Every finding on record at Bennett Hills Rehabilitation and Care Center

Based on record review, review of the State Agency's Long-Term Care Reporting Portal, staff interviews, and review of the facility policies, the facility failed to ensure residents were free from accidents. This was true for 1 of 2 residents (Resident #8) reviewed for transportation. This failure caused injury for this resident. Findings include:The facility's Transportation Policy/Procedure policy revision date 12/30/25, documented Loading Passengers - insert the four tie down mechanisms to the fixture on the floor. Make certain that they are secured, and locked in. The facility's Fleet Safety Program manual revision date 4/14/21, documented employees are expected to operate vehicles safely to prevent accidents which may result in injuries and property loss. Resident #8 was initially admitted to the facility 11/21/25, and readmitted [DATE], with multiple diagnoses including dependence on renal dialysis and diabetes. On 4/28/26 at 3:00 PM, reviewed the facility's investigation. Based on the facility's investigation:-on 12/27/25 at 8:12 AM, Resident #8 fell backwards in his wheelchair, hitting his head and back on the back door of the facility van while being transported back from his dialysis treatment. Resident #8 reported pain in his neck after the fall.- Resident #8 was sent to the hospital for evaluation.-on 12/27/25, the facility van was inspected by the Maintenance Supervisor and no issues or concerns were found. The facility determined the incident had occurred because the straps had not been connected correctly to Resident #8's wheelchair and had come loose during the transport resulting in his wheelchair falling backwards.The facility's investigation substantiated the failure to prevent injury to a resident when the van driver did not secure the resident's wheelchair properly before transporting him. On 4/28/26 at 3:54 PM, the Administrator stated she (the Driver) did not latch the front wheels of Resident #8's wheelchair and she should have. These findings represent past non-compliance with this regulatory requirement. The facility did the following:The resident was immediately taken to the emergency room for evaluation. The resident's wheelchair and the facility van continued to be inspected throughout the week. No issues noted. Van inspections completed for the 2014 van on 9/30/25, 10/31/25, 11/30/25, 12/31/25, 1/31/26, 2/27/26, and 3/31/26. No issues noted. Van inspection completed for the 2021 van on 9/30/25, 10/31/25, 11/30/25, 12/31/25, 1/31/26, 2/27/26, and 3/31/26. Issue noted = cracked windshield. Facility staff and other residents interviewed, and no issues noted. A laminated pre-departure checklist created, completed, and placed in each van on 1/2/26. A new competency completed with transportation employees on 12/30/25 - 1/2/26. Competency audits were done weekly for 4 weeks, then monthly for 4 months starting 1/5/26. After the completion of the monthly competency, competency tests will be done quarterly. The facility's Transportation policy was revised 1/2/26 and updated the post incident response to policy (if injury call facility or 911, don't handle situation yourself). The resident continued to be monitored for psychosocial harm and latent injuries until 1/2/26. No psychosocial harm or latent injuries noted. The incident, van inspections, and staff competencies will be reviewed by QAPI. Staff were In-service regarding proper communication and proper action post incident occurring with transport team completed 1/2/26. There was sufficient evidence the facility corrected the non-compliance as of 1/2/26, as there was no further resident accidents involving transportion in the facility van after this date. At the time of the survey, the facility was in substantial compliance and therefore does not require a plan of correction.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all residents who resided in the facility whose environment were observed. This deficient practice created the potential for harm if residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, or undignified or residents were injured due to unsafe areas in the facility. Findings include: The facility's Safe, Homelike Environment policy, dated October 2007, documented the facility would provide a safe, clean, comfortable, and homelike environment.The following areas were observed:On 4/27/26 and 4/28/26 - observed South Hall shower with: - moderate amount of strands of black hair in the shower drain - broken tiles with jagged edged holes in shower stall tiles - cracks in multiple shower tiles - dark residue matter in the shower tile grout. - multiple small round holes in shower stall walls On 4/28/26 at 3:58 PM, the Maintenance Supervisor stated he was concerned about a trip hazard and should fix the tiles. On 4/29/26 at 6:58 AM, observed resident room [ROOM NUMBER]-A with the resident's prior night's dinner tray with dishes and a full bowl of vegetables sitting on his bed. On 4/29/26 at 9:17 AM, observed the East Hall shower room with multiple missing floor tiles and dark black residue debris between shower floor tiles. On 4/29/26 at 9:27 AM, observed North Hall shower room with missing tiles on the floor at the door frame and in the middle of the shower room floor. The shower drain with a half dollar size brown formed matter and moderate amount of dark strands of hair in the drain. On 4/27/26 at 10:50 AM, observed in room [ROOM NUMBER]-A: - two metal bars sticking out of the wall to the left of the commode. - the inside side of bathroom door was missing approximately 3 X 2 piece of wood, by the hinges. - the vent in the bathroom had a thick gray substance. On 4/27/26 at 11:17 AM, the Maintenance Supervisor stated the brackets were missing the roll of toilet paper and he should have cleaned the vents and fixed the door. On 4/27/26 11:23 AM, observed room [ROOM NUMBER] with a hole on the outside of the bathroom door. On 4/27/26 at 3:50 PM, observed in room [ROOM NUMBER]: - to the left of the bed, two holes each approximately 3- 4 in size. - observed the door to the bathroom had been removed. On 4/27/26 at 3:57 PM, Resident #49 (room [ROOM NUMBER]) stated the holes in the wall were there when she moved into the room and there has not been a door into the bathroom since she moved in. On 4/28/26 at 12:05 PM, observed in the dining room: - a thick, gray substance on the vent by the television. - thick, long cobwebs on the ceiling by the dividing beam. On 4/28/26 at 12:25 PM, observed the vents on the east hall ceiling with a gray substance. On 4/29/26 at 11:04 AM, the Maintenance Supervisor stated the vents should have been cleaned, the toilet paper holder had been fixed but came off again, and room [ROOM NUMBER]'s bathroom should have had a door on it. On 4/29/26 at 11:22 AM, the Administrator stated the dining room ceiling and vents should have been cleaned by housekeeping staff and had not been. On 4/29/26 at 11:41 AM, observed the kitchen ceiling, pipes, and the vents with a thick, gray, fuzzy substance. On 4/29/26 at 11:42 AM, the DM stated the kitchen did have a cleaning schedule, but it did not include the ceiling, vents or pipes. She also stated it was the Maintenance Supervisor job to clean that area.

Based on record review and staff interview, it was determined the facility failed to refer residents for further mental health evaluation when residents stayed beyond a 30 day exemption for 1 of 1 resident (Resident #7) and the facility failed to request a Level II Pre-admission Screening and Resident Review (PASARR) for 2 of 3 residents (#10 and #38) reviewed for PASARR screenings. This failure created the potential for harm if residents required but did not receive specialized services for mental health while residing in the facility. Findings include:Resident #7 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including right femur fracture and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior).On [DATE] at 9:20 AM, Resident #7's Level II PASRR dated [DATE], documented a 30-day exemption rehabilitation, directing staff that if he stayed beyond 30 days, the facility must submit the most current MDS, MD orders, social notes and psych notes to BLTC. Resident #7's medication record had no documentation any additional information had been submitted to BLTC after the 30-day extension expired. Resident #10 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (progressive lung disease characterized by increasing breathlessness) and Bipolar II disorder.On [DATE] at 9:10 AM, Resident #10's Level I PASRR completed on [DATE], noted bipolar disorder with an onset date of [DATE], but the facility had not requested a Level II PASRR.Resident #38 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and dementia.On [DATE] at 3:38 PM, Resident #38's Level I PASRR dated [DATE], documented depressive and anxiety disorders with delusional disorder and REM Sleep behavior disorder, and the following medications, Haldol and Depakote. Based on the documented diagnoses and medications, the facility requested a Level II PASRR.The Level II PASRR dated [DATE], for Resident #38 documented under comments, participant has depression, anxiety, delusional disorder, and REM sleep behavior disorder; medications prescribed for mental health were Haldol and Valproic Acid/Depakote.Resident #38's diagnoses in her medical record had not listed depressive and anxiety disorders, delusional disorder or REM Sleep behavior disorder.Resident #38's physician orders for current and discontinued medications had not documented Haldol or Valproic Acid/Depakote as being prescribed for the resident. On [DATE] at 2:33 PM, the DON stated the documented information in Resident #38's Level I PASRR was incorrect and should have been corrected but had not been.On [DATE] at 8:43 AM, the DON stated additional information should have been submitted to mental health for Resident #7 and a Level II PASRR should have been requested for Resident #10 and had not been.

Based on observation, resident and staff interview, and record review, it was determined the facility failed to ensure professional standards of practice were followed for 2 of 2 Residents (#7 and #26) reviewed for quality of care. This failed practice had the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practices. Findings include: Resident #7 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including right femur fracture and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior). On 4/28/26 at 2:49 PM, observed an albuterol and fluticasone inhaler in Resident #7's room on his bedside table. Resident #7 stated the nurses gave it to him and let him keep it in the room because they sometimes cannot make it down to his room quick enough. On 4/28/26 at 3:35 PM, Resident #7's medical record had no documentation that a physician had ordered an inhaler medication. On 4/28/26 at 3:40 PM, Resident #7's medical record had not documented that a self-administration assessment had been completed for the inhaler medication. On 4/29/26 at 4:30 PM, the DON stated Resident #7 should not have the inhaler in his room because there was no order for it. Resident #26 was admitted to the facility on [DATE], with multiple diagnoses including acute embolism and thrombosis of left popliteal vein (blood clot) and depression. On 4/27/26 at 11:34 AM, observed Resident #26's Sage boots (pressure prevention) were lying in the chair next to the resident's bed. On 4/27/26 at 11:38 AM, LPN #1 stated Resident #26 should have been wearing the Sage boots but had not been. On 4/27/26 at 12:08 PM, Resident #26's medical record documented physician order dated 4/6/26, Sage boots to bilateral feet at all times, document refusals. On 4/27/26 at 12:17 PM, Resident #26's medical record had not documented resident's refusal of Sage boots for 4/27/26. On 4/29/26 at 1:47 PM, the DON stated Resident #26 should have been wearing the Sage boots but had not been.

Based on observation, staff interview, record review, and policy review it was determined the facility failed to ensure medications were properly stored, locked, and controlled medications were stored and kept secure from potential theft and/or diversion. This was true for 2 of 17 Residents (#18 and #26) and the facility. These deficient practices created the potential for adverse effects if residents self-administered medications inappropriately, undetected misuse of medications and/or diversion of controlled medications and had the potential to affect all residents who receive medication in the facility. Findings include: The facility's Self Administration of Medications policy, revision date 05/2023, documented; Procedures 2. If a resident desires to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status. 9. Appropriate notations of these determinations will be placed in the resident's care plan. The facility's Controlled Medications - Storage and Reconciliation policy, revision date 3/2025, documented; It is the policy of this facility to safeguard access and storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse using separately locked, permanently affixed compartments. The State Operations Manual, Appendix PP, updated 7/23/25, Schedule II-IV medications must be maintained in separately locked, permanently affixed compartments. Resident #26 was admitted to the facility on [DATE], with multiple diagnoses including acute embolism and thrombosis of left popliteal vein (blood clot) and depression. On 4/27/26 at 11:36 AM, observed one tube of zinc oxide on Resident #26's overbed table and one tube of antifungal cream on Resident #26's bedside table. On 4/27/26 at 11:37 AM, Resident #26 stated staff had left the tubes of medicine in his room and he could not apply the cream independently by himself. On 4/27/26 at 11:51 AM, Resident #26's medical record had not documented an Interdisciplinary Team (IDT) assessment for self-administration of medications. On 4/27/26 at 11:52 AM, Resident #26's medical record had not documented a physician order to leave medication at the bedside. On 4/28/26 at 3:07 PM, RCN stated Resident #26 should not have had the zinc oxide and antifungal medications left at his bedside. The following was observed for controlled medications. On 4/29/26 at 8:10 AM, observed two clear plastic cups each containing one bottle of Lorazepam nasal spray (Schedule IV controlled medication) stored on the medication refrigerator shelf. On 4/29/26 at 8:21 AM, the DON stated the Lorazepam had not been stored in an affixed box but should have been. Resident #18 was initially admitted to the facility on [DATE], and readmitted [DATE], with multiple diagnoses including congestive heart failure (a chronic condition where the heart cannot pump blood efficiently enough to meet the body's needs) and diabetes. On 4/27/26 at 10:31 AM, observed on Resident #18's bedside table a tube of Biofreeze (topical pain reliever). On 4/27/26 at 10:45 AM, Resident #18 stated she uses the Biofreeze cream on her left knee but could not apply it herself, the staff apply it for her. On 4/27/26 at 10:58 AM, a record review of Resident #18's medical record did not document an order for the Biofreeze cream. On 4/27/26 at 11:39 AM, the ADON stated Resident #18 did not have an order or care plan for the Biofreeze cream, her family must have brought it in On 4/27/26 at 9:40 AM, observed the north hall medication cart had been left unattended, unlocked, and one medication drawer was left pulled open. On 4/27/26 at 10:46 AM, the DON stated the medication cart should not have been left unlocked with a drawer open unattended.

Based on record review, staff interview, and policy review it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include: The facility's Controlled Medications - Storage and Reconciliation policy, revision date 03.2025 documented. Procedure 8. A reconciliation or physical inventory of all controlled medications is conducted by two licensed nurses and is documented on an audit record at each shift change. On 4/29/26 at 7:59 AM, observed during the East Hall medication cart audit, the Narcotic Audit Shift Count sheets, with start date 2/14/26, and start date 4/1/26, with 1 licensed nurse signature not documented on 2/15/26 for 0600 count, on 2/15/26 for 1800 count, and on 4/6/26 for 0630 count. On 4/29/26 at 8:04 AM, LPN #3 stated two nurses should have signed the Narcotic Audit Shift Count sheet and had not. On 4/29/26 at 10:16 AM, the DON stated two nurses should have signed the Narcotic Audit Count sheets when they accepted the medication cart or released the medication cart and had not.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure a resident's call light was within reach for 1 of 17 residents (Resident #45) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention. Findings include: Resident #45 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease and chronic atrial fibrillation (irregular heart rate). On 4/29/26 at 7:51 AM, observed Resident #45 lying in bed with his call light plugged into the wall and hanging down the wall and under the head of his bed and not within his reach. Resident #45 unable to independently reach call light. On 4/29/26 at 7:53 AM, RN #1 stated Resident #45's call light should be within reach and had not been. On 4/29/26 at 3:48 PM, the RCN stated residents' call light should have been within reach and had not been.

Based on record review and staff interview, it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a major mental illness, intellectual disability, or a related condition. This was true for 1 of 3 residents (Resident #7) reviewed for Level II PASARR evaluations. This deficient practice had the potential to cause harm if resident's specialized services for mental health needs were not evaluated by an appropriate state-designated authority. Findings include: Resident #7 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including right femur fracture and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior).Resident #7's Level I PASRR dated 3/23/26 had not documented the schizophrenia disorder diagnosis with an onset date 3/21/22.On 4/30/26 at 8:45 AM, the DON stated the schizophrenia diagnosis for Resident #7 should have been documented on the Level I PASRR and had not been.

Based on record review and staff interview, it was determined the facility failed to ensure residents' care plans were developed or revised to reflect current needs and interventions. This was true for 2 of 6 residents (#10 and #38) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being developed or revised as residents' needs changed. Findings include:Resident #10 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (progressive lung disease characterized by increasing breathlessness) and Bipolar II disorder.On 4/27/26 at 1:56 PM, Resident #10's care plan dated 3/25/26 to 6/23/26, had the following interventions missing.- At risk for impaired cognitive function/dementia or impaired thought processes. Date Initiated: 3/25/26- ADL Self Care Performance Deficit. Date Initiated: 3/25/26- At risk for falls r/t (SPECIFY) Date Initiated: 3/25/26- Has nutritional problem or potential nutritional problem (SPECIFY) r/t Date Initiated: 3/25/26- Has pressure ulcer or potential for pressure ulcer development (SPECIFY location) r/t Date Initiated: 3/25/26- Has acute/chronic pain (SPECIFY) r/t Date Initiated: 3/25/26Resident #10's prior care plan dated 6/3/24 to 4/5/26, had either resolved or cancelled for every issue noted and ongoing issues were not carried forward to the newest care plan.Resident #38 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and dementia.Resident #38's care plan was initially started on 2/11/26 and signed off on 2/19/26, 15 days after she was admitted on [DATE].On 4/30/26 at 8:42 AM, the DON stated Resident #10 and Resident #38's care plans should have been completed in a timely manner and had not been.

Based on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 2 of 5 residents (#7 and #9) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels. Findings include: Resident #7 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including right femur fracture and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior). On 4/27/26 at 11:25 AM, observed Resident #7's oxygen concentrator was set at 4 lpm, was turned on, and he was not using it during our visit. Resident #7 stated he only uses it at night or when he thinks he needs it during the day. Resident #7's physician oxygen order dated 3/23/26, documented oxygen continuously at 3 lpm via NC, every shift. On 4/29/26 at 4:39 PM, the DON stated Resident #7 should be using his oxygen at 3 lpm as ordered and was not. On 4/29/26 at 6:58 AM, observed during his medication pass Resident #7 sitting in his wheelchair in his room not wearing his oxygen. On 4/29/26 at 7:03 AM, observed LPN #2 ask Resident #7 why he was not wearing his oxygen and Resident #7 stated he had not needed it. On 4/29/26 at 7:04 AM, LPN #2 stated, Resident #7 should have been using his oxygen but had not been. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (a disease process which causes decreased ability of the lungs to function) and respiratory failure. On 4/27/26 at 10:28 AM and 4/28/26 at 2:27 PM, observed Resident #9 wearing his oxygen nasal cannula and the oxygen concentrator set at 2.5 L/min. On 4/28/26 at 2:31 PM, Resident #9's medical record documented a physician order dated 3/25/26, Oxygen continuously at 4 L via n/c every shift. On 4/28/26 at 2:49 PM, CNA #1stated Resident #9's oxygen had been set to 2.5 L/min and should have been set at 4 L/min via n/c. On 4/28/26 at 3:03 PM, the RCN stated Resident #9's oxygen had not been set at 4 L/min via n/c as ordered and should have been.

