CNA #4 did not go to the resident or try to calm him in any way. 3. The August 2015 Activity Calendar (obtained from the AUD on 8/25/15) for the B Hall documented the following activities for 8/25/15: 9:00 a.m. Current Events 10:00 a.m. Exercise 2:00 p.m. Music 4:00 p.m. Let's Paint 7:00 p.m. Healing Touch On 8/25/15 observation made for B Unit were as follows: a. At 8:46 a.m., the television was on in the day room. There were 4 residents in the area that were not watching the television. Resident #22 had a yellow substance food spill on her top and lap. Multiple crumbs covered the wheelchair foot pedal cover. b. At 9:02 a.m., Resident #22 remained in the day area with the food spills on her clothing. Music was playing on the television. Four other residents were in the day room. Resident #26 ambulated out of the day room and down the hall. Resident #7 sat in a reclined wheelchair in the day area and three flies landed on the resident and crawled on her clothing. No active listening/participation in the music was observed. No staff was present to assist or encourage residents with the music activity. c. At 9:12 a.m., CNA #4, CNA #5 and the Alzheimer's Unit Director (AUD) were in the room of Resident #28 related to a fall leaving no staff to monitor the residents in the day room/dining room/hallway. d. At 9: 20 a.m., no staff was present in the day room or dining room areas to monitor the residents. e. At 9:32 a.m., there was no activity provided. The music program on the television was no longer playing. Resident #22 remained with the same food spills on her clothing. f. At 9:35 a.m., Resident #29 was at the locked door yelling, President of the United States! Help! They won't let me go where I want to go! No staff was present. g. At 9:41 a.m., the facility cosmetologist was present. Four residents were near the locked door. Resident #12 sat at a dining room table and Resident #24 sat in the dining room near Resident #12. The residents in the day area/hall were verbalizing loudly. h. At 9:43 a.m., the AUD entered the hall. The cosmetologist stated that Resident #29 liked to play the piano. The AUD left the unit and returned with a keyboard and placed it on a dining room table. The Housekeeping Supervisor was talking with Resident #25. A few residents were assisted to the dining room and Resident #29 played the keyboard briefly and then moved away. Resident #26 ambulated into the hall and then the dining room. She had multiple food spills on her pants from the upper left front side down the left side to the knee. i. At 9:49 a.m., the AUD provided fluids/Kool-aid to some of the residents present in the dining room and the adjoining hall and day room. CNA #4 removed Resident #24 from the area to her room. There was an odor of feces coming from the resident. j. At 9:53 a.m., the cosmetologist attempted to get Resident #25 to drink the red Kool-aid. Resident #25 was crying out for her children and threw the fluids at the cosmetologist and cried out, My children! Take me home to my children! The AUD came to Resident #25 and attempted to calm the resident. The AUD or other staff did not offer fluids to all the residents present. Resident #7 was in the day room and facing the television that was not turned on. Resident #29 was at the locked door kicking it with his feet. Many of the residents were loudly verbalizing, yelling and many were moving about. k. At 9:56 a.m., the cosmetologist performed nail care for Resident #27 in the dining room. Resident #25 stated, I want to go home. Resident #25 attempted to get out of the exit door. CNA #4 came to the resident and talked softly to her. Licensed Practical Nurse (LPN) #4 arrived at 10:00 a.m. Resident #25 stated, I want help to get out of this place! LPN #4 talked softly to the resident about her family. The resident was crying and calling out her daughter's name. Resident #24 was returned to the day area from her room by CNA #5, the wheelchair tray was in place. Her name was written in large black print letters across the back shoulder area of the clothing she was wearing. There was a hole in the left sleeve cuff and a smaller hole on the right cuff. l. At 10:07 a.m., CNA #5 talked to Resident #25 who calmed briefly and when the CNA told the resident of need to change pants (from the Kool-aid spill), the resident stated, No. CNA #5 stated, You're wet. Resident #25 stated, They'll dry. CNA #5 obtained a moistened paper towel to wash her face. m. At 10:10 a.m., CNA #5 asked Resident #22 if she wanted to go to the bathroom. CNA #5 then left the resident to move a shower chair. CNA #4 took the resident to her room. n. At 11:17 a.m., Resident #22 continued with the same shirt with food spills. Music was playing in the day room. CNA #5 was asked what do you do when not giving care. CNA #5 stated, I give care. Talk to them. TV, radio. It gets a little loud some days. My partner (CNA #4) is at lunch now. CNA #5 did not have assistance on the unit. o. At 2:17 p.m., there was no activity provided on the unit. Multiple residents were moving about in wheelchairs. Resident #27 rolled her wheelchair into the day room over Resident #21's right foot/toe, who was sitting in a chair on the left just inside the door. Resident #21 cried out in pain. Resident #27 stated loudly, What're you hollering for? CNA #4 came from the dining room to check on the resident. CNA #4 went out of the hall to inform the nurse. Resident #26 continued with the same pants on with spills/stains. LPN #3 assessed Resident #21 where the resident sat in the day room. The multiple residents in the area were vocally loud. 4. The August 2015 Activity Calendar (obtained from the AUD on 8/25/15) for the B Hall documented the following: 9:00 a.m. Current Events 10:00 a.m. Exercise 2:00 p.m. Music 4:00 p.m. Craft corner 7:00 p.m. Pretty nails On 8/26/15 observations made for B Unit were as follows: a. At 8:08 a.m., CNA #5 was feeding Resident #12. LPN #4 was at a medication cart parked between the dining room and day room. CNA #6 was serving drinks to residents in the dining room. Resident #16 was in the day room lying on the couch. The television was on. He was not watching the television. b. At 8:10 a.m., CNA #6 was assisting Resident #27 with fluids in the dining room. c. At 8:38 a.m., the television was on in the day room. Three residents were in the day room. One was watching the news/weather on the television by standing closely in front of the television. d. On 8/26/15 at 8:42 a.m., CNA #5 was asked how many staff was on the B hall and stated, Only me and another aide. At this time both CNAs were in Resident #7's room to do a 2 person gait belt transfer, there was no staff on the hall to monitor the other residents. CNA #5 stated, She (AUD) wants us to do activities. I can't do it all with what I've got to do. It was bad yesterday, noisy. When I got home, I just blew up. e. At 9:26 a.m., multiple residents sat in the day room and near the day room door. The AUD entered the hall and asked Resident #28 if she liked sports. Resident #28 said she did not, very loudly and continued to talk loudly. The AUD then asked Resident #29 if he liked sports - baseball and began talking to the resident. 5. On 8/27/15 observations made for B Unit were as follows: At 1:50 p.m., the majority of the residents who resided on the unit were in the day room/hall. There was no activity provided. There was no nursing staff on the hall. The 2 CNAs assigned to the hall were in Resident #28's room assisting the resident. A housekeeper was mopping the dining room floor. Resident #26 ambulated into the dining room and walked on the wet floor in socks. 6. Resident #7 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/3/14 documented, Section F - Preferences for Customary Routine and Activities . Conduct res (resident) interview for daily/activity prefs (preferences) . 0. No (resident is rarely/never understood and family/significant other not available) . Conduct staff assessment for daily/activity prefs . BLANK . There were no preferences documented. The Quarterly MDS with an ARD of 6/16/15 documented the resident scored 0 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), sometimes made self-understood, was inattentive, had disorganized thinking and psychomotor [MEDICAL CONDITION], had minimal depression, required extensive assistance for bed mobility, transfer, locomotion, dressing, eating, toilet use, personal hygiene and bathing and was always incontinent of bladder and bowel. a. The Brief Cognitive Rating Scale (BCRS) dated 12/15/14 documented a score of 6. There was no current BCRS in the clinical record. b. An Individual Support Plan dated 12/15/14 and signed 1/5/15 by Licensed Practical Nurse (LPN) #16 documented, Area: Resident likes, dislikes, routine choices and customs: Resident enjoys bingo, Bible study, arts and crafts, games, trivia and reminiscing . Interventions/Services/Special Approaches: Staff will encourage resident to participate in activities of choice. Staff will encourage resident to continue to participate in family style dining. Allow Resident to make simple decisions in daily care. Staff will supervise ADLs (Activities of Daily Living) and assist when needed . c. The Care Plan dated 3/11/15 documented the following: Problem . I have a life long history of depression . Approaches . 1:1 visits with me. Allow me opportunities to make choices regarding my schedule. Observe me for changes in my mood status. Evaluate for environmental changes to enhance my mood. Allow me to select seating at activities and in dining room . Monitor me for suicidal ideation . Visit with me and discuss my interests, past social patterns in community. Record/monitor me for patterns of target behaviors. Provide opportunities for me for increased socialization with others on my unit and during mealtimes. Provide opportunities for me to correspond with others outside of facility via writing letters, sending emails, or making telephone calls. Problem . Activities: Resident participates in group programming of interest with reminders & (and) encouragement at times. (Resident #7) enjoys helping in the kitchen with snacks, bingo, family style dining and story time . Approaches . Offer opportunities for success and praise as often as possible. Encourage resident to socialize with other resident and staff. Give resident verbal reminders of activity before commencement of activity and assist as needed. Offer activity programs directed toward specific interests of resident. Engage resident in group activities of interest and capabilities such as music, spiritual, exercise, social functions, cooking, folding, trivia, bingo, word games, etc. 'Life's Simple Pleasure taking care of her baby and playing bingo . Problem . I have difficulty making my own decisions . Approaches . Please approach me from the front in a calm, unhurried manner . Ask about my preferences throughout the day. Provide me with a quiet environment when sharing important information . I need limited/supervision assistance with my activities of daily living (ADLs) . Approaches: Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician . Please observe/document/report any functional decline you notice and provide increased assistance; please notify charge nurse of changes noted . Problem . I wander into unsafe situations . Approaches . Place me in area where frequent observation is possible .Provide diversional activities for me . d. The Closet Care Plan dated 3/18/15 documented, Bed Mobility assist of 1 or 2 . Ambulation/mobility assist of 1 or 2 gait belt . Eating cueing . Mental attitude: Moody, Confused, Forgetful . Mouth care total care . Personal Hygiene . comb hair, peri care, shave, assist of 1 or 2 . Dressing assist of 1 or 2 . Toileting incontinent . The Closet Care plan did not address any targeted behaviors or activity preferences. e. A Nurses Note dated 4/17/15 at 1:18 p.m. documented, Spoke with daughter about possible room move. She voiced verbal permission to move to room (number) on B hall (AACU). All personal belongings and resident to room (number) at this time. Both nurses notified and dietary notified. An undated Initial Activity Assessment documented the resident resided in room (Room number, bed number) and listens to music, watches TV, goes outside. f. A Nurses Note dated 6/12/15 documented, Late entry for 6/11/15 Resident moved to room (Room number, bed number), Family notified and voiced agreement. g. An Activity Note dated 6/15/15 documented, Resident enjoys coming in and out of all activities, she really enjoys music activities and she likes food socials, she is sweet and she loves to visit with the staff and other residents. h. The August 2015 ADL sheet documented, Nursing Assistant to encourage activity participation & (and) record weekend activities, FYI (For Your Information) - Resident preferences for meals, bathing, other include: (no check marks to identify any listed items) . The form also documented, Behavior observations. There were no specific behaviors documented to observe. All shifts from 8/1/15 through 8/31/15 documented a zero or was blank except for 8/4/15 at 10:30 p.m. there