Every finding on record at Villa Feliciana Chronic Disease

Based on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status by failing to implement interventions for 2 (#11 and #65) of 4 residents reviewed for Tube Feeding/Nutrition. The facility failed to complete weekly weights for Resident #11 and #65.Review of the facility's policy titled Weights-Obtaining Accurate Weights, updated on 10/2022, revealed the following: Purpose: To insure that accurate body weights are obtained on all residents at admission, and at least monthly thereafter, unless ordered more frequently by the attending physician. Policy: B. The nursing staff.will be responsible for obtaining and documenting the weights on the Electronic Health Record (EHR). C. In addition to the above, all residents will be weighed once a month, unless ordered more frequently by the attending physician. Procedure: G. If a resident refuses to be weighed at any time, the nurse must document this in the resident's EHR in the Nursing progress notes. Resident #11 Review of the clinical record for Resident #11 revealed he admitted to the facility on [DATE] and had diagnoses which included the following: Type 2 DM, GERD, and Dysphagia. Review of Resident #11's Quarterly MDS with an ARD of 11/13/2025 revealed a Brief Interview for Mental Status (BIMS) of 99, which indicated severe cognitive impairment. Review of the current physician orders for Resident #11 revealed the following, in part: -Weekly weights – every day shift every Monday – Start date: 08/18/2025 Review of the Nutrition Services Care Plan for Resident #11 revealed the following: Problem: Need for Adequate Nutrition due to medical conditions. Goal: Resident's tube feeding will be nutritionally adequate Approach: Resident's nutrition needs – Monitor weight: Weekly Review of the Care Plan for Resident #11 revealed the following: Problem: I have the need for adequate nutrition due to my diagnoses Approaches: 08/11/2025 – Weekly weights Review of the weight log for Resident #11 revealed the following: 01/12/2026 – 139.5# 01/11/2026 – 139.5# 01/05/2026 – 142.9# 12/17/2025 – 145.6# 11/13/2025 – 145.1# 10/15/2025 – 142.3# 09/01/2025 – 142.2# 08/25/2025 – 140.6# 08/18/2025 – 142.4# On 01/22/2026 at 9:43 a.m., an interview was conducted with S5CNAS. S5CNAS stated CNAs were responsible for weighing residents and [NAME] clerks were responsible for transferring weights from the weight log into the computer. She reviewed Resident #11's documented weights and confirmed he had not received weekly weights. On 01/22/2026 at 11:15 a.m., an interview was conducted with S4RD. S4RD reviewed Resident #11's Physician's Orders and confirmed he should have been receiving weekly weights. On 01/22/2026 at 11:30 a.m., an interview was conducted with S3LPN. S3LPN reviewed the documented weights for Resident #11 and confirmed weights were not obtained weekly. Resident #65Review of the clinical record for Resident #65 revealed he admitted to the facility on [DATE] and had diagnoses which included the following: Malignant Neoplasm of the Prostate and Type 2 Diabetes Mellitus without Complications. Review of Resident #65's Annual MDS with an ARD of 10/02/2025 revealed a BIMS of 04, which indicated severe cognitive impairment. Review of the current physician orders for Resident #65 revealed the following, in part:11/05/2024 - weekly weights Review of the Care Plan for Resident #65 revealed the following:Problem: I have a need for adequate nutrition/hydration due to my Metastatic Prostate Cancer. Interventions: weekly weights Review of the weight log for Resident #65 revealed the following:01/08/2026- 114.4#12/18/2025- 118.6#12/10/2025- 106.1#12/09/2025- 100.0#12/07/2025- 100.0#11/10/2025- 122.0#11/04/2025- 123.0#There were no weights documented for the following weeks: 11/17/2025, 11/24/2025, 12/01/2025, 12/22/2025, and 12/29/2025. On 01/22/2026 at 8:35 a.m., an interview was conducted with S8LPN. She stated Resident #65 had a weight loss and was weighed weekly. She reviewed Resident #65's clinical record at this time and confirmed he was not weighed weekly as ordered. On 01/22/2026 at 11:50 a.m., an interview was conducted with S4RD. S4RD reviewed Resident #65's Physician's Orders and confirmed he should have been receiving weekly weights. On 01/22/2026 at 3:10 p.m., an interview was conducted with S1DON. S1DON reviewed Resident #11's and #65's physician's orders and confirmed they should have been receiving weekly weights. S1DON further reviewed Resident #11's and #65's documented weights and confirmed they had not been receiving weekly weights according to physician's orders and should have been.

Based on observation, interviews, and record reviews, the facility failed to ensure there were sufficient numbers of Certified Nursing Assistants on a 24-hour basis to provide nursing care to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 3 (#14, #53 and #104) of 38 residents reviewed for staffing in the initial pool.Review of the facility's Resident Census dated 01/20/2026 revealed there were 162 residents who resided in the facility. Further review of the Census revealed there were 24 residents who resided on Unit 3 and 25 residents who resided on Unit 5. Review of the facility's daily Staffing Assignment Sheet for the 6:00 a.m. - 6:00 p.m. shift revealed the following number of required staff assignments:Unit 1 - 2 CNAs;Unit 2 - 2 CNAs;Unit 3 - 2 CNAs;Unit 4 - 2 CNAs;Unit 5 - 2 CNAs;Unit 6 - 2 CNAs;Unit 7 - 1 CNA; andUnit 8 - 1 CNA. Review of the facility's Staffing Assignment Sheets dated 01/01/2026 through 01/21/2026 revealed the following, in part:01/01/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to Unit 3;01/02/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to Unit 3;01/03/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to Unit 5;01/04/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to Unit 5;01/05/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to Unit 5;01/06/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to each Unit 3 and Unit 5;01/07/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to each Unit 3 and Unit 5;01/09/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to Unit 5;01/10/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to Unit 3;01/11/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to each Unit 3 and Unit 5;01/12/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to Unit 3;01/13/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to each Unit 1, Unit 5, and Unit 6;01/14/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to each Unit 3, Unit 5, and Unit 6;01/15/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to each Unit 3 and Unit 5;01/16/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to each Unit 1 and Unit 3;01/17/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to each Unit 1, Unit 5, and Unit 6;01/18/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to each Unit 3, Unit 5, and Unit 6;01/19/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to each Unit 3, Unit 5 and Unit 6;01/20/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to Unit 3; and01/21/2026 from 6:00 a.m. to 6:00 p.m. - 1 CNA was assigned to Unit 3. Resident #14Review of Resident #14's Clinical Record revealed an admission date of 06/17/2015 and diagnoses, which included Personal History of Traumatic Brain Injury and Morbid Obesity. Review of Resident #14's Quarterly MDS with an ARD of 12/14/2025 revealed she had a BIMS of 15, which indicated she was cognitively intact. Further review revealed Resident #14 was dependent on staff for activities of daily living and was incontinent of bladder and bowel. Review of Resident #14's current Care Plan revealed the following, in part:Problem: I cannot take care of myself. I am bed/chair bound and have Osteoarthritis and Morbid Obesity. I need the help of 2 plus staff members for transfers. I am able to make my needs known and make my own decisions. An interview was conducted with Resident #14 on 01/20/2026 at 9:46 a.m. Resident #14 resided on unit Resident #14 stated there were not enough CNAs to meet the needs of the residents on Unit 3. Resident #14 stated she required incontinence care. Resident #14 stated she was aware when she needed her brief changed. Resident #14 stated she called for staff to change her, and it often took them about one hour to provide incontinence care. An interview was conducted with S13CNAS on 01/21/2026 at 11:43 a.m. She stated she was the only CNA for Unit 3 today. She stated she had been working Unit 3 without the assistance of another CNA daily. She stated there were twenty-four residents on the unit. She stated there were not any residents on the unit who were completely independent. She stated there were 5 residents who required total care from the staff. She stated Unit 3 needed two CNAs. She stated there was sometimes only one nurse and one CNA for Unit 3. She stated she would be able to address the needs of the residents more timely and effectively with two CNAs on Unit 3. She explained overtime was taken away from the staff, and staff could only work extra shifts for compensatory leave time. She stated when overtime was taken away, it made the staffing situation for the facility worse because no staff wanted to work for straight compensatory leave time. An interview was conducted with S10RN on 01/21/2026 at 10:59 a.m. She confirmed she was assigned to Unit 3. She stated there were twenty-four residents who resided on the unit. She stated sometimes residents had to wait up to an hour for assistance with incontinence care or showering, which was too long. She stated residents' requests for care needed to be addressed as soon as possible, and within five minutes to meet their needs. She stated she often had to provide ADL care due to the CNA not being available, which took her away from her nursing duties. She stated half of the residents on the hall required assistance. She stated there should have been two nurses and two CNAs for Unit 3 to effectively meet the residents' needs. She stated today, there were two nurses and one CNA. An interview was conducted with S9RN on 01/21/2026 at 11:08 a.m. She confirmed she was assigned to Unit 3. She stated there were twenty-four residents on Unit 3. She stated there was one CNA for Unit 3 today. She stated all of the residents on the unit required some level of assistance. She stated the residents on Unit 3 had behaviors and psychological conditions which required direction, redirection, and assistance with tasks. She stated the residents' ADL care was not able to be met timely and effectively with one CNA and two nurses. She stated Unit 3 often only had one nurse and one CNA. She stated she assisted with CNA tasks when she was available, but she also had nursing duties. She stated there were three residents on Unit 3 who required two person assistance with ADLs and bed mobility. She stated when there was one CNA and one nurse, Resident #14 and other residents who required two person assistance often had to wait a long time for assistance because both staff had to be available to assist. She stated she often had to tell residents they would have to wait for incontinence care until someone else was available to assist. She stated she has reported to S11RNS that the unit needed at least two CNAs to carry out the functions of the unit timely. An interview was conducted with S15CNA on 01/22/2026 at 8:16 a.m. She confirmed she was assigned to Unit 3. She stated Unit 3 required two CNAs to meet the residents' needs effectively and timely. Unit 5An observation was conducted of unit 5 on 01/21/2026 from 11:00 a.m. to 11:40 a.m. Resident #53 was noted pacing up and down the hall, stating he wanted a shower. S17RN redirected Resident #53 multiple times during the observation. Resident #53 was noted with his face against the glass window and softly hitting the glass at the nurse's station. At 11:40 a.m., Resident #53 was noted looking through and hitting the glass of the locked doors leading into Unit 5. An interview was conducted with S18CNA on 01/21/2026 at 11:44 a.m. She stated it was not possible to complete all tasks for residents timely with only one CNA on Unit 5. An interview was conducted with S19CNA on 01/21/2026 at 11:52 a.m. She stated she could not complete every 30 minute rounding and every 2 hour incontinent care on Unit 5 with 1 CNA. She stated Unit 5 had 15 bed bound residents and 3 residents that required to be fed. An interview was conducted with S8LPN on 01/22/2026 at 8:30 a.m. She stated there was one CNA assigned to both halls on Unit 5 today. She stated there were 25 total residents, with 15 residents that required total care and 3 that required to be fed. She stated last night there was not a CNA on Unit 5. She stated rounding was not completed every 30 minutes when one CNA was scheduled on Unit 5. She stated residents had to wait 30 minutes to 2 hours for a bed bath or shower. She stated Resident #53 requested a shower daily and got agitated when he waited for 30 minutes or longer. She stated Resident #53 yelled and beat on the door when he was agitated while he waited for assistance. An interview was conducted with S20LPN on 01/22/2026 at 8:40 a.m. He stated Resident #53 requested a shower every day and got agitated when he waited for 30 minutes or longer. He stated Resident #53 yelled and beat on the door when he was agitated while he waited for assistance. He further stated non facility security officers redirected Resident #53 from entering other resident's rooms when the facility staff was not available. An interview was conducted with a non-facility security officer on 01/22/2026 at 3:45 p.m. She stated the facility did not have enough staff on Unit 5 to provide residents with timely assistance. She stated residents on Unit 5 did not get perineal care every 2 hours due to short staffing. She stated the residents received perineal care at 6:00 a.m. and 3:00 p.m. She stated Resident #104 became agitated when his brief was wet and attempted to get up. She stated the security officers would stand outside his room to ensure his safety when staff were not available. She stated, on 01/22/2026, Resident #104 stood up, and his brief was soaked and fell to the ground. She further stated non facility security officers stopped Resident #53 from entering other residents' rooms when staff were not available. A telephone interview was conducted with S11RNS on 01/22/2026 at 10:44 a.m. She stated the facility needed more CNAs to timely and effectively meet the needs of the residents. She stated the following nurse staffing was needed on the following units: Unit 1 - 2 nurses; Unit 2 - 1 nurse; Unit 3 - 2 CNAs; Unit 4 - 1 CNA; Unit 5 - 2 CNAs; Unit 6 - 2 CNAs; Unit 7 - 1 CNA; Unit 8 - 1 CNA. She stated there were twenty-four residents on Unit 3. She explained there were multiple residents residing on Unit 3 with psychological conditions and extensive behaviors, therefore, she preferred to have 2 nurses on the unit if the staff were available. She stated the extra nurse on Unit 3 was not put there to perform CNA duties. She stated S13CNAS had been assigned to Unit 3 due to there not being another CNA available. She stated there were fifteen bed bound residents on Unit 5 who were totally dependent on staff for ADLs. She stated Unit 5 needed two CNAs and Unit 6 needed two CNAs. She stated S13CNAS needed to be rounding and not assigned to a unit. An interview was conducted with S12RNM on 01/22/2025 at 11:33 a.m. He stated the following nursing staff on the following units were needed to effectively meet the needs of the residents: Unit 1 - 2 CNAs; Unit 2 - 2 CNAs; Unit 3 - 2 CNAs; Unit 4 - 2 CNAs; Unit 5 - 2 CNAs; Unit 6 - 2 CNAs; Unit 7 - 1 CNA; Unit 8 - 2 CNAs. He confirmed the facility was not currently staffed at the aforementioned numbers and barely ever was. He stated there have been times when residents' requested incontinence care, the CNA and nurses were busy, and the resident had to wait thirty minutes to one hour to receive the care. He stated the facility needed to be staffed fully to meet the needs of the residents effectively and timely. He confirmed the facility had a nurse and CNA staffing problem. He explained overtime was taken away from staff, and staff could only work extra shifts for compensatory leave time. He stated when overtime was taken away, it made the staffing situation for the facility worse because no staff wanted to work for straight compensatory leave time. An interview was conducted with S1DON and S14ADON on 01/22/2026 at 3:14 p.m. S1DON and S14ADON stated the following number of CNAs were needed on the following units: Unit 1 - 2 CNAs; Unit 2 - 2 CNAs; Unit 3 - 2 CNAs; Unit 4 - 2 CNAs; Unit 5 - 2 CNAs; Unit 6 - 2 CNAs; Unit 7 - 1 CNA; and Unit 8 - 2 CNAs. S1DON explained overtime was taken away from staff, and staff could only work extra shifts for compensatory leave time. S1DON stated when overtime was taken away, it made the staffing situation for the facility worse because no staff wanted to work for straight compensatory leave time. S1DON stated it was impossible for one CNA to be able to carry out the ADLs of all residents on unit 5 timely and effectively. S1DON and S14ADON confirmed the facility was unable to staff enough CNAs each shift to meet the acuity of the facility's residents.

Based on observations and interviews, the facility failed to ensure medications were stored properly in accordance with currently accepted professional principles. The facility failed to ensure expired medications were not available for use for Resident #71 and Resident #131 in Medication Cart a, and for Resident #65 in Medication Cart b of 5 medication carts reviewed. On 01/20/2026 at 1:55 p.m., an observation was made of Medication Cart a with S6LPN. The following was observed:One bottle of Latanoprost Ophthalmic Solution 0.005% with an expiration of 12/2025 for Resident #71; andOne bottle of Latanoprost Ophthalmic Solution 0.005% with an expiration of 12/2025 for Resident #131. On 01/20/2026 at 2:03 p.m., an interview was conducted with S6LPN. She confirmed the Latanoprost Ophthalmic Solution 0.005% bottles for Resident #71 and Resident #131 were expired and available for use. S6LPN confirmed expired medications should not have been available for use. On 01/21/2026 at 8:51 a.m., an observation of was made of Medication Cart b with S7LPN. The following was observed: One bottle of Latanoprost Ophthalmic Solution 0.005% with an expiration of 12/2025 for Resident #65. On 01/21/2026 at 9:04 a.m., an interview was conducted with S7LPN. She confirmed the bottle of Latanoprost Ophthalmic Solution 0.005% for Resident #65 was expired and available for use. S7LPN confirmed an expired medication should not have been available for use. On 01/22/2026 at 3:44 p.m., an interview was conducted with S1DON. S1DON stated nurses were responsible for checking the medication carts for expired medications. S1DON confirmed expired medications should not have been available for use.

Based on observations, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect the residents who were served food from the facility's kitchen. Review of the facility's policy with a revision date of 02/2023, titled Food Storage: Cold Foods revealed in part, the following:Procedures5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. On 01/20/2026 at 8:52 a.m., an observation of the dry storage room in Kitchen b revealed the following:1 opened, 1/2 full, gallon container of soy sauce, with no open date, with a label which read Refrigerate after opening. On 01/20/2026 at 8:59 a.m., an observation of Kitchen b revealed the following: 1opened, 16 ounce block of margarine, with no open date, unsealed. On 01/20/2026 at 9:00 a.m., an interview was conducted with S16DM. S16DM confirmed the above findings. S16DM confirmed the container of soy sauce should have been refrigerated after opening, and the block of margarine should have been sealed, labeled, and dated. On 01/22/2026 at 11:55 a.m., an interview was conducted with S4RD. S4RD confirmed the container of soy sauce should have been refrigerated after opening, and the block of margarine should have been sealed, labeled, and dated.

Based on observations, interviews, and record review, the facility failed to ensure the oxygen tubing was labeled with the date and time for 1(#54) of 5 residents reviewed for respiratory care.Review of the facility's undated policy titled Oxygen Administration revealed the following, in part, Procedure: O. Document date, time, oxygen flow rate, route and frequency and duration of treatment. S. Replace tubing, cannula or mask at least every week when oxygen is used intermittently or as needed. Resident #54 was admitted to the facility on [DATE] with diagnoses that included, in part, Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbations, Pleural Effusion, and Atrial Fibrillation. Review of Resident #54's Care Plan revealed the following, in part: Problem: The resident has oxygen therapy related to diagnosis of COPD, Pleural effusion Intervention: Monitor for signs/symptoms of respiratory distress and report to MD as needed. O2 via Nasal Cannula as needed, keeps sats >93%. Problem: The resident is at risk for altered respiratory status/difficulty breathing related to diagnosis of COPD, Allergic rhinitis, and Pleural effusion Interventions: Monitor /document changes in orientation, increased restlessness, anxiety, and air hunger. On 01/20/2026 at 10:30 a.m. an observation revealed no date and time on Resident #54's oxygen tubing. On 01/20/2026 at 1:50 p.m. an observation revealed no date and time on Resident #54's oxygen tubing. On 01/20/2026 at 2:00 p.m., an observation made with S2LPN. S2LPN confirmed Resident #54's O2 tubing was not labeled and should have been. On 01/22/2026 at 3:10 p.m., an interview was conducted with S1DON. S1DON stated she expected staff to label oxygen tubing with the date and time that it was changed.

Based on observations, interviews, and record reviews, the facility failed to protect the residents' right to be free from physical abuse and psychosocial harm for 3 (#1, #3, and #R1) of 5 residents reviewed for abuse. The facility failed to protect:1. Resident #3 from physical abuse by Resident #R2;2. Resident #R1 from physical abuse by Resident #2;3. Resident #3 from physical abuse by Resident #2; and4. Resident #1 from physical abuse by Resident #2. This deficient practice resulted in physical and psychosocial harm on 10/28/2025 at 5:45 p.m. for Resident #3, a severely cognitively impaired resident with a history of a traumatic brain injury, when Resident #R2 drug Resident #3 from the bench onto the ground and hit him with balled fist at least 7 times in the face and head causing Resident #3 to bleed from the lip and mouth. Due to Resident #3's history of traumatic brain injury, he was sent to the emergency room for evaluation. All scans were negative. Upon interview with Resident #3 he pointed to his head and stated it hurt and verbalized he was scared during the incident. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Resident #3, it could be determined a reasonable person would be likely to experience physical and psychosocial harm as a result of the physical abuse since a reasonable person would not expect to be treated in this manner in their own home or a health care facility.Findings:Review of the facility's policy titled, Abuse and Neglect Policy with a revised date of March 2025 revealed the following, in part:Purpose: The facility is committed to preserving the right of each person receiving services to be free from abuse.D. Definitions: Abuse - the willful infliction of injury, resulting in physical harm, pain or mental anguish.i. Physical abuse - physical contact which results in significant physical injury. Physical injury is any injury requiring medical attention beyond first aid. 1. Review of Resident #R2's Clinical Record revealed an admission date of 10/03/2024 with diagnoses which included Borderline Intellectual Functioning, and Schizoaffective Disorder. Review of Resident #R2's Annual MDS with an ARD of 10/09/2025 revealed a BIMS of 6, which indicated he was severely cognitively impaired. Review of Resident #R2's Care Plan revealed the following, in part:Problem: The resident has a behavior problem related to diagnosis of Schizophrenia, Borderline Intellectual Functioning and Neurocognitive Disorder.Interventions: 10/28/2025 - Staff to keep Resident #3 and #R2 separate; staff to remain on smoker's patio while residents are present and immediately intervene on behavior occurrences to ensure safety of resident and others; Resident #R2 to remain on 1:1 observation. Review of the facility's Incident Report dated 10/28/2025 at 5:45 p.m. revealed the following, in part: Type of incident: Resident to Resident Activity.Description of incident: Security staff assisted Resident #3 to the nurse's station and reported that Resident #3 and Resident #R2 had an altercation outside. Resident #3 received a scratch under his left eye and the upper left side of chest area, mouth and lip were bloody. Signed by S17LPN.Registered Nurse supervisor review: by S8RN: Do you suspect Abuse: Yes. Review of Resident #R2's Nurses Notes revealed the following:On 10/29/2025 at 6:00 p.m. per S9RN: Late entry for 10/28/2025 at 5:45 p.m.: Resident #R2 had an altercation with Resident #3, Resident #3 was trying to take Resident #R2's cigarette got mad and starting swinging at Resident #3. Resident #3 received a cut to left eye area, left chest area. Resident #3 also received a cut to his lip/mouth with bleeding noted to his mouth area. Resident #R2 noted with no injuries noted.On 10/28/2025 at 8:41 p.m. per S9RN: order received to place resident on 1:1 with security for aggressive behaviors. Review of Resident #R2's MD Orders dated 10/1/2025 to 11/10/2025 revealed the resident was placed on 1:1 observation on 10/28/2025 through 10/31/2025 when the physician discontinued the intervention. Several observations of Resident #R2 conducted during survey revealed Resident #R2 remained in staffs line of sight during observations. Resident #3Review of Resident #3's Clinical Record revealed an admission date of 04/15/2024 with diagnoses, which included Dementia with Agitation, Major Depressive Disorder, Impulse Disorder, and Personal History of Traumatic Brain Injury. Review of Resident #3's Quarterly MDS with ARD of 07/29/2025 revealed a BIMS of 2, which indicated he was severely cognitively impaired. Review of Resident #3's Current Care Plan dated 10/21/2025 revealed the following, in part: Problem: Resident has impaired cognitive function or impaired thought processes related to medical history of Dementia, Amnesia, Depressive Disorder, Traumatic Brain Injury, and Impulse Disorder.Problem: Resident has a communication problem related to medical history of Dementia, Amnesia, and Traumatic Brain Injury. He is usually understood and usually understands. Problem: Resident incoherent and has difficulty keeping track of what is said at times. On 10/30/2025 per S15MDS: Resident #3 was moved to a room closer to the nurse's station and away from Resident #R2's room. Resident #R2 is currently on 1:1 observation due to his aggressive behaviors. Treatment team recommendations: Staff to keep residents separate; Staff to remain on smoker's patio while residents are present and immediately intervene on behaviors occurrences to ensure safety of resident and others; Resident #R2 to remain on 1:1 observation due to aggressive behaviors. An observation was made of video surveillance on the smoking patio with S7MM on 11/12/2025 at 3:00 p.m. Video surveillance dated 10/28/2025 at approximately 5:45 p.m. revealed the following: There were four male residents sitting under a green pavilion. Resident #3 and Resident #R2 were sitting on the same bench. A random resident sitting across from Resident #3 handed him a cigarette. Once the cigarette was in Resident #3's hand, Resident #R2 grabbed Resident #3 by the right shoulder and right leg and drug him from the bench onto the ground and began hitting him with a balled fist in his head and left side of his face. Both Resident #3 and Resident #R2 rolled on the ground. Resident #R2 completed a minimum of 7 punches to Resident #3's face and head. At 5:46 p.m., a security guard arrived and assisted Resident #3 to his feet. Resident #3 was bleeding from the left side of his lip/mouth. An interview was conducted on 11/12/2025 at 3:30p.m.with Resident #3. He stated he was hit in the head and chest a few weeks ago. He pointed to the left side of his head and stated it hurt. He could not report an exact date or say who hit him but was able to verbalize he felt scared and it hurt. An interview was conducted with S3CR on 11/12/2025 at 2:19 p.m. S3CR confirmed the incident on 10/28/2025 between Resident #3 and Resident #R2 was physical abuse. 2.Resident #R1Review of Resident #R1's Clinical record revealed an admission date of 08/29/2024 with diagnoses, which included Schizoaffective Disorder - Bipolar Type and Depression. Review of Resident #R1's Annual MDS with an ARD of 09/09/2025 revealed a BIMS of 15, which indicated she was cognitively intact. Review of Resident #R1's incident report dated 09/17/2025 at 3:20 p.m. revealed the following, in part:Type if incident: Resident to Resident activityDescription of incident: Resident #2 slapped Resident #R1 in the face when she asked him to buy her a drink.Registered Nurse Supervisor review by S10RN: Do you suspect abuse or neglect: yes. Resident #2Review of Resident #2's Clinical Record revealed an admission date of 08/12/2013 and diagnoses, which included Anxiety Disorder, Insomnia, Restlessness and Agitation, Unspecified Psychosis, Unspecified Disorder of Adult Personality and Behavior, and Schizoaffective Disorder. Review of Resident #2's Annual MDS with an ARD of 08/10/2025 revealed a BIMS of 6, which indicated severe cognitive impairment. Review of Resident #2's Incident report dated 09/17/2025 at 3:20 p.m. revealed the following, in part:Where incident occurred: day roomDescription of incident: Resident #2 was sitting in the day room watching television when Resident #R1 rolled toward him in her wheelchair. Resident #2 slapped Resident #R1 in the face. S11LPN asked what happened, and Resident #2 stated Resident #R1 was bothering him so he slapped her in the face.Nurse competing report: S11LPN Review of Resident #2's Nurse's Notes dated September 2025 through October 2025 revealed the following, in part:09/17/2025 at 3:27 p.m. by S11LPN - a physician's order was given to increase observation to every fifteen minutes for safety. Further review of the nurses' notes revealed Resident #2 was admitted to the hospital for psychiatric evaluation on 09/18/2025. Resident #2 returned to the facility on [DATE], on every fifteen minute observation by staff, and with medication changes. Review of Resident #2's current care plan revealed the following, in part:Problem: Incidents/Behaviors09/17/2025 - I was sitting in the dayroom and Resident #R1 rolled up to me. I slapped her in the face. She was asking me for a coke.Interventions:09/17/2025 - Both residents were separated by staff. No injuries. Residents remain on observation for behaviors; Psychiatric consult immediately; 09/18/2025 - special staffing completed and Resident #2 was placed on one-on-one (1:1) observation with male security and sent to a secure unit; Resident #2 was then sent to a local hospital for a psychiatric evaluation and inpatient psychiatric treatment. An interview was conducted with S12SSC on 11/12/2025 at 2:15 p.m. She stated she was in the common area on 09/17/2025. She stated Resident #R1 wheeled up to Resident #2 while he was seated in the stationary chair watching television. She stated Resident #R1 asked Resident #2 for a soda, and when she asked again, Resident #2 hit Resident #R1 in the face with his posterior hand. She stated Resident #R1 was not injured but stated, Ouch, I didn't deserve that. She confirmed Resident #2 physically abused Resident #R1. An interview was conducted with S11LPN on 11/12/2025 at 12:55 p.m. She confirmed she was assigned to Resident #2 on 09/17/2025. She stated it was reported to her Resident #R1 was continuously asking Resident #2 for a soda, and Resident #2 hit Resident #R1 in the face. She stated both residents were immediately separated and did not have any further contact. She stated both residents were placed on every fifteen minute monitoring. She stated, the following day, Resident #2 was placed on 1:1 observation and moved to another unit. She confirmed Resident #2 slapping Resident #R1 was physical abuse. An interview was conducted with S10RN on 11/12/2025 at 1:02 p.m. She stated, on 09/17/2025, she received a call from S11LPN of the incident between Residents #2 and #R1. She stated it was reported to her that Resident #R1 was repeatedly asking for a soda and Resident #2 hit Resident #R1 in the face. She stated security immediately separated the residents and they did not have any other contact. She stated both residents were placed on every fifteen minute monitoring by security, and Resident #2 was transferred to another building the following day. She confirmed Resident #2 hitting Resident #R1 was physical abuse. An interview was conducted with S3CR on 11/12/2025 at 10:44 a.m. He reviewed the incident between Residents #2 and #R1. He confirmed Resident #2 physically abused Resident #R1 on 09/17/2025. 3.Resident #3Review of Resident #3's Clinical Record revealed an admission date of 04/15/2024 with diagnoses, which included Dementia with Agitation, Major Depressive Disorder, Impulse Disorder, and Personal History of Traumatic Brain Injury. Review of Resident #3's Incident Report dated 10/10/2025 at 3:10 a.m. revealed the following, in part:Type of incident: alleged abuse-neglect; resident to resident activity; unsafe act.Description of incident: Resident #3 was standing at the window trying to put his jacket on, and Resident #2 punched him in the face trying to take the resident's jacket.Assessment: bleeding inside the mouth on the left side of mouth and arm has some scratches and bruising noted.Report completed by S14LPN.Registered Nurse Supervisor review by S9RN. Resident #2Review of Resident #2's Incident Report dated 10/10/2025 at 3:10 a.m. revealed the following, in part:Type of incident: alleged abuse-neglect; resident to resident activity, unsafe act, threatening staffDescription of incident: While Resident #3 was putting on his jacket, Resident #2 grabbed Resident #3's right arm, and with a balled fist, hit Resident #3 on the left side of his face. Resident #2 stated Resident #3 had on his jacket and he wanted it back. This nurse summoned assistance from security.Signature of person completing form: S14LPN.Registered Nurse Supervisor review by S9RN. Review of Resident #2's Nurses' Notes dated October 2025 revealed the following, in part: 10/10/2025 at 6:23 a.m. - an order received to transfer Resident #2 to a local hospital for evaluation and treatment of escalating, aggressive, and volatile behaviors. Further review of the nurses' notes revealed Resident #2 returned to the facility on [DATE]. Resident #2 readmitted to a different building and unit, on 1:1 observation, and with medication changes. Review of Resident #2's current care plan revealed the following, in part:Problem: Incidents/Behaviors10/10/2025 - I grabbed Resident #3's right arm, and with a balled fist, hit Resident #3 on the left side of his face. I stated Resident #3 took my jacket and I chased him to his room.Interventions:10/10/2025 - Security was notified and assisted with de-escalating incident; MD ordered for Resident #2 to be sent to a local hospital for evaluation and treatment of escalating behavior. An interview was conducted with Resident #2 on 11/10/2025 at 11:36 a.m. He stated there was an incident when he hit Resident #3. He stated Resident #3 had his leather jacket on and was saying it was his, so he hit him with a fist in the face. A telephone interview was conducted with S14LPN on 11/13/2025 at 3:28 p.m. She confirmed she was present for the incident between Residents #2 and #3 on 10/10/2025. She stated Resident #2 and Resident #3 were outside of the nurses' station conversing when Resident #2 removed his jacket and assisted Resident #3 with putting the jacket on. She stated Resident #2 then grabbed Resident #3 and punched him in the face. She confirmed Resident #2 punching Resident #3 was physical abuse. She stated Residents #2 and #3 were immediately separated, Resident #2 was sent for a psychiatric evaluation, and Resident #2 did not return to Resident #3's unit. An interview was conducted with S9RN on 11/12/2025 at 4:32 p.m. She stated, on 10/10/2025 at 3:10 a.m., she was summoned to Residents #2 and #3's unit by S14LPN. She stated Resident #2 and Resident #3 were fighting over a jacket. She stated S14LPN reported Resident #2 punched Resident #3 in the face. She confirmed Resident #2 punching Resident #3 was physical abuse. An interview was conducted with S3CR on 11/12/2025 at 10:44 a.m. He reviewed the incident between Resident #2 and Resident #3. He confirmed Resident #2 physically abused Resident #3 on 10/10/2025. 4.Resident #1Review of Resident #1's Clinical Record revealed an admission date of 07/22/2015 and diagnoses, which included Paraplegia. Review of Resident #1's Quarterly MDS with an ARD of 10/17/2025 revealed a BIMS of 15, which indicated he was cognitively intact. An observation of video footage with S7MM on 11/10/2025 at 3:10 p.m., dated 10/21/2025 revealed the following:At 3:44:28 p.m. Resident #R3 rolled out onto smoking patio in his wheelchair. Resident #1 was observed on the smoking patio in his wheelchair.At 3:44:53 p.m. Resident #2 walked out the door onto the smoking patio.At 3:44:58 p.m. Resident #2 swung at Resident #1's left side of face with his right hand in a balled fist, and Resident #1's face turned toward the right. 3:45:00 p.m. S5CGT walked out the door onto smoking patio, and brought Resident #1 back inside the facility. Resident #2Review of Resident #2's Nurses' Notes dated October 2025 through November 2025 revealed the following, in part:10/21/2025 at 3:50 p.m. - Resident was observed by the Psychiatrist and nurse. New order obtained to transfer resident to a local hospital for a psychiatric evaluation with a Physician Emergency Certificate. Resident left the facility at 4:24pm. Further review of the nurses' notes revealed Resident #2 returned to the facility on [DATE] with medication changes and on 1:1 observation with security staff. An interview was conducted with Resident #1 on 11/10/2025 at 10:33 a.m. Resident #1 reported, on 10/21/2025 around 4:00 p.m., Resident #1 and Resident #R3 were sitting on the smoking patio when Resident #2 came out of the facility door and struck Resident #1 on the left side of his jaw with a closed fist. He stated, shortly after Resident #2 made contact with his jaw, S5CGT removed Resident #2 from the smoking patio and escorted him back into the facility. An interview was conducted with Resident #2 on 11/10/2025 at 11:36 a.m. He stated, about one month ago, he hit Resident #1 in the face with his fist. He stated S5CGT walked him back to his ward. An interview was conducted with Resident #R3, a cognitively intact resident, on 11/10/2025 at 1:37 p.m. Resident #R3 confirmed he was sitting on the patio on the afternoon of 10/21/2025 with Resident #1. Resident #R3 stated Resident #2 came out the door yelling, Give me some money m***** f***er. He stated Resident #2 swung a balled fist at Resident #1 and made physical contact with Resident #1's face. He stated S5CGT came out the door and brought Resident #2 back inside the facility. An interview was conducted with S5CGT on 11/10/2025 at 10:32 a.m. He stated, on 10/21/2025, Resident #2 was on 1:1 observation. He stated, that afternoon, Resident #2 began running down the hallway by the dining area toward the opposite units. He stated he followed Resident #2, and Resident #2 proceeded to go outside onto the smoking patio. He stated Resident #1 was seated on the smoking patio. He stated he immediately escorted Resident #2 back into the building. He stated he did not witness Resident #2 make any physical contact with Resident #1. He stated if Resident #2 hit Resident #1, it was physical abuse. An interview was conducted with S2DON on 11/13/2025 at 9:28 a.m. S2DON confirmed she was unaware of the incident from 10/21/2025 between Resident #1 and Resident #2. She confirmed that one resident hitting another resident with a balled fist was physical abuse. An interview was conducted with S1ADM on 11/13/2025 at 11:15 a.m. S1ADM confirmed physical abuse included physical contact such as hitting.

Based on interviews and record reviews, the facility failed to report allegations and incidents of physical abuse to Administration and/or the State Agency for 3 (#1, #3, and #R1) of 5 residents reviewed for abuse. The facility failed to ensure:The State Agency was notified when Resident #R1 was physically abused by Resident #2; The State Agency was notified when Resident #3 was physically abused Resident #2;Staff reported an allegation of physical abuse to Administration when Resident #1 notified staff he was physically abused Resident #2; and The State Agency was notified when Resident #3 physically abused Resident #R2.Findings: On 11/12/2025 a review of the facility's policy titled Abuse and Neglect Policy with a revised date of March 2025 revealed the following, in part: d. Duty to Report:ii. Procedure to Report Abuse/ Neglect- any employee1. To the Immediate Supervisor: Immediately, if at all possible, but in no case later than one hour after knowledge or suspicion, the written report shall be submitted to the Registered Nurse Supervisor as soon as possible, but no later than two hours after the verbal report. 12. During the weekdays and when on call, the Adult Protective Services will be notified by the Clients Rights Officer upon receiving the report of the alleged abuse. iv. Clients rights Officer: The functions of the Client Rights Officer or the designee is as follows: 2. At the direction of the Administrator, report allegations of abuse and neglect to the APS and assure that information is entered into the state agency Incident System. v. Duties of the Administrator: 7. Ensure all reporting requirements are followed. e. Identification of Possible Incidents or Allegations that need investigation: i. Identification of possible incidents or allegations of abuse/ neglect are identified by reviewing the incident report and receiving direct verbal report of such cases. h. Reporting of Incidents, investigations, and facility response to the results of their investigations: i. Person who has witnessed or has been notified by a resident of a case of abuse or neglect will report the case immediately and no later than 1 hour to the Registered Nurse supervisor or Administrator. 1.Resident #R1Review of Resident #R1's Clinical Record revealed an admission date of 08/29/2024. Review of Resident #R1's incident report dated 09/17/2025 at 3:20 p.m. revealed the following, in part:Type if incident: Resident to Resident activityDescription of incident: Notified by social service staff that Resident #2 slapped Resident #R1 in the face when she asked him to buy her a drink.Registered Nurse Supervisor review by S10RN: Do you suspect abuse or neglect: yes; Administrator notified: yes Resident #2Review of Resident #2's Clinical Record revealed an admission date of 08/12/2013. Review of Resident #2's incident report dated 09/17/2025 at 3:20 p.m. revealed the following, in part:Where the incident occurred: day roomDescription of incident: Resident #2 was sitting in the day room watching television when Resident #R1 rolled toward him in her wheelchair. Resident #2 slapped Resident #R1 in the face. S11LPN asked what happened, and Resident #2 stated Resident #R1 was bothering him so he slapped her in the face.Nurse competing report: S11LPN An interview was conducted with S12SSC on 11/12/2025 at 2:15 p.m. She confirmed she witnessed the incident above. She confirmed Resident #2 physically abused Resident #R1 on 09/17/2025 when he hit her in the face. An interview was conducted with S11LPN on 11/12/2025 at 12:55 p.m. She confirmed Resident #2 hitting Resident #R1 was considered physical abuse. She stated she reported the incident to S10RN. An interview was conducted with S10RN on 11/12/2025 at 1:02 p.m. She stated, on 09/17/2025, she was informed Residents #2 hit Resident #R1. She confirmed she notified S1ADM and S3CR of the incident. An interview was conducted with S3CR on 11/12/2025 at 10:44 a.m. He confirmed he was notified of the incident between Residents #2 and #R1. He confirmed Resident #2 physically abused Resident #R1 on 09/17/2025. He confirmed the incident was not reported to the State Agency. 2.Resident #3Review of Resident #3's Clinical Record revealed an admission date of 04/15/2024. Review of Resident #3's Incident Report dated 10/10/2025 at 3:10 a.m. revealed the following, in part: Type of incident: alleged abuse-neglect; resident to resident activity; unsafe act.Description of incident: Resident #3 was standing at the window trying to put his jacket on, and Resident #2 punched him in the face trying to take the resident's jacket. Assessment: Resident #3 had bleeding on the inside of the left side of mouth and arm had some scratches and bruising. Report completed by S14LPN.Registered Nurse Supervisor review by S9RN. Resident #2Review of Resident #2's Incident Report dated 10/10/2025 at 3:10 a.m. revealed the following, in part:Type of incident: alleged abuse-neglect; resident to resident activity, unsafe act, threatening staffDescription of incident: While Resident #3 was putting on his jacket, Resident #2 grabbed Resident #3's right arm, and with a balled fist, hit Resident #3 on the left side of his face. Resident #2 stated that Resident #3 had on his jacket and he wanted it back.Signature of person completing form: S14LPN.Registered Nurse Supervisor review by S9RN. A telephone interview was conducted with S14LPN on 11/13/2025 at 3:28 p.m. She confirmed she witnessed the incident between Residents #2 and #3. She confirmed Resident #2 punching Resident #3 was considered physical abuse. She stated she reported the incident to S9RN. An interview was conducted with S9RN on 11/12/2025 at 4:32 p.m. She stated, on 10/10/2025 at 3:10 a.m., she was summoned to Residents #2 and #3's unit. She stated S14LPN reported Resident #2 punched Resident #3 in the face. She confirmed Resident #2 punching Resident #3 in the face was considered physical abuse. She stated the incident was reported to S3CR. An interview was conducted with S3CR on 11/12/2025 at 10:44 a.m. He confirmed he was notified of the incident between Residents #2 and #3. He confirmed Resident #2 physically abused Resident #3 on 10/10/2025. He confirmed the incident was not reported to the State Agency. 3.Resident #1,Review of Resident #1's Clinical Record revealed an admission date of 07/22/2015. An interview was conducted with S4LPN on 11/10/2025 at 11:21 a.m. S4LPN stated, on 10/25/2025, Resident #1 verbalized he was hit by Resident #2 on 10/21/2025. S4LPN stated she reported this incident to S6RN on 10/25/2025. An interview was conducted with S16CNA on 11/10/2025 at 1:05 p.m. She stated Resident #1 reported to her (on a date she did not recall) Resident #2 had hit him. She confirmed she did not report this allegation as she did not see it occur. She further confirmed the aforementioned incident was considered physical abuse, and she should have been reported it to administration or the nurse as soon as she became aware of it. An interview was conducted with S6RN on 11/10/2025 at 2:25p.m. S6RN stated staff had not reported an allegation of abuse to him between Resident #1 and Resident #2. S6RN confirmed if one resident hit another resident it was considered physical abuse. He confirmed all allegations of abuse should be reported to the State Agency within two hours after the allegation is made. An interview was conducted with S3CR on 11/12/2025 at 10:44 a.m. He stated he was made aware of Resident #2 hitting Resident #1 on 11/07/2025. He confirmed the facility had not reported this incident of physical abuse to the State Agency. An interview was conducted with S1ADM on 11/13/2025 at 11:15 a.m. S1ADM confirmed S3CR was responsible for investigating and reporting any allegations of abuse to the State Agency. He confirmed the incident on 10/21/2025 between Resident #1 and Resident #2 should have been reported to himself or S3CR. 4.Resident #3Review of Resident #3's Clinical Record revealed an admission date of 04/15/2024. Review of Resident #R2's Clinical Record revealed he was admitted to the facility on [DATE]. Review of the facility's Incident Report dated 10/28/2025 revealed the following, in part:Incident occurred: 10/28/2025 at 5:45 p.m. in the smoking area.Type of incident: Resident to Resident ActivityDescription of incident: Security staff assisted Resident #3 to the nurses' station and reported that Resident #3 and Resident# R2 had an altercation outside. Resident #3 received a scratch under his left eye and the upper left side of chest area, mouth and lip were bloody. Signed by S17LPN Assessment: Resident#3 was alert and verbal, bleeding noted under left eye and left chest area. Also, bleeding noted from mouth/ lip area. RN supervisor review: Signed by S8RN: Do you suspect Abuse: Yes An interview was conducted with S3CR on 11/12/2025 at 10:44 a.m. He confirmed the incident on 10/28/2025 was not reported to the State Agency. He stated he discussed all resident to resident incidents and altercations with S1ADM. He stated the facility's policy and directive from S1ADM was to only report resident to resident abuse to the State Agency if it resulted in significant injury or death. An interview was conducted with S1ADM on 11/13/2025 at 11:15 a.m. S1ADM confirmed physical abuse included physical contact such as hitting. He confirmed the aforementioned incidents were not reported to the State Agency. He stated it was the facility's policy not to report resident to resident altercations to the State Agency unless the altercation resulted in significant injury.

Based on observation, record review and interviews, the facility failed to provide a functioning assistance device for supervision to prevent an accident from occurring for 1 (RR1) of 2 (#3 and RR1) residents who required assistant devices. Findings: Review of Resident R1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included, Unspecified Psychosis, Unspecified Dementia, and Schizophrenia. Review of Resident R1's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/04/2025 revealed Resident R1 was assessed by the facility to have a BIMS (Brief Interview Mental Status) of 3, indicating the resident was severely cognitively impaired. Further review revealed he used a wander/elopement alarm daily. A review of Resident R1's active Physician Orders, dated 05/28/2025, revealed the following, in part: 03/17/2025 - Wanderguard; check bracelet every shift to ensure functioning and in place every day and night shift. A review of Resident R1's elopement risk assessment revealed no elopement assessment was completed. On 05/28/2025 on 8:35 a.m., an observation was conducted of Resident R1 exiting door A with staff and the alarm did not sound. On 05/28/2025 at 11:37 a.m., an interview was conducted with S4LPN. S4LPN stated Resident R1 frequently wandered and required a Wanderguard bracelet for safety. She stated on the weekend of 05/17/2025, Resident R1 exited door A with staff and the alarm did not sound. She stated she reported the Wanderguard system not working to S3RNS. She stated if the Wanderguard system did not work it was possible for a resident to exit the building onto the facility's grounds without staffs' knowledge and allowing an increase chance for accidents to occur. On 05/28/2025 at 12:34 p.m., an interview was conducted with S3RNS. She stated residents with a Wanderguard bracelet were not safe unsupervised outside. She stated if the alarm did not sound, staff would not be aware a resident exited the building and could result in an accident. She stated she did not recall being informed the Wanderguard system was not working on the weekend of 05/17/2025. On 05/28/2025 at 1:20 p.m., an observation was conducted with S2MAN. S2MAN exited door A with a Wanderguard bracelet and the alarm did not sound. S2MAN stated he tested the Wanderguard system weekly but the last test was completed on 05/13/2025 because he had been on leave. On 05/28/2025 at 1:50 p.m., an interview was conducted with S1DON. She stated they did not complete elopement risk assessments at the facility. She further stated based on quarterly documentation and behaviors, the IDT identified residents at risk for accidents due to wandering unsupervised. She stated a resident identified with a higher risk for accidents would receive an order for a Wanderguard bracelet for the resident's safety. She stated if a resident with a Wanderguard bracelet exited the building it would notify staff and they would redirect them back to the unit. She confirmed she was not aware the Wanderguard system was not working properly and the Wanderguard system should be working.

Based on record review and interviews, the facility failed to have sufficient nursing staff to provide nursing and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident based on the Facility Assessment. The deficiency had the potential to affect the facility's total census of 153 residents. Findings: Review of the Facility Assessment Tool, dated 04/16/2025 revealed the following, in part: Staffing Plan . Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Position: Licensed nurses providing direct care- 6 total number needed per shift Nurse Aides- 14 total number needed per shift Other Nursing Personnel (those with administrative duties) - 5 total number needed per shift Review of the facility staff assignment sheets revealed the following: 04/24/2025 night shift (6 p.m. - 6 a.m.)- 8 CNA, 6LPN, 3RN which included RN supervisor providing direct care on the unit 04/25/2025 night shift (6 p.m. - 6a.m.)- 7 CNA, 8LPN, 1RN 04/26/2025 day shift (6 a.m. - 6 p.m.)- 12 CNA, 6 LPN, 3 RN which included 2 RN supervisors providing direct care on the unit. 04/26/2025 night shift (6 p.m. - 6 a.m.)- 6 CNA, 5 LPN, 4 RN which included 2 RN supervisors providing direct care on the unit. 04/27/2025 day shift (6 a.m. - 6 p.m.)- 13 CNA, 4 LPN, 4 RN which included 2 RN supervisors providing direct care on the unit 04/27/2025 night shift (6 p.m. - 6 a.m.)- 6CNA, 8LPN, 2RN 04/28/2025 day shift (6 a.m. - 6 p.m.)- 8CNA, 6 LPN, 3 RN which included RN supervisor providing direct care on the unit 04/28/2025 night shift (6 p.m.-6a.m.) - 8CNA, 8 LPN, 2 RN which included RN supervisor providing direct care on the unit On 04/28/2025 at 10:20 a.m., an interview was conducted with S8CNA. S8CNA confirmed she worked the day shift and when she had multiple hall assignments she could not complete 30 minute rounds on all residents and residents had to wait greater than 30 minutes for assistance. S8CNA stated she could not meet the needs of all of her residents due to staff shortages. On 04/28/2025 at 1:48 p.m., an interview was conducted with S5LPN. She reported she worked day shift and her resident load was unmanageable due to staff shortages. She confirmed there was not enough staff to meet the residents' needs. On 04/28/2025 at 2:00 p.m., an interview was conducted with S6CNA. She reported she was responsible for 23 residents on day shift. She stated when she was assigned 23 residents she could not complete 30 minute rounds on all residents and residents had to wait greater than 30 minutes for assistance. S6CNA confirmed she could not meet the needs of all of her assigned residents due to staff shortages. On 04/28/2025 at 2:12 p.m., an interview was conducted with S11LPN. She confirmed staff shortages including working a unit without a CNA was unmanageable to meet all resident's and pass medications timely. On 04/29/2025 at 9:22a.m., an interview was conducted with S3CR. S3CR confirmed the facility did not have enough staff to meet the needs of the residents. On 04/29/2025 at 10:20 a.m., an interview was conducted with S2DON. S2DON reviewed the Facility Assessment and confirmed the staffing requirements for the facility included 14 CNA's, 6 licensed nurses, and 5 other nursing personnel with administrative duties per shift. On 04/29/2025 at 3:57 p.m., an interview was conducted with S10RN. She confirmed she was responsible for completing nursing assignments for the facility. She confirmed she did not complete assignments according to the Facility Assessment because she was unaware of the Facility Assessment or the staff required each shift. She reviewed the Facility Assessment and confirmed the staffing requirements were not met during the aforementioned timeframe. On 04/29/2025 at 2:35p.m., an interview was conducted with S1ADM. He confirmed the Facility Assessment listed the accurate staffing needs for the facility. He confirmed the facility was not staffed per the Facility Assessment.

Based on observations, interviews, and record review the facility failed to ensure residents who were capable of using the call system had call bells accessible for 5 (#2, #R4, #R5, #R6, and #R7) of 7 ((#1, #2, #3, #R4, #R5, #R6, and #R7) sampled residents. Findings: Review of the facility's Policy titled Resident Call System dated effective 11/1999 revealed the following, in part: Purpose: to respond to resident's needs and requests Procedure: I. Keep all lights within reach of residents, either clipped to sheets on bed, tied to the side rail or clipped to beside chair. On 04/28/2025 at 9:33 a.m., observations revealed the following: Resident #2 lying in bed. No call bell available in the wall system. Resident #R4 lying in bed call bell behind bed on the floor out of reach. Resident #R5 lying in bed. No call bell available in the wall system. Resident #R6 in bed with feet on the floor out the left side of the bed and upper body in the bed with head of bed elevated. Call bell behind the bed on the floor out of reach. Resident #R7 lying in bed. No call bell available in the wall system. Review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/25/2025 revealed Resident #2 had no impairment of upper extremities. Review of Resident#R4's Quarterly MDS with an ARD of 02/06/2025 revealed Resident #R4 had no impairment of upper extremities. Review of Resident #R5's admission MDS with an ARD of 02/20/2025 revealed Resident #R5 had no impairment of upper extremities. Review of Resident #R6's Quarterly MDS with an ARD of02/26/2025 revealed Resident #R6 had no impairment of upper extremities. Review of Resident #R7's Quarterly MDS with an ARD of 03/27/2025 revealed Resident #R7 had no impairment of upper extremities. On 04/28/2025 at 9:35 a.m., an interview was conducted with S7LPN after she made call bell observations for Residents #2, #R4, #R5, #R6, and #R7. She confirmed the aforementioned observations. She confirmed all of the above residents were physically able to use the call bell system. She confirmed each resident should have a call bell accessible and within reach to call for assistance, but did not. On 04/29/2025 at 1:49 p.m., an interview was conducted with S9PD. He confirmed Residents #2, #R4, #R5, #R6, and #R7 could physically use a call bell system. He confirmed each room should have a call bell available in the room, which should be in reach of the resident. On 04/29/2025 at 2:35 p.m., an interview was conducted with S1ADM. He confirmed all residents should have a call bell accessible in their room for use and it should be within reach of the resident.

Based on observations and interviews, the facility failed to ensure a safe, clean, comfortable homelike environment for 1 (#2) of 7 (#1, #2, #3, #R4, #R5, #R6, and #R7) sampled resident's rooms observed. Findings: On 04/28/2025 at 9:33 a.m., an observation of Resident #2's room revealed a urine soiled brief on the floor between his bed and his roommate's bed. On 04/28/2025 at 9:35 a.m., an interview was conducted with S7LPN. She confirmed through observation Resident #2 had a brief soiled with urine on the floor. She confirmed the soiled brief should not be on Resident #2's floor. On 04/28/2025 at 2:38 a.m., an observation was conducted of Resident#2's room and revealed the urine soiled brief remained on the floor. On 04/29/2025 at 10:20 a.m. an interview was conducted with S2DON. She stated it was not acceptable to have a soiled brief on the floor in a resident's room. On 04/29/2025 at 1:49 p.m., an interview was conducted with S9PD. He confirmed he was director of housekeeping. He further confirmed having a urine soiled brief remain on the floor in Resident #2's room for 5 hours was not acceptable.

Based on record review, interviews, and observations, the facility failed to have sufficient certified nursing assistant staff to provide direct care and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (Unit 2B) of 2 (Unit 1A and Unit 2B) resident units reviewed for staffing. This had the potential to affect the 20 residents residing on Unit 2B. Findings: Review of the facility's Nursing Staffing Pattern revealed the facility required 2 CNA's assigned per shift for Unit 2B. Review of the facility's census dated 03/03/2025 revealed there were 20 residents residing on Unit 2B. Review of the facility's Daily Assignment Sheet dated 03/03/2025 revealed the following, in part: 6:00 a.m. to 6:00 p.m.: S9CNA - Unit 2B Further review revealed no other CNA assigned to Unit 2B. Review of the facility's Daily Assignment Sheet dated 03/05/2025 revealed the following, in part: 6:00 a.m. to 6:00 p.m.: S10CNA - Unit 2B Further review revealed no other CNA assigned to Unit 2B. An observation was made on 03/03/2025 at 9:00 a.m. of Unit 2B. Observed 5 residents tapping their hands against the nurses' station glass windows. Observed 2 staff nurses, preparing medications inside the nurses' station and ask the residents if there was anything they required help with. Observed 1 CNA, S9CNA, on Unit 2B. Observed S9CNA attempt to redirect a resident into his room for a brief change. Observed this resident refusing to go into his room while 2 other residents ask for S9CNA to change them. Observed the 5 residents continue to tap the glass windows on the nurses' station for 15 minutes. An interview was conducted with S9CNA on 03/03/2025 at 9:36 a.m. She stated she was a full time CNA on Unit 2B from 6:00 a.m. to 6:00 p.m. She confirmed she was often the only CNA assigned to Unit 2B on her shift. She explained the acuity and behaviors on Unit 2B were too much for one CNA to complete all care timely. She stated multiple residents required two staff members for ADL assistance due to behaviors. She stated residents initiated their call lights and she had to explain she would return after she completed another residents' task. She stated it often took a while to find someone to assist. She stated residents would have to wait 20 to 30 minutes before they received assistance. She stated twenty to thirty minutes was too long for any resident to have to wait, especially residents on Unit 2B with behaviors. She stated one CNA was not sufficient staff for this unit. An interview was conducted with S5LPN on 03/03/2025 at 9:45 a.m. She confirmed there was often only one CNA assigned to Unit 2B during her shifts. She explained the acuity and behaviors on Unit 2B were too much for one CNA to complete all care timely. She stated multiple residents required two staff members for ADL assistance due to behaviors. She stated residents initiated their call lights and she had to explain she would return after she completed another residents' task. She stated S9CNA had to wait for the nurse to complete their task before they were available to assist. She stated residents would have to wait 20 to 30 minutes before they received assistance. She stated twenty to thirty minutes was too long for any resident to have to wait, especially residents on Unit 2B with behaviors. She stated one CNA was not sufficient staff for this unit. An interview was conducted with S8LPN on 03/03/2025 at 9:55 a.m. She confirmed there was often only one CNA assigned to Unit 2B during her shift. She explained the acuity and behaviors on Unit 2 were too much for one CNA to complete all care timely. She stated multiple residents required two staff members for ADL assistance due to behaviors. She stated residents initiated their call lights and she had to explain she would return after she completed another residents' task. She stated S9CNA had to wait for the nurse to complete their task before they were available to assist. She stated residents would have to wait 20 to 30 minutes before they received assistance. She stated twenty to thirty minutes was too long for any resident to have to wait, especially residents on Unit 2B with behaviors. She stated one CNA was not sufficient staff for this unit. An interview was conducted with S10CNA on 03/05/2025 at 9:18 a.m. She confirmed she was often the only CNA assigned to Unit 2B on her shift. She explained the acuity and behaviors on Unit 2B were too much for one CNA to complete all care timely. She stated multiple residents required two staff members for ADL assistance due to behaviors. She stated residents initiated their call lights and she had to explain she would return after she completed another residents' task. She stated sometimes it took a while to find someone to assist. She stated residents would have to wait 20 to 30 minutes before they received assistance. She stated twenty to thirty minutes was too long for any resident to have to wait, especially residents on Unit 2B with behaviors. She stated one CNA was not sufficient staff for this unit. An observation was made on 03/05/2025 at 4:10 p.m. of Unit 2B. Observed 4 residents tapping their hands against the nurses' station glass windows. Observed 2 staff nurses, preparing medications inside nurses' station and ask the residents if there was anything they required help with. Observed 1 CNA, S10CNA, on Unit 2B. Observed S10CNA attempt to redirect a resident to the day room. Observed this resident refuse to go to the day room while 3 other residents asked for S10CNA to change them. Observed the 4 residents continue to tap the glass windows on the nurses' station for 20 minutes. An interview was conducted with S6LPN on 03/05/2025 at 4:12 p.m. She confirmed there was often only one CNA assigned to Unit 2B during her shift. She explained the acuity and behaviors on Unit 2 were too much for one CNA to complete all care timely. She stated multiple residents required two staff members for ADL assistance due to behaviors. She stated residents initiated their call lights and she had to explain she would return after she completed another residents' task. She stated S10CNA had to wait for the nurse to complete their task before they were available to assist. She stated residents would have to wait 20 to 30 minutes before they received assistance. She stated twenty to thirty minutes was too long for any resident to have to wait, especially residents on Unit 2B with behaviors. She stated one CNA was not sufficient staff for this unit. An interview was conducted with S7LPN on 03/05/2025 at 4:15 p.m. She confirmed there was often only one CNA assigned to Unit 2B during her shift. She explained the acuity and behaviors on Unit 2 were too much for one CNA to complete all care timely. She stated multiple residents required two staff members for ADL assistance due to behaviors. She stated residents initiated their call lights and she had to explain she would return after she completed another residents' task. She stated S10CNA had to wait for the nurse to complete their task before they were available to assist. She stated residents would have to wait 20 to 30 minutes before they received assistance. She stated twenty to thirty minutes was too long for any resident to have to wait, especially residents on Unit 2B with behaviors. She stated one CNA was not sufficient staff for this unit. An interview was conducted with S16RNS on 03/05/2025 at 10:26 a.m. She stated she was responsible for staffing Unit 2B. She stated she based staffing on her knowledge of the facility's residents and their acuity. She stated there was no specific method the supervisors used to determine staffing. She stated Unit 2B did have residents with behaviors, and should be staffed with 2 CNAs. She was informed of surveyors' observation on 03/03/2025 of Unit 2B having only one CNA. She stated she did not think one CNA on Unit 2B was sufficient staffing. An interview was conducted with S15RNS on 03/10/2025 at 11:56 a.m. She stated Unit 2B contained residents that were at risk for elopement, escaping, and had schizophrenia. She stated Unit 2B should be staffed with two CNAs at all times. 48912

Based on record reviews and interviews, the facility failed to ensure residents' Medication Administration Record (MAR) were accurately documented for 2 (#1 and #2) of 3 (#1, #2, and #3) residents reviewed for pharmaceutical services. This deficient practice had to the potential to affect any of the 153 residents residing in the facility. Findings: Review of the facility's policy titled Medication Administration with revision date of August 2018 revealed the following, in part: Procedure: M. The nurse must document medication administration on the resident's MAR/electronic MAR immediately after administering the medications. N. If a resident refuses a medication, indicate on MAR/electronic MAR noting the specific date/time, document in resident's clinical record on the nurses' notes, and notify physician. Resident #1 Review of Resident #1's Clinical Record revealed an admitted [DATE], with diagnoses which included Schizoaffective Disorder, Dementia, Epilepsy, Hypertension, Diabetes Mellitus-Type 2, Chronic Embolism and Thrombosis, and Major Depressive Disorder. Review of Resident #1's February 2025 Physician Orders revealed in part, the following: Amlodipine Oral Tablet 10 mg, give 1 tablet by mouth one time a day. Cymbalta Oral Capsule 30mg, give 1 capsule by mouth in the morning. Flomax Oral Capsule 0.4 mg, give 1 capsule by mouth one time a day. Neurontin Oral Capsule 300 mg, give 1 capsule by mouth one time a day. Coreg Oral Tablet 6.25 mg, give 1 capsule by mouth two times a day. Depakote Oral Tablet Delayed Release 125mg, give one tablet by mouth two times a day. Docusate Sodium Oral Capsule 100mg, give 1 capsule by mouth two times a day. Eliquis Oral Tablet 2.5 mg, give 1 tablet by mouth two times a day. Keppra Oral Tablet 500mg, give 1 tablet by mouth two times a day. Metformin Oral Tablet 1,000mg, give 1 tablet by mouth two times a day. Risperdal Oral Tablet 2mg, give 1 tablet by mouth two times a day. Seroquel Oral Tablet 50mg, give 1 tablet by mouth two times a day. Insulin Regular Solution inject as per sliding scale: if 151 -200 = 2 units, sliding scale less than 60 =8 ounces of juice and call MD; 201 -250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units recheck in 2 hours, if not less by 50mg/dL call MD, subcutaneously before meals and at bedtime. Review of Resident #1's February 2025 MAR revealed in part, the following: -No documented evidence Resident #1 received or refused the above-mentioned medications on 02/08/2025 through 02/10/2025 at 7:00 a.m. -No documentation of insulin administration or blood glucose check being completed or refused on 02/08/2025 through 02/10/2025 at 7:00 a.m. -No documentation of insulin administration or blood glucose check being completed or refused on 02/08/2025 and 02/09/2025 at 11:00 a.m. -No documentation of insulin administration or blood glucose check being completed or refused on 02/08/2025 through 02/10/2025 at 4:00 p.m. Review of Resident #1's physical Clinical Record revealed no paper MARs. On 03/05/2025 at 1:33 p.m., a telephone interview was conducted with S14RN. She stated she provided care for Resident #1 on 02/08/2025 and 02/09/2025 from 6:00 a.m. to 6:00 p.m. She stated she was responsible for the administration of Resident #1's 6:00 a.m. and 7:00 a.m. medications on her shifts. S14RN stated she did not have access to the facility's electronic software for those shifts. She stated she documented the medication administration for Resident #1 in his physical Clinical Record on a paper MAR. S14RN was informed of Resident #1's February 2025 MAR findings, and she confirmed the appropriate way to document medication administration or refusal should be done on MAR. On 03/10/2025 at 12:02 p.m., an interview was conducted with S17LPN. She stated she provided care for Resident #1 on 02/10/2025 from 6:00 a.m. to 6:00 p.m. She stated she was responsible for the administration of Resident #1's 6:00 a.m. and 7:00 a.m. medications on her shift. S17LPN confirmed she did not document Resident #1's administration or refusal of medications and blood glucose checks on the MAR and should have. On 03/10/2025 at 11:56 a.m., an interview was conducted with S15RNS. She stated staff should accurately document medication administration during medication pass. She stated the process if nurses could not access the facility's electronic software was to notify S2DON and use the paper MARs in the binder at the nurse's station. She stated when paper MARs are used nurses should document medication administration or refusals on the paper forms. S15RNS stated she was made aware of S14RN not having access to facility's electronic software on 02/05/2025 and S2DON reset her password immediately. S15RNS stated she did not recall S14RN informing her of not having access on 02/08/2025 or 02/09/2025, she further stated if she did not S14RN should have documented medication administration on paper MARs. S15RNS reviewed Resident #1's February 2025 MAR, and she confirmed aforementioned findings were blank and administrations or refusals were not documented. On 03/10/2025 at 12:16 p.m., an observation interview was conducted with S15RNS. S15RNS reviewed the binder in which she stated should contain the units paper MARs for all residents, and it failed to contain any current paper MARs for any residents. Further review revealed paper MARs were dated December 2024. She stated the process was for the night shift nurses to remove all old MARs from the binder and place them on the resident's physical Clinical Record on the last day of the month. S15RNS reviewed Resident #1's physical Clinical Record, and confirmed it failed to reveal any paper MARs. S15RN further confirmed she could not provide documentation of medications being administered or refused for Resident #1 for 02/08/2025 through 02/10/2025 and she should have. Resident #2 Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE], with diagnoses which included Diabetes Mellitus-Type 2, Dementia, Major Depressive Disorder, Epilepsy, Hypertension, Aphasia, Hemiplegia and Hemiparesis, and Constipation. Review of Resident #2's February 2025 Physician Orders revealed in part, the following: Hydrochlorothiazide Oral Capsule 12.5mg, give 1 capsule by mouth in the morning. Norvasc Oral Tablet 10mg, give 1 tablet by mouth in the morning. Plavix Oral Tablet 75mg, give 1 tablet by mouth in the morning. Docusate Sodium Oral Capsule 250mg, give 1 capsule by mouth two times a day. Fibercon Oral Tablet 625mg, give 1 tablet by mouth two times a day. Keppra Oral Tablet 500mg, give 1 tablet by mouth two times a day. Review of Resident #2's February 2025 MAR revealed in part, the following: - No documented evidence Resident #2 received or refused the above-mentioned medications on 02/13/2025 at 7:00 a.m. Review of Resident #2's physical Clinical Record revealed no paper MARs. On 03/05/2025 at 4:15 p.m., an interview was conducted with S6LPN. She stated she provided care for Resident #2 on 02/13/2025 from 6:00 a.m. to 6:00 p.m. S6LPN stated she was responsible for administering Resident #2's 7:00 a.m. medications on her shift. S6LPN reviewed Resident #2's February 2025 MAR, and confirmed she did not document these medications as administered and should have. On 03/10/2025 at 1:53 p.m., an interview was conducted with S2DON. She stated she expected all staff to accurately document medication administration on the MAR at the time of administration. S2DON stated there was no current process for staff to use in the event in which they could not access facility's electronic software. She stated S14RN should have had access to facility's electronic software on 02/08/2025 and 02/09/2025 and there was no excuse for her to not properly document her medication administration on the MAR. She further stated she reset S14RN's password and educated her on how to gain access if she were to get locked out again. S2DON was informed of all the aforementioned findings for Resident #1 and #2, and she confirmed all medication administrated and glucose checks completed or refused should have been documented on the resident's MARs, and they were not. 48912