Based on observation, record review, and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 6 of 17 residents (#3, #14, #16, #47, #52, and #108) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in their care plan. Findings include: The facility's Comprehensive Person-Centered Care Planning policy, revised December 2023, documented the resident's care plan would include their needs and any specialized services. The following was observed for care plan review: 1. Resident #3 was admitted to the facility 2/13/25, with multiple diagnoses including respiratory failure and hypertension. Resident #3's Physician order dated 3/8/25, documented she was a full code. Resident #3's care plan did not document her code status. 2. Resident #14 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including sacral spina bifida with hydrocephalus (a condition where the spinal cord does not close properly during development and excess fluid builds up in the brain) and major depressive disorder. Resident #14's Physician order dated 12/17/24, documented she was a DNR, do not attempt resuscitation. Resident #14's care plan had not contained any information related to her resuscitation code status. 3. Resident #16 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including diabetes and chronic obstructive pulmonary disease (a group of lung diseases that cause progressive and irreversible airflow obstruction, leading to breathing difficulties). Resident #16 Physician order dated 4/16/24, documented she was a DNR with limited additional interventions, Yes to IV fluids, Yes to ABX, No to feeding tube, No to blood products. Resident #16's care plan had not contained information related to her resuscitation code status. 4. Resident #47 was admitted [DATE], with multiple diagnoses including heart failure and dementia. Resident #47's Physician order dated 3/18/25, documented her code status was DNR with selective treatment: Yes, to IV fluids, Yes to antibiotics, No feeding tube, and No blood products. Resident #47's care plan did not document her code status. 5. Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including pneumonia and hypertension. Resident #52's physician order dated 2/14/25, documented his code status was DNR-No to blood and feeding tube, Yes to IV fluids and ABX. Resident #52's care plan did not document his code status. 6. Resident #108 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves) and dementia. Resident #108's Physician order dated 3/7/25, documented her code status was Full Code. Resident #108's care plan did not document her code status. On 3/19/25 at 3:12 PM, the DON stated the resident's code status had not been documented in their care plans and it should have been. 51121

Based on observation and interview, the facility failed to provide a safe, clean, homelike environment. This failure had the potential to impact all residents, by placing them at risk for injury and infections. Findings include: On 3/19/25 at 11:17 AM, observed in room [ROOM NUMBER] with CMA #1 present, the sharps container was filled past the full line. On 3/19/25 at 11:28 AM, CMA #1 stated the sharps container should have been changed when it was full. On 3/19/25 at 1:48 PM, observed with the DON present, overfilled sharps container with multiple used razors poking out of the opening, in the south hall shower room and fuzzy black mold-like substance on the shower tiles. On 3/19/25 at 1:53 PM, observed with the DON present, overfilled sharps container with multiple used razors poking out of the opening, in the north skilled hall shower room and fuzzy black mold-like substance by ceiling vent. On 3/19/25 at 3:18 PM, the Maintenance Supervisor stated he felt the black stuff on and next to the shower ceiling vent was mold, but he was not too sure about the black on the tiles in the other shower room. On 3/20/25 at 8:51 AM, the DON stated the facility does not have a policy for housekeeping, cleaning, showers, or sharps containers but the showers should have been cleaned after each use but were not and the sharps containers should have been changed when full. 49552

Based on review of the State Operations Manual-Appendix PP, the Resident Assessment Instrument (RAI), record review, and staff interview, it was determined the facility failed to ensure a resident's diagnosed medical condition was documented on the resident's comprehensive MDS assessment. This was true for 1 of 7 residents, (Resident #9) whose MDS assessments were reviewed. This failure created the potential for harm if care decisions were based upon inaccurate or lack of information. Findings include: The State Operations Manual, Appendix PP, revised 8/8/24, documented a facility must make a comprehensive assessment using the RAI specified by CMS and include active disease diagnoses and health conditions. The RAI, revised October 2024, documented diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period, needed to be coded in section I, Active Diagnosis. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including renal failure (when kidneys cannot filter waste products from the blood), diabetes, and hyponatremia (when the sodium level in the blood is too low). Resident #9's care plan updated 2/27/25, documented she had the potential for a psychosocial well-being problem related to a recent cancer diagnosis. Resident #9's comprehensive MDS assessment dated [DATE], had not documented she had a diagnosis of cancer. On 3/19/25 at 3:15 PM, the DON and MDS Resource Nurse stated the MDS did not document Resident #9's diagnosis of cancer and should have.

Based on review of the State Operations Manual, Appendix PP, policy review, employee record review, and staff interview, it was determined the facility failed to ensure policies were implemented to protect residents from potential physical and/or psychosocial harm. This was true for 1 of 6 facility staff (NA #1), whose personnel files were reviewed for pre-employment background checks. This had the potential to place each of the residents residing in the facility at increased risk for physical and/or psychosocial harm. Findings include: The State Operations Manual, Appendix PP revised 8/8/24, documented, a facility must have written procedures for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. The facility's Abuse: Prevention of and Prohibition Against policy revised December 2023, documented prior to hire, the facility will screen potential employees for history of abuse, neglect, exploitation, or misappropriation of resident property. On 6/13/24, NA #1 was hired by the facility. On 3/19/25, a review of NA #1's personnel file had not documented a pre-employment background check was completed. On 3/20/25, the Administrator stated he could not find where NA #1 had a completed background check. On 3/21/25 at 7:44 AM, the Administrator provided a copy of NA #1's background check dated 12/6/24, 6 months after hire date.

Based on observation and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and stored appropriately, this was true for 2 of 2 medication carts audited for labeling and storage of medication. This failure created the potential for residents to have missed doses of medication. Findings include: On 3/19/25 at 8:05 AM, the East Hall medication cart was audited with CMA #1 present. Observed on the bottom of the third drawer; 1 oval shaped white tablet, 1 small round white tablet, 1 large oblong white tablet. On 3/19/25 at 8:13 AM, CMA #1 stated the pills should not have been loose in the medication cart. On 3/19/25 at 9:34 AM, the Skilled Hall medication cart was audited with LPN #1 present. Observed on the bottom of the third drawer; 2 small, round white pills. On 3/19/25 at 9:42 AM, LPN #1 stated the pills should not have been loose in the medication cart and should have been destroyed. On 3/19/25 at 2:20 PM, the DON stated the nurses or medication aides should have destroyed the loose pills.

Based on observation and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include: The State Operation Manual, Appendix PP revised on 8/8/24, documented the facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. On 3/20/25 at 11:47 AM, a review of the posted nursing staff hours dated October 2024 - March 2025 was conducted with the following results. - On 10/18/24, the posted nurse staff hours was blank. - On 1/9/25, the posted nurse staff hours was blank. On 3/20/25 at 12:15 PM, the Administrator stated all the posted nursing hours should have been completed.

Based on observation, staff interview, and review of the Idaho Food Code, the facility failed to appropriately store and label food products, and cover meal trays correctly. This failure had the potential to impact all residents in the facility. This placed residents at risk for use of spoiled foods, and potential contamination, and adverse health outcomes including food-borne illnesses. Findings include: The Idaho Food Code, revised February 2021, stated, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded . 1. The following were related to labeling and storage of food products: On 3/17/25 at 9:51 AM, the following was observed in the dry food storage area, with the DS present: - Dry pasta, open date 10/9/24, should have been disposed on 3/9/25. - Barley dry food, use by date of 12/24. - Ragu pasta sauce use by date of 3/13/25. - Three #10 size cans of Bountiful Harvest Foundations pineapple tidbits and beans with no received date. On 3/17/25 at 9:58 AM, the DS stated the #10 cans should have been marked with a received date and the dry food items and refrigerator items should have been removed and disposed. On 3/17/25 at 11:44 AM, the following was observed in the resident dining room during the lunch meal: - Soy sauce bottle given to resident to use on her plate of food, had no use by dates on bottle. On 3/17/25 at 11:49 AM, The DS stated the bottle of soy sauce should have had a use by date. On 3/20/25 at 12:33 PM, the following was observed in the resident refrigerator, with a CNA #4 present: - A container of salsa with white fuzzy substance growing on the inside of the container. On 3/20/25 at 12:35 PM, the CNA #4 stated the salsa should have been discarded. 2. On 3/17/25 at 12:15 PM, the following was observed during the meal delivery to residents' rooms: - Observed CNA #1 take the meal trays from the food cart and delivered them down the hall to room [ROOM NUMBER], #36, #40, and #42 without covers on the bread or dessert. On 3/17/25 at 12:18 PM, CNA #1 stated the food should have been covered. On 3/20/25 at 12:30 PM, the DS stated the food is supposed to be taken from the food cart directly to the resident's room. The food should have been covered if it is going down the hall. 49552

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure resident's rights to be free from abuse were protected. This was true for 1 of 1 resident (Resident #36) reviewed for abuse. This failure placed all residents at risk for ongoing abuse and potential physical and psychosocial harm. Findings include: The facility's Abuse: Prevention of and Prohibition Against policy revision date December 2023, documented it was the policy of the facility that each resident had the right to be free from abuse, neglect, misappropriate of resident property, exploitation, and mistreatment. Resident #36 was admitted to the facility on [DATE], with the multiple diagnoses including dementia and cognitive communication deficit. A facility reported incident dated 12/20/24 documented the following: - CNA #3 heard CNA #2 verbally abusing Resident #36. - CNA #3 immediately told CNA #2 to leave Resident #36's room. - The Administrator was notified and CNA #2 was suspended pending investigation. - Resident #36 was assessed for physical and psychosocial harm. No harm noted. - Other residents were interviewed, and no abuse was reported. - Staff were in-serviced on abuse. - CNA #2 was terminated on 12/23/24. This finding represents past noncompliance with this regulatory requirement. There is sufficient evidence the facility corrected the noncompliance on 12/23/24.

Based on observation, record review, policy review, and staff interview, the facility failed to ensure the dish machine was monitored adequately in accordance with the manufacturer's specifications for temperature and sanitizer concentration; sanitizing solutions for wiping kitchen surfaces and for pot washing were adequate in sanitizer concentration; and foods in the residents' refrigerator on the nursing unit were labeled and dated in the facility's kitchen. These deficiencies placed the 52 residents residing in the facility who received meals from the kitchen at risk for food borne illness. Findings include: The facility provided the undated Idaho Food Code, [Chapter 4], Idaho Department of Health & Welfare, Division of Public Health when the request for their kitchen sanitation policy was made. Review of the Idaho Food Code stated under 4-501 Warewashing [process of cleaning and sanitizing kitchen items] Machines, Manufacturers' Operating Instructions, A warewashing machine [commercial dishwasher] and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions . Under 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization . stated, A quaternary ammonium compound solution shall: . have a concentration . as indicated by the manufacturer's use directions included in the labeling . The Manual Dishwashing Three Compartment procedure, undated, provided by the facility, stated chlorine solution should be mixed to a concentration of 100 parts per million (PPM). The facility's Food Brought in for Patients/Residents policy, undated, stated Purpose To ensure the safe consumption of food brought in to patients/residents .Storing Food Brought in that Requires Refrigeration: .Food items that require refrigeration must be labeled with patient's/resident's name and date the food was brought in . Food must be stored in a closed container to prevent contamination . 1. On 5/13/24 from 10:53 AM through 11:30 AM, The initial tour of the kitchen was conducted with the DM. The DM stated all kitchen equipment was working properly. During the tour the following concerns were observed: a. The manufacturer's data plate affixed to the dish machine stated the minimum wash and rinse temperatures were 120 degrees Fahrenheit (F). The machine used a chemical sanitizer by Ecolab named Ultra San, utilizing sodium hypochlorite (chlorine bleach) as the sanitizer with a requirement to be mixed between 50 - 100 PPM. The Dish Machine Log for March 2023, April 2023, and May 2023, documented none of the rinse temperatures, measured three times a day, met the minimum temperature of 120 degrees F. The rinse temperatures ranged from 36 degrees F to 90 degrees F. Most of the rinse temperatures were in the 70s and 80s. The column for measuring PPM of the chemical sanitizer was blank (not measured) on all the logs. The form stated, If temperature or chemical concentration does not meet parameters, stop washing and alert a manager or designee. b. During observation, the sanitizer solution for kitchen surfaces was in a spray bottle; the sanitizing agent was quaternary ammonia. The DM tested the concentration of the sanitizing solution in the spray bottle using a quaternary ammonia test strip; the test strip did not change color indicating minimal/no sanitizer was present. The DM stated the solution should have been mixed to a concentration of between 200 - 400 PPM. The DM verified the lack of sanitizer in the spray bottle. She stated the procedure for use was to spray the solution on surfaces and let it evaporate. c. The refrigerator at the nursing station for storing residents' personal food was observed. The refrigerator was full of food. In the front were two partially consumed McDonald's shakes in plastic cups with lids. There was no label with the residents' names or dates noted on the shakes. In addition, there were two open cardboard containers of french fries that were not covered, and without a label with residents' names or dates. There was a Styrofoam cup with a lid with what looked like refried beans without a label with the resident's name or dates. The DM verified the refrigerator needed to be cleaned out and verified the lack of labels on the foods observed. 2. During a follow up kitchen observation on 5/15/24 from 9:12 AM through 9:48 AM, the following concerns were noted: a. Cook #1 was washing pots in the three-sink pot washing sink. Cook #1 verified the sanitizer was Eco lab Multi Quat, with quaternary ammonia as the sanitizer. The sanitizer solution was checked for concentration by Cook #1 using a quaternary ammonia test strip. The color of the test strip barely changed color, reading close to zero PPM and less than the next level on the legend of 150 PPM, which was verified by Cook #1. Cook #1 then checked the concentration of the sanitizer in the spray bottle for sanitizing kitchen surfaces and it also barely changed color, reading close to zero PPM which was verified by Cook #1. Cook #1 stated she mixed both sanitizers (in the sink and spray bottle) around 6:00 AM. Cook #1 added more sanitizer to both solutions and retested them and the levels came up to 200 PPM. Cook #1 stated the PPM should have been at least 200 PPM. b. Observation of the commercial dishwasher use was conducted. The wash temperatures were adequate; however, the temperature gauge showed the rinse temperature was 74 degrees F during observation of two dishwashing cycles. The DM stated she was not aware the rinse temperature had to be 120 degrees F and verified all the rinse temperatures on the current log for May 2024, were below 120 degrees F. The DM was asked about the sanitizer concentration and the column on the log that was consistently blank for sanitizer level. The DM verified the log was not filled out for sanitizer levels and stated she did not know the sanitizer should have been checked and recorded on the log. The DM stated the required sanitizer level for the chlorine sanitizer Ultra San should have been between 50 - 100 PPM. During an interview on 5/16/24 at 4:41 PM, the Maintenance Director stated he was not notified, but should have been, regarding the low rinse temperatures recorded on the Dish Machine Log. The Maintenance Director verified the dish machine functioned as a low temperature, chemical sanitizing machine and the sanitizer levels should have been checked. During an interview on 5/17/24 at 10:06 AM, the RD was informed of the dish machine rinse temperature levels according to the gauge and stated the rinse temperatures were too low and stated the concentration of the sanitizer should have been monitored since it was a low temperature, chemical sanitizing machine. The RD stated dietary staff should have notified maintenance or the manufacturer about the low rinse temperature. The RD stated the sanitizer solutions for wiping kitchen surfaces and in the pot washing sink should have been at the correct level and should have been tested to ensure they were at the correct level.