was a check mark indicating behaviors but did not specify what the behaviors were. i. On 8/24/15 at 10:10 a.m., the resident was up in the wheelchair with her feet on the floor. The television in the day room was on a game show. Resident #7 sat with her head down and her eyes closed. There was no staff monitoring or encouraging residents in the activity. j. On 8/25/15 at 8:45 a.m., the resident was up in a wheelchair in her room. CNA #4 and CNA #5 were in the room where they had just returned the resident to her wheelchair after providing care. There was no staff monitoring the residents in the day room and dining room while the CNA provided care for the resident in her room. k. On 8/25/15 at 9:02 a.m., the resident was in a reclined wheelchair in the day area with 4 other residents. Music was playing. No active participation was observed from the resident. No staff assisted during the music activity. At 9:37 a.m., the resident was slumped back in a reclined wheelchair in the day area with eyes closed. At 9:53 a.m., the resident was in the day room and facing the television set that was not turned on. Other residents in the area were yelling and moving about. The facility cosmetologist and AUD were present attempting to calm another resident who was crying, yelling out. At 11:20 a.m., the resident was up in the wheelchair reclined in the day room. Music was playing. Her eyes were closed. No staff was in the day room monitoring or encouraging residents in the activity. At 2:15 p.m., CNA #4 and CNA #5 had just completed care on the resident. No staff was on the hall to monitor the other residents when they were providing care to this resident. l. On 8/26/15 at 8:42 a.m., CNA #6 pushed the resident in a wheelchair to her room. CNA #5 gathered supplies for care and brought a shower chair to the room. With the 2 CNAs in the resident's room, there was no staff monitoring the other residents. When asked about staff on the unit, CNA #5 stated, Me and another aide. (AUD) wants us to do activities. I can't do it all with what I've got to do. The resident was transferred with a gait belt to the shower chair, wrapped in a bath blanket and pushed to the shower room on the F hall. CNA #5 stated they could not use the shower room on the B hall. CNA #6 remained on the hall to monitor the residents. At 9:25 a.m., CNA #5 and CNA #6 provided peri care for the resident in her room after returning from the F hall shower room. 7. Resident #12 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 12/31/14 documented Section F - Preferences for Customary Routine and Activities, Conduct res interview for daily/activity prefs 1. yes. The items at F0400A (Interview for Daily Preferences) through F0500H (Interview for Activity Preferences) documented, 9. No response or non-responsive. The item F0600 Daily and Activity Preferences Primary Respondent documented, 9. Interview could not be completed by resident or family/significant other (No response to 3 or more items.) Item F0700 Should the Staff Assessment for Daily and Activity Preferences be Conducted documented, 1. yes (because 3 or more items in Interview for Daily and Activity Preferences (F0400 and F0500) were not completed by resident or family/significant other. The only items checked as a preference was discuss care with family/other, listening to music, and being around animals/pets. The Quarterly MDS with an ARD of 6/23/15 documented the resident scored 0 (0 - 7 indicates severely impaired) on the BIMS, was inattentive, had disorganized thinking and altered level of consciousness, required supervision only for eating, required extensive assistance in bed mobility, transfers, locomotion, dressing, toileting and personal hygiene, was totally dependent for bathing and was always incontinent of bladder and bowel. a. The July 2015 Physicians Orders sheet documented the orders were in effect for 60 days unless otherwise noted and an order 1/17/08 . Admit to ACU (Alzheimer's Care Unit). (The resident did not reside on the ACU at the time of the survey, the resident resided on the Advanced Alzheimer Care Unit on the B hall.) On 8/27/15 at 12:15 p.m., a family member stated the resident had moved to the B hall about 2 1/2 to 3 years ago. b. The Care Plan dated 7/14/14 documented the following: Problem . I need max assistance with my activities of daily living . Approaches . I need you to assist me with my ADLs . I need assistance with meals . I must be fed by staff . I am unable to perform my own oral care . I need you to bathe me . I am unable to reposition myself while up in chair . I am unable to propel myself in w/c (wheel chair). Please provide transportation to/from room for all events . I require the use of a mechanical lift and 2 staff for all transfers . Problem . Resident has DX (Diagnosis) of [MEDICAL CONDITION] . Approaches . Activities/Social Services to monitor for any psychosocial needs . Problem . I have poor safety awareness . Approaches . Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician . 5/13/14 - Resident to Resident (no) injury monitor for s/s of emotional distress x 24 (hours) . Problem/Need . Activities: Resident participates in group programming of interest with reminders and encouragement at times . Approaches . Offer opportunities for success and praise as often as possible. Encourage resident to socialize with other resident and staff. Give resident verbal reminders of activity before commencement of activity and assist as needed. Offer activity programs directed toward specific interests of resident. Engage resident in group activities of interest and capabilities such as music, spiritual, exercise, social functions, cooking, folding, trivia, bingo, word games, etc . Problem/Need . I wander into unsafe situations . Approaches . Provide diversional activities for me . Problem . Mood state: Resident has episodes of verbal and/or physically abusive behavior . Approaches: Always approach resident calmly and unhurriedly, speak in a quiet, calm voice . Attempt to refocus behavior to something positive when resident is showing abusive behavior . Encourage activities of choice and preferences. Notify MD if behavior interferes with functioning . Separate residents immediately if alteration occurs . Problem . I wander into unsafe situations . Approaches . Place me in area where frequent observation is possible . Provide diversional activities for me . c. The Brief Cognitive Rating Scale dated 1/15/15 documented a score of 6.2. d. The Closet Care Plan (undated) documented, Mental attitude: Alert, Confused, Forgetful. It did not document target behaviors to monitor or activity preferences. e. An Individual Support Plan dated 1/22/15 documented, Area: Physical/Medical/Health related issues . Approaches: Encourage resident to participate in activities of choice . Area: Resident likes, dislikes, routine choices and customs: Resident enjoys music, movies, some art, physical exercise at times, word searches. Approaches: Encourage resident to participate in activities of choice. Allow resident to perform as much of her ADLs herself as possible. Allow resident to make simple decisions regarding daily care. Invite resident to all activities . f. An Activity Note dated 4/2/15 documented, Resident does not enjoy being around people, she likes to be left alone, she does enjoy reading and listening to music, she does not enjoy going outside. g. On 8/24/15 at 10:00 a.m., CNA #9 and CNA #8 were in the resident's room. Resident #12 was in a wheelchair and the CNAs planned to use a mechanical lift to move the resident to the bed. While the CNAs were in the resident room, there was no staff monitoring the other residents in the day room and dining room. h. On 8/25/15 at 8:45 a.m. the resident was up in a wheelchair at a dining room table. She was positioned with her back to the day room. She remained in the same position at 9:05 a.m., 9:41 a.m. and at 11:20 a.m. Music was playing in the day room at 9:02 a.m. No staff assisted the resident to the day room for the music. 8. Resident #29 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 8/19/15 documented the resident scored 0 (0 -7 indicates severely impaired) on the BIMS, had disorganized thinking, required extensive assistance in ADLs, used a wheelchair, and was frequently incontinent of bladder and bowel, Section F - Preferences for Customary Routine and Activities documented the items very important to the resident were choose clothes to wear, take care of personal belongings, choose tub/bath/shower/sponge, have snacks between meals, choose own bedtime, discuss care with family/friends, lock things to keep them safe, have books, newspaper, mags (magazines) to read, listen to music, be around animals/pets, keep up with news, do favorite activities, go outside when good weather and participate in religious practices per resident interview. a. The August 2015 Physician order [REDACTED]. The admitted on the bottom of the order sheet was 8/12/15. There was no order to admit the resident to the locked unit. b. The Care Plan undated documented the following: Problem onset date: 8/25/15 I require extensive assist (assistance) x 1 staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing and require extensive assist x 1 staff locomotion . Approaches . Please assist me to specific areas when I am up in my w/c such as activities, therapy, dining room, and my room . Problem/need . I like activities and if you let me, I would attend offered activities daily. Goal .I will attend activities such as games such as chess, pet therapy activities, watching sports. Approaches . Allow me to participate in as many activities as I can without interfering with my daily needs. Encourage me to participate in activities. c. There was no activity calendar in the current activity documentation book for this resident. d. On 8/24/15 at 3:30 p.m., the resident was agitated and repeatedly stated he wanted out. CNA #4 walked in the hall. CNA #4 stated, He gets worse as the day goes on. Sundowners. He'll be better when his family comes in. CNA #4 did not go to the resident or try to calm him in any way. e. On 8/25/15 at 9:35 a.m., the resident was at the locked doors yelling, President of the United States! Help! They won't let me go where I want to go! No staff was present. At 9:43 a.m., the facility cosmetologist informed the AUD that the resident liked to play the piano. The AUD brought in a keyboard and placed it on a table in the dining room. Resident #29 played the keyboard briefly before wandering away. At 9:53 a.m., the resident was at the locked door kicking it with his feet. No staff approached the resident. 9. Resident #28 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 8/4/15 documented the resident scored 0 (0 - 7 indicates severely impaired) on the BIMS, was inattentive, had [MEDICAL CONDITION] and an altered level of consciousness, was totally dependent for ADLs, was always incontinent of bladder and bowel and used a wheelchair. a. The Care Plan dated 12/19/13 documented the following: Problem/need . I display socially inappropriate/disruptive behavior . Approaches . Monitor and document my behavior. Do not argue with me. Praise me for demonstrating desired behavior. Administer my behavior medications as ordered by physician. Talk with me in calm voice when my behavior is disruptive. Remove me from public area when behavior is disruptive and unacceptable . Problems/need . I have memory loss with impaired decision making. I do not always understand the intent of the message. I have a hx (history) of making inappropriate sexual remarks to males . Approaches . Ask about my preferences each day. Remind me of what your name is when you care for me. Validate my thoughts/feelings when I get confused or anxious . Encourage me to be as independent as possible and to participate in facility activities. When expressing inappropriate remarks, cue and remind me that my behavior is inappropriate. Remove me from the situation . Problem . I have no plans to discharge . Approaches . Post a calendar of events and remind me of the activities. Assist to activities prn . Problem/need . I wander into unsafe situations . Approaches . Place me in area where frequent observation is possible. Alert staff to my wandering behavior. Provide diversional activities for me. Approach me positively and in calm, accepting manner . b. The August 2015 Physician order [REDACTED]. Admit to AACU. c. The 2015 Activity Calendar for this resident documented the following activities for the week of 8/24/15 through 8/27/15: 8/25/15 at 4:00 p.m. Let's Paint and at 7:00 p.m. Healing Touch. There was no other activity documented for these dates. 10. Resident #25 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD dated 7/9/15 documented the resident scored 0 (0 - 7 indicates severely impaired) on the BIMS, was inattentive, had disorganized thinking, altered level of consciousness, and psychomotor [MEDICAL CONDITION], had behavior symptoms not directed toward others, behavior symptoms that interfered with social activities and disrupted care or living environment, required extensive assistance with ADLs, used a wheelchair and was frequently incontinent of bladder and bowel. Section F - Preferences for Customary Routine and Activities documented it was very important for the resident to discuss care with family/friend and participate in religious practices. a. The August 2015 Physician order [REDACTED]. Admit to LTC (long term care) services of (physician). b. An ISP (individual support plan)Quarterly update dated 4/15/15 documented, . residing on AACU with DX (diagnosis) of [MEDICAL CONDITION]. She is alert and oriented to self only. Short and long term memory loss present. Resident uses w/c for mobility with staff to propel. Incontinent of bowel and bladder mostly with peri-care provided prn by staff. Fed per staff most of the time, fair appetite noted. Fluids offered, snacks offered TID (three times a day) and taken fair. Weight is 136.4 which is weight loss this quarter. She had been started on [MEDICATION NAME] which she had a reaction to resulting in severe anxiety and behaviors. She was taken off of it recently and has had an improvement through still requires staff to feed her for most meals. She enjoys table games such as dominoes with her family when they visit along with arts/crafts, music and social activities . Will continue with current ISP at this time. c. The Care Plan dated 4/24/15 documented, Problem . I have difficulty making my own decisions . Approaches: Please approach me from the front in a calm, unhurried manner . Provide me

