Based on observation, staff interview, and facility document review, the facility staff failed to safeguard resident private information on 1 of 4 units, 2 front. The findings included: Facility staff failed to close the narcotic book or the computer screen when leaving the medication cart unattended on the hallway. 06/28/23 8:35 a.m., the surveyor observed a medication pass and pour observation with Licensed Practical Nurse (LPN) #1. Upon approaching the medication cart the surveyor observed LPN #1 to walk away from their medication cart and enter a residents room. LPN #1 left the computer screen up and running and the narcotic book was observed to be open exposing resident information. A male visitor and several staff were observed to be in the vicinity of the medication cart. LPN #1 returned to their medication cart and prepared a residents medication for administration. After preparing the medication LPN #1 again left their computer screen and the narcotic book open. Walked away from the cart and entered a residents room to administer the medications. Upon returning to the medication cart the surveyor observed that the computer screen and narcotic book remained open and in full view of anyone that walked by. 06/29/23 9:00 a.m., the Director of Nursing (DON) stated they were providing education in regard to privacy of residents information. 06/29/23 9:25 a.m., DON provided the survey team with their policy titled, Confidentiality of Patient Information/HIPAA. This policy read in part, .Employees are expected to protect the confidentiality of all patient and employee information .Employees are expected to protect documents and computer screens from inadvertent access by unauthorized parties . 06/30/23 11:50 a.m., this issue was reviewed with the Administrator, Assistant Administrator, DON, and Nurse Consultant. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on resident interview, clinical record review, and staff interview, the facility staff failed to review and revise the residents Comprehensive Care Plan (CCP) for 1 of 39 residents, Resident #145. The findings included: The facility staff failed to review and revise the residents CCP when they fell and fractured their left distal fibula. Resident #145's diagnoses included, but were not limited to, fracture of the left distal fibula, muscle weakness and difficulty in walking. Section C (cognitive patterns) of Resident #145's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/06/23 included a brief interview for mental status (BIMS) summary score of 15 out of a possible 15 points. Section G (functional status) was coded to indicate the resident required minimal assistance of one person for transfers. Walk in room/corridor was coded to indicate the resident required extensive assistance of one person. Resident #145 was coded as using a walker for mobility. 06/27/23 1:10 p.m., Resident #145 stated their leg had given out when they were trying to get into their closet, they had fallen and broken their ankle. The clinical record included an X ray report dated 06/15/23 indicating Resident #145 had a Nondisplaced fracture distal fibula with mark associated soft tissue swelling. A review of Resident #145's CCP revealed that the CCP had not been revised to capture the fracture. 06/29/23 4:30 p.m., during an end of day meeting with the Administrator, Director of Nursing, and Nurse Consultant the issue with the missing CCP information regarding the fracture was reviewed. 06/30/23 10:05 a.m., Licensed Practical Nurse (LPN) #2 stated the CCP had been updated to reflect the fracture. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5%. There were two errors in 25 opportunities for a medication error rate of 8%. These errors effected Resident's #106 and #149. The findings included: For Resident #149, the facility nursing staff administered a whole tablet of Quetiapine (25 mg) when the order was for one half a tablet (12.5 mg) of Quetiapine. For Resident #106 the facility nursing staff failed to shake the residents liquid Carafate prior to administering. During a medication pass and pour observation on 06/28/23 8:35 a.m., the surveyor observed Licensed Practical Nurse (LPN) #1 prepare and administer Resident #149's medication. LPN #1 pulled a card of Quetiapine (Seroquel) from the medication cart and popped one full pill into the medication cup and handed the medication card to the surveyor. This card read, give 1 tablet by mouth at bedtime for delusional disorder. The surveyor stated to LPN #1 that the card read to administer at night. LPN #1 reviewed the medication card label and stated that sometimes the labels are incorrect. The surveyor reconciled the medication using Resident #149's clinical record. The clinical record included two orders for the medication Quetiapine. One that read, Quetiapine oral tablet 25 mg give 0.5 tablet by mouth one time a day. The time on the medication administration record (MAR) was documented as 9:00 a.m. The second order read Quetiapine 25 mg give 1 tablet by mouth at bedtime. The time on the MAR read 9:00 p.m. Both orders included the order date of 06/06/23. 06/28/23 9:45 a.m., LPN #1 pulled two cards of Quetiapine from the medication drawer one card contained a whole tab and read to administer at night. One medication card contained tablets that were cut in half and read to give 0.5 tablet by mouth one time a day. Indicating LPN #1 had administered the bedtime dosage in the morning. 06/28/23 8:50 a.m., the surveyor observed Registered Nurse (RN) #2 prepare and administer Resident #106's morning medications to include Carafate. RN #2 pulled the liquid Carafate from the medication drawer and poured 10 ml's into a clear medication cup. RN #2 did not shake this medication prior to pouring the medication into the medication cup. After the medication administration the surveyor and RN #2 checked the Carafate medication bottle this bottle read SHAKE WELL BEFORE USE. RN #2 was asked if they should have shaken the medication and stated most definitely, they should have. The facility staff provided the surveyor with a copy of their policy titled, Administration Procedures for All Medications. This policy read in part, .Check the MAR .for the order .Check the label against the order on the MAR .Note any supplemental labeling that applies (fractional tablet .shake well .etc.) . 06/28/23 4:15 p.m., during a meeting with the Director of Nursing (DON), Nurse Consultant, Administrator, and Assistant Administrator the issue regarding the medication errors were reviewed. The administrative staff were made aware that their medication error rate was 8%. 06/30/23 10:00 a.m., DON provided the surveyor with a copies of medication error/disciplinary action reports regarding these two medications. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observations, interviews, and the review of documents, it was determined the facility staff failed ensure treatment and/or care was provided for a skin tear for one (1) of 30 sampled residents (Resident #47). The findings included: The facility staff failed to ensure Resident #47 received care/treatment for a skin tear according to the medical provider's orders. Resident #47 minimum data set (MDS) assessment, with an assessment reference date (ARD) of 4/8/21, was signed as completed on 4/9/21. Resident #47 was assessed as usually being able to make self understood and as usually being able to understand others. Resident #47's brief interview for mental status (BIMS) summary score was documented as 13 out of 15. Resident #47 was documented as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #47's diagnoses included, but were not limited to: anemia, high blood pressure, diabetes, dementia, and lung disease. On 6/9/21 at 09:50 a.m., Resident #47 was observed to have a dressing on the outer part of their left lower leg. The dressing was not dated and was not initialed. During an interview on 6/9/21 at 10:13 a.m., RN #21 reported they could not find a medical provider order for the dressing to the left, lower leg. On 6/9/21 at 10:18 a.m., RN (registered nurse) #21 confirmed the dressing was neither dated nor initialed. On 6/9/21 at 10:18 a.m., Resident #47's dressing and wound to left, outer, lower leg was assessed by NP (nurse practitioner) #22. On 6/9/21 at 10:28, NP #22 reported it did not appear as if the wound was approximated but indicated they were unsure if the wound was able to be reapproximated. The following information was found in a note documented by NP #22 on 6/9/21 at 10:29 a.m.: .Dimensions of left lower leg wound are as follows: 4x3x0.1 cm. Skin flap does not appear approximated today but wound appears stable. The following information was found in a note documented by NP #22 on 6/9/21 at 11:16 a.m.: Wound appears to have possibly occurred from a trauma of the skin. Per staff report, patient picks at (their) skin often due to (their) diagnosis of dementia/(their) altered mental status. Appears to be a slight abrasion of skin/skin tear with no skin flap approximated noted. Wound is stable. On 6/9/21 at 10:20 a.m., RN #23 (with RN #24 present) was asked about documentation of the aforementioned wound. RN #23 reported they found a note dated 4/7/21 of the initial wound care but did not see additional documentation related to wound care of this area. Resident #47's documentation included a nursing note dated 4/7/21 at 3:17 p.m. This note indicated the resident received a skin tear on 4/7/21 while self transferring to their wheelchair. This documentation indicated the skin tear was 'cleaned and dressed'. A nursing note dated 4/7/21 at 6:43 p.m. stated Resident #47's dressing was reinforced (due to) bleeding. Resident #47's clinical record included the following medical provider order dated 8/16/19 at 4:44 p.m.: May continue to use standing orders as signed upon admission, unless otherwise specified by physician. The following standing order was found in a document titled NURSING HOME STANDING ORDERS: Wound (skin abrasion/skin tear)--------[sic] Cleanse with (normal saline) reapproximate skin edges if intact and apply steri-strips. Apply triple antibiotic ointment and cover with dry dressing. Notify physician on rounds weekly. (Reapproximate, as related to wounds, means to bring the skin together to close a wound.) Documentation assessing the size of and providing a description of the skin tear Resident #47 received on 4/7/21 was neither found by nor provided to the surveyor (prior to documentation entered by NP #22 after being asked about the wound on 6/9/21). No documentation was found to address if the skin tear had been reapproximated at the time of the initial wound care. No documentation was found to address if the skin tear had had steri-strips applied or needed at the time of the initial wound care. The following information was found in a facility document titled Skin Tears - Abrasions and Minor Breaks, Care of (with a revised date of September 2013): . Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage . Apply the ordered dressing and secure with tape or bordered dressing per order . Label with date and initials to top of dressing . The following information was found in a facility document titled Dressing, Dry/Clean (with a revised date of September 2013): Verify that there is a physician's order for this procedure. (Note: This may be generated from a facility protocol.) Resident #47's aforementioned skin tear was discussed during a survey team meeting on 6/9/21 at 5:19 p.m. The facility's Administrator, Director of Nursing (DON), and Nurse Consultant were present during this meeting. The following issues related to Resident #47's 4/7/21 skin tear was discussed: (a) an absence of measurements and/or description of the skin tear, (b) the absence of documentation addressing if steri-strips were needed or not, and (c) the failure to document dressing changes.

Based on staff interview and clinical record review the facility document review the facility staff failed to ensure a complete and accurate clinical record for 2 of 30 residents, Residents #142 and #92. The findings included: 1. For Resident #142 the facility staff failed to initial eMAR's (electronic medication administration record). Resident #142's face sheet listed diagnoses which included, but not limited to dementia, depression, anxiety, insomnia, encephalopathy and constipation. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/27/21 assigned the resident a BIMS (brief interview for mental status) score of 9 out of 15 is section C, cognitive patterns. Resident #142's clinical record was reviewed and contained a physician's order summary (POS) for the month of May 2021, which read in part Abilify Tablet 10 MG (ARIPiprazole) Give 1 tablet by mouth one time a day for dementia with behavioral disturbances, Linzess Capsule 290 MCG (linaCLOtide) Give 1 capsule by mouth 1 time a day for IBS (irritable bowel syndrome), Increase fluids strain urine for stone every shift for Kidney stones increase fluids strain urine for stones, Intrusive wandering: Insomnia-wandering unit in other residents rooms every shift (Provide any additional detail as needed in progress note), Pain score every shift every shift for pain, S/E (side effects) Tracking-ANTIDEPRESSANTS-Observation and documentation of potential side effects: Nausea, increased appetite and weight gain, Fatigue and drowsiness, insomnia, Dry mouth, Blurred vision, Constipation, Dizziness, Agitation, Irritability, Anxiety every shift related to OTHER RECURRENT DEPRESSIVE DISORDERS (Provide any additional detail in progress notes) and S/E Tracking-ANTIPSYCHOTICS-Observation and documentation of potential side effects: Blurred vision, Dry mouth, Drowsiness, Muscle spasms or tremors, Weight gain, Tardive dyskinesia every shift (Provide any additional detail in progress note). Resident #142's eMAR's for the month of May were reviewed and contained entries as above. The entry for Abilify was coded as 9 on 05/01/21, 05/06-07/21, and 05/08-09/21. The entry for Linzess was coded as 9 on 05/01-02/21, 05/05-06/21 and 05/11/21. Chart code 9 is equivalent to other/see nurses notes. Resident #142's nurse's notes were reviewed and there were no related notes. The other entries were not initialed on 05/15-16/21, evening shift and 05/30/21, day shift. Surveyor spoke with the DON (director of nursing) on 06/10/21 at approximately 1:30 pm. Surveyor asked DON if there should have been a note for the coding of 9 on the eMAR and DON stated that there should have been, because with a note there is no way to determine if the medication was given or not. DON also stated that blanks on the eMAR are uncalled for. The concern of the incomplete documentation of the eMAR's was discussed with the administrative team (administrator, administrator in training, DON, ADON (assistant director of nursing) on 06/10/21 at approximately 4:30 pm. No further information was provided prior to exit. 2. For Resident #92 the facility staff failed to ensure eMAR's (electronic medication administration record) were complete. Resident #92's faced sheet listed diagnoses, which included but not limited to chronic obstructive pulmonary disease, psychosis, convulsions, anemia, dementia, hypertension, and chronic pain. The most recent significant change MDS (minimum data set) with an ARD (assessment reference date) of 05/06/21 assigned the resident a BIMS (brief interview for mental status) score of 0 out of 15 in section C, cognitive patterns. This indicates the resident is not cognitively intact. Resident #92's clinical record contained a physician's order summary for the month of May 2012, which read in part Mighty Shake two times a day for wt loss prevention-w (with)/ L (lunch) & D (dinner) trays -start date- 05/08/2021 1200, Fall mat every shift related to UNSPECIFIED FRACTURE OF RIGHT FEMUR, SUBSEQUENT ENTCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING, Monitor for pain every shift related to UNSPECIFIED FRACTURE OF RIGHT FEMUR, SUBSEQUENT ENTCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING, Pain Score every shift .every shift for pain, Physically abusive: attempting to hit staff while providing every shift (Provide any additional detail as needed in progress note), Raised edge mattress every shift related to UNSPECIFIED FRACTURE OF RIGHT FEMUR, SUBSEQUENT ENTCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING, S/E (side effects) Tracking-ANTIPSYCHOTICS-Observation and documentation of potential side effects: Blurred vision, Dry mouth, Drowsiness, Muscle spasms or tremors, Weight gain, Tardive dyskinesia every shift (Provide details in progress note). Resident #92's eMAR's for the month of May 2021 were reviewed and contained entries as above. The entry for Mighty Shakes was not initialed on 05/06/21 at 5 pm, 05/07/21 at 12 pm and 05/24/21 at 5 pm. The other entries were not initialed on05/15/21, evening shift and 05/30/21, day shift. Surveyor spoke with the DON (director of nursing) on 06/10/21 at approximately 1:30 pm regarding the eMAR's not being initialed. DON stated that blanks on the eMAR's are uncalled for. The concern of the incomplete documentation of the eMAR's was discussed with the administrative team (administrator, administrator in training, DON, ADON (assistant director of nursing) on 06/10/21 at approximately 4:30 pm. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. For Resident #28, the facility staff failed to implement facility policy regarding reporting and investigating a resident to resident altercation occurring on 3/15/21. Resident #28's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Dementia with Behavioral Disturbance, Essential Primary Hypertension, Anxiety Disorder Unspecified, Blindness One Eye Low Vision Other Eye, Muscle Weakness Generalized, and Difficulty in Walking. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 3/25/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15 in section C, Cognitive Patterns. A review of Resident #28's clinical record revealed the following documentation: A SBAR (Situation, Background, Appearance, Review) Communication Form dated 3/15/21 at 11:43 am states in part, Resident standing at nurses desk with walker, another resident came and shoved resident in the back. Resident fell, hitting right cheek on nurses desk as went down into the floor. Landed on (his/her) buttocks. Assessed from head to toe with red slightly raised area noted on right cheek. No other complaints voiced. On 6/09/21 at 11:42 am, survey team met with the administrator and DON (director of nursing) to discuss the facility process for resident to resident altercations. The DON stated resident to resident altercations can be a form of abuse. Surveyor asked if the facility submits FRIs (facility reported incidents) for resident to resident altercations and the DON stated if there's an injury. The administrator stated they try to follow their policy. Surveyor requested the FRI report for the aforementioned incident involving Resident #28 occurring on 3/15/21. The following day at 10:52 am, surveyor spoke with the DON who stated the incident was reported to them and they then reported it to the administrator but could not find an FRI for the incident. On 6/10/21 at 1:28 pm, surveyor team spoke with the DON concerning resident to resident altercations. The DON stated that following altercations, residents are assessed and if there is not an injury, there is nothing to report. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing), surveyor discussed the concern of the facility not implementing facility policy regarding an incident of a resident to resident altercation involving Resident #28. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. 6. For Resident #26 and #134, the facility staff failed to implement facility policy regarding reporting a resident to resident altercation occurring on 6/03/21 to Adult Protective Services. Resident #26's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Dementia without Behavioral Disturbance, Type 2 Diabetes Mellitus without Complications, Iron Deficiency Anemia Unspecified, and Muscle Weakness Generalized. Resident #26's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 3/22/21 assigned the resident a BIMS (brief interview for mental status) score of 4 out of 15 in section C, Cognitive Patterns. Resident #134's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Dementia with Behavioral Disturbance, Schizophrenia Unspecified, Bipolar Disorder Unspecified, and Unstable Angina Pectoris. Resident #134's most recent quarterly MDS with an ARD of 5/24/21 assigned the resident a BIMS score of 15 out of 15 in section C, Cognitive Patterns. On 6/08/21 at 1:55 pm during initial rounds, surveyor observed Resident #26 with redness under the left eye and bruising to the left side of the face from the left eye down to the cheek area. Surveyor asked the resident what caused the bruising and the resident stated they hit their face on the door and then stated they must have fallen. At 2:08 pm, surveyor spoke with TCNA (temporary certified nursing assistant) #1 concerning the cause of the bruising and TCNA #1 stated it was reported to them that Resident #134 punched this resident. Surveyor spoke with the administrator and DON (director of nursing) on 6/09/21 at 11:42 am concerning the bruising on Resident #26's face and the DON stated a FRI (facility reported incident) was completed and they are working on the final report now. At 12:30 pm, the DON provided the initial and final FRI report to the surveyor. The follow-up to the FRI dated 6/04/21 for the incident date of 6/03/21 involving Resident #26 and #134 states in part, Reported by staff that the residents mentioned above had a resident-to-resident altercation. It was reported that (Resident #26) wheeled (his/her) self into (Resident #134's) room and started going through (his/her) personal belongings. (Resident #134) asked (him/her) to leave (his/her) 'stuff' alone, (Resident #134) also asked (Resident #26) to leave (his/her) room due to this being (his/her) room and not (his/hers). (Resident #134) was unable to redirect (Resident #26) from (his/her) personal belongings. (Resident #134) stated, '(he/she) started cussing me and I hit (him/her)'. (Resident #26) was assessed, and staff observed a red area on the left side of the forehead. I, (name omitted), DON, upon entering the facility the next morning assessed (Resident #26) and I observed a discolored area to the left side of the forehead, staff was verbally instructed to continue to monitor for [NAME] [sp] and symptoms of any distress. The FRI report did not include the date that APS (adult protective services) was notified of the resident to resident altercation. On 6/10/21 at 11:45 am, surveyor spoke with the DON and asked if APS was notified of the resident to resident altercation between Resident #26 and #134, the DON stated no because there was no injury. At 11:52 am, surveyor spoke with the administrator who stated APS was not notified and it was a team decision. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing) surveyor discussed the concern of the facility not implementing facility policy regarding reporting an incident of a resident to resident altercation involving Resident #26 and Resident #134 to APS. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. 7. For Resident #140, the facility staff failed to implement facility policy regarding reporting resident to resident altercations occurring on 3/21/21 and 4/05/21. Resident # 140's diagnosis list indicated diagnoses, which included, but not limited to Parkinson's Disease, Alzheimer's Disease Unspecified, Unspecified Dementia with Behavioral Disturbance, and Chronic Obstructive Pulmonary Disease Unspecified. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 5/25/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, Cognitive Patterns. A review of Resident #140's clinical record revealed the following documentation: A nursing progress note dated 3/21/21 19:55 (7:55 pm) states This resident and another (male/female) resident locked hand [sp] together and with hands joined, pushed and shoved each other back and forth. Staff intervened and separated residents. Received two small (.5 cm) skin tears to right fingers. A 4/05/21 09:45 (9:45 am) eINTERACT SBAR Summary for Providers note states in part, resident entered another residents room and hit resident, denies pain no injuries noted staff immediately intervened and ensured both residents safety staff witnessed and stated 'As I entered the room another Resident was in this residents room hitting this resident, staff immediately moved both residents to safety. On 6/09/21 at 11:42 am, survey team met with the administrator and DON (director of nursing) to discuss the facility process for resident to resident altercations. The DON stated resident to resident altercations can be a form of abuse. Surveyor asked if the facility submits FRIs (facility reported incidents) for resident to resident altercations and the DON stated if there's an injury. The administrator stated they try to follow their policy. Surveyor requested the FRI reports for the aforementioned incidents involving Resident #140. On 6/09/21 at 12:30 pm, the DON provided the surveyor with a risk management form, Incident #827 for Resident #140. Incident #827 form states in part, This resident and another (male/female) resident locked hand [sp] together and with hands joined, pushed and shoved each other back and forth. Staff intervened and separated residents. Received two small (.5 cm) skin tears to right fingers. In the section Resident Description, it is documented I told (him/her) to shut up and quit cussing. On 6/10/21 at 1:28 pm, surveyor team spoke with the DON concerning resident to resident altercations. The DON stated that following altercations, residents are assessed and if there is not an injury, there is nothing to report. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing) surveyor discussed the concern of the facility not implementing the facility policy regarding the reporting of two incidents of resident to resident altercations involving Resident #140. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. 8. For Resident #53, the facility staff failed to implement facility policy regarding reporting and investigating a resident to resident altercation occurring on 6/08/21. Resident #53's diagnosis list indicated diagnoses, which included, but not limited to Chronic Obstructive Pulmonary Disease Unspecified, Major Depressive Disorder Recurrent Unspecified, and Spinal Stenosis Site Unspecified. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 4/13/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15 in section C, Cognitive Patterns. On 6/08/21 at approximately 12:05 pm, surveyor #2 observed Resident #53 hit at another resident around the head and TCNA (temporary certified nursing assistant) #1 separated the two residents. At 2:08 pm, this surveyor spoke with TCNA #1 and asked if Resident #53 made contact with the other resident when they hit at them earlier and TCNA #1 stated yes, the resident made contact with the back of the other resident's head. TCNA #1 also stated that the nurse was sitting right there and saw it. A nursing progress noted dated 6/08/21 14:11 (2:11 pm) states in part, Behavior episodes this day with resident attempting to hit other residents. On 6/09/21 at 11:42 am, survey team met with the administrator and DON (director of nursing) to discuss the facility process for resident to resident altercations. The DON stated resident to resident altercations can be a form of abuse. Surveyor asked if the facility submits FRIs (facility reported incidents) for resident to resident altercations and the DON stated if there's an injury. The administrator stated they try to follow their policy. Surveyor spoke with the DON (director of nursing) concerning the above incident and progress note dated 6/08/21 14:11, DON stated it should have been documented and reported to me. We will do education on that and do what needs to be done. On 6/09/21 at 12:28 pm, the DON and TCNA #1 met with the survey team and TCNA #1 stated Resident #53 swatted the other resident's hat off from behind them and it was not a slap across the face. On 6/10/21 at 1:28 pm, surveyor team spoke with the DON concerning resident to resident altercations. The DON stated that following altercations, residents are assessed and if there is not an injury, there is nothing to report. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing) surveyor discussed the concern of the facility not implementing facility policy regarding reporting and investigating an incident of a resident to resident altercation involving Resident #53. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. 9. For Resident #115, the facility staff failed to implement facility policy regarding reporting of resident to resident altercations occurring on 4/05/21 and 5/26/21. Resident #115's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease Unspecified, Unspecified Dementia with Behavioral Disturbance, Obsessive-Compulsive Disorder Unspecified, Hypothyroidism Unspecified, and Essential Primary Hypertension. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 5/16/21 assigned the resident a BIMS (brief interview for mental status) score of 0 out of 15 in section C, Cognitive Patterns. A review of Resident #115's clinical record revealed the following documentation: An eInteract Change in Condition Evaluation dated 4/05/21 09:45 (9:45 am) states in part, resident entered this residents room and hit resident, discolored area to left eye, denies pain no injuries noted staff immediately intervened and ensured both residents safety. A nursing progress note dated 5/26/21 14:00 (2:00 pm) states resident noted to have a discolored raised area with scratched area in the center. resident nonambulatory, bedbound. residents roommate has been witnessed standing over this resident's bed, cursing (him/her), hitting (his/her) fist into (his/her) hand in a threatening manner. upon interview with residents in this room with both having a BIMS score of 0, neither could voice any type of incident. roommate stated I didn't do anything, resident stated no I didn't roll out of bed. no other resident observed going in and out of room. rp (responsible party) and FNP (family nurse practitioner) notified. spoke with RP regarding move to another room, RP in agreeance to move resident up the hall to another room as a precaution/prevention. On 6/09/21 at 11:42 am, survey team met with the administrator and DON (director of nursing) to discuss the facility process for resident to resident altercations. The DON stated resident to resident altercations can be a form of abuse. Surveyor asked if the facility submits FRIs (facility reported incidents) for resident to resident altercations and the DON stated if there's an injury. The administrator stated they try to follow their policy. Surveyor requested the FRI reports for the incidents involving Resident #115 occurring on 4/05/21 and 5/26/21. At 12:30 pm, the DON provided risk management reports dated 4/05/21 and 5/26/21 and stated FRIs were not done. On 6/10/21 at 1:28 pm, surveyor team spoke with the DON concerning resident to resident altercations. The DON stated that following altercations, residents are assessed and if there is not an injury, there is nothing to report. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing) surveyor discussed the concern of the facility not implementing facility policy regarding reporting incidents of resident to resident altercations involving Resident #115 occurring on 4/05/21 and 5/26/21. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation it was determined that the facility staff failed to implement facility policy and procedures in regards to reporting and investigating incidents for 10 of 30 Residents, Residents #72, #111, #108, #131, #28, #26, #140, #53, #134, and #115. The findings included: 1. For Resident #72 the facility staff failed to implement facility policy in regards to reporting/investigating resident to resident altercations Resident #72's face sheet listed diagnoses which included, but not limited to major depressive disorder, dementia with behavioral disturbance, anxiety, convulsions and gastroesophageal reflux disease. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 04/26/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15. This indicates that the resident is cognitively intact. Resident #72's comprehensive care plan was reviewed and contained a care plan for Inappropriate behavior at times, history of verbal/physical agitation/aggression towards other residents related to Cognitive impairment, traumatic brain injury. The goal for this care plan is to decrease/minimize episodes of verbal/physical abuse. Resident #72's clinical record was reviewed and contained nurse's progress notes, which read in part 09/19/2020 15:24 CNA (certified nurse's aide) observed this resident slap her roommate because she was 'using her sink'. this resident turned the water off at the cutoff so other resident couldn't use it. Reminded this resident that roommate can use sink and other areas of the room as well, 09/20/2020 14:57 CNA reported to nurse that this resident 'slammed' another resident in to a chair. Reminded resident she shouldn't be putting her hands on other people, 09/20/2020 15:26 this resident hit another resident on the right side of the face. separated residents, 09/20/2020 15:34 Notified DON (director of nursing) of resident's behavior. Explained to resident that the police can be called if she hits anyone else. Room change to 323 B, 09/23/2020 18:20 Second floor staff called to tell this nurse that they observed . (Resident #72) place her hand over another resident's face and nose. She then hit the other resident, 10/04/2020 18:52 Rsd (resident) found in room with curtain pulled hitting roommate. Writer was informed of what staff had observed. Will continue to observe., 10/06/2020 11:04 Residents were up at nurse's station watching TV and talking. This resident smacked the resident beside her in the head for no apparent reason. The residents were separated and unit manager notified, 4/7/2021 10:10 this nurse entered activity room, this resident walked over to another resident and smacked her twice to right side of face to point you heard the second slap. resident that was slapped was sitting in chair in corner with a drink in her hands. no injury noted. resident removed from area. when asked why she slapped other resident she stated 'she was staring at me'. MD and RP (responsible party) notified and 4/9/2021 16:43 the nurses aides ([names omitted]) relayed to me that the resident pushed another resident ([name omitted]) three times. resident did not sustain any injury or fall. (name omitted) stated 'He was going to hit her if she did not quit'. the two were separated, no further issues at this time. Will continue to monitor. Surveyor spoke with the administrator and DON on 06/09/21 at approximately 11:40 am. Surveyor asked the DON if resident to resident altercations were considered to be abuse, and DON stated they were some form of abuse. The administrator stated the facility follows their policy on what is defined as abuse. Surveyor asked if the facility submitted facility reported incidents for resident to resident altercations and DON stated only if there is an injury. Surveyor reviewed the facility policy entitled Abuse Prevention Program which read in part, As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representative, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Surveyor also reviewed the facility Abuse Investigation and Reporting policy, which read in part Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. the local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The concern of the facility not implementing their policy for reporting/investigating incidents of resident to resident altercations was discussed with the administrative team during a meeting on 06/10/21 at approximately 4:30 pm. No further information was provided prior to exit. THIS IS A COMPLAINT DEFICIENCY 2. For Resident #111 the facility staff failed to implement facility policy in regards to report a resident to resident altercation. Resident #111's face sheet listed diagnoses which included, but limited to chronic obstructive pulmonary disease, bipolar disorder, Alzheimer's disease, hypothyroidism, and schizophrenia. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/13/21 assigned the resident a BIMS (brief interview for mental status) score of 11 out of 15 in section C, cognitive patterns. This indicates the resident is cognitively intact. Resident #111's comprehensive care plan was reviewed and contained a care plan for At risk for behavior symptoms related to Alzheimer's disease/dementia, Bipolar; Resident will approach residents/others to hug and kiss in face, makes repetitive statements demanding pudding/food and hugs. Resident #111's clinical record was reviewed and contained nurse's progress notes, which read in part 9/23/2020 18:20 This nurse received a phone call from 2nd flood staff stating that staff saw another resident place her hand over . (Resident #111) mouth and nose, and then hit . (Resident #111). Unit manager and DON (director of nursing) notified, residents were separated and will be monitored, 10/4/2020 19:13 Rsd (resident) has been hit by roommate. Writer has completed head to toe assessment and no injuries noted at this time. Family and MD have been notified no new orders. Rsd is safe sitting at nurses station. Will continue to observe, and 4/7/2021 12:08 this nurse entered the activity room, when another resident walked over to this resident and smacked her twice to right side of face to point you heard the second slap. this resident was sitting in chair in corner with a drink in her hands when smacked. no injury noted. other resident removed from area. rp (responsible party) and md notified. Surveyor spoke with the administrator and DON on 06/09/21 at approximately 11:40 am. Surveyor asked the DON if resident to resident altercations were considered to be abuse, and DON stated they were some form of abuse. The administrator stated the facility follows their policy on what is defined as abuse. Surveyor asked if the facility submitted facility reported incidents for resident to resident altercations and DON stated only if there is an injury. Surveyor reviewed the facility policy entitled Abuse Prevention Program which read in part, As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representative, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Surveyor also reviewed the facility Abuse Investigation and Reporting policy, which read in part Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. For Resident #28, the facility staff failed to report a resident to resident altercation occurring on 3/15/21. Resident #28's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Dementia with Behavioral Disturbance, Essential Primary Hypertension, Anxiety Disorder Unspecified, Blindness One Eye Low Vision Other Eye, Muscle Weakness Generalized, and Difficulty in Walking. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 3/25/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15 in section C, Cognitive Patterns. A review of Resident #28's clinical record revealed the following documentation: A SBAR (Situation, Background, Appearance, Review) Communication Form dated 3/15/21 at 11:43 am states in part, Resident standing at nurses desk with walker, another resident came and shoved resident in the back. Resident fell, hitting right cheek on nurses desk as went down into the floor. Landed on (his/her) buttocks. Assessed from head to toe with red slightly raised area noted on right cheek. No other complaints voiced. On 6/09/21 at 11:42 am, survey team met with the administrator and DON (director of nursing) to discuss the facility process for resident to resident altercations. The DON stated resident to resident altercations can be a form of abuse. Surveyor asked if the facility submits FRIs (facility reported incidents) for resident to resident altercations and the DON stated if there's an injury. The administrator stated they try to follow their policy. Surveyor requested the FRI report for the aforementioned incident involving Resident #28 occurring on 3/15/21. The following day at 10:52 am, surveyor spoke with the DON who stated the incident was reported to them and they then reported it to the administrator but could not find an FRI for the incident. On 6/10/21 at 1:28 pm, surveyor team spoke with the DON concerning resident to resident altercations. The DON stated that following altercations, residents are assessed and if there is not an injury, there is nothing to report. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing), surveyor discussed the concern of the facility not reporting an incident of a resident to resident altercation involving Resident #28. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. 6. For Resident #26 and #134, the facility staff failed to report a resident to resident altercation occurring on 6/03/21 to Adult Protective Services. Resident #26's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Dementia without Behavioral Disturbance, Type 2 Diabetes Mellitus without Complications, Iron Deficiency Anemia Unspecified, and Muscle Weakness Generalized. Resident #26's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 3/22/21 assigned the resident a BIMS (brief interview for mental status) score of 4 out of 15 in section C, Cognitive Patterns. Resident #134's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Dementia with Behavioral Disturbance, Schizophrenia Unspecified, Bipolar Disorder Unspecified, and Unstable Angina Pectoris. Resident #134's most recent quarterly MDS with an ARD of 5/24/21 assigned the resident a BIMS score of 15 out of 15 in section C, Cognitive Patterns. On 6/08/21 at 1:55 pm during initial rounds, surveyor observed Resident #26 with redness under the left eye and bruising to the left side of the face from the left eye down to the cheek area. Surveyor asked the resident what caused the bruising and the resident stated they hit their face on the door and then stated they must have fallen. At 2:08 pm, surveyor spoke with TCNA (temporary certified nursing assistant) #1 concerning the cause of the bruising and TCNA #1 stated it was reported to them that Resident #134 punched this resident. Surveyor spoke with the administrator and DON (director of nursing) on 6/09/21 at 11:42 am concerning the bruising on Resident #26's face and the DON stated a FRI (facility reported incident) was completed and they are working on the final report now. At 12:30 pm, the DON provided the initial and final FRI report to the surveyor. The follow-up to the FRI dated 6/04/21 for the incident date of 6/03/21 involving Resident #26 and #134 states in part, Reported by staff that the residents mentioned above had a resident-to-resident altercation. It was reported that (Resident #26) wheeled (his/her) self into (Resident #134's) room and started going through (his/her) personal belongings. (Resident #134) asked (him/her) to leave (his/her) 'stuff' alone, (Resident #134) also asked (Resident #26) to leave (his/her) room due to this being (his/her) room and not (his/hers). (Resident #134) was unable to redirect (Resident #26) from (his/her) personal belongings. (Resident #134) stated, '(he/she) started cussing me and I hit (him/her)'. (Resident #26) was assessed, and staff observed a red area on the left side of the forehead. I, (name omitted), DON, upon entering the facility the next morning assessed (Resident #26) and I observed a discolored area to the left side of the forehead, staff was verbally instructed to continue to monitor for [NAME] [sp] and symptoms of any distress. The FRI report did not include the date that APS (adult protective services) was notified of the resident to resident altercation. On 6/10/21 at 11:45 am, surveyor spoke with the DON and asked if APS was notified of the resident to resident altercation between Resident #26 and #134, the DON stated no because there was no injury. At 11:52 am, surveyor spoke with the administrator who stated APS was not notified and it was a team decision. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing) surveyor discussed the concern of the facility not reporting an incident of a resident to resident altercation involving Resident #26 and Resident #134 to APS. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. 7. For Resident #140, the facility staff failed to report resident to resident altercations occurring on 3/21/21 and 4/05/21. Resident # 140's diagnosis list indicated diagnoses, which included, but not limited to Parkinson's Disease, Alzheimer's Disease Unspecified, Unspecified Dementia with Behavioral Disturbance, and Chronic Obstructive Pulmonary Disease Unspecified. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 5/25/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, Cognitive Patterns. A review of Resident #140's clinical record revealed the following documentation: A nursing progress note dated 3/21/21 19:55 (7:55 pm) states This resident and another (male/female) resident locked hand [sp] together and with hands joined, pushed and shoved each other back and forth. Staff intervened and separated residents. Received two small (.5 cm) skin tears to right fingers. A 4/05/21 09:45 (9:45 am) eINTERACT SBAR Summary for Providers note states in part, resident entered another residents room and hit resident, denies pain no injuries noted staff immediately intervened and ensured both residents safety staff witnessed and stated 'As I entered the room another Resident was in this residents room hitting this resident, staff immediately moved both residents to safety. On 6/09/21 at 11:42 am, survey team met with the administrator and DON (director of nursing) to discuss the facility process for resident to resident altercations. The DON stated resident to resident altercations can be a form of abuse. Surveyor asked if the facility submits FRIs (facility reported incidents) for resident to resident altercations and the DON stated if there's an injury. The administrator stated they try to follow their policy. Surveyor requested the FRI reports for the aforementioned incidents involving Resident #140. On 6/09/21 at 12:30 pm, the DON provided the surveyor with a risk management form, Incident #827 for Resident #140. Incident #827 form states in part, This resident and another (male/female) resident locked hand [sp] together and with hands joined, pushed and shoved each other back and forth. Staff intervened and separated residents. Received two small (.5 cm) skin tears to right fingers. In the section Resident Description, it is documented I told (him/her) to shut up and quit cussing. On 6/10/21 at 1:28 pm, surveyor team spoke with the DON concerning resident to resident altercations. The DON stated that following altercations, residents are assessed and if there is not an injury, there is nothing to report. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing) surveyor discussed the concern of the facility not reporting two incidents of resident to resident altercations involving Resident #140. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. 8. For Resident #53, the facility staff failed to report a resident to resident altercation occurring on 6/08/21. Resident #53's diagnosis list indicated diagnoses, which included, but not limited to Chronic Obstructive Pulmonary Disease Unspecified, Major Depressive Disorder Recurrent Unspecified, and Spinal Stenosis Site Unspecified. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 4/13/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15 in section C, Cognitive Patterns. On 6/08/21 at approximately 12:05 pm, surveyor #2 observed Resident #53 hit at another resident around the head and TCNA (temporary certified nursing assistant) #1 separated the two residents. At 2:08 pm, this surveyor spoke with TCNA #1 and asked if Resident #53 made contact with the other resident when they hit at them earlier and TCNA #1 stated yes, the resident made contact with the back of the other resident's head. TCNA #1 also stated that the nurse was sitting right there and saw it. A nursing progress noted dated 6/08/21 14:11 (2:11 pm) states in part, Behavior episodes this day with resident attempting to hit other residents. On 6/09/21 at 11:42 am, survey team met with the administrator and DON (director of nursing) to discuss the facility process for resident to resident altercations. The DON stated resident to resident altercations can be a form of abuse. Surveyor asked if the facility submits FRIs (facility reported incidents) for resident to resident altercations and the DON stated if there's an injury. The administrator stated they try to follow their policy. Surveyor spoke with the DON (director of nursing) concerning the above incident and progress note dated 6/08/21 14:11, DON stated it should have been documented and reported to me. We will do education on that and do what needs to be done. On 6/09/21 at 12:28 pm, the DON and TCNA #1 met with the survey team and TCNA #1 stated Resident #53 swatted the other resident's hat off from behind them and it was not a slap across the face. On 6/10/21 at 1:28 pm, surveyor team spoke with the DON concerning resident to resident altercations. The DON stated that following altercations, residents are assessed and if there is not an injury, there is nothing to report. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing) surveyor discussed the concern of the facility not reporting an incident of a resident to resident altercation involving Resident #53. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. 9. For Resident #115, the facility staff failed to report resident to resident altercations occurring on 4/05/21 and 5/26/21. Resident #115's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease Unspecified, Unspecified Dementia with Behavioral Disturbance, Obsessive-Compulsive Disorder Unspecified, Hypothyroidism Unspecified, and Essential Primary Hypertension. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 5/16/21 assigned the resident a BIMS (brief interview for mental status) score of 0 out of 15 in section C, Cognitive Patterns. A review of Resident #115's clinical record revealed the following documentation: An eInteract Change in Condition Evaluation dated 4/05/21 09:45 (9:45 am) states in part, resident entered this residents room and hit resident, discolored area to left eye, denies pain no injuries noted staff immediately intervened and ensured both residents safety. A nursing progress note dated 5/26/21 14:00 (2:00 pm) states resident noted to have a discolored raised area with scratched area in the center. resident nonambulatory, bedbound. residents roommate has been witnessed standing over this resident's bed, cursing (him/her), hitting (his/her) fist into (his/her) hand in a threatening manner. upon interview with residents in this room with both having a BIMS score of 0, neither could voice any type of incident. roommate stated I didn't do anything, resident stated no I didn't roll out of bed. no other resident observed going in and out of room. rp (responsible party) and FNP (family nurse practitioner) notified. spoke with RP regarding move to another room, RP in agreeance to move resident up the hall to another room as a precaution/prevention. On 6/09/21 at 11:42 am, survey team met with the administrator and DON (director of nursing) to discuss the facility process for resident to resident altercations. The DON stated resident to resident altercations can be a form of abuse. Surveyor asked if the facility submits FRIs (facility reported incidents) for resident to resident altercations and the DON stated if there's an injury. The administrator stated they try to follow their policy. Surveyor requested the FRI reports for the incidents involving Resident #115 occurring on 4/05/21 and 5/26/21. At 12:30 pm, the DON provided risk management reports dated 4/05/21 and 5/26/21 and stated FRIs were not done. On 6/10/21 at 1:28 pm, surveyor team spoke with the DON concerning resident to resident altercations. The DON stated that following altercations, residents are assessed and if there is not an injury, there is nothing to report. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing) surveyor discussed the concern of the facility not reporting incidents of resident to resident altercations involving Resident #115 occurring on 4/05/21 and 5/26/21. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. Based on staff interview, facility document review, clinical record review and in the course of a complaint survey it was determined that the facility staff failed to report incidents for 10 of 30 Residents, Residents #72, #111, #108, #131, #28, #26, #140, #53, #134, and #115. The findings included: 1. For Resident #72 the facility staff failed to report incidents of resident to resident altercations. Resident #72's face sheet listed diagnoses which included, but not limited to major depressive disorder, dementia with behavioral disturbance, anxiety, convulsions and gastroesophageal reflux disease. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 04/26/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15. This indicates that the resident is cognitively intact. Resident #72's comprehensive care plan was reviewed and contained a care plan for Inappropriate behavior at times, history of verbal/physical agitation/aggression towards other residents related to Cognitive impairment, traumatic brain injury. The goal for this care plan is to decrease/minimize episodes of verbal/physical abuse. Resident #72's clinical record was reviewed and contained nurse's progress notes, which read in part 09/19/2020 15:24 CNA (certified nurse's aide) observed this resident slap her roommate because she was 'using her sink'. this resident turned the water off at the cutoff so other resident couldn't use it. Reminded this resident that roommate can use sink and other areas of the room as well, 09/20/2020 14:57 CNA reported to nurse that this resident 'slammed' another resident in to a chair. Reminded resident she shouldn't be putting her hands on other people, 09/20/2020 15:26 this resident hit another resident on the right side of the face. separated residents, 09/20/2020 15:34 Notified DON (director of nursing) of resident's behavior. Explained to resident that the police can be called if she hits anyone else. Room change to 323 B, 09/23/2020 18:20 Second floor staff called to tell this nurse that they observed . (Resident #72) place her hand over another resident's face and nose. She then hit the other resident, 10/04/2020 18:52 Rsd (resident) found in room with curtain pulled hitting roommate. Writer was informed of what staff had observed. Will continue to observe., 10/06/2020 11:04 Residents were up at nurse's station watching TV and talking. This resident smacked the resident beside her in the head for no apparent reason. The resident were separated and unit manager notified, 4/7/2021 10:10 this nurse entered activity room, this resident walked over to another resident and smacked her twice to right side of face to point you heard the second slap. resident was slapped was sitting in chair in corner with a drink in her hands. no injury noted. resident removed from area. when asked why she slapped other resident she stated 'she was staring at me'. MD and RP (responsible party) notified and 4/9/2021 16:43 the nurses aides ([names omitted]) relayed to me that the resident pushed another resident ([name omitted]) three times. resident did not sustain any injury or fall. (name omitted) stated 'He was going to hit her if she did not quit'. the two were separated, no further issues at this time. Will continue to monitor. Surveyor spoke with the administrator and DON on 06/09/21 at approximately 11:40 am. Surveyor asked the DON if resident to resident altercations were considered to be abuse, and DON stated they were some form of abuse. The administrator stated the facility follows their policy on what is defined as abuse. Surveyor asked if the facility submitted facility reported incidents for resident to resident altercations and DON stated only if there is an injury. Surveyor asked the DON if the incidents should have been reported and DON stated, They should have been documented and reported to me. We will do education on that and do what needs to be done. Surveyor reviewed the facility policy entitled Abuse Prevention Program which read in part, As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representative, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Surveyor also reviewed the facility Abuse Investigation and Reporting policy, which read in part Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. the local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The concern of the facility not reporting incidents of resident to resident altercations was discussed with the administrative team during a meeting on 06/10/21 at approximately 4:30 pm. No further information was provided prior to exit. THIS IS A COMPLAINT DEFICIENCY 2. For Resident #111 the facility staff failed to report an incident of resident to resident altercation. Resident #111's face sheet listed diagnoses which included, but limited to chronic obstructive pulmonary disease, bipolar disorder, Alzheimer's disease, hypothyroidism, and schizophrenia. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/13/21 assigned the resident a BIMS (brief interview for mental status) score of 11 out of 15 in section C, cognitive patterns. This indicates the resident is cognitively intact. Resident #111's comprehensive care plan was reviewed and contained a care plan for At risk for behavior symptoms related to Alzheimer's disease/dementia, Bipolar; Resident will approach residents/others to hug and kiss in face, makes repetitive statements demanding pudding/food and hugs. Resident #111's clinical record was reviewed and contained nurse's progress notes, which read in part 9/23/2020 18:20 This nurse received a phone call from 2nd flood staff stating that staff saw another resident place her hand over . (Resident #111) mouth and nose, and then hit . (Resident #111). Unit manager and DON (director of nursing) notified, residents were separated and will be monitored, 10/4/2020 19:13 Rsd (resident) has been hit by roommate. Writer has completed head to toe assessment and no injuries noted at this time. Family and MD have been notified no new orders. Rsd is safe sitting at nurses station. Will continue to observe, and 4/7/2021 12:08 this nurse entered the activity room, when another resident walked over to this resident and smacked her twice to right side of face to point you heard the second slap. this resident was sitting in chair in corner with a drink in her hands when smacked. no injury noted. other resident removed from area. rp (responsible party) and md notified. Surveyor spoke with the administrator and DON on 06/09/21 at approximately 11:40 am. Surveyor asked the DON if resident to resident altercations were considered to be abuse, and DON stated they were some form of abuse. The administrator stated the facility follows their policy on what is defined as abuse. Surveyor asked if the facility submitted facility reported incidents for resident to resident altercations and DON stated only if there is an injury. Surveyor asked the DON if the incidents should have been reported and DON stated, They should have been documented and reported to me. We will do education on that and do what needs to be done. Surveyor reviewed the facility policy entitled Abuse Prevention Program which read in part, As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representative, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Surveyor also reviewed the facility Abuse Investigation and Reporting policy, which read in part Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator , or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. the local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (in[TRUNCATED]

3. For Resident #28, the facility staff failed to investigate a resident to resident altercation occurring on 3/15/21. Resident #28's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Dementia with Behavioral Disturbance, Essential Primary Hypertension, Anxiety Disorder Unspecified, Blindness One Eye Low Vision Other Eye, Muscle Weakness Generalized, and Difficulty in Walking. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 3/25/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15 in section C, Cognitive Patterns. A review of Resident #28's clinical record revealed the following documentation: A SBAR (Situation, Background, Appearance, Review) Communication Form dated 3/15/21 at 11:43 am states in part, Resident standing at nurses desk with walker, another resident came and shoved resident in the back. Resident fell, hitting right cheek on nurses desk as went down into the floor. Landed on (his/her) buttocks. Assessed from head to toe with red slightly raised area noted on right cheek. No other complaints voiced. On 6/09/21 at 11:42 am, survey team met with the administrator and DON (director of nursing) to discuss the facility process for resident to resident altercations. The DON stated resident to resident altercations can be a form of abuse. Surveyor asked if the facility submits FRIs (facility reported incidents) for resident to resident altercations and the DON stated if there's an injury. The administrator stated they try to follow their policy. Surveyor requested the FRI report for the aforementioned incident involving Resident #28 occurring on 3/15/21. The following day at 10:52 am, surveyor spoke with the DON who stated the incident was reported to them and they then reported it to the administrator but could not find an FRI for the incident. Surveyor then requested the facility investigation of the incident, however, none was provided prior to the survey exit. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Role of the Administrator: 1. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. Role of the Investigator: 1. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident. 5. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing) surveyor discussed the concern of the facility not investigating an incident of a resident to resident altercation involving Resident #28 occurring on 3/15/21. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. 4. For Resident #53, the facility staff failed to investigate a resident to resident altercation occurring on 6/08/21. Resident #53's diagnosis list indicated diagnoses, which included, but not limited to Chronic Obstructive Pulmonary Disease Unspecified, Major Depressive Disorder Recurrent Unspecified, and Spinal Stenosis Site Unspecified. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 4/13/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15 in section C, Cognitive Patterns. On 6/08/21 at approximately 12:05 pm, surveyor #2 observed Resident #53 hit at another resident around the head and TCNA (temporary certified nursing assistant) #1 separated the two residents. At 2:08 pm, this surveyor spoke with TCNA #1 and asked if Resident #53 made contact with the other resident when they hit at them earlier and TCNA #1 stated yes, the resident made contact with the back of the other resident's head. TCNA #1 also stated that the nurse was sitting right there and saw it. A nursing progress noted dated 6/08/21 14:11 (2:11 pm) states in part, Behavior episodes this day with resident attempting to hit other residents. On 6/09/21 at 11:42 am, survey team met with the administrator and DON (director of nursing) to discuss the facility process for resident to resident altercations. The DON stated resident to resident altercations can be a form of abuse. Surveyor asked if the facility submits FRIs (facility reported incidents) for resident to resident altercations and the DON stated if there's an injury. The administrator stated they try to follow their policy. Surveyor spoke with the DON (director of nursing) concerning the above incident and progress note dated 6/08/21 14:11, DON stated it should have been documented and reported to me. We will do education on that and do what needs to be done. On 6/09/21 at 12:28 pm, the DON and TCNA #1 met with the survey team and TCNA #1 stated Resident #53 swatted the other resident's hat off from behind them and it was not a slap across the face. Surveyor requested and received the facility policy entitled Abuse Investigation and Reporting which states in part: Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Role of the Administrator: 1. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. Role of the Investigator: 1. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident. 5. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator. On 6/10/21 at 4:45 pm, during a meeting with the administrator, administrator in training, DON, and ADON (assistant director of nursing) surveyor discussed the concern of the facility not investigating an incident of a resident to resident altercation involving Resident #53. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/10/21. Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation it was determined that the facility staff failed to investigate alleged incidents of abuse for 4 of 30 residents, Residents #72, #131, #28 and #53. The findings included: 1. For Resident #72 the faciltiy staff failed to investigate incidents of resident to resident altercations. Resident #72's face sheet listed diagnoses which included, but not limited to major depressive disorder, dementia with behavioral disturbance, anxiety, convulsions and gastroesophageal reflux disease. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 04/26/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15. This indicates that the resident is cognitively intact. Resident #72's comprehensive care plan was reviewed and contained a care plan for Inappropriate behavior at times, history of verbal/physical agitation/aggression towards other residents related to Cognitive impairment, traumatic brain injury. The goal for this care plan is to decrease/minimize episodes of verbal/physical abuse. Resident #72's clinical record was reviewed and contained nurse's progress notes, which read in part 09/19/2020 15:24 CNA (certified nurse's aide) observed this resident slap her roommate because she was 'using her sink'. this resident turned the water off at the cutoff so other resident couldn't use it. Reminded this resident that roommate can use sink and other areas of the room as well, 09/20/2020 14:57 CNA reported to nurse that this resident 'slammed' another resident in to a chair. Reminded resident she shouldn't be putting her hands on other people, 09/20/2020 15:26 this resident hit another resident on the right side of the face. separated residents, 09/20/2020 15:34 Notified DON (director of nursing) of resident's behavior. Explained to resident that the police can be called if she hits anyone else. Room change to 323 B, 09/23/2020 18:20 Second floor staff called to tell this nurse that they observed . (Resident #72) place her hand over another resident's face and nose. She then hit the other resident, and 4/9/2021 16:43 the nurses aides ([names omitted]) relayed to me that the resident pushed another resident ([name omitted]) three times. resident did not sustain any injury or fall. (name omitted) stated 'He was going to hit her if she did not quit'. the two were separated, no further issues at this time. Will continue to monitor. Surveyor spoke with the administrator and DON on 06/09/21 at approximately 11:40 am. Surveyor asked the DON if resident to resident altercations were considered to be abuse, and DON stated they were some form of abuse. The administrator stated the facility follows their policy on what is defined as abuse. Surveyor asked if the facility investigated the incident of resident to resident altercation, and the DON stated, We take it to risk management. Surveyor asked if these specific incidents had been investigated, and the facility could not provide any information to indicate that they had. Surveyor reviewed the facility policy entitled Abuse Prevention Program which read in part, As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representative, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Surveyor also reviewed the facility Abuse Investigation and Reporting policy, which read in part All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse') shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The concern of the facility not investigating resident to resident altercations was discussed with the administrative team during a meeting on 06/10/21 at approximately 4:30 pm. No further information was provided prior to exit. THIS IS A COMPLAINT DEFICIENCY 2. For Resident # 131 the facility staff failed to investigate incidents of resident to resident altercations. Resident #131's face sheet listed diagnoses which included, but limited to dementia with behavioral disturbance, hypertension, hypothyroidism, depression, psychotic disorder, and anxiety. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/23/21 assigned the resident a BIMS (brief interview for mental status score of 0 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #131's comprehensive care plan was reviewed and contained a care plan for Verbal/physical agitation/aggression related to dementia. Goals for this care plan are Will not harm self or others. Resident #131's clinical record was reviewed and contained a nurse's progress note, which read in part 2/18/201 01:41 On rounds, other nurse called this to resident's room. Resident was seen hitting roommate with a knotted sock by other nurse. When this nurse entered the room, resident was in a rage, screaming loudly, swinging and hitting this nurse and other nurse. Resident threatened to 'beat the shit out of her', speaking of roommate. Resident attempted multiple times to go back over to roommate and hit roommate. Other nurse and this nurse intervened and separated resident. Resident attempted multiple times to shut the door on this nurse and other nurse while separating residents. Resident continued to hit, scratch, and pinch this nurse and other nurse. Resident tied a knot in her sheet and swung and hit this nurse with it. This nurse was able to take sheet and attempted to redirect resident by lying down and rubbing shoulders. Resident continued to be in a rage, refused to lie down. Supervisor notified. Surveyor spoke with the administrator and DON on 06/09/21 at approximately 11:40 am. Surveyor asked the DON if resident to resident altercations were considered to be abuse, and DON stated they were some form of abuse. The administrator stated the facility follows their policy on what is defined as abuse. Surveyor asked if the facility investigated the incident of resident to resident altercation, and the DON stated, We take it to risk management. Surveyor asked if this specific incident had been investigated, and the facility could not provide any information to indicate that is had. Surveyor reviewed the facility policy entitled Abuse Prevention Program which read in part, As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representative, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Surveyor also reviewed the facility Abuse Investigation and Reporting policy, which read in part All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse') shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The concern of the facility not investigating a resident to resident altercation was discussed with the administrative team during a meeting on 06/10/21 at approximately 4:30 pm. No further information was provided prior to exit. THIS IS A COMPLAINT DEFICIENCY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, staff interview, and clinical record review, the facility staff failed to ensure an accurate DDNR form for 2 of 36 Residents in the survey sample, Resident # 56, and Resident # 89. The findings included: 1. The facility staff failed to ensure that the information documented on the DDNR (durable do not resuscitate) was accurate for Resident #56. The facility staff documented that Resident # 56 executed a written advanced directive, which appointed a person to consent on Resident # 56's behalf with authority that life-prolonging procedures be withdrawn or withheld, when in fact Resident # 56 did not wish to be a DNR and desired full code status. Resident # 56 was a [AGE] year-old-female who was originally admitted to the facility on [DATE], with a readmission date of [DATE]. Diagnoses included but were not limited to, bipolar disorder, anxiety, type 2 diabetes mellitus, and congestive heart failure. The clinical record for Resident # 56 was reviewed on [DATE] at 4:40 pm. The most recent MDS (minimum data set) assessment was a quarterly assessment, with an ARD (assessment reference date) of [DATE]. Section B of the MDS assesses hearing, speech, and vision. In Section B0700, the ability to express ideas and wants was assessed. The facility staff documented that Resident # 56 was Usually understood-difficulty communicating some words or finishing thoughts but is able if prompted or given time. Section B0800 assesses the ability to understand others. The facility staff documented that Resident # 56 Understands-clear comprehension. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 56 had a BIMS (brief interview for mental status) score of 10 out of 15, which indicated that Resident # 56's cognitive status was moderately impaired. The current plan of care for Resident # 56 was reviewed and revised on [DATE]. The facility staff documented a focus area for Resident # 56 as, Advanced Directives DNR (do not resuscitate). The goal for this focus area was documented as, Resident's advance directives will be honored through next review. Interventions included but were not limited to, Copy of living will in legal section of chart, and Discuss advanced directives with patient, family, or legal representative at admission and quarterly. The current physician's orders for Resident # 56 were signed by the physician on [DATE]. Orders included but were not limited to, Code status do not resuscitate. On [DATE] at 4:50, pm, the surveyor reviewed the DDNR form dated [DATE] in Resident # 56's clinical record. The surveyor observed a handwritten check mark documented next to the following statement on the DDNR form, 2. The patient is INCAPABLE of making an informed decision about providing, withholding or withdrawing a specific medical treatment because he/she is unable to understand the nature, extent or probable consequences of the proposed medical decision, or to make a rational evaluation of the risks and benefits of alternatives to that decision. The surveyor also observed a handwritten checkmark documented next to the following statement on the DDNR form, B. While capable of making an informed decision, the patient has executed a written advanced directive which appoints a Person Authorized to Consent on the Patient's Behalf with the authority to direct that life-prolonging procedures be withheld or withdrawn. The surveyor observed that the guardian for Resident # 56 had signed the back of the DDNR form authorizing the DDNR status. The surveyor further reviewed the clinical record for Resident # 56 and did not locate a written advanced directive that appointed a person authorized to consent on Resident # 56's behalf. The surveyor did observe a facility Cardiopulmonary Resuscitation Directive form, which was dated [DATE] in the clinical record for Resident # 56. The surveyor observed a handwritten checkmark documented next to the following statement of the cardiopulmonary resuscitation directive form, B. In the event that my/my loved one's heart stops beating and/or breathing stops, I DO WANT Cardiopulmonary Resuscitation. The surveyor observed the following documentation at the bottom of the form, I, the physician of Resident # 56 agree with the above decision. The surveyor observed that the word agree had a single handwritten line drawn through it and the word disagree was handwritten above it. This document was signed by the physician on [DATE]. On [DATE] at 4:57 pm, the surveyor conducted a Resident interview with Resident # 56. The surveyor asked Resident # 56 if she wanted CPR to bring her back if her heart stops beating. Resident # 56 stated Yes. The surveyor asked Resident # 56 again for clarification to ensure that Resident # 56 understood what was being asked if she wanted CPR to try to bring her back to life if her heart and breathing stops. Resident # 56 stated, Yes Resident # 56 does. If my heart stops beating, I want them to try to bring me back. On [DATE] at 6:00 pm, the surveyor spoke with the facility administrator and director of nursing and asked if Resident # 56 had been declared incompetent. The facility administrator stated, She's been here a long time, I believe she has been declared incompetent. The surveyor requested to see paperwork declaring Resident # 56 incompetent. On [DATE] at 8:03 am, the surveyor was approached by the director of nursing who provided the surveyor with a copy of guardianship papers for Resident # 56. The director of nursing informed the surveyor that she did not locate any paperwork that stated that Resident # 56 had been declared incompetent. The director of nursing stated, While I was going through her chart last night, I learned a lot of things that I did not know. I found a paper in her chart that stated that she (Resident # 56) wanted to go to a particular funeral home and that she wanted to wear a red dress. The surveyor then informed the director of nursing that she did not locate an advance directive in Resident # 56's clinical record as the DDNR form stated that an advance directive had been executed. The director of nursing stated, All we have is the DNR form. But there is a document in her chart where she stated that she did not want to be resuscitated. The surveyor informed the director of nursing that the document in Resident # 56's clinical record stated that Resident # 56 did want to be resuscitated. The director of nursing reviewed the cardiopulmonary resuscitation directive form for Resident # 56 along with the surveyor and the director of nursing agreed that the form contained documentation that Resident # 56 wished to be resuscitated. The director of nursing also observed the documentation at the bottom of the form documented as, I, the physician of Resident # 56 agree with the above decision. The director of nursing along with the surveyor observed that the word agree had a single handwritten line drawn thorough it and the word disagree was handwritten above it. The surveyor asked the director of nursing if she felt that it was appropriate to disregard what Resident # 56 had expressed as her wishes and initiate a DNR order even though Resident # 56 desired to be a full code. The director of nursing stated, No. The surveyor asked the director of nursing if Resident # 56 was able to express her wants and needs on a daily basis. The director of nursing stated, Yes. The director of nursing stated she would contact the guardian for Resident # 56 to see if she can get more information. On [DATE] at 12:23 pm, the director of nursing provided the surveyor with a copy of Resident # 56's DDNR that had been faxed from the agency of Resident # 56's court appointed guardians. The director of nursing informed the surveyor that she had been unable to reach the guardians for Resident # 56 and she had spoken to someone else in the office to try to obtain additional information and the DDNR was all that was sent to the facility from the agency. On [DATE] at 1:58 pm, the surveyor interviewed the facility social worker. The surveyor along with the facility social worker reviewed the cardiopulmonary resuscitation directive for Resident # 56. The facility social worker observed documentation on the cardiopulmonary resuscitation directive that stated that Resident # 56 wished to be resuscitated if her heart or breathing stopped, and that physician documented that he disagreed with Resident # 56's decision. The surveyor asked the facility social worker if Resident # 56 was able to express her needs and wants. The facility social worker agreed that Resident # 56 was able to express her needs and wants. The surveyor asked the facility social worker if she felt it was appropriate that the physician and guardian made the decision to make Resident # 56 a DNR even after she had expressed that she wanted to be resuscitated. The facility social worker stated, I understand what you mean and we will definitely look into this. On [DATE] at 3:10 pm, the surveyor spoke with the facility social worker. The surveyor asked the facility social worker if she attended care plan meetings for Resident # 56. The facility social worker stated that she did attend the care plan meetings for Resident # 56. The surveyor asked the facility social worker if Resident # 56 attended her care plan meetings. The stated, She is invited, but she does not come. The surveyor asked the social worker if the guardians for Resident # 56 attended the care plan meetings. The social worker informed the surveyors that guardians for Resident # 56 attended her care plan meetings and if they were unable to attend the staff communicated with the guardians for Resident # 56 by telephone. The surveyor asked the social worker who reviewed the plan of care during the care plan meetings for Resident # 56 and determined if the focus areas needed to be continued, revised or resolved. The social worker stated that the guardians and facility staff discussed the care areas and determined what areas needed to be continued, revised, or resolved. The surveyor asked the social worker if Resident # 56 had any input with regard to her plan of care. The facility social worker stated, No. The surveyor asked the social worker if she had offered to discuss Resident # 56's plan of care with her in her room in an environment that may be more comfortable to her so that she would be able to provide input in her plan of care. The social worker stated, I have not. On [DATE] at 4:30 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on [DATE]. 2. The facility staff failed to ensure Resident #89 expressed wishes for end of life were honored. Resident #89 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, diabetes, dementia, anxiety disorder and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE], the resident was coded as requiring extensive assistance of 2 staff members for dressing, personal hygiene and was totally dependent on 2 staff members for bathing. During the clinical record review on [DATE], the surveyor noted that a signed DDNR was dated for [DATE] with both the physician's and resident representative's signatures present. The surveyor reviewed the physician orders sheets for the months of March and [DATE] and the resident's code status was Full Code. The surveyor notified unit manager #1 on [DATE] at 2 pm. She reviewed the above documented findings and stated, The code status doesn't match. One is for Full Code and the other is DDNR. The surveyor notified the administrative team of the above documented findings on [DATE] at 4:43 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, facility document review and in the course of a complaint survey the facility staff failed to report an injury of unknown origin for 1 of 36 Residents, Resident #363. The findings included: For Resident #363 the facility staff failed to report an unwitnessed fall resulting in an injury. Resident #363 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to anemia, pneumonia, depression, coronary artery disease, hypothyroidism, gastroesophageal reflux disease, benign prostatic hyperplasia and insomnia. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/14/18 coded the Resident as 7 out of 15 in section C, cognitive status. Section G, functional status, coded the Resident as needing extensive with two-person physical assist in the area of transfer ((how Resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). Moving from a seated to standing position was coded as not steady, only able to stabilize with staff assistance. Resident #363's CCP (comprehensive care plan) was reviewed and contained a care plan for At risk for falls due to impaired balance/poor coordination, and unsteady gait and confusion at times. This care plan was initiated on 02/27/15. Interventions for this care plan included, assist of 2 staff member to bathroom (initiated 02/21/17, revised 03/04/19), assist Resident to be up in w/chair and out at desk when repeatedly tries to get up without help , and has no family present (initiated 12/09/17, revised 03/04/19), assist to chair and take to nsg desk to monitor when repeatedly trying to stand or get up by self, notify family to come and stay with Resident if continues to be non-compliant with instructions (initiated 08/09/18, revised 03/04/19) frequent visual checks (initiated 02/27/17, revised 03/04/19), frequently assess toileting needs and assist to restroom if needed (initiated 08/07/16, revised 03/04/19), keep lift chair controller out of reach of Resident, prevent from lifting it to max height (initiated 05/07/16, revised 02/14/19), and keep remote to recliner in reach of Resident, place to where remote will not fall to floor (initiated 01/28/18, revised 02/14/19). Resident #363's clinical record was reviewed on 04/15/19. It contained a fall risk evaluation, which indicated the Resident was at high risk for falls. Resident #363's clinical record also contained a signed physician's order summary for the month of February 2019, which read in part fall precautions. Resident #363's clinical record contained nurse's progress notes, which read in part 12/20/2018 22:53 Resident has made multiple attempts to get out of bed unassisted. attempts at redirection are only successful for a short time before Resident is attempting to get up unassisted again. call light and PO (by mouth) fluids at bedside, 12/24/2018 03:31 12/24/18 1900-2330 Resident has been awake majority of shift since 2200 .12/25/18 0001-315 repeatedly attempted to get out of bed since 0200 redirected every few minutes unsuccessful. has gotten crossways of bed x 2. assisted up to his chair at this x (time), and 1/3/2019 14:00 Change in condition noted related to Called into room by staff observed Resident laying on right side on floor hit head with v shaped laceration to right side of forehead and right eye red and swollen. Skin tear to left ring finger. Resident pushed button to recliner said he had . Resident #363's clinical record contained an emergency room report dated 01/03/19, which read in part admission date: 1/3/2019 Chief complaint: Fall and intracranial hemorrhage HPI (history of present illness): This is [AGE] year old male with past medical history of coronary artery disease, pacemaker, dementia, enlarged prostate, GERD, gout, hyperlipidemia, hypothyroidism presents to ER today as a transfer form .(facility name omitted) for neurosurgery consult for intracranial hemorrhage. The patient is a Resident at (facility name/address omitted). HPI is obtained from patient's family as the patient has dementia. The family reports that the patient gets of (sic) in a lift chair daily. When the patient is in the lift chair, the motor is supposed to be turned off so that he cannot lift himself out of the chair. Apparently, the motor was not turned off today, and the patient was able to raise the chair up and fell forward out of the chair, striking his head on the floor. The patient has a small laceration of the middle frontal forehead. Patient also has right periorbital edema and ecchymosis. He was taken to .(facility name omitted) for evaluation. A CT scan of the head indicated intracranial hemorrhage and the patient was transferred to .(facility name omitted) for neurosurgical evaluation Principle Problem: Subdural hematoma. Active Problems: Dementia, hypertension, HLD (hyperlipidemia) Subarachnoid hemorrhage, closed fracture of right orbit, fall, closed fracture of frontal sinus. Surveyor spoke with LPN #1 (licensed practical nurse) on 04/16/19 at approximately 0900 regarding Resident #363. LPN #1 stated she had been in Resident's room to administer a breathing treatment at approximately 1200 on 01/0319. LPN #1 stated that Resident was sitting up in his power recliner chair. LPN #1 stated that the remote to the chair was kept in the side pocket of the chair LPN #1 stated that approximately 1345, the CNA (certified nurse's aide) called for her to come to Resident's room. LPN #1 stated that when she entered the room, Resident #363 was lying on his right side, in the floor in front of the chair. Surveyor spoke with CNA #1 on 04/16/19 at approximately 0905. CNA #1 stated that she had entered the Resident's room during the lunch meal and told another CNA that she would assist Resident #363 with his meal. CNA #1 stated that after assisting Resident with his meal, she left him sitting upright in his power recliner chair. Surveyor asked CNA if Resident could operate the chair, and CNA #1 responded, I don't think so. CNA #1 also told surveyor that the chair was plugged into a power strip, which was off when she left the room. Surveyor spoke with RN #1 (registered nurse) on 04/16/19 at approximately 0910. RN #1 stated that had been called to come to Resident's room on 01/03/19. She stated that Resident was in the floor and the chair was raised to the highest position. Surveyor asked RN #1 if anyone saw the Resident fall, and RN #1 responded, Not that I know of. Surveyor asked RN #1 if Resident #363 said what had happened, and RN #1 responded, I don't remember if he said what happened or not. Surveyor spoke with the DON (director of nursing) on 04/16/19 at approximately 1110 regarding Resident #363. DON stated that through her investigation of the Resident's fall, she determined that the Resident had raised his chair to the highest position, causing him to fall out into the floor. Surveyor requested and the DON provided copy of the facility policy, entitled Abuse Investigation and Reporting which read in part All reports of Resident abuse, neglect, exploitation, misappropriation of Resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local , state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The failure of the facility to report an unwitnessed fall with major injury was discussed with the administrative team during a meeting on 04/16/19 at approximately 1645. No further information was provided prior to exit. This is a complaint deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure an accurate MDS assessment for 1 of 36 residents in the survey sample, Resident #164. The findings included: The facility staff incorrectly documented that Resident # 164 was discharged to an acute hospital on the discharge assessment. Resident # 164 was a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to, anxiety disorder, seizures, major depressive disorder, and closed fracture. On 4/16/19 at 12:45 pm, the surveyor observed a Leaving Against Medical Advice form that had been signed by Resident # 164 on 2/2/19. The form contained documentation that stated, I have been informed of the risks of leaving the facility against medical advice and understand those risks. Upon review of the Nursing Home Discharge MDS (minimum data set) assessment with an ARD (assessment reference date) of 2/2/19, the surveyor observed in Section A2100 Discharge status, the facility staff documented that Resident # 164 had been discharged to an acute hospital. On 4/16/19 at 12:57 pm, the surveyor interviewed MDS nurse # 1 regarding the discharge status of the Resident # 164. MDS nurse #1 along with the surveyor reviewed Section A2100 on the discharge assessment for Resident # 164. MDS nurse # 1 agreed that discharge status listed on the MDS is acute hospital. MDS nurse # 1 stated, Let me look into that. On 4/16/19 at 1:01 pm, MDS nurse # 1 spoke with the surveyor and agreed that acute hospital was marked in error. Stated I'm sorry we will get it corrected. On 4/16/19 at 4:30 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 4/16/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review the facility staff failed to review and revise a CCP (comprehensive care plan) for 1 of 36 Residents, Resident #363. The findings included: For Resident #363 the facility staff failed to review and revise the care plan for risk of falls. Resident #363 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to anemia, pneumonia, depression, coronary artery disease, hypothyroidism, gastroesophageal reflux disease, benign prostatic hyperplasia and insomnia. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/14/18 coded the Resident as 7 out of 15 in section C, cognitive status. Section G, functional status, coded the Resident as needing extensive with two-person physical assist in the area of transfer ((how Resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). Moving from a seated to standing position was coded as not steady, only able to stabilize with staff assistance. Resident #363's CCP (comprehensive care plan) was reviewed and contained a care plan for At risk for falls due to impaired balance/poor coordination, and unsteady gait and confusion at times. This care plan was initiated on 02/27/15. Interventions for this care plan included, keep lift chair controller out of reach of Resident, prevent from lifting it to max height (initiated 05/07/16, revised 02/14/19), and keep remote to recliner in reach of Resident, place to where remote will not fall to floor (initiated 01/28/18, revised 02/14/19). Both interventions were in place during the same period. Surveyor spoke with the DON on 04/16/19 at approximately 1110 regarding Resident #363's CCP. Surveyor pointed out to DON that the two interventions, which were contradictory to one another, were both in place during the same time. DON responded, Yeah, I know, that care plan is jacked-up. The concern of facility staff to review and revise the Resident's CCP was discussed with the administrative staff during a meeting on 04/16/19 at approximately 1645. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, facility policy and scope of nursing practice for LPNs (licensed practical nurses) in the State of Virginia it was determined the facility staff failed to follow current professional standards of practice while caring for 1 of 33 residents (Resident #82). Findings: Facility staff failed to follow current professional standards of practice while cutting Resident #82's toenails. The resident's clinical record was reviewed on 4-15-19. Resident #82 was admitted to the facility on [DATE]. Her current diagnoses included diabetes, hypertension and dementia. The latest MDS (minimum data set) dated 3-11-19 coded the resident with severe cognitive impairment. The resident required facility staff assistance to accomplish all the ADLs (activities of daily living). Resident #82's CCP (comprehensive care plan) reviewed and revised on 3/12/19 indicated the resident had a self-deficit in ADL care related to physical limitations and altered thought processes. The staff interventions included Assist with daily hygiene, grooming, dressing, oral care, eating and nail care as needed. Resident #82's physician's orders documented the resident as an insulin-dependent diabetic. She received 8 units of Levemir every evening at bedtime. The resident had a physician order for off loading boots to the bilateral lower extremities when in bed, as tolerated. 04/14/19 at 04:50 PM the surveyor observed CNA I repositioning Resident #82 in her bed. CNA I pulled the resident's boots off her feet so the surveyor could observe her feet. The resident's toenails were overgrown and curling. The resident's toes were brownish black and appeared to have pressure areas at various points on both feet. During this observation the resident complained of pain when CNA I was moving her feet and putting the boots back on her. CNA I said she was going to report the resident's discomfort to the nurse. LPN I came into check on the resident's pain and to look at her feet with the surveyor. Resident #84 complained of back pain to LPN I. The LPN said she was going to get the resident something for pain. The RN unit manager (RN I) entered the room to observe the resident's feet. She looked at the great toe on her left foot and said she thought she needed to get a wash cloth and clean it off and maybe it will come off (darkened debris on toes and feet). RN I rubbed a spot on the left foot and the red spot just fell off. RN I said it just looked like dead skin on the feet and toes and stated, It looks like it needs to be cleaned. The resident's right foot had a lot of dead skin falling away as RN I proceeded the examination. RN I stated, She needs a good foot washing/soaking and some lotion. Her toenails need clipping too. RN I said she was going to get a wash cloth and clean her feet and clip her toenails. They are all long and curving/unkempt. The CNAs should wash her feet and put lotion on her feet. The surveyor asked who's responsibility it was to see that the CNA's provided foot care. Both LPN I and RN I said it was their responsibility to make sure the CNAs cleaned the resident's feet. They agreed it should be the charge nurses and unit manager that oversee what the CNAs do. LPN I had a pair of toenail clippers and started to clip the resident's toenails. The surveyor asked if LPNs were allowed to cut her toenails since the resident was diabetic. LPN said she thought she could do it--but the unit manager said they prefer RNs to do that and she took the clippers from LPN I and resumed trimming the resident's toenails. RN I said she would have to check the facility policy to determine if LPNs could cut a diabetic's toe nails at the facility. She stated, I think they do--but I will have to check and see for you. On 4-16-19 at 10:00 AM the facility DON was informed of the surveyor's findings. She was asked if it was within the LPN's scope of practice to cut a diabetic's toenails at the facility. She stated it was not within an LPN's scope of practice to trim a diabetic's toenails, only RNs could perform that task. The DON provided the facility's policy on the care of finger and toenails at the facility. The policy included the following: 1. Nail care includes daily cleaning and regular trimming. 2. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. No additional information was provided prior to the survey team exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility document review, it was determined the facility staff failed to assist 1 of 33 residents (Resident #82) with sufficient foot and toenail care. Findings: Facility staff failed to follow current professional standards of practice while cutting Resident #82's toenails. The resident's clinical record was reviewed on 4-15-19. Resident #82 was admitted to the facility on [DATE]. Her current diagnoses included diabetes, hypertension and dementia. The latest MDS (minimum data set) dated 3-11-19 coded the resident with severe cognitive impairment. The resident required facility staff assistance to accomplish all the ADLs (activities of daily living). Resident #82's CCP (comprehensive care plan) reviewed and revised on 3/12/19 indicated the resident had a self-deficit in ADL care related to physical limitations and altered thought processes. The staff interventions included Assist with daily hygiene, grooming, dressing, oral care, eating and nail care as needed. Resident #82's physician's orders documented the resident as an insulin-dependent diabetic. She received 8 units of Levemir every evening at bedtime. The resident had a physician order for off loading boots to the bilateral lower extremities when in bed, as tolerated. 04/14/19 at 04:50 PM the surveyor observed CNA I repositioning Resident #82 in her bed. CNA I pulled the resident's boots off her feet so the surveyor could observe her feet. The resident's toenails were overgrown and curling. The resident's toes were brownish black and appeared to have pressure areas at various points on both feet. During this observation the resident complained of pain when CNA I was moving her feet and putting the boots back on her. CNA I said she was going to report the resident's discomfort to the nurse. LPN I came into check on the resident's pain and to look at her feet with the surveyor. Resident #84 complained of back pain to LPN I. The LPN said she was going to get the resident something for pain. The RN unit manager (RN I) entered the room to observe the resident's feet. She looked at the great toe on her left foot and said she thought she needed to get a wash cloth and clean it off and maybe it will come off (darkened debris on toes and feet). RN I rubbed a spot on the left foot and the red spot just fell off. RN I said it just looked like dead skin on the feet and toes and stated, It looks like it needs to be cleaned. The resident's right foot had a lot of dead skin falling away as RN I proceeded the examination. RN I stated, She needs a good foot washing/soaking and some lotion. Her toenails need clipping too. RN I said she was going to get a wash cloth and clean her feet and clip her toenails. They are all long and curving/unkempt. The CNAs should wash her feet and put lotion on her feet. The surveyor asked who's responsibility it was to see that the CNA's provided foot care. Both LPN I and RN I said it was their responsibility to make sure the CNAs cleaned the resident's feet. They agreed it should be the charge nurses and unit manager that oversee what the CNAs do. LPN I had a pair of toenail clippers and started to clip the resident's toenails. The surveyor asked if LPNs were allowed to cut her toenails since the resident was diabetic. LPN said she thought she could do it--but the unit manager said they prefer RNs to do that and she took the clippers from LPN I and resumed trimming the resident's toenails. RN I said she would have to check the facility policy to determine if LPNs could cut a diabetic's toe nails at the facility. She stated, I think they do--but I will have to check and see for you. On 4-16-19 at 10:00 AM the facility DON was informed of the surveyor's findings. The DON provided the facility's policy on the care of finger and toenails at the facility. The policy included the following: 1. Nail care includes daily cleaning and regular trimming. 2. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. No additional information was provided prior to the survey team exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, physician interview, staff interview, clinical record review, and facility document review, facility staff failed to consult with activities professionals for individualized diversional activities for 1 of 36 residents in the survey sample (Resident #11). The findings included: The facility staff failed to consult with activities professionals for individualized diversional activity for Resident #11. Resident #11 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, hip fracture, dementia, depression, psychotic disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/16/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 9 out of possible score of 15. During the clinical record review on 4/15 and 4/16/19, the surveyor noted a progress note dated for 11/8/18, which read in part, Consult Activities for diversional activity . The surveyor notified the DON (director of nursing) of the above physician order on 4/15/19. The surveyor requested copies of the activities that Resident #11 participates in. The surveyor received the requested copies of the activities that Resident #11 participates in on 4/16/19 at approximately 11 pm. The surveyor asked the DON where is the documentation from the activities department that they provided Resident #11 with diversional activities as the physician had ordered on 11/8/19. The DON stated, Activities department are always doing activities with the residents on the 3rd wing of the facility. The resident has the right to not participate in the activities. We can't make them do something that they don't want to do. The surveyor requested any documentation of the activities department since 11/8/18 when the physician wrote to consult activities for diversional activities. At 1 pm, the DON returned to the surveyor in the conference room and stated, I don't have any documentation that the activities department was consulted due to the physician order on 11/8/18 or what extra activities they had provided. The surveyor spoke with ____ (name of physician) via phone this afternoon at 4:05 pm. The surveyor read the progress note for Resident #11 in which the physician had written to consult activities for diversional activities. On 11/8/18, the physician saw the resident at which time the resident had continued with wandering in hallways and going through the garbage. The physician stated, . the walking that the resident was doing was not the issue but rather the anxiety that the resident was experiencing with the walking was the issue. I wanted a consult with activities to see if an individual patient based activity could be done for this the resident because he was a farmer most of his life. I wanted to see if there was anything that the resident might find more relaxing to him to decrease his anxiety of feeling. The MD also stated that if he could listen to [NAME] radio and listen to 40's and 50's music to relax him it would be a better answer than to add medication to the resident for this. I have spoken to ____ (name of administrator) on several different times on this and just don't believe that we are where we should be with all of this occurring. The surveyor notified the administrative team of the above documented findings on 4/16/19 at 4:45 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 4/16/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, facility staff failed to administer an antibiotic medication as ordered for 1 of 36 residents in the survey sample (Resident #145). Resident #145 was admitted to the facility on [DATE] with diagnoses including pressure ulcer, difficulty walking, kidney failure, respiratory failure, and essential hypertension. On the admission Minimum Data Set assessment with assessment reference date 4/6/19, the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behaviors affecting others. On 04/14/19 during a preliminary interview, the resident reported having MRSA in a wound. The resident had an isolation cart outside the room. The nurse reported is just on contact isolation for the wound to the foot. It's contained to the wound vac, so no precautions are necessary if you don't plan to touch anything. During clinical record review, the surveyor noted the following order dated 4/15: 'hold dose of IV Vancomycin for 11:30 today due to previous dose completed late; restart on 4/16 at 11:00; draw vanc trough 30 min prior to start dose on 11/16'. The resident was admitted on [DATE] with an order for vancomycin 1750 grams intravenous every 36 hours. The infusion order medication administration record (MAR) documented the resident received a the medication on 4/1/19 at 4 AM, 4/2 at 4 PM, 4/6/19 8 AM and 4/7 at 8 PM, 4/9 at 11:30 AM, 4/10 at 11:30 PM, 4/12 at 11:30 AM, and 4/13 at 11:30 PM, and 4/14 at 11:30 PM. The surveyor asked the nurse and director of nursing about the irregular antibiotic administration schedule on 4/15/19. The director of nursing revealed the resident received a dose of IV anomy at 11 PM last night (4/14/19) when no dose was scheduled, which the resident said finished running at 4:30 AM. The gaps in administration on 4/4 and 4/9 were the result of unavailability of the medication because the pharmacy had sent two doses per shipment and the next doses did not arrive in time for scheduled administration. Each time, the physician was informed and the remaining doses were rescheduled. The administrator and director of nursing were notified of the concern with failure to administer the intravenous antibiotic as ordered during a summary meeting on 4/15/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, facility staff failed to provide for delivery of oxygen per physician orders for 1 of 36 residents in the survey sample (Resident #56). The findings included: The facility staff failed to provide for delivery of oxygen per physician orders for Resident #111. Resident #111 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, diabetes, anxiety disorder, depression, manic depression, Schizophrenia and asthma. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/25/19, the resident was coded as having a BIMS (Brief Interview or Mental Status) score of 5 out of a possible score of 15. Resident #111 was also coded as requiring limited assistance of 1 staff member for dressing, personal hygiene and extensive assistance of 1 staff member for bathing. On 4/15/19 at approximately 11 am, the surveyor observed the resident lying in bed with eyes closed. The resident was receiving oxygen by facemask at 2 l/min (liter/minute). The surveyor reviewed the clinical record of Resident #111 on 4/15/19. It was noted that the physician's order for oxygen was to be delivered to resident by nasal cannula and not the facemask as the surveyor observed. At 11:30 am on 4/15/19, the surveyor notified Resident #111's nurse on dayshift (LPN #1) of the above documented findings. LPN (licensed practical nurse) #1 stated, I bet someone forgot to write the orders for that. She has pneumonia now, but I will check with the doctor to see which way he prefers for her to get her oxygen. The surveyor notified the administrative team on 4/16/19 at 4:43 pm of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 4/16/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, staff interview, and clinical record review, the facility staff failed to provide appropriate social services to meet the needs of 1 of 36 residents in the survey sample, Resident # 56. The findings included: The facility staff failed to assist and communicate with Resident # 56 regarding her wishes regarding resuscitation in the event of cardiac arrest, resulting in Resident # 56 having an active do not resuscitate order when she had in fact expressed that she did want resuscitation measures implemented in the event of cardiac arrest. Resident # 56 was a [AGE] year-old-female who was originally admitted to the facility on [DATE], with a readmission date of [DATE]. Diagnoses included but were not limited to, bipolar disorder, anxiety, type 2 diabetes mellitus, and congestive heart failure. The clinical record for Resident # 56 was reviewed on [DATE] at 4:40 pm. The most recent MDS (minimum data set) assessment was a quarterly assessment, with an ARD (assessment reference date) of [DATE]. Section B of the MDS assesses hearing, speech, and vision. In Section B0700, the ability to express ideas and wants was assessed. The facility staff documented that Resident # 56 was Usually understood-difficulty communicating some words or finishing thoughts but is able if prompted or given time. Section B0800 assesses the ability to understand others. The facility staff documented that Resident # 56 Understands-clear comprehension. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 56 had a BIMS (brief interview for mental status) score of 10 out of 15, which indicated that Resident # 56's cognitive status was moderately impaired. The current plan of care for Resident # 56 was reviewed and revised on [DATE]. The facility staff documented a focus area for Resident # 56 as, Advanced Directives DNR (do not resuscitate). The goal for this focus area was documented as, Resident's advance directives will be honored through next review. Interventions included but were not limited to, Copy of living will in legal section of chart, and Discuss advanced directives with patient, family, or legal representative at admission and quarterly. The current physician's orders for Resident # 56 were signed by the physician on [DATE]. Orders included but were not limited to, Code status do not resuscitate. On [DATE] at 4:50, pm, the surveyor reviewed the DDNR form dated [DATE] in Resident # 56's clinical record. The surveyor observed a handwritten check mark documented next to the following statement on the DDNR form, 2. The patient is INCAPABLE of making an informed decision about providing, withholding or withdrawing a specific medical treatment because he/she is unable to understand the nature, extent or probable consequences of the proposed medical decision, or to make a rational evaluation of the risks and benefits of alternatives to that decision. The surveyor also observed a handwritten checkmark documented next to the following statement on the DDNR form, B. While capable of making an informed decision, the patient has executed a written advanced directive which appoints a Person Authorized to Consent on the Patient's Behalf with the authority to direct that life-prolonging procedures be withheld or withdrawn. The surveyor observed that the guardian for Resident # 56 had signed the back of the DDNR form authorizing the DDNR status. The surveyor further reviewed the clinical record for Resident # 56 and did not locate a written advanced directive that appointed a person authorized to consent on Resident # 56's behalf. The surveyor did observe a facility Cardiopulmonary Resuscitation Directive form, which was dated [DATE] in the clinical record for Resident # 56. The surveyor observed a handwritten checkmark documented next to the following statement of the cardiopulmonary resuscitation directive form, B. In the event that my/my loved one's heart stops beating and/or breathing stops, I DO WANT Cardiopulmonary Resuscitation. The surveyor observed the following documentation at the bottom of the form, I, the physician of Resident # 56 agree with the above decision. The surveyor observed that the word agree had a single handwritten line drawn thorough it and the word disagree was handwritten above it. This document was signed by the physician on [DATE]. On [DATE] at 4:57 pm, the surveyor conducted a Resident interview with Resident # 56. The surveyor asked Resident # 56 if she wanted CPR to bring her back if her heart stops beating. Resident # 56 stated Yes. The surveyor asked Resident # 56 again for clarification to ensure that Resident # 56 understood what was being asked if she wanted CPR to try to bring her back to life if her heart and breathing stops. Resident # 56 stated, Yes Resident # 56 does. If my heart stops beating, I want them to try to bring me back. On [DATE] at 6:00 pm, the surveyor spoke with the facility administrator and director of nursing and asked if Resident # 56 had been declared incompetent. The facility administrator stated, She's been here a long time, I believe she has been declared incompetent. The surveyor requested to see paperwork declaring Resident # 56 incompetent. On [DATE] at 8:03 am, the surveyor was approached by the director of nursing who provided the surveyor with a copy of guardianship papers for Resident # 56. The director of nursing informed the surveyor that she did not locate any paperwork that stated that Resident # 56 had been declared incompetent. The director of nursing stated, While I was going through her chart last night, I learned a lot of things that I did not know. I found a paper in her chart that stated that she (Resident # 56) wanted to go to a particular funeral home and that she wanted to wear a red dress. The surveyor then informed the director of nursing that she did not locate an advance directive in Resident # 56's clinical record as the DDNR form stated that an advance directive had been executed. The director of nursing stated, All we have is the DNR form. But there is a document in her chart were she stated that she did not want to be resuscitated. The surveyor informed the director of nursing that the document in Resident # 56's clinical record stated that Resident # 56 did want to be resuscitated. The director of nursing reviewed the cardiopulmonary resuscitation directive form for Resident # 56 along with the surveyor and the director of nursing agreed that the form contained documentation that Resident # 56 wished to be resuscitated. The director of nursing also observed the documentation at the bottom of the form documented as, I, the physician of Resident # 56 agree with the above decision. The director of nursing along with the surveyor observed that the word agree had a single handwritten line drawn thorough it and the word disagree was handwritten above it. The surveyor asked the director of nursing if she felt that it was appropriate to disregard what Resident # 56 had expressed as her wishes and initiate a DNR order even though Resident # 56 desired to be a full code. The director of nursing stated, No. The surveyor asked the director of nursing if Resident # 56 was able to express her wants and needs on a daily basis. The director of nursing stated, Yes. The director of nursing stated she would contact the guardian for Resident # 56 to see if she can get more information. On [DATE] at 12:23 pm, the director of nursing provided the surveyor with a copy of Resident # 56's DDNR that had been faxed from the agency of Resident # 56's court appointed guardians. The director of nursing informed the surveyor that she had been unable to reach the guardians for Resident # 56 and she had spoken to someone else in the office to try to obtain additional information and the DDNR was all that was sent to the facility from the agency. On [DATE] at 1:58 pm, the surveyor interviewed the facility social worker. The surveyor along with the facility social worker reviewed the cardiopulmonary resuscitation directive for Resident # 56. The facility social worker observed documentation on the cardiopulmonary resuscitation directive that stated that Resident # 56 wished to be resuscitated if her heart or breathing stopped, and that physician documented that he disagreed with Resident # 56's decision. The surveyor asked the facility social worker if Resident # 56 was able to express her needs and wants. The facility social worker agreed that Resident # 56 was able to express her needs and wants. The surveyor asked the facility social worker if she felt it was appropriate that the physician and guardian made the decision to make Resident # 56 a DNR even after she had expressed that she wanted to be resuscitated. The facility social worker stated, I understand what you mean and we will definitely look into this. On [DATE] at 3:10 pm, the surveyor spoke with the facility social worker. The surveyor asked the facility social worker if she attended care plan meetings for Resident # 56. The facility social worker stated that she did attend the care plan meetings for Resident # 56. The surveyor asked the facility social worker if Resident # 56 attended her care plan meetings. The stated, She is invited, but she does not come. The surveyor asked the social worker if the guardians for Resident # 56 attended the care plan meetings. The social worker informed the surveyors that guardians for Resident # 56 attended her care plan meetings and if they were unable to attend the staff communicated with the guardians for Resident # 56 by telephone. The surveyor asked the social worker who reviewed the plan of care during the care plan meetings for Resident # 56 and determined if the focus areas needed to be continued, revised or resolved. The social worker stated that the guardians and facility staff discussed the care areas and determined what areas needed to be continued, revised, or resolved. The surveyor asked the social worker if Resident # 56 had any input with regard to her plan of care. The facility social worker stated, No. The surveyor asked the social worker if she had offered to discuss Resident # 56's plan of care with her in her room in an environment that may be more comfortable to her so that she would be able to provide input in her plan of care. The social worker stated, I have not. On [DATE] at 4:30 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, facility staff failed to ensure antibiotic medications were available for administration for 2 of 36 residents in the survey sample (Residents #122 and 145). 1. For Resident #145, facility staff failed to ensure Intravenous vancomycin was available for administration. Resident #145 was admitted to the facility on [DATE] with diagnoses including pressure ulcer, difficulty walking, kidney failure, respiratory failure, and essential hypertension. On the admission Minimum Data Set assessment with assessment reference date 4/6/19, the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behaviors affecting others. On 04/14/19 during a preliminary interview, the resident reported having MRSA in a wound. The resident had an isolation cart outside the room. The nurse reported is just on contact isolation for the wound to the foot. It's contained to the wound vac, so no precautions are necessary if you don't plan to touch anything. During clinical record review, the surveyor noted the following orders: 4/4/19 -hold Vancomycin 1750 mg until received from the pharmacy, -when received from the pharmacy, restart Vancomycin 1750 mg IV pharmacy dosing of 36 hours and 4/9/19 - hold vanc pharmacy to dose, - restart Vanc dosing at 11:30 AM Vanc 1750 mg IV @ 15 ml/hr Q 36 hours. The infusion order medication administration record (MAR) documented the resident received the medication on 4/1/19 at 4 AM, 4/2 at 4 PM, 4/6/19 8 AM and 4/7 at 8 PM, 4/9 at 11:30 AM, 4/10 at 11:30 PM, 4/12 at 11:30 AM, and 4/13 at 11:30 PM, and 4/14 at 11:30 PM. The surveyor asked the nurse and director of nursing about the irregular antibiotic administration schedule on 4/15/19. They reported the gaps in administration on 4/4 and 4/9 were the result of unavailability of the medication because the pharmacy had sent two doses per shipment and the next doses did not arrive in time for scheduled administration. Each time, the physician was informed and the remaining doses were rescheduled. The administrator and director of nursing were notified of the concern with failure to administer the intravenous antibiotic as ordered during a summary meeting on 4/15/19. 2. For Resident 122, facility staff failed to ensure gentamycin was available for administration. Resident #122 was readmitted to the facility on [DATE]. Diagnoses included hypertension, neurogenic bladder, diabetes mellitus, paraplegia, anxiety, depression, and gastroesophageal reflux. On the quarterly minimum data set assessment with assessment reference date 3/28/19, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. During clinical record review on 4/16/19, the surveyor noted an order dated 4/8/19 for gentamycin 240 milligram /100 ml(milliliter) normal saline 60 ml via supra catch into bladder & clamp off for 30 min then allow to drain QED (daily). A verbal order was written on 4/14/19 to hold the entrancing until available from the pharmacy. The treatment administration record documented administration 4/10-4/13. The surveyor discussed the concern with lack of availability of the antibiotic with the director of nursing. The director of nursing stated that they had been unable to get the pharmacy to provide the antibiotic for administration. The administrator and director of nursing were informed of the concern during a summary meeting on 4/16/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, facility staff failed to monitor targeted behaviors for 1 of 36 residents in the survey sample (Resident #89). The findings included: The facility staff failed to monitor specific targeted behaviors while Resident #89 was taking Zoloft, Ativan, Risperidone and Trazodone. Resident #89 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, diabetes, dementia, anxiety disorder and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/13/19, the resident was coded as requiring extensive assistance of 2 staff members for dressing, personal hygiene and was totally dependent on 2 staff members for bathing. During the clinical record review on Resident #89's medical record on 4/15 and 4/16/19, the surveyor noted the physician had ordered the following medications for the resident to receive: Lorazepam (Ativan) 0.5 mg (milligram) twice a day for anxiety/agitation Risperidone 0.5 mg once a day for dementia with behaviors Sertraline (Zoloft) 50 mg daily for depression Trazodone 50 mg at bedtime for insomnia The surveyor also reviewed the behavioral monitoring sheets for March and April 2019 for Resident #89. For the medication, Risperidone, the monitoring sheet had behaviors and psychosis listed for the specific targeted behaviors to be monitored while the resident was receiving this medication. For the medication, Zoloft, the monitoring sheets had depression for the specific targeted behaviors while the resident was receiving this medication. For the medication, Ativan, the monitoring sheet had the behavior of anxiety for the specific targeted behaviors to be monitored while the resident was receiving this medication. In addition, for Trazodone, the monitoring sheet had the behavior of not sleeping as a specific targeted behavior to be monitored while the resident was receiving this medication. The surveyor notified the DON (director of nursing) of the above documented findings on 4/16/19 at 1 pm. The DON stated, They just wrote depression like for this one but they didn't put how the resident acts when depressed. The surveyor notified the administrative team of the above documented findings on 4/16/19 at 4:45 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 4/16/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility document review it was determined the facility staff failed to provide clean and sanitary food service to 2 of 33 facility residents (Residents #25 and #140). Facility staff failed to don gloves when handling the resideglovgnt's ready made foods. Findings: 1. Facility staff failed to provide clean and sanitary food service to Resident #25. The resident's clinical record was reviewed on 4-16-19 at 9:00 AM. Resident #25 was admitted to the facility on [DATE]. Her diagnoses included diabetes, hypertension, anemia and depression. The latest MDS (minimum data set) assessment, dated 1-30-19, coded the resident as cognitively unimpaired. The resident required staff assistance for all the ADLs (activities of daily living) and a set-up and physical assistance of one staff member to eat. Resident #25's CCP (comprehensive care plan) reviewed and revised on 11-6-18 indicated the resident required assistance with ADLs. Staff interventions included assisting with daily hygiene, grooming, dressing, oral care and eating as needed. On 4-14-19 at 12:57 PM the surveyor observed the resident's meal service in her room. WH I (wing helper I) brought the resident's lunch tray into her room and set it up on the overbed table for the resident. WH I was observed to remove a sandwich from the paper wrapper and place it on the resident's plate with her bare hands. On 4-16-19 at 10:15 AM this observation was reported to the facility DON. The DON told the surveyor the staff were trained in safe food practices and said wearing gloves when handling ANY food was a part of that training. The DON provided the surveyor with a copy of the facility policy on meal assistance. The policy addressed employee training for staff members providing meal assistance. The policy included that staff would be trained and would demonstrate competency in the prevention of food borne illnesses, including hygiene practices and safe food handling. No additional information was provide prior to the survey team exit. 2. Facility staff failed to provide clean and sanitary food service to Resident #140. The resident's clinical record was reviewed on 4-16-19 at 9:15 AM. Resident #140 was admitted to the facility on [DATE]. Her diagnoses included dementia, hypertension, and depression. The latest MDS (minimum data set) assessment, dated 4-5-19, coded the resident as cognitively impaired. The resident required staff assistance for all the ADLs (activities of daily living) and the physical assistance of one staff member to eat. Resident #140's CCP (comprehensive care plan) reviewed and revised on 1-10-19 indicated the resident required assistance with ADLs. Staff interventions included assisting with daily hygiene, grooming, dressing, nail care, oral care and eating as needed. On 4-14-19 at 1:04 PM the surveyor observed the resident's meal service in her room. CNA I brought the resident's lunch tray into her room and set it up on the overbid table for the resident. CNA I did not don gloves during the tray set-up and was observed to remove a sandwich from the paper wrapper and place it on the resident's plate with her bare hands. On 4-16-19 at 10:15 AM this observation was reported to the facility DON. The DON told the surveyor the staff were trained in safe food practices and said wearing gloves when handling ANY food was a part of that training. The DON provided the surveyor with a copy of the facility policy on meal assistance. The policy addressed employee training for staff members providing meal assistance. The policy included that staff would be trained and would demonstrate competency in the prevention of food borne illnesses, including hygiene practices and safe food handling. No additional information was provide prior to the survey team exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to provide a dignified dining experience for 4 of 36 residents in the survey sample (Resident #111, 127, 11, and 13). The findings included: 1. The facility staff failed to provide a dignified dining experience for Resident #111. Resident #111 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, diabetes, anxiety disorder, depression, manic depression, Schizophrenia and asthma. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/25/19, the resident was coded as having a BIMS (Brief Interview or Mental Status) score of 5 out of a possible score of 15. Resident #111 was also coded as requiring limited assistance of 1 staff member for dressing, personal hygiene and extensive assistance of 1 staff member for bathing. During the initial tour of the 3rd wing in the facility on 4/14/19 at 12:30 pm, the surveyor heard the unit manager and several other nurses and CNA (certified nursing assistants) being directed by the unit manager to Take the feeders back to their rooms for lunch today. This surveyor and the team leader surveyor went to the unit manager that was standing in the hallway outside of the dining room and asked what was going on. The unit manager stated, We got into trouble with a regulation for having the feeders in the same dining room as other residents that were eating. So they will have to be taken back to their rooms and be fed by the staff there. This surveyor asked the unit manager that if a resident verbalized that they wanted to remain in the dining room to eat, could they not stay. The unit manager stated, They have to be taken to their rooms for now, then if they want to come back and eat in the dining room, the staff will bring them back and feed them in there. The 2 surveyors that were present in the hallway and observing staff removing the feeders to their rooms. Three of the residents that was being taken out of the dining room verbalized to the staff that they wanted to stay in the dining room to eat. The surveyors observed the facility staff telling the residents, that were being removed from the dining room, they could come back in the dining room after everyone has been fed lunch. Resident #111 was coded on the MDS with ARD of 3/25/19 as needing supervision, oversight, encouragement or cueing of 1 staff member for physical assistance in eating. On 4/15/19 at 12:30 pm, the surveyor observed 1 resident sitting at the table with 2 other residents that were eating. The surveyor asked the wing helper why this resident was still in the dining room watching the other residents eating. The wing helper stated, She is usually fed in here after all the residents have finished eating. The surveyor notified the administrative team of the above documented findings on 4/16 19 at 4:45 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 4/16/19. 