Based on review of the job description for the Certified Dietary Manager (CDM) and staff interview, it was determined the facility failed to ensure there was a qualified Dietary Manager with required competencies and skills. This had the potential to affect the meal/food satisfaction of all 52 residents residing in the facility who received food from the kitchen. Findings include: The Dietary Supervisor (Dietary Manager) Job Description provided by the facility documented the individual was responsible for directing the overall operation of the dietary department. The DM was to ensure that quality nutritional services were provided, and the dietary department was maintained in a clean, safe, and sanitary manner. Education and experience requirements include a minimum of two years' experience in a supervisory capacity in a hospital, skilled nursing care facility or other related medical facility. The Job Description stated if the DM was not a qualified Dietitian or Nutritional Professional, the individual must be a Certified Dietary Manager (CDM), Certified Food Service Manager or have a similar national certification; have an Associate's degree or higher in food service management or in hospitality or meet State requirements for food service managers or dietary managers in states that have established requirements. On 5/13/24 at 10:53 AM, the DM stated she had been in her position since January 2024. The DM stated she worked at the facility previously as a Cook and did not have experience as a DM prior to January 2024. The DM stated she planned to become a CDM, and the course was scheduled to begin in August 2024. The DM stated the RD came to the facility monthly and was available by phone. On 5/17/24 at 10:06 AM, the RD stated the DM was signed up to begin the CDM course in August 2024. The RD stated the course would take about six to eight months to complete. The RD stated the DM would not be fully qualified until the course was completed, which would be more than a year after she started in her position. On 5/17/24 at 1:02 PM, the Administrator stated the DM started her employment in January 2024; however, accepted the position as DM in February 2024. He stated the month of January 2024 was a trial period for the position. The Administrator stated there was a CDM course in January 2024; however, the DM missed the course due to being in her trial period. The Administrator stated the DM did not currently meet the educational or experience requirements or the certification requirements for the position.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when nursing staff did not perform proper hand hygiene during resident cares and properly put on their face mask and face shield during their shift. This was true for 2 of 7 residents (#8 and #10) observed during resident cares and 1 of 6 staff (LPN #2) observed for wearing PPE. These failures had the potential to impact all residents, staff, and visitors entering the facility by placing them at risk of infection due to cross contamination. Findings include: 1. The facility's Universal PPE (personal protective equipment) policy, updated 11/13/20, stated the facility planned to implement universal masking for employees and visitors while in the building. Universal masking meant the application and continual wearing of a standard ear-loop face mask and eye protection by all visitors and staff entering the building for the entire time they were in the building. The facility's Exposure Control Plan policy, revised June 2007, stated eating, drinking, applying cosmetics or lip balm and handling contact lenses were prohibited in work areas where there was occupational exposure. These policies were not followed: On 3/9/21 at 6:42 PM, two surveyors were outside the facility entrance door waiting to be screened for symptoms of COVID-19 before entering the facility. LPN #2 was inside the facility and was observed in front of the medication cart with no face mask or face shield on. When LPN #2 saw the surveyors, she walked to the nurse's station and put on a face mask and a face shield. At 6:48 PM, LPN #2 screened the surveyors before they entered the facility. LPN #2's face mask was positioned under her nose and her face shield was pushed backward over her head such so it covered the top of her nose and forehead. LPN #2 said she removed her face mask and face shield to have a bite of her dinner which was at the nurse's station. LPN #2 said staff were told to eat their food in the employees' Break Room. On 3/10/21 at 4:30 PM, the ADON said staff should eat their meals in the employees' Break Room or their offices and not at the nurse's station. The ADON also said she expected the staff to wear their face mask and face shield during their shift or while in the building. 2. The facility's Hand Hygiene policy, updated 10/7/20, directed staff to perform hand hygiene before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, after contact with resident's skin, and after removing gloves. This policy was not followed. On 3/11/21 at 11:10 AM, CNA #1 and CNA #2 performed hand hygiene, put on gloves and entered Resident #10's room with the Hoyer (mechanical) lift. CNA #1 then unfastened Resident #10's soiled incontinence brief, wiped her front with a cleansing wipe and then assisted Resident #10 to turn on her left side towards CNA #2. CNA #1 then wiped Resident #10's bottom, applied barrier cream to Resident #10's bottom, removed her gloves, performed hand hygiene and put on new gloves. CNA #1 did not change her gloves or perform hand hygiene before applying barrier cream to Resident #10's bottom. CNA #1 then rolled the soiled incontinence brief underneath Resident #10 and applied a new incontinence brief to her. CNA #2 assisted Resident #10 to roll on her right side, removed the soiled incontinence brief and threw it in the trash can. CNA #1 then pulled the new incontinence brief and both CNAs assisted Resident #10 to lie on her back and fastened the new incontinence brief. CNA #1 and CNA #2 then transferred Resident #10 to her wheelchair using the Hoyer lift. CNA #1 combed Resident #10's hair, pulled it together and tied it in a bun with her gloved hands while wearing the same gloves she had used when removing the soiled incontinence brief of Resident #10. CNA #1 then put a facemask on Resident #10 with the same gloves. CNA #1 and CNA #2 performed hand hygiene and moved to Resident #8's bed to assist Resident #8 to her wheelchair. CNA #2 unfastened Resident #8's soiled incontinence brief, wiped her front and assisted Resident #8 to turn to her right side towards CNA #1. CNA #2 then wiped Resident #8's bottom, rolled the soiled incontinence brief underneath Resident #8, and placed a new incontinence brief on. CNA #1 assisted Resident #8 to roll back to her left side. CNA #1 removed the soiled incontinence brief and threw it in the trash can. CNA #1 then assisted Resident #10 to lie on her back and CNA #2 fastened Resident #8's new incontinence brief. CNA #2 then placed Resident #8's booties on her feet. CNA #1 and CNA #2 assisted Resident #8 to her wheelchair. CNA #2 then combed Resident #8's hair, with her gloved hands and put a facemask on Resident #8. CNA #2 did not change her gloves or perform hand hygiene before she combed Resident #8's hair and before she placed a facemask onResident #8. On 3/11/21 at 11:35 AM, CNA #2 pushed the Hoyer lift to the storage room, locked the room and walked away. On 3/11/21 at 11:40 AM, CNA #2 said she did not change her gloves or perform hand hygiene before she combed Resident #8's hair. CNA #2 said she should have removed her gloves, performed hand hygiene and put on new gloves before she combed Resident #8's hair. On 3/11/21 at 11:48 AM, CNA #1 said she did not change her gloves or perform hand hygiene before she combed Resident #10's hair and before she put a facemask on her.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed to prevent the development and worsening of a wound. This was true for 4 of 5 residents (#1, #2, #6, and #8) reviewed for quality of care. This failure resulted in harm when Resident #8's pressure ulcer on her coccyx developed an infection and required her to take an antibiotic by injection and Resident #6 developed a blister on her right thigh. Findings include: The National Pressure Injury Advisory Panel website, accessed on 3/22/21, defined pressure ulcers as follows: Stage 1- Intact skin with a localized area of non-blanchable [CONDITION(S)] (red discoloration of skin as a result of injury) which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate a deep tissue pressure injury. Stage 2 - Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough (non-viable yellow, tan, gray, green, or brown tissue) and eschar (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 - Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) and tunneling (channels that extend from a wound into and through the tissue or muscle below) may occur. Fascia, muscle, tendon, ligament, cartilage or bone is not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 - Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable - Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed. Deep tissue pressure injury - Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The Potter and Perry Fundamentals of Nursing, tenth edition, page 1255, guidance to prevent pressure ulcer development included establishing and posting [documenting] an individualized turning schedule, and turn patient off at risk areas often, provide a pressure-redistribution surface, protect pressure points from medical devices such as oxygen tubing, feeding tubes and casts, clean the peri area with a no-rinse perineal cleanser and protect skin with a moisture-barrier ointment after each incontinent episode, and to keep skin dry and free of maceration (softening and break down of skin resulting from prolonged exposure to moisture). The facility's Skin Management System policy, revised 12/2019, documented: * Any resident who entered the facility without pressure ulcers had appropriate preventive measures to ensure the resident did not develop pressure ulcers, or residents admitted with wounds did not develop signs and symptoms of infection, unless the resident's condition made the development unavoidable. * Residents had a head to toe assessment by a licensed nurse at the time of admission. * A Braden Scale Assessment (evaluates patient's risk for developing a pressure ulcer) was completed on admission to identify residents at risk for skin breakdown. A score of 10 or above was considered high risk and had a plan of care developed to address elements of the assessment that put a resident at risk of breakdown. * A plan of care addressing the actual skin breakdown was developed to address areas of actual skin breakdown. The plan of care was reviewed and revised as needed. * Residents' head to toe assessment were done weekly. * CNA's completed a Body Shower Check sheet daily on every resident and turned it in to the charge nurse for possible follow-up of any new skin conditions. 1. Resident #8 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. An admission MDS assessment, dated 10/14/20, documented Resident #8 had severe cognitive impairment. The MDS assessment documented she required extensive assistance of one to two staff members for all cares. The MDS assessment also documented she had two unhealed Stage 3 pressure ulcers present upon admission and she had pressure reducing devices to her chair and bed. A potential impairment to Skin Integrity care plan, directed staff to place a pressure relieving/reducing cushion on Resident #8's chair to protect her skin while she was up in a chair and a pressure relieving/reducing mattress on her bed and to use caution when transferring her to prevent striking her arms, legs, and hands against any sharp or hard surface. These interventions were initiated on 6/3/20. Resident #8's care plan did not include a turning or repositioning program. A Pressure Ulcer care plan, directed staff to administer treatment to Resident #8 as ordered and monitor for effectiveness, assess/record/monitor her wound, measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, and report improvements and declines to the physician. These interventions were initiated on 10/28/20. A Bowel and Bladder incontinence care plan, directed staff to check Resident #8 as required for incontinence, wash, rinse and dry her perineum, and change her clothing after incontinence episodes. This intervention was initiated on 7/10/20. The care plan did not include how often Resident #8 would be checked and changed by the staff. The Skin Evaluation-PRN Weekly Report, dated 10/7/20, documented Resident #8 had a Stage 2 pressure ulcer on her coccyx which was first observed upon admission. A Skin Pressure Ulcer Weekly assessment, documented Resident #8 had a Stage 2 pressure injury on her coccyx first observed upon admission. The report documented the following measurements: * On 10/16/20 at 1:30 PM, the wound was documented as 1.1 cm 1.0 cm x 0.1 cm, with minimal drainage to the dressing and moderate odor. * On 10/23/21 at 4:17 PM, the wound was documented as 1.3 cm x 1.0 cm x 0.2 cm. The wound was not causing pain to Resident #8 at that time. * On 10/30/20 at 12:29 PM, the wound was documented as 1.3 cm x 0.7 cm x 0.2 cm. with scant serous discharge and slight odor. The wound was not causing pain to Resident #8 at that time. * On 11/6/20 at 9:22 AM, the wound was documented as 1.0 x 0.2 cm x 0.0 cm and with a small amount of serosanguinous (pale red or pink, thin, and watery) discharge. * On 11/13/20 at 10:26 AM, the wound was documented 1.2 cm x 0.2 cm x 0.0 cm with a small amount of serosanguinous discharge. It was cleansed and dressed per physician orders. * On 11/20/20 at 8:45 AM, the wound was documented as 1.0 cm x 0.5 cm x 0.2 cm with a scant amount of serosanguinous discharge. It was cleansed and dressed and no changes for treatment at that time. * On 11/26/20 at 5:44 PM, the wound was documented as 1.4 cm x 0.4 cm with a small amount of serous (clear to pale yellow) discharge. The wound was staged as Stage 3. It was cleansed and dressed per orders and the order was changed to use Exuderm ([MEDICATION(S)] wound dressing for wound with light exudate [discharge]) every two days. A nurse's note, dated 11/26/20 at 6:12 PM, documented Resident #8 received a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *On 12/11/20 at 2:21 PM, the wound was documented as measuring 0.8 cm x 0.3 cm x 0.1 cm with no discharge. The report documented the wound was staged as a Stage 2 pressure ulcer. * On 12/25/20 at 3:04 PM, the wound was documented as measuring 1.0 x 0.3 cm. It was cleansed and dressed per physician order. The wound was staged as a Stage 2 pressure ulcer. * On 1/1/21 at 12:35 PM, the wound was documented as 1.0 cm x 0.2 cm with a scant amount of serosanguinous discharge. The wound was staged as a Stage 3 pressure ulcer. * On 1/8/21 at 1:03 PM, the wound was documented as 1.0 cm x 0.1 cm with a small amount of serosanguinous discharge. The wound was staged as a Stage 3 pressure ulcer and the treatment was changed. Resident #8's Pressure Ulcer care plan was updated on 1/14/21, and directed staff to avoid positioning Resident #8 on her back, ensure to reposition her frequently from side to side, and to follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] * On 1/15/21 at 12:22 PM, the wound was documented as 1.0 cm x 0.2 cm with a small amount of serosanguinous discharge. It was cleansed and dressed per physician order. The wound was staged as a Stage 3 pressure ulcer. * On 1/22/21 at 2:04 PM, the wound was documented as 1.0 cm x 0.2 cm. The wound was cleansed and dressed. Resident #8 had no signs and symptoms of pain during treatment. The wound was staged as a Stage 2 pressure ulcer. A nurse's note, dated 1/22/21 at 2:10 PM, documented Resident #8's wound assessment on her coccyx dated 11/26/20, 1/1/21, 1/8/21, and 1/15/21 were incorrectly staged as a Stage 3 pressure ulcer. The note stated the wound was a Stage 2 pressure ulcer. A nurse's note, dated 1/29/21 at 11:45 AM, documented Resident #8's pressure wound on her coccyx remained open with a pink wound bed and a small amount of serosanguineous drainage. The wound was cleansed, hydrogel (a type of gel to treat wounds) was applied and it was covered with an [MEDICATION(S)] dressing. Resident #8's February 2021 MAR, directed staff to clean Resident #8's pressure ulcer on her coccyx with wound cleanser, apply skin prep (a liquid film-forming dressing that upon application to the skin forms a protective film to help reduce friction during removal of tape) to the surrounding skin, apply hydrogel and cover the area with an [MEDICATION(S)] dressing every three days during the day shift and PRN, ordered on 1/28/21. Resident #8's wound dressing was not changed on 2/6/21 as scheduled. A nurse's note, dated 2/2/21 at 6:00 PM, documented Resident #8 was provided wound care on her coccyx. A nurse's note, dated 2/12/21 at 2:58 PM, documented Resident #8's pressure wound on her coccyx remained open, had a pink wound bed with slough (dead tissue) and a small amount of serosanguineous drainage. The nurse's note documented Resident #8's wounds were healing without complications. A nurse's note, dated 2/19/21 at 5:53 PM, documented Resident #8's pressure wound on her coccyx was slightly worse, continued as a Stage 3 presure ulcer, measuring 1.8 cm x 1.0 cm x 0.7 cm with 30% friable (skin tissue that easily tears, fragments, or bleeds) granulation, and 70% necrotic/slough type tissue (able to visualize granulation under the necrotic tissue), there was moderate serosanguineous drainage and the surrounding tissue was inflamed and macerated (skin lighter in color and wrinkly in appearance which occurs when skin is in contact with moisture for too long) but there was no signs and symptoms of infection. The nurse's note documented the physician was notified and new wound orders were received. The note documented Resident #8's care plan was reviewed and updated. There was no update on Resident #8's care plan during this time. Resident #8's February 2021 MAR, directed staff to clean her Stage 3 pressure ulcer wound on her coccyx with wound cleanser, apply skin prep to the surrounding skin, and pack the wound with Alginate (type of wound dressing) and cover with [MEDICATION(S)] every day shift, ordered on 2/20/21. A nurse's note, dated 3/3/21 at 1:27 PM, documented Resident #8's Stage 3 pressure ulcer on her coccyx was cleansed with wound cleanser, skin prep was applied to the surrounding skin, the wound was packed with Alginate and covered with an [MEDICATION(S)] dressing. The nurse's note also documented Resident #8 felt pain during the dressing of her wound. A physician's progress note, dated 3/4/21, documented Resident #8 complained of greater pain with the wound dressing and there was a foul odor coming from her wound. The physician requested Resident #8's blood be drawn for a CBC (complete blood count) and a CMP (complete metabolic panel) and to culture (collect a sterile sample of drainage or tissue and test it for infection) Resident #8's wound bed. A nurse's note, dated 3/4/21 at 2:23 PM, documented a foul smell was noted upon removal of Resident #8's old dressing from her Stage 3 pressure ulcer on her coccyx and there was a yellow thick discharge. The wound was cleansed with wound cleanser, skin prep was applied to the surrounding skin, and the wound was packed with Alginate and covered with an [MEDICATION(S)] dressing. A physician's progress note, dated 3/8/21, documented Resident #8's wound culture result showed presence of Proteus mirabilis (bacteria causing wound infection) and E. coli (bacteria causing wound infection as a result of fecal contamination). A new order was received to administer [MEDICATION(S)] (an antibiotic) 1 mg IM (intramuscular) every 24 hours for five days and [MEDICATION(S)] (oral antibiotic) DS (double strength) two times a day for seven days to Resident #8. b. The Skin Evaluation-PRN Weekly Report, dated 10/7/20, documented Resident #8 had a Stage 3 pressure ulcer on her right heel which was first observed upon admission. A Skin Pressure Ulcer Weekly Assessment, documented the following: * On 10/16/20, the wound measured 0.5 cm x 0.5 cm * On 10/23/20, the wound measured 0.5 cm x 0.5 cm x 0.1 cm. * On 10/30/20, the wound was closed and the skin was dry and flaky. * On 11/6/20, the wound measured 0.8 cm x 0.7 cm. * On 11/13/20, the wound measured 0.5 cm x 0.7 cm. * On 11/20/20, 11/26/20, and 12/11/20, the wound measured 1.5 cm x 1.5 cm. * On 12/25/20, the wound measured 1 cm x 1 cm. * On 1/1/21, the wound measured 1 cm x 1 cm There was no further documentation of Resident #8's right heel wound noted in her record, c. Resident #8 developed a new skin impairments as follows: * Right Buttock A nurse's note, dated 11/13/20 at 8:46 AM, documented Resident #8 was provided wound care on her right buttock with [MEDICATION(S)] (an anti-microbial wound cleanser) and an [MEDICATION(S)] dressing was applied. A Skin Integrity Report, dated 11/20/20, documented Resident #8's wound on her right buttock was related to her incontinence and was closed. A Skin Integrity Report, dated 11/26/20, documented Resident #8's wound on her right buttock was closed. * Left Heel A Skin Evaluation-PRN Weekly Report, dated 3/5/21 at 8:29 PM, documented Resident #8 had a suspected deep tissue injury on her left heel. The report documented the area was red, non-blanchable with a dark area to the proximal portion of the wound. The wound measurement was as 2.0 cm x 2.3 cm. The report documented skin prep would be applied to her left heel every shift and her heels would be floated (positioned in such a way to remove all contact between the heels and the bed) as she allowed. A Change in Condition form, dated 3/5/21 at 3:24 PM, documented the nurse and Clinical Resource Nurse noted Resident #8 had a 2.0 cm x 2.5 cm deep tissue injury on her left lateral heel, with a dark area to the proximal portion of the non-blanchable area. The form documented the physician and Resident #8's representative were notified on the same day. Resident #8's care plan for her deep tissue injury on her left lateral heel, updated on 3/5/21, directed staff to administer treatment as ordered and to monitor for effectiveness of the treatment, float her heels, follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's progress note, dated 3/8/21, directed staff to cleanse Resident #8's left heel and apply skin prep to her left heel. On 3/9/21 at 10:05 AM, the ADON said Resident #8 had a pressure reducing device on her wheelchair and on her bed. When asked about Resident #8's positioning program, the ADON reviewed the care plan and said the care plan did not include Resident #8's positioning program. The ADON said the facility did not document how often Resident #8 was assisted with repositioning. On 3/9/21 at 2:27 PM, RN #1 said the facility did not have a Wound Nurse since August of 2020. RN #1 said wound assessment and wound dressings were completed by the nurse on duty. On 3/11/21 at 10:55 AM, the Clinical Resource Nurse said residents should be checked routinely and PRN. The Clinical Resource Nurse said residents' care plans should be resident specific and Resident #8's care plan should have indicated how often she should be checked. When asked about education provided to the nursing staff regarding residents' assessments, the Clinical Resource Nurse was unable to provide the documentation. 2. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment, dated 9/30/20, documented Resident #6 had a urinary catheter, Resident #6's Initial Nursing Assessment, dated 9/24/20, documented she had a urinary catheter and no skin problems on admission. Resident #6's care plan for [CONDITION(S)] Bladder, directed staff to position her urinary catheter bag and tubing below the level of her bladder and away from the entrance door [of her room], provide catheter care every shift and as needed, monitor for signs and symptoms of urinary discomfort and frequency, secure urinary catheter to facilitate flow of urine, prevent kinking of tubing, and accidental removal, and monitor/record/report to the physician signs and symptoms of a [CONDITION(S)] such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills and altered mental status. Resident #6's Potential Impairment to Skin Integrity care plan, directed staff to provide her with a pressure relieving/reducing cushion on her chair to protect her skin while up in a chair, and to provide her with a pressure relieving/reducing mattress to protect her skin while in bed. These interventions were initiated on 9/24/20. A Braden Scale for Predicting Pressure Sore Risk, dated 9/24/20, documented Resident #6 was at low risk of developing a pressure ulcer. A Change of Condition Evaluation form, dated 11/8/20 at 9:48 AM, documented Resident #6 had weeping [CONDITION(S)] on her posterior left thigh due to her scratching the area. A Change of Condition Evaluation form, dated 11/15/20 at 9:26 AM, documented Resident #6 had a 14.4 cm x 9 cm dry, red rash to her left lateral posterior thigh with no open area noted. The Change of Condition form documented the CNA noted on and off drainage from the area. The physician was notified and recommended to monitor the area for signs and symptoms of worsening. A Skin Ulcer Non-Pressure Weekly assessment, dated 11/20/20 at 9:08 AM, documented Resident #6 had a 14 cm x 9 cm red, dry blotchy area on her left lateral posterior thigh. A Skin Ulcer Non-Pressure Weekly assessment, dated 11/26/20 at 5:49 PM, documented Resident #6 had 14 cm x 6 cm red blotchy area on her left lateral posterior thigh which was first noted on 11/14/20. The area was cleansed and patted dry. A Skin Ulcer Non-Pressure Weekly assessment, dated 12/11/20 at 1:54 PM, documented Resident #6's red blotchy area on her left lateral thigh was resolved. A physician's progress note, dated 12/23/20, documented Resident #6 had excoriation on her left buttock and the physician directed staff to keep the area clean and dry, apply [MEDICATION(S)]-based barrier cream to the area twice a day with cleansing and PRN, and to turn the resident every 2 hours to offload her left hip. Resident #6's care plan was updated on 1/4/21 to include a Bowel and Bladder incontinence care plan, directing staff to check her as required for incontinence, wash, rinse and dry her perineum, and change her clothing PRN after incontinence episodes. A Skin Evaluation-PRN/Skin Weekly report, dated 2/14/21 at 6:47 AM, documented Resident #6 had no open areas or other skin issues noted. A Skin Evaluation-PRN/Weekly report, dated 2/17/21 at 2:31 PM, documented Resident #6 had a 0.5 cm x 13.5 Stage 2 pressure ulcer on her left rear thigh. A Change of Condition evaluation form, dated 2/17/21 at 12:09 PM, documented Resident #6 had a 0.5 cm x 13.5 cm Stage 2 pressure ulcer on her inner thigh related to her urinary catheter causing pressure between her thighs. The area was cleaned with wound cleanser, skin prep was applied and the pressure ulcer was covered with Exuderm (a dressing to absorb exudate). The form documented the physician and Resident #6's representative were notified of her change of condition on the same day. An IDT progress note, dated 2/17/21 at 12:09 PM, documented Resident #6 did not like her catheter tube to be repositioned. The progress note documented education was provided to Resident #6 regarding the necessity of repositioning her catheter tubing in order to prevent development of pressure area between her thighs. Resident #6 voiced understanding and allowed adjustment of the catheter. A physician order, dated 2/17/21 at 12:25 PM, directed staff to monitor Resident #6's wound on her left inner thigh every shift and to ensure her dressing remained intact and surrounding skin was free of signs and symptoms of inflammation. The physician also directed staff to cleanse Resident #6's wound with wound cleanser, apply skin prep to the surrounding tissue, allow to dry, and apply an Exuderm dressing to the wound every three days and PRN. Resident #6's Pressure Ulcer care plan, updated on 2/17/21, directed staff to administer treatment as ordered and monitor for effectiveness, assess/record/monitor her wound healing, measure length, width and depth where possible, assess and document status of the wound perimeter, wound bed and healing progress, report improvement and declines to the physician and follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's progress note, dated 2/18/21, documented Resident #6 had a blister on her left inner thigh which appeared to be related to her catheter insertion and it was moisture associated skin damage. The progress note also documented the physician ordered the catheter to be repositioned and secured to her right leg, the blistered area kept clean and dry, and covered with [MEDICATION(S)] (wound dressing). A nurse's note, dated 2/18/21 at 10:37 AM, documented Resident #6's urinary catheter came out with the balloon (an area of the catheter that is inflated to help prevent the catheter from sliding out of the body) still intact. The nurse's note also documented Resident #6's urinary catheter was changed with a 16 French (urinary catheter size) catheter. A nurse's note, dated 2/18/21 at 11:38 PM, documented Resident #6 pulled out her urinary catheter. The nurse's note documented the physician was notified and gave an order to discontinue Resident #6's urinary catheter. A nurse's note, dated 2/19/21 at 4:17 PM, documented Resident #6 had a 0.3 cm x 11 cm x 0.1 cm open area on her left upper thigh which appeared to be related to urinary catheter placement. The progress note also documented Resident #6's urinary catheter was discontinued. A Pressure Ulcer care plan, updated on 2/23/21, directed staff to ensure Resident #6's urinary catheter was frequently repositioned to protect her skin from the catheter tubing. A Skin Evaluation-PRN/Weekly report, dated 2/24/21 at 10:43 AM, documented Resident #6 had a blister like appearance on her left inner thigh. Resident #6's February MAR, directed staff to: * Cleanse her left upper thigh/buttocks excoriation with Vashe wound solution (used in cleansing, irrigating, moistening and [MEDICATION(S)] acute and chronic wounds), gently pat dry, and apply a [MEDICATION(S)]-based barrier cream to the affected area every shift and PRN, ordered on 12/24/20. * Reposition her frequently to offload her left hip and buttock, ordered on 12/24/20. * Keep the area to her left upper thigh/buttocks excoriation clean and dry every shift, ordered on 12/24/20. * Monitor the left upper thigh/buttocks excoriation for signs and symptoms of infection or worsening, and notify the provider immediately, ordered on 12/24/20. * Cleanse the wound with wound cleanser, apply skin prep to surrounding tissue, allow to dry, apply an Exuderm dressing to the wound every 3 days and PRN ordered on 2/17/21 A Skin Integrity report, dated 3/5/21, documented Resident #6's 0.7 cm x 2.0 cm and 0.1 cm Stage 2 pressure ulcer on her upper thigh had 100% granulation. On 3/10/21 at 11:54 AM, the Clinical Resource Nurse said she expected the staff to perform weekly skin checks on residents and during their showers. The Clinical Resource Nurse also stated Resident #6's urinary catheter should have been repositioned or the urinary catheter attachment should have been rotated. The Clinical Resource Nurse then reviewed Resident #6's care plan and said repositioning/rotating of Resident #6's urinary catheter attachment should have been in the care plan and it was not. When asked how often Resident #6 should be checked for incontinence episode, the Clinical Resource Nurse said residents should be checked at least every two hours and as necessary. The Clinical Resource Nurse said Resident #6's care plan did not indicate how often she should have been checked on and changed for incontinence and it should have been in her care plan. 3. Resident #1 was admitted to the to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Admission MDS, dated [DATE], documented she had severe cognitive impairment and was incontinent of bowel and bladder. Resident #1's care plan documented she had actual skin impairment on her rectal area related to fragile skin caused by moisture associated skin damage. The care plan directed staff to encourage good nutrition and hydration to promote healthier skin and follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 did not have a Bowel and Bladder care plan. A nurse's note, dated 8/16/20 at 10:59 PM, documented Resident #1 was noted to have redness on her groin (between the abdomen and thigh) area. The area was cleaned, and a [MEDICATION(S)]-based lotion was applied. The nurse's note documented the physician was notified and a message was left for her representative. A physician;s progress note, dated 8/17/20, documented Resident #1 had excoriation on her groin area and it was moisture associated. The progress note directed staff to keep Resident #1's groin area clean and apply [MEDICATION(S)] every shift after cleansing and after being soiled or wet. A nurse's note, dated 8/17/20 at 10:27 AM, documented Resident #1 was seen by the nurse practitioner related to the skin issues. No new order was given. A nurse's note, dated 8/22/20 at 1:06 AM, documented Resident #1 was incontinent of bowel and bladder. The note also documented her skin continued with redness, it was cleaned, and a barrier cream was applied. On 3/9/20 at 2:27 PM, RN #1 said residents should be checked for incontinence at least every two hours and PRN. When asked if Resident #1 was checked every two hours, RN #1 said it was a standard nursing practice to check residents for incontinence. When asked about Resident #1's bowel and bladder care plan, RN#1 reviewed Resident #1's record and said she did not have one. 4. Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note, dated 10/19/20 at 6:03 PM, documented Resident #2 refused to allow the nurse to assess her skin. A nursing note, dated 10/19/20 at 9:49 PM, documented Resident #2 refused skin checks by staff. Resident #2's care plan for ADLs (activities of daily living), dated 10/19/20, documented she had limited mobility and she required one person assist for bed mobility and required a two person assist for toileting. Resident #2's care plan for potential impairment to skin integrity, dated 10/19/20, documented she had an unstageable pressure ulcer to her coccyx and refusal of cares. The care plan directed staff to educate resident/family/caregivers of causative factors and measures to prevent skin injury and encourage good nutrition and hydration in in order to promote healthier skin. An initial admission skin assessment, dated 10/21/20 at 8:35 AM, documented Resident #2 had a 7 cm by 2 cm pressure ulcer on her left gluteal fold which was unstageable. There was no further description of the pressure ulcer documented. There was an order to apply [MEDICATION(S)] to Resident #2's buttocks and right upper thigh after each incontinent episode and each shift until resolved. There were no orders documented for care of the unstageable pressure ulcer on Resident #2's left gluteal fold. A weekly skin evaluation, dated 10/26/20 at 6:16 AM, documented Resident #2 Res [Resident #2] has no new skin issues noted at this time. There was no documentation, description, or measurement for the unstageable pressure ulcer on her left gluteal fold. A weekly skin evaluation, dated 10/27/20 at 5:27 PM, documented Resident #2 had a skin tear to her right forearm, left forearm, and left thumb. There was no documentation of measurements or further description of the skin tears identified. There was no documentation, description, or measurement for the unstageable pressure ulcer on her left gluteal fold. Resident #2's care plan was updated, dated 10/28/20, to include pressure ulcers. The interventions included to administer treatments as ordered and monitor for effectiveness and to have weekly head to toe skin assessments. A nursing note, 10/29/20 at 11:13 AM, documented Skin changes noted to the assessments done by wound nurse, she does have a coccyx wound. The note documented Resident #2 had a pressure reducing device for her bed and chair. There was no documentation of measurements, wound care, or treatment being provided to the unstageable pressure ulcer which was identified on admission.