Based on observation, record review and interview, the facility failed to ensure Resident #s 7, 12, 16, 21, 22, 23, 24, 26, 27, 28 and 29 who had Dementia and who displayed behaviors received the appropriate treatment and services to maintain the highest level of mental and psychosocial functioning. The facility failed to ensure programs/activities that incorporated resident preferences were developed and to ensure sufficient staff to consistently implement the planned programs/activities to maintain maximum mental and psychosocial functioning for 13 of 13 (Resident #s 7, 12, 16, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30) case mix residents who resided on the Advanced Alzheimer Care Unit (AACU). This failed practice resulted in a pattern of harm for 13 residents (Resident #s 7, 12, 16, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30) who did not consistently receive a program of activities to prevent the potential for decline in mental function and resided on the AACU according to the census list provided by the Assistant Director of Nurses (ADON) on 8/24/15. The findings are: 1. The Alzheimer's Care Advanced Alzheimer Care Units (AACU) Admission Criteria/Discharge Criteria for B-hall received from the Alzheimer Unit Director on 8/27/15 at 12:32 p.m. documented the following: Resident must have a primary [DIAGNOSES REDACTED]. The resident will be pre-screened by the ACD (Alzheimer's Care Director) and must score between 6.5 and 7 on the Global Deterioration Scale. This score will be determined by administering the Brief Cognitive Rating Scale. Resident must have a physical exam to rule out any treatable medical cause for the cognitive loss. Resident's cognitive loss may not be the result of head trauma, mental [MEDICAL CONDITION] or mental illness or alcohol or drug induced. The resident must not exhibit behaviors that may result in injury to self or others. Physical abuse, combativeness, continual yelling or screaming that disrupts programming and escalates others, or self-destructive behavior will result in discharge from the unit. The resident will be medically stable at the time of admission and free of any communicable disease or infection that would require isolation. At any time, should the resident's medical condition be so acute as to require skilled care for aggressive curative (rather than palliative) treatment, the resident may be transferred into the skilled unit for care. Residents should be mobile, either by independent or assisted ambulation. Use of walkers, gerichairs, canes or 1 person assist for ambulation is permissible. The facility should consider the safety and homelike nature of the environment to determine the maximum number of walkers and gerichairs that will be permitted on the unit at any given time. When a resident has care needs that exceed what can reasonably be provided on the Unit, he/she must be transferred to the Skilled Unit. This will ensure the appropriate level of care for that resident and allow Unit staff to continue to provide care and programming for the other Advanced Care residents. The hospice benefit will be offered to every resident who meets the hospice criteria. If the responsible party declines the hospice benefit when it is recommended, or if the facility lacks a contract with a hospice program that is trained to provide services to Alzheimer patients, the resident should be transferred to the skilled section of the SNF to receive appropriate care. No resident with tube feeding or IV (Intravenous) therapy will be admitted or retained on the AACU. This will ensure the safety of all the residents. Routine oxygen may be considered. There will be a responsible party for each resident. Resident's family/responsible party and attending physician must be in agreement for the resident to be seen for a psychiatric evaluation and medication therapy as deemed appropriate by the interdisciplinary team. This is due to the possible escalation of anxiety, depression, hallucinations, delusions and harmful behavior that results during the later progression of the disease process. Resident's family/responsible party must be in agreement with the admission criteria of the Advanced Alzheimer's Care Unit. These individuals will receive and sign a copy on or prior to admission to the unit. There will be a 30 day evaluation period following admission to the AACU to ensure that the unit can address and successfully manage the new resident's needs and behaviors. The resident's family/responsible party, physician and the referring facility or unit will be advised of this policy and encouraged to keep a bed available for the resident during this evaluation period. 2. Resident #7 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/3/14 documented, Section F - Preferences for Customary Routine and Activities . Conduct res (resident) interview for daily/activity prefs (preferences) . 0. No (resident is rarely/never understood and family/significant other not available) . Conduct staff assessment for daily/activity prefs . BLANK . There were no preferences documented. The Quarterly MDS with an ARD of 6/16/15 documented the resident scored 0 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), sometimes made self-understood, was inattentive, had disorganized thinking and psychomotor [MEDICAL CONDITION], had minimal depression, required extensive assistance for bed mobility, transfer, locomotion, dressing, eating, toilet use, personal hygiene and bathing and was always incontinent of bladder and bowel. a. The Brief Cognitive Rating Scale (BCRS) dated 12/15/14 documented a score of 6. There was no current BCRS in the clinical record. b. An Individual Support Plan dated 12/15/14 and signed 1/5/15 by Licensed Practical Nurse (LPN) #16 documented, Area: Resident likes, dislikes, routine choices and customs: Resident enjoys bingo, Bible study, arts and crafts, games, trivia and reminiscing . Interventions/Services/Special Approaches: Staff will encourage resident to participate in activities of choice. Staff will encourage resident to continue to participate in family style dining. Allow Resident to make simple decisions in daily care. Staff will supervise ADLs (Activities of Daily Living) and assist when needed . c. The Care Plan dated 3/11/15 documented the following: Problem . I have a life long history of depression . Approaches . 1:1 visits with me. Allow me opportunities to make choices regarding my schedule. Observe me for changes in my mood status. Evaluate for environmental changes to enhance my mood. Allow me to select seating at activities and in dining room . Monitor me for suicidal ideation . Visit with me and discuss my interests, past social patterns in community. Record/monitor me for patterns of target behaviors. Provide opportunities for me for increased socialization with others on my unit and during mealtimes. Provide opportunities for me to correspond with others outside of facility via writing letters, sending emails, or making telephone calls. Problem . Activities: Resident participates in group programming of interest with reminders & (and) encouragement at times. (Resident #7) enjoys helping in the kitchen with snacks, bingo, family style dining and story time . Approaches . Offer opportunities for success and praise as often as possible. Encourage resident to socialize with other resident and staff. Give resident verbal reminders of activity before commencement of activity and assist as needed. Offer activity programs directed toward specific interests of resident. Engage resident in group activities of interest and capabilities such as music, spiritual, exercise, social functions, cooking, folding, trivia, bingo, word games, etc. 'Life's Simple Pleasure taking care of her baby and playing bingo . Problem . I have difficulty making my own decisions . Approaches . Please approach me from the front in a calm, unhurried manner . Ask about my preferences throughout the day. Provide me with a quiet environment when sharing important information . I need limited/supervision assistance with my activities of daily living (ADLs) . Approaches: Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician . Please observe/document/report any functional decline you notice and provide increased assistance; please notify charge nurse of changes noted . Problem . I wander into unsafe situations . Approaches . Place me in area where frequent observation is possible .Provide diversional activities for me . d. The Closet Care Plan dated 3/18/15 documented, Bed Mobility assist of 1 or 2 . Ambulation/mobility assist of 1 or 2 gait belt . Eating cueing . Mental attitude: Moody, Confused, Forgetful . Mouth care total care . Personal Hygiene . comb hair, peri care, shave, assist of 1 or 2 . Dressing assist of 1 or 2 . Toileting incontinent . The Closet Care plan did not address any targeted behaviors or activity preferences. e. A Nurses Note dated 4/17/15 at 1:18 p.m. documented, Spoke with daughter about possible room move. She voiced verbal permission to move to room (number) on B hall (AACU). All personal belongings and resident to room (number) at this time. Both nurses notified and dietary notified. An undated Initial Activity Assessment documented the resident resided in room (Room number, bed number) and listens to music, watches TV, goes outside. f. A Nurses Note dated 6/12/15 documented, Late entry for 6/11/15 Resident moved to room (Room number, bed number), Family notified and voiced agreement. g. An Activity Note dated 6/15/15 documented, Resident enjoys coming in and out of all activities, she really enjoys music activities and she likes food socials, she is sweet and she loves to visit with the staff and other residents. h. The August 2015 ADL sheet documented, Nursing Assistant to encourage activity participation & (and) record weekend activities, FYI (For Your Information) - Resident preferences for meals, bathing, other include: (no check marks to identify any listed items) . The form also documented, Behavior observations. There were no specific behaviors documented to observe. All shifts from 8/1/15 through 8/31/15 documented a zero or was blank except for 8/4/15 at 10:30 p.m. there was a check mark indicating behaviors but did not specify what the behaviors were. i. On 8/24/15 at 10:10 a.m., the resident was up in a low wheelchair with her feet on the floor. The television in the day room was on a game show. The resident had her head down and her eyes were closed. There was no staff monitoring or encouraging residents during this activity. j. On 8/25/15 at 8:45 a.m., the resident was in a wheelchair in her room. (Certified Nurse Assistant) CNA #4 and CNA #5 were in her room where they had just returned the resident to her wheelchair after providing care. There was no staff monitoring the residents in the day room and dining room. At 9:02 a.m., the resident was in a reclined wheelchair in the day area with 4 other residents. Music was playing. No active participation was observed from the resident. No staff assisted with the music activity. At 9:37 a.m., the resident was slumped in a reclined wheelchair in the day area with her eyes closed. At 9:53 a.m., the resident was in the day room in a wheelchair facing the television set that was not turned on. Other residents in the area were yelling and moving about. The facility cosmetologist and AUD (Alzheimer's Unit Director) were present attempting to calm another resident who was crying and yelling out. At 11:20 a.m., the resident was in a wheelchair reclined in the day room. Music was playing. Her eyes were closed. No staff was present in the day room monitoring or encouraging residents in the activity. At 2:15 p.m., CNA #4 and CNA #5 had just completed care for the resident in the resident's room. No other staff was present on the hall to monitor the other residents when they were providing care to this resident. k. On 8/26/15 at 8:42 a.m., CNA #6 pushed the resident in the wheelchair to her room. CNA #5 gathered supplies for care and brought a shower chair to the room. With the 2 CNAs in the resident's room, there was no staff monitoring the other residents. When asked about staff on the unit, CNA #5 stated, Me and another aide. (AUD) wants us to do activities. I can't do it all with what I've got to do. The resident was transferred with a gait belt to the shower chair, wrapped in a bath blanket and pushed to the shower room on F hall. CNA #5 stated they could not use the shower room on B hall. CNA #6 remained on the hall to monitor the residents. At 9:25 a.m., CNA #5 and CNA #6 performed peri-care for the resident in her room after return from the F hall shower room. l. On 8/27/15 at 10:25 a.m., the AUD was asked for any documentation related to assessments, behaviors and interventions for Residents #7. As of 8/29/15 at7:45 p.m., no documentation was provided. 