Based on record review, observations, and interviews, the facility failed to prevent misappropriation of resident property by S4RN for 2 (#1 and #2) of 3 (#1, #2, and #3) sampled residents. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. This deficient practice resulted in an Immediate Jeopardy situation on 02/01/2025 when S4RN withheld Resident #1 and Resident #2's 7:00 p.m. 01/31/2025 medications. Two staff members observed both Resident #1 and Resident #2's 7:00 p.m. 01/31/2025 dose of medications inside of S4RN's personal bag after S4RN verbalized the resident's refused the medications. These medications included cardiac, hypertension, seizure, diabetic, and psychiatric medications. Residents are likely to suffer serious harm, impairment, or death as a result of staff misappropriating of residents' property. S1DON was notified of the Immediate Jeopardy on 03/10/2025 at 4:50 p.m. Findings: Review of the facility's policy titled Abuse and Neglect Policy revised on 03/2023, revealed in part, the following: A. Purpose-It is the policy to prohibit neglect, exploitation of residents. Ciii. Examples: 5. Exploitation: Some examples include taking money or other personal property from a resident for one's own use, taking residents medication for own personal use. Resident #1 Review of Resident #1's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Schizoaffective Disorder, Dementia, Epilepsy, Hypertension, Diabetes Mellitus-Type 2, Chronic Embolism and Thrombosis, and Major Depressive Disorder. Review of Resident #1's MDS with an ARD of 12/18/2024 revealed a BIMS of 00, which indicated he was severely cognitively impaired. Review of Resident #1's Nursing Progress Note dated 02/01/2025 at 6:30 a.m. revealed S5LPN wrote: on 02/01/2025 at approx. 6:30 a.m., I observed S4RN placing Resident #1's medication packets into her personal bag. Review of Resident #1's January 2025 Physician Orders revealed in part, the following: Coreg Oral Tablet 6.25 mg, give 1 capsule by mouth two times a day. Depakote Oral Tablet Delayed Release 125mg, give one tablet by mouth two times a day. Docusate Sodium Oral Capsule 100mg, give 1 capsule by mouth two times a day. Eliquis Oral Tablet 2.5 mg, give 1 tablet by mouth two times a day. Keppra Oral Tablet 500mg, give 1 tablet by mouth two times a day. Metformin Oral Tablet 1,000mg, give 1 tablet by mouth two times a day. Risperdal Oral Tablet 2mg, give 1 tablet by mouth two times a day. Seroquel Oral Tablet 50mg, give 1 tablet by mouth two times a day. Unable to interview Resident #1 due to Resident #1's cognitive impairment. Resident #2 Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE], with diagnoses which included Diabetes Mellitus-Type 2, Unspecified Dementia, Major Depressive Disorder, Epilepsy, Essential Hypertension, Aphasia Following Cerebral Infarction, and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Unspecified Side. Review of Resident #2's MDS with an ARD of 01/07/2025 revealed a BIMS of 99, which indicated he was severely cognitively impaired. Review of Resident #2's Nursing Progress Note dated 02/11/2025 at 2:29 p.m. revealed S5LPN wrote: Late entry: On 02/01/2025 at approx. 6:30 a.m., I observed S4RN placing Resident #2's medication packets into her personal bag. Review of Resident #2's January 2025 Physician Orders revealed in part, the following: Docusate Sodium Oral Capsule 250mg, give 1 capsule by mouth two times a day. Fibercon Oral Tablet 625mg, give 1 tablet by mouth two times a day. Keppra Oral Tablet 500mg, give 1 tablet by mouth two times a day. Crestor Oral Tablet 10mg, give 1 tablet by mouth at bedtime. Zoloft Oral Tablet 100mg, give 1 tablet by mouth at bedtime. Review of facility's Incident Investigation Report dated 02/01/2025, revealed in part, the following: Name of Resident: Resident #1 Date Incident Occurred: 02/01/2025 Time Incident Occurred: 6:30 a.m. Where Incident Occurred: Nurses' Station Description of Incident: I observed S4RN placing this resident's medication packet into her personal bag. Witness: S13CGT Other Resident Involved: Resident #2 Signature Person Completing This Form: S5LPN An observation was made on 03/03/2025 at 9:18 a.m. with S5LPN of photography provided by the facility dated 02/01/2025 revealed in part, the following: 1. Medication packets which included resident names: Resident #1 2. 01/31/2025, 7:00 p.m. doses, and medication listed present: Coreg Oral Tablet 6.25 mg Depakote Oral Tablet Delayed Release 125mg Docusate Sodium Oral Capsule 100mg Eliquis Oral Tablet 2.5 mg Keppra Oral Tablet 500mg Metformin Oral Tablet 1,000mg Risperdal Oral Tablet 2mg Seroquel Oral Tablet 50mg 3. Medication packets which included resident names: Resident #2 4. 01/31/2025, 7:00 p.m. doses, and medication listed present: Docusate Sodium Oral Capsule 250mg Fibercon Oral Tablet 625mg Keppra Oral Tablet 500mg Crestor Oral Tablet 10mg Zoloft Oral Tablet 100mg 5. Multiple opened medication packets. 6. 1 clear medication crush bag with white residue inside. Unable to interview Resident #2 due to Resident #2's cognitive impairment. An interview was conducted on 03/03/2025 at 9:18 a.m. with S5LPN. She stated on 02/01/2025 around 6:00 a.m. shift change, she and S4RN conducted a medication cart count. She stated S4RN had her left hand closed during the count and was acting erratically with incoherent speech. She stated S4RN reported Resident #1 and Resident #2 refused their 01/31/2025 7:00 p.m. medications. She stated S4RN went into the nurses' station after the count was completed. S5LPN stated she and S13CGT witnessed S4RN open her left hand and remove pills, which she then placed into a medication crush bag. S4RN then rolled the bag up, and placed it in her pocket. She stated she observed S4RN place resident medication packets into her personal bag and then enter the restroom. She stated while S4RN was in the restroom, she and S12RN looked into S4RN's personal bag and observed unopened medication packets with Resident #1 and Resident #2's names, dated 01/31/2025 7:00 p.m. doses. She stated they also observed multiple empty medication packets and a medication pill crush bag with white residue inside S4RN's personal bag. She stated pictures were taken of the contents of S4RN's personal bag. She stated she notified S11RNS around 6:30 a.m. of S4RN's impairment, unopened medication packets inside S4RN's personal bag, and documented the incident. She stated she immediately assessed Resident #1 and Resident #2, obtained vital signs, notified the nurse practitioner, and RP. She stated Resident #1 and Resident #2 had no negative outcomes, however both were likely to have a seizure or serious injury due to staff misappropriating their property and not continually receiving their prescribed medications. She stated S4RN documented Resident #1 and #2's 01/31/2025 7:00 p.m. medications were administered on the MARs. She stated S4RN remained in the restroom for hours before security escorted her to the local hospital for a drug screen. She stated S4RN did not return for any further shifts. She stated she received in-services related to medication administration, documentation of administration, neglect, exploitation, and reporting in February 2025. She stated S2DON and a pharmacy consultant conducted audits and monitored all medication carts since this incident. S5LPN reviewed the pictures with surveyor and stated you could see Resident #1 and Resident #2's name, the medications listed in the packets, and the medications were due to be administered on 01/31/2025 at 7:00 p.m. An interview was conducted on 03/05/2025 at 8:50 a.m. with S13CGT. She stated on 02/01/2025 around 6:00 a.m., S5LPN and S4RN conducted a medication cart count. She stated S4RN spoke to her and was acting erratically and her words were incoherent. She stated S4RN went into the nurses' station. She stated she and S5LPN witnessed S4RN place medications from her left hand into a medication crush bag, roll the bag up, and place the bag in her pocket. She stated she observed S4RN place medication packets into her personal bag and then enter the restroom. She stated while S4RN was in the restroom, she and S5LPN looked into S4RN's personal bag and observed unopened medication packets with Resident #1 and Resident #2's names, dated 01/31/2025 7:00 p.m. doses. She stated they also observed multiple empty medication packets and a medication pill crush bag with white residue inside of it in S4RN's personal bag. She stated pictures were taken of the contents of S4RN's personal bag. She stated Resident #1 and Resident #2 did had no negative outcomes. She stated S4RN remained in the restroom for hours before security escorted her to the local hospital for a drug screen. She stated S4RN did not return for any further shifts. She stated she received in-services related to neglect, exploitation, and reporting in February 2025. She stated S2DON and a pharmacy consultant conducted audits and monitored all medication carts since this incident. Multiple attempts to interview S4RN during survey dates 03/03/2025-03/10/2025 were made. All attempts were unsuccessful. An interview was conducted on 03/05/2025 at 9:10 a.m. with S3ADON. She stated S5LPN notified her on 02/01/2025 of residents' medication packets in S4RN's personal bag and possible impairment. She stated it was S11RNS's responsibility to report this incident to S1ADM. She stated S5LPN immediately assessed Resident #1 and Resident #2, obtained vital signs, notified the nurse practitioner, and RP. She stated Resident #1 and Resident #2 had no negative outcomes, however both were likely to have a seizure or serious injury due to staff misappropriating their property and not receiving their prescribed medications. She stated S4RN documented 01/31/2025 7:00 p.m. medications as administered for both Resident #1 and Resident #2 MARs. She stated in the photography of the unopened medication packets, you could see the resident's name, dosage, date, and time to be administered which was 01/31/2025 7:00 p.m. She stated you could see empty medication packets and a clear pill crush bag. She stated S4RN remained in the restroom for hours before security escorted her to the local hospital for a drug screen. She stated S4RN did not return for any further shifts. S3ADON stated she received in-services related to medication administration, documentation of administration, neglect, exploitation, and reporting in February 2025. She stated S2DON and a pharmacy consultant conducted audits and monitored all medication carts since this incident. An interview was conducted on 03/05/2025 at 11:21 a.m. with S21NP. He stated Resident #1 and Resident #2 both had the likelihood of suffering from potential serious harm by not receiving their prescribed medications. An interview was conducted on 03/10/2025 at 3:57 p.m. with S11RNS. He stated on 02/01/2025 around 6:30 a.m. he was notified of possible impairment of S4RN. He stated a drug screen was ordered for S4RN and S1ADM was notified of possible impairment of S4RN. He stated later around 3:00 p.m., he was notified of residents' medication packets in S4RN's personal bag. He stated Resident #1 and Resident #2 had no negative outcomes, however both were likely to have a seizure or serious injury due to staff misappropriating their property and not receiving their prescribed medications. He stated S4RN did not return for any further shifts. He stated he received in-services related to medication administration, documentation of administration, neglect, exploitation, and reporting in February 2025. He stated S2DON and a pharmacy consultant conducted audits and monitored all medication carts since this incident. An interview was conducted on 03/10/2025 at 2:00 p.m. with S2DON. She stated S3ADON notified her on 02/01/2025 of residents' medication packets in S4RN's personal bag and possible impairment. She stated S5LPN immediately assessed Resident #1 and Resident #2, obtained vital signs, notified the nurse practitioner, and RP. She stated Resident #1 and Resident #2 had no negative outcomes, however both were likely to have a seizure or serious injury due to staff misappropriating their property and not receiving their prescribed medications. She stated S4RN documented 01/31/2025 7:00 p.m. medications as administered for both Resident #1 and Resident #2 MARs. She stated S4RN remained in the restroom for hours before security escorted her to the local hospital for a drug screen. She stated S4RN did not return for any further shifts. She reviewed the photography with surveyor which was taken on 02/01/2025 and confirmed Resident #1 and Resident #2's name could be seen as well as the medications and date of 01/31/2025 7:00 p.m. She stated she received in-services related to medication administration, documentation of administration, neglect, exploitation, and reporting in February 2025. She stated she and a pharmacy consultant conducted audits and monitored all medication carts since this incident. An interview was conducted on 03/10/2025 at 12:57 p.m. with S1ADM. He stated on 02/01/2025, S11RNS notified him of possible impairment of S4RN. He stated he was not made aware of residents' medication packets in S4RN's personal bag until 02/04/2025. He stated Resident #1 and Resident #2 had no negative outcomes. He stated S4RN remained in the restroom for hours before security escorted her to the local hospital for a drug screen. He stated S4RN did not return for any further shifts. He stated all staff received in-services related to medication administration, documentation of administration, neglect, exploitation, and reporting in February 2025. He stated S2DON and a pharmacy consultant conducted audits and monitored all medication carts since this incident. Throughout the survey from 03/03/2025 to 03/10/2025, observations, record review, and staff interviews revealed staff received training on the facility's medication administration, documentation of administration, neglect, exploitation, and reporting policies and procedures. Interviews revealed staff were knowledgeable of the types of neglect and exploitation, and were aware to report these incidents to administration immediately. The facility had implemented the following actions to correct the deficient practice: 1. Corrective actions were accomplished on 02/27/2025 for residents found to be affected by the alleged to include: a. S4RN was ordered to undertake a drug screen. b. S4RN placed on investigatory leave. c. Case reported to Adult Protective Services, Registered Nursing Board, Pharmacy Consultant, and law enforcement. Responsible parties of all potential victims were notified. 2. All staff in-serviced on abuse, neglect, medication administration, and controlled drug policy. 3. Medication carts were randomly audited by administrative staff and pharmacy consultant. 4. Medication carts remain audited on monthly basis or as needed. 5. Corrective action will be completed by 02/27/2025 with 100% staff trained. 48912

Based on record review and interviews, the facility failed to ensure allegations of neglect/misappropriation of property were reported in the required timeframe for 2 (#1 and #2) of 5 (#1, #2, #3, R1, and R2) sampled residents. Findings: Review of the facility's policy titled Abuse and Neglect Policy revised on 03/2023, revealed in part, the following: 5. Exploitation: Some examples include taking money or other personal property from a resident for one's own use, taking residents medication for own personal use. 7. Neglect: Acts of omissions by a person responsible for providing care of treatment which placed the resident at risk for harm, or which deprived a resident of sufficient or appropriate services, treatment or basic care. Civ. Procedure to Report Neglect-Any Employee: 1. To the Immediate Supervisor: Immediately, but in no case later than one hour after knowledge or suspicion. 5. If unable to report face to face or by phone to supervisor or any supervisor, report immediately by phone or face to face to Client Rights Officer. Cv. Responsibility of RN Supervisor: 2. Immediately, but in no case later than one hour, after knowledge or suspicion, make a verbal report to the Administrator. 11. Notify local law enforcement for any allegations of any allegation of exploitation. Resident #1 Review of Resident #1's clinical record revealed he was admitted to the facility on [DATE], with diagnoses which included Schizoaffective Disorder, Dementia, Epilepsy, Hypertension, Diabetes Mellitus-Type 2, Chronic Embolism and Thrombosis, and Major Depressive Disorder. Review of Resident #1's Nursing Progress Note dated 02/01/2025 at 6:30 a.m. S5LPN wrote: on 02/01/2025 at approx. 6:30 a.m., I observed nursing supervisor placing this resident's medication packets into her personal bag. Resident #2 Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE], with diagnoses which included Diabetes Mellitus-Type 2, Unspecified Dementia, Major Depressive Disorder, Epilepsy, Essential Hypertension, Aphasia Following Cerebral Infarction, and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Unspecified Side. Review of Resident #2's Nursing Progress Note dated 02/11/2025 at 2:29 p.m. S5LPN wrote: Late entry: On 02/01/2025 at approx. 6:30 a.m., I observed nursing supervisor placing this resident's medication packets into her personal bag. Review of facility's Incident Investigation Report dated 02/01/2025, revealed in part, the following: Name of Resident: Resident #1 Date Incident Occurred: 02/01/2025 Time Incident Occurred: 6:30 a.m. Date Incident Discovered: 02/01/2025 Time Incident Discovered: 6:30 a.m. Where Incident Occurred: Nurses' Station Type of Incident: Alleged Neglect Description of Incident: I observed nursing supervisor placing this resident's medication packet into her personal bag. Witness: S13CGT Other Resident Involved: Resident #2 Signature Person Completing This Form: S5LPN Review of facility's email to Adult Protective Services revealed in part, the following: Date: 02/04/2025 Time: 1:57 p.m. Notification of allegation of possible exploitation against a resident(s) by a staff member. An interview was conducted on 03/03/2025 at 9:18 a.m. with S5LPN. She stated on 02/01/2025 around 6:00 a.m. during shift change, she and S4RN conducted a medication cart count. She stated S4RN had her left hand closed the entire time she was speaking to her and was acting erratically and speaking incoherently. She stated S4RN reported to her that Resident #1 and Resident #2 refused their 01/31/2025 7:00 p.m. medications. She stated S4RN then went into the nurses' station. S5LPN stated she and S13CGT witnessed S4RN place medications from her left hand into a medication crush bag, roll the bag up, and place the bag in her pocket. She stated she was unsure what medications S4RN placed into the medication crush bag. She stated she observed S4RN place medication packets into her personal bag and then enter the restroom. She stated while S4RN was in the restroom, she and S12RN looked into S4RN's personal bag and observed unopened medication packets labeled with Resident #1 and Resident #2's names and dated 01/31/2025 7:00 p.m. doses. She stated they also observed multiple empty medication packets and a medication pill crush bag with white residue inside S4RN's personal bag. S5LPN stated pictures were taken at this time of the contents of S4RN's personal bag. She stated she notified S11RNS around 6:30 a.m. of S4RN's impairment, medication packets located inside S4RN's personal bag, and documented the incident. An interview was conducted on 03/05/2025 at 9:10 a.m. with S3ADON. She stated S5LPN notified her on 02/01/2025 of residents' medication packets observed in S4RN's personal belonging bag and possible impairment. She stated she notified S2DON of residents' medication packets observed in S4RN's personal belonging bag and possible impairment on 02/01/2025. She stated it was S11RNS's responsibility to report this incident to S1ADM. An interview was conducted on 03/10/2025 at 3:57 p.m. with S11RNS. He stated on 02/01/2025 around 6:30 a.m. he was notified of possible impairment of S4RN. He stated a drug screen was ordered at the local hospital for S4RN and S1ADM was notified of possible impairment of S4RN. He stated later around 3:00 p.m., he was notified of residents' medication packets observed in S4RN's personal bag. He confirmed he did not notify S1ADM of this and should have. He stated S1ADM was not made aware of the residents' medication packets observed in S4RN's personal bag until 02/04/2025. An interview was conducted on 03/10/2025 at 2:00 p.m. with S2DON. She stated S3ADON notified her on 02/01/2025 of residents' medication packets observed in S4RN's personal bag and possible impairment. She stated it was S11RNS's responsibility to report this incident to S1ADM. An interview was conducted on 03/10/2025 at 12:57 p.m. with S1ADM. He stated on 02/01/2025, S11RNS notified him of possible impairment of S4RN. He stated he was not made aware of residents' medication packets observed in S4RN's personal bag until 02/04/2025 and should have been notified by S11RNS on 02/01/2025. He stated this incident was not reported to the state survey agency until 02/04/2025.

48333 Based on observations, interviews, and record review, the facility failed to ensure staff utilized appropriate PPE during care with residents who required EBP (Enhanced Barrier Precautions) for 3 (#35, #52, and #54) of 3 (#35, #52, and #54) of 3 (#35, #52, and #54) residents observed during chronic wound care and use of indwelling medical devices. This deficient practice had the potential to affect any of the 20 residents residing in the facility on Enhanced Barrier Precautions. Findings: Review of the facility's policy titled Implementation of PPE use in LTC (Long Term Care) setting to prevent the spread of MDROs (Multi-Drug Resistant Organisms) Dated 10/24/2022, revealed the following, in part: Residents for whom EBP applies to include any resident with an indwelling medical device or wound. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing, Providing Hygiene, Device care or use: feeding tube, and tracheostomy, and wound care: any skin opening requiring a dressing. Resident #35 Review of Resident #35's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Encounter for Attention to Tracheostomy and Gastrostomy. On 11/04/2024 at 4:00 p.m., an observation was conducted of Resident #35's door and room. There was no signage indicating Resident #35 was on Enhanced Barrier Precautions and there was no PPE present. On 11/06/2024 at 9:36 a.m., an observation was conducted of S4RN administering medications via Resident #35's gastrostomy tube. S4RN did not have on a gown. On 11/06/2024 at 9:50 a.m., an interview was conducted with S4RN. S4RN stated she was not aware Resident #35 was on Enhanced Barrier Precautions due to no signage on Resident #35's door. S4RN confirmed she did not wear a gown when she administered medications via Resident #35's gastrostomy tube. Resident #52 Review of Resident #52's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Pressure Ulcers. On 11/04/2024 at 10:32 a.m., an observation was conducted of Resident #52's door and room. There was no PPE present. On 11/06/2024 at 9:25 a.m., an observation was conducted of S8WCN performing wound care on Resident #52. S8WCN did not have on a gown. On 11/06/2024 at 11:33 a.m., an interview was conducted with S8WCN. She confirmed she did not wear a gown when she performed Resident #52's wound care. She confirmed Resident #52 had chronic Pressure Ulcers. Resident #54 Review of Resident #54's Clinical Record revealed he was admitted on [DATE] with diagnoses which included Encounter for Attention to Tracheostomy, Colostomy, and Gastrostomy. On 11/04/2024 at 4:00 p.m., an observation was conducted of Resident #54's door and room. There was no signage indicating Resident #54 was on Enhanced Barrier Precautions and there was no PPE present. On 11/06/2024 at 9:30 a.m., an observation was conducted of S5CNA entering Resident #54's room without a gown. S5CNA changed Resident#54's colostomy bag, provided personal hygiene, and changed his clothing. On 11/06/2024 at 9:56 a.m., an interview was conducted with S5CNA. S5CNA reported she changed Resident #54's colostomy bag, provided personal hygiene, and changed his clothing. She confirmed she did not wear a gown when she performed the above aforementioned resident care. On 11/06/2024 at 1:14 p.m., an interview was conducted with S3RN. S3RN confirmed Resident #35, #52, and #54 had Enhanced Barrier Precautions initiated. He confirmed Resident #35, #52, and #54 should have had signage on their door indicating the use of Enhanced Barrier Precautions and did not. He stated staff should have worn gowns when performing care on residents with Enhanced Barrier Precautions in place. On 11/07/2024 at 1:09 p.m., an interview was conducted with S2DON. She confirmed Resident #35, #52, and #54 had Enhanced Barrier Precautions initiated. She confirmed Resident #35, #52, and #54 should have had signage on their door indicating the use of Enhanced Barrier Precautions and did not. She stated staff should have worn gowns when performing care on residents with Enhanced Barrier Precautions in place.

Based on observations, interviews, and record review, the facility failed to maintain an environment which promotes quality of life through dignity and respect for 1 (#94) of 5 (#10, #16, #94,#107, and #150) residents reviewed for resident rights. The facility failed to ensure residents were assisted with meals in a dignified manner as evidenced by staff standing over Residents #94 while assisting him to eat. Findings: Review of the facility's policy titled Feeding a Resident with an effective date of November 1999 revealed the following, in part: Procedure: R. If possible, sit facing the resident while feeding is taking place A review of Resident #94's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction and Acquired Absence of Right Fingers. A review of Resident #94's Quarterly Minimum Data Set with an Assessment Reference Date of 10/22/2024 revealed functional limitation in range of motion to bilateral upper extremities and dependent on staff for eating. On 11/06/2024 at 12:48 p.m., an observation was conducted of S5CNA and Resident #94. S5CNA stood over Resident #94 feeding him. A chair was noted behind S5CNA. S5CNA continued to feed Resident #94 standing next to his bed until his meal was completed. S5CNA stated she does not sit when feeding Resident #94. S5CNA confirmed Resident #94 was dependent on staff for feeding assistance and she should have been sitting on his level when assisting him with his meal. On 11/07/2024 at 1:09 p.m., an interview was conducted with S2DON. S2DON confirmed S5CNA should sit when assisting Resident #94 with meals.

Based on interviews and record review, the facility failed to ensure an effective system was in place to incorporate Level II PASARR determination recommendations in the resident's care planning for 1 (#106) of 3 (#33, #106, and #145) residents reviewed for PASARR. This deficient practice had the potential to affect any of the 58 residents residing in the facility with a PASARR Level II as determined by the facility. Findings: Review of Resident #106's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Schizoaffective Disorder - Bipolar Type. Review of Resident #106's Level II PASARR Determination dated 08/08/2024 revealed the following, in part: Specialized Services Recommendations: Individual outpatient therapy - checked Other - checked Other specialized services: schedule a psychiatric evaluation - include treatment recommendations Review of Resident #106's current Care Plan revealed no documented evidence of a Level II PASARR or any recommended interventions. Review of Resident #106's electronic and paper Clinical Record revealed no evidence a psychiatric evaluation was conducted. Further review revealed no documented evidence outpatient individual therapy services were implemented or offered. An interview was conducted with S9SSC on 11/06/2024 at 10:59 a.m. She stated S10MRA tracked PASARR Level IIs and reviewed recommendations. She stated she did not review any resident Level II PASARRs and/or implement any recommendations. She confirmed she did not notify the Psychologist of the need for a psychiatric evaluation for Resident #106. She confirmed she did not offer and Resident #106 had not received individual outpatient therapy services. An interview was conducted with S10MRA on 11/07/2024 at 9:35 a.m. She stated all resident Level II PASARR determinations were sent to the resident's social service counselor. She stated the social service counselor was responsible for ensuring the Level II determination recommendations were implemented. She reviewed Resident #106's PASARR Level II determination dated 08/08/2024 and confirmed individual outpatient therapy services and a psychiatric evaluation were recommended. She stated S9SSC was Resident #106's social services counselor and was responsible to implement Resident #106's Level II PASARR recommendations. She reviewed Resident #106's Clinical Record and confirmed there was no documented psychiatric evaluation after the Level II PASARR was issued on 08/08/2024. She stated S9SSC should have notified the psychologist of the need for a psychiatric evaluation. An interview was conducted with S2DON on 11/07/2024 at 9:15 a.m. She stated S10MRA was aware of the process for implementing Level II PASARR recommendations. She reviewed Resident #106's Clinical Record and confirmed a psychiatric evaluation had not been completed in the past year. She stated S9SSC would have been aware if Resident #106 had been offered and/or received outpatient therapy services. An interview was conducted with S11SSD on 11/07/2024 at 9:52 a.m. She stated there was not a specific process in place to ensure Level II PASARR recommendations were implemented. She reviewed Resident #106's Level II PASARR dated 08/08/2024 and confirmed individual outpatient therapy services and a psychiatric evaluation should have been implemented.

Based on observations, interviews, and record review, the facility failed to ensure services provided met professional standards of quality by failing to ensure nursing staff accurately documented Pressure Ulcer treatment as performed for 1 (#52) of 4 (#45, #52, #65, and #139) residents reviewed with Pressure Ulcers. This deficient practice had the potential to affect any of the 13 residents residing at the facility with Pressure Ulcers. Findings: Review of the facility's undated policy titled, Wound Care Policy and Procedures revealed the following, in part: Documentation: A. Treatment Documentation: Treatments will be initiated per physician orders. Treatments will be documented .as ordered. Review of Resident #52's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Pressure Ulcers and Paraplegia. Review of Resident #52's Quarterly MDS with an ARD of 10/22/2024 revealed a BIMS summary score of 15, which indicated he was cognitively intact. Review of Resident #52's current Physician Orders dated November 2024 revealed the following, in part: Start date: 10/03/2024 - Left Proximal/Distal Lateral Lower Leg Pressure Injury: apply non-adhering dressing to exposed tendon then apply wound vacuum at 125 mm/Hg continuous pressure. Apply twice a week on Mondays and Thursdays and as needed. Review of Resident #52's electronic Wound Documentation dated 11/04/2024 revealed a checkmark with S6LPN's initials, which indicated Resident #52's left leg wound treatment was completed per the physician orders. An interview was conducted with Resident #52 on 11/04/2024 at 10:32 a.m. An interview was conducted with Resident #52 on 11/04/2024 at 10:32 a.m. He stated his left leg treatment was completed this morning by S6LPN and S7LPN. He stated S6LPN and S7LPN did not place the wound vacuum and put a dry dressing on his left leg. An observation of Resident #52's left leg was conducted at that time. There was no wound vacuum in place to the resident's left leg. An interview was conducted with S6LPN on 11/04/2024 at 11:19 a.m. She stated she performed wound care for Resident #52 this morning with S7LPN's assistance. She stated Resident #52's wound vacuum was removed this morning and not replaced. She stated she and S7LPN placed a dry dressing to Resident #52's left leg wound. An interview was conducted with S7LPN on 11/07/2024 at 1:02 p.m. She confirmed she and S6LPN performed Resident #52's wound treatment on 11/04/2024. She stated Resident #52's wound vacuum was removed this morning, not replaced and a dry dressing was placed on Resident #52's left leg wound. She confirmed Resident #52 had a left leg wound vacuum ordered at all times with changes to be completed on Mondays, Thursdays and as needed. She further confirmed S6LPN documented Resident #52's wound care was completed as ordered and it was not. An interview was conducted with S2DON on 11/07/2024 at 2:24 p.m. She stated Resident #52 had a left leg wound vacuum ordered at all times with changes to be completed on Mondays, Thursdays and as needed. She confirmed Resident #52's treatment was not completed as ordered, it was documented completed as ordered, and should not have been.

Based on observations, interviews, and record review, the facility failed to ensure a resident with Pressure Ulcers received treatment and services consistent with professional standards by failing to implement the physician ordered treatment for 1 (#52) of 2 (#52 and #62) residents reviewed with wound vacuums. This deficient practice had the potential to affect any of the 13 residents with Pressure Ulcers as listed on the facility's CMS-802. Findings: Review of the facility's undated policy titled, Wound Care Policy and Procedures revealed the following, in part: Documentation: A. Treatment Documentation: Treatments will be initiated per physician orders. Treatments will be documented .as ordered. Review of Resident #52's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Pressure Ulcers and Paraplegia. Review of Resident #52's Quarterly MDS with an ARD of 10/22/2024 revealed a BIMS summary score of 15, which indicated he was cognitively intact. Review of Resident #52's current Physician Orders dated November 2024 revealed the following, in part: Start date: 10/03/2024 - Left Proximal/Distal Lateral Lower Leg Pressure Injury: apply non-adhering dressing to exposed tendon then apply wound vacuum at 125 mm/hg continuous pressure. Apply twice a week on Mondays and Thursdays and as needed. An interview was conducted with Resident #52 on 11/04/2024 at 10:32 a.m. He stated his left leg treatment was completed this morning by S6LPN and S7LPN. He stated S6LPN and S7LPN did not place the wound vacuum and put a dry dressing on his left leg. An observation was made of Resident #52's left leg at that time. There was no wound vacuum noted in place to the resident's left leg. An interview was conducted with S6LPN on 11/04/2024 at 11:19 a.m. She stated she performed wound care for Resident #52 this morning with S7LPN's assistance. She stated Resident #52's wound vacuum was removed this morning and not replaced. She stated she and S7LPN placed a dry dressing to Resident #52's left leg wound. An interview was conducted with S7LPN on 11/07/2024 at 1:02 p.m. She confirmed she and S6LPN performed Resident #52's wound treatment on 11/04/2024. She reviewed Resident #52's current physician ordered wound care treatment. She confirmed Resident #52's wound vacuum dressing should have been removed and a new wound vacuum dressing applied on 11/04/2024 and was not. An observation and concurrent interview was conducted with Resident #52 on 11/06/2024 at 7:00 a.m. Resident #52 was lying in bed with no wound vacuum in place to his left leg. Resident #52 stated the wound vacuum was removed on 11/04/2024 and had not been replaced. An interview was conducted with S8WCN on 11/06/2024 at 11:33 a.m. She confirmed Resident #52 had a left leg wound vacuum ordered at all times with changes to be completed on Mondays, Thursdays and as needed. S8WCN confirmed she performed Resident #52's wound treatment on 11/05/2024. She confirmed Resident #52's wound vacuum was not in place on the resident's left leg on 11/05/2024 and she did not replace Resident #52's wound vacuum. She further confirmed Resident #52's left leg wound vacuum dressing should have been placed as ordered on 11/04/2024 and 11/05/2024. An interview was conducted with S2DON on 11/06/2024 at 2:34 p.m. She confirmed Resident #52 had a left leg wound vacuum ordered at all times with changes to be completed on Mondays, Thursdays and as needed. She stated Resident #52's left leg wound vacuum dressing should have been placed as ordered on 11/04/2024 and 11/05/2024.

44965 47191 Based on observations, interviews, and record reviews, the facility failed to protect each residents' right to be free from abuse for 3 (#8, #9, and #13) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12 and #13) residents reviewed for abuse. The facility failed to protect: 1. Resident #8 from mental abuse by S11CNA; 2. Resident #9 from physical abuse by Resident #10; and 3. Resident #13 from physical abuse by Resident #11. This deficient practice resulted in an actual psychosocial harm on 05/10/2024 around 6:00 p.m., when S11CNA made degrading comments about Resident #8's bowel condition loudly at the Nurses' Station with Resident #8 seated nearby. Resident #8 experienced crying, sadness, and felt degraded after S11CNA's comments about him. Findings: Review of the facility's policy titled, Abuse and Neglect Policy, with a revision date of March 2023, revealed the following, in part: Purpose: It is the policy of this facility and the state agency, to prohibit the abuse, neglect, exploitation, or extortion of patients/residents (henceforth referred to as resident). This facility is committed to preserving the right of each person receiving services to be free from abuse. All forms of abuse of residents by other residents or employees of this facility are prohibited. Definitions: Physical abuse - physical contact such as hitting, slapping, pinching, kicking, choking, scratching. Verbal/Emotional/Psychological abuse - may be abusive because of either the manner of communication or the content of the communication; use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation; includes the use of oral, written, or gestured communication or sounds to residents, within hearing distance, regardless of age, ability to comprehend, or disability. Examples include but are not limited to: harassing a resident, mocking, insulting, ridiculing, yelling . Mental abuse/Violation of Privacy - may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. 1. Resident #8 Review of Resident #8's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Major Depressive Disorder, Generalized Anxiety Disorder, Acquired Absence of Right Leg Above Knee, and Acquired Absence of Left Leg Above Knee. Review of Resident #8's Quarterly MDS with an ARD of 06/05/2024 revealed he had a BIMS of 15, which indicated he was cognitively intact. Review of Resident #8's current Care Plan revealed the following, in part: Problem: ADLs - I need help with dressing, bathing, and personal hygiene due to my Bilateral Above Knee Amputations and Chronic Diarrhea . Problem: Alteration in bowel elimination related to I am incontinent. Review of Resident #8's Nurse's Note dated 05/15/2024 at 12:15 a.m. revealed the following, in part: Tonight I assisted Resident #8 in writing a statement regarding the way he was treated by a staff member on night shift on 05/10/2024. Resident #8 reported to me that the staff member embarrassed him by stating comments about his stomach/bowel issues in front of other residents, causing Resident #8 to get upset and cry. Resident #8 stated he was reluctant to report staff member for fear of possibly being further mistreated. Statement given to shift manager and the CNA assignment changed so the staff member is not assigned to the resident tonight. Signed: S10LPN Review of Resident #8's Incident Report revealed the following, in part: Date incident occurred: 05/10/2024 Date incident discovered: 05/15/2024 at 12:30 a.m. Type of incident: alleged abuse - emotional/verbal abuse Description of incident: Statement from Resident #8: On 05/10/2024, I was sitting in my wheelchair when the night shift arrived. S11CNA stated to me that she hoped I did not s*** my chair up the way that I s*** my bed up. S11CNA claimed she did not have time for that tonight. S11CNA said out in the hallway outside the day room and Nurses' Station in front of multiple other residents which was very embarrassing to me. I then rolled outside where the smoking area was and actually cried thinking this is how I have to live and I don't want to inconvenience anyone, but at the same time I have never been rude to S11CNA before. My feelings were hurt and I was embarrassed. When I rolled back into the building, I then told my nurse that I was ready to go to bed. I can put myself back to bed on my own. My nurse, S10LPN, then stuck her head out the smoking area door and stated to S11CNA that I would like to go to bed and would she please go and ensure that my bed was ready and that I was not soiled. At this time, S11CNA yelled at S10LPN, he can put himself to bed, she didn't have time to be bothered with my a**, and that I shouldn't be up in my chair anyway. S10LPN then came back into the building, and S12CNA came with her and ensured I was in bed and dry. Signed: Resident #8. Signature of person completing this form: S8RNM 05/15/2024 Supervisor review: do you suspect abuse or neglect? yes. On 06/04/2024 at 10:08 a.m., an interview was conducted with Resident #8. He stated, on 05/10/2024, he was by the medication cart outside the Nurses' Station at shift change, around 6:00 p.m. when S11CNA came out of the Nurses' Station and said something like, I hope you don't mess up the chair because you're hard enough to clean already. He stated S9LPN and S10LPN were at the medication cart giving report and heard the comments S11CNA made. He stated the comment made him feel bad, he went by the big window in the front of the facility, and cried and wondered what he did to end up here in this position. He stated after some time, he came back inside and asked for assistance getting back in bed. He stated S10LPN and S11CNA had words, S11CNA refused to assist him back to bed, and S10LPN and S12CNA assisted him back to bed. He stated he had chronic diarrhea for a long time and struggled with Depression because he never saw himself being in a place like this. He stated after the incident, he was sad for a few days. On 06/04/2024 at 10:35 a.m., an interview was conducted with S13CNA. She confirmed she was assigned to Resident #8 today. She stated she was aware of the incident that occurred on 05/10/2024 with Resident #8 and S11CNA. She stated following the incident, Resident #8 was sad about the situation and did not get out of the bed for a couple days. On 06/04/2024 at 1:34 p.m., a telephone interview was conducted with S8RNM. She stated an incident occurred between Resident #8 and S11CNA on 05/10/2024, and she was made aware of the incident on the night shift of 05/14/2024. She stated Resident #8 was very [NAME] and quiet. She stated Resident #8 was tearful when he explained to her that S11CNA said I hope you don't s*** your chair like you s*** your bed. She stated Resident #8 reported the incident occurred in front of other residents, S10LPN and S9LPN. She confirmed the above described incident was verbal and emotional abuse and when S11CNA was removed from Resident #8's unit, he began coming out of his room and engaging with other residents and staff. On 06/05/2024 at 9:32 a.m., a telephone interview was conducted with S9LPN. She stated Resident #8 was always very pleasant, friendly, and never had any behaviors. She stated, on 05/10/2024 at shift change, in a very loud in frustrated tone, S11CNA complained that Resident #8 was still up and every time he gets back in bed, he gets s*** everywhere and she did not want to clean it up. She stated Resident #8 was up in his wheelchair at the time the statement was made but was unsure of his exact location. She stated Resident #8 would have been able to hear the statements made by S11CNA if he was seated outside the Nurses' Station. She explained if Resident #8 overheard S11CNA, he would be very upset because he was generally very bothered and emotional related to his chronic diarrhea. She confirmed the statements made by S11CNA were very disrespectful. On 06/05/2024 at 2:04 p.m., a telephone interview was conducted with S11CNA. She confirmed Resident #8 had frequent diarrhea. She stated she never had a conversation with anyone about Resident #8's bowel movements. She stated she did not recall ever making a comment about Resident #8's bowel movements or him having a bowel movement in his chair or his bed. She stated if she had, that would have been abuse. Telephone interviews were unsuccessful with S10LPN on 06/04/2024 at 12:17 p.m., 06/04/2024 at 2:45 p.m., 06/05/2024 at 8:15 a.m., 06/0 5/2024 at 10:41 a.m., 06/05/2024 at 1:07 p.m., and 06/05/2024 at 2:51 p.m. Review of the State Agency Investigator's Report for Resident #8 revealed the following, in part: Incident date: 05/10/2024 Discovered: 05/15/2024 Alleged Victim: Resident #8 Statement by S10LPN: On 05/10/2024, I was working the night shift, Resident #8 was in his wheelchair outside of the Nurses' Station, as well as S11CNA. I could not really make out what was being said, but voices were raised and then all residents along with S11CNA went out to the smoking area. When I walked out back to this area, Resident #8 was in his wheelchair and had rolled down the sidewalk away from everyone else. Resident #8 appeared to be upset and possibly had been crying. After ten minutes, Resident #8 came back inside the building and stated he was ready to get in his bed. I went to get S11CNA, and informed her Resident #8 was ready to get into his bed. S11CNA began to yell at me outside in front of other residents. She said I don't have time to fool with him right now, he shouldn't even be up right now. I then came back into the building and was assisted by S12CNA to get Resident #8 in bed. I then asked the resident while in his room what was wrong and if something had happened. Resident #8 told me he didn't understand why staff were mean because he was never mean to anyone. He also told me how he can't help he has bad diarrhea, does not want to be like this, and surely doesn't do it on purpose. I encouraged the resident to report staff when they are mean and explained to him that is abuse. Resident stated that he was afraid to make anything worse but that he would think about it and let me know if he decided to report anything. When I came back to work, my RN Manager came to me and told me to go and help Resident #8 do a statement since he can't write. Statement done and signed by resident. Even though I did not hear exactly what S11CNA said to the resident, the attitude she had toward myself and the resident was not therapeutic and not conducive to patient care. Whatever S11CNA did say to the resident upset him enough that his demeanor changed to very sad and he obviously had been crying as it appeared he had tears in his eyes. On 06/05/2024 at 12:45 p.m., an interview was conducted with S6APS. He confirmed he investigated an allegation S11CNA emotionally abused Resident #8. He confirmed he interviewed S10LPN during his investigation. He stated S10LPN reported she did not hear S11CNA say anything directly to Resident #8 but when she went outside there were a lot of other residents outside and they were laughing and Resident #8 appeared to be crying. He stated S10LPN reported S11CNA was yelling at her as well. He stated S10LPN explained based on how Resident #8 reacted and S11CNA acted, she believed Resident #8 was abused by S11CNA. On 06/05/2024 at 4:00 p.m., an interview was conducted with S2DON. She stated Resident #8 had never made false reports against staff and was a very pleasant resident. She stated if S11CNA said what Resident #8 accused her of, that was abuse. On 06/05/2024 at 12:30 p.m., an interview was conducted with S5AA. He confirmed a state agency investigator investigated the allegation S11CNA abused Resident #8. He stated he reviewed the state agency investigator's report and investigation. He confirmed he substantiated the allegation because there was enough evidence to show S11CNA mentally abused Resident #8. 2. Resident #10 Review of Resident #10's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Infarction and Unspecified Psychosis. Review of Resident #10's quarterly MDS with an ARD 04/18/2024 revealed a BIMS of 3, which indicated resident had severe cognitive impairment. Review of Resident #10's Nurse's Notes dated 05/18/2024 at 11:34 a.m. by S14RN revealed Resident #9 was bumping into Resident #10's Gerichair several times, Resident #9 grabbed Resident #10 and scratched Resident #10's nose. On 06/04/2024 at 1:22 p.m., an interview was conducted with S16LPN. S16LPN stated Resident #10 does not like noise and will curse at others when agitated. S16LPN stated if you are close enough to Resident #10 he will grab at you. Resident #9 Review of Resident #9's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Moderately Intellectual Disabilities, Epilepsy, Schizophrenia and Extrapyramidal Movement Disorder. Review of Resident #9's quarterly MDS with an ARD of 05/09/2024 revealed a BIMS of 3, which indicated severe cognitive impairment. Review of Resident #10's Nurse's Notes dated 05/18/2024 at 9:38 a.m. by S17LPN revealed Resident #9 bumped into Resident#10's Geri chair several times, Resident #10 then grabbed Resident #9's face and scratched the right side of Resident #9's nose. Upon exam slight bleeding to right side, cleansed TAO applied. On 06/04/2024 at 1:58 p.m., an observation of the surveillance video was made with S18APD. On 05/18/2024 at approximately 9:38 a.m. both Resident #9 and Resident #10 were in the day room. Resident #9 backed up his wheelchair next to Resident #10's Geri chair, Resident #9 then leaned over Resident #10 and raised her right arm, Resident #10 immediately swatted his left arm and grabbed at Resident #9's face. Security immediately stepped in and separated both residents. On 06/04/2024 at 1:59 p.m., an interview was conducted with S18APD. S18APD confirmed Resident #10 grabbed Resident #9's face and it was considered physical abuse. 06/05/2024 at 10:00 a.m., an interview was conducted with S3CRO. S3CRO stated he was responsible for completing incident reports. S3CRO and S18APD reviewed surveillance of the incident that occurred between Resident #9 and Resident #10. S3CRO confirmed physical abuse occurred. 3. Resident #11 Review of Resident #11's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses which included Unspecified Intracranial Injury with Loss of Consciousness, Dementia, Major Depressive Disorder, Other Frontotemporal Neurocognitive Disorder, and Amnestic Disorder due to Known Physiological Condition. Review of Resident #11's Quarterly MDS with an ARD of 02/29/2024 revealed a BIMS of 1, which indicated severe cognitive impairment. Resident #13 Review of Resident #13's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Personal History of Other Mental and Behavioral Disorders. Review of Resident #13's annual MDS with an ARD of 02/29/2024 revealed a BIMS of 15, which indicated he was cognitively intact. Review of Resident #13's Nurse's Note dated 05/19/2024 at 5:17 p.m. by S4RN revealed I heard yelling in the hallway by the dining room door. I saw Resident #13 on the floor next to his rollator walker. Resident #13 reported he could not get out of Resident #11's way, and Resident #11 pushed him to the floor. On 06/04/2024 at 10:54 a.m., an interview was conducted with Resident #13. He stated a few weeks ago Resident #11 pushed him to the floor while he was waiting to go into the dining area. He denied any pain or injuries as a result of this incident. On 06/04/2024 at 11:51 a.m., an interview was conducted with S4RN. She stated she recalled the incident that took place between Resident #11 and Resident #13. She stated she was in the hallway when she heard a lot of noise and commotion. She stated upon assessment of the noise, she observed Resident #13 sitting on the floor with his rollator walker next to him. She stated Resident #13 was cognitively intact, and when she asked him what happened, he stated, I couldn't get out of Resident #11's way fast enough so he pushed me out the way. On 06/05/2024 at 1:34 p.m., an interview was conducted with S3CRO. S3CRO confirmed he reviewed the video footage from 05/19/2024 involving Resident #11 and #13. He stated Resident #11 grabbed Resident #13 and pushed him to the floor with force. He confirmed he considered the altercation physical abuse. On 06/05/2024 at 2:01 p.m., an observation of the facility's surveillance footage was conducted with S2DON. On 05/19/2023 at 5:19 p.m., Resident #13 was observed standing in the hallway near the exit of the dining room door when Resident #11 forcefully shoved Resident #13 to the floor with both hands. Immediately following the observation, and interview was conducted with S2DON. S2DON stated Resident #11 grabbed Resident #13 and pushed him to the floor with force. She confirmed she considered the altercation physical abuse.

Based on observations, interviews and record reviews, the facility failed to protect the resident's right to be free from physical abuse by another resident for 3 (#RF7, #F47, and #F125) of 11 (#F6, #F11, #F13, #F75, #F47, #F120, #F125, #F132, #F338, #RF7, and #RF8) residents reviewed for abuse. The facility failed to ensure: 1. Resident #RF7 was free from physical abuse by Resident #F132; 2. Resident #F47 and Resident #F125 were free from physical abuse by each other. This deficient practice resulted in an actual harm for Resident #RF7 on 01/05/2024 at 12:41 p.m. when he was punched in the face by Resident #F132 and sustained multiple facial fractures. Resident #RF7 took a canned beverage from Resident #F132's meal tray and Resident #F132 approached Resident #RF7 and punched him in the face. As a result, Resident #RF7's diagnostic scans revealed fractures to the Left Inferior Medial Orbital Floor, Superior Medial Maxillary Sinus Wall, Inferior Medial Orbital Wall, Left Inferior Lateral Maxillary Sinus Wall, and Anterior Inferior Maxillary Sinus Wall and blood and fluid in the Left Maxillary Sinus. This deficient practice resulted in an actual harm for Resident #F47 and Resident #F125 on 01/23/2024 at 11:25 a.m. when Resident #F125 removed the wheelchair arm rest and struck Resident #F47 on the right hand. Resident #F47 then approached and hit Resident #F125 on the right side of the head with his wheelchair arm rest. As a result, Resident #F47's diagnostic scans revealed a fracture to the Right Index Proximal Phalanx Fracture of the Second Finger. Resident #F125 was sent to emergency room where he received a CT of his Maxillofacial Structures and brain due to contusion and swelling of head. Findings: Review of the facility's policy titled, Abuse and Neglect Policy revealed the following, in part: A. Purpose: It is the policy of this facility to prohibit the abuse of residents. This facility is committed to preserving the right of each person receiving services to be free from abuse. All forms of abuse of residents by other residents are prohibited. b. Abuse - the willful infliction of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm . i. Physical Abuse - physical contact such as hitting . 1. Resident #F132 Review of Resident #F132's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #F132's Quarterly MDS with an ARD of 10/20/2023 revealed a BIMS of 15, which indicated he was cognitively intact. Review of Resident #F132's current Care Plan revealed the following, in part: Problem: 01/05/2024 - Hit another resident for taking his food. Review of Resident #F132's Nurse's Note dated 01/05/2024 at 12:55 p.m. revealed the following, in part: SF5LPN was summoned to hallway by staff. SF5LPN visualized Resident #F132 standing in front of Resident #RF7. Resident #F132 stated, don't touch anything on my f****** walker again, and punched Resident #RF7 in his left eye. Once Resident #F132 was calmed, he stated, he stole my cold drink off my walker when I walked in the dining room. Signed: SF5LPN Review of the Resident #F132's Incident Report dated 01/05/2024 at 12:38 p.m. revealed the following, in part: Where incident occurred: Hall Type of incident: resident to resident activity Description of incident: while conducting watch in the kitchen SF9CGT heard an argument outside in the hall. At this time, SF9CGT saw SF10C and SF8CGT in front of Resident #F132 who was cursing at Resident #RF7 saying you stole my f****** drink. Witnessed: SF8CGT, SF10C, and SF11C. Completed by: SF9CGT Review of Resident #F132's Post Incident Huddle Report dated 01/05/2024 revealed the following, in part: Interventions needed or provided after the incident: order for increased observation due to hitting Resident #RF7 in the left eye. Any previous incidents: No Resident #RF7 Review of Resident #RF7's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Unspecified Impulse Disorder. Review of Resident #RF7's MDS with an ARD of 11/24/2023 revealed a BIMS of 15, which indicated he was cognitively intact. Review of Resident #RF7's Incident Report dated 01/05/2024 at 12:45 p.m. revealed the following, in part: Where incident occurred: Hall Type of incident: resident to resident activity Description of Incident: See Nurses' Note Assessment: Small scratch noted under right eye. Nurse completing report: SF4RN Review of Resident #RF7's Nurse's Note dated 01/05/2024 at 1:08 p.m. revealed the following, in part: Unwitnessed resident to resident altercation: nurse writer was in dining hall serving lunch, during this time altercation was heard outside of the door, upon walking to the area, the nurse writer witnessed Resident #RF7 and Resident #F132 in a verbal confrontation but were separated by security staff. Upon nurse writer interviewing residents, Resident #F132 was yelling stating that Resident #RF7 had taken his soda from meal tray, and Resident #RF7 was yelling Resident #F132 had hit him in the face. Assessment was completed. Small scratch noted under left eye. Signed: SF4RN Review of the facility's video footage of the hallway leading to the dining room from Resident #F132 and Resident #RF7's units was conducted on 01/11/2024 at 9:17 a.m. with SF6APM who confirmed the below observation: Video footage dated 01/05/2024 beginning at 12:40 p.m.: Resident #RF7 took a canned drink off of a tray resting on a rollator walker outside of the dining room. Resident #RF7 proceeded to propel himself up the hallway toward the day room with the canned drink. Resident #F132 then exited the dining room and spoke with a resident seated in the hallway. Resident #F132 immediately ambulated with his rollator walker and approached Resident #RF7. At 12:41 p.m., Resident #F132 stood in front of Resident #RF7 and hit Resident #RF7 in his face with his right fist then left fist. Resident #RF7 then crossed both of his arms in front of his face and SF10C intervened. An observation was made of Resident #RF7 on 01/10/2024 at 1:58 p.m. He had bruising surrounding his left eye. He had purplish-red bruising under his left eye and yellowish bruising laterally. He had a purple discoloration on the left side of his mouth. He had a large section of purple discoloration on his neck. His left eye and cheek were visibly swollen compared to the right side of his face. An interview was conducted with Resident #RF7 on 01/10/2024 at 2:00 p.m. He stated, on 01/05/2024, he was trying to pass Resident #F132 in the hallway when the other resident punched him on his left eye. An interview was conducted with Resident #F132 on 01/10/2024 at 2:39 p.m. He stated, on 01/05/2024 at lunch time, he retrieved his meal tray and placed it on the seat of his rollator to go back to his room to eat. He stated he left the rollator in the hallway while he went back into the dining room to get ketchup, and when he came back out, Resident #RF7 had taken his cold drink off of his tray. He stated he then went to Resident #RF7 and punched him in the face. An interview was conducted with SF4RN on 01/10/2024 at 2:30 p.m. She stated, on 01/05/2024, there was an incident involving Resident #RF7 and Resident #F132. She stated she heard a commotion in the hallway leading to the dining room, and then, saw security separating the two residents. She stated security reported to her Resident #F132 punched Resident #RF7 in the face. She stated immediately following the incident, Resident #RF7 had bruising under his left eye. She stated Resident #RF7 did not normally have any discoloration to his face or neck. She confirmed Resident #F132 physically abused Resident #RF7. An interview was conducted with SF5LPN on 01/11/2024 at 10:12 a.m. She stated, on 01/05/2024, she was assigned to Resident #F132. She stated she reported to the hallway outside of the dining room around lunch because a staff member was yelling for help. She stated when she arrived, Resident #F132 was standing in front of Resident #RF7. She stated Resident #F132 then punched Resident #RF7 in the face with a closed fist. She confirmed Resident #F132 punching Resident #RF7 in the face was physical abuse. She stated immediately following the incident, Resident #F132 was placed on increased observation and was educated to notify staff if another resident takes something from him. An interview was conducted with SF11C on 01/11/2024 at 10:21 a.m. She stated, on 01/05/2024 around lunch, she heard Resident #F132 and Resident #RF7 yelling in the hallway leading to the dining room. She stated Resident #F132 then punched Resident #RF7 in the eye with a closed fist. She stated SF10C, SF9CGT, and SF8CGT separated the residents. She confirmed Resident #F132 punching Resident #RF7 in the face was physical abuse. She stated she had never seen Resident #F132 become physically aggressive prior to this incident. A telephone interview was conducted with SF10C on 01/11/2024 at 11:21 a.m. He stated he recalled the incident involving Resident #F132 and Resident #RF7 on 01/05/2024. He stated when he first walked up, Resident #F132 hit Resident #RF7 in the face with a closed fist. He stated Resident #RF7 was screaming for help. He stated he separated the two residents. He stated immediately following the incident, Resident #RF7 had a bruise and swelling around his left eye. He confirmed Resident #F132 physically abused Resident #RF7. He stated he had never seen Resident #F132 become physically aggressive prior to this incident. An interview was conducted with SF8CGT on 01/11/2024 at 11:28 a.m. He stated, around 12:45 p.m. on 01/05/2024, he was in the dining area, and Resident #F132 and Resident #RF7 were in the hallway leading to the dining area. He stated he heard commotion going on in the hallway, and he responded. He stated by the time he got there, Resident #F132 was standing over Resident #RF7, and Resident #F132 hit Resident #RF7 in the face with a closed fist. He confirmed Resident #F132 physically abused Resident #RF7. He stated he had never seen Resident #F132 become physically aggressive prior to this incident. He stated immediately following the incident, Resident #F132 was placed on increased observation. An interview was conducted with SF9CGT on 01/11/2024 at 11:52 a.m. She stated, on 01/05/2024 at lunch, she was in the dining area. She stated Resident #F132 and Resident #RF7 were in the hallway leading to the dining room. She stated she heard hollering and approached the situation. She stated when she responded the residents were being separated, and Resident #F132 was yelling and saying Resident #RF7 stole his cold drink. She stated Resident #RF7 was wheelchair bound, and Resident #F132 walked around and was more mobile than Resident #RF7. She stated Resident #F132 punching Resident #RF7 in the face was physical abuse. She stated she had never seen Resident #F132 become physically aggressive prior to this incident. An interview was conducted with SF7LPN on 01/10/2024 at 2:13 p.m. She stated she was currently assigned to Resident #RF7. She confirmed Resident #RF7 had bruising surrounding his left eye from an incident between him and Resident #F132. She confirmed one resident punching another resident was physical abuse. She stated SF2NP ordered facial x-rays for Resident #RF7 on 01/08/2024 related to his facial bruising. She stated after SF2NP received Resident #RF7's x-ray report, he ordered a facial CT. An interview was conducted with SF3CRN on 01/11/2024 at 2:07 p.m. He stated he was responsible for abuse investigations. He stated after the incident occurred with Resident #F132 and Resident #RF7 on 01/05/2024, he reviewed the facility's camera footage. He stated Resident #F132's rollator was out in the hallway leading to the dining room with a meal tray and cold drink. He stated Resident #RF7 was also in the hallway and took Resident #F132's cold drink off of the tray. He stated when Resident #F132 returned to his rollator, another resident in the hallway notified Resident #F132 that Resident #RF7 took his cold drink. He stated then, Resident #F132 confronted Resident #RF7 and punched him in the face. He confirmed Resident #F132 physically abused Resident #RF7, and Resident #RF7 received facial fractures from the incident. He stated immediately following the incident, Resident #F132 was placed on increased observation. Review of Resident #RF7's X-ray Report dated 01/08/2024 at 11:58 a.m. revealed the following, in part: Exam: XR facial bones 3 views Indications: Altercation Impression: Limited examination with evidence of air-fluid level in the left maxillary sinus and possible fractured tooth, likely in the left mandible (the orbital floor appears intact although the limited views do not totally exclude possibility of orbital floor blowout fracture as a source of the left maxillary fluid). Review of Resident #RF7's Hospital Records from a local hospital dated 01/10/2024 revealed the following, in part: ED triage description of symptoms: Was hit in the face by other patient. Physical Exam: Head traumatic with ecchymosis of the left face. CT facial dated 01/10/2024 at 7:13 p.m.: Clinical indication: contusion, swelling Impression: There is a left inferior medial orbital floor and superior medial maxillary sinus wall with mild comminuted fragments and the mild comminuted fragments may be exaggerated by motion artifact. Majority of the inferior orbital wall is intact with only fracture at the inferior medial aspect .There is also fractures of the left inferior lateral maxillary sinus wall and anterior inferior maxillary sinus wall with mild depression and partially comminuted with partial opacification of the left maxillary sinus with blood and fluid. A telephone interview was conducted with SF2NP on 01/11/2024 at 8:56 a.m. He confirmed Resident #F132 punched Resident #RF7 in the face on 01/05/2024. He stated he ordered x-rays to Resident #RF7's face to be completed on 01/08/2024 related to his facial bruising from the incident. He stated the x-rays were unclear so he ordered a computed tomography scan, which was completed at a local hospital on [DATE]. SF2NP confirmed Resident #RF7 received facial fractures when Resident #F132 punched him in the face. An interview was conducted with SF1AA on 01/11/2024 at 2:44 p.m. He confirmed Resident #F132 punched Resident #RF7 in the face on 01/05/2024, which was physical abuse. He stated immediately following the incident, Resident #F132 was placed on increased observation. 2. Resident # F47 Review of Resident # F47's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Quadriplegia. Review of Resident # F47's Quarterly MDS with ARD of 12/19/2023 revealed a BIMS of 15, which indicated intact cognition. Review of Resident #F47's Nurse's Notes dated 01/23/2024 at 12:20 p.m. revealed the following, in part: Resident #F47 came to the nurse's station and reported to SF20CNA that Resident #F125 hit him with his wheelchair armrest. SF20CNA reported the incident to SF19LPN. SF19LPN saw Resident #F47's index finger was dislocated, swollen, and painful and she began to ask Resident #F47 what happened. Resident #F47 stated, he was in the bathroom and Resident #F125 was trying to come in and he told him he could not come in and to get out. Resident #F125 took off his armrest and hit him. Resident #F47 stated he took off his armrest and hit Resident #F125 since he hit him. Resident #F47 was instructed to stay at nurse's station while SF19LPN went to assess Resident#F125. Signed SF19LPN Review of Resident #F47's Incident report dated 01/23/2024 at 11:25 a.m. revealed the following, in part: Where incident occurred: Resident's room Type of incident: Resident to resident activity Description of incident: See Nurse's note Witnessed: None Completed by: SF21RNS Review of Resident #F47's Post Incident Huddle Report dated 01/23/2024 revealed, in part: Interventions needed or provided after the incident: Resident sent to local hospital for evaluation of finger. Environmental factors or equipment involved: armrest of wheelchair. Any previous incidents: No Review of Resident #F47's hospital records X-ray Report dated 01/23/2024 revealed the following, in part: Exam: Right Index Finger- 3 views Indications: Pain Impression: Acute essentially non-displaced fracture of the proximal metadiaphyseal junction of the proximal phalanx. There is prominent dorsal angulation. No other fractures. No destructive lesions. Exam: XR Finger RT min 2V Indications: Post Reduction Impression: Proximal phalanx fracture of the second finger has been reduced. Overlying cast material obscures osseous detail. Review of Resident #F47's current physician's orders revealed, in part: Start date: 01/23/2024 Hydrocodone/APAP 5-325mg until Hydrocodone/APAP 7.5-325mg is available Review of Resident #F47's Medication Administration Record for January 2024 revealed Hydrocodone-Acetaminophen 5-325mg was administered once on 01/23/2024 and twice on 01/24/2024. Resident #F47 received Hydrocodone-Acetaminophen 7.5-325mg once on 01/25/2024. An observation was made of Resident #F47 on 01/24/2024 at 12:57 p.m. Resident #F47's right hand from fingertips to wrist was noted to be wrapped with gauze and an ace wrap. Resident #F47's right index and middle fingers were noted to be splinted. An interview was conducted with Resident #F47 on 01/24/2024 at 12:57 p.m. He stated on 01/23/2024 when he came out of his bathroom Resident #F125 hit him with a wheelchair arm rest on his right hand. Resident #F47 stated his pain was currently a 7 out of 10. He stated the splint was uncomfortable. Resident #47 stated his hand hurts when he touches things. He stated his right hand was his dominant hand and since the altercation staff had to do more for him. He stated staff had to bath, dress, and help him get in the wheelchair and did not have to prior to the incident on 01/23/2024. An interview was conducted with Resident #F47 on 01/25/2024 at 12:30 p.m. He stated his right hand still ached. Review of Resident #F125's Clinical Record revealed he was admitted to the facility on [DATE], with diagnoses which included, in part: Unspecified Sequelae of Cerebral Infarction, and Personality Disorder. Review of Resident #F125's Quarterly MDS with ARD of 11/17/2023 revealed a BIMS of 99, which indicated the BIMS could not be completed. Review of Resident #F125's Care Plan revealed, in part: Problem: onset 01/23/2024-I have had an actual Injury/Behavior Review of Resident #F125's Nurses Notes dated 01/23/2024 at 12:19 p.m. revealed the following, in part: Resident #F125 was sitting in WC on side of his bed, right eye was swollen, bleeding, and bruised. When Resident #F125 was asked what happened he stated someone hit me. Signed SF19LPN Review of Resident #F125's Incident report dated 01/23/2024 at 11:25 a.m. revealed the following, in part: Where incident occurred: Resident's room Type of incident: Resident to resident activity Description of incident: See Nurse's note Witnessed: None Completed by: SF21RNS Review of Resident #F125's Post Incident Huddle Report dated 01/23/2024 revealed, in part: Interventions needed or provided after the incident: Resident was sent to ER via ambulance for evaluation of eye trauma s/p altercation. Environmental factors or equipment involved: armrest of wheelchair Any previous incidents: No Review of Resident #F125's Hospital Records dated 01/23/2024 revealed the resident received a CT of his Maxillofacial Structures as indicated due to contusion and swelling. Further review revealed he received a CT of the Brain without contrast as indicated due to head injury. No abnormalities were noted. An observation was made of Resident #F125 on 01/24/2024 at 1:16 p.m. Resident #F125's right eye was noted to have dry scabbing and discoloration to the corner and under the eye. An interview was conducted with Resident #F125 on 01/24/2024 at 1:16 p.m. Resident #F125 stated he did not recall an altercation with another resident. Resident #F125 could not answer probing questions. An interview was conducted with SF21RNS on 01/24/2024 at 1:30 p.m. She stated she completed the incident investigation and post huddle incident form for the altercation between Residents #F47 and #F125. She confirmed the altercation between Resident #F47 and #F125 was a form of physical abuse. A telephone interview was conducted with SF19LPN on 01/25/2024 at 11:17 a.m. She confirmed SF20CNA notified her of the altercation between Resident #F47 and Resident #F125. She confirmed Resident #F47's index finger was dislocated, swollen, and painful. She confirmed Resident #F125's right eye was swollen, bleeding, and bruised. She confirmed she dressed Resident #F125's right eye with a gauze dressing. An interview was conducted with SF18DON on 01/25/2024 at 4:23 p.m. She confirmed the altercation between Resident #F47 and #F125 was resident to resident physical abuse. An interview was conducted with SF17ADM on 01/25/2024 at 4:35 p.m. He stated he was informed of the altercation between Resident #F47 and #F125 on 01/23/2024 by SF21RN. He confirmed the details of altercation stating Resident #F125 attempted to enter the bathroom in his designated room, his roommate Resident #F47 was occupying the bathroom. Resident #F125 began yelling at Resident #F47 to hurry up. Resident #F125 then entered the bathroom, removed his detachable armrest from his wheelchair and stuck Resident #F47 on the hand. Resident #F47 also removed his arm rest and struck Resident #F125 in the face. She confirmed the incident between Resident #F47 and #F125 was physical abuse.