Based on staff interview, policy review, record review, and review of I&A reports, the facility failed to ensure sufficient supervision of residents to prevent falls. This was true for 3 of 4 residents (#1, #7, and #8) reviewed for falls.This resulted in harm to Resident #1 when, after a fall, her decreased alertness was not acted upon in a timely manner. This deficient practice resulted in harm to Resident #7 when he sustained multiple falls with injuries without appropriate supervision and interventions to prevent falls. Resident #8 was harmed when she experienced two unwitnessed falls and sustained bruises, abrasions, and lacerations which were required to be sutured as a result of the falls. Findings include: The facility's Fall Management System policy, revised 6/2018, directed staff to identify residents who were at risk for falls and develop an individualized care plan which included measurable objectives and timeframe, interventions to prevent falls, addressed the risk factors and evaluated what put the resident at risk for falls. The policy also documented a Fall Risk Evaluation was completed after the fall and the IDT reviewed the root cause analysis of the fall, and their recommendations was documented in the resident's record. The policy also documented the resident's care plan was updated to reflect the IDT recommendations. This policy was not followed. 1. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including left [CONDITION(S)], muscle weakness, and dementia. A quarterly MDS assessment, dated 10/14/20, documented Resident #8 had severe cognitive impairment. Resident #8's care plan identified she was at Risk for Falls related to her limited ability and it was initiated on 6/3/20. The care plan interventions included directing staff to ensure she was wearing appropriate footwear when ambulating or in her wheelchair, make sure her call light was within her reach and encourage her to use it to call for assistance as needed, place her bed in the lowest position, avoid rearranging her furniture, keep her needed items within her reach, keep her floor free from spills and/or clutter, and provide her with glare free light. An I&A report, dated 10/27/20 at 12:40 AM, documented Resident #8 had an unwitnessed fall. Resident #8 had an open wound on the right side of her forehead when she was found on the floor in her room. The report documented the physician was notified at 1:24 AM and he gave an order to transfer Resident #8 to the hospital for further evaluation. Resident #8's representative was also notified at 1:30 AM on the same day. A hospital report, dated 10/27/20, documented Resident #8 sustained a 2.5 cm x 3 cm laceration on her right frontal scalp, a 3 cm x 4 cm area of tissue avulsion (when a portion of the skin and/or other soft tissue is partially or completely torn away) surrounding the laceration that was excised and sutured and a 2 cm laceration on her right outer eyebrow which was also sutured. The hospital report documented Resident #8 had bruises on her right shoulder and right knee. The report also documented Resident #1 had a pelvic x-ray which showed bilateral hip prosthesis, what appeared to be a vertical shear fracture of the medial trochanter (part of the thigh bone) of the right hip. The report stated the radiologist thought the shear fracture was old, but he had no comparison films, so did not know if it was an old or new fracture. A Summary of Fall Investigation with Injury report, dated 10/27/20, documented the ADON spoke to Resident #8's representative regarding her right hip x-ray result. Resident #8's representative requested for all her x-ray results to be sent to her orthopedic physician as she had a right [CONDITION(S)] in the past. When Resident #8's orthopedic physician received her x-ray result they stated it was not clear and scheduled her to visit their office on 11/3/20 for her to have a new x-ray done. The report documented Resident #8's representative stated since Resident #8 was not having pain they strongly believed it was an old fracture and did not want her to be taken to her orthopedic physician's clinic and the appointment was canceled. A Fall Risk Evaluation, dated 10/27/20, documented Resident #8 was at high risk for falls. Resident #8's care plan, revised on 10/27/20, directed staff to increase supervision to Resident #8 with visual checks and neurological checks. The care plan did not specify how frequently staff were to conduct these checks. An I&A report, dated 11/15/20 at 1:10 PM, documented Resident #8 had an unwitnessed fall and she was found on the floor in her room. The report documented Resident #8 slid out of her wheelchair. The report also documented she had a small skin tear on her right elbow and a red area on her upper right shoulder. The report documented the physician was notified at 1:15 PM on the same day. An IDT report, dated 12/9/20 at 11:12 AM, documented Resident #8 was severely cognitively impaired and staff were directed to anticipate her needs. The report stated Resident #8 was placed on increased supervision. Resident #8's care plan, revised on 12/9/20, directed nursing staff to provide increased supervision to Resident #8. Resident #8's care plan included interventions for increased supervision with visual checks and neurological checks from revisions dated 10/27/20. The care plan did not specify what increased supervision by nursing staff meant or how it was different from the visual and neurological checks. A nurse's note, dated 1/23/21 at 8:00 PM, documented Resident #8 was pushed in her wheelchair down the facility's East hall when she put her feet down and fell out onto the floor. The nurse's note documented the physician and Resident #8's representative were both notified of the incident. The physician gave an order to send Resident #8 to the hospital due to her fall with injury. An I&A report, dated 1/24/21 at 12:40 AM, documented Resident #8 put her feet down to the floor while being pushed by a CNA in her wheelchair and fell out of her wheelchair onto the floor. Resident #8 was found to have an open abrasion on the right side of her head, a skin tear on her right forearm, and a skin tear on the knuckles of her left hand which were all actively bleeding. The physician was notified at 10:01 PM and gave an order to send Resident #8 to the hospital for further evaluation. Resident #8's representative was also notified at 10:05 PM on 1/23/21. Resident #8's care plan included ADL Self Care Performance, revised on 1/23/21, which directed staff to place foot pedals on her wheelchair when she was being transported. An IDT report, dated 2/12/21 at 2:45 PM, documented Resident #8 was able to self-propel her wheelchair for short distances using her feet. The report stated Resident #8 wandered into another resident's room and when the staff assisted her out of the other resident's room she put her feet down on the floor and flipped out of her wheelchair. The report also stated Resident #8 sustained injuries and was sent to the hospital. The IDT report documented the CNA was educated to make sure Resident #8 had her foot pedals on her wheelchair while it was being pushed. On 3/9/21 at 10:05 AM, the ADON said Resident #8 did not have foot pedals on her wheelchair and she was able to propel her wheelchair for short distances. The ADON said Resident #8 had no history of wandering. When asked about Resident #8's increased supervision with visual and neurological checks, the ADON said it meant increased supervision of Resident #8 during the duration of her neurological checks. When asked about the increased supervision by the nursing staff which was stated on her care plan dated 12/9/20, the ADON said she could not give a definite answer but she said the care plan should have indicated how often Resident #1 should have been checked or supervised. The ADON said Resident #8's frequent checks were not being documented by the facility. 2. Resident #1 was admitted to the to the facility on [DATE], with multiple diagnoses including [CONDITION(S)] and [CONDITION(S)] (paralysis or weakness on one side of the body) following cerebral infarction (stroke). A Fall Risk Evaluation, dated 8/7/20, documented Resident #1 was at risk for falls. Resident #1's care plan, initiated on 8/10/20, documented she was at risk for falls related to cognitive changes. The care plan directed staff to avoid rearranging her furniture, be sure her call light was within her reach and encourage her to use it to call for assistance as needed, and have therapy evaluate her per physician order. An I&A report, dated 8/19/20 at 6:15 PM, documented Resident #1 had an unwitnessed fall. She had footwear on when she was found on the floor in her room partially under her bed. The report documented the physician was notified on 8/20/20 at 8:03 AM, and Resident #1's representative was notified on 8/20/20 at 5:03 PM. A Neurological Assessment Flow Sheet, was started on 8/19/20 at 6:15 PM and completed on 8/22/20 sometime in the evening, there was no time documented. Resident #1 was documented as alert for her level of consciousness during her neurological assessments. Resident #1's care plan was revised on 8/19/20 and directed staff to keep her bed in the lowest position, check her range of motion, perform neurological checks as ordered and determine and address the cause of the fall. An IDT fall review, dated 8/20/20 at 2:29 PM, documented Resident #1 was assisted into her wheelchair by staff and was next to her bed then staff left to get dinner trays from the dining room. The IDT review documented it was believed Resident #1 slid out of her wheelchair with her feet/legs under her bed. The review documented Resident #1 was wearing non-skid socks and her bedside table and call light were within reach. The IDT review documented neurological checks and frequent checks were initiated. The review did not state how frequently Resident #1 was to be checked. An SBAR (Situation, Background, Assessment, Recommendation) communication form, dated 9/1/20, documented Resident #1 had increased confusion and the physician was notified at 12:00 PM. A physician progress note, dated 9/1/20, documented Resident #1 had a stroke and [CONDITION(S)] (damage or disease that affects the brain which can lead to an altered mental state). The note stated this made Resident #1's preferences and sentiments difficult to interpret but staff thought Resident #1 was more alert and awake and interactive. The physician documented he would like to do a gradual dose reduction (GDR) of Resident #1's [MEDICATION(S)] (a narcotic-like pain reliever) if able. The note stated the [MEDICATION(S)] was only PRN HS[bedtime] at present. A nurse's note, dated 9/2/20 at 5:47 AM, documented Resident #1 continued to have decreased cognition. The note documented her [MEDICATION(S)] was discontinued. A physician progress note, dated 9/3/20, documented Resident #1 was awake and sitting up at the dining room table for breakfast, stable, and not in respiratory distress. A nurse's note, dated 9/3/20 at 2:23 AM, documented Resident #1 continued to have decreased cognition. A nurse's note, dated 9/4/20 at 12:13 AM, documented Resident #1 was more awake and communicative. A nurse's note, dated 9/5/20 at 7:54 PM, documented Resident #1 was nonverbal when the nurse attempted to give her medications. The note also documented Resident #1 would not open her mouth and her intake had declined. An I&A report, dated 9/6/20 at 7:30 AM, documented Resident #1 had an unwitnessed fall. She was found on the floor in her room next to her bed on her stomach. Resident #1 was repositioned two times prior to the fall because she rolled herself on the edge of her bed. The report also documented the physician and Resident #1's representative were notified on the same day at 9:00 AM. An SBAR form, dated 9/6/20, documented Resident #1 rolled out of her bed. There were no injuries noted and neurological checks were initiated. The form documented the physician recommended to monitor Resident #1. An Actual Fall care plan, directed staff to perform neurological checks on Resident #1. This was initiated on 9/6/20. Resident #1's neurological assessment started on 9/6/20 at 7:30 AM and ended on 9/6/20 at 4:30 PM. At 6:30 PM, the neurological assessment form documented Resident #1 was in the hospital. The assessment documented Resident #1's level of consciousness was drowsy from 7:30 AM through 4:30 PM. An SBAR form, dated 9/6/20 at 5:30 PM, documented Resident #1 had an altered mental status, functional decline, abnormal speech, decreased level of consciousness and was unable to focus on nurse's head to toe assessment of her. The form documented Resident #1's change of condition started in the afternoon and the physician and her representative were notified at 5:00 PM on the same day. The form documented the physician recommended to send Resident #1 to the hospital if the family wanted her to go. A handwritten note on the form documented Resident #1 was sent to the hospital at 5:30 PM. A Nursing Home to Hospital Transfer form, dated 9/6/20 at 7:31 PM, documented Resident #1 was transferred to the hospital due to disorientation and possible stroke. An IDT fall review, dated 9/9/20 at 12:45 PM, documented Resident #1 rolled out of bed onto the floor. Resident #1's bed was positioned at its lowest. Neurological checks were initiated as were frequent checks for positioning. The review also documented Resident #1 preferred to lie on the very edge of her bed with her feet hanging off and she was encouraged to stay in the middle of her bed. On 3/10/21 at 9:14 AM, LPN #1 reviewed Resident #1's 9/6/20 neurological assessment. LPN #1 said she performed Resident #1's neurological assessment from 10:30 AM to 4:30 PM on 9/6/20. When asked about Resident #1's level of consciousness on 9/6/20, LPN #1 said according to the Neurological Assessment flow sheet Resident #1 was drowsy. When asked if the physician was notified of Resident #1's level of consciousness as drowsy earlier during the day, LPN #1 reviewed Resident #1's record again and said she could not remember if she notified the physician Resident #1 was drowsy. LPN #1 also said she did not know if she was the one who transferred Resident #1 to the hospital. When asked why the observation column of the neurological assessment documented Resident #1's oxygen saturation, LPN #1 said they always document oxygen saturation in the observation column and any observation of the resident was documented in the nursing notes. LPN #1 then reviewed Resident #1's nursing notes and said there was no documentation about Resident #1's condition in the nursing notes. When asked why there was no documentation in the nurse's note regarding Resident #1's condition and transfer to the hospital. LPN #1 did not provide an answer. On 3/10/21 at 9:41 AM, the ADON said the physician should be notified of any change in a resident's condition. When asked when the nurse should notify the physician about Resident #1's drowsiness, the ADON said the nurse was to establish Resident #1's level of consciousness baseline. The ADON said once the nurse determined it was not Resident #1's baseline the nurse should notify the physician. The ADON also stated she expected more documentation in the nurse's note regarding Resident #1's change of condition. 3. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including stroke and traumatic brain injury (a disruption of the normal function of the brain caused by an injury to the head). Resident #7's care plan related to falls, dated 9/11/20, documented he was at risk for falls related to [CONDITION(S)], limited mobility, prior falls, and poor safety awareness. The interventions initiated on 9/11/20 for the prevention of falls for Resident #7 were as follows: Avoid rearranging furniture, ensure Resident #7 was wearing appropriate footwear when ambulating or wheeling in his wheelchair, keep needed items within reach, and maintain a clear pathway. These interventions were not followed. A fall report, dated 9/18/20 at 1:55 PM, documented Resident #7 fell , which resulted in a skin tear above his left elbow. A new fall focus was documented on Resident #7's care plan. The care plan did not include new interventions to prevent subsequent falls. A fall report, dated 9/25/20 at 7:12 PM, one week after the previous fall, Resident #7 fell and sustained a head injury. A nursing note dated 9/28/20 at 3:26 PM, documented Resident #7 was in the bathroom changing his clothes when he lost his balance, fell , and hit his head. It further documented Resident #7 went to the hospital for this fall where he was diagnosed with a subdural hematoma (a collection of blood that forms inside the skull of the head most often as a result from a head injury) and transferred to the hospital. A new fall focus was added to Resident #7's care plan, which documented it as a fall with major injury. The care plan did not include new interventions to prevent falls after the fall on 9/25/20. A fall report, dated 10/17/20 [time not legible on copy], documented Resident #7 was found by therapy staff on the floor next to his bed. He had on regular socks and no shoes. There was a new fall focus on Resident #7's care plan related to this fall and included a new intervention Resident #7 would be in line of sight of staff at all times when he sat in his wheelchair. A fall report, dated 10/18/20 at 2:30 AM documented Resident #7 was found on the floor in his room in front of his wheelchair. The report documented the nurse saw him in his wheelchair 45 minutes prior to being found on the floor. Multiple skin tears were noted on his right arm and shoulder. A new fall focus on Resident #7's care plan stated to keep Resident #7's bed in the lowest position. A fall report, dated 10/18/20 at 5:28 PM, documented Resident #7 was found on the floor yelling for help. He had on socks and no shoes and had a new skin tear on his left elbow. A new fall focus on Resident #7's care plan stated he had an actual fall with injury. The care plan did not include new interventions to prevent falls. A fall report, dated 10/18/20 at 9:15 PM, documented Resident #7 was found lying on the floor on his right side. There was a new fall focus on Resident #7's care plan and a new intervention for a floor mat. A fall report, dated 10/22/20 at 9:03 PM, documented Resident #7 was in the dining room at the table when he pushed himself away from the table and fell out of his wheelchair. A nursing note, dated 10/23/20 at 1:08 PM, documented after the fall on 10/22/20 at 9:03 PM, Resident #7 was assisted back to his room and into bed. It documented a few minutes later the RN went to check on him and found him out of the bed on his knees. The note documented at the next 15-minute check he was found out of bed and a fall mat was placed beside his bed. This fall mat placement was 5 days after it was a noted intervention for the fall on 10/18/20. The next check by staff found Resident #7 on his knees with his arms on the bed and he was assisted back to bed. The next check found Resident #7 lying on the fall mat on the floor. On 3/10/21 at 9:10 AM, the Clinical Resource Nurse stated nurses have a cares notebook they use to direct cares and an IDT fall review was conducted on 10/23/20. The IDT fall review did not include interventions for preventing falls for Resident #7.