3. Resident #12 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 12/31/14 documented Section F - Preferences for Customary Routine and Activities, Conduct res interview for daily/activity prefs 1. yes. The items at F0400A (Interview for Daily Preferences) through F0500H (Interview for Activity Preferences) documented, 9. No response or non-responsive. The item F0600 Daily and Activity Preferences Primary Respondent documented, 9. Interview could not be completed by resident or family/significant other (No response to 3 or more items.) Item F0700 Should the Staff Assessment for Daily and Activity Preferences be Conducted documented, 1. yes (because 3 or more items in Interview for Daily and Activity Preferences (F0400 and F0500) were not completed by resident or family/significant other. The only items checked as a preference was discuss care with family/other, listening to music, and being around animals/pets. The Quarterly MDS with an ARD of 6/23/15 documented the resident scored 0 (0 - 7 indicates severely impaired) on the BIMS, was inattentive, had disorganized thinking and altered level of consciousness, required supervision only for eating, required extensive assistance in bed mobility, transfers, locomotion, dressing, toileting and personal hygiene, was totally dependent for bathing and was always incontinent of bladder and bowel. a. The July 2015 Physicians Orders sheet documented the orders were in effect for 60 days unless otherwise noted and an order 1/17/08 . Admit to ACU (Alzheimer's Care Unit). (The resident did not reside on the ACU at the time of the survey, the resident resided on the Advanced Alzheimer Care Unit on the B hall.) On 8/27/15 at 12:15 p.m., a family member stated the resident had moved to the B hall about 2 1/2 to 3 years ago. b. The Care Plan dated 7/14/14 documented the following: Problem . I need max assistance with my activities of daily living . Approaches . I need you to assist me with my ADLs . I need assistance with meals . I must be fed by staff . I am unable to perform my own oral care . I need you to bathe me . I am unable to reposition myself while up in chair . I am unable to propel myself in w/c (wheel chair). Please provide transportation to/from room for all events . I require the use of a mechanical lift and 2 staff for all transfers . Problem . Resident has DX (Diagnosis) of [MEDICAL CONDITION] . Approaches . Activities/Social Services to monitor for any psychosocial needs . Problem . I have poor safety awareness . Approaches . Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician . 5/13/14 - Resident to Resident (no) injury monitor for s/s of emotional distress x 24 (hours) . Problem/Need . Activities: Resident participates in group programming of interest with reminders and encouragement at times . Approaches . Offer opportunities for success and praise as often as possible. Encourage resident to socialize with other resident and staff. Give resident verbal reminders of activity before commencement of activity and assist as needed. Offer activity programs directed toward specific interests of resident. Engage resident in group activities of interest and capabilities such as music, spiritual, exercise, social functions, cooking, folding, trivia, bingo, word games, etc . Problem/Need . I wander into unsafe situations . Approaches . Provide diversional activities for me . Problem . Mood state: Resident has episodes of verbal and/or physically abusive behavior . Approaches: Always approach resident calmly and unhurriedly, speak in a quiet, calm voice . Attempt to refocus behavior to something positive when resident is showing abusive behavior . Encourage activities of choice and preferences. Notify MD if behavior interferes with functioning . Separate residents immediately if alteration occurs . Problem . I wander into unsafe situations . Approaches . Place me in area where frequent observation is possible . Provide diversional activities for me . c. The Brief Cognitive Rating Scale dated 1/15/15 documented a score of 6.2. d. The Closet Care Plan (undated) documented, Mental attitude: Alert, Confused, Forgetful. It did not document target behaviors to monitor or activity preferences. e. An Individual Support Plan dated 1/22/15 documented, Area: Physical/Medical/Health related issues . Approaches: Encourage resident to participate in activities of choice . Area: Resident likes, dislikes, routine choices and customs: Resident enjoys music, movies, some art, physical exercise at times, word searches. Approaches: Encourage resident to participate in activities of choice. Allow resident to perform as much of her ADLs herself as possible. Allow resident to make simple decisions regarding daily care. Invite resident to all activities . f. An Activity Note dated 4/2/15 documented, Resident does not enjoy being around people, she likes to be left alone, she does enjoy reading and listening to music, she does not enjoy going outside. h. On 8/24/15 at 10:00 a.m., CNA #9 and CNA #8 were in the resident's room. Resident #12 was in a wheelchair and the CNAs planned to use a mechanical lift to move the resident to the bed. While the CNAs were in the resident room, there were no staff monitoring the other residents in the day room and dining room. i. On 8/25/15 at 8:45 a.m., the resident was up in a wheelchair at a dining room table. She was positioned with her back to the day room. Music was playing in the day room at 9:02 a.m. The resident remained in the same position at 9:05 a.m., 9:41 a.m. and at 11:20 a.m. No staff assisted the resident to the day room to be included in the activity. j. On 8/27/15 at 10:25 a.m., the AUD was asked for any documentation related to assessments, behaviors and interventions for Residents #12. As of 8/29/15 at 7:45 p.m., no documentation was provided. 4. Resident #29 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 8/19/15 documented the resident scored 0 (0 -7 indicates severely impaired) on the BIMS, had disorganized thinking, required extensive assistance in ADLs, used a wheelchair, and was frequently incontinent of bladder and bowel, Section F - Preferences for Customary Routine and Activities documented the items very important to the resident were choose clothes to wear, take care of personal belongings, choose tub/bath/shower/sponge, have snacks between meals, choose own bedtime, discuss care with family/friends, lock things to keep them safe, have books, newspaper, mags (magazines) to read, listen to music, be around animals/pets, keep up with news, do favorite activities, go outside when good weather and participate in religious practices per resident interview. a. The August 2015 Physician order [REDACTED]. The admitted on the bottom of the order sheet was 8/12/15. There was no order to admit the resident to the locked unit. b. The Care Plan undated documented the following: Problem onset date: 8/25/15 I require extensive assist (assistance) x 1 staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing and require extensive assist x 1 staff locomotion . Approaches . Please assist me to specific areas when I am up in my w/c such as activities, therapy, dining room, and my room . Problem/need . I like activities and if you let me, I would attend offered activities daily. Goal .I will attend activities such as games such as chess, pet therapy activities, watching sports. Approaches . Allow me to participate in as many activities as I can without interfering with my daily needs. Encourage me to participate in activities. c. There was no activity calendar in the current activity documentation book for this resident. d. On 8/24/15 at 3:30 p.m., the resident was agitated and repeatedly stated loudly that he wanted out. CNA #4 walked in the hall. CNA #4 stated, He gets worse as the day goes on. Sundowners. He'll be better when his family comes in. CNA #4 did not go to the resident or try to calm him in any way. e. On 8/25/15 at 9:35 a.m., the resident was at the locked doors yelling, President of the United States! Help! They won't let me go where I want to go! No staff were present. At 9:43 a.m., the facility cosmetologist informed the AUD that the resident liked to play the piano. The AUD brought in a keyboard and placed it on a table in the dining room. Resident #29 played the keyboard briefly before wandering away. At 9:53 a.m., the resident was at the locked door kicking it with his feet. No staff approached the resident. 5. Resident #28 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 8/4/15 documented the resident scored 0 (0 - 7 indicates severely impaired) on the BIMS, was inattentive, had [MEDICAL CONDITION] and an altered level of consciousness, was totally dependent for ADLs, was always incontinent of bladder and bowel and used a wheelchair. a. The Care Plan dated 12/19/13 documented the following: Problem/need . I display socially inappropriate/disruptive behavior . Approaches . Monitor and document my behavior. Do not argue with me. Praise me for demonstrating desired behavior. Administer my behavior medications as ordered by physician. Talk with me in calm voice when my behavior is disruptive. Remove me from public area when behavior is disruptive and unacceptable . Problems/need . I have memory loss with impaired decision making. I do not always understand the intent of the message. I have a hx (history) of making inappropriate sexual remarks to males . Approaches . Ask about my preferences each day. Remind me of what your name is when you care for me. Validate my thoughts/feelings when I get confused or anxious . Encourage me to be as independent as possible and to participate in facility activities. When expressing inappropriate remarks, cue and remind me that my behavior is inappropriate. Remove me from the situation . Problem . I have no plans to discharge . Approaches . Post a calendar of events and remind me of the activities. Assist to activities prn . Problem/need . I wander into unsafe situations . Approaches . Place me in area where frequent observation is possible. Alert staff to my wandering behavior. Provide diversional activities for me. Approach me positively and in calm, accepting manner . b. The August 2015 Physician order [REDACTED]. Admit to AACU. c. The August 2015 Activity Calendar for this resident documented the following activities attended for the week of 8/24/15 through 8/27/15: Let's Paint on 8/25/15 at 4:00 p.m. and Healing Touch at 7:00 p.m. There was no other activity documented for these dates (8/24 - 27). d. On 8/24/15 at 12:30 p.m., the resident was at a dining room table calling out loudly and repeatedly, Come here! Come here! No staff approached the resident or asked her what she needed. e. On 8/26/15 at 9:26 a.m., the AUD came into the unit and asked the resident who sat in a wheelchair in the hallway between the day room and dining room if she was interested in sports. The resident stated, No. The AUD moved to a resident in the day room to discuss sports. Resident #28 continued to talk loudly. There were multiple residents in the day room and congested in the hallway. 