2. The facility staff failed to provide a dignified dining experience for Resident #127. Resident #127 readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, peripheral vascular disease, dementia and psychotic disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) OF 4/1/19, coded the resident as having short and long-term memory problems with being moderately impaired in making daily decisions. Resident #127 was also coded as requiring extensive assistance of 1 staff member for eating, and being totally dependent on 1-2 staff members for personal hygiene and bathing. During the initial tour of the 3rd wing in the facility on 4/14/19 at 12:30 pm, the surveyor heard the unit manager and several other nurses and CNA (certified nursing assistants) being directed by the unit manager to Take the feeders back to their rooms for lunch today. This surveyor and the team leader surveyor went to the unit manager that was standing in the hallway outside of the dining room and asked what was going on. The unit manager stated, We got into trouble with a regulation for having the feeders in the same dining room as other residents that were eating. So they will have to be taken back to their rooms and be fed by the staff there. This surveyor asked the unit manager that if a resident verbalized that they wanted to remain in the dining room to eat, could they not stay. The unit manager stated, They have to be taken to their rooms for now, then if they want to come back and eat in the dining room, the staff will bring them back and feed them in there. The 2 surveyors that were present in the hallway and observing staff removing the feeders to their rooms. Three of the residents that was being taken out of the dining room verbalized to the staff that they wanted to stay in the dining room to eat. The surveyors observed the facility staff telling the residents, that were being removed from the dining room, they could come back in the dining room after everyone has been fed lunch. On 4/15/19 at 12:30 pm, the surveyor observed 1 resident sitting at the table with 2 other residents that were eating. The surveyor asked the wing helper why this resident was still in the dining room watching the other residents eating. The wing helper stated, She is usually fed in here after all the residents have finished eating. The surveyor notified the administrative team of the above documented findings on 4/16 19 at 4:45 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 4/16/19. 3. The facility staff failed to provide a dignified dining experience for Resident #11. Resident #11 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, hip fracture, dementia, depression and psychotic disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/16/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 9 out of a possible score of 15. Resident #11 was also coded as requiring extensive assistance of 1-2 staff members for dressing, personal hygiene and being totally dependent on 1 staff member for bathing and eating. During the initial tour of the 3rd wing in the facility on 4/14/19 at 12:30 pm, the surveyor heard the unit manager and several other nurses and CNA (certified nursing assistants) being directed by the unit manager to Take the feeders back to their rooms for lunch today. This surveyor and the team leader surveyor went to the unit manager that was standing in the hallway outside of the dining room and asked what was going on. The unit manager stated, We got into trouble with a regulation for having the feeders in the same dining room as other residents that were eating. So they will have to be taken back to their rooms and be fed by the staff there. This surveyor asked the unit manager that if a resident verbalized that they wanted to remain in the dining room to eat, could they not stay. The unit manager stated, They have to be taken to their rooms for now, then if they want to come back and eat in the dining room, the staff will bring them back and feed them in there. The 2 surveyors that were present in the hallway and observing staff removing the feeders to their rooms. Three of the residents that was being taken out of the dining room verbalized to the staff that they wanted to stay in the dining room to eat. The surveyors observed the facility staff telling the residents, that were being removed from the dining room, they could come back in the dining room after everyone has been fed lunch. On 4/15/19 at 12:30 pm, the surveyor observed 1 resident sitting at the table with 2 other residents that were eating. The surveyor asked the wing helper why this resident was still in the dining room watching the other residents eating. The wing helper stated, She is usually fed in here after all the residents have finished eating. The surveyor notified the administrative team of the above documented findings on 4/16 19 at 4:45 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 4/16/19. 4. The facility staff failed to provide a dignified dining experience for Resident #13. Resident #13 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, pneumonia, dementia, seizure disorder, depression, psychotic disorder and Schizophrenia. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/16/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 5 out of a possible score of 15. Resident #13 was also coded as requiring extensive assistance of 1 staff member for dressing, eating, personal hygiene and being totally dependent on 1 staff member for bathing. During the initial tour of the 3rd wing in the facility on 4/14/19 at 12:30 pm, the surveyor heard the unit manager and several other nurses and CNA (certified nursing assistants) being directed by the unit manager to Take the feeders back to their rooms for lunch today. This surveyor and the team leader surveyor went to the unit manager that was standing in the hallway outside of the dining room and asked what was going on. The unit manager stated, We got into trouble with a regulation for having the feeders in the same dining room as other residents that were eating. So they will have to be taken back to their rooms and be fed by the staff there. This surveyor asked the unit manager that if a resident verbalized that they wanted to remain in the dining room to eat, could they not stay. The unit manager stated, They have to be taken to their rooms for now, then if they want to come back and eat in the dining room, the staff will bring them back and feed them in there. The 2 surveyors that were present in the hallway and observing staff removing the feeders to their rooms. Three of the residents that was being taken out of the dining room verbalized to the staff that they wanted to stay in the dining room to eat. The surveyors observed the facility staff telling the residents, that were being removed from the dining room, they could come back in the dining room after everyone has been fed lunch. On 4/15/19 at 12:30 pm, the surveyor observed 1 resident sitting at the table with 2 other residents that were eating. The surveyor asked the wing helper why this resident was still in the dining room watching the other residents eating. The wing helper stated, She is usually fed in here after all the residents have finished eating. The surveyor notified the administrative team of the above documented findings on 4/16 19 at 4:45 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 4/16/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, facility staff failed to ensure fresh water was readily available at the bedside for 8 of 36 residents in the survey sample (Resident #84, #111, #136, #67, #127, #15, #11 and #13). The findings included: 1. The facility staff failed to ensure fresh water was readily available at the bedside of Resident #84. Resident #84 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, high blood pressure, peripheral vascular disease, psychotic disorder, Schizophrenia and respiratory failure. On the quarterly MDS (Minimum Data Set) with an ARD of 3/12/19 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 14 out of a possible score of 15. Resident #84 was also coded as requiring extensive assistance of 1-2 staff members for dressing, personal hygiene and is totally dependent on 2 staff members for bathing. During the initial tour on 4/14/19 at 12 noon, the surveyor observed the water cup that the facility has for each resident was empty and the outside of it was not wet from the ice melting in the cup. On the lid of the cup, there was a date of 4/13/19. The surveyor asked the resident how often he gets fresh water. The resident stated, I don't know, maybe yesterday. At 1 pm on 4/14/19, the surveyor asked CNA (certified nursing assistant) #1 how often they put fresh water by the bedside of the resident. CNA #1 stated, once a shift. That is the wing helper's job. This morning there was a call in by another CNA and I stayed over this morning to help them out. We have just been so busy and we haven't had help so we haven't had time to give out fresh water this morning. The surveyor notified the administrative staff of the above documented findings on 4/16/19 at 4:45 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 4/16/19. 2. The facility staff failed to ensure fresh water was readily available at the bedside of Resident #111. Resident #111 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, diabetes, anxiety disorder, depression, manic depression, Schizophrenia and asthma. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/25/19, the resident was coded as having a BIMS (Brief Interview or Mental Status) score of 5 out of a possible score of 15. Resident #111 was also coded as requiring limited assistance of 1 staff member for dressing, personal hygiene and extensive assistance of 1 staff member for bathing. During the initial tour on 4/14/19 at 12 noon, the surveyor observed the water cup that the facility has for each resident was empty and the outside of it was not wet from the ice melting in the cup. On the lid of the cup, there was a date of 4/13/19. At 1 pm on 4/14/19, the surveyor asked CNA (certified nursing assistant) #1 how often they put fresh water by the bedside of the resident. CNA #1 stated, once a shift. That is the wing helper's job. This morning there was a call in by another CNA and I stayed over this morning to help them out. We have just been so busy and we haven't had help so we haven't had time to give out fresh water this morning. The surveyor notified the administrative staff of the above documented findings on 4/16/19 at 4:45 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 4/16/19. 3. The facility staff failed to ensure fresh water was readily available at the bedside of Resident #136. Resident #136 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, high blood pressure, diabetes, dementia, seizure disorder and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/4/19, the resident was coded as requiring extensive assistance of 2 staff members for dressing, personal hygiene and being totally dependent on 2 staff members for bathing. During the initial tour on 4/14/19 at 12 noon, the surveyor observed the water cup that the facility has for each resident was empty and the outside of it was not wet from the ice melting in the cup. On the lid of the cup, there was a date of 4/13/19. At 1 pm on 4/14/19, the surveyor asked CNA (certified nursing assistant) #1 how often they put fresh water by the bedside of the resident. CNA #1 stated, once a shift. That is the wing helper's job. This morning there was a call in by another CNA and I stayed over this morning to help them out. We have just been so busy and we haven't had help so we haven't had time to give out fresh water this morning. The surveyor notified the administrative staff of the above documented findings on 4/16/19 at 4:45 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 4/16/19. 4. The facility staff failed to ensure fresh water was readily available at the bedside of Resident #67. Resident #67 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to coronary artery disease, high blood pressure, dementia, depression and asthma. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/11/19; the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 3 out of a possible score of 15. Resident #67 was also coded as requiring extensive assistance of 2 staff members for dressing, personal hygiene and being totally dependent on 2 staff members for bathing. During the initial tour on 4/14/19 at 12 noon, the surveyor observed the water cup that the facility has for each resident was empty and the outside of it was not wet from the ice melting in the cup. On the lid of the cup, there was a date of 4/13/19. At 1 pm on 4/14/19, the surveyor asked CNA (certified nursing assistant) #1 how often they put fresh water by the bedside of the resident. CNA #1 stated, once a shift. That is the wing helper's job. This morning there was a call in by another CNA and I stayed over this morning to help them out. We have just been so busy and we haven't had help so we haven't had time to give out fresh water this morning. The surveyor notified the administrative staff of the above documented findings on 4/16/19 at 4:45 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 4/16/19. 5. The facility staff failed to ensure fresh water was readily available at the bedside of Resident #127. Resident #127 readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, peripheral vascular disease, dementia and psychotic disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) OF 4/1/19, coded the resident as having short and long-term memory problems with being moderately impaired in making daily decisions. Resident #127 was also coded as requiring extensive assistance of 1 staff member for eating, and being totally dependent on 1-2 staff members for personal hygiene and bathing. During the initial tour on 4/14/19 at 12 noon, the surveyor observed the water cup that the facility has for each resident was empty and the outside of it was not wet from the ice melting in the cup. On the lid of the cup, there was a date of 4/13/19. At 1 pm on 4/14/19, the surveyor asked CNA (certified nursing assistant) #1 how often they put fresh water by the bedside of the resident. CNA #1 stated, once a shift. That is the wing helper's job. This morning there was a call in by another CNA and I stayed over this morning to help them out. We have just been so busy and we haven't had help so we haven't had time to give out fresh water this morning. The surveyor notified the administrative staff of the above documented findings on 4/16/19 at 4:45 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 4/16/19. 6. The facility staff failed to ensure fresh water was readily available at the bedside of Resident #15. Resident #15 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, coronary artery disease, high blood pressure, diabetes, arthritis, and dementia. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/18/19, the resident was coded as requiring extensive assistance of 2 staff members for dressing, personal hygiene and being totally dependent on 2 staff members for bathing. During the initial tour on 4/14/19 at 12 noon, the surveyor observed the water cup that the facility has for each resident was empty and the outside of it was not wet from the ice melting in the cup. On the lid of the cup, there was a date of 4/13/19. At 1 pm on 4/14/19, the surveyor asked CNA (certified nursing assistant) #1 how often they put fresh water by the bedside of the resident. CNA #1 stated, once a shift. That is the wing helper's job. This morning there was a call in by another CNA and I stayed over this morning to help them out. We have just been so busy and we haven't had help so we haven't had time to give out fresh water this morning. The surveyor notified the administrative staff of the above documented findings on 4/16/19 at 4:45 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 4/16/19. 7. The facility staff failed to ensure fresh water was readily available at the bedside of Resident #11. Resident #11 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, hip fracture, dementia, depression and psychotic disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/16/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 9 out of a possible score of 15. Resident #11 was also coded as requiring extensive assistance of 1-2 staff members for dressing, personal hygiene and being totally dependent on 1 staff member for bathing and eating. During the initial tour on 4/14/19 at 12 noon, the surveyor observed the water cup that the facility has for each resident was empty and the outside of it was not wet from the ice melting in the cup. On the lid of the cup, there was a date of 4/13/19. At 1 pm on 4/14/19, the surveyor asked CNA (certified nursing assistant) #1 how often they put fresh water by the bedside of the resident. CNA #1 stated, once a shift. That is the wing helper's job. This morning there was a call in by another CNA and I stayed over this morning to help them out. We have just been so busy and we haven't had help so we haven't had time to give out fresh water this morning. The surveyor notified the administrative staff of the above documented findings on 4/16/19 at 4:45 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 4/16/19. 8. The facility staff failed to ensure fresh water was readily available at the bedside of Resident #13. Resident #13 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, pneumonia, dementia, seizure disorder, depression, psychotic disorder and Schizophrenia. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/16/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 5 out of a possible score of 15. Resident #13 was also coded as requiring extensive assistance of 1 staff member for dressing, eating, personal hygiene and being totally dependent on 1 staff member for bathing. During the initial tour on 4/14/19 at 12 noon, the surveyor observed the water cup that the facility has for each resident was empty and the outside of it was not wet from the ice melting in the cup. On the lid of the cup, there was a date of 4/13/19. At 1 pm on 4/14/19, the surveyor asked CNA (certified nursing assistant) #1 how often they put fresh water by the bedside of the resident. CNA #1 stated, once a shift. That is the wing helper's job. This morning there was a call in by another CNA and I stayed over this morning to help them out. We have just been so busy and we haven't had help so we haven't had time to give out fresh water this morning. The surveyor notified the administrative staff of the above documented findings on 4/16/19 at 4:45 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 4/16/19.