Based on observations, policy review, review of I&A reports, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were met related to management of urinary tract infections, physician notification of change in condition, and neurological assessment. This was true for 4 of 9 residents (#1, #2, #7, and #8) reviewed for standards of practice. Specifically: * Resident #7 was harmed when treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures culminating in Resident #7's transfer to a hospital where he was diagnosed with [CONDITION(S)] (potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues). * Resident #2 was harmed when staff failed to notify the physician of ongoing behavioral and physical signs of a [CONDITION(S)] and she became and remained unresponsive (unconscious or otherwise unable to respond) and her transfer to a hospital was delayed for 6 hours. * Resident #1 was harmed when she experienced a decreased level of consciousness after a fall, the physician was not promptly notified, and her transfer to the hospital for a possible stroke was delayed. * Resident #8 was placed at risk of undetected neurological changes due to a lack of neurological assessments after a fall. Findings include: The facility's policy for Significant Change in Condition, revised 5/2017, documented nursing provided documentation regarding a change of condition to the appropriate department which provided treatment to maintain the residents at their highest functional ability. The facility's policy for Infection Control Tracking, revised 9/2017, documented during the initial assessment, the physician or provider would help identify individuals who had a recent infection or who were at risk at developing an infection. The policy stated the charge nurse reported residents displaying any signs/symptoms of infection on the 24-hour Report, and all potential/actual infections must be treated as a change of condition. The policy further stated any questions about infections and cultures were brought to the attention of the Infection Preventionist. These policies were not followed. Examples include: 1. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note, dated 9/11/20 at 12:34 PM, documented Resident #7 was alert, oriented to person, place, date, time, and had no active symptoms affecting his level of consciousness, thinking ability, sleep or behavior. It documented his urine was clear yellow without odor. A physician admission note, dated 9/14/20, stated Resident #7 was admitted to the facility and was alert and answering questions appropriately. It documented Resident #7 was recently discharged from a hospital after experiencing hallucinations and was diagnosed with [CONDITION(S)] (low blood sugar) and a urinary tract infection while there. A nursing discharge planning note, dated 9/23/20 at 9:50 AM, documented Resident #7 was walking with a walker and planned to discharge home with outpatient services. A nursing note, dated 10/4/20 at 11:55 PM, documented Resident #7 was confused, would not stay in his bed, and did not want to wear clothes. There was no documentation the physician was notified of this change in condition. A nursing note, dated 10/11/20 at 10:14 PM, documented Resident #7 was oriented only to self, and would not keep clothes on. There was no documentation the physician was notified of this change in condition. A nursing note, dated 10/13/20 at 12:04 AM, documented Resident #7 had increasing confusion, would not stay dressed, and 15-minute safety checks were added to his care. There was no documentation the physician was notified of this change in condition. On 10/15/20 a physician's progress note documented Resident #7 was alert to self only and there was no indication for a urinalysis. A nursing note, dated 10/16/20 at 4:01 AM, documented Resident #7's POA requested Resident #7 have a urinalysis to check for a urinary tract infection. It further documented Resident #7's primary care provider visited him. There was no order for a urinalysis documented. A nursing note, dated 10/16/20 at 3:00 PM, documented Resident #7 had a gradual decline in orientation. It documented Resident #7 continued to undress himself and began to have incontinence episodes when he was regularly continent. The note stated the CNAs notified the LN Resident #7's urine was dark and foul smelling. The LN documented Resident #7's POA stated Resident #7 had these symptoms in the past and was diagnosed with a [CONDITION(S)]. A facility care path for changes in behavior, dated 2014, documented when a resident had a change in behavioral symptoms such as inappropriate disrobing, the resident should be further evaluated for [CONDITION(S)] symptoms. There was no documentation the care path was followed regarding Resident #7's symptoms. A facility care path for symptoms of a urinary tract infection, undated, documented vital signs were taken if symptoms or signs of a urinary tract infection such as incontinence were noted and if vital signs were stable the physician was notified immediately and a urinalysis with cultures was considered for the resident. There was no documentation in Resident #7's record this care path was followed regarding Resident #7's symptoms. A nursing assessment note, dated 10/16/20 at 9:09 AM, documented Resident #7 had acute back pain rated 4 out of 10 (10 being the highest) on the pain scale. There was no documentation in Resident #7's record the physician was notified of Resident #7's back pain. A fall incident report, dated 10/17/20, documented Resident #7 had an unwitnessed fall. It documented Resident #7 was confused and repeatedly stated I'm about dead. A physician's note, dated 10/18/20, documented Resident #7's increased confusion was possibly due to [CONDITION(S)], and [MEDICATION(S)] (an oral antibiotic) would be started for a 5-day course. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #7 twice a day for five days until 10/24/20 for a [CONDITION(S)]. The facility's incident and accident reports documented Resident #7 had a change in ADL's (activities of daily living) related to unwitnessed falls. On 10/18/20 at 2:30 AM, 5:28 PM, and 9:15 PM, Resident #7 experienced three unwitnessed falls. The facility's care path for falls, undated, documented when a resident had a fall, after vital signs were taken the nurse evaluated for signs of mental status changes and if there were none, the nurse evaluated for an acute decline in ADL's and considered contacting the physician for a urinalysis (UA) with urine culture. There was no documentation this care path was followed for Resident #7. Nursing notes dated 10/20/20 documented the following: * From 1:09 AM - 5:25 AM, Resident #7 required constant supervision to prevent falls. There was no documentation the physician was notified of this change in condition. * At 12:48 PM, Resident #7 had multiple falls in the last few days, increased confusion and the provider ordered a UA. The U.S. Food and Drug Administration website, revised 8/2012, accessed on 3/15/21, documented [MEDICATION(S)] was indicated for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . coli, [CONDITION(S)], enterobacter, morganella morganii, proteus mirabilis, and proteus vulgaris infections. It further stated that [MEDICATION(S)] should be used only to treat infections that are proven or strongly suspected to be caused by susceptible bacteria. The website did not include [MEDICATION(S)] was indicated for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] A urine microbiology culture result from Resident #7's UA, received in the facility on 10/20/20, documented Resident #7's urine culture had coagulase negative staphylococcus. It contained a signature of a provider with a received 10/22/20 date stamp and two nurses' signatures. There was no documentation the IP reviewed the microbiology culture result. There was no documentation Resident #7's antibiotic was changed from [MEDICATION(S)] to an antibiotic that would kill the coagulase negative staphylococcus growing in Resident #7's body. A nursing note, dated 10/23/20 at 1:08 PM, documented an IDT fall review noted Resident #7 fell 4 times in one hour on 10/22/20. It documented Resident #7's provider completed a chart and lab review and spoke with the Medical Director regarding labs and symptoms. Resident #7 was started on [MEDICATION(S)] (antipsychotic used to treat [CONDITION(S)]). A physician's progress note, dated 10/23/20 at 8:20 PM, documented Resident #7 had significant [CONDITION(S)]/[CONDITION(S)] over the past week and his labs were without signs or symptoms of an infection, Resident #7 had poor oral intake and he was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . No new medication orders were documented. A nursing note, dated 10/24/20 at 3:11 AM, documented antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #7. A nursing note, dated 10/25/20 at 6:31 PM, documented Resident #7 continued to decline and he required supplemental oxygen. The provider was notified of changes in Resident #7's condition and Resident #7 was sent to the hospital. A nursing note, dated 10/26/20 at 12:40 AM, documented a follow-up call was made to the hospital where Resident #7 was taken and Resident #7 was diagnosed with [CONDITION(S)]. On 10/26/20 at 12:00 PM, a situation report was added to the Bureau of Facility Standards Long term care Reporting system by the DON which documented facility staff were notified by the Medical Director of concerns by hospital staff regarding poor care and neglect when Resident #7 was sent to the hospital on 10/25/20. On 3/10/20 at 1:19 PM, the ADON was interviewed regarding Resident #7's care. She stated due to Resident #7's increased confusion and agitation, her expectation was the nursing staff would be aware of changes intensifying and notify the physician. When asked about the facility's care path for changes in behavior being followed, she stated the nurses were trying to follow it, but it looked like they were not. When asked about the facility's tracking of antibiotic use and the appropriateness of antibiotic use, she stated they did not have a designated IP (Infection Preventionist) at that time. On 3/11/21 at 9:10 AM, the Regional Resource Nurse was asked about staff nursing education for UTIs, guidelines for physician notification, fall prevention, changes of behavior, and mental status changes. She stated the staff used a care path notebook which included algorithms for different concerns and staff followed the algorithms regarding symptoms. On 3/11/21 at 2:00 PM, the Clinical Resource Nurse stated there was no follow up related to antibiotic use by Resident #7 or tracking of his symptoms. She stated the care path notebook for care of residents with changes was not followed. 2. Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility care path for urinary tract infections, undated, documented if a resident was not eating or drinking the physician was notified and to consider ordering a urinalysis and urine culture. The facility care path for changes in behavior, undated, documented for new or worsening behavioral symptoms and the resident had no changes in vital signs, the nurse was to further evaluate the resident's [CONDITION(S)] system, skin and pain. If there were no concerns, the physician was notified and a urinalysis with cultures was considered for the resident. These care paths were not followed. Nursing notes, dated 10/19/20, documented the following: * At 6:03 PM, Resident #2 refused to allow the nurse to assess her skin, and refused all food and drink. * At 9:49 PM, Resident #2 would not allow skin checks, refused to get into bed and refused medications. * At 10:46 PM, Resident #2 refused medications, food, and drink. A nursing note, dated 10/20/20 at 11:09 AM, documented the ADON would request follow up labs and urinalysis would be considered by the physician related to abnormal lab values in Resident #2's history and physical assessment. The note stated prior to this admission Resident #2 was in the hospital for a [CONDITION(S)] and skin infection. A physician's progress note, dated 10/20/20 documented Resident #2 refused lab draws and was diagnosed with a mild neurocognitive disorder and she had hallucinations that distressed her. The provider documented Resident #2 had difficult behaviors with poor compliance. There were no laboratory tests ordered. A nursing note, dated 10/23/20 at 11:50 PM, documented Resident #2 complained of right hip pain. A nursing note, dated 10/24/20 at 9:59 AM, documented Resident #2's urine was dark yellow with a faint odor. It also documented Resident #2 was resistive to cares and combative with staff. There was no follow-up assessment in Resident #2's record regarding her [CONDITION(S)] system, skin, or pain level when changes in Resident #2's behavior occurred. There was no documentation in Resident #2's record the physician was notified of the change in the color and odor of her urine and her combativeness. A social services summary, dated 10/26/20 at 10:30 AM, documented Resident #2 chose to have her status as do not resuscitate (DNR) with comfort measures which included IV fluids and antibiotics. A nursing note, dated 10/31/20 at 12:14 AM, documented Resident #2 refused cares and when she allowed staff to clean her she had redness and skin breakdown to her groin and thighs. On 11/3/20 the following nursing notes were documented: * At 2:28 AM, Resident #2 was very violent toward staff. There was no documentation the physician was notified. There was no documentation Resident #2 was assessed for concerns that could result from changes in mentation and behavior. * At 1:52 PM, Resident #2's assessment included her urine being yellow with a faint odor. * At 9:31 PM, Resident #2 refused daily medications three times. There was no documentation the physician was notified about Resident #2's change in the odor of urine or her refusal of mediations. On 11/8/20 the following nursing notes were documented: * At 4:48 AM, Resident #2 refused care and her incontinence caused increased skin breakdown. * At 7:29 AM, Lorazepam (a medication used to relieve anxiety) 0.5 mg was given to Resident #2. Resident #2 became lethargic, unable to drink through a straw, and refused food. A nursing note, dated 11/9/20 at 2:30 AM, documented Resident #2 stated It hurts, to nursing staff. She refused to take medication for discomfort. There was no documentation the physician was notified about Resident #2's complaint of pain or refusal to take medication. There was no documentation of an in-depth assessment to evaluate the location and severity of Resident #2's pain. A nursing note, dated 11/12/20 at 11:47 PM, documented Resident #2 was sedated and unable to swallow medications effectively. There was no documentation the physician was notified. On 11/13/20 the following was documented in the nursing notes: * At 8:52 AM, Resident #2 had thick yellow urine with a faint odor. There was no documentation the physician was notified of this change in Resident #2's urine. * At 10:42 PM, Resident #2 lost the ability to speak. There was no documentation the physician or family were notified of Resident #2's change in condition. On 11/14/20 the following was documented in the nursing notes: * At 7:36 AM, Resident #2 was unresponsive. * At 8:52 AM Resident #2 was evaluated for motor response and had decreased movement of all extremities. * At 10:49 AM, the physician and family were informed of changes in Resident #2's neurological status. * At 4:54 PM, Resident #2 was transferred to a hospital and was unresponsive at the time of transfer. A review of Resident #2's lab work documented no lab work was collected and no urinalysis was ordered or collected for her. On 3/10/21 at 11:21 AM, RN #1 was interviewed regarding Resident #2's care. She stated when a resident was not eating, drinking, or taking medications she would encourage the resident repeatedly and try alternative means of administering medications. She stated when Resident #2's urine became thick she would call the physician. She stated the 6-hour gap between Resident #2's change in condition and the transport time to the hospital may have been related to concern over comfort measures, but she did not know for sure. On 3/10/21 at 1:19 PM, the ADON was interviewed regarding Resident #2's care and treatment. When asked about Resident #2's increased behaviors and noted thick yellow urine she stated she would have expected a urinalysis to be ordered for Resident #2 as her symptoms of a [CONDITION(S)] had increased. When asked why the nurses did not notify the provider when Resident #2 was refusing to eat or drink, she stated staff should have been following the facility's change in behavior care path. When asked why the change in behavior care path and the care path for symptoms of a urinary tract infection were not followed for Resident #2's care, the ADON stated she thought nursing staff were trying to follow the pathways, but she could see the steps were not followed in Resident #2's care. When asked why there was a 6-hour gap between when Resident #2 became unresponsive and when she left for the hospital the ADON stated it may be a charting issue. On 3/11/21 at 2:00 PM, the Clinical Resource Nurse stated the care path notebook for care of residents with changes was not followed. 3. Resident #1 was admitted to the to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's admission MDS, dated [DATE], documented she had severe cognitive impairment. Resident #1's Risk for Falls care plan related to her cognitive changes, initiated on 8/10/20, directed staff to avoid rearranging her furniture, be sure her call light was within her reach and encourage her to use it to call for assistance as needed and have therapy evaluate her per physician order. Resident #1's fall care plan, initiated on 8/19/20, directed staff to keep her bed in the lowest position, check her range of motion, perform neurological checks as ordered, and determine and address the causative factors of the fall. An SBAR (Situation, Background, Assessment, Recommendation) communication form, dated 9/1/20, documented Resident #1 had increased confusion and the physician was aware of her condition. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #1's preferences and sentiments difficult to interpret but staff thought she was more alert and awake and interactive. A nurse's note, dated 9/2/20 at 5:47 AM, documented Resident #1 continued to have decreased cognition. The nurse's note documented Resident #1's [MEDICATION(S)] (a narcotic-like pain medication) was discontinued. A nurse's note, dated 9/3/20 at 2:23 AM, documented Resident #1 continued to have decreased cognition. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was stable and not in respiratory distress. A nurse's note, dated 9/4/20 at 12:13 AM, documented Resident #1 was more awake and communicative. A nurse's note, dated 9/5/20 at 7:54 PM, documented Resident #1 was nonverbal when the nurse attempted to give her medications. The nurse's note also documented Resident #1 would not open her mouth and her intake declined. An I&A report, dated 9/6/20 at 7:30 AM, documented Resident #1 had an unwitnessed fall. She was found on the floor in her room next to her bed on her stomach. The report also documented the physician and Resident #1's representative were notified on the same day at 9:00 AM. Resident #1's neurological assessment started on 9/6/20 at 7:30 AM and ended on 9/6/20 at 4:30 PM. At 6:30 PM, the neurological assessment form documented Resident #1 was in the hospital. The neurological assessment form had several columns and the headings were Date, Time, Level of Consciousness, Pupil Response, Motor Functions, Pain Response, Vitals, Observations, and Signature. Under Level of Consciousness columns were the letters: A, D, S and C, which stood for Alert, Drowsy, Stuporous and Comatose. Under the Observations column were seizures, headache, vomiting and paralysis. Resident #1's level of consciousness was documented as drowsy from 7:30 AM through 4:30 PM. Resident #1's oxygen saturation levels (measurement of the amount of oxygen levels in the blood) were documented under the Observations column, and observations were not documented. An SBAR form, dated 9/6/20 at 5:30 PM, documented Resident #1 had an altered mental status, functional decline, abnormal speech, decreased level of consciousness and was unable to focus on the nurse's head to toe assessment of her. The form documented Resident #1's change of condition started in the afternoon and the physician and her representative were notified at 5:00 PM on the same day. The form documented the physician recommended sent [sic] to [hospital] if family wishes. A handwritten note on the form documented Resident #1 was sent to the hospital at 5:30 PM. The neurological assessment form, dated 9/6/20 documented Resident #1 was drowsy from 7:30 AM to 4:30 PM. The SBAR, dated 9/6/20 at 5:30 PM, documented the physician was notified of Resident #1's change in condition at 5:00 PM, 9 hours and 30 minutes after Resident #1 had the documented change in condition. An IDT fall review, dated 9/9/20 at 12:45 PM, documented Resident #1 rolled out of bed onto the floor. Resident #1's bed was positioned at its lowest position. Neurological checks were initiated as were frequent checks for positioning. The fall review also documented Resident #1 preferred to lie on the very edge of her bed with her feet hanging off and she was encouraged to stay in the middle of her bed. A Nursing Home to Hospital Transfer form, dated 9/6/20 at 7:31 PM, documented Resident #1 was transferred to the hospital due to disorientation and possible stroke. On 3/10/21 at 9:14 AM, LPN #1 reviewed Resident #1's 9/6/20 neurological assessment. LPN #1 said she performed Resident #1's neurological assessments from 10:30 AM to 4:30 PM on 9/6/20. When asked about Resident #1's level of consciousness on 9/6/20, LPN #1 said according to the Neurological Assessment flow sheet Resident #1 was drowsy. When asked if the physician was notified of Resident #1's level of consciousness as drowsy earlier during the day LPN #1 reviewed Resident #1's record again and said she could not remember if she notified the physician Resident #1 was drowsy. LPN #1 also said she did not know if she was the one who transferred Resident #1 to the hospital. When asked why the Observation column of the neurological assessment documented Resident #1's oxygen saturation, LPN #1 said they always document oxygen saturation in the Observation column and any observation of the resident was documented in the nursing notes. LPN #1 then reviewed Resident #1's nursing notes and said there was no documentation of Resident #1's condition in the nursing notes. On 3/10/21 at 9:41 AM, the ADON said the physician should be notified of any change in a resident's condition. When asked when the nurse should notify the physician about Resident #1's drowsiness, the ADON said the nurse was to establish Resident #1's level of consciousness baseline. The ADON said once the nurse determined it was not Resident #1's baseline the nurse should notify the physician. The ADON also stated she expected more documentation in the nurse's note regarding Resident #1's change of condition. 4. The facility's Neurological Evaluation policy, revised 3/2021, directed staff to perform a neurological evaluation of residents who had unwitnessed falls or had an injury on their head. A comprehensive neurological assessment would be done as follows: *Every 15 minutes x 4 (one hour) *Every 30 minutes x 4 (two hours) *Every hour x 4 (four hours) *Every shift x 72 hours This policy was not followed. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS, dated [DATE] and a quarterly MDS, dated [DATE], documented Resident #8 had severe cognitive impairment. Resident #8's Risk for Falls related to her limited ability care plan, initiated on 6/3/20, directed staff to ensure she was wearing appropriate footwear when ambulating or wheeling in her wheelchair, make sure her call light was within her reach and encourage her to use it to call for assistance as needed, place her bed in the lowest position, avoid rearranging her furniture, keep her needed items within her reach, keep her floor free from spills and/or clutter and provide her with glare free light. An I&A report, dated 10/27/20 at 12:40 AM, documented Resident #8 had an unwitnessed fall. Resident #8 had an open wound on the right side of her forehead with a depth of about 0.3 cm when she was found on the floor in her room. The report documented the physician was notified at 1:24 AM and gave an order to transfer Resident #8 to the hospital for evaluation. Resident #8's representative was also notified at 1:30 AM on the same day. A hospital report, dated 10/27/20, documented Resident #8 sustained a 2.5 cm x 3 cm laceration on her right frontal scalp, a 3 cm x 4 cm area of tissue avulsion (when a portion of the skin and/or other soft tissue is partially or completely torn away) surrounding the laceration that was excised and sutured, and a 2.0 cm laceration on her right upper lateral eyebrow which was also sutured. The report also documented Resident #8 had a contusion (bruise) on her right shoulder and right knee. A nurse's note, dated 10/27/20 at 5:00 AM, documented Resident #8 returned from the hospital with a bandage on her right forehead. A fall risk evaluation, dated 10/27/20, documented Resident #8 was at high risk for falls. Resident #8's care plan for falls, revised on 10/27/20, directed staff to increase supervision to Resident #8 with visual checks and neurological checks. There was no documentation in Resident #8's record neurological assessments were completed after the unwitnessed fall on 10/27/20. On 3/9/21 at 9:20 AM, the ADON said neurological assessments should be done after unwitnessed falls or when residents hit their head. The ADON was unable to provide documentation neurological assessments were completed for Resident #8.