6. Resident #25 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD dated 7/9/15 documented the resident scored 0 (0 - 7 indicates severely impaired) on the BIMS, was inattentive, had disorganized thinking, altered level of consciousness, and psychomotor [MEDICAL CONDITION], had behavior symptoms not directed toward others, behavior symptoms that interfered with social activities and disrupted care or living environment, required extensive assistance with ADLs, used a wheelchair and was frequently incontinent of bladder and bowel. Section F - Preferences for Customary Routine and Activities documented it was very important for the resident to discuss care with family/friend and participate in religious practices. a. The August 2015 Physician order [REDACTED]. Admit to LTC (long term care) services of (physician). b. An ISP (individual support plan)Quarterly update dated 4/15/15 documented, . residing on AACU with DX (diagnosis) of [MEDICAL CONDITION]. She is alert and oriented to self only. Short and long term memory loss present. Resident uses w/c for mobility with staff to propel. Incontinent of bowel and bladder mostly with peri-care provided prn by staff. Fed per staff most of the time, fair appetite noted. Fluids offered, snacks offered TID (three times a day) and taken fair. Weight is 136.4 which is weight loss this quarter. She had been started on [MEDICATION NAME] which she had a reaction to resulting in severe anxiety and behaviors. She was taken off of it recently and has had an improvement through still requires staff to feed her for most meals. She enjoys table games such as dominoes with her family when they visit along with arts/crafts, music and social activities . Will continue with current ISP at this time. c. The Care Plan dated 4/24/15 documented, Problem . I have difficulty making my own decisions . Approaches: Please approach me from the front in a calm, unhurried manner . Provide me with a quiet environment when sharing important information. Give me verbal cues/reminders when I cannot remember . Problem . I wander into unsafe situations . Approaches: Place me in area where frequent observation is possible . Provide diversional activities for me . Monitor and document my behavior . d. An Individual Support Plan dated 7/16/15 documented the following: Area: Physical/Medical/Health related issues . Propelled per staff about unit. Requires extensive assist with ADLs, transfers, feeding, toileting . Approaches: Encourage resident to participate in activities of choice to stimulate physical skills. Staff to supervise resident during ADLs and assist only when needed. Allow resident to make simple decisions regarding daily care . Area: Behaviors/Cognitive/Functional Status and expressions of disease process or factor of confusion: Alert, oriented to name only with moderate cognitive impairment noted. Propelled mostly by staff about unit in WC. Resident often thinks the facility is her home and for staff to get these people out of my house . Interventions/Services/Special Approaches: Allow resident to make simple decisions in daily care. Encourage resident to participate in activities that stimulate cognitive and social abilities . Area: Resident likes, dislikes, routine choices and customs: Resident enjoys activities such as music, singing, art, games, and social activities. She enjoys wearing skirts while up in w/c . Approaches: Allow resident to make simple decisions in daily care. Encourage resident to participate in activities that stimulate cognitive and social abilities . e. The August 2015 Activity calendar for this resident documented the resident attended the following activities between 8/24/15 and 8/27/15: Let's Paint on 8/25/15 at 4:00 p.m. No other activities were recorded for these dates (8/24 -8/27). f. On 8/25/15 at 9:53 a.m., the resident was crying out for her children, counting her 6 children and naming them on her fingers. The cosmetologist attempted to get the resident to drink red cool aid. The resident threw the cup of cool aid at the cosmetologist with some spilling on the resident's lap. The resident continued to cry out, My children! Take me home to my children! The AUD came to the resident and attempted to calm her. The resident continued to cry out. At 9:56 a.m. the resident stated, I want to go home. The resident attempted to get out of the exit door between the day room and the dining room. CNA #4 came to the resident and talked softly to her. Licensed Practical Nurse (LPN) #4 arrived at 10:00 a.m. The resident stated, I want help to get out of this place! LPN #4 talked softly to the resident about her family. The resident continued to cry and call out her daughter's name. At 10:07 a.m., the resident calmed briefly. CNA #5 told the resident of the need to change her pants, from the cool aid spill, the resident stated, No. CNA #5 stated, You're wet. Resident #25 stated, They'll dry. CNA #5 obtained a paper towel for the resident's face. The resident remained agitated but less vocal. During this time, multiple other residents were gathered in the day room and hall way. The hallway was congested with wheelchairs and a housekeeping cart. 7. Resident #22 had [DIAGNOSES REDACTED]. The 5 day admission MDS with an ARD of 6/17/15 documented the resident scored 0 (0 - 7 indicates severely impaired) on the BIMS, was inattentive and had disorganized thinking, had delusions, required extensive assistance for ADLs, used a wheelchair, and was frequently incontinent of bladder and bowel. a. The August 2015 Physician order [REDACTED]. The admitted on the bottom of the sheet was 6/10/15. b. The undated Care Plan documented the following: Problem Onset 08/25/15 I require extensive assist x 2 staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing and require extensive assist x 1 staff with locomotion . Approaches . Please assist me to specific areas when I am up in w/c such as activities, therapy, dining room and my room . c. The August 2015 Activity calendar for this resident documented the activities attended for the dates between 8/24/15 through 8/27/15: Healing Touch on 8/25/15 at 7:00 p.m. Pretty Nails on 8/26/15 at 7:00 p.m. d. On 8/25/15 at 8:46 a.m., the television was on in the day room. There were 4 residents in the day room. Resident #22 was pushed in her wheelchair into the day room by CNA #4. She had a yellow substance that resembled egg or butter on her top and lap. At 9:02 a.m., the resident remained in the day room with the other residents. Her clothing had not been changed. Music was playing on the television. At 9:32 a.m., the music was no longer playing. The resident continued in the same position with the food spills on her clothing. At 11:17 a.m., the resident continued with the same

Complaint # substantiated (all or in part) in these findings: A. Based on record review, observation and interview, the facility failed to ensure falls were thoroughly investigated to determine causative factors and planned interventions were consistently implemented and evaluated for effectiveness for 1 (Resident #1) of 4 (Residents #1, #3, #4 and #5) case mix residents who had a history of [REDACTED].#1) case mix resident, whose last fall on 11/24/11 resulted in a hip fracture, and had the potential to affect 40 residents who were at risk for falls according to the list provided by the Nurse Consultant on 12/9/11. The facility also failed to ensure a resident was not left unattended on a shower chair for 1 (Resident #6) of 3 (Resident #1, #4 and #6) case mix residents who used a shower chair. This failed practice had the potential to affect 46 residents who used a shower chair for bathing according to a list provided by the Administrator on 12/9/11. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 11/11/11 documented the resident scored 4 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), required extensive assistance of one person for transfer, locomotion, and toileting, and extensive assist of two plus persons for ambulation. a. A Nurse's Notes dated 2/17/11 at 2:30 p.m. documented, "12 NOON: Resident arrived via facility van accompanied by driver from (hospital) and admitted to room... Alert and oriented to person/name only. Disoriented to time, date and situation. Pleasant and cooperative with staff and others. Resident has a history of falls with bed and chair alarm ordered upon admit and placed on admit..." b. A Resident Incident Report dated 2/18/11 at 6:15 p.m. documented, "Incident Type: Fall/no head injury Location: Resident Room Activity at time: From bed w/o (without) assist. Immediate Post-Incident Action: Keep up in W/C (wheelchair) longer at nurses' station after supper, till sleepy, bed alarm on bed ...Incident Investigation ... New Interventions: Bed placed in low position. Bed alarm. Keep resident up longer after dinner until sleepy." There was no documentation to indicate if the bed alarm was functioning. c. A Nurse's Notes dated 2/18/11 at 7:30 p.m. documented, "...Resident was put to bed after supper, aide left room, nurse walk to room in time to see Resident slide to floor off bed with call light in hand, skin tear 2 CM (centimeters) X (by) 0.5 CM on right elbow, wound cleaner, and skin barrier, and Island Dressing applied, Daughter here, DR. (Doctor) notified, RN (Registered Nurse) on call notified, bed alarm in place on bed for safety, chair alarm in place." d. A Fall Risk assessment dated [DATE] documented a score of 13 (Total Score above 10 represents high fall risk). e. A Resident Incident Report dated 4/11/11 at 1:25 a.m. documented, "Incident Type: Fall/no head injury Location: Resident Room Activity at time: From bed w/o assist... Post-Incident Actions...Immediate Post-Incident Action: Explained to res to please call for assistance when needing to transfer from chair to bed." There was no documentation of investigation into reasons/causes of the incident. f. A Nurse's Notes dated 4/11/11 at 6:14 a.m. documented, "Res (Resident) heard yelling. Found sitting beside bed on floor. Res states 'I started slipping and could not stop.' Res denies pain. Upon inspection a half CM skin tear to upper L (left) arm near elbow. Area cleansed, no more bleeding. Res helped back to bed. Res is alert but confused. No other injuries found. Educated resident to please call for assistance when needing to get up or transfer..." On 12/9/11 at 1:20 p.m., the DON (Director of Nursing) was asked if she thought an intervention to instruct the resident to ask for help with transfers for a resident with a BIMS score of 4 was an appropriate intervention, and she stated, "No." g. A Resident Incident Report dated 4/20/11 at 6:08 p.m. documented, "Incident Type: Fall with head injury Type Of Injury: Skin tear, Hematoma Property Involved: Floor-tile/wood Location: Dining room Equipment: Wheelchair... Additional Follow-ups: 4/21/11 Resident sent to hospital due to pain in hip and hematoma to right eye... Incident Investigation ... Why: Resident was found on floor. Resident ambulates in room ad lib. New Interventions: Resident sent to hospital due to hematoma to right eye and pain in right hip. When return from hospital, bed and chair alarm will be initiated for safety." There was no documentation of the chair alarm, which was ordered at admit, being in use at the time of the incident. h. A Nurse's Notes dated 4/20/11 at 9:59 p.m. documented, "...Resident in dining room for dinner, fell into floor, no one witnessed this, but heard when resident hit the floor, had large skin tear on right elbow and right eye, dialed 911 for ambulance took resident to (hospital), have not heard anything on her condition." i. A Physician's Telephone Orders dated 5/18/11 documented, "Cont (continue) bed and chair alarm for safety as previously." j. A Resident Incident Report dated 7/13/11 at 6:00 p.m. documented, "Incident Type: Fall with head injury Type of Injury: Abrasion, Hematoma, Bruise Location: Resident Room Property Involved: Floor-tile/wood Activity at time: From chair without assist Equipment: Wheelchair-non-motorized." There was no documentation of an investigation to determine the cause/reason for the incident. There was no documentation of a chair alarm being in use. k. A Nurse's Notes dated 7/13/11 at 9:34 p.m. documented, "6 PM: Called to room by CNA (Certified Nurses Aide), found resident face down with feet tangle in wheelchair and head against bathroom door. Checked resident for injuries with none noted, then carefully turned resident on back and found to left eyebrow area a small laceration along with formed hematoma. Resident saying 'Oh my hip!!!' Applied pressure to facial laceration to stop bleeding. Placed call to Dr. with new orders received: Send to (hospital) for evaluation and treatment as indicated due to fall..." On 12/9/11 at 1:20 p.m. the DON was asked was it investigated to find out what happened, and she answered, "No." When asked what interventions were put into place she answered, "Staff education." When asked can you tell me what staff was educated on she stated, "No." l. A Fall Risk assessment dated [DATE] documented a score of 15 (A Score Above 10 Indicates Resident is at Risk for Falls). m. A Resident Incident Report dated 11/24/11 at 8:05 a.m. documented, "Incident Type: Fall/no head injury Equipment: Bed non-electric Activity at time: From bed w/o assist ... Immediate Post-Incident Action: Res up in w/c (wheelchair) at nurse's station." There was no documentation of an investigation into the reasons/causes for the incident. There was no documentation to indicate if the bed alarm was in use. n. A Nurse's Notes dated 11/24/11 at 9:46 p.m. documented, "Res was found behind room door on floor. Small area of blood noted at R (right) elbow and smear of BM (bowel movement) on floor. Res states she scooted out of bed and slid to floor. Assisted to bed per staff X's 2. 