Based on observations, interviews, and record reviews, the facility failed to ensure cognitively impaired residents were free from physical abuse by a cognitively intact resident for 4 (Residents #2, #5, Random Resident #1, and Random Resident #2) out of 8 (Residents #1, #2, #3, #4, #5, #6, Random Resident #1 and Random Resident #2 ) sampled residents reviewed for abuse. The deficient practice resulted in an Immediate Jeopardy situation for Resident #5 on 05/02/2022, when Resident #6, who was cognitively intact, forcefully pushed Resident #5, who was severely cognitively impaired, across the hall. The physical abuse continued for Resident #5, Resident #2, Random Resident #1 and Random Resident #2. On 05/15/2022 at 8:20 a.m., Resident #6 slapped Random Resident #1's left arm. On 05/15/2022 at 11:50 a.m., Resident #6 leaned his shoulder into Resident #5 and pushed him across the hallway. On 07/11/2022, Resident #6 rammed Random Resident #2 with his walker. On 07/16/2022 Resident #6 attacked Resident #2 and pushed him to the floor. The facility failed to implement effective interventions to protect Resident #2, Resident #5, Random Resident #1 and Random Resident #2 who resided on Hall A from the aggressive physical abusive actions of Resident #6, who also resided on Hall A. S1ADM and S2DON was notified of the Immediate Jeopardy on 07/20/2022 at 3:25 p.m. The Immediate Jeopardy was removed on 07/21/2022 at 4:30 p.m. when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following had been initiated and/or implemented prior to exit. The Immediate Jeopardy Plan of Removal included the following: The facility shall ensure that all residents who reside in Hall A shall be free from abuse and neglect, specifically pertaining to Resident #6 as identified through State Agency complaint survey initiated on 07/18/2022. All clinical staff (in house and agency) have been in-serviced upon the requirements of 1:1 staffing of Resident #6. Observation checklist have been assigned to supervising staff member for completion to ensure compliance. No staff shall be allowed to work on this unit until education and in-servicing is complete. -Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the non-compliance. -All residents on Hall A have the potential to be adversely affected by the behaviors and actions of Resident #6. -Specify actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring. -Clinical staff has been assigned direct supervision (1:1) on Resident #6 to ensure that all residents on Hall A are free from abuse -All staff working on current shift(s) a.m./p.m. have been in-service on 1:1 observation on 07/20/2022. -MD was consulted and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -Direct supervision of Resident #6 was ordered on 07/20/2022. Direct supervision will remain indefinitely. -All staff assigned to Hall A shall have education and in-servicing on abuse and neglect completed by Monday 07/25/2022. -CNAs will document on Resident #6 1:1 every 15 minutes; managers shall monitor documentation every shift; documentation shall be turned in daily to nursing services. Any incident report involving a 1:1 resident shall be reviewed to ensure that 1:1 is working. DON will complete a quality assurance report for August reviewing the data and this will continue indefinitely beginning 07/20/2022. The deficient practice had the potential for more than minimal harm for the other 20 residents residing on Hall A. Findings: Review of the facility's policy entitled Abuse-Prevention and Prohibition Policy and Procedure included, in part: Purpose: It is the policy of the facility to prohibit the abuse, neglect, exploitation or extortion of patients/residents. III. Prevention Policy and Procedures: Statement of Policy: The facility is committed to preserving the right of each person receiving services to be free from abuse. All forms of abuse of residents of the facility are prohibited. While definitions and examples of abuse are provided in this policy, it must be understood that all possible situations cannot be anticipated and each case must be evaluated based on the particular facts available. Examples of Abuse: 1. Physical Abuse: Physical contact such as hitting, slapping, pinching, kicking, choking, scratching, pushing, twisting of head, arms, and legs, tripping; the use of physical force which is unnecessary or excessive; and inappropriate or unauthorized use of restraint. Resident #5 Resident #5 was admitted to the facility on [DATE] with diagnosis, which included: [CONDITION(S)], Major Depressive Disorder, history of [CONDITION(S)] and Cerebral Infarct, Alzheimer's Disease, and Dementia. A review of the quarterly MDS with an ARD of 06/19/2022 revealed the resident had a BIMS of 0, indicating he was severely cognitively impaired. Review of the Incident/Accident Log for Resident #5 revealed the following: Incident Date/Time: 07/30/2021 at 2:25 p.m. Alleged Victim: Resident #5 Investigation Details: Resident #5 was standing in front of nurses' station when Resident #6 walked up hollering and pushed Resident #5 into the wall. Resident #6 then pushed Resident #5 across hallway into linen door. Allegations: Physical Abuse Alleged Perpetrator: Resident #6 Injury to the individual- no injuries Describe steps taken to protect the individual from harm, including health assessment of care: Both residents were separated, Resident #6 was counseled by staff. Review of the Incident/Accident Log for Resident #5 revealed the following: Incident Date/Time: 07/30/2021 at 2:32 p.m. Alleged Victim: Resident #5 Investigation Details: Resident #6 was walking down hall and punched Resident #5 in the stomach and continued hollering at him. Allegations: Physical Abuse Alleged Perpetrator: Resident #6 Injury to the individual- no injuries Describe steps taken to protect the individual from harm, including health assessment of care: Both residents were separated, Resident #6 was counseled by staff. Review of the Nurse's Notes revealed the following: 07/30/2021 at 3:15 p.m. Resident #5 was standing in front of nurses' station when Resident #6 walked up screaming at him and pushed him into the wall. Resident #6 then pushed him again across the hallway into the linen room door. Residents were separated and RN supervisor was informed. Then Resident #6 punched Resident #5 in the stomach as he was walking down the hall and was screaming at him. Residents separated again. Two RN supervisors and DON on unit. Resident #5 was taken to the shower room to bath him and change his clothes. DON and supervisor attempted to calm Resident #6. MD notified of the above. S4LPN. Review of the Incident/Accident Log for Resident #5 revealed the following: Incident Date/Time: 05/02/2022 at 11:23 a.m. Alleged Victim: Resident #5 Investigation Details: Resident #5 was standing in the doorway of Resident #6's room when Resident #6 pushed this resident into hallway forcefully. Allegations: Physical Abuse Alleged Perpetrator: Resident #6 Injury to the individual- no injuries Describe steps taken to protect the individual from harm, including health assessment of care: Resident #6 was counseled on calling staff for help when another resident is in his room and to not push others. Review of the Nurse's Notes revealed the following: 05/02/2022 at 11:43 a.m. Resident #5 was standing at the doorway to Resident #6's room when Resident #6 came to the door and pushed Resident #5 back forcefully into the hallway and then slammed the door. S4LPN. Review of the Incident/Accident Log for Resident #5 revealed the following: Incident Date/Time: 05/15/2022 at 11:50 a.m. Alleged Victim: Resident #5 Investigation Details: Resident #5 was standing in hallway when Resident #6 leaned into Resident #5 with his shoulder and pushed him across hallway. Resident #5 caught himself on the wall and did not fall. Allegations: Physical Abuse Alleged Perpetrator: Resident #6 Injury to the individual- no injuries Describe steps taken to protect the individual from harm, including health assessment of care: Resident #6 was counseled by staff on not hitting other residents and was redirected away from other residents. Review of the Nurses Notes revealed the following: 05/15/2022 at 1:42 p.m. At approximately 11:50 a.m. Resident #5 was seen guided out of the dayroom by Resident #6 when Resident #6 pushed him into the hallway with his shoulder. Resident #6 was redirected, RN supervisor, MD, and RP notified. S4LPN. Resident #2 Resident #2 was admitted to the facility on [DATE] with diagnosis, which included [CONDITION(S)] Disorder, [CONDITION(S)], Pressure Ulcer of Right Hip, and Inguinal hernia. Review of the MDS with an ARD of 05/27/2022 revealed Resident #2 had a BIMS of 3 which indicated he had severe cognitive impairment. Review of the Incident/Accident Log for Resident #2 revealed the following: Incident Date/Time: 07/16/2022 at 3:15 p.m. Alleged Victim: Resident #2 Investigation Details: Resident #2 stated Resident #6 attacked him in his room and pushed him to the floor. Resident #2 doesn't recall having other resident's walker. Allegations: Physical Abuse Alleged Perpetrator: Resident #6 Injury to the individual- no injuries Describe steps taken to protect the individual from harm, including health assessment of care: Counseled by staff to not push others and notify staff when there is a problem Review of Resident #2's Nurse's Notes revealed the following: 07/16/2022 at 4:16 p.m. Today around 3:22 p.m., we heard Resident #2 yell in his room. Upon entering Resident #6 was walking out of the room with his walker. When asked Resident #2 what happened, he stated Resident #6 attacked him. When asked Resident #6 what happened he stated Resident #2 stole his personal items (his walker he had left outside the television room). Explained to resident he cannot put his hands on another resident and to come to the nurse's station to ask for assistance. S9RN. Random Resident #1 Random Resident #1 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Traumatic Subdural Hematoma, Assault by unarmed brawl or fight, [CONDITION(S)], Hypertension, and Obstructive Pulmonary Disease. Review of the quarterly MDS with an ARD of 04/05/2022 revealed Random Resident #1 had a BIMS of 10, which indicated he had moderate cognitive impairment. Review of the Incident/Accident Log for Random Resident #1 revealed the following: Incident Date/Time: 05/15/2022 at 8:20 a.m. Alleged Victim: Random Resident #1 Investigation Details: Random Resident #1 was standing in hallway by dining room door when Resident #6 walked by and slapped his left arm and told him to go away. Allegations: Physical Abuse Alleged Perpetrator: Resident #6 Injury to the individual - no injury Describe steps taken to protect the individual from harm, including health assessment of care: Resident #6 was counseled by nurse to not hit others. Random Resident #2 Random Resident #2 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS with an ARD of 06/02/2022 revealed Random Resident #2 had a BIMS of 3 which indicated he had severe cognitive impairment. Review of the Incident/Accident log for Random Resident #2 revealed the following: Incident Date/Time: 07/11/2022 at 7:40 a.m. Alleged Victim: Random Resident #2 Investigation Details: Random Resident #2 was in the doorway of the day room when Resident #6 rammed Random Resident #2 with his walker. Allegations: Physical Abuse Alleged Perpetrator: Resident #6 Injury to the individual - no injury Describe steps taken to protect the individual from harm, including health assessment of care: Medication change and counseled by staff to not hit others. Resident #6 Resident #6 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)] Disorder, Intermittent Explosive Disorder, Other Impulse Disorder, Personal History of Traumatic Brain Injury, Hypertension, and [CONDITION(S)] Disorder. Review of the quarterly MDS with an ARD of 05/02/2022 revealed Resident #6 had a BIMS of 14 which indicated he was cognitively intact. Review of Resident #6's Care Plan revealed the following, in part: Problem: Violence, self-directed or directed at others 05/02/2022: Counseled on calling staff for help if another resident comes in his room, to not push others. 05/15/2022 Counseled to not push others and keep my hands to myself. 07/10/2022 Residents separated. Resident #6 sent to Hall B for cooling off period. Give [MEDICATION(S)] and Benadryl now for agitation. 07/11/2022 Medications changed, counseled by staff to not hit others. 07/16/2022 Counselled by staff to not push others and notify staff when there is a problem. Review of Resident #6's Psychiatric Physicians Report to court revealed the following, in part: Date and time of exam: 06/29/2022 at 10:30 a.m. On 01/20/2022, the social worker noted Resident #6 continued to have falls and was so rambunctious and could not slow down when his gait is not steady. The facility continued to try to keep him safe but he was defiant and headstrong to do what he wants. On 02/21/2022, he was caught taking food from a tray belonging to another resident. These behaviors were again noted on 02/28/2022, at which time he was specifically targeting residents with dementia. On 03/16/2022, the social worked noted that he remains belligerent and non-complaint to staff and others. On 05/15/2022, he reportedly, without preamble, walked by and slapped another resident and told him to go way. The LPN subsequently instructed Resident #6 to keep his hands to himself and he responded to this by calling the nurse a b****. Later that day, he was observed pushing another resident and demanded that this other resident get out of the day room. On 06/25/2022, staff found him grabbing food from another resident's tray and upon redirection, proceeded to try to enter another resident's room. After this he was found walking back in the resident's room and was overheard saying give me your tray to this other resident. Conclusion of Report: Resident #6 remained a danger to self and others. At this time he was on the waiting list equipped to manage individuals with psychiatric disorders and significant behavioral problems. An interview was conducted on 07/19/2022 at 1:00 p.m. with S10CNA. She said she provided care to Resident #2 and Resident #6. She said she was aware of an altercation that occurred between Resident #2 and Resident #6 on 07/16/2022. She said Resident #2 unintentionally took Resident #6's walker to his room. She said when Resident #6 realized his walker was gone, he went to look for it. She said Resident #6 found it in Resident #2's room, then Resident #6 pushed Resident #2 down and walked out of the room with his walker. She said Resident #2 was yelling help from the floor in his room. She said Resident #6 was aggressive with the other residents on the unit, and he goes into other resident rooms and attempts to fight them. She said he targets other males on the unit. She said he will hit and punch other residents for no reason. She said it was too many instances of aggressive behavior to count. She said Resident #2 was not a fighter and would not intentionally instigate a fight with another resident. She said Resident #6 was mobile with his walker, got around quickly, and it was hard to keep him in eye sight. She said there were no specific interventions in place to provide a safe environment for the residents while Resident #6 was on the unit. An interview was conducted on 07/19/2022 at 1:15 p.m. with S11CNA. She said she was aware of Resident #6's behaviors. She said Resident #6 often stole personal belongings and meals from other residents on the unit. She said he has hit other residents when he does not get what he wants. She said he was verbally and physically aggressive with other residents. She said he curses residents even when unprovoked. She said the residents on the unit attempt to stay away from Resident #6 because of his aggressive behavior. She said the facility had not initiated any specific interventions to keep the other residents safe from Resident #6. She said the staff attempted to watch Resident #6 closely because staff never know when he would hit a resident. She said she informed the nurse with each physical behavior from Resident #6. She said there were no specific interventions in place to protect the other residents from Resident #6. An interview was conducted on 07/19/2022 at 1:55 p.m. with S9RN. She said she was Building A's Supervisor. She stated Resident #6 was known for hitting other residents and stealing their belongings. She said Resident #6 had never had 1:1 care. She said most of the residents attempted to stay away from him because of his behaviors. An interview was conducted on 07/19/2022 at 2:41 p.m. with S12CNA. He stated Resident #6 was known for being aggressive. He stated administration didn't do anything to protect residents from Resident #6. He stated the nurses would report Resident #6's aggression to the supervisors, but no intervention was done. An interview was conducted on 07/20/2022 at 9:00 a.m. with S3SW. She said Resident #6 was difficult to redirect, short tempered, and aggressive. She said Resident #6 was placed on the secure unit to protect himself from falling because the unit was smaller and locked. She said his aggressive behaviors had progressively worsened, and the facility does not have the appropriate resources for his needs. She said he needed staffing supervision with eyes on him at all times. An interview was conducted on 07/20/2022 at 9:40 a.m. with S4LPN. She said on Hall A, the resident population was a mixture of residents with psychiatric and dementia diagnosis. She said she reported to administration it was not a good mix of residents. She said Resident #6 was aggressive and was known for hitting and stealing other resident's belongings. She said administration was aware of Resident #6's behaviors and all incidents that occurred with Resident #6. She said was aware of the incidents that occurred on 07/30/2021, 07/11/2022 and 07/16/2022. On 07/30/2022, Resident #6 pushed Resident #5 in the hallway. She stated after the incident, the residents were separated. Then Resident #6 found Resident #5 again and punched Resident #5 in the stomach. She said after the incident on 07/30/2021 Resident #6 was counseled on not hitting other residents. On 07/11/2022, she was passing medications and Resident #6 was leaned against the wall when Random Resident 2 walked into the day room and Resident #6 rammed him with his walker. She said she separated the two residents and Resident #6 was still attempting to ram him again with his walker and she had to intervene. She said on 07/16/2022, Resident #6 thought Resident #2 stole his walker. She said Resident #6 went into Resident #2's room and hit him. She said there were no specific interventions in place to ensure Resident #6 did not hurt other residents. She said Resident #6 needed constant redirection. She said he would benefit from one on one observation, but the facility never implemented it. She said the staff attempted to watch Resident #6 closely to ensure he did not hurt another resident. An interview was conducted on 07/20/2022 at 9:50 am, with S5LPN. She stated she was familiar with Resident #6 and he was aggressive with other residents on Hall A. She was concerned Resident #6 was going to hurt someone or himself. An interview was conducted on 07/20/2022 at 11:27 a.m. with S7MD. She said she was familiar with Resident #6 and he was aggressive with other residents on Hall A. She said the facility was not an appropriate facility to provide the supervision Resident #6 required. She said he needed one on one supervision, but they could not do that here at this facility due to lack of resources. An observation was conducted on 07/20/2022 at 11:45 a.m. Resident #6's room is at the end of the hall on the right side. The end of the hall is not visible from inside the nurse's station. An interview was conducted on 07/20/2022 at 11:45 a.m. with resident #6, all resident would say is you are pretty and sexy. An observation was conducted on 07/20/2022 at 12:45 p.m. Resident #6 walking down the hall toward his room. Resident #6 noted walking into another room. Staff went to redirect Resident #6 who was in another resident's money drawer. An interview was conducted on 07/21/2022 at 8:50 a.m. with S6CNA. He stated resident #6 was known for being a bully and aggressive to other residents, especially the dementia residents. He stated the dementia residents were not safe with him. An interview was conducted on 07/21/2022 at 9:30 a.m. with S8PMD. He said Resident #6 was a difficult resident to manage due to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He said this facility was not an appropriate facility for the necessary supervision needed for Resident #6. An interview was conducted on 07/20/2022 at 12:00 p.m. with S2DON. She stated Resident #6 was volatile and aggressive with other residents. She stated they had implemented multiple interventions to redirect him and stop the behavior, but nothing had helped. An interview was conducted with on 07/20/2022 at 1:35 p.m. with S1ADM. He stated at this facility, resident to resident altercations are not considered abuse. He stated he was aware of all the resident to resident altercations by Resident #6.

Based on observations, interviews, and record review, the facility failed to administered its resources effectively to ensure 4 (#2, #5, Random Resident #1, and Random Resident #2) out of 8 (#1, #2, #3, #4, #5, #6, Random Resident #1 and Random Resident #2 ) sampled residents reviewed were not physically abused by Resident #6. This deficient practice resulted in an Immediate Jeopardy situation for Resident #5 beginning on 05/02/2022 when the facility's administration failed to use its resources to protect the residents and prevent any further abuse. Resident #6 continued to be physically abusive towards cognitively impaired residents, #2, #5, Random Resident #1, and Random Resident #2 on 05/15/2022, 07/11/2022, and 07/16/2022. S1ADM and S2DON were notified of the Immediate Jeopardy on 07/20/2022 at 3:25 p.m. The Immediate Jeopardy was removed on 07/21/2022 at 4:30 p.m. when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following had been initiated and/or implemented prior to exit. The Immediate Jeopardy Plan of Removal included the following: The facility shall ensure that all residents in Hall A shall be free from abuse and neglect, specifically pertaining to resident #6 as identified through State Agency complaint survey initiated on 07/18/2022. All clinical staff (in house and Agency) have been in-serviced upon the requirements of One on One staffing of resident #6. Observation checklist have been assigned to supervising staff member for completion to ensure compliance. No staff shall be allowed to work on this unit until education and in-servicing is complete. -Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the non-compliance. -All residents on Hall A have the potential to be adversely affected by the behaviors and actions of resident #6. -Specify actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring. -Clinical staff has been assigned direct supervision (1 on 1) on Resident #6 to ensure that all residents on Hall A are free from abuse -All staff working on current shift(s) AM/PM have been in-service on 1:1 observation on 07/20/2022. -MD was consulted and order for 1:1 was received on 07/20/2022. -Include a date by which the entity asserts the likelihood for serious harm to any recipient no longer exist. -Direct supervision of Resident #6 was ordered on 07/20/2022. Direct supervision will remain indefinitely -All staff assigned to Hall A shall have education and in-servicing on abuse and neglect completed by Monday 07/25/2022. -CNAs will document resident on 1:1 every 15 minutes; Managers shall monitor documentation every shift; documentation shall be turned in daily to nursing services. Any incident report involving a 1:1 resident shall be reviewed to ensure that 1:1 is working. DON will complete a quality assurance report for August reviewing the data and this will continue indefinitely beginning 07/20/2022. -The facility will continue to follow State Agency abuse and neglect policy; the facility's abuse and neglect policy to be reviewed and updated per State Agency deputy assistant secretary or designee. -All administrative personnel shall be in-serviced on abuse and neglect policy by 07/21/2022. -Resident #6 will remain on 1:1 until alternate placement is found. The deficient practice had the potential for more than minimal harm for the other 20 residents residing on Hall A. Findings: Cross Reference F600 Review of the facility's policy entitled Abuse-Prevention and Prohibition Policy and Procedure included, in part: Purpose: It is the policy of the facility to prohibit the abuse, neglect, exploitation or extortion of patients/residents. III. Prevention Policy and Procedures: Statement of Policy: The facility is committed to preserving the right of each person receiving services to be free from abuse. All forms of abuse of residents of the facility are prohibited. While definitions and examples of abuse are provided in this policy, it must be understood that all possible situations cannot be anticipated and each case must be evaluated based on the particular facts available. Examples of Abuse: -Physical Abuse: Physical contact such as hitting, slapping, pinching, kicking, choking, scratching, pushing, twisting of head, arms, and legs, tripping; the use of physical force which is unnecessary or excessive; and inappropriate or unauthorized use of restraint. Procedure to report abuse/neglect: -Duties of the Administrator: the administrator, or designee, shall direct the client rights officer, or designee, to notify the Adult Protective Services of the allegation and administrative action that has been ordered. Investigation of incidents and allegations: -All allegations of abuse and neglect will be investigated by a designated investigator who has been trained and certified by Adult Protection Services to conducted investigations. Review of the Incident/Accident log for Resident #5 revealed the following: Incident Date/Time: 07/30/2021 at 2:25 p.m. Alleged Victim: Resident #5 Investigation Details: Resident #5 was standing in front of nurses' station when Resident #6 walked up hollering and pushed Resident #5 into the wall. Resident #6 then pushed Resident #5 across hallway into linen door. Allegations: Physical Abuse Alleged Perpetrator: Resident #6 Injury to the individual- no injuries Describe steps taken to protect the individual from harm, including health assessment of care: Both residents were separated, Resident #6 was counseled by staff. Review of the Incident/Accident log for Resident #5 revealed the following: Incident Date/Time: 07/30/2021 at 2:32 p.m. Alleged Victim: Resident #5 Investigation Details: Resident #6 was walking down hall and punched Resident #5 in the stomach and continued hollering at him. Allegations: Physical Abuse Alleged Perpetrator: Resident #6 Injury to the individual- no injuries Describe steps taken to protect the individual from harm, including health assessment of care: Both residents were separated, Resident #6 was counseled by staff. Review of the Incident/Accident log for Resident #5 revealed the following: Incident Date/Time: 05/02/2022 at 11:23 a.m. Alleged Victim: Resident #5 Investigation Details: Resident #5 was standing in the doorway of Resident #6's room when Resident #6 pushed this resident into hallway forcefully. Allegations: Physical Abuse Alleged Perpetrator: Resident #6 Injury to the individual- no injuries Describe steps taken to protect the individual from harm, including health assessment of care: Resident #6 was counseled on calling staff for help when another resident is in his room and to not push others. Review of the Incident/Accident log for Random Resident #1 revealed the following: Incident Date/Time: 05/15/2022 at 8:20 a.m. Alleged Victim: Random Resident #1 Investigation Details: Random Resident #1 was standing in hallway by dining room door when Resident #6 walked by and slapped his left arm and told him to go away. Allegations: Physical Abuse Alleged Perpetrator: Resident #6 Injury to the individual - no injury Describe steps taken to protect the individual from harm, including health assessment of care: Resident #6 was counseled by nurse to not hit others. Review of the Incident/Accident log for Resident #5 revealed the following: Incident Date/Time: 05/15/2022 at 11:50 a.m. Alleged Victim: Resident #5 Investigation Details: Resident #5 was standing in hallway when Resident #6 leaned into Resident #5 with his shoulder and pushed him across hallway. Resident #5 caught himself on the wall and did not fall Allegations: Physical Abuse Alleged Perpetrator: Resident #6 Injury to the individual- no injuries Describe steps taken to protect the individual from harm, including health assessment of care: Resident #6 was counseled by staff on not hitting other residents and was redirected away from other residents. Review of the Incident/Accident log for Random Resident #2 revealed the following: Incident Date/Time: 07/11/2022 at 7:40 a.m. Alleged Victim: Random Resident #2 Investigation Details: Random Resident #2 was in the doorway of the day room when Resident #6 rammed Random Resident #2 with his walker. Allegations: Physical Abuse Alleged Perpetrator: Resident #6 Injury to the individual - no injury Describe steps taken to protect the individual from harm, including health assessment of care: Medication change and counseled by staff to not hit others. Review of the Incident/Accident log for Resident #2 revealed the following: Incident Date/Time: 07/16/2022 at 3:15 p.m. Alleged Victim: Resident #2 Investigation Details: Resident #2 stated Resident #6 attacked him in his room and pushed him to the floor. Resident #2 doesn't recall having other resident's walker. Allegations: Physical Abuse Alleged Perpetrator: Resident #6 Injury to the individual- no injuries Describe steps taken to protect the individual from harm, including health assessment of care: Counseled by staff to not push others and notify staff when there is a problem An interview was conducted on 07/20/2022 at 11:27 a.m. with S7MD. She said she was familiar with Resident #6, and he was aggressive with other residents on Hall A. She said the facility was not an appropriate facility to provide the supervision Resident #6 required. She said he needed one on one supervision, but they could not do that here at this facility due to lack of resources. An interview was conducted on 07/20/2022 at 12:00 p.m. with S2DON. She stated Resident #6 is volatile and aggressive with other residents. She stated they have implemented multiple interventions to redirect him and stop the behavior, but nothing has helped. An interview was conducted with on 07/20/2022 at 1:35 p.m. with S1ADM. He stated at this facility, resident to resident altercations are not considered abuse and do not have to be reported to the state. He stated they only report abuse when it is staff to resident. He stated he was aware of the all resident to resident altercations by Resident #6.

Based on observations, interviews, and record review, the facility failed to ensure residents were free of accident hazards and received adequate supervision by: 1. Failing to implement an effective system to assess adjustable headboards and footboards or areas of entrapment for 1 (#15) of 5 (#15, #47, #74, #120, #142) residents reviewed for accident hazards; 2. Failing to educate staff on assessing and monitoring residents to prevent entrapment by headboard, bed frame, and mattress for 1 (#15) of 5 (#15, #47, #74, #120, #142) residents reviewed for accident hazards. 3. Failing to ensure adequate supervision was provided to prevent a resident, with wandering behaviors, from exiting the building unsupervised for 1 (#67) of 1 resident(s) investigated as a risk for wandering. This deficient practice resulted in an Immediate Jeopardy for Resident #15, a nonverbal cognitively impaired resident, on 10/28/2021 at 4:45 a.m. when S35CNA found her trapped between the bed frame and headboard of her bed. Resident #15 was lying prone, partially in bed, with her head and upper body wedged between the headboard and bed frame and both arms pinned behind her back. It took four staff members approximately 20 minutes to free the resident. Resident #15 was sent to a local emergency roiagnom on [DATE] where she was found to have multiple abrasions on her head, arms, and back. Administration was notified of the Immediate Jeopardy on 11/08/2021 at 3:30 p.m. The Immediate Jeopardy was removed on 11/09/2021 at 1:30 p.m., when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following had been initiated and/or implemented prior to exit. The Immediate Jeopardy Plan of removal included: In-services - All clinical staff will be in-serviced regarding bed safety and entrapment risk (see attached for details) - In-services commenced 11/08/2021 at approximately 3:45 p.m. and shall be completed by 6:30p.m. on 11/10/2021. Attachment A Clinical Supervisors over each team have conducted and will continue to conduct mandatory in-servicing to all clinical staff. Registered Nurse Supervisors have been educated on entrapment risk and bed safety. Director of Nursing shall be responsible for collection and review of in-service sign in sheet to ensure all clinical staff have been educated. Additional bed safety education will be added to the annual education modules to ensure competency and knowledge of the skill set. Admissions Checklist - Bed assessment has been added to the admissions checklist to help identify all bed equipment is functioning properly and adjust according to the patient's needs. Completed. Attachment B Checklist will be implemented immediately. All admits and readmits shall have the checklist completed upon admission. Director of Nursing will review all admissions checklist monthly to ensure bed safety assessments were completed as part of admissions checklist. Attached is a bed assessment made by Maintenance staff to ensure that all resident beds are functioning and in the appropriate position. Completed. Attachment C Safety Task Force staff have been in serviced on the addition to bed risk and entrapment risk. All safety task force shall complete training by 11/19/2021. Safety Risk Manager will be responsible for collecting monthly STF completion documentation. Safety Risk Manager will be responsible for reporting any repairs or replacements to Maintenance Supervisor within 24 hours. Routine bed safety assessments have been added to the Safety Task Force (STF) rounds to ensure continued compliance. Completed. Attachment D Bed assessment rounds were completed on 11/08/2021. Rounds shall be completed weekly until Plan of Correction is accepted by state agency, additional and permanent monitoring will be dictated by Plan of Correction. All bed owner's manual will be reviewed by maintenance staff to ensure proper understanding of bed mechanics and safety precautions. Maintenance Supervisor shall review and be responsible for keeping documentation to ensure audits are completed timely and repairs/replacements are made timely. Findings: Resident #15 Review of the manufacturer's manual for the type of bed Resident #15 used revealed, in part: Entrapment Warning: Reducing the risk of entrapment. Proper patient assessment and monitoring, along with proper maintenance and use of the hospital bed system is required to reduce the risk of entrapment. The term hospital bed system encompasses the bed frame and its components, including the mattress, side rails, head and footboards and accessories to the bed. Variations in bed rail dimensions and mattress thickness, size and /or density could increase the risk of entrapment. Review of the facility's Bed Safety Policy revealed the following, in part: 2. Purpose To provide a safe sleeping environment for all residents 4. Policy The residents sleeping environment shall be assessed by the interdisciplinary team, considering the residents safety, medical conditions, comfort, and freedom of movement as well as input from the resident and family regarding previous sleeping habits and bed environment to try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks. c. Ensure .other pertinent safety guidance to ensure proper fit (e.g., ensure proper distance from the headboard and footboard, etc.). d. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.). f. The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury including entrapment. Review of Resident #15's Medical Record revealed she was a [AGE] year old cognitively impaired female admitted to the facility on [DATE]. She had diagnoses, which included Other [CONDITION(S)] without Behavior Disturbance, [CONDITION(S)], Anxiety Disorder, [CONDITION(S)] Disorder, Inhalant Abuse, and Dysphasia. Further review revealed the resident's most recent weight and height were 104.6 pounds and 64 inches. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/03/2021 revealed Resident #15 had a Brief Intervention for Mental Status (BIMS) of 09, which indicated she was moderately cognitively impaired. She required assistance with bed mobility and transfer. Review of the Incident Report for Resident #15 revealed: 10/28/2021 at 4:45 a.m. Resident activity - Accident Description of Incident: Resident #15 was stuck between head of bed and metal frame. Her upper and lower body was lodged and the frame was broken or malfunctioned. Resident had to be worked loose from being stuck. Assessment - patient had numerous abrasions over body, upper and lower extremities. Abrasion on right forehead area and back with redness. Signature - S34LPN Review of Resident #15's Nurses' Notes revealed: 10/28/2021 at 5:25 a.m. At 5:45 a.m., Resident #15 was discovered in her room lodged between the headboard and metal frame of the bed, upside down with her body pressing against the metal frame with the side of her head lying on floor. S22MD at 5:15 a.m. gave an order to send Resident #15 to a local hospital for evaluation and rule out fracture. Resident #15's left upper arm with redness, right upper arm across midsection with mild abrasion, on her backside a red mark from the metal frame pressing on that area while trying to free her from getting lodged and bilateral legs was also red with abrasion. Right forearm red and around waistline. S34LPN Review of the physician's orders for Resident #15 revealed: 10/29/2021 at 5:15 a.m. Okay to send to local emergency room for evaluation to rule out fracture. Telephone order: S22MD/S38RN Review of the Hospital Record for Resident #15 revealed: 10/28/2021 Diagnoses: Fall, Multiple abrasions History: Chief Complaint - Patient presents with fall- Patient found between mattress and headboard at nursing home. Abrasion noted to forehead. Patient is nonverbal. She has an abrasion on her left arm, right forehead, and left lower leg. Review of Resident #15's care plan revealed: Problem Onset of 10/28/2021 Found stuck between the head of bed and frame- Multiple abrasions over body, upper and lower extremities, abrasions on forehead, redness to back. Goal Target Date - 12/29/2021 Will not have further incident of being between head of bed and frame. Approaches - Monitor for changes in level of consciousness and notify medical doctor. Keep bed low and locked. An interview was conducted on 11/05/2021 at 9:35 a.m. with S32ED. He reviewed the Maintenance Log for October 2021 and verified there were no entries for bed repairs for Resident #15. An observation was made on 11/03/2021 at 9:20 a.m. of Resident #15. She was nonverbal. She had a quarter-sized scab on the right side of her forehead. She had two ½ to 1 inch linear scabbed [CONDITION(S)] on her left anterior, lower leg. A telephone interview was conducted on 11/04/2021 at 5:34 p.m. with S34LPN. He confirmed he worked at the facility on 10/28/2021 when Resident #15 was found lodged between her headboard and bed frame. He said he was called to Resident #15's room at approximately 4:45 a.m. by S33CNA. He said when he entered the room he observed Resident #15 looking like a human pretzel. He explained Resident #15 was stuck between the headboard and mattress by her waist with her head underneath the bedframe, face lying on floor, and her bottom up in the air. He said the resident's arms were pinned behind her between the frame and mattress. He said each time they would try to dislodge the resident by pushing or pulling, her arms would get stuck behind her and prevent them from freeing her. He said it took him and three other staff, S33CNA, S35CNA, and S39CNAS, grabbing and pulling Resident #15's body for 20 minutes or more to get her dislodged from the bed. He said Resident #15 was nonverbal and only grunted a couple of times during the incident. He said once she was removed she was transferred to the emergency room for assessment. He said the space between the headboard and the bed frame was about the width of a pillow, 2 feet or less. He said S5ADM and S32ED fixed Resident #15's bed that same morning, but he was never informed of what happened to the bed for the space to be that large. He said he had not received training since the incident regarding assessing residents for entrapment risk or bed safety. He denied having any new responsibilities in place to ensure the resident's beds were free from areas of entrapment. An interview was conducted on 11/05/2021 at 9:35 a.m. with S41MM and S32ED. Both confirmed being aware of the incident on 10/28/2021 when Resident #15 got wedged between the headboard and bed frame. S32ED said he observed the bed after Resident #15 was removed and noticed the headboard was extended all the way out from the bedframe. He explained some of the beds in the facility were adjustable and the headboard and footboard would extend out from the frame. He said he adjusted the bed by pushing the headboard back into the frame and showed S5ADM how to do the same. Both S41MM and S32ED said the Maintenance department checked the beds upon admission or bed change to ensure the functionality of the bed was in order, but the nurses were responsible for routinely checking to ensure residents' mattresses fit the beds, and there were no large spaces for entrapment. Both S41MM and S32ED said after the incident, they checked all of the beds to make sure no other beds were extended out or had large spaces. A telephone interview was conducted on 11/05/2021 at 11:34 a.m. with S33CNA. She confirmed she worked on 10/28/2021 when Resident #15 was found stuck between the headboard and bed frame of her bed. She said when she entered Resident #15's room she saw her head down under the bedframe and her butt up in the air. She explained the resident's body had gone through the space between the bedframe and the headboard. She said there was a space about the size of a 12-inch ruler between the head of the bed and the mattress. She said she thought the resident's bed had malfunctioned causing the space. She said she was not responsible for checking beds, headboards, or mattresses for possible areas of entrapment. She said she had not received training on large spaces in the bed or adjusting headboards and footboards since 10/28/2021. She said she had not been instructed to begin looking at any of the residents beds for possible areas of entrapment since the incident occurred. A telephone interview was conducted on 11/05/2021 at 12:42 p.m. with S35CNA. She confirmed she was working when Resident #15 on 10/28/2021 when the resident was found stuck between the headboard and bed frame. She said at approximately 4:45 a.m., she entered Resident #15's room and saw Resident #15's head underneath the bedframe and body stuck between the headboard and bedframe by her waist. She stated she was not sure how long Resident #15 was entrapped in the bed before she found her. She said it took four staff including herself, S33CNA, S39CNAS, and S34LPN to dislodge the resident. S35CNA said Resident #15 was usually nonverbal. She described the resident as nervous and shook up during the incident. S35CNA said Resident #15 had bruises on her leg and arm. She explained the space between the headboard and bed frame was about the size of a 12-inch ruler and had been present for at least 2 months. She said she reported the space to S51CNA multiple times during a shift change since she began working at the facility. She said she would put a wedge between the bedframe and headboard to fill the space. She said she did not know the headboard and footboard was adjustable on the bed. She said she had not been trained on bed safety or monitoring for unsafe spaces in the beds since the incident on 10/28/2021. She said she was not responsible for making sure the bed mattress and headboard did not have areas the residents could become entrapped in. A telephone interview was conducted on 11/05/2021 at 2:14 p.m. with S38RN. She confirmed she was working on 10/28/2021 when Resident #15 was found stuck in her bed. She explained she was called to the unit by the S34LPN requesting assistance because Resident #15 was stuck between the bed frame and the headboard. She said Resident #15 was observed to be wedged between the bed frame and headboard bent in a prone position with her upper torso down, face touching the floor, buttocks up in the bed, and arms bent under her. She said she left the room to call the local ambulance and the doctor to request help for Resident #15 .She said S34LPN said it took him, S33CNA, S35CNA, and S39CNAS to get Resident #15 unstuck. She said Resident #15 was unable to express herself, but appeared distraught and startled after she was removed from the bed. She said Resident #15 had multiple areas of redness and abrasions on her waist and arms. She said the resident had a bad abrasion, open like a laceration, to her left forearm. She said she had requested the bed be removed so the incident would not happen again. She said maintenance was responsible for making sure the beds were compatible with the different parts and safe. She denied being aware the headboard and footboard on Resident #15's bed was adjustable. She said she had not received training on how to check or monitor the beds to make sure a resident could not become entrapped. A telephone interview was conducted on 11/05/2021 at 2:34 p.m. with S39CNAS. He confirmed he worked on 10/28/2021 when Resident #15 was found stuck between the headboard and bed frame. He said he received a phone call from a CNA reporting an emergency in Building A, Hall 3 He said when he arrived he observed Resident #15 lodged in a 12 -13 inch-space between the headboard and bed frame. He explained S34LPN was pushing Resident #15's upper torso, and he and S35CNA were pulling on her bottom trying to get her dislodged. S39CNAS said Resident #15 had a small abrasion above her eyebrow. He said he had not received any training on monitoring or checking the beds or adjusting the headboard to prevent entrapment of a resident. An interview was conducted on 11/05/2021 at 10:45 a.m. with S36LPN. She said she had not received training on assessing beds for areas of entrapment since 10/28/2021. An interview was conducted on 11/05/2021 at 1:23 p.m. with S37RN. He said the nurses were responsible for assessing beds for areas of entrapment. He said no training or monitoring had been provided to nurses or staff on how to assess and monitor beds for areas of entrapment. An observation was made on 11/05/2021 at 1:28 p.m. of Resident #15's bed with S41MM and S32ED present. Both staff manually extended the headboard of the resident's bed outward the full amount from the bed frame to observe the space. S32ED confirmed when extended fully there was an 8-inch space between the bed frame and the headboard. S32ED said the facility would extend the headboard or footboard to accommodate a resident's height. S32ED confirmed Resident #15's bed was fully extended when he arrived to the facility on [DATE]. An interview was conducted on 11/08/2021 at 10:55 a.m. with S5ADM and S20DON. S5ADM confirmed on 10/28/2021 Resident #15 was found stuck between her bed and headboard. He said Resident #15 was able to become entrapped because the headboard was extended, which made a gap between the bed and headboard. He said the facility was not sure how long the space between the headboard and bed frame was present prior to the incident. S5ADM and S20DON said maintenance assessed all beds in the facility on 10/28/2021 to ensure no other beds were in the same position with the headboard extended out. An interview was conducted on 11/08/2021 at 11:47 a.m. with S20DON. She explained she had not trained nursing staff to assess or monitor the resident's beds for areas of entrapment. S20DON verified training the staff to assess the residents beds for areas of entrapment could prevent residents from becoming entrapped between the headboard and bed frame. She further confirmed the facility should have trained the staff. She explained the Safety Task Force, which consisted of an interdisciplinary team from the facility, would check rooms and beds once a week. She clarified the Safety Task Force only checked beds on about one hall each week. She said each bed was checked about once every 8 weeks. She confirmed the facility did not implement interventions to check the beds for areas of entrapment since the incident on 10/28/2021. An observation was made on 11/08/2021 at 1:30 p.m. of Building B, Hall 3, Room A There were three beds in the room. One bed with the footboard facing the entry/exit door was observed to have the headboard extended outward with an 8 space between the frame and the headboard. An interview was conducted on 11/08/2021 at 1:33 p.m. with S52LPN. She confirmed the beds in Room A were currently unoccupied, but the beds could be used if there was an admission. An observation on 11/08/2021 at 2:15 p.m. of Building B, Hall 3, Room A with S41MM and S32ED. S32ED confirmed the bed with the footboard facing the entrance/exit door had the headboard fully extended outward from the bed frame 8 inches. He said he adjusted the headboard inwards within the last 10 minutes. He confirmed the bed had not been adjusted after 10/28/2021 or prior to the surveyor's observation at 1:30 p.m. He said he did not understand why it mattered because the nursing staff were supposed to check the beds for safety prior to a resident being placed in it. S41MM provided a list of the total number of 56 adjustable beds in the facility on 11/09/2021 at approximately 2:00 p.m. He confirmed there were total 56 beds with the capability of extending the headboard or footboard from the bed frame. Resident #67 Review of the facility's Wander Guard Policy revealed, in part, the following: Purpose: The Wander Guard System is intended to provide a protective measure for residents displaying a pattern of wandering. Wandering is defined as a resident identified by the treatment team as straying into unsafe territories with the potential for harm. In no circumstance should a resident be assigned a Wander Guard bracelet as a punitive measure. The Wander Guard system is intended to provide a safety measure for residents who have been identified as wanderers; it will provide back-up system to alert staff when a wanderer attempts to exit a building. The alarm alerts staff that a resident may be in need of extra guidance or security. The system will be used to help each resident achieve and maintain his highest functional level in a safe manner. SCOPE: All wards on Building A at the facility. PROCEDURE: 1. Requirements: a. The treatment team has identified a resident as a wanderer and a candidate for the Wander Guard. b. A resident or their guardian must participate in the decision to place the resident in the Wander Guard system. c. Documentation ensuring the resident his/her family and/or his/her legal guardian has been provided information on the Wander Guard system. d. Care plans must address the reasons for the resident being placed on the system, and how the facility is meeting the resident's needs and concerns. e. All residents will participate in social and recreational activities appropriate to their individual needs. 2. Care and Supervision: a. Once the wander guard system requirements have been met for a resident the Unit Nursing Staff will be responsible for; attaching the bracelet, helping the resident understand limitations, monitoring the operation of the bracelet and ensuring the bracelet stays dry and secure. b. Once the bracelet is secured the system will be monitored by each nursing. c. Nursing will check the resident's wander guard bracelet each shift to ensure the bracelet is secure and not causing discomfort. Check will be documented. d. When an alarm is activated by the system the monitoring station monitor on the wall will be reviewed to identify what door is activated. All staff are to assist in finding and redirecting the resident. e. Nursing staff will reset the alarm once the resident is identified and located. Review of the Medical Record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses that included Paranoid [CONDITION(S)], Anxiety, [CONDITION(S)] Disorder, [CONDITION(S)], Delusional Disorders, [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. Review of the most recent Quarterly MDS with an Assessment Reference Date 08/23/2021 revealed Resident #67 had a Brief Interview of Mental Status (BIMS) score of 8, which indicated he was moderately impaired cognitively. He was assessed as ambulatory and able to walk around his unit of the facility independently. He was identified as a Wanderer with a risk of getting into dangerous places with this behavior occurring 1 to 3 days per week. Resident #67 was identified as requiring a wander/elopement alarm daily. Review of the most recent Care Plan for Resident #67 revealed the following, in part: PROBLEM /NEED: ONSET DATE: 09/05/2017. GOAL TARGET DATE: None identified. APPROACH: Be aware of where I am every 30 minutes per routine care. I have wandered and rummaged since admit. PROBLEM /NEED: I need to participate in activities to promote my social skills and social well-being. ONSET DATE: 08/31/2021. GOAL TARGET DATE: None identified. APPROACH: I am at risk for wandering, be aware of my whereabouts. PROBLEM /NEED: I have a potential for injury due to some of my medications for [CONDITION(S)], Anxiety, [CONDITION(S)] Disorder and I have a history of wandering/going to the gate. ONSET DATE: 08/31/2021. GOAL TARGET DATE: None identified. APPROACH: 1.) I need a Wander Guard. Check bracelet every shift to ensure functioning and in place. When an alarm is activated, identify if I have went out the door and redirect back to unit, then reset the alarm. 2.) I need staff to watch for signs/symptoms of escalating behavior, including wandering. Document behaviors in Nurse Notes. 3.) I need activities to provide me with outside activities; such as riding the golf carts, walks, etc. Review of Resident #67's Physician's Orders revealed the following order dated 04/23/2019: Wander Guard - Check bracelet every shift to ensure functioning and in place. When an alarm is activated, identify if resident went out the door and redirect back to unit then reset the alarm. Signed by S22MD Review of Resident #67's May 2021 to November 2021 Medication Administration Record/Treatment Administration Record revealed the following: 1. Observe for Behaviors including Wandering. Indicated behaviors should be documented in Nurse Notes, ordered 08/13/2017 by S22MD. 2. Wander Guard. Check bracelet every shift to ensure functioning and in place. When alarm is activated, identify if resident went out the door and redirect back to unit then reset the alarm, ordered 04/23/2021 by S22MD. Review of the Incident Reports from August 2021 through November 2021 for Resident #67 revealed the following, in part: 08/23/2021: Resident found sitting outside under breezeway in front of Building A. Resident denied falling or hurting self. No injuries noted. Resident stated I just want to sit outside. Refused to come inside until lunch. Assessment: No apparent injury noted. Wander Guard intact and alarms when exiting building. 09/12/2021: Attempted Elopement. RN Supervisor was called by the Front Gate and alerted to a resident at the gate. RN Supervisor brought resident back to building. Resident stated I was just going outside. Assessment: No injuries noted. 10/26/2021: Gate called reporting resident had walked to the gate. Alarm did not go off. Wander Guard is on right wrist. Resident returned to unit with staff escort. Assessment: Resident denies any pain. He stated, I want to walk out the gate. I am a Federal Prisoner. I need to go to jail. Review of the Psychologist's Progress Notes for Resident #67 revealed the following: 08/23/2021 at 05:05 p.m. - Provided supportive services to resident today and reviewed rules associated with Wander Guard, which is likely minimally useful due to mental status impairment. Resident with delayed processing speed, unable to recall lunch or date and losing track in conversation despite polite and courteous interaction. Was able to state that the bracelet goes off when he crosses certain boundaries and able to recall this writer's name. Constricted affect with wandering reported by staff on today. Signed by S42MDphD 10/08/2021 at 01:33 p.m. - On 10/05/2021, LPN noted resident wandered on three separate occasions. Also indicated resident wandering significantly increased over the last month. Signed by S42MDphD 10/18/2021 at 08:32 a.m. - Resident continues to walk to the gate voicing the delusion that someone is waiting for him. This is a distinct and notable change in behavior with increased vocalization of delusional content and subsequent elopement attempts/wandering. Resident also has substantial cognitive impairment and apathy. Staff should continue to closely monitor resident and provide encouragement and redirection as needed. Signed by S42MDphD Review of the Social Service Progress notes for Resident #67, dated 09/10/2021, revealed, in part, the following: Resident recently tried to elope and was placed on the secure unit for a short time. Signed by S46SS Review of the Nurse Notes for Resident #67 revealed the following, in part: 10/05/2021 - Resident attempted to and/or successfully left the unit 3 times during the day shift. Signed by S45LPN 10/13/2021 at 4:16 p.m. - Resident has repeatedly exited the building attempting to walk to the front gate. He believes someone is waiting for him at the gate. Although we have explained there is no one waiting for him, he continues to make his way to the front gate. Signed by S44RN 10/26/2021 at 05:49 p.m. - Resident walked off unit at 4:45 p.m. today and was returned to his room. At 5:20, gate called reporting resident had walked to gate. The Wander Guard alarm did not go off. Signed by S43RN 11/03/2021 at 10:45 a.m. - Received a call from S46SS, stating that patient was at gate and was going to be escorted back to unit by herself. Wander Guard did not alarm. Patient returned to room. Signed by S15LPN Review of the alarm company's Work Order/Ticket, dated November 03, 2021, indicated technicians were sent out due to reports of Wander Guard in Building A not working. Further review of the ticket revealed sensitivity issues and tag detector issues. On 11/03/2021 at 10:37 a.m., an observation was made of Resident #67 walking across the grounds from Building A to the security gate at the front entrance of the facility grounds. Resident was stopped at the gate by a security guard and S46SS. S46SS then escorted Resident #67 back to Building A, Hall 1. The distance from the front gate to Building A is estimated to be roughly a half a mile. On 11/03/2021 at 12:05 p.m., an interview was conducted with S47CNA. She stated Resident #67 woke up wanting to go see/meet a family member this morning; and since then, he has been determined to do just that. She stated the resident has episodes, at times, where he attempts to leave every few minutes for a day or so and the alarm will sound constantly. On 11/04/2021 at 8:20 a.m., an interview was conducted with S46SS. She stated she escorted Resident #67 back to his unit after she saw him at the security gate on 11/03/2021. She stated Resident #67 was not supposed to be out of his building by himself. She was in her car at the gate and saw Resident #67 approach the security desk/gate. She stated Resident #67 had a Wander Guard in place to his wrist. She stated the facility had been having issues with the Wander Guard system not functioning properly. She verified Resident #67 had the Wander Guard in use because he was not safe to leave the unit by himself. On 11/05/2021 at 9:00 a.m., an interview was conducted with S43RN. She confirmed she worked with Resident #67 on a regular basis. She stated they had been having ongoing issues with the Wander Guard system for some time now. She stated they recently received a new system within the past few months and they continue to have difficulties with the sensitivity of the sensors. She stated Resident #67 figured out how to beat the system. She said he would position himself so the bracelet was out of reach of the sensor and he could exit the doorway without the sensor picking it up. She stated resident #67 has made continued attempts to exit the unit/building for quite some time and frequently set the alarm off throughout every shift she has been present for. She stated staff had made their supervisors aware of the concerns/issues and knows the contracted company for Wander Guard had been out to work on the system several times but it was still an issue. She stated the unit nurse was supposed to check the resident at least once per shift to confirm the Wander Guard bracelet was in place and functioning, as it should b [TRUNCATED]

Based on observations, interviews and record reviews, the facility failed to ensure a resident's right to be free from neglect for 1 (Resident #1) of 6 (Residents #1, #2, #3, #4, #5, #6 ) sampled residents. This was evidenced by the facility's failure to: 1. Protect a resident who was incapable of protecting herself from injury when observed in self-injurious behaviors, 2. Ensure staff assessed and provided medical care immediately when the resident was noted to have sustained injuries after being found on the floor. This failed practice resulted in an Immediate Jeopardy situation on 08/22/18 at 5:00 a.m. when Resident #1 was observed by staff on the floor yelling and hitting her head on the floor and wall. She was bleeding from her face and the back of her head. During this period of time, several staff members walked past the resident. There was no staff assistance or intervention provided. The resident remained on the floor without assistance yelling and hitting her head on the wall and floor until 5:57 a.m. S1ADM was notified of the Immediate Jeopardy on 09/17/18 at 5:45 p.m. The Immediate Jeopardy was removed on 09/17/2018 at 7:00 p.m. when the facility submitted an Immediate Jeopardy Plan of Removal which included the following: 1. Resident #1 was affected by this cited deficient practice. 2. Residents in the facility who exhibit impulsive/behavioral disorders have the potential to be affected by this deficient practice. Measures put in place, see #3. 3. S9LPN was found to have failed to provide care and neglected Resident #1. She has been placed on administrative leave pending dismissal from VFMC. She will be reported to the LPN board. Placed on Administrative leave 09-17-2018. Human Resources is preparing pre-disciplinary letter for legal's review, anticipated date of review 09-21-2018. Although S17CNA provided care for Resident #1, she left her crawling on the floor with the potential of further harming herself and never offered assistance. S17CNA neglected Resident #1 to the point of possible injury. S17CNA has been placed on administrative leave pending reception of her dismissal letter. VFMC will provide any documentation requested by the CNA Registry for evaluation of loss of CNA certification. Placed on Administrative leave 09-14-2018. S13CNA came to assist the Resident, but left her standing while she retrieved the Geri-chair. This left Resident #1 vulnerable to injury. S13CNA has been placed on administrative leave pending further investigation. Placed on administrative leave 09-14-2018. S8LPN, who was a float nurse at the time of the incident, walked past Resident #1 numerous times as the Resident crawled on the floor. S8LPN was moved to another unit after this incident, until further investigation, and on 09-17-2018, was placed on administrative leave pending further disciplinary action. Placed on Administrative leave 09-17-2018. S5RNM was a witness to Resident #1 lying and sitting on the floor. S5RNM called the Night Nurse Manager to come assist the Resident. S5RNM looked at Resident #1 to assess, but failed to remove the Resident from the floor. S5RNM was placed on administrative leave on 09-17-2018, pending further investigation. Placed on Administrative leave 09-17-2018. The facility began in-service training on 08/29/2018. Training will continue on the care of the Resident until 100% of nursing staff are trained. All training will be completed by 09-27-2018. Training will be incorporated in orientation for all new staff. Training will involve Abuse and Neglect and reporting and handling resident incidents. Nursing Administration and Staff Education and training will provide the in-service training. Training will be oral, written, computer based and test will be administered for competency. Training will be monitored through review of incidents on a daily basis indefinitely. Passing score for competency exam is 80%. Resident #1 has [DIAGNOSES REDACTED]. She has impulsive nature, is easily agitated and uncooperative. She has a difficult [DIAGNOSES REDACTED].#1's room was updated to include additional padding: padding for areas that were exposed and that could cause harm from flailing and thrashing. A wall and door were added to enclose the area of her bed and padding was added to both, an additional helmet was obtained for the Resident on 08/30/18 and placed on Resident for safety and protection as allowed and appropriate. The investigation of this incident is on-going. 4. On 09-19-2018 a copy of the Incident Investigation Checklist form with instructions will be e-mailed to Nurse Managers. Nurse Managers will review and sign off on Incident Reports on a daily basis. For any Incident Report involving a cognitively impaired resident, the Nurse Manager will fill out an Incident Investigation Checklist form and attach to the Incident Report. The Incident Report and Incident Investigation Checklist form will be reviewed by the Quality Assurance Manager on a daily basis and any issues of concern will be reviewed with appropriate department heads to ensure the safety and security of residents is maintained. If deemed appropriate, 2 members of the administrative staff will review facility camera footage. Effective 09-19-2018 until re-evaluated (MONTH) 2019. Effective 09-19-2018. Nursing Administration will review the 24 hour report on a daily basis. Nursing administration will meet with Day Shift Nurse Managers Monday-Friday to discuss issues/concerns and complaints. Immediate corrections will be made to issues of concern arising from Managers and verified through monitoring of camera system. Administration will track the progress of the disciplinary process to ensure the employees that received disciplinary letters are dealt with in an expedient manner in accordance with Civil Service Rules. Effective 09-14-2018 through final resolution and issuance of final disposition letters. Trends, patterns and data will be reported and evaluated beginning in the (MONTH) monthly Quality Assurance meeting (scheduled for 10-17-2018) Start date 09/19/18. Date of Completion: 09/27/18 This deficient practice continued at a potential for more than minimal harm for the other 19 residents (#R1 - #R19) incapable of making their needs knowm on Building 2. Findings: Review of the facility's policy entitled Abuse and Neglect included the following: Purpose: It is the policy of the facility and LDH to prohibit the abuse, neglect, exploitation or extortion of patients/residents. Seven Key Components of Policy: I. Screening of Potential Hires: 1. Have you ever been disciplined for any acts of patient/resident abuse or neglect attributed to you? III. Prevention Policy and Procedures: 7. Neglect: Acts of omissions by a person responsible for providing care of treatment, which caused harm to a patient/resident of sufficient or appropriate services, treatment or basic care. Failure to provide appropriate services, treatment or care by gross errors in judgement, inattention or ignoring may also be considered a form of neglect. Examples include, but are not limited to: a. Failure to establish and carry out an appropriate program or treatment plan. b. Failure to provide, or withholding of, adequate nutrition, clothing or health care. c. Failure to provide a safe environment. d. Failure to provide or obtain needed medical treatment. e. Failure to supervise a patient/resident such that the patient/resident is placed in danger. B. Responsibility of RN Supervisor: Upon receiving a report of abuse, facility supervisor shall: 5. If allegation involves staff, contact the supervisor of the staff involved and initiate administrative action to ensure protection of patient/resident. C. Violation of the abuse and neglect policy may be grounds for disciplinary action. Violations include the following: 1. Committing abuse, neglect, exploitation or extortion. H. Duties of the Administrator 1. Ensure patient/resident is removed from danger. 7. Evaluate the recommendation of the IRC. Should any recommendations be rejected, the administrator shall give written explanation for such rejection, propose written corrective action plan, attach the corrective action plan to the IRC report and return within 5 days to the IRC chairperson with copies going to the Chief Risk Officer and APS. 8. Notify accused facility staff of findings and, if indicated, take appropriate disciplinary action if the allegation in confirmed. If the allegation is confirmed, the administrator shall notify the employee's supervisor that the employee's relocation is no longer necessary. 10. Develop and forward the corrective action plan to the appropriate employee who has responsibility for its implementation and monitoring. 11. Designate appropriate personnel to make reports of confirmed finding regarding licensed professionals to respective board of examiners. Review of the Grievance Log for (MONTH) - September, (YEAR) revealed no grievances for Resident #1 On 9/17/18 at 11:54 a.m., surveillance video observations were made of four different camera views with S1ADM and S2DON. S1ADM and S2DON identified staff and residents during the viewing of the video. Observations revealed: The date stamp on the video read 8/22/18. Camera: hallway facing A/BNS (outside Resident#1's room visible): 4:30 a.m.: hallway clear. 4:39 a.m.: S17CNA stood outside Resident#1's door near her linen cart. 4:40 a.m.: S17CNA rolled cart down A hall away from nurse's station and towards the exit. door. 5:11 a.m. S17 CNA entered Resident #1's room. 5:15 a.m.: S14CNA stood outside Resident #1's room. 5:19 a.m.: S17CNA came out of Resident #1's room, brought linens up hall. 5:22 a.m. S10LPN came in the building. 5:23 a.m.: S10LPN looked into Resident #1's room. 5:33 a.m.: S14CNA and S17CNA stopped and look into Resident#1's room, then proceeded down A Hall towards the nurse's station. 5:34 a.m.: S17CNA stood in the hall near nurse's station talking to S9LPN. S17CNA walked back up hall, then stood outside of Resident #1's room for less than a minute. 5:35 a.m.: S17CNA walked to A Hall beside Resident #1's room. 5:36 a.m.: S17CNA went into Resident #1's room. 5:37 a.m.: S14CNA stood outside Resident #1's room then walked into the room. Both CNAs (S17CNA and S14CNA) remained in room until S14CNA came out at 5:37 a.m. (she wasn't in the room a full minute). S14CNA walked into the nurse's station at 5:38 a.m. S14CNA stopped at the nurse's station to tell S9LPN something; S9LPN then moved on to another hall. 5:38 a.m.: S17CNA came out of Resident #1's room and went into another resident's room. 5:39 a.m.: S17CNA exited the other room, walked past Resident #1's room and to the nurse's station. 5:39 a.m.: S15CNA walked up A Hall and stopped to look into Resident#1's room then went back to the nurse's station at 5:40 a.m. 5:42 a.m. S17CNA stood in the hallway outside of Resident #1's room again. S8LPN was coming on to day shift and looked towards Resident #1's room, S9LPN was standing by S17CNA in hall. 5:43 a.m.: Resident #1's head appeared in the hall, she was beating it against the floor. S9LPN crossed the hall by walking from the exit door hall towards the nurse's station. 5:44 a.m.: S9LPN walked back across the hall towards the exit from the nurse's station. Resident #1 is still in the doorway of the hall/her room. Resident #1 worked her way out into the hall to where half her body was lying out of the door - she was observed flailing about, and beating the back of her head against the hall floor. S15CNA walked up the A Hall going towards the exit. S8LPN walked across the hall at 5:46 a.m. then walked back toward the nurse's station. S13CNA entered the hall at 5:46 a.m., got her linen cart and walked to hall behind A/BNS. Resident#1 remained on the floor, flailing, twisting and beating her head. 5:46 a.m. S13CNA walked into A Hall, turned back around and walked away. Resident #1 turned over onto her front and at this point was now lying all the way in the hall. 5:48 a.m.: Resident #1 was on her knees, then back on her stomach and was totally out in the hallway flailing and rolling. S17CNA walked down A Hall away from Resident #1 towards A/BNS, then back up the hall again near the exit hall alongside Resident #1's door. 5:49 a.m.: Resident #1 was kicking, flailing, rolling, beating against the floor, then she stood herself up. 5:50 a.m.: S13CNA came up to Resident #1, stopped and then walked into Resident #1's room to get her Geri chair. S13CNA left Resident #1 standing alone in A Hall. Resident #1 then fell to the floor while S13CNA was in Resident #1's room. S13CNA pushed the Geri chair back out of the room, not addressing Resident #1 lying on the floor, then continued down the hall toward the nurse's station. 5:52 a.m.: S13CNA looked out into A Hall towards Resident #1 then went back towards A/BNS. S15CNA left nurse's station and went back up the hall towards the B Hall. 5:54 a.m.: S16CNA came to get the blood pressure machine in the hallway beside Resident #1, who was on her back. S16CNA looked at Resident #1 then continued on down the hall with the machine toward her assigned hall (B Hall) 5:56 a.m. S15CNA went back up the hall towards the nurse's station. S13CNA peeked out again at Resident #1 then went back toward nurse's station. 5:57 a.m.: Resident #1 continued moving (kicking/flailing/rolling). S10LPN came up the hall to Resident #1, went to her cart, got/put on her gloves Resident #1 was still rolling on the floor. S10LPN came back to Resident #1. 5:58 a.m.: S12CNA came up to assist S10LPN. 5:59 a.m.: S10LPN was holding Resident #1's hand while S12CNA put on her gloves. Resident #1 sat up in the floor; S10LPN and S12CNA started assisting Resident #1 up into the Geri chair. 6:00 a.m.: S13CNA came up A Hall to assist in getting Resident #1 off the floor into the Geri chair. Resident #1 was still flailing/kicking. Resident #1 in chair. 6:02 a.m.: S11PAS, S8LPN and S5RNM walked up A Hall towards Resident #1 and other staff. 6:03 a.m.: Resident #1 was still in the hall in the Geri chair, flailing/kicking, staff had walked away. 6:04 a.m.: S18CNA came up A Hall towards Resident #1 then went back down the hall. 6:06 a.m.: S6RNM, S5RNM, S11PAS came up A Hall to attend to Resident #1. 6:07 a.m.: Staff brought Resident#1 back into her room. S13CNA mopping floor in hall. Review of the clinical record revealed Resident #1 was admitted with [DIAGNOSES REDACTED]. Review of the MDS included the following: Section B: Hearing, Speech, Vision. Speech Clarity-Unclear speech-slurred or mumbled words. Makes self-understood- Sometimes understood- ability is limited to making complete requests. Ability to understand others- Usually understands- misses some part/intent of message but comprehends most conversation. Section C: Cognitive Patterns: Should resident interview be conducted- No. Cognitive Skills for daily decision making. - Moderately impaired- decisions poor, cues/supervision required. Section D: Mood: Should resident interview be conducted= no. Section E: Behavior: [MEDICAL CONDITION]: none of the above checked. Section G: Functional Status: Bed Mobility- Support provided- one person physical assist. Transfer- self-performance- Limited Assistance- resident highly involved in activities. Walk in room- limited assist. Locomotion on Unit- Total Assistance. Dressing- Extensive assistance. Section H: Bladder and Bowel: urinary- always incontinent, bowel- always incontinent. Review of the Care Plan included the following: Onset: 12/18/2017 -I have the potential for being injured due to my impulsive nature, [MEDICAL CONDITION]'s chorea, Depression, Anxiety, [NAME]D, Personality D/O, & Polypharmacy/ [MEDICAL CONDITION] drug use. Onset: 12/19/2017 -I am at risk of falling because of my polypharmacy and [MEDICAL CONDITION]/antianxiety drug therapy (daily use) spastic gait, [MEDICAL CONDITION]'s chorea, impulsive nature, and long history of falls. Interventions for falls are as follows: -I am mobile per Geri-chair only. Please assist me with all transfers. (CNA, N) -Please report any unsafe situations to my unit nurse (CNA) -I am on Fall Precautions. Be alert for signs over my bed and on my door. I should have an armband, but sometimes choose not to wear it. My call light should be within reach. Please encourage me to use it. (CNA, N) -When washing my helmet, do so with soap and water at bedtime. Allow it to dry so that it will be available to me the next day. -Please monitor my gait. Over time, it will probably deteriorate because of my [MEDICAL CONDITION]'s chorea Disease. Offer me immediate assist should you notice me up walking unattended. (CNA, N) -Ensure that all staff know that because of my disease process and medications, I am at risk of falling (CNA, N) -Please encourage me to use my Physical Therapy recommended mobility devices. (N) -I need to be reminded to report falls immediately when they occur. If I am discovered after the fact, I will be reminded of the importance of notifying CNA or nurse of any fall immediately. -I transfer with 1 person's assistance. If you notice me getting up, intervene as soon as possible. -Assist and encourage me to wear my helmet during the day. It can be removed at night. -Ensure all staff know to wash my helmet with soap/water by hand and allow to dry naturally at bedtime so that it is dry and ready for me to wear when I wake up in the morning. Onset: 12/19/2017 - My behavior is often inappropriate because of my [MEDICAL CONDITION]'s chorea Disease, Depression, Anxiety Disorder, [MEDICAL CONDITION], Sleep Disturbance, and Personality Disorder. I am often defiant and ignore staff's attempts to communicate with me. I also yell and scream at others. I have trouble communication at times due to my impulsive nature. I have a history of attempting to hit staff. Each behavior is addressed on the care plan with the date it occurred and interventions. Interventions: -Please maintain a quiet, calm, non-threatening environment. -Please monitor, document and report all abnormal/unacceptable behaviors to my MD. -I respond well to consistency and set limits. -Encourage me to respond to questions or request. -Please allow me time to respond. At times, I may take several seconds to give an answer. -Please allow me to wake up before asking me questions or giving direction. Use the buddy system to ensure everyone's safety. -Please minimize excitary stumili but if I withdraw, stimulate me frequently by talking to me casually as if I am conversing with you. Eventually this breaks through my wall. -I should be reminded that I am responsible for my actions. -Please consult the Psychiatric MD should I need it. -I should be encouraged to report other resident's behavior to the nurse rather than retaliating with violence. -Please attempt to identify the cause of my violent behavior towards my mother and my withdrawn behavior towards everyone if either should occur. Allow me time to respond. -Offer encouragement and praise me for my proper response. Try to allay all fears. -I do best with simple instructions and yes or no answers. -Observe me for S/S of escalating behavior, change in my sleep patterns, pacing, refusing care and medications, anxious mood changes in my mood, wandering, delusions, and hallucinations. Document behaviors in the nurse notes. -Remove me from shared space when my behavior is inappropriate. -Attempt to calm me and understand the reason behind my behavior. -I need [MEDICATION NAME] 5 mg by mouth twice daily and 10 mg [MEDICATION NAME] twice daily for a total of 15 mg. -Treat me as an adult and be patient with me when I am frustrated, attempt to determine the cause -06/27/18- When I am upset, please calm me by quietly saying its ok, you're alright to me repeatedly. It calms me. Ensure Safety belt in use when resident OOB. Review of the resident's nurse's notes included the following: 08/22/2018 at 6:16 a.m. I was notified that Resident #1 was on the floor by S13CNA. S13CNA stated that resident had blood on her left eye and the back of her head. As S10LPN walked to Hall 2. And noted the resident was lying on the floor kicking, screaming with blood noted above right/left eyelid and to the back of her head. There was also blood smudges to the left of the door frame leading into her room. Resident #1 had several smidges of blood surrounding her. Initially I attempted to raise resident to a sitting position. But she resisted and attempted to pull me down onto her. S13CNA came down the hall and stated that she and S12CNA could do it. Resident #1 was raised to a standing position, and I went into the resident's room for the Geri chair, and placed it behind her. Resident #1 then sat in the chair and was secured. Upon closer inspection of the resident's wounds, an old wound less than ¼ inch approx. was underneath her left brow. An old wound to the back of her head was reopened and oozing bright red blood. Resident #1 was throwing her head back and forth against the back of the Geri chair. S5RNM was notified, S6RNM was coming down the hallway at that time and was also notified. Both managers came to residents' side and assessed the situation. Resident #1 was then taken into her room by the Managers for assessment of wounds and first aid. 08/22/2018 at 06:45 a.m. the MD was notified of resident being in hallway with wounds to her left brow and to the back of her head. The MD stated that she would come to unit to see the resident. 08/22/2018 at 8:31 a.m. MD here to assess resident. 08/22/2018 at 11:31 a.m. An order was received from MD for an x-ray for residents' left hip and a skull series. 08/22/2018 at 11:45 a.m. Resident #1 refused to be taken to X-ray department. 08/22/2018 at 11:50 a.m. S3ADON and MD were notified regarding residents' refusal to go to X-ray. Review of physician orders [REDACTED]. [MEDICATION NAME] EC 250 mg tablet one by mouth three times a day. Clean scalp with normal saline apply [MEDICATION NAME] and bandaid/dressing daily and PRN until healed. Clean cut to posterior scalp with normal saline apply [MEDICATION NAME] and band aid /dressing daily and PRN until healed. On 09/13/2018 at 5:15 a.m., an observation was performed of Resident #1. She was sleeping with the covers pulled up to her head. The bed was in low position with padded mats covering the floor. Padded mats were also standing up against the wall of the room around her bed. On 09/13/2018 at 10:00 a.m., an observation was performed of Resident # 1. She was in the day room, up in her Geri chair with a helmet on. She was asleep with her soft seat belt on. On 09/13/2018 at 12:15 p.m., an observation was performed of Resident # 1. She was in the day room, up in her Geri chair with a helmet on. Soft belt in place. She was awake and smiled when spoken to. Two staff were in the day room monitoring the residents. On 09/18/2018 at 10:45 a.m., an observation was performed of Resident #1. She was sitting up in the wheel chair fully clothed in the whirl pool room. She had a soft helmet in place. The helmet was removed by staff and the injury to her head was viewed. It is located on the occipital area of her head. The wound size originally was 1 inch in length. It had healed on both ends with a small open area to the center of the wound. The open area was approx. 1/8th of an inch in length and width. On 09/18/2018 at 10:45 a.m., an observation was performed of Resident #1's room. The bed frame was padded as was the base of the bed. The bed was low to the floor. There were thick pink and purple mats to the floor. The walls were padded with pink and purple mats. An entrance gate had been built and was padded. This sectioned off the area around the bed. There was no unpadded area around the bed once the gate was closed. On 09/14/2018 at 8:30 a.m., an interview was conducted with S17CNA. She was asked to explain the circumstances of the incident with Resident #1 the morning of 08/22/18. She stated that on 08/22/2018 around 5:00 -5:30 a.m. she had completed her rounds. She went into Resident #1's room and she woke her to change her. The resident was still in the bed when she left the room. S17CNA started getting the dirty linen together and she went to the linen closet. She got the trash together and took it out. When S17CNA came back to the hall she got her clean linens off the cart. When she walked up the hall Resident #1 was sitting on the floor in her room. S17CNA went into the room and tried to help her up. Resident #1 jerked away from her and S17CNA walked out. She asked where the nurse was and the other aid went to get S9LPN. The nurse did not come right away. When S9LPN did come she asked S17CNA what was going on. S17CNA explained that she had been back in the room and there was blood on the floor. S9LPN stated she was coming and walked away. S17CNA assumed that the nurse was going to get supplies to care for the Resident. S17CNA stated Resident #1 had an area on her head that she had re-injured. S17CNA stated she went back to look at the Resident again. She was inside her room and still on the floor. There was no mat covering the entire floor at this time. There was a mat right next to her bed and up on the wall. S17CNA was asked if there was a mat in the spot where Resident #1 was sitting. She stated there was no mat. S17CNA stated she then went and sat down in a chair on the hall next to an exit. She explained she was waiting to assist the nurse. When S9LPN returned she passed by the aide and went out the exit. S9LPN stated she had already given the keys over to the day shift. S17CNA stated S9LPN never checked Resident #1. S9LPN said she was going to her car. S17CNA stated the nurses, aides and everyone was walking by and she didn't know what else to do. S17CNA stated she did not try to get her up. She was asked what Resident #1 was doing at this point. She stated Resident #1 had scooted out in the hall and was bleeding from the back of her head. S17CNA stated that Resident #1 then started showing out, laying out in the hall and hollering. She explained that everyone was asking her to get up and she wouldn't get up. S17CNA was asked what she (S17CNA) was doing at this time. She stated she was still sitting in the chair, was waiting on a nurse. She was asked what the Resident was doing. She stated Resident #1 was hitting her head up against the wall. She was asked how long the Resident was in the floor. She stated the Resident was on the floor maybe 15 minutes. S17CNA was asked what were you doing during this 15 minutes? She replied, I was sitting in the chair watching her. S17CNA stated the day shift nurse and one of the CNAs got her up. S17CNA was asked if there was anything she thought she could have done differently. She stated maybe called another nurse or got the morning supervisor involved. She stated she thought after she made the report to the nurse that she had done what she should have done. The CNA was asked if she attempted to assist the resident from the floor. She stated, We are very short staffed and there was no one to help me. She was asked if there was any training provided to staff after this incident. She stated she read an in-service, the night manager explained the in-service to her and had her sign the papers. She said, the in-service was about assisting residents when they need assistance. On 09/14/2018 at 10:00 a.m., an interview was conducted with S11PAS. She stated she had worked at the facility for twenty-three years and was a CNA supervisor. She stated she came into work at 5:45 a.m. and Resident #1 was peeking out her bedroom door and she was sitting on the floor. S11PAS then put her stuff up, went into nurse's station and started working on her assignments. About 15 minutes later she heard a CNA say that blood was everywhere. She had heard Resident #1 yelling and she assumed the CNA was talking about Resident #1. She stated S17CNA was sitting in a chair by the exit door looking toward the nurse's station. S11PAS got up and by the time she got to the Resident, staff had put her in the Geri chair. S17CNA was still sitting in the chair and did not get up to assist. She stated Resident #1 had blood on her face and on the back of her head. There was blood on the floor in the hall and in her room. S11PAS stated she immediately went and got S5RNM. S5RNM came and assessed the resident. S9LPN had already left the unit. S11PAS was asked as a supervisor what was expected of her staff. She stated they were expected to immediately go assist the resident. She further stated, the expectation was to go to the RN manager, get help and get the resident up. On 09/14/2018 at 10:59 a.m., an interview was conducted with S14CNA. She had worked at the facility a year. She stated she was bringing her linen from 1C night shift to A Hall where Resident #1 was housed. She stated she saw Resident #1 on the floor inside her room. She informed S17CNA who was assigned to Resident #1. She took her linens out and she and S17CNA came back together. Resident #1 was still sitting inside her room. The Resident had a cut on the side of her eyebrow. S17CNA went into Resident #1's room. S14CNA went to S9LPN to let her know that S14CNA was now on duty for Resident #1. S14CNA informed S9LPN that Resident #1 was on the floor and bleeding and she said okay. She stated she stayed on A Hall and finished her duties. She was asked if she had any in-services since this incident. S14CNA stated no, she had not. On 09/14/2018 at 11:22 a.m., an interview was conducted with S13CNA. She was asked to explain what happened during the incident involving Resident #1. S13CNA stated when she came in to work the day shift, she put her things down. She had not clocked in yet. S17CNA was sitting down in a chair in the hall and Resident #1 was acting out. S13CNA saw the Resident on the floor in the hallway. Resident #1 was yelling while on the floor. She stated S17CNA was assigned to Resident #1 and S17CNA was just sitting there. When S13CNA came back S10LPN and S12CNA (day shift) where attempting to get the Resident up. S13CNA went to help the staff get the Resident up. S13CNA stated that Resident #1 was bleeding from the back of the head, her nose, an old wound over her eye had re-opened and was bleeding. S13CNA stated she went into Resident #1's room to get the Geri chair and the staff put her in the chair. S11PAS went to get S5RNM. S5RNM came, assessed the resident and then called S6RNM. S6RNM came, cleaned and dressed the Resident's wounds. S13CNA stated she mopped the blood up out of the hall, cleaned the blood off the wall in the hall and then she mopped up the blood from the floor of the Resident's room. Resident #1 was put in hall in her Geri chair. She stated the Resident got out of the self-releasing soft belt restraint and stood up. Staff took the resident for a bath. She seemed to calm down after the bath. S13CNA stated that lot of times when the Resident was yelling and screaming because she wanted her shirt changed or some pudding to eat. She further explained that if staff did these things she would calm down. She was asked if the facility did any in-services/trainings after this incident. S13CNA stated, no- not to her knowledge. S13CNA stated the reason she left the resident on the floor was because her aide (S17CNA) was sitting there looking and didn't do anything. On 09/14/2018 at 11:45 a.m., an interview was conducted with S12CNA. She stated she had been employed at the facility since (MONTH) (YEAR). She stated she came into work on the day shift on 8/22/18. She spoke to S17CNA saying, Is this hap