Based on staff interview, record review, and policy review, it was determined the facility failed to ensure the infection prevention and control program (IPCP) included an antibiotic stewardship program that optimized the use of antibiotics in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failed practice resulted in harm when Resident #7 had a significant deterioration in his condition which resulted in him being sent to a hospital. Findings include: A facility Surveillance of Infections and Reporting policy, revised 9/2017, documented the facility would treat all potential/actual infections as a change of condition and the physician, family, and DNS would be notified. This policy documented an infection control surveillance log would be maintained by the Infection Preventionist (IP), be reviewed daily, and all validated infections would be trended using McGeer's criteria (used for retrospectively counting true infections) on a monthly basis. This policy was not followed. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note, dated 9/11/20 at 12:34 PM, documented Resident #7 was alert, oriented to person, place, date, time, and had no active symptoms effecting his level of consciousness, thinking ability, sleep or behavior. It documented his urine was clear yellow without odor. A physician admission note, dated 9/14/20, stated Resident #7 was alert and answered questions appropriately. A nursing discharge planning note dated 9/23/20 at 9:50 AM, documented Resident #7 was walking using a walker and was planning to discharge home with outpatient services. A nursing note dated 10/13/20 at 12:04 AM, documented Resident #7 had increasing confusion, would not stay dressed, and 15-minute safety checks were being added to his care. There was no documentation the physician was notified of the change in his condition. A physician's progress note, dated 10/15/20, documented Resident #7 was alert to self only and there was no indication for a urinalysis. A nursing note, dated 10/16/20 at 4:01 AM, documented Resident #7's significant other requested Resident #7 have a urinalysis to check for a urinary tract infection and Resident #7's primary care provider was going to evaluate him that day. There was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] A nursing note, dated 10/16/20 at 3:00 PM, documented Resident #7 had a gradual decline in orientation. The note documented Resident #7 continued to undress himself and had began to have incontinence episodes when he was previously continent. The note documented the CNA notified the LN Resident #7's urine was dark and foul smelling. A nursing note, dated 10/16/20 at 9:09 AM, documented Resident #7 had acute back pain rated 4 out of 10 on 1 to 10 pain scale with 10 being the worst. There was no documentation noting the provider was notified of Resident #7's back pain. A provider note, dated 10/18/20, documented increased confusion possibly due to a urinary tract infection ([CONDITION(S)]) and [MEDICATION(S)] (an antibiotic) was started for a 5-day course. The facility's I &A reports documented Resident #7 had a change in ADLs (activities of daily living) related to unwitnessed falls. On 10/18/20 at 2:30 A.M., 5:28 P.M., and 9:15 P.M. Resident #7 experienced three unwitnessed falls. The facility had a care path for resident falls, undated, which stated when a resident had a fall after vital signs are taken the nurse should evaluate for signs of mental status changes and if there are none, the nurse should evaluate for acute decline in ADLs and consider contacting the physician for a urinalysis with urine culture. There was no documentation the nurse contacted the physician for Resident #7's acute decline in ADLs. A physician's order, dated 10/19/20 documented [MEDICATION(S)] antibiotic to be given twice a day for five days until 10/24/20 for [CONDITION(S)]. Per the FDA website, accessed on 3/15/21, [MEDICATION(S)] is indicated for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The FDA further stated that [MEDICATION(S)] should be used only to treat infections that are proven or strongly suspected to be caused by susceptible bacteria. Nursing notes, dated 10/20/20 from 1:09 AM to 5:25 AM, documented Resident #7 required constant supervision to prevent falls. There was no documentation the physician was notified of this change in condition. A nursing note, dated 10/20/20 at 12:48 PM, documented Resident #7 had multiple falls in the last few days, an increase in confusion, and the provider had ordered a UA. A urine microbiology culture result for Resident #7, dated received on 10/20/20, documented Resident #7's urine culture had coagulase negative staphylococcus. It contained a signature of a provider with a received 10/22/20 stamp and two nurse signatures. Per the FDA, coagulase negative staphylococcus is not affected by [MEDICATION(S)]. There was no documentation the IP had reviewed the microbiology culture result. There was no documentation Resident#7's antibiotic was changed from [MEDICATION(S)] to an antibiotic that would kill the coagulase negative staphylococcus growing in Resident #7's body. A physician's progress note, dated 10/23/20 at 8:20 PM, documented Resident #7 had significant [CONDITION(S)]/[CONDITION(S)] over the past week, his labs were without signs or symptoms of an infection, Resident #7 had poor oral intake and he had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . No new antibiotic orders were documented. A nursing note dated 10/24/20 at 3:11 AM, documented antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #7. A nursing note dated 10/25/20 at 6:31 PM, documented Resident #7 continued to decline in all aspects. His oxygen level was 76% on room air and supplemental oxygen was started. The provider was notified of changes in condition and Resident #7 was sent to a hospital. A nursing note dated 10/26/20 at 12:40 AM, documented a follow up call was made to the hospital where Resident #7 had been taken and Resident #7 was diagnosed with [CONDITION(S)] (the body's extreme response to an infection that is life threatening) On 10/26/20 at 12:00 PM, a situation report was added to the Bureau of Facility Standards Long term care Reporting system by the DON which documented facility staff were notified by the medical director of concerns by hospital staff regarding poor care and neglect when Resident #7 was sent to theER on [DATE]. On 3/10/20 at 1:19 PM, the ADON was interviewed regarding Resident #7's care. She stated due to Resident #7's increasing confusion and agitation her expectation was the nursing staff would be aware of changes intensifying and notify the physician. When asked about the facility's tracking of antibiotic use and the appropriateness of antibiotic use, she stated they did not have a designated ICP at that time. On 3/11/21 at 2:00 PM, the Clinical Resource Nurse stated there was no tracking or documentation for antibiotic stewardship during the months of October 2020 and November 2020. She stated there was no follow up related to antibiotic use by Resident #7 nor tracking of his symptoms.