3 CM skin tear noted to R elbow cleansed and left open to air. 2 inch contusion to R knee given prn (as needed) pain med (medication) C/O (complains of) leg pain. Normal ROM (Range of Motion) noted to both lower extremities. Res agitated, refused to stay in bed. Transferred to WC (wheelchair) and up propelling self at nurse's station." o. A Nurse's Notes dated 11/25/11 at 6:39 p.m. documented, "5 PM: Results of x-ray as follows:...Hip Right-2 view results: There is a right intertrochanteric fracture with no displacement....New order received from Dr. : Send to (hospital) for Evaluation and TX (treatment)." On 12/9/11 at 12:40 p.m., Licensed Practical Nurse (LPN) #2 was asked who found the resident on 11/24/11 and she answered, "I did, I was doing my med pass and I heard her calling, when I opened the door I could only get it open about a foot and a half or so because she was laying behind the door. When you asked, she (Resident #1) said she got out of bed because she needed help. When I asked how she got this far, she said I crawled over here." When asked if the resident had a bed alarm ordered LPN#2 stated, "Yes." The LPN was asked, can you remember if it was going off, and she stated, "It wasn't going off, I heard her yelling." p. A Summary Report of Meeting dated 11/25/11 documented, "Type of Meeting: CNA Inservice 11p-7a Preventing (Resident #1) from falling. Subjects Covered included: Mat in front of bed, Bed always in lowest position." q. The Care Plan reviewed 10/4/11 and revised 12/1/11 documented, "Resident is at high risk for falls... Bed/Chair alarm-check for placement every shift... Do not place in room alone. First one out of dining room after meals..." The revised care plan did not document the interventions of mat in front of bed and bed always in lowest position. r. On 12/4/11 at 2:00 p.m., 12/7/11 at 1:25 p.m. and 1:50 p.m., 12/8/11 at 8:35 a.m., 10:00 a.m. and 1:10 p.m., and 12/9/11 at 8:05 p.m., the resident was in bed, the bed was not in low position and no mat was on the floor at the bedside. On 12/4/11 at 2:00 p.m., the resident was in the bed and the bed alarm was hooked at the top of the bed and turned "Off", the clip was laying under the draw pad on the bed and was not attached to the resident. On 12/8/11 at 8:35 a.m., the resident was in the bed and the bed alarm clip was attached to the resident's pillow and not to the resident. s. The facility's policy received from the DON on 12/9/11 titled "Incident Documentation and Investigation" documented, "Policy: It is the intent of the facility that all incidents involving resident care will be investigated and documented on the Incident Documentation and Investigation Tool to enable the facility to evaluate the care given to residents, to assist in prevention of incidents, and evaluate intervention given in the event of an incident...Incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measures to reduce the occurrence of incidents ... Procedure: a) The Charge Nurse at the time of the resident care incident is responsible for conducting an investigation of the circumstances surrounding the incident, and for notifying the Director of Nursing and/or CEO ..." 2. Resident #6 had [DIAGNOSES REDACTED]. The 14-day MDS with an ARD of 11/20/11 documented a BIMS score of 13 (13-15 indicates cognitively intact), required extensive assist of 2 plus persons for transfer, and extensive assist of one person for toileting, personal hygiene and bathing. a. A Fall Risk assessment dated [DATE] documented a score of 16, (a score of above 10 indicates resident is at risk for falls) for the resident. The assessment documented, "Narrative: Total score 16 and resident at risk for falls. Requires assist X2 with ADL's (Activities of Daily Living) and transfers." b. On 12/7/11 at 1:40 p.m., Resident #6 was observed sitting on a shower chair in the room, the door was open, and the resident was unattended. CNA #3 arrived in the room as the surveyor entered. The CNA was observed turning the resident in the shower chair to face the bed, left the room and closed the door, leaving the resident unattended. CNA #3 retrieved linen from the linen closet and re-entered the room. c. On 12/8/11 at 2:45 p.m., CNA #3 was asked should she ever leave a resident alone on a shower chair and the CNA answered, "No." When asked if she left Resident #6 alone in her room on a shower chair, the CNA answered, "I did for a second to throw some stuff out." B. Based on observation and interview, the facility failed to ensure medication and treatment carts were locked when unattended to prevent possible chemical hazards and were not parked in the middle of the fire doors. This failed practice had the potential to affect 16 cognitively impaired mobile residents according to the listing received from the Administrator on 12/9/11. The findings are: 1. On 12/4/11 at 9:42 a.m., the medication cart for one half of E hall and F hall was parked in the middle of the fire doors on E hall. The medication cart was unlocked and there were no staff members present in the hallway. Licensed Practical Nurse (LPN) #1 was present in room 45 approximately 17 feet from the closest end of the medication cart. LPN #1's back was to the door way and the medication cart was approximately 4 feet from the doorway of the room and would not have been visible if LPN #1 was facing the door. LPN #1 returned to the medication cart and was asked, "Should the med cart be unlocked and unattended?" LPN #1 stated, "No." LPN #1 was asked, "Could you see the medication cart from the resident's room?" LPN #1 stated, "No." LPN #1 was asked, "Why am I concerned about where it's parked?" LPN #1 stated, "The fire door wouldn't close." 2. On 12/4/11 at 10:25 a.m., a treatment cart was observed sitting between halls C and D in front of the nurse's station unlocked and unattended, there was no one at the nurse's station. The unlocked treatment cart was shown to RN #1. When asked if the treatment cart was unlocked she stated, "Yes." According to a list provided by the DON on 12/4/11 the treatment cart contents and MSDS (Material Safety Data Sheet) warnings for these contents were as follows: Top Drawer: a) Nystatin Topical Powder b) Antifungal Cream- MSDS Emergency and First Aid Procedures: Eye contact: Flush with water. Get medical attention if irritancy persists. Ingestion: If large quantities are ingested, get medical attention. c) IDDO/HC/Whitfield Compound d) Metronidazole Topical Cream 0.75% e) Medicated Chest Rub- MSDS Hazard Identification: Eye: Eye contact with the product may produce mild, transient, superficial irritation. Ingestion: Possible mild gastrointestinal irritation with nausea and vomiting and diarrhea, if large quantities are ingested. f) Sureprep Protective wipes- MSDS Health Hazards: Ingestion, inhalation Exposure to high air concentrations may cause mild irritation to eyes, nose and throat. Ingestion of product may cause drowsiness, burning of the gastrointestinal tract, and death. g) Adhesive Remover Wipe h) Mometasone Furoate 0.1% Cream i) Silver Sulfadiazine Cream j) Clotrimazole Cream 1% k) Betamethasone Dipropionate 0.05% Cream l) Calazime Skin Protectant- MSDS Health Hazard Data: Ingestion: If swallowed, give 3-4 glasses of water. Contact a doctor or poison control center immediately. m) Multidex Gel n) Epi-Clenz Hand Sanitizer- MSDS Health Hazard Data: Inhalation: Excessive amounts may cause coughing, irritation to nose, throat and mucous membranes, nausea, dizziness and headache. Ingestion: Excessive amounts may cause tissue damage to the digestive tract, nausea, vomiting, discomfort, dizziness, headache and gastrointestinal cramps. o) Nystatin Cream p) Starswab II q) Hydrocortisone 1% Anti-itch Cream r) Triple Antibiotic Ointment s) Ketoconazole Cream Drawer 2: a) Maxorb AG Rope- MSDS Potential Health Effects: Eye: Can cause irritation to the eyes b) Santyl Ointment c) Permethrin 5% Cream d) Skin Intergrity Wound Cleanser- MSDS Health Hazard Data: Health Hazards (Acute and Chronic) Acute: May irritate respiratory tract, high concentrations may cause sore throat and irritation. Emergency And First Aid Procedures: Eye contact: Immediately flush eyes with plenty of water for at least 15 minutes. Skin contact: Immediately remove contaminated clothing, flush area with large quantities of water. e) Xeroform f) Unna Boot with Zinc and Calamine Drawer 3: a) Wound Cleanser b) Silversorb Gel Drawer 4: a) Epsom Salt- Hazards Identification: Inhalation and ingestion: Causes nausea, vomiting, abdominal cramps and diarrhea; First Aid Measures; Ingestion: If large quantities of the material are swallowed, call a physician immediately. b) Betadine Swabs c) Calazime Lotion d) Sani-Wipes- MSDS Hazards Identification Emergency overview: Causes irreversible eye damage. Harmful if absorbed through skin. Do not get in eyes, on skin or on clothing. Wash thoroughly with soap and water after handling and before eating, drinking, chewing gum or using tobacco. Remove and wash contaminated clothing before reuse. e) Skin Cleanser-Wound Cleanser f) Hydrogen Peroxide- MSDS Health Hazard Data, Emergency and First Aid procedures: Ingestion: Induce vomiting, call physician g) Multidex h) Stratosorb On 12/9/11 at 7:15 p.m., RN #2 was asked are these the only MSDS sheets you have for the items in the treatment cart, he stated, "Yes, they are."

Complaint # was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure Resident #s 3, 5, 6 and 8 who had pressure sores received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing and Resident #9who was at risk for the development of pressure sores received the necessary treatment and services to prevent the development of pressure sores: The facility failed to ensure a physician order [REDACTED]. The facility failed to ensure a planned intervention to provide a Roho cushion in the wheelchair was consistently implemented to promote healing of the pressure ulcers and decrease the potential for further deterioration for 2 of 2 case mix residents (Resident #s 6 and 8) with physician orders [REDACTED]. The facility failed to ensure a planned intervention to provide elbow protectors was implemented consistently to decrease the potential for breakdown for 1 of 1 case mix resident (Resident #8) care planned for elbow protectors. The facility failed to ensure a planned intervention for Podus boots was consistently implemented to decrease the potential for skin breakdown for 2 (Resident #s 6 and 8) of 4 (Resident #s 3, 6, 7 and 8) case mix residents with physician orders [REDACTED]. The facility failed to ensure the physician was consulted for treatment orders prior to initiating treatment to a pressure ulcer for 1 (Resident #3) of 9 (Resident #s 2, 3, 4, 5, 6, 7, 8, 9 and 11) case mix residents at risk for pressure ulcers. The facility failed to ensure dressings were replaced promptly to decrease the potential for infection and cross contamination and to ensure the skin was cleansed with soap and water or peri wash when providing incontinent care to decrease the risk of skin breakdown 1 (Resident #5) of 8 (Resident #s 2, 3, 4, 5, 6, 7, 8, and 11) case mix residents with pressure ulcers or who were at risk for pressure ulcers and were incontinent. The facility failed to ensure treatments were provided in accordance with current standards of nursing practice to promote healing for 3 (Resident #s 5, 6 and 8) of 5 (Resident #s 3, 4, 5, 6, and 8) case mix residents with pressure ulcers that required wound care. The facility failed to ensure infection control measures were followed during dressing changes to decrease the potential for cross contamination and infection for 3 (Residents #3, 6, and 8) of 5 (Resident #s 3, 4, 5, 6, and 8) case mix residents with pressure ulcers who received wound care. The facility failed to ensure planned interventions to offload heels or ankles were consistently implemented to decrease the potential for skin breakdown and failed to ensure an adequate number of pillows were available to meet the needs of residents who required offloading of heels for 4 (Resident #s 3, 5, 8 and 9) of 5 (Resident #s 3, 4, 5, 6, and 8) case mix residents with pressure ulcers of the heels or ankles or were at risk for the development of pressure ulcers. The facility failed to ensure a resident was turned and repositioned every 2 hours to limit the potential for skin breakdown for 1 (Resident # 9) of 9 (Resident #s 2, 3, 4, 5, 6, 7, 8, 9 and 11) case mix residents at risk for pressure ulcers and who required assistance with bed mobility. The failed practices likely caused a pattern of actual harm for Resident #6, 5 and 8, whose pressure ulcer failed to show signs of healing and Resident #6 who developed new deep tissue injury and exposed bone, and were likely to cause more than minimal harm for 39 residents who were at risk for pressure ulcers and required assistance with bed mobility, according to a list provided by Registered Nurse (RN) #1 on 6/23/11 and 8 residents who had pressure sores according to the Resident Census and Conditions of Residents form dated 6/20/11. The findings are: 1. The facility Policy and Procedure for Pressure Ulcer, Prevention of received from the Assistant Director of Nurses on 6/23/11 documented, " Procedure... Use appropriate support surface in the resident's bed or chair...Use pressure reducing or relieving devices as necessary...Use elbow and heel protectors as necessary. Establish a turning and position schedule in bed and chair to meet the resident's needs...Position with appropriate surfaces to protect bony prominences... If a pressure ulcer is present, the Licensed Nurse is responsible to record condition of the skin, including stage, size site, depth, color drainage and odor as well as the treatment provided. Notification of the Physician when a new pressure ulcer is identified as well as when treatment is not effective. " 2. Resident #6 had [DIAGNOSES REDACTED]. The Significant Change in Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/27/11 documented the resident scored 13 (13-15 indicated cognitively intact) on a Brief Interview for Mental Status (BIMS, required extensive assistance of 2 persons for bed mobility and transfers, was totally dependent with dressing, toilet use, personal hygiene and bathing, had functional limitation in range of motion of the lower extremities on both sides, used a wheelchair for mobility, was always incontinent of bowel and bladder, was at risk for pressure ulcers and had 1 Stage III and 2 Stage IV pressure ulcers. a. A review of the Nurses Notes dated 1/27/11 thru 5/17/11 documented the following findings: 1) An initial Nurses Note dated 1/27/11 at 2:23 p.m. documented, "Initiated treatment ...Stage 4 pressure ulcer to coccyx with normal saline, fill wound with [MEDICATION NAME] extra alginate rope dressing and cover with border gauze QD (every day). Wound measures at 5 x 8.5 x 3 cm (centimeters). 