Based on interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physical for 1 (Resident #1) of 6 (Resident #1, #2, #3, #4, #5, #6) sampled residents as evidenced by failure to : 1. Protect a resident (Resident #1) who was incapable of protecting herself from self- injurious behaviors; 2. Assist or assess the resident after she was observed on the floor with injuries; 5. Provide re-training to staff following a substantiated neglect incident. This failed practice resulted in an Immediate Jeopardy situation on 08/22/2018 at 5:00 a.m. when Resident #1 was observed by staff on the floor yelling and hitting her head on the floor and wall, bleeding from her face and the back of her head. During this period of time, as several staff members walked past the resident. There was no staff assistance or intervention provided. The resident remained on the floor without assistance yelling and hitting her head on the wall and floor until 5:57 a.m. S1ADM was notified of the Immediate Jeopardy on 09/17/2018 at 5:45 p.m. The Immediate Jeopardy was removed on 09/17/2018 at 7:00 p.m. when the facility submitted an Immediate Jeopardy plan of removal which included the following: 1. Resident #1 was affected by this cited deficient practice. 2. Residents in the facility who exhibit impulsive/behavioral disorders have the potential to be affected by this deficient practice. Measures put in place, see #3. 3. S9LPN was found to have failed to provide care and neglected Resident #1. She has been placed on administrative leave pending dismissal from VFMC. She will be reported to the LPN board. Placed on Administrative leave 09-17-2018. Human Resources is preparing pre-disciplinary letter for legal's review, anticipated date of review 09-21-2018. Although S17CNA provided care for Resident #1, she left her crawling on the floor with the potential of further harming herself and never offered assistance. S17CNA neglected Resident #1 to the point of possible injury. S17CNA has been placed on administrative leave pending reception of her dismissal letter. VFMC will provide any documentation requested by the CNA Registry for evaluation of loss of CNA certification. Placed on Administrative leave 09-14-2018. S13CNA came to assist the Resident, but left her standing while she retrieved the Geri-chair. This left Resident #1 vulnerable to injury. S13CNA has been placed on administrative leave pending further investigation. Placed on administrative leave 09-14-2018. S8LPN, who was a float nurse at the time of the incident, walked past Resident #1 numerous times as the Resident crawled on the floor. S8LPN was moved to another unit after this incident, until further investigation, and on 09-17-18, was placed on administrative leave pending further disciplinary action. Placed on Administrative leave 09-17-2018. S5RNM was a witness to Resident #1 lying and sitting on the floor. S5RNM called the Night Nurse Manager to come assist the Resident. S5RNM looked at Resident #1 to assess, but failed to remove the Resident from the floor. S5RNM was placed on administrative leave on 09-17-18, pending further investigation. Placed on Administrative leave 09-17-2018. The facility began in-service training on 08/29/2018. Training will continue on the care of the Resident until 100% of nursing staff are trained. All training will be completed by 09-27-2018. Training will be incorporated in orientation for all new staff. Training will involve Abuse and Neglect and reporting and handling resident incidents. Nursing Administration and Staff Education and training will provide the in-service training. Training will be oral, written, computer based and test will be administered for competency. Training will be monitored through review of incidents on a daily basis indefinitely. Passing score for competency exam is 80%. Resident #1 has [DIAGNOSES REDACTED]. She has impulsive nature, is easily agitated and uncooperative. She has a difficult [DIAGNOSES REDACTED].#1's room was updated to include additional padding: padding for areas that were exposed and that could cause harm from flailing and thrashing. A wall and door were added to enclose the area of her bed and padding was added to both, an additional helmet was obtained for the resident on 08/30/18 and placed on Resident for safety and protection as allowed and appropriate. The investigation of this incident is on-going. 4. On 09-19-2018 a copy of the Incident Investigation Checklist form with instructions will be e-mailed to Nurse Managers. Nurse Managers will review and sign off on Incident Reports on a daily basis. For any Incident Report involving a cognitively impaired resident, the Nurse Manager will fill out an Incident Investigation Checklist form and attach to the Incident Report. The Incident Report and Incident Investigation Checklist form will be reviewed by the Quality Assurance Manager on a daily basis and any issues of concern will be reviewed with appropriate department heads to ensure the safety and security of Residents is maintained. If deemed appropriate, 2 members of the administrative staff will review facility camera footage. Effective 09-19-2018 until re-evaluated (MONTH) 2019. Effective 09-19-2018. Nursing Administration will review the 24 hour report on a daily basis. Nursing administration will meet with Day Shift Nurse Managers M-F to discuss issues/concerns and complaints. Immediate corrections will be made to issues of concern arising from Managers and verified through monitoring of camera system. Administration will track the progress of the disciplinary process to ensure the employees that received disciplinary letters are dealt with in an expedient manner in accordance with Civil Service Rules. Effective 09-14-2018 through final resolution and issuance of final disposition letters. Trends, patterns and data will be reported and evaluated beginning in the (MONTH) monthly Quality Assurance meeting (scheduled for 10-17-2018) Start date 09/19/2018. Date of Completion: 09/27/2018 This deficient practice continued at a potential for more than minimal harm for the other 19 (R1-R19) residents incapable of making decisions on Building 2. Findings: Cross reference to F600 Review of the facility's policy entitled Abuse and Neglect included: Purpose: It is the policy of the facility and LDH to prohibit the abuse, neglect, exploitation or extortion of patients/residents. Seven Key Components of Policy: I. Screening of Potential Hires: 1. Have you ever been disciplined for any acts of patient/resident abuse or neglect attributed to you? III. Prevention Policy and Procedures: 7. Neglect: Acts of omissions by a person responsible for providing care of treatment, which caused harm to a patient/resident of sufficient or appropriate services, treatment or basic care. Failure to provide appropriate services, treatment or care by gross errors in judgement, inattention or ignoring may also be considered a form of neglect. Examples include, but are not limited to: a. Failure to establish and carry out an appropriate program or treatment plan. b. Failure to provide, or withholding of, adequate nutrition, clothing or health care. c. Failure to provide a safe environment. d. Failure to provide or obtain needed medical treatment. e. Failure to supervise a patient/resident such that the patient/resident is placed in danger. B. Responsibility of RN Supervisor: Upon receiving a report of abuse, facility supervisor shall: 5. If allegation involves staff, contact the supervisor of the staff involved and initiate administrative action to ensure protection of patient/resident. C. Violation of the abuse and neglect policy may be grounds for disciplinary action. Violations include the following: 1. Committing abuse, neglect, exploitation or extortion. H. Duties of the Administrator 1. Ensure patient/resident is removed from danger. 7. Evaluate the recommendation of the IRC. Should any recommendations be rejected, the administrator shall give written explanation for such rejection, propose written corrective action plan, attach the corrective action plan to the IRC report and return within 5 days to the IRC chairperson with copies going to the CRO and APS. 8. Notify accused facility staff of findings and, if indicated, take appropriate disciplinary action if the allegation in confirmed. If the allegation is confirmed, the administrator shall notify the employee's supervisor that the employee's relocation is no longer necessary. 10. Develop and forward the corrective action plan to the appropriate employee who has responsibility for its implementation and monitoring. 11. Designate appropriate personnel to make reports of confirmed finding regarding licensed professionals to respective board of examiners. On 09/17/18 at 10:30 a.m., an interview was conducted with S2DON. She stated she was aware of the incident of 08/22/2018 involving Resident #1 when the resident was found on the floor, hitting her head on the wall and floor, and bleeding from a laceration to her head. She verified there were staff members near the resident who observed the incident but failed to assist the resident to ensure her safety. She stated the week afterwards a training was done that involved responding to an incident as soon as it is witnessed. However, it was not gone into any further due to the pending investigation. She explained the facility did not want to discuss the incident in detail with staff because it was under investigation. On 09/17/2018 at 12:00 p.m., an interview was conducted with S1ADM. He explained that S9LPN, S13CNA and S17CNA were placed on administrative leave pending termination on 09/14/2018. He was asked what was done immediately after the incident with the staff. He stated staff were reassigned to different units on building 2. He was asked when staff was reassigned were the managers on that unit made aware of what happened and were they to monitor staff more closely. He stated, along with the S2DON, that RN managers had gotten letters of reassignment. He stated they monitor the staff more closely. This information was not documented but was shared verbally. S1ADM stated, there were no monitoring tools but the information was reported verbally.

Based on observations, interviews and record reviews, the facility failed to ensure one (#150) of three (#13, #121, and #150) residents investigated for falls received adequate supervision and assistance to prevent accidents. This deficient practice resulted in an actual harm for Resident #150 on 6/12/2018 at 9:30 a.m. when the resident, who had not been secured with a shoulder/lap belt, fell out of his wheelchair onto the facility transportation van's floor when the van driver applied the brakes. Resident #150 was assisted back into the wheelchair and brought to the emergency room of a local hospital for an evaluation. The resident was diagnosed with [REDACTED]. On 6/13/2018, the resident underwent [REDACTED]. The facility implemented corrective actions, which were completed prior to the State Agency's investigation; thus, it was determined to be a Past Noncompliance citation. Findings: Review of the clinical record revealed Resident #150 was a fifty-two year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #150's Quarterly MDS, with an Assessment Reference Date of 7/30/18, revealed a BIMS score of 15, indicating he was cognitively intact. The MDS also revealed the resident used a wheelchair for mobility and was independent for transfers and locomotion. He exhibited ROM impairment on both sides of his lower extremities. Review of Resident #150's Care Plan revealed the following: I am at risk for injury because of my [MEDICAL CONDITION] Recent fall in van with Femur fracture, (MONTH) (YEAR). Review of the Hospital Discharge Summary, dated 6/15/18, included the following: Resident #150 is a [AGE] year-old male patient, paraplegic since 2005, residing in a nursing home since (YEAR), was brought to the emergency room for left knee/thigh pain. Patient was being transported from the nursing home to wound clinic. While on his way, the van had to stop abruptly. The patient, who was in his wheelchair, was not able to remain on his wheelchair and fell forward, on his left lower extremity. He started experiencing left lower extremity pain and back pain. Further imaging revealed a spiral fracture through the mid to distal shaft of the left femur. Hospital course: Left femoral fracture s/p surgical repair. Patient admitted to the floor. Discharge Diagnosis: [REDACTED]. An interview was conducted with S1Admin on 8/20/18 at 12:05 p.m. He stated Resident #150 was on the transportation van in route to a clinic appointment when the van stopped at a red light. Resident #150 was found on the floor by the staff and assisted back into the wheelchair by the staff. He verified the transportation driver was responsible for securing Resident #150's wheelchair with four point restraints at the base of the wheelchair and securing the shoulder/lap seatbelt prior to departure. He verified S8MEO, Mobile Equipment Operator, admitted she did not latch the shoulder/lap belt on Resident #150 on the date of the accident, 6/12/18. He stated S8MEO was terminated and the remaining staff received training after the incident. An interview was conducted on 8/22/18 at 12:43 p.m. with S7TS. He stated on 6/12/18 at 9:00 a.m. Resident #150 was assisted on the facility van for transport to a clinic appointment. He said the transportation driver, S8MEO, had only been employed by the facility for 3 weeks at that time. He said, after Resident #150 was assisted on the facility van in his wheelchair, the transportation driver secured the wheelchair with the 4 point restraints used to secure the wheelchair to the van floor. He stated S8MEO did not secure the lap/shoulder belt on Resident #150 prior to departing the facility. He said, while the van was approaching a traffic light, the driver applied the brakes as the traffic light turned yellow. He stated Resident #150 fell out of the wheelchair onto the van floor. He said staff assisted the resident back into the wheelchair and applied the shoulder/lap belt. He said Resident #150 requested to go to the clinic appointment and after the clinic appointment, Resident #150 agreed to go to the emergency room for evaluation and treatment of [REDACTED]. He further verified, after the incident on 6/12/18, S8MEO was removed from transporting residents and eventually terminated on 6/16/18. He stated all transportation personnel received training after this incident. An interview was conducted on 8/22/18 at 3:56 p.m. with Resident #150. He said he was riding in the transportation van when the van came to a sudden stop and he did not have enough time to brace himself. He said he did not notice his lap and shoulder belts were not fastened at the beginning of the trip. He said he had gone on numerous transports in the van prior to and after the accident and had not known of a time when he was not restrained with 4-point floor restraints on his wheelchair, as well as the lap and shoulder belt across his person. He said he felt the bone snap and was in deep pain. He said the driver wanted to take him back to the facility but he said he wanted to go to wound care appointment. He said he would let the wound doctor look at his leg. He said when the wound doctor looked at his leg, he told him he needed to go to the emergency room and have it checked. He said that is when he went to the emergency room , he had a MRI and the doctor told him he needed surgery to fix his broken femur. Throughout the survey of dates 8/20/18 - 8/23/18, five transportation staff and five CNAs were interviewed. These staff members were knowledgeable of the facility's transportation policy and their roles and responsibilities during transport of residents in wheelchairs. Throughout the survey of dates 8/20/18 - 8/23/18, three observations were conducted of residents in wheelchairs being secured by transportation staff prior to departure from the facility. There were no concerns. The facility implemented the following actions to correct the deficient practice on 6/12/18: 1. A full transportation staff in-service was conducted on 6/14/18. The title of the presentation was Seatbelt Safety for Residents and Staff (Seat and Safety Belt secured). Training Aide utilized included handouts. The presenter: S7TS. Eight transportation staff signatures were noted on the sign-in sheet. 2. Transportation supervisor maintains monitoring by documenting each transport on the facility transportation information/communication sheet. Documentation includes: All Residents/Patients and staff secured properly, Circle one: Yes or No. Each document is signed by facility gate personnel. Monitoring has been in place at the facility gate since (MONTH) (YEAR). 3. Policy and procedure entitled Transporting was implemented by the Nursing Department in (MONTH) (YEAR). Policy states nursing staff should verify the resident has been secured by the transportation personnel.

Based on interview and record review the facility failed to reassess 2 (#12, #15) of 15 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15) residents reviewed for accident hazards/supervision when the interventions already in place failed. The facility failed to: 1. Ensure staff discuss issues/problems during the Multidisciplinary Staffing Meeting for a severely cognitively impaired resident (#12) who was known to have gorged food and would eat anything he could get out of the trash can and revise interventions. (#12) 2. Ensure all trash cans were secured in an area where staff could observe the trash cans so that a severely cognitively impaired resident (#12) who was known to have gorged food and to eat anything he could get out of the trash would not get food from the trash cans. (#12) 3. Identify and implement new interventions as a means of interrupting/stopping scavenging for food from other sources for a severely cognitively impaired resident (#12) for which redirection had continually failed in the past. 4. Prevent continued elopement attempts for a resident who exhibited unsafe wandering and elopement while under close observation. (#15) 5. Accurately assess the resident's needs after each elopement. (#15) The Administrator was notified of the Immediate Jeopardy on [DATE] at 7:10 p.m. The Immediate Jeopardy began for Resident #12, a severely cognitively impaired resident, on [DATE] when he returned to the facility from a hospitalization that required intubation, which resulted from choking on food debris. The facility failed to put interventions in place to increase supervision and monitoring on this resident with a significant history of scavenging food from the garbage ( and other sources) and choking to prevent him from scavenging and eating from the trash cans. The Immediate Jeopardy ended on [DATE] at 4:45 a.m. when Resident #12 expired. The Immediate Jeopardy was lowered to a Level III isolated, actual harm on [DATE] at 4:45 a.m. when Resident #12 expired. The Administrator was notified of the Immediate Jeopardy on [DATE] at 7:10 p.m. for Resident #15. The Immediate Jeopardy began on [DATE] when the facility failed to ensure supervision of Resident #15 after his second elopement attempt where he was found trying to climb over the closed gate while under close observation. The facility failed to increase supervision and monitoring on [DATE] when 2 elopement attempts occurred while under close observation with no further interventions in place and no increase in monitoring. On [DATE] Resident #15 eloped out of the facility, past the gate and ran to the highway, flagged down a female motorist, began choking her in her car while on close observation. No new interventions for increased supervision or monitoring were put into place. On [DATE] Resident #15 eloped while under close observation off of facility grounds and traveled 1.6 miles to the grounds of a local nursing facility. This immediate jeopardy was lifted when Resident #15 was PEC'd to a local hospital on [DATE] at 5:10 p.m. and returned as 1:1 supervision. The Immediate Jeopardy was lowered to a Level II - pattern on [DATE] for Resident #15. Findings: Review of the facility's policy for Close Observation and One- To-One Monitoring revealed the following: Purpose: To establish guidelines for nursing staff to implement and follow when close observation or one -to -one monitoring is ordered on a resident . Examples of reasons for ordering close observation or one -to- one monitoring include, but are not necessarily limited to wandering, sexually inappropriate behavior, aggressive behavior toward other residents, and behavior that poses a danger to the resident or others. Procedure for: 1. Close observation: The resident must be within assigned staff member's line of vision at all Times; One -to -One: Assigned staff member must be within six feet of resident at all times 2. The nurse must have a physician's orders [REDACTED]. The order must include the reason and verbal orders must be signed by the physician within 24 hours. The order will remain active/valid until discontinued. 3. Close Observation Monitoring record will be initiated by nursing staff when the resident is placed on one -to- one monitoring. 4. The staff member assigned to monitor the resident will document every 15 minutes on the Close Observation or One -to- One monitoring Record. 5. The resident will not be permitted to attend off- unit functions until the precautions are discontinued. Resident #12: Review of Resident #12's clinical record revealed the following: Date of Birth: [DATE]; Date of Admission: [DATE] and a [DIAGNOSES REDACTED]. Review of Resident #12's most recent Minimum Data Set (MDS), Assessment Reference Date (ARD): [DATE]; Type: Quarterly, revealed the following: Cognitive Patterns: Brief interview for Mental Status ( BIMS): should resident interview be conducted: No ( resident is rarely/never understood); Cognitive skills for daily decision making: 3. Severely impaired- never/rarely made decisions Acute onset mental status change: No Swallowing/Nutritional status: Swallow disorder: none of the above: checked Height (in inches): 70 Weight(in pounds): 245 Nutrition approach: Resident: mechanically altered diet: checked; Nutrition approach: Resident: therapeutic diet: checked. Review of the facility nurses notes revealed the following entries, in part: [DATE] 11:00 a.m. Redirected multiple times out of garbage cans. Counseling ineffective; [DATE] 11:00 p.m. goes in to other patient ' s rooms and steals any food he finds; [DATE] (no time documented: decision making skills: severely impaired: poor insight and judgment, eats out of the trash, counseling and redirection ineffective [DATE] (no time documented) Ability to understand: sometimes understands: redirected frequently to eat food slowly; [DATE] 7:20 a.m. S24CNA, noted that patient( pt.) had food in mouth and hand. Pt. sitting on side of nurses ' station. S24CNA asked pt. what he had in his hand. Pt. unresponsive to CNA- S40CNA called this nurse (S36LPN) to pt. Noted pt. slumped over in chair attempted to perform the [MEDICATION NAME], abdominal thrust, and back blows. CPR also attempted, all without success. Attempted to suction without success 7:25 a.m. S38MD notified, instructed to continue all efforts until he arrived to unit. S25RN notified. Efforts continued 7:30a.m. S50RN arrived to ward for assistance. Efforts continued patient gasping for air, oxygen started with an oxygen mask at 15 liters and oxygen saturation of 92% on 100% oxygen (maximum amount of oxygen that can be delivered), Pulse 105; 7:35 a.m.: Medical doctor (MD) on ward to assess patient. Efforts continue, patient continues gasping, eyes are open but unfocused 7:40 a.m.: Local ambulance transfer to area hospital with lights and sirens. Patient breathing improves marginally. Continue to monitor 7:55 a.m.: local ambulance service arrives, patient attempting to stand. Instructed patient to stay lying on floor. Patient appears confused. Breathing becomes more labored. Patient is assisted to stretcher 5:15 p.m.: Received update from area hospital. Patient admitted to intensive care unit with aspiration pneumonia, [MEDICAL CONDITIONS], and intubation. [DATE] 2:27 p.m. Return from local hospital, ambulatory, accompanied by CNA. Resident alert to name only. Follow simple instructions with redirection 2:43 p.m. MD on unit. Exam resident. Mental status unchanged, answering "yes" to all questions. Instruct staff to monitor closely- trash cans and barrel from locker area are now removed [DATE] 4:45 p.m.: reported by CNA, another resident went to room and struck Resident #12 with a metal object several times on the buttocks. Resident #12 sustained no injuries. The other resident stated Resident #12 had eaten his cookies out of his room. Unable to counsel Resident #12 due to impaired thought process and insight. Review of the Resident #12's physician progress notes [REDACTED]. 1:45 p.m. Called by nurse that patient was eating in dining room and got choked, vomited, and he left and came to day room with CNA following , patient on sofa and continue to struggle to breathe. Stridor (harsh breathing sound associated with obstruction) was heard by staff. ,[DATE] pulse, 71 oxygen saturation, 99% on 100% re-breather (oxygen mask), with room air was 87%, now trying to get up and wander, still raspy sounding in throat, patient was pulse less and on sofa, placed on floor and [MEDICATION NAME] done, then patient started respirations and pulse returned; Impression: Aspiration of chopped meat; Plan: Transfer to area hospital. [DATE] 7:50 a.m.: Patient still digging through garbage cans, trying to get in to cars, Plan: Continue Care, yard/cigarettes from garbage cans, continue medications [DATE] 8:26 a.m.: Patient the same wandering and eating out of garbage, Plan: Continue medications, continue care [DATE] 11:10 a.m.: Patient still eating from garbage can and trying to get in cars on the grounds, Plan: Continue medications, Continue care [DATE] 8:30 a.m. Patient doing the same, wandering grounds, trying to get in cars, picking up things from the ground and garbage cans and eating them: Plan: Continue medications, Continue care, Keep special appointments; [DATE] (no time documented): Still eating from garbage cans, Plan: continue medications, Continue care [DATE] (no time documented): Transfer note: Patient found falling over, choking. [MEDICATION NAME] and abdominal thrust done. Nothing recovered, may have aspirated cornbread, patient supine on floor, now minimally responsive, heart rate 108, respiratory rate 16, with decreased breath sounds right anterior chest, abdomen with positive bowel sounds, 1. Aspiration, 2. Airway- partial occlusion 3.[MEDICAL CONDITION] 4. Mental [MEDICAL CONDITION] 5. Constipation; Plan: to area hospital emergency room via local ambulance service. [DATE] 2:49 p.m.: status [REDACTED]. Review of Resident #12's Multidisciplinary staffing notes revealed the following entries, in part: [DATE]: Comments: Counseled on staying out of the garbage cans for food, etcetera (etc.). [DATE]: Comments: Counseled on staying out of the garbage cans for food, etc. [DATE]: reason for staffing: on [DATE]: transferred to area hospital emergency room : airway partial occlusion and aspiration, [DATE]: Returned from area hospital , [DATE]: Psychiatric consult: Continue medications, Comments: Counseled on staying out of garbage cans for food, etc. Review of Resident #12's Social Services Notes revealed the following entries, in part: [DATE]: Behavior: Supervision with meals; Patient continues to ramble over parking lot looking for open car doors, goes in to garbage searching for food. Goals/Plan: Rambles around all day hunting for food anywhere he can find it. He must be redirected many times for eating out of garbage cans. He goes in other patients' rooms hunting for food also [DATE]: Patient choked on food- was sent to an area hospital. Now in Intensive Care Unit and intubated ( has a breathing tube) - has aspiration pneumonia [DATE]: Behavior: Eats out of trashcans Goals/Plans: Resident continues to walk searching for food in the cars and in the garbage. Resident on routine diet with chopped meats, Needs Constant Supervision and Care. Transported to an area hospital for choking and Intensive Care Unit (ICU) care: Returned to facility on [DATE]; [DATE]: Returned from area hospital after a choking episode. He eats out of the garbage cans and can't be stopped. He continues to walk aimlessly hunting for food in the garbage and in the workers' cars if he can have access to them. He is severely disabled with mental [MEDICAL CONDITION]. Review of Resident #12's Nutritional Staffing Note, dated [DATE], revealed the following, in part: Regular quarterly staffing; Other disciplines: Nursing: choking incident on [DATE]. Comments: Resident #12 had a choking incident last week. He choked on a piece of meat. Unsure of where he got it from, just that it wasn't on his tray. The meat was expelled and he was transferred to a local hospital emergency room for evaluation. He returned later that day. Chopped meats appropriate secondary to choking potential. [DATE]: Comments: he remains ambulatory and still requires redirection due to getting food from trash bins; Diet Prescription (Rx): Routine with chopped meat, offer a.m. and h.s. snacks. [DATE]: Diet Rx.: Routine with chopped meat, offer a.m. and h.s. snacks Review of Resident #12's physician orders [REDACTED]. Closely observe Do not leave anything in resident room that he can eat, drink, or spray Routine diet: offer a.m. and hour of sleep (h. s.) snacks Supervision at meals Review of Resident #12's re-admission physician orders, dated [DATE] 2:48 p.m. (after the [DATE] hospitalization ) revealed the following, in part: 1. ... 2. status [REDACTED]. 3. Continue all previous orders. Review of the Facility Patient Critical Incident Report revealed the following, in part: Date incident occurred: [DATE] Time: 4:05 a.m.; Vital signs: no vital signs; full respiratory/[MEDICAL CONDITION]; briefly describe incident: patient came from outside area and collapsed in front of the nurses station. Patient was unresponsive due to occluded airway. Food particles in airway. Attempted to clear airway. Ventilations attempted with ambu bag without success; Supervisor's review/recommendation: (include probable cause of injury) Foreign body obstructed airway. Airway cleared of vomitus/debris and after multiple abdominal thrusts removed chicken bone; Do you suspect abuse/neglect: No, Patient had a history of [REDACTED]. Review of the facility Code Record, dated [DATE], 4:45 a.m., revealed the following: Condition upon discovery: Unresponsive, no respirations; Airway: Occluded with foreign body; CPR initiated, 4:05 a.m. Under the Action/Patient Response section of the Code Record was the following notation: Patient collapsed in front of nurses station. Respiratory arrest secondary to airway obstruction (chicken bones). Review of Resident #12's current Care Plan revealed the following, in part: Problem/Need: Potential for injury related to (R/T) behavioral problems as evidenced by History of eating cigarette butts out of the ashtrays, History of eating feces, and Eating out of trash can, etc., Tries to get in to employees cars; Goal andTarget date: There will be no incident of injury by next staffing date. (Goal/Target Dates were : [DATE], [DATE], [DATE]); Approaches: Staff monitor more closely; Closely Observe-do not leave anything in Resident #12 room that he can drink or spray; Watch trays and garbage in dining room, keep him away; There was hand written notation which read: [DATE]: Transferred to area hospital emergency room airway partial occlusion, aspiration pneumonia, [MEDICAL CONDITIONS]. Patient found falling over and choking. [MEDICATION NAME] and abdominal thrusts done. Nothing recovered (may have aspirated cornbread) [DATE] Returned from area hospital. [MEDICATION NAME] 0.4milligrams by mouth every day, [MEDICATION NAME] 250 milligrams by mouth every day x 5 days for pneumonia. Problem/Need: History of choking due to filling mouth too full, Eating too fast, Mechanically altered diet secondary to cognitive status and poor dentition; Problem Onset: [DATE]: Handwritten notation: [DATE]-choking episode; Hanbwritten Notation: [DATE]: Choking episode; Goal: Resident #12 will be able to consume food without choking (Goal/Target dates were : [DATE], [DATE], [DATE]); Approaches: Watch trays and garbage in dining room away from him; Monitor for chewing and swallowing difficulty; Refer for evaluation if Resident #12 has signs/symptoms of chewing or swallowing problems; Evaluate diet as needed; Serve diet as ordered; Encourage to eat slowly and not stuff mouth; If chokes then initiate [MEDICATION NAME] maneuver--- call MD; staff to monitor closely. Review of the facility's 24 Hour Report, dated [DATE], Team A, Shift revealed the following, in part: 6A-6P Resident #12 - ICU at a local hospital. Aspiration Pneumonia/Intubated. [MEDICAL CONDITIONS]. Resident #12 - Choking episode resulting in loss of conscious ...Employees (S41CNA & S44Custodian) performed [MEDICATION NAME] maneuver. Patient was conscious and moving extremities. Patient was eating food out of garbage. Review of the facility Patient Ward Round Sheet for Unit E, dated [DATE], 6 p.m.-6 a.m. shift, revealed the following notations regarding Resident #12's locations/activities: 6 p.m.-6 a.m.shift 2:00 a.m.: hallway 2:30 a.m.: day area 3:00 a.m.: patio 3:30 a.m.: patio 4:00 a.m.: hallway 4:30 a.m.; hallway 5:00 a.m.: hallway 5:30 a.m.: hallway. Review of Resident #12's physician progress notes [REDACTED]. Date of Admission: [DATE] date of death : [DATE] Admission Diagnoses: [REDACTED]. Discharge Diagnoses: [REDACTED]. Mouth cleared but airway with debris. CPR begun. Multiple abdominal thrusts and attempted mouth sweeps without success. [MEDICAL CONDITION] also occurred and [MEDICATION NAME], Sodium [MEDICATION NAME] given without success. After 40 minutes CPR, agonal (abnormal) rhythm briefly seen on monitor, then asystole. Pronounced dead by me (S38MD) at 4:45 hours [DATE]. ( pupils fixed and dilated and no heartrate on auscultation after 1 minute). Spoke with S43Coroner at 5:15 a.m. regarding above. S43Coroner will review as coroner ' s case and stated okay to release body to funeral home. An interview was conducted on [DATE] at 12:20 p.m. with S3ADON. She verified that the resident choked on [DATE]. She verified the resident gorged and ate out of the trash and ate employees' food. She said the resident had tried to get into peoples' cars. She said she did not know why except that it was a "ritual" to him. She said the October and November choking incidents both involved chicken bones. She said there was nothing that could have been done to prevent the resident from getting into garbage cans and trying to get into peoples' cars. She said if something was going on, such as the Bayou Classic, it was hard to staff the facility. She said the nurses rotated out on the units to help out with observations. She said Resident #12 was not ever put on Close Observations and that he was not a danger to anyone else. She said he was "benign" . She said they all "kinda" watched him. She said it was a task to keep up with him. She said trash cans were removed from the nurse's station and his room after his choking episode in October, 2012. She said he was in bad shape when he first came to the facility and she thought they did a pretty good job keeping him alive for [AGE] years. An interview was conducted on [DATE] at 12:40 p.m. with S12CNA. She said she had to redirect the Resident #12 away from the trash cans. She said she worked the night shift the morning Resident #12 expired. She said she saw Resident #12 walk into the facility from outside and fall on the floor in front of the nurse's station. She said his mouth was clenched. She said after he collapsed, she swept his mouth and removed a bone from his mouth. She said all staff in the facility came to the scene. S12CNA further stated that she was assigned to conduct 1:1 Observations of Resident #15 that shift. She said Resident #15 was in the same room with another resident (Resident #17) who had been receiving Close Observations by S34LPN. S12CNA said while S34LPN administered medications at 8:00 p.m., she (S12CNA) helped him (S34LPN) out by watching (Resident#17) in addition to watching Resident #15. She said she also handed out snacks to the residents. She said all the staff helped out. She said on the night shift that night S37CNA did the clothes, handed out cigarettes, and was assigned Close Observations on Resident#18 and Resident #2. When asked what 1:1 Observations meant, she said within hands reach. She said there was a floater CNA that helps out the CNAs doing Close Observation. She said the maximum number of residents they can watch on Close Observation is 2. An interview was conducted on [DATE] at 1:35 p.m. with S9LPN. She worked Resident #12's hall for several years on the day shift. She said after the resident had the choking incident on [DATE], the facility removed the garbage cans out from the locker room on the resident's hall, the resident ' s room and the nurse's station. She said she had worked with the resident after he was readmitted back to the facility after the October choking incident. She said he was not on Close Observations because she was told not to put him on Close Observations. She said she monitored him when he went to garbage cans and redirected him. She said he would always go back to the trash can and redirection was not always effective. She said placing the resident on Close Observations was determined by the doctor. She said she did not ask the doctor (S39MD) if the resident could be placed on Close Observations because she felt like it was the doctor's decision. She said the doctor was aware the resident ate food out of the garbage. She said residents were placed on Close Observations if they wandered away or hurt themselves or others ...such as he (Resident #12) was doing. She said the resident walked all over the place, went the recreation room, went to his room and lay in his bed. An interview was conducted on [DATE] at 2:15 p.m. with S46Counselor. She said she was a counselor and not a licensed social worker. She said Resident #12 would eat anything he could find. She said they staffed him every 3 months. She explained that Dietary, Physical Therapy, MDS Coordinator, Recreation, S28SSD, and S9LPN attended staffing. She said that they did not discuss putting Resident #12 on Close Observations or increasing his supervision during the meeting. She said he could not help his actions because of his mental status. An interview was conducted on [DATE] at 2:20 p.m. with S28SSD. She said her first staffing she attended on the resident was about a week before he died . She said no one had discussed placing the resident on Close Observations or increased supervision to 1:1 at the meeting. An interview was conducted on [DATE] at 2:30 p.m. with S47MDSCoordinator. She said it was the MDS nurse's responsibility to discuss problems and address issues about the residents with the doctor after the staffing meeting. She also said the MDS nurse was responsible for updating the care plan. She said S4RN had not mentioned to her that it had been discussed in the Staffing Meetings to increase the Resident #12's supervision or close observation since the resident's choking incident in October, 2012. On [DATE] at 6:05 p.m., an interview was held with S33RNSupervisor, regarding Resident#12. She explained that Resident #12 gorged food. She said he was always seeking food. She stated that Resident #12 was not placed on Close Observation or 1:1 Supervision, to her knowledge, after the choking incident on [DATE]. She further stated that she was not sure if he had access to the garbage cans in other parts of the building besides the ones in the area of his room. She also said that Resident #12 walked the grounds frequently. On [DATE] at 7:10 p.m. an interview was held with S1Administrator regarding Resident #12. He stated that he felt that that he and the staff had done everything they could to supervise the resident. On [DATE] at 8:40 a.m. a telephone interview was held with S36LPN, regarding Resident #12. She said that Resident #12 had a history of [REDACTED]. She said he also had a history of [REDACTED]. She further stated that Resident #12 was not on Close Observation or 1:1Supervision prior to or after the incident on [DATE]. She said she heard S38MD talking about placing the resident on Close Observation if he returned to the facility that day. She said the resident ended up staying in the hospital until [DATE] and changing his status to Close Observation or 1:1 Supervision was never initiated. She explained that counseling the resident not to eat from the trash cans was not effective because the resident was unable understand due to his mental deficits. She further stated that it took multiple efforts to redirect the resident and he would still return to the garbage seeking food. On [DATE] at 9 a.m. a telephone interview was held with S37CNA, regarding Resident #12. She said that the resident had a history of [REDACTED]. She also said that the resident had a history of [REDACTED]. She said she had given Resident #12 extra snacks to try to keep him from going outside to look for food from the trash cans. Review of the facility's policy and procedure for wandering/elopement revealed the following, in part: Purpose: to identify residents at risk for wandering/elopement and implement measures to prevent harm and ensure safety; Wandering- resident strays into unsafe territories and may be harmed ...Elopement- most dangerous form of wandering. Can be differentiated from those that only wander by their purposeful, overt, and repeated attempts to leave the building or premises; Procedure: Elopement: A. residents at risk for elopement are identified by nursing staff through direct observation. The resident's behavior is documented in the resident's medical record; B. The resident is assessed by the treatment team and specific issues that may trigger his/her desire to elope are identified ...C. When a wandering incident occurs the nursing staff will immediately place the wandering resident on close observation and the physician will be notified within 1 hour for additional orders to confirm close observation. D. The physician order [REDACTED]. The resident is assessed by the treatment team and specific issues that may trigger his/her desire to elope are identified. Interventions to address the issues triggering the desire to elope are addressed in the care plan and implemented by nursing staff. Monitoring/tracking devices are used to monitor those residents at risk of elopement. C. The physician is notified of the resident's risk for elopement and orders for One-to-One (1:1) Observation are entered on the resident's medical record ... Resident #15 Review of Resident #15's clinical record revealed the resident was admitted to the facility on [DATE]. His date of birth was [DATE]. His Medical [DIAGNOSES REDACTED]. Review of Resident #15's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] revealed a BIMS (Brief Interview for Mental Status) was not conducted on the resident. The MDS revealed the resident was rarely/never understood. An observation was conducted on ,[DATE] at 1:15 p.m. of Resident #15. He was active and alert walking in and out of his room participating in conversations with other residents and staff. S41CNA was observed sitting in the hallway outside of Resident #15's room. An interview was conducted with S41CNA at that time. He verified he was performing one on one observations of Resident #15. An interview was conducted on [DATE] at 8:45 a.m. with S36LPN regarding Resident #15's 1:1 observation status. She stated that Resident #15 had a history of [REDACTED]. When asked why the resident stayed on close observation and was not increased to 1:1 status after multiple elopement attempts and she responded, "I guess the MD thought close observation was enough supervision." An interview was conducted on [DATE] at 9:10 a.m. with S37CNA, regarding Resident #15's elopement behavior. She stated that the resident had a violent temper and had eloped from the facility on the other nursing shift. An interview was conducted on [DATE] at 11:38 p.m. with S3ADON. She confirmed that Resident #15 was on Close Observations during his elopements from the facility. When asked why it took so long for Resident #15 to be placed on 1:1 observations after having eloped from the building numerous times she replied that it was the doctor ' s decision to change a resident from close observations to 1:1 observations. She further explained that Close Observations involved one staff member to three Close Observation residents. When asked if it was the facility's policy for staff to be assigned to perform close observations on a resident at risk for elopement along with close observation of 2 other residents, she responded that other facility staff watched the remaining residents if staff was required to pursue a resident eloping. An interview was conducted on [DATE] at 12:00 with S42CNA. She stated she was familiar with Resident #15 and had been assigned to do observations on him. She said he eloped on Saturday afternoon ([DATE]) when she was assigned close observations on him. She explained that while she was in the restroom S40CNA (floater CNA) was assigned, in her place, to watch Resident #15. She further explained while she was in the restroom Resident #15 eloped and ran toward the entrance gate. She stated he was much faster than they were and he knew exactly where he wanted to go. She said he eloped to (named area nursing facility) and was PEC'd after the facility picked him up. She said upon return to the facility from the hospital, the resident was placed on 1:1 observations. She said he had not eloped before on her shift, but that he had eloped before on the opposite nursing team. In addition, she explained that she and the other CNAs did not think they were supposed to be assigned to watch more than 2 close observation residents at one time on the day shift, but the facility told them it was ok to do so. An interview was conducted on [DATE] at 12:27 p.m. with S2DON. She was asked how a resident's supervision level was increased to close observation or 1:1 supervision and she responded that it must be ordered by an MD (Medical Doctor). She explained that any nurse who felt a resident needed increased supervision could discuss his or her concerns with the MD. The DON confirmed Resident #15 had eloped from the facility while being on close observation. She was asked why, after multiple elopement attempts, Resident #15 had remained on close observation and was not increased to 1:1 supervision until [DATE]. She said making Resident #15 1:1 would have just looked good on paper and that it would not have done any good because the resident would have continued to attempt elopement. She said she and S1Administrator asked staff why Resident #15 continued to elope despite close observation and they responded that "He is

Based on interview and record review the facility failed to review and revise the care plan for 3 ( #12, #1, #15) of 15 (#1, #2, #3, #4, #5, #6,#7,#8, #9,#10, #11, #12, #13, #14, #15) residents reviewed for accidents/supervision. The facility failed to: 1. Review and revise interventions for a a severely cognitively impaired resident (#12), with a significant history of choking and of scavenging/eating food from the garbage, when he returned from a hospitalization that required intubation as a result of a choking incident. The facility had knowledge that redirection had not been effective in the past.(#12) 2. Identify and implement new interventions and approaches to prevent physical altercations between Resident #1 and other facility residents after the incident on [DATE] when Resident #1 was involved in an altercation with resident #3 on [DATE] in which Resident #3 received a broken ankle. 3. Identify and implement new interventions to prevent physical altercations between Resident #1 and other residents following a fist fight between Resident #1 and another resident on [DATE], after Resident #1 punched another resident in the mouth on [DATE], and after physical altercations with another resident on [DATE] and [DATE]. 4. Revise and impliment interventions for a resident who exhibited unsafe wandering and elopement while under close supervision. (#15) The Immediate Jeopardy began for Resident #12 on [DATE] when he returned to the facility from a hospitalization that required intubation, which resulted from choking on food debris. The facility failed to review and revise the care plan interventions regarding supervision and monitoring on this resident with a significant history of scavenging food from the garbage ( and other sources) and choking to prevent him from scavenging and eating from the trash cans. The Administrator was notified of the Immediate Jeopardy on [DATE] at 7:10 p.m. The Immediate Jeopardy ended on [DATE] at 4:45 a.m. when Resident #12 expired. The Immediate Jeopardy was lowered to a Level III isolated, actual harm on [DATE] at 4:45 a.m. when Resident #12 expired. The Administrator was notified of the Immediate Jeopardy on [DATE] at 12:30 p.m. for Resident #1. Other residents, who came in contact with Resident #1, were placed in Immediate Jeopardy from the aggressive, violent behaviors initiated by Resident #1. The facility failed to implement a system of supervision and monitoring of Resident #1 to prevent his aggressive, violent behaviors from hurting other residents. The Immediate Jeopardy began on [DATE] when the facility failed to ensure supervision of Resident #1 was increased after Resident #1 fractured Resident #3's ankle in an altercation. The Immediate Jeopardy continued when Resident #1 continued to have multiple altercations with other residents. Resident #1 fractured Resident #2's nose on [DATE] during an altercation. On [DATE] Resident #3 received a loose tooth, swollen lip, and cheek abrasion during an altercation with Resident #1. Resident #1 was placed on an Physician Emergency Certificate on [DATE] and [DATE]. Supervision of Resident #1 was not increased after these incidents. The Immediate Jeopardy ended on [DATE] at 12:00 p.m. when Resident #1 was placed on Close Observations. The Immediate Jeopardy was lowered to a Level II -pattern on [DATE] for Resident #1. The Administrator was notified of the Immediate Jeopardy on [DATE] at 7:10 p.m. for Resident #15. The Immediate Jeopardy began on [DATE] when the facility failed to ensure supervision of Resident #15 after his second elopement attempt where he was found trying to climb over the closed gate while under close observation. The facility failed to increase supervision and monitoring on [DATE] when 2 elopement attempts occurred while under close observation with no further interventions in place and no increase in monitoring. On [DATE] Resident #15 eloped out of the facility, past the gate and ran to the highway, flagged down a female motorist, began choking her in her car while on close observation. No new interventions for increased supervision or monitoring were put into place. On [DATE] Resident #15 eloped while under close observation off of facility grounds and traveled 1.6 miles to the grounds of a local nursing facility. This immediate jeopardy was lifted when Resident #15 was PEC'd to a local hospital on [DATE] at 5:10 p.m. and returned as 1:1 supervision. The Immediate Jeopardy was lowered to a Level II - pattern on [DATE] for Resident #15. Findings: Review of the facility's policy for Close Observation and One- To-One Monitoring revealed the following: Purpose: To establish guidelines for nursing staff to implement and follow when close observation or one -to -one monitoring is ordered on a resident . Examples of reasons for ordering close observation or one -to- one monitoring include, but are not necessarily limited to wandering, sexually inappropriate behavior, aggressive behavior toward other residents, and behavior that poses a danger to the resident or others. Procedure for: 1. Close observation: The resident must be within assigned staff member's line of vision at all Times; One-to-One: Assigned staff member must be within six feet of resident at all times 2. The nurse must have a physician's orders [REDACTED]. The order must include the reason and verbal orders must be signed by the physician within 24 hours. The order will remain active/valid until discontinued. 3. Close Observation Monitoring record will be initiated by nursing staff when the resident is placed on one-to-one monitoring. 4. The staff member assigned to monitor the resident will document every 15 minutes on the Close Observation or One -to- One monitoring Record. 5. The resident will not be permitted to attend off- unit functions until the precautions are discontinued. Resident #12 Review of Resident #12's clinical record revealed the following: Date of Birth: [DATE] Date of Admission: [DATE] [DIAGNOSES REDACTED]. Review of Resident #12's most recent Minimum Data Set (MDS), Assessment Reference Date (ARD): [DATE]; Type: Quarterly, revealed the following: Cognitive Patterns: Brief interview for Mental Status ( BIMS): should resident interview be conducted: No ( resident is rarely/never understood); Cognitive skills for daily decision making: 3. Severely impaired- never/rarely made decisions Acute onset mental status change: No Swallowing/Nutritional status: Swallow disorder: none of the above: checked Height (in inches): 70 Weight(in pounds): 245 Nutrition approach: Resident: mechanically altered diet: checked; Nutrition approach: Resident: therapeutic diet: checked; Occupational Therapy: blank Review of the Resident #12's physician progress notes [REDACTED]. Stridor (harsh breathing sound associated with obstruction) was heard by staff. ,[DATE] pulse, 71 oxygen saturation, 99% on 100% re-breather (oxygen mask), with room air was 87%, now trying to get up and wander, still raspy sounding in throat, patient was pulse less and on sofa, placed on floor and [MEDICATION NAME] done, then patient started respirations and pulse returned; Impression: Aspiration of chopped meat; Plan: transfer to area hospital [DATE], 7:50 a.m.: patient still digging through garbage cans, trying to get in to cars, Plan: Continue Care, yard/cigarettes from garbage cans, continue medications [DATE], 8:26 a.m.: patient the same wandering and eating out of garbage, plan: continue medications, continue care [DATE], 11:10 a.m.: Patient still eating from garbage can and trying to get in cars on the grounds, Plan: continue medications, continue care [DATE], 8:30 a.m. Patient doing the same, wandering grounds, trying to get in cars, picking up things from the ground and garbage cans and eating them: plan: continue medications, continue care, keep special appointments [DATE]: (no time documented): still eating from garbage cans, plan: continue medications, continue care [DATE], (no time documented): Transfer note: Patient found falling over, choking. [MEDICATION NAME] and abdominal thrust done. Nothing recovered, may have aspirated cornbread, patient supine on floor, now minimally responsive, heart rate 108, respiratory rate 16, with decreased breath sounds right anterior chest, abdomen with positive bowel sounds, 1. Aspiration, 2. Airway- partial occlusion 3.[MEDICAL CONDITION] 4. Mental [MEDICAL CONDITION] 5. Constipation; Plan: to area hospital emergency room via local ambulance service [DATE]; 2:49 p.m.: status [REDACTED]. Review of Resident #12's Nutritional Staffing Notes, [DATE], revealed the following entries, in part: Regular quarterly staffing; Other disciplines: Nursing: choking incident on [DATE]; Comments: Resident #12 had a choking incident last week. He choked on a piece of meat. Unsure of where he got it from, just that it wasn't on his tray. The meat was expelled and he was transferred to a local hospital emergency room for evaluation. He returned later that day. Chopped meats appropriate secondary to choking potential; [DATE]: Comments: He remains ambulatory and still requires redirection due to getting food from trash bins; Diet Prescription (Rx): Routine with chopped meat, offer a.m. and hour of sleep (h.s) snacks; [DATE]: Diet Rx.: Routine with chopped meat, offer a.m. and h.s. snacks Review of Resident #12's Physician order [REDACTED]. Do not leave anything in resident room that he can eat, drink, or spray Routine diet: offer a.m. and hour of sleep (h. s.) snack Supervision at meals Review of Resident #12's re-admission physician orders, dated [DATE] 2:48 p.m. (after the [DATE] hospitalization ) revealed the following, in part: 1. ... 2. status [REDACTED]. 3. Continue all previous orders. Review of Resident #12's current Care Plan revealed the following, in part: Problem/Need: Potential for injury related to (R/T )behavioral problems as evidenced by History of eating cigarette butts out of the ashtrays, History of eating feces, and Eating out of trash can, etcetera (etc.), tries to get in to employees cars. Goal and Target date: There will be no incident of injury by next staffing date. (Goal/Target dates were : [DATE], [DATE], [DATE]) Approaches: Staff monitor more closely; Closely Observe-do not leave anything in Resident #12 room that he can drink or spray; Watch trays and garbage in dining room, Keep him away; Hand written notation on Care Plan: [DATE]: Transferred to area hospital emergency room : Airway partial occlusion, aspiration pneumonia, [MEDICAL CONDITIONS]. Patient found falling over and choking. [MEDICATION NAME] and abdominal thrusts done. Nothing recovered (may have aspirated cornbread) [DATE]: Returned from area hospital. [MEDICATION NAME] 0.4milligrams by mouth every day, [MEDICATION NAME] 250 milligrams by mouth every day x 5 days for pneumonia Problem/Need; History of choking due to filling mouth too full, eating too fast, mechanically altered diet secondary to cognitive status and poor dentition Problem Onset [DATE]; [DATE]-choking episode [DATE]: choking episode Goal: Resident #12 will be able to consume food without choking (Goal/Target dates were : [DATE], [DATE], [DATE]) Approaches: Watch trays and garbage in dining room away from him; Monitor for chewing and swallowing difficulty; Refer for evaluation if Resident #12 has signs/symptoms of chewing or swallowing problems; Evaluate diet as needed; Serve diet as ordered; Encourage to eat slowly and not stuff mouth; if chokes then initiate [MEDICATION NAME] maneuver--- call MD; staff to monitor closely Review of the facility nurses notes revealed the following entries, in part: [DATE], 11:00 a.m. Redirected multiple times out of garbage cans. Counseling ineffective [DATE], 11:00 p.m. Goes in to other patient 's rooms and steals any food he finds [DATE], (no time documented): Decision making skills: Severely impaired: Poor insight and judgment, Eats out of the trash, Counseling and redirection ineffective [DATE], (no time documented): Ability to understand: Sometimes understands: Redirected frequently to eat food slowly [DATE], 7:20 a.m. S24CNA, noted that patient( pt.) had food in mouth and hand. Pt. sitting on side of nurses' station. S24CNA asked pt. what he had in his hand. Pt. unresponsive to CNA- S40CNA called this nurse (S36LPN) to pt. Noted pt. slumped over in chair attempted to perform the [MEDICATION NAME], abdominal thrust, and back blows. CPR also attempted, all without success. Attempted to suction without success [DATE], 7:25 a.m.: S38MD notified, instructed to continue all efforts until he arrived to unit. S25RN notified. Efforts continued [DATE], 7:30a.m. S50RN arrived to ward for assistance. Efforts continued patient gasping for air, oxygen started with an oxygen mask at 15 liters and oxygen saturation of 92% on 100% oxygen (maximum amount of oxygen that can be delivered), Pulse 105 [DATE], 7:35 a.m.: Medical doctor (MD) on ward to assess patient. Efforts continue, patient continues gasping, eyes are open but unfocused [DATE], 7:40 a.m.: Local ambulance transfer to area hospital with lights and sirens. Patient breathing improves marginally. Continue to monitor. [DATE], 7:55 a.m.: local ambulance service arrives, patient attempting to stand. Instructed patient to stay lying on floor. Patient appears confused. Breathing becomes more labored. Patient is assisted to stretcher. [DATE], 5:15 p.m.: Received update from area hospital. Patient admitted to intensive care unit with aspiration pneumonia, [MEDICAL CONDITIONS], and intubation. [DATE], 2:27 p.m. Return from local hospital, ambulatory, accompanied by CNA. Resident alert to name only. Follow simple instructions with redirection [DATE], 2:43 p.m. MD on unit. Exam resident. Mental status unchanged, answering "yes" to all questions. Instruct staff to Monitor Closely- trash cans and barrel from locker area are now removed [DATE], 4:45 p.m.: reported by CNA, another resident went to room and struck Resident #12 with a metal object several times on the buttocks. Resident #12 sustained no injuries. The other resident stated Resident #12 had eaten his cookies out of his room. Unable to counsel Resident #12 due to impaired thought process and insight. Review of the facility's 24 Hour Report, dated [DATE], Team A, Shift revealed the following, in part: 6 a.m.-6 p.m. Resident #12 - ICU at a local hospital. Aspiration Pneumonia/Intubated. [MEDICAL CONDITIONS]. Resident #12 - Choking episode resulting in loss of conscious ...Employees (S41CNA & S44Custodian) performed [MEDICATION NAME] maneuver. Patient was conscious and moving extremities. Patient was eating food out of garbage. Review of Resident #12's Multidisciplinary Staffing Notes revealed the following entries, in part: [DATE]: Comments: Counseled on staying out of the garbage cans for food, etc. [DATE]: Comments: Counseled on staying out of the garbage cans for food, etc. [DATE]: Reason for staffing: On [DATE]: Transferred to area hospital emergency room : Airway partial occlusion and aspiration, [DATE]; Returned from area hospital , [DATE]: Psychiatric Consult: Continue medications, Comments: Counseled on staying out of garbage cans for food, etc. Review of Resident #12's Social Services Notes revealed the following entries, in part: [DATE] Behavior: Supervision with meals; Patient continues to ramble over parking lot looking for open car doors, goes in to garbage searching for food. Goals/Plan: Rambles around all day hunting for food anywhere he can find it. He must be redirected many times for eating out of garbage cans. He goes in other patients' rooms hunting for food also. [DATE] Patient choked on food- was sent to an area hospital. Now in Intensive Care Unit and intubated (has a breathing tube) - has aspiration pneumonia. [DATE] Behavior: Eats out of trashcans, Goals/Plans: Resident continues to walk searching for food in the cars and in the garbage. Resident on routine diet with chopped meats, Needs constant supervision and care. Transported to an area hospital for choking and intensive care unit (ICU) care: Returned to facility on [DATE]. [DATE] Returned from area hospital after a choking episode. He eats out of the garbage cans and can't be stopped. He continues to walk aimlessly hunting for food in the garbage and in the workers' cars if he can have access to them. He is severely disabled with mental [MEDICAL CONDITION]. Review of Resident #12's CNA Activities of Daily Living (ADL) Sheets for ,[DATE]-,[DATE] revealed the following, in part: Observe patient for choking at meal times; Supervision at meals to keep patient from eating extra food Do not leave anything in patient's room that he can eat, drink, or spray. The ADL sheets were documented upon daily, every 12 hours. Review of Resident #12's History and Physical, dated [DATE] (from the area hospital where he was admitted on [DATE]), revealed the following, in part: Chief complaint: patient was transferred from the nursing home when he was found to be choking, short of breath, and tachypneic, patient was intubated and admitted to Intensive Care Unit for pneumonia; Respiratory : patient intubated; Impression: Pneumonia(aspiration), Acute [MEDICAL CONDITION], continue ventilator support. . Review of the Facility Patient Critical Incident Report revealed the following, in part: Date incident occurred: [DATE], Time: 4:05 a.m.; Vital signs: no vital signs; full respiratory/[MEDICAL CONDITION]; briefly describe incident: patient came from outside area and collapsed in front of the nurses station. Patient was unresponsive due to occluded airway. Food particles in airway. Attempted to clear airway. Ventilations attempted with ambu bag without success Supervisor's Review/Recommendation: (include probable cause of injury) Foreign body obstructed airway. Airway cleared of vomitus/debris and after multiple abdominal thrusts removed chicken bone; Do you suspect Abuse/Neglect: No, Patient had a history of [REDACTED]. Review of the facility Code Record, dated [DATE], 4:45 a.m., revealed the following: Condition upon discovery: Unresponsive, no respirations; Airway: Occluded with foreign body; CPR initiated 4:05 a.m. Under the Action/Patient Response section of the Code Record was the following notation: Patient collapsed in front of nurses station. Respiratory arrest secondary to airway obstruction (chicken bones). Review of the facility Patient Ward Round Sheet for Unit E dated [DATE], 6 p.m.-6 a.m. shift, revealed the following notations regarding Resident #12's location/activities: 2:00 a.m.: hallway 2:30 a.m.: day area 3:00 a.m.: patio 3:30 a.m.: patio 4:00 a.m.: hallway 4:30 a.m.: hallway 5:00 a.m.: hallway 5:30 a.m.: hallway. Review of Resident #12's physician progress notes [REDACTED]. Date of Admission: [DATE] date of death : [DATE] Admission Diagnoses: [REDACTED]. Discharge Diagnoses: [REDACTED]. Mouth cleared but airway with debris. CPR begun. Multiple abdominal thrusts and attempted mouth sweeps without success. [MEDICAL CONDITION] also occurred and [MEDICATION NAME], Sodium [MEDICATION NAME] given without success. After 40 minutes CPR, agonal( abnormal) rhythm briefly seen on monitor, then asystole. Pronounced dead by me (S38MD) at 4:45 hours [DATE]. ( pupils fixed and dilated and no heartrate on auscultation ( listening) after 1 minute). Spoke with S43Coroner at 5:15 a.m. regarding above. S43Coroner will review as coroner's case and stated okay to release body to funeral home. An interview was conducted on [DATE] at 12:20 p.m. with S3ADON. She verified that Resident #12 choked on [DATE]. She verified the resident gorged and ate out of the trash and ate employees' food. She said the resident had tried to get into peoples' cars. She said she did not know why except that it was a "ritual" to him. She said the October and November choking incidents both involved chicken bones. She said there was nothing that could have been done to prevent the resident from getting into garbage cans and trying to get into peoples' cars. She said the nurses rotated out on the units to help out with observations. She said Resident #12 was not ever put on Close Observations and that he was not a danger to anyone else. She said he was "benign" . She said they all "kinda" watched him. She said it was a task to keep up with him. She said trash cans were removed from the nurse's station and his room after his choking episode in October, 2012. An interview was conducted on [DATE] at 1:35 p.m. with S9LPN. She worked Resident #12's hall for several years on the day shift. She said after the resident had the choking incident on [DATE], the facility removed the garbage cans out from the locker room on the resident's hall, the resident's room and the nurse's station. She said she had worked with the resident after he was readmitted back to the facility after the October choking incident. She said he was not on Close Observations because she was told not to put him on Close Observations. She said she monitored him when he went to garbage cans and redirected him. She said he would always go back to the trash can and redirection was not always effective. She said placing the resident on Close Observations was determined by the doctor. She said she did not ask the doctor (S39MD) if the resident could be placed on Close Observations because she felt like it was the doctor's decision. She said the doctor was aware the resident ate food out of the garbage. She said residents were placed on Close Observations if they wandered away or hurt themselves or others ...such as he (Resident #12) was doing. She said the resident walked all over the place, went the recreation room, went to his room and lay in his bed. An interview was conducted on [DATE] at 2:15 p.m. with S46Counselor. She said she was a counselor and not a licensed social worker. She said Resident #12 would eat anything he could find. She said they staffed him every 3 months. She explained that the following staff members attended the staffing meeting: Dietary, Physical Therapy, MDS Coordinator, Recreation, S28SSD, and S9LPN. She said that they did not discuss putting Resident #12 on Close Observations or increasing his supervision during the meeting. She said he could not help his actions because of his mental status. She said the resident had a change on his MDS after he returned from the hospital and she had to complete a portion on the MDS. An interview was conducted on [DATE] at 2:20 p.m. with S28SSD. She said her first staffing she attended on the resident was about a week before he died . She said no one had discussed placing the resident on Close Observations or increased Supervision to 1:1 at the meeting. An interview was conducted on [DATE] at 2:30 p.m. with S47MDSCoordinator. She said she had been the MDS Coordinator since August, 2012. She said S4RNCarePlan was the MDS nurse assigned to the resident. She said it was the MDS nurse's responsibility to discuss problems and address issues about the residents with the doctor after the staffing meeting. She also said the MDS nurse was responsible for updating the care plan. She said S4RN had not mentioned to her that it had been discussed in the Staffing Meetings to increase the Resident #12's Supervision or Close Observation since the resident's choking incident in October, 2012. On [DATE] at 6:05 p.m., an interview was held with S33RNSupervisor, regarding Resident#12. She explained that Resident #12 gorged food. She said he was always seeking food. She stated that Resident #12 was not placed on Close Observation or 1:1 Supervision, to her knowledge, after the choking incident on [DATE]. She further stated that she was not sure if he had access to the garbage cans in other parts of the building besides the ones in the area of his room. She also said that Resident #12 walked the grounds frequently. On [DATE] at 8:40 a.m. a telephone interview was held with S36LPN, regarding Resident #12. She said that Resident#12 had a history of [REDACTED]. She said he also had a history of [REDACTED]. She further stated that Resident #12 was not on Close Observation or 1:1 Supervision prior to or after the incident on [DATE]. She said she heard S38MD talking about placing the resident on Close Observation if he returned to the facility that day. She said the resident ended up staying in the hospital until [DATE] and changing his status to Close Observation or 1:1 Supervision was never initiated. She explained that counseling the resident not to eat from the trash cans was not effective because the resident was unable understand due to his mental deficits. She further stated that it took multiple efforts to redirect the resident and he would still return to the garbage seeking food. On [DATE] at 12:30 p.m. an interview was conducted with S48QualityManagement regarding Resident #12. She verified that the resident's care plan should have been updated and should have reflected that the resident was to be watched more closely. Resident #1 Review of Resident #1's clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses, in part, included [MEDICAL CONDITION] disorder, Personality disorder, Late Effect [MEDICAL CONDITION] with [MEDICAL CONDITIONS], Intermittent Explosive Behavior Disorder, Old Head Injury, Depression, and Aggressive Behavior. Review of the Minimum Data Set, Assessment Reference Date (ARD) [DATE], revealed a BIMS (Brief Interview Mental Status) score of 15 (independent). Section E-Behavior, E0200A: Physical behavior symptoms directed toward other indicated the behavior had occurred 1 to 3 days. Review of the Minimum Data Set (MDS), ARD [DATE], revealed a BIMS score of 15. Section E-Behavior, E0200A: Physical behavior symptoms directed toward others indicated the behavior had occurred 1 to 3 days. Review of documentation from a Behavior Center hospitalization revealed the resident was admitted on [DATE] and discharged on [DATE] back to the nursing home he was residing at in the northern part of the state. His discharge [DIAGNOSES REDACTED]. The documentation revealed the resident had problems related to social environment, psychosocial, environmental, primary support group and housing. Review of documentation of a consultation report from a hospital in the northern part of the state, dated [DATE], revealed the resident was hospitalized for [REDACTED]. The consultation revealed the resident was admitted to the Senior Care Unit for increased agitation after hitting another resident at the nursing home in the northern part of the state. Review of the Psychiatric Evaluation revealed the resident said he hit another resident on the head 3 times. The evaluation revealed the resident had a history of [REDACTED]. Review of the physician's orders [REDACTED]. Review of a Psychiatry Consultation Report (current facility), dated [DATE], revealed the resident was calm and cooperative during the session. The Impression was [MEDICAL CONDITION] Disorder, Personality Disorder and Intermittent [MEDICAL CONDITION]. The plan was to continue current medications and to follow the resident. Review of the Social Service Notes, dated [DATE], revealed the resident had been cooperative since admission, but had a history of [REDACTED]. Review of a Physician's Note, dated [DATE], revealed the resident told the Physician that he used to be a Tasmanian devil and can still be at times. A Physician's Note, dated [DATE] at 14:08, revealed Resident #1 hit another resident after the resident's wheelchair scrapped Resident #1's knee. The other resident received a small abrasion above the left eyebrow. The note continued that the other resident hit Resident #1 first. A Physician's Note, dated [DATE] at 20:00, revealed Resident #1's violent behavior had been escalating over the last 10 days. The note revealed Resident #1 was fighting with another resident last week who received a broken ankle during the fight. The note continued that on [DATE] Resident #1 started fighting with his roommate, knocked the roommate's TV over, threatened to kill his roommate that night, scratched the roommate, closed the nurse's hand in the door and struck her with a pillow, and struck an aide with a pillow. The note revealed that the resident was sent to the hospital on a Physician's Emergency Certificate (PEC). The resident was sent to the hospital on [DATE] at 2025. A Physician's Note, dated [DATE], revealed the resident returned to the facility from the hospital in a much better mood. The note revealed there were no needed changes. [MEDICATION NAME] 2 mg. by mouth every 6 hours as needed was ordered. A Physician's Note, dated [DATE], revealed Resident #1 was in a verbal altercation with another resident after Resident #1 ran over the other resident's feet. A Physician's Note, dated [DATE], revealed Resident #1 was kicked in the groin at 12:20 during an altercation with Resident #4. The note said there was no [MEDICAL CONDITION] or obvious injury to the groin. The plan was for the staff to monitor. A Psychiatric Consult note, dated [DATE], revealed the resident was hospitalized for [REDACTED]. The note continued there were no changes in the resident's medications. A Physician's Note, dated [DATE], revealed Resident #1 was accused by Resident #2 of hitting him in the right side of the face. Resident #2 had an abrasion and red sclera. The alleged incident was not witnessed and Resident #1 denied hitting Resident #2. A Physician's note, dated [DATE], revealed Resident #1 became angry about not getting a cigarette when he wanted it. The note continued that Resident #1 became violent, cursing staff and patients and trying to fight patients. The note said that Resident #1 was throwing chairs and pushing a table. The note said the resident was sent to the hospital under a Physician's Emergency Certificate. A Physician's Note, dated [DATE], revealed the resident returned to the facility with no medication changes. A Physician's Note, dated [DATE], revealed Resident #1 denied he hit another resident on the mouth and forehead causing injury to the other resident, who went to the hospital. The note said the incident was witnessed. R

Based on interview and record review the facility failed to meet professional standards of quality for 3 (#12, #1, #15) of 15 ( #1, #2, #3, #4, #5, #5, #6, #7,#8,#9,#10,#11,#12,#13,#14,#15). The facility failed to ensure residents received increased supervision after being involved in multiple physical altercations with other residents (#1), having eloping from the facility on multiple occasions (#15), and a resident with a choking problem experienced a life threatening choking episode after eating food without staff supervision (#12). The facility failed to: 1. Assess the need for changes in interventions regarding the level of supervision required for a severely cognitively impaired resident (#12), with a significant history of choking and of scavenging and eating food from the garbage, when he returned to the facility on [DATE], after a life threatening choking event which required hospitalization and intubation. 2. Ensure that increased supervision/monitoring was initiated after a severely cognitively impaired resident (#12) returned to the facility after choking on food debris on [DATE] that resulted in a life threatening event which required hospitalization and intubation. 3. Ensure staff involved in the multidisciplinary staffing meeting discussed issues/problems and revise interventions to prevent him from eating food out garbage cans without staff supervision for a severely cognitively impaired resident (#12) known to gorge food, who staff knew would eat anything he could get out of the trash can and for whom the interventions of redirecting away from the garbage cans was noted to be ineffective after he returned to the facility on [DATE] following a hospitalization for a life threatening choking event on [DATE]. 4. Identify and implement new interventions and approaches to prevent altercations between Resident #1 and other resident after [DATE] when Resident #1 was involved in an altercation with resident #3 on [DATE] in which Resident #3 received a broken ankle. 5. Implement a system of increased supervision and monitoring of Resident #1 on [DATE] to prevent altercations with other resident after Resident #1 was involved in an altercation with Resident #3 on [DATE] in which Resident #3 received a broken ankle. 6. Identify and implement a system of increased supervision and monitoring of Resident #1 on [DATE] after Resident #1 started a fight with his roommate, knocked the roommate's TV over, threatened to kill his roommate, scratched the roommate, and closed the nurse's hand in the door on [DATE]. 7. Identify and implement new interventions to prevent physical altercations between Resident #1 and other residents following a fist fight between Resident #1 and another resident on [DATE], after Resident #1 punched another resident in the mouth on [DATE], and after physical altercations with another resident on [DATE] and [DATE]. 8. Implement a system of increased supervision and monitoring of Resident #1 on [DATE] after Resident #1 broke Resident #2's nose during a physical altercation on [DATE]. 9. Have a system in place to protect other residents from Resident #1's aggressive, violent behaviors 10. Have a system in place to protect Resident #1 from physical and verbal altercations initiated by other residents after [DATE] when he was kicked in the groin on [DATE] by another resident. 11. Ensure staff reassessed Resident #15 for a need for changes of interventions and approaches regarding supervision to prevent elopement after elopement attempts and successful elopements from the facility on [DATE], [DATE], [DATE],[DATE] while under close observation by facility staff. The Administrator was notified of the Immediate Jeopardy on [DATE] at 7:10 p.m. On [DATE], Resident #12, a severely cognitively impaired resident, was transferred to an area emergency room with partial airway occlusion, aspiration pneumonia after choking on possible food debris. Resident #12's history was significant for digging in garbage cans for food and choking. Due to his cognitive status, intervention of redirection was ineffective for this resident per facility's staff documentation. Resident #12 was placed in Immediate Jeopardy on [DATE] when he returned from the hospital and the facility failed to identify and implement new interventions to prevent him from digging in garbage cans and eating food without staff supervision. On [DATE] at approximately 4:05 a.m., Resident #12 came in from outside area and collapsed in front of the nurses station. Resident #12 was unresponsive due to occluded airway. During attempts to clear airway, food particles, including a chicken bone were removed from Resident #12's airway. Despite [MEDICATION NAME] Maneuver and initiation of CPR, Resident #12 expired. The Immediate Jeopardy ended for Resident #12 on [DATE] at 4:45 a.m. when he expired. The Immediate Jeopardy was lowered to a Level III isolated, actual harm on [DATE] at 4:45 a.m. when Resident #12 expired. The Administrator was notified of the Immediate Jeopardy on [DATE] at 12:30 p.m. for Resident #1. Other residents, who came in contact with Resident #1, were placed in Immediate Jeopardy from the aggressive, violent behaviors initiated by Resident #1. The facility failed to implement a system of supervision and monitoring of Resident #1 to prevent his aggressive, violent behaviors from hurting other residents. The Immediate Jeopardy began on [DATE] when the facility failed to ensure supervision of Resident #1 was increased after Resident #1 fractured Resident #3's ankle in an altercation. The Immediate Jeopardy continued when Resident #1 continued to have multiple altercations with other residents. Resident #1 fractured Resident #2's nose on [DATE] during an altercation. On [DATE] Resident #3 received a loose tooth, swollen lip, and cheek abrasion during an altercation with Resident #1. Resident #1 was placed on an Physician Emergency Certificate on [DATE] and [DATE]. Supervision of Resident #1 was not increased after these incidents. The Immediate Jeopardy ended on [DATE] at 12:00 p.m. when Resident #1 was placed on Close Observations. The Immediate Jeopardy was lowered to a Level II -pattern on [DATE] for Resident #1. The Administrator was notified of the Immediate Jeopardy on [DATE] at 7:10 p.m. for Resident #15. The Immediate Jeopardy began on [DATE] when the facility failed to ensure supervision of Resident #15 after his second elopement attempt where he was found trying to climb over the closed gate while under close observation. The facility failed to increase supervision and monitoring on [DATE] when 2 elopement attempts occurred while under close observation with no further interventions in place and no increase in monitoring. On [DATE] Resident #15 eloped out of the facility, past the gate and ran to the highway, flagged down a female motorist, began choking her in her car while on close observation. No new interventions for increased supervision or monitoring were put into place. On [DATE] Resident #15 eloped while under close observation off of facility grounds and traveled 1.6 miles to the grounds of a local nursing facility. This immediate jeopardy was lifted when Resident #15 was PEC'd to a local hospital on [DATE] at 5:10 p.m. and returned as 1:1 supervision. The Immediate Jeopardy was lowered to a Level II - pattern on [DATE] for Resident #15. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses Subpart, I. Practical Nurse, under subchapter E. Curriculum Requirements revealed in part ..."3. development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with [MEDICATION NAME], including increased and ongoing development of self awareness, sound judgment, prudence, ethical thinking and behaviors, problem solving and critical thinking abilities...7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, IV therapy, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety an infection control, communication and documentation, and working as a member of the interdisciplinary health care team..." Review of the facility's policy for Close Observation and One- To-One Monitoring revealed the following: Purpose: To establish guidelines for nursing staff to implement and follow when close observation or one -to -one monitoring is ordered on a resident . Examples of reasons for ordering close observation or one -to- one monitoring include, but are not necessarily limited to wandering, sexually inappropriate behavior, aggressive behavior toward other residents, and behavior that poses a danger to the resident or others. Procedure for: 1. Close observation: The resident must be within assigned staff member's line of vision at all Times; One -to -One: Assigned staff member must be within six feet of resident at all times 2. The nurse must have a physician's order to initiate close observation or one -to- one on a resident. The order must include the reason and verbal orders must be signed by the physician within 24 hours. The order will remain active/valid until discontinued. 3. Close Observation Monitoring record will be initiated by nursing staff when the resident is placed on one -to- one monitoring. 4. The staff member assigned to monitor the resident will document every 15 minutes on the Close Observation or One -to- One monitoring Record. 5. The resident will not be permitted to attend off- unit functions until the precautions are discontinued. Review of the facility policy and procedure for wandering/elopement revealed the following, in part: Purpose: to identify residents at risk for wandering/elopement and implement measures to prevent harm and ensure safety; Wandering- resident strays into unsafe territories and may be harmed ...Elopement- most dangerous form of wandering. Can be differentiated from those that only wander by their purposeful, overt, and repeated attempts to leave the building or premises; Procedure: Elopement: A. residents at risk for elopement are identified by nursing staff through direct observation. The resident's behavior is documented in the resident's medical record; B. The resident is assessed by the treatment team and specific issues that may trigger his/her desire to elope are identified ...C. When a wandering incident occurs the nursing staff will immediately place the wandering resident on close observation and the physician will be notified within 1 hour for additional orders to confirm close observation. D. The physician order must include the reason and must be signed by the physician with 24 hours ...The resident is assessed weekly by the physician in the progress notes ...B. The resident is assessed by the treatment team and specific issues that may trigger his/her desire to elope are identified. Interventions to address the issues triggering the desire to elope are addressed in the care plan and implemented by nursing staff. Monitoring/tracking devices are used to monitor those residents at risk of elopement. C. The physician is notified of the resident's risk for elopement and orders for One-to-One Observation are entered on the resident's medical record ... Resident #12 Review of Resident #12's clinical record revealed the following: Date of Birth: [DATE]; Date of Admission: [DATE] and a [DIAGNOSES REDACTED]. Review of Resident #12's most recent Minimum Data Set (MDS), Assessment Reference Date (ARD): [DATE]; Type: Quarterly, revealed the following: Cognitive Patterns: Brief interview for Mental Status ( BIMS): should resident interview be conducted: No ( resident is rarely/never understood); Cognitive skills for daily decision making: 3. Severely impaired- never/rarely made decisions Acute onset mental status change: No Swallowing/Nutritional status: Swallow disorder: none of the above: checked Height (in inches): 70 Weight(in pounds): 245 Nutrition approach: Resident: mechanically altered diet: checked; Nutrition approach: Resident: therapeutic diet: checked Review of the facility nurses notes revealed the following entries, in part: [DATE] 11:00 a.m. Redirected multiple times out of garbage cans. Counseling ineffective; [DATE] 11:00 p.m. goes in to other patient's rooms and steals any food he finds; [DATE] (no time documented): Decision making skills: Severely impaired: poor insight and judgment, eats out of the trash, Counseling and redirection ineffective [DATE] (no time documented): Ability to understand: Sometimes understands: Redirected frequently to eat food slowly; [DATE] 7:20 a.m. S24CNA, noted that patient( pt.) had food in mouth and hand. Pt. sitting on side of nurses' station. S24CNA asked pt. what he had in his hand. Pt. unresponsive to CNA- S40CNA called this nurse (S36LPN) to pt. Noted pt. slumped over in chair attempted to perform the [MEDICATION NAME], abdominal thrust, and back blows. CPR also attempted, all without success. Attempted to suction without success 7:25 a.m. S38MD notified, instructed to continue all efforts until he arrived to unit. S25RN notified. Efforts continued 7:30 a.m. S50RN arrived to ward for assistance. Efforts continued patient gasping for air, oxygen started with an oxygen mask at 15 liters and oxygen saturation of 92% on 100% oxygen (maximum amount of oxygen that can be delivered), Pulse 105; 7:35 a.m.: Medical doctor (MD) on ward to assess patient. Efforts continue, patient continues gasping, eyes are open but unfocused 7:40 a.m.: Local ambulance transfer to area hospital with lights and sirens. Patient breathing improves marginally. Continue to monitor 7:55 a.m.: Local ambulance service arrives, patient attempting to stand. Instructed patient to stay lying on floor. Patient appears confused. Breathing becomes more labored. Patient is assisted to stretcher 5:15 p.m.: Received update from area hospital. Patient admitted to intensive care unit with aspiration pneumonia, [MEDICAL CONDITIONS], and intubation. [DATE] 2:27 p.m. Return from local hospital, ambulatory, accompanied by CNA. Resident alert to name only. Follow simple instructions with redirection 2:43 p.m. MD on unit. Exam resident. Mental status unchanged, answering "yes" to all questions. Instruct staff to Monitor Closely- trash cans and barrel from locker area are now removed [DATE] 4:45 p.m.: Reported by CNA, another resident went to room and struck Resident #12 with a metal object several times on the buttocks. Resident #12 sustained no injuries. The other resident stated Resident #12 had eaten his cookies out of his room. Unable to counsel Resident #12 due to impaired thought process and insight. Review of the Resident #12's physician progress notes [REDACTED]. 1:45 p.m. called by nurse that patient was eating in dining room and got choked, vomited, and he left and came to day room with CNA following , patient on sofa and continue to struggle to breathe. Stridor (harsh breathing sound associated with obstruction) was heard by staff. ,[DATE] pulse, 71 oxygen saturation, 99% on 100% re-breather (oxygen mask), with room air was 87%, now trying to get up and wander, still raspy sounding in throat, patient was pulse less and on sofa, placed on floor and [MEDICATION NAME] done, then patient started respirations and pulse returned; Impression: Aspiration of chopped meat; Plan: transfer to area hospital. [DATE] 7:50 a.m.: patient still digging through garbage cans, trying to get in to cars, Plan: Continue Care, yard/cigarettes from garbage cans, continue medications [DATE] 8:26 a.m.: Patient the same wandering and eating out of garbage, Plan: Continue medications, Continue care [DATE] 11:10 a.m.: Patient still eating from garbage can and trying to get in cars on the grounds, Plan: Continue medications, Continue care [DATE] 8:30 a.m. Patient doing the same, wandering grounds, trying to get in cars, picking up things from the ground and garbage cans and eating them: Plan: Continue medications, Continue care, keep special appointments; [DATE] (no time documented): Still eating from garbage cans, Plan: Continue medications, Continue care; [DATE] (no time documented): Transfer note: Patient found falling over, choking. [MEDICATION NAME] and abdominal thrust done. Nothing recovered, may have aspirated cornbread, patient supine on floor, now minimally responsive, heart rate 108, respiratory rate 16, with decreased breath sounds right anterior chest, abdomen with positive bowel sounds, 1. Aspiration, 2. Airway- partial occlusion 3. [MEDICAL CONDITION] 4. Mental [MEDICAL CONDITION] 5. Constipation; Plan: to area hospital emergency room via local ambulance service. [DATE] 2:49 p.m.: status [REDACTED]. Review of Resident #12's Multidisciplinary staffing notes revealed the following entries, in part: [DATE]: Comments: Counseled on staying out of the garbage cans for food, etcetera (etc.). [DATE]: Comments: Counseled on staying out of the garbage cans for food, etc. [DATE]: Reason for staffing: On [DATE]: transferred to area hospital emergency room : Airway partial occlusion and aspiration, [DATE]; Returned from area hospital , [DATE]: Psychiatric consult: continue medications, Comments: counseled on staying out of garbage cans for food, etcetera. Review of Resident #12's Social Services Notes revealed the following entries, in part: [DATE]: Behavior: Supervision with meals; Patient continues to ramble over parking lot looking for open car doors, goes in to garbage searching for food. Goals/Plan: Rambles around all day hunting for food anywhere he can find it. He must be redirected many times for eating out of garbage cans. He goes in other patients ' rooms hunting for food also [DATE]: Patient choked on food- was sent to an area hospital. Now in Intensive Care Unit and intubated ( has a breathing tube) - has aspiration pneumonia [DATE]: Behavior: Eats out of trashcans Goals/Plans: Resident continues to walk searching for food in the cars and in the garbage. Resident on routine diet with chopped meats, Needs constant supervision and care. Transported to an area hospital for choking and Intensive Care Unit (ICU) care: Returned to facility on [DATE]; [DATE]: Returned from area hospital after a choking episode. He eats out of the garbage cans and can' t be stopped. He continues to walk aimlessly hunting for food in the garbage and in the workers ' cars if he can have access to them. He is severely disabled with mental [MEDICAL CONDITION]. Review of Resident #12's Nutritional Staffing Note, dated [DATE], revealed the following, in part: Regular quarterly staffing; Other disciplines: Nursing: choking incident on [DATE]. Comments: Resident #12 had a choking incident last week. He choked on a piece of meat. Unsure of where he got it from, just that it wasn't on his tray. The meat was expelled and he was transferred to a local hospital emergency room for evaluation. He returned later that day. Chopped meats appropriate secondary to choking potential. [DATE]: Comments: he remains ambulatory and still requires redirection due to getting food from trash bins; Diet Prescription (Rx): Routine with chopped meat, offer a.m. and hour of sleep ( h.s.) snacks. [DATE]: Diet Rx.: Routine with chopped meat, offer a.m. and h.s. snacks Review of Resident #12's physician orders for ,[DATE]- ,[DATE] revealed the following orders: Closely observe Do not leave anything in resident room that he can eat, drink, or spray Routine diet: offer a.m. and hour of sleep (h. s.) snacks Supervision at meals Review of Resident #12's re-admission physician orders, dated [DATE] 2:48 p.m. (after the [DATE] hospitalization ) revealed the following, in part: 1. ... 2. status [REDACTED]. 3. Continue all previous orders. Review of Resident #12's current Care Plan revealed the following, in part: Problem/Need: Potential for injury related to (R/T) behavioral problems as evidenced by History of eating cigarette butts out of the ashtrays, History of eating feces, and Eating out of trash can, etc., Tries to get in to employees cars; Goal and Target date: There will be no incident of injury by next staffing date. (Goal/Target dates were : [DATE], [DATE], [DATE]); Approaches: Staff monitor more closely; Closely Observe-do not leave anything in Resident #12 room that he can drink or spray; watch trays and garbage in dining room, keep him away; There was hand written notation which read: [DATE]: Transferred to area hospital emergency room Airway partial occlusion, aspiration pneumonia, [MEDICAL CONDITIONS]. Patient found falling over and choking. [MEDICATION NAME] and abdominal thrusts done. Nothing recovered (may have aspirated cornbread) [DATE] returned from area hospital. [MEDICATION NAME] 0.4 milligrams by mouth every day, [MEDICATION NAME] 250 milligrams by mouth every day x 5 days for pneumonia; Problem/Need: History of choking due to filling mouth too full, Eating too fast, Mechanically altered diet secondary to cognitive status and poor dentition; Problem Onset [DATE]; [DATE]-choking episode; [DATE]: choking episode; Goal: Resident #12 will be able to consume food without choking ( Goal/Target dates were : [DATE], [DATE], [DATE]); Approaches: Watch trays and garbage in dining room away from him; Monitor for chewing and swallowing difficulty; Refer for evaluation if Resident #12 has signs/symptoms of chewing or swallowing problems; Evaluate diet as needed; Serve diet as ordered; Encourage to eat slowly and not stuff mouth; If chokes then initiate [MEDICATION NAME] maneuver--- call MD; Staff to Monitor Closely Review of the facility's 24 Hour Report, dated [DATE], Team A, Shift revealed the following, in part: 6A-6P Resident #12 - ICU at a local hospital. Aspiration Pneumonia/Intubated. [MEDICAL CONDITIONS]. Resident #12 - Choking episode resulting in loss of conscious ...Employees (S41CNA & S44Custodian) performed [MEDICATION NAME] maneuver. Patient was conscious and moving extremities. Patient was eating food out of garbage. Review of Resident #12's Multidisciplinary staffing notes revealed the following entries, in part: [DATE]: Comments: Counseled on staying out of the garbage cans for food, etc. [DATE]: Comments: Counseled on staying out of the garbage cans for food, etc. [DATE]: Reason for staffing: On [DATE]: transferred to area hospital emergency room : Airway partial occlusion and aspiration, [DATE]; Returned from area hospital , [DATE]: Psychiatric consult: Continue medications, Comments: Counseled on staying out of garbage cans for food, etc. Review of Resident #12's CNA Activities of Daily Living (ADL) Sheets for ,[DATE]-,[DATE] revealed the following, in part: Observe patient for choking at meal times; Supervision at meals to keep patient from eating extra food; Do not leave anything in patient's room that he can eat, drink, or spray. The ADL sheets were documented upon daily, every 12 hours. Further review of the facilities records revealed the only other documentation of Resident #12's activities/location was the Ward Round sheets which document all of the residents' location/activities who are on that ward, not just Resident #12. Review of Resident #12's History and Physical, dated [DATE] (from the area hospital where he was admitted on [DATE]), revealed the following, in part: Chief complaint: Patient was transferred from the nursing home when he was found to be choking, short of breath, and tachypneic, patient was intubated and admitted to Intensive Care Unit for pneumonia; Respiratory : patient intubated; Impression: Pneumonia(aspiration), Acute [MEDICAL CONDITION], continue ventilator support. . Review of the Facility Patient Critical Incident Report revealed the following, in part: Date incident occurred: [DATE] Time: 4:05 a.m.; Vital signs: no vital signs; full respiratory/[MEDICAL CONDITION]; briefly describe incident: patient came from outside area and collapsed in front of the nurses station. Patient was unresponsive due to occluded airway. Food particles in airway. Attempted to clear airway. Ventilations attempted with ambu bag without success; Supervisor's Review/Recommendation: (include probable cause of injury): Foreign body obstructed airway. Airway cleared of vomitus/debris and after multiple abdominal thrusts removed chicken bone; Do you suspect Abuse/Neglect: No, Patient had a history of [REDACTED]. Review of the facility Patient Ward Round sheet for unit E, dated [DATE], 6 p.m.-6 a.m. shift, revealed the following notations: 6 p.m.-6 a.m. shift 2:00 a.m.: hallway 2:30 a.m.: day area 3:00 a.m.: patio 3:30 a.m.: patio 4:00 a.m.: hallway 4:30 a.m.; hallway 5:00 a.m.: hallway 5:30 a.m.: hallway. Review of Resident #12's physician progress notes [REDACTED]. Date of Admission: [DATE] date of death : [DATE] Admission Diagnoses: [REDACTED]. Discharge Diagnoses: [REDACTED]. Mouth cleared but airway with debris. CPR begun. Multiple abdominal thrusts and attempted mouth sweeps without success. [MEDICAL CONDITION] also occurred and [MEDICATION NAME], sodium [MEDICATION NAME] given without success. After 40 minutes CPR, agonal rhythm briefly seen on monitor, then asystole. Pronounced dead by me (S38MD) at 4:45 hours [DATE]. ( pupils fixed and dilated and no heartrate on auscultation after 1 minute). Spoke with S43Coroner at 5:15 a.m. regarding above. S43Coroner will review as coroner's case and stated okay to release body to funeral home. An interview was conducted on [DATE] at 12:20 p.m. with S3ADON. She verified that the resident choked on [DATE]. She verified the resident gorged and ate out of the trash and ate employees' food. She said the resident had tried to get into peoples' cars. She said she did not know why except that it was a "ritual" to him. She said the October and November choking incidents both involved chicken bones. She said there was nothing that could have been done to prevent the resident from getting into garbage cans and trying to get into peoples' cars. She said if something was going on, such as the Bayou Classic, it was hard to staff the facility. She said the nurses rotated out on the units to help out with observations. She said Resident #12 was not ever put on Close Observations and that he was not a danger to anyone else. She said he was "benign" . She said they all "kinda" watched him. She said it was a task to keep up with him. She said trash cans were removed from the nurse's station and his room after his choking episode in October, 2012. She said he was in bad shape when he first came to the facility and she thought they did a pretty good job keeping him alive for [AGE] years. An interview was conducted on [DATE] at 12:40 p.m. with S12CNA. She said she had to redirect the Resident #12 away from the trash cans. She said she worked the night shift the morning Resident #12 expired. She said she saw Resident #12 walk into the facility from outside and fall on the floor in front of the nurse's station. She said his mouth was clenched. She said after he collapsed, she swept his mouth and removed a bone from his mouth. She said all staff in the facility came to the scene. S12CNA further stated that she was assigned to conduct 1:1 Observations of Resident #15 that shift. She said Resident #15 was in the same room with another resident (Resident #17) who had been receiving Close Observations by S34LPN. S12CNA said while S34LPN administered meds at 8:00 p.m., she (S12CNA) helped him (S34LPN) out by watching (Resident#17) in addition to watching Resident #15. She said she also handed out snacks to the residents. She said all the staff helped out. She said on the night shift that night S37CNA did the clothes, handed out cigarettes, and was assigned Close Observations on Resident #18 and Resident #2. When asked what 1:1 Observations meant, she said within hands reach. She said there was a floater CNA that helps out the CNAs doing close observations. She said the maximum number of residents they can watch on close observation is 2. An interview was conducted on [DATE] at 1:35 p.m. with S9LPN. She worked Resident #12's hall for several years on the day shift. She said after the resident had the choking incident on [DATE], the facility removed the garbage cans out from the locker room on the resident's hall, the resident's room and the nurse's station. She said she had worked with the resident after he was readmitted back to the facility after the October choking incident. She said he was not on Close Observations because she was told not to put him on Close Observations. She said she monitored him when he went to garbage cans and redirected him. She said he would always go back to the trash can and redirection was not always effective. She said placing the resident on Close Observations was determined by the doctor. She said she did not ask the doctor (S39MD) if the resident could be placed on Close Observations because she felt like it was the doctor's decision. She said the doctor was aware the resident ate food out of the garbage. She said residents were placed on Close Observations if they wandered away or hurt themselves or others ...such as he (Resident #12) was doing. She said the resident walked all over the place, went to the recreation room, went to his room and lay in his bed. An interview was conducted on [DATE] at 2:15 p.m. with S46Counselor. She said she was a counselor and not a licensed social worker. She said Resident #12 would eat anything he could find. She said they staffed him every 3 months. She explained that the following staff members attended the staff meeting: Dietary, Physical Therapy, MDS Coordinator, Recreation, S28SSD, and S9LPN. She said that they did not discuss putting Resident #12 on Close Observations or increasing his supervision during the meeting. She said he could not help his actions because of his mental status. An interview was conducted on [DATE] at 2:20 p.m. with S28SSD. She said her first staffing she attended on the resident was about a week before he died . She said no one had discussed placing the resident on Close Observations or increased Supervision to 1:1 at the meeting. An interview was conducted on [DATE] at 2:30 p.m. with S47MDSCoordinator. She said she had been the MDS Coordinator since August, 2012. She said S4RNCarePlan was the MDS nurse assigned to the resident. She said S4RNCareplan was presently out of the facility. She said it was the MDS nurse's responsibility to discuss problems and address issues about the residents with the doctor after the staffing meeting. She also said the MDS nurse was responsible for updating the care plan. She said S4RN had not mentioned to her that it had been discussed in the Staffing Meetings to increase the Resident #12's supervision or Close Observation since the resident's choking incident in October, 2012. On [DATE] at 6:05 p.m., an interview was held with S33RNSupervisor, regarding Resident#12. She explained that Resident #12 gorged food. She said he was always seeking food. She stated that Resident #12 was not pla

Based on interview and record review the facility failed to keep the residents free from accident hazards for 3 (#12, #1, #15) of 15 ( #1, #2, #3,#4,#5, #6, #7, #8, #9, #10, #11,#12,#13, #14, #15) residents reviewed for accidents/supervision. The facility failed to: 1. identify and implement new interventions on [DATE], to prevent a severely cognitively impaired resident(#12) from digging in the trash for food and eating food without staff knowledge after he returned from the hospital on [DATE] following an incident where he aspirated food debris scavenged from the trash, without staff knowledge and developed aspiration pneumonia requiring intubation. 2. ensure nursing staff clarified a physician's orders [REDACTED].#12) 3. identify and implement new interventions and approaches to prevent physical altercations between Resident #1 and other facility residents after the incident on [DATE] when Resident #1 was involved in an altercation with Resident #3 on [DATE] in which Resident #3 received a broken ankle. 4. implement a system of increased supervision and monitoring of Resident #1 on [DATE] to prevent altercations with other residents after Resident #1 was involved in a physical altercation with Resident #3 on [DATE] in which Resident #3 received a broken ankle. 5. identify and implement a system of increased supervision and monitoring of Resident #1 on [DATE] to protect other residents at the facility from his explosive aggressive behaviors after Resident #1 started a fight with his roommate, knocked the roommate's TV over, threatened to kill his roommate, scratched the roommate, and closed the nurse's hand in the door on [DATE]. 6. identify and implement new interventions to prevent physical altercations between Resident #1 and other residents following a fist fight between Resident #1 and another resident on [DATE], after Resident #1 punched another resident in the mouth on [DATE], and after physical altercations with another resident on [DATE] and [DATE]. 7. implement a system of increased supervision and monitoring of Resident #1 on [DATE] after Resident #1 broke Resident #2's nose during a physical altercation on [DATE]. 8. have a system in place to protect other residents from Resident #1's aggressive, violent behaviors 9. have a system of supervision and monitoring in place to protect Resident #1 from physical and verbal altercations initiated by other residents after [DATE] when he was kicked in the groin on [DATE] by another resident. 10. identify and implement new interventions for supervision to prevent elopement from the facility for a cognitively impaired resident (#15) after his second elopement attempt [DATE] where he was found trying to climb over the closed gate on [DATE] while under orders for close observation. 11. identify and implement new interventions for supervision to prevent elopement on [DATE] after a cognitively impaired resident ( #15) had two elopement attempts on [DATE] while under close observation. 12. identify and implement new interventions for supervision on [DATE] to prevent a cognitively impaired resident (#15) from eloping from the facility after he eloped off of the facility grounds on [DATE], flagged down a female motorist and began choking her in her car while under orders for close observation. 13. identify and implement interventions to prevent a cognitively impaired resident (#15) from eloping from the facility and travelling to the grounds of a local nursing facility on [DATE] while under orders for close observation. The Administrator was notified of the Immediate Jeopardy on [DATE] at 7:10 p.m. on [DATE], Resident #12, a severely cognitively impaired resident, was transferred to an area emergency room with partial airway occlusion and aspiration pneumonia after choking on possible food debris. Resident #12's history was significant for digging in garbage cans for food and choking. Due to his cognitive status, intervention of redirection was ineffective for this resident per facility's staff documentation. Resident #12 was placed in Immediate Jeopardy on [DATE] when he returned from the hospital and the facility failed to identify and implement new interventions to prevent him from digging in garbage cans and eating food without staff supervision. On [DATE], at approximately 4:05 a.m., Resident #12 came in from outside area and collapsed in front of the nurses station. Resident #12 was unresponsive due to occluded airway. During attempts to clear airway, food particles, including a chicken bone were removed from resident #12's airway. Despite the Heimlich maneuver and initiation of cardiopulmonary resuscitation (CPR), Resident #12 expired. The Immediate Jeopardy ended for the resident on [DATE] at 4:45 a.m. when he expired. The Immediate Jeopardy was lowered to a Level III isolated, actual harm on [DATE] at 4:45 a.m. when Resident #12 expired. The Administrator was notified of the Immediate Jeopardy on [DATE] at 12:30 p.m. for Resident #1. Other residents, who came in contact with Resident #1, were placed in Immediate Jeopardy from the aggressive, violent behaviors initiated by Resident #1. The facility failed to implement a system of supervision and monitoring of Resident #1 to prevent his aggressive, violent behaviors from hurting other residents. The Immediate Jeopardy began on [DATE] when the facility failed to ensure supervision of Resident #1 was increased after Resident #1 fractured Resident #3's ankle in an altercation. The Immediate Jeopardy continued when Resident #1 continued to have multiple altercations with other residents. Resident #1 fractured Resident #2's nose on [DATE] during an altercation. On [DATE] Resident #3 received a loose tooth, swollen lip, and cheek abrasion during an altercation with Resident #1. Resident #1 was placed on an Physician Emergency Certificate on [DATE] and [DATE]. Supervision of Resident #1 was not increased after these incidents. The Immediate Jeopardy ended on [DATE] at 12:00 p.m. when Resident #1 was placed on Close Observations. The Immediate Jeopardy was lowered to a Level II -pattern on [DATE] for Resident #1. The Administrator was notified of the Immediate Jeopardy on [DATE] at 7:10 p.m. for Resident #15. The Immediate Jeopardy began on [DATE] when the facility failed to ensure supervision of Resident #15 after his second elopement attempt where he was found trying to climb over the closed gate while under close observation. The facility failed to increase supervision and monitoring on [DATE] when 2 elopement attempts occurred while under close observation with no further interventions in place and no increase in monitoring. On [DATE] Resident #15 eloped out of the facility, past the gate and ran to the highway, flagged down a female motorist, began choking her in her car while on close observation. No new interventions for increased supervision or monitoring were put into place. On [DATE] Resident #15 eloped while under close observation off of facility grounds and traveled 1.6 miles to the grounds of a local nursing facility. This immediate jeopardy was lifted when Resident #15 was PEC'd to a local hospital on [DATE] at 5:10 p.m. and returned as 1:1 supervision. The Immediate Jeopardy was lowered to a Level II - pattern on [DATE] for Resident #15. Findings: Review of the facility ' s policy for Close Observation and One- To-One Monitoring revealed the following: Purpose: To establish guidelines for nursing staff to implement and follow when close observation or one -to -one monitoring is ordered on a resident . Examples of reasons for ordering close observation or one -to- one monitoring include, but are not necessarily limited to wandering, sexually inappropriate behavior, aggressive behavior toward other residents, and behavior that poses a danger to the resident or others. Procedure for: 1. Close observation: The resident must be within assigned staff member's line of vision at all Times; One -to -One: Assigned staff member must be within six feet of resident at all times 2. The nurse must have a physician's orders [REDACTED]. The order must include the reason and verbal orders must be signed by the physician within 24 hours. The order will remain active/valid until discontinued. 3. Close Observation Monitoring record will be initiated by nursing staff when the resident is placed on one -to- one monitoring. 4. The staff member assigned to monitor the resident will document every 15 minutes on the Close Observation or One -to- One monitoring Record. 5. The resident will not be permitted to attend off- unit functions until the precautions are discontinued. Resident #12 Review of Resident #12's clinical record revealed the following: Date of Birth: [DATE]; Date of Admission: [DATE] and a [DIAGNOSES REDACTED]. Review of Resident #12's most recent Minimum Data Set (MDS), Assessment Reference Date (ARD): [DATE]; Type: Quarterly, revealed the following: Cognitive Patterns: Brief interview for Mental Status ( BIMS): should resident interview be conducted: No ( resident is rarely/never understood); Cognitive skills for daily decision making: 3. Severely impaired- never/rarely made decisions; Acute onset mental status change: No; Swallowing/Nutritional status: Swallow disorder: none of the above: checked; Height (in inches): 70; Weight(in pounds): 245; Nutrition approach: Resident: mechanically altered diet: checked; Nutrition approach: Resident: therapeutic diet: checked; Occupational Therapy: blank Review of Resident #12 ' s physician progress notes [REDACTED]. Stridor (harsh breathing sound associated with obstruction) was heard by staff. ,[DATE] pulse, 71 oxygen saturation, 99% on 100% re-breather (oxygen mask), with room air was 87%, now trying to get up and wander, still raspy sounding in throat, patient was pulse less and on sofa, placed on floor and Heimlich done, then patient started respirations and pulse returned; Impression: Aspiration of chopped meat; Plan: transfer to area hospital; [DATE], 7:50 a.m.: patient still digging through garbage cans, trying to get in to cars, Plan: Continue care, yard/cigarettes from garbage cans, continue medications; [DATE] 8:26 a.m.: patient the same wandering and eating out of garbage, Plan: Continue medications, continue care; [DATE], 11:10 a.m.: Patient still eating from garbage can and trying to get in cars on the grounds, Plan: Continue medications, continue care; [DATE] 8:30 a.m. Patient doing the same, wandering grounds, trying to get in cars, picking up things from the ground and garbage cans and eating them: Plan: Continue medications, continue care, keep special appointments; [DATE]: Still eating from garbage cans, Plan: Continue medications, continue care; [DATE]: Transfer note: patient found falling over, choking. Heimlich and abdominal thrust done. Nothing recovered, may have aspirated cornbread, patient supine on floor, now minimally responsive, heart rate 108, respiratory rate 16, with decreased breath sounds right anterior chest, abdomen with positive bowel sounds, 1. Aspiration, 2. Airway- partial occlusion 3.Schizophrenia 4. Mental retardation 5. Constipation; Plan: To area hospital emergency room via local ambulance service; [DATE] 2:49 p.m.: status [REDACTED]. Review of Resident #12 ' s Nutritional Staffing Note, dated [DATE], revealed the following, in part: Regular quarterly staffing; Other disciplines: Nursing: choking incident on [DATE]; Comments: Resident #12 had a choking incident last week. He choked on a piece of meat. Unsure of where he got it from, just that it wasn ' t on his tray. The meat was expelled and he was transferred to a local hospital emergency room for evaluation. He returned later that day. Chopped meats appropriate secondary to choking potential; [DATE]: Comments: he remains ambulatory and still requires redirection due to getting food from trash bins; Diet Prescription (Rx): Routine with chopped meat, offer a.m. and hour of sleep (h.s.) snacks; [DATE]: Diet Rx.: Routine with chopped meat, offer a.m. and h.s.snacks Review of Resident #12 ' s physician orders [REDACTED]. s. snacks **** Supervision at meals Review of Resident #12 ' s re-admission physician orders, dated [DATE] 2:48 p.m. (after the [DATE] hospitalization ) revealed the following, in part: 2. status [REDACTED]. Continue all previous orders. Review of Resident #12 ' s current Care Plan revealed the following, in part: Problem/Need: Potential for Injury related to (R/T) behavioral problems, as evidenced by history of eating cigarette butts out of the ashtrays, history of eating feces, and eating out of trash can, etcetera (etc.), tries to get in to employees cars; Goal and Target Date: There will be no incident of injury by next staffing date. (Goal/Target Dates were : [DATE], [DATE], [DATE]); Approaches: Staff monitor more closely; Closely Observe-Do not leave anything in Resident #12 room that he can drink or spray; Watch trays and garbage in dining room, keep him away; The following was noted as a hand written notation on the care plan: [DATE]: Transferred to area hospital emergency room airway partial occlusion, aspiration pneumonia, pulmonary edema. Patient found falling over and choking. Heimlich and abdominal thrusts done. Nothing recovered (may have aspirated cornbread); The following was noted as a hand written notation on the care plan: [DATE]: Returned from area hospital. Flomax 0.4milligrams by mouth every day, Zithromax 250 milligrams by mouth every day x 5 days for pneumonia; Problem/Need: History of choking due to filling mouth too full, eating too fast, mechanically altered diet secondary to cognitive status and poor dentition; Problem Onset : [DATE]; Hand written notation: [DATE]-choking episode; Hand written notation: [DATE]: choking episode; Goal: Resident #12 will be able to consume food without choking (Goal/Target dates were : [DATE], [DATE], [DATE]); Approaches: Watch trays and garbage in dining room away from him; Monitor for chewing and swallowing difficulty; Refer for evaluation if Resident #12 has signs/symptoms of chewing or swallowing problems; Evaluate diet as needed; Serve diet as ordered; Encourage to eat slowly and not stuff mouth; If chokes then initiate Heimlich maneuver--- call MD; Staff to Monitor Closely Review of the facility nurses notes revealed the following entries, in part: [DATE], 11:00 a.m. Redirected multiple times out of garbage cans. Counseling ineffective; [DATE], 11:00 p.m. goes in to other patient 's rooms and steals any food he finds; [DATE], no time documented: Decision making skills: Severely impaired: Poor insight and judgment, eats out of the trash, counseling and redirection ineffective; [DATE], no time documented: Ability to understand: Sometimes understands: Redirected frequently to eat food slowly; Further review of the facility nurses notes for Resident #12, dated [DATE], revealed the following entries: 7:20 a.m. S24CNA, noted that patient (pt.) had food in mouth and hand. Pt. sitting on side of nurses' station. S24CNA asked pt. what he had in his hand. Pt. unresponsive to CNA- S40CNA called this nurse (S36LPN) to pt. Noted pt. slumped over in chair attempted to perform the Heimlich, abdominal thrust, and back blows. CPR also attempted, all without success. Attempted to suction without success; 7:25 a.m.: S38MD notified, instructed to continue all efforts until he arrived to unit. S25RN notified. Efforts continued; 7:30a.m. S50RN arrived to ward for assistance. Efforts continued patient gasping for air, oxygen started with an oxygen mask at 15 liters and oxygen saturation of 92% on 100% oxygen (maximum amount of oxygen that can be delivered), Pulse 105; 7:35 a.m.: Medical doctor (MD) on ward to assess patient. Efforts continue, patient continues gasping, eyes are open but unfocused; 7:40 a.m.: Local ambulance transfer to area hospital with lights and sirens. Patient breathing improves marginally. Continue to monitor; 7:55 a.m.: local ambulance service arrives, patient attempting to stand. Instructed patient to stay lying on floor. Patient appears confused. Breathing becomes more labored. Patient is assisted to stretcher; 5:15 p.m.: Received update from area hospital. Patient admitted to intensive care unit with aspiration pneumonia, pulmonary edema, and intubation. Further review of Resident #12's facility nurses notes revealed the following entry: [DATE]: 2:27 p.m. Return from local hospital, ambulatory, accompanied by CNA. Resident alert to name only. Follow simple instructions with redirection; 2:43 p.m. MD on unit. Exam resident. Mental status unchanged, answering " yes " to all questions. Instruct staff to Monitor Closely- trash cans and barrel from locker area are now removed; [DATE], 4:45 p.m.: reported by CNA, another resident went to room and struck Resident #12 with a metal object several times on the buttocks. Resident #12 sustained no injuries. The other resident stated Resident #12 had eaten his cookies out of his room. Unable to counsel Resident #12 due to impaired thought process and insight. Review of the facility's 24 Hour Report, dated [DATE], Team A, Shift 6A-6P revealed the following, in part: Resident #12 - ICU at a local hospital. Aspiration Pneumonia/Intubated. Pulmonary Edema. Resident #12 - Choking episode resulting in loss of conscious ...Employees (S41CNA & S44Custodian) performed Heimlich maneuver. Patient was conscious and moving extremities. Patient was eating food out of garbage. Review of Resident #12's Multidisciplinary staffing notes revealed the following entries, in part: [DATE]: Comments: Counseled on staying out of the garbage cans for food, etc.; [DATE]: Comments: Counseled on staying out of the garbage cans for food, etc.; [DATE]: Reason for staffing: On [DATE]: Transferred to area hospital emergency room : Airway partial occlusion and Aspiration, [DATE]; Returned from area hospital , [DATE]: Psychiatric consult: Continue medications, Comments: Counseled on staying out of garbage cans for food, etc. Review of Resident #12's Social Services Notes revealed the following entries, in part: [DATE]: Behavior: Supervision with meals; Patient continues to ramble over parking lot looking for open car doors, goes in to garbage searching for food. Goals/Plan: Rambles around all day hunting for food anywhere he can find it. He must be redirected many times for eating out of garbage cans. He goes in other patients' rooms hunting for food also; [DATE]: Patient choked on food- was sent to an area hospital. Now in Intensive Care Unit (ICU)and intubated (has a breathing tube) - has Aspiration Pneumonia; [DATE]: Behavior: Eats out of trashcans, Goals/Plans: Resident continues to walk searching for food in the cars and in the garbage. Resident on routine diet with chopped meats, Needs Constant Supervision and Care. Transported to an area hospital for choking and ICU care: Returned to facility on [DATE]; [DATE]: Returned from area hospital after a choking episode. He eats out of the garbage cans and can't be stopped. He continues to walk aimlessly hunting for food in the garbage and in the workers' cars if he can have access to them. He is severely disabled with mental retardation. Review of Resident #12 ' s CNA Activities of Daily Living (ADL) Sheets for ,[DATE]-,[DATE] revealed the following, in part: Observe patient for choking at meal times; Supervision at meals to keep patient from eating extra food; Do not leave anything in patient's room that he can eat, drink, or spray. The ADL sheets were documented upon daily, every 12 hours. Further clinical record review revealed that the only other documentation/monitoring of Resident #12's activities/movements throughout the day were documented on the Ward Round check sheets. These sheets monitor the activities/location of all of the residents on the wards, not just Resident #12. Review of Resident #12's History and Physical, dated [DATE] (from the area hospital where he was admitted on [DATE] from the facility for choking), revealed the following, in part: Chief complaint: Patient was transferred from the nursing home when he was found to be choking, short of breath, and tachypneic; Patient was intubated and admitted to Intensive Care Unit for pneumonia; Respiratory : Patient intubated; Impression: Pneumonia(aspiration), Acute respiratory failure, Continue ventilator support. Review of the Facility Patient Critical Incident Report revealed the following, in part: Date incident occurred: [DATE], Time: 4:05 a.m.; Vital signs: No vital signs; Full Respiratory/Cardiac Arrest; Briefly describe incident: Patient came from outside area and collapsed in front of the nurses station. Patient was unresponsive due to occluded airway. Food particles in airway. Attempted to clear airway. Ventilations attempted with ambu bag without success; Supervisor's Review/Recommendation: (include probable cause of injury): Foreign body obstructed airway. Airway cleared of vomitus/debris and after multiple abdominal thrusts removed chicken bone; Do you suspect Abuse/Neglect: No, Patient had a history of [REDACTED]. Review of the facility Code Record, dated [DATE], 4:45 a.m., revealed the following: Condition upon discovery: Unresponsive, no respirations; Airway: Occluded with foreign body; CPR initiated 4:05 a.m. Under the Action/Patient Response section of the Code Record was the following notation: Patient collapsed in front of nurses station. Respiratory arrest secondary to airway obstruction (chicken bones). Review of the facility Patient Ward Round Sheet for Unit E, dated [DATE], 6 p.m.-6 a.m. shift, revealed the following notations: 2:00 a.m.: hallway; 2:30 a.m.: day area; 3:00 a.m.: patio; 3:30 a.m.: patio; 4:00 a.m.: hallway; 4:30 a.m.; hallway; 5:00 a.m.: hallway; 5:30 a.m.: hallway. These observations of Resident #12 ' s locations were recorded by S37CNA during ward rounds. Review of Resident #12 ' s physician progress notes [REDACTED]. Mouth cleared but airway with debris. CPR begun. Multiple abdominal thrusts and attempted mouth sweeps without success. Cardiac arrest also occurred and Epinephrine, Atropine, Sodium Bicarbonate given without success. After 40 minutes CPR, agonal rhythm briefly seen on monitor, then asystole. Pronounced dead by me (S38MD) at 4:45 hours [DATE]. ( pupils fixed and dilated and no heartrate on auscultation (listening) after 1 minute). Spoke with S43Coroner at 5:15 a.m. regarding above. S43Coroner will review as Coroner's case and stated okay to release body to funeral home. An interview was conducted on [DATE] at 12:20 p.m. with S3ADON. She verified that the resident choked on [DATE]. She said she spoke with staff at State Office about filing an Otis Report and was told by staff at State Office that the incident was not reportable because the facility had nothing in place regarding close observations and removing trash cans prior to the incident. She verified the resident gorged and ate out of the trash and ate employees' food. She said the resident had tried to get into peoples' cars. She said she did not know why except that it was a " ritual " to him. She said the October and November choking incidents both involved chicken bones. She said there was nothing that could have been done to prevent the resident from getting into garbage cans and trying to get into peoples' cars. She said if something was going on, such as the Bayou Classic, it was hard to staff the facility. She said the nurses rotated out on the units to help out with observations. She said Resident #12 was not ever put on close observations and that he was not a danger to anyone else. She said he was " benign ". She said they all " kinda " watched him. She said it was a task to keep up with him. She said trash cans were removed from the nurse's station and his room after his choking episode in October, 2012. She said he was in bad shape when he first came to the facility and she thought they did a pretty good job keeping him alive for [AGE] years. When asked where the resident's nurses' notes were after [DATE] and before [DATE] she said there were none. She said the resident was ICF (Intermediate Care Facility) during that time period and only required charting every 14 days. An interview was conducted on [DATE] at 12:40 p.m. with S12CNA. She said she had worked at the facility for [AGE] years. She said she had to redirect Resident #12 away from the trash cans. She said she worked the night shift the morning Resident #12 expired. She said she saw Resident #12 walk into the facility from outside and fall on the floor in front of the nurse's station. She said his mouth was clenched. She said after he collapsed, she swept his mouth and removed a bone from his mouth. She said all staff in the facility came to the scene. S12CNA further stated that she was assigned to conduct 1:1 Observations of Resident #15 that shift. She said Resident #15 was in the same room with another resident (Resident #17) who had been receiving Close Observations by S34LPN. S12CNA said while S34LPN administered medications at 8:00 p.m., she (S12CNA) helped him (S34LPN) out by watching (Resident#17) in addition to watching Resident #15. She said she also handed out snacks to the residents. She said all the staff helped out. She said on the night shift that night S37CNA did the clothes, handed out cigarettes, and was assigned Close Observations on Resident#18 and Resident #2. When asked what 1:1 Observations meant, she said within hands reach. She said there was a floater CNA that helps out the CNAs doing Close Observation. She said the maximum number of residents they can watch on Close Observation is 2. An interview was conducted on [DATE] at 1:35 p.m. with S9LPN. She said she had been working at the facility for [AGE] years. She worked Resident #12's hall for several years on the day shift. She said after the resident had the choking incident on [DATE], the facility removed the garbage cans out from the locker room on the resident's hall, the resident's room and the nurse's station in that area. She said she had worked with the resident after he was readmitted back to the facility after the October choking incident. She said he was not on close observations because she was told not to put him on close observations. She said she monitored him when he went to garbage cans and redirected him. She said he would always go back to the trash can and redirection was not always effective. She said placing the resident on close observations was determined by the doctor. She said she did not ask the doctor (S39MD) if the resident could be placed on close observations because she felt like it was the doctor's decision. She said the doctor was aware the resident ate food out of the garbage. She said residents were placed on close observations if they wandered away or hurt themselves or others ...such as he (Resident #12) was doing. She said the resident walked all over the place, went the recreation room, went to his room and lay in his bed. An interview was conducted on [DATE] at 2:15 p.m. with S46Counselor. She said she was a counselor and not a licensed social worker. She said Resident #12 would eat anything he could find. She said they staffed him every 3 months. She explained that the following staff members attended the staff meeting: Dietary, Physical Therapy, MDS Coordinator, Recreation, S28SSD, and S9LPN. She said that they did not discuss putting Resident #12 on close observations or increasing his supervision during the meeting. She said he could not help his actions because of his mental status. She said the resident had a change on his MDS after he returned from the hospital and she had to complete a portion on the MDS. An interview was conducted on [DATE] at 2:20 p.m. with S28SSD. She said her first staffing she attended on the resident was about a week before he died . She said no one had discussed placing the resident on close observations or increased supervision to 1:1 at the meeting. An interview was conducted on [DATE] at 2:30 p.m. with S47MDSCoordinator. She said she had been the MDS Coordinator since August, 2012. She said S4RNCarePlan was the MDS nurse assigned to the resident. She said S4RNCareplan was presently out of the facility. She said the resident did not have a significant change MDS completed after his return to the facility after the [DATE] choking incident because he was back to his " running around " when he returned to the facility. She verified no significant MDS was completed because the resident had not experienced a decline in 2 areas. She said it was the MDS nurse ' s responsibility to discuss problems and address issues about the residents with the doctor after the staffing meeting. She also said the MDS nurse was responsible for updating the care plan. She said S4RN had not mentioned to her that it had been discussed in the Staffing Meetings to increase the Resident #12 ' s supervision or close observation since the resident ' s choking incident in October, 2012. On [DATE] at 6:05 p.m., an interview was held with S33RNSupervisor, regarding Resident#12. She explained that Resident #12 gorged food. She said he was always seeking food. She stated that Resident #12 was not placed on Close Observation or 1:1 Supervision, to her knowledge, after the choking incident on [DATE]. She further stated that she was not sure if he had access to the garbage cans in other parts of the building besides the ones in the area of his room. She also said that Resident #12 walked the grounds frequently. She stated that she was working the night the resident expired. She said she was working in another building that night and at around 4:03 a.m. - 4:04 a.m. S34LPN called her and reported that Resident #12 had collapsed, in the hall, in front of the nurses' station. S34LPN stated that Resident #12 had shallow respirations and a blocked airway. She said that she told S34LPN to keep trying to clear the resident's airway until she got there. She arrived at 4:05a.m. She said the resident was lying unresponsive, on the floor, in front of the nurses station. She said S35PsychiatricAideSupervisor was bagging Resident #12 and that he had minimal rise/fall of the chest wall with each breath administered. She said she asked S35PsychiatricAideSupervisor to pause bagging and she checked the oral airway. She said at that time she noted vomit, food particles, and pieces of paper in Resident #12's mouth. She explained that she removed the vomit, food particles, and pieces of paper from the resident's mouth and did a rapid head to toe assessment. She further stated that at approximately 4:08 a.m. the resident was in full cardiac and respiratory arrest. She said cardiopulmonary resuscitation (CPR) and ventilations (breaths administered with a breathing bag and mask) were continued at that time. She also said that particles of debris, paper, and a

Based on interview, clinical record review the facility failed to have a sytem in place to ensure the residents were provided the necessary clinical supervision/monitoring by staff for 3 (#12, #1, #15) of 15 ( #1, #2, #3,#4,#5, #6, #7, #8, #9, #10, #11,#12,#13, #14, #15) residents. The facility failed to ensure the Director of Nursing : 1. Monitored the staff make sure the plan of care was effective. (#12, #1, #15) 2. Identified interventions already in place were not working and staff implemented new interventions for ongoing problems. (#12, #1, #15) 3. Identified and implemented new interventions on [DATE], to prevent a severely cognitively impaired resident(#12) from digging in the trash for food and eating food without staff knowledge after he returned from the hospital on [DATE] following an incident where he aspirated food debris scavenged from the trash, without staff knowledge and developed aspiration pneumonia requiring intubation. 4. Staff clarified a physician's orders [REDACTED].#12) 5. Identified and implemented new interventions and approaches to prevent physical altercations between Resident #1 and other facility residents after the incident on [DATE] when Resident #1 was involved in an altercation with Resident #3 on [DATE] in which Resident #3 received a broken ankle. 6. Implemented a system of increased supervision and monitoring of Resident #1 on [DATE] to prevent altercations with other residents after Resident #1 was involved in a physical altercation with Resident #3 on [DATE] in which Resident #3 received a broken ankle. 7. Identified and implemented a system of increased supervision and monitoring of Resident #1 on [DATE] to protect other residents at the facility from his [MEDICAL CONDITION] behaviors after Resident #1 started a fight with his roommate, knocked the roommate's TV over, threatened to kill his roommate, scratched the roommate, and closed the nurse's hand in the door on [DATE]. 8. Identified and implemented new interventions to prevent physical altercations between Resident #1 and other residents following a fist fight between Resident #1 and another resident on [DATE], after Resident #1 punched another resident in the mouth on [DATE], and after physical altercations with another resident on [DATE] and [DATE]. 9. Implemented a system of increased supervision and monitoring of Resident #1 on [DATE] after Resident #1 broke Resident #2's nose during a physical altercation on [DATE]. 10. Had a system in place to protect other residents from Resident #1's aggressive, violent behaviors 11. Had a system of supervision and monitoring in place to protect Resident #1 from physical and verbal altercations initiated by other residents after [DATE] when he was kicked in the groin on [DATE] by another resident. 12. Identified and implemented new interventions for supervision to prevent elopement from the facility for a cognitively impaired resident (#15) after his second elopement attempt [DATE] where he was found trying to climb over the closed gate on [DATE] while under orders for close observation. 13. Identified and implemented new interventions for supervision to prevent elopement on [DATE] after a cognitively impaired resident ( #15) had two elopement attempts on [DATE] while under close observation. 14. Identified and implemented new interventions for supervision on [DATE] to prevent a cognitively impaired resident (#15) from eloping from the facility after he eloped off of the facility grounds on [DATE], flagged down a female motorist and began choking her in her car while under orders for close observation. 15. Identified and implemented interventions to prevent a cognitively impaired resident (#15) from eloping from the facility and travelling to the grounds of a local nursing facility on [DATE] while under orders for close observation. The Administrator was notified of the Immediate Jeopardy on [DATE] at 7:10 p.m. on [DATE], Resident #12, a severely cognitively impaired resident, was transferred to an area emergency room with partial airway occlusion and aspiration pneumonia after choking on possible food debris. Resident #12's history was significant for digging in garbage cans for food and choking. Due to his cognitive status, intervention of redirection was ineffective for this resident per facility's staff documentation. Resident #12 was placed in Immediate Jeopardy on [DATE] when he returned from the hospital and the facility failed to identify and implement new interventions to prevent him from digging in garbage cans and eating food without staff supervision. On [DATE], at approximately 4:05 a.m., Resident #12 came in from outside area and collapsed in front of the nurses station. Resident #12 was unresponsive due to occluded airway. During attempts to clear airway, food particles, including a chicken bone were removed from resident #12's airway. Despite the [MEDICATION NAME] maneuver and initiation of cardiopulmonary resuscitation (CPR), Resident #12 expired. The Immediate Jeopardy ended for the resident on [DATE] at 4:45 a.m. when he expired. The Immediate Jeopardy was lowered to a Level III isolated, actual harm on [DATE] at 4:45 a.m. when Resident #12 expired. The Administrator was notified of the Immediate Jeopardy on [DATE] at 12:30 p.m. for Resident #1. Other residents, who came in contact with Resident #1, were placed in Immediate Jeopardy from the aggressive, violent behaviors initiated by Resident #1. The facility failed to implement a system of supervision and monitoring of Resident #1 to prevent his aggressive, violent behaviors from hurting other residents. The Immediate Jeopardy began on [DATE] when the facility failed to ensure supervision of Resident #1 was increased after Resident #1 fractured Resident #3's ankle in an altercation. The Immediate Jeopardy continued when Resident #1 continued to have multiple altercations with other residents. Resident #1 fractured Resident #2's nose on [DATE] during an altercation. On [DATE] Resident #3 received a loose tooth, swollen lip, and cheek abrasion during an altercation with Resident #1. Resident #1 was placed on an Physician Emergency Certificate on [DATE] and [DATE]. Supervision of Resident #1 was not increased after these incidents. The Immediate Jeopardy ended on [DATE] at 12:00 p.m. when Resident #1 was placed on Close Observations. The Immediate Jeopardy was lowered to a Level II -pattern on [DATE] for Resident #1. The Administrator was notified of the Immediate Jeopardy on [DATE] at 7:10 p.m. for Resident #15. The Immediate Jeopardy began on [DATE] when the facility failed to ensure supervision of Resident #15 after his second elopement attempt where he was found trying to climb over the closed gate while under close observation. The facility failed to increase supervision and monitoring on [DATE] when 2 elopement attempts occurred while under close observation with no further interventions in place and no increase in monitoring. On [DATE] Resident #15 eloped out of the facility, past the gate and ran to the highway, flagged down a female motorist, began choking her in her car while on close observation. No new interventions for increased supervision or monitoring were put into place. On [DATE] Resident #15 eloped while under close observation off of facility grounds and traveled 1.6 miles to the grounds of a local nursing facility. This immediate jeopardy was lifted when Resident #15 was PEC'd to a local hospital on [DATE] at 5:10 p.m. and returned as 1:1 supervision. The Immediate Jeopardy was lowered to a Level II - pattern on [DATE] for Resident #15. Findings: Review of the facility ' s policy for Close Observation and One- To-One Monitoring revealed the following: Purpose: To establish guidelines for nursing staff to implement and follow when close observation or one -to -one monitoring is ordered on a resident . Examples of reasons for ordering close observation or one -to- one monitoring include, but are not necessarily limited to wandering, sexually inappropriate behavior, aggressive behavior toward other residents, and behavior that poses a danger to the resident or others. Procedure for: 1. Close observation: The resident must be within assigned staff member's line of vision at all Times; One -to -One: Assigned staff member must be within six feet of resident at all times 2. The nurse must have a physician's orders [REDACTED]. The order must include the reason and verbal orders must be signed by the physician within 24 hours. The order will remain active/valid until discontinued. 3. Close Observation Monitoring record will be initiated by nursing staff when the resident is placed on one -to- one monitoring. 4. The staff member assigned to monitor the resident will document every 15 minutes on the Close Observation or One -to- One monitoring Record. 5. The resident will not be permitted to attend off- unit functions until the precautions are discontinued. Resident #12 Review of Resident #12's clinical record revealed the following: Date of Birth: [DATE]; Date of Admission: [DATE] and a [DIAGNOSES REDACTED]. Review of Resident #12's most recent Minimum Data Set (MDS), Assessment Reference Date (ARD): [DATE]; Type: Quarterly, revealed the following: Cognitive Patterns: Brief interview for Mental Status ( BIMS): should resident interview be conducted: No ( resident is rarely/never understood); Cognitive skills for daily decision making: 3. Severely impaired- never/rarely made decisions; Acute onset mental status change: No; Swallowing/Nutritional status: Swallow disorder: none of the above: checked; Height (in inches): 70; Weight(in pounds): 245; Nutrition approach: Resident: mechanically altered diet: checked; Nutrition approach: Resident: therapeutic diet: checked; Occupational Therapy: blank Review of Resident #12 ' s physician progress notes [REDACTED]. Stridor (harsh breathing sound associated with obstruction) was heard by staff. ,[DATE] pulse, 71 oxygen saturation, 99% on 100% re-breather (oxygen mask), with room air was 87%, now trying to get up and wander, still raspy sounding in throat, patient was pulse less and on sofa, placed on floor and [MEDICATION NAME] done, then patient started respirations and pulse returned; Impression: Aspiration of chopped meat; Plan: transfer to area hospital; [DATE], 7:50 a.m.: patient still digging through garbage cans, trying to get in to cars, Plan: Continue care, yard/cigarettes from garbage cans, continue medications; [DATE] 8:26 a.m.: patient the same wandering and eating out of garbage, Plan: Continue medications, continue care; [DATE], 11:10 a.m.: Patient still eating from garbage can and trying to get in cars on the grounds, Plan: Continue medications, continue care; [DATE] 8:30 a.m. Patient doing the same, wandering grounds, trying to get in cars, picking up things from the ground and garbage cans and eating them: Plan: Continue medications, continue care, keep special appointments; [DATE]: Still eating from garbage cans, Plan: Continue medications, continue care; [DATE]: Transfer note: patient found falling over, choking. [MEDICATION NAME] and abdominal thrust done. Nothing recovered, may have aspirated cornbread, patient supine on floor, now minimally responsive, heart rate 108, respiratory rate 16, with decreased breath sounds right anterior chest, abdomen with positive bowel sounds, 1. Aspiration, 2. Airway- partial occlusion 3.[MEDICAL CONDITION] 4. Mental [MEDICAL CONDITION] 5. Constipation; Plan: To area hospital emergency room via local ambulance service; [DATE] 2:49 p.m.: status [REDACTED]. Review of Resident #12 ' s Nutritional Staffing Note, dated [DATE], revealed the following, in part: Regular quarterly staffing; Other disciplines: Nursing: choking incident on [DATE]; Comments: Resident #12 had a choking incident last week. He choked on a piece of meat. Unsure of where he got it from, just that it wasn ' t on his tray. The meat was expelled and he was transferred to a local hospital emergency room for evaluation. He returned later that day. Chopped meats appropriate secondary to choking potential; [DATE]: Comments: he remains ambulatory and still requires redirection due to getting food from trash bins; Diet Prescription (Rx): Routine with chopped meat, offer a.m. and hour of sleep (h.s.) snacks; [DATE]: Diet Rx.: Routine with chopped meat, offer a.m. and h.s.snacks Review of Resident #12 ' s physician orders [REDACTED]. s. snacks **** Supervision at meals Review of Resident #12 ' s re-admission physician orders, dated [DATE] 2:48 p.m. (after the [DATE] hospitalization ) revealed the following, in part: 2. status [REDACTED]. Continue all previous orders. Review of Resident #12 ' s current Care Plan revealed the following, in part: Problem/Need: Potential for Injury related to (R/T) behavioral problems, as evidenced by history of eating cigarette butts out of the ashtrays, history of eating feces, and eating out of trash can, etcetera (etc.), tries to get in to employees cars; Goal and Target Date: There will be no incident of injury by next staffing date. (Goal/Target Dates were : [DATE], [DATE], [DATE]); Approaches: Staff monitor more closely; Closely Observe-Do not leave anything in Resident #12 room that he can drink or spray; Watch trays and garbage in dining room, keep him away; The following was noted as a hand written notation on the care plan: [DATE]: Transferred to area hospital emergency room airway partial occlusion, aspiration pneumonia, [MEDICAL CONDITIONS]. Patient found falling over and choking. [MEDICATION NAME] and abdominal thrusts done. Nothing recovered (may have aspirated cornbread); The following was noted as a hand written notation on the care plan: [DATE]: Returned from area hospital. [MEDICATION NAME] 0.4milligrams by mouth every day, [MEDICATION NAME] 250 milligrams by mouth every day x 5 days for pneumonia; Problem/Need: History of choking due to filling mouth too full, eating too fast, mechanically altered diet secondary to cognitive status and poor dentition; Problem Onset : [DATE]; Hand written notation: [DATE]-choking episode; Hand written notation: [DATE]: choking episode; Goal: Resident #12 will be able to consume food without choking (Goal/Target dates were : [DATE], [DATE], [DATE]); Approaches: Watch trays and garbage in dining room away from him; Monitor for chewing and swallowing difficulty; Refer for evaluation if Resident #12 has signs/symptoms of chewing or swallowing problems; Evaluate diet as needed; Serve diet as ordered; Encourage to eat slowly and not stuff mouth; If chokes then initiate [MEDICATION NAME] maneuver--- call MD; Staff to Monitor Closely Review of the facility nurses notes revealed the following entries, in part: [DATE], 11:00 a.m. Redirected multiple times out of garbage cans. Counseling ineffective; [DATE], 11:00 p.m. goes in to other patient 's rooms and steals any food he finds; [DATE], no time documented: Decision making skills: Severely impaired: Poor insight and judgment, eats out of the trash, counseling and redirection ineffective; [DATE], no time documented: Ability to understand: Sometimes understands: Redirected frequently to eat food slowly; Further review of the facility nurses notes for Resident #12, dated [DATE], revealed the following entries: 7:20 a.m. S24CNA, noted that patient (pt.) had food in mouth and hand. Pt. sitting on side of nurses' station. S24CNA asked pt. what he had in his hand. Pt. unresponsive to CNA- S40CNA called this nurse (S36LPN) to pt. Noted pt. slumped over in chair attempted to perform the [MEDICATION NAME], abdominal thrust, and back blows. CPR also attempted, all without success. Attempted to suction without success; 7:25 a.m.: S38MD notified, instructed to continue all efforts until he arrived to unit. S25RN notified. Efforts continued; 7:30a.m. S50RN arrived to ward for assistance. Efforts continued patient gasping for air, oxygen started with an oxygen mask at 15 liters and oxygen saturation of 92% on 100% oxygen (maximum amount of oxygen that can be delivered), Pulse 105; 7:35 a.m.: Medical doctor (MD) on ward to assess patient. Efforts continue, patient continues gasping, eyes are open but unfocused; 7:40 a.m.: Local ambulance transfer to area hospital with lights and sirens. Patient breathing improves marginally. Continue to monitor; 7:55 a.m.: local ambulance service arrives, patient attempting to stand. Instructed patient to stay lying on floor. Patient appears confused. Breathing becomes more labored. Patient is assisted to stretcher; 5:15 p.m.: Received update from area hospital. Patient admitted to intensive care unit with aspiration pneumonia, [MEDICAL CONDITIONS], and intubation. Further review of Resident #12's facility nurses notes revealed the following entry: [DATE]: 2:27 p.m. Return from local hospital, ambulatory, accompanied by CNA. Resident alert to name only. Follow simple instructions with redirection; 2:43 p.m. MD on unit. Exam resident. Mental status unchanged, answering " yes " to all questions. Instruct staff to Monitor Closely- trash cans and barrel from locker area are now removed; [DATE], 4:45 p.m.: reported by CNA, another resident went to room and struck Resident #12 with a metal object several times on the buttocks. Resident #12 sustained no injuries. The other resident stated Resident #12 had eaten his cookies out of his room. Unable to counsel Resident #12 due to impaired thought process and insight. Review of the facility's 24 Hour Report, dated [DATE], Team A, Shift 6A-6P revealed the following, in part: Resident #12 - ICU at a local hospital. Aspiration Pneumonia/Intubated. [MEDICAL CONDITIONS]. Resident #12 - Choking episode resulting in loss of conscious ...Employees (S41CNA & S44Custodian) performed [MEDICATION NAME] maneuver. Patient was conscious and moving extremities. Patient was eating food out of garbage. Review of Resident #12's Multidisciplinary staffing notes revealed the following entries, in part: [DATE]: Comments: Counseled on staying out of the garbage cans for food, etc.; [DATE]: Comments: Counseled on staying out of the garbage cans for food, etc.; [DATE]: Reason for staffing: On [DATE]: Transferred to area hospital emergency room : Airway partial occlusion and Aspiration, [DATE]; Returned from area hospital , [DATE]: Psychiatric consult: Continue medications, Comments: Counseled on staying out of garbage cans for food, etc. Review of Resident #12's Social Services Notes revealed the following entries, in part: [DATE]: Behavior: Supervision with meals; Patient continues to ramble over parking lot looking for open car doors, goes in to garbage searching for food. Goals/Plan: Rambles around all day hunting for food anywhere he can find it. He must be redirected many times for eating out of garbage cans. He goes in other patients' rooms hunting for food also; [DATE]: Patient choked on food- was sent to an area hospital. Now in Intensive Care Unit (ICU)and intubated (has a breathing tube) - has Aspiration Pneumonia; [DATE]: Behavior: Eats out of trashcans, Goals/Plans: Resident continues to walk searching for food in the cars and in the garbage. Resident on routine diet with chopped meats, Needs Constant Supervision and Care. Transported to an area hospital for choking and ICU care: Returned to facility on [DATE]; [DATE]: Returned from area hospital after a choking episode. He eats out of the garbage cans and can't be stopped. He continues to walk aimlessly hunting for food in the garbage and in the workers' cars if he can have access to them. He is severely disabled with mental [MEDICAL CONDITION]. Review of Resident #12 ' s CNA Activities of Daily Living (ADL) Sheets for ,[DATE]-,[DATE] revealed the following, in part: Observe patient for choking at meal times; Supervision at meals to keep patient from eating extra food; Do not leave anything in patient's room that he can eat, drink, or spray. The ADL sheets were documented upon daily, every 12 hours. Further clinical record review revealed that the only other documentation/monitoring of Resident #12's activities/movements throughout the day were documented on the Ward Round check sheets. These sheets monitor the activities/location of all of the residents on the wards, not just Resident #12. Review of Resident #12's History and Physical, dated [DATE] (from the area hospital where he was admitted on [DATE] from the facility for choking), revealed the following, in part: Chief complaint: Patient was transferred from the nursing home when he was found to be choking, short of breath, and tachypneic; Patient was intubated and admitted to Intensive Care Unit for pneumonia; Respiratory : Patient intubated; Impression: Pneumonia(aspiration), Acute [MEDICAL CONDITION], Continue ventilator support. Review of the Facility Patient Critical Incident Report revealed the following, in part: Date incident occurred: [DATE], Time: 4:05 a.m.; Vital signs: No vital signs; Full Respiratory/[MEDICAL CONDITION]; Briefly describe incident: Patient came from outside area and collapsed in front of the nurses station. Patient was unresponsive due to occluded airway. Food particles in airway. Attempted to clear airway. Ventilations attempted with ambu bag without success; Supervisor's Review/Recommendation: (include probable cause of injury): Foreign body obstructed airway. Airway cleared of vomitus/debris and after multiple abdominal thrusts removed chicken bone; Do you suspect Abuse/Neglect: No, Patient had a history of [REDACTED]. Review of the facility Code Record, dated [DATE], 4:45 a.m., revealed the following: Condition upon discovery: Unresponsive, no respirations; Airway: Occluded with foreign body; CPR initiated 4:05 a.m. Under the Action/Patient Response section of the Code Record was the following notation: Patient collapsed in front of nurses station. Respiratory arrest secondary to airway obstruction (chicken bones). Review of the facility Patient Ward Round Sheet for Unit E, dated [DATE], 6 p.m.-6 a.m. shift, revealed the following notations: 2:00 a.m.: hallway; 2:30 a.m.: day area; 3:00 a.m.: patio; 3:30 a.m.: patio; 4:00 a.m.: hallway; 4:30 a.m.; hallway; 5:00 a.m.: hallway; 5:30 a.m.: hallway. These observations of Resident #12 ' s locations were recorded by S37CNA during ward rounds. Review of Resident #12 ' s physician progress notes [REDACTED]. Mouth cleared but airway with debris. CPR begun. Multiple abdominal thrusts and attempted mouth sweeps without success. [MEDICAL CONDITION] also occurred and [MEDICATION NAME], Sodium [MEDICATION NAME] given without success. After 40 minutes CPR, agonal rhythm briefly seen on monitor, then asystole. Pronounced dead by me (S38MD) at 4:45 hours [DATE]. ( pupils fixed and dilated and no heartrate on auscultation (listening) after 1 minute). Spoke with S43Coroner at 5:15 a.m. regarding above. S43Coroner will review as Coroner's case and stated okay to release body to funeral home. An interview was conducted on [DATE] at 12:20 p.m. with S3ADON. She verified that the resident choked on [DATE]. She said she spoke with staff at State Office about filing an Otis Report and was told by staff at State Office that the incident was not reportable because the facility had nothing in place regarding close observations and removing trash cans prior to the incident. She verified the resident gorged and ate out of the trash and ate employees' food. She said the resident had tried to get into peoples' cars. She said she did not know why except that it was a " ritual " to him. She said the October and November choking incidents both involved chicken bones. She said there was nothing that could have been done to prevent the resident from getting into garbage cans and trying to get into peoples' cars. She said if something was going on, such as the Bayou Classic, it was hard to staff the facility. She said the nurses rotated out on the units to help out with observations. She said Resident #12 was not ever put on close observations and that he was not a danger to anyone else. She said he was " benign ". She said they all " kinda " watched him. She said it was a task to keep up with him. She said trash cans were removed from the nurse's station and his room after his choking episode in October, 2012. She said he was in bad shape when he first came to the facility and she thought they did a pretty good job keeping him alive for [AGE] years. When asked where the resident's nurses' notes were after [DATE] and before [DATE] she said there were none. She said the resident was ICF (Intermediate Care Facility) during that time period and only required charting every 14 days. An interview was conducted on [DATE] at 12:40 p.m. with S12CNA. She said she had worked at the facility for [AGE] years. She said she had to redirect Resident #12 away from the trash cans. She said she worked the night shift the morning Resident #12 expired. She said she saw Resident #12 walk into the facility from outside and fall on the floor in front of the nurse's station. She said his mouth was clenched. She said after he collapsed, she swept his mouth and removed a bone from his mouth. She said all staff in the facility came to the scene. S12CNA further stated that she was assigned to conduct 1:1 Observations of Resident #15 that shift. She said Resident #15 was in the same room with another resident (Resident #17) who had been receiving Close Observations by S34LPN. S12CNA said while S34LPN administered medications at 8:00 p.m., she (S12CNA) helped him (S34LPN) out by watching (Resident#17) in addition to watching Resident #15. She said she also handed out snacks to the residents. She said all the staff helped out. She said on the night shift that night S37CNA did the clothes, handed out cigarettes, and was assigned Close Observations on Resident#18 and Resident #2. When asked what 1:1 Observations meant, she said within hands reach. She said there was a floater CNA that helps out the CNAs doing Close Observation. She said the maximum number of residents they can watch on Close Observation is 2. An interview was conducted on [DATE] at 1:35 p.m. with S9LPN. She said she had been working at the facility for [AGE] years. She worked Resident #12's hall for several years on the day shift. She said after the resident had the choking incident on [DATE], the facility removed the garbage cans out from the locker room on the resident's hall, the resident's room and the nurse's station in that area. She said she had worked with the resident after he was readmitted back to the facility after the October choking incident. She said he was not on close observations because she was told not to put him on close observations. She said she monitored him when he went to garbage cans and redirected him. She said he would always go back to the trash can and redirection was not always effective. She said placing the resident on close observations was determined by the doctor. She said she did not ask the doctor (S39MD) if the resident could be placed on close observations because she felt like it was the doctor's decision. She said the doctor was aware the resident ate food out of the garbage. She said residents were placed on close observations if they wandered away or hurt themselves or others ...such as he (Resident #12) was doing. She said the resident walked all over the place, went the recreation room, went to his room and lay in his bed. An interview was conducted on [DATE] at 2:15 p.m. with S46Counselor. She said she was a counselor and not a licensed social worker. She said Resident #12 would eat anything he could find. She said they staffed him every 3 months. She explained that the following staff members attended the staff meeting: Dietary, Physical Therapy, MDS Coordinator, Recreation, S28SSD, and S9LPN. She said that they did not discuss putting Resident #12 on close observations or increasing his supervision during the meeting. She said he could not help his actions because of his mental status. She said the resident had a change on his MDS after he returned from the hospital and she had to complete a portion on the MDS. An interview was conducted on [DATE] at 2:20 p.m. with S28SSD. She said her first staffing she attended on the resident was about a week before he died . She said no one had discussed placing the resident on close observations or increased supervision to 1:1 at the meeting. An interview was conducted on [DATE] at 2:30 p.m. with S47MDSCoordinator. She said she had been the MDS Coordinator since August, 2012. She said S4RNCarePlan was the MDS nurse assigned to the resident. She said S4RNCareplan was presently out of the facility. She said the resident did not have a significant change MDS completed after his return to the facility after the [DATE] choking incident because he was back to his "running around" when he returned to the facility. She verified no significant MDS was completed because the resident had not experienced a decline in 2 areas. She said it was the MDS nurse's responsibility to discuss problems and address issues about the residents with the doctor after the staffing meeting. She also said the MDS nurse was responsible for updating the care plan. She said S4RN had not mentioned to her that it had been discussed in the Staffing Meetings to increase the Resident #12's supervision or close observation since the resident's choking incident in October, 2012. On [DATE] at 6:05 p.m., an interview was held with S33RNSupervisor, regarding Resident#12. She explained that Resident #12 gorged food. She said he was always seeking food. She stated that Resident #12 was not placed on Close Observation or 1:1 Supervision, to her knowledge, after the choking incident on [DATE]. She further stated that she was not sure if he had access to the garbage cans in other parts of the building besides the ones in the area of his room. She also said that Resident #12 walked the grounds frequently. She stated that she was working the night the resident expired. She said she was working in another building that night and at around 4:03 a.m. - 4:04 a.m. S34LPN called her and reported that Resident #12 had collapsed, in the hall, in front of the nurses' station. S34LPN stated that Resident #12 had shallow respirations and a blocked airway. She said that she told S34LPN to keep trying to clear the resident's airway until she got there. She arrived at 4:05a.m. She said the resident was lying unresponsive, on the floor, in front of the nurses station. She said S35PsychiatricAideSupervisor was bagging Resident #12 and that he had minimal rise/fall of the chest wall with each breath administered. She said she asked S35PsychiatricAideSupervisor to pause bagging and she checked the oral airway. She said at that time she noted vomit, food particles, and pieces of paper in Resident #12's mouth. She explained that she removed the vomit, food particles, and pieces of paper from the resident's mouth and did a rapid head to toe assessment. S

Based on interview and record review the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for 3 (#12, #1, #15) of 15 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15) residents reviewed for accident prevention/supervision. The facility failed to: 1. Ensure staff assessed, identified and implemented new interventions for supervision and monitoring on [DATE] to prevent a severely cognitively impaired resident (#12) from digging food out of garbage cans and eating food without staff knowledge after he returned from the hospital on [DATE] following a severe choking episode that occurred at the facility on [DATE]. 2. Have a system in place to ensure staff identified and implemented new interventions for supervision to prevent elopement from the facility for a cognitively impaired resident (#15) after his second elopement attempt on [DATE] where he was found trying to climb over the closed gate on [DATE] while under orders for close observation. 3. Have a system in place to ensure staff identified and implemented new interventions for supervision to prevent elopement on [DATE] after a cognitively impaired resident (#15) had two elopement attempts on [DATE] while under close observation by facility staff. 4. Have a system in place to ensure staff identified and implemented new interventions for supervision on [DATE] to prevent a cognitively impaired resident (#15) from eloping from the facility after he eloped off of the facility grounds on [DATE], flagged down a female motorist and began choking her in her car while under close observation by facility staff. 5. Identify and implement interventions to prevent a cognitively impaired resident (#15) from eloping from the facility and traveling to the grounds of a local nursing facility on [DATE] while under orders for close observation by facility staff. 6. Ensure nursing staff clarified a physician order [REDACTED]. (#12) 7. Have a system in place to ensure facility staff identified and implemented new interventions to protect facility residents from Resident #1's aggressive, explosive behaviors following an altercation between Resident #1 and Resident #3 on [DATE] which resulted in the other resident (#3) sustaining a broken ankle. 8. Have a system in place to ensure staff identified and implemented new interventions to supervise Resident #1 on [DATE] following an incident on [DATE] where Resident #1 started a fight with his roommate, knocked over the roommate's TV, threatened to kill his roommate, scratched the roommate and closed the nurse's hand in the door. 9. Have a system in place to ensure facility staff identified and implemented new interventions to prevent physical altercations between Resident #1 and other residents following a fist fight between Resident #1 and another resident on [DATE], after Resident #1 punched another resident in the mouth on [DATE], and after physical altercations with another resident on [DATE] and [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 7:10 p.m. On [DATE] Resident #12, a severely cognitively impaired resident, was transferred to an area emergency room with partial airway occlusion, aspiration pneumonia after choking on possible food debris. Resident #12's history was significant for digging in garbage cans for food and choking. Due to his cognitive status, intervention of redirection was ineffective for this resident per facility's staff documentation. Resident #12 was placed in Immediate Jeopardy on [DATE] when he returned from the hospital and the facility failed to identify and implement new interventions to prevent him from digging in garbage cans and eating food without staff supervision. On [DATE], at approximately 4:05 a.m. Resident #12 came in from an outside area and collapsed in front of the nurse's station. Resident #12 was unresponsive due to occluded airway. During attempts to clear the resident's airway, food particles, including a chicken bone, were removed from Resident #12's airway. Despite [MEDICATION NAME] Maneuver and initiation of CPR (Cardiopulmonary Resuscitation), Resident #12 expired. The Immediate Jeopardy ended for Resident #12 on [DATE] at 4:45 a.m. when he expired. The Immediate Jeopardy was lowered to a Level III isolated, actual harm on [DATE] at 4:45 a.m. when Resident #12 expired. The Administrator was notified of the Immediate Jeopardy on [DATE] at 12:30 p.m. for Resident #1. Other residents, who came in contact with Resident #1, were placed in Immediate Jeopardy from the aggressive, violent behaviors initiated by Resident #1. The facility failed to implement a system of supervision and monitoring of Resident #1 to prevent his aggressive, violent behaviors from hurting other residents. The Immediate Jeopardy began on [DATE] when the facility failed to ensure supervision of Resident #1 was increased after Resident #1 fractured Resident #3's ankle in an altercation. The Immediate Jeopardy continued when Resident #1 continued to have multiple altercations with other residents. Resident #1 fractured Resident #2's nose on [DATE] during an altercation. On [DATE] Resident #3 received a loose tooth, swollen lip, and cheek abrasion during an altercation with Resident #1. Resident #1 was placed on an Physician Emergency Certificate on [DATE] and [DATE]. Supervision of Resident #1 was not increased after these incidents. The Immediate Jeopardy ended on [DATE] at 12:00 p.m. when Resident #1 was placed on Close Observations. The Immediate Jeopardy was lowered to a Level II -pattern on [DATE] for Resident #1. The Administrator was notified of the Immediate Jeopardy on [DATE] at 7:10 p.m. for Resident #15. The Immediate Jeopardy began on [DATE] when the facility failed to ensure supervision of Resident #15 after his second elopement attempt where he was found trying to climb over the closed gate while under close observation. The facility failed to increase supervision and monitoring on [DATE] when 2 elopement attempts occurred while under close observation with no further interventions in place and no increase in monitoring. On [DATE] Resident #15 eloped out of the facility, past the gate and ran to the highway, flagged down a female motorist, began choking her in her car while on close observation. No new interventions for increased supervision or monitoring were put into place. On [DATE] Resident #15 eloped while under close observation off of facility grounds and traveled 1.6 miles to the grounds of a local nursing facility. This immediate jeopardy was lifted when Resident #15 was PEC'd to a local hospital on [DATE] at 5:10 p.m. and returned as 1:1 supervision. The Immediate Jeopardy was lowered to a Level II - pattern on [DATE] for Resident #15. Findings: Review of the facility's policy for Close Observation and One- To-One Monitoring revealed the following: Purpose: To establish guidelines for nursing staff to implement and follow when close observation or one -to -one monitoring is ordered on a resident . Examples of reasons for ordering close observation or one -to- one monitoring include, but are not necessarily limited to wandering, sexually inappropriate behavior, aggressive behavior toward other residents, and behavior that poses a danger to the resident or others. Procedure for: 1. Close observation: The resident must be within assigned staff member's line of vision at all Times; One-to-One: Assigned staff member must be within six feet of resident at all times 2. The nurse must have a physician's orders [REDACTED]. The order must include the reason and verbal orders must be signed by the physician within 24 hours. The order will remain active/valid until discontinued. 3. Close Observation Monitoring record will be initiated by nursing staff when the resident is placed on one-to-one monitoring. 4. The staff member assigned to monitor the resident will document every 15 minutes on the Close Observation or One-to-One monitoring Record. 5. The resident will not be permitted to attend off- unit functions until the precautions are discontinued Resident #12. Review of Resident #12's clinical record revealed the following: Date of Admission: [DATE] and a [DIAGNOSES REDACTED]. Review of Resident #12's most recent Minimum Data Set (MDS), Assessment Reference Date (ARD): [DATE]; Type: Quarterly, revealed the following: Cognitive Patterns: Brief interview for Mental Status ( BIMS): should resident interview be conducted: No ( resident is rarely/never understood); Cognitive skills for daily decision making: 3. Severely impaired- never/rarely made decisions; Acute onset mental status change: No; Swallowing/Nutritional status: Swallow disorder: none of the above: checked; Height (in inches): 70; Weight(in pounds): 245; Nutrition approach: Resident: mechanically altered diet: checked; Nutrition approach: Resident: therapeutic diet: checked; Occupational Therapy: blank Review of the Resident #12's physician progress notes [REDACTED]. [DATE] 1:45 p.m. called by nurse that patient was eating in dining room and got choked, vomited, and he left and came to day room with CNA following , patient on sofa and continue to struggle to breathe. Stridor (harsh breathing sound associated with obstruction) was heard by staff. ,[DATE] pulse, 71 oxygen saturation, 99% on 100% re-breather (oxygen mask), with room air was 87%, now trying to get up and wander, still raspy sounding in throat, patient was pulse less and on sofa, placed on floor and [MEDICATION NAME] done, then patient started respirations and pulse returned; Impression: Aspiration of chopped meat; Plan: transfer to area hospital [DATE] 7:50 a.m. patient still digging through garbage cans, trying to get in to cars, Plan: Continue Care, yard/cigarettes from garbage cans, continue medications [DATE] 8:26 a.m. Patient the same wandering and eating out of garbage, Plan: Continue medications, Continue care [DATE] 11:10 a.m. Patient still eating from garbage can and trying to get in cars on the grounds, Plan: Continue medications, Continue care [DATE] 8:30 a.m. Patient doing the same, wandering grounds, trying to get in cars, picking up things from the ground and garbage cans and eating them: plan: continue medications, continue care, keep special appointments [DATE] (not timed) still eating from garbage cans, plan: continue medications, continue care [DATE]: Transfer note (Not timed) patient found falling over, choking. [MEDICATION NAME] and abdominal thrust done. Nothing recovered, may have aspirated cornbread, patient supine on floor, now minimally responsive, heart rate 108, respiratory rate 16, with decreased breath sounds right anterior chest, abdomen with positive bowel sounds, 1. Aspiration, 2. Airway- partial occlusion 3. [MEDICAL CONDITION] 4. Mental [MEDICAL CONDITION] 5. Constipation; Plan: to area hospital emergency room via local ambulance service [DATE] 2:49 p.m.: status [REDACTED]. Review of Resident #12's Nutritional Staffing Notes revealed the following in part: [DATE] Regular quarterly staffing; Other disciplines: Nursing: Choking incident on [DATE]; Comments: Resident #12 had a choking incident last week. He choked on a piece of meat. Unsure of where he got it from, just that it wasn't on his tray. The meat was expelled and he was transferred to a local hospital emergency room for evaluation. He returned later that day. Chopped meats appropriate secondary to choking potential. [DATE] Comments: He remains ambulatory and still requires redirection due to getting food from trash bins; Diet Prescription (Rx): Routine with chopped meat, offer a.m. and hour of sleep (h.s.) snacks; [DATE] : Diet Rx.: Routine with chopped meat, offer a.m. and h.s. snacks Review of Resident #12's physician orders [REDACTED]. Do not leave anything in resident room that he can eat, drink, or spray Routine diet: Offer a.m. and hour of sleep (h. s.) snacks Supervision at meals Review of Resident #12's re-admission physician orders, dated [DATE] 2:48 p.m. (after the [DATE] hospitalization ) revealed the following, in part: 1. ... 2. status [REDACTED]. 3. Continue all previous orders. Review of Resident #12's current Care Plan revealed the following, in part: Problem/Need: Potential for injury related to (R/T) behavioral problems as evidenced by history of eating cigarette butts out of the ashtrays, history of eating feces, and eating out of trash can, etcetera, tries to get in to employees cars; Goal and Target date: There will be no incident of injury by next staffing date. (Goal/Target dates were : [DATE], [DATE], [DATE]); Approaches: Staff monitor more closely; closely observe-do not leave anything in Resident #12 room that he can drink or spray; watch trays and garbage in dining room, keep him away; The written notation on the care plan read: [DATE]: Transferred to area hospital emergency room airway partial occlusion, aspiration pneumonia, [MEDICAL CONDITIONS]. Patient found falling over and choking. [MEDICATION NAME] and abdominal thrusts done. Nothing recovered (may have aspirated cornbread); [DATE] Returned from area hospital. [MEDICATION NAME] 0.4 milligrams by mouth every day, [MEDICATION NAME] 250 milligrams by mouth every day x 5 days for pneumonia; Problem/Need: History of choking due to filling mouth too full, eating too fast, mechanically altered diet secondary to cognitive status and poor dentition; Problem Onset [DATE]; [DATE]-Choking episode; [DATE]: Choking episode; Goal: Resident #12 Will be able to consume food without choking ( Goal/Target dates were : [DATE], [DATE], [DATE]); Approaches: Watch trays and garbage in dining room away from him; Monitor for chewing and swallowing difficulty; refer for evaluation if Resident #12 has signs/symptoms of chewing or swallowing problems; Evaluate diet as needed; Serve diet as ordered; Encourage to eat slowly and not stuff mouth; If chokes then initiate [MEDICATION NAME] maneuver--- call MD; Staff to Monitor Closely Review of the facility nurses notes revealed the following entries, in part: [DATE] 11:00 a.m. Redirected multiple times out of garbage cans. Counseling ineffective; [DATE] 11:00 p.m. Goes in to other patient's rooms and steals any food he finds; [DATE] (no time documented): Decision making skills: severely impaired: poor insight and judgment, eats out of the trash, counseling and redirection ineffective; [DATE] (no time documented): Ability to understand: Sometimes understands: Redirected frequently to eat food slowly; [DATE] 7:20 a.m. S24CNA, noted that patient( pt.) had food in mouth and hand. Pt. sitting on side of nurses' station. S24CNA asked pt. what he had in his hand. Pt. unresponsive to CNA- S40CNA called this nurse (S36LPN) to pt. Noted pt. slumped over in chair attempted to perform the [MEDICATION NAME], abdominal thrust, and back blows. CPR also attempted, all without success. Attempted to suction without success; 7:25 a.m.: S38MD notified, instructed to continue all efforts until he arrived to unit. S25RN notified. Efforts continued; 7:30 a.m. S50RN arrived to ward for assistance. Efforts continued patient gasping for air, oxygen started with an oxygen mask at 15 liters and oxygen saturation of 92% on 100% oxygen (maximum amount of oxygen that can be delivered), Pulse 105; 7:35 a.m.: Medical doctor (MD) on ward to assess patient. Efforts continue, patient continues gasping, eyes are open but unfocused; 7:40 a.m.: Local ambulance transfer to area hospital with lights and sirens. Patient breathing improves marginally. Continue to monitor; 7:55 a.m.: Local ambulance service arrives, patient attempting to stand. Instructed patient to stay lying on floor. Patient appears confused. Breathing becomes more labored. Patient is assisted to stretcher; 5:15 p.m.: Received update from area hospital. Patient admitted to intensive care unit with aspiration pneumonia, [MEDICAL CONDITIONS], and intubation. [DATE]: 2:27 p.m. Return from local hospital, ambulatory, accompanied by CNA. Resident alert to name only. Follow simple instructions with redirection; 2:43 p.m. MD on unit. Exam resident. Mental status unchanged, answering "yes" to all questions. Instruct staff to Monitor Closely- trash cans and barrel from locker area are now removed; [DATE], 4:45 p.m.: Reported by CNA, another resident went to room and struck Resident #12 with a metal object several times on the buttocks. Resident #12 sustained no injuries. The other resident stated Resident #12 had eaten his cookies out of his room. Unable to counsel Resident #12 due to impaired thought process and insight. Review of the facility's 24 Hour Report, dated [DATE], Team A, Shift 6A-6P revealed the following, in part: Resident #12 - ICU at a local hospital. Aspiration Pneumonia/Intubated. [MEDICAL CONDITIONS]. Resident #12 - Choking episode resulting in loss of conscious ...Employees (S41CNA & S44Custodian) performed [MEDICATION NAME] maneuver. Patient was conscious and moving extremities. Patient was eating food out of garbage. Review of Resident #12's Multidisciplinary Staffing Notes revealed the following entries, in part: [DATE]: Comments: Counseled on staying out of the garbage cans for food, etcetera (etc.).; [DATE]: Comments: Counseled on staying out of the garbage cans for food, etc.; [DATE]: Reason for staffing: On [DATE]: Transferred to area hospital emergency room : Airway partial occlusion and aspiration, [DATE]; Returned from area hospital , [DATE]: Psychiatric consult: Continue medications, Comments: Counseled on staying out of garbage cans for food, etc. Review of Resident #12's Social Services Notes revealed the following entries, in part: [DATE]: Behavior: Supervision with meals; Patient continues to ramble over parking lot looking for open car doors, goes in to garbage searching for food. Goals/Plan: Rambles around all day hunting for food anywhere he can find it. He must be redirected many times for eating out of garbage cans. He goes in other patients' rooms hunting for food also; [DATE]: Patient choked on food- was sent to an area hospital. Now in Intensive Care Unit and intubated ( has a breathing tube) - has aspiration pneumonia; [DATE]: Behavior: Eats out of trash cans, Goals/Plans: Resident continues to walk searching for food in the cars and in the garbage. Resident on routine diet with chopped meats, Needs constant supervision and care. Transported to an area hospital for choking and intensive care unit (ICU) care: Returned to facility on [DATE]; [DATE]: returned from area hospital after a choking episode. He eats out of the garbage cans and can't be stopped. He continues to walk aimlessly hunting for food in the garbage and in the workers' cars if he can have access to them. He is severely disabled with mental [MEDICAL CONDITION]. Review of Resident #12's CNA Activities of Daily Living (ADL) Sheets for ,[DATE]-,[DATE] revealed the following, in part: Observe patient for choking at meal times; Supervision at meals to keep patient from eating extra food; Do not leave anything in patient's room that he can eat, drink, or spray. The ADL sheets were documented upon daily, every 12 hours. Further clinical record review revealed that the only other documentation/monitoring of Resident #12's activities/movements throughout the day were documented on the Ward Round check sheets. These sheets monitor the activities/location of all of the residents on the wards, not just Resident #12. Review of Resident #12's History and Physical, dated [DATE] (from the area hospital where he was admitted on [DATE] for choking) revealed the following, in part: Chief complaint: patient was transferred from the nursing home when he was found to be choking, short of breath, and tachypneic, patient was intubated and admitted to Intensive Care Unit for pneumonia; Respiratory : patient intubated; Impression: Pneumonia(aspiration), Acute [MEDICAL CONDITION], continue ventilator support. . Review of the Facility Patient Critical Incident Report revealed the following, in part: Date incident occurred: [DATE] Time: 4:05 a.m.; Vital signs: no vital signs; full respiratory/[MEDICAL CONDITION]; briefly describe incident: Patient came from outside area and collapsed in front of the nurses station. Patient was unresponsive due to occluded airway. Food particles in airway. Attempted to clear airway. Ventilations attempted with ambu bag without success; Supervisor's Review/Recommendation: (include probable cause of injury) Foreign body obstructed airway. Airway cleared of vomitus/debris and after multiple abdominal thrusts removed chicken bone; Do you suspect Abuse/Neglect: No, Patient had a history of [REDACTED]. Review of the facility Code Record, dated [DATE], 4:45 a.m., revealed the following: Condition upon discovery: Unresponsive, no respirations; Airway: Occluded with foreign body; CPR initiated 4:05 a.m. Under the Action/Patient Response section of the Code Record was the following notation: Patient collapsed in front of nurses station. Respiratory arrest secondary to airway obstruction (chicken bones). Review of the facility Patient Ward Round Sheet for Unit E revealed the following notations: [DATE], 6 p.m.-6 a.m. shift: 2:00 a.m. hallway 2:30 a.m. day area 3:00 a.m. patio 3:30 a.m. patio 4:00 a.m. hallway 4:30 a.m. hallway 5:00 a.m. hallway 5:30 a.m. hallway Review of Resident #12's physician progress notes [REDACTED]. Death Note: [DATE] 5:25 a.m.: Date of Admission: [DATE] date of death : [DATE] Admission Diagnoses: [REDACTED]. Discharge Diagnoses: [REDACTED]. Patient fell to the floor in respiratory arrest. Mouth cleared but airway with debris. cardiopulmonary resuscitation (CPR) begun. Multiple abdominal thrusts and attempted mouth sweeps without success. [MEDICAL CONDITION] also occurred and [MEDICATION NAME], Sodium [MEDICATION NAME] given without success. After 40 minutes CPR, agonal ( abnormal) rhythm briefly seen on monitor, then asystole. Pronounced dead by me (S38MD) at 4:45 hours [DATE]. (pupils fixed and dilated and no heartrate on auscultation after 1 minute. Spoke with S43Coroner at 5:15 a.m. regarding above. S43Coroner will review as coroner's case and stated okay to release body to funeral home. An interview was conducted on [DATE] at 12:20 p.m. with S3ADON. She verified that the resident choked on [DATE]. She said she spoke with staff at State Office about filing an Otis Report and was told by staff at State Office that the incident was not reportable because the facility had nothing in place regarding close observations and removing trash cans prior to the incident. She verified the resident gorged and ate out of the trash and ate employees' food. She said the resident had tried to get into peoples' cars. She said she did not know why except that it was a "ritual" to him. She said the October and November choking incidents both involved chicken bones. She said there was nothing that could have been done to prevent the resident from getting into garbage cans and trying to get into peoples' cars. She said if something was going on, such as the Bayou Classic, it was hard to staff the facility. She said the nurses rotated out on the units to help out with observations. She said Resident #12 was not ever put on Close Observations and that he was not a danger to anyone else. She said he was "benign" . She said they all " kinda" watched him. She said it was a task to keep up with him. She said trash cans were removed from the nurse's station and his room after his choking episode in October, 2012. She said he was in bad shape when he first came to the facility and she thought they did a pretty good job keeping him alive for [AGE] years. When asked where the resident's nurse's notes were after [DATE] and before [DATE] she said there were none. She said the resident was ICF (Intermediate Care Facility) during that time period and only required charting every 14 days. An interview was conducted on [DATE] at 12:40 p.m. with S12CNA. She said she had worked at the facility for [AGE] years. She said she had to redirect Resident #12 away from the trash cans. She said she worked the night shift the morning Resident #12 expired. She said she saw Resident #12 walk into the facility from outside and fall on the floor in front of the nurse's station. She said his mouth was clenched. She said after he collapsed, she swept his mouth and removed a bone from his mouth. She said all staff in the facility came to the scene. S12CNA further stated that she was assigned to conduct 1:1 Observations of Resident #15 that shift. She said Resident #15 was in the same room with another resident (Resident #17) who had been receiving Close Observations by S34LPN. S12CNA said while S34LPN administered medications at 8:00 p.m., she (S12CNA) helped him (S34LPN) out by watching (Resident#17) in addition to watching Resident #15. She said she also handed out snacks to the residents. She said all the staff helped out. She said on the night shift that night S37CNA did the clothes, handed out cigarettes, and was assigned Close Observations on Resident#18 and Resident #2. When asked what 1:1 Observations meant, she said within hands reach. She said there was a floater CNA that helped out the CNAs doing Close Observations. She said the maximum number of residents they can watch on Close Observation is 2. An interview was conducted on [DATE] at 1:35 p.m. with S9LPN. She said she had been working at the facility for [AGE] years. She worked Resident #12's hall for several years on the day shift. She said after the resident had the choking incident on [DATE], the facility removed the garbage cans out from the locker room on the resident's hall, the resident's room and the nurse's station. She said she had worked with the resident after he was readmitted back to the facility after the October choking incident. She said he was not on close observations because she was told not to put him on close observations. She said she monitored him when he went to garbage cans and redirected him. She said he would always go back to the trash can and redirection was not always effective. She said placing the resident on close observations was determined by the doctor. She said she did not ask the doctor (S39MD) if the resident could be placed on Close Observations because she felt like it was the doctor's decision. She said the doctor was aware the resident ate food out of the garbage. She said residents were placed on Close Observations if they wandered away or hurt themselves or others ...such as he (Resident #12) was doing. She said the resident walked all over the place, went the recreation room, went to his room and lay in his bed. An interview was conducted on [DATE] at 2:15 p.m. with S46Counselor. She said she was a counselor and not a licensed social worker. She said Resident #12 would eat anything he could find. She said they staffed him every 3 months. She explained that the following staff members attended the staff meeting: Dietary, Physical Therapy, MDS Coordinator, Recreation, S28SSD, and S9LPN. She said that they did not discuss putting Resident #12 on Close Observations or increasing his Supervision during the meeting. She said he could not help his actions because of his mental status. She said the resident had a change on his MDS after he returned from the hospital and she had to complete a portion on the MDS. An interview was conducted on [DATE] at 2:20 p.m. with S28SSD. She said her first staffing she attended on the resident was about a week before he died . She said no one had discussed placing the resident on Close Observations or increased Supervision to 1:1 at the meeting. An interview was conducted on [DATE] at 2:30 p.m. with S47MDSCoordinator. She said she had been the MDS Coordinator since August, 2012. She said S4RNCarePlan was the MDS nurse assigned to the resident. She said S4RNCareplan was presently out of the facility. She said the resident did not have a significant change MDS completed after his return to the facility after the [DATE] choking incident because he was back to his "running around" when he returned to the facility. She verified no significant change MDS was completed because the resident had not experienced a decline in 2 areas. She said it was the MDS nurse's responsibility to discuss problems and address issues about the residents with the doctor after the staffing meeting. She also said the MDS nurse was responsible for updating the care plan. She said S4RN had not mentioned to her that it had been discussed in the Staffing Meetings to increase the Resident #12's Supervision or Close Observation since the resident ' s choking incident in October, 2012. On [DATE] at 6:05 p.m., an interview was held with S33RNSupervisor, regarding Resident#12. She explained that Resident #12 gorged food. She said he was always seeking food. She stated that Resident #12 was not placed on Close Observation or 1:1 Supervision, to her knowledge, after the choking incident on [DATE]. She further stated that she was not sure if he had access to the garbage cans in other parts of the building besides the ones in the area of his room. She also said that Resident #12 walked the grounds frequently. She stated that she was working the night the resident expired. She said she was working in another building that night and at around 4:03 a.m.- 4:04 a.m. S34LPN called her and reported that Resident #12 had collapsed, in the hall, in front of the nurses' station. S34LPN stated that Resident #12 had shallow respirations and a blocked airway. She said that she told S34LPN to keep trying to clear the resident's airway until she got there. She arrived at 4:05 a.m. She said the resident was lying unresponsive, on the floor, in front of the nurses station. She said S35PsychiatricAideSupervisor was bagging Resident #12 and that he had minimal rise/fall of the chest wall with each breath administered. She said she asked S35PsychiatricAideSupervisor to pause bagging and she checked the oral airway. She said at that time she noted vomit, food particles, and pieces of paper in Resident #12's mouth. She explained that she removed the vomit, food particles, and pieces of paper from the resident's mouth and did a rapid head to toe assessment. She further stated that at approximately 4:08 a.m. the resident was in full cardiac and respiratory arrest. She said cardiopulmonary resuscitation (CPR) and ventilations (breaths administered with a breathing bag and mask) were continued at that time. She also said that particles of debris, paper, and a "Y" shaped chicken bone were obtained from the resident's airway and at that time the bone was placed aside for evidence. She also explained that she started an intravenous (IV) line in the resident's left arm. The resident continued to have poor perfusion (passage of blood to tissues and organs). She said she paused CPR, checked the resident's airway, and was unable to see anything. She further stated that multiple abdominal thrusts were performed and more debris was removed from the resident's mouth. She said leads were attached to the resident's chest and connected to the cardiac monitor. IV fluids were

Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision to ensure the residents' safety for 6 (#3, #29, #66, #108, #136, #173) of 8 (#3, #16, #29, #108, #130, #136, #170, #173) residents reviewed for accidents during stage II by failing to: 1. Increase supervision for cognitively impaired residents that wandered from building 1 and experienced unwitnessed falls (#29, #66); 2. Implement effective interventions within the plan of care to prevent a cognitively impaired resident from leaving the building unsupervised after the resident eloped from the building on two prior incidents and sustained falls during those incidents (#66); 3. Implement appropriate interventions within the plan of care for cognitively impaired residents that had been identified with multiple falls (#29, #136); 4. Evaluate the effectiveness of the interventions implemented on the plan of care for falls (#29, #66, #136); 5. Ensure that a resident that was on one to one observation was supervised and monitored to prevent accidents (#136); 6. Ensure that residents that were to receive close observation, were supervised and monitored by staff as set forth by the facility's close observation protocol (#108, #173); 7. Ensure a visually impaired resident was not served hot liquids and left unassisted (#3); and 8. Ensure the whirlpool doors were locked when not in use on building 1. On 5/17/12 at 7:45 a.m., Resident #66 was observed lying on his right side in a fetal position on a sidewalk that was approximately ten feet from the road. The resident was confused and observed to have bleeding from his bilateral palms, right elbow, and right forearm. Resident #66 had wandered away from building 1, where he resided. Resident #66 was placed in Immediate Jeopardy on 5/17/12 when he returned to building 1 and there was no increase in his supervision. On 5/17/12 at 5:25 p.m., the facility Administrator (S1) and S2DON were notified of the Immediate Jeopardy. On 5/18/12 at 2:35 p.m., the Immediate Jeopardy was lifted when the facility put a plan in to place that included Resident #66 being placed on close observation. The plan also included that when a wandering incident occurred, the nursing staff would immediately place the wandering resident on close observation and the physician would be notified within one hour for additional orders to confirm close observation; the wandering resident would remain on close observation until assessed by the physician/treatment team; interventions to address the issues triggering the wandering behavior will be addressed in the resident's care plan and implemented by staff; the nurse would document every shift while the resident was on close observation and the documentation would include attempts to redirect the resident's behavior/response; direct care staff would be in-serviced regarding identification of wanders, issues that triggered wandering behavior, and preventative interventions; and wander guard bracelets would be purchased and placed on identified wanders. The deficient practice continued at an actual harm for Residents #66 and at a level 2 with the potential for more than minimal harm for residents that had a history of [REDACTED].#29, #108, #136). Findings: Resident #66 Resident #66 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS with ARD of 3/6/12 included a BIMS score of 3. This indicated the resident had severe cognitive impairment. On 5/17/12 at 7:45 a.m., an observation was made of Resident #66 lying on the sidewalk near the road upon driving to building 1 (one). Upon immediate observation of Resident #66, he was noted to be lying on a sidewalk that was within ten feet of the road. He was lying on his right side in a fetal position. He was covered in grass clippings and had bright red blood oozing from his bilateral palms. He was observed to have socks on but was not wearing shoes. The resident was confused and stated that he was trying to get to the bank. S3ADON approached the scene at 7:46 a.m. S3ADON observed the resident, then called (via cell phone) and informed the nurse to send a CNA with a wheelchair to escort Resident #66 back to the building. While waiting for the CNA to bring the wheelchair, observed bright red blood to the resident's right elbow and right forearm. The resident complained of pain to his left hand when questioned. At 7:51 a.m., S14CNA arrived to the area where Resident #66 was lying on the ground. She stated she was the assigned CNA for Resident #66. S14CNA was upset and informed S3ADON that there was no way she could watch all of her assigned residents and provide baths. S3ADON stated that at the moment they needed to get Resident #66 back to the building for evaluation. At 7:52 a.m., S15CNA arrived to the area with a wheelchair. At this time, S16Recreations arrived at the scene. S15CNA and S16Recreations assisted Resident #66 to a standing position. The resident's balance was unsteady. Resident #66 was then seated in the wheelchair and was transported back to 1D where he resided. On 5/17/12 at 7:55 a.m., Resident #66 was observed to be in his room sitting in a wheelchair. The resident was oriented to his name only. During this observation, S14CNA was present. An interview was held with S14CNA at this time. She stated the resident was confused and would wander around the facility. She stated the resident's gait was unsteady. S14CNA stated that she had given Resident #66 a shower "this" morning and had not seen him since then. She could not recall an approximate time of the shower. She further explained that each morning the resident was usually supervised by the nurse after he received his bath. She said she did not know why the nurse had not been monitoring the resident this morning. An observation was made of Resident #66' skin with S17LPN on 5/17/12 at 7:58 a.m. The following acute skin anomalies were noted: Right shoulder: large reddened area with abrasions/scrapes noted. Right palm (near small finger): small open skin tear, approximately ? inch, with bloody drainage Right elbow: skin tear, approximately 1 inch, with bloody drainage, Right forearm: skin tear, approximately ? inch, with bloody drainage Right knee: large abrasion/scrapes Left palm (near small finger): small open skin tear, approximately ? inch, with bloody drainage Left great toe (medial): small open skin tear, approximately ? inch, with bloody drainage The resident had full range of motion to upper extremities and denied pain with movement. Upon assessment of range of motion to lower extremities, Resident #66 complained of pain to the right knee. An interview was held with S17LPN on 5/17/12 at 8:10 a.m. S17LPN stated that she had given Resident #66 medications the morning of 5/17/12 at approximately 6:00 a.m. She stated after the resident received his medications, he went to get a shower. She stated she did not see the resident again between the times he was given meds and was found outside of the building on the sidewalk. She stated that most mornings when she worked, the resident would stay in a chair in front of the nurses' station or stay next to the medication cart as she passed medications. S17LPN stated Resident #66 was confused and did wander around the facility. She stated the resident required frequent checks/supervision from staff. An interview was held with S18CNA on 5/17/12 at 9:45 a.m. She stated she had seen Resident #66 walking towards the front entrance of the building this morning (5/17/12) prior to breakfast. She stated that she redirected him away from the building entrance. S18CNA stated she walked Resident #66 back to1C/D day room and seated him in a chair. She stated she left him in the chair and went to the dining room to assist with breakfast. S18CNA stated there were no staff present in the C/D day room when she left resident #66. S18CNA stated that was the last time she had seen Resident #66 prior to him leaving the building and falling outside on the sidewalk near the road. She stated she was assigned to unit 1C and Resident #66 resided on unit 1D. She said she had worked both units and was familiar with Resident #66's care. S18CNA described Resident #66 as being easily distracted and that he frequently wandered throughout the building. Review of the incident investigation dated 5/17/12 revealed in part: RN Manager Summary: Patient s/p MI with hypoxic brain injury. During early am med pass and bath time, he wandered off and fell outside. An interview was held with S13RNManager on 5/17/12 at 10:45 a.m. She described Resident #66 as being confused and having behaviors of wandering. She verified the resident had incidents of unsupervised falls outside of the building prior to the 5/17/12 occurrence. She stated there had not been any interventions implemented to prevent the resident from leaving the building unsupervised prior to 5/17/12. Review of the Care Plan included: I. Problem: Potential for injury related to history of falls, high score on fall risk assessment. Approaches with goal date 6/1/12: Close supervision when walking Updates: (1) 1/22/12: Attempted to elope and fell outside on sidewalk. Hematoma and abrasion of right knee. Place on close observation until seen by MD in am. On 1/23/12 - close observation discontinued. (2) 1/29/12: Eloped outside toward the gate and fell . Abrasions noted to bilateral hands, right knee, and under right eye. TAO with dressing until healed. Monitor pt more closely. (3) 2/29/12: Attempting to elope and another resident was blocking his exit. He struck the other resident and the other resident struck him. Small laceration to upper lip. Monitor for s/s of infections. II. Problem: Poor cognitive skills-forgetful, confused and delusional at times. III. Problem: Thought process impaired related to confusion. IV. Problem: Poor judgment, lack insight into disease process and care. Review of incident investigations related to Resident #66 revealed in part: (1) 1/22/12 at 1:20 p.m.: fell on sidewalk. Resident was walking fast toward gate and attempted to start to run, tripped and fell . Per physician: Pt attempts to get out at night a lot, no need to change meds, was running and tripped per gate guard and CNAs. Placed on close observation last pm, mild hematoma and abrasion to right knee, moves extremities without pain. (2) 1/29/12 at 10:20 p.m.: Fall - eloped and ran toward the gate, fell down and received injury to both his hands on the palmar side by the 5th digit and an abrasion under right eye. Pt will leave building and go outside if not watched closely. CNA was watching pt and CNA went to closet to get blanket for another pt, when she returned, pt was gone out of building. (3) 2/29/12 at 1:18 p.m. (only included documentation of resident to resident altercation, no documentation of resident elopement) Review of the most recent MDS with ARD of 3/6/12 included the resident's balance was not steady and he required limited assistance when ambulating off of unit. An interview was held with S11MDSNurse on 5/21/12 at 2:40 p.m. She stated she was responsible for updating and initiating Resident #66's care plan. She stated she served on the fall committee and explained that during the meetings all falls were discussed. She verified that Resident #66 had sustained falls by leaving the building without supervision. She stated that was discussed during the fall committee meetings and the most appropriate, least restrictive interventions were attempted. She stated that the interventions implemented for Resident #66 to help prevent falls had been ineffective because he continued to leave the building without supervision and fall. She stated supervision was not increased until after the 5/17/12 fall. She concluded that the facility had failed to identify new interventions to prevent falls when current interventions were ineffective. An interview was held with S2DON on 5/21/12 at 3:00 p.m. She stated Resident #66 had a history of [REDACTED]. She stated there had not been an increase in supervision after the resident had more than one incident of leaving the building unsupervised and falling until 5/17/12. Resident #29 Review of the clinical record revealed Resident #29 had [DIAGNOSES REDACTED]. Review of the most recent MDS with ARD of 3/20/12 included a BIMS score of 3. This indicated the resident had severe cognitive impairment. Further review of the MDS revealed Resident #29 had unsteady balance, required supervision for transfers, and required one person extensive assistance when ambulating off the unit. On 5/14/12 at 7:10 a.m. an observation was made of Resident #29 as he was ambulating outside the front of building 1 without assistance or staff supervision. While ambulating, the resident was observed to stay bent at the waist. His gait was unsteady. Observed near the doorway of the building was a merry walker (walker/chair combination that allows the resident to ambulate independently). During the observation, an interview was held with Resident #29. His speech was difficult to understand. He was oriented to his name and stated that the merry walker belonged to him. The resident was observed to return to the merry walker and sit down. He was observed to maneuver the latch at the front cross bar of the merry walker to a closed position. There was no staff observed outside or in the front entrance lobby of the building during this observation. An interview was held with S49CNA on 5/14/12 at 2:00 p.m. She stated she was routinely assigned to Resident #29. She described the resident as being confused and able to ambulate with use of the merry walker. She stated the resident did not require assistance with ambulation. She stated the resident also had behaviors of wandering throughout the facility. S49CNA stated that in the past Resident #29 had falls outside of the building. When asked how the resident was supervised when he ambulated around the facility, she stated that the nursing staff did the best they could. An observation was made of Resident #29 on 5/14/12 at 11:00 a.m. while he was lying on a bench in front of building 1. He was awake, but did not speak when spoken to. The merry walker was observed to be in the front lobby of building 1. There was no staff observed outside or within the front lobby during this observation. At 12:25 p.m., S14CNA roused Resident #29 to take him inside and eat lunch. The resident was noted to be drowsy and could not walk without assistance. He was positioned in the seat of the merry walker and required total assistance S14CNA to the dining room. On 5/14/12 at 12:30 p.m., an interview was held with S14CNA. She stated she routinely was assigned to Resident #29. She stated the resident used a merry walker for mobility due to his unsteady gait and poor posture. She said the resident was able to remove the front bar latch and get out of the merry walker. S14CNA stated the resident had sustained unsupervised falls outside of the building because he would remove the front bar latch and ambulate without assistance. She said all nursing staff tried to work together to supervise the residents, but it was difficult to supervise so many residents when they wandered around the building. An observation was made of Resident #29 on 5/16/12 at 1:25 p.m. standing next to the merry walker by the 1D unit D nurses' station. During this time, S56LPN observed the resident and instructed him to return to his chair. The resident followed instructions and was observed to latch the front cross bar of the merry walker. Review of the May 2012 physician's orders [REDACTED]. Review of the Care Plan revealed goal dates of 7/4/12 and included: I. Problem: Fall protocol in progress. Approaches: Encourage him to ask for assistance before getting out of merry walker. Updates: (1) 10/10/11: Raised the safety bar and strap from merry walker and fell . Reoriented on use of merry walker. (2) 11/6/11: Slid off bench in front of building. Counseled on not getting out of merry walker without assistance. (3) 12/26/11: Found on floor in day room. (Lined through and initialed by S11MDS Nurse) (4) 2/5/12: Slid out of merry walker on to floor. Strap broken. PT fixed strap on 2/6/12. II. Problem: History of alcohol abuse Approaches: Observe resident and know his whereabouts at all times. III. Problem: Behavior - secondary to lack of judgment, decision making, and disease process. Approaches: Close supervision at all times An interview was held with S56LPN on 5/16/12 at 1:35 p.m. She stated she was routinely assigned to Resident #29. She stated the resident was confused but would follow simple directions. She stated the resident used a merry walker during ambulation due to his unsteady gait and poor posture. She said the resident had always had postural problems. She stated at times he would release the front bar of the merry walker and ambulate without assistance. She stated all nursing staff tried to work together to supervise residents that wandered around the facility, but there were times that the residents would get out of sight and outside of the building. She stated Resident #29 had a history of [REDACTED]. She stated the resident was not on close observation. Upon reviewing the care plan, she stated that "close supervision" meant that the resident was to closely monitored by staff and that staff checked on the resident's whereabouts every one to two hours. Review of the Nurses Notes included: 10/10/11 at 6:55 a.m.: Resident found on floor out of merry walker near door of 1D nurses' station. Resident stated he removed safety bar and strap from merry walker and this caused him to fall. Counseled on safety. 11/6/11 at 3:00 p.m.: CNA from 1C reported that another resident told her that resident (#29) was on the concrete pavement in front of the building. CNA from 1D stated resident was sitting out on the bench in front of the building and one of the visitors stated resident had slid off the bench onto the concrete pavement. CNA stated merry walker found in front lobby. Resident capable of unlocking merry walker. 12/26/11 at 1:00 a.m.: Pt found asleep on floor in day room lying on stomach with head turned to right side. 5/17/12 at 10:00 a.m.: PT (S10) reported pt was out on grass near rear smoking patio. Pt without merry walker. Review of the incident investigations related to Resident #29 revealed the following: (1) 10/10/11 at 6:55 a.m.: Resident removed safety strap and bar on merry walker and fell on to the floor. No injuries. No witness to fall. 1C CNA reported resident found on floor. (2) 11/6/11 at 3:00 p.m.: Merry walker found inside building and resident found outside of building on bench. No witness to fall. CNA states resident was on the bench in front of building when she went outside to check on him, he had fell . No injuries. Resident had unlocked merry walker bar and set on bench outside of building, accidentally slid off bench. (3) 12/26/11 at 12:20 a.m.: Found lying face first on floor of C/D day room with merry walker behind him. Safety bar unfastened and wheels unlocked. Pt refuses to stay in walker or use the safety belt. No injuries. No witness to fall. (4) 5/17/12 at 10:01 a.m.: Found by S10PT outside on ground without merry walker. Fall was unwitnessed. Review of the physician's Progress Notes revealed in part: 2/6/12: Pt slid out of chair last pm. Pt constantly getting up and trying to walk without assistance. Repeat counseling and redirection. 5/17/12: Pt found out on smoking patio this am on ground. Did not have merry walker present. An interview was held with S11MDS Nurse on 5/21/12 at 2:40 p.m. She stated she was responsible for updating and implementing Resident #29's care plan. She stated she served on the fall committee and explained that during the meetings all falls were discussed and appropriate interventions were put into place to help prevent further falls. She verified Resident #29 had sustained multiple, unwitnessed falls. She said the resident was capable of getting out of his merry walker. She reviewed the resident's care plan and verified that two of the four interventions implemented were to remind the resident to use his merry walker. She verified the resident was cognitively impaired. She stated that she had lined through the 12/26/11 fall because she thought she had seen documentation of the resident laying on the floor instead of falling. She stated that Resident #29 did have a history of wandering outside of the facility. S11MDS further stated that no new interventions were implemented after the resident repeatedly got out of the merry walker and fell . An interview was held with S2DON on 5/21/12 at 3:00 p.m. She stated Resident #29 had a history of [REDACTED]. S2DON stated that the staff should supervise and know the whereabouts of all assigned residents. Resident #136 Resident #136 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS with ARD of 4/16/12 included a BIMS score of 4. This indicated Resident #136 had severe cognitive impairment. Further review of the MDS included the resident had an unsteady balance with impaired range of motion to bilateral upper extremities and was independent with transfers, walking in room, and locomotion on unit. Review of the May 2012 physician's orders [REDACTED]. Resume present orders (original date of 2/27/12) - orders included: One to One Review of the physician's Progress Notes included: 2/14/12: Returned from (psych) hospital and within ten minutes had attacked a CNA, sending her to the ER. Three weeks earlier, he attacked a nurse, breaking her nose and sending her to ER also. Both attacks seemed to be without provoking pt. Pt given 2mg of Ativan (antianxiety medication) IM. Now calm as long as there are four staff members standing over him. Impression: Violent behavior. Delusions vs. Auditory Hallucinations Plan: Transfer to ER via ambulance. 2/27/12: Pt returned from acute psych center acting calm, coherent. Plan: One to One secondary to violent behavior. Review of the One to One Monitoring form indicated the assigned staff member must be within six (6) feet of resident at all times. Review of the Care Plan revealed goal dates of 6/6/12 and included the following: I. Problem: Behavior - Impulse Control Disorder/Intermittent Explosive Disorder Updates (1) 2/27/12: 1:1 observation II. Problem: Impaired physical mobility related to Huntington's Chorea, tremors and history of falls. III. Problem: Fall protocol in progress Updates: (1) 3/2/12: Tripped over feet and fell while going to bathroom. Complained of lower back pain. Remind resident to ask for assistance when going to bathroom. (2) 3/3/12: Tripped over feet and fell while going to bathroom. Abrasion to scalp. Offer assistance to pt when going to bathroom in early am. Pt refused toileting program. (3) 3/8/12: Rolled out of bed onto floor. No injuries. Will request low bed and mats. 3/12/12 - no low beds available. 3/20/12 - mats given to pt, but refuses to leave mats at bedside. 3/21/12 - Fall committee meeting: low bed requested, informed no low beds available. Refuses mats, will offer toileting program and assistance. Side rails up x 3 for pt's protection. (4) 3/17/12: Rolled out of bed. Abrasion to forehead. No low beds available. Refuses mats. Side rails up x 3 for protection from falls. (5) 3/20/12: fell outside with family at gazebo (reported on 3/21/12). Fractured left 5th digit. Instruct family on fall precautions and to report falling to nurse. (6) 3/21/12: fell while going to bathroom. Tripped over own feet. No injuries. Will offer assistance with toileting at night. Attempt modified bowel/bladder program. Approaches: Offer assistance to the bathroom each time he awakens. (7) 4/17/12: Running down hall and fell hitting forehead. Severe laceration to forehead. Transferred to ER, returned with sutures. Utilize gait belt for ambulation. Review of the orthopedic consultation notes dated 3/22/12 revealed: Assessment: Left small finger P1 fracture Recommendations: Will place him in an ulnar gutter short arm cast. Return in 3 weeks. Review of the hospital Emergency Department Discharge Instructions dated 4/17/12 included the resident was treated for [REDACTED]. Review of the incident investigations related to Resident #136 revealed in part the following: (1) 3/2/12 at 4:40 a.m.: fell while attempting to go to bathroom. Resident has unsteady gait. No injuries. (2) 3/3/12 at 4:25 a.m.: Tripped over feet, lost balance while attempting to use bathroom. Falls when waking up and attempting to use bathroom. Abrasion to back of head. History of Huntingtons - has unsteady gait. Continue 1:1 observation. (3) 3/8/12 at 1:45 a.m.: Resident rolled out of bed to floor, got up, went to bathroom, then went back to sleep. Very little action needed, resident stood up. History of Huntingtons, unsteady gait. No injuries. (4) 3/17/12 at 1:30 a.m.: Was notified by CNA that he rolled out of bed, hitting head on floor. Small laceration to forehead. Low bed has been requested. (5) 3/20/12 (time unknown): Resident reported that he fell while outside by the gazebo with his family. He stated he lost his balance while turning to get drink off table. Complained of pain to left fifth (5th) finger. X-ray and splint had per doctor orders. Orthopedics appointment on 3/22/12. (6) 4/17/12 at 3:40 a.m.: Resident started to run toward his room after smoking cigarettes, lost his balance, and fell in hall. Deep jagged laceration to forehead. Per doctor orders: Transfer to ER due to severity of laceration. (7) 5/8/12 at 10:05 a.m.: Resident attacked by another resident and was struck on back of head. This caused this resident to fall and hit head on door way frame. Witnessed by S18CNA. Not responding verbally or to oral stimuli. Resident nonresponsive for greater than ten (10) minutes. Transferred by ambulance. Review of the Nurses Notes dated 5/8/12 included: 10:05 a.m.: Struck on back of head by another resident (#173), causing resident (#136) to fall and hit head on door frame. No verbal response. Doctor (S66MD) was on unit and notified. Attempted to start IV in right AC but unsuccessful. At 10:40 a.m., pulse 63, pulse ox 98%, remains nonresponsive. Notified ambulance service for transport. At 10:45 a.m., ambulance arrived and resident was transferred out to ER at 10:50 a.m. 4:08 p.m.: Resident returned to unit. Complained of headache. Tylenol given. Review of the physician's Progress Notes dated 5/8/12 included: Pt returned from hospital, awake, alert, oriented. Head hurts, all C-T negative per ER nurse. Clear liquid tonight, resume regular diet in am. Review of the hospital's Emergency Department Discharge Instructions revealed the resident was treated for [REDACTED]. An observation was made of Resident #136 on 5/17/12 at 8:50 a.m. The resident was resting in bed with his eyes closed. He was noted with tremors to his upper body during the observation. There was a healed vertical scar, approximately 2-3 inches in length observed to the center of the resident's forehead. During the observation, S58CNA was observed to be seated outside of the resident's doorway. An interview was held with S58CNA at this time. S58CNA stated that she was assigned to Resident #136 for one to one observation. She stated she had been assigned to the resident in the past and was familiar with his care. She stated that she positioned herself outside the doorway so she could see the resident at all times. S58CNA further stated that Resident #136 was unsteady when walking but refused assistance. She stated the resident had sustained multiple falls by rolling out of the bed or by falling while using the bathroom. She said the resident would trip over his own feet during ambulation. S58CNA stated that the staff had tried to assist the resident, but that most of the time he would refuse assistance and become combative. She stated she did not notify the nurse each time the resident refused to allow staff assistance because the nurses already knew this. S58CNA stated that if a resident was on one to one observation, the assigned staff member was to stay within arm reach of the resident when the resident was out of the room. She said if the resident was in the room, then the staff stayed outside of the room and monitored from the doorway. An interview was held with S18CNA on 5/17/12 at 9:00 a.m. S18CNA stated she was familiar with Resident #136 and had been assigned to work with the resident as one to one observation in the past. She described Resident #136 as having aggressive, combative behaviors and at times refused care or assistance from staff. She stated the resident was unsteady when he walked and had sustained several falls. She stated that if a resident was on one to one observation, then the staff would stay within a few feet of them at all times. She verified she had witnessed the incident that involved Resident #136 being hit by another resident and resulted in the resident being unresponsiveness and transferred to the hospital. She stated she was not assigned to Resident #136 on 5/8/12, but had been assigned to the resident (#173) that hit Resident #136. She stated that the assigned staff were present, but that the incident occurred so quickly, that the staff did not have time to prevent it from occurring. S18CNA stated that both residents had histories of violent behaviors. Review of the Nurses Notes dated 5/17/12 was noted with a late entry timed for 5:40 p.m. that included the resident was "on the floor". Review of the incident investigation dated 5/17/12 and timed for 5:40 p.m. included that Resident #136 was found on floor outside of bathroom door in room. Had came out of bathroom, lost balance, hit wall and fell to floor. Laceration to head. Has Huntington's Chorea and unsteady gait/balance. On one to one but still uncooperative. Send to ER. Review of the Emergency Department Discharge Instructions dated 5/17/12 revealed Resident #136 was treated for [REDACTED]. An observation was made of Resident #136 on 5/18/12 at 1:50 p.m. The resident was sitting upright in a wheelchair and was having his vital signs taken by S41CNA. He was cooperative with the staff during the observation. The resident was noted to have a large (approximately 4 inch) horizontal suture line across his forehead. The suture line extended from each of his eye brows. The area was noted to be surrounded by redness and swelling. There was no drainage. Due to the swelling, was unable to count number of sutures. At this time, an interview was held with Resident #136. He recalled the incident that occurred on the evening of 5/17/12. He stated he was coming out of the bathroom and tripped over his feet while walking back to his bed. He said he fell and hit his head on the wall. The resident stated the injury did not cause pain when it occurred and he further stated that presently, he was not in pain as a result of the injury. Review of the One to One Monitoring form for 5/17/12 revealed documentation by S15CNA of Resident #136 being in the bedroom between the times of 5:30 p.m. and 5:45 p.m. On 5/18/12 at 1:55 p.m., an interview was held with S41CNA. She stated that she had just started her shift and had relieved S58CNA. She stated that S15CNA was currently on a break. An interview was held with S47LPN on 5/18/12 at 2:00 p.m. She stated that S15CNA was on a break and should return in approximately twenty (20) to thirty

