Every finding on record at Bayshore Residence and Rehabilitation Center

Based on observation, interview, and document review, the facility failed to properly dispose of medications in the second-floor medication storage room. This had the ability to affect any resident who received medications from the second-floor medication storage room. Findings include: During a tour of the second-floor medication room with licensed practical nurse (LPN)-D on 6/25/26 at 9:23 a.m., multiple medications were observed to be expired. LPN-D stated that he wasn't sure of the process to remove the expired medications and I would have to follow up with director of nursing (DON). LPN-D stated that a lot of the medications in the medication storage room were overflow. Expired medications included the following: -saline nasal gel, expired 4/28/25-magnesium chloride, expired 4/9/26-docusate sodium, expired 12/4/25-cephalaxin, filled 9/16/25-Tylenol assigned to R19, expired 6/18/25. During an interview on 6/25/26 at 12:34 p.m., the director of nursing (DON) stated the nurse managers, or her audit medication carts monthly, but she had not audited the second-floor medication storage room. The expectation would be that nurses would put the expired medications in in the medication disposal bank on the first floor. Facility policy, Storage of Medications, undated, identified that discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview and document review the facility failed to ensure meals were palatable for 8 of 14 residents (R17, R12, R10, R4, R5, R58, R61, R81) who expressed dissatisfaction with palatability of meals. In addition, the facility failed to ensure the temperature of foods was maintained when transported to resident rooms. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified R17 was moderately cognitively intact. During an interview on 6/22/26 at 2:30 p.m., R17 stated the food was pretty much terrible. During an observation on 6/24/26 at 1:02 p.m., R17 was no longer in the main dining room. He had eaten only a few bites of the meal which was a French dip sandwich, French fries, and a creamy cucumber salad. R12's quarterly MDS dated [DATE], identified R12 was cognitively intact. During an interview on 6/22/26 at 3:15 p.m., R12 stated the food was poor quality, said the cooks didn't know how to cook, and went on to state the hot food was not hot, and ice cream was served melted. R12 stated they were also not able to get oil and vinegar for a salad. During an observation and interview on 6/23/26 at 12:55 R12 stated she had not received any dressing for the salad. The meal was nacho chicken, shredded lettuce and tomato, refried beans, corn, and frosted marble cake. R10's quarterly MDS dated [DATE], identified R10 was cognitively intact. During an interview on 6/22/26 at 12:45 p.m., R10 stated the eggs were served cold and overcooked. R10 stated there was no variety and no seasoning. During an observation and interview on 6/23/26 at 12:59 p.m., R10 had a lunch of chicken breast, corn, refried beans, he touched his food and stated it was cold. R4's quarterly MDS dated [DATE], identified R4 was cognitively intact. During an interview on 6/22/26 at 5:33 p.m., R4 stated the food had gone downhill, the hot food was not hot, and the cold food was not cold. R5's quarterly MDS dated [DATE], identified R5 was cognitively intact. During an interview on 6/22/26 at 3:00 p.m., R5 stated that lots of the food was bad. R81's quarterly MDS dated [DATE], identified R81 was cognitively intact. During an interview on 6/22/26 at 1:11 p.m., R81 stated the food was awful, no taste for the potatoes, the chicken was dry and in general the food was overcooked. During an observation and interview on 6/23/26 at 1:00 p.m., R81 stated his food was awful, staff had removed it to reheat it. During an observation on 6/23/26 at 12:20 p.m., a speed cart arrived with a plastic covering. The entrees were covered as were the beverages. At 12:27 p.m., staff added coffee to cups and placed them on the meal trays At 12:30 p.m., staff began passing out the meal trays to the residents who were eating in their rooms At 12:41 p.m., a second tray arrived on another hallway with a plastic covering, staff performed hand hygiene and began passing out the meal trays to resident who were eating in their rooms During an interview on 6/26/26 at 8:15 a.m., the director of nursing (DON) stated they were aware of the food complaints since February. R58's quarterly Minimum Data Set (MDS) dated [DATE], identified R58 was cognitively intact. R61's quarterly MDS dated [DATE], identified R61 was cognitively intact. During an observation on 6/24/26 at 12:44 p.m., lunch trays were being delivered to resident rooms from an open ladder rack with plates in insulated serving dishes and milk cartons on the tray. The culinary director (CD) took temperatures on the last room tray served. The roast beef on a bun was 100.4 degrees Fahrenheit (F), the cup of au jus was 106.5 degrees F, and the carton of milk was 54.3 degrees F. During an interview on 6/24/26 at 12:44 p.m., CD confirmed the temperatures of foods on the last tray served were not what they expected for food quality. They stated their main concern was related to quality and palatability, and indicated safety would be a concern if it had been greater than 2 hours. During resident council interview on 6/25/26 at 9:57 a.m., R58 and R61 indicated the food concerns had not been fully addressed. They stated food quality and temperature were not great, food was always cold when eating in their room, and cold food was not always reheated by staff when requested. During an interview on 6/25/26 at 10:33 a.m., activity director (AD), indicated they were aware of the cold food concerns. They brought all food concerns to Quality Assurance and Performance Improvement (QAPI) and the food department manager. During an interview on 6/26/26 at 8:45 a.m., the director of nursing (DON) stated they expected trays delivered to resident rooms were hot, and cold items cold. They had concerns about food quality. Review of Resident Council meeting minutes: Resident Council Meeting minutes dated 2/12/26 at 10:00 a.m., with 18 residents attending, indicated concerns about cold food and needing staff to reheat the food. Resident Council Meeting minutes dated 4/9/26 at 10:00 a.m., with 15 residents attending, indicated residents were asked for any concerns, compliments, or suggestions for dietary. Resident Council Meeting minutes dated 6/11/26 at 10:00 a.m., with 22 residents attending, indicated concerns about food quality including food being overcooked and rubbery. Food Temperatures policy dated 2026, instructed that foods sent to the units for distribution will be transported and delivered to maintain temperatures at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods.

Based on observation, interview, and document review, the facility failed to consistently track and monitor dishwasher temperatures for both the wash and rinse cycles, and take timely action to correct the temperatures, for 1 of 1 dishwasher. This had the potential to affect all current residents, as well as staff or visitors, who ate food served from dishes and tableware that were cleaned in the dishwasher. Additionally, the facility failed to ensure proper sanitary storage of cleaning products and personal protective equipment and failed to ensure staff appropriately covered facial hair.Findings include: Dishwasher temperatures:During an observation on 6/25/26 at 9:38 a.m., dietary aide (DA)-A was operating the dirty side of the dishwasher and DA-B was removing dishes on the clean side of the dishwasher. DA-A completed a wash cycle. On the dishwasher, the rinse temperature was observed to be 180 degrees Fahrenheit (F), and the wash temperature gauge was not functioning.During an interview on 6/25/26 at 10:11 a.m., DA-A stated dishwasher temperatures were logged by staff working the clean side of the dishwasher every shift. DA-A started a wash cycle, observed the temperature gauges, and confirmed the wash temperature gauge was not functioning. DA-A stated this was not good because the wash temperature was not known.During an observation on 6/25/26 at 10:15 a.m., dishwashing logs for May 2026 and June 2026 were reviewed and included columns labeled wash and rinse for each meal. The June 2026 dishwashing temperature log had no temps logged for all meals 15 out of 25 days, no temps were logged for dinner, and all recorded breakfast rinse temps were logged below 180 degrees F, ranging from 170-175 degrees F, with no follow-up notations. The May 2026 dishwashing temperature log had no temps logged for all meals 23 out of 31 days and no temps were logged for dinner.During an interview on 6/25/26 at 10:17 a.m., cook (C)-A reviewed the dishwasher temperature logs for May 2026 and June 2026. C-A confirmed that temperatures were not logged consistently, and several recorded rinse temperatures were below 180 degrees F and was concerned that dishes were not heated for proper sanitation.During an interview on 6/25/26 at 10:19 a.m., DA-B stated dishwasher temperatures were logged every shift. DA-B confirmed they had not logged the morning temperatures and stated they were running late that morning.During an interview on 6/25/26 at 10:29 a.m., culinary director (CD) observed the dishwasher running and confirmed the wash temperature gauge was not moving and the rinse temperature was 175 degrees F. CD asked DA-B about the wash gauge and DA-B stated, sometimes it works, sometimes it doesn't. CD was concerned that if the dishwasher was not reaching appropriate temperatures, it may not be killing germs. CD stated they expected staff to log temperatures twice daily and let them know if there were issues. CD stated the dishwasher was leased from Ecolab, they needed to call for service, and asked staff to use the 3-compartment sink until it was resolved.During an interview on 6/25/26 at 12:55 p.m., Ecolab technician identified the dishwasher as a high-temperature dishwasher and confirmed the wash temperature gauge had failed. They stated the minimum wash temperature for the machine was 160 degrees F and the minimum rinse temperature was 180 degrees F. They identified during their service call on 6/25/26, a T60 test strip applied to a ceramic plate during dishwasher run had turned black which verified the dish reached 160 degrees F and was sanitized.The dishwasher temperature gauges indicated wash temperature minimum was 160 degrees F and rinse temperature minimum was 180 degrees F.A copy of dishwashing logs for May 2026 and June 2026 were requested but not received.Cleaning Dishes Using a Dish Machine policy dated 2026, instructed that proper temperatures and machine function should be verified prior to use, and staff should check the dish machine gauges throughout the cycle to ensure proper temperatures for sanitation. It identified for a high-temperature dishwasher that the wash cycle reaches 150 to 165 degrees F and the rinse cycle reach 180 degrees F.Ecolab manufacturer instructions dated 2020, identified the following water temperature requirements:Wash temperature (hot water sanitizing) 160 FRinse temperature (hot water sanitizing) 180 FSanitary Storage:During a kitchen observation on 6/25/26 at 9:45 a.m., a closet between the kitchen and the entrance to the dirty side of the dishwasher was observed to be open and disorganized with open chemical containers, open boxes of gloves, and more than a dozen flies swarming and landing on the closet contents.During an interview on 6/25/26 at 10:36 a.m., CD observed the closet and stated they had not seen the closet before as they were new to the facility. CD identified the open chemicals as partially full Ecolab Solitaire dish detergent. CD stated they expected the closet to be closed, organized, and the chemical containers covered. CD had concerns for contamination from the flies.Chemical storage policy, personal protective equipment storage policy, and pet control policy were requested but not received.Facial Hair:During a kitchen observation on 6/25/26 at 11:50 a.m., other kitchen staff (O)-D was placing fruit and dessert cups on resident trays on a ladder rack. O-D was observed to have a full beard and mustache that were not covered with a facial hair net.During an interview on 6/25/26 at 11:50 a.m., O-D stated hairnets are required for facial hair, confirmed they should have a hairnet covering their beard, and stated the concern was for hair falling into the food.During an interview on 6/25/26 at 12:37 p.m., CD stated hair nets are required if facial hair was long enough to grab. CD was concerned for hair falling into food and possibly carrying pathogens if facial hair was not covered while serving food.

Based on interview and document review, the facility failed to ensure residents were informed of and consented to medications prescribed and given for mental health intervention for 1 of 5 residents (R2) reviewed for unnecessary medications.Findings include:R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact.R2's diagnoses included heart failure, renal insufficiency, schizoaffective disorder, non-Alzheimer's dementia, and arthritis.R2's care plan dated 6/26/26, identified R2 uses psychotropic medications related to behavior management. R2's provider orders dated 8/18/25, included mirtazapine oral tablet 15 mg: Give 15 mg by mouth at bedtime for depression. R2's provider orders dated 8/19/25, included risperidone oral tablet 0.5 mg: Give 1 tablet by mouth two times a day for mood disorder.R2's Informed Consent for Required Medications dated 2/5/24, for risperidone 2.5 mg two times a day for bipolar, was signed by R2.R2's medical record had no Informed Consent for Required Medications for mirtazapine.During interview on 6/26/26 at 9:06 a.m., director of nursing (DON) stated consents for psychotropic medications were obtained by a resident's physician, and nursing staff should ensure the consents were in the medical record. DON stated the physician should be updating the consents when prescribing new medications. DON confirmed R2 had no consent for mirtazapine in their medical record, and stated concern for lacking informed consent from R2.Antipsychotic Medication Use policy dated 4/26/2025, instructed that the resident record must include provider diagnosis, indication for use and documentation that the resident acknowledged consent to receive prescribed psychotropic medications.

Based on interview and document review, the facility failed to ensure that a resident who was assessed to be unable to self-administer medications did not self-administer nebulizer treatments. This affected 1 of 1 resident (R8) reviewed for self-administration of medication.Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 as cognitively intact. Diagnosis included chronic obstructive pulmonary disease (COPD) and rheumatoid arthritis (RA). R8's MDS further indicated that she was assessed as unable to self-administer medications. R8's current orders, reviewed 6/24/26, included Albuterol Sulfate Inhalation Nebulization Solution 2.5 milligrams (mg), inhale orally three times a day. Current orders failed to indicate R8 was able to self-administer medications. During observation on 6/24/26 at 11:00 a.m., R8's nebulizer sat atop her bedside table with noted droplets in the nebulizer chamber. During interview on 6/24/26 at 11:47 a.m., R8 stated that she uses her nebulizer three times daily. Staff sets it up and I turn it on. They don't come back to clean it. During interview on 6/24/26 at 12:24 p.m., registered nurse (RN)-F stated that she can't say the last time she passed meds on R8's unit, but if they can self-administer medications it should show on the medication administration record (MAR) or in their orders. During interview on 6/24/26 at 1:12 p.m., trained medication aide (TMA)-A stated that she sets up R8's nebulizer, R8 completes the treatment, and she later goes back to clean the nebulizer. There are currently three people on this unit that can self-administer oral medications once set up, and R8 is not one of them. Residents usually have a separate order to self-administer nebulizers themselves. On 6/25/26 at 12:38 p.m., the director of nursing (DON) confirmed that R8 was assessed as unable to self-administer medications and there was not a current order for R8 to self-administer medications. The DON stated the expectation would be that a resident would have a SAM assessment indicating that they can self-administer an albuterol nebulizer. Facility policy, Self-Administration of Medications, undated, identified If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications. The IDT evaluates options which allow residents to safely participate in the medication administration process if they wish to do so.

Based on observation, interview, and record review the facilty failed to honor shaving preferences and needed assistance for 1 of 1 residents (R112) who required minimal assistance with shaving and oral care. Findings include:R112's admission Minimum Data Set (MDS) dated [DATE], status: ready for export, indicated R112 was cognitively intact with the diagnoses of encounter for orthopedic after care, kidney disease, diabetes, congestive heart failure and muscle weakness. Section GG indicated R112 required setup or clean-up assistance for personal hygiene including shaving and oral hygiene. R112's care plan last updated dated 6/23/26, did not include R112's general preferences or activities of living (ADL) preferences. The Focus area Functional Discharge Goals included: hygiene goal: set up or clean up assistance with personal hygiene. The oral hygiene goal identified was to be independent with oral hygiene. On 6/22/26 at 2:04 p.m., R112 stated staff had not offered to help them get set up to brush their teeth, they had to ask them to help, or it wouldn't get done. R112 touched their face and said they hadn't been able to shave since they got to the facility. They had asked multiple staff but so far nobody had helped them. R112 explained at home they only kept a goatee, and they didn't want all the new whiskers as they were itchy. R112 wanted to be cleaned shaved just like they were at home. It was noted R112 had significant whisker stubble on their face and under their chin. During an interview on 6/24/26 at 9:09 a.m., R112 was noted to have significant whisker growth on the face and neck outside of their goatee. R112 stated they had not been able to shave yet, they had now been waiting three days for help. R112 stated they had asked for help once today, three times yesterday, and multiple times the day before that. R112 thought they had asked at least three or four different staff for assistance. Today, staff had said they were working on it, but nothing had happened yet. During an interview on 6/24/26 at 1:19 p.m., nursing assistant (NA-A) stated the facility had disposable razors that could be used to shave a resident if they didn't have their own shaver or razors. NA-A stated if a resident asked to be shaved staff should do it. During an interview on 6/24/26 at 1:45 p.m., registered nurse manager (RN-D) stated resident preferences were looked at during admission by the charge nurse. In addition, RN-D indicated they and the social worker did a meet and greet with the resident and reviewed their preferences which included shaving and oral care. RN-D stated they would expect shaving to get done when a resident asked.During an interview on 6/25/26 at 9:20 a.m., NA-D stated as NA's they did shave residents. We ask residents if they want to be shaved and then we do it if that is what they wanted. Stock supply razors would be used if a resident did not have their own razor or shaver.During an interview on 6/25/26 at 9:23 a.m., R112 continued to have whisker growth on their face and neck. R112 stated staff had not offered to assist them with brushing their teeth or with getting shaved yesterday or today even after they had asked to shave yesterday. They really needed to shave because they were sick of their face constantly being itchy.During an interview on 6/25/26 at 2:12 p.m., RN-D, stated staff should be setting up and offering assistance with ADLs to residents who have triggered for some level of assistance on the MDS. During an interview on 6/25/26 at 3:03 p.m., the director of nursing (DON) stated when a resident requested to shave, they expected staff to assist the resident to shave as soon as able the same day. They also expected staff to go in and offer assistance and or set up residents so they could shave/brush their teeth themselves. If residents were not doing those things for themselves, the DON expected staff to complete those cares without having to be asked by residents.The facility policy Activities of Daily Living (ADLs), Supporting dated 6/25/26, instructed residents will be provided with care, treatment and services as appropriate, to maintain or improve their ability to carry out activities of daily living. Services identified included bathing, dressing, grooming, and oral care. The facility policy Resident Rights dated 7/14/21, identified that residents had the right to self-determination.

Based on observation, interview and record review the facility failed to ensure a resident could smoke safely for 1 of 1 resident (R10) reviewed for safe smoking.Findings include:R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 was cognitively intact and had no rejections of care. In addition, R10's MDS identified he required set up for eating and was dependent on staff for activities of daily living.R10's Diagnosis Report dated 6/26/26, identified R10 had diagnoses which included heart failure (a condition where the heart muscle is too weak or too stiff to pump blood efficiently), lymphedema (a chronic condition characterized by the abnormal buildup of protein-rich lymph fluid, which causes swelling [edema] in the body's soft tissues), cellulitis of left finger, acquired absence of left finger(s), burn of unspecified degree of multiple sites of left and right wrist and hand, diabetes mellitus, open wound of left middle finger, open wound of left ring finger.R10's Medication Review Report dated 6/26/26, identified R10 had orders for dressing changes to left hand wounds twice daily and as needed for nonadherence/soilage. Cleanse left hand wounds with wound cleanser. Then apply collagen and gauze, secure with Coban.R10's care plan dated 1/7/26, identified R10 as using tobacco. Interventions included to determine if he had a desire to quit smoking, to educate on the risks and health effects of tobacco use, to provide education regarding the adverse effects of smoking, to provide resources on smoking cessation, and to provide with a cigarette holder to use while smoking. In addition, R10's care plan identified current functional performance as follows: Resident uses soft touch call light due to limited dexterity in both hands, dated 5/28/26 Dressing - Total assist dated 3/18/25 Eating - Independent/ set-up help only dated 3/14/25R10's smoking assessment dated [DATE], identified he smoked 6-10 cigarettes daily, had medical contraindications to smoking, and was able to safely hold, light, smoke, extinguish the cigarette and secure lighter in a safe manner without assistance. Question six related to prior to the start of the observation, does the resident have existing burn holes in clothing, it was answered no. Question seven related to burns or holes in clothing from falling ashes was answered as no. The conclusion included the following interventions, smoking apron, smoking materials kept at the nurse's station.R10's smoking assessment dated [DATE], identified he smoked 10-20 cigarettes daily, had medical contraindications to smoking, and was able to safely hold, light, smoke, extinguish the cigarette and secure lighter in a safe manner without assistance. Question six related to prior to the start of the observation, does the resident have existing burn holes in clothing, it was answered yes. Question seven related to burns or holes in clothing from falling ashes was yes. The conclusion included the following interventions, adaptive equipment and smoking apron. It also included he had been provided with a cigarette holder and smoking apron for use during smoking.R10's smoking assessment dated [DATE], identified he smoked 5-10 cigarettes daily. Question two related to any medical contraindications to smoking was answered as no. Question six related to prior to the start of the observation, does the resident have existing burn holes in clothing, it was answered yes. Question seven related to burns or holes in clothing from falling ashes was yes. Question nine related to an accident related to smoking was answered yes. Interventions included adaptive equipment, smoking apron, smoking materials kept at nurse's station and violated smoking policy - will reassess per plan. Included he would not use a smoking apron. He signed a risk versus benefit, on 4/11/26, identifying he understood the risks associated with smoking and not using a smoking apron.The facility provided a list of residents who were approved current smokers on 6/22/26, R10's name was not included on the list.During an observation on 6/22/26 at 12:46 p.m., R10's clothing appeared soiled with white spots on shirt and pants and small holes in shirt (across abdomen) and in his pants in the thigh area.During an interview on 6/22/26 at 12:54 R10 stated he smoked independently.During an observation on 6/23/26 at 2:21 p.m., R10 was seated in his wheelchair in his room, he was wearing clean clothes. Both the shirt and pants had several small holes.During an observation on 6/24/26 at 2:09 p.m., R10 was headed outside, he had a pack of cigarettes in his breast pocket. His clothing was clean but had small holes in the shirt and pants. He declined to have anyone accompany him to the smoking area.During an observation on 6/24/26 at 2:17 p.m., there were food crumbs on the floor under the overbed table where R10 ate in his room.During an interview on 6/24/26 at 2:18 p.m., nursing assistant (NA)-A verified there were crumbs on the floor and what he stated looked like spilled milk on the overbed table. NA-A stated they had to wait for him to leave the room as he would not let them clean up after each meal.During an interview on 6/24/26 at 2:26 p.m., licensed practical nurse (LPN)-A verified there were food crumbs on the floor and the overbed table was wet from a beverage that had been spilled. LPN-A stated he would sometimes use adaptive eating utensils but would also eat using his hands. LPN-A stated he would not use the cigarette holder and stated the wounds on his hands were from burns from smoking. LPN-A verified the holes in his clothing were from burn holes from cigarette smoking but stated he would say they were not.During an interview on 6/24/26 at 2:28 p.m., registered nurse (RN)-A stated she had tried different options to have R10 hold a cigarette (related to his lack of fine motor coordination), but he was not receptive. RN-A verified R10's care plan identified he needed to use a cigarette holder to smoke. RN-A verified the holes in his clothing were from burn holes from cigarette smoking. During an interview on 6/26/26 at 8:04 a.m., the director of nursing (DON) verified R10 would not use a smoking apron and that RN-A and now occupational therapy were working with him for a safe option to hold a cigarette (related to his lack of fine motor coordination and safety with smoking). Smoking Policy - Residents dated 3/2/26, identified the facility would establish and maintain safe resident smoking practices. A resident's ability to smoke safely would be evaluated upon admission/readmission, quarterly, upon a significant change (physical or cognitive) and as determined by the staff. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) would be noted in the care plan, and all personnel caring for the resident would be alerted to these issues.

Based on observation, interview and document review, the facility failed to ensure Enhanced Barrier Precautions (EBP) protocols were followed for 1 of 1 resident (R103) reviewed for infection control.Findings include:R103's quarterly Minimum Data Set (MDS) dated [DATE], identified R103 was cognitively intact.R103's diagnoses included diabetes mellitus, renal insufficiency, neurogenic bladder, hypertension, anemia, arthritis, anxiety, and depression.R103's care plan dated 6/17/26, identified the resident was on EBP related to a suprapubic (SP) catheter and chronic wounds, and directed care staff to follow EBP and to utilize gowns and gloves for all personal care. R103's provider orders dated 12/11/25, included SP catheter cleansing and maintenance for neuromuscular dysfunction of bladder.During an observation on 6/24/26 at 12:58 p.m., R103's door had a sign indicating R103 was on EBP. The sign instructed staff to wear a gown and gloves for high-contact resident care activities, including dressing and transferring. Nursing assistant (NA)-C was observed in R103's room, without wearing a gown, squatting at R103's feet at bedside.During an interview on 6/24/26 at 1:33 p.m., NA-C confirmed they had not gowned when entering R103's room. NA-C stated they prepared R103 for an appointment, assisted with dressing, and transferred R103 from bed to wheelchair. NA-C stated they were squatting at bedside to put R103's compression socks on. NA-C stated they only needed to gown for EBP if taking care of an open wound. NA-C reviewed the EBP sign on R103's door and stated even though the sign indicated to wear a gown with dressing, they did not need to gown since they were not in contact with R103's wound. NA-C stated gowning for EBP was important to prevent transferring an infection to staff or other residents.During an interview on 6/24/26 at 3:01 p.m., registered nurse (RN)-C stated staff wear gown and gloves when providing cares to residents on EBP. RN-C expected staff to wear gown and gloves when assisting R103 with getting dressed and stated a concern for spreading infection if EBP was not followed.During an interview on 6/26/26 at 8:25 a.m., director of nursing (DON) stated staff were expected to read the EBP sign when entering a resident's room and apply the appropriate personal protective equipment (PPE). DON confirmed that staff needed to wear gown and gloves when assisting with dressing a resident on EBP and stated a concern for cross contamination of infection to staff if a gown was not worn.Facility provided Enhanced Barrier Precautions sign received 6/26/26, instructed providers and staff must wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care, and wound care.

Based on observation, interview and document review the facility failed to ensure residents did not have to share a living space with a resident (R72) who would not shower or change clothing. This deficient practice affected 3 of 3 residents (R52, R65, R44) reviewed for environment.Findings include:R72's quarterly Minimum Data Set (MDS) dated [DATE], identified he had diagnoses which included anemia, heart disease, hypertension, arthritis, depression, panlobular emphysema (an irreversible type of chronic obstructive pulmonary disease [progressive, incurable lung disease that blocks airflow and makes breathing difficult]), hypomagnesemia (a low level of magnesium in the blood), cannabis use, and gastroesophageal reflux disease (when stomach acid flows back up into the esophagus and causes heartburn). In addition, R72's MDS identified he was cognitively intact, had no rejections of care and was independent with activities of daily living (ADLS) including personal hygiene.R72's Medication Review Report dated 6/26/26, identified he had an order for a weekly bath audit on shower day every evening shift on Tuesdays.R72's care plan dated 2/4/26, identified R72 had a risk for self-care deficit related to bathing and dressing. Interventions included to evaluate his ability to perform ADLS, to maintain a consistent schedule, minimize environmental stimuli, to provide assistance with ADLs as needed, and to complete a risk versus benefit for bathing refusals. A review of R72's Weekly Bath Audits from January 2026 through June 2026, identified he had refused bath/showers every week for the past six months.A review of risk versus benefit on refusing showers and skin checks dated 2/4/26, identified two staff signed the document but there was no signature for R72.R72's provider notes identified the following:-12/26/25, identified he was declining any help with personal hygiene. He is illkept, matted hair.-1/30/26, identified he declined any help with showers. He is illkept, matted hair.-2/11/26, Refuses any bathing or hygiene care frequently and appears disheveled. Not interested in decreasing ETOH (alcohol), tobacco, or marijuana at this time. is in bed still at 11:00 today and disheveled appearing.-5/15/26, Refuses any bathing or hygiene care frequently and is quite disheveled. Disheveled and unkempt.R52's comprehensive MDS dated [DATE], identified R52 was moderately cognitively intact.During an interview on 6/24/26 at 11:38 a.m., R52 stated he shared a room with R72 and didn't want to be in the same room with him. R52 stated that he coughed all the time. R52 stated sometimes the bathroom would be dirty (the toilet) but he didn't have to clean it up staff would. R52 stated he had asked for a different room about five times.R65's quarterly MDS dated [DATE], identified R65 was cognitively intact.During an interview on 6/24/26 at 10:46 a.m., R65 stated he shared a bathroom with R72 and sometimes there would be poop on the toilet. R65 stated when that happened, he would tell nursing and they would come and clean it up.R44's quarterly MDS dated [DATE], identified R44 was cognitively intact.During an interview on 6/25/26 at 1:18 p.m. R44 stated sometimes the shared bathroom would be dirty with stool on the toilet, but he would tell nursing and they would clean it up. During the course of the survey 6/22/26-6/26/26, a staff member who wished to remain anonymous reported R72 had not showered in over a year, didn't change his clothing, didn't wash his hair (stated his hair was matted), and shared a bathroom with three other residents. The anonymous staff member stated the resident drank alcohol and messes his pants, they stated the other three residents would complain about the bathroom being dirty.During an interview on 6/25/26 at 11:42 a.m., housekeeper (H)-A stated R72's room was odorous and R72's use of alcohol made it hard to keep the room and bathroom clean. H-A stated R72 didn't always make it to the bathroom in time when he needed to use it. H-A stated sometimes there would be stool on the floor, walls, toilet, and on his bed linen. H-A stated they believed he had not bathed, washed his hair, or changed his clothes for eight months. H-A stated housekeeping would use a deodorant spray when he was out of his room, check his bed to see if his bed linen needed to be changed (said it was often stained with stool) and would alert nursing to change the bed linens. H-A stated bed linens were typically changed on shower days but R72 would refuse his shower. H-A stated R52 has told her in the past that nothing happens if he complained about the room and the bathroom. H-A stated R65 has also complained to her about how dirty the bathroom would be after R72 used it. H-A stated the bathroom accidents usually occurred overnight, and she would find dried stool in the bathroom when she arrived in the morning about three times a week. H-A stated R52 and R65 would use the main bathroom/shower room when the bathroom would get too bad.During an interview on 6/25/26 at 12:00 p.m., nursing assistant (NA)-B stated she was aware of R72 refusing to shower and stated she didn't think he changed his clothes daily.During an interview on 6/25/26 at 12:04 p.m., licensed practical nurse (LPN)-B stated he was aware R72 refused to shower. LPN-B verified R52, R65, and R44 would come out and tell nursing staff when the bathroom was dirty and stated in fact R65 had told him that morning that the toilet seat had stool on it. LPN-B verified the room could be odorous.During an interview on 6/25/26 at 12:08 p.m., registered nurse (RN)-B stated R72 had not showered for the past six months, maybe longer. RN-B stated he was somehow able to obtain alcohol, and wouldn't change his clothes or wash his hair. RN-B stated she was not aware that R52, R65, and R44 would sometimes use the shower room bathroom because the shared bathroom was so dirty. RN-B verified a reasonable person would not want to share a room or a bathroom with someone who refused to shower or change their clothing.During an interview on 6/26/26 at 7:58 a.m., the director of nursing (DON) stated it had been a very, very, long time since R72 had showered. The DON verified she has had to clean the shared bathroom of stool. The DON verified a reasonable person would not want to share a room or a bathroom with someone who refused to shower or change their clothes. Weekly Skin Care Policy and Procedure dated 4/10/26, Residents will have weekly scheduled showers/baths. The policy identified skin care would enhance the quality of life for all residents residing in the facility. The policy did not address refusals to bathe or shower.

Based on interview and document review, the facility failed to ensure that mail was delivered to residents on Saturdays. This had the ability to affect all residents who received mail to the facility.Findings include: R101's annual Minimum Data Set (MDS) dated , 5/21/26, identified R101 as cognitively intact. R85's annual MDS dated [DATE], identified R85 as cognitively intact. During interview on 6/25/26 at 9:57 a.m., R101 stated that if mail comes on Saturday, it is not being delivered until Monday. R85 confirmed that mail gets delivered to the front desk on Saturday and is sorted and delivered on Monday. During interview on 6/25/26 10:54 a.m., the front desk receptionist and business office manager (BOM)-A stated they deliver to residents during the week. On Saturday if they are expecting something for mail, they can come and grab it, otherwise we go though it on Monday and deliver it out through the facility. Facility policy, Mail and Electronic Communication, undated, indicated mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries).

Based on interview and document review the facility failed to ensure residents right to leave the facility was honored for 2 for 3 residents (R1, R2) reviewed who had physicians orders restricting their rights to a leave of absence.R1's admission Record indicated she admitted to the facility on [DATE]. Diagnoses include type 2 diabetes mellites (DMII), infection of left hip, pain, weakness and gait abnormalities.R1's care plan dated 2/10/24, indicated she was at low risk for elopement. The care plan identified substance abuse/dependence as evidenced by resident having alcohol and drug paraphernalia/admitting to substance use and indicated leave of absence (LOA) privileges revoked per physician.R1's Physician Order Report dated 10/20/25, identified the following order dated 7/10/25: Revoked privileges of LOA. Resident not allowed to leave facility per provider.R2's admission Record indicated he admitted to the facility 2/13/25. Diagnoses included: depression, head laceration, anemia, tobacco use and alcohol dependence.R2's care plan dated 9/4/25, indicated R2 had a history of impaired decision making related to choices that put his health and safety at risk despite education and a risk for self-harm related to chemical dependency. The care plan further indicated LOA privileges revoked per provider.R2's Order Summary Report dated 9/2/25, identified the following order dated 8/7/25, indicated LOA suspended due to patient safety concerns. A written agreement between R2 and the administrator dated 8/26/25, indicated R2 agrees to go to the bank and a couple of stores today. R2 promised he would not consume beer or alcohol of any kind while on his shopping trip today. R2 would be home by 5:00 p.m. This will be a one-time trip and will be reported to his physician.A written agreement between R2 and the administrator dated 8/29/25, indicated R2 agrees to go to the bank and a couple of stores today. R2 promised he would not consume beer or alcohol of any kind while on his shopping trip today. R2 would leave facility after 9:00 a.m. and return before 2:00 p.m. This will be a one-time trip and will be reported to his physician.During interview on 10/23/25 at 2:01 p.m., social services designee (SSD)-A stated R1's LOA privileges were revoked because she was using drugs and alcohol. SSD-A said typically residents were allowed to leave the facility with family or friends and said the facility asked for information about leaving and returning. During interview on 10/23/25 at 2:07 p.m., the administrator stated R1 had an order from the physician to rescind her LOA status. The administrator stated the facility safety policy trumped the resident's rights. The administrator stated he suspected R1 had been bringing drugs and alcohol into the facility. The administrator said R2 had been doing unsafe things and was warned he would need to discontinue his behavior. After many violations, R2 had his LOA privileges revoked. The administrator said R2 had been allowed to walk around the facility grounds and the building. The administrator said R2 did well and had been set up with some trial leaves and then at one point he did not return to the facility and showed up at the hospital.During interview on 10/23/25 at 3:02 p.m., licensed social worker (LSW)-A stated R1 had gone on leaves from the facility and had not returned on time. LSW-A said they suspected R2 had been under the influence. LSW-S said the physician ordered urinalysis but R1 refused so the physician wrote an order that she could not leave the facility. LSW-A was asked if any less restrictive options were discussed prior to restricting R1's right to leave the facility and said she was not aware of any and had not been directly involved. LSW-A said according to facility policy, leaving the facility was a privilege, not a right and the privilege could be revoked.Facility policy Resident Leave of Absence/Pass privileges dated 5/10/22, indicated the facility recognizes the right of the residents for whom reside at this facility that it is their home and they can choose to leave the facility for limited periods for therapeutic reasons. The facility also recognizes the need of the residents to leave to prepare for discharge. It is not in the best interest of the residents to leave the facility, but it is encouraged to enjoy the facility grounds between times during the provision of medical care. Because the purpose of admission is to provide a continuum of care and treatment, the facility leave of absence policy may be granted in accordance with specific guidelines.Purpose:To clarify circumstances under which authorization for leaving the facility is needed.To establish guidelines regarding the right to return to the facility upon termination of anauthorized pass.Procedure1. Upon admission, resident wanting to leave the facility during the assessment period will onlybe allowed to leave with a responsible party. Demographic information, including purpose,will be required. The order will read, Resident Ok for pass privileges with responsible party.This order will automatically generate upon the resident arrival/admission to the facility.2. Until the resident is fully assessed by both occupational therapy and the attending physician,the physician will deem that the resident is safe to leave the facility and will issue an order Resident Ok for independent leave of absence pass privileges.3. The MD also has the authorization to not grant leave of absence pass privileges. Thus, theorder will read resident not ok for leave of absence pass privileges d/t.4. Residents leaving the facility must sign the designated leave of absence pass IN/OUT form.This book/binder is located at each nurse's station. The resident must complete the formwhich includes leaving time from facility, expected return time and purpose for pass. Inaddition, the staff nurse must initial that this form is complete. Those residents who requireresponsible party signatures will also be required to provide this information before leavingthe facility. Failure to complete this process will result in pass privilege termination.5. The resident and/or responsible party must alert facility staff (preferably the nurse) upon arrivalback to the facility.6. Medications that must be administered while the resident is out will be given to theresident/person signing the resident out. No narcotic medications will be issued.7. Written and/or oral instructions on when and how to administer the medication will be providedto the resident or to the person signing the resident out. Only medications that must beadministered while the resident is out will be issued.8. Resident leave of absence/pass times is daily from 10:00 am to 9:00pm. These timesmay be adjusted per Administrator discretion, inclement weather, etc.Failure to ReturnResidents who have not returned by 9:00pm but by midnight, the following will occur:a. Responsible party/guardian will be called.b. If no response, 911 will be contacted.c. Pass privileges will be suspended pending IDT review.

Based on interview and document review the facility failed to ensure appropriate discharge rights for 1 of 3 residents (R1) who was discharged from the facility following a leave of absence. R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis include DMII, infection of left hip, pain, weakness and gait abnormalities.R1's care plan dated 2/10/24 indicated she was at low risk for elopement. The care plan identified substance abuse/dependence as evidenced by resident having alcohol and drug paraphernalia/admitting to substance use and indicated leave of absence (LOA) privileges revoked per physician.R1's Physician Order Report dated 10/20/25, identified the following order dated 7/10/25: Revoked privileges of LOA. Resident not allowed to leave facility per provider.R1's Resident Discharge Summary indicated she discharged from the facility 10/20/25. the summary identified R1's discharge location as other and indicated, unable to meet her needs.R1's Progress Notes indicated the following:10/20/25 at 5:33 p.m., R1 left the faciity on an LOA, against medical advice (AMA), despite having LOA privileges revoked per physician order. R1 departed the facility with her family. Both R1 and her family were aware privileges had been revoked. Per facility policy and physicians order, leaving the facility under these circumstances was considered leaving AMA. R1 later contacted the facility by phone and was informed she violated the revoked LOA order and was officially considered to have left AMA. R1 was advised she could come back to the facility and collect her belongings.10/20/25. 6:18 p.m., R1 and family member came to the facility to grab R1's coat, writer and nurse went to the car to have R1 sign AMA form. R1 refused to sign the form, arguing the facility was stealing her wheelchair which belonged to the facility. R1 educated if she refused to sign the form, staff would sign with a witness. Writer went to get signature from R1's daughter and R1 repeatedly told her daughter not to sign the form. Daughter said she would sign the form the next morning when they came to get the rest of R1's belongings. AMA form was signed by writer and nurse. 10/21/25, 9:47 a.m., Writer asked R1's daughter to sign AMA paperwork as she stated she would the previous night. Daughter stated she was not signing anything.During interview on 10/23/25 at 1:40 p.m., registered nurse (RN)-A stated she believed R1 was currently with her daughter. RN-A said R1 had previously had her LOA privileges revoked because she had tested positive for drugs and brought alcohol back to the facility. RN-A stated R1 had gone out the previous month and had been re-educated. RN-A said the previous Monday, R1 left the facility without telling staff and the administrator told staff to proceed with the AMA due to not following the physician order and said when R1 called she told her since she broke the policy, she was considered discharged AMA and family could pack her belongings. RN-A said R1 had every intention of coming back to the facility but the administrator said she could not. During interview on 10/23/25 at 2:01 p.m., social services designee (SSD)-A stated R1's LOA privileges were revoked because she was using drugs and alcohol. SSD-A said typically residents were allowed to leave the facility with family or friends and said the facility asked for information about leaving and returning. During interview on 10/23/25 at 2:07 p.m., the administrator stated R1 had an order from the physician to rescind her LOA status. The administrator stated he suspected R1 had been bringing drugs and alcohol into the facility and providing them to other residents. The administrator said there were many discussions with the physicians about why R1 could not leave the facility and indicated the decision was for R1's safety. The administrator said RN-A had reported to him, R1 had left the facility and he told RN-A to follow the AMA procedure.During interview on 10/23/25 at 3:49 p.m., the director of nursing (DON) stated the facility did not have any evidence R1 was giving drugs or alcohol to other residents, only suspicion.During interview on 10/23/25 at 3:02 p.m., licensed social worker (LSW)-A stated R1 had gone on leaves from the facility and had not returned on time. LSW-A said they suspected R1 had been under the influence. LSW-S said the physician ordered urinalysis but R1 refused so the physician wrote an order that she could not leave the facility. During interview on 10/23/25 at 4:53 p.m., the administrator stated R1 did well when she was sober and family was able to visit and he felt it was healthier for R1 to remain at the facility and not go on LOA.Facility policy Transfer or Discharge Notice dated 7/22/16, indicated:Except as specified below, a resident, and/or his or her representative (sponsor) will be given a thirty (30)-day advance notice of an impending transfer or discharge from our facility and a bed hold notice given tothe resident and/or representative for emergent transfers or therapeutic leave:a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility.b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so theresident no longer needs the services provided by the facility.c. The safety of individuals in the facility is endangered.d. The health of individuals in the facility would otherwise be endangered.e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid underMedicare or Medicaid) a stay at the facility.f. An immediate transfer or discharge is required by the resident's urgent medical needs.g. The resident has not resided in the facility for thirty (30) days; and/orh. The facility ceases to operate.

Based on observation, interview, and document review, the facility failed to ensure biologic medications were labeled with a pharmacy label indicating the resident's name and prescription information and to ensure biologic medications were destroyed after their beyond-use-date (BUD) in 1 of 3 medication carts reviewed for medication labeling and storage. This had potential to impact any resident receiving insulin in the Harbor Light community. Findings include: During an observation and interview on [DATE] at 1:45 p.m., in the Harbor Light community, licensed practical nurse (LPN)-D confirmed there was an insulin aspart ,d+[DATE] mix pen in the top drawer of the medication cart. LPN-D stated she was not aware of who this belonged to, they did go through the carts regularly for expired or beyond use medication. LPN-D confirmed with a printed resource on the medication cart indicating insulin aspart was good for 28 days after opening. LPN-D stated the insulin will be destroyed. During an interview on [DATE] at 3:56 p.m., the director of nursing (DON) stated she would expect insulin to be labeled with the resident's name, opened-on date and to be removed from use after it reaches the BUD. A policy, Labeling of Medication Containers dated [DATE], identified all medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. Medication labels must be legible at all times. Individual resident medications must include all necessary information such as resident name, prescriber's name, name, address, and phone number of pharmacy, name, strength and quantity of the drug, prescription number, date medication was dispensed, cautionary statements, the expiration date and directions for use. The expiration or BUD is checked prior to medication administration.

Based on observation, interview, and documents review the facility failed to remove medications after each use for a resident not approved to keep at bedside. This affected 1 of 1 resident (R33) reviewed for self-administration of medication. Findings include: R33's significant change Minimum Data Set (MDS) dated [DATE], identified R33 had intact cognition. Diagnosis included dementia and Parkinson's disease. R33's Self Administration of Medication (SAM) assessment dated [DATE], identified R33 could not identify expiration date of each medication and to continue plan of care. R33's SAM assessment dated [DATE], identified R33 could not identify expiration date of each medication and to continue plan of care. The SAM also identified either R33 did not want to self-administer medications or was unable to determine. R33's care plan undated, lacked documentation related to R33's SAM assessment. During observation on 4/14/25, at 2:16 p.m., a bottle of nystatin powder with R33's name on it was noted on the bedside table in R33's room. During a second observation on 4/16/25 at 7:43 a.m., a bottle of nystatin powder with R33's name on it was again observed on the bedside table in R33's room. During an interview on 4/16/25 at 7:46 a.m., licensed practical nurse (LPN)-A stated to keep medications at the bedside there needs to be a SAM assessment completed that showed the resident was safe to self-administer medication and to keep the medication at bedside. There also needs to be a provider order to keep the medication at bedside. LPN-A entered R33's room and confirmed a bottle of nystatin powder was on R33's bedside table. LPN-A stated R33 did not have a SAM that okayed medications to be kept at bedside because R33 could not self-administer. During an interview on 4/17/25, at 12:31 p.m. registered nurse (RN)-A stated the SAM assessment indicating the resident is cleared to self -administer medication and a provider order needed to be in place before a resident could self-administer medications or keep medications at bedside. During an interview on 4/17/25 at 12: 38 p.m., the director of nursing (DON) stated the SAM assessment and provider order need to be in place to store medications at bedside. Facility policy Self-Administration of Medication last reviewed 12/13/21, indicated if the facility determined a resident was not safe to self-administer medications, the nursing staff would administer the medications. The policy did not discuss if it was safe to store medications at bedside if the resident could not safely self-administer medications.