15% tunneling noted to left upper site. Old heel ulcer site noted to left heel. Brown scab at [MEDICAL CONDITION] cm. Closed ..." 2) A Nurses Note dated 2/25/11 documented, "Stage IV on coccyx at 5.5 x 3.5 x 1.5 cm, 15% tunneling, red, beefy, no odor ..." 3) A Nurses Note dated 3/19/11 at 12:29 p.m., documented, "Stage IV on coccyx at 5.2 x 3.9 x 1 cm with 10% tunneling. Red, beefy, no odor ..." 4) A Nurses Note dated 4/3/11 documented, "Stage IV on coccyx at 7.5 x 2 x 1.5 cm with 5% tunneling. White peri, red beefy, no odor ..." 5) A Nurses Note dated 4/10/11 at 2:21 p.m. documented, "Large Black Necrotic area noted to right buttocks with open area to lower end of wound. ...measures approx. (approximately) 10 cc." 6) A Nurses Note dated 4/11/11 documented, " ...Stated ...he did not feel well ...Resident to (hospital) ER (emergency room ) for eval and tx ..." 7) A Nurses Note dated 4/23/11 documented, "Resident readmitted to room ..." A Nurses Note dated4/23/11 at 2:34 a.m. documented, " ...Massive Stage IV on coccyx. Stage III on L (left) buttock with necrotic tissue observed. ..." There were no measurements documented. 8) A Nurses Note dated 5/2/11 at 3:40 a.m. documented, "Changed Res (resident) dressing to coccyx and R (right) buttock. Decub (decubitus) much worse. Tunneling to end of coccyx bone. The bone is protruding through wound. Decub on R (right) buttoc not merging with main coccyx decube (decubitus). Puralent drainage from both wounds. More necrotic tissue moving closer to rectum. .." 9) A Nurses Note dated 5/12/11 at 1:18 p.m. documented, "Call received from (Physician) recommends set up appointment with (wound clinic) ..." Nurses Note dated 5/12/11 at 3:29 p.m. documented, Stage 4 pressure ulcer to coccyx/sacrum/buttocks is at 21 x 7 x 5 cm. Tunneling, red/yellow in color with necrotic areas ..." b. A Nursing Assessment and Treatment form from the wound Clinic dated 5/17/11 documented, "Location sacrum, length (L) 23 cm, width (W) 12 cm, depth (D) 4.5 cm, undermining 9.2 cm. at 1 O'Clock ...eschar none; slough, fibria, necrotic tissue moderate; granulation tissue pink, red; Exposed bone ...Character of wound/ulcer post debridement: L 22.5 W 13.5 D 4.5. ... Wheel chair cushion, Specialty Bed low air loss mattress ..." c. A Physicians Telephone Order dated 5/17/11 documented, "Cleanse Stage IV pressure ulcer to coccyx/sacral area with wound cleanser apply [MEDICATION NAME] ointment to wound bed, line wound bed with Ag (silver) Ca (calcium) Alginate pack with 4 x 4's cover with ABD (abdominal) pad and secure with tape q (every) day and prn (as needed)." d. A Nursing Assessment and Treatment form from the wound Clinic dated 5/24/11 at 9:50 a.m., documented, "Location sacrum; length 21.5; width 12; depth 4.5; undermining 9.2 at 1 O'Clock; ...Exposed bone ...(written at bottom of page was the following) undermining - 1oclock, 9.2 cm, progressive to 3 oclock (at) 1.5 cm advancing to 1 O'Clock, necrotic tissue 3.3 x 3.3 x(right) ischial; necrotic tissue 2.5 x 1.5 left buttock ...Character of wound/ulcer post debridement: L 21.7; W 12.3; D 4.6 ...(written at the bottom of page) needs low air loss or clinitron bed ..." The wound clinic Physician order [REDACTED]. The form titled Home Care Instruction from wound clinic had hand written instruction that documented at the bottom of the page designated for the patient signature as follows, "Copy of MD (Medical Doctor) orders sent (with) nsg (Nursing) Home Staff 5/24/11 time 1000 (10:00 a.m.) ..." A documented statement received from the Director of Nursing on 7/8/11 at 6:00 p.m. documented, "On 5/24/11 after receiving order from wound clinic, a low -air loss mattress was place on (Resident #6) bed." e. A Nursing Assessment and Treatment form from the wound Clinic dated 6/1/11 at 9:35 a.m. documented, " ...Location sacrum; length 20 cm; width 11; depth 4.5 cm; undermining 9 cm at 1 O'Clock ...Wound Inferior edge has some new DTI (deep tissue injury) (and) necrotic tissue. Still not on low air loss or clinitron bed. The wound clinic Physician order [REDACTED]. The Home Health Care Instruction dated 6/1/11 at 9:30 a.m. documented, "copy of MD orders (and) progress notes sent (with) staff to NH (Nursing Home) ..." The facility Quality Assurance Skin Record dated 6/01/11 documented, "Description (WxLxD site drainage) ... 21.7 x 12 x 4.6 cm, coccyx, partial coverage eschar, slough, [MEDICATION NAME], necrotic tissue, yellow/pink, bone exposed, minimal (amount) serous/yellow drainage, no odor. Treatment: Gent/Ag CA Alg/ABD ([MEDICATION NAME]/silver/calcium/Alginate/Abdominal pad) (and) 4x4 or Kerlix/skin prep/tape. ..." f. A Nursing Assessment and Treatment form from the wound Clinic dated 6/08/11 at 10:30 a.m., documented, "Location sacrum; length 23; width 11; depth 4.4; undermining 7.5 at 1 - 3 O'Clock; ... (the form documented no exposed bone) ... Inferior aspect of wound continues to deteriorate. Pt (patient) does not have a Roho cushion (and) has been spending a large amount of time in his wheel chair. Still doesn't have a special bed which had been ordered for quite some time ...(increased) order (with) new necrotic tissue (right) ischial area ... Character of wound/ulcer post debridement, L 24.2; W 12.6; D 4.5 ...Plan of Care ...Pt must have clinitron Bed (and) Roho cushion in order for wound to heal ..." The wound clinic Physician order [REDACTED]. 1) A Nurses Note dated 6/8/11 at 3:28 p.m., documented, "Resident seen in wound clinic today for sacrum/coccyx Stage 4 pressure ulcer. Measuring at 24.2 x 12.6 x4.5 cm post debridement. Area debrided 14x12 x2.5 cm. ...Undermining 7.5 cm from 12 to 3 O'clock progressing to 3 at 1.5 cm and 12 at 1.5 cm." 2) The Quality Assurance Skin Record dated 6/08/11 documented, "Description (WxLxD site drainage) ... 24.7 x 12 x 4.5 cm post debridement, sacrum/Coccyx, partial coverage eschar, slough, [MEDICATION NAME], necrotic tissue, yellow/red, large serous/yellow/green drainage, no odor. Treatment: Gent/Ag CA Alg/ABD ([MEDICATION NAME]/silver/calcium/Alginate/Abdominal pad) (and) 4x4 or Kerlix/skin prep/tape. ..." g. A Nursing Assessment and Treatment form from the wound Clinic dated 6/15/11 at 11:20 a.m., documented, "Location sacrum; length 23; width 11; depth 4.2; undermining 7.2 at 12 - 3 O'Clock; ...No exposed bone ...(hand written under) subjective/objective: ...Unable to get pressure reduction mattress or Roho - No financial help or ability available. ... Character of wound/ulcer post debridement; Improved; L 23; W 11; D 4.2 ...Subjective/objective: ...unable to get pressure reduction mattress or Roho - no financial help or ability available...Character of wound/ulcer post debridement, L 24.2; W 11; D 4.2 ...Plan of Care ...Pt must have clinitron Bed (and) Roho cushion in order for wound to heal ..." h. On 6/19/11 at 7:50 p.m., the resident was lying in bed on a low air loss mattress. The wheelchair sitting in the room had a pressure relieving cushion, not a Roho cushion. On 6/20/11 at 7:18 a.m., 7:40 a.m., 8:05 a.m., 10:15 a.m., 2:43 p.m. and 4:32 p.m., the resident was in lying in bed on a low air loss mattress. The wheelchair sitting in the room had a pressure relieving cushion, not a Roho cushion On 6/21/11 at 8:36 a.m., the resident was lying in bed on a low air loss mattress. The wheelchair sitting in room had a pressure relieving cushion but did not a Roho cushion. i. On 6/21/11 at 9:15 a.m., the Treatment Nurse changed the dressing on the Stage IV pressure ulcer located on the resident ' s sacral area. The pressure ulcer had the appearance of an upside down v shape extending down to the bilateral buttocks. The wound bed was beefy red with some tunneling at the top of the wound on the right side of the pressure ulcer at the base of the wound with an area of dark yellowish exudate/slough appearance. The pressure ulcer measured on the right side approximately 22 cm (centimeters) in length by 5 cm and 5.8 cm in width, with the exudate area measuring 5.5 cm by 4x4 cm. The left side measured approximately 12 cm by 5.6 cm with a depth that varied with tunneling at the top of the wound. The Treatment Nurse applied [MEDICATION NAME] to the Ag Ca Alginate rope and laid on the outer edge of the wound. The Treatment Nurse was asked if the dressing was to cover the entire wound bed. The Treatment Nurse stated, "No just the outer edges." The area that was dark yellowish slough and approximately 2 cm above this yellowish exudate and inner areas of the pressure ulcer was only covered by a 4 x 4. The Treatment Nurse continued to pack the remaining areas of the wound with 4 x 4 and covered with ABD pad and secured with tape. 1) On 6/22/11 at 9:37 a.m., the Wound Clinic was called and the surveyor spoke with the Physician Nurse #1. The Nurse was asked if the [MEDICATION NAME] and Ag Ca Alginate was to cover the entire wound bed. The Nurse stated, "Yes, it should cover the entire wound bed." 2) On 6/22/11 10:20 a.m., the Assistant Director of Nursing (ADON) was asked, when doing a dressing for Resident #6, if the [MEDICATION NAME] and Ag Ca Alginate cover the entire wound bed. The ADON stated, "Yes." 3) On 6/22/11 at 10:35 a.m. the Director of Nursing (DON) was asked about the dressing change for the pressure ulcer for Resident #6. The DON read the order. The DON was asked how the [MEDICATION NAME] and Ag Ca Alginate should be applied. The DON stated, "[MEDICATION NAME] and the Ag Ca Alg should cover the whole wound bed." j. A Nursing Assessment and Treatment form from the wound Clinic dated 6/22/11 at 11:30 a.m., documented, "Location sacrum; length 22; width 11; depth 4.2; undermining 7.5 at 12 - 3 O'Clock; ... (the form documented no exposed bone) ...Subjective/Objective: ...Wound at (R) distal aspect continues to deteriorate. NH unable to get speciality mattress or Roho. Wound infected (with) Morganella (and) will need IV (intravenous) ABX (antibiotics) ... Character of wound/ulcer post debridement, L 22.2; W 11.3; D 4.2 ...(had written) area debrided 7.2 x 7.4 x 2.5 ...Plan of Care ...Pt is to be up in chair for no more than 1 (hour) at a time (and) 4 hrs (hours) per day. Rotate pt in bed Q (every) 2 hrs ..." k. On 6/22/11 at 10:35 a.m., the DON was asked about the Physician order [REDACTED]. The DON stated that she had spoken with the Doctor and it was okay to use the low air loss mattress. The DON was asked if there was any documentation that she had spoken with the Physician. On 6/22/11 at 2:30 p.m., the DON was asked if she had found any documentation regarding Resident #6's Clinitron Bed. The DON stated that she couldn't find any documentation. The DON stated they had not gotten the Clinitron bed or Roho Cushion because the insurance would not pay for it and, "I took it as suggestion." The DON was asked if the page from the Wound Clinic was the physician's orders [REDACTED]." The DON was asked if the Clinitron bed had been repeated on the subsequent orders and would this not be considered an order. The DON stated, "Yes." l. On 6/23/11 at 8:32 a.m., the Wound Clinic was called and the Physicians Nurse, (Physician Nurse #2) was asked about the orders for the Clinitron bed and Roho cushion. Physician Nurse #2 stated that the Clinitron bed and Roho cushion were Physician order [REDACTED]. m. On 6/23/11 at 8:45 a.m., the resident was lying in bed on a low air loss mattress. The resident's wheelchair was sitting at the foot of the bed and had a pressure relieving cushion in the wheelchair that was not a Roho cushion. n. On 6/23/11 at 9:32 a.m., the DON stated she had called the Vice President yesterday and had been approved to order the Clinitron Bed and the Roho Cushion. The DON stated the Clinitron Bed and Roho cushion had been ordered and would be in the facility today. On 6/23/11 at 6:30 p.m. when Surveyors exited the building, the resident did not have the Clinitron Bed or the Roho Cushion as ordered by the Physician. 