Based on observations, interviews, and record reviews, the facility failed to have sufficient nursing staff to maintain the highest practicable physical well being of each resident in accordance with the individual plans of care for 10 (#3, #29, #66, #108, #136, #137, #156, #163, #170, #173) residents reviewed out of a sample of 63 Stage 2 residents by failing to: 1. Provide supervision to prevent cognitively impaired residents with wandering behaviors from sustaining unsupervised accidents (#29, #66); 2. Ensure that a resident that was on one to one observation was supervised and monitored closely in order to prevent accidents (#136); 3. Ensure that residents that were to receive close observation, were supervised and monitored by staff as set forth by the facility's close observation protocol (#108, #137, #170, #173); and 4. Provide supervision and assistance with meals (#3, #156, #163). On 5/17/12 at 7:45 a.m., Resident #66 was observed lying on his right side in a fetal position on a sidewalk that was approximately ten feet from the road. The resident was confused and observed to have bleeding from his bilateral palms, right elbow, and right forearm. He was covered in grass clippings and had bright red blood oozing from his bilateral palms. He was observed to have socks on but was not wearing shoes. The resident was confused and stated that he was trying to get to the bank. Resident #66 had wandered away from building 1, where he resided. S3ADON approached the scene at 7:46 a.m. S3ADON observed the resident, then called (via cell phone) and informed the nurse to send a CNA with a wheelchair to escort Resident #66 back to the building. At 7:51 a.m., S14CNA arrived to the area where Resident #66 was lying on the ground. She stated she was the assigned CNA for Resident #66. S14CNA was upset and informed S3ADON that there was no way she could watch all of her assigned residents and provide baths. At 7:52 a.m., S15CNA arrived to the area with a wheelchair. At this time, S16Recreations arrived at the scene. S15CNA and S16Recreations assisted Resident #66 to a standing position. The resident's balance was unsteady. Resident #66 was then seated in the wheelchair and was transported back to 1D where he resided. Resident #66 was placed in Immediate Jeopardy on 5/17/12 when he returned to building 1 and there was no increase in his supervision. On 5/17/12 at 5:25 p.m., the facility Administrator (S1) and S2DON were notified of the Immediate Jeopardy. On 5/18/12 at 2:35 p.m., the Immediate Jeopardy was lifted when the facility put a plan in to place that included Resident #66 being placed on close observation. The plan also included that when a wandering incident occurred, the nursing staff would immediately place the wandering resident on close observation and the physician would be notified within one hour for additional orders to confirm close observation; the wandering resident would remain on close observation until assessed by the physician/treatment team; interventions to address the issues triggering the wandering behavior would be addressed in the resident's care plan and implemented by staff; the nurse would document every shift while the resident was on close observation and the documentation would include attempts to redirect resident's behavior/response; direct care staff would be in-serviced regarding identification of wanderers, issues that trigger wandering behavior, and preventative interventions; wander guard bracelets would be purchased and placed on identified wanderers; daily staffing pattern form would be completed daily by the RN manager to ensure that all units on building 1 were adequately staffed; staffing would be increased as needed to provide nursing care to residents in accordance with resident care plans and to maintain compliance with minimal standards; and nursing administration will monitor staffing patterns daily to ensure adequate coverage. The deficient practice continued at an actual harm for Residents #66 and at a level 2 with the potential for more than minimal harm for the remaining 9 residents (#3, #29, #108, #136, #137, #156, #163, #170, #173) that were effected by the insufficient staffing. Findings: Resident #66 Resident #66 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #66 resided on 1D until he was moved to 1C on 5/17/12. Review of the most recent MDS with ARD of 3/6/12 included a BIMS score of 3. This indicated the resident had severe cognitive impairment. On 5/17/12 at 7:45 a.m., an observation was made of Resident #66 lying on the sidewalk near the road upon driving to building 1 (one). Upon immediate observation of Resident #66, he was noted to be lying on a sidewalk that was within ten feet of the road. He was lying on his right side in a fetal position. He was covered in grass clippings and had bright red blood oozing from his bilateral palms. He was observed to have socks on, but was not wearing shoes. The resident was confused and stated that he was trying to get to the bank. S3ADON approached the scene at 7:46 a.m. S3ADON observed the resident, then called (via cell phone) and informed the nurse to send a CNA with a wheelchair to escort Resident #66 back to the building. While waiting on the CNA to bring the wheelchair, observed bright red blood to the resident's right elbow and right forearm. The resident complained of pain to his left hand when questioned. At 7:51 a.m., S14CNA arrived to the area where Resident #66 was lying on the ground. She stated she was the assigned CNA for Resident #66. S14CNA was upset and informed S3ADON that there was no way she could watch all of her assigned residents and provide baths. S3ADON stated that at the moment they needed to get Resident #66 back to the building for evaluation. At 7:52 a.m., S15CNA arrived to the area with a wheelchair. At this time, S16Recreations arrived at the scene. S15CNA and S16Recreations assisted Resident #66 to a standing position. The resident's balance was unsteady. Resident #66 was then seated in the wheelchair and was transported back to 1D where he resided. On 5/17/12 at 7:55 a.m., Resident #66 was observed to be in his room sitting in a wheelchair. The resident was oriented to his name only. During this observation, S14CNA was present. An interview was held with S14CNA at this time. She stated the resident was confused and would wander around the facility. She stated the resident's gait was unsteady. S14CNA stated that she had given Resident #66 a shower this morning and had not seen him since then. She could not recall an approximate time. She further explained that each morning the resident was usually supervised by the nurse after he received his bath. She said she did not know why the nurse had not been monitoring the resident this morning. S14CNA stated that she was assigned to the entire hall and that there was no way she could provide baths, assist with grooming/toileting, and supervise all assigned residents. She stated there were staff present, but many are sitting with close observation or one to one residents. S14CNA stated that the residents that resided on building 1 had mental disorders and most had combative behaviors. She stated that the CNAs had voiced concerns about staffing before, but that nothing was ever done. An observation was made of Resident #66's skin with S17LPN on 5/17/12 at 7:58 a.m. The following acute skin anomalies were noted: Right shoulder: large reddened area with abrasions/scrapes noted. Right palm (near small finger): small open skin tear, approximately ? inch, with bloody drainage Right elbow: skin tear, approximately 1 inch, with bloody drainage, Right forearm: skin tear, approximately ? inch, with bloody drainage Right knee: large abrasion/scrapes Left palm (near small finger): small open skin tear, approximately ? inch, with bloody drainage Left great toe (medial): small open skin tear, approximately ? inch, with bloody drainage The resident had full range of motion to upper extremities and denied pain with movement. Upon assessment of range of motion to lower extremities, Resident #66 complained of pain to the right knee. An interview was held with S17LPN on 5/17/12 at 8:10 a.m. S17LPN stated that she had given Resident #66 medications the morning of 5/17/12 at approximately 6:00 a.m. She stated after the resident received his medications, he went to get a shower. She stated she did not see the resident again between the times he was given meds and was found outside of the building on the sidewalk. She stated that most mornings when she worked, the resident would stay in a chair in front of the nurses' station or stay next to the medication cart as she passed medications. S17LPN stated Resident #66 was confused and did wander around the facility. She stated the resident required frequent checks/supervision from staff. S17LPN verified that she made the staffing assignments for the shift. She stated that she had been employed on the day shift for 2 years. She stated that she was assigned to 1D usually. She said there were 37 residents that resided on 1D. She explained that one CNA was watching residents that were on close observation and she was responsible for the care of all the other residents on the hall. She stated one of the CNAs was pulled from 1D to 1C to ensure coverage on that unit. She stated that she had no control over how many CNAs were sent to the unit 1D because the RN Manager overseen making sure each unit was adequately staffed. S17LPN said the manager always tried to make sure the unit was covered but unit 1D had been short on staffing on an ongoing basis, for months. Review of the 1D Daily Assignment form dated 5/17/12 revealed: S14CNA = 16 residents, included Resident #66 S49CNA = 19 residents S73CNA = close observation of Resident #82 and Resident #157 On 5/17/12 at 8:45 a.m. an interview was held with S38CNA. She stated she had been pulled to work 1C. S38CNA stated that she had been pulled to 1C for a few months. She described 1D staffing as usually having 4 CNAs, but further stated that one CNA was out sick, had been for a week or so, and the other CNA, S74, was assigned to perform close observation of two of the residents. She stated that when she was assigned to work, that she reported to duty at approximately 5:30 a.m. each morning. She stated this would allow some time for the staff to overlap and she would utilize this time to get some of her bathing done. She stated that she did not want to get into trouble for saying anything about the staffing but that that there was no way one person could supervise the residents that were walking around on the hall and also be in the shower/whirlpool room providing AM care. She stated that most of the residents that resided on building 1, units C and D, had mental illness and wandered around the premises. She stated all residents on units 1C and 1D must be observed while eating their meals in the dining room. An interview was held with S58CNA on 5/17/12 at 8:50 a.m. She stated she was assigned to 1C on a close observation. She said she usually worked the other shift rotation, but had been asked to work overtime today to help with staffing coverage. She stated that she was familiar with units 1C and 1D. S58CNA stated the staffing was short on this rotation because they always needed someone to work overtime. She stated that all residents that resided on 1C and 1D required supervision during meals and AM care. She said that did not include the assistance that some of the residents needed during toileting or if the resident required total assistance, incontinent care. She stated that if the CNA was assigned to work the hall, that it was impossible to provide the appropriate care to each resident and adequately supervise the assigned residents. She stated that most of the residents on units 1C and 1D had mental illness with behavior issues. She stated that there was no way for one CNA to monitor/supervise 15-20 residents that were walking around the facility while providing incontinent care or toileting to another. On 5/17/2012 at 9:02 a.m. an interview was held with S49CNA. She stated that she routinely worked this shift rotation. She stated that they were usually short staffed. She stated that she and one other CNA supervised the residents on 1D. She stated the other CNA was pulled to 1C this morning. She stated the staff shortage had been ongoing for months. She stated that when she was working, that she was unable to supervise all residents while providing care to another resident. She explained that if she was providing care to a resident on 1D, then there was no way she could supervise the other residents that were ambulating around the unit. An interview was held with S18CNA on 5/17/12 at 9:45 a.m. She stated she had seen Resident #66 walking towards the front entrance of the building this morning prior to breakfast. She stated that she redirected him away from the building entrance. S18CNA stated she walked Resident #66 back to1C/D day room and seated him in a chair. She stated she left him in the chair and went to the dining room to assist with breakfast. S18CNA stated there were no staff present in the C/D day room when she left Resident #66. S18CNA stated that was the last time she seen Resident #66 prior to him leaving the building and falling outside on the sidewalk near the road. She stated she was assigned to unit 1C and Resident #66 resided on unit 1D. She stated that she had worked both units and further stated that there was a shortage of staff (CNAs). She stated that with the type of residents that resided on building 1, that more supervision was needed. She stated that the staffing had been short for over a year. She stated that on most days there was only one CNA to each ward to supervise all residents except the ones that were on close observation or 1:1 observation. She stated the RN manager did try to pull from other units to make sure there was adequate coverage on each of the units, but that it was short all over the facility. She stated that this morning, the RN manager pulled a CNA from building 2 to come to 1C and help cover the close observation requirement. S18CNA stated that although the staff tried to work together, that it was impossible to supervise all residents with staffing being the way it was. She described the residents that resided on 1C and 1D as having behavioral problems that included aggressiveness and wandering. She stated that some of the residents were incontinent and required total assist from the CNAs for incontinent care. She said that all residents were monitored throughout meals and while the CNAs were in the dining room, there was no one to monitor the residents once they left the dining room. She stated that she had asked S3ADON about hiring new staff and was told that she was trying to hire new CNAs. S18CNA stated that she had not seen any new staff yet. An interview was held with S47LPN on 5/17/12 at 9:50 a.m. She verified she was the assigned nurse for the unit 1C. She stated there was a total of 37 residents that resided on 1C. She stated C1 (1st hall) had 19 residents and C2 (second hall) had 18 residents. She said the following assignments were in progress: S18CNA = close observation for Resident #34 and Resident #113 S44CNA = close observation with Resident #108 and Resident #173 S58CNA = one to one with Resident #136 S15CNA = working C1 (1st hall) = 15 residents S60CNA = one to one with Resident #142 S38CNA = working C2 (2nd hall) = 18 residents An interview was held with S44CNA on 5/17/12 at 10:15 a.m. She stated she usually worked on building 2. She stated that she was frequently pulled to building 1 due to a shortage of staff. S44CNA stated that there was not enough staff on the units to provide adequate supervision and care to all the residents on building 1. She further explained that there were usually at least sixteen (16) residents, sometimes more, assigned to one CNA. S44CNA stated that when working building 1, there was no way to supervise all assigned residents while bathing another resident. She said that most of the residents that resided on building 1 had behaviors that included wandering and fighting. On 5/17/12 at 10:20 a.m. an interview was held with S15CNA. He stated he routinely worked 1C as the "floater". S15CNA explained that the "floater" was responsible for all residents on both halls (C1/C2) that 1C included. He clarified that there would be CNAs assigned to individual residents that required one to one or close observation, but that he would be responsible for the remaining portion of the hall. S15CNA stated that he stayed busy and was unable to supervise all residents on the unit 1C because it was only him covering both halls. He said he tried to do his best, but felt the residents that resided on building 1 would be better supervised if the facility had more direct care staff. An interview was held with S60CNA on 5/17/12 at 10:25 a.m. She stated that she was usually assigned to perform one to one observation with Resident #142. She stated building 1 was always short on staffing. She said that if a staff member got ill, there was no one to replace them. She said there were many residents that were on close observation and one to one monitoring. She said that left no CNAs to cover the remaining residents. She said there was no way for one CNA to monitor over twenty (20) residents at one time. S60CNA explained that nearly all of the residents that resided on building 1 had behavioral problems and this included being combative with others and wandering. She said many times she had offered to work overtime to assist with staffing and it was declined. She said she had never been given an explanation as to why it was declined. On 5/17/12 at 10:30 a.m. an interview was held with S47LPN. She stated she was routinely assigned to 1C. She stated there were several residents that required close observation and one to one observation and this occupied many staff members. She said all residents must be supervised during meals and baths. She stated that the assigned CNA was responsible for the supervision of each of her residents. She stated that included all residents that wandered the facility. S47LPN stated the CNA was responsible for providing incontinent care when needed and for each of their assigned resident's baths. When asked how one CNA can bath a resident and supervise other residents that were wandering the facility, she replied that they do the best they can. She stated that the RN manager tried to ensure coverage for building 1 but that if she had nothing to pull from then there was nothing else she could do. S47LPN said a couple of CNAs recently retired and one was out sick. She said there had not been any new CNAs hired to help with the nursing staff shortage to her knowledge. She said she felt that they could use more staff to help supervise the residents. Review of the incident investigation for Resident #66 dated 5/17/12 revealed in part: RN Manager Summary: Patient s/p MI with hypoxic [MEDICAL CONDITION]. During early am med pass and bath time, he wandered off and fell outside. An interview was held with S13RN Manager on 5/17/12 at 10:45 a.m. She described Resident #66 as being confused and having behaviors of wandering. She verified the resident had incidents of unsupervised falls outside of the building prior to the 5/17/12 occurrence. S13RN Manager further stated that she was aware of the staffing issues and that there had been days that staffing was short. She said she always tried to pull CNAs from another building to ensure adequate coverage for building 1. She said two CNAs recently retired, two were on workman's comp, and two were out sick. She stated that there were two CNAs on building 1 that were working overtime today. She stated many of the CNAs were overseeing residents that were ordered to have one to one and close observation monitoring. She stated some of those residents did not require that type of monitoring but the physicians would not change the orders. She said the S2DON and S3ADON were aware of the staffing issues because each day she completed a staffing form and sent it to the DON. She stated that she had spoke with S3ADON about hiring other CNAs, but if a person was hired, they would only stay through the orientation phase, then leave. She further stated that the types of residents the facility was receiving had changed and they were getting more violent residents that had significant behaviors. She stated they were being told that they had to accept the residents because "Baton Rouge" was mandating it due to the closing of other state facilities. She said most staff assumed that "Baton Rouge" means the state. She said although the facility had accepted more residents, they had not had new staff hired to supervise and care for the residents. An observation was made of 1D staffing on 5/18/12 at 8:30 a.m. with the following noted: (1) S61CNA = Close observation for Resident #82 and Resident #157 (2) S3CNA = D2 (1st hall of 1D) - 16 residents (3) S14CNA = D1 (2nd hall of 1D) - 19 residents An observation of the staffing was made of 1C at 8:40 a.m. on 5/18/12 with the following noted: (1) S18CNA = Close observation for Resident #66 and Resident #113 (2) S58CNA = One to one observation with Resident #136 (3) S60CNA = One to one observation with Resident #142 (4) S15CNA = C1 (first hall of 1C) - 14 residents (5) S48CNA = Close observation for Resident #108 and Resident #173 and C2 (second hall of 1C) - 19 residents An interview was held with S48CNA on 5/18/12 at 8:30 a.m. She after she was observed bringing a resident out of C2 shower room. During that observation, Residents' #108 and #173 were observed in bed in their shared room. There was no staff member assigned to monitor the residents for close observation. During the interview with S48CNA, she stated that she was the only CNA on the hall but had been told that another CNA was coming in to assist her. She stated she did not know who was coming in or what time they would be in. She said she was aware that Residents' #108 and #173 required close observation, but the other residents had needs as well and were ready to get up, showered, and ready for breakfast. She stated she was doing the best she could and could not just ignore the other residents on the hall. On 5/18/12 at 8:40 a.m., an interview was held with S47LPN. She stated she was aware that there was only one CNA down hall C2. She verified that Resident #108 and Resident #173 required close observation and that the CNA was not able to do that and assist the other residents. She stated that S13RN Manager had made phone calls to try and get another CNA to come in and help on C2. S47LPN stated that she did not know who or if any other staff member would be in to assist with staffing on 1C. Resident #136 Resident #136 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS with ARD of 4/16/12 included a BIMS score of 4. This indicated Resident #136 had severe cognitive impairment. Further review of the MDS included the resident had an unsteady balance with impaired range of motion to bilateral upper extremities and was independent with transfers, walking in room, and locomotion on unit. Review of the May 2012 physician's orders [REDACTED]. Resume present orders (original date of 2/27/12) - orders included: One to One Review of the physician's Progress Notes included: 2/14/12: Returned from (psych) hospital and within ten minutes had attacked a CNA, sending her to the ER. Three weeks earlier, he attacked a nurse, breaking her nose and sending her to ER also. Both attacks seemed to be without provoking pt. Pt given 2mg of [MEDICATION NAME] (antianxiety medication) IM. Now calm as long as there are four staff members standing over him. Impression: Violent behavior. [MEDICAL CONDITION] vs. Auditory Hallucinations Plan: Transfer to ER via ambulance. 2/27/12: Pt returned from acute psych center acting calm, coherent. Plan: One to One secondary to violent behavior. Review of the One to One Monitoring form indicated the assigned staff member must be within six (6) feet of resident at all times. Review of the Care Plan revealed goal dates of 6/6/12 and included the following: I. Problem: Behavior - Impulse Control Disorder/Intermittent [MEDICAL CONDITION] Updates (1) 2/27/12: 1:1 observation II. Problem: Impaired physical mobility related to [MEDICAL CONDITION]'s Chorea, tremors and history of falls. III. Problem: Fall protocol in progress Updates: (1) 3/2/12: Tripped over feet and fell while going to bathroom. Complained of lower back pain. Remind resident to ask for assistance when going to bathroom. (2) 3/3/12: Tripped over feet and fell while going to bathroom. Abrasion to scalp. Offer assistance to pt when going to bathroom in early am. Pt refused toileting program. (3) 3/8/12: Rolled out of bed onto floor. No injuries. Will request low bed and mats. 3/12/12 - no low beds available. 3/20/12 - mats given to pt, but refuses to leave mats at bedside. 3/21/12 - Fall committee meeting: low bed requested, informed no low beds available. Refuses mats, will offer toileting program and assistance. Side rails up x 3 for pt's protection. (4) 3/17/12: Rolled out of bed. Abrasion to forehead. No low beds available. Refuses mats. Side rails up x 3 for protection from falls. (5) 3/20/12: fell outside with family at gazebo (reported on 3/21/12). Fractured left 5th digit. Instruct family on fall precautions and to report falling to nurse. (6) 3/21/12: fell while going to bathroom. Tripped over own feet. No injuries. Will offer assistance with toileting at night. Attempt modified bowel/bladder program. Approaches: Offer assistance to the bathroom each time he awakens. (7) 4/17/12: Running down hall and fell hitting forehead. Severe laceration to forehead. Transferred to ER, returned with sutures. Utilize gait belt for ambulation. Review of the orthopedic consultation notes dated 3/22/12 revealed: Assessment: Left small finger P1 fracture Recommendations: Will place him in an ulnar gutter short arm cast. Return in 3 weeks. Review of the hospital Emergency Department Discharge Instructions dated 4/17/12 included the resident was treated for [REDACTED]. Review of the incident investigations related to Resident #136 revealed in part the following: (1) 3/2/12 at 4:40 a.m.: fell while attempting to go to bathroom. Resident has unsteady gait. No injuries. (2) 3/3/12 at 4:25 a.m.: Tripped over feet, lost balance while attempting to use bathroom. Falls when waking up and attempting to use bathroom. Abrasion to back of head. History of [MEDICAL CONDITION] - has unsteady gait. Continue 1:1 observation. (3) 3/8/12 at 1:45 a.m.: Resident rolled out of bed to floor, got up, went to bathroom, then went back to sleep. Very little action needed, resident stood up. History of [MEDICAL CONDITION], unsteady gait. No injuries. (4) 3/17/12 at 1:30 a.m.: Was notified by CNA that he rolled out of bed, hitting head on floor. Small laceration to forehead. Low bed has been requested. (5) 3/20/12 (time unknown): Resident reported that he fell while outside by the gazebo with his family. He stated he lost his balance while turning to get drink off table. Complained of pain to left fifth (5th) finger. X-ray and splint had per doctor orders. Orthopedics appointment on 3/22/12. (6) 4/17/12 at 3:40 a.m.: Resident started to run toward his room after smoking cigarettes, lost his balance, and fell in hall. Deep jagged laceration to forehead. Per doctor orders: Transfer to ER due to severity of laceration. (7) 5/8/12 at 10:05 a.m.: Resident attacked by another resident and was struck on back of head. This caused this resident to fall and hit head on door way frame. Witnessed by S18CNA. Not responding verbally or to oral stimuli. Resident nonresponsive for greater than ten (10) minutes. Transferred by ambulance. Review of the Nurses Notes dated 5/8/12 included: 10:05 a.m.: Struck on back of head by another resident (#173), causing resident (#136) to fall and hit head on door frame. No verbal response. Doctor (S66MD) was on unit and notified. Attempted to start IV in right AC but unsuccessful. At 10:40 a.m., pulse 63, pulse ox 98%, remains nonresponsive. Notified ambulance service for transport. At 10:45 a.m., ambulance arrived and resident was transferred out to ER at 10:50 a.m. 4:08 p.m.: Resident returned to unit. Complained of headache. Tylenol given. Review of the physician's Progress Notes dated 5/8/12 included: Pt returned from hospital, awake, alert, oriented. Head hurts, all C-T negative per ER nurse. Clear liquid tonight, resume regular diet in am. Review of the hospital's Emergency Department Discharge Instructions revealed the resident was treated for [REDACTED]. An observation was made of Resident #136 on 5/17/12 at 8:50 a.m. The resident was resting in bed with his eyes closed. He was noted with tremors to his upper body during the observation. There was a healed vertical scar, approximately 2-3 inches in length observed to the center of the resident's forehead. During the observation, S58CNA was observed to be seated outside of the resident's doorway. An interview was held with S58CNA at this time. S58CNA stated that she was assigned to Resident #136 for one to one observation. She stated she had been assigned to the resident in the past and was familiar with his care. She stated that she positioned herself outside the doorway so she could see the resident at all times. S58CNA further stated that Resident #136 was unsteady when walking but refused assistance. She stated the resident had sustained multiple falls by rolling out of the bed or by falling while using the bathroom. She said the resident would trip over his own feet during ambulation. S58CNA stated that the staff had tried to assist the resident, but that most of the time he would refuse assistance and become combative. She stated she did not notify the nurse each time the resident refused to allow staff assistance because the nurses already knew this. S58CNA stated that if a resident was on one to one observation, the assigned staff member was to stay within arm reach of the resident when the resident was out of the room. She said if the resident was in the room, then the staff stayed outside of the room and monitored from the doorway. An interview was held with S18CNA on 5/17/12 at 9:00 a.m. S18CNA stated she was familiar with Resident #136 and had been assigned to work with the resident as one to one observation in the past. She described Resident #136 as having aggressive, combative behaviors and at times refused care or assistance from staff. She stated the resident was unsteady when he walked and had sustained several falls. She stated that if a resident was on one to one observation, then the staff would stay within a few feet of them at all times. She verified she had witnessed the incident that involved Resident #136 being hit by another resident and resulted in the resident being unresponsiveness and transferred to the hospital. She stated she was not assigned to Resident #136 on 5/8/12, but had been assigned to the resident (#173) that hit Resident #136. She stated that the assigned staff were present, but that the incident occurred so quickly, that the staff did not have time to prevent it from occurring. S18CNA stated that both residents had histories of violent behaviors. Review of the Nurses Notes dated 5/17/12 was noted with a late entry timed for 5:40 p.m. that included the resident was "on the floor". Review of the incident investigation dated 5/17/12 and timed for 5:40 p.m. included that Resident #136 was found on floor outside of bathroom door in room. Had came out of bathroom, lost balance, hit wall and fell to floor. Laceration to head. Has [MEDICAL CONDITION]'s Chorea and unsteady gait/balance. On one to one but still uncooperative. Send to ER. Review of the Emergency Department Discharge Instructions dated 5/17/12 revealed Resident #136 was t

Based on observations, interviews, and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well being of each resident for 3 (#29, #66, #136) of 8 (#3, #16, #29, #108, #130, #136, #170, #173) residents reviewed for accidents and staffing during stage II; 1 (#77) of 6 (#7, #25, #55, #77, #85, #89) residents reviewed for pressure ulcers during stage II; and 1 (#93) of (#73, #93) residents observed while receiving an accucheck on building 2. The facility failed to: 1. Increase supervision for cognitively residents that wandered from building 1 and experienced an unwitnessed falls (#29, #66); 2. Ensure that a resident that was on one to one observation was supervised and monitored to prevent accidents (#136); 3. Implement appropriate interventions within the plan of care for a resident that had been identified with multiple falls (#29, #66, #136); 4. Evaluate the effectiveness of the interventions implemented on the plan of care for falls (#29, #66, #136); 5. Maintain an effective nursing staffing pattern to ensure residents were supervised to prevent accidents (#29, #66, #136); 6. Ensure systems were in place to prevent the development and to identify pressure ulcers (#77); and 7. Ensure proper disinfecting procedures were used on multi-resident equipment when used on residents in contact isolation (#93). On 5/17/12 at 7:45 a.m., Resident #66 was observed lying on his right side in a fetal position on a sidewalk that was approximately ten feet from the road. The resident was confused and observed to have bleeding from his bilateral palms, right elbow, and right forearm. He was covered in grass clippings and had bright red blood oozing from his bilateral palms. He was observed to have socks on but was not wearing shoes. The resident was confused and stated that he was trying to get to the bank. Resident #66 had wandered away from building 1, where he resided. S3ADON approached the scene at 7:46 a.m. S3ADON observed the resident, then called (via cell phone) and informed the nurse to send a CNA with a wheelchair to escort Resident #66 back to the building. At 7:51 a.m., S14CNA arrived to the area where Resident #66 was lying on the ground. She stated she was the assigned CNA for Resident #66. S14CNA was upset and informed S3ADON that there was no way she could watch all of her assigned residents and provide baths. At 7:52 a.m., S15CNA arrived to the area with a wheelchair. At this time, S16Recreations arrived at the scene. S15CNA and S16Recreations assisted Resident #66 to a standing position. The resident's balance was unsteady. Resident #66 was then seated in the wheelchair and was transported back to 1D where he resided. Resident #66 was placed in Immediate Jeopardy when he returned to building 1 on 5/17/12 and there was no increase in his supervision. On 5/17/12 at 5:25 p.m., the facility Administrator (S1) and S2DON were notified of the Immediate Jeopardy. On 5/18/12 at 2:35 p.m., the Immediate Jeopardy was lifted when the facility put a plan in to place that included Resident #66 being placed on close observation. The plan also included that when a wandering incident occurs, the nursing staff would immediately place the wandering resident on close observation and the physician would be notified within one hour for additional orders to confirm close observation; the wandering resident would remain on close observation until assessed by the physician/treatment team; interventions to address the issues triggering the wandering behavior would be addressed in the resident's care plan and implemented by staff; the nurse would document every shift while the resident was on close observation and the documentation would include attempts to redirect resident's behavior/response; direct care staff would be in-serviced regarding identification of wanderers, issues that trigger wandering behavior, and preventative interventions; wander guard bracelets would be purchased and placed on identified wanderers; daily staffing pattern form would be completed daily by the RN Manager to ensure that all units on building 1 were adequately staffed; staffing would be increased as needed to provide nursing care to residents in accordance with resident care plans and to maintain compliance with minimal standards; and nursing administration will monitor staffing patterns daily to ensure adequate coverage. The deficient practice continued at an actual harm for Residents #66 and at a level 2 with the potential for more than minimal harm for cognitively impaired residents that require increased supervision due to a history of accidents (#29, #66, #136). Resident #77 was placed in an Immediate Jeopardy situation on 4/30/12 when the staff failed to have a system in place to ensure that accurate daily skin assessments were being performed and failed to ensure that the resident was being turned every 2 hours. The facility failed to discover a new pressure ulcer to the resident's right hip until it reached a Stage IV in severity. Upon discovery of the Stage IV pressure ulcer the the physician was not notified to assess the residents facility acquired Stage IV pressure ulcer to his right outer hip and write orders for treatment of [REDACTED]. Skin assessment was completed on Resident #77 on 5/18/12. Order obtained for right hip wound. Skin assessments were completed by nursing staff on 5/21/12 on residents at high risk for developing decubitus ulcers. Skin assessments were completed on 5/21/12 on residents with wounds to assess for new skin breakdown. Nursing staff will review residents with wound care orders to ensure that all wounds have been addressed. Unit nurses will assess nonambulatory residents' skin daily and document assessment. Unit Nurses will be inserviced on accurate skin assessments and documentation. CNA's will be inserviced on skin assessment and the importance of reporting changes in skin condition to the unit nurse. RN wound care nurse will assess nonambulatory residents weekly for new skin breakdown. The deficient practice continued at an actual harm for Residents #77 and at a level 2 with the potential for more than minimal harm for the 12 residents listed on the Quality Care and Quality of Life Indicator (QCLI) report that the facility determined to be at high risk for development of pressure ulcers. Resident #93 was placed in Immediate Jeopardy on 5/16/12 at 11:05 a.m. when the S29RN, assigned to resident #73, did not disinfect the glucometer after using it on resident #73. Resident #73 was on contact isolation related to a [DIAGNOSES REDACTED]. He used the same glucometer that was used for Resident #73 without disinfecting it according to CDC guidelines. This action placed all other residents on Building 2 Unit A that had accuchecks performed with the same glucometer in Immediate Jeopardy. The Administrator was notified of the Immediate Jeopardy on 5/18/12 at 3:55 p.m. A Plan of Removal was presented by the Administrator which read: A glucometer machine was placed in Resident #73's Contact Isolation room. The machine will remain in the residents' room for use with this resident only. The Policy/Procedure for cleaning and disinfection of glucometers has been revised to include the use of product solutions that prevent the spread of[DIAGNOSES REDACTED]icile spores. Nursing staff have been inserviced on the technique for cleaning and disinfecting glucometers according to the revised policy. A Clorox bleach solution (1 part bleach:10 parts water) has been placed on units for nursing staff to use when disinfecting glucometers after use with each resident. The Immediate Jeopardy was removed on 5/21/12 at 10:20 a.m. when the facility came up with a plan to clean and disinfect the glucometers before and after each residents' use with an cleaning agent that kills [MEDICAL CONDITION]. The deficient practice remains at a level 2 for a potential for more than minimal harm for all residents on on Building 2 Unit A that had accuchecks performed. Findings: Falls Resident #66 Resident #66 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS with ARD of 3/6/12 included a BIMS score of 3. This indicated the resident had severe cognitive impairment. On 5/17/12 at 7:45 a.m., an observation was made of Resident #66 lying on the sidewalk near the road upon driving to building 1 (one). Upon immediate observation of Resident #66, he was noted to be lying on a sidewalk that was within ten feet of the road. He was lying on his right side in a fetal position. He was covered in grass clippings and had bright red blood oozing from his bilateral palms. He was observed to have socks on, but was not wearing shoes. The resident was confused and stated that he was trying to get to the bank. S3ADON approached the scene at 7:46 a.m. S3ADON observed the resident, then called (via cell phone) and informed the nurse to send a CNA with a wheelchair to escort Resident #66 back to the building. While waiting on the CNA to bring the wheelchair, observed bright red blood to the resident's right elbow and right forearm. The resident complained of pain to his left hand when questioned. At 7:51 a.m., S14CNA arrived to the area where Resident #66 was lying on the ground. She stated she was the assigned CNA for Resident #66. S14CNA was upset and informed S3ADON that there was no way she could watch all of her assigned residents and provide baths. S3ADON stated that at the moment they needed to get Resident #66 back to the building for evaluation. At 7:52 a.m., S15CNA arrived to the area with a wheelchair. At this time, S16Recreations arrived at the scene. S15CNA and S16Recreations assisted Resident #66 to a standing position. The resident's balance was unsteady. Resident #66 was then seated in the wheelchair and was transported back to 1D where he resided. On 5/17/12 at 7:55 a.m., Resident #66 was observed to be in his room sitting in a wheelchair. The resident was oriented to his name only. During this observation, S14CNA was present. An interview was held with S14CNA at this time. She stated the resident was confused and would wander around the facility. She stated the resident's gait was unsteady. S14CNA stated that she had given Resident #66 a shower this morning and had not seen him since then. She further explained that each morning the resident was usually supervised by the nurse after he received his bath. She said she did not know why the nurse had not been monitoring the resident this morning. An observation was made of Resident #66's skin with S17LPN on 5/17/12 at 7:58 a.m. The following acute skin anomalies were noted: Right shoulder: large reddened area with abrasions/scrapes noted. Right palm (near small finger): small open skin tear, approximately ? inch, with bloody drainage Right elbow: skin tear, approximately 1 inch, with bloody drainage, Right forearm: skin tear, approximately ? inch, with bloody drainage Right knee: large abrasion/scrapes Left palm (near small finger): small open skin tear, approximately ? inch, with bloody drainage Left great toe (medial): small open skin tear, approximately ? inch, with bloody drainage, less than pencil eraser size The resident had full range of motion to upper extremities and denied pain with movement. Upon assessment of range of motion to lower extremities, Resident #66 complained of pain to the right knee. An interview was held with S17LPN on 5/17/12 at 8:10 a.m. S17LPN stated that she had given Resident #66 medications the morning of 5/17/12 at approximately 6:00 a.m. She stated after the resident received his medications, he went to get a shower. She stated she did not see the resident again between the times he was given meds and was found outside of the building on the sidewalk. She stated that most mornings when she worked, the resident would stay in a chair in front of the nurses' station or stay next to the medication cart as she passed medications. S17LPN stated Resident #66 was confused and did wander around the facility. She stated the resident required frequent checks/supervision from staff. An interview was held with S18CNA on 5/17/12 at 9:45 a.m. She stated she had seen Resident #66 walking towards the front entrance of the building this morning prior to breakfast. She stated that she redirected him away from the building entrance. S18CNA stated she walked Resident #66 back to1C/D day room and seated him in a chair. She stated she left him in the chair and went to the dining room to assist with breakfast. S18CNA stated there were no staff present in the C/D day room when she left Resident #66. S18CNA stated that was the last time she saw Resident #66 prior to him leaving the building and falling outside on the sidewalk near the road. She stated she was assigned to unit 1C and Resident #66 resided on unit 1D. She said she had worked both units and was familiar with Resident #66's care. S18CNA described Resident #66 as being easily distracted and that he frequently wandered throughout the building. Review of the incident investigation dated 5/17/12 revealed in part: RN Manager Summary: Patient s/p MI with hypoxic [MEDICAL CONDITION]. During early am med pass and bath time, he wandered off and fell outside. An interview was held with S13RN Manager on 5/17/12 at 10:45 a.m. She described Resident #66 as being confused and having behaviors of wandering. She verified the resident had incidents of unsupervised falls outside of the building prior to the 5/17/12 occurrence. She stated there had not been any interventions implemented to prevent the resident from leaving the building unsupervised prior to 5/17/12. Review of the Care Plan included: I. Problem: Potential for injury related to history of falls, high score on fall risk assessment. Approaches with goal date 6/1/12: Close supervision when walking Updates: (1) 1/22/12: Attempted to elope and fell outside on sidewalk. Hematoma and abrasion of right knee. Place on close observation until seen by MD in a.m. On 1/23/12 - close observation discontinued. (2) 1/29/12: Eloped outside toward the gate and fell . Abrasions noted to bilateral hands, right knee, and under right eye. TAO with dressing until healed. Monitor pt more closely. (3) 2/29/12: Attempting to elope and another resident was blocking his exit. He struck the other resident and the other resident struck him. Small laceration to upper lip. Monitor for s/s of infections. II. Problem: Poor cognitive skills-forgetful, confused and delusional at times. III. Problem: Thought process impaired related to confusion. IV. Problem: Poor judgment, lack insight into disease process and care. Review of incident investigations related to Resident #66 revealed in part: (1) 1/22/12 at 1:20 p.m.: fell on sidewalk. Resident was walking fast toward gate and attempted to start to run, tripped and fell . Per physician: Pt attempts to get out at night a lot, no need to change meds, was running and tripped per gate guard and CNAs of pt. Placed on close observation last pm, mild hematoma and abrasion to right knee, moves extremities without pain. (2) 1/29/12 at 10:20 p.m.: Fall - eloped and ran toward the gate, fell down and received injury to both his hands on the palmar side by the 5th digit and an abrasion under right eye. Pt will leave building and go outside if not watched closely. CNA was watching pt and CNA went to closet to get blanket for another pt, when she returned, pt was gone out of building. (3) 2/29/12 at 1:18 p.m. (only included documentation of resident to resident altercation, no documentation of resident elopement) Review of the most recent MDS with ARD of 3/6/12 included the resident's balance was not steady and he required limited assistance when ambulating off of unit. An interview was held with S11MDS Nurse on 5/21/12 at 2:40 p.m. She stated she was responsible for updating and initiating Resident #66's care plan. She stated she served on the fall committee and explained that during the meetings all falls were discussed. She verified that Resident #66 had sustained falls by leaving the building without supervision. She stated that was discussed during the fall committee meetings and the most appropriate, least restrictive interventions were attempted. She stated that the interventions implemented for Resident #66 to help prevent falls had been ineffective because he continued to leave the building without supervision and fall. She stated supervision was not increased until after the 5/17/12 fall. An interview was held with S2DON on 5/21/12 at 3:00 p.m. She stated Resident #66 had a history of [REDACTED]. She stated there had not been an increase in supervision after the resident had more than one incident of leaving the building unsupervised and falling until 5/17/12. Resident #29 Review of the clinical record revealed Resident #29 had [DIAGNOSES REDACTED]. Review of the most recent MDS with ARD of 3/20/12 included a BIMS score of 3. This indicated the resident had severe cognitive impairment. Further review of the MDS revealed Resident #29 had unsteady balance, required supervision for transfers, and required one person extensive assistance when ambulating off the unit. On 5/14/12 at 7:10 a.m. an observation was made of Resident #29 as he was ambulating outside the front of building one (1) without assistance or staff supervision. While ambulating, the resident was observed to stay bent at the waist. His gait was unsteady. Observed near the doorway of the building was a merry walker. During the observation, an interview was held with Resident #29. His speech was difficult to understand. He was oriented to his name and stated that the merry walker belonged to him. The resident was observed to return to the merry walker and sit down. He was observed to maneuver the latch to the front cross bar of the merry walker to a closed position. There was no staff observed outside or in the front entrance lobby of the building during this observation. An interview was held with S49CNA on 5/14/12 at 2:00 p.m. She stated she was routinely assigned to Resident #29. She described the resident as being confused and able to ambulate with use of the merry walker. She stated the resident did not require assistance with ambulation. She stated the resident also had behaviors of wandering throughout the facility. S49CNA stated that in the past Resident #29 had falls outside of the building. When asked how the resident was supervised when he ambulated around the facility, she stated that the nursing staff did the best they could. An observation was made of Resident #29 on 5/14/12 at 11:00 a.m. while he was lying on a bench in front of building 1. He was awake, but did not speak when spoken to. The merry walker was observed to be in the front lobby of building 1. There was no staff observed outside or within the front lobby during this observation. At 12:25 p.m., S14CNA roused Resident #29 to take him inside and eat lunch. The resident was noted to be drowsy and could not walk without assistance. He was positioned in the seat of the merry walker and required total assistance from S14CNA to the dining room. On 5/14/12 at 12:30 p.m., an interview was held with S14CNA. She stated she routinely was assigned to Resident #29. She stated the resident used a merry walker for mobility due to his unsteady gait and poor posture. She said the resident was able to remove the front bar latch and get out of the merry walker. S14CNA stated the resident had sustained unsupervised falls outside of the building because he would remove the front bar latch and ambulate without assistance. She said all nursing staff tried to work together to supervise the residents, but it was difficult to supervise so many residents when they wandered around the building. An observation was made of Resident #29 on 5/16/12 at 1:25 p.m. standing next to the merry walker by the 1D nurses' station. During this time, S56LPN observed the resident and instructed him to return to his chair. The resident followed instructions and was observed to latch the front cross bar of the merry walker. An interview was held with S56LPN on 5/16/12 at 1:35 p.m. She stated she was routinely assigned to Resident #29. She stated the resident was confused but would follow simple directions. She stated the resident used a merry walker during ambulation due to his unsteady gait and poor posture. She said the resident had always had postural problems. She stated at times he would release the front bar of the merry walker and ambulate without assistance. She stated all nursing staff tried to work together to supervise residents that wandered around the facility, but there were times that the residents would get out of sight and outside of the building. She stated Resident #29 had a history of [REDACTED]. Review of the May 2012 physician's orders [REDACTED]. Review of the Care Plan revealed goal dates of 7/4/12 and included: I. Problem: Fall protocol in progress. Approaches: Encourage him to ask for assistance before getting out of merry walker. Updates: (1) 10/10/11: Raised the safety bar and strap from merry walker and fell . Reoriented on use of merry walker. (2) 11/6/11: Slid off bench in front of building. Counseled on not getting out of merry walker without assistance. (3) 12/26/11: Found on floor in day room. (Lined through and initialed by S11MDS Nurse) (4) 2/5/12: Slid out of merry walker on to floor. Strap broken. PT fixed strap on 2/6/12. II. Problem: History of [MEDICAL CONDITION] Approaches: Observe resident and know his whereabouts at all times. III. Problem: Behavior - secondary to lack of judgment, decision making, and disease process. Approaches: Close supervision at all times Review of the Nurses Notes included: 10/10/11 at 6:55 a.m.: Resident found on floor out of merry walker near door of 1D nurses' station. Resident stated he removed safety bar and strap from merry walker and this caused him to fall. Counseled on safety. 11/6/11 at 3:00 p.m.: CNA from 1C reported that another resident told her that resident (#29) was on the concrete pavement in front of the building. CNA from 1D stated resident was sitting out on the bench in front of the building and one of the visitors stated resident had slid off the bench onto the concrete pavement. CNA stated merry walker found in front lobby. Resident capable of unlocking merry walker. 12/26/11 at 1:00 a.m.: Pt found asleep on floor in day room lying on stomach with head turned to right side. 5/17/12 at 10:00 a.m.: PT (S10) reported pt was out on grass near rear smoking patio. Pt without merry walker. Review of the incident investigations related to Resident #29 revealed the following: (1) 10/10/11 at 6:55 a.m.: Resident removed safety strap and bar on merry walker and fell on to the floor. No injuries. No witness to fall. 1C CNA reported resident found on floor. (2) 11/6/11 at 3:00 p.m.: Merry walker found inside building and resident found outside of building on bench. No witness to fall. CNA states resident was on the bench in front of building when she went outside to check on him, he had fell . No injuries. Resident had unlocked merry walker bar and set on bench outside of building, accidentally slid off bench. (3) 12/26/11 at 12:20 a.m.: Found lying face first on floor of C/D day room with merry walker behind him. Safety bar unfastened and wheels unlocked. Pt refuses to stay in walker or use the safety belt. No injuries. No witness to fall. (4) 5/17/12 at 10:01 a.m.: Found by S10PT outside on ground without merry walker. Fall was unwitnessed. Review of the Physician's Progress Notes revealed in part: 2/6/12: Pt slid out of chair last pm. Pt constantly getting up and trying to walk without assistance. Repeat counseling and redirection. 5/17/12: Pt found out on smoking patio this am on ground. Did not have merry walker present. An interview was held with S11MDS Nurse on 5/21/12 at 2:40 p.m. She stated she was responsible for updating and implementing Resident #29's care plan. She stated she served on the fall committee and explained that during the meetings all falls were discussed and appropriate interventions were put into place to help prevent further falls. She verified Resident #29 had sustained multiple, unwitnessed falls. She said the resident was capable of getting out of his merry walker. She reviewed the resident's care plan and verified that two of the four interventions implemented were to remind the resident to use his merry walker. She verified the resident was cognitively impaired. She stated that she had lined through the 12/26/11 fall because she thought she had seen documentation of the resident laying on the floor instead of falling. She stated that Resident #29 did have a history of wandering outside of the facility. S11MDS further stated that no new interventions were implemented after the resident repeatedly got out of the merry walker and fell . An interview was held with S2DON on 5/21/12 at 3:00 p.m. She stated Resident #29 had a history of [REDACTED]. S2DON stated that the staff should supervise and know the whereabouts of all assigned residents. Resident #136 Resident #136 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS with ARD of 4/16/12 included a BIMS score of 4. This indicated Resident #136 had severe cognitive impairment. Further review of the MDS included the resident had an unsteady balance with impaired range of motion to bilateral upper extremities and was independent with transfers, walking in room, and locomotion on unit. Review of the May 2012 physician's orders [REDACTED]. Resume present orders (original date of 2/27/12) - orders included: One to One Review of the Physician's Progress Notes included: 2/14/12: Returned from (psych) hospital and within ten minutes had attacked a CNA, sending her to the ER. Three weeks earlier, he attacked a nurse, breaking her nose and sending her to ER also. Both attacks seemed to be without provoking pt. Pt given 2mg of [MEDICATION NAME] IM. Now calm as long as there are four staff members standing over him. Impression: Violent behavior. [MEDICAL CONDITION] vs. Auditory Hallucinations Plan: Transfer to ER via ambulance. 2/27/12: Pt returned from acute psych center acting calm, coherent. Plan: One to One secondary to violent behavior. Review of the Care Plan revealed goal dates of 6/6/12 and included the following: I. Problem: Behavior - Impulse Control Disorder/Intermittent [MEDICAL CONDITION] Updates (1) 2/27/12: 1:1 observation II. Problem: Impaired physical mobility related to [MEDICAL CONDITION]'s Chorea, tremors and history of falls. III. Problem: Fall protocol in progress Updates: (1) 3/2/12: Tripped over feet and fell while going to bathroom. Complained of lower back pain. Remind resident to ask for assistance when going to bathroom. (2) 3/3/12: Tripped over feet and fell while going to bathroom. Abrasion to scalp. Offer assistance to pt when going to bathroom in early am. Pt refused toileting program. (3) 3/8/12: Rolled out of bed onto floor. No injuries. Will request low bed and mats. 3/12/12 - no low beds available. 3/20/12 - mats given to pt, but refuses to leave mats at bedside. 3/21/12 - Fall committee meeting: low bed requested, informed no low beds available. Refuses mats, will offer toileting program and assistance. Siderails up x 3 for pt's protection. (4) 3/17/12: Rolled out of bed. Abrasion to forehead. No low beds available. Refuses mats. Siderails up x 3 for protection from falls. (5) 3/20/12: fell outside with family at gazebo (reported on 3/21/12). Fractured left 5th digit. Instruct family on fall precautions and to report falling to nurse. (6) 3/21/12: fell while going to bathroom. Tripped over own feet. No injuries. Will offer assistance with toileting at night. Attempt modified bowel/bladder program. Approaches: Offer assistance to the bathroom each time he awakens. (7) 4/17/12: Running down hall and fell hitting forehead. Severe laceration to forehead. Transferred to ER, returned with sutures. Utilize gait belt for ambulation. Review of the orthopedic consultation notes dated 3/22/12 revealed: Assessment: Left small finger P1 fracture Recommendations: Will place him in an ulnar gutter short arm cast. Return in 3 weeks. Review of the hospital Emergency Department Discharge Instructions dated 4/17/12 included the resident was treated for [REDACTED]. Review of the incident investigations related to Resident #136 revealed in part the following: (1) 3/2/12 at 4:40 a.m.: fell while attempting to go to bathroom. Resident has unsteady gait. No injuries. (2) 3/3/12 at 4:25 a.m.: Tripped over feet, lost balance while attempting to use bathroom. Falls when waking up and attempting to use bathroom. Abrasion to back of head. History of [MEDICAL CONDITION] - has unsteady gait. Continue 1:1 observation. (3) 3/8/12 at 1:45 a.m.: Resident rolled out of bed to floor, got up, went to bathroom, then went back to sleep. Very little action needed, resident stood up. History of [MEDICAL CONDITION], unsteady gait. No injuries. (4) 3/17/12 at 1:30 a.m.: Was notified by CNA that he rolled out of bed, hitting head on floor. Small laceration to forehead. Low bed has been requested. (5) 3/20/12 (time unknown): Resident reported that he fell while outside by the gazebo with his family. He stated he lost his balance while turning to get drink off table. Complained of pain to left fifth (5th) finger. X-ray and splint had per doctor orders. Orthopedics appointment on 3/22/12. (6) 4/17/12 at 3:40 a.m.: Resident started to run toward his room after smoking cigarettes, lost his balance, and fell in hall. Deep jagged laceration to forehead. Per doctor orders: Transfer to ER due to severity of laceration. (7) 5/8/12 at 10:05 a.m.: Resident attacked by another resident and was struck on back of head. This caused this resident to fall and hit head on door way frame. Witnessed by S18CNA. Not responding verbally or to oral stimuli. Resident nonresponsive for greater than ten (10) minutes. Transferred by ambulance. Review of the Nurses Notes dated 5/8/12 included: 10:05 a.m.: Struck on back of head by another resident (#173), causing resident (#136) to fall and hit head on door frame. No verbal response. Doctor (S66MD) was on unit and notified. Attempted to start IV in right AC but unsuccessful. At 10:40 a.m., pulse 63, pulse ox 98%, remains nonresponsive. Notified ambulance service for transport. At 10:45 a.m., ambulance arrived and resident was transferred out to ER at 10:50 a.m. 4:08 p.m.: Resident returned to unit. Complained of headache. Tylenol given. Review of the Physician's Progress Notes dated 5/8/12 included: Pt returned from hospital, awake, alert, oriented. Head hurts, all C-T negative per ER nurse. Clear liquid tonight, resume regular diet in am. Review of the hospital's Emergency Department Discharge Instructions revealed the resident was treated for [REDACTED]. An observation was made of Resident #136 on 5/17/12 at 8:50 a.m. The resident was resting in bed with his eyes closed. He was noted with tremors to his upper

Based on observation, record review and interview the facility failed to ensure that residents received the necessary treatment and services to prevent the development of avoidable pressure sores for 2(#7, #77) of 6 (#7, #25, #55, #77, #85, #89) residents reviewed for pressure sores in Stage 2 out of a total sample of 62 residents. The facility failed to: 1. Ensure accurate skin audits were conducted every shift as specified in the care plan on a resident with a history of pressure ulcers(#77) and/or who was prone to the development of pressure ulcers (#7&, #77), 2. Ensure daily skin assessments were monitored for accuracy on residents with a history of pressure ulcers (#77,#7) 3. Ensure CNAs implemented care plan interventions to turn and/or reposition residents every two hours in order to relieve pressure on residents identified as being at High Risk for the development of pressure ulcers. (#77) 4. Ensure skin assessments were accurately documented in the resident's record (#7, #77). 5. Ensure Nurses notify the Physician and Wound Care Nurse once a new pressure ulcer was identified so that the Physician could assess the pressure ulcer and start treatment to it, (#77) 6. Notify the physician when the resident developed a Stage IV pressure ulcer on the right hip on 3/30/12 (#77). 7. Obtain physician orders [REDACTED].#77). 8. Provide therapeutic treatment for [REDACTED].#77). 9. Notify the physician when a pressure ulcer to the resident's right buttock increased in size as stated in the resident's plan of care (#77). 10. Educate the resident on the importance of staying off of the area where the pressure sore was located (#7). 11. Care plan and implement new interventions when a pressure ulcer increased in size despite treatment (#77). 12. Ensure that assessment of pressure sore potential was conducted and documented quarterly on a resident (#7) Resident #77 was placed in an Immediate Jeopardy situation on 4/30/12 when the staff failed to have a system in place to ensure that accurate daily skin assessments were being performed and failed to ensure that the resident was being turned every 2 hours. The facility failed to discover a new pressure ulcer to the resident's right hip until it reached a Stage IV in severity. Upon discovery of the Stage IV pressure ulcer, the physician was not notified to assess the resident's facility acquired Stage IV pressure ulcer to his right outer hip and write orders for treatment of [REDACTED]. The Immediate Jeopardy was removed on 5/21/12 at 4:00 p.m. when the facility put a plan in place to ensure that all residents who had pressure ulcers and/or were prone to developing pressure ulcers would be accurately assessed by facility staff. Skin assessment was completed on Resident #77 on 5/18/12. Order obtained for right hip wound. Skin assessments were completed by nursing staff on 5/21/12 on residents at high risk for developing decubitus ulcers. Skin assessments were completed on 5/21/12 on residents with wounds to assess for new skin breakdown. Nursing staff will review residents with wound care orders to ensure that all wounds have been addressed. Unit nurses will assess nonambulatory residents' skin daily and document assessment. Unit Nurses will be inserviced on accurate skin assessments and documentation. CNA's will be inserviced on skin assessment and the importance of reporting changes in skin condition to the unit nurse. RN wound care nurse will assess nonambulatory residents weekly for new skin breakdown. The deficient practice continued at an actual harm for Residents #77 and at a level 2 with the potential for more than minimal harm for the 12 residents listed on the Quality Care and Quality of Life Indicator (QCLI) report that the facility determined to be at high risk for development of pressure ulcers. Findings: Review of the facility's Patient Assessment Policy presented by S2DON in response to surveyor request for a Skin Assessment Policy revealed the following in part: PATIENT ASSESSMENT Purpose: To assure care provided for each patient is based on assessment of the patient's relevant physical, psychological, and social needs. Policy: 1. Each patient is assessed by a licensed nurse using a head to toe format according to hospital documentation protocol and as warranted due to significant change in patient's condition..... 2. Each nurse is to follow hospital protocol and document full assessment by utilizing the nurse's notes. 3. ...Assessment should be an ongoing procedure to identify significant change in patient's condition... Resident #77 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #77's Assessment of Pressure Sore Potential dated 12/2/11 revealed that the resident's mental status was intact and had a total score of 5; Low Risk for developing pressure ulcers. Further review of the document noted above revealed the following: Note: A low score does not necessarily constitute a low risk. It is simply a guideline. The assessor must still look at the resident and apply clinical judgment. If, in the judgment of the assessor, the resident was at risk, then the appropriate Protocol should be followed. Review of Resident #77's Physician order [REDACTED]. (1) Change right hip (buttock) ulcer care to clean with Normal Saline(NS), apply 1/2 strength Dakin's Solution soaked gauze and Dry Compression Dressing(DCD) every (q) day and as needed (prn) soiling. Apply [MEDICATION NAME] to periwound area. (2) Change right thigh care to clean with NS, apply Puracol and [MEDICATION NAME], then DCD q day and prn soiling. (3) Left buttocks clean with NS, apply Puracol and DCD q day and prn soiling. Review of Resident #77's Comprehensive Plan of Care for Impaired Skin Integrity for Stage 4 Pressure Ulcers with a problem onset date of 8/26/11 revealed the following in part: Goals: (1) Wounds will heal without infections by next scheduled care conference 6/1/12 Approaches: (1) Assess skin q shift for any red areas or breaks in the skin (2) Turn patient q 2 hrs while in bed and reposition for comfort, maintain proper body alignment (3) Perform wound care as ordered Monitor for signs and symptoms of infections, increased temperature, warmth of the skin, redness and drainage (4) Notify Medical Doctor (MD) for change in wound On 5/16/12 at 11:54 a.m. an observation of S19Treatment Nurse performing the resident's wound care to the right/left buttocks and right thigh as follows: (1) Applied gloves (2) Removed old dressing from right thigh (3) Placed old dressing in biohazard bag on cart (4) Applied hand sanitizer (5) Applied gloves (6) Cleansed Stage 4 to right thigh with NS (7) Applied Aloe Vista (8) Applied Hydrogel (9) Applied [MEDICATION NAME] (10) Removed gloves (11) Applied hand sanitizer (12) Applied gloves (13) Removed old dressing right and left buttock (14) Removed gloves (15) Applied hand sanitizer (16) Applied gloves (17) Cleansed Stage 4 to right buttock with NS (18) Applied Aloe Vista to right outer edges (19) Applied Puracol (20) Applied dressing (21) Removed gloves (22) Applied hand sanitizer (23) Applied gloves (24) Cleansed Stage 4 to left buttock with NS (25) Applied Aloe Vista (26) Applied Puracol (27) Applied dressing (28) Removed gloves (29) Applied hand sanitizer Review of Resident #77's Wound Care sheets from August 2011 to present revealed the following wound care measurements for the Stage IV to the resident's left/right buttock: Left Buttock 08/25/11 6.5 x 2.5 x 1.5 08/31/11 6.5 x 2.5 x 1.5 No documentation of wound care done week of 9/5/11 09/12/11 Resident refused 09/19/11 6 x 2.5 x 1.3 09/30/11 6.3 x 4.2 x 1.5 10/07/11 6.5 x 7 x 1.5 10/13/11 6.5 x 6 x 1.5 10/20/11 6.5 x 5.5 x 1.2 10/24/11 6.5 x 4 x 1.2 10/31/11 6.3 x 4 x 1.2 11/11/11 6.0 x 3 x 0.5 11/18/11 7.0 x 3 x 1 11/25/11 7.5 x 3 x 1 12/02/11 8 x 3.5 x 1.2 12/09/11 8 x 3.5 x 1.2 12/16/11 7.4 x 3 x 1 12/21/11 7 x 2 x 1 12/28/11 6.5 x 2.5 x 1.3 01/03/12 5.5 x 3.0 x 1.5 01/10/12 5.2 x 2.5 x 1.3 01/17/12 Resident refused to be measured 01/24/11 Resident refused to be measured 01/31/12 Resident refused to be measured 02/07/12 6 x 2.5 x 1.3 No documentation noted from 2/8/12 to 3/12/12 03/13/12 6 x 2.5 x 1.3 03/30/12 6.0 x 3.0 x 0.5 04/06/12 Refuse to allow nurse to assess 04/09/12 6.0 x 3.0 x 0.5 04/16/12 Refused assessment & treatment 04/23/12 6.0 x 3.0 x 0.5 05/03/12 6.5 x 3.0 x 0.5 05/11/12 6.5 x 3.0 x 0.5 05/18/12 5 x 1.2 x 2 Right Buttock 08/25/11 5 x 5.5 x 1.3 08/31/11 5 x 5.5 x 1.3 09/05/11 No measurements found for this week 009/19/11 5 x 5.5 x 1.3 09/26/11 Resident refused 09/30/11 5.3 x 5.8 x 1.5 100/7/11 6 x 6 x 2.3 10/12/11 6 x 5.5 x 2 10/19/11 6.3 x 5 x 1.5 10/24/11 6.5 x 4.5 x 1 10/31/11 6.5 x 4.5 x 1 11/11/11 5.5 x 4.0 x 0.4 11/18/11 5.5 x 4.5 x 0.6 11/25/11 5.5 x 4.5 x 0.6 12/02/11 5.5 x 5 x 1 12/09/11 5.5 x 5 x 1 12/16/11 5.8 x 4 x 1 12/21/11 6 x 3.5 x 1 12/28/11 5.8 x 3.3 x 1 01/03/12 5.5 x 3 x 1.4 01/10/12 5.3 x 2.8 x 1.0 01/17/12 Resident refused to be measured 01/24/12 Resident refused to be measured 01/31/12 Resident refused to be measured 02/07/12 6 x 3.5 x 1.0 No documentation found for 2/8/12 to 3/12/12 03/13/12 5.5 x 2.5 x 2.2 No documentation found 3/14/12 to 3/29/12 03/30/12 5.5 x 4.5 x 1.0 04/06/12 Refused to allow nurse to assess 04/09/12 5.5 x 4.3 x 1.0 04/16/12 Refused assessment and treatment 04/23/12 5.5 x 4.5 x 1.5 05/03/12 7.0 x 6.2 x 1.5 05/11/12 7.0 x 6.2 x 1.5 05/18/12 5 x 4.2 x 3 Review of Resident #77's medical record revealed no documentation that the MD was notified when the resident's wound changed in size; as noted above or when the resident refused assessment of his wounds. Further review of the wound care documentation revealed a facility acquired Stage IV pressure ulcer to the resident's right hip that was first discovered on 3/30/12 with measurements as noted below: 3/30/12 2.0 x 1.0 x 1.01 4/09/12 2.0 x 1.0 x 1.01 4/16/12 Refused assessment and treatment0 4/23/12 2.0 x 1.0 x 1.01 5/03/12 2.0 x 1.0 x 0.7 5/11/12 2.0 x 1.0 x 0.7 5/18/12 2 x 0.8 x 0.1 On 5/17/12 at 9:02 a.m. an interview was conducted with S5RN Supervisor. She confirmed that there was no documentation in the resident's medical record for wound measurements for the resident's left/right buttock Stage 4 pressure ulcers from 2/8/12 to 3/12/12 and stated that there should have been. She also confirmed that they were not in the resident's thinned records either. Review of Resident #77's Physician's Progress Notes revealed no documentation that the resident was assessed for a facility acquired pressure ulcer to his right outer hip area on 3/30/12. Review of Resident #77's May 2012 Treatment Sheets revealed no documentation of a treatment for [REDACTED]. Review of Certified Nursing Assistant(CNA) Activities of Daily Living (ADL) sheets for January through May 2012 revealed no documentation that the resident was turned and repositioned q 2 hrs for comfort. On 5/17/12 at 9:31 a.m. an interview was conducted with S5RN Supervisor. She stated that she was the supervisor over the wound care team. She also confirmed that there was no new intervention put in place when the resident's Stage IV to his left buttock increased in size from 6.0 x 3 x 0.5 on 11/11/11 to 8 x 3.5 x 1.2 on 12/9/11. She acknowledged that the resident's Comprehensive Plan of Care for Skin Integrity listed as an intervention to notify the MD of a change in the wound, turn the resident q 2 hrs and assess the resident's skin q shift for any areas or breaks in the skin. There was no documentation to indicate that the physician was notified of the Stage IV to the resident's hip, of the resident being turned q 2 hrs or that the resident was accurately assessed q shift for red areas or breaks in the skin. The facility acquired Stage IV wound to the resident's right outer hip was discovered on 3/30/12. She said that there was no physicians or wound care treatment orders for the newly discovered Stage IV pressure ulcer to the resident's right outer hip; but acknowledged that there was documentation that the wound was being measured weekly by S33RN from 3/30/12 to 5/11/12 . She stated that the facility's protocol was that if a resident developed a new wound, the physician was supposed to assess the wound and order a wound care treatment. On 5/17/12 at 8:49 a.m. an interview was conducted with S21CNA. She stated that the resident turned himself in the bed. Review of Resident #77's Nurses Notes in the Skin Integrity Section noted an assessment of the resident's skin integrity q shift that revealed the following in part : 5/17/12 warm, dry, normal, skin intact 5/15/12 multiple decubitus to bilateral buttock 5/14/12 warm, dry, normal, skin intact 5/13/12 warm, dry, normal, skin intact 5/12/12 warm, dry normal 5/11/12 warm, cool, normal dressings to right thigh/sacral wounds 5/10/12 warm, cool, normal, dressings to right thigh/sacral wounds 5/9/12 warm, dry, normal, right thigh, right and left buttocks 5/8/12 warm, dry, normal, decubitus 5/7/12 warm, cool, normal, dressings, right thigh/sacral wounds 5/6/12 warm, cool, normal, dressings, right thigh/sacral wounds 5/5/12 warm, cool, normal, dressings right thigh/sacral wound 5/4/12 warm, dry, normal, right thigh, right & left buttocks 5/3/12 warm, dry, normal, right thigh, right & left buttocks 5/2/12 warm, cool, normal, dressings, right thigh/sacral wounds 5/1/11 warm, dry, normal, decubitus ulcers(multiple) 4/26/12 warm, dry, normal, multiple decubitus buttocks 4/25/12 warm, dry, normal, decubitus 4/24/12 warm, dry, normal, right thigh, right & let buttocks 4/23/12 warm, cool, dry, normal, dressing, right thigh/sacral wound 4/22/12 warm, dry, normal, dressings, right thigh/sacral wound 4/21/12 multiple decubitus ulcers 4/20/12 warm, dry, multiple wounds 4/19/12 warm, dry, normal, multiple wounds 4/18/12 warm, dry, normal, dressings, right thigh/sacral wound 4/17/12 warm, dry, normal, dressings, right thigh/sacral wounds 4/16/12 warm, dry, decubitus Review of the documentation revealed that the nurses were documenting inaccurate assessments of the resident's skin being warm, dry, normal and intact. Further review of the documentation noted that some of the nurses documentation revealed a assessment of the resident's skin, that the dressing was intact. On 5/18/12 at 1:20 p.m. an observation of Resident #77's body audit being performed by S19Treatment Nurse accompanied per S3ADON revealed that the resident had a white dry compression dressing secure and intact to his right outer thigh. Upon removal of the dressing the resident had what appeared to be a white substance in the center of the wound. Further observation noted that the wound was open, the edges were well approximated with no drainage and had pink tissue to the wound bed. An interview was conducted with S19Treatment Nurse at that time and she stated that the resident appeared as if he had Puracol in his wound with a dry compression dressing securing it in place. She verified that there was no treatment on the resident's Wound Treatment Sheets for the wound to his right outer hip area; but confirmed that a staff was applying a treatment to the wound and dressing it. She stated that when she performed the resident's treatment on 5/16/2012 that she was not aware that the resident had a Stage IV decubitus to his right outer hip area nor did he have a dressing to the area at the time. She stated that she did not assess his skin in that area because the resident's Wound Treatment sheets identified the areas that she needed to perform a wound care treatment on. She verified that the treatment sheets did not indicate an order for [REDACTED]. She stated that the wound to the resident's right outer hip appeared to be closed and that she did not think it was a current problem and that it was old in nature. She then asked S19Treatment Nurse did she think it was closed and she affirmed by saying "Yes". She verified that wound was first discovered on Resident #77 on 3/30/12 by S33RN and assessed at a Stage IV in severity. She also confirmed that a dressing was secure and intact to the resident's right outer hip and upon removal it had a white substance applied to the wound's bed. She stated that there was no documentation in the resident's medical record that indicated that the physician was notified of the newly discovered Stage IV pressure ulcer to the resident's right outer thigh or that treatment orders were obtained. On 5/18/12 at 2:03 p.m. an interview was conducted with S5RNSupervisor. She confirmed that the wound measured 2.0 x .8 x 0 and that it was not a healed wound. She stated that the reason Resident #77's wound to his right outer hip was staged at a Stage IV was because the wound's tissue was close to the resident's bone and you can feel how hard it was. She stated that the resident appeared to have an old scar on his right hip that he probably bumped transferring to and from his wheelchair on 3/30/12; when the pressure ulcer was first discovered at a stage IV in severity. On 5/21/12 at 12:11 p.m. an interview was conducted with S2DON. She stated that the floor staff was supposed to perform a daily skin assessment q shift on Resident #77's skin and the wound care nurse does weekly measurements and dressed the resident's wounds as ordered. She stated that the regular staff was responsible for general assessments of the residents skin, that was not covered with a dressing. She stated that the wound care assessments were done by a Registered Nurse(RN) who took pictures, measured and staged the resident's wound once a week. She said that the regular staff should list the wounds in the Skin Integrity Section of their Nurse's Notes. She verified that some of the floor nurses were documenting that Resident #77's skin was intact and normal with dressings. She agreed that was an inaccurate assessment of the resident's skin and that the staff may not have understood when a resident has a wound that they should not document skin intact . She said that the facility needed to inservice the staff and get that clarified with them. She stated that the Stage IV to the resident's right outer hip was facility acquired and that the resident should have been assessed by his physician and had a treatment ordered. She confirmed that there was no Physician or treatment order for the Stage IV to the resident's right outer hip and that there should have been. She said that if the facility staff discovered a new wound, the staff nurse should alert the physician so that he can assess the resident's wound and write an order for [REDACTED]. She stated that each time the wound increased in size and a new intervention was done, it should be documented on the care plan. She confirmed that the resident's Comprehensive Plan of Care of Skin Integrity was not revised to indicate new interventions that were put in place when the resident's Left Buttock Stage IV wound increased in size and it should have. She also confirmed that the resident's care plan included as an intervention that the resident was supposed to be turned by the facility staff q 2 hours and that skin assessments were to be performed. She stated that the care plan should have been carried out as ordered and was not. Resident #7 Review of the clinical record revealed the following diagnoses; [MEDICAL CONDITION], anxiety, [MEDICAL CONDITION], chronic [MEDICAL CONDITION] single kidney, [MEDICAL CONDITION] disorder, [MEDICAL CONDITION], status [REDACTED]. An observation and interview was held with Resident #7 on 5/15/12 at 1:45 p.m. He was alert and verbal. He was ambulating down the hall in his wheelchair. There was approximately 2 inches of space between his hips and the sides of his wheelchair. There was also a cushion noted in his wheelchair. He said that he was on the way to use the bathroom. Review of the quarterly MDS with an ARD of 4/24/12 revealed the following: BIMs score of 10 (moderately cognitively impaired); bed mobility independent; transfer limited assistance 1 person; and always continent of bowel and bladder. Review or the nurse's notes dated 1/17/12 at 1345 revealed returned from hospital with [DIAGNOSES REDACTED]. Review of the Nutritional Staffing Note dated 4/17/12 revealed the recommendations for a pre-[MEDICATION NAME] level. Review of the comments section revealed: 1/06 right [MEDICAL CONDITION], transferred hospital ER. 1/17 returned; 3/13 annual H&P; 3/18 left hip decubitus ulcer; 3/30 appt with renal associates, RTC in 5 months; ADLs reflect a good appetite eating most meals at 100%; he does have some weight loss but not significant and still within his IBW range; [MEDICATION NAME] is decreased from previous results, also below acceptable range referring to RD for review; Per dietary manager trainee. S8RD documented decreased [MEDICATION NAME] indicated compromised protein status which is common with diminished kidney function; see above recommendation for a pre [MEDICATION NAME] level to review current protein status; no further weight loss is desired will monitor and follow up PRN. Review of the clinical record revealed the following weights: 1/17/12 210# 2/7/12 191# 3/13/12 189# 4/3/12 184# 5/4/12 187#. Review of resident #7's lab work revealed the following: 3/14/12 total protein 7.1 (normal 6.3-8.2), [MEDICATION NAME] 2.9 (normal 3.4 -5), Na 144 (normal 136-145), K 5 (normal 3.5 -5.1), Cl 109 (normal 98-107), BUN 41 (normal 5-22), Crea 1.47 (normal .6 - 1.7), gluc 81 (normal 65 - 110), WBC 7.9 (normal 5-10), RBC 3.65 (normal 4.5 - 6.2), HGB 10.3 (normal 13.7 - 18), and HCT 30.9 (normal 40 - 54). Review of the MD progress notes revealed the following: 3/13/12 annual H&P. New. 2+ [MEDICAL CONDITION] right leg, non pitting, good pulse, sp orif. R hip FX x 2 months. Pt still using w/c for ambulation. 3/18/12 revealed left lateral hip ulcer with yellow slough. Appears to be related to wheelchair pressure on area. About dime sized ulcer. Normal Saline, santyl & dcd, gel cushion to w/c. 3/21/12 Increased in size has large amount of slough in center depth cannot be fully checked with slough present. Probably from pressure of w/c. Continue santyl. Wound care to evaluate. Review of the Weekly Wound Evaluation revealed the following regarding left trochanter: 3/22/12 Unstageable 1.0 cm X 1.0 cm no exudate Tissue Type: slough No odor No Tunneling 3/29/12 Unstageable 1.0 cm X 1.0 cm no exudate Tissue Type: slough No odor No Tunneling 4/5/12 Unstageable 1.0 cm X 1.0 cm no exudate Tissue Type: slough No odor No Tunneling 4/11/12 Unstageable 1.0 cm X 1.0 cm no exudate Tissue Type: slough No odor No Tunneling 4/18/12 Unstageable .6 cm X .6 cm no exudate Tissue Type: slough No odor No Tunneling 4/26/12 Unstageable .7 cm X .5 cm no exudate Tissue Type: slough No odor No Tunneling 5/2/12 Unstageable .7 cm X .5 cm no exudate Tissue Type: slough No odor No Tunneling 5/9/12 Unstageable .6 cm X .5 cm no exudate Tissue Type: slough No odor No Tunneling 5/16/12 Unstageable .6 cm X .5 cm no exudate Tissue Type: slough No odor No Tunneling Review of the Nurses Notes revealed skin intact on the following dates for the month of May: 5/20/12, 5/19/12, 5/16/12, 5/8/12, 5/7/12, 5/6/12, 5/5/12, and 5/2/12. An interview was held with S9CNA on 5/21/12 at 8:35 a.m. She verified that she was assigned to Resident #7. She said that he feeds himself and usually eats all of his food. She said that he uses a wheelchair. She said that he has a wound on the opposite hip that he broke. She explained that he turns himself in bed. She said that he does not like to lie on the hip that he broke. She said that he is allowed to lay on his back or either hip while he is in bed. An interview was held with Resident #7 on 5/21/12 at 8:50 a.m. He was sitting in his wheelchair in his room, and his hips were not touching the sides of his wheelchair. He explained that the wheelchair he was sitting in was the only wheelchair that he had ever used at this facility that he could remember. An observation was made of his room, but there was no turn schedule noted. He said that he could not remember anyone ever telling him not to lie on the hip that had the pressure ulcer wound. An interview was held with S10PT on 5/21/12 at 8:52 a.m. He verified that the current wheelchair that Resident #7 was using was the same wheelchair that he was issued when he returned from the hospital with the [DIAGNOSES REDACTED]. An interview was held with S11MDSNurse on 5/12/12 at 9:08 a.m. She verified the last assessment of pressure sore potential was completed on 8/11/10. She verified that the assessments should be completed quarterly. She verified the 8/11/10 assessment revealed a score of a 5 which was low risk. She also verified that the care plan did not reveal that the resident had a pressure ulcer. After reviewing the MDS assessment dated [DATE] she verified that it revealed that Resident #7 was not at risk for pressure ulcers. An interview was held on 5/21/12 at 9:14 a.m. with S12LPN. She said that Resident #7 transfers himself and turns himself in bed. She also explained that he feeds himself and he is continent of bowel and bladder. She said at night they check him to make sure he turns. She said he can lay on either side or his back. She said that his right side bothers him so he does not stay on it long. An observation was made of wound care performed by S12LPN on 5/21/12 at 9:30 a.m. She cleaned the left hip with normal saline, applied santyl, and covered the wound with a clean, dry dressing. The wound was noted to be pink and dime size. The center of the wound was noted to have an area of yellow slough approximately .5 cm. An interview was held on 5/21/12 at 11:46 a.m. with S5RNSupervisor. She explained that she was the supervisor for wound care and the MDS coordinator for building 2. She said that she also monitors the other MDS nurses. She verified that some of the other MDS nurses are behind on their assessments. She said that she encouraged them to get them completed. She said that she did not report it to administration. She said that she monitors the other MDS nurses through the computer system. She said that she can see when the assessments are not complete. She explained that the Assessments of Pressure Sore Potential were to be completed quarterly. She said all the MDS nurses do a peer review which is completed monthly. She explained during the peer reviews the nurses check the chart to see if changes occurred and the care plans were changed. She explained there are 3 MDS nurses and each monitors 10 charts per month. She verified during the peer reviews they had found that some care plans did not reflect the resident's current condition. She said they changed the care plans at the time when they found the problems. She said that the peer review findings had not been reported to S2DON. She verified that the last Assessment of Pressure Sore Potential for Resident #7 was dated 8/11/10. After reviewing the care plan she verified there was no care plan regarding his pressure ulcer. She explained that currently the wound care RN completes weekly measurements on all wounds. She said the nurses on the unit are responsible for completing skin assessments daily on building 2 and daily on skilled nursing residents on building 1. After reviewing Resident #7's Nurses Notes, she verified that they revealed skin intact when he did have a pressure ulcer. She verified that currently there is no one responsible for monitoring the accuracy of the skin integrity assessment noted on the Nurses Notes. She explained that she had observed this problem in the past, and she provided verbal in-services to her day shift staff nurses. She said that she reported this problem to S2DON, and she sent the RN managers emails to notify them of the problem. She said that no further monitoring was done to see if the accuracy of skin integrity assessments improved. When asked what system she had in place to make sure that nurses were completing daily skin audits, she explained that no monitoring was in place and it is the nurse's responsibility to accurately complete the assessment. An interview was held with S4RNManager on 5/21/12 at 3:02 p.m. She said that she had received an email from S5RNSupervisor regarding inaccurate skin assessments on the nurses' notes. S4RNManager said that she reminded the staff to be accurate with the assessments, but she did not have any documentation of her in-services. She said that she did not put a system in place to monitor for accuracy of skin assessments after she received the email from S5RNSupervisor regarding inaccurate assessments. An interview was held with S2DON on 5/21/12 at 3:43 p.m. She verified the MD wrote a note on 3/18/12 which revealed Resident #7 had a dime size pressure ulcer to his left hip. She verified that there was no nursing assessment for 3/18/12 regarding the pressure ulcer on the left hip. She said that she was not aware there was a problem regarding inaccurate skin assessment until S5RNSupervisor told her. She said that she thought S5RNSupervisor told her about this several months ago. S2DON explained that she emailed S5RNSupervisor and told her to contact the managers to discuss the skin integrity documentation which was inconsistent and not accurate. She said that she did not put any monitoring system in place for the problem regarding accuracy of skin assessments. She verified Resident #7's last Assessment of Pressure Sore Potential was dated 8/11/10. She said that it should have been done quarterly when the nurse did the MDS. She said that she had not been made aware that the Assessments of Pressure Sore Potentials were not up to date. She explained that the MDS nurses are to do a peer review on each other's MDS which includes monitoring for completion of assessments. She said that she does not get the peer review results. She said that the MDS nurses keep a book with the results, and she had not received anything from them regarding problems observed during peer reviews. She said that she does not monitor the book which contains the peer review results.