Based on interview and record review, the facility failed to maintain respect and dignity for personal space for 2 of 3 resident's (R31, R55) reviewed who had their room searched without consent. Findings include: R31's clinical admission undated, indicated R31 was her own responsible party. R31's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R31 had intact cognition. Diagnoses included heart failure, anxiety and depression. R31's care plan last updated 5/31/24, indicated resident had a behavior problem related to false accusations and blaming others of mistreatment. One documented trigger for behavior listed under interventions was room searches. R31's active order list dated 7/29/24, indicated search room in pairs after each leave of absence, family visit, and as needed. Review of R31's progress notes from 11/1/24 to 4/16/25 indicated the following: - 4/14/25 at 5:54 p.m., writer did a room search with social services and administrator after visitor left. Resident refused search of person and purse. After much discussion regarding choices that have led up to current life choices resident let staff search purse. - 4/10/25 at 5:03 p.m., resident had visitor. Room search completed. Resident allowed but stated: this is a violation of my rights. - 4/8/25 at 10:33 a.m., a Situation, Background, Assessment and Recommendation (SBAR) report was sent to provider that indicated a room search was completed and items found. Recommendations included to restrict leave of absence rights and revoke rights to leave the facility and was signed by the provider. - 4/7/25 at 10:01 p.m., resident son and another visitor came. Resident and visitors went outside at 9:45 and room search was completed. - 4/7/25 at 3:50 p.m. a routine room search was conducted in accordance with facility policy. - 1/2/25 at 9:54 p.m., room search completed as ordered. - 12/5/24 at 9:44 p.m. room search completed. - 11/30/24 at 3:25 p.m. the resident's room was searched this afternoon. (the medical record indicated the resident had been hospitalized from 11/28/24 to 12/3/24). During an interview on 4/15/25 at 2:07 p.m., R31 stated the facility kept performing searches of her room at all times of the day. They come in two at a time anytime I have a visitor and search my furniture, go through the drawers and purse. Sometimes they even try to search me. They never tell me why; they just walk in and start going through my stuff. Sometimes they ask for permission, but I do not consent to the search. When I don't voluntarily consent to the search they keep talking and pushing until I finally given in and say they can search my stuff. During an interview on 4/16/25 at 7:46 a.m., licensed practical nurse (LPN)-A stated there were residents who had orders to search their rooms after visitors had been present or when the resident left the facility and returned. LPN-A confirmed R31 was one of those residents but LPN-had not done any searches in R31's room. LPN-A believed they did need permission before doing any searches. During an interview on 4/16/25 at 7: 56 a.m., the social services designee (SSD) stated she had participated in room searches of R31's property. All searches were done according to facility policy. R31 did not always give consent voluntarily to perform the search, but after talking with her she would eventually give consent. During an interview on 4/16/25 at 11:58 p.m., registered nurse (RN)-A stated staff did not need permission to perform room searches in R31's room. If we had a concern, our policy allowed us to do the room searches based on those concerns. We would ask R31 for permission, but she did not always give it. During an interview on 4/16/25 at 1:17 p.m., the administrator stated all room searches were done following facility policy. The facility policy Resident Personal Possession Search last reviewed 10/18/22, indicated there would be a reasonable suspicion that a resident had contraband prior to conducting a room/belonging search. Before the search took place, the search must first be approved by the administrator. The items in plain view could be taken by staff. Otherwise, any resident possessions, the resident and/or resident representative must understand why the search was conducted and provided verbal consent before a search of personal items and person was executed. The verbal consent would be documented by the administrator and the provider would be notified by the director of nursing.

Based on observation and interview, the facility failed to ensure a resident's room was clean and homelike for 1 of 3 residents (R45) reviewed for environment. Findings include: R45's admission Minimum Data Set (MDS) dated [DATE], identified an admitted [DATE], and primary diagnosis as orthopedic care following surgical amputation of the right lower leg. During observation and interview on 4/14/25 at 4:02 p.m., R45 stated his room was too dark, there were stains and holes in the walls, one of the blinds wouldn't raise or lower and these things bothered him. On observation, there were several screw holes in the wall between the two windows, and multiple streaks of a brownish-black substance four to five inches long on the wall behind his bed and chair that bothered him. The light over the sink area had droplets of a brown, dried substance on it, and a glob of something brown and thick of about 1 inch long on the front of the light. There was one light over the sink, one over his bed, and one over his chair. R45 stated he has complained to staff about this room. During observation and interview on 4/16/25 at 10:53 a.m., maintenance worker (MW)-B stated they didn't have a routine for checking rooms for maintenance issues because they are in and out of the rooms quite a bit. MW-B said when a room is vacated, they check the lights, doors, toilet, sink, drawers, and closet doors. MW-B stated he was familiar with R45's room and they had painted that room shortly after a resident passed, then R45 was the next resident in the room. MW-B stated R45 had complained about the lighting, so he replaced some bulbs, but he wasn't aware of the holes in the wall and would say that wasn't homelike. As far as the stains on the walls and light fixtures, housekeeping would be responsible for those. During an observation and interview on 4/17/25 at 12:18 p.m., housekeeper (HSK)-A stated every room was house kept daily and included wiping down all surfaces, bathroom, sinks, toilet, sweep and mop the floor. Once a month, or if the resident was out of the building, they will do a deep cleaning of the room. HSK-A stated they didn't have a schedule but just kind of do it on their own. HSK-A observed the stains on R45's walls and light fixture, and acknowledged she could wipe them down, but the lights would have to be maintenance. HSK-A confirmed there was a process for maintenance requests for things that needed to be fixed. During an interview on 4/17/25 at 2:21 p.m., the administrator stated deep room cleaning was done annually and when there was a vacancy. Maintenance had a list of things to go through, including wall repair. The administrator stated he was familiar with R45's room and declined touring it at this time. The administrator's expectation was for resident's rooms to be clean and homelike. A policy, Homelike Environment dated 12/8/21, identified its purpose was for residents to be provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The policy didn't address repairs to walls.

Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) for 2 of 4 residents (R65, R86) reviewed for accuracy of assessments. Findings include: R65: R65's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and a diagnosis of morbid obesity. Section N of the MDS identified R65 received one injection of insulin during the assessment period. R65's provider orders dated 1/10/24, identified Trulicity (an injectable non-insulin medication used to improve blood sugar levels) one time weekly. R65's medication administration record for February 2025 identified Trulicity administration on 2/21/25. During an interview on 4/16/25 at 10:35 a.m., registered nurse (RN)-B confirmed the only injectable medication R65 was taking between 2/17 and 2/24/25 would have been Trulicity. During an interview on 4/17/25 at 10:42 a.m., RN-E confirmed she was the nurse responsible for R65's MDS of 2/24/25. RN-E stated her process was to review the resident's orders and other charting to gather information. RN-E reviewed the medication list from the assessment period and confirmed R65 was using Trulicity and she must have coded it as insulin. RN-E state accurate MDS' were important because they affect case mix. A policy for MDS completion was requested but not received. R86: R86's MDS dated [DATE], indicated R86 was cognitively intact with diagnoses of cancer, atrial fibrillation, and generalized muscle weakness. R86's Care Plan Report last updated on 4/16/25, listed resident performance eating - independent/set-up help only provide verbal cues to swallow as needed and take small bites. Head should be upright/forward not leaning back when drinking liquid. The care plan did not identify R86 had dysphasia and lacked instruction for supervised meals. R86's Order Summary Report Active Orders as of 4/17/25, included the following orders: -regular diet ground meat texture, thin liquids -ensure mouth is clean before and after every meal, per speech therapy recommendations -eating: staff supervision, provide verbal cues to swallow as needed, take small bites. head upright/forward when drinking liquids, not leaning back every shift. -Speech eval and treat A Swallow Evaluation Document dated 3/14/25, completed by an Essentia Health Speech therapist indicated R86 had oropharyngeal dysphasia characterized by weakness and decreased coordination. The evaluation recommended cues for head positioning, cues for small bites/sips and follow-up therapy after neurology consult. A nursing note entered on 3/24/25, indicated R86 had had an episode where they could not swallow chicken and had coughed it up on their own. The note referred to speech therapy recommendations and orders in chart for supervision with meals. A provider note dated 3/25/25, included the diagnosis oropharyngeal dysphagia and indicated R86 had been prescribed a new diet order for ground meat post choking episode without overt aspiration. R86's MDS assessment dated [DATE], lacked the following coding: -Section I Active Diagnoses failed to identify R86 had a diagnosis of dysphagia. -Section K Swallowing/Nutrition disorder part K0100 did not identify documented symptoms of possible swallowing disorder that had been identified in R86's medical record. -MDS Section GG - Functional Abilities and Goals failed to identify R86 required supervision with eating. During an interview on 4/17/25 2:07 p.m., RN-E explained when completing the MDS documentation for the seven day look back period gets reviewed. We also meet and review GG during facility IDT meetings. R86 should have been coded for supervision with meals, the risks factors for swallowing should have been coded and the dysphagia diagnosis should have been coded and added to R86's active diagnoses. It is important for these things to be coded correctly so additional changes can be made to update the resident's plan of careplan and the Kardex for staff to follow. The policy Electronic Transmission of the MDS dated [DATE], indicated the MDS coordinator was responsible for all ensuring all appropriate edits were completed prior to the transmission of MDS data.

Based on interview and document review, the facility failed to ensure fluid restrictions were monitored for 2 of 2 residents (R5, R31) reviewed for quality of care. In addition, the facility failed to notify the provider upon resident refusal of medication and when a resident's weight went outside prescribed parameters for 1 of 1 resident (R45). Findings include: R5: R5's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R5 had intact cognition. Diagnoses included anemia and end stage renal disease. R5 currently received hemodialysis. R5's care plan dated 11/14/24 indicated a risk for altered fluid balance related to (R/T) kidney disease and heart disease: 1200 milliliter (ml) fluid restriction. R5's provider orders dated 3/15/25 indicated a 1200 ml fluid restriction to be documented on each shift. Review of R5's medical record indicated the following: - On 4/9/25 1580 ml of fluid was received - Fluid intake documentation was missed on 3 shifts, NA was charted on 3 shifts and an X was charted on 3 shifts instead of that shift's fluid intake. R31: R31's significant change MDS assessment dated [DATE], indicated R31 had intact cognition. Diagnoses included anemia, heart failure, and renal insufficiency. R31's care plan last revised on 1/31/25, indicated resident had congestive heart failure with an intervention that included a 64 ounce/day (1920 ml) fluid restriction. R31's orders dated 7/29/24 indicated a 64 ounce/day (1920 ml) fluid restriction to be charted on every shift. Review of R31's treatment records for 1/25-4/25 indicated the following: - During month of 1/25 3 shifts did not document any kind of intake, and 13 shifts documented NA instead of an intake number. - During the month of 2/25 9 shifts did not document any kind of intake, and 6 shifts documented NA instead of an intake number. - During the month of 3/25 7 shifts did not document any kind of intake, and 5 shifts documented NA instead of an intake number. - During the month of 4/25 4 shifts did not document any kind of intake. During an interview on 4/16/25 at 7:46 a.m., licensed practical nurse (LPN)-A stated dietary would send up a set amount of liquid with each meal. Nursing staff also had a set amount of fluid that could be given outside of mealtime. The nurse assistants kept track of the numbers and gave them to nursing to enter in the computer each shift for a total amount every 24 hours. LPN-A confirmed R5 and R31 were on fluid restrictions of some kind. During an interview on 4/16/25 at 10:59 a.m., registered nurse (RN)-C stated nursing entered the total number of intakes each shift. She confirmed R5 and R33 had shifts that either had no documentation or NA as documentation for the month of 4/25. Keeping track of fluid intake when residents have ordered fluid restrictions was important because of the increased risk of fluid overload for residents with heart failure or on dialysis. During an interview on 4/16/25 at 11:18 a.m., the director of nursing (DON) stated fluid intake should be documented on all shifts. A fluid restriction policy was not provided. 48109 R45: R45's significant change in status Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of atrial fibrillation (an irregular heart rhythm), morbid obesity, chronic kidney disease, hypertension, and chronic obstructive pulmonary disease (COPD, a lung and airway disease which restricts breathing). R45's provider orders dated 3/21/25, identified to weigh R45 every other day in the morning before eating or drinking. Call the Heart Center for weight gain of three pounds overnight accompanied by any symptoms of fluid retention; Weight gain or loss of five pounds or more in a week. An order dated 3/13/25 identified Torsemide (a diuretic used to treat fluid retention) 20 milligrams (mg) one time daily. R45's care plan dated 3/24/25, identified a risk for ineffective peripheral tissue perfusion related to edema (excess fluid). Interventions included evaluating for edema, to educate R45 on the necessity to provide care and treatment due to his history of refusing medications and treatments, to notify provider of new-onset findings, and to provide verbal feedback to resident. R45's electronic medical record (EMR) for April 2025 identified the following weights: -4/10 366.4 -4/12 373 -4/14 R45 refused to be weighed. -4/16 380.4 On 4/16/25, R45's medication administration record (MAR) for April 2025, identified R45 refused torsemide from 4/10/25 through 4/16/25. R45's progress notes in the EMR didn't reflect provider notification of weight gain or refusals of medication. During an interview on 4/14/25 at 3:53 p.m., R45 stated he refused the diuretic because it made him go to the bathroom so much, he couldn't control his bladder, so he refused it daily. During an interview on 4/16/25 at 1:40 p.m., licensed practical nurse (LPN)-B confirmed she was the nurse caring for R45 today. LPN-B stated the provider was aware of R45's refusals of torsemide and they normally make a progress note when they update the provider, but sometimes information got put in a provider rounding book which was not part of the EMR. LPN-B stated would call the provider if a resident's weight was up or down five pounds, otherwise they fax the weights to the heart center every couple of months. During an interview on 4/16/25 at 1:55 p.m., registered nurse (RN)-B nurse manager stated she wasn't aware R45 had been missing his diuretic or had weight gain. RN-B stated she would expect the nurse to update the heart center with five pound or more gain or loss. For R45, the risk of having too much fluid would be going into heart failure. During an interview on 4/17/25 at 1:23 p.m., RN-B nurse manager stated she had found an SBAR (acronym for situation, background, assessment, and recommendation) communication on 4/10/25 updating the provider of torsemide not taken that day. The communication wasn't part of the EMR. During an interview on 4/17/25 at 3:54 p.m., the director of nursing (DON) would expect a provider be notified when a resident with weight parameters gained weight and would expect vital signs and an assessment be done when a resident like R45 gains weight, and that the weights were reported to the provider. A policy, Refusal of Treatment dated 6/30/21, identified the facility shall honor a resident's request not to receive medical treatment as prescribed by their physician, as well as care routines outlined on the resident's assessment and plan of care. The policy identified if a resident refused a treatment the unit manager, DON, or charge nurse would interview the resident to determine why they were refusing and to try address the concern. Detailed information about the resident refusal should be documented in the medical record. Documentation must contain the date and time of attempted treatment or medication, what was refused, the resident's response and reason for refusing, the name of the person attempting the treatment or medication, that the resident was informed of the reason for the treatment and possible consequences of not receiving the medication or treatment, date and time physician was notified, and the resident's condition. Notification of physician must be made in a time frame determined by the resident's condition and potential serious consequences of the refusal.

Based on interview and document review, the facility failed to ensure weekly skin checks were performed for a resident who developed a pressure ulcer in the facility, to ensure the resident care plan included the presence of actual pressure ulcers, with individualized interventions based on assessment to include turning and repositioning frequency, the presence of integrated wound therapies, an actual wound infection, and manufacturer's recommendations for checking inflation of a Roho (specially designed inflatable wheel chair cushion) for 1 of 2 (R21) residents reviewed for pressure ulcer care. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of multiple sclerosis (MS), quadriplegia, muscle weakness and unstageable pressure wound to left buttock. The MDS identified R21 had limited range of motion in the upper and lower extremities and needed maximum assistance with bed mobility. The 3/6/25 MDS indicated a risk for pressure sores but no actual pressure sore. R21's provider orders identified: -Weekly skin checks on bath days, with a revision on 3/31/25 to include checking the Roho cushion to make sure it was inflated every Tuesday evening. -On 4/4/25 an order for protein supplement shakes three times per day and sulfamethoxazole-trimethoprim (an antibiotic used to treat infections) for 10 days for wound infection. -On 4/10/25 an order for Dakin's half-strength to left ischial tuberosity (bony prominence under buttock) every day shift, cleanse with wound cleanser, apply Dakin's wet to dry, cover with abdominal pad and tape in place. R21's care plan dated 6/17/24 identified a risk for pressure ulcer development related to diagnoses with interventions to monitor for signs and symptoms of infection, administer pain medication as ordered, pressure reducing custom cushion in wheelchair, pressure reduction mattress, weekly treatment documentation, and a new intervention dated 4/9/25 to check Roho cushion for proper inflation. R21's care plan also identified a risk for infection related to chronic wound dated 4/11/25 with interventions to evaluate for signs and symptoms of infection, and to put enhanced barrier precautions in place. R21's electronic medical record (EMR) identified the following: -3/18/25 Weekly Bath Audit V9 completed, no skin issues noted -3/22/25 progress note: Resident had shower this evening. Staff noted redness on perineal/buttock area. Barrier cream applied and oncoming night shift nurse notified. - 3/25/25 progress note: Skin clean, dry and intact. Nothing unusual. - 3/30/25 progress note: Resident has wound to left buttock. Dressing had drainage and odor, cleaned with wound cleanser and covered with foam border dressing. -3/31/25 progress note: Tylenol for sore backside with pain rated 7/10 -3/31/25 first picture and measurements of the wound which measured 7.6 centimeters (cm) by 4.2 cm by 2.4 cm deep. -3/31/25 progress note: Notified that resident has new open area on left buttock. Resident states My ass hurts, it's like someone put a cigarette out on it Writer and Nurse manager assessed area. Unstageable pressure injury to left ischium present measuring 4.3 x 2.5 x 0.1 cm. Wound bed is 100% slough with odor present. Foam border dressing applied. Resident is currently on a foam pressure reducing mattress and a ROHO cushion in his wheelchair. ROHO was noted to be flat, resident states that probably has been that way for a while as he noted discomfort while sitting in wheelchair. ROHO was properly reinflated. Eldercare NP notified and saw resident on facility rounds. Received order to cleanse, then apply Santyl and foam border dressing daily and to have Integrated Wound Care (IWC) evaluate and treat on next rounding day. Resident is his own responsible party. -4/1/25 Weekly Bath Audit V9 completed noting open are on left buttock. Old dressing fell off and new dressing completed. -4/3/25 Interdisciplinary Team (IDT) met and reviewed wounds. Resident seen by ADON and LPN NM on 4/2/25. Currently monitoring unstageable pressure injury to left ischium which is new this week. See wound assessment for measurements and orders for treatment. Current interventions include ROHO cushion in w/c and foam mattress in bed, encourage to offload area while in bed. Will add to IWC rounds next week. -4/9/25 Skin and Wound Evaluation form identified a new, unstageable pressure ulcer but didn't have sections filled out for assessment and plan. No other assessments for that wound were located. During an interview on 4/14/25 at 5:57 p.m., R21 stated he had a sore on his bottom, it hurts sometimes but not right now. R21 said they changed the dressing every day. R21 was positioned with a pillow under the left hip. During an interview on 4/15/25 at 2:57 p.m., nursing assistant (NA)-C stated they were positioning R21 every hour when they could, but for sure before two hours. NA-C stated R21 did get up in the wheelchair sometimes, but not so much lately because of his sore, but he wasn't aware of anything special they needed to do with his cushion. NA-C stated he would either look at the care plan or ask someone to know how to care for residents. During an interview on 4/15/25 at 3:15 p.m., physical therapy assistant (PTA)-E confirmed he was currently working with R21 for range of motion in the upper and lower body. They have had to modify the lower body stretches because of the sore on his left buttock. PTA-E stated R21 has had the Roho cushion for as long as he has worked here. PTA-E said as he understands it, the cushion was found to be flat after resident had been using it, and an occupational therapist refilled it. PTA-E wasn't sure if any education was done with staff about the cushion and proper inflation, he would say to check inflation daily, especially if a resident has a sore. In PTA-E's opinion, R21 wouldn't be able to shift his weight on his own even if he was reminded, he needed physical assistance. During an interview on 4/15/25 at 3:34 p.m., NA-E stated she had not been taught anything about R21's Roho cushion, but she would just press on it before using it and if it was good and firm she would use it. If not, NA-E would report to the nurse. During an interview on 4/17/25 at 9:17 a.m., NA-D stated he knew there was a special cushion for R21's wheelchair but wasn't aware of anything special that needed to be done with it. During an interview on 4/17/25 at 12:14 p.m., licensed practical nurse (LPN)-B confirmed she was familiar with R21 and what they were doing differently since he had a wound was to make sure the Roho cushion was fully inflated. LPN-B added that a spare pump was in his room now, and they were all educated on making sure the cushion was full. LPN-B stated there wasn't repositioning on his care plan yet, they all just knew to reposition him, she would guess it is more frequent than every two hours. During an interview on 4/17/25 at 1:09 p.m., registered nurse (RN)-B nurse manager stated the intervention added to R21's care plan after he developed the wound was to check every week that the Roho cushion was fully inflated. RN-B stated therapy came up and made sure the cushion was properly reinflated after it was found to be flat, and some verbal education was done with floor nursing staff. RN-B stated she wasn't familiar with the Roho cushion manufacturer's directions but could look them up. The assistant director of nursing (ADON) added they relied on the standard of care for repositioning every two to three hours. The interventions on the care plan were all standard, but they could personalize it. The ADON stated the expectation was that weekly bath audits were done weekly, even if the resident refused their bath or shower, they should offer a bed bath, document, and still do the skin inspection. The ADON feels they may have been able to put interventions in sooner if the skin inspections had been done. During an interview on 4/17/25 at 3:53 p.m., the director of nursing (DON) stated it was her expectation to reposition residents routinely, which was every two to three hours, and she would expect skin inspections to be done weekly. The DON stated it would be impossible to say whether or not the wound would have been found sooner if weekly skin checks were done because they weren't done. A policy, Prevention of Pressure Injuries dated 9/29/21, identified its purpose was to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. The policy indicated all residents at risk for or with actual pressure ulcers will be repositioned on an individualized schedule as determined by the interdisciplinary care team. A document submitted by the facility, Annual Education dated November 2024, identified mandatory education topics for NAs. Topics listed included positioning and wound reporting, but the document didn't contain information on the curriculum. Education material provided to staff regarding Roho cushion inflation was requested but not received.

Based on observation, interview and document review, the facility failed to comprehensively assess prior to resident use of bed rails for 1 of 1 resident (R52) reviewed for bed rail use. Findings include: The Guidance for Industry and Federal Drug Administration (FDA) Staff, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued on 3/10/24, indicated a comprehensive assessment to prevent entrapment should be looked at when bedrails are considered for a resident. The comprehensive assessment included seven zones to look at and take measurements of which included the following: Zone 1: Within the rail Zone 2: Under the rail, between the rail supports or next to a single rail support. Zone 3: Between the rail and the mattress. Zone 4: Under the rail and the mattress. Zone 5: Between split bed rails. Zone 6: Between the end of the rail and the side edge of the head or footboard. Zone 7: Between the head or foot board and the mattress end. R52's quarterly Minimum Data Set (MDS) dated [DATE], indicated R52 had moderate to severe cognitive impairment. Diagnoses included dementia, Huntington's disease and depression. Section G- Functional Abilities and Goals indicated R52 had impairments to both sides of the upper and lower body and was dependent for all mobility needs. R52's care plan dated 4/17/25, indicated a physical mobility impairment related to Huntington's disease and intervention included assist resident to perform movements/tasks. It further identified an activity of daily living self-care need with interventions that included extensive assist of two staff to turn and reposition in bed. Bedrail in place to promote independence. R52's Bedrail Risk Assessment (BRA) dated 9/13/24, indicated four sections are looked at: - Section one looked at risk of climbing out of bed, resident confusion state and if bedrails present a higher risk to falling out of bed. - Section two looked at has an alternate to bedrails been looked at, can resident roll, slip or slide out of bed; has resident been consulted about rails; does resident understand the purpose for bedrails, is family involved. - Section three looked at is the resident small in stature, does the resident have a large head, is there a gab between the lower rail and the mattress will the bedrail fall off the bed and if any of the mentioned will create an entrapment hazard? - Section four looked at the gap between the bedrail and the headboard, if the bedrail fits correctly, is secure, is compatible with the bed and in working order. The BRA lacked information related to zone 1, Zone 2, the footboard portion of zone 6, and zone 7. The BRA also lacked documentation what alternatives were attempted prior to the use of bedrails. On 4/14/25 at 2:27 p.m., R52's bed was observed and there was a half bedrail attached to both sides of the bed, in the middle of each side of the bed. During an interview on 4/15/25 at 11:48 a.m., the maintenance supervisor (MS) stated when a request is made for a bedrails, they made sure there were provider orders entered into the resident medical record. Once orders were confirmed the bedrails would be placed on the bed. The MS stated they did not do any measurements or other items related to bed assessments that involved concerns related to entrapment. During an interview on 4/16/25 at 12:33 p.m., the administrator stated therapy department did the evaluations each time bedrails were recommended for a resident and assessments were completed based on policy. During an interview on 4/17/25 at 8:55 a.m., physical therapy assistant (PTA)-A stated she performed the bedrail assessments for all residents who had bedrails recommended to be placed. The assessment was performed on the same day maintenance placed the rails on the beds. There was a form that was filled out that looked at all parts of the bed and the bedrail to make sure everything is safe. Measurements were taken from the top of the rail to the headboard and then I made sure the gap between the bedrail and the mattress was no bigger than the width of my hand. There were no other measurements taken when risk of entrapment was looked at. PTA-A reviewed R52's BRA dated 9/13/24 and acknowledged she had performed that assessment and this was the most recent/last assessment she had completed. Facility policy Bed Safety and Bed Rails last reviewed 10/18/22, indicated bed frames, mattresses and bedrails would be checked for compatibility and size prior to use. Regardless of mattress type, width, length, and/or depth, bedframe, bed rail and mattress will leave no gap wide enough to entrap a residents head or body. Any gaps in the bed system are within the safety dimensions established by the FDA.

Based on observation, interview, and document review, the facility failed to ensure residents were free from mental and emotional abuse for 4 of 4 residents (R1, R2, R3, R4) when nursing assistant (NA)-A took humiliating photographs of residents and video recordings of residents which NA-A then posted on Snapchat (social media). In addition, the facility failed to ensure residents were free from physical abuse when NA-A physically abused R1 when assisting R1 into bed. NA-A also video taped this abuse and posted on Snapchat. These actions had the potential to cause serious psychosocial and physical harm to residents. This deficient practice resulted in an immediate jeopardy (IJ). The IJ began on 6/17/24, when the Minnesota Department of Health received an allegation that NA-A shared numerous pictures and videos on social media of R1, R2, R3 and R4. The pictures contained exposed resident private areas, residents in underwear, lewd gestures from NA-A to residents, and videos of NA-A abusing a resident. The administrator and director of nursing (DON) were informed of the IJ on 6/24/24, at 5:32 p.m. The IJ was removed on 6/26/24, at 4:11 p.m. but non-compliance remained at the lower scope and severity, of a level 2 at an E-pattern, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 6/24/24, at 10:25 a.m. during an interview reporter (R)-A stated she had been sent pictures and videos of various residents currently at the facility by NA-A. R-A stated NA-A had been taking and sending pictures for months, however the images and videos seemed to be getting worse in nature. R-A stated she had called the facility administrator sometime between Thanksgiving 2023 and Christmas 2023 and informed him that NA-A was taking pictures of residents and posting them on Snapchat. R-A stated the facility administrator told her that if NA-A was taking photos he would be aware due to the fact that there were cameras in the facility. NA-A stated she had told the administrator that she had proof of this however he did not request to see the photos. R-A stated the photos and videos NA-A had been taking and posting on social media seemed to be getting worse. R-A stated she had both video and photos that she would send to the state agency (SA). R-A stated NA-A had been taking video and photos for approximately 12 months and the last time NA-A had posted residents on social media was a week ago. On 6/24/24, at 12:24 p.m. the SA received both video and photos sent by R-A. The photos and videos were reviewed and revealed the following: On 6/24/24, at 12:34 p.m. review of an undated video which lasted approximately 29 seconds revealed the following. Nursing assistant (NA)-A is seen setting up a camera to record her interaction with R1. NA-A is seen aggressively throwing R1 into bed. NA-A is then seen removing R1's shoes and throwing them on top of R1's bare chest and hitting him in the face with one of the shoes. R1 is heard mumbling what sounds like ouch. NA-A proceeds to give R1 the middle finger. On 6/24/24, review of photographs revealed a picture taken by a cell phone by an unidentified staff giving R1 the middle finger while R1 was seated in his wheel chair. On 6/24/24, review of photographs revealed a picture taken by a cell phone with R2 lying in her bed holding a cell phone with a picture of a penis with the caption Not XXX (included the name of the resident) showing me the dick pick she gets. On 6/24/24, review of photographs taken by a cell phone revealed R3 lying on his back in his bed with only his underwear on. On 6/24/24, review of photographs taken by a cell phone revealed a picture of R4 lying in her bed on her left side with no clothing on. R4's bare back, buttocks, wound dressing on sacral region and female genitalia exposed along with what appears to be Kleenex with BM. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included cerebral palsy, congenital deformities of the hip, and mental disorder. R1's MDS indicated R1's cognition was moderately impaired. R1's care plan dated 8/23/23, indicated R1 had a self-care deficit related to weakness and required assistance with activities of daily living (ADLs) and requires extensive assist by staff to turn and reposition in bed and assist with feeding and meal set up. R1's care plan also indicated R1 had a risk and a potential for abuse due to physical impairments, communication impairments and cognitive impairments. R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had diagnosis which included history of stroke, immobility and depressive disorder. R2's MDS indicated R2 was alert and orientated. R2's care plan dated 5/23/23, indicated R2 required extensive assist with ADLs such as transferring, repositioning, and dressing. R2's care plan also indicated a potential communication problem and difficulty communicating her needs related to slurring of speech. R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 had diagnosis which included psychological development and anxiety disorder. R3's MDS indicated R3 cognition was moderately impaired. R3's MDS also indicated lacks insight, is impulsive and misinterprets information. R3's care plan dated 5/29/24, indicated R3 uses antidepressants related to medication, anxiety and depression. R3's care plan also indicated R3's behaviors included restlessness, extreme fixation on events to the point of emotional distress, inappropriate boundaries. R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had diagnosis which included morbid obesity, right below the knee amputation and pressure ulcer of the sacral region. R4's MDS indicated R4 was alert and orientated. R4's care plan dated 5/15/23, indicated R4 required extensive assist with ADLs such as transferring, repositioning, and dressing. R4's care plan indicated R4 has a history of misconstrued relationships with staff as being more than professional without the knowledge of the caregiver. Resident may attempt to have inappropriate caregiver relationships by using social media to contact or get information about caregiver. R4 will maintain a professional only relationship with caregiver and staff will provide education to resident as needed regarding appropriate and inappropriate relationship with caregivers. On 6/24/24, at 1:05 p.m. NA-A was shown video and interviewed: -NA-A was shown the video of a female staff setting up a camera to record her interaction with R1. NA-A verified the staff in the video was herself. NA-A verified she aggressively threw R1 into bed. NA-A verified she removed R1's shoes and throwing them on top of R1's bare chest and hitting him in the face with one of the shoes. NA-A verified she gave R1 the middle finger prior to shutting off the phone. NA-A verified it was her cell phone used to take this video. NA- A verified she had posted this picture on the social media site Snapchat. -NA-A was shown the picture with R1 being given the middle finger by an unidentified staff. NA-A verified she had taken this picture of herself giving R1 the middle finger with her cell phone and also had posted this picture on the social media site Snapchat. -NA-A was shown the picture with R2 lying in her bed holding a cell phone with a picture of a penis with the caption Not XXX (included the name of the resident)showing me the dick pick she gets. NA-A verified she had taken this picture with her cell phone and also had posted this picture on the social media site Snapchat. -NA-A was shown the picture that revealed R3 lying on his back in his bed with only his underwear on NA-A verified it was her cell phone used to take this photo. NA-A verified she had posted this picture on the social media site Snapchat. -NA-A was shown the picture of R4 lying in her bed on her left side with no clothing on. R4's bare back, buttocks and female genitalia exposed along with what appears to be Kleenex with BM. NA-A verified it was her cell phone used to take this photo. NA-A verified she had posted this picture on the social media site Snapchat. On 6/24/24 at 1:05 p.m., NA-A was interviewed and stated she was aware of the facilities no phone policy while providing care to the residents. NA-A further stated she was aware of the no posting of any residents on social media. NA-A stated this was for the resident's privacy. NA-A stated throwing a resident into bed and throwing shoes on top of a resident could cause injury. NA-A further stated she had no excuse for taking and posting of the pictures. NA-A stated her actions were considered abusive. On 6/24/24 at 1:19 p.m. the facility administrator and director of nursing (DON) were interviewed. The facility administrator stated cell phones were not allowed on the floor. The facility administrator further stated posting of any residents on social medical was not allowed and would be a violation of the resident's privacy. The DON and administrator both indicated their expectation was that all staff were following the cell phone policy and social medial polices which were important to ensure all residents privacy. When shown the video and photos, facility administrator instructed the DON to remove NA-A immediately from the floor and to call the police. The administrator denied ever receiving a phone call where it had been reported to him that NA-A had been taking abusive and humiliating photos and videos of residents and then posting them on social media. On 6/24/24, NA-A was terminated for violation of the facilities social media policy. A facility form titled Disciplinary Action Form dated 6/24/24, which was signed by NA-A, HR-A, DON, and administrator indicated the reason for termination as Violation of Social Media Policy. The form also included NA-A's comment I have no excuse for my actions, and I am extremely sorry for what I did. On 6/24/24, at 2:09 p.m. R3 was interviewed and stated he would be embarrassed to have a picture taken of him in his underwear. R3 further stated he would never want someone to see him without his clothing on. R3 also stated NA-A always had her phone on her when she is providing cares for him. On 6/25/24, at 12:15 p.m. Medical Director (MD)-A was interviewed and stated the administrator had emailed him on 6/25/24, informing him that a NA had been taking photos and videos of residents and posting them on Snapchat. MD-A stated this event was tragic and law enforcement had been notified. MD-A stated from what he was told by the facility administrator there were no words to describe the videos and photos NA-A had taken of residents and posted on social media. MD-A stated he did not want to see the videos or photos however from what he had been told they were horrific. MD-A stated as the medical director his expectation was that all staff were following facility policies and procedures to ensure resident safety and prevent abuse from occurring, On 6/26/24, at 1:25 p.m. FM-A was interviewed and stated he was the responsible party and brother for R1. FM-A stated the facility had called to informed him that R1 had been mistreated by a staff. FM-A stated the facility informed him it involved staff being rough with R1 and it was on video. FM-A stated R1 would not be able to recall any events due to his medical conditions. FM-A stated he cannot believe this happened to R1 and his expectation was that staff were following rules which would prevent these things from occurring. On 6/26/24, at 2:18 p.m. FM-B was interviewed and stated he was the responsible party and brother for R3. FM-B stated the facility had called to inform him that a staff had taken a photo of R3 in his underwear and posted it somewhere. FM-B stated he was very upset that this had occurred and was going to contact local law enforcement himself. FM-B further stated during a visit on 6/26/24, R3 had told FM-B that NA-A had taken pictures of another residents' feces and showed it to R3. FM-B stated this was awful and never should have happened to R3. On 6/26/24, at 2:37 p.m. NA-B was interviewed and stated she had witnessed NA-A giving residents the middle finger as well as throwing food at residents. NA-B stated giving the middle finger to a resident and throwing food at a resident was considered abuse. NA-B stated she had not reported this to facility leadership. NA-B further stated staff was afraid of NA-A and NA-A could be loud and aggressive but had never seen NA-A be physically abusive towards residents. On 6/27/24, at 9:27 a.m. R4 was interviewed and stated she had been informed by the local law enforcement that NA-A had taken a picture of her with no clothing on and completely exposed and posted the photo on Snapchat. R4 started to cry during the interview and stated she considered NA-A her friend and didn't understand why she would do this to her. R4 stated she felt violated and humiliated. R4 further stated she feared that because this was on social media, she would have no idea how many people had seen the photograph of her unclothed. R4 stated she hoped that NA-A was charged legally so that NA-A could never do this to another person. R4 further stated NA-A was always on her phone when providing care on the unit but never thought she was using her phone to take pictures of her. R4 stated she felt safe at the facility. On 6/27/24, at 948 a.m. R2 was interviewed and stated she had been informed by the local law enforcement that NA-A had taken a picture and posted it on social media. R2 stated she had been told it was a picture taken by a cell phone with R2 lying in her bed holding a cell phone with a picture of a penis with the caption Not XXX (included the name of the resident) showing me the dick pick she gets. R2 started to cry and stated she was so embarrassed and concerned that others had seen this photo which was on the Internet. R2 further stated she was upset that her privacy was violated but felt safe at the facility. The IJ was removed on 6/26/24, at 4:11 p.m. when it was verified the facility had submitted and implemented an acceptable removal plan which included policy review and appropriate education and training of all employees, including licensed nurses, nursing assistants, therapy staff, activity staff, dietary staff and housekeeping staff. This was verified through interviews, policy review and education transcripts/training attendance records. The facility policy titled Abuse Prevention Policy revision date 1/9/24, directed staff to provide a safe living environment to all residents of the facility and to provide guidelines for investigating and reporting of suspected maltreatment. The policy description of abuse included the following, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Which included the following: -Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. -Use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability Sexual harassment and sexual abuse. -Physical abuse, hitting, slapping, kicking, biting, scratching, pushing, pinching or any other corporal punishment. -Mental abuse, unnecessary exposure of residents, inappropriate teasing, ridiculing, patronizing speech or behavior toward a resident. All health care workers, regardless of place of employment, who provide services in a facility are mandated reporters. The facility policy titled Videotaping, Photographing, and Other Imaging of Residents review date 12/8/21, included the purpose of the policy is to ensure residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities. The policy directed that staff may not take or release images or recordings of any resident without explicit written consent, transmitting unauthorized images of any resident through email, Internet or social media is considered a violation of resident rights and any image or recording taken that may be construed as humiliating or demeaning to a resident or residents is considered resident abuse and will be reported and investigated as such. The facility policy titled Telephones, Employee Use of review date 7/21, directed staff cellular phones may be used for personal calls and text messaging ONLY when the employee is on authorized meal and break periods. Employee cell phones will remain off and/or silent during all other work hours and failure to comply with cellular phone policies may result in disciplinary action.

Based on interview and document review, the facility failed to ensure a resident's advance directives were accurately and consistently documented in the resident's electronic health record (EHR) banner, Provider Order for Life Sustaining Treatment (POLST) and physician orders to ensure the residents wishes would be followed in the event of a cardiac arrest. This resulted in an immediate jeopardy for 1 of 34 residents (R86) who's code status was not accurately documented and was reviewed for advanced directives. The immediate jeopardy (IJ) began on [DATE], at R86's first care conference. The care conference identified R86 and family member (FM)-A as being in attendance. Section C Nursing included the following: Resident continues to be a full code. Section E Social Services identified R86's code status as Full Code. R86's POLST located in the EHR scanned documents dated [DATE], identified R86 as Do Not Resuscitate. In addition, when the facility became aware of the discrepancy they changed the banner in the EHR to DNR to match the POLST, which was against the resident's wishes to be resuscitated. The administrator was notified of the immediate jeopardy on [DATE] at 5:44 p.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level D, which indicated no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: On [DATE] at 7:56 a.m., R86's EHR banner in point click care (PCC) identified R86 as a full code. R86's Order Summary report dated [DATE], indicated full code status. R86's most current Physician's Orders for Life Sustaining Treatment (POLST) located in the scanned EHR, signed via telephone by R86's family member (FM)-A and medical doctor (MD)-A on [DATE] and [DATE], identified R86's wishes were do not resuscitate (DNR). On [DATE] at 8:54 a.m., licensed practical nurse (LPN)-A reviewed the POLST book at the nurses station for R86. The book revealed R86's POLST dated [DATE], as DNR. LPN-A verified the computer and the book did not match and she said she thought R86 was a full code. On [DATE] at 9:01 a.m. LPN-B stated he would check a resident's code status by looking in the computer or in the POLST book. LPN-B stated the POLST book would be the most up to date, but if it didn't match the computer staff would need to do CPR. On [DATE] at 9:07 a.m., the assistant director of nursing (ADON) stated she would expect staff to verify the code status by checking the POLST book located on each nursing unit. The ADON reviewed the POLST book and the EHR and verified they did not match. The ADON stated code status should be reviewed at each care conference. On [DATE] at 9:20 a.m., R86's Order Summary identified R86's code status as DNR. This DNR order was recently created by the assistant director of nursing (ADON), following the facility becoming aware of the discrepancy. On [DATE] at 9:38 a.m., registered nurse (RN)-A stated staff could check a resident's code status in the computer or in the POLST book, and said the POLST book should be the most up to date. RN-A stated she would go by the POLST book if they did not match, which indicated DNR. On [DATE] at 1:55 p.m., FM-A said she recalled September of 2023 as very busy but thought originally R86's code status was DNR. FM-A stated she recalled a meeting over the telephone (she was unsure of the date) and said R86 wanted to be full code so his status was changed to full code. FM-A stated R86's current wishes were to be resuscitated. On [DATE] at 2:26 p.m., the ADON stated they changed R86's order to DNR to match the POLST but they had not talked with FM-A. The ADON stated they had a phone call out to her but had not heard back. A review of R86's care conferences notes dated [DATE], [DATE], and [DATE], identified the code status was listed as full code. The care conferences attendees included FM-A, LSW(s), and nursing services. On [DATE] at 3:12 p.m., licensed social worker (LSW)-A and the ADON verified at each care conference the code status is reviewed by stating the status aloud. This would give anyone present to agree or disagree. They would not review the actual POLST unless there was a concern. On [DATE] at 4:22 p.m., RN-B stated she recalled the care conference on [DATE], and stated it was the initial care conference. RN-B stated she reviewed code status and explained in detail what CPR entails. She recalled the code status as full code and no objections were made by R86 or FM-A. RN-B stated the process was to review the code status by looking at the EHR banner and not by reviewing the actual POLST. LSW-B stated her recollection of the care conference was the same as RN-B's. On [DATE] at 5:03 p.m., the EHR banner in PCC identified resident code status as DNR. The POLST in the EHR was the POLST dated [DATE] and continued to indicate DNR A chart review of R86's care conference notes identified the following: -[DATE], R86 and FM-A were in attendance, section E identified Full Code -[DATE], R86 and FM-A were in attendance, section E identified Full Code Social Service progress note dated [DATE] at 1:47 p.m., identified they spoke to FM-A who verified originally the POLST was DNR, but was shortly after changed to CPR per R86's wishes. FM-A stated the current code status should be CPR. The immediate jeopardy that began on [DATE]. was removed when the facility developed and implemented a systematic removal plan. The removal plan was verified on [DATE], through interview and document review. The facility had corrected the code status for R86 to full code. R86's POLST in the EHR was listed as full code dated [DATE], per R86's wishes. In addition, the facility completed a facility wide audit to ensure there were no other code status discrepancies, reviewed polices and procedures, and provided education for staff involved with care conferences.