3. Resident #3 had [DIAGNOSES REDACTED]. The Medicare 14 day Minimum Data Set with an Assessment Reference Date (ARD) of 5/17/11 documented the resident scored 13 (13-15 indicated cognitively intact) on a Brief Interview for Mental Status (BIMS), required extensive assistance of 2 persons for bed mobility, transfers and ambulation, was at risk for pressure ulcer and had no skin problems. a. Nurses Notes dated 6/9/11 thru 6/15/00 were reviewed with the following findings: 6/9/11 at 9:20 p.m. documented, "Right heel has blisters" 6/10/11 at 12:59 a.m. documented, "Blister noted to heels bilat. (bilaterally)." There was no documentation in the Nurses Notes that the Physician was consulted regarding the skin breakdown on the heels. b. A Skin Audit report dated 6/15/11 at 10:10 a.m. did not document the blister on the resident's right heel. c. The Nurses Notes dated 6/19/11 at 1:32 a.m. documented, "Has stage II decub.(decubitus) heels are elevated off bed. Will inform tx (treatment) nurse and oncoming nurse." There was no documentation the Physician was consulted. d. On 6/19/11 at 4:44 p.m., the resident was lying in bed. The resident had a stage II pressure ulcer to the right heel measuring approximately 4 centimeters (cm) by 3.5 cm. The blister had ruptured and the wound bed was red in appearance and there was no dressing on the resident's heel. The resident stated that the area hurt whenever something touched it. The right heel was lying flat on the bed with a blue Spenco boot lying in the bed (not being used) and a round donut type device was lying in a chair in the room. e. On 6/19/11 at 6:30 p.m., the resident was lying on her right side with the right heel lying flat on the bed. There was no dressing on the pressure ulcer on the right heel. The clinical record was reviewed and there was no documentation of a Pressure Ulcer to the right heel and no treatment for [REDACTED]. The clinical records were reviewed at this time and there was no documentation in the treatment book or physician orders [REDACTED]. f. On 6/20/11 at 7:25 a.m., the resident was lying in bed with the heel lying flat on the mattress. There was a dressing on the right heel. On 6/20/11 at 8:45 a.m., the resident stated, "I had the blister for weeks ...The Therapist saw the blister." g. On 6/20/11 at 9:20 a.m. the Physical Therapist was asked if she had ever noted any redness to the resident ' s heels. The Physical Therapist stated on 6/1/11 the resident had a stage I pressure ulcer to the right heel and she put the blue Spenco boot on the resident's foot. The Physical Therapist was asked if she told the Nurse. The Physical Therapist stated, "Yes I told (Licensed Practical Nurse (LPN) #1)." The Physical Therapist was asked if she had any documentation about the pressure ulcer. On 6/23/11 at 11:38 a.m., the Physical Therapist provided documentation as follows: 6/1/11 Plan of care, "Patient with a Stage I pressure ulcer to lateral Right heel. Informed patients LPN, (LPN #1)." h. On 6/20/11 at 8:45 a.m., the Treatment Nurse removed the dressing from the resident's right heel. The blister had refilled with the outer edge of the blister open on the inner aspect of the heel. The blister measured approximately 4.5 cm by 4 cm with an opened area measuring approximately 1 cm by 3 cm. The Treatment Nurse looked at the blister and stated she would have to get an order. The Treatment Nurse laid the resident's right foot back into the blue Spenco boot with no dressing on the wound. The right foot was lying directly on the mattress, not elevated. The resident was asked how long she had had the blister. The resident stated, "Weeks." The Treatment Nurse left the room. The Treatment Nurse was asked, "If a Nurse finds a new pressure ulcer, what are they supposed to do? " The Treatment Nurse stated, "If I am not available, the Nurse should check the TAR (treatment administration record) for any orders. If there are no orders, they should call the MD (Medical Doctor)." i. On 6/20/11 at 9:15 a.m., the resident remained in bed with the right foot in the Spenco boot. The resident had a dressing on the right heel. The June 2011 Nurses Notes, Physician order [REDACTED]. There was no documentation of a physician order [REDACTED]. On 6/20/11 9:18 a.m., the ADON was asked if the blue booty (spenco boot) was a pressure relieving device. The ADON stated, "No." The ADON was then asked, "When a Nurse finds a Pressure Ulcer on a resident's foot what should the Nurse do?" The ADON stated, "She should call the Doctor." At 9:30 a.m., the Director of Nursing was asked, "When a Nurse finds a new pressure ulcer what should she do?" The DON stated, "The Nurse should call the Doctor right then." The DON was asked if a Nurse should apply a dressing without a Physician Order. The DON stated, "No." The DON was asked if she was aware that the pressure ulcer had been documented in the Nurses Notes starting on 6/9/11. The DON stated, "No." j. On 6/20/11 at 11:48 a.m., the resident was sitting in a wheelchair with a gray heel lift type boot on the right foot. The resident stated, "The Nurse put a dressing on." k. On 6/21/11 at 8:58 a.m., the Treatment Nurse removed the soiled dressing from the pressure ulcer on the resident's right heel with gloved hands. The blister had refilled with fluid measuring approximately 4.5 cm by 3.5 cm. The Treatment Nurse did not change gloves prior to cleaning the pressure ulcer with wound cleanser. 4. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an assessment reference date of 5/30/11 documented the resident scored 4 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), required extensive assistance of 2 or more persons for toilet use, was always incontinent of urine and bowel, had 3 Stage II pressure ulcers that were not present on admit/reentry with "ongoing" documented for the date of the oldest Stage II pressure ulcer, had one unstaged pressure ulcer due to dressing, and one unstageable pressure ulcer due to slough/eschar. a. The Certified Nurse Assistant (CNA) "kiosk" care plan dated 4/8/11 documented, "Problem: Requires extensive assist with ADLs (Activities of Daily Living) ... Approaches: ... Assist with turning/re-positioning (every) 2 hours as needed; float heels when in bed ... Incontinent of Bowel ... peri care as per plan and as needed." b. The Care Plan with a review date of 4/19/11 documented, "Problem: Pressure Ulcers: I am high risk for pressure ulcers... Approaches: Reposition me every 2 hours... I need to float my heels off the bed. I need elbow protectors. I need pillows or other supportive devices to assist with positioning... Problem: Requires extensive assist with ADLs... Approaches: ... Incontinent of Bowel... peri care as per plan and as needed..." c. A physician order [REDACTED]." d. On 6/19/11 at 3:55 p.m., the resident was on her left side with a splint to the left leg. The left ankle area was not elevated off the bed. e. On 6/19/11 at 3:55 p.m., the resident was on her left side with a splint to the left leg. The left ankle area was not elevated. A bunny boot was on the floor on the left side of the bed. f. On 6/20/11 at 10:35 a.m., Certified Nursing Assistants (CNAs) #1 and 2 transferred the resident to bed. CNA #1 removed the splint from the left leg and a hydrogel dressing fell off the resident's left outer ankle. CNA #1 picked the dressing up off the bed and stuck it back on the ankle. After a few minutes of care, the dressing fell off the left ankle again. There was no dressing on the left outer thigh pressure ulcer area. At 10:58 a.m., CNA #1 positioned the resident on the left side and placed a pillow to the resident's back. The left outer ankle was flat on the bed with no dressing present. g. On 6/20/11 at 11:12 a.m., the Treatment Nurse left the room. CNA #1 showed this surveyor the left outer ankle. A dressing was present that was dated 6/20/11. There was no dressing on the left outer thigh. The left outer ankle was positioned flat on the bed. h. On 6/20/11 at 12:02 p.m. , the resident was in bed on the left side with the outer left ankle flat on the bed. i. On 6/21/11 at 3:07 p.m., CNA #14, currently assigned to the resident's hall for 1 month, was asked, "Is there anything special you do with (Resident #5's) left leg?" CNA #14 stated, "She had a splint. We kept a pillow between her legs. Kept heels off the bed. Keep a pillow under her legs when she's on her back." CNA #14 was asked, "Were you told to keep pressure off the left ankle or keep the resident off the left side?" CNA #14 stated, "No." j. On 6/21/11 at 3:20 p.m., CNA # 2 was asked, "Were you told to do anything special with (Resident #5's) left leg?" CNA # 2 stated, "Only that the splint could not be taken off until yesterday. It's off now. They told us not to turn her to the left when she first got the splint. Then they said her bottom was healed and I forgot about her ankle being sore later on so she was on her left side when you saw her. " k. On 6/21/11 at 11:30 a.m., the Treatment Nurse provided wound care. There was no dressing on the outer left thigh. The Treatment Nurse was asked, "Why no dressing on the thigh?" The Treatment Nurse did not respond. The Treatment Nurse measured and staged the pressure ulcers on the left outer thigh. One measured 0.6 centimeters (cm) by (x) 0.7 cm x 0.1 cm. The Treatment Nurse stated this pressure ulcer was a "Stage 2." A second pressure ulcer on the left outer thigh measured 0.2 cm x 0.4 cm x 0.1 cm. The Treatment Nurse stated this pressure ulcer was a "Stage 2." A third pressure ulcer measured 0.3 cm x 0.3 cm. The Treatment Nurse stated, "Scab, Unstageable ." The Stage II pressure ulcers identified by the Treatment Nurse were shallow in depth and the base of the wound was pink in color. The Treatment Nurse provided wound care and applied a Hydrogel dressing over the pressure ulcers on the left outer thigh. The Treatment Nurse then provided wound care and measured the left outer ankle. The wound bed was yellow in color with 3 dark brown areas. The Treatment Nurse stated the pressure ulcer was "Stage 2." The pressure ulcer measured 1.8 cm x 2.1 cm x 0.2 cm. The Treatment Nurse was asked, "What is in the center of the wound bed?" The Treatment Nurse stated, "Slough." The Treatment Nurse was asked, "If slough is present, what is the stage?" The Treatment Nurse stated, "Unstageable." The Treatment Nurse was asked, "Why is it unstageable?" The Treatment Nurse stated, "Because of necrotic tissue and slough." The facility's "Pressure Ulcer Staging Scale " documented, " ... Stage 2: Partial-thickness wound involving tissue loss into the dermis. Shallow - clean open ulcer, red to pink base, without slough. ... Stage 3: Full thickness wound involving tissue loss into the subcutaneous fat. Exposure of subcutaneous fat. Possibly necrotic tissue, undermining and tunneling. ... Unstageable Pressure Ulcer: Full thickness wound covered by necrotic tissue, therefore unable to be staged accurately. Staging cannot be assessed until enough necrotic tissue has been removed to reveal the wound base..." l. The "Pressure/Status Ulcer Report " received from the Nurse Consultant on 6/21/11 documented the following for the resident: "Skin Concern #: 2. B. Date first observed: 5/28/11; Site: (Left) ankle; Stage: (Blank); Size (LWD) (length, width, depth): 1.2 x 0.6 x 0.2... Tx (treatment): Dermagel (Hydrogel)... Date: 6/16/11; Concern #: 2; Site: (Left) ankle; Stage: II; Size (cm's): 2 x 0.9 x 0.2... Appearance: Yellow... Skin Concern #: 3. B. Date first observed: 5/28/11; Site: (Left) thigh; Stage: II; Size (LWD): 0.8 x 0.9 x 0.2... Tx: Dermagel Hydrogel... Date: 6/16/11; Concern #: 3; Site: (Left) thigh; Stage: (arrow pointing down); Size (cm's): 0.7 x 1.1 x 0.1... Appearance: Yellow... Skin Concern #: 4. B. Date first observed: 5/28/11; Site: (Left) thigh; Stage: II; Size (LWD): 0.4 x 0.6 x 0.1... Tx: Dermagel Hydrogel... Date: 6/16/11; Concern #: 4; Site: (Left) thigh; Stage: (arrow pointing down); Resolved..." m. The Departmental Notes dated 6/22/11 at 9:57 a.m. documented, "Unstageable pressure ulcer left ankle at 1.8 x 2.1 x 0.2 cm. Yellow slough ...Left outer thigh unstageable pressure ulcers x 3. Will refer to as Site A, B and C. Site A measuring 0.6 x 0.7 x 0.1 cm. yellow slough noted... Site B measuring 0.2 x 0.4 x 0.1 cm. Brown/yellow in color with slough and scabbing noted. ...Site C measuring 0.3 x 0.3. Brown scab in place... " n. On 6/22/11 at 9:15 a.m., the Director of Nurses (DON) was asked, "Will the current wound treatment clean slough and necrotic areas from the wound bed?" The DON stated, "No." o. On 6/23/11 at 11:40 a.m., the Director of Nurses (DON) was asked, "Have you ever observed (Resident #5's) skin under the splint? " The DON stated, "No." The DON was asked, "Has (Treatment Nurse) talked with you about her skin or staging of pressure ulcers?" The DON stated, "No." The DON was