Based on observations, interview and record review the facility failed to establish and maintain an Infection Control Program designed to prevent the development and transmission of disease and infection by failing to: (1) Disinfect the glucometer machine according to Centers for Disease Control(CDC) Standards after an accucheck was obtained on a resident (#73) who was in contact isolation due to Clostridium Difficile(C Diff). 2) Ensure the glucometer machine used on a resident in contact for[DIAGNOSES REDACTED] was disinfected properly prior to use on Resident #93. (3) Handle, store and transport linens to prevent the spread of infection by not covering clean linen carts on 2 of 2 Halls (A, B). (4) Ensure staff use proper handwashing techniques before, during and after performing wound care for 1 of 3 residents viewed for pressure ulcers(#7) and 1 of 8 residents reviewed for accidents (#66). (5) Ensure staff washed their hands after coming in contact with bloody fluids while performing accuchecks. Resident #93 was placed in Immediate Jeopardy on 5/16/12 at 11:05 a.m. when the S29RN, assigned to resident #73, did not disinfect the glucometer after using it on Resident #73. Resident #73 was on contact isolation related to a [DIAGNOSES REDACTED]. He used the same glucometer that was used for Resident #73 without disinfecting it according to CDC guidelines. This action had the potential to place all other residents on Building 2 Unit A that had accuchecks performed with the same glucometer in an Immediate Jeopardy. The Administrator was notified of the Immediate Jeopardy on 5/18/12 at 3:55 p.m. A Plan of Removal was presented by the Administrator which read: A glucometer machine was placed in Resident #73's Contact Isolation room. The machine will remain in the residents' room for use with this resident only. The Policy/Procedure for cleaning and disinfection of glucometers has been revised to include the use of product solutions that prevent the spread of[DIAGNOSES REDACTED]icile spores. Nursing staff have been inserviced on the technique for cleaning and disinfecting glucometers according to the revised policy. A Clorox bleach solution (1 part bleach:10 parts water) has been placed on units for nursing staff to use when disinfecting glucometers after use with each resident. The Immediate Jeopardy was removed on 5/21/12 at 10:20 a.m. when the surveyors confirmed that the facility's plan of removal to clean and disinfect the glucometer was implemented. The deficient practice remains at a level 2 for a potential for more than minimal harm for all residents on Building 2 Unit A that had accuchecks performed. Findings: Review of the facility's Infection Control Policy revealed the following in part : Contact Precautions Private room is preferred. When a private room is not available, place the resident in a room with another resident with the same infection, but with no other infection (cohorting). Consider the epidemiological pattern of the microorganism and resident population when determining resident placement. Do not place a resident with MRSA infection or colonization in a room with another resident who had VRE infection or colonization. Wash hands immediately with soap and water or alcohol-based hand rub. If the organism being isolated is Clostridium difficile, soap and water are recommended. When possible, dedicate equipment to a single resident or cohorted residents. If equipment must be removed from the room, it must be adequately cleaned and disinfected before another resident's use. In long-term care facilities, consider the individual patient's clinical situation in deciding whether or not to implement Contact Precautions as described by the CDC. Review of the CDC's Infection Prevention during Blood Glucose Monitoring and Insulin Administration Policy revealed the following in part: ...Blood Glucose Meters Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared... Routine cleaning should be performed prior to disinfection. EPA-registered disinfectants with sporicidal claim have been used where surveillance and epidemiology indicate ongoing transmission of Clostridium Difficile(C Diff)... Resident #73 was a [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. On 5/16/12 at 10:53 a.m. an observation was made of S29RN performing Resident #73's accucheck. Further observation noted a sign on the resident's door that revealed he was on Contact Isolation. S29RN performed the resident's accucheck as follows: (1) Applied gown and gloves (2) Pricked Resident #73's finger and obtained results of accucheck results (3) Washed hands (4) Applied hand soap(contained greater that 2% [MEDICATION NAME]) and water to paper towel (5) Cleansed glucometer machine with hand soap,water and dried it off with a paper towel (6) Placed glucometer machine in a basket (7) Wiped hands with paper towel (8) Retrieved the basket that the glucometer machine was in; walked down the hall and applied hand sanitizer Further observation noted that S29RN did not disinfect the accucheck machine with a solution that kills the Clostridium Difficile bacteria before placing it back in the basket. Review of Resident #73's Doctor's Orders Sheet revealed on 5/1/12 at 1:40 p.m. to transfer the resident to isolation for[DIAGNOSES REDACTED] and place on Contact Isolation. Review of the facility's Safety Data Sheet revealed that the soap used out of the wall dispenser to clean the glucometer contained [MEDICATION NAME] greater than 2%. On 5/16/12 at 11:05 a.m. observation of S29RN performing Resident #93's accucheck, who was on another hall, with the same machine was noted as follows: (1) Applied gloves (2) Pricked resident's finger and obtained accucheck results (3) Washed hands with soap and dried with paper towel (4) Applied soap and water to paper towel (5) Retrieved glucometer machine; cleansed, dried and placed in basket (6) Washed hands and dried with the paper towel On 5/16/12 at 11:13 a.m. an interview was conducted with S29RN. He confirmed that Resident #73 was on Contact Isolation and that he cleaned the accucheck machine with soap and water. He stated that he did not disinfect the machine after using it on Resident#73 who was positive for[DIAGNOSES REDACTED]. On 5/18/12 at 4:52 p.m. an interview was conducted with S28LPN. She stated that she was never trained on what to clean an accucheck machine with, for a resident who was on Contact Isolation. She said that if she had to guess she would clean it with an alcohol prep. On 5/18/12 at 4:54 p.m. an interview was conducted with S22LPN. She stated that she had never been informed of what to clean an accucheck machine with after using it on person who was on Contact Isolation. She said that she usually worked on another unit where they don't have residents with[DIAGNOSES REDACTED] or on Contact Isolation. She stated that if she had a person with[DIAGNOSES REDACTED] on Contact Isolation; she would clean the accucheck machine with an alcohol swab. On 5/21/12 at 12:11 p.m. an interview was conducted with S2DON. She stated that when the staff took the glucometer machine in a resident's room who was on Contact Isolation, their protocol was to clean the machine with soap and water and wipe it before they went to the next resident. She said this was done universally for all residents. She acknowledged that the soap S29RN used to clean the accucheck machine contained [MEDICATION NAME] greater that 2% but did not contain a disinfectant. She confirmed that their Infection Control Policy said that the accucheck machine had to be cleaned and disinfected after using it on a person with[DIAGNOSES REDACTED], who was on Contact Isolation, before using it on another resident. She verified that the staff did not disinfect the accucheck machine after using it on Resident #73 who had[DIAGNOSES REDACTED] before going to another resident and he should have. Clean Linen Cart On 5/14/12 at 6:15 a.m. an observation was noted on initial tour of the clean linen cart sitting on "A" hall uncovered. On 5/14/12 at 6:30 a.m. an observation was noted on initial tour of a clean linen cart sitting on "B" Hall uncovered. On 5/15/12 at 1:30 p.m. an observation was noted on initial tour of the clean linen cart sitting on "A" hall uncovered. On 5/16/12 at 2:20 p.m. an observation was noted on initial tour of the clean linen cart sitting on "B" hall uncovered. On 5/22/12 at 6:17 a.m. an observation was noted of S27CNA coming down the hall with a clean linen cart uncovered. On 5/22/12 at 6:18 a.m. an interview was conducted with S27CNA. She confirmed that the cart was suppose to be covered and that she was not supposed to be pushing it down the hall uncovered. On 5/22/12 at 6:30 a.m. an interview was conducted with S22LPN. She confirmed that the clean linen cart was supposed to be covered when its on the hall and verified that it was not. An observation was made of Resident #7's wound care performed by S12LPN on 5/21/12 at 9:30 a.m. She cleaned the left hip with normal saline, removed her gloves, applied another pair of gloves, applied santyl, and covered it with a clean dry dressing. She failed to wash her hands after cleaning the wound, before applying the clean dressing. She verified that she failed to wash her hands after cleaning the wound and before applying a clean pair of gloves. An observation was made of S31LPN performing Resident #25's wound care on 5/21/12 at 9:35 a.m. She washed her hands, applied gloves, cleaned the pressure ulcer with normal saline, removed her gloves, applied another pair of gloves, applied santyl, and covered the pressure with a clean dry dressing. She verified that she did not wash her hands after cleaning the wound and before applying clean gloves. An interview was held with S3ADON on 5/22/12 at 9:34 am. She verified that the nurses are to wash their hands when gloves are removed. On 5/14/12 at 12:40 p.m. an observation was made of S17LPN performing an accucheck on Resident #29. During the observation, S17LPN was observed to perform the accucheck without the use of gloves. She cleaned Resident #29's finger with a alcohol wipe, then performed a finger stick on the resident's finger. After obtaining enough blood on the test strip, S17LPN was observed to apply the alcohol wipe to the resident's finger where there was bloody drainage. She applied pressure to the finger and bloody drainage was observed to penetrate the alcohol wipe. She had to put a band aid on the resident's finger to stop the bleeding. S17LPN did not wear gloves or wash her hands or use an alcohol hand gel before or after coming into contact with bloody drainage. An observation was made of S17LPN perform an accucheck on Resident #66 on 5/17/12 at 7:55 a.m. The resident had sustained a fall causing injuries to bilateral hands. Both hands/fingers were noted with bloody drainage from the injuries to his hands. She was noted to perform the accucheck without use of gloves. Her fingers were in direct contact with bloody drainage. She did not wash her hands after performing the accucheck. An observation was made on 5/17/12 at 7:58 a.m., of S17LPN providing care to skin tears Resident #66 received after sustaining a fall. The following was observed: S17LPN entered Resident #66's room with plastic basket of wound care supplies, sat the basket on the Resident #66's bed, applied gloves, and began assessment of resident. She did not wash her hands prior glove application or touching of resident. Resident #66 was observed with the following injuries: Right shoulder: large reddened area with abrasions/scrapes noted. Right palm (near small finger): small open skin tear, approximately ? inch, with bloody drainage Right elbow: skin tear, approximately 1 inch, with bloody drainage, Right forearm: skin tear, approximately ? inch, with bloody drainage Right knee: large abrasion/scrapes Left palm (near small finger): small open skin tear, approximately ? inch, with bloody drainage Left great toe (medial): small open skin tear, approximately ? inch, with bloody drainage S17LPN cleaned all areas with normal saline and covered with dressings or Band-Aids. During the observation, S17LPN maintained the same gloves and was observed to reach into the clean basket of wound supplies for new items with her soiled gloves intact. She was observed to grab the top of the normal saline bottle with her soiled gloves when cleaning each of the wounds. S17LPN recapped the normal saline and placed it back into the wound care basket. She then removed her gloves and placed them in the biohazard bag. She picked up the biohazard bag, placed the bag against her clothing to withdraw the air from the bag, and tied it in a knot. She then exited the room without washing her hands. She was observed walking down the hall with the biohazard bag. Upon questioning, S17LPN stated she was going to put the bag in the biohazard room (was located at end of hall 1C, outside door of unit on 1C). During this time, S17LPN was observed to touch 4 doors (knobs) on the way to the biohazard room, the keys to open the biohazard room door, and then the 4 doors upon returning to the unit 1D. She then was observed to enter the snack room on 1D and begin washing her hands. An interview was held with S17LPN on 5/17/12 at 8:30 a.m. She verified she had been in contact with bloody drainage and had left the resident's room prior to washing her hands. She stated the snack room was used for the residents' snacks. She verified she had used the sink in the snack room to wash her hands. She stated that she did not wash her hands prior to leaving the resident #66's room because she was taking the biohazard bag out of the room. She verified she had cleaned all wounds that contained bloody drainage with gloves on and used the same dirty gloves to remove clean dressings from the wound care basket and touched to top of the normal saline bottle. She said the wound care basket was maintained in the medication room and was used on all residents. She stated the basket was taken from room to room. She stated she should have washed her hands prior to leaving the room. Review of the facility's policy entitled, Hand Washing, included: Handwashing facilities are readily accessible in patient care areas and in bathrooms. Proper handwashing includes the use of running water, allowing the water to run distally down the arm or hand, soap, and a friction-creating technique making sure to clean all surfaces of the hands and fingers. Hands should be washed: before and after patient contact; after handling used equipment; after gloves and other barriers have been removed; whenever hands are soiled. If hands are inadvertently soiled with body substances, handwashing is done as soon as reasonably possible. An interview was held with S64RN Infection Control Nurse on 5/22/12 at 11:05 a.m. She stated all staff were to wash their hands with soap and water prior to leaving a resident's room once their hands had been in contact with a body substance. She stated gloves should be worn when coming into contact with body fluids, such as blood. She said all staff have been trained on hand washing and should know when to wash their hands. She said the LPN should not have washed her hands in the snack room, she should have washed her hands prior to leaving the resident's room.

Based on record reviews and interviews, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care for 1 (#32) of 14 (#32, #133, #26, #28, #93, #18, #112, #39, #30, #90, #33, #101, #36, & #47) sampled residents requiring assistance with transfers out of a total of 35 residents that require assistance with transfers by failing to: 1) Ensure that the CNAs were aware of the number of staff needed for transfers of residents requiring assistance with transfers and the location of this documentation. (#32) 2) Ensure two person physical assist was provided during transfers (#32) as care planned, 3) Ensure the use of a lift when transferring a resident to chair/bed (#32) as care planned, and 4) Provide supervision / monitoring of staff to ensure that identified interventions/approaches were implemented in accordance with the plan of care to prevent a resident from falling. (#32) Resident #32 required total dependence of two persons with transfers. An actual harm occurred when one person assistance was provided, and resident #32 was lowered to the ground by the CNA resulting in tibia and fibular fractures of the RLL extremity of resident #32. The resident experienced a decrease in activities of daily living including no longer getting out of bed due to pain resident #32 described as a 10 (greatest on the pain scale). He also developed [MEDICAL CONDITION] of the RLL which was treated with antibiotics. Findings: Resident #32 Review of the resident's record revealed that the resident was admitted to the facility on 3/24/11 and transported to the hospital on [DATE]. Review of the record revealed the resident had the following Diagnoses: [REDACTED]. 6/29/11 - Proximal tibia & fibular fractures. Review of the Care Plan revealed: Problem Onset 3/25/11 Potential for injury related to fall risk. Goal & Target Date: Will have no incident of injury through next staffing. 6/23/11 Approaches: Use 2-man lift when moving patient. Use draw sheet when moving patient. Turn and reposition for comfort. Use lift when transferring to chair/bed. Review of the Quarterly MDS with an ARD of 6/19/11 revealed the resident was assessed as requiring total dependence in transfers and needing two person physical assist in transfers. Review of the June 2011 CNA-ADL Sheets revealed ambulate PRN. Review of the CNA-ADL Sheets did not reveal an entry to identify to use 2 staff members when moving the resident or a lift when transferring the resident to the chair or bed. An interview was held with S10RNSupervisor on 7/28/11 at 10:50 a.m. After reviewing resident #32's June 2011 CNA-ADL sheet, she verified the entry for ambulate PRN was not correct for this resident. She also verified there was no entry on the CNA-ADL sheet which identified 2 staff member to assist with transfers. She said the transfer information did not have to be on the CNA-ADL sheets, but it needed to be in the care plan. Review of the Nurses Notes dated 6/28/11 at 0750 revealed the CNA reported that she was transferring resident to his chair and his legs gave way and she eased him to the floor. Resident AOX3 yelling loudly. No injuries or acute distress observed. Notified S9MD. Review of resident #32's Fall Incident Report dated 6/28/11 revealed the following information: Fall Location: Shower room Surface Condition: wet Mobility: Non Ambulant, Assist X 1 Comments: CNA X 1 was assisting. Type of Fall: legs gave way Usual Mental State: AO X 3 Resident's description of fall: "I fell off my chair" Brief description of fall: CNA states "I was transferring resident to his chair and his legs gave way and I eased him to the floor. Verbal Response: oriented Comment: Resident yelling out loudly. Doctor Notified: yes at 0750 on 6/28/11 - S9MD Seen by doctor: yes at 1625 on 6/28/11 - S9MD Doctor Orders: Elevate legs in bed. Systems Checked: Muscular / skeletal, sensory X-rays: none RN Manager - Summary of fall: CNA reported to unit nurse that client legs gave away while transferring him to his chair. Causes, outcome, and action taken: Unit nurse instructed CNA to get assistance d/t him having leg(s) weakness. Review of the Investigative Report regarding resident #32 revealed: Summary of Evidence: On the 28th of June at about 7:50 am resident #32 a resident at ... was in the shower room taking a shower. When he finished the CNA helped him get dressed and tried to help him get back in his gerichair. While trying to get back in the chair resident #32 fell . The CNA could not get resident #32 up off the floor. Two other employees were there and helped resident #32 up off the floor and got him back in his chair. After resident #32 was back in his chair he was brought to his room and was transferred to his bed. Statements Were Obtained From the Following: Resident #32 On June 28th at about 7:50 a.m. resident #2 was in the shower room. After resident #2 has his shower the CNA dressed resident #32. After resident #32 was dressed the CNA tried to help resident #32 to his gerichair and that is when he fell . After the fall two or three people came and helped resident #32 up off the floor and put him in his chair. At this point resident #32 was brought back to his room and put to bed. The doctor was called and x-ray was done of leg and foot. This statement was written by this investigator at the request of resident #32. Review of the Investigative Statement of S9MD, dated 7/1/11 at 0940 hrs revealed: Patient #... on a.m. 6/28/11 sat on floor (helped by staff) due to "legs gave out" . No reported injuries. Exam at 1625 hrs showed no hip pain and some [MEDICAL CONDITION] LLE and RLE (R>L) but no [MEDICAL CONDITION] / [MEDICAL CONDITION] evidence. Had small area dried blood both anterior shins. Elevation of legs ordered. At 0835 6/29/11, pt seen due to staff report of RLE worsening. Exam showed RLE red, hot to touch, large bleb (blister) and decreased pulse at ankle. Transferred to ER by ambulance. Found to have proximal tibia /fibula fracture but no [MEDICAL CONDITION] or [MEDICAL CONDITION] evidence per ER MD. Splint placed in ER and patient given appointment with Orthopedist for 6/30/11 and pt returned to facility. Review of the Investigative Statement of S11CNA, dated 7/7/11 revealed: On the Date of 6/28/11 she gave resident #32 a shower after that she dried him dressed and assist in the chair. She pulled the chair up locked it. So while standing resident #32 up he stood straight but when she went to put him in the chair he started buckling and said he was weak and went down to the floor. So she assist him to the floor but his leg went under him and she didn't know it until he started screaming and in the process she started calling for some assisting. My co-workers came and help me put him in the chair and then to his bed. S20SocialServiceCounselor notified S9MD. Review of the physician progress notes [REDACTED]. T 97.2, R 18, BP 152/86, P 72; No hip pain elicited. Both lower extremities with some [MEDICAL CONDITION] right greater than left. No evidence [MEDICAL CONDITION] or [MEDICAL CONDITION]. Pt. with small area dried blood anterior shins. [MEDICAL CONDITIONS] disorder, and paranoia. Elevate legs in bed. Monitor. Review of the physician's orders [REDACTED]. Review of the Nurses Notes dated 6/29/11 at 0340 revealed summoned to pt room by CNA, pt noted to have a large blister to right leg, along with swelling noted to knee, leg, and foot, pt. received pain med for pain of right leg. Will inform oncoming shift of this. Will continue to monitor the rest of this shift. Review of the Nurses Notes dated 6/29/11 at 0730 revealed right lower leg red swollen and warm to touch. Blister noted to lower right knee. S9MD notified will continue to monitor. Review of the physician progress notes [REDACTED]. Pt in some discomfort. T 98.7, P 90, R 20, BP 136/73. Ext left lower extremity ok, right lower extremity red with large bleb, positive popliteal pain. Some decreased pulse right posterior tibialis compared to left. [MEDICAL CONDITION], possible [MEDICAL CONDITIONS]. To ER via ambulance. Review of the physician's orders [REDACTED]. Stat CBC, BMP Dx: [MEDICAL CONDITION]. 2. Hep lock. 3. Transfer to ER for further evaluation of RLE [MEDICAL CONDITION] & possible [MEDICAL CONDITION] - send via ambulance. Review of the physician's orders [REDACTED]. Review of the X-ray dated 6/29/11 revealed right proximal tibia and fibular fractures. Review of the Nurses Notes dated 6/29/11 at 1600 revealed resident returned to facility. Review of the Physician's Progress Notes dated 6/29/11 at 1615 revealed Pt returned from L ... ER (Per Dr. T ... in ER, pt with proximal tibial fibula fracture and no evidence [MEDICAL CONDITION] or [MEDICAL CONDITION] and had normal WBC). Pt in bed. Splint on RLE. Ext - LLE without [MEDICAL CONDITION]. RLE less [DIAGNOSES REDACTED] (vesicle area covered by splint) Right toes pink, brisk capillary refill, warm and with about 1 plus [MEDICAL CONDITION] to foot. F/U with Dr. W ... (ortho) 6/30/11 10:30 a.m. for further treatment. [MEDICATION NAME] 10 mg po q 4 hrs prn pain. Monitor right toes for cap. refill, coolness, pain, [MEDICAL CONDITION]. Review of the physician's orders [REDACTED]. Increase [MEDICATION NAME] to 10 mg / 500 mg 1 po q 4 hrs prn pain. 2. Bedrest until seen by Dr. W ... (Ortho) 6/30/11 at 10:30 hrs at his office. 3. Check Right toes q 4 hrs & notify MD if capillary refill time > 3 secs, toes become cool / cold to touch, or pt with increased pain / swelling to foot. Review of the physician orders [REDACTED]. another [MEDICATION NAME] at 9 a.m. prior to transport. Review of the physician orders [REDACTED]. Pt's appt with Dr. W ... changed to today at 1300 hrs. Review of the physician progress notes [REDACTED]. W ... (ortho) Review of the Nurse's Notes dated 7/2/11 at 1915 revealed Stat labs order per MD. For fever 103.4 degrees Fahrenheit. Review of the physician orders [REDACTED]. Review of the physician orders [REDACTED]. Review of the physician progress notes [REDACTED]. Repeat Temp 98.7. Last pm temp 103. Pt ' s labs WNL last pm. Bld culture pending. Pt awake alert denies pain, cough, or N&V. Denies dysuria but pt. has partial [MEDICAL CONDITION]. [MEDICATION NAME] IM Q D I gm X 3, repeat labs 7/5/11. If fever worsens or symptoms will transfer to ER. Review of the physician orders [REDACTED]. [MEDICATION NAME] 1 gm IM Q 24 hrs X 3 more days. 2. CBC, BMP 7/5/11. Dx: FUO, decubitus. 3. UA 7/5/11 Dx: FUO. Review of the physician progress notes [REDACTED]. Plan continue [MEDICATION NAME], wait for final blood culture report, monitor vitals, labs in AM. Review of the physician progress notes [REDACTED]. OK. T 101, P 111, R 20, BP 136/94. Toes pink with good capillary refill (< 2 secs). FUO, [MEDICAL CONDITION], Right tib/fib (proximal) fracture, [MEDICAL CONDITION] disorder, & positive bld culture. Continue [MEDICATION NAME], repeat bld C&S 7/6, contact Dr. W ... (ortho) to discuss. Review of the physician progress notes [REDACTED]. Dr. W ... request pt be sent to his office tomorrow at 0900 hrs for further evaluation/treatment. Review of the physician orders [REDACTED]. Blood C&S AM 7/6/11 2. Appt with Dr. W ... 0900 hrs tomorrow 7/6/11 for follow-up RLE. Review of the physician progress notes [REDACTED]. W ... spoke with S9MD at 1100 hrs today and stated pt has [MEDICAL CONDITION] to RLE. Has splint (knee brace) on RLE. [MEDICAL CONDITION] RLE, R tib/fib fx, [MEDICAL CONDITION], muscle spasms. [MEDICATION NAME] 1 gram IV q 12 X 10 day, [MEDICATION NAME] 1 gram IV q day X 1 wk, hep lock, pain med given. Review of the physician orders [REDACTED]. Begin [MEDICATION NAME] 1 gram IV every day X 1 Week. 2. [MEDICATION NAME] 1 gram IV every 12 hours X 10 days. 3. [MEDICATION NAME] Lock. Review of the physician progress notes [REDACTED]. C/O pain to leg. T 100.4, P 96, R 20, BP 138/80. Pt in some pain (grimace with RLE dressing evaluation) RLE with [DIAGNOSES REDACTED], but no open areas noted. Foot with pulse & some [MEDICAL CONDITION]. [MEDICAL CONDITION] RLE, Right tib/fib fx, and increased pain. Continue IV meds, change to [MEDICATION NAME] 7.5 mg po q 4 hrs X 24 hrs, then q 4 prn pain (D/C [MEDICATION NAME]). Review of the physician orders [REDACTED]. D/C [MEDICATION NAME]. 2. [MEDICATION NAME] 7.5 mg po q 4 hrs X 24 hrs then 7.5 mg po q 4 hrs PRN pain. Review of the physician orders [REDACTED]. Non weight bearing to right lower extremity. Pt return to clinic in one month. Interviews: An interview was held with S2DON on 7/28/11 at 10:00 a.m. She said that she wasn't involved in resident #32's fall investigation. She said that she did know that S11CNA got a letter of counseling. An interview was held with S3ADON on 7/28/11 at 10:20 a.m. S3ADON said S11CNA was counseled regarding proper procedure for transferring patients requiring max assist. She said that she should have had assistance in transferring the resident. An interview was held with S10RNSupervisor on 7/28/11 at 10:50 a.m. After reviewing the MDS, she verified that resident #32 required total dependence of 2 staff members during transfers. She verified that the care plan revealed that 2 staff members were to assist with resident #32 during transfers. An interview was held on 7/28/11 at 1:00 p.m. with S19RNSupervisor. After reviewing the physician orders, she verified the physician had increased resident #32's pain medication since his fractures. After reviewing the MAR and narcotic records, she verified that since resident #32 fractured his leg, he had an increase in his pain level and an increase in the amount of pain medication he was taking. An interview was held on 7/28/11 at 1:55 p.m. with S7SafetyManager. He said all falls are investigated and then brought to the monthly Safety meetings to be discussed and recommendations made. He said that he gathers the statements during the investigations and turns them into S6QualityManagement. He explained that he makes a copy of all of the fall Incident Reports and brings them to the Safety meeting. When asked what recommendations were made regarding resident #32's fall on 6/28/11, he said that fall never got brought up at the safety meeting so no recommendations were made. He said that he forgot to make a copy of the incident report so it was not addressed at the safety meeting. An interview was held with S27CNASupervisor on 7/29/11 at 9:20 a.m. She said that she had been working the floor for the past month and not supervising because they were short CNAs. An interview was held with S11CNA on 7/29/11 at 10:00 a.m. She said that when she finished bathing and dressing resident #32 on 6/28/11, he stood with her help on the count of 3. She said that he started to get weak, and she sat him down on the floor and his leg was under him. She said that resident #32 could stand, and she always transferred him by herself. She said that the S8PT had told her that resident #32 could stand with her assistance. S11CNA explained she asked the nurse what type of transfer technique was to be used if she was not familiar with a resident. She said she did not know if the type of transfer to be used for the resident was documented anywhere so they could read it so she just asked her nurse. She said the only thing that she looks at on how to care for the resident is the ADL book. She said there is no information in it that shows if a resident needs 2 people or a lift for transfers. An interview was held with S15LPN on 7/29/11 at 10:11 a.m. She verified that resident #32 was assigned to her on the day he fell in the shower. She said S11CNA should not have transferred resident #32 without assistance. She said that she has not seen in the resident's chart where it identifies how many people are needed to transfer the resident or if a lift is to be used. When asked how she knows when a resident needs 2 people for transfers or a lift to be used for transfer, she said that she looks at the resident's height, weight, and diagnoses. She said resident #32 was heavy, and he could not ambulate. She said that they did not have to use the mechanical lift for resident #32, but they did need to use 2 people to transfer him. An interview was held with S8PT on 7/29/11 at 10:19 a.m. He said that resident #32 could be transferred with one person on a good day. When asked what he meant by a good day, he explained when resident #32 was not irritated or resistive to care. He said he would tell the CNAs on a daily basis if resident #32 could be transferred with 1 CNA. He also said that he worked 5 days a week on the day shift. He said that he had showed the CNAs how to stand resident #32 and pivot him with one person assist. He said that he did not have a sign-in sheet for the training of the CNAs. He could not remember for certain if he had trained S11CNA on how to transfer resident #32, but he felt like he had because he had shown all the day shift aides. An interview was held with S12CNASupervisor on 7/29/11 at 10:27 a.m. She verified that she was S11CNA's supervisor. She said resident #32 was usually transferred with one person. She explained that she looked at the resident to see if 2 people or a lift were needed to transfer a resident. She also said she asked the nurse to find out about the transfer information. She explained that anytime a resident couldn't ' t walk or support himself then 2 staff members were needed for the transfer. When asked how she monitored the CNAs to ensure they were using two CNAs when necessary to transfer residents, she said that she couldn't be with everybody every day. She said that she told the CNAs to use the proper equipment, and she gave them help if they needed it. An interview was held with S2DON on 7/29/11 at 2:40 p.m. After reviewing the facility policy, she verified that 2 staff members were to assist with transfer when a resident had to be lifted. She said that CNAs should go by their policy of 2 people with transfers and also the care plan. She said they were not to go by what therapy or ancillary staff say because it may start off as a good transfer and something could happen. She said the CNAs should do what they have been taught and trained. She said that she depends on the RN managers to be observing at frequent intervals to make sure that this is happening. She said that everybody was told the location of the care plans. She said that she was not aware of a specific training of usage of care plans, but everyone could use them. When asked what training related to falls and transfers had been done for the staff since 6/28/11, she said there had been no specific training related to transfers or falls since resident #32's fall. An interview was held with resident #32 on 8/2/11 at 8:45 a.m. He said that he stayed up and out of his room most of the day until he broke his leg. He said that since he broke his leg he stays in bed because it hurts to move. He explained before he broke his leg, he would go to the whirlpool room for his bath, get dressed, and go to the day room to watch TV, play bingo, or have Bible study. He said that he liked going to the whirlpool room to get his bath. He said he would eat in the day room or kitchen sometimes. He said that he has not played bingo or had Bible study since he broke his leg. He said that he loves to be out of his room so he can talk to the other residents. He said that his leg hurts to bad to get out of bed. He said before he broke his leg he got pain medicine for neck pain. He rated his neck pain as a 7 on a scale of 1 - 10 (10 being the greatest pain). He said since he broke his leg he has been in more pain. He rated his leg pain as a 10. He said when they turn him he cries out and moans. An interview was held with S18RN on 8/2/11 at 8:55 a.m. She said before resident #32 broke his leg, he would get out of bed and into his chair and go to the day room. She explained that he really liked to be up in his chair on Sundays and watch the preacher. She said that he was very spiritual. She said that S9MD said resident #32 could get up in a geri chair, but he was hurting so bad that he wants to stay in bed. She said that he complains of pain when they have to turn him. An interview was held with S21CNA, on 8/2/11 at 9:05 a.m. She said that she had worked at the facility for 3 years. She said before resident #32 broke his leg, he would go to the whirlpool room on Mondays, Wednesdays, and Fridays for his bath. She said that he always liked to go to the day room to watch church services and eat. She said that he usually went back to bed after lunch or either around 4:00 p.m. She said he is in more pain since he broke his leg. She said that he hollers a lot now when they move him. She said he doesn't want to get out of bed since he broke his leg. An interview was held with S2DON on 8/2/11 at 10:48 a.m. She said there had been no increase supervision or monitoring S11CNA for transfers after resident #32's fall. S2DON said no staff was instructed to do so. She said there had been no directive sent out from administration for supervision, monitoring, or education regarding transfers with S11CNA. She said S3ADON handles problems with the CNA staff. S2DON said that she was out on vacation the week when resident #32 fell and S3ADON was the acting DON at the time. She said the only thing that had been done was the letter of counseling for S11CNA. She said that nothing had been done facility wide regarding to help prevent falls of this nature in the future. She explained that recommendations are made in the Safety meetings when all falls are discussed by the fall committee. She said that no recommendations were made since the fall was not discussed in the safety meeting. An interview was held with S3ADON on 8/2/11 at 11:12 a.m. She said that she issued the letter of counseling to S11CNA. She said after the fall, she said that she reiterated to S11CNA's supervisor, S13RNManager that staff need to call for help and use good judgment. S3ADON said this was done verbally, and she did not have a sign-in sheet for the meeting. She said that S11CNA had not received transfer training, monitoring of transfers, or increase in supervision since the incident on 6/28/11. S3ADON said that nothing specifically had been done for all staff regarding falls or transfers since 6/28/11. She said those type of recommendations are made at the safety meeting when all the falls are discussed. She said that she did not remember resident #32's fall being discussed. On 8/2/11 at 2:15 p.m. an interview was held with S2DON. Surveyor advised S2DON of the need to see a signed copy of the letter of counseling dated 7/20/11 addressed to S11CNA. S2DON said that S3ADON would have a copy. On 8/2/11 at 2:25 p.m. an interview was held with S6QualityManagement. S6QualityManagement said she notified S3ADON on 7/12/11 that S3ADON needed to do a letter of counseling for S11CNA because of resident #32's fall and fractures. S6QualityManagement said this was her decision and not a recommendation which had been made by a committee. An interview was held with S3ADON on 8/2/11 at 2:28 p.m. She said she did not have a copy of the signed letter of counseling for S11CNA. She said that she wrote the letter of counseling. She said that she had not presented it to S11CNA. She said that S1Administrator and S2DON had to sign off on it. S3ADON said she could not remember if she brought the letter to the administrator or notified him of the letter of counseling. She said if she did bring the letter to the S1Administrator, she did not follow-up to get the signed letter back from the administrator to present it to S11CNA. Resident #32 suffered an actual harm when the facility failed to provide appropriate care and services resulting in an avoidable fracture which resulted in severe pain.

Based on record reviews, interviews, and observations, the facility failed to ensure that adequate supervision/monitoring and assistance devices were provided to by failing to: 1) Ensure that residents identified by the facility as requiring two person assistance for transfers were transferred with the proper assistance for 2 (#32, #18, ) of 6 (#32, #18, #30, #88, #76, #36) residents reviewed for transfers out of 35 residents requiring two person assistance for transfers. 2) Ensure that a resident with a history of biting other residents was closely observed in an effort to prevent further incidents of biting for 1 (#30) of 1 (#30) residents reviewed with a history of biting. 3) Ensure that 1:1 monitoring ordered by the physician was implemented for a resident with a history of falls in an effort to prevent future falls for 1(#110) of 2 (#110, #58) residents reviewed for accidents out of 2 residents meeting the accidents' criteria. 4) Ensure that fall interventions were modified after the resident continued to fall for 3 (#32, #133, #110) of 4 (#32, #110, #133, #58) residents reviewed for falls. 5) Ensure that 1:1 supervision ordered by the physician was implemented for 1(#143) of 1 (#143) residents reviewed with a with a history of violent behaviors. 6) Supervise staff to ensure 1:1 supervision was being provided for 1 (#143) of 3(#58, #110, & #143) residents as ordered by the physician. Resident #32 was a resident with a [DIAGNOSES REDACTED]. It was also verified by S2DON that according to facility policy two staff members were to assist with transfers when a resident had to be lifted. An accident hazard was presented for Resident #32 when S11CNA attempted to transfer Resident #32 to his chair after showering him, without the assistance of other staff on 6/28/11. Resident #32 suffered an actual harm when the facility failed to provide supervision when S11CNA transferred resident #32 without assistance, and he sustained a fracture of the right tibia and fibula. Findings: Resident #32 Review of resident #32's clinical record revealed that he was admitted to the facility on [DATE]. Review of the resident's List of [DIAGNOSES REDACTED]. 6/29/11 - Proximal tibia & fibular fractures. Review of the Quarterly MDS for Resident #32 with an ARD of 6/19/11 revealed the following information: B0700. Makes Self Understood = 0 (Understood) B0800. Ability to Understand Others = 0 (Understands - clear comprehension) G1B. Transfer = 4 / 3 (Total dependence of 2 persons). Review of the Care Plan revealed: Problem Onset: 3/25/11 Self care deficit r/t needs assistance with ADLs. Goal & Target Date: Resident #2 will feed self and utilize urinal with minimal assistance through next scheduled care conference. 6/23/11 (with a line drawn through it). Needs will be met by staff on a daily basis. Approaches: Daily whirlpool bath. Careful transfer, care not to bump extremities and no friction to buttocks. Problem Onset 3/25/11 Impaired Mobility R/T Bed / Chair bound. Goal & Target Date: Will have no further skin breakdown through next scheduled care conference. Will have no decrease in ROM through next scheduled care conference. 6/23/11 Approaches: Careful transfer, care not to bump extremities and no friction to buttocks. Turn & reposition q 2 hrs & prn, use pillows for comfort and good body alignment. Monitor pt while in W/C. Rehab as ordered. Problem Onset 3/25/11 Potential for injury related to fall risk. Goal & Target Date: Will have no incident of injury through next staffing. 6/23/11 Approaches: Use 2-man lift when moving patient. Use draw sheet when moving patient. Turn and reposition for comfort. Use lift when transferring to chair/bed. The following information was handwritten on the care plan: 6/28/11 Legs gave way CNA assisted to floor. 6/29/11 Transferred to L ... RLE edema. Hospital called stated broken leg. Appt with ortho 6/30/11. Orders to check capillary refill. 6/30/11 F/U with Dr. W ... orth in 4 wks. Cast in place. Hand written note revealed 5/17/11 refusing to allow lift pad to be used for transfer. Problem Onset 3/25/11 Thought processes impaired r/t on psychotropic medication: Old head injury, new environment. Hand written - 4/29/11 psych consult ordered. Goal & Target Date: Needs will be anticipated and met through next scheduled care conference. 6/23/11 Approaches: Assess level of orientation q shift and prn. Provide the patient with a consistent, routine environment. Use diversion tactics when patient becomes agitated or aggressive. Provide reality orientation q shift and prn. Maintain a quiet, calm, non-threatening environment. Provide environmental stimulation as needed. Give medications as ordered and assess for side-effects. Speak slowly and distinctly -face the patient when speaking. Give simple instructions. Maintain a calendar in the patient's room if possible. Problem Onset 3/25/11 Need for PT/OT. Goal & Target Date: Resident will be able to feed self with cueing through next staffing. Will increase functional mobility through next staffing. 6/23/11 Approaches: PT 3-5 X / week. OT 3 - 5 X / Week. Review of the CNA-ADL Sheets for Resident #32 revealed an entry of: ambulate PRN. There was no entry on the CNA- ADL sheet regarding the amount of assistance that the resident required with transfers. Review of the Nurses Notes dated 6/28/11 at 0750 revealed that a CNA had reported that she was transferring a resident to his chair and his legs gave way and she eased him to the floor. Documentation in the Nurses Note also revealed: Resident was AOX3 and yelling loudly. No injuries or acute distress observed. Notified S9MD. Review of the Physician's Progress Notes dated 6/28/11 at 1625 revealed the following: pt sat on floor this a.m. (by staff) when legs gave out. T 97.2, R 18, BP 152/86, P 72; No hip pain elicited. Both lower extremities with some edema right greater than left. No evidence of cellulitis or DVT. Pt. with small area dried blood anterior shins. Edema, Quadriplegia, seizure disorder, and paranoia. Elevate legs in bed. Monitor. Review of the physician's orders [REDACTED]. Review of the Nurses Notes dated 6/29/11 at 0340 revealed the following: summoned to pt room by CNA, pt noted to have a large blister to right leg, along with swelling noted to knee, leg, and foot, pt. received pain med for pain of right leg. Will inform oncoming shift of this. Will continue to monitor the rest of this shift. Review of the Nurses Notes dated 6/29/11 at 0730 revealed the following: right lower leg red swollen and warm to touch. Blister noted to lower right knee. S9MD notified will continue to monitor. Review of the Physician's Progress Notes dated 6/29/11 at 0835 revealed the following: Transfer Note - Pt's right leg with increased edema and pain today. Pt in some discomfort. T 98.7, P 90, R 20, BP 136/73. Ext left lower extremity ok, right lower extremity red with large bleb, positive popliteal pain. Some decreased pulse right posterior tibialis compared to left. Cellulitis, possible DVT, seizure, quadriplegia. To L ... ER via ambulance, stat CBC and BMP, and hep lock. Review of the physician's orders [REDACTED]. Stat CBC, BMP Dx: Cellulitis. 2. Hep lock. 3. Transfer to L ... ER for further evaluation of RLE edema & possible DVT - send via ... Ambulance. Review of the Nurses Notes dated 6/29/11 at 0920 revealed ambulance arrives on ward to transfer pt to hospital. Review of the X-ray dated 6/29/11 revealed right proximal tibia and fibular fractures. Review of the Nurses Notes dated 6/29/11 at 1600 revealed the following: resident returned to unit via facility transport with CNA. To bed with immobilizer to right knee /leg. Toes warm, circulation adequate capillary refill 3 seconds. Examined per S9MD. N.O. to increase Lortab 10 mg/500 mg q 4 hrs PRN, bed rest until orthopedist appt on 6/30/11, check toes right foot every 4 hours. Notify MD if cap refill > 3 seconds feet / toes cold or c/o increased pain / swelling to right foot. Review of the Physician's Progress Notes dated 6/29/11 at 1615 revealed the following: Pt returned from L ... ER (Per Dr. T ... in ER, pt with proximal tibial fibula fracture and no evidence DVT or cellulitis and had normal WBC). Pt in bed. Splint on RLE. Ext - LLE without edema. RLE less [DIAGNOSES REDACTED] (vesicle area covered by splint) Right toes pink, brisk capillary refill, warm and with about 1 plus edema to foot. F/U with Dr. W ... (ortho) 6/30/11 10:30 a.m. for further treatment. Lortab 10 mg po q 4 hrs prn pain. Monitor right toes for cap. refill, coolness, pain, edema. Review of the physician's orders [REDACTED]. Increase Lortab to 10 mg / 500 mg 1 po q 4 hrs prn pain. 2. Bedrest until seen by Dr. W ... (Ortho) 6/30/11 at 10:30 hrs at his office. 3. Check Right toes q 4 hrs & notify MD if capillary refill time > 3 secs, toes become cool / cold to touch, or pt with increased pain / swelling to foot. Review of the Physician's Progress Notes dated 6/30/11 at 1350 revealed the following: rec'd faxed x-ray reports from L ..... 1. Minimally displaced fractures of proximal tibia & proximal fibula. Knee remains normally aligned. Severe DJD present. 2. No hip fracture or dislocation. 3. No ankle fracture ("there appears to be a soft tissue laceration in anterior lower leg") Review of the physician's orders [REDACTED]. Call & make appt with Dr. W ..... for F/U in 4 wks. 2. Pt must keep cast dry at all times. Please elevate leg above heart for 30-45 mins q 3 hrs. Wrap blue pad around the cast to keep from getting wet while urinating. Review of the Fall Incident Report dated 6/28/11 involving Resident #32 revealed the following information: Fall Location: Shower room Surface Condition: wet Mobility: Non Ambulant, Assist X 1 Comments: CNA X 1 was assisting. Type of Fall: legs gave way Usual Mental State: AO X 3 Resident's description of fall: "I fell off my chair" Brief description of fall: CNA states "I was transferring resident to his chair and his legs gave way and I eased him to the floor. Verbal Response: oriented Comment: Resident yelling out loudly. Doctor Notified: yes at 0750 on 6/28/11 - S9MD Seen by doctor: yes at 1625 on 6/28/11 - S9MD Doctor Orders: Elevate legs in bed. Systems Checked: Muscular / skeletal, sensory X-rays: none RN Manager - Summary of fall: CNA reported to unit nurse that client legs gave away while transferring him to his chair. Causes, outcome, and action taken: Unit nurse instructed CNA to get assistance d/t him having leg(s) weakness. Review of the Investigative Report regarding the fall on 6/28/11 involving resident #32 revealed the following: Summary of Evidence: On the 28th of June at about 7:50 am resident #32 a resident at ... was in the shower room taking a shower. When he finished the CNA helped him get dressed and tried to help him get back in his gerichair. While trying to get back in the chair resident #32 fell . The CNA could not get resident #32 up off the floor. Two other employees were there and helped resident #32 up off the floor and got him back in his chair. After resident #32 was back in his chair he was brought to his room and was transferred to his bed. Statements Were Obtained From the Following: Resident #32 On June 28th at about 7:50 a.m. resident #32 was in the shower room. After resident #32 had his shower the CNA dressed him. After the resident was dressed, the CNA tried to help him to his gerichair and that was when he fell . After the fall, two or three people came and helped resident #32 up off the floor and put him in his chair. At this point resident #32 was brought back to his room and put to bed. The doctor was called and x-ray was done of leg and foot. This statement was written by this investigator at the request of resident #32. Review of the Investigative Statement of S9MD, dated 7/1/11 at 0940 hrs revealed the following: Patient #... on a.m. 6/28/11 sat on floor (helped by staff) due to "legs gave out". No reported injuries. Exam at 16:25 hrs showed no hip pain and some edema LLE and RLE (R>L) but no cellulitis / DVT evidence. Had small area dried blood both anterior shins. Elevation of legs ordered. At 0835 6/29/11, pt seen due to staff report of RLE worsening. Exam showed RLE red, hot to touch, large bleb (blister) and decreased pulse at ankle. Transferred to ER by ambulance. Found to have proximal tibia /fibula fracture but no DVT or cellulitis evidence per ER MD. Splint placed in ER and patient given appointment with Orthopedist for 6/30/11 and pt returned to facility. Review of the Investigative Statement of S11CNA, dated 7/7/11 revealed the following: On the date of 6/28/11 I gave resident #32 a shower after that I dried him dressed and assist in the chair. I pulled the chair up locked it. So while standing resident #32 up he stood straight but when I went to put him in the chair he started buckling and said he was weak and went down to the floor. So I assist him to the floor but his leg went under him and I didn't know it until he started screaming and in the process I started calling for some assisting. My co-workers came and help me put him in the chair and then to his bed. S20Social Worker notified S9MD. Interviews: An interview was held with S8PT on 7/28/11 at 9:00 a.m. S8PT said resident #32 had a recent fracture. S8PT explained that something had happened while resident #32 was in the whirlpool room. S8PT said that resident #32 had the [DIAGNOSES REDACTED]. S8PT said that resident #32 could stand up due to the tone in his legs, but he had no control. S8PT said when he does a pivot transfer with resident #32 that resident #32 thought that he was moving himself without S8PT's help. S8PT went on to say that resident #32 could feed himself. An interview was held with S3ADON on 7/28/11 at 10:20 a.m. She said that S11CNA was bathing resident #32 in the whirlpool room and attempted to transfer him from the whirlpool to the wheelchair or gerichair without assistance. She explained that upon transfer resident #32's legs gave way, his weight shifted on S11CNA, and she lowered him to the floor. She said he was assessed, and he sustained a fracture from the incident. S3ADON said S11CNA was counseled regarding proper procedure for transferring patients requiring max assistance. She added that S11CNA should have had assistance in transferring the resident. An interview was held with S10RNSupervisor on 7/28/11 at 10:50 a.m. After reviewing the care plans, S10RNSupervisor verified there were no interventions initiated after the fall on 6/28/11 to prevent future falls of this nature. She also verified the care plans were not up to date. She verified the care plans should have been updated by 6/23/11. She verified that the care plan revealed that 2 staff members were to assist with resident #32's transfers. After reviewing resident #32's June 2011 CNA-ADL sheet, she verified the entry for ambulate PRN was not correct for this resident. She also verified there was no entry on the CNA-ADL sheet which identified 2 staff members to assist with transfers. She said the transfer information did not have to be on the CNA-ADL sheets, but it needed to be in the care plan. After reviewing the MDS, she verified that resident #32 required total dependence of 2 staff members during transfers according to the MDS. An interview was held on 7/28/11 at 1:55 p.m. with S7SafetyManager. He said all falls were investigated and then brought to the monthly Safety meetings to be discussed and recommendations made. He said that he gathered the statements during the investigations and turned them into S6QualityManagement. He explained that he made a copy of all of the fall Incident Reports and brought them to the Safety meetings. When asked what recommendations were made regarding resident #32's fall on 6/28/11, he said that the fall was never reviewed at the safety meeting so no recommendations were made. He said that he had forgotten to make a copy of the incident report so it was not addressed at the safety meeting. An interview was held with S27CNASupervisor on 7/29/11 at 9:20 a.m. She said that she had been working the floor for the past month and not supervising because they were short CNAs. An interview was held with S11CNA on 7/29/11 at 10:00 a.m. She said that when she finished bathing and dressing resident #32 on 6/28/11, he stood with her help on the count of 3. She said that he started to get weak, and she sat him down on the floor and his leg was under him. She said that resident #32 could stand, and she always transferred him by herself. She said that S8PT had told her that resident #32 could stand with her assistance. S11CNA explained she asked the nurse what type of transfer technique was to be used if she was not familiar with the resident. She said she did not know if the type of transfer to be used for the resident was documented anywhere so they could read it so she just asked her nurse. She said the only thing that she looked at on how to care for the resident was the ADL book. She said there was no information in it that showed if a resident needed 2 people or a lift for transfers. An interview was held with S8PT on 7/29/11 at 10:19 a.m. He said that resident #32 could be transferred with one person on a good day. When asked what he meant by a good day, he explained when resident #32 was not irritated or resistive to care. He said he would tell the CNAs on a daily basis if resident #32 could be transferred with 1 CNA. He also said that he worked 5 days a week on the day shift. He said that he had showed the CNAs how to stand resident #32 and pivot him with one person assist. He said that he did not have a sign-in sheet for the training of the CNAs. He could not remember for certain if he had trained S11CNA on how to transfer resident #32, but he felt like he had because he had shown all the day shift aides. An interview was held with S12CNASupervisor on 7/29/11 at 10:27 a.m. She verified that she was S11CNA supervisor. She said resident #32 was usually transferred with one person. She explained that she looked at the resident to see if 2 people or a lift were needed to transfer a resident. She also said she asked the nurse to find out about the transfer information. She explained that anytime a resident couldn't walk or support himself then 2 staff members were needed for the transfer. When asked how she monitored the CNAs to ensure they were using two CNAs when necessary to transfer residents, she said that she couldn't be with everybody every day. She said that she told the CNAs to use the proper equipment, and she gave them help if they needed it. An interview was held with S2DON on 7/29/11 at 2:40 p.m. After reviewing the facility policy, she verified that 2 staff members were to assist with transfers when a resident had to be lifted. She said that CNAs should go by the facility policy of using 2 people with transfers and also the care plan. She said the CNAs were not to go by what therapy or ancillary staff told them because it may start off as a good transfer and something could happen. She said the CNAs should do what they have been taught and trained. She said that she depended on the RN managers to be observing at frequent intervals to make sure that this was happening. She said that everybody was told the location of the care plans. She said that she was not aware of a specific training of usage of care plans, but everyone could use them. When asked what training related to falls and transfers had been done for the staff since 6/28/11, she said there had been no specific training related to transfers or falls since resident #32's fall. An interview was held with S2DON on 8/2/11 at 10:48 a.m. She said there had been no increase in supervision or monitoring of S11CNA performing transfers since resident #32's fall. S2DON said that no staff had been instructed to monitor S11CNA. She said there had been no directive sent out from administration for supervision, monitoring, or education regarding transfers with S11CNA. She said that S3ADON was responsible for handling problems with the CNA staff. S2DON said that she was out on vacation the week that resident #32 fell , and S3ADON was the acting DON at the time. After reviewing the care plan, S2DON verified that no interventions had been initiated after the fall to prevent future falls of this nature. She said the only thing that had been done was the letter of counseling for S11CNA. She said that nothing had been done facility wide regarding prevention of falls of this nature in the future. She explained that recommendations were made in the Safety meetings since all falls were to be discussed by the fall committee. She said that no recommendations were made since the fall was not discussed in the safety meeting. An interview was held with S6QualityManagement on 8/2/11 at 10:50 a.m. She said that no other recommendations were made after the fall investigation of resident #32 other than the letter of counseling. An interview was held with S3ADON on 8/2/11 at 11:12 a.m. She said that she issued the letter of counseling to S11CNA. She said that after the fall she reiterated to S11CNA's supervisor and S13RNManager that staff need to call for help and use good judgment. S3ADON said this was done verbally, and she did not have a sign-in sheet for the meeting. She said that S11CNA had not received transfer training, had not been monitored performing transfers, or had increase in supervision since the incident on 6/28/11. S3ADON said that nothing specifically had been done for all staff regarding falls or transfers since 6/28/11. She said those type of recommendations were made at the safety meeting when all the falls were discussed. She said that she did not remember resident #2's fall being discussed. On 8/2/11 at 2:15 p.m., an interview was held with S2DON. During the interview, a signed copy of the letter of counseling dated 7/20/11 and addressed to S11CNA was requested from S2DON as the copy originally presented was not signed. S2DON said that S3ADON would have a copy. On 8/2/11 at 2:25 p.m., an interview was held with S6QualityManagement. S6QualityManagement said that she notified S3ADON on 7/12/11 that S3ADON needed to do a letter of counseling for S11CNA because of resident #32's fall and fractures. S6QualityManagement said this was her decision and not a recommendation which had been made by a committee. An interview was held with S3ADON on 8/2/11 at 2:28 p.m. She said that she wrote the letter of counseling. She said that she had not counseled S11CNA and had not presented the letter of counseling to her. She said that S1Administrator and S2DON had to sign off on it. S3ADON said she could not remember if she brought the letter to the administrator or notified him of the letter of counseling. She said that if she did bring the letter to S1Administrator that she had not followed up to get the signed letter back from the administrator to present it to S11CNA. An interview was held with S2DON on 8/2/11 at 2:40 p.m. She said that she had just been made aware that S11CNA had not been presented the letter of counseling. Resident #18 Review of Resident #18's clinical record revealed the following Diagnoses: [REDACTED]. Review of the annual MDS with an ARD of 6/26/11 revealed that she required total dependence of 2 persons with transfers. Review of the care plan revealed assist up to gerichair as tolerated. Review of the CNA-ADL flow sheet did not reveal to use 2 persons for transfers. An interview was held with S4MDSNurseCoordinator on 7/29/11 at 10:59 a.m. After reviewing the MDS, she verified resident #3 needed total dependence with 2 persons for transfers. She verified the care plan and CNA-ADL flow sheet did not reveal to use the lift or 2 persons with transfer. An interview was held with S29LPN on 7/29/11 at 10:50 a.m. She said that she was assigned to resident #18. She said that 2 people should transfer resident #18. An interview was held on 7/29/11 at 8:30 a.m. with S22CNA. She said that normally 2 people transfer resident #18. She said that she was the only CNA on her side of the hall so she was going to do it herself. She said that they could transfer her with one person every now and then. On 7/29/11 at 8:30 a.m. an observation was made of S22CNA transferring resident #18 from the bed to the gerichair using the lift without the assistance of another staff member. An interview was held with S29LPN on 7/29/11 at 10:50 a.m. S29LPN verified that resident #18 required 2 persons assistance with transfers. Resident #30 Review resident #30's care plan revealed the problem of potential for injury related to behavior problem "biter" dated 11/8/10. Approaches - After lunch may go to bed for 2 hours; keep him at a distance from any resident; close supervision at all times; watch for signs and symptoms of escalating behavior: change in sleep patterns refusing care & medications agitated mood; keep MD informed of behavior; approach in calm way; call him by name; attempt to identify cause of hostility or aggression; explain to him to bring problems to staff; try diversionary tactics; remind with each inappropriate incident that he is responsible for his behavior; notify MD of uncontrollable behavior; set limits; psychiatric consult prn. Hand written notes: Dated 4/20/11 Continues to bite other resident when they get close to him. Dated 5/8/11- patient was yelling out and another resident tried to stuff paper towels down his moth to quiet patient. Patient bit the other res. right thumb, causing small abrasion. Patient sustained right cheek & lateral eyebrow abrasion during altercation. Dated 8/3/11 - Bit a resident in day room broke skin, labs done, HIV negative. Plan Keep arms length from other residents monitor closely - all staff. Dated 8/4/11 bit pt 8/3/11 labs drawn follow care plan. Review of resident #30's May and August 2011 CNA-ADL flow sheet revealed keep him at a distance from other pts d/t history of biting, spitting & scratching others with a start date of 9/1/07. Review of resident #143's May 2011 physician orders [REDACTED]. Review of resident #30's incident report dated 5/8/11 at 1322 revealed the following: Where did incident occur? 1C/D day room Briefly Describe Incident: Resident yelling out in day room. Told to stop by resident #143 when not stop yelling out resident #143 got out of his seat & attempted to put a paper towel in resident #30's mouth. Resident #30 bit resident #143 on right thumb and resident #143 struck resident #30 in the face. Resident #30 sustained an abrasion on right cheek and small cut on right eye lid. Supervisor's review and recommendations: Physical confrontation between 2 residents with this one receiving non life threatening injury. Do you suspect Abuse or Neglect? No. Residents were separated. Verbal intervention effective by staff. Review of Resident #30's Nurse's Notes dated 5/8/11 at 1322 revealed called to 1C/D day room. Resident #30 and resident #143 in a physical confrontation. Resident #143 reported resident #30 was yelling out and he could not hear the tv. Reported resident #143 got up out his seat approached resident #30 & resident #143 attempted to put a paper towel in resident #30's mouth. Resident #30 grabbed resident #143 and bit resident #143 on the right thumb. Resident #30 was struck on the side of his face. Resident #30 sustained an abrasion on right cheek and cut on right eye lid. swelling at side. Ice pack to right side of face. Review of resident #30's incident report dated 8/3/11 at 1915 revealed the following: Where did incident occur? 1A Briefly Describe Incident: Resident #30 bit right forearm and left wrist of resident #28 and punctured skin, punctures and abrasions cleaned with NS and betadine. These 2 residents were in the day room at time of incident. Witness if any: S64Housekeeping Supervisor's review and recommendations: As Per Above Do you suspect Abuse or Neglect? This patient is known to have aggression to others by history. This patient is Hep C+ Hep B immune. Will do VDRL & HIV in am per protocol. Review of resident #30's Nurse's Notes dated 8/3/11 at 1915 revealed resident #30 was sitting in a geri chair in tv room & bit the right forearm and left wrist of resident #28. Resident #30 has known history of biting. Review of resident #143's physician progress notes [REDACTED]. #143 became upset with resident #30 yelling out & resident #143 unable to watch TV in day room. Resident #143 struck resident #30 on the face and attempted to put paper towel in resident #30's mouth & resident #143 was bitten on right thumb by resident #30. Resident #143 has a small abrasion to right thumb with dried blood noted after band aid removal. Review of resident #143's May 2011 physician orders [REDACTED]. An interview was held with S65RNSupervisor on 8/11/11 at 1:30 p.m. She said the incident on 8/3/11 occurred in the day room on the unit. She also said that a staff member was supposed to be present in the day room with the residents. She said she updated the care plan by adding to keep resident #30 an arm's length away from other residents. She verified that on 5/8/11 and 8/3/11 resident #30 was to be kept away from other residents and to be under close supervision. She verified that on 5/8/11 and 8/3/11 the care plan was not followed since the resident #30 was to be kept away from other residents and to be under close supervision. Interview was held with S10RNSupervisor on 8/11/11 at 2:33 p.m. After reviewing the care plan, she verified no changes were made to the care plan after resident #30 bit resident #143. She explained that resident #143 was on 1:1 supervision when resident #30 bit him. She could not explain how resident #143 got close enough to resident #30 to attempt to put paper towels in his mouth without staff intervention since resident #30 was on close observation and resident #143 was on 1:1 supervision. An interview was held on 8/11/11 at 2:45 p.m. with S65RNSupervisor. She verified that resident #30's August and May CNA-ADL flow sheet revealed to keep him at a distance from other residents due to his history of biting. She explained that close supervision meant to watch resident #30 closely and make sure no resident gets close to him. Resident #133 Review of the clinical record revealed resident #133 was admitted from the hospital to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Order of Recording form completed by the physician and dated 12/7/10 revealed the resident was attempting to elope from the hospital. Review of the admission MDS with assessment reference dated (ARD) of 12/20/10 revealed the resident scored a "3" for cognition. This indicated he had severe cognitive impairment. Further review of the MDS indicated resident #133 was independent with walking. Review of the admission orders [REDACTED]. Further review of the physician's orders [REDACTED]. Review of the December 2010 through March 2011 CNA-ADL Sheets included 1:1 arms length secondary to elopement. The time codes were indicated in shifts: 6a-2p, 2p-10p, and 10p-6a. There were chec

Based on interviews, observations, and record reviews, the facility failed to ensure that CNAs demonstrated competency in skills and techniques necessary to provide care identified through resident assessments and described in the plan of care for 2 (#32, #18) of 14 (#133, #26, #28, #93, #112, #39, #30, #90, #33, #101, #36, & #47) sampled residents requiring assistance with transfers. There were a total of 35 residents that required assistance with transfers. The facility failed to ensure: a) CNAs demonstrated competency by reviewing the appropriate documents to determine the means of transfer and number of staff for transfer for a non ambulatory resident (#32 & #18) b) CNAs used two persons to physically assist in transfers for residents requiring total dependence in transfers as documented on the MDS (#32 & #18). This resulted in actual harm for Resident #32 who fell on [DATE] and sustained right proximal tibia and fibular fractures when S11CNA attempted to transfer him to his chair after showering him, without the assistance of other staff. Findings: Resident #32 Review of the Nurses Notes dated 6/28/11 at 0750 revealed while CNA was transferring resident to his chair the resident's legs gave away, and the CNA eased him to the floor. No injuries or acute distress observed. Notified S9MD. Review of the Nurses Notes dated 6/29/11 at 0340 revealed summoned to pt room by CNA, pt noted to have a large blister to right leg, along with swelling noted to knee, leg, and foot, pt. received pain med for pain of right leg. Will inform oncoming shift of this. Will continue to monitor the rest of this shift. Review of the Nurses Notes dated 6/29/11 at 0730 revealed right lower leg red swollen and warm to touch. Blister noted to lower right knee. S9MD notified will continue to monitor. Review of the physician progress notes [REDACTED]. Pt's right leg with increased [MEDICAL CONDITION] and pain today. Right lower extremity red with large bleb, positive popliteal pain. Some decreased pulse right posterior tibialis compared to left. [MEDICAL CONDITION], possible [MEDICAL CONDITION]. To ER via ambulance. Review of the X-ray dated 6/29/11 revealed right proximal tibia and fibular fractures. Review of the Quarterly MDS with an ARD of 6/19/11 revealed the resident was assessed as requiring total dependence in transfers and needing two person physical assist in transfers. Review of the Care Plan revealed: Problem Onset 3/25/11 Potential for injury related to fall risk. Goal & Target Date: Will have no incident of injury through next staffing. 6/23/11 Approaches: Use 2-man lift when moving patient. Use draw sheet when moving patient. Turn and reposition for comfort. Use lift when transferring to chair/bed. Review of the CNA-ADL Sheets did not reveal an entry to identify to use 2 staff members when transferring the resident. An interview was held with S10RNSupervisor on 7/28/11 at 10:50 a.m. She said the transfer information did not have to be on the CNA-ADL sheets, but it needed to be in the care plan. Review of resident #32's Fall Incident Report dated 6/28/11 revealed the following information: Fall Location: Shower room Surface Condition: wet Mobility: Non Ambulant, Assist X 1 Comments: CNA X 1 was assisting. Type of Fall: legs gave way Usual Mental State: AO X 3 Resident's description of fall: " I fell off my chair " Brief description of fall: CNA states " I was transferring resident to his chair and his legs gave way and I eased him to the floor. Verbal Response: oriented Comment: Resident yelling out loudly. Doctor Notified: yes at 0750 on 6/28/11 - S9MD Seen by doctor: yes at 1625 on 6/28/11 - S9MD Doctor Orders: Elevate legs in bed. Systems Checked: Muscular / skeletal, sensory X-rays: none RN Manager - Summary of fall: CNA reported to unit nurse that client legs gave away while transferring him to his chair. Causes, outcome, and action taken: Unit nurse instructed CNA to get assistance d/t him having leg(s) weakness. Review of the Investigative Report regarding resident #32 revealed: Summary of Evidence: On the 28th of June at about 7:50 am resident #32 a resident at ... was in the shower room taking a shower. When he finished the CNA helped him get dressed and tried to help him get back in his gerichair. While trying to get back in the chair resident #32 fell . The CNA could not get resident #32 up off the floor. Two other employees were there and helped resident #2 up off the floor and got him back in his chair. After resident #32 was back in his chair he was brought to his room and was transferred to his bed. Statements Were Obtained From the Following: Resident #32 On June 28th at about 7:50 a.m. resident #32 was in the shower room. After resident #32 has his shower the CNA dressed him. After he was dressed the CNA tried to help resident #32 to his gerichair and that is when he fell . After the fall two or three people came and helped resident #32 up off the floor and put him in his chair. At this point resident #32 was brought back to his room and put to bed. The doctor was called and x-ray was done of leg and foot. This statement was written by this investigator at the request of resident #32. Review of the Investigative Statement of S11CNA dated 7/7/11 revealed: On the Date of 6/28/11 she gave resident #32 a shower after that she dried him dressed and assist in the chair. She pulled the chair up locked it. So while standing resident #32 up he stood straight but when she went to put him in the chair he started buckling and said he was weak and went down to the floor. So she assist him to the floor but his leg went under him and she didn't know it until he started screaming and in the process she started calling for some assisting. Her co-workers came and help me put him in the chair and then to his bed. S20SocialServiceCounselor notified S9MD. An interview was held with S11CNA on 7/29/11 at 10:00 a.m. She said that when she finished bathing and dressing resident #32 on 6/28/11, he stood with her help on the count of 3. She said that he started to get weak, and she sat him down on the floor and his leg was under him. She said that resident #32 could stand, and she always transferred him by herself. She said that the S8PT had told her that resident #32 could stand with her assistance. S11CNA explained she asked the nurse what type of transfer technique was to be used if she was not familiar with the resident. She said she did not know if the type of transfer to be used for the resident was documented anywhere so they could read it so she just asked her nurse. She said the only thing that she looks at on how to care for the resident is the ADL book. She said there is no information in it that shows if a resident needs 2 people or a lift for transfers. An interview was held with S12CNASupervisor on 7/29/11 at 10:27 a.m. She verified that she was S11CNA's supervisor. She said resident #32 was usually transferred with one person. She explained that she looked at the resident to see if 2 people or a lift are needed to transfer a resident. She also said she asked the nurse to find out about the transfer information. She explained that anytime a resident can't walk or support himself then 2 staff members are needed for the transfer. When asked how she monitors to ensure her staff are using 2 CNAs when necessary to transfer residents, she said that she can't be with everybody every day. She said that she tells the CNAs to use the proper equipment, and she gives them help if they need it. On 7/28/11 at 12:30 p.m. an interview was held with S22CNA, S23CNA, and S24CNA. They said they look at the CNA - ADL sheets and listen to the nurse about how many people are needed to transfer a resident. They said they do not look at the care plans. An interview was held with S25CNA on 7/29/11 at 9:10 a.m. When asked how she knows which transfer technique was need for each resident, she said that she doesn't look at any paperwork. She said the transfer type is written on the ADL sheet. She said that she also talked to the nurses and physical therapist. She said that she had never been told that she could look at the care plan. An interview was held with S26CNA on 7/29/11 at 9:18 a.m. She said there was no documented information on how a resident was to be transferred. She said that she asked the nurse if a lift is to be used or if 2 CNAs are needed to transfer the resident. She said that she does not look at the care plans. An interview was held with S28CNA on 7/29/11 at 9:30 a.m. She said she asks the nurse if the resident needs a lift and or 2 people to transfer the resident. She also said she could look at the care plan to see how the resident is to be transferred, but she did not know where the care plans were kept. She said that she did not know if the way the resident was to be transferred was written on the CNA flow sheet. An interview was held with S15LPN on 7/29/11 at 10:11 a.m. She verified that resident #2 was assigned to her on the day he fell in the shower. She said S11CNA should not have transferred resident #2 without assistance. S15LPN said that she has not seen in the resident's chart where it identifies how many people are needed to transfer the resident or if a lift is to be used. When asked how she knows when a resident needs 2 people for transfers or a lift to be used for transfer, she said that she looks at the resident's height, weight, and diagnoses. She said that resident #2 was heavy, and he could not ambulate. She said that they did not have to use the mechanical lift for resident #2, but they did need to use 2 people to transfer him. An interview was held with S30CNA on 7/29/11 at 1:25 p.m. She explained that the nurse tells her if a resident is to be transferred with a lift or if 2 CNAs are needed for transfers. She explained the ADL sheet shows the staff if the patient needs some, total, or no assistance. An interview was held with S4MDSNurseCoordinator on 7/29/11 at 1:43 p.m. She explained that the type of transfer of 1 person assist, 2 person assist, or a mechanical lift for assistance was not on the CNA-ADL sheets. She said this information would be in the care plans. An interview was held with S2DON on 7/29/11 at 2:40 p.m. After reviewing the facility policy, she verified that 2 staff members were to assist with transfer when a resident had to be lifted. She said that CNAs should go by their policy of 2 people with transfers and also the care plan. She said that she was not aware of a specific training of usage of care plans, but everyone could use them. S11CNA failed to review the plan of care to identify the need for 2 persons assistance with transfers for resident #32. S11CNA attempted to transfer resident #32 without assistance, and he sustained a right proximal tibia and fibular fractures. Resident #18 Review of Resident #18's clinical record revealed the following Diagnoses: [REDACTED]. Review of the annual MDS with an ARD of 6/26/11 revealed that she required total dependence of 2 persons with transfers. Review of the care plan revealed assist up to gerichair as tolerated. Review of the CNA-ADL flow sheet did not reveal to use 2 persons for transfers. An interview was held with S4MDSNurseCoordinator on 7/29/11 at 10:59 a.m. After reviewing the MDS, she verified resident #3 needed total dependence with 2 persons for transfers. She verified the care plan and CNA-ADL flow sheet did not reveal to use the lift or 2 persons with transfer. An interview was held on 7/29/11 at 8:30 a.m. with S22CNA. She said that normally 2 people transfer resident #18. She said that she was the only CNA on her side of the hall so she was going to do it herself. She said that they could transfer her with one person every now and then. An observation was made at this time of S22CNA transferring resident #18 from the bed to the gerichair using the lift without the assistance of another staff member. An interview was held with S29LPN on 7/29/11 at 10:50 a.m. She said that she was assigned to resident #18. S29LPN verified that resident #18 required 2 persons assistance with transfers.