Based on interview and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) who was at risk for elopement. This resulted in an immediate jeopardy (IJ) for R1 when he eloped from the facility, was not identified as missing for 1.25 hours and found 2 miles away from the facility. The IJ began on 4/15/24 at 6:37 a.m. when nursing assistant (NA)-A saw R1 outside of the facility on the sidewalk in front of the building, mistook him for a visitor, and cleared the wanderguard door alarm without searching for a missing resident. The administrator and director of nursing (DON) were informed of the IJ on 4/18/24 at 4:30 p.m. The facility had implemented corrective action on 4/16/24, prior to the start of the survey and was therefore Past Noncompliance. Findings include: R1's Face Sheet undated indicated R1 had diagnoses of bipolar disorder and metabolic encephalopathy. R1's Elopement Risk Evaluation dated 4/10/24, indicated R1 had a history of exit seeking and attempting to leave the building which put him at risk for elopement. R1's Brief Interview for Mental Status (BIMS) dated 4/16/24, indicated R1 had moderate cognitive impairment. R1's Medication Administration Record dated 4/18/24, indicated R1 had a wanderguard on his right wrist from 4/11/24 at 10:00 p.m. to 4/15/25 at 9:48 a.m. R1's care plan dated 4/20/24, indicated R1 was at high risk for elopement and wandering. R1's progress note dated 4/15/24 at 9:49 a.m., indicated at around 8:00 a.m. staff where unable to locate R1. R1's guardian and management were notified, and a code 99 (missing resident) was called. The facility staff were unable to locate R1 and the police where called. Administrator reviewed cameras and saw R1 walking out the front doors of the building at 6:37 a.m. Family (F)-A received a call from R1 stated he needed a ride from the Government Building, two miles away, to request a ride back to the facility after checking his food stamp balance. R1's F-A returned R1 to the facility at 9:37 a.m. On 4/18/24 at 10:43 a.m., nursing assistant (NA)-A stated on 4/15/24 she was walking into the building around 6:30 a.m. and heard the Wanderguard alarm going off. She stated she saw a man outside that looked like a visitor. She had never seen him before but did not see anyone else. She asked the maintenance man to turn off the alarm. It was not until the code for a missing person (code 99) was called which included a description of what the missing resident was wearing. She realized it was the man (R1) she mistakenly thought was a visitor she had seen outside when she was walking into the building. On 4/18/24 at 11:04 a.m., maintenance worker (MW)-A stated on 4/15/24 at around 6:30 a.m., the Wanderguard alarm was going off. NA-A told him the man outside was going to smoke and he did it all weekend, and to turn off the alarm. MW-A stated he had never seen the man outside before. So he turned off the alarm. On 4/18/24 at 12:27 p.m., registered nurse (RN)-A stated she was unable to locate R1 on 4/15/24 and she did not hear an alarm going off that she could recall. RN-A updated the nurse manager on not being able to find R1. On 4/18/24 at 12:47 p.m., RN-B stated on 4/15/24, RN-A came to her at around 7:45 a.m. and stated she could not find R1. RN-B called a code 99 and started looking for R1 (approximately 1.25 hours after R1 was last seen outside) . While talking to staff she found out NA-A heard the alarm going off when she arrived to work and had MW-A assist her with turning off the alarm but they did not look to see if anyone was missing. On 4/18/24 at 1:02 p.m., the director of nursing (DON) stated on 4/15/24 RN-A and RN-B where the ones who came and told her R1 was missing. When the Wanderguard alarm was going off, she would expect staff to find the resident, and if they couldn't, they were to check to make sure everyone is in house. On 4/18/24 at 1:29 p.m., the administrator stated if the alarms go off at any door, staff should go to the alarm and find the person. If they were unable to find anyone, they should do a house sweep to make sure everyone is in house. The facility Elopement Policy reviewed 4/16/24 directed if an employee discovers an alarm going off without a resident present, he/she should: Search the immediate vicinity inside and outside the building for a resident with a wanderguard. If no resident is found, notify charge nurse and director of nursing services and ensure all residents with wanderguard are accounted for. The past noncompliance immediate jeopardy began on 4/15/24. The immediate jeopardy was removed, and the deficient practice was corrected by 4/16/24, after the facility implemented a systemic plan that included the following actions: Elopement policy and process education for all staff, audits being completed to ensure staff understand Elopement Policy and process 3 times weekly for one week then 1 time weekly for a month and then they will review in QAPI. R1 is currently located in a secured unit. Verification of corrective action was confirmed by observation, interview, and document review on 4/18/24.

Based on observation, interview, and document review, the facility failed to protect a resident from sexual abuse and failed to implement protective measures to prevent ongoing abuse for 1 of 1 resident (R1) reviewed for abuse. This deficient practice resulted in an immediate jeopardy (IJ) when R3 was discovered sitting on top of R1 in the bed and pulling her pants down while R2 was standing next to the bed with their pants down below their knees. Further, the facility failed to implement protective measures, assess for ability to consent, and notify R1's physician of the incident. The IJ began on 2/17/23, when family member (FM)-A reported to registered nurse (RN)-C R1's R2 and R3 were found in R1's room. R3 was sitting on top of R1's legs, in her bed, pulling her pants down. R2 was standing next to R1's bed. The regional director of operations for Minnesota (RDO) and director of nursing (DON) were notified of the IJ for R1 on 3/8/23, at 2:21 p.m. The IJ was removed on 3/9/23, at 2:39 p.m. when the facility successfully implemented a removal plan; however, non-compliance remained at an isolated scope of potential for more than minimal harm (Level D). Findings include: R2's annual Minimum Data Set (MDS) dated [DATE], indicated a BIMS (brief interview for mental status) of 3, severe cognitive impairment and lacked evidence of any behaviors. R2's care plan 3/7/23, indicated potential for aggressive physical/verbal behaviors toward other related to severe cognitive impairment. R2's progress notes lack any evidence of physical or verbal behaviors toward other residents on 2/17/23. R3's significant change MDS dated [DATE], indicated a BIMS of 00, severe cognitive impairment and lacked evidence of any behaviors. R3's care plan 3/7/23, lacked any evidence of aggressive behavior or issue with relating to other resident. R3's progress note dated 2/17/23, at 9:21 p.m. indicated R3 had behaviors this shift. He followed a female resident into her room and attempted to assist her remove her pajama pants. Both residents [R2 and R3] were taking their shoes and started to take off their clothing when nursing assistant intervened. R1's admission MDS dated [DATE], indicated a BIMS of 00, severe cognitive impairment. R1 was independent for activities of daily living (ADLs) with set up and cues. Diagnoses included Alzheimer's disease and dementia. R1's care area assessment (CAA) indicated cognitive loss/dementia and behavioral symptoms were special need areas the facility would need to address. R1's care plan dated 2/13/23, indicated R1 had severely impaired cognitive function and impaired thought process. Interventions included cue, re-orient and supervise. The care plan also indicated R1 would be kept safe and free from abuse. R1's care plan lacked interventions to protect R1 from R2 or R3. During an interview on 3/7/23, at 10:58 a.m. FM-A stated: -On 2/17/23, FM-A came to visit. His wife's door was closed. He walked into R1's room and found R3 sitting on top of R1 with his buttocks on R1's ankles. R3 had R1's knees between R3's knees. R3 was actively pulling R1's jeans down. However, R1 had pajama pants on under the jeans. R2 was standing next to R1's bed. FM-A stated R1 started wearing jeans over her pajamas after she moved into the facility. FM-A stated he reported immediately R3 sitting on R1's ankle to the registered nurse (RN)-C on duty. -On 2/18/23, R3 had barged into R1's room, stopped and exited room when R3 realized FM-A was visiting. FM-A stated he reported this to RN-C -On 3/2/23, FM-A visited in the evening. R1 was asleep when he entered the room. FM-A woke R1. She sat up and pointed to a parka on the bedside table with R2's name in it. FM-A reported the parka to the RN-B immediately. -FM-A stated since 2/17/23, R1 cried and could not say why. On several occasions R1 had pointed to R2 and R3 and said they are bad men, she didn't like them. R1 was not able to explain why she felt this way. R1's progress note dated 2/17/23, at 8:29 p.m. indicated husband, family member (FM-A) reported concerns about an issue with a male resident who was following R1 in the halls and was found in R1's room removing R1's pajama pants. He states two male residents have exhibited this behavior toward his wife. Per nursing assistant (NA) R1 and R3 were removing both of their clothing and shoes. R1 and R3 were separated by staff and became upset. Nurse manager was notified. Staff to continue to monitor. However, R1's chart lacked evidence R1 was assessed for safety/injury, notification of provider, whether R3 was on top of R1's ankles, or if R2 was found in R1's room as reported by FM-A. R1's progress note dated 3/3/23, at 12:44 p.m. indicated FM-A had found R2's coat on R1's bedside table in her room. R1's Social Service-Resident Vulnerability and Susceptibility to Abuse-V3 form dated 2/20/23, at 3:22 p.m. indicated R1 was at risk for abuse related to cognitive impairment and physical impairment. R1 was also a vulnerable adult unable to report concerns related to abuse. Progress noted dated 2/20/23, at 3:11 p.m. social worker (SW) attempted to complete a PHQ-9 (mood assessment). Resident (R1) has been noted to have a couple tearful episodes. R1 was unable to state what made her upset. On 3/7/23, at 10:43 a.m. R3 was observed entering R1's room and then closed the door behind him. He left R1's room approximately 1 minute later. R1 was not in her room. During an interview on 3/7/23, at 11:43 a.m. RN-A stated on 2/17/23, she was notified of an incident which involved R1 and R3. Both residents were found in R1's room with their clothes partially off. RN-A talked with the staff and R1. She notified the director of nursing (DON). RN-A stated she had not talked with any of the other residents to see if they felt safe. The facility started R1 and R3 on 15-minute checks that ended at 8:00 a.m. on 2/20/23. RN-A reviewed the 15-minute check logs from 2/17/23 through 2/20/23. She confirmed R1 and R3's logs lacked documentation 15-minute checks were completed from 2:15 p.m. to 9:45 p.m. on 2/18/23. RN-A stated she was not aware R3 had reentered R1's room on 2/18/23. RN-A stated R3 could have re-entered R1's room and staff would not have been aware of it since 15-minute checks were not documented which indicated they had not been completed. RN-A stated after 2/20/23, there were no interventions in place to keep R1 safe from R3. RN-A stated R1, R2 and R3 were on a locked memory care unit and residents wandered into other resident rooms. Residents undressing other residents was normal behavior the facility was not worried about. During an interview on 3/7/23, at 12:26 p.m. nurse assistant (NA)-C stated R3 attempted to go into R1's room at least twice a day. She was not working on 2/17/23, but was aware that R1, R2 and R3 were on 15-minute checks from 2/17/23 to 2/20/23. After 2/20/23, there had been no interventions to keep R1, R2 and R3 separated. Staff were watching them and R1, R2, R3 were allowed to do, and gather like all other residents. NA-C stated residents were never allowed to assist other residents get undressed. Since the residents on the memory care unit were confused, acts such as sexual assault could happen if they help each other get undressed, especially since they would not know or be able to give consent related to their dementia. On 3/7/23, at 12:13 p.m. phone call to RN-C. Message was left to return call. During an interview on 3/7/23, at 12:58 p.m. the certified nurse practitioner (CNP)-A stated she had not been made aware of the incident on 2/17/23, involving R1, R2 and R3 and she should have been notified when the incident occurred. The facility should have followed their sexual assault/abuse protocol since the residents were found partially undressed and were unable to make decision themselves about being unclothed together. During an interview on 3/7/23, at 1:14 p.m. NA-E stated R3 had told her several times R1 was his girlfriend. NA-E saw R1 and R3 walking around the unit holding hands and standing close to each other a few times. She attempted to separate them but R3 would get mad and say R1 was his girlfriend. During an interview on 3/7/23, at 1:27 p.m. registered nurse (RN)-B stated on 3/3/23, FM-A brought a parka out of R1's room that had R2's name written on it. She confirmed the parka belonged to R2 and returned to R2. RN-B stated she did not know how the parka eneded up in R1's room because R2 would always wear the parka everywhere and would not let it out of his site. During an interview on 3/7/23, at 1:42 pm licensed social worker (LSW)-A stated when a resident-to-resident altercation occurred she talked with the resident, provided supportive measures for mental health and if needed worked with nursing orders for mental health providers to evaluate the residents affected. She was part of the interdisciplinary team (IDT) and resident to resident altercations would be discussed during meetings. She was aware of the concerns related to R1, R2 and R3 but had not checked on R1 to see how her mental health was since the incident on 2/17/23. LSW-A stated the IDT had never discussed R1, R2 and R3's incident in one of their meetings to see how to keep R1 safe from R2 or R3. During an interview on 3/7/23, at 2:26 p.m. NA-A stated she witnessed the incident on 2/17/23. R1 and R3 were in R1's room by her bed with their pants down below their knees. They were actively pulling up their jeans when she entered the room. NA-A stated R1 had a pair of pajamas on under her jeans that were still pulled up. R3's underwear was exposed, and R2 was sitting in the chair next to the bed. During an interview on 3/7/23, at 2:36 p.m. NA-B stated she witnessed the incident on 2/17/23, R1 and R3 were in R1's room by her bed with their pants down below their knees. They were actively pulling up their jeans when he entered the room. NA-B stated R1 had a pair of pajamas on under her jeans that were still pulled up, R3's underwear was exposed, and R2 was sitting in the chair next to the bed. During an interview on 3/7/23, at 1:52 p.m. the director of nursing (DON) stated she had been notified R1, R2 and R3 were in R1's room with clothes partially removed. She discussed it with the administrator. DON did not talk with any other staff or residents to see if there were concerns related to R3 or if the residents felt safe in the facility. DON stated residents in a memory care help other residents get undressed. We did not see it as sexual abuse because R1 did not make an accusation of abuse and nobody witnessed anything happened other than that two residents had their pants partially off. Just because the residents both had their pants off did not make it sexual abuse. All residents involved had severe cognitive impairment and were unable to consent to having their clothes removed by another resident. The facility did not place any interventions to keep R1 safe from R2 and R3 because we did not feel it was sexual abuse. During an interview on 3/7/23, at 3:16 p.m. the administrator stated the only investigation done was to get a statement from the NAs who worked 2/17/23 on the memory care unit and the nurse manager. Since nobody witnessed anything and R1 reported nothing happened, it did not need to be reported. Nor did the facility need to protect R1 from R2 and R3. On 3/8/23, at 8:33 a.m. and 10: 43 a.m. phone calls placed to RN-C. Messages left to return call. RN-C never returned phone call. Facility policy, Bayshore Residence and Rehabilitation Center Abuse Prevention 2023 indicated the policy was to provide a safe living environment to all residents of the facility. The policy also indicated residents, the alleged perpetrator, and other staff would be protected from harm during an investigation. The policy lacked information about protecting the residents after the investigation. The IJ which began on 2/17/23, was removed on 3/9/23, when the facility had assessed all residents for safety, educated all staff on the abuse policy and assessed R1 for any abnormal findings.

Based on interview and document review, the facility failed to develop a system to ensure medications were correctly transcribed for 1 of 3 residents (R1). This resulted in an Immediate Jeopardy (IJ) situation for R1 when her [MEDICATION(S)] (diuretic) was inadvertently discontinued which resulted in R1 not receiving diuretic medication for 11 days, and subsequently hospitalized with heart failure. The immediate jeopardy began on 3/24/22, when R1's [MEDICATION(S)] had been incorrectly discontinued. On 4/4/22, R1 was sent to the emergency department (ED) with low oxygen saturation levels (68% on room air) and difficulty breathing. R1 was admitted to the hospital and was given intravenous (IV) [MEDICATION(S)] (diuretic). Upon investigation, it was discovered R1's [MEDICATION(S)] was incorrectly discontinued on 3/24/22. The administrator and the director of nursing (DON) were notified of the immediate jeopardy at 2:30 p.m. on 4/13/22. The IJ was removed on 4/14/22, at 3:30 p.m. but scope and severity remained at a level D, no actual harm with potential for more than minimal harm. Findings include: R1's Face Sheet printed on 4/11/22, indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. R1 required assistance of staff with hygiene, dressing and transfers, bed mobility, locomotion and toilet use. R1's Order Recap Report from 3/1/22, through 4/30/22, included [MEDICATION(S)] ([MEDICATION(S)]) 40 milligrams (mg) by mouth two times a day for water pill. The report indicated R1's [MEDICATION(S)] was ordered and started on 3/8/22, and was discontinued with an end date on 3/24/22. A Physician/Prescriber Please Sign and Return form dated 3/24/22, indicated a voice order was received from nurse practitioner (NP)-B and signed by registered nurse (RN)-A. The order directed to discontinue the following supplements: [NAME] capsule, milk [NAME] capsule, alpha lipoic acid capsule, evening primrose capsule, [NAME] oil capsule, lactobacillus capsule, turmeric capsule, [MEDICATION(S)] Q10, and the cinnamon capsule. The order did not include to discontinue [MEDICATION(S)]. A facility investigation indicated on 4/4/22, R1 was sent to the ED with difficulty breathing and low oxygen saturation levels of 68% on room air. Upon investigation, the facility discovered R1's [MEDICATION(S)] had been discontinued on 3/24/22. Registered nurse (RN)-A had inadvertently discontinued R1's [MEDICATION(S)] on 3/24/22, while discontinuing R1's supplements. The investigation indicated the transcription error was not caught until a medication review was completed when R1 went to the ED on 4/4/22. R1 was admitted to the hospital and was given IV [MEDICATION(S)]. RN-A was re-educated on the need to have all transcribed orders triple checked for accuracy and verbalized understanding. Medication order audits would also be occurring. The ED to Hospital Admission report dated 4/4/22, indicated R1 was brought into the ED via ambulance. R1 suddenly became short of breath without chest pain that afternoon. While in the ED, R1 was noted to be wheezy and per the paramedics, R1's oxygen saturation was 60% while on room air. R1 was placed on [CONDITION(S)] (a type of ventilator device that helps with breathing) and her oxygen saturation increased to 100%. R1 was somewhat hypertensive (elevated blood pressure) and continued to be [CONDITION(S)] (a heart rate of over 100 beats per minute). A chest x-ray showed bilateral pulmonary [CONDITION(S)] (excess fluid in the lungs). R1 was admitted to the hospital. The report further indicated [MEDICATION(S)] was not on R1's medication list from the facility. R1 improved significantly when given IV [MEDICATION(S)] and was starting to [MEDICATION(S)] (excess fluid was removed from the body). On 4/12/22, at 10:17 a.m. R1's family member (FM)-A was interviewed. FM-A stated there was nothing more the hospital could do for R1, and hospice care had been suggested. On 4/12/22, at 10:56 a.m. R1's hospital physician (MD)-A was interviewed and stated R1 came into the hospital with heart failure and a knee infection. MD-A stated R1 had difficulty breathing and required IV [MEDICATION(S)]. MD-A stated R1 had acute systolic heart failure, was hypoxic (low oxygen in the blood), and required an IV diuretic and antibiotics. MD-A stated R1 not receiving the [MEDICATION(S)] for 11 days could have contributed to her heart failure. On 4/12/22, at 1:37 p.m. RN-A was interviewed and stated she received orders on 3/24/22, from the nurse practitioner (NP)-B to discontinue R1's vitamin supplements. RN-A stated there was a long list of supplements to discontinue. RN-A stated she went to R1's electronic medical record and discontinued the supplements, and somehow discontinued the [MEDICATION(S)]. RN-A stated she did not know how or have any reason as to why the [MEDICATION(S)] was discontinued. RN-A stated she then put out R1's chart to have the transcription double checked. RN-A stated the person who double checked the order would only check to make sure the supplements listed were discontinued, and the order was completed. RN-A stated she made a mistake resulting in R1 having to go to the hospital and she felt pretty sick about it. On 4/12/22, at 2:58 p.m. the director of nursing (DON) was interviewed and stated discontinuing the [MEDICATION(S)] was an error on RN-A's part. The DON stated RN-A was re-educated on how to process orders. The DON stated when the second and third checks were done, the person doing the checks was only able to see the medications that were ordered to be discontinued, were discontinued. The DON stated there was no way to see if a medication that had not been ordered to be discontinued, had been discontinued. On 4/13/22, at 11:42 a.m. R1's cardiac nurse practitioner (NP)-A was interviewed. NP-A stated she had been following R1 in the hospital. NP-A stated R1 was admitted to the hospital with both an acute episode of CHF, and elevated troponin levels. NP-A stated the elevated troponin levels indicated R1 may have also had a non-ST-elevation [CONDITION(S)] (NSTEMI) heart attack. NP-A stated R1 had chest pain, and this indicated she had heart blockage. NP-A stated not receiving the [MEDICATION(S)] would not have had anything to do with heart blockage. NP-A stated not getting the [MEDICATION(S)] put R1 into heart failure. NP-A stated CHF is caused by a fluid overload, and the [MEDICATION(S)] would have helped keep fluid off of R1's heart. NP-A stated not receiving the [MEDICATION(S)] put R1 at risk for death. The facility's How to Process an Order policy undated, directed to enter the order into the electronic record as accurately as possible. Place a check mark and initials on the paper copy after every order. Place the order in the second box for the floor nurse to double check. The nurse manager for the unit would then complete a triple check of the order. The order would then be placed in a fourth box on the unit for medical records to collect for shredding or long term storage. The IJ was removed on 4/14/22, after the Medication Order policy was reviewed by the facility's clinical leadership. The facility's How to Process an Order guidelines were revised to include direction to and how to check for discontinued medications in the electronic orders. All nurses, health unit coordinators (HUC), trained medication administrators (TMA) and medical records were re-educated on the Medication Order policy and the How to Process an Order guidelines. The facility reviewed all resident medication records from 3/24/22, to current to ensure all medications had corresponding physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and document review, the facility failed to ensure a resident with a food allergy was not served the food for 1 of 3 residents (R1) reviewed for food allergies. The resident was fed the allergen, had an [MEDICATION(S)] reaction, and was sent to the emergency department (ED) for treatment. The deficient practice was identified as an immediate jeopardy (IJ) situation, however, the provider had already implemented corrective action prior to the investigation so the deficiency is issued as past non-compliance. The IJ began on 12/26/21, at 1:00 p.m. when R1 was served a lunch tray which included fish. R1 had an severe allergy to fish and seafood. After eating the fish, R1 was not feeling well and was sent to the ED for treatment. The administrator and director of nursing (DON) were informed of the IJ on 12/30/21, at 10:25 a.m. The facility had implemented corrective action to prevent recurrence by 12/28/21, so F806 was issued at past non-compliance. Findings include: R1's Admission Record printed 12/30/21, indicated R1's diagnoses included fractures of the hand and finger, and depression. R1 Admission Record also included allergies of seafood and fish. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, fed herself, and did not have swallowing issues. R1's care plan dated 11/3/21, indicated allergies of fish and seafood. Interventions included to provide and serve the diet as ordered of cardiac diet, regular texture and thin liquids. The interventions also included allergies to fish and shellfish. R1's lunch tray ticket from 12/26/21, indicated allergies of fish and shellfish. Items to be served included apple juice, rice pilaf, buttered carrots, lemon meringue pie and coffee. The meal ticket did not include fish or an alternative protein. Progress notes indicated the following: On 12/26/21, at 5:04 p.m. licensed practical nurse (LPN)-C was called into R1's room. R1 reported she was having an allergic reaction. R1 had eaten fish for lunch of which R1 was allergic to. R1 stated she felt hot and flushed. R1 reported she had a severe reaction to fish in the past and had become unresponsive. LPN-C confirmed with the kitchen staff that R1 was served fish. LPN-C called 911. Paramedics arrived, evaluated R1, and transported R1 to the ED. On 12/26/21, at 4:14 a.m. R1 returned to the facility by her son. R1 was diagnosed with an allergic reaction to fish. R1 stated she felt much better, and did not have any further itching or feeling different. On 12/28/21, at 4:54 p.m. (as a late entry for 12/26/21) by the DON indicated at 1:08 p.m. the LPN informed the DON of R1 receiving fish at lunch. R1 was sent to the ED for evaluation due to a fish allergy. At 4:00 p.m. the LPN informed the DON that R1 had returned to the facility, and the ED stated R1 would be okay. The facility's investigation indicated on 12/26/21 at 1:00 p.m. R1's dietary card and R1's electronic medical record stated R1 had an allergy to fish and seafood. Dietary sent fish on R1's tray despite no protein being written on the dietary card. Nursing staff did not recognize the protein on the tray as fish, and served the fish to R1. R1 was sent to the ED with shortness of breath and heart palpitations. The dietary manager (DM)-A and the DON would conduct all staff education on reading and following dietary cards. A written statement provided by DM-A dated 12/29/21, of why the incident happened indicated R1 was served fish when R1 had a fish and seafood allergy. The statement indicated R1's allergy to fish was printed on the tray ticket, however, the alternate protein for the allergy did not generate onto the meal ticket for the lunch meal. DM-A made the correction to prevent this from happening again. A written statement provided by cook (C)-A undated, indicated the top of the meal ticket where the fish and shellfish allergy was documented was covered up, and C-A did not see R1's allergies. A dietary Ticket Education form dated 12/28/21, indicated the DON educated nursing assistant (NA)-A via phone. The DON's education included: You must check the diet ticket to make sure the resident was not receiving any food of which they were allergic or intolerant to. If there were any questions, check with the dietary department to ensure the resident received the proper food on their tray. The Allergy to Food Intolerance policy was also reviewed. An interview with NA-A was also conducted by the DON. NA-A stated the entree looked like chicken, and NA-A served it to R1. A Dietary Ticket Completion Education form dated 12/28/21, indicated DM-A was educated by the DON regarding dietary tickets needed to be completed and checked with each admission, including holidays. If DM-A was not available to complete and check the tickets, someone from the kitchen would be designated to complete the process. DM-A would also educate C-A who was on duty regarding the need to follow dietary tickets including allergies and intolerances. A Dietary Ticket Completion Education form dated 12/29/21, indicated C-A was educated by DM-A on the dietary tickets must be followed for the diet order and textures for the residents to be served. On 12/29/21, at 11:00 a.m. the DON and the assistant director of nursing (ADON) were interviewed. The DON stated R1 did not sustain harm after she ate the fish. The DON stated she had started staff education right away. On 12/29/21, at 12:00 p.m. R1 was interviewed. R1 stated the fish she was served was cod and breaded with seasoning. R1 stated she only ate a small piece before she realized it was fish. R1 stated she was on a heart healthy diet and ate a lot of chicken. R1 stated after eating the fish, she felt like she was going to break out in a sweat. R1 stated she did not have any difficulty breathing. R1 stated she was sent to the ED and did not receive any treatment as the reaction she was feeling had passed. R1 stated she has had anaphylactic shock three times in the past and knew what to expect. On 12/29/21, at 12:20 p.m. R1's lunch meal ticket was reviewed. R1's meal ticket included the allergies of fish and seafood on the top and the bottom and were highlighted. On 12/29/21, at 3:56 p.m. DM-A was interviewed. DM-A stated when R1 discharged home on either 12/21/21, or 12/22/21, her tray ticket was placed on hold. R1 readmitted to the facility on [DATE]. DM-A stated when he reopened R1's tray ticket when she returned, the protein alternate for the fish was deleted by the system and did not carry over. Therefore, a protein was not listed on R1's meal ticket. DM-A stated R1's allergy to fish and shellfish was listed on the top of the meal ticket, but was covered by a cup, and C-A did not see R1's allergies. DM-A stated the meal tickets have now been revised to list the resident's allergies on the top and bottom of the ticket. DM-A explained on the top of the tray ticket the allergy is printed in red and highlighted in yellow. On the bottom of the tray ticket now the allergy is printed in blue and highlighted in orange. Therefore, if the allergy was covered in one area it could be seen in the other. DM-A stated he would have expected C-A to move the cup and review R1's allergies before serving R1 fish. In addition, DM-A stated the meal ticket listed the foods of which R1 was to receive. R1's meal ticket did not include a protein. DM-A stated he would have expected C-A to call the nursing unit and have the nursing staff ask R1 what she wanted as the alternate protein. On 12/29/21, at 4:38 p.m. NA-A was interviewed and verified she served R1 the lunch tray with the fish as the entree. NA-A stated she was aware of R1's fish allergy. NA-A stated R1's meal ticket did not indicate fish, and the fish on the tray looked like parmesan crusted chicken. NA-A stated she had compared the meal ticket to the food. NA-A stated R1 put on the call light and reported she ate fish, and this was then reported to the nurse. NA-A stated the kitchen was notified and verified the entree was fish. NA-A stated R1 was upset she ate fish, 911 was called, and R1 did not want to go to the ED, but agreed after talking to her son. NA-A stated a protein was not listed on R1's meal ticket. NA-A stated again she assumed the protein was chicken, it did not smell or look like fish. NA-A stated she should have asked if the meal ticket did not have a protein listed. NA-A stated she was reeducated on resident allergies and intolerances, reviewing the meal tickets, and notifying the kitchen if anything stood out and what to do if allergic reaction. On 12/29/21, at 4:45 p.m. the DON stated NA-A should have notified the nurse and or called the kitchen when R1's meal ticket did not indicate what the protein was. On 12/30/21, at 1:17 p.m. C-A was interviewed and verified he plated R1's food. C-A stated the top of R1's meal ticket was covered with milk, and he missed the allergies. C-A stated he discussed with DM-A the following day, and it was decided to add the allergies on the bottom of the meal tickets also. C-A stated he should have moved the milk to check for any allergies. C-A stated from now on, he would be moving items from the meal tickets to visualize the allergies. C-A stated he did not know R1 had an allergy to fish. The facility's Food Allergies and Intolerances policy dated 12/9/21, indicated residents with food allergies or intolerances were identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps were taken to prevent resident exposure to allergens. The facility implemented corrective action to prevent recurrence by 12/28/21, when the facility implemented a systemic plan that included the following actions: On 12/27/21, through 12/28/21, immediate education was done for all staff on tray tickets, food allergies and the Food Allergies and Intolerances policy. On 12/27/21, through 12/28/21, dietary staff was re-educated on reviewing tray tickets to assure proper meals were distributed with resident likes, dislikes, allergies and intolerances honored, and tray tickets shall be second reviewed by floor staff delivering meals to assure proper meals were distributed with resident likes, dislikes, allergies and intolerances honored. All staff received a copy of the Food Allergies and Intolerances policy when they received their education. Tray cards were reviewed on all residents with food allergies or intolerances on 12/27/21. This was verified through staff interviews on 12/30/21, from approximately 1:00 p.m. through 2:00 p.m. and policy review on 12/30/21, at approximately 1:10 p.m.

Based on interview and document review, the facility failed to notify the health care power of attorney (POA) and the primary care provider (PCP) of refusals of [CONDITION(S)], medications, and parcentesis for 1 of 3 residents (R1) reviewed for [CONDITION(S)]. This resulted in an immediate jeopardy (IJ) when R1 refused [CONDITION(S)], medications, and paracentesis, and the facility did not notify the health care POA or the physician, and R1 subsequently died . The IJ began on [DATE], when R1 began refusals of [CONDITION(S)], medications, and paracentesis. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 4:18 p.m. The IJ was removed on [DATE], at 2:08 p.m. but non-compliance remained at the lower scope and severity of a D, potential for more than minimal harm. Findings Include: R1's Admission Record printed [DATE], indicated R1 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had no cognitive impairment, had complex medical conditions, required [CONDITION(S)] (acts as the kidneys, filtering and purifying the blood using a machine), required paracentesis (procedure in which fluid is removed from the abdominal cavity), and required extensive assistance with activities of daily living (ADLs). R1's MDS also indicated she had rejection of care ,d+[DATE] days in the past 7 days. R1's baseline care plan initiated [DATE], lacked indication R1 received [CONDITION(S)] and had daily paracentesis. The care plan also lacked interventions for rejection of treatments and medications. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], at 8:39 a.m. R1's family member (FM)-A was interviewed and stated she had faxed the facility the paperwork which indicated FM-A was R1's POA for health care. FM-A stated R1 had been receiving [CONDITION(S)] prior to being admitted to the nursing home, and she also required paracentesis. FM-A stated R1 had never refused [CONDITION(S)] treatments while in the hospital prior to her nursing home stay. FM-A stated R1 had told her she wanted to continue the [CONDITION(S)] to extend her life, to see her grandchildren grow up. FM-A stated she had told the facility if R1 became confused, it was a change in condition for her. FM-A stated the facility had not notified her of R1's refusals of [CONDITION(S)], medications, or paracentesis. FM-A stated had she been notified, she would have gone to see R1 to make sure this was what R1 wanted. On [DATE], a progress note indicated R1 refused to go to [CONDITION(S)]. The progress note lacked indication if R1's primary care provider (PCP) or FM-A were notified. R1's medical record lacked any further documentation of when she did not attend [CONDITION(S)]. The [CONDITION(S)] center provided the following information: On [DATE], an Absence and hospitalization Record indicated R1 did not receive [CONDITION(S)] that day. On [DATE], an Absence and hospitalization Record indicated R1 did not receive [CONDITION(S)] that day. On [DATE], an Absence and hospitalization Record indicated R1 did not receive [CONDITION(S)] that day. Review of R1's [DATE], and [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] abdominal drain (paracentesis) had been refused on [DATE], [DATE], [DATE], [DATE], and [DATE]. [MEDICATION(S)] 250 mg po daily had been refused on [DATE], [DATE], [DATE], and [DATE]. [MEDICATION(S)] 20 gr per 30 mls, 20 gr once daily had been refused on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. [MEDICATION(S)] capsule ,d+[DATE] units ordered for 2 capsules 3 times a day had been refused on [DATE], 2 doses; [DATE], 1 dose; [DATE], 2 doses; [DATE], 2 doses; [DATE], 2 doses; [DATE], 2 doses [DATE], 3 doses; [DATE], 1 dose; and [DATE], 1 dose. Renal Capsule 1 mg once daily had been refused on [DATE], [DATE], ,d+[DATE], and all days from [DATE], through [DATE]. Midodrene 10 mg three times a day had been refused on [DATE], 2 doses; [DATE], through [DATE], 1 dose each day; [DATE], 2 doses; [DATE], 1 dose; and [DATE], 2 doses. R1's medical record lacked documentation if FM-A or R1's PCP were notified of R1's refusal of medications. A Physician Visit Report dated [DATE], written by nurse practitioner (NP)-A indicated R1 allowed the [MEDICATION(S)] drain to be drained today. The report further indicated R1 was tolerating medications. The report lacked indication of R1's refusal of [CONDITION(S)] or refusal of medications. On [DATE], at 9:43 p.m. a progress note indicated FM-A had called to check on R1, and stated that she was R1's POA for health care decisions. FM-A stated she would be faxing the paperwork in the morning. On [DATE], at 5:18 p.m. a progress note indicated R1 refused to let the nurse look at her drain. R1 stated, It is just fine. The progress note lacked indication if FM-A or R1's PCP were notified of R1's refusal. On [DATE], at 6:33 p.m. a progress note indicated R1 had been refusing just about everything. R1 would not let the nurse look at her [MEDICATION(S)] drain. R1 stated it was just fine and did not need to be emptied. R1 was also refusing most of her pills and meals. The note indicated FM-A would be called and updated. The progress note lacked indication if R1's PCP was notified, and lacked indication if FM-A had been called. On [DATE], at 4:16 p.m. a progress note indicated R1 had been refusing some of her medications, and had been refusing the [MEDICATION(S)] drainage over the last three days. The note indicated the refusals were discussed with R1. R1 had been having some difficulty breathing due to the increase of abdominal fluid buildup. The note indicated the physician would be notified, but lacked indication if he/she was. The note also lacked indication if FM-A was notified. On [DATE], at 9:19 p.m. a progress note indicated R1 stated, It (paracentesis) was drained yesterday and does not need to be done today. The progress note lacked indication if R1's PCP or FM-A were notified of R1's refusal. On [DATE], at 3:59 a.m. a progress note indicated R1 was yelling, Help me holding onto her abdomen. R1 reported severe pain in her abdomen. Used [MEDICATION(S)] drainage system to remove 1100 ml of fluid. Administered as needed (PRN) [MEDICATION(S)] (narcotic pain medication) 10 mg with effective results. On [DATE], at 1:35 p.m. a progress note indicated staff had entered R1's room at 12:15 p.m. to deliver lunch. R1 was lethargic, weak, pale in appearance and dusky in color. R1's respirations were shallow, and her abdomen was distended due to fluid overload. R1 refused [CONDITION(S)] on Friday [DATE], and again today. R1 had also been refusing many of her medications and her [MEDICATION(S)]. R1 was requesting to go to the hospital. R1 had a full code resuscitation status. FM-A and R1's physician were notified, and R1 was sent to the emergency department (ED) via ambulance. On [DATE], an ED note indicated R1 apparently voluntarily skipped [CONDITION(S)] last week. R1 was noted to be hypotensive (low blood pressure) in the nursing home and was sent to the ED for evaluation. The note further indicated upon arrival to the ED, R1's blood pressure was very low, R1 was listless, and minimally responsive. R1's abdomen was slightly distended, and a [MEDICATION(S)] catheter was noted in the right abdomen. On [DATE], at 6:57 p.m. a progress note indicated the hospital had called and informed the facility R1 had expired at 6:25 p.m. On [DATE], at 10:23 a.m. the director of nursing (DON) was interviewed and stated she would have expected FM-A and R1's PCP to have been notified of R1's refusal to go to [CONDITION(S)], and her refusals of paracentesis and medications. The DON verified staff did not consistently document R1's refusals of [CONDITION(S)], paracentesis or medications, and she would expect them to. On [DATE], at 2:55 p.m. NP-A was interviewed and stated he had only seen R1 as a patient one time on [DATE]. NP-A stated the facility had reached out to him on [DATE], with concerns related to R1's refusal of the paracentesis. NP-A stated if a resident refused cares or treatments, he would expect to be notified. The facility policy [CONDITION(S)] Care dated [DATE], directed any significant change in the resident's status related to clinical complications or emergent situations, the nursing home staff will communicate with and notify the attending physician/practitioner, resident/resident representative and [CONDITION(S)] staff. This notification will be documented in the resident's electronic medical record. Refusal of treatment, missed appointments, canceling or postponing treatment, the nursing home staff will contact the [CONDITION(S)] and will begin daily observation and medical management until [CONDITION(S)] is rescheduled/resumed. The facility policy Refusal of Treatment updated [DATE], directed Treatment is defined as a care provided for purposes of maintaining/restoring health, improving health, improving function level, or relieving symptoms. The policy directed staff if a resident refuses treatment, the unit manager, Charge Nurse, or Director of Nursing Services will interview the resident to determine what and why the resident is refusing in order to address the residents concern and explain the consequences of the refusal. If a resident's refusal brings about a significant change, a reassessment will be made, and such information will be incorporated into the resident's care plan. The policy further directed staff that documentation of the refusal of treatment include that the resident was informed of the purpose of the treatment and the consequences of not receiving the medication/or treatment as well as the date and time the physician and resident representative was notified as well as the physician's response to the refusal. The immediate jeopardy that began on [DATE], was removed on [DATE], at 2:08 p.m. when the facility completed an audit of all resident records to ensure physicians and if applicable residents designated representative had been notified of all recent refusals of [CONDITION(S)], physician ordered treatments and medications. In addition, all licensed staff members were re-educated on what steps to take if residents had a refusal of [CONDITION(S)], physician ordered treatments and or medications. These actions were verified through interview and record review.

Based on interview and document review, the facility failed to ensure neglect did not occur when they received reports a resident (R2) was selling his [MEDICATION NAME] to other residents. This resulted in an immediate jeopardy for R1, when she purchased narcotics from R2, and was sent to the emergency room (ER) with an overdose of narcotics. This had the potential to effect all 99 residents currently residing in the facility. The IJ began on 9/13/20, when R2 was reported to have been selling his prescribed narcotic medications to residents in the facility. The facility failed to act on the allegations. As a result, R1 was sent to the ER for possible narcotic overdose, and was treated with [MEDICATION NAME] (medication used for treatment of [REDACTED]. The administrator and director of nursing (DON) were informed of the IJ on 9/23/20, at 3:17 p.m. The IJ was removed on 9/24/20, at 3:12 p.m., but non-compliance remained at the lower scope and severity of a G, actual harm that is not immediate jeopardy. Findings Include: R2's Admission Record printed 9/24/20, indicated R2's [DIAGNOSES REDACTED]. R2's quarterly MDS dated [DATE], indicated R2 had mild cognitive impairment, and was administered opioid medication 7 out of 7 days during review period. R2's care plan revised 9/24/20, directed staff to notify supervisor if illegal drug or alcohol use was suspected, then two staff should complete a room search and remove any alcohol or drugs from his room. Supervisor should notify physician if illegal drug or alcohol use was suspected. R2's Physician order [REDACTED]., but must wait at least one hour after MS ER 60 mg tablet for MS solution. Please place this medication in separate cup and perform mouth check. R1's Admission Record printed 9/24/20, indicated R1's [DIAGNOSES REDACTED]. R1's annual Minimum Data Set ((MDS) dated [DATE], indicated R2 had no cognitive impairment, and had no opioid mediations administered during 7 day review period. R1's care plan initiated 2/14/18, indicated R1 was known to have and ingested illegal substances. Interventions included: if illegal drug or alcohol use is suspected, notify supervisor, then two staff should complete a room search and remove any alcohol or drugs from her room. Supervisor should notify physician. On 9/13/20, R2's progress note indicated R7 had reported to nursing staff that R2 had been saving his [MEDICATION NAME] tablets and giving them to residents. R2's progress note further indicated, just to be on the safe side R2's [MEDICATION NAME] was to be put into a separate med cup by itself, and then given to R2 to ingest. R2 was informed of the new administration method for controlled substances, and this procedure was to ensure that resident were taking their medications. The progress note lacked indication if an investigation had been done to see if R2 had been giving other residents his narcotics. On 9/16/20, R1's progress note indicated R1 was unable to keep her eyes open, she was lethargic, warm to the touch, and the right side of her face was drooping. An order was obtained and R1 was sent to the ER. On 9/21/20, R1's Patient Discharge Orders from the hospital included opioid intoxication as the principle active diagnosis. On 9/21/20, R1's progress note indicated R1 returned from the hospital and had tested positive for opioid use. R1 also had a [DIAGNOSES REDACTED]. R1 was readmitted to the facility into a different room. The progress note indicated R1 had requested staff to go to her previous room to get her money, and when staff went to the room, they discovered a MS 60 mg tablet wrapped inside of R1's money. Staff brought the MS tablet to the administrator. An undated facility incident report indicated on 9/21/20, staff had found a tablet in R1's previous room. The tablet was identified as MS 60 mg. R2 was identified as the only resident on the unit who was prescribed 60 mg MS. The administrator, registered nurse (RN)-A, and maintenance staff preformed a complete room safety check of R2's room. During R2's room search, staff located a cigarette pack filled with what RN-A conformed to be MS 60 mg tablets. R2 denied selling or sharing his medications at that time. Law enforcement was notified of the findings, as were both R1 and R2's physicians. An undated facility document signed by the administrator indicated 159 MS 60 mg tablets were found stored inside a cigarette package, and were recovered from R2's personal locked drawer on 9/21/20. On 9/22/20, at 2:04 p.m. the administrator was interviewed and stated on 9/13/20, R7 made the allegation that R2 was selling his medications to R5. The administrator stated at that time, both R2 and R5 were interviewed, and both denied sharing/selling of any medications. The administrator stated both R2 and R5 had room searches completed, however, staff had not searched R2's lockbox at that time. The administrator stated the facility tried to respect the privacy of R2 at the time of 9/13/20, incident. The administrator stated no additional steps were taken to investigate the allegation of possible selling of medications on 9/13/20, nor was this alleged incident reported to the State Agency (SA). The administrator stated on 9/21/20, a MS 60 mg tablet along with money was found in R1's room. The administrator stated neither R1 nor R2 would give information about the MS 60 mg tablet found in R1's previous room when interviewed. The administrator stated because R2 had money, and R1 was previously on R2's unit, it was assumed the pills found came from R2. The administrator stated R2 was the only resident in the facility with an order for [REDACTED]. On 9/22/20, at 2:52 p.m. R2 was interviewed and stated he had been saving his noon MS 60 mg dose in his mouth after staff administered it to him. R2 stated he would then put the medication in his lockbox. R2 stated he had been doing this for months and months. R2 stated he did not sell his [MEDICATION NAME] to other residents, but stated his friends knew where they were, and maybe they just came in and got a pill or two. R2 stated R1 knew of the pills in his lockbox, and stated R1 may have went into his room and taken the pills herself. On 9/23/20, at 7:47 a.m. R1 was interviewed and stated she had purchased the [MEDICATION NAME] that resulted in her overdose from R2. R1 stated she had been given [MEDICATION NAME] in the ER for opioid overdose. R1 stated she had only purchased one tablet from R2 on 9/16/20. R1 stated she had purchased another [MEDICATION NAME] from R2 previously, and this was the pill that was found in her room. R1 stated she had no plan to purchase additional pills from R2 again, especially since she was no longer on R2's unit. On 9/23/20, at 9:02 a.m. R7 refused to be interviewed. On 9/23/20, at 9:30 a.m. R6 was interviewed and denied knowing R2. R6 stated he knew nothing about R2 selling or trying to sell his medications. R6 further stated he had his own medications and he did not need to take anyone else's. On 9/23/20, at 9:36 a.m. trained medication aide (TMA)-A stated R2 was now required to have a mouth check completed to ensure he swallowed his medications. TMA-A stated R2's MS 60 mg tablet was also now placed in a separate pill cup for administration. TMA-A stated after R1's overdose, R2 told her he had been cheeking (storing in his mouth) and saving his noon MS 60 mg dose. On 9/23/20, at 11:07 a.m. RN-A stated on 9/13/20, R7 made an allegation that R2 was selling his medications. RN-A stated R7 was considered an unreliable source. RN-A stated the facility interviewed R2, R5, and R7 after the allegation. RN-A stated they had not searched R2's lock box on 9/14/20, nor had they interviewed residents known to associate with R2. RN-A stated he was working the day R1 was sent to the ER. RN-A stated R1 appeared intoxicated, but he did not smell alcohol on R1 at that time. RN-A stated he called the ER and requested they conduct a toxicity screen for possible drug use. RN-A stated he went into the hospital electronic record on 9/17/20, and R1's record indicated she had tested positive for opioids. RN-A stated the administrator was made aware of R1's opioid use on 9/17/20. RN-A stated the facility had not completed a search for additional pills in R1's room, nor did they conduct an investigation after learning R1 tested positive for opioids. RN-A further stated the facility had not made a report to the SA until 9/21/20, when the additional [MEDICATION NAME] tablet was found in R1's personal belongings. RN-A stated at that time, the facility searched R2's room. RN-A stated during R2's room search, the facility also searched R2's lockbox. RN-A stated R2's lockbox contained 159 MS 60 mg tables in a cigarette pack. RN-A stated both R1 and R2 denied sharing or selling medications when interviewed by facility. RN-A stated law enforcement was called and informed of the 159 MS 60 mg tablets in R2's possession. RN-A stated R2 had a current [DIAGNOSES REDACTED]. On 9/23/20, at 2:26 p.m. the emergency room physician (MD)-A was interviewed. MD-A stated immediately upon her arrival to the ER, R1 required 2 doses of [MEDICATION NAME] be administered immediately. MD-A stated R1's hospital admission [DIAGNOSES REDACTED]. On 9/24/20, at 4:10 p.m. the director of nursing (DON) stated on 9/13/20, a concern was brought to their attention related to R2 selling his medications. The DON stated on 9/14/20, the administrator had searched R2's room, however, R2's lockbox had not been searched at that time. The DON stated residents known to associate with R2 were not interviewed or educated on the risk of taking medications not prescribed to them. The DON stated she had no involvement or conversation with R2 at that time. The DON stated she was not involved in sending R1 to theER on [DATE]. The DON stated at morning meeting on 9/17/20, RN-A informed her and the administrator R1 had tested positive for opioids. The DON stated at that time, no investigation was initiated by the facility to identify where R1 obtained opioids. The DON stated on 9/21/20, the day additional pills were found in both R1 and R2's possession, she was not working. The DON stated when interviewed by staff, both R1 and R2 denied selling or sharing or medications. The DON stated, We are not a jail, and people can make poor choices. The DON stated the facility should have completed an investigation after the allegation on 9/13/20, and after R2's opioid overdose on 9/16/20. The DON stated failure to properly investigate and educate all residents could have resulted in additional residents taking medications not prescribed to them, resulting in harm. The facility implemented corrective action to prevent recurrence by 9/23/20. The facility completed a questionnaire with all residents to assure pills were not being shared/sold/bartered between residents. The facility identified no residents currently possessed narcotics. The facility completed room searches on R1 and R2, and no medications were found. R1 signed a behavior contract agreeing not to buy, barter, give, borrow, sell, steal, drugs, alcohol, smoking material, or medication. In addition, R2 signed a behavior contract ensuring that medications will be swallowed as given. R2's physician directed the facility to decrease his [MEDICATION NAME] ER 60 mg from three times per day, to two times daily, and to follow up 9/29/20, for further taper. The order was entered into R2's medical record. All nurses and TMA's were re-educated to ensure residents were swallowing their medications. The corrective actions were verified by interviews with staff, and document review. On 9/23/20, and 9/24/20, law enforcement was called. Messages were left, however, there was no return call. The facility policy Administering Medications dated 11/20/19, directed medications ordered for a resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nursing Services.

Based on interview and document review, the facility failed to administer [MEDICATION NAME] for 1 of 3 residents (R1) who required immediate medical treatment after being fed an allergen, and had an [MEDICATION NAME] reaction, and died . The deficient practice was identified as an immediate jeopardy (IJ) situation. The IJ began on [DATE], when R1 was served a lunch tray that contained peanut fluff desert. R1 had an allergy to peanut butter and peanut butter, and this was not followed resulting in an [MEDICATION NAME] emergency and ultimate death of R1. The administrator and director of nursing (DON) were informed of the incident on [DATE], and corrective action was immediately implemented. The administrator and DON were informed of the IJ on [DATE], at 12:35 p.m. The facility implemented corrective action on [DATE], prior to the onsite investigation, so the deficiency is being issued at past non-compliance. Findings include: R1's Admission Record printed [DATE], indicated R1's [DIAGNOSES REDACTED]. R1's Allergy Report printed [DATE], indicated R1's allergies included peanut butter and peanut oil. R1's Provider Orders for Life-Sustaining Treatment (POLST) signed [DATE], indicated R1's wishes were to receive full life sustaining treatment, and was be listed as a full code status (receive cardiopulmonary resuscitation). R1 admission paperwork received from the hospital dated [DATE], indicated R1 had a food allergy to peanuts, peanut butter, and peanut oil, and ingesting these would cause an [MEDICATION NAME] reaction R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated had intact cognition. R1's Admission Nutritional Assessment completed on [DATE], indicated R1 had an allergy to peanuts and peanut oil. R1's Physician order [REDACTED]. solution auto-injector ([MEDICATION NAME]) 0.3 milligrams (mg)/0.3 milliliters(ml). The order directed licensed nursing staff to inject 0.3 ml intramuscularly as needed for [MEDICATION NAME] up to one dose, related to reaction to peanut allergy. R1's care plan initiated [DATE], identified R1 had potential nutritional problems. Interventions included to provide and serve diet as ordered. R1's care plan also indicated R1 had a deficit in activities of daily living (ADLs), and interventions included set up food tray for all meals, and give all medications as ordered. On [DATE], at 6:37 p.m. a progress note indicated [REDACTED]. R1 became short of breath, his face was red, and he began drooling. Staff administered R1's [MEDICATION NAME], and called emergency services. R1 was taken to the hospital for [MEDICATION NAME] reaction after eating peanuts. On [DATE], at 12:32 a.m. a progress note indicated R1 returned to the facility after being treated at the hospital for [MEDICATION NAME] related to ingesting peanuts. New orders included [MEDICATION NAME] 20 mg tablet for 4 days. Current order for [MEDICATION NAME] solution auto-injector 0.3mg/0.3ml remained in place. The order directed licensed nursing staff to inject 0.3 ml intramuscularly as needed for [MEDICATION NAME] up to one dose, related to reaction to peanut allergy. On [DATE], at 4:09 p.m. a progress note indicated trained medication aide (TMA)-A was walking past R1's room and heard R1 trying to vomit at approximately 3:15 p.m TMA-A alerted registered nurse (RN)-A of R1's condition change. RN-A entered R1's room at 3:15 p.m At that time, R1 was found to have a faint pulse, shallow respirations, his lips were noted to be blue, and RN-A was unable to obtain a blood pressure. R1 did not respond to sternal rub, and 911 was called. TMA-A stated to the RN that R1 may have eaten the peanut butter fluff served as dessert that day. The paramedics arrived at the facility at 3:20 p.m An [MEDICATION NAME] was administered to R1 by the paramedics with no results. R1 then went into [MEDICAL CONDITION]. Cardiopulmonary resuscitation (CPR) was started by the paramedics, and R1 was intubated. CPR was performed until approximately 3:45 p.m. when the paramedics called the physician, and CPR was stopped. R1 was pronounced dead. R1's medical record lacked indication the facility attempted to administer R1's [MEDICATION NAME]. On [DATE], a discharge note indicated R1 expired on [DATE], due to [MEDICATION NAME] shock due to ingestion of peanuts. On [DATE], at 10:10 a.m. TMA-A stated R1 was sleeping when lunch trays were being passed, so his tray was saved in the refrigerator. TMA-A stated at approximately 1:30 p.m. she went into R1's room to administer medications. TMA-A stated NA-A had walked by R1's room, and stated since he was awake she would go get his lunch tray. NA-A served R1 the lunch tray with the peanut butter fluff dessert. TMA-A stated she believed staff never looked at the meal tickets nor did they pay attention to the food allergies, but relied on kitchen staff to ensure menu items were correct. TMA-A stated staff did not know how to respond in this emergency, and the nursing staff had not been able to locate R1's [MEDICATION NAME]. On [DATE], at 2:06 p.m. NA-B stated he was working with R1 on the afternoon of [DATE]. NA-B stated R1 had been lying in bed, and told him he was sick. NA-B stated he assisted R1 to the bathroom, and while R1 was on the toilet he said he was going to vomit. NA-B assisted R1 to the floor to kneel by the toilet bowl, where he threw up a small amount. NA-B stated he assisted R1 back into his bed, when R1 told him he was still sick, and he had eaten the peanut butter fluff dessert at lunch time. NA-B stated he immediately found TMA-A, and she then went to get help from RN-[NAME] NA-B stated nursing staff was looking for the CPR status board, and R1's and [MEDICATION NAME]. NA-B stated the nursing staff could not locate the [MEDICATION NAME]. On [DATE], at 3:05 p.m. RN-A stated she was the RN working on the unit R1 lived at on the afternoon of [DATE]. RN-B stated her shift and was getting report from the dayshift RN when NA-B had come to her to report R1 was throwing up. RN-A stated this was approximately 2:00- 2:15 p.m. RN-B stated she instructed TMA-A to keep an eye on R1. When asked why RN-A did not initially go assess R1, RN-A stated she initially believed R1 had a [MEDICAL CONDITION] given his medical history. RN-A then stated at around 3:00 p.m. staff contacted her and informed her R1 did not look or sound right. RN-A stated she obtained vitals at that time and was unable to get a blood pressure reading. RN-A stated R1 was still breathing at that time and was able to feel a pulse. RN-A stated she then found out R1 had ingested peanut butter. RN-A stated she then called 911. RN-A stated she could not find R1's EPI pen to administer. RN-A stated by the time R1's EPI pen was located EMS was already at the facility providing life saving measures for R1. Per the report CPR was stopped at 3:45 p.m. and R1 was pronounced dead. RN-A stated had R1's EPI pen been administered immediately R1 may have still been alive. RN-A stated EPI pens are now located in the RN medication carts and meal tickets have been changes to better identify residents allergies. Review of the facility menu for the week of [DATE], through [DATE], indicated on [DATE], the lunch meal included peanut butter fluff as a dessert. On [DATE], at 1:07 p.m. dietary manager (DM)-A was interviewed. DM-A stated resident food allergies were listed in red print at the top of resident's individual meal tickets. DM-A stated after the incident on [DATE], the facility also put into place highlighting of the food allergies and all kitchen staff have received additional training regarding food allergies. DM-A stated now there was a binder put on every unit that included resident food allergies. DM-A stated education was provided upon hire for all dietary staff on diet orders which included food allergies. DM-A stated on [DATE], cook (C)-A prepared the lunch meal tray for R1, and had missed the peanut allergy listed on the meal ticket. DM-A stated the peanut butter fluff dessert was placed on R1's lunch tray and delivered to his room. DM-A stated R1 was sleeping when trays were being passed, but his tray was saved so he could eat when he woke up. When he woke up, NA-A brought R1 his food tray which included the peanut butter fluff. The lunch tray was left for R1 to eat, and he consumed the peanut butter fluff dessert. Review of the facility recipe titled Peanut Butter Fluff Cup served on [DATE], listed ingredients that included creamy natural peanut butter. On [DATE], at 10:20 a.m. NA-A stated she was the staff responsible for serving R1 the lunch tray with the peanut butter fluff dessert on [DATE]. NA-A stated she had provided cares for R1 numerous times however, was not aware of his peanut butter allergy. NA-A stated kitchen staff prepared the food trays, and nursing staff are responsible for serving them. NA-A stated the food allergies were listed on the meal tickets however, she did not read the ticket before serving R1 his tray. NA-A stated staff counted on the cooks to prepare the meal trays accurately according to the orders and needs of the residents. On [DATE], at 2:47 p.m. dietary aid (DA)-A stated she was the staff responsible for preparing R1's lunch tray on [DATE]. DA-A stated her typical routine included placing desserts on the trays first. DA-A stated she routinely looked for food allergies that are listed on the resident's meal ticket, but she had missed the peanut allergy listed on R1's meal ticket on [DATE]. DA-A stated there was also a second staff member responsible to check the meal ticket for accuracy when liquids were placed on the trays, but the allergy had been missed during that check as well, resulting in R1 being served the peanut butter fluff dessert. On [DATE], at 2:47 p.m. RN-B stated he was the clinical manager for the unit R1 had lived on. RN-B stated he was not made aware of the incident until the morning of [DATE]. RN-B stated he learned R1 had been served a meal tray which included a dessert with peanut butter, and experienced an allergic reaction. RN-B stated R1 did have an order for [REDACTED]. On [DATE], at 11:50 p.m. the director of nursing (DON) stated the facility had put in place additional training regarding food allergies since R1's death. The DON stated the food tickets now have allergies listed in red and highlighted with yellow to better alert the staff of the food allergies. The DON also stated there are binders in place on all units which detail each resident's food allergy. The DON stated training for all staff has been completed through small groups, 1:1's, and handouts. The DON stated the facility will continue to perform food tray audits. The DON stated the facility also recognized the need for training to be completed for all staff regarding responding timely on a code/emergency situation. On [DATE], at 11:28 p.m. R1's certified nurse practitioner (CNP) stated she was R1's primary care provider, and had was familiar with R1's medical conditions. CNP stated she was informed of R1's death on [DATE]. CNP stated she was told R1 received a dessert containing peanuts, and went into [MEDICAL CONDITION]. CNP stated the facility had not made her aware that nursing staff had not immediately located R1's [MEDICATION NAME]. CNP stated had R1 in fact ingested peanuts, experienced an [MEDICATION NAME] reaction, and received his [MEDICATION NAME] as ordered, the outcome could have been very different. CNP further stated R1 had a similar event occur in the summer of 2019, and staff had administered the [MEDICATION NAME] as ordered. CNP stated she filled out the death record for R1, and the cause of death was [MEDICAL CONDITION] related to [MEDICATION NAME]. The facility implemented corrective action to prevent recurrence by [DATE]. The facility revised the food tickets to highlight allergies in yellow, placed food allergy binders on each unit, trained all staff, and began audits of meal service. The corrective actions were verified by interview with staff and policy review. The facility policy Administering Medications dated ,[DATE], directed staff to administer all medications in a safe and timely manner, as prescribed.

Based on interview and document review, the facility failed to ensure a resident with a food allergy was not served the food for 1 of 3 residents (R1) reviewed for food allergies. The resident was fed the allergen, had an [MEDICATION NAME] reaction, and died . The deficient practice was identified as an immediate jeopardy (IJ) situation. The IJ began on [DATE], when R1 was served a lunch tray that contained peanut fluff desert. R1 had an allergy to peanut butter and peanut oil, and this was not followed resulting in an [MEDICATION NAME] emergency and ultimate death of R1. The administrator and director of nursing (DON) were informed of the incident on [DATE], and corrective action was immediately implemented. The administrator and DON were informed of the I on [DATE], at 12:35 p.m. The facility implemented corrective action by [DATE], prior to the onsite investigation, so the deficiency is being issued at past non-compliance. Findings include: R1's Admission Record printed [DATE], indicated R1's [DIAGNOSES REDACTED]. R1's Allergy Report printed [DATE], indicated R1's allergies included peanut butter and peanut oil. R1's Provider Orders for Life-Sustaining Treatment (POST) signed [DATE], indicated R1's wishes were to receive full life sustaining treatment, and was be listed as a full code status (receive cardiopulmonary resuscitation). R1 admission paperwork received from the hospital dated [DATE], indicated R1 had a food allergy to peanuts, peanut butter, and peanut oil, and ingesting these would cause an [MEDICATION NAME] reaction R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated had intact cognition. R1's Admission Nutritional Assessment completed on [DATE], indicated R1 had an allergy to peanuts and peanut oil. R1's Physician order [REDACTED]. solution auto-injector ([MEDICATION NAME]) 0.3 milligrams (mg)/0.3 milliliters(ml). The order directed licensed nursing staff to inject 0.3 ml intramuscularly as needed for [MEDICATION NAME] up to one dose, related to reaction to peanut allergy. R1's care plan initiated [DATE], identified R1 had potential nutritional problems. Interventions included to provide and serve diet as ordered. R1's care plan also indicated R1 had a deficit in activities of daily living (ADLs), and interventions included set up food tray for all meals, and give all medications as ordered. On [DATE], at 6:37 p.m. a progress note indicated [REDACTED]. R1 became short of breath, his face was red, and he began drooling. Staff administered R1's [MEDICATION NAME], and called emergency services. R1 was taken to the hospital for [MEDICATION NAME] reaction after eating peanuts. On [DATE], at 12:32 a.m. a progress note indicated R1 returned to the facility after being treated at the hospital for [MEDICATION NAME] related to ingesting peanuts. New orders included [MEDICATION NAME] 20 mg tablet for 4 days. Current order for [MEDICATION NAME] solution auto-injector 0.3 mg/0.3 ml remained in place. The order directed licensed nursing staff to inject 0.3 ml intramuscularly as needed for [MEDICATION NAME] up to one dose, related to reaction to peanut allergy. On [DATE], at 4:09 p.m. a progress note indicated trained medication aide (TMA)-A was walking past R1's room and heard R1 trying to vomit at approximately 3:15 p.m TMA-A alerted registered nurse (RN)-A of R1's condition change. RN-A entered R1's room at 3:15 p.m At that time, R1 was found to have a faint pulse, shallow respirations, his lips were noted to be blue, and RN-A was unable to obtain a blood pressure. R1 did not respond to sternal rub, and 911 was called. TMA-A stated to the RN that R1 may have eaten the peanut butter fluff served as dessert that day. The paramedics arrived at the facility at 3:20 p.m An [MEDICATION NAME] was administered to R1 by the paramedics with no results. R1 then went into [MEDICAL CONDITION]. Cardiopulmonary resuscitation (CPR) was started by the paramedics, and R1 was intubated. CPR was performed until approximately 3:45 p.m. when the paramedics called the physician, and CPR was stopped. R1 was pronounced dead. R1's medical record lacked indication the facility attempted to administer R1's [MEDICATION NAME]. On [DATE], a discharge note indicated R1 expired on [DATE], due to [MEDICATION NAME] shock due to ingestion of peanuts. On [DATE], at 10:10 a.m. TMA-A stated R1 was sleeping when lunch trays were being passed, so his tray was saved in the refrigerator. TMA-A stated at approximately 1:30 p.m. she went into R1's room to administer medications. TMA-A stated NA-A had walked by R1's room, and stated since he was awake she would go get his lunch tray. NA-A served R1 the lunch tray with the peanut butter fluff dessert. TMA-A stated she believed staff never looked at the meal tickets nor did they pay attention to the food allergies, but relied on kitchen staff to ensure menu items were correct. TMA-A stated staff did not know how to respond in this emergency, and the nursing staff had not been able to locate R1's [MEDICATION NAME]. On [DATE], at 2:06 p.m. NA-B stated he was working with R1 on the afternoon of [DATE]. NA-B stated R1 had been lying in bed, and told him he was sick. NA-B stated he assisted R1 to the bathroom, and while R1 was on the toilet he said he was going to vomit. NA-B assisted R1 to the floor to kneel by the toilet bowl, where he threw up a small amount. NA-B stated he assisted R1 back into his bed, when R1 told him he was still sick, and he had eaten the peanut butter fluff dessert at lunch time. NA-B stated he immediately found TMA-A, and she then went to get help from RN-[NAME] NA-B stated nursing staff was looking for the CPR status board, and R1's and [MEDICATION NAME]. NA-B stated the nursing staff could not locate the [MEDICATION NAME]. On [DATE], at 3:05 p.m. RN-A stated she was the RN working on the unit R1 lived at on the afternoon of [DATE]. RN-B stated her shift and was getting report from the dayshift RN when NA-B had come to her to report R1 was throwing up. RN-A stated this was approximately 2:00- 2:15 p.m RN-B stated she instructed TMA-A to keep an eye on R1. When asked why RN-A did not initially go assess R1, RN-A stated she initially believed R1 had a [MEDICAL CONDITION] given his medical history. RN-A then stated at around 3:00 p.m. staff contacted her and informed her R1 did not look or sound right. RN-A stated she obtained vitals at that time and was unable to get a blood pressure reading. RN-A stated R1 was still breathing at that time and was able to feel a pulse. RN-A stated she then found out R1 had ingested peanut butter. RN-A stated she then called 911. RN-A stated she could not find R1's EPI pen to administer. RN-A stated by the time R1's EPI pen was located EMS was already at the facility providing life saving measures for R1. Per the report CPR was stopped at 3:45 p.m. and R1 was pronounced dead. RN-A stated had R1's EPI pen been administered immediately R1 may have still been alive. RN-A stated EPI pens are now located in the RN medication carts and meal tickets have been changes to better identify residents' allergies. Review of the facility menu for the week of [DATE], through [DATE], indicated on [DATE], the lunch meal included peanut butter fluff as a dessert. On [DATE], at 1:07 p.m. dietary manager (DM)-A was interviewed. DM-A stated resident food allergies were listed in red print at the top of resident's individual meal tickets. DM-A stated after the incident on [DATE], the facility also put into place highlighting of the food allergies and all kitchen staff have received additional training regarding food allergies. DM-A stated now there was a binder put on every unit that included resident food allergies. DM-A stated education was provided upon hire for all dietary staff on diet orders which included food allergies. DM-A stated on [DATE], cook (C)-A prepared the lunch meal tray for R1, and had missed the peanut allergy listed on the meal ticket. DM-A stated the peanut butter fluff dessert was placed on R1's lunch tray and delivered to his room. DM-A stated R1 was sleeping when trays were being passed, but his tray was saved so he could eat when he woke up. When he woke up, NA-A brought R1 his food tray which included the peanut butter fluff. The lunch tray was left for R1 to eat, and he consumed the peanut butter fluff dessert. Review of the undated facility recipe titled, Peanut Butter Fluff Cup served on [DATE], listed ingredients that included creamy natural peanut butter. On [DATE], at 10:20 a.m. NA-A stated she was the staff responsible for serving R1 the lunch tray with the peanut butter fluff dessert on [DATE]. NA-A stated she had provided cares for R1 numerous times however, was not aware of his peanut butter allergy. NA-A stated kitchen staff prepared the food trays, and nursing staff are responsible for serving them. NA-A stated the food allergies were listed on the meal tickets however, she did not read the ticket before serving R1 his tray. NA-A stated staff counted on the cooks to prepare the meal trays accurately according to the orders and needs of the residents. On [DATE], at 2:47 p.m. dietary aid (DA)-A stated she was the staff responsible for preparing R1's lunch tray on [DATE]. DA-A stated her typical routine included placing desserts on the trays first. DA-A stated she routinely looked for food allergies that are listed on the resident's meal ticket, but she had missed the peanut allergy listed on R1's meal ticket on [DATE]. DA-A stated there was also a second staff member responsible to check the meal ticket for accuracy when liquids were placed on the trays, but the allergy had been missed during that check as well, resulting in R1 being served the peanut butter fluff dessert. On [DATE], at 2:47 p.m. RN-B stated he was the clinical manager for the unit R1 had lived on. RN-B stated he was not made aware of the incident until the morning of [DATE]. RN-B stated he learned R1 had been served a meal tray which included a dessert with peanut butter, and experienced an allergic reaction. RN-B stated R1 did have an order for [REDACTED]. On [DATE], at 11:50 p.m. the director of nursing (DON) stated the facility had put in place additional training regarding food allergies since R1's death. The DON stated allergies are now listed in red and highlighted with yellow to better alert the staff of the food allergies. The DON also stated there are binders in place on all units which detail each resident's food allergy. The DON stated training for all staff has been completed through small groups, 1:1's, and handouts. The DON stated the facility will continue to perform food tray audits. The DON stated the facility also recognized the need for training to be completed for all staff regarding responding timely on a code/emergency situation. On [DATE], at 11:28 p.m. R1's certified nurse practitioner (CNP) stated she was R1's primary care provider, and was familiar with R1's medical conditions. CNP stated she was informed of R1's death on [DATE]. CNP stated she filled out the death record for R, and the cause of death was [MEDICAL CONDITION] related to [MEDICATION NAME]. The facility implemented corrective action to prevent recurrence by [DATE]. The facility revised the food tickets to highlight allergies in yellow, placed food allergy binders on each unit, trained all staff, and began audits of meal service. The corrective actions were verified by interview with staff and policy review. The facility policy Food Allergies and Intolerances updated [DATE], directed staff that all residents with food allergies and/or intolerances will be identified upon admission, and steps will be taken to prevent resident exposure to the allergen(s). The policy further described peanut and shellfish as the most sever forms of allergic reactions. The policy directed staff to administer appropriate medications and or interventions per physician order.

Based on interview and document review, the facility failed to ensure medically related social services were implemented to provide a safe and appropriate discharge for 1 of 9 residents (R1) who required medical services and was given a discharge notice from the facility. This resulted in an immediate jeopardy situation for R1 when R1 was discharged to a homeless shelter without medical services and pain medications, and was subsequently transferred to the hospital. In addition, the discharge notice given to 5 of 9 residents (R1, R5, R7, R9, and R10) designated a homeless shelter as the place of discharge. The immediate jeopardy began on [DATE], when R1 was discharged from the facility and dropped off at the homeless shelter by the administrator without medical services and pain medications, and was subsequently hospitalized when the homeless shelter called 911 due to the inability to provide medical services and meet R1's complex medical needs. The immediate jeopardy was identified on [DATE], and the administrator was notified of the immediate jeopardy on [DATE], at 4:19 p.m. The immediate jeopardy was removed on 1/13/20, at 4:55 p.m. but noncompliance remained at the lower scope and severity level of a D, no actual harm with potential for more than minimal harm. Findings include: R1's Admission Record dated 7/5/19, indicated R1 was most recently admitted on [DATE], was his own responsible party, and [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively intact, and had no [MEDICAL CONDITIONS], mood symptoms or behaviors of any kind during the assessment period. R1's MDS further indicated R1 required limited assistance of one staff for bed mobility and transfers, did not ambulate, was independent with locomotion in his wheelchair, and required extensive assistance with dressing, toilet use, and personal hygiene. R1's MDS indicated R1 received intermittent catheterization, was continent of bladder, and occasionally incontinent of bowel. In addition, the MDS indicated R1 had pain almost constantly, rated at a 10 out of 10 (severe), that did not interfere with sleep or day-to-day activities, received scheduled pain medications and opioid (controlled narcotic) medications. R1 had a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). R1 was at risk for further pressure ulcer development, and received pressure ulcer care. R1's care plan initiated 8/19/13, identified R1 as a vulnerable adult, at risk for injury and abuse from others related to his impaired mobility, and indicated R1 had a history of [REDACTED].>-manipulative and dishonest behaviors in an attempt to take advantage of others, -rejection of cares, refusals to follow through with appointments, non-compliance with repositioning, wound care, contributing to a risk for decline in medical condition, -verbally and physically abusive behaviors toward others. R1's interventions for his mood and behavior concerns did not include discharge from the facility. R1's care plan further indicated R1 had a sacral pressure ulcer, a history of a pressure ulcer of the coccyx (tailbone) with a related surgical procedure, and was able to reposition self in bed with the use of grab bars. R1's care plan indicated R1 was non-ambulatory, transferred self, and required assistance of one staff to transfer to and from bed and wheelchair with a gait belt, though had a risk versus benefit in place for self transfers. R1's care plan further indicated R1 required intermittent self-catheterization related to a [MEDICAL CONDITION] bladder, and had a [MEDICAL CONDITION] bacteria in his urine. R1's Physician order [REDACTED]. every 8 hours as needed for pain, [MEDICATION NAME] (muscle relaxant), [MEDICATION NAME] aerosol (inhaler for [MEDICAL CONDITION]), [MEDICATION NAME] [MED] nebulizer (for [MEDICAL CONDITION]), and self catheterization twice daily, and nutritional supplement. R1's physician orders [REDACTED]. R1's Medication Administration Record [REDACTED]. R1's MAR for 1/20, indicated R1 received and took [MEDICATION NAME] release every 12 hours, and received [MEDICATION NAME] [MED] 5 mg 3 times between 1/1/20, and [DATE]. R1's Vulnerability and Susceptability (sic) to Abuse assessment dated [DATE], identified R1 as a vulnerable adult but able to report maltreatment, with identified vulnerabilities as alcohol/substance abuse, been convicted of a crime involving assault or predatory offender, and physical impairment. R1's Psychosocial assessment dated [DATE], indicated R1 had no psychosocial symptoms related to cognitive status, listed no mood or behavior concerns since last assessment, declined mental health services, indicated no concerns with other residents or staff members, and discharge plan was to remain in facility for long term placement. R1's Weekly Wound assessment dated [DATE], indicated R1's facility acquired Stage 4 coccyx-area pressure ulcer was first identified on 2/14/18, measured 3.0 centimeters (cm) x 2.6 cm x 0.6 cm, was 100% granulation tissue (new connective tissue) with a ligament visible at the base of the wound, and a moderate amount of drainage. R1's pressure ulcer also had undermining of 1.5 cm at 12-6 o'clock, with moderate pain eased by pain medications. R1's wound assessment indicated R1 was compliant with wound care at that time. Risk vs. Benefit forms had been completed for R1's request to have an egg crate foam over an air mattress due to fear of falling, refusal of wound care and skin assessments, self-transferring, refusing blood pressure medication, and for not turning side-to-side following surgery. R1 lacked a risk vs. benefit for aggressive behaviors. R1's physician visit notes dated 8/20/19, indicated MD was knowledgeable about R1's behaviors that led to assault charges and court hearing, but lacked documentation of potential discharge. R1's physician visit notes dated 9/17/19, 10/15/19, and 11/12/19, lacked documentation that would indicate MD was informed and aware of the discharge plan to discharge R1 with further aggressive behaviors. R1's progress notes dated 10/31/19, indicated an interdisciplinary team (IDT) had met to discuss R1's resident-to-resident altercation that led to police involvement and charges filed against R1. R1's progress note indicated during a care conference on 8/7/19, R1 had been informed by his brother and the facility administrator that any further incidents would result in R1 being discharged from the facility. R1's progress note indicated R1 had a history of [REDACTED]. R1 was noted to have no further behavioral outbursts since the resident-to-resident altercation. Social worker was meeting with R1 weekly, and no concerns were noted. R1's progress notes dated [DATE], indicated R1 was swearing at another resident over a garbage can R1 had removed from their shared bathroom, because the other resident would put the garbage can in front of his door, so it was in the way. R1 threw a water pitcher at the other resident. Staff separated the residents and put them on 15 minute checks. A 30-day discharge notice for endangerment of others dated [DATE], indicated R1 was to be discharged to a homeless shelter on 1/3/20. R1's discharge notice cited the following incidents: 8/2/18: Verbal Aggression initiated to another resident 8/3/18: Verbal aggression initiated to another resident 4/15/19: Physical aggression initiated to another resident 6/25/19: Physical aggression initiated to another resident 7/29/19: Physical aggression initiated to another resident [DATE]: Verbal and physical aggression initiated to another resident R1's progress notes dated 12/6/19, indicated social worker (SW)-B had met with R1 regarding the altercation on [DATE], R1 promised he would not lose his temper anymore, and agreed to talk to a SW when he was mad. R1 refused to talk with a counselor. R1's progress notes dated 12/12/19, indicated IDT met related to R1's altercations, and noted R1 had been given a 30-day discharge notice due to repeat altercations. R1 was meeting with a SW, and working toward appropriate interactions and social environment. R1's progress notes dated 12/13/19, as a late entry for 12/12/19, indicated SW-B had offered R1 an opportunity to see a counselor or psychologist to help him cope with frustrations. R1 declined and said it was the way others treated him, so he defended himself. R1's progress notes dated 12/24/19, indicated R1 told SW-B he was staying out of trouble, though some situations would have previously led to him punching someone. R1 continued to decline to meet with a counselor. SW-B documented she would continue to meet with R1 and assist as needed. R1's progress notes dated 1/3/20, as a late entry for 1/2/20, indicated SW-B asked R1 if he wanted SW-B to check about opening at other places, since he would likely be discharged that day. R1 declined as he had in the past, stated he wanted to stay at this facility and didn't want to go anywhere else, and stated the administrator had indicated he could possibly stay at the facility. R1's progress note indicated SW-B would assist R1 if he requested. R1's progress note dated [DATE], at 3:36 p.m. indicated R1 was discharged to the homeless shelter with the administrator, and some items were sent with R1. R1's brother was to pick up the remainder of his belongings in the next couple of days. R1's progress note lacked an indication of any medical supplies or medications sent with R1. R1's progress note on [DATE], at 8:49 p.m. indicated a hospital had called to inform the facility R1 was at the hospital, and requested a copy of R1's medication list. The facility faxed the copies of the MAR indicated [REDACTED]. R1's medical record lacked documentation of any attempts by the facility to arrange alternative safe living arrangements with medical services, follow-up physician and medical appointments, communication with physician regarding R1's behaviors and intent to discharge R1 from the facility, medication and other discharge orders, and documentation of medical supplies and medications sent with R1. On 1/9/20, at 2:59 p.m. the administrator was interviewed. The administrator stated the grounds for R1's discharge was for continued resident-to-resident altercations. The administrator stated R1 got a last notice on 8/7/19, during meeting with family, R1's brother, SW-B, and the administrator, and was informed of discharge if altercations continued. R1 had an altercation on [DATE], and was given a 30-day notice on [DATE]. The administrator stated they put down a homeless shelter as the discharge location because people can go there when they are without housing. The administrator stated they try to make other arrangements when they give residents discharge notices, and SW-B tried to get R1 to make other arrangements, but he would not do that. The administrator stated R1 was a survivor, and could go up and down the curbs on the street in his wheelchair. The administrator stated he assessed the homeless shelter as a place that was warm and safe, and stated it was only one step down to the foyer, so was handicap accessible. The administrator stated they sent wound care supplies for R1's pressure ulcer, catheter supplies, and thought SW-B had made arrangements or referrals to a home care company to go out to the homeless shelter. The administrator stated others have gone to the homeless shelter, and home care companies had seen them there. The administrator stated seven other residents had been given 30 day discharge notices to go to the homeless shelter as well, and those residents worked to find alternative arrangements. The administrator stated one of the other seven, R5, was bed-bound and was set to be discharged to the homeless shelter, but passed away. The administrator stated in some cases residents who have been given discharge notices may stay at the facility if they follow the rules and pay their bills. The administrator stated all of the other seven residents who have received a discharge notice for non-payment had been resolved, and they were not discharged to the homeless shelter. The administrator verified the homeless shelter did not have medical staff to care for R1 or other residents who may be discharged there, but stated the resident could go to the emergency room (ER) or have home care. The administrator stated residents make their own decisions, and R1 was his own responsible party. The administrator stated he was not sure if R1's physician was involved with the discharge or wrote discharge orders. On 1/9/20, at 3:25 p.m. the hospital social worker (SW)-C was interviewed and stated R1 was in theER on [DATE], and was in observation status until admitted to the hospital on [DATE], with an admitting [DIAGNOSES REDACTED]. On 1/9/20, at 3:31 p.m. hospital case manager (CM)-A was interviewed and stated R1 was evicted from the facility, dropped at a homeless shelter with open sores, and was wheelchair bound, so the homeless shelter was not an appropriate setting for R1. CM-A stated they were trying to find placement for R1, and stated R1 was going to appeal the eviction, and had spoken to the ombudsman. On 1/9/20, at 3:50 p.m. hospital SW-D was interviewed and stated R1 wanted to go back to the facility, stated he was comfortable there, and was going to appeal his eviction. SW-D stated R1 was dropped off at the homeless shelter which was not wheelchair accessible. R1 had stated he had lived at facility several years. R1 reported he had a disagreement with another resident and threw a pitcher of water at him. SW-D stated R1 did not need to be in the hospital, and wanted to go back to the facility. SW-D stated if R1 was evicted from the facility, it would be difficult to get him into another facility. On 1/9/20, at 4:07 p.m. SW-B was interviewed and stated she had a lot of conversations about where R1 could go, but he did not want to go anywhere else. SW-B verified she had not made any discharge plans for R1. SW-B stated she had these conversations about alternative settings when he had altercations with other residents. SW-B stated she did not put a lot of time into finding another place for R1, as he didn't know where he would go or if another place would accept him. SW-B stated R1 was not accepting to seeing a psychologist. SW-B did not know if R1's physician was involved with his discharge or placement. SW-B stated she would usually make arrangements for home care and needed medical equipment, and present that to the physician. SW-B verified she had not involved R1's physician in his discharge, and had not arranged home care for R1. SW-B verified R1 went to a non-medical facility, and although she thought he would need care for his pressure ulcer, she thought he would go to the wound clinic for wound care, but verified she was not involved in that. SW-B thought the homeless shelter was wheelchair accessible, but had not been there herself. SW-B stated she had not had other residents go to the homeless shelter since she had been there. On [DATE], at 9:25 a.m. the administrator stated R1 had refused all treatment, refused to look at other facilities, and was his own responsible party. The administrator stated R1 had been discharged with all his medications except for his narcotics, and was given a record of his medications. The administrator stated he did not think R1 had a physician signed discharge summary, and stated R1 would have to see his primary physician (MD) for further prescriptions. The administrator stated R1 was rarely taking his as needed narcotic medications. On [DATE], at 11:25 a.m. physician (MD)-A was interviewed and stated she was R1's rounding physician at the nursing home, and was also on call for the emergency room the day R1 was discharged from the facility and was transported from the homeless shelter to the emergency room . MD-A stated she had not been informed of R1's 30 day discharge notice prior to his discharge from the facility to the homeless shelter. MD-A stated she had not been involved in discharge planning and did not write discharge orders for R1. MD-A stated the homeless shelter was not wheelchair accessible for R1, and they would not be able to provide wound care to his pressure ulcers. MD-A stated R1 had complex medical conditions including high blood pressure, [MEDICAL CONDITION], and chronic pain for which he took opioids. MD-A stated R1 was not provided his opioid medications, and would have gone through opioid withdrawals if he had not received his medication at the homeless shelter, which would not have been safe. MD-A stated R1 did take his opioid medications routinely, and was dependent on them. MD-A stated R1 had pain from bullet fragments next to his spine that were unable to be removed. MD-A stated R1 had been in a skilled nursing facility since 2006, he had not been in a situation where he had self-administered medications, and she did not know that he could properly administer his own medications. MD-A stated she had heard about R1's aggression, and had discussed his behaviors with him, but R1 usually had an excuse of why it happened, and seemed remorseful after the fact. MD-A stated she usually did not hear about his behaviors until well after they occurred, and had not been involved in a behavior plan for R1. MD-A stated R1 may be able to be in a setting other than a nursing home, such as a group home, but may need to be weaned off the narcotics first. MD-A stated she did not think the facility had looked at other options, until they provided R1 with a list after the 30-day discharge notice. On [DATE], at 11:45 a.m. the administrator verified they did not involve the medical director in R1's discharge from the facility. On [DATE], at 11:52 a.m. an employee of the homeless shelter (SE)-A was interviewed and stated he was at the shelter when R1 was dropped off there. SE-A stated stated R1 was just dropped off, like the facility was just washing their hands of him and R1 was not longer their problem. SE-A stated they had not received previous notice that R1 was going to be dropped off there. SE-A stated R1 wasn't doing very good and had bed sores, was in a wheelchair, and required medical attention that they could not provide. SE-A stated the shelter is wheelchair accessible. SE-A stated they were not required to administer medications to their clients, but sometimes try to help them take their medications. SE-A stated they called the hospital and had him transported there so he could receive care. SE-A stated as far as he knew, they had not received other clients from this facility. On [DATE], at 12:25 p.m. R1 was interviewed by telephone. R1 stated at the facility, the resident next door had an issue with the garbage cans in the bathroom and would place them in the way of R1's door, so R1 took them out of the bathroom and forgot to put them back in the bathroom. The other resident banged on R1's door with his cane, and was yelling about the garbage can when R1 was sleeping. R1 stated he threw a pitcher of water at the door, not at the other resident. R1 stated the facility gave him a 30-day discharge notice, but R1 was going to try to appeal it. R1 stated he wanted to return to the facility, and did not feel he should have been discharged . R1 stated he was dropped off at the homeless shelter, and they couldn't provide him with his needs and wound care. R1 stated he was mad that he was dropped off. R1 stated he was feeling anxious about the changes, and stated he would stay out of trouble and avoid incidents. R1 stated he usually went back to his room and to bed to stay out of trouble. R1 stated the facility did not find another place for him, but he likes it at the facility, and wanted to stay there. R1 stated the facility did not provide him with a list of other places he could be discharged to, and never found another place for him. R1 thought they were trying to find a place. R 1 stated he thought he was going to be able to stay at the facility, and had been staying out of trouble. R1 stated he felt it was not his fault, he was not a threat to other residents and was sad leaving the facility. They just dropped me off, and left. On [DATE], at 3:19 p.m. registered nurse manager (RN)-A was interviewed and stated they have discharge packets that included addressing resident needs, home care, personal care attendant services, equipment, and medications for home which is dependent on insurance. RN-A stated discharge planning with R1 basically was a 30-day notice because he was assaulting people, and the incident with the waste can was the final straw. RN-A stated R1 threw a pop bottle at another resident, he would point a home-made wrist rocket at other residents, once took a resident's hat and threw it up on the roof, and had an assault charge against him last summer. RN-A stated R1 was discharged to the homeless shelter because he would not agree to go anywhere else. RN-A stated R1 was given written directions on discharge, but no orders were in place. RN-A stated there were no future appointments with R1's primary care physician or wound care set up. RN-1 stated he had heard R1 was discharged with some dressing supplies and medications, but no narcotic medications. On [DATE], at 3:27 p.m. SW-A was interviewed and stated what they do for a discharge depended on what type of discharge it was. SW-B stated they involve the doctor, do a referral, get MD orders, set up services, and make arrangements for a waiver if necessary. SW-A stated R1 did not want assistance, and if he was refusing help, they could not do anything. SW-A stated she did not know if any services were offered to R1, but would expect services to be offered. SW-A stated a homeless shelter could be a safe discharge if he was able to seek out services. SW-A stated R1 was his own person, and they could not force services on him. SW-A did not acknowledge R1 was a vulnerable adult, and continued to say he was his own person. On 1/13/20, at 12:00 p.m. the administrator stated he had talked to R1 at the hospital during the weekend, and R1 had come up with ideas so he would not endanger others, and he would be having R1 return to the facility, but had no definite plan as to a specific time. On 1/13/20, at 4:15 p.m. a call was placed to the medical director and requested a return call. A return call was not received from the medical director. On 1/13/20, at 4:23 p.m. fiscal office manager (FOM) was interviewed and she only handled discharge notice for non-payment, and the administrator would decide on discharge notices for abuse or behaviors. FOM stated R1 was the first resident discharged for abusive behaviors. FOM stated she would prepare the discharge notices and would include why they are being discharged , where they were to be discharged to, send an email to the ombudsman, include the current bill, and any recent progress notes. The social workers were included on the email. FOM stated they do a 30-day discharge notice for non-payment to get residents to see how serious it is and they pay their bill, but it is a last-resort. FOM stated the other notices for non-payment were taken care of, including the one for R7. FOM stated about 99% of the discharge notices are to the homeless shelter, but they end up being rescinded when payment comes through, and residents don't go there. FOM stated they are making some changes and setting up services, even if the resident refuses. It is the right thing to do. The IJ was removed on 1/13/20, at 4:55 p.m. when the following was verified: The administrator stated all staff involved in discharges had been educated on discharge process, including the director of nursing (DON) who was not currently in the facility. The procedure was emailed to the DON, arrangements had been made for R1 to return to the facility on [DATE], and placed in a private room with a private bathroom, next to social services. Nursing, social services and financial staff were interviewed regarding discharge process and were found to be educated on the changes in the facility discharge process. The facility policy for Transfer or Discharge Notice was updated 1/13/20, to include, Medically related social services shall be provided for all discharging residents. A facility fax sheet template indicated the physician would be provided with the resident's discharge information, including where the resident would be transferred to, a request for discharge orders, orders for necessary equipment, non-narcotic medications to be sent with, and home care or outpatient services. An undated Discharge Preparation Checklist was provided with the IJ removal plan that listed responsibilities of nursing and social services to ensure a complete discharge and included obtaining a discharge form, completing and providing an interagency referral, discharge instructions, communication with discharge agency, and transportation. On 1/14/20, at 3:55 p.m. R1 was sitting in his new room in the facility, and said he was glad to be back. The facility policy and procedure for Transfer or Discharge Notice updated 2/19, directed a 30-day notice of an impending transfer of discharge would be provided with the exception of specific situations including: the safety or health of individuals in the facility would be endangered, or the resident had failed, after reasonable and appropriate notice, to pay for a stay at the facility. The resident would be transferred to the most appropriate setting to meet his or her needs in terms of quality, service and location. The facility undated Medical Social Worker Job Description duties included to assist with appropriate discharge planning to involve resident, families and appropriate agencies, conduct discharge conferences on all resident being transferred to a lower level of care, and facilitate making community referrals for home services and/or equipment. In addition, medical Social Workers were to make referrals as needed to outside agencies, such as mental health, and chart in medical record all pertinent contacts. R5's Admission Record printed 1/14/20, indicated R5 was admitted to the facility on [DATE], was his own responsible party, and [DIAGNOSES REDACTED]. R5's quarterly MDS dated [DATE], indicated R5 was cognitively intact, had no behaviors, required extensive assistance with bed mobility, dressing, toileting cares, and personal hygiene and required total assistance with transfers and locomotion. R5 did not ambulate, had limited range of motion (ROM) of both upper and lower extremities, and used a wheelchair. R5's MDS further indicated R5 had an indwelling catheter, was always incontinent of bowel, had severe pain almost constantly, and received opioid medications. R5's care plan initiated 5/1/19, identified R5 as a vulnerable adult due to physical impairment, and R5's goal was to remain safe and not be victim of abuse or injury. R5's care plan further indicated R5 had a self-care deficit related to weakness, decline in mobility, cancer, end stage [MEDICAL CONDITION], non-ambulatory, medications and history of falls. R5 had the potential for urinary tract infections (UTI's) due to indwelling catheter, bleeding due to anticoagulant use, had pressure ulcers with the potential for development of further pressure ulcers. R5's physician orders [REDACTED]. R5's Vulnerability and Susceptability (sp) to Abuse dated 10/25/19, identified R5 as a vulnerable adult but able to report maltreatment, with vulnerabilities identified as cognitive impairment and physical impairment. A 30-day discharge notice for non-payment dated 12/11/19, indicated R5 was to be discharged on [DATE], to his apartment or to the homeless shelter if he no longer had his apartment. R5's Palliative Care Consult note dated [DATE], indicated R5 was in intensive care unit (ICU) at the hospital. R5's daughter had informed provider she had not been informed of the hospital admission and R5 had been given a discharge notice for non-payment. R5's daughter planned to pay the remainder of the balance and was hopeful that R5 would not have to find another place to live. R5's provider note indicated R5 had swallowing problems and was not compliant with speech therapy recommendations. R5's progress notes dated [DATE], through [DATE], indicated R5 had several hospital visits, and was admitted to intensive care unit on [DATE]. R5's progress notes lacked any indication discharge notice had been served to R5, and lacked any documentation of social services interactions or interventions to find and secure a safe living arrangement following discharge, ensure medical services arranged following discharge, or ensure arrangements for payment. R7's Admission Record printed 1/14/20, indicated R7 was most recently admitted [DATE], and [DIAGNOSES REDACTED]. R7's annual MDS dated [DATE], indicated R7 was cognitively intact, had no behaviors, was independent with ADLs, did not ambulate, used a wheelchair, was continent of bowel and bladder, and received oxygen and opioid medications. R7's care plan initiated 4/25/17, indicated R7 required oxygen for respiratory diagnoses, was at risk for pressure ulcers, pain, and falls, and had a [MEDICAL CONDITION] disorder with related treatments. R7's care plan further indicated R7 was alert and oriented, was his own decision maker, and had short and long term memory loss with limited insight and poor decision making ability. R7's care plan indicated R7 required assistance with incontinent cares and upon request. R7's physician order [REDACTED]. R7's orders dated 1/14/20, no longer indicated R7 was receiving hospice services. R7's Assessment for vulnerability and Susceptibility to Abuse dated 6/14/18, identified R7 as a vulnerable adult but able to report maltreatment, with vulnerabilities including alcohol/substance abuse and physical impairment R7's Vulnerability and Susceptability (sp) to Abuse assessment dated [DATE], identified R7 as a vulnerable adult but able to report maltreatment, with vulnerabilities including alcohol/substance abuse and physical impairment. A 30-day discharge notice for non-payment dated 6/27/18,

Based on interview and document review, the facility failed to follow manufacturer's guidelines for the proper use of a shower chair to prevent accident hazards for 1 of 3 residents (R1) who utilized a shower chair for bathing. This deficient practice resulted in actual harm for R1, who sustained a closed right [MEDICAL CONDITION] and severe pain after falling from a shower chair. Findings include: R1 quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R1 had [DIAGNOSES REDACTED]. The MDS also identified R1 was cognitively intact. The MDS indicated R1 required extensive assistance of staff for bed mobility and transfers. The MDS identified R1 was not steady with moving from a seated to a standing position, on and off the toilet, surface to surface, and needed staff assistance to stabilize. The MDS further identified R1 had impairment on one side of his upper extremities, and impairment on both side of his lower extremities, and utilized a wheelchair. R1 was not identified as having had any falls from his prior assessment. R1's Fall Risks and Mobility assessment (a fall assessment) dated 12/5/18, indicated R1 was a high risk for falls due to impairment on one side of the upper extremities, impairment on both sides of the lower extremities, was not steady moving from seated to standing position, on and off toilet, surface to surface, was confined to wheel chair, and had limb prosthesis. R1's care plan revised on 2/25/19, indicated R1 had an activity of daily living self care deficit related to bilateral [MEDICAL CONDITION]. The care plan indicated R1 needed total staff assistance to provide a bath weekly and as necessary. The care plan futher indicated R1 was at risk for falls related to unsteadiness, was non-ambulatory, was incontinent, and received medications that may alter risk for falls. The facility's Witnessed Fall Report dated 2/7/19, indicated a nursing assistant (NA) was assisting R1 with a shower, and R1 fell out of the shower chair while leaning forward getting his back washed. The report indicated R1 hit the right side of his forehead against the wall, but landed mostly on his right hip/leg. R1 complained of pain at an 8 out of 10 to the right hip/leg. Range of motion (ROM) was within normal limits to R1's left upper and lower extremities, but R1 was unable to tolerate left lower extremity ROM, and he received abrasions to bilateral knees. Right knee abrasion measured 1.5 centimeters (cm) x 1.3 cm, left knee abrasion measured 0.5 cm x 0.5 cm, no swelling or bruising noted at that time. The report indicated the shower chair seat belt was not buckled, and the wheels were not locked while the NA gave R1 his shower. The facility Incident Report Summary dated 2/7/19, at 4:51 p.m. indicated neglect of care occurred on 2/7/19, at 4:30 p.m. from a fall. Description of incident indicated NA was in shower room assisting R1 with shower, he did not have a seat belt on, and R1 fell out of the shower chair. On 2/7/19 at 4:45 p.m. a progress note indicated NA was assisting R1 with a shower, R1 fell out of the shower chair while leaning forward getting his back washed. R1 hit right side of forehead against wall, landed mostly on right hip/leg. R1 complained of 8 out of 10 pain to right hip/leg and bilateral stumps, notable pain symptoms, denies pain else where. Range of motion (ROM) within normal limits to left upper and lower extremities, unable to tolerate left lower extremity ROM and received abrasions to bilateral knees. Right knee measured 1.5 centimeters (cm) x 1.3 cm, left knee measured 0.5 cm x 0.5 cm, no swelling or bruising noted at present, denies headache, light headedness, dizziness and remained alert and oriented times four. Vital signs: temperature 97.3, pulse 65, respirations 18, blood pressure 147/78, and oxygen levels 95 percent on room air. Shower chair seat belt was not buckled and wheels were not locked while NA gave shower. On 2/7/19, at 10:03 p.m. a progress note indicated the facility received X-ray results for right hip/femur, no fracture or dislocation. On 2/8/19, at 2:20 p.m. a progress note indicated R1 had refused cares and was swearing at NAs that day. R1 had complaints of pain rated level 10. Nursing staff had spoken to nurse the practitioner who prescribed new pain MEDICATION ORDERS FOR [REDACTED]. On 2/8/19, a physician progress notes [REDACTED]. (R1) complained of significant pain. Imaging ruled out acute fracture or dislocation. Unable to visualize the right leg given position of bed in the room however, a large contusion on the right lateral side of thigh is palpated. On 2/11/19, Physician/Prescriber Orders indicated an order was received for R1 to be sent to the emergency room via ambulance for further evaluation of right hip pain due to fall on 2/7/19. On 2/11/19, at 10:45 a.m. a progress note indicated R1 was assessed at 10:00 a.m. in regard to ongoing right hip pain since fall on 2/7/19. The note indicated R1 had received [MEDICATION NAME] 5/325 milligrams (mg) as needed which was effective over the weekend. R1 also had a portable X-ray done at facility which was negative, but not a very good image. The note included, On assessment of right hip it appears that it is internally rotated but he is an [MEDICAL CONDITION], he is tender to touch at trochanter head with definite hematoma at this site. To rule out fracture or dislocation of this hip, will need an order to send to emergency room for further evaluation of this hip. Will get an order to be medicated with [MEDICATION NAME] prior to transfer. On 2/11/19, at 11:04 a.m. a progress note indicated orders were received to transport R1 via ambulance for further evaluation of right hip pain, and to medicated with [MEDICATION NAME] prior to transfer. R1 left facility via ambulance at 10:45 a.m. in route to emergency room . On 2/12/19, at 3:56 p.m. the facility Investigation Report Summary indicated under investigation summary: CNA was assisting (R1) with a shower, (R1) leaned forward and fell out of the shower chair. (R1) was assessed with [REDACTED]. (R1) complained of right hip pain, portable X-ray was contacted and saw (R1) with in about one half hour after fall. X-ray results indicated no abnormalities, (R1) received Tylenol for pain. On 2/11/19 (R1) was experiencing severe pain and was sent to the emergency room , (R1) again was X-rayed and found to have a [MEDICAL CONDITION]. (R1) remains hospitalized at this time. Under description of harm the report indicated an abrasion to both knees and right [MEDICAL CONDITION]. On 2/14/19, R1's Orthopedic Surgery Discharge Summary indicated R1 was admitted to the hospital on [DATE], had a closed right [MEDICAL CONDITION], and closed displaced intertrochanteric fracture of right femur. R1 had surgical repair to right hip trochanteric fixation. R1 was hospitalized for [REDACTED]. R1 was a bilateral below the knee [MEDICAL CONDITION], and debilitated by past [MEDICAL CONDITION]. R1 was at a skilled nursing facility when he fell in the shower and sustained the right [MEDICAL CONDITION]. On 5/16/19, at 10:30 a.m. NA-A was interviewed and stated he was the NA who gave R1 his shower. NA-A stated R1 drove his power wheelchair into the bath tub room and was transferred from his wheelchair to the shower chair via mechanical lift. NA-A stated he began to give R1 a shower and was washing his back when R1 leaned forward and fell out of the shower chair. NA-A stated he had never used the shower chair's belt on R1 when he gave him a shower. NA-A stated the brakes on the shower chair were not locked when he gave R1 a shower. NA-A stated R1 had X-rays done, and ended up with a broken hip from the fall from the shower chair. On 5/16/19, at 1:32 p.m. registered nurse (RN)-A confirmed R1 was a fall risk and had fallen from the shower chair. RN-A indicated a portable X-ray was done, it was negative, and not clear. RN-A stated R1 went to the hospital and had a fracture of his hip. RN-A stated this was a safety issue and she would expect staff to follow the care plan. RN-A verified she would also exspect staff to put the seat belts on residents, and to make sure the brakes were locked on the shower chair when staff were giving showers. RN-A stated, You break every code of safety by not locking the breaks on the shower chair when providing a shower. On 5/16/19, at 2:44 p.m. nurse practioner (NP)-A confirmed R1 had fallen on 2/7/19, when the shower chair tipped over. NP-A stated R1 complained of hip pain, and had a X-ray done which was negative. NP-A stated R1 had a lot of pain with bruising to the hip area, went to the hospital on [DATE], and had a displaced fracture of his hip. NP-A stated the fall from the shower chair was the cause of the fracture, and stated the brakes should have been locked on the shower chair. On 5/16/19, at 3:36 p.m. the director of nursing (DON) confirmed R1 needed assistance with activites of daily living and showering, and used the same shower chair all the time. The DON confirmed staff did not lock the brakes, and did not fasten the seat belt on R1 when staff was providing a shower for R1. The DON verified R1 leaned forward in the shower chair and fell from the shower chair sustaining a fracture to his hip. The DON stated education was provided on using the brakes on the shower chair to NA-A after the incident. The DON stated it should have been common sense, and NA-A should have locked the brakes on the shower chair. The DON stated staff should be following the care plan and the manufacture's guidelines for the use of the shower chair. On 5/16/19, at 5:16 p.m. physician (P)-A was interviewed by telephone and confirmed R1 had a fall from the shower chair on 2/7/19. P-A verified R1's fall from the shower chair resulted in the fracture to his hip, and stated he would expect staff to follow manufacture's guidelines for the use of the shower chair by locking the brakes on the shower chair. P-Stated the facility should be following the standards of practice for safety. Review of Operation Instructions for Shower Chairs undated, indicated under showering: all chairs are equipped with at least two locking canisters. Push the chair backwards so the wheels are facing out and lack all locking casters before any transfer, transfer user into the chair, move the user into shower area and lock canisters. Under precautions: never leave an at risk user unattended in the chair and exaggerated user movement in any direction or sitting on the edge of the seat may cause the chair to tip. Under the MM International corporation under warning: indicated never allow the user to lean outside the frame of the equipment, never allow the user to suddenly shift weight in any way crating a tipping hazard for the user and the equipment, always use the equipments safety belt and/or shoulder harness when provided, the improper use of their equipment or failure to comply with all directions and warning may result in death or injury and always apply the brakes on canisters when needed. The facility policy Shower/Tub Bath dated 11/28/17, directed staff to assist the resident into the bath chair if applicable (Note: be sure the wheels are locked, and/or the chair is stead to prevent the resident form falling). The facilty policy Fall and Fall Risk, Managing dated 11/28/17, directed based on previous evaluations and current data, the staff will identify interventions related to the residents specific risks and causes to try to prevent the resdient from fall and to try to minimize complications from falling.

Based on observation, interview, and document review, the facility failed to ensure staff utilized proper infection control practices of cleaning surfaces and proper hand washing to prevent and control the transmission of a highly infectious bacteria salmonellosis from a salmonella infection when caring for 5 of 28 residents (R1, R2, R3, R4, and R5) who had a known cases of this bacterium. Eleven of 28 residents had symptoms of salmonella infection. This resulted in an Immediate Jeopardy (IJ) with the potential for serious harm, injury, or death for the other 28 residents who resided on the facility's second floor. The Immediate Jeopardy (IJ) began on 8/31/2017, when R1 and R2 were diagnosed with [REDACTED]. The facility was not properly disinfecting the equipment, floors, resident rooms, or using proper hand hygiene when caring for residents and in between residents. The administrator and director of nursing (DON) were notified of the IJ on 9/14/17, at 4:45 p.m. The IJ was removed on 9/19/2017, at 4:20 p.m. Non-compliance remained at the lower scope and severity level of actual harm. Findings Include: R1's medical record was reviewed. R1 was admitted to the facility with dementia, adult failure to thrive, and dysphagia. R1's care plan dated 7/14/2016, indicated R1 was at risk of falling related to dementia, and dehydration related to poor oral intake. The residents refused to leave his/her room. R1 required assistance for all activities of daily living including person hygiene and transferring. R1 was admitted to a local hospital on [DATE], at 2:30 p.m. for nausea, fever, vomiting, diarrhea, and crackles in the right lung base. During routine screening, the local hospital found salmonella infection and reported the [DIAGNOSES REDACTED]. R2's medical record was reviewed. R2 was admitted to the facility, with cerebral infarct with [DIAGNOSES REDACTED] and hemiparesis, heart failure, [DIAGNOSES REDACTED]and type 2 diabetes. R2's care plan dated 5/19/2017, indicated R2 was at risk of constipation and is immobile. R2 required assistance for all activities of daily living including person hygiene and transferring. R2 was admitted to a different local hospital on [DATE], with severe diarrhea for four days. The diarrhea was so severe, R2 was hypovolemic and hypotension. R2 was admitted to the intensive care unit for treatment for [REDACTED]. R3's medical record was reviewed. R3 was admitted to the facility on [DATE], with sepsis, urinary tract infection, asthma and type 2 diabetes. R3's care plan dated 9/1/2016, indicated R3 was at risk of nutritional and hydration deficiency, functional bladder and incontinence. R3 required assistance with all activities of daily living including personal hygiene and transferring. R4's medical record reviewed. R4 was admitted to the facility with [DIAGNOSES REDACTED], schizophrenia, and epilepsy. R4's care plan 4/23/2015, indicated R4 was at risk of frequent incontinence, hypertension, [DIAGNOSES REDACTED]and heart valve replacement. R4 required assistance with all activities of daily living including personal hygiene and transferring. R5's medical record was reviewed. R5 was admitted to the facility with [DIAGNOSES REDACTED] and hemiparesis, cerebral infarction, and adult failure to thrive, Dementia. R5 required assistance with all activities of daily living including personal hygiene and transferring. R6's medical record was reviewed. R6 was admitted to the facility with dementia, anxiety, and psychosis. R6 required assistance with all activities of daily living including person hygiene and transferring. A letter to the facility dated 9/8/2017 from the Minnesota Department of Health, Foodborne Diseases Unit indicated it identified Salmonella infection in two residents, R1 and R2, and an additional 11 residents and four staff had a history of [REDACTED]. Based on the site visit on 9/6/2017 from the Foodborne Disease Unit it was determined that the illness was unlikely to be foodborne and the following steps should be implemented promptly: at the start of every shift staff need to be asked about gastrointestinal symptoms; any staff with diarrhea illness are to remain restricted from patient care that involves oral care, feeding, or anything with hand-to-mouth actions, and staff with symptoms should be tested ; the facility needs to track all residents and staff in the facility with diarrhea illness; reinforce good hand hygiene and glove use among staff; and increase the frequency of cleaning, especially bathrooms. Additional recommendations included: environmental consultation regarding the facility cleanliness and ensure the infection preventionist meet with the Minnesota Department of Health Infection Control Assessment and Response Program to discuss long term changes and improvements. During an observation on 9/13/2017, at 9:45 a.m. of all shower rooms with environmental services director (ES)-T and the administrator, the shower room on 2 floor center had a lotion 8 ounces which had been used in the cabinet with clean items in it. During an observation on 9/13/2017, at 1:00 p.m. NA-V pushed R7's wheelchair to his/her room and touched R7's shirt, left the room without cleansing NA-V's hands, went to dining room and asked NA-A to assist putting R5 to bed. NA-V and NA-A used a hoyer lift to put R5 to bed. Changed R5's brief and left the room. NA-A and took the hoyer out into the hallway without cleaning hands or the hoyer equipment walked down the hallway to the nurses station. During an observation on 9/14/2017, at 7:00 a.m. of NA-aa assisted R8 to get dressed and comb R8's hair. NA-aa left R8's room without cleaning hands. Then went to the laundry cart, got clean laundry of the cart and took the linen into R5's room and put the linens on the bed. During an interview on 9/12/2017 at 1:00 p.m. with the director of nurses (DON) and the administrator, the director of nurses stated the facility does not use isolation precautions for the salmonella outbreak just standard precautions, which includes handwashing and gloving. The administrator stated Minnesota Department of Health made the facility aware of the outbreak. During an interview and observation on 9/12/2017, at 2:15 p.m. nursing assistant (NA)-A stated the nursing assistants clean the wheelchairs, hoyer lift equipment, bedside commodes, shower chair and the showers between residents use. NA-A said they were out of disinfectant for the showers so NA-A got some from the housekeepers. NA-A said s/he did not read the directions s/he just mixed it. NA-A said s/he put about 1/3 of the spray bottle full of CDC disinfectant and the rest water. NA-A said no one had been trained on how to use the product. NA-A confirmed there was no date or content label on the bottle. All residents on this unit use this shower room. Sitting on an over bed table in the shower room was a partially used 8 ounce bottle of shampoo, a partially used 8 ounce bottle of body wash, a partially used 10 ounce bottle of lotion, open shaving cream and open deodorant. NA-A said each resident is supposed to get their own hygiene products but sometimes the staff just use what is sitting there. NA-A stated the nursing assistants have not had any training about mixing cleaning products and or cleaning the equipment. NA-A was not aware of any cleaning schedule for equipment or anywhere to sign off that you cleaned equipment. During an interview on 9/12/2017, at 4:00 p.m. NA-B and trained medication assistant (TMA)-F stated Nursing assistants clean the shower room and shower chairs to the best of their knowledge. Both NA-B and TMA-F think the cleaning products come from housekeeping. Neither was sure because they do not get the product. NA-B and TMA-F reported there is no schedule for cleaning or anywhere to document when the shower room or equipment are cleaned. During an interview on 9/12/2017, at 4:30 p.m. registered nurse (RN)-G said s/he is the shift supervisor. S/he has never watched the NAs clean the equipment. RN-G was not aware of any schedule to monitor compliance to cleaning equipment or the shower room. RN-G said is not aware of any training of how to clean the shower room, the equipment or washing hands. RN-G is not aware of the contents of the spray bottle the NAs were using to clean the shower room and acknowledged the bottle was not labeled. During an interview on 9/12/2017, at 5:00 p.m. with housekeeping (HK)-B stated they clean the floor with a disinfectant. HK-B said the solution was mixed 1 part disinfectant and 10 parts water. The facility does not use a measuring device; the housekeepers guess how much disinfectant to put in the water. HK-B said a previous environmental services manager trained them more than a year ago. During an interview on 9/12/2017, at 5:30 p.m. with the administrator stated you spray the cleanser on and let it sit, than wipe it off is what the directions indicate. The administrator acknowledged the spray bottle is not labeled with the contents. The administrator compared the color of the solution in the spray bottle to the color of the disinfectant, which was not supposed to be mixed. The administrator agreed the content of the spray bottle was mixed with water and not used straight as the directions indicate. During an interview on 9/13/17, at 7:10 a.m. licensed practical nurse (LPN)-M stated the nursing assistants use the spray bottle in the shower room to clean the shower. LPN-M said they use what is in the spray bottle and LPN-M is not aware of what is in the bottle. LPN-M stated the spray bottle was not labeled. During an interview on 9/13/2017, at 7:00 a.m. NA-N said the housekeepers clean the shower room and the patient equipment. This is different from what other staff reported. NA-N did not know where to find the disinfectant that goes in the spray bottle. During an interview on 9-13-2017, at 7:05 a.m. NA-D stated we clean if we can find the cleaner. Sometimes we do not have any disinfectant in a spray bottle; we do not clean the shower room or equipment when that happens. We are often out of cleaning products. If we do not have a carpet cleaner, we just spray the carpet with disinfectant. We are not supposed to re-use lotions on different residents but sometimes we do. Often we are out of hygiene supplies for residents. During an interview on 9/13/2017, at 7:50 a.m. HK-Q stated we have been out of the disinfectant that we use to clean the floors so we are using a detergent right now. We have been out of the disinfectant since last week. I am not sure when we ran out. HK-Q said s/he is not sure if management knows or not. During an interview on 9/13/2017, at 8:30 a.m. the administrator said he just became aware the facility was out of the disinfectant to clean the floors. The staff have been using detergent, but not disinfectant to clean the floors. The administrator stated the facility was getting the disinfectant that morning. During an interview on 9/13/2017, at 10:15 a.m. ES-T stated the facility does not have a process to know when to order disinfectant/cleaning products. The product got ordered if a staff person tells me we are out. ES-T was not able to produce a documentation of tracking cleaning products. During an interview on 9/13/2017, at 2:00 p.m. with assistant director of nurses (ADON) said the facility does handwashing audits by telling the staff s/he will be watched them wash their hands. The ADON said she has never audited handwashing by watching people do their work to see if they actually do wash their hands. No other handwashing audits were done. That data was reported to the quality committee and handwashing audit even though it was inaccurate. During an interview on 9/14/2017, at 6:30 a.m. HK-X, HK-Y, and HK-Z who said they do deep cleaning of the resident rooms. The staff mark which rooms were done and turn them into ES-T. There is no schedule of what rooms to do and when to deep clean the resident's room. The staff do not mark what they clean in the resident rooms, just that they clean it. During an interview on 9/14/2017, at 9:10 a.m. the manufacturer of the disinfectant stated the product the facility was using to clean the shower room was not supposed to be mixed. It is ready to use. If it is mixed, it will not kill viruses and bacteria. During an interview on 9/14/2017, at 11:45 a.m. ES-T said there was no cleaning logs, or tracking sheet of when a product needs to be ordered so the staff do not run out of disinfectants. During an interview on 9/18/2017, at 11:00 a.m. the medical director (MD) stated he over sees the quality process and influenza immunizations. He was aware of the salmonella outbreak but was not aware of the lack of disinfecting equipment and floors the staff not using proper handwashing. An undated policy titled Cleaning and Disinfection of Resident Care Items and equipment indicated care items will be disinfected. An undated policy entitled Cleaning and Disinfection of Environmental Surfaces indicated proper cleaning a disinfecting will be done of equipment when used. Protective gloving will be done and proper handwashing will be completed. The infection control plan is a group of infection control policies. The immediate jeopardy (IJ) began on 9/14/2017 was removed and the administrator and director of nursing were notified at 9/19/2017 at 4:20 p.m. after verification of the removal plan through observation, document review, and interviews. The facility had disinfectants stocked to ensure supply for cleaning, observation of 23 staff being trained by the administrator on topic on hand hygiene and environmental cleaning, the housekeeping closets and nursing unit were audited to ensure they contained the common chemical education guide and all the measuring cups were present to ensure accurate dilution as directed, a deep cleaning schedule was created and staff were educated on the schedule and interviews were conducted to ensure the staff were familiar with the schedule. A competency was created regarding hand hygiene and 54% of the staff had completed it. A plan was created to ensure all of the staff would get the competency before their next working shift. A handwashing audit was created and the managers were trained for its use. Thirteen staff were interviewed and demonstrated knowledge of how to clean and what product to use. Facility wide cleaning was observed. Every resident room had a sign posted to remind staff to their sanitize hands. Housekeeping staff had received their daily assignments, the schedule of which room to deep clean and the sign off sheet. The facility inquired each employee's health status before their shifts starts. Noncompliance remained at the lower scope and severity level of isolated actual harm that is not immediate jeopardy.

Based on observation, interview, and document review, the facility failed to ensure comprehensive assessments were completed and individualized interventions were developed and implemented to minimize the risk for falls for 1 of 2 residents (R61) reviewed for falls. The facility failed to evaluate the causative factors of resident falls to determine the efficacy of current interventions and if new interventions were appropriate. The facility's failure resulted in an immediate jeopardy, with actual harm (hip fracture) for R61. In addition, the facility failed to ensure side rails were appropriately secured for 1 of 1 residents (R42), reviewed for side rails. The immediate jeopardy began on 10/22/15, when R61 returned from the hospital following a significant fall with subdural hematoma. R61 experienced a significant change in condition following that hospitalization . Upon return, the facility failed to assess R61's multiple changes including fall risk in order to assist in developing appropriate individualized interventions to minimize the risk for ongoing falls. The director of nursing (DON) was notified of the immediate jeopardy (IJ) for R61 on 11/12/15, at 6:23 p.m. The immediate jeopardy was removed on 11/18/15, at 10:30 a.m. but noncompliance remained at the lower scope and severity of a G, which indicated actual harm that was not immediate jeopardy due to fractured hip. Findings include: R61's admission record indicated multiple [DIAGNOSES REDACTED]. R61 experienced multiple falls, some of which resulted in significant injury. The facility did not evaluate the causative factors of the fall, the efficacy of interventions and the need for additions to the individualized interventions to assist in minimizing the risk for ongoing falls. R61's quarterly Minimum Data Set ((MDS) dated [DATE], identified he was cognitively intact and independent when ambulating in his room and in the hallway. On 9/21/15 he was admitted to the hospital with [REDACTED]. R61 returned from the hospital on [DATE]. R61's MDS dated [DATE], indicated R61 was severely cognitively impaired and had no behavior problems. The MDS further identified R61 required extensive assistance of one staff for activities of daily living (ADLs). The MDS also identified R61's balance during transfers was not steady, but he was able to stabilize without assistance. The MDS identified R61 had pain, received pain medication daily, was at risk of falls, and had a history of [REDACTED]. R61's Fall Care Area Assessment (CAA) dated 11/2/15, indicated R61 was at high risk for falls with a history of falls in the past. The Fall CAA did not address individualized interventions in place, their efficacy or the need for changes. R61 had multiple Fall Risk Assessments completed, most recently on 11/12/15, however, they were checklists containing data which did not comprehensively assess R61's fall risk to ensure appropriate interventions were implemented. The data gathered indicated R61 was at a high risk for falls, had decreased coordination, used assistive devices, and had multiple falls. R61's care plan initiated on 1/13/14, indicated he was a high risk for falls related to impaired balance and cognition, history of CVA (cerebral vascular accident), incontinence, diabetes and multiple falls with injuries. The identified goal was The resident will be free of minor injury through the review date. R61's care plan dated 11/9/15, identified the following interventions: call light within reach and encourage use, prompt response to call lights, ensure appropriate footwear in use, PT as ordered, activities for diversion/distraction, TAB alarm in bed and wheelchair (w/c), pressure alarm in bed, transfer with assist of 1, gait belt and back brace. The care plan was revised on 11/9/15, following multiple observations of a motion sensor alarm not being appropriately implemented. Observation on 11/9/15, at 5:05 p.m. identified R61 lying in bed with his call light on the overbed table. The overbed table was approximately three feet away from R61's reach and the motion alarm was turned off. The TAB alarm was attached to him. Registered nurse (RN)-M verified the motion alarm was turned off and the call light was out of reach. RN-M turned the motion alarm on and identified it was not functioning. RN-M changed the batteries and was able to get the alarm to work. On 11/9/15, at 5:20 p.m. the motion alarm was found turned off. RN-A came in with R61's meal tray and left the room with out turning the alarm on. When asked to verify the motion alarm was turned off she stated it was. RN-A further stated the alarm was a problem as it was always sounding so we don't turn it on all the time. On 11/9/15, at 6:20 p.m. R61's motion alarm was found to be turned off. This was verified by RN-A. RN-A turned the alarm back on again. Review of R61's progress note dated 8/22/15, at 2:13 a.m. identified the resident self reported a fall. R61 stated he was walking around the bed in his room and tripped on the bed. R61 stated he hit his head and also complained of slight shoulder pain. Another progress note dated 9/21/15, at 3:51 p.m. identified R61 had fallen and hit his head. R61 was sitting on the edge of the bed and stated he hit his head. R61 stated he was in the bathroom when he fell and hit the back of his head on the doorknob of the bathroom door. R61 was not utilizing his walker at the time of the fall. R61 complained of dizziness, ringing in ears, and pain on palpation to back of head. R61 stated he was dizzy, his legs gave out, and he fell . The on call physician directed staff to monitor for any neurological changes and increased pain to head or back. On 9/22/15 at 7:15 a.m. R61 continued to complained of ringing in ears, dizziness, and a headache. R61 had increased back pain and was unable to roll or sit up in bed or ambulate. His blood pressure dropped to 94/53 and pulse was 53. R61 was sent to the emergency room and was admitted with a subdural hematoma (brain bleed) and fractured back. A progress note dated 10/22/15, at 1:47 p.m. indicated R61 returned form the hospital. On 10/24/15, at 1:11 a.m. a medication administration note indicated R61 was restless and climbing out of bed multiple times. R61 was up walking alone going through his closet. The alarm was off and did not sound. A nursing note dated 10/25/15, at 10:59 p.m. identified R61 was on neurological checks due to a fall in the morning. R61 was up walking in the hallway looking for his dogs. R61 was unsteady on his feet. He had 3 alarms in place, however, he had one alarm tucked in his pants pocket, one alarm wrapped up in a blanket, and the third alarm did not sound. A progress note dated 10/29/15, at 6:18 p.m. identified R61 was found on the floor in the middle of the room. Although R61 had 2 TAB alarms and a motion alarm on the floor, none of the alarms sounded. The nursing progress note dated 10/31/15, at 9:22 a.m. indicated R61 was unable to bear weight on his right lower extremity (RLE) and was complaining of pain. Staff reported R61 complained on 10/30/15 as well. R61 had significant pain when up in the wheelchair. R61 was sent to the emergency room and was admitted with a right acetabulum (head/ball of the femur) fracture. R61 returned to the facility on [DATE] with a plan for non-surgical management of the hip fracture. On 11/12/15, at 2:45 p.m. R61 was observed by the surveyor to be sitting on the foot pedals of his wheelchair. R61 was in his room with his door closed. No alarms were sounding when he was discovered on his foot pedals. After being called to the room, LPN-A and RN-B agreed there were no alarms sounding and there was no call light within reach. An incident note dated 11/12/15, at 11:31 p.m. indicated R61 slid out of his wheelchair and was being held onto by RN-B. R61 slid out of his chair and was not quite on the ground. R61 stated he wanted to go to bed, and was trying to get there when he slid off his chair. RN-B and licensed practical nurse (LPN)-A returned R61 to bed with the mechanical lift. R61's falls were reviewed with the director of nursing (DON) on 11/12/15, at 3:58 p.m. and the DON indicated the fall of 8/22/15, was a slip off the recliner with no injury. The DON stated R61 was independent with ambulation at that time so there were no specific interventions for falls at that time. The DON stated the next fall was on 9/21/15, when R61 fell in his bathroom, got himself up and went to the side of the bed. The DON said R61 self-reported the fall. R61 was not using his walker and there was no obvious injury. R61 reported he hit the back of his head on the bathroom door knob. The DON stated she wasn't sure when the TAB alarm was placed on R61. Other interventions in place at that time included: physical therapy (PT) to evaluate, call light within reach, appropriate foot wear, and transfer with assist of one, gait belt, and back brace on. The DON indicated when R61 fell on [DATE], at 10:30 a.m. he was found crawling toward his roommate's bed. The fall was unwitnessed. The DON stated R61 had gripper socks on at the time and he was confused. The DON identified a motion sensor alarm was added at that time. The DON further stated between this fall and the one on 10/29/15, alarms were the only additional interventions. The DON also indicated staff was trying to manage his pain as they felt the restlessness may have been related to his difficulty expressing pain. The DON stated R61 also fell on [DATE], at 6:30 a.m. None of the alarms were sounding when R61 was found. The TAB alarm was wrapped up in his blanket. The DON said there were no new interventions at that time. The DON stated she did not believe the hip fracture was a result of the fall because R61 did not report the problem until 2 days after the fall. The DON went on to say when R61 was found on the pedals of his wheelchair on 11/12/15, she did not believe that was a fall. The DON stated R61 slipped off the chair. However, the DON could not explain how R61 slipped out of the wheelchair. When asked about reviewing the specific fall interventions, the DON invited the nurse manager over to answer specific questions. RN-A stated after the 11/12/15, incident she placed a pressure pad alarm in R61's wheelchair with dycem (non-skid sheet) on the top and bottom of the pressure pad. RN-A also said they asked for a pharmacist review of R61's medications. A request was also sent to therapy for a reassessment. RN-A was informed about the alarms not sounding and indicated she was not aware there had been issues. When asked about an interdisciplinary team comprehensive assessment of the falls to determine the root cause of the falls, the efficacy of current interventions and identify other interventions that may be appropriate to minimize R61's risk for falls, both the DON and RN-A stated they had not done that. An interview on 11/9/15, at 1:00 p.m. with physical therapist (PT)-A identified they saw R61 from 10/22/15, to 10/30/15, and again 11/3/15, to current. PT-A said when they saw him back in 3/15, he was discharged as independent with a 4 wheeled walker (WW). PT-A stated when R61 came back from the hospital following his subdural hematoma in 10/15, he had orders for all three disciplines (physical, occupational, and speech) to assess and treat. PT-A stated therapy staff saw R61 for eight days. Staff attempted to ambulate him but he could not ambulate. PT-A stated R61 had a lot of pain due to his back fracture. PT-A stated the next request for therapy services was on 11/3/15, after returning from the hospital with the acetabulum fracture from another fall. R61's orders were for weight bearing as tolerated. Therapy staff utilized an TENS (Transcutaneous Electrical Nerve Stimulation) unit for his pain. PT-A stated R61 rated his pain at a 10/10 and staff could tell by R61's facial expressions when he was in pain. A subsequent interview on 11/12/15, at 12:45 p.m. PT-A stated physical therapy did an evaluation on 11/6/15, post fall with injury, she said they changed his wheelchair at that time because it didn't fit him well. PT-A was aware leg kept sliding off the leg of the wheelchair. She said they put a calf pad in place that morning. After notification of the IJ on 11/13/15, updated interventions for R61's fall care plan included the following interventions. However, the interventions were not observed to be implemented right away, or staff were not knowledgeable about the changes. · Anticipate and meet the resident's needs. · Do not leave the resident unattended when up in w/c. · Follow facility fall protocol. · Hoyer lift with assist of two staff for all transfers. · Review information on past falls and attempt to determine cause of falls. Record potential root causes. Alter any potential causes if possible. Educate resident/family caregivers/IDT · Provide diversion and distraction such as news, music, socials and special events. · Offer a snack (food and drink) when restless, states he's hungry or unable to sleep and monitor effectiveness. · PT evaluate and treat as ordered. · The resident uses TAB electronic alarm in bed and w/c. Pressure alarm in bed and w/c. Dycem on top and bottom of pressure mat in w/c. During an interview on 11/13/15, at 8:17 a.m. trained medication assistant (TMA)-K stated R61 had one pressure alarm in his chair and a pressure alarm in his bed. An observation on 11/13/15, at 10:00 a.m. R61 was sitting by the nurses station in the hallway with his TAB alarm on but not in attendance at the nearby activities program. During interview on 11/13/15, at 11:28 a.m. activities (A)-A said R61 went to activities but didn't attend much since returning from the hospital. A-A said they do 1:1's. She said if the documentation identified R61 as unavailable, he was usually in bed in a lot of pain or not feeling well. An interview on 11/13/15, at 2:25 p.m. nursing assistant (NA)-A said they did not receive report on any changes to R61's care. NA-G said on 11/13/15, at 2:28 p.m. they work on the other hall but, I know he is always in pain and yelling in pain. An interview on 11/13/15, at 2:37 p.m. RN-F said she was told he was on fall precautions, so he has alarms in his chair and a TAB alarm. She was not aware of any new plan of care since yesterday. An interview on 11/13/15, at 11:06 a.m. with family member (FM)-K indicated when R61 fell in September he slipped and fell in the bathroom. R61 told FM-K he was tired of waiting so long to get help. FM-K stated prior to his head injury, R61's mind was clear. An interview on 11/16/15 at 3:43 p.m. NA-G stated, I didn't know he fell . He is in a lot of pain. He has a back brace and is a full mechanical lift. NA-G further stated she hadn't been informed of any changes in his plan of care in the last couple days NA-G was aware he had alarms on his chair and his bed. During an interview with RN-D on 11/16/15, at 3:47 p.m. stated the changes in R61's plan of care included: alarms in the wheelchair and bed, and when up he needs to be in the dining room or by the nurses station. R61 had a TAB alarm in his wheelchair and a pressure alarm in his bed. There was education for staff of the changes and staff signed after receiving the education. An interview with RN-A on 11/16/15, at 4:07 p.m. stated staff placed a pressure pad and and a TAB alarm in his bed and wheelchair. R61 was not to be left unattended while in the wheelchair. He is to be engaged in activities. The pharmacist reviewed R61's medications and the medical doctor will as well. The physician ordered a scheduled a pain medication. RN-A further stated she has seen R61 in a lot of pain and agreed he did not have adequate pain control. She said she has seen him grimace in pain. RN-A stated all staff should be using the same pain scale and they are not. She said they do not us any non pharmacological pain interventions and we should. RN-A stated since survey started R61 doesn't have good pain control. She further stated R61's pain may be affecting his restlessness so staff requested a regular pain medication. His new pain order is for oxycodone 10 mg 3 times daily. Interview on 11/16/15, at 4:28 p.m. with the DON indicated they changed the process of reviewing falls to include a weekly IDT meeting, including PT, to review all high risk fall residents. The new committee will review falls to ensure interventions are in place and all of residents were reviewed for fall risks. An interview on 11/17/15, at 8:35 a.m. A-A stated she had him in 3-4 activities a week. She said R61 will be visited 3-4 times a week. This plan started on 11/13/15. Before then, A-A had R61 do things independently, now he will have more planned 1:1's. The team planned to have weekly fall meetings and she will attend those meetings. An observation on 11/17/15, at 9:05 a.m. PT-M was doing therapy for R61. When he was asked about his wheelchair leg being too short, she agreed and said the right leg could be lengthened a little. The w/c leg was lengthened at that time. An interview on 11/17/15, at 11:05 a.m. NA-J said the DON was on the unit and educated everyone on what to do for R61's falls. An interview on 11/17/15, at 12:24 p.m. RN-A said the pharmacist and medical doctor's recommendations regarding R61's falls were in place. An interview on 11/17/15, at 12:39 p.m. RN-F said she had accident investigation training when she started but not with in the last couple months. The immediate jeopardy that began on 10/22/15, was removed on 11/18/15, when the facility implemented the following interventions to minimize the risk of falls for R61. However, noncompliance remained at the lower scope and severity level of G - isolated, scope and severity level, which indicated actual harm that is not immediate jeopardy for R61. Actions taken to remove the IJ, which were verified through observation, interview and record review were as follows: 1. Comprehensive fall risk assessment was completed. 2. Physician orders [REDACTED]. 3. R61 was not left alone in his room during observations. 4. R61 was included in more activities and 1:1 sessions. 5. Alarms were in place in the wheelchair and in bed. 6. NA care sheets were changed and signed by the NAs. 7. Care plan was updated. 8. The medication and treatment administration records were updated as ordered. 9. The pharmacist and physician's recommendations were completed as ordered. 10. Weekly IDT meeting related to resident falls was implemented. 11. Fall risk assessments will be done quarterly with high risk residents being focused on at the weekly IDT meeting. On 11/13/15 at 2:01 p.m. the DON confirmed the undated Root Cause Analysis Authors was the fall prevention policy. The policy identified, During the daily standup meeting falls are discussed focusing on safety, fall risk, fall management, devices, care plan adjustments and updates to group sheets that direct the non-license staff care. The facility policy entitled, Alarms for Bed and Chair reviewed 10/14 indicated, Alarms do not substitute for proper care and supervision. R42's right side rail was not secured to prevent movement to the side rail. R42's quarterly MDS dated [DATE], indicated R42 was cognitively intact and needed extensive assistance with bed mobility. The MDS included multiple [DIAGNOSES REDACTED]. R42's care plan dated 10/1/15, indicated R42 used side rails as ordered by the physician for safety while in bed and to assist with bed mobility. The care plan directed staff to observe for injury or entrapment related to side rail use. On 11/10/15, at 9:28 a.m. and 11/12/15, at 7:45 a.m. R42's right side rail was not secured. When checking for the function of the right side rail it moved freely up and down at an angle. When pulling on the side rail a gap occurred that could entrap a body part, creating a potential hazard to R42. On 11/12/15, at 7:45 a.m. R42 verified that the right side rail was too loose for him and he had reported it to staff the day on 11/11/15. On 11/17/15, at 7:21 a.m. the right side rail was observed to be tightened up. There was no longer a gap. When interviewed on 11/17/15, at 9:24 a.m. NA- D stated that the side rails become loose at times and when R42 reports he did not feel safe, staff put in a maintenance ticket to have it tightened. NA-D verified that the right side rail had been tightened, but was not sure when. When interviewed on 11/17/15, at 3:43 p.m. the director of maintenance (DM)-B stated the side rails for R42's were the correct rails for the bed. He added, they do loosen up with use. DM-B stated the facility does not have a process in place to routinely check the safety and function of side rails. The facility policy Bed Safety dated 12/07, directed maintenance staff to inspect all bed equipment to try and prevent deaths/injuries from the beds and equipment including sides rails .

Based on observation, interview and document review, the facility failed to comprehensively assess pain and implement interventions to relieve moderate to severe pain following lumbar (low back) and acetabulum (ball of femur) fractures for 1 of 1 residents (R61) reviewed for pain. This deficient practice caused actual harm to R61. In addition, the facility failed to provide coordination of care between the facility and the hospice agency for 1 of 1 residents (R109) reviewed for hospice. The facility also failed to provide services to a resident as directed by the physician for 1 of 1 residents (R143). Findings include: R61's admission record identified multiple [DIAGNOSES REDACTED]. R61's admission Minimum Data Set ((MDS) dated [DATE], indicated R61 was severely cognitively impaired and had no behavior problems. The MDS identified R61 had pain and received pain medication daily, and was at risk of falls with a history of falls with injury. The MDS further identified R61 required extensive assistance of one staff for activities of daily living (ADLs) and had not ambulated the past seven days. Pain assessments were completed [DATE], [DATE] and [DATE]. R61 was awakened at night from the pain. The pain was rated moderate to severe on all. The most recent assessment dated [DATE], identified daily pain and pain medications needed. The Care Area Assessment (CAA) dated [DATE], indicated verbal behaviors such as moaning, groaning, and crying to demonstrate pain. The characteristics, frequency and intensity of the pain was not completed. R61's care plan dated [DATE], identified a potential for pain. The care plan directed pain medications as ordered, monitor for and report changes in routine or appetite and verbal/non-verbal complaints of pain. The care plan did not include any non-pharmacological interventions to help alleviate pain. The Medication Administration Record [REDACTED]. R61 started receiving [MEDICATION NAME] every three hours as needed (PRN) on [DATE], until [DATE], (during survey) when the medication order was change to provide pain medication at scheduled times. The [MEDICATION NAME] was given 9 times in ,[DATE], of the 60 potential opportunities for PRN doses, and was given 26 times in ,[DATE], of the 96 potential opportunities for PRN doses which could have been provided. An observation of R61 on [DATE], at 10:38 a.m. lying in his bed with his knees up and a pillow under them. When asked he rated his pain at a ,[DATE] (a verbal pain scale where 1 was no pain and 10 was the most pain he has ever had). An interview on [DATE] at 1:00 p.m. with physical therapist (PT)-A identified they had started seeing R61 [DATE], to [DATE], and restarted [DATE] to current. She said when he came back from the hospital after his subdural hematoma in ,[DATE], he had orders for all three disciplines (physical, occupational, speech) to assess and treat him. PT-A stated they use a Wong-Baker pain scale (facial pictures) with R61 to measure his pain. PT-A continued to state after the [DATE], referral they only saw him for eight days. They attempted to ambulate him but he could not ambulate. He could only ambulate ,[DATE] steps from bed to chair with a walker. PT-A said, He was in a lot of pain cause of his back (lumbar fracture). The next request for therapy services was on [DATE], after returning from the hospital with the [MEDICAL CONDITION] from another fall. R61's orders were for weight bearing as tolerated and all three disciplines evaluated him. They tried a TENS unit (transcutaneous electrical nerve stimulation) for his pain. R61 rated his pain at a ,[DATE] and you could tell by his facial expressions if he was in pain. An interview on [DATE], at 8:50 a.m. physical therapy assistant (PTA)-A asked R61 to rate his pain using the Wong-Baker faces pain scale. R61 rated his pain a ,[DATE]. PTA-A said she always utilized that pain scale. PTA-A verified he was given pain medication at 8:13 a.m PTA-A indicated she evaluated R61's wheelchair on [DATE]. She stated the leg of the wheelchair was too short for R61. She could not explain why the leg rest had not been adjusted for R61. PTA-A put R61's leg on a stool and R61 hollered out in pain. PTA-A told PT-D that his leg kept falling off the leg rest as the leg rest on the wheelchair was too short for him. R61 moaned and whimpered the whole time PTA-A was moving his leg. R61 repeatedly said it hurts and ouch, ouch, ouch. At 8:54 a.m. PTA-A asked R61 what his pain level was and he said ,[DATE]. PTA-A was not able to continue the therapy on his legs so she used a balloon to play ball. A subsequent interview on [DATE], at 9:02 a.m. PTA-A said R61 has not been able to move his leg due to pain. PTA-A stated he was weight bearing as tolerated but can't walk due to his pain level. She said she usually walks people sooner after an injury but has not walked him due to extreme pain. She said she didn't ask if they gave him something for pain. She said it is important to have scheduled pain medications. Interview on [DATE], at 10:11 a.m. nursing assistant (NA)-H stated R61 cried out in pain a lot because of his back and hip injury. He said the pillow between R61's legs in bed was because he wouldn't straighten his leg out. She went on to say R61's wheelchair did not fit him and the wheelchair hurt him. An interview on [DATE], at 10:38 a.m. while R61 was lying in bed, this writer asked R61 to rate his pain and he rated his pain at an ,[DATE]. On [DATE], at 12:45 p.m. PT-A stated her expectation was a resident would get a pain medication when they are in pain. She said R61 rated his pain as ,[DATE]. PT-A said if the resident is still able to move and transfer they go ahead with therapy. PT-A said he used the sliding board to the Nu Step but R61 grimaced in pain. PT-A said there were no non pharmacological interventions used for R61's pain today. She didn't know why the TENS was not put on him. PT-A said when physical therapy did an evaluation on [DATE], post fall with injury, she said they changed his wheelchair because it didn't fit him well. PT-A was aware his wheelchair leg didn't fit him well and his leg kept sliding off the leg of the wheelchair. She said they put a calf pad in place that morning after the discussion with PTA-A. An interview on [DATE], at 8:47 a.m. occupational therapy (OT)-K asked R61 to rate his pain and he rated it at a ,[DATE] located near his left hip. She told him she would tell the nurse. NA-G said on [DATE], at 2:28 p.m. that she normally works another hall but I know he is always in pain and yelling in pain. An interview on [DATE], at 2:29 p.m. trained medication assistant (TMA)-K said she used a pain scale called pain AD. She said it uses breathing, negative vocalization, facial expression, body language and consolable to determine pain level. She didn't know what others used to determine pain levels. The order was for [MEDICATION NAME] 5 mg (milligram) 1 - 2 tablets every 3 hours for pain PRN. She said if R61 had a pain level of ,[DATE] /10 she gave 1 tablet. If he had a pain level of ,[DATE] /10 she give 2 tablets. An interview with registered nurse (RN)-A on [DATE], at 4:07 p.m. stated she has seen R61 in a lot of pain and agreed he did not have adequate pain control. She said she has seen him grimace in pain. RN-A stated all staff should be using the same pain scale and they are not. She said they do not us any non pharmacological pain interventions and we should. RN-A stated since survey started R61 doesn't have good pain control. She further stated R61's pain may be affecting his restlessness so staff requested a regular pain medication. His new pain order is for [MEDICATION NAME] 10 mg 3 times daily. A progress note dated [DATE], at 1:11 a.m. identified R61 was restless and climbing out of bed several times. When asked if he had pain and wanted a pain pill R61 said yes. An observation on [DATE], at 9:05 a.m. PT-M said the TENS unit blocks the nerve synapse. She said it is a 15 minute treatment. PT-M indicated R61 had horrible pain some day's. PT-M stated therapy used a Wong Baker pain scale. R61 rated his pain as a lot on the Baker Wong scale before he started physical therapy. While PT-M was working with his left leg, R61 was saying his right side hurt. PT-M did not ask a nurse if he had his pain medication before therapy and did not apply the TENS unit. An interview on [DATE], at 7:55 a.m. RN-H stated she didn't use a pain scale. She just asked the resident if their pain was mild, moderate or severe. The last time she asked R61 about his pain, he said it was moderate. She said she was not aware of any standardized method in the facility, for pain management assessments. Interview with the DON on [DATE] at 7:58 a.m. identified R61 was placed on some non-pharmocological interventions for pain on [DATE]. We saw that as a need for him. A facility policy titled: PAIN ASSESSMENT PROTOCOL reviewed ,[DATE], indicated, It is the policy of Bayshore to provide for the optimum quality of life for every resident. Quality of Life includes individualized management of pain. Management of pain includes accurate assessment, pharmacological and non-pharmacological methods, and physical and psychosocial interventions. R109 received hospice services, and the facility failed to provide coordination of care. Findings include: R109's Admission Record identified [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R109 had severe cognitive impairment, and required extensive to total assistance of staff with bed mobility, transfers, dressing, eating, mobility, personal hygiene, bathing and toileting. R109 began receiving hospice services on [DATE], for end of life services due to the [DIAGNOSES REDACTED]. On [DATE], at 1:27 p.m. nursing assistant (NA)-K was interviewed, and stated the hospice NA came to the facility two or three times a week. NA-K stated they came at different times of the week, and different times of the day. NA-K stated the facility was unaware of when the hospice NA was going to be at the facility to care for R109. On [DATE], at 9:36 a.m. registered nurse (RN)-C was interviewed, and stated the hospice NA schedule was sporadic and they just come. RN-G stated the facility does not have the hospice NA-s schedule, and they do not call the facility prior to coming out. RN-G further stated the hospice NA's have their own schedule, and the facility does not know when they are coming. On [DATE], at 11:57 a.m. the director of nursing (DON) was interviewed and stated she assumed the facility was aware of the hospice NA visit schedule. The facility policy and procedure on Hospice Program dated ,[DATE], directed when a resident participates i the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed. R143 did not receive timely and accurate assessments of clinical changes with corresponding physician updates as needed. According to his admission face sheet, R143 was admitted on [DATE], with a short term admission plan for rehabilitation services. The resident [DIAGNOSES REDACTED]. admission orders [REDACTED]>250 milligrams/deciliter mg/dL or <70 mg/dL; daily weights - if resident gains more than 3# overnight or 5# or more in one week - call MD; and multiple medications. R143's admission weight was 233 pounds. R143's admission Minimum (MDS) data set [DATE], identified he needed extensive to full assistance with cares and was moderately confused. In addition, it identified R143 did not have a shortened life expectancy. On [DATE] at 12:22 p.m. the Medication Administration Record [REDACTED]. There was no assessment for [MEDICAL CONDITION] (high BS) and the physician was not updated as ordered. R143 was on no medications to assist with blood sugar management. No weight was obtained on [DATE]. On ,[DATE]-,[DATE] R143 weighed 230 pounds. There was no weight obtained on [DATE]. On [DATE] R143 weighed 231 pounds. On [DATE] no weight was obtained. On [DATE] a fax was sent to the primary physician identifying Many abnormal values for labs. There was no further assessment information documented or relayed to the physician. The physician responded indicating the low hemoglobin was the only critical one. The physician then ordered medications changes and to check stool for occult blood, orthostatic blood pressure - tell me if >20 millimeter systolic drop - will see him on [DATE]. On [DATE] at 10:58 p.m. R143 had a BS of 277 mg/dL. The physician was not updated and there was no assessment for [MEDICAL CONDITION]. On [DATE] another fax was sent to the physician identifying increased swelling to the scrotum and right side of penis. The daily weight had not been obtained and there was no assessment to correspond with this identified problem. At 2:00 p.m. R143 had a BS of 260 mg/dL. The physician was not updated and there was no assessment for [MEDICAL CONDITION]. There was no daily weight on [DATE]. In addition on ,[DATE] at 5:51 a.m. R143's blood pressure was ,[DATE]. His previously documented blood pressures had never gone above ,[DATE]. No other assessment was completed and the physician was not updated. Another fax was sent to the physician on [DATE] identifying on [DATE] R143's weight was 231.5 pounds and today was 242.3 pounds. It further identified R143 had a notable increase in [MEDICAL CONDITION] of legs, scrotum, hands/arms. There was no further assessment obtained or provided. On [DATE] the physician ordered labs and medication changes and requested the facility fax the results of the stool occult and orthostatic blood pressures. In addition the physician ordered a chest x-ray (CXR), and electrocardiogram (ECG). Although the orders were written on [DATE] they were not transcribed until [DATE]. The blood for the lab work was no collected until [DATE]. Interview with RN-A on [DATE] at 1:10 p.m. revealed she did not know why the transcription and implementation of the new physician orders [REDACTED]. On ,[DATE] the ECG identified possible coronary ischemia. There was no evidence the physician was informed. The CXR dated [DATE] identified a pulmonary [MEDICAL CONDITION] pattern which was faxed to the physician on [DATE]. There was no daily weight obtained [DATE]. On [DATE] the occult stools came back positive. There was no evidence it was faxed to the physician. Although it was stamped Faxed the area for date/time/initials was blank. Interview with Registered Nurse (RN)-A on ,[DATE] at 1:10 p.m. indicated there was no indication in the record the physician had been notified of the occult stool results. On [DATE] R143's weight was 258.5 pounds for a total gain of pounds 25 since admission on [DATE]. No further assessments were completed and no further physician updates were provided. On [DATE] at 2:00 a.m. progress notes identified a caregiver answered the call light. He stated his back hurt wanted to be turned on his side. While the caregiver was talking to the resident he became cyanotic and unresponsive. A code blue was called and cardiopulmonary resuscitation was provided until paramedics arrived. R143 was determined to be expired at 3:05 a.m. Interview with RN-A on [DATE] at 1:10 p.m. indicated there had been no assessments of R143's condition. RN-A stated the physician was not updated with the blood sugars and nothing was being monitored for those changes. RN-A stated the facility had begun monitoring for hyper/[DIAGNOSES REDACTED] every shift but that had not been initiated here. RN-A further stated she recalled the physician being updated on some weights but just not every day. RN-A stated she would have to believe we notified him. However, she also stated it was unusual and suspicious that there was nothing documented and no further orders had the physician been updated. RN-A stated she remembered (R143) and was aware of some of the problems but I can't say I was updated on all of them. RN-A acknowledged that as she reviewed things she would have gone forward and updated the physician. She further said she would have sent R143 to the emergency room had she received no response from the physician. Interview with the residents physician (P)-A on [DATE] at 2:45 p.m. indicated he had seen R143 on [DATE]. He had been updated in R143's weight gain and he suspected ascites (fluid in the abdominal cavity) and fluid overload. P-A further indicated R143 had multiple co-morbidities and the facility had not received a lot of information at the time of this resident's admission. Based on the results received from the tests ordered on [DATE], things looked terrible, going on to say R143 had the fluid overload, ascites, and pancytopenia (deficiency of all three cellular components of the blood - red cells, white cells, and platelets). P-A went on to say he believed R143 had bone marrow issues that would have required very aggressive tests to determine what the issues were followed by very aggressive treatment. . When interviewed on [DATE] at 11:36 a.m. the director of nursing (DON) stated she did not have a quality review process for the care provided in death records. The DON stated when she reviewed a death record she reviewed for notifications but since I've been here there hasn't been a question of wrongful death. The DON further stated that the majority of deaths were hospice or expected and no physician had ever questioned a death so death records weren't reviewed. The DON stated R143 was refusing things and it was difficult to get him to cooperate.

Based on observation, interview, and record review the facility failed to ensure 3 of 4 residents (R1, R2, R3) were free from significant medication errors. This caused actual harm to R1 and R2 who required hospitalization aggressive medical treatment required to correct the results of the omission. Findings include: R1's medical record was reviewed. R1 had [DIAGNOSES REDACTED]. R1 had several medications for [MEDICAL CONDITION] disorder according to the signed physician's orders [REDACTED]. The progress notes indicated that R1 had been hospitalized from [DATE] to 8/18/2015. The hospital discharge summary dated 8/18/2015 indicated R1 had been treated for [REDACTED]. Another anti-epileptic medication [MEDICATION NAME] (Zonesamide) was added. The discharge summary noted that R1 had breakthrough [MEDICAL CONDITION] and ongoing problems with generic [MEDICATION NAME] causing variable bioavailability (level of the medication in the bloodstream). The neurologist progress note dated 8/15/15 indicated Looking over the last several DPH ([MEDICATION NAME]) levels there has been no correlation between dose and levels, I wonder if this is being administered accurately. The nurse progress note dated 9/18/2015 indicated R1 was sent to the emergency room (ER) on 9/18/2015 for increased [MEDICAL CONDITION] activity, garbled speech, and jerking movements. The nursing progress note dated 9/18/2015 indicated R1 returned from an emergency room (ER) visit 9/18/2015 with new orders for [MEDICAL CONDITION] medication. The Emergency Department summary dated 9/18/2015 indicated R1 had been evaluated for increased [MEDICAL CONDITION], the physician's orders [REDACTED]. The summary directed to continue all other medications as before.The MAR for September 2015 documented lacosamide ([MEDICATION NAME]) was discontinued at 4:40 pm on 9/18/2015, and was restarted on 9/23/2015 at 6:30 a.m. There was no record of lacosamide ([MEDICATION NAME]) administered on 9/18/2015 at bedtime, until it was given in the morning on 9/23/15, missing a total of 9 doses over 5 days. The MAR for September 2015 documented 300 mg of [MEDICATION NAME] ([MEDICATION NAME]) given on the evening dose on 9/18/2015, the order for 200 mg twice a day (bid) was not updated, and the MAR indicated [REDACTED]. R1 was sent to theER on [DATE] for increased [MEDICAL CONDITION] activity, the ER record noted the recent change from 200 mg bid to 300 mg bid on 9/18/2015. The discharge summary from the ER dated 9/20/2015 indicated after discussion with your neurologist, you should stay on the same dose of [MEDICATION NAME]. The physician (neurologist) caring for R1 was interviewed on 10/23/2015 at 12:30 p.m. and verified that R1 should have stayed on 300 mg bid of [MEDICATION NAME]. The September 2015 MAR indicated [REDACTED]. The facility medication error report dated 9/23/2015 indicated R1 had lacosamide ([MEDICATION NAME]) discontinued without an order from the physician from 9/18/2015 to 9/23/2015. The lacosamide ([MEDICATION NAME]) 100 mg bid had been discontinued by error by the nurse when processing orders on return from the hospital ER, and not given until 9/23/2015. The nursing progress notes documented: on 9/19/2015, R1 had increased confusion and a fall on the night shift. On 9/20/2015 R1 was observed to have 2 [MEDICAL CONDITION], was sent to the ER and returned to the facility. On 9/22/2015 R1 had a [MEDICAL CONDITION], and in the morning of 9/23/2015 was noted to be confused with garbled speech and was hospitalized for [REDACTED]. The neurologist noted on 10/1/2015 R1 was at his neurological baseline. R1 returned to the facility on [DATE]. The nurses progress notes dated 10/6/2015 indicated R1 was assessed to have lung congestion and was seen in the ER, diagnosed with [REDACTED]. The nurse manager RN-C was interviewed on 10/21/2015 at 2:30 p.m., and verified that R1 did not receive [MEDICATION NAME] ([MEDICATION NAME]) 300 mg bid from 9/19/2015 to 9/23/2015 as ordered. The nurse manager stated that R1 usually had a couple [MEDICAL CONDITION] a month as a baseline, but his [MEDICAL CONDITION] activity increased in August 2015 when his [MEDICAL CONDITION] medicines were changed. RN- D was interviewed at 2 p.m. on 10/12/2015 and stated the Lacosamide ([MEDICATION NAME]) was discontinued by error when the orders were being processed on 9/18/15 when R1 returned from the ER. RN-D stated that the increase of dosage for another [MEDICAL CONDITION] medication [MEDICATION NAME] ([MEDICATION NAME]) was put into the computer and the additional 100 mg was given on 9/18/2015. The physician (neurologist) caring for R1 was interviewed on 10/23/2015 at 12:30 p.m. and verified that R1 not receiving both the anti-epileptic medications at the correct doses was an increased risk for [MEDICAL CONDITION] activity. He further stated that the confusion and garbled speech noted by the nursing staff could have been unrecognized [MEDICAL CONDITION]. The Director of Nursing (DON) was interviewed at 8:20 a.m. on 10/12/2015 and stated the error happened due to the nurse discontinuing the medication lacosamide ([MEDICATION NAME]) inadvertently on the computer record when the resident returned from theER on [DATE], and that retraining had been done with the nurses. R2 medical record was reviewed. R2 had [DIAGNOSES REDACTED]. Since admission to the facility R2 had received [MEDICATION NAME] ([MEDICATION NAME]) at a dose of 2.5- 5 mg on a daily basis with regular monitoring of the [MEDICATION NAME] INR. [MEDICATION NAME] ([MEDICATION NAME]) is an anticoagulant medication given to prevent blood clots, and the blood is periodically monitored for clotting time with a laboratory test of the [MEDICATION NAME] international normalized ratio (INR) to determine the correct dosage.Hospital discharge orders dated 9/29/2015 indicated R2 had been treated for [REDACTED]. The September and October 2015 MAR indicated [REDACTED]. The nursing progress note dated 10/3/2015 documented that R1 was sent to theER on [DATE] at 6 p.m. due to a clotting [MEDICATION NAME] international normalized ratio (INR) of 1.2 and complaints of leg pain. The nurse progress note dated 10/4/2015 at 1 a.m. indicated R2 returned to the facility after receiving additional injectable anticoagulant medications and diagnostic procedures to determine there was no blood clot. The medication error report dated 10/3/2015 documented that R2 returned from the hospital 9/29/2015, R2 did not have [MEDICATION NAME] orders and no one followed up. R2 had an INR checked, it was called to the medical doctor and the doctor ordered R2 to be evaluated at the ER. R2 was interviewed at 2:30 p.m. on 10/12/15 and stated he knew that his medications were not given correctly. He said things got straightened out but that he was still worried and checked the pills he was given. A large bruise on his left lower abdomen was observed, and he said it was from the injectable anticoagulant medications. The primary physician for R2 was interviewed on 10/21/15 at 9:45 a.m. and stated that she had been called when the facility noted the error on 10/3/2015 and R2 had not received wafarin since 9/29/2015. An immediate INR [MEDICATION NAME] was completed, the [MEDICATION NAME] was 1.2, which was a risk for R2 because of his history of clots. She stated that R2 was sent to the ER and needed to have [MEDICATION NAME] and an injectable anticoagulant [MEDICATION NAME] ([MEDICATION NAME]) was given. The additional [MEDICATION NAME] was administered for 10 doses. R2's physician stated that this omission of [MEDICATION NAME] put R2 at a higher risk for developing additional clots, and it was physically uncomfortable for R2 to have additional injectable medication.The nurse manager RN-C stated in an interview at 2:30 p.m. on 10/12/2015 that the orders for wafarin were not entered into the computer correctly for transcription. She stated that some of the orders were misplaced by the health unit coordinator's desk and were not entered timely. She acknowledged that this was not the expected process and that the nurse was re-educated. R3 medical record was reviewed, the September 2015 MAR indicated [REDACTED]. R3 had [MEDICATION NAME] ([MEDICATION NAME]) an anticoagulant medication ordered daily to prevent blood clots. The September MAR for R3 had an order dated 8/28/2015 of [MEDICATION NAME] 4 mg until 9/4/2015, and to have an INR done on 9/4/2015. September 2015 MAR indicated [REDACTED]. The nurse progress note dated 9/7/2015 documented R3 did not have INR checked on 9/4/15 per order, R3 did not receive [MEDICATION NAME] on 9/4/15, 9/5/15, or 9/6/15. The nurse notified the physician, the INR value was checked and wafarin was ordered by the physician. A nurse progress note dated 9/8/2015 indicated there was no adverse effects from the medication error on 9/4/15. The facility policy titled Adverse Consequences and Medication Errors dated 2001, noted that a medication error would include an omission for a drug that is ordered but not administered, and the wrong dose given. The orientation and training for nurses included transcription of medication orders on the computer system, and that orders needed to be double checked for accuracy. The DON stated in an interview at 1:15 p.m. on 10/12/2015 that the facility identified errors with transcription of orders on return from the hospital, INR tests being completed, and orders obtained. She stated she had the assistant director of nursing (ADON) send an e-mail to all nurses that included training to double check all orders, and that additional training would be done at the October 2015 nurse's meeting. She stated audits were being done by nurse managers on all resident's on return from the ER or hospital to assure the orders were correct.

Based on interview and record review, the facility failed to assess and implement fall interventions to minimize the risk of falls for 1 of 3 residents (R1) who sustained injuries due to falls from the wheelchair. This resulted in actual harm when R1 sustained a head injury in a fall from the wheelchair, and later died . Findings include: Record review established R1 was diagnosed with [REDACTED]. R1 had resided on the dementia locked unit. A health status note dated [DATE] assessed R1 to be at a high risk for falls related to psychotropic drug use, incontinence, and poor safety awareness. The interventions noted were the bed in low position and alarms. The physical therapy assessment dated [DATE] noted the resident had recent falls, was a high risk for falls due to impulsiveness, poor safety awareness and insight into limitations. R1 was not able to clearly verbalize wants and needs to the staff, the health status note dated [DATE] noted that R1 was sometimes understood and speech was garbled and unclear. Review of the progress notes revealed that R1 had ten falls from [DATE], until he was discharged to the hospital on 11/ ,[DATE]. Nine of the falls occurred on the evening shift and eight of the falls the resident fell out of the wheelchair. The "Care Area Assessment" (CAA) dated [DATE] noted that R1 was a high risk of falls and noted the seat belt and alarms. The assessment noted that R1 should have "high visible placing while up in the wheelchair for closer monitoring" because of R1 standing up suddenly on his own. The care plan dated [DATE] noted that R1 was at risk of falls and had a history of [REDACTED]. The care plan noted that staff should anticipate R1's needs and observe for unsafe transfers and ambulation. Other interventions were to toilet every 2 hours, put call light in reach, follow the facility fall protocol. The care plan noted that staff were to check blood sugars if indicated, observe for seizure activity, and medication side effects. The care plan also noted to regularly give R1 snacks of pudding in the evenings, to assist R1 to stand up and ambulate when R1 appeared restless, and to have a non skid material on the seat of the wheelchair. The bed was to be in low position with a floor mat, and an alarm was used in the bed and in the wheelchair. The care plan noted that R1 used a regular wheelchair without footrests and would propel himself short distances. Supervision of R1 while up in the wheelchair was not addressed in the care plan. The Nursing Assistant assignment sheet dated [DATE] noted an alarm was to be used in the wheelchair and if R1 was trying to stand repetitively, to ambulate with him as tolerated. Supervision of R1 while up in the wheelchair was not addressed. The activity calendar documenting activities provided to R1 for [DATE] was reviewed, there were no activities provided to R1 after 4 p.m. R1 would engage in activities offered, the care conference note date [DATE] noted R1 would take part in sensory, music, snack, and reading. The care plan dated ,[DATE] noted that a Velcro self releasing seat belt was worn when in wheelchair as a fall prevention. The "Device Assessment" dated [DATE] for R1 noted that the belt was able to be removed by the resident, the facility did not have a more recent assessment. The care conference note on [DATE] reflected that the family had agreed to a trial to discontinue the seatbelt, the reason to discontinue the belt was not noted. There was no assessment on the risks and benefits of discontinuing the seatbelt on the restraint assessment dated [DATE], the belt was noted to be discontinued on [DATE]. The restraint assessment dated [DATE] noted that the seat belt was used for unsafe mobility and during a trial of not using the belt there were no increased falls, which was not accurate. The progress notes reflected that R1 had unwitnessed falls on [DATE] out of bed, and on [DATE] at 7:15 p.m. there was a fall when R1 tipped over the wheelchair in an unwitnessed fall in his room. These falls were not noted on the assessment for the use of the seatbelt. Progress notes and incident reports dated [DATE], [DATE], and [DATE] documented R1 had a series of 3 falls from the wheelchair after a velcro self releasing seatbelt was discontinued for a trial period, there was no assessment of the falls for patterns and root causes to develop interventions to reduce the risks of falls. The "Resident Incident Report" dated [DATE] at 4:20 p.m., R1 was unobserved in the activity room and was found on his knees next to the wheelchair with the alarm sounding, which had been in use as of the care plan dated ,[DATE]. There was no observed injury, a form titled "Post Fall Huddle Investigation Worksheet" noted it was not known what R1 was attempting to do when the fall occurred. No new interventions were implemented and the fall was not reviewed for a pattern of similar falls. Another fall was documented on a fall incident report dated [DATE] at 3:45 p.m., an aid observed R1 "lunged forward out of the wheelchair falling face first on the floor" in a lounge area. It was noted that the resident hit his head, and no injury was identified. The nurse started neurological checks and at 6:45 p.m. noted that R1 was drowsy and leaning to the left side, the physician was notified by phone and the next neurological check was normal. The "Post Fall Huddle Investigation Worksheet" was dated [DATE] with no new interventions added, and a pattern of falls was not reviewed. A fall incident report dated [DATE] at 5 p.m., R1 had another fall out of the wheelchair. R1 was in the activity room and had an unwitnessed fall, he was found by a nursing assistant (NA) when the alarm sounded. R1 was found on his back a few feet from the wheelchair, an injury to the back of R1's head was noted, " a 3 centimeter (c.m.) by 2 c.m. abrasion". A neurological check at that time was normal. The nurse notified a family member and noted on the "Post Fall Huddle" dated [DATE] that there was a request from the family to put the seatbelt back in use. The nurse recommended changing the care plan and the fall risk assessments. Neurological checks were done according to facility policy and were within normal limits. The resident was given first aid and ice applied to the injury on the back of the head. The progress note dated [DATE] at 8 p.m., noted the NA alerted the nurse that R1 "didn't look right and wasn't himself". The nurse noted R1 was pale, non-responsive, and not moving his extremities. R1 was transported to the hospital, he was evaluated to have several subdural hematomas (bleeding in the brain). The hospital discharge summary dated [DATE], noted the falls R1 had resulted in three brain hemorrhages (bleeding), The resident was placed on hospice care. The resident died on [DATE] and the death certificate dated [DATE] noted the cause of death was intracerebral hemorrhage. Nursing assistant (NA)(E) was interviewed on [DATE] at 10:10 a.m. and was familiar with R1, NA-E stated R1 did the best during the day, but would get restless and agitated in the late afternoon. R1 would stand and try to walk from the wheelchair, but would enjoy visiting and could be distracted. NA-E stated that most of the residents on the memory unit need to have supervision for safety, and this could be difficult while giving cares in rooms and it was best to have one person available for supervision of residents on the unit. Nursing assistant (NA)(G) was interviewed on [DATE] at 11:45 a.m. and stated that R1 was frequently restless in the evenings. R1 would stand up unexpectedly and quickly while in the wheelchair. She stated R1 did better if involved in activities and kept busy, but there had been a decrease in activity staff in the evenings on R1's unit. The evening registered nurse (RN)(J) was interviewed on [DATE] at 11:10 a.m. and verified that the evening RN covered other units on the first floor besides the memory care unit, and a nurse was not on the unit at all times. The unit was staffed with 2 nursing assistants which relied on the nursing assistant assignment sheet to direct cares with residents. RN-J stated that R1 was frequently agitated on the evening shift and did better if he was occupied, would hold a baseball and would settle. RN-J was not aware of activities occurring on the memory care unit on the evening shift. RN-J had discussed with the nursing assistants to keep R1 in sight when up in the wheelchair because of suddenly standing and trying to walk. The nurse manager (RN-B) was interviewed on [DATE] at 10:50 a.m. and verified that there had been concern about the seatbelt in use for R1 because he was not able to release it on his own and it would be a restraint. R1 had tipped over in his wheelchair with the belt in place. RN-B was not aware of any substitute interventions implemented at that time to reduce the risk of R1 suddenly standing and having a fall. RN-B could not verify when the trial occurred for not using the seatbelt and if there was an assessment of the risks and benefits of using the belt. RN-B noted the process to review falls at morning stand up and at an interdisciplinary meeting should occur but was not able to verify that there had been discussion of the falls for R1, or an overall assessment of the interventions and whether they were effective to reduce the risk of falls. The facility policy for falls titled "Falls- Clinical Protocol" dated ,[DATE] was reviewed. The policy noted that a resident should be assessed for fall risk on admission and document risk factors. The policy directs staff to evaluate falls to identify causes of falls. The policy noted that staff should evaluate the timing of falls, identify patterns, and any underlying medical cause of falls. It is noted that if a resident continued to fall and a cause cannot be identified the nursing staff will discuss the situation with the attending physician and medical director. The interim director of nursing (DON) was interviewed on [DATE] at 1 p.m. and verified that the system in place at the facility to prevent falls had been identified as an issue, and a consulting agency had been in place to improve the system. She was not able to identify when the seatbelt was started for R1 or if an assessment had been completed at that time. She verified that the belt was discontinued on [DATE], and an assessment of the risks and benefits had not been done at that time. The DON verified that there was not a comprehensive assessment of the falls for R1 to identify patterns and effective interventions, there was not a review of falls to pull the information together and evaluate. She verified there had not been an assessment of the wheelchair for safety, an increase in diversional activities or supervision, a pharmacy evaluation for falls, or a medical condition identified as contributing to falls. The DON stated that the interdisciplinary team (IDT) had not been actively identifying and resolving issues with falls. The administration management consultant was interviewed on [DATE] at 12 p.m. and outlined the interventions that were planned for the facility and noted that falls was a main concern. There was training planned for [DATE] and the policy was to be updated. A major emphasis would be to have the IDT review falls and create assessments that review each fall and the root cause analysis.

Based on interview and document review the facility failed to provide the ordered treatment for 1 of 3 residents (R1) who had a stage IV ischemic ulcer. Harm occurred when the facility failed to follow the treatment ordered by the physician and the wound worsened. Findings include: R1's medical record was reviewed and established R1 had [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. The quarterly review assessment dated [DATE] established R1 required assistance for all areas of mobility, dressing, bathing and grooming. The cognitive assessment in the progress notes dated 8/6/2014 measured R1's Brief Interview for Mental Status (BIMS) score to be 5/15 indicating severe cognitive impairment. The Nurse Practitioner (NP) progress notes dated 8/12/2014 provided information that R1 had an open stage IV ischemic ulcer (Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) to the lower left leg Achilles tendon area. The note indicated the wound was found with the wrong dressing on it and the dressing did not absorb moisture causing the wound to be too wet. The note described the wound bed as macerated (prolonged exposure to moisture causing skin breakdown) and the tendon showing white with [DIAGNOSES REDACTED] (red and swollen) round the wound edges. On 8/20/2014 around 11:00 a.m. the NP was interviewed and stated she had been monitoring the wound closely and had written orders for a specific type of dressing to be applied to R1's wound on 8/5/14. She ordered a high absorbency type dressing called Allevyn to aid in the healing of the wound bed. The NP stated when she returned two days later to re-assess the wound she found the wrong dressing on the wound and the wound had worsened as a result. The NP described the wrong dressing found as a 1/4" inch piece of foam with no absorption qualities. She stated she had ordered Allevyn (a high absorbency wound product). The NP described when the foam dressing was removed; "fluid came pouring out of the wound", the wound bed was macerated and the skin around the wound was red and swollen. The NP stated the facility had run out of the Allevyn and no one from the facility had called to obtain a different order. The Nurse Progress notes dated 8/17/2014 indicated a late entry for 8/5/2014 and provided information that the ischemic ulcer on R1's left Achilles measured 4.0 x 2.0 centimeters (cm) when the Allevyn was ordered by the NP on 8/5/2014. The NP provided new treatment orders on 8/7/2014 after finding the wrong dressing had been applied for 2 days. The new orders were not implemented until 8/9/2014 because the pharmacy had not delivered the medication ordered needed for the new treatment until 8/9/2014. On 8/12/2014 the wound measured 6.5 x 3.0 cm. On 8/21/2014 at 12:45 p.m. registered nurse manager (RN)-D was interviewed and verified the wrong dressing had been applied to R1's wound. She stated the NP had been monitoring R1's ulcer very closely and had ordered Allevyn on 8/5/2014. RN-D stated licensed practical nurse (LPN)-E applied a foam dressing on 8/6/2014 when the facility ran out of Allevyn. It was discovered on 8/7/2014 by the NP that the wrong dressing had been applied for 2 days. On 8/21/2014 at 2:45 p.m. Licensed Practical Nurse (LPN)-E was interviewed and stated the facility had run out of the Allevyn on 8/6/2014 and she was told by the supply coordinator (SC)-F (who orders supplies) that the [MEDICATION NAME] product was the same as the Allevyn and she should use that instead. LPN-E verified she put the [MEDICATION NAME] dressing on R1's wound and did not call the NP to obtain an order for [REDACTED]. the new orders for the treatment were not available until 8/9/2014. During the investigator interview, LPN-D was informed that the medication for the new orders was not in the facility until 8/9/2014; LPN-D stated she could not recall what treatment she provided to R1 on 8/8/14.

Based on observation, interview and document review, the facility failed to provide necessary services by not developing a system in which physician's orders were transcribed properly and implemented timely for 4 of 7 residents (R1, R2, R3 and R5). This resulted in a delay of treatment for [REDACTED]. Findings include: The interagency referral form dated 10/2/2013 and the facility [DIAGNOSES REDACTED]. Other documentation indicated R1 was waiting for a liver transplant and was medically fragile. R1 was admitted to the facility with an order on the interagency referral to check ammonia levels daily. The order had been missed and R1's ammonia had not been checked for three days. The nurses notes dated from 10/4/2013 to 10/7/2013 documented R1 had become more confused/disoriented to place and time, had fallen twice and complained of muscle aches. When the facilility discovered the order and checked R1's ammonia level on 10/7/2013 it was found to be 152 (critically high). R1 had to be sent to the emergency department and was admitted to the hospital for treatment for [REDACTED]. Had the ammonia level been monitored; treatment could have been started sooner. The demographic sheet indicated R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nurses notes dated 11/25/2013 recorded R2 had diminished lung sounds with congestion. The nurse documented a note was placed in the rounding book. The Nurse Practioner (NP) note dated 11/26/2013 provided information R2 had a fever and low oxygen saturation levels for 1-2 days. The NP ordered a chest X-ray to be completed 11/26/2013. The chest X-ray results indicated the X-ray was completed on 11/27/2013. On 12/12/2013 at 12:30 p.m. the NP stated the order was supposed to be done the day it was written however, when the NP came in the next day it still had not been completed and she had to request that staff order the X-ray. The NP stated antibiotics would have been ordered one day sooner had the orders been followed and resulted in a delay of treatment for [REDACTED]. R3's physician progress notes [REDACTED]. R3 required the use of supplemental oxygen via nasal cannula. The physician order dated 12/6/2013 written by the hospice NP discontinued several of R3's medications including Toresemide (a diuretic) and [MEDICATION NAME] (a heart medication). The nurses notes dated 12/6/2013 through 12/11/2013 indicated R3 was having increased difficulty breathing and low oxygen saturation levels. On 12/12/2013 at 12:30 p.m. the NP was interviewed and stated R3 was experiencing an increase in shortness of breath related to some of her medications being discontinued. The NP stated she had ordered them to be restarted on 12/10/2013. On 12/13/2013 at 10:05 a.m. LPN-B was observed finding a physician's order slip under some papers dated 12/10/2013 for R3. The order directed staff to resume the Toresemide and [MEDICATION NAME]. LPN-B stated the order had not been transcribed and the medications had not been restarted. LPN-B stated she did not know why the order was not completed. R3 was interviewed on 12/13/2013 at 10:20 a.m. and appeared short of breath. R3 was wearing a nasal cannula to deliver oxygen and stated her breathing had been worse the last few days but the nurse had told her they were going to increase some of her medications so she hoped it would be better soon. The oxygen tank was observed to be set at 5L/pm. R3's treatment was delayed for three days. R5's demographic sheet was reviewed and indicated R5 had [DIAGNOSES REDACTED]. The dietician's note dated 10/8/2013 described R5 had a 19.6 pound weight gain in 30 days. The weight gain was not planned and not beneficial. The note described R5 had an order for [REDACTED]. The Medication Administration Record [REDACTED]. The nurses note dated 10/11/2013 provided information R5 could move independently in and out of bed however, with recent increased [MEDICAL CONDITION] was requiring more help. The physician progress notes [REDACTED]. R5 had increased dyspnea (shortness of breath) on exertion, orthopnea (shortness of breath while lying flat), increased lower extremity [MEDICAL CONDITION] and a weight gain of over 20 lbs in a month. R5 had been experiencing the symptoms for days.

Based on interview and document review, the facility failed to ensure 1 of 6 residents (R5) was free from significant medication errors when R5 did not receive as needed [MEDICATION NAME] (a diuretic) as ordered by the physician. This caused actual harm to R5 related to the aggressive medical treatment required to correct the results of the omission. Findings include: R5 had [DIAGNOSES REDACTED]. The brief individual mental status (BIMS) test dated 4/24/2013, indicated R5 was moderately cognitively impaired. The medication administration record (MAR) for September 2013 included a physician's orders [REDACTED]. The [MEDICATION NAME] order on the MAR directed staff to give 20 milligrams (mg) 1 tablet PRN for fluid retention weight gain if 2-6 pounds (lbs) in one day or five lbs in one week give additional dose. R5's daily weights were documented on the MAR. R5's weight increased 17 lbs from 9/12/2013 to 9/15/2013. There was no indication the PRN [MEDICATION NAME] was given or the weight rechecked. R5's weight increased again by 6 lbs from 9/22/2013 to 9/24/2013. R5 was not given PRN [MEDICATION NAME].The dietary note dated 10/8/2013 provided information that R5 had a significant weight gain of 19.6 lbs in 30 days; the weight gain was unplanned and not beneficial. The PRN [MEDICATION NAME] was available however, not given. The dietician noted the information would be passed along to the Registered Nurse (RN) manager and the Doctor (MD). The nurses note dated 10/11/2013 provided information R5 could move independently in and out of bed however, with recent increased [MEDICAL CONDITION] was requiring more help. The physician progress notes [REDACTED]. R5 had increased dyspnea (shortness of breath) on exertion, orthopnea (shortness of breath while lying flat), increased lower extremity [MEDICAL CONDITION] and a weight gain of over 20 lbs in a month. R5 had been experiencing the symptoms for days. The physician orders [REDACTED]. The lab results dated 10/15/2013 revealed R5's sodium level was 125 milli -Equivalent per liter (mEq/L) (normal range is 134-143 mEq/L). Based on that result the physician changed the order to include a fluid restriction and a sodium tablet. The nurses note dated 10/18/2013 provided information as follows: Resident (R5) still becoming very angry and upset with staff regarding the fluid restriction, does not understand, comprehend the reasoning for it, no matter what staff tell her or how, she does not get it, and gets difficult reasoning with her. She starts to cry, shake and physically gets angry. Received new physician orders [REDACTED]. The nurses note professed that R5 had not been receiving the sodium tablet ordered on [DATE]; missing three doses. On 12/12/2013 at 1:00 p.m. Licensed Practical Nurse (LPN)-C verified she had been documenting R5's daily weights but did not know the reason for the daily weights; she stated she was not aware of the PRN [MEDICATION NAME] order for R5 and had not given it. On 12/13/2013 at 1:30 p.m. the MD verified she had been notified by the dietician regarding R5. The MD stated she spoke with LPN-C and discovered no one had been giving the PRN [MEDICATION NAME] based on R5's weight as ordered. The MD stated R5 required aggressive treatment to [MEDICATION NAME] the extra fluid that had been retained due to not receiving the PRN [MEDICATION NAME].

Based on interview, record review and policy review, the facility failed to assure that all allegations of potential abuse and neglect, injuries of unknown source and resident to resident altercations were investigated, reported to the administrator and to the state agency for 15 of 17 residents in the sample reviewed for abuse. Injuries of unknown origin were not investigated or reported for R91, R43 and R30; frostbite was not investigated or reported for R164;[MEDICAL CONDITION] hot packs were not reported for R76 and R26; rough treatment by staff and staff rudeness were not reported to the administrator, investigated or reported to the state agency for R36 and R10; and resident to resident altercations were not investigated or reported to the administrator or to the state agency for R83, R64, R13, R175, R178, R180 and R22. R91, R164 and R76 sustained actual harm as a result of the incidents described. The lack of identification, investigation, resident protection and reporting constituted immediate jeopardy for R91, R164, R76 and R36 and the administrator was notified at 3:15 pm on 3/21/2011. In addition, it was determined that multiple incidents were not identified as potential abuse/neglect, were not investigated to determine if abuse /neglect had occured; residents were not protected, and incidents were not reported to the administrator or state agency. The systemic failure to report and investigate incidents of potential abuse/neglect had the potential to affect most residents in the facility. The facility initiated an IJ removal plan that included review and revision of the abuse prevention plan and training was provided to all staff on each shift and prior to resident contact. Direct care staff, housekeeping staff and licensed nursing staff were interviewed and were able to explain their responsibility for identification of incidents of potential mistreatment; internal reporting; resident protection, investigation and external reporting as defined in the revised abuse prevention plan. The IJ was removed at 3:30 pm on 3/22/2011 and the scope and severity reduced to no actual harm with a potential for no more than minimal harm, pattern. Findings included: The facility abuse prevention policy for 2010/2011 indicated the following: The policy indicated "Incidents are reported, documented, and investigated internally using the Ecumen Bayshore Incident Reporting policy and procedure," and "The Administrator and DON must be promptly notified of suspected mistreatment. If such incidents occur or are discovered after normal working hours, the Administrator and DON must still be contacted, e.g., called at home, by voice mail or paged." Under "External Reporting" the policy indicated, "All alleged incidents of mistreatment are reported to the state agency and to all other agencies are required and all necessary corrective actions, depending on the result of the investigation, are taken. Immediately means as soon as possible, but not more than 24 hours after discovery of the incident." The administrator, interviewed at 4:35 p.m. on 3/21/2011, stated all resident accident reports, incident reports, and VA reports were reviewed at morning meeting on weekdays. In addition, the reports were reviewed at quarterly quality assurance meetings. The administrator stated the current review system failed to identify inadequate investigation and reporting of incidents in the VA system. Fracture of unknown source: R91 sustained a fracture to the left knee that was not identified as potential mistreatment, not investigated to identify potential causative factors or reported to the state agency. Painful bruising of R91's left knee was identified on 10/27/2010, and a portable Xray in the facility was inconclusive. The fracture was identified by a second Xray on 11/3/2010. The subsequent investigation focused on the time between 10/27/2010 and 11/3/2010. There was no investigation to determine the source of the injury that occurred prior to 10/27/2010. The source of the injury was not determined and there was no consideration of protecting R91 from further injury. The fracture was not reported to the administrator or to the state agency. The quarterly Minimum Data Set ((MDS) dated [DATE] (prior to the knee injury), indicated R91 had moderate cognitive deficit with long and short term memory loss. R91 was independent with bed mobility and transfers, but required 1 person physical assistance with both bed mobility and transfers. R91 was not ambulatory and had no known falls. The significant change MDS dated [DATE], indicated R91 required extensive assistance of 2 staff for bed mobility and transfers and had no falls. The quarterly MDS dated [DATE], indicated R91 required extensive assistance of 2 staff for all activities of daily living (ADL)s and had no falls. The incident report (IR) dated 11/3/2010 indicated R91 had a large painful bruise on the lateral left leg (7 inches by 3 inches). The IR indicated R91's left foot was rotated slightly outward and ROM caused increased pain. R19 stated she fell out of bed and that she fell in the bathroom. The IR indicated R91 had severe dementia and was not a reliable reporter. The IR stated an Xray of the left knee on 10/27/2010 indicated there was no obvious fracture. There was no IR completed when the painful bruising was identified on 10/27/2010, and no investigation to determine potential causative factors. An undated and unsigned document provided by facility staff indicated R91 complained of sharp left shin pain at 3:50 am on 10/27/2010. Later on 10/27/2010, R91 complained of left hip and knee pain and a mobile X-ray in the facility showed no obvious fracture or other acute findings. On 11/2/2010 a large yellow purple bruise was noted on the outer aspect of the left thigh, knee and calf. On 11/3/2010, R91 was sent to the ER for evaluation of left hip and knee pain. X-ray results indicated a lateral plateau [MEDICAL CONDITION] knee. The document indicated "The nurse manager interviewed staff and there were no falls or other injuries noted by staff during this time period." The post incident analysis dated 11/4/2010, indicated R91 had impaired mobility, balance problems, incontinence, impaired cognition and judgement/safety awareness deficit. The analysis indicated R91 was found with a bruise on her left knee and was not able to tell where/what happened due to dementia. The post incident analysis did not include an investigation of the circumstances around the original injury reported on 10/27/2010. Review of written staff statements in the investigation file indicated the following: Nursing assistant (NA)-N's statement dated 11/5/2010, indicated R91 had left leg pain on 10/26/2010, that was reported to the evening licensed nurse; and, "over the next two weeks resident continues to complain of left leg pain...reported to the nurse on the unit." Nursing notes verified R91's left leg pain was documented daily. There was no information regarding events prior to the injury being reported on 1/026/2010. NA-Q's statement dated 11/4/2010, indicated "Last Wed night (10/27/10) after shower, (R91) pulled self to rail and as she was pulling self up she caught her foot on the bed rail and started rubbing leg and said it was sore" and, "Tuesday noted what looked like varicose veins on left outer leg. Wednesday leg looks increased bruising." There was no evidence that NA-Q was interviewed to obtain more information in regard to R91 catching her foot on the bed rail. There was no information regarding events prior to the injury being reported on 10/27/2011. NA-R's written statement dated 11/4/2010, indicated "Two days ago (R91) was sleeping at the dining room table saying she did not feel good and she hurt. Yesterday she woke up and I answered the light. She wanted to get up so I pulled the covers back and saw bruising on leg and foot and foot turned out funny. Said it was hurting bad. I came and got the nurse." There was no information regarding events prior to 10/27/2010 when the injury was first identified. Licensed Practical Nurse (LPN)-F's written statement dated 11/4/2010, described actions following discovery of bruising on 11/3/2010 and did not contain any information prior to 10/27/2010 when the injury was first identified. LPN-G's written statement dated 11/5/2011 indicated R91 was added to the report book regarding left leg pain. Earlier report of left leg pain on 10/27/10. Xray 10/27 inconclusive. Assessed lateral bruising to left knee and quad. There was no documentation to indicate causative factors of the injury were considered. Record review indicated there was no evidence to indicate that staff caring for R91 prior to the injury discovered on 10/26/2010 were interviewed. NA-N stated pain was first noted and reported to licensed nursing staff on 10/26/2010; however, there was no documentation until 10/27/2010. The social worker (SW)-A. interviewed at 10:20 am on 3/18,2011, stated the investigation was completed by collecting written staff statements. There was no further investigation and the fracture was not reported to the administrator or to the state agency. Frostbite: R164 sustained frostbite to the toes of both feet from exposure to extreme cold when outside smoking. The incident, determined to cause actual harm to R164, was not investigated or reported to the administrator or to the state agency. R164 required staff assistance to light the first cigarette. R164 was assisted to smoke outside in extreme cold winter weather without appropriate protection for her feet. At 7:51 p.m. on 3/14/2011, interview with Registered Nurse (RN-D) verified the frostbite was discovered on 1/16/2011. She further indicated an incident report was not completed because "we knew what caused the issue... We were able to determine the root cause." RN-D also confirmed the incident was not investigated to determine potential mistreatment or neglect, nor was it reported to the state agency. At approximately 1:00 p.m. on 3/18/2011, the Director of Nursing (DON) verified the incident was not investigated to determine potential mistreatment and was not reported to the administrator or to the state agency. Burn R76 sustained actual harm when a hot pack caused a burn. According to the incident report (IR) dated 10/30/2010, R76 had multiple open and intact blisters on the right knee following the hot pack treatment. The care plan dated 1/13/2006, indicated R76 had impaired decision making with short and long term memory loss. The mobility care plan dated 1/17/2006, indicated R76 had an alteration in mobility related to erratic involuntary movements due to [MEDICAL CONDITION]'s disease and used a wheelchair for all mobility. The IR dated 10/30/2010, indicated R76 had multiple open and intact blisters on the right knee. R76 stated a heating pack was applied by a nursing assistant the night before. R76 stated he knew the hot pack was too hot but did not ask the nursing assistant who was present to remove it. R76 had nine open, measurable areas with multiple water blisters in between them. R76 rated his pain a 10 out of 10. The post incident analysis was completed by registered nurse (RN)-G on 10/31/2010. The RN analysis indicated a hot pack was placed on R76's right knee during the night by nursing assistant. The hot pack was too hot and resulted in multiple blisters requiring medical treatment. R76 stated he knew the hot pack was too hot but did not remove it or call for assistance. The post incident analysis did not indicate that vulnerable adult internal investigation and reporting procedures were initiated. The director of nursing (DON) signed the IR on 11/3/2010. The form was not signed by the administrator or the medical director. The incident analysis did not mention a previous incident of a resident being burned by a hot pack (R26) and did not indicate follow up to determine why the required Aqua K pack was not utilized. The investigation dated 11/1/2010, indicated R76 received a burn to the right knee from a heating pack applied by a nursing assistant (NA). The NA made a hot pack out of wash cloths and carried it with bare hands into R76's room where it was placed on R76's right knee. R76 stated he knew it was too hot but did not remove it or ask for assistance. R76 had no sensory impairment to the lower extremities that would inhibit the ability to feel pain and was capable of communicating pain. The on call physician was notified and ordered the hot pack discontinued. Verbal education was given to staff to not use heating devices when the temperature could not be monitored. There was no documentation in regard to the hot pack policy or if the NA what been provided direction prior to the incident. At 3:05 p.m. 3/21/2011, the DON stated there was no vulnerable adult (VA) internal investigation and reporting procedure completed and the incident was not reported to the state agency. A staff communication form dated 12/1/2010, (30 days after the original burn) and signed by the DON, informed staff that an Aqua "K" pad was the only sanctioned application of heat than could be provided by nursing because it had a temperature control that could be set and locked. Nursing was not to use any device that was micro waved, hot water heated or hot packs. No electric heating pads. K pads only if necessary. Therapy was the only department that could apply heat. R26 had a minor burn from a hot pack on 8/17/2010. The IR dated 8/17/2010, indicated R26 had a possible burn to the neck from a heat pack. The skin was intact and no blisters were present. R26 denied pain and indicated she did not know she was burned until the NA discovered the area. A cold compress was applied. Interventions implemented to prevent further incidents consisted of checking the temperature of the heat pack before placing it on the resident. The post incident analysis dated 8/17/2010, indicated burn was related a hot pack applied for pain from [MEDICAL CONDITION] arthritis and R26 had impaired mobility, impaired range of motion, and voluntary movement. The analysis indicated R26 had a slight reddened area on the left side of the neck and a small area on the back. The post incident analysis indicated the facility did initiate a vulnerable adult (VA) internal investigation and reporting procedure. A notation dated 8/18/2010, at the bottom of the post incident analysis, indicated staff was educated on the temperature of the hot packs and to check frequently for skin changes. On 8/18/2010, the DON signed the post incident analysis. The post incident analysis was not signed by the administrator or the medical director. At 2:30 p.m. on 3/21/2011, the registered nurse manager (RNM)-D stated the hot pack that burned R26 was made from a wash cloth placed in a plastic bag. The RN could not remember who applied the hot pack; however, the hot pack procedure was changed to Aqua K pads (water temperature controlled heating pad) only. NA-L, interviewed at 10:56 a.m. on 3/21/2011, stated they did not think they were allowed to apply hot packs or ice. NA-L would report a resident request for heat or ice to the licensed nurse. At 11:00 a.m. on 3/21/2011, NA-M stated the licensed nurse applies heat or cold packs. Staff treatment of [REDACTED]. R36 stated a staff member had treated her roughly. She reported it to two staff members, but the staff member who had allegedly maltreated her was still caring for her. R36's [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) dated 1/25/2011, indicated a BIMS score of 14 (a BIMS score of 13-15 indicates a person is cognitively intact). R36, interviewed at 1:46 p.m. on 3/15/2011, stated that she had been treated "roughly" by a nursing assistant (NA). She stated the NA makes her feel "uneasy," he is "rough and tough" with her, treated her "like a sack of potatoes" when he worked with her. R36 told the NA to "take it easy" with her. R36 stated it had been occurring several times weekly over the past few months and she reported it to 2 other NAs but nothing has been done because the NA still cares for her. At 8:56 am on 3/17/2011, R36 stated the man that was rough with her worked last night. She did not want to say his name because he has worked there a long time and she didn't want to get him in trouble. The Registered Nurse Manager (RNM-B) was interviewed at 1:51 p.m., on 3/17/2011, and stated that she was unaware of R36's allegations. RNM-B stated she would expect all staff to report to her any indications of alleged mistreatment. RNM-B interviewed R36, and documented at 3:37 p.m., on 3/17/2011, R36 was afraid the staff member who allegedly maltreated her would retaliate against her. The Social Worker (SW-A) was interviewed at 11:04 a.m., on 3/18/2011 and stated she was unaware R36 had complaints of rough handling by staff. She would expect all staff would report any indications of mistreatment. At 2:00 p.m. on 3/19/2011, an interview with the Director of Nursing (DON) verified there was no prompt action in relation to reports of alleged mistreatment. R10 reported staff rudeness that was not appropriately investigated by nursing administrative staff. R10, interviewed on 3/15/2011, at 12:30 p.m., stated LPN-F was rude and "talked snotty" to R10. R10 stated she "feels like a kid and I don't like that." R10 stated she told the the Unit Manager (RN-C). R10 stated that she reported it even though she was afraid LPN-F would "take it out on me." R10 stated LPN-F still took care of her and would be working that day. On 3/17/2011, at 1:50 p.m., R10 stated that LPN-F talked "very rude" to her, and also stated no staff have ever come and talked with her regarding her concerns with LPN-F. The annual MDS dated [DATE], indicated R10's Brief Interview for Mental Status (BIMS) score was 15, indicating she was cognitively intact. The behavioral plan of care interventions dated March 2011, included "Refocus the behavior by changing the topic." and "Approach calmly, offer encouragement, may need to use gentle firmness." RN-C, interviewed at 1:00 pm on 3/15/2011, stated she received R10's complaint on 2/27/2011 but there was no documentation regarding the complaint and no IR was completed. RN-C stated that on 2/28/2011, she advised LPN-F to attend the awaking program (inservice training). RN-C stated she reviewed LPN-F's performance and, on 3/15/2011 (during the survey), completed an Employee Warning/Disciplinary Notice indicating, "It has been brought to our attention that there are some concerns in regards to your response in certain situations and following facility policy. For example: working with resident's behaviors, negative verbal statements, administering two medications at one time via [DEVICE], and skin documentation." A correction plan was developed which included completing a video from Awakenings and meeting with the social worker to reviewing resident rights. RN-C stated she planned to meet with LPN-F when she came on duty for the afternoon shift that day. At that time RN-H stated she talked with LPN-F informally about R10's complaints but never documented the discussions. RN-C and RN-G stated they would not make an IR regarding the reported staff rudeness because R10's plan of care addressed her behaviors. RN-C stated residents are encouraged residents to file complaint forms and R10 had never done so. The DON, interviewed at 2:00 p.m. on 3/19/2011, stated the alleged mistreatment had been reported by a nursing assistant on 2/28/2011. According to the DON the following events occurred: On 2/25/2011, the LPN in question reported to her supervisor that R10 was upset with her because she did not give R10 candy when her blood glucose was elevated. On 2/26/2011, the LPN's supervisor provided educated on how to deal with residents. The DON verified that there was no formal plan to monitor LPN-F until 3/15/2011. The DON verified LPN-F had worked a couple of shifts before receiving the formal educational plan. The DON also verified that the facility did not act promptly to report the alleged mistreatment and there was no investigation when the nursing assistant first reported the incident. Injuries of unknown source R43 had a 10x8 cm purple bruise on his left arm. There was no investigation to determine if abuse/mistreatment had occurred. The bruise was not reported the injury of unknown source to the administrator or to the state agency. R43's [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) completed on 1/14/2011, indicated R43 had a score of 7 (a score of 0-7 indicates severe cognitive impairment). The IR dated 10/23/2010, indicated R43 had a 10x8 cm bruise on his left arm. R43 did not know how it happened. Interventions implemented on the IR were to continue with current plan of care. The IR was not reviewed by the administrator. Interdisciplinary progress notes dated 10/23/2010 identified the bruise, but did not indicate any further investigation. RNM-B was interviewed at 10:01 a.m. on 3/21/2011, and verified no investigation was completed and the bruise was not reported to the administrator. R30 had a large bruise on her leg that was not investigated to determine if abuse/mistreatment had occurred. R30's Cognitive Resident Assessment Protocol (RAP) dated 9/24/2010, indicated R30's cognitive deficits put her at risk for safety. The care plan dated December 2010, indicated R30 had long and short term memory loss with cognitive deficits and impaired decision making; self care deficits in mobility, dressing and bathing; and required 2 staff for transfers. The IR dated 12/2/2010, indicated staff reported a large bruise (7.5 cm in diameter with a 1 cm scab in the center) on the outside of R30's right leg. The cause of the bruise was unknown. The bruise was light blue-green in color and painful when palpated. The post incident analysis dated 12/2/2010, indicated R30 had a bruise on her leg and that R30 had not been transferring well and most likely bumped her leg with a transfer and will discuss the need for a Hoyer lift (a mechanical lift used for transfers). At 2:15 p.m. on 3/21/2011, the DON verified the lack of investigation related to the source of the bruise and incident was not reported to the state agency. Resident to resident altercations R22 ran into other residents with a power wheelchair on four occasions that were not investigated or reported to the state agency. R22 was discharged from the facility on 1/28/2011. On 12/25/2010, a resident reported that R22 "ran into him with her power wheel chair" and bumped into his left arm. When R22 was interviewed, she stated "I didn't do it on purpose but he wouldn't get out of my way. Next time I will hit him harder." R22 was placed on 15 minute checks and educated about safety with the power chair. There were no interventions initiated to prevent recurrence. Three days later, on 12/28/2010, the same resident reported to staff that R22 "purposefully" ran into him. R22 was interviewed regarding the incident and stated she knew he was behind her but she "backed up anyway because he wouldn't move." The Post Incident Analysis did not indicate an investigation was completed nor was the incident reported to the administrator or to the state agency. The IR dated 1/2/2011, indicated R22's electric wheel chair became attached to another resident's wheel chair. The report indicated that R22 was aware of the wheel chair lock-up but continued to drive her chair with the other chair attached until the other resident's chair ran into a steam table. When interviewed, R22 stated she did not know the other chair was hooked up and that she stopped when she "heard the other resident yelling." Although the report and witnesses's stated that R22 knew the wheelchairs were attached, the cause of the incident was documented as a "tangled purse." The incident was not reported to the administrator or to the state agency. The IR dated 1/23/2011 indicated, "res (resident) riding in hallway in power with excessive speed, was going in between 2 res in hallway and according to (illegible), (R22) intentionally ran into (resident) w/c (wheel chair). (The back of his w/c)." The report indicated that R22 was spoken to about the safety of others and responded by swearing back at the staff. The post incident analysis indicated that R22 had a cognitive disorder, was verbally abusive and had up and down behavior issues, prior incidents of hitting others with her wheel chair and staff were unable to redirect her. The incident was not reported to the administrator or to the state agency. None of R22's resident to resident altercations were considered vulnerable adult concerns or reported to the state agency. Interview with the DON on 3/18/2011 at 3:15 P.M. indicated these incidents would not be reported because no one was hurt. The DON stated that deliberate, aggressive collisions, or attempted collisions, with other residents by use of an electric wheel chair is a type of assault and should should have been reported and investigated as assault. R83 was involved in verbal altercations that included threatening gestures toward other residents. The incidents were not not reported to the state agency. R83 was discharged on [DATE]. R83's IR dated 10/14/2010 described a verbal altercation with another resident. The IR stated, "he put his finger up the his neck like he was to slit his throat." The IR dated 10/19/2010, indicated R83 was "pointing his butter knife at (second resident) and shaking it in a threatening manner." Record review indicated R83's behavior was reported to the case worker because R83 was on a provisional discharge from Anoka State Hospital (ASH). R83 was not discharged until 11/23/2010 when a opening occurred at ASH. The registered nurse clinical manager (RN)-D, interviewed on 3/18/2011 at 3:00 pm, stated that these incidents were not reported to the state agency. R64 was involved in a physical altercation with another resident (R13) that was not reported to the state agency. The IR dated 2/14/2011 indicated R64 and R13 were slapping at each other and R64 grabbed a tissue box and slapped R13 in the face with it. The Behavior Incident Follow-up Document described the incident as above, stating R64 was alert with dementia. R64's [DIAGNOSES REDACTED]. NA-R, interviewed at 10:07 am on 3/18/2011, stated R64 sticks up for herself and would hit back. R64 has instigated altercations with other residents RN-B, interviewed at 10:20 am on 3/18,2011, stated she witnessed the altercation between R64 and R13 and documented in the nursing notes; however, the notes somehow disappeared from the electric medical record (EMR). RN-B stated that on 2/14/2011, R64 was "shadowing" R13 and R13 tried to push R64 out of the way. R64 bonked R13 with a Kleenex box. RN-B and the social worker (SW)-A verified the incident was not reported to the state agency. R175 was involved in a physical altercation with R178 that was not reported to the state agency. The IR at 7:00 pm on 11/10/2010, indicated staff noted blood on R175's hand after he slammed the bathroom door into another resident's (R178)'s w/c. The IR indicated the two residents were face to face and staff separated them. R178 reported R175 hit him several times in face and chest. The RN analysis indicated that R175 attempted to slam the bathroom door into R178's wheelchair. Nursing notes on 11/11/2010, indicated R178 had faint red areas to upper left arm and right upper chest, but no bruising was noted. R178 stated fear of staying in the same room with R175 overnight. R175 was moved to another room for his safety. The nurse practitioner note dated 11/13/2010, indicated R175 had dementia with impulsive paranoid behavior with incidents of striking out at caregivers and fighting with another resident. The DON, interviewed at 3:14 p.m. on 3/18/2011, verified that verbal altercations between residents had not been reported to the state agency. The DON stated that the facility does not report resident to resident altercations unless there is an injury as a result of the altercation. R180 verbally threatened another resident. There was no investigation to determine potential potential abuse/mistreatment and the altercation was not reported to the state agency. The care plan dated January 2011, stated R180 was able to communicate all her wants and needs and was independent with ADLs. R180 had [DIAGNOSES REDACTED]. The IR dated 2/5/2011, indicated R180 reported to staff that she was going to "smash in that girls face" referring to another resident. R180 stated the the other resident was pounding on the bathroom door telling R180 to turn down her television. The IR indicated R180 stated she wouldn't physically harm the other resident but would "cuss" her out if she talked to her again. The Post Incident Analysis form dated 2/5/2011, stated the other resident continued to ask R180 to turn down her television and music and that upsets R180. The facility implemented 15 minute safety checks on R180 for 24 hours. No further altercations were noted per progress note dated 2/26/2011. Both residents were spoken to by staff regarding inappropriate behavior, however, the resident to resident altercation was not investigated or reported to the the state agency. The DON, interviewed at 3:14 p.m. on 3/18/2011, verified that the verbal altercation between the residents had not been reported to the state agency. The DON stated that the facility does not report resident to resident altercations unless there is an injury as a result of the altercation. The director of nurses (DON), interviewed at approximately 1:15 pm on 3/18/2011, verified the facility was not aware of the need to report resident to resident altercations to the state agency unless there was serious injury.

Based on interview, record review and policy review, the facility failed to assure that all allegations of potential abuse and neglect, injuries of unknown source and resident to resident altercations were investigated, reported to the administrator and to the state agency for 15 of 17 residents in the sample reviewed for abuse. Injuries of unknown origin were not investigated or reported for R91, R43 and R30; frostbite was not investigated or reported for R164;[MEDICAL CONDITION] hot packs were not reported for R76 and R26; rough treatment by staff and staff rudeness were not reported to the administrator, investigated or reported to the state agency for R36 and R10; and resident to resident altercations were not investigated or reported to the administrator or to the state agency for R83, R64, R13, R175, R178, R180 and R22. R91, R164 and R76 sustained actual harm as a result of the incidents described. The lack of identification, investigation, resident protection and reporting constituted immediate jeopardy for R91, R164, R76 and R36 and the administrator was notified at 3:15 pm on 3/21/2011. In addition, it was determined that multiple incidents were not identified as potential abuse/neglect, were not investigated to determine if abuse /neglect had occured; residents were not protected, and incidents were not reported to the administrator or state agency. The systemic failure to report and investigate incidents of potential abuse/neglect had the potential to affect most residents in the facility. The facility initiated an IJ removal plan that included review and revision of the abuse prevention plan and training was provided to all staff on each shift and prior to resident contact. Direct care staff, housekeeping staff and licensed nursing staff were interviewed and were able to explain their responsibility for identification of incidents of potential mistreatment; internal reporting; resident protection, investigation and external reporting as defined in the revised abuse prevention plan. The IJ was removed at 3:30 pm on 3/22/2011 and the scope and severity reduced to no actual harm with a potential for no more than minimal harm, pattern. Findings included: The facility abuse prevention policy for 2010/2011 indicated the following: The policy indicated "Incidents are reported, documented, and investigated internally using the Ecumen Bayshore Incident Reporting policy and procedure," and "The Administrator and DON must be promptly notified of suspected mistreatment. If such incidents occur or are discovered after normal working hours, the Administrator and DON must still be contacted, e.g., called at home, by voice mail or paged." Under "External Reporting" the policy indicated, "All alleged incidents of mistreatment are reported to the state agency and to all other agencies are required and all necessary corrective actions, depending on the result of the investigation, are taken. Immediately means as soon as possible, but not more than 24 hours after discovery of the incident." The administrator, interviewed at 4:35 p.m. on 3/21/2011, stated all resident accident reports, incident reports, and VA reports were reviewed at morning meeting on weekdays. In addition, the reports were reviewed at quarterly quality assurance meetings. The administrator stated the current review system failed to identify inadequate investigation and reporting of incidents in the VA system. The failure to implement policies in regard to identification, investigation, resident protection and reporting constituted immediate jeopardy for R91. In addition, it was determined that multiple incidents were not identified as potential mistreatment; were not investigated to determine potential mistreatment; residents were not protected, and incidents were not reported to the administrator or state agency. The IJ was called on 3/21/2011, at 3:15 p.m.. The facility initiated an IJ removal plan that included review and revision of the abuse prevention plan and training was provided to all staff on each shift and prior to resident contact. Direct care staff, housekeeping staff and licensed nursing staff were interviewed and were able to explain their responsibility for identification of incidents of potential mistreatment; internal reporting; resident protection, investigation and external reporting as defined in the revised abuse prevention plan. The IJ was removed at 3:30 pm on 3/22/2011 and the scope and severity reduced to an E. The facility abuse prevention policy for 2010/2011 indicated the following: The policy indicated "Incidents are reported, documented, and investigated internally using the Ecumen Bayshore Incident Reporting policy and procedure," and "The Administrator and DON must be promptly notified of suspected maltreatment. If such incidents occur or are discovered after normal working hours, the Administrator and DON must still be contacted, e.g., called at home, by voice mail or paged." Under "External Reporting" the policy indicated, "All alleged incidents of maltreatment are reported to the state agency and to all other agencies are required and all necessary corrective actions, depending on the result of the investigation, are taken. Immediately means as soon as possible, but not more than 24 hours after discovery of the incident." The policy did not direct investigation and reporting of resident to resident altercations. R91 sustained a fracture to the left knee that was not investigated to identify potential causative factors or to identify potential maltreatment. Although staff written statements were obtained following identification of the fracture, there was no evidence to indicate that staff caring for R91 prior to the injury noted on 10/26/2010, were interviewed as part of a thorough investigation into potential causative factors. The incident report (IR) dated 11/3/2010 indicated the presence of a large painful bruise on lateral left leg (7 inches by 3 inches). The IR indicated R91's left foot was rotated slightly outward and ROM caused increased pain. R19 stated she fell out of bed and that she fell in the bathroom. The IR indicated R91 had severe dementia and was not a reliable reporter. The IR stated that a portable Xray of the left knee on 10/27/2010 indicated there was no obvious fracture. An undated and unsigned document provided by facility staff indicated R91 complained of sharp left shin pain at 3:50 am on 10/27/2010. Later on 10/27/2010 R91 complained of left hip and knee pain and a mobile X-ray in the facility showed no obvious fracture or other acute findings. On 11/2/2010 a large yellow purple bruise was noted on the outer aspect of the left thigh, knee and calf. On 11/3/2010, R91 was sent to the ER for evaluation of left hip and knee pain. X-ray results indicated a lateral plateau [MEDICAL CONDITION] knee. The document indicated, "The nurse manager interviewed staff and there were no falls or other injuries noted by staff during this time period". The post incident analysis dated 11/4/2010, indicated R91 had impaired mobility, balance problems, incontinence, impaired cognition and judgement/safety awareness deficit. The analysis indicated R91 was found with a bruise on her left knee and was not able to tell where/what happened due to dementia. No further investigation was completed to determine potential causative factors prior to 10/27/2010, when the injury was first identified. The social worker (SW)-A. interviewed at 10:20 am on 3/18,2011, stated the investigation was completed by collecting written staff statements. There was no further investigation and the fracture was not reported to the administrator or to the state agency R164 sustained actual harm with frostbite to the toes of both feet from exposure to extreme cold when outside smoking. There was no incident report and the incident was not investigated or reported to the state agency. R164 required staff assistance to light the first cigarette. R164 was assisted to smoke outside in extreme cold winter weather without appropriate protection for her feet. Interdisciplinary Progress Notes (IPN) at 3:38 p.m. on 1/16/2011, stated, "...staff noted toes of both feet to be discolored." The note indicated R164 did not wear any covering on her toes when going out to smoke in the cold weather. There was no description of the toes and no further nursing assessment of the frostbitten toes. R164's [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], indicated R164 was cognitively intact, required extensive assistance with most Activities of Daily Living (ADL's) and was independent with wheelchair locomotion both on and off the unit. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/25/2011, identified the resident demonstrated poor decision making "...as evidenced by refusals of care." The ADL Functional/Rehabilitation CAA dated 10/25/2010, identified R164 had functional limitations to bilateral upper and lower extremities and, "contractures to upper extremities with loss of fine motor skills." The Psychosocial Well-Being CAA dated 10/25/2010, further indicated, "(R164) smokes multiple times a day and is safe to smoke but does have to request someone to light (the) initial cigarette." The quarterly MDS dated [DATE], identified no functional changes for R164. The Smoking assessment dated [DATE], indicated R164 was independent with smoking, but needed assistance from facility staff to light the first cigarette. At 7:51 p.m. on 3/14/2011, Registered Nurse (RN-D) checked the chart and confirmed the frostbite was discovered on 1/16/2011. RN-D stated the "Skin Assessment (Other than Ulcer)" form was the skin assessment for the frostbite. She further indicated an incident report was not completed because "we knew what caused the issue... We were able to determine the root cause." RN-D also confirmed the incident was not investigated to determine potential maltreatment or neglect and was not reported to the administrator or to the state agency. At approximately 1:00 p.m. on 3/18/2011, the Director of Nursing (DON) verified the incident was not investigated to determine potential maltreatment and was not reported to the administrator or to the state agency. At 2:44 p.m. on 3/18/2011, the Nurse Practitioner (NP) stated she saw R164 out at the smoking area inappropriately dressed and assessed the frostbite on the day it was identified, "It was one of the worst cases of frostbite, no cap (capillary) refill and very brown in color...that's why I ordered the wound consult." R76 sustained actual harm when a hot pack caused a burn. According to the incident report (IR) dated 10/30/2010, R76 had multiple open and intact blisters on the right knee following the hot pack treatment. The care plan dated 1/13/2006, indicated R76 had impaired decision making with short and long term memory loss. The mobility care plan dated 1/17/2006, indicated R76 had an alteration in mobility related to erratic involuntary movements due to [MEDICAL CONDITION]'s disease and used a wheelchair for all mobility. The IR dated 10/30/2010, indicated R76 had multiple open and intact blisters on the right knee. R76 stated a heating pack was applied by a nursing assistant the night before. R76 stated he knew the hot pack was too hot but did not ask the nursing assistant who was present to remove it. R76 had nine open, measurable areas with multiple water blisters in between them. R76 rated his pain a 10 out of 10. The post incident analysis was completed by registered nurse (RN)-G on 10/31/2010. The RN analysis indicated a hot pack was placed on R76's right knee during the night by nursing assistant. The hot pack was too hot and resulted in multiple blisters requiring medical treatment. R76 stated he knew the hot pack was too hot but did not remove it or call for assistance. The post incident analysis did not indicate that vulnerable adult internal investigation and reporting procedures were initiated. The director of nursing (DON) signed the IR on 11/3/2010. The form was not signed by the administrator or the medical director. The documentation did not indicate awareness of a previous resident burn (R26) or why an Aqua K pad was not utilized as directed in August 2010 following R26's burn. The investigation dated 11/1/2010, indicated R76 received a burn to the right knee from a heating pack applied by a nursing assistant (NA). The NA made a hot pack out of wash cloths and carried it with bare hands into R76's room where it was placed on R76's right knee. R76 stated he knew it was too hot but did not remove it or ask for assistance. R76 had no sensory impairment to the lower extremities that would inhibit the ability to feel pain and was capable of communicating pain. The on call physician was notified and ordered the hot pack discontinued. Verbal education was given to staff to not use heating devices when the temperature could not be monitored. There was no documentation in regard to the hot pack policy or if the NA what been provided direction prior to the incident. At 3:05 p.m. 3/21/2011, the DON stated there was no vulnerable adult (VA) internal investigation and reporting procedure completed and the incident was not reported to the administrator or to the state agency. A staff communication form dated 12/1/2010, (30 days after the original burn) and signed by the DON, informed staff that an Aqua "K" pad was the only sanctioned application of heat than could be provided by nursing because it had a temperature control that could be set and locked. Nursing was not to use any device that was micro waved, hot water heated or hot packs. No electric heating pads. K pads only if necessary. Therapy was the only department that could apply heat. R26 had a minor burn from a hot pack on 8/17/2010. The IR dated 8/17/2010, indicated R26 had a possible burn to the neck from a heat pack. The skin was intact and no blisters were present. R26 denied pain and indicated she did not know she was burned until the NA discovered the area. A cold compress was applied. Interventions implemented to prevent further incidents consisted of checking the temperature of the heat pack before placing it on the resident. The post incident analysis dated 8/17/2010, indicated burn was related a hot pack applied for pain from [MEDICAL CONDITION] arthritis and R26 had impaired mobility, impaired range of motion, and voluntary movement. The analysis indicated R26 had a slight reddened area on the left side of the neck and a small area on the back. The post incident analysis indicated the facility did initiate a vulnerable adult (VA) internal investigation and reporting procedure. A notation dated 8/18/2010, at the bottom of the post incident analysis, indicated staff was educated on the temperature of the hot packs and to check frequently for skin changes. On 8/18/2010, the DON signed the post incident analysis. The post incident analysis was not signed by the administrator or the medical director. At 2:30 p.m. on 3/21/2011, the registered nurse manager (RNM)-D stated the hot pack that burned R26 was made from a wash cloth placed in a plastic bag. The RN could not remember who applied the hot pack; however, the hot pack procedure was changed to Aqua K pads (water temperature controlled heating pad) only. NA-L, interviewed at 10:56 a.m. on 3/21/2011, stated they did not think they were allowed to apply hot packs or ice. NA-L would report a resident request for heat or ice to the licensed nurse. At 11:00 a.m. on 3/21/2011, NA-M stated the licensed nurse applies heat or cold packs. Staff treatment of [REDACTED]. R36 stated a staff member had treated her roughly. She reported it to two staff members, but the staff member who had allegedly maltreated her was still caring for her. R36's [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) dated 1/25/2011, indicated a BIMS score of 14 (a BIMS score of 13-15 indicates a person is cognitively intact). R36, interviewed at 1:46 p.m. on 3/15/2011, stated that she had been treated "roughly" by a staff member. She stated the staff member makes her feel "uneasy," he is "rough and tough" with her, and she has told the staff member to "take it easy" with her. R36 stated it had been occurring several times weekly over the past few months and she reported it to 2 other staff members. R36 stated the staff member continued to provide her daily cares. The Registered Nurse Manager (RNM-B) was interviewed at 1:51 p.m., on 3/17/2011, and stated that she was unaware of R36's allegations. RNM-B stated she would expect all staff to report to her any indications of alleged maltreatment. RNM-B interviewed R36, and documented at 3:37 p.m., on 3/17/2011, R36 was afraid the staff member who allegedly maltreated her would retaliate against her. The Social Worker (SW-A) was interviewed at 11:04 a.m., on 3/18/2011 and stated she was unaware R36 had complaints of rough handling by staff. She would expect all staff would report any indications of maltreatment. At 2:00 p.m. on 3/19/2011, an interview with the Director of Nursing (DON) verified there was no prompt action in relation to reports of alleged maltreatment. R10 reported staff rudeness that was not appropriately investigated by administrative nursing staff. R10, interviewed on 3/15/2011, at 12:30 p.m., stated LPN-F was rude and "talked snotty" to R10. R10 stated she "feels like a kid and I don't like that." R10 stated she told the the Unit Manager (RN-C). R10 stated that she reported it even though she was afraid LPN-F would "take it out on me." R10 stated LPN-F still took care of her and would be working that day. On 3/17/2011, at 1:50 p.m., R10 stated that LPN-F talked "very rude" to her, and also stated no staff have ever come and talked with her regarding her concerns with LPN-F. RN-C, interviewed at 1:00 pm on 3/15/2011, stated she received R10's complaint on 2/27/2011 and there was no documentation regarding the complaint and no IR was completed. RN-C stated that, on 2/28/2011, she advised LPN-F to attend the awaking program (inservice training). RN-C stated she reviewed LPN-F's performance and, 3/15/2011 (during the survey), completed an Employee Warming/Disciplinary Notice indicating, "It has been brought to our attention that there are some concerns in regards to your response in certain situations and following facility policy. For example: working with resident's behaviors, negative verbal statements, administering two medications at one time via [DEVICE], and skin documentation." A correction plan was developed which included completing a video from Awakenings and meeting with the social worker to reviewing resident rights. RN-C stated she planned to meet with LPN-G when she came on duty for the afternoon shift that day. At that time RN-H stated she talked with LPN-F informally about R10's complaints but never documented the discussions. RN-C and RN-G stated they would not make an IR regarding the reported staff rudeness because R10's plan of care addressed her behaviors. RN-C stated residents are encouraged residents to file complaint forms and R10 had never done so. The DON, interviewed at 2:00 p.m. on 3/19/2011, stated the alleged maltreatment had been reported by a nursing assistant on 2/28/2011. According to the DON the following events occurred: On 2/25/2011, the LPN in question reported to her supervisor that R10 was upset with her because she did not give R10 candy when her blood glucose was elevated. On 2/26/2011, the LPN's supervisor provided educated on how to deal with residents. The DON verified that there was no formal plan to monitor the LPN until 3/15/2011. The DON verified the LPN had worked a couple of shifts before receiving the formal educational plan. The DON also verified that the facility did not act promptly to report the alleged maltreatment and there was no investigation when the nursing assistant first reported the incident. R43 had a 10x8 cm purple bruise on his left arm. There was no investigation to determine if abuse/mistreatment had occurred and the injury of unknown source was not reported to the administrator or to the state agency. R43's [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) completed on 1/14/2011, indicated R43 had a score of 7 (a score of 0-7 indicates severe cognitive impairment). The IR dated 10/23/2010, indicated R43 had a 10x8 cm bruise on his left arm. R43 did not know how it happened. Interventions implemented on the IR were to continue with current plan of care. The IR was not reviewed by the administrator. Interdisciplinary progress notes dated 10/23/2010 identified the bruise, but did not indicate any further investigation. RNM-B was interviewed at 10:01 a.m. on 3/21/2011, and verified no investigation was completed and the bruise was not reported to the administrator. R30 had a large bruise on her leg that was not investigated to determine if abuse/mistreatment had occurred. The injury of unknown source was not reported to the administrator of to the state agency. R30's Cognitive Resident Assessment Protocol (RAP) dated 9/24/2010, indicated R30's cognitive deficits put her at risk for safety. The care plan dated December 2010, indicated R30 had long and short term memory loss with cognitive deficits and impaired decision making; self care deficits in mobility, dressing, and bathing; and required 2 staff for transfers. The IR dated 12/2/2010, indicated staff reported a large bruise (7.5 cm in diameter with a 1 cm scab in the center) on the outside of R30's right leg. The cause of the bruise was unknown. The bruise was light blue-green in color and painful when palpated. The post incident analysis dated 12/2/2010, indicated R30 had a bruise on her leg and that R30 had not been transferring well and most likely bumped her leg with a transfer and will discuss the need for a Hoyer lift (a mechanical lift used for transfers). At 2:15 p.m. on 3/21/2011, the DON verified the lack of investigation related to the source of the bruise and incident was not reported to the state agency. Resident to resident altercations: R22 ran into other residents with a power wheelchair on four occasions that were not investigated or reported to the state agency. R22 was discharged from the facility on 1/28/2011. On 12/25/2010, a resident reported that R22 "ran into him with her power wheel chair" and bumped into his left arm. When R22 was interviewed, she stated "I didn't do it on purpose but he wouldn't get out of my way. Next time I will hit him harder." R22 was placed on 15 minute checks and educated about safety with the power chair. There were no interventions initiated to prevent recurrence. Three days later, on 12/28/2010, the same resident reported to staff that R22 "purposefully" ran into him. R22 was interviewed regarding the incident and stated she knew he was behind her but she "backed up anyway because he wouldn't move." The Post Incident Analysis did not indicate an investigation was completed nor was the incident reported to the state agency. The IR dated 1/2/2011, indicated R22's electric wheel chair became attached to another resident's wheel chair. The report indicated that R22 was aware of the wheel chair lock-up but continued to drive her chair with the other chair attached until the other resident's chair ran into a steam table. When interviewed, R22 stated she did not know the other chair was hooked up and that she stopped when she "heard the other resident yelling." Although the report and witnesses's stated that R22 knew the wheelchairs were attached, the cause of the incident was documented as a "tangled purse." The IR dated 1/23/2011 indicated, "res (resident) riding in hallway in power with excessive speed, was going in between 2 res in hallway and according to (illegible), (R22) intentionally ran into (resident) w/c (wheel chair). (The back of his w/c)." The report stated that R22 was spoken to about the safety of others and responded by swearing back at the staff. The post incident analysis indicated that R22 had a cognitive disorder, was verbally abusive and had up and down behavior issues, prior incidents of hitting others with her wheel chair and staff were unable to redirect her. None of R22's resident to resident altercations were considered vulnerable adult concerns or reported to the state agency. Interview with the DON on 3/18/2011 at 3:15 P.M. indicated these incidents would not be reported because no one was hurt. The DON stated that deliberate, aggressive collisions, or attempted collisions, with other residents by use of an electric wheel chair is a type of assault and should should have been reported and investigated as assault. R83 was involved in verbal altercations that included threatening gestures toward other residents. The incidents were not not reported to the state agency. R83's IR dated 10/14/2010 described a verbal altercation with another resident. The IR stated, "he put his finger up to his neck like he was to slit his throat." The IR dated 10/19/2010, indicated R83 was "pointing his butter knife at (second resident) and shaking it in a threatening manner." Record review indicated R83's behavior was reported to the case worker because R83 was on a provisional discharge from Anoka State Hospital (ASH). R83 was not discharged until 11/23/2010 when a opening occurred at ASH. The registered nurse clinical manager (RN)-D, interviewed on 3/18/2011 at 3:00 pm, stated that these incidents were not reported to the state agency. R64 was involved in a physical altercation with another resident (R13) that was not reported to the state agency. The IR dated 2/14/2011 indicated R64 and R13 were slapping at each other and R64 grabbed a tissue box and slapped R13 in the face with it. The Behavior Incident Follow-up Document described the incident as above, stating R64 was alert with dementia. R64's [DIAGNOSES REDACTED]. NA-R, interviewed at 10:07 am on 3/18/2011, stated R64 sticks up for herself and would hit back. R64 has instigated altercations with other residents RN-B, interviewed at 10:20 am on 3/18,2011, stated she witnessed the altercation between R64 and R13 and documented in the nursing notes; however, the notes somehow disappeared from the EMR. RN-B stated that on 2/14/2011, R64 was "shadowing" R13 and R13 tried to push R64 out of the way. R64 bonked R13 with a Kleenex box. RN-B and the social worker (SW)-A verified the incident was not reported to the administrator or to the state agency. R175 was involved in a physical altercation with R178 that was not reported to the state agency. The IR at 7:00 pm on 11/10/2010, indicated staff noted blood on R175's hand after he slammed the bathroom door into another resident's (R178)'s w/c. The IR indicated the two residents were face to face and staff separated them. R178 reported R175 hit him several times in face and chest. The RN analysis indicated that R175 attempted to slam the bathroom door into R178's wheelchair. Nursing notes on 11/11/2010, indicated R178 had faint red areas to upper left arm and right upper chest, but no bruising was noted. R178 stated fear of staying in the same room with R175 overnight. R175 was moved to another room for his safety. The nurse practitioner note dated 11/13/2010, indicated R175 had dementia with impulsive paranoid behavior with incidents of striking out at caregivers and fighting with another resident. The DON, interviewed at 3:14 p.m. on 3/18/2011, verified that verbal altercations between residents had not been reported to the state agency. The DON stated that the facility does not report resident to resident altercations unless there is an injury as a result of the altercation. R180 verbally threatened another resident. There was no investigation to determine potential potential abuse/mistreatment and the altercation was not reported to the state agency. The care plan dated January 2011, stated R180 was able to communicate all her wants and needs and was independent with ADLs. R180 had [DIAGNOSES REDACTED]. The IR dated 2/5/2011, indicated R180 reported to staff that she was going to "smash in that girls face" referring to another resident. R180 stated the the other resident was pounding on the bathroom door telling R180 to turn down her television. The IR indicated R180 stated she wouldn't physically harm the other resident but would "cuss" her out if she talked to her again. The Post Incident Analysis form dated 2/5/2011, stated the other resident continued to ask R180 to turn down her television and music and that upsets R180. The facility implemented 15 minute safety checks on R180 for 24 hours. No further altercations were noted per progress note dated 2/26/2011. Both residents were spoken to by staff regarding inappropriate behavior, however, the resident to resident altercation was not investigated or reported to the the state agency. The DON, interviewed at 3:14 p.m. on 3/18/2011, verified that the verbal altercation between the residents had not been reported to the state agency. The DON stated that the facility does not report resident to resident altercations unless there is an injury as a result of the altercation. The director of nurses (DON), interviewed at approximately 1:15 pm on 3/18/2011, verified the facility was not aware of the need to report resident to resident altercations to the state agency unless there was serious injury. The administrator, interviewed at 4:35 p.m. on 3/21/2011, stated all resident accident reports, incident reports, and VA reports were reviewed at morning meeting on weekdays. In addition, the reports were reviewed at quarterly quality assurance meetings. The administrator stated the current review system failed to identify inadequate investigation and reporting of incidents in the VA system.

Based on observation, interview, record review and policy review, the facility failed to assure freedom from neglect for 1 of 3 residents (R164) in the sample observed to smoke outside. Facility staff assisted R164 to light the first cigarette and were aware that R164 was not wearing appropriate foot wear. The neglect of supervision resulted in actual harm with frostbite to the toes of both feet. findings included: R164 required staff assistance to light the first cigarette. R164 was assisted to smoke outside in extreme cold winter weather without appropriate protection for her feet. Interdisciplinary Progress Notes (IPN) at 3:38 p.m. on 1/16/2011, stated, "...staff noted toes of both feet to be discolored." The note indicated R164 did not wear any covering on her toes when going out to smoke in the cold weather. There was no description of the toes and no further nursing assessment of the frostbitten toes. A Telephone Order (TO) dated 1/18/2011, directed a wound consult for R164 for, "Dx: (diagnosis) Frostbite to bi (bilateral) toes, right greater then left also noted on right superior ankle." R164's [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], indicated R164 was cognitively intact, required extensive assistance with most Activities of Daily Living (ADL's) and was independent with wheelchair locomotion both on and off the unit. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/25/2010, identified the resident demonstrated poor decision making "...as evidenced by refusals of care." The ADL Functional/Rehabilitation CAA dated 10/25/2010, identified R164 had functional limitations to bilateral upper and lower extremities and, "contractures to upper extremities with loss of fine motor skills." The Psychosocial Well-Being CAA dated 10/25/2010, further indicated, "(R164) smokes multiple times a day and is safe to smoke but does have to request someone to light (the) initial cigarette." The quarterly MDS dated [DATE], identified no functional changes for R164. The Smoking assessment dated [DATE], indicated R164 was independent with smoking, but needed assistance from facility staff to light the first cigarette. The care plan dated 1/11/2011, identified R164 was resistive to cares and refused showers, appointments, therapy, tube feedings, medications, treatments, range of motion, repositioning and other ADL's. The 1/20/2011, smoking care plan identified, "Smoker: at risk for possible injury. Resident smokes independently after someone lights her cigarette for her. Unable to use lighter d/t (due to) disability." The smoking care plan further identified the goal of "Resident will remain free from injury while smoking independently" and directed to complete the smoking assessment quarterly, monitor behaviors such as, "are they giving others smokes (cigarettes) that should not have (them)," and remind the resident of designated smoking areas. A hand written update on 2/3/2011(after the 1/16/11 incident) indicated, "Resident refuses to wear appropriate covering on feet when out in cold weather," and directed, "Staff to assist with covering feet with sock (thick) after getting up in w/c (wheelchair) prior to going outside. Document refusals per policy and notify nurse." The wound clinic "Clinic Referral" dated 1/25/2011, indicated R164 sustained, "Superficial injury to feet consistent with frostbite." The referral identified the frostbite would be treated topically with [MEDICATION NAME] cream to toes twice daily and to follow up as needed. The nurse practitioner's dictated "Nursing Home Office Note" dated 1/25/2011, indicated R164 had an "extensive" history of noncompliance. The note further identified, "(R164) has shown extremely poor judgement and insight in regards to basic safety. For example, sustained frostbite secondary to inappropriate dress while outside." The "Nursing Home Office Note" dated 1/28/2011 indicated, "HISTORY OF PRESENT ILLNESS: (R164 age and gender)...quadriplegic...with profound history of medical noncompliance who has now developed signs and symptoms of frostbite to (their) feet. (R164) has been observed on more than 1 occasion going outside inappropriately dressed. The patient acknowledges that indeed (R164) has been inappropriately dressing for the outdoor, but has no explanation for this behavior. Staff has noticed a change in coloration to the toes bilaterally; left greater than right. Right toes are blanchable (an indicator of capillary refill and potential damage to skin tissues), but there is no blanching noted on the left toes. Currently there is no issue with swelling." The note further described, "EXAMINATION: Has brown discoloration to the integument (skin) of (the) toes bilaterally. I can note that (their) right foot discolored areas are blanchable, but left toes are not. Pedal (foot) pulses are present bilaterally. There is no other integument or structural issues noted." The "Skin Assessment (Other than Ulcer)" indicated R164 had frostbite to the toes of both feet. Monitoring documentation indicated the frostbite was not healed until 2/28/2011 (6 weeks later). At 7:51 p.m. on 3/14/2011, Registered Nurse (RN-D) stated the frostbite occurred when RN Manager-C (RNM-C) "was gone." RN-D checked the chart and confirmed the frostbite was discovered on 1/16/2011 and stated the IPN note from 2/11/2011 was the charting for the incident. RN-D stated the "Skin Assessment (Other than Ulcer)" form was the skin assessment for the frostbite. She further indicated an incident report was not completed because "we knew what caused the issue... We were able to determine the root cause." RN-D also confirmed the incident was not investigated to determine potential mistreatment or neglect, nor was it reported to the state agency. At 9:48 a.m. on 3/18/2011, R164 was observed at smoking area. R164 was able to push the handicap button to open the door and safely extinguish the cigarette in ash tray. R164 confirmed that facility staff had to light the cigarette. At 10:05 a.m. on 3/18/2011, R164's toes were observed with the assistance of the licensed practical nurse (LPN-A) and appeared pink and intact. LPN-A stated the resident was monitored for noncompliance with completion of the full amount of tube feeding, compliance with repositioning, use of the CPM machine and "General other things" which had to do with R164's "wellbeing." LPN-A stated the monitoring for wearing socks and dressing appropriately in cold weather would fall into the "other" category. At 2:44 p.m. on 3/18/2011, the Nurse Practitioner (NP) stated she saw R164 out at the smoking area inappropriately dressed and assessed the frostbite on the day it was identified, "It was one of the worst cases of frostbite, no cap (capillary) refill and very brown in color...that's why I ordered the wound consult." At approximately 1:00 p.m. on 3/18/2011, the Director of Nursing (DON) verified there was no incident report and the incident was not investigated to determine potential mistreatment and was not reported to the administrator or to the state agency. The Administrator, interviewed at 4:35 p.m. on 3/21/2011, stated all resident incident/accident reports were reviewed at the morning meeting each weekday and he was usually notified of incidents at that meeting. In addition, all incident/accident reports were reviewed at the quarterly quality assurance meetings. The administrator confirmed the committee did not identify inadequate investigations and lack of reporting in the vulnerable adult system, Review of the facility's "Abuse Prevention Plan for Minnesota Skilled Nursing Facilities 2010-2011" policy and procedure indicated the following: "3. Neglect (1) (CMS Definition) Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (2) (MN State Definition) (a) The failure of a caregiver to supply a resident with the care or services including but not limited to food, clothing, shelter, healthcare or supervision which is reasonable and necessary to obtain or maintain the residents physical and mental health or safety, considering the physical or mental dysfunction of the resident which is not the result of an accident or therapeutic conduct. The policy indicated "Incidents are reported, documented, and investigated internally using the Ecumen Bayshore Incident Reporting policy and procedure," and "The Administrator and DON must be promptly notified of suspected mistreatment. If such incidents occur or are discovered after normal working hours, the Administrator and DON must still be contacted, e.g., called at home, by voice mail or paged." Under "External Reporting" the policy indicated, "All alleged incidents of mistreatment are reported to the state agency and to all other agencies are required and all necessary corrective actions, depending on the result of the investigation, are taken. Immediately means as soon as possible, but not more than 24 hours after discovery of the incident."

Based on observation, interview and record review, the facility did not provide assessment and appropriate repositioning to prevent the development of pressure ulcers for 1 of 3 residents (R195) in the sample. R195 sustained actual harm with the development of a stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). R195 had a stage 4 coccyx pressure ulcer and was observed to be inappropriately positioned in bed on the afternoon of 3/1/7/2011, and the morning of 3/18/2011. R195's [DIAGNOSES REDACTED]. The afternoon of 3/17/2011, R195 was observed lying in bed on an alternating air mattress, with a body pillow positioned under the left side from the upper back down to below the lower buttocks. The upper body was positioned slightly to the right; however, the lower body was supine with the lower coccyx area resting on the body pillow and mattress. R195 was not positioned properly on her side. From 7:49 a.m. to 9:26 a.m. (1 hour, 37 minutes) on 3/18/2011, R195 was observed in bed with the upper body slightly facing the right side. R195 had a body pillow behind the upper back all the way down below the lower buttocks, and was not positioned on her side. R195 was awake, but non-verbal. There were large square heel protectors on both feet and both feet were facing up towards the ceiling, not to the right. Although R195's upper body appeared slightly turned towards the right, the lower body was supine. At 9:26 a.m. a nursing assistant (NA-M) entered the room and closed the door. When the surveyor entered the room R195 had been repositioned. NA-M stated she checked R195's incontinent product and repositioned her. A body pillow was "tucked" under R195's upper right side down below the lower buttocks. R195 was not on her left side to relieve pressure from the coccyx area. NA-M stated R195 had last been repositioned at 7:38 a.m. and required every two hour repositioning. A "Braden Scale" (a tool used to evaluate pressure ulcer risk) dated 10/11/2010, identified R195 had a score of "11" (a score of 18 and below indicated a high risk for pressure ulcers). A "Skin Risk Data Collection and Assessment" dated 10/12/2010, indicated R195 was incontinent of bladder, had contractures to upper extremities, was diaphoretic, and had "Rooke" boots for positioning of the lower extremities. R195 was on a tube feeding, and was to be repositioned every two hours along with a check and change of the brief. The admission Minimum Data Set ((MDS) dated [DATE], indicated R195 had short and long-term memory problems with severe cognitive impairment; did not speak; and rarely/never understood or understands. R195 required the total assistance of one to two staff for all activities of daily living (ADL's); was totally incontinent of bowel and bladder; utilized a feeding tube, and was non-ambulatory. The MDS identified R195 was at risk for pressure ulcers, and had no current pressure ulcers. The pressure ulcer Care Area Assessment (CAA) dated 10/22/2010, identified R195 was at risk for pressure ulcers due to total dependence on staff in all functional mobility, ADL's and incontinence. The assessment identified multiple risk factors for skin impairment such as pertinent diagnoses, nutrition, cognition, communication, mobility, incontinence, and a blanchable reddened area to the coccyx which measured 3.0 x 1.0 cm. There was no evidence that tissue tolerance was assessed to determine appropriate interventions for repositioning in the bed and wheelchair (w/c). A "Skin Risk Data Collection and Assessment" dated 11/2/2010, indicated R195 had a pink 2 x 2 cm area to the bony prominence on the coccyx, and was repositioned every two hours. The area was blanchable, and not open. A Physician consultation dated 12/14/2010, indicated R195 was seen during a hospitalization for a "decubitus ulceration over the sacrum." The ulcer was not described or staged. The record further indicated R195 "could be turned onto her side to keep pressure off the sacrum and this could be done with nursing care at (the facility) every two hours." An "Occupational Therapy Daily Treatment Note" dated 12/20/2010, identified a "ROHO" cushion (reduces pressure) was issued for R195 for the w/c. The quarterly MDS dated [DATE], indicated there were no changes in cognitive or functional abilities from the previous assessment. The MDS identified R195 now had a indwelling urinary catheter; had weight loss of 5% or more in the last month or loss of 10% or more in the last six months; and had two unstageable pressure ulcers with wound beds covered with slough and or eschar. A "Skin Risk Data Collection and Assessment" dated 1/11/2011, indicated R195 had two stage II areas (partial thickness loss of skin presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) on "buttocks/coccyx" present with unstageable wound beds. R195 was identified to be having poor tube feeding tolerance with slow increases in feedings. The record identified an air mattress was on the bed, and further indicated "tolerates 2hr (two hour) tissue tolerance testing in bed did 0 (not) attempt in w/c (wheelchair)." The documentation was incomplete and did not indicate what bony prominences were tested in the bed. The skin integrity care plan dated 1/21/2011, indicated R195 had several risk factors for skin breakdown and had a slow healing stage IV pressure ulcer to the coccyx. The care plan interventions included PEMF BID; position side to side every two hours, thin sheet under blue chucks on bed, keep skin clean and dry; observe for changes every shift and update team leader of any changes; pressure relieving cushion in w/c; alternating air mattress on bed; weekly skin assessment and prn; tissue tolerance on admission, quarterly and with any significant change; and redistribute pressure repositioning as to residents tissue tolerance. The nursing assistant (NA) group sheet dated 3/18/2011, directed "stay in bed at all times! Side to side repositioning only" and reposition every two hours. Physician's progress notes dated 1/20/2011, and 2/15/2011, indicated R195 was seen by the wound nurse. The 1/20/2011, note indicated the staff was turning R195 every two hours and trying to avoid back lying. The 2/15/2011, note indicated "Turning every 2 hrs & time limits on sitting." A "Clinic Referral" dated 2/23/2011, indicated "sacral decub appears stage IV", and a new treatment was ordered. A "Clinic Referral" dated 3/17/2011, ordered a change in R195's pressure ulcer treatment and directed "complete pressure relief to area at all times." A "Skin Assessment" dated 3/17/2011, indicated R195 had an alternating air mattress; nutritional supplements in place; a ROHO cushion in the w/c; limiting time up in w/c; PEMF in place (a device which emits wave-like impulses to an area to promote healing); and side to side repositioning in bed. The record further indicated "tissue tolerance in bed, tolerated." The record lacked any information regarding the results of the tissue tolerance evaluation to determine an appropriate repositioning schedule. Review of the weekly skin monitoring sheets from 10/13/2010, to 3/15/2011, indicated R195 had a pink area on the coccyx from 10/13 to 11/16 (the size varied from 3 cm x 1cm to 3cm x3cm) which was intact. On 11/17/2010, R195 had three new superficial areas in a cluster on the coccyx documented documented as stage II (1cm x 0.4cm, 0.8cm x0.4cm, 0.3cm x 0.3cm) on 11/17, and stages I and II on 11/30 and 12/1. An Allevyn dressing was applied on 11/17 and the Physician was notified. On 12/8/2010, one stage II pressure ulcer was documented which measured 3cm long x 0.8cm wide with serous drainage. No depth was documented. On 1/11/2011, the pressure ulcer had decreased in size (1.2cm x 1cm) but was unstageable . On 1/17/2011, the pressure ulcer increased in size (3.2 cm length by 1.4 width). The ulcer remained unstageable until 3/15/2011, where the record noted a stage IV pressure ulcer at 3.0cm long x 2.0cm wide. No depth was documented. From 7:49 a.m. to 9:26 a.m. (1 hour, 37 minutes) on 3/18/2011, R195 was observed in bed with the upper body slightly facing the right side. R195 had a body pillow behind the upper back all the way down below the lower buttocks, and was not positioned on her side. R195 was awake, but non-verbal. There were large square heel protectors on both feet and both feet were facing up towards the ceiling, not to the right. Although R195's upper body appeared slightly turned towards the right, the lower body was more supine. At 9:26 a.m. a nursing assistant (NA-M) entered the room and closed the door. When the surveyor entered the room R195 had been repositioned. NA-M stated she checked R195's incontinent product and repositioned her. A body pillow was "tucked" under R195's upper right side down below the lower buttocks; however, R195 was not on her left side and positioned off the coccyx area. NA-M stated R195 had last been repositioned at 7:38 a.m. and required every two hour repositioning. At 10:15 a.m. on 3/18/2011, the surveyor and a Registered nurse (RN-D) observed R195's positioning in bed with NA-M present. R195's hip/buttocks area was slightly lifted to the right side with a body pillow "tucked" underneath. Both feet now had braces on them, and were facing the ceiling. When checked for pressure relief the coccyx was off the mattress approximately one inch and directly resting on the tucked pillow. The RN stated it was very hard to position R195 because she was so stiff and verified pressure was not totally relieved from the coccyx area. RN-D stated OT was working with her positioning. RN-D confirmed R195's lower torso was resting partly on the pillow and partly on the bed mattress. When questioned as to if that was how R195 was usually positioned in the bed NA-M stated, "usually the pillow was pushed a little farther under the buttocks." At 10:44 a.m. on 3/18/2011, a dressing change of R195's stage IV pressure ulcer was observed with the Licensed Practical Nurse (LPN-A) and NA- M. There was a moderate amount of serosanguinous drainage noted on the old dressing. The pressure ulcer was located directly on the bony prominence of the coccyx and was observed to be slightly larger than the size of a quarter, deep, with bone exposed in the center of the ulcer. There was redness noted in the skin approximately one inch out and around the pressure ulcer. At 3:45 p.m. on 3/18/2011, RNM-C was interviewed in regard to R195's positioning and stage IV coccyx pressure ulcer. RNM-C reviewed the chart with the surveyor and stated the following: On 10/13/2010, a pressure reducing mattress was placed in R195's bed due to a 3x1 cm pink, blanchable area on the coccyx. Barrier cream was applied, and R195 was repositioned every two hours. From 10/17/2010 -10/22/2010, R195 was hospitalized and was assessed to have a pink 2 x 2cm blanchable area on the coccyx upon return which was not open. RNM-C stated she could not locate an evaluation of tissue tolerance at that time. On 11/17/2010, a non-blanchable stage I coccyx ulcer was identified. The ulcer described as (3 clustered areas 1cm x 0.4cm. 0.8 x 0.4cm, 0.3 x 0.3cm). On 11/20/2010, an alternating air mattress was applied on the bed. RNM-C confirmed no tissue tolerance evaluation was completed. On 11/22/2010, an Allevyn dressing was started on the coccyx, and R195 was still getting up in the w/c twice a day for two hours, and repositioned in bed every two hours. On 12/7/2010, R195 was out for two appointments "for 4+ hours up in w/c." On 12/8/2010, during the weekly check, the area was noted to increase in size 3cm x 0.8cm. Therapy was notified for a possible new w/c cushion. A ROHO was given for the w/c. The coccyx ulcer was a stage II at that time and had drainage. RNM-C verified no tissue tolerance evaluation was completed to determine if the cushioning was effective. On 12/13/2010-12/17/2010, R195 was hospitalized . RNM-C stated the assessment on R195's return dated 12/18/2010, noted a stage II pressure ulcer on the sacral area 4cm in size. On 12/22/2010, started PEMF treatments twice a day x 30 minutes. Used blue chucks instead of a thin sheet. Limited time up in the w/c to 1 hour twice a day, and changed to only side to side repositioning in bed every two hours. Again there was no tissue tolerance evaluation to determine if the interventions were appropriate. On 1/1/2011, noted another 2cm x 2cm superficial open area caused by the dressing removal right next to the coccyx. On 1/4/2011, the coccyx ulcer decreased in size 2.6 x 0.2cm. On 1/11/2011, RNM-C stated the skin assessment indicated a tissue tolerance in bed showed R195 could tolerate every two hour repositioning. RNM-C verified a tissue tolerance was not completed in the wheelchair. On 1/20/2011, the wound nurse indicated the coccyx ulcer had increased in size and was now unstageable due to slough covering. 3cm x1.2cm .7 [MEDICAL CONDITION]. A new treatment was started. On 1/25/2011, dietary started R195 on zinc and vitamin C to promote wound healing. RNM-C stated the second open area by the coccyx was resolved by 2/1/2011; however, the coccyx ulcer increased in size to 3.2 x 1.6cm and was still unstageable. R195 was still getting up in w/c twice a day for one hour, and was changed to every two hour positioning in bed side to side only. A wound culture was completed on 2/13/2011, due to a decline in the pressure ulcer after R195 had been at a medical appointment in the w/c for >2 hours. The culture was positive. On 2/15/2011, the wound nurse recommended continued current treatment and limit time up in w/c. Turning every 2 hours. On 2/17/2011, the Physician ordered R195 be transported to appointments via a stretcher, and a plastic surgery consult was ordered. On 2/23/2011, R195 had a plastic surgery consult. Continued current treatment. Still unstageable, changed R195 to being up in the w/c twice a day for 1 hour and every 2 hour side to side repositioning in bed. On 2/25/2011, limited to 1 hour daily up in the chair. On 3/2/2011, undermining was noted 0.7cm. from 12 to 5 and 10 to 11. Some maceration on base of wound. 2.9cm x 2.0cm On 3/7/2011, there was decline in the coccyx pressure ulcer and the physician was notified. An increase in drainage and odor was expected. On 3/15/2011, no soft tissue was left in the stage 4 pressure ulcer. The physician was notified. On 3/17/2011, the plastic surgeon ordered complete pressure relief. R195 not getting up in the w/c anymore. RNM-C stated she would be consulting therapy regarding bed positioning. Although numerous interventions were implemented to address the emergence and progression of R195's pressure ulcer, there was no assessment to determine appropriate repositioning needs. In addition, most interventions were implemented after the pressure ulcer had developed. At 2:00 p.m. on 3/21/2011, the DON verified all residents who are at risk for pressure ulcers should be checked for tissue tolerance as part of the comprehensive assessment. At 2:35 p.m. on 3/21/2011, the RNM-C stated she was not able to locate any further information regarding any further tissue tolerance evaluation for R195. The facility's Skin Assessment and Care policy dated as reviewed/revised August 2009, directed staff "Within 14 days after admission, a comprehensive skin assessment is completed." An "evaluation of the skin integrity and tissue tolerance" was directed as a component in the comprehensive skin assessment. The policy further indicated a comprehensive assessment would be completed on at least an annual basis, and a registered nurse must complete a skin assessment if a new pressure ulcer develops. "The assessment must include a review of the residents tissue tolerance to pressure. "

Based on observation, interview and record review the facility failed investigate and initiate appropriate interventions related to burns from hot packs for 2 of 2 residents (R76, R26) in the sample known to use hot packs; failed to assess the safety for use of an electric heating pad for 1 resident in the sample (R164) observed to use a heating pad; failed to supervise 1 of 3 residents (R164) to prevent frostbite when smoking outdoors in the winter; failed to provide assessment related to multiple falls for 3 of 3 residents (R130, R124, R109) reviewed for falls; and failed to ensure safe smoking areas were provided for 2 of 3 residents (R26, R164) observed to smoke outside. R76 sustained actual harm with a burn from a hot pack on 10/30/2010 and R164 sustained actual harm with frost bite on the toes of both feet on 1/17/2011. In addition, the outdoor smoking area had a large space between the sidewalk and the patio blocks with loose sand. Burns R76 sustained actual harm when a hot pack caused a burn. According to the incident report (IR) dated 10/30/2010, R76 had multiple open and intact blisters on the right knee following the hot pack treatment. The care plan dated 1/13/2006, indicated R76 had impaired decision making with short and long term memory loss. The mobility care plan dated 1/17/2006, indicated R76 had an alteration in mobility related to erratic involuntary movements due to Huntington's disease and used a wheelchair for all mobility. The IR dated 10/30/2010, indicated R76 had multiple open and intact blisters on the right knee. R76 stated a heating pack was applied by a nursing assistant the night before. R76 stated he knew the hot pack was too hot but did not ask the nursing assistant who was present to remove it. R76 had nine open, measurable areas with multiple water blisters in between them. R76 rated his pain a 10 out of 10. The on call physician was notified at 7:30 p.m. on 10/30/2010, and ordered bacitracin ointment and a Telfa (non stick) dressing to the area. The physician discontinued the heating pad and instructed staff to monitor the heating pad temperatures closer in the future. The post incident analysis was completed by registered nurse (RN)-G on 10/31/2010. The RN analysis indicated a hot pack was placed on R76's right knee during the night by a nursing assistant. The hot pack was too hot and resulted in multiple blisters requiring medical treatment. R76 stated he knew the hot pack was too hot but did not remove it or call for assistance. The post incident analysis did not indicate that vulnerable adult internal investigation and reporting procedures were initiated. The director of nursing (DON) signed the IR on 11/3/2010. The form was not signed by the administrator or the medical director. The blisters and open areas on R76's right knee were described as follows: Anterior knee- top of knee cap, 1 by 1 centimeter (cm) intact blister, 1 by 1.2 cm open area with clear fluid and a scab forming, 0.6 by 0.9 cm intact blister. Anterior knee, below and to the right of the knee cap, 0.9 by 0.9 cm open area with clear fluid and a scab forming. Anterior knee, below the knee cap, 1.9 by 1.1 cm open area with clear fluid and a scab forming. Anterior knee on the left inside, 4.6 by 3.1 cm open area with a red center, with clear fluid and the edges starting to scab, 2.8 by 2 cm open area with a red center with clear fluid and the edges starting to scab. Left side, posterior, inner knee, 1.4 by 1 cm intact, formed scab, 2.8 by 1.8 cm open area with clear fluid and a scab forming. The investigation dated 11/1/2010, indicated R76 received a burn to the right knee from a heating pack applied by a nursing assistant (NA). The NA made a hot pack out of wash cloths and carried it with bare hands into R76's room where it was placed on R76's right knee. R76 stated he knew it was too hot but did not remove it or ask for assistance. R76 had no sensory impairment to the lower extremities that would inhibit the ability to feel pain and was capable of communicating pain. The on call physician was notified the ordered the hot pack discontinued. Verbal education was given to staff to not use heating devices when the temperature could not be monitored. There was no documentation in regard to the hot pack policy or if the NA had been provided direction prior to the incident. At 3:05 p.m. 3/21/2011, the DON stated there was no vulnerable adult (VA) internal investigation and reporting procedure completed and the incident was not reported to the administrator or to the state agency. A staff communication form dated 12/1/2010, (30 days after the burn) and signed by the DON, informed staff that an Aqua "K" pad was the only sanctioned application of heat than could be provided by nursing because it had a temperature control that could be set and locked. Nursing was not to use any device that was micro waved, hot water heated or hot packs. No electric heating pads. K pads only if necessary. Therapy was the only department that could apply heat. The documentation did not indicate why a hot pack was used instead of an Aqua K pad. Smoking supervision R164 was assisted to smoke outside in extreme cold winter weather without appropriate protection for her feet. This resulted in actual harm with frost bite on the toes of both feet. Interdisciplinary Progress Notes (IPN) at 3:38 p.m. on 1/16/2011, stated, "...staff noted toes of both feet to be discolored." The note indicated R164 did not wear any covering on her toes when going out to smoke in the cold weather. There was no description of the toes and no further nursing assessment of the frostbitten toes. At 2:44 p.m. on 3/18/2011, the Nurse Practitioner (NP) stated she saw R164 out at the smoking area inappropriately dressed and assessed the frostbite on the day it was identified, "It was one of the worst cases of frostbite, no cap (capillary) refill and very brown in color...that's why I ordered the wound consult." R164's [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], indicated R164 was cognitively intact, required extensive assistance with most Activities of Daily Living (ADL's) and was independent with wheelchair locomotion both on and off the unit. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/25/2011, identified the resident demonstrated poor decision making "...as evidenced by refusals of care." The ADL Functional/Rehabilitation CAA dated 10/25/2010, identified R164 had functional limitations to bilateral upper and lower extremities and, "contractures to upper extremities with loss of fine motor skills." The Psychosocial Well-Being CAA dated 10/25/2010, further indicated, "(R164) smokes multiple times a day and is safe to smoke but does have to request someone to light (the) initial cigarette." The quarterly MDS dated [DATE], identified no functional changes for R164. The Smoking assessment dated [DATE], indicated R164 was independent with smoking after needed staff assistance to light the first cigarette. The care plan dated 1/11/2011, identified R164 was resistive to cares and refused showers, appointments, therapy, tube feedings, medications, treatments, range of motion, repositioning and other ADL's. The 1/20/2011, smoking care plan identified, "Smoker: at risk for possible injury. Resident smokes independently after someone lights her cigarette for her. Unable to use lighter d/t (due to) disability." The smoking care plan further identified the goal of "Resident will remain free from injury while smoking independently" and directed to complete the smoking assessment quarterly, monitor behaviors when smoking, for example, "are they giving others smokes (cigarettes) that should not have (them)," and remind the resident of designated smoking areas. A hand written update on 2/3/2011 (after the frostbite) indicated, "Resident refuses to wear appropriate covering on feet when out in cold weather," and directed, "Staff to assist with covering feet with sock (thick) after getting up in w/c (wheelchair) prior to going outside. Document refusals per policy and notify nurse." There was no evidence that R164 was reassessed for safe smoking. The incident was not investigated to determine potential maltreatment and the injury was not reported to the state agency. At approximately 1:00 p.m. on 3/18/2011, the Director of Nursing (DON) verified the incident was not investigated to determine potential maltreatment and was not reported to the administrator or to the state agency. R26 received a burn after a hot pack was applied on 8/17/2010. The mobility care plan dated 1/20/2011, indicated R26 had an alteration in mobility related to a below knee amputation and impaired range of motion/voluntary movement and was able to communicate her needs. The IR dated 8/17/2010, indicated R26 had a possible burn to the neck from a heat pack. The skin was intact and no blisters were present. R26 denied pain and indicated she did not know she was burned until the NA discovered the area. A cold compress was applied. Interventions implemented to prevent further incidents consisted of checking the temperature of the heat pack before placing it on the resident. The post incident analysis dated 8/17/2010, indicated burn was related a hot pack applied for pain from rheumatoid arthritis and R26 had impaired mobility, impaired range of motion, and voluntary movement. The analysis indicated R26 had a slight reddened area on the left side of the neck and a small area on the back. The post incident analysis indicated the facility did initiate a vulnerable adult (VA) internal investigation or reporting procedure. On 8/18/2010, the DON signed the post incident analysis. The post incident analysis was not signed by the administrator or the medical director. A notation dated 8/18/2010, at the bottom of the post incident analysis, indicated staff was educated on the temperature of the hot packs and to check frequently for skin changes. At 2:30 p.m. on 3/21/2011, the registered nurse manager (RNM)-D stated the hot pack that burned R26 was made from a wash cloth placed in a plastic bag. The RN could not remember who applied the hot pack; however, the hot pack procedure was changed to Aqua K pads (water temperature controlled heating pad) only. NA-L, interviewed at 10:56 a.m. on 3/21/2011, stated they were not allowed to apply hot packs or ice. NA-L would report a resident request for heat or ice to the licensed nurse. At 11:00 a.m. on 3/21/2011, NA-M stated the licensed nurse applies heat or cold packs. R164 was not assessed for potential safety risks associated with independent use of an electric heating pad. R164's [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], indicated R164 was cognitively intact, required extensive assistance with most Activities of Daily Living (ADL's) and was independent with wheelchair locomotion both on and off the unit. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/25/2011, identified R164 demonstrated poor decision making skills "at times as evidenced by refusals of care." The ADL Functional/Rehabilitation CAA identified R164 had functional limitations to both sides of upper and lower extremities and, "Contractures to upper extremities with loss of fine motor skills." The quarterly MDS dated [DATE], identified no functional changes for R164. The "Functional/Safety Assessment" dated 10/15/2011, indicated R164 had no communication, visual or hearing problems; R164 required assistance with ADL's and also identified the presence of hand contractures. The assessment indicated the resident may need a restorative program for range of motion and the resident was working with Occupational Therapy (OT) and Physical Therapy (PT) for "deep muscle massage, hand therapy and chiropractor." Review of the Interdisciplinary Progress Notes (IPN) for 12:06 p.m. on 1/6/2011 indicated, "Did note electric heating pad in room and discussed risks associated with use. (R164) stated (that they do not) want it taken away and discussed with clinical NM (nurse manager)." A Functional/Safety Assessment review dated 1/11/2011, recapitulated the information from the previous safety assessment and indicated the resident was noncompliant with cares and treatments. The review did not address the use or the potential risks associated with the use of the electric heating pad. Review of R164 care plan indicated the ongoing use of the electric heating pad was not identified or addressed in the plan of care. At 8:17 p.m. on 3/15/2011, R164 was observed using an electric heating pad on the left hand. R164 stated, "I signed a waiver so that I could use this. I have my mind yet, I know what I'm doing." The resident explained the electric heating pad was used on both hands to assist with treating discomfort associated with bilateral hand contractures. At 9:50 a.m. at 3/18/2011, the RN Manager-C (RNM-C) verified that the use of the electric heating pad was brought to her attention, "We had (the resident) sign a 'risk benefit.' I offered a K-pad and informed (the resident they) needed to discontinue the use of the electric heating pad." RNM-C stated the electric heating pad was a potential for injury and the facility did not use them. RNM-C confirmed she was aware R164 used the electric heating pad "continuously." RNM-C stated facility staff "can't place it on or turn it on" for the resident. RNM-C further stated, "We do weekly skin checks to ensure (R164) is safe. We assess any problems and report to MD as needed. Has had no burn or injury or skin changes related to the electric heating pad." A copy of the signed "waiver"/risk benefit was requested multiple times throughout the survey and was not provided. The RN Manager-E, (RNM-E), (present during the interview with RNM-C) at 10:05 a.m. on 3/18/2011, stated the facility nurses do a "head to toe assessment weekly, if they identify an issue, then we document the issue on the skin assessment form and then monitor it." RNM-E stated R164 was "able to put it (electric heating pad) on independently" and that there "may not be an immediate response" if the resident was injured from the heating pad. RNM-E also stated, "There is special needs charting to check her hands for cleaning and would then identify if there was an issue with the heating pad. Both RNM-C and RNM-E both confirmed the electric heating pad was neither assessed, nor care planned at 10:05 a.m. on 3/18/2011. A copy of a memo from the Director of Nursing (DON) to the nursing staff dated 12/1/2010 indicated, "Applying heat is an intervention. An Aqua "K pad" is the only sanctioned application of heat that can be provided by nursing because it has a temperature control that can be set and locked. Nursing cannot use any device that is microwaved, hot water heated or hot packs. No electric hating pads. K pad only if necessary. Therapy is the only department that can apply heat. If you have any questions please ask your nurse manager." R130 had multiple falls without appropriate assessment and interventions to reduce the risk of injury from additional falls. R130 experienced 7 falls between 10/8/2010, and 3/2/2011, and did not have interventions to reduce the risk of subsequent falls. R130 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R130 was observed at 9:15 am on 3/18/2011, seated in the wheel chair in his room. A personal alarm was attached to his wheel chair and the call light was within reach. A pressure alarm was on his bed which was equipped with positioning rails and a concave mattress. R130 had a seat belt on the wheel chair, although it was not fastened. The IR at 11:00 pm on 10/8/2010, indicated R130 was found on the floor near his bed without an alarm sounding to alert the staff. Interventions implemented to prevent further incidents were, "continue with current care plan. Remind staff to check for alarms and make sure they are working." The Post Fall analysis indicated no changes were needed to the care plan, nor was there an Vulnerable Adult internal investigation to determine the cause of the fall even if staff needed reminding to check alarms and assure they are functional. The IR at 2:00 am 10/18/2010, indicated [REDACTED]. Although an alarm was attached it was not functional and ultimately replaced. No further information provided as to the cause of the faulty alarm. The IR at 8:10 pm on 12/5/2010, indicated R130 was found sitting on the floor with alarms sounding. R130 was reminded to use the call light when trying to transfer, and "placed lift sheet centered on bed with alarm attached." The post fall analysis stated that no changes to the care plan were needed and that R130 was at risk of falls related to impaired safety awareness, dementia and past and present history of falls. At 10:00 pm on 12/10/2010, R130 was found kneeling next to his bed with the alarms sounding. The intervention to prevent further falls and the post fall analysis stated "remind resident to use call light (for assistance)." At 9:40 pm on 12/11/2010, the IR stated that R130 was found lying on his bed, face down with the chair alarm sounding. A Personal Body Alarm (PBA) was applied to the chair because "pressure alarm in chair was not very loud." R130 was reminded to use the call light and wait for assistance with transfers. At 10:15 pm on 12/27/2010, R130 was found on the floor near his bed without alarms sounding. Interventions implemented were, "educate on call light use." Care Plan updates were "not needed." R130 experienced another fall on 3/2/2011, at 2:00 am and was found on the floor with the alarm sounding. R130 was educated to use the call light and wait for assistance. The post fall analysis indicated no change in the current care plan. The Functional/Safety assessment dated [DATE] identified R130 at risk for falls related to self transfer attempts, "impaired cognition, making alerting staff for assistance challenging." A Fall Risk assessment dated [DATE] established R130 was at high risk for falls with a score of 80 (High Risk 45 and higher) related to weakness, dementia and forgetting his limitations. The Functional/Safety assessment dated [DATE], noted R130's bed was moved against the wall and the use of a body pillow was initiated on 2/4/2011. A Fall Risk assessment dated [DATE] indicated R130 was at high risk for falls with a score of 65 (High Risk 45 and higher) with multiple risk factors for falls including forgetting to use the call light, self transfer attempts and impulsivity. R130's care plan dated 2/2011 indicated "alteration in cognition related to short term memory deficits, impaired decision making skills due to dementia." Interventions included, "explain all procedures using simple directions, repeat as necessary." R130 was also determined to have an alteration in mobility with a wheel chair to all destinations and staff assist to all destinations. R130's Falls care plan dated 5/22/2010, (reviewed 2/11) stated he was, "at risk due to poor safety judgements, past and present fall history, decreased strength in standing balance independently." "Remind resident of call light use before leaving room and to use it when needing staff assist," and "educate resident not to stand or ambulate without assistance until safe - and to call for assistance if falling." The DON was interviewed on 3/17/2010 at 3:05 pm and stated that more appropriate interventions should have been put into place for R130 after the second fall on 10/18/2010. She said that reminding the resident to use his call light and ask for assistance did not work. R124 sustained multiple falls without assessment to determine appropriate interventions to reduce the risk of additional falls. R124 was admitted on [DATE], and had [DIAGNOSES REDACTED]. The IR dated 11/5/2010, established R124 was found on the floor near his bed after removing the Personal Body Alarm (PBA). R124 hit his head in the fall and was sent to the ER for staples to approximate a head laceration. "Interventions to prevent further incidents" stated "Sent to ER." The Post Incident Analysis noted the fall was related to "impaired cognition, judgement/safety awareness deficit, impaired mobility and balance." There was no Vulnerable Adult internal investigation although R124 had a history of [REDACTED]. No interventions were implemented to reduce the risk of another fall. The IR at 6:00 am on 11/21/2010, R124 was found sitting on the floor with the alarms sounding. Interventions were described as, "instructed/educated ... on importance of call light usage." The Post Incident Analysis noted the fall was related to Parkinsonism, medications, "impaired cognition, judgement/safety awareness deficit," and "impaired mobility and balance, incontinence." A second fall on 11/21/2010 occurred at 11:30 am. Again, the PBA was sounding and R124 was found next to his bed with blood on the floor, his face and forehead, as a result of a 1.5 cm abrasion. R124 was encouraged to call for help with using the bathroom and "continue with plan of care." The urinalysis and culture was ordered (negative), orthostatic blood pressures for 3 days, and a physical therapy (PT) evaluation were ordered. The PT evaluation, completed on 11/24/2010, noted that R124 needed the assist of one staff for transfers. No new interventions were implemented. R124 reported to staff that he fell on [DATE] at 3:30 pm. R124 was sitting in the wheelchair and had a jagged 5 cm skin tear to the right outer elbow. The injury was treated, the alarms were changed to pressure pad on the bed and chair, and the bed was placed against the wall. Another urinalysis was collected on 12/1/2010, that was positive and he was treated with an antibiotic. The IR at 11:30 pm on 1/3/2011, indicated R124 walked into another resident room after using the bathroom, fell on the floor and was found between a Hoyer lift and a dresser. There were no injuries. The IR stated the fall, "Happened because he did not have assistance to bathroom. Disoriented to ask for help." The IR stated R124 was interviewable but did not indicate what R124 said at the time. The intervention: "was told to ask for help to the bathroom. to use call light and await for assistance." Every 2 hour toileting was added to 24 hour report. R124 was observed at 9:30 am on 3/18/2011, attending an activity in the second floor dining room in his wheel chair. There was a personal alarm attached to his wheel chair. The wheelchair also had auto brakes and anti back tip bars. At 9:28 am a personal alarm was observed on R124's bed. The Fall Risk assessment dated [DATE], determined R124 scored 80 (high risk was 45 and higher) because of impulsiveness, self transfers and his history of falls. A Self Releasing Device assessment dated [DATE] for the use of a seat belt was completed. Nursing notes dated 3/2/2011 noted R124 requested the seat belt for comfort and feelings of safety, although the notes stated it was due to bipolar disease, anxiety disorder and dementia. R124's fall Care Area Assessment Notes (CAAs), dated 3/11/2011, indicated a history of falls, use of an antipsychotic and cardiovascular medications. It stated R124 needed assistance with all mobility, had a history of [REDACTED]. R124 had "numerous mental health issues with resultant decision making impairment and cognitive impairments... He has impaired safety judgement." It added that R124 was not always aware of of his need for assist with mobility for safety or of potentially unsafe situations. The Care Plan dated March 2011, stated R124 was at risk for falls due to impaired mobility and cognition, psychotropic and cardiovascular medication, decreased safety judgement, history of falls and lowering self to floor. R124 was noted to have an unsteady gait secondary to Parkinson's disease, hypertension and dementia. Staff were directed to assist with all transfers, remind R124 not to stand or ambulate without assistance until safe - and to call for assistance. When interviewed on 3/18/2011 at 3:02 pm, the DON stated the care plan should have been updated, "certainly by the second fall." She acknowledged that reminding and educating R124 on the use of the call light was not an appropriate or effective fall intervention, given his [DIAGNOSES REDACTED]. R109 had 13 falls from the bed from 10/29/2010, to 3/10/2011, and was not re-assessed after the falls to determine potential causal factors of the falls in an attempt to prevent further falls and develop appropriate interventions. R109's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R109 had a Brief Interview for Mental Status (BIMS) score of 12 (a score of 8 to 12 suggests moderate cognitive impairment). The MDS indicated R109 required the extensive assistance of one staff with bed mobility, transferring, toilet use, and ambulation in her room; was frequently incontinent of bladder; and had a fall within one month prior to admission. The MDS further identified R109 had one fall with a minor injury since the previous assessment. The falls Care Area Assessment (CAA) dated 7/13/2010, indicated R109 was at risk for falls due to a history of falls, falls within the last six months, and antidepressant medication. The CAA identified left leg weakness, past CVA's, unsteady gait, a past healed hip fracture, and "chooses not to use her call light for staff assist and will attempt self transfer putting herself at high risk for falls." The falls care plan dated January 2011, indicated R109 was at risk for falls due to impaired mobility, impaired cognition, psychotropic medications, history of falls, past CVA's, unsteady gait, and attempts to self transfer. Interventions in the bed included pressure pad in bed; motion sensor at the foot of the bed; alarm on bathroom door; keep w/c (wheelchair) at bedside and keep bedside stand close to resident within reach to avoid resident having to reach to grab items; low bed; no grab bars; toilet per plan of care (every two hours); lipped mattress in bed to define parameters; call light within reach and remind to use; and trial commode at bedside (started 2/10/2011). At 8:18 a.m. on 3/17/2011, R109 was observed in the main dining room with an alarmed seat belt on, and a pressure alarm on the wheelchair (w/c). R109 also had anti rollbacks on the wheelchair. At 8:30 a.m. a modified concave mattress, a pressure alarm , and a sensor alarm was noted on the bed. The bed was in low position. The floor in the room was carpeted and a commode was at the bedside. At approximately 2:00 p.m. on 3/17/2011, R109 was observed to wheel herself into the bathroom by the nurses desk. The alarm sounded and the RN Manager (RNM-C) entered the bathroom. R109 had released her w/c seatbelt and was in the process of transferring herself from the w/c onto the toilet. The brakes were on the w/c. Review of the Incident Reports for R109 from 10/29/2010, to 3/10/2011, were as follows: R109 had 12 falls from bed with 10 of the falls between 2:00 a.m. and 7:30 a.m. In three of the falls R109 sustained minor injuries (left knee abrasion/laceration twice, and had broken a front tooth with a lacerated lip once). On most occasions R109 was attempting to go to the bathroom. On 11/12/2010, and 2/18/2011, R109 was attempting to get a magazine that was out of reach. On both occasions she was educated on call light use, and the bedside stand was placed closer to the bed. On 12/9/2010, the record indicated the alarm was not on the bathroom door where it should have been, and on 11/9/2010, and 1/1/2011, an alarm did not sound so the batteries were replaced. Six of the falls interventions indicated R109 was educated to use the call light and ask for assistance with transferring. Although the facility implemented several physical devices to prevent falls, the medical records lacked any evidence an assessment was completed after the falls to determine the potential causal factors, or that the risk factors were further assessed for possible changes or additional risk factors. For the falls where the interventions were not in place, or the alarms were not functioning properly, there was no evidence the falls were further investigated so further interventions could be placed in an attempt to decrease the risk of future falls (such as staff education or device monitoring). In addition, R109's physical needs were not assessed to determine other potential causes for the falls such as hunger, thirst, or possibly more frequent toileting needs. At 10:44 a.m. on 3/18/2011, the DON verified R109 lacked assessments after the falls, and stated some of the interventions did not make sense such as educating to use the call light as R109 rarely used the call light. According to the facility's "Fall prevention" policy reviewed/revised 3/2009, a "Post Fall Analysis" would be completed within 24 hours by an RN after each fall and any change in interventions would be noted on the residents care plan. Environment The floor surface inside the smoking shelter was uneven with an open area of exposed soft sand, creating a potential trip hazard for ambulatory residents and a tip hazard for wheelchair bound residents. At approximately 3:30 p.m. on 3/17/2011, R164 was observed to be leaving the smoking shelter in the electric motorized wheelchair. R164 stated "did you see the sand trap in there (smoking shelter)? There is only room for one wheelchair in there and the wheelchair gets stuck in the sand." A large rectangular area with loose, soft sand between the sidewalk and patio blocks on the ground of the smoking shelter was observed (smoking shelter was built to partially extend over the side walk and over the ground). At 9:48 a.m. 3/18/2011, R164 was observed near the smoking shelter, R164 again stated that they "did not like the smoking shelter" because "only my wheelchair will fit" and there was a "sand trap" in the middle. The soft, loose sand remained exposed between the concrete of the side walk and the patio blocks. At 10:30 a.m. on 3/21/2011, the uneven soft, loose exposed sand area on the floor of the shelter was measured to be 12 inches wide by 72 inches long. To the left of the area was the concrete side walk and to there right of the area were 2 rows of square concrete patio blocks placed in the ground. The sand area was soft and giving when stepped on and there was an approximate 1 1/2 inch depression from the surface of the patio blocks to the sand. At 11:15 a.m., the Administrator confirmed there should have been patio blocks in the area of the soft sand. "We had to put sand down and didn't put replacement patio blocks in place" The Administrator stated there "had not been patio blocks in place" for that area previously. The Administrator confirmed the loose and soft sand was a potential tripping/tipping hazard for resident safety. R26, interviewed at 2:09 p.m. on 3/15/2011, stated that staff take her outside to smoke at the end of the Beach Walk West hall. R26 stated she stays outside for about 10 minutes and then the staff come and get her. One time the staff forgot her and she was left outside for about a half an hour. R26 indicated it was in the summer and not too cold or too hot out. R26 indicated she could not access the doorbell and there was no handicap door opener to open the door. The smoking care plan dated 11/6/2009, indicated R26 was an independent smoker at risk for possible injury. The care plan directed staff to do a smoking assessment quarterly, monitor for burn