Based on a complaint from the general public received by the Bureau of Facility Standards on 4/19/11, review of the facility's Abuse & Neglect Prohibition Program, staff interviews, record review, and review of the Change in Status Report - 2 shifts (CSR), it was determined the facility's managers contributed to the ongoing abuse of residents when they made decisions not to record, report, investigate, or provide interventions/supervision to prevent cognitively impaired residents, who resided in the Alzheimer's Care Unit (ACU), from performing aggressive physical and/or sexual acts towards other cognitively impaired residents. These residents were also not provided with supervision to be protected from these abuses. This failed practice resulted in ongoing serious harm, constituting immediate jeopardy, to 6 of 16 (#1, 2, 3, 7, 9, 11) residents on the ACU and had the potential to affect all residents of the facility. Specifically, the facility failed to: a) Ensure a cognitively impaired female resident (Resident #3) was protected from sexual contact by a second cognitively impaired female resident (Resident #2) who was not supervised; b) Ensure a cognitively impaired male resident (Resident #1) was supervised and made no physical and/or sexual contact towards other residents residing in the unit. This impacted Resident #s 9 and 11 and had the potential to impact all residents in the ACU; c) Ensure Resident #1 was not allowed by staff to wander into the private living areas of all residents in the ACU. Resident #1 entered the private living area of a female resident (Resident #7), resulting in a resident-to-resident altercation. The complainant alleged that on 4/18/11, an identified staff member was overheard telling a second identified staff member that on 4/16/11, on the day shift, Resident #2 was found in Resident #3's room and in bed with Resident #3. Resident #2 had her hand down Resident #3's pants. According to the complainant, the first staff member said she was told not to complete an Incident/Accident report and not to document the incident in the residents' records. Family members were not notified of the incident. The complainant also alleged that on the approximate week of 4/3/11, Resident #1 was wandering in and out of other residents' rooms on the ACU, and getting into other residents' belongings. Resident #1 went into Resident #7's room, and Resident #7 hit Resident #1. The complainant alleged that the staff inservice book documented staff were to allow Resident #1 to wander in other residents' rooms. The facility's failed practice was brought to the attention of the facility's Administrator, DON, and Corporate RN consultant on 4/21/11, at 5:10 pm, and the facility was provided with specific details of the failure to ensure residents were not being sexually, physically, and emotionally abused by other residents. NOTE: On 4/22/11 at 12:12 pm, the survey team called a second immediate jeopardy related to the facility's failure to respond to allegations of resident abuse. Refer to F 225 for specifics of the facility's failed practice. On 4/25/11 at 1:45 pm, the facility presented the survey team with an acceptable plan of correction and the immediate jeopardy was abated. The plan of correction included in part: * "Resident #1 identified by the survey team was placed on one-to-one supervision on 4/21/11 at approximately 6:00 pm, until transfer to the hospital. With the involvement and assistance of the Medical Director, physician orders [REDACTED].) The family was notified on 4/21/11 by the Alzheimer's (ACU) Director and agreed with this placement. Per the Medical Director this resident will not be returning to this facility and the hospital agreed to find other appropriate placement on a Behavioral Unit. The resident was transferred on 4/21/11 at 8:30 pm, per physician's orders [REDACTED]. * Resident #2 identified by the survey team was examined by the Medical Director on 4/21/11. The Medical Director provided orders for transfer of this resident to (name and address of a psychiatric hospital.) The family was notified on 4/21/11 by the Alzheimer's Director and agreed with this placement. Per the Medical Director, this resident will not be returning to this facility and the hospital agreed to find other appropriate placement on a Behavioral Unit. The resident was transferred on 4/21/11 at 8:30 pm, per physician's orders [REDACTED]. * On 4/21/11, the Staff Development Coordinator, RN, BSN, reviewed residents residing on the Alzheimer's Care Unit (ACU), their ADL records, care plans, behavior monitoring sheets, and nursing notes for the purpose of identifying any other residents who may have been negativity (sic) affected by sexual abuse. * Residents on the ACU will be evaluated by the Licensed Social Worker on 04-25-11 staff on shift are being interviewed by the Regional Director of Nurses on 04-22-11 and will continue until all ACU staff have been interviewed. * Staffing on the ACU has been increased to include a Licensed Nurse staff 24 hours per day, three Certified Nurse Aides; two to provide care and one as a monitor each shift. * Re-education was initiated on 4-21-11 by the Staff Development Coordinator, RN, BSN and completed on 4-22-11 for all active scheduled employees. Staff on LOA (leave of absence) or vacation will be re-educated prior to beginning their next scheduled shift. Staff on duty were immediately re-educated by the SDC regarding the (name of Corporation) Policy on Abuse Prevention and State of Idaho Facility Standards Abuse/Neglect guidelines. Remaining staff will be re-educated before the beginning of their next shift on the (name of Corporation) Policy on Abuse Prevention and State of Idaho Facility Standards Abuse/Neglect guidelines. Residents in the center will be monitored for sexual behavior. * Staff education with on (sic) Sexual Abuse will include examples for male to female, female to female and male to male. Examples would be: Holding hands, kissing cheek, forehead, hands, or other body parts, touching other residents anywhere, co-mingling in other resident's (sic) rooms, and/or lying on the bed together. * The Center held an Ad hoc Performance Improvement Committee meeting on 4-21-11 at 6:00 pm...Any identified issues will be immediately investigated and staff will be re-educated as warranted and notification will be made to the Physician, responsible party and State Agency... * Staff will be educated on the Chain of Command 04-25-11 by Acting Administrator." Findings include: The facility's Abuse & Neglect Prohibition Program, revised 11/2010, included in part: * "...Complaints/allegations, observations, or suspicion of neglect, abuse...must be thoroughly investigated and reported in a consistent and uniform manner... * Residents most at risk are those who have dementia, psychosocial deficits, infrequent or no visitors, are bedfast and totally dependent on care. These are our vulnerable residents... * The law presumes that instances of abuse of residents, even those in a coma, may cause physical harm, pain or mental anguish... * Sexual abuse is sexual contact with a resident without that person's consent, sexual harassment, sexual coercion, or sexual assault... * The resident has the right to be free from verbal, sexual, physical, and mental abuse... * The center must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source...are REPORTED IMMEDIATELY TO THE ADMINISTRATOR OF THE CENTER... * The center must prevent further potential abuse/harm while the investigation is in progress... * Mandatory Reporters - ALL employees of a center, regardless, of position or department are required by law to report any reasonable suspicion of a crime against a resident, including any known or suspected abuse, neglect...immediately upon identifying a concern... * Regardless of what your position is at the center, or what department you work in...YOU must report any known or suspected allegations of crime, abuse or neglect upon identifying a concern or potential concern... * The regulation does not give us the leeway to decide if an allegation is valid before we report it...You can never assume that an event didn't happen...Do not dismiss allegations as confusion - report it..." RESIDENT BACKGROUND and MDS INFORMATION * Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His admission MDS assessment, dated 3/17/11, coded: Usually understood and usually understands others; Severely impaired cognitive skills for daily decision making; Being short tempered, easily annoyed; Verbal behavioral symptoms directed toward others; Wandering which significantly intruded on the privacy or activity of others, daily. * Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 1/15/11, coded a BIMS score of 8 indicating moderately impaired cognitive skills for daily decision making. * Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Her most recent quarterly MDS assessment, dated 2/28/11, coded: Sometimes understood and sometimes understands others; Short-term and Long-term memory problems; Severely impaired cognitive skills for daily decision making; Wandering behavior occurred daily. * Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her 4/1/10 annual MDS assessment coded: Moderately impaired cognitive skills for daily living; Periods of restlessness; Sometimes understands others. * Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 4/11/11, coded: moderately impaired cognitive skills for daily decision making; wanders daily. * Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 2/15/11, coded, severely impaired cognitive skills for daily decision making, wandered daily. * Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Her 5/5/10 admission MDS assessment coded: Moderately impaired cognitive skills for daily decision making; Short and long term memory problems; Physically abusive behavioral symptoms; Deteriorated behavioral symptoms. The survey team entered the facility on 4/21/11 at 8:30 am, and requested that the Administrator provide all the Incident/Accident investigation reports and all Abuse/Neglect investigation reports from January 2011 through the current date. The team also requested the list of all direct care staff on duty at the time of entrance and for the time-period of 4/11 through 4/20/11. At 9:00 am, the Administrator provided one Resident-to-Resident abuse investigation report and stated that was the only one for the requested time period. NOTE: The investigation report involved an incident between Resident #s 1 and 7. Refer to F 225. The survey team interviewed 20 employees on 4/21 and 4/22/11. In order to keep the interview information anonymous, the employees were assigned random identification numbers which did not correspond to the order each employee was interviewed. Each employee's title/role was excluded from this report. The date/time of each interview was also excluded from this report, to ensure anonymity. The employees were asked a series of general questions about their knowledge of the facility's abuse prohibition policy. The employees were then asked if they had witnessed any recent incidents of physical, sexual or emotional abuse, particularly resident to resident. The following information was received: - Employee (#24) stated cognitively impaired residents could be intrusive, and wander. They needed to be re-directed. The employee gave an example that Resident #1 was receiving the medication [MEDICATION NAME] for behaviors of hitting and intrusive closeness. The employee stated, "Sometimes they lose their inhibitions and do not realize that this is unacceptable behavior." The employee named Resident #2 as a second resident example. The employee stated the resident, "Put her arm around another resident." Recently, Resident #2 was holding hands with another resident and trying to take the resident to Resident #2's room. The employee stated she did not witness this but it was told this in report and the incident was written down on the 24 hour report. The employee stated she had not witnessed any inappropriate resident contact in the ACU and had not heard of any occurrences. - Employee (#13) stated, "We have a couple females in ACU. One believes the other is a male, calling her a 'he-she.'" The employee stated the two residents have been observed holding hands and, "kissing on the lips." The employee named Resident #s 2 and 3. "(Resident #2) believes (Resident #3) is the male." The employee stated staff separate the two residents when these incidents occur. "(Resident #2) used to be the aggressor. (Resident #2) took (Resident #3's) arm and directed (Resident #3) to (Resident #2's or Resident #3's) room. (Resident #2) says (Resident #3) is he-she because (Resident #3) wears her hair short." Employee (#13) stated, "I have walked in and (Resident #3) was in bed with (Resident #2) in (Resident #2's) bed. (Resident #2) had her clothes off and (Resident #2) had her clothes on." The employee stated the incident occurred at bedtime, approximately near Christmas. "I believe I wrote a statement." The employee also stated, "I walked in...(Resident #2) was facing the wall and (Resident #3's) chest was to (Resident #2's) back." The employee placed a gown on Resident #3 and assisted her to Resident #3's room. The employee stated the incident was immediately reported to the nurse on the ACU. She again stated, "I believe I wrote a statement." The employee was asked by the survey team if management staff interviewed the employee. The employee stated there were no follow-up questions by administration. The employee indicated other staff members have also witnessed and/or heard of incidents in the ACU. Employee (#13) stated the incidents do get reported to the nurse working in the ACU, then to the Alzheimer's Program Director (APD), then the APD follows through with the DON. Employee (#13) also stated that on Saturday, 4/16/11, she heard that staff, "Caught (Resident #2) with her hand down (Resident #3's) pants." - Employee (#21) stated there were a few residents on the ACU, "two females who hold hands, (Resident #s 2 and 3.)" The employee stated she did not witness any sexual abuse, however, did hear "rumors." The employee did not comment further. - Employee (#26) had not witnessed any resident to resident abuse, however, was told about an incident of inappropriate sexual conduct and behavior. "We have a lady that thinks a lady is a man...(Resident #2) is confused and thinks (Resident #3) is a man and they were in the bed, cuddling in the bed and kissed." Employee (#26) also stated, "Everyone knows (Resident #2) has this behavior." The employee stated the sexual conduct between the two residents has not been charted, so could not be addressed by staff. "Something so bad happened between these two residents that has not been addressed." The employee stated, "Everyone knows, everyone's scared, everyone is intimidated they may lose their jobs." The employee stated the Administrator "is aware." Employee (#26) stated staff were told that Resident #1 was allowed to go into other residents' rooms. "He upsets other residents." The employee stated the staff received an in-service to allow the resident to wander in other residents' rooms. The employee stated the in-service was written. Employee (#26) was told Resident #1 went into other residents' rooms. The employee stated, "(Resident #9) came out of her room with only her attends on. This got (Resident #1) excited and he kissed another resident (Resident #11) on the forehead and cheek." The incident took place in the hall in the ACU. The employee stated that to her knowledge this incident was reported to the DON and written in the resident's record. However, to the employee's knowledge, there was no incident report written. Employee (#26) also stated there have been no incident reports written on any of the inappropriate occurrences in the ACU and no documentation in resident records. The employee stated the staff, "need to be able to chart exactly what behaviors are occurring and be able to write the accurate monitoring." Employee (#26) stated, "(Resident #2) got caught with her hand down (Resident #3's) pants. This happened on the day shift last Saturday (4/16/11)...The person who witnessed it reported it to the DON. The person who saw it was told not to chart it and that it would be taken care of." The employee stated, "If I were the family I would think I would want to know...The whole ACU (staff) knows what's going on." The employee described this encounter between the residents as, "This was more extreme. This should be wrote up. This has been going on but staff was told not to write it up." - Employee (#23) stated, "The Administrative staff is hiding things. There were resident-to-resident sexual incidents occurring a lot on the ACU. I report it." The employee stated that during the week of 4/10/11 on the night shift, Resident #9 came out of her room with only her attends on. "That turned (Resident #1) on and he kissed (Resident #11) on the forehead and cheek. He became lovey/dovey with staff." The employee stated there were only two staff in the unit at the time. "(Resident #11) is strict (name of a religious preference.) She was not the same after the incident. She was crying the next day after the kiss." Employee (#23) also indicated that during the week of 4/10/11, on the night shift (names of two staff) were in a resident's room performing cares. There was no other staff in the unit during that time. It was reported that the nurse came into the unit and observed Resident #1 in Resident #10's room. "The in-service record says (Resident #1) can go into other residents' rooms. That's wrong." The employee also stated Resident #1 was known to stay awake most of the night walking around the unit. The resident would sleep on the couch for about 1/2 hour around 4:30 am. Employee (#23) stated she had not witnessed any female to female inappropriate physical contact but had been told about incidents between Resident #s 2 and 3. "They've been caught together kissing and touching, quite abit." The employee stated she was unaware if these incidents had been reported. - Employee (#15) stated the staff try their best to keep the residents in the ACU "occupied and separated." The employee stated she has not witnessed any inappropriate physical contact between residents. She has received information during shift report, approximately 2-3 days a week, about Resident #s 2 and 3 kissing. At times the report was that the two residents, "Were kissing, a romantically engaged kiss." The employee also heard during the week of 4/10/11, about the two residents involved in a more sexual contact, described to her as "genital touching." The employee thought there may have been an in-service to keep the two residents separated and involved in activities. Employee (#15) was asked how the ACU was staffed. She stated it was her understanding that there were two CNAs on the evening shift, and an LN until 7:00 pm. After that time, there was no LN coverage in the unit through the night, until the next morning at 6:00 am. The LN, who works the 7:00 pm to 6:00 am shift, makes rounds into the ACU during the night. The employee stated she thought that during the night shift the CNAs could call to the staff working in other parts of the facility, "but they are busy as well." At times there was no one to assist the night shift CNAs when staff needed to enter a resident's room to perform two person cares. "There is no one out there (in the ACU) to watch the other residents." Employee (#15) stated Resident #1 was easily re-directed and follows staff around the unit. The resident liked to watch movies and read. "He would read everything he sees...He gets confused and needs to be re-directed." On 4/21/11 at 3:40 pm, LN #7 was interviewed. She stated she witnessed Resident #2 put her hand down Resident #3's pants on the day shift on Saturday, 4/16/11. "(Resident #3) was in (Resident #2's) room. I walked in and (Resident #2) pulled her hand out of (Resident #3's) pants." The LN stated she re-directed the residents, then called the DON. "She (DON)notified everyone else. She asked me to write a statement. Nothing was put in the chart by me. I was instructed not to. The DON said, 'Write a statement and put it under my door.'" The LN stated, "I wrote it on a blank piece of paper, the IDT form, and slipped it under (name of DON's) door before I left for the night." The LN was asked by the survey team to describe more accurately what she witnessed. The LN stated, "I was doing cares with another resident. I knocked on (Resident #2's) door. (Resident #3) was sitting on (Resident #2's) bed. (Resident #2) was standing in front of (Resident #3) and (Resident #2's) hand was coming out of (Resident #3's) pants, the front of her pants...I don't know how far she had her hand down there. I know (Resident #3) is not supposed to be in (Resident #2's) room. (Resident #2) knew what she did was wrong." The LN was asked if she notified the physician. She acknowledged she did not. She was also asked if she immediately assessed Resident #3 for physical injuries or for any emotional distress. "I did a head-to-toe assessment on Resident #3." She acknowledged she did not document the assessment. "I should have, but I didn't." She also stated, "I questioned it as abuse and called my DON and she said they would discuss it on Monday. She stated the DON would notify the ACU Director and the Administrator." The LN stated no one interviewed her. The LN stated, "I should have done an I/A even though they said they would do it." The LN was asked what immediate safety interventions were initiated. "We kept them separated and involved them in activities." She acknowledged no additional staff was provided for 1:1 staff supervision for Resident #2 and to ensure Resident #3's protection from Resident #2. The LN was asked how the staff ensured the residents' safety without additional staff. "They both (Residents #s 2 and 3) go to bed after supper, so they were separated." The LN also stated, "The next nurse that came on (duty) I told the details and to keep them apart and told the aides to keep them apart." The LN stated that to her knowledge the physician and family were not notified of the incident. The LN also stated she was not certain if the residents' care plans or behavior sheets were updated to reflect the incident. The LN stated she had not heard of any other incidents between Resident #s 2 and 3. She stated that several months ago she read in the Change in Status report- 2 shifts, that "(Resident #3) was found in bed with her pants off with (Resident #2)." She stated she was unaware if after that incident any interventions had been placed for the two residents. The LN was asked how the facility staffed the ACU. She stated the unit has a resident capacity for 22 residents, and recently there have been 16 residents. The day shift staffed one LN and two CNAs. The LNs work 12 hours shifts. After 7:00 pm, there are usually two CNAs but no LN assigned to the ACU. The LN stated that on night shift she works the entire facility and she walks the halls and would go back to the ACU to help. The LN was asked how the facility ensures abuse is not occurring on the night shift. She stated, "There used to be three aides on the night shift." NOTE: Refer to F353 as it addresses the facility's failure to adequately staff the ACU. On 4/22/11 at 1:10 pm, the DON was interviewed by the survey team. She was informed of an allegation made by multiple staff and the complainant that a staff member witnessed Resident #2 with her hand down the pants of Resident #3 while they were in Resident #2's room. The DON was also informed that the survey team received no investigation report of this incident when such instances of alleged abuse investigations were requested upon entrance on 4/21/11. The DON stated, "I did receive a phone call from (LN #7) last Saturday (4/16/11). I told her I'd contact (Administrator) and that's what I did, (Administrator and ACU director.) My direction to (LN #7) was to keep eyes on (Resident #2) and make sure they're separated...She (Administrator) did not give me any further direction at that time." The DON was asked if there was an investigation after the incident. The DON stated, "To my knowledge there was no investigation." The DON was asked if LN #7 performed an assessment on Resident #3 after the incident to assess for possible injuries. The DON stated, (LN #7) did not do a head to toe assessment on (Resident #3.)" The DON was asked, if observations were made/reported by staff of any physical sexual contact by a resident, be it female to female, male to female, or male to male, what would these observations be considered to be. The DON stated, "I don't know. I guess I don't have a response." The DON acknowledged she did not document the phone calls with the LN, Administrator, or the ACU director, or any instructions received or given." She stated, "I asked (LN #7) to write a statement and stick it under my door." The DON stated she did not ask any other staff to write statements. The DON also stated, "(LN#7) asked, 'What should I chart?' I said don't chart anything." The DON stated she showed the statement by LN #7 to the Administrator who talked to the ACU director about the incident. Resident #2 was placed on behavior monitoring and the treating physician came in and evaluated the resident. The DON was asked if she thought the incident should have been reported to the state. "I don't want to throw anyone under the bus, but it was discussed. We did discuss whether or not this was reportable." The DON was asked what was her understanding of incidents required to be reported. The DON stated, "Any physical abuse, immediately, verbal altercations if it causes agitation or ill harm to that resident...I hate to plead ignorance, it's no excuse." The DON stated Resident #s 2 and 3 have been observed to sit and hold hands, place head on shoulders. They were lost souls who had kind of found each other." The DON stated, "(LN #7) is an awesome LPN but she does have a history of, not over-reacting, but tends to make things larger than they are. When (Administrator) and I discussed it, human touch, holding hands, kissing someone on the cheek, we never interpreted it as sexual abuse or sexual assault." The DON was asked if she considered that Resident #3 may have been a victim. "I guess until yesterday, no I did not think that (Resident #3) was a victim." The DON stated Resident #2 thought Resident #3 was a male, and had referred to her as a "boyfriend." When Resident #2 was told that Resident #3 was not a male, Resident #2 said,"Well I know that." The DON was asked if Resident #2 thought her actions were appropriate towards Resident #3, then why did she pull her hand quickly out of Resident #3's pants when observed. "I don't know." The DON was asked her knowledge of any other staff who allegedly witnessed an incident in December, 2010, where the two same residents were lying in bed together and Resident #2 was dressed, but Resident #3 was lying naked against Resident #2 with her front body facing Resident #2's back, as in the "spooning" position. The DON stated, "It was reported to me that they were laying on the bed, not that (Resident #3) was naked, but they were laying on the bed." The DON acknowledged there was no investigation into this incident. She was not certain if staff who reported the incident to her had documented the incident in the residents' records. "There should be something in the care plan for redirection of (Resident #2 out of Resident #3's) room." The DON was asked if there was any documentation of a sexual relationship between the two residents. "Not that I'm aware of." The DON was asked again about the 4/16/11 (Saturday) incident between the two residents. The DON was asked if there was any reason why the incident would not be documented in each resident's record. The DON stated, "I'm thinking she (LN #7) may have asked, 'How do you want me to document this?' I said, 'just don't, just put it under my door.' I don't want to tell her how to document this. (Administrator) and I will talk about it on Monday." The DON was asked how the facility ensured Resident #3's safety. She stated staff were to "keep the resident in eyesight." The incident would be discussed the following Monday. The DON acknowledged she did nothing further after calling the Administrator. There were no additional interventions placed for the remainder of the weekend. The DON stated, "We've known they (Resident #s 2 and 3) were holding hands, seeking each other out, knew they were laying in bed together." The DON was asked if the staff thought it was all right for residents to lay in bed together. "I don't know." At this time the survey team requested a copy of LN #7's written statement. The DON returned at approximately 2:00 pm, with the copy of LN #7's written statement, signed/dated "4/16/11, 1300 (1:00 pm.)" which documented: "(Name of DON.) At 1130 (AM) I had one aid finishing lunch...At 1145 (AM) I personally knocked on (Resident #2's door). Upon entering (Resident #3) was sitting on (Resident #2's) bed and (Resident #2) was pulling her hand out of the front of (Resident #3's) pants. (Resident #2) voiced, 'I know that I can't do that and that she is not supposed to be in my room.(') (Resident #2) got upset due to the separation and refused lunch. Up to the timeframe of doing cares (Resident #s 2 and 3) were in day room sitting apart from each other and visiting with one another. (Resident #3) has shown no distress over the situation." On 4/22/11 at 2:00 pm, the Administrator was interviewed. She was asked her role in the facility's investigative process as it pertained to allegations of abuse. The Administrator stated staff members were to immediately call the DON, who would in turn call her. "Then we investigate it. If it's a reportable event either (DON) or I would call it in." The Administrator was then asked her role in the incident which involved Resident #s 2 and 3. She stated, "I was called that afternoon, (DON) called me and told me the nurse walked in, (Resident #3) was sitting leaned forward, (Resident #2) was in front of her, and the nurse saw her (Resident #2) pull her hand up. I said we need to keep these ladies apart and investigate this." The Administrator also stated that at that time she was unaware that the allegation also included that Resident #2 had her hand down Resident #3's pants. "On Monday, I still did not see how the nurse could have seen the hand in the pants. Then the story changed. On Tuesday the nurse says, 'Oh, her hands were in her pants'...Then she (LN #7) said, 'no, her hands came out of the waist band of her pants.'..When you have somebody reenact what happened, visualize it in your mind, there is no way in my mind that her hands were in her pants." The Administrator was informed that during the teams' interview with LN #7, the LN told the same account of the incident as she had documented in her written statement. The Administrator acknowledged she had not read the written statement by the LN. The Administrator was informed that the facility had not provided any documentation that the incident was investigated, that the resi

Based on a complaint from the general public received by the Bureau of Facility Standards (BFS) on 4/19/11, BFS Information Letter #2005-1, review of the facility's Abuse & Neglect Prohibition Program, the Event Management Reports (EMRs), staff interviews, record review, and review of the Change in Status Report - 2 shifts (CSR), it was determined the facility failed to thoroughly investigate all incidents/accidents, including injuries of unknown origin, to ensure residents were not being abused. Further, the facility failed to investigate and act on incidents of known resident abuse. These failed practices impacted 9 of 16 sampled residents (#1, 2, 3, 7, 8, 13, 14, 15, 16). This failed practice resulted in harm to Residents #2, 3, 14, 15, and 16, and had the potential to impact all residents, especially cognitively impaired residents in the facility who could not be interviewed by staff to explain the events or the cause of suspicious bruising/injuries. This failed practice constituted immediate jeopardy. Specifically, the facility failed to: a) immediately contact residents' responsible party and/or treating physician; b) immediately initiate investigations to determine the probable cause of the incidents, for example, if injury/ies sustained were caused by abuse, or by staff mistakes, AND, to protect residents from further potential abuse; c) interview all pertinent staff/witnesses and document the statements; d) notify the BFS of incidents, when required, per BFS Informational Letter #2005-1; e) ensure the Administrator signed/dated the investigation reports as complete. RESIDENT INCIDENT SUMMARY: A. On 4/16/11, Resident #3 was observed in Resident #2's room. Both residents resided on the ACU. Resident #2 had her hand down Resident #3's pants. The facility failed to initiate any investigation into the sexual contact between the two residents. (a, b, c, d, e) B. Resident #1, also on the ACU, had multiple incidents of invading other residents' rooms without staff . One of these events resulted in Resident #1 knocking Resident #7 to the ground. Resident #1 also had incidents of inappropriate sexual conduct with female cognitively impaired residents. The facility failed to investigate, report, and intervene in these ongoing behaviors resulting in resident abuse. C. On 1/11/11, Resident #16, who resided on the ACU, was found on the floor in her room by a resident who reported this to the staff. The resident suffered a left elbow fracture and multiple rib fractures requiring a four day hospitalization . The facility failed to perform the above interventions (b, c, e). D. On 11/1/10, Resident #14, who resided on the ACU, was observed with a hematoma on her forehead up to her hairline, which measured 4 centimeters (cms) by 5 cms. The facility failed to perform the above interventions (a, b, c, d, e). E. Residents #3, 7, 8, 13, and 15 had multiples falls, abrasions and/or bruises of unknown origin that were not investigated to rule out abuse or neglect, not reported, and not acted on to prevent further occurrances. The complainant alleged that on 4/18/11, an identified staff member was overheard telling a second identified staff member that on 4/16/11, on the day shift, Resident #2 was found in Resident #3's room and in bed with Resident #3. Resident #2 had her hand down Resident #3's pants. According to the complainant, the first staff member said she was told not to fill out an Incident/Accident report and not to document the incident in the residents' records. Family members were not notified of the incident. The complainant also alleged that on the approximate week of 4/3/11, Resident #1 was wandering in and out of other residents' rooms on the ACU, and getting into other residents' belongings. Resident #1 went into Resident #7's room, and Resident #7 hit Resident #1. The complainant alleged that the staff inservice book documented staff were to allow Resident #1 to wander in other residents' rooms. The facility's failed practice was brought to the attention of the facility's Administrator, DON, and RN consultant on 4/22/11, at 12:12 pm, and the facility was provided with specific details of the failed practice. On 4/25/11 at 1:45 pm, the facility presented the survey team with an acceptable plan of correction and the immediate jeopardy was abated. The plan of correction included in part: * "Incidents and Accidents of the Identified Residents...were reviewed for the past thirty days on 4-22-11 by the Acting DON for alleged or potential violations involving mistreatment, neglect, or abuse including injuries of unknown origin. A head-to-toe assessment was also completed for each of the residents on 4-22-11 by the Acting DON to ensure the resident's current status is reflected. * Incidents and Accidents for Residents of (name of facility) were reviewed... * Interviewable residents were interviewed by a Licensed Master Social Worker employed by (name of Corporation) on 4/24/11. There were no concerns expressed regarding abuse, neglect, or misappropriation. * Re-education was initiated on 4-22-1 by the Acting DON and completed on 4-23-11 for all active scheduled employees. Re-education was specific to the (name of Corporation) policy on Abuse Prevention and the State of Idaho Facility Standards abuse/Neglect guidelines.. * The Center held an Ad hoc Performance Improvement Committee meeting on 4-22-11 at 7:00 pm, with the Medical Direct to discuss the Plan of Correction... * The Administrator, Director of Nurses, and Alzheimer's Care Unit Director were suspended on 4/22/11, pending investigation. Determination of their continued employment will be determined based on results of the investigation being completed by the Region Vice President. If their employment is maintained, they will be reeducated specific to the (name of Corporation's) Policy on Abuse Prevention and the State of Idaho Facility Standards Abuse/Neglect guidelines, immediate protection of the resident from further abuse, incident and accident reporting policies and procedures, thorough investigation and determination of root cause, and reporting of injuries of unknown origin to the Region Vice President and Region Director of Clinical Operations. Oversight will be provided by the Region Vice President/Designee and the Region Director of Clinical Operations/Designees through review of event reports, center visits and staff interviews." Findings include: The facility's Abuse & Neglect Prohibition Program, revised 11/2010, included in part: * "...Complaints/allegations, observations, or suspicion of neglect, abuse...must be thoroughly investigated and reported in a consistent and uniform manner... * Residents most at risk are those who have dementia, psychosocial deficits, infrequent or no visitors, are bedfast and totally dependent on care. These are our vulnerable residents... * The law presumes that instances of abuse of residents, even those in a coma, may cause physical harm, pain or mental anguish... * Sexual abuse is sexual contact with a resident without that person's consent, sexual harassment, sexual coercion, or sexual assault... * The resident has the right to be free from verbal, sexual, physical, and mental abuse... * The center must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source...are REPORTED IMMEDIATELY TO THE ADMINISTRATOR OF THE CENTER... * The center must prevent further potential abuse/harm while the investigation is in progress... * Mandatory Reporters - ALL employees of a center, regardless, of position or department are required by law to report any reasonable suspicion of a crime against a resident, including any known or suspected abuse, neglect...immediately upon identifying a concern... * Regardless of what your position is at the center, or what department you work in...YOU must report any known or suspected allegations of crime, abuse or neglect upon identifying a concern or potential concern... * The regulation does not give us the leeway to decide if an allegation is valid before we report it...You can never assume that an event didn't happen...Do not dismiss allegations as confusion__report it..." The BFS Information Letter #2005 - 1, Resident Abuse Reporting in Skilled Nursing Facilities (SNFs), directs in part: * "State law and federal regulations require the SNFs report certain events to the survey agency... *Types of Abuse that must be Reported: - Physical abuse. This is non-accidental contact with a resident including hitting, kicking, slapping, biting, pinching... - Sexual abuse. This includes sexual harassment or sexual assault. This further includes sexual behavior between two individuals, at least one of whom cannot make informed consent. For example, sexual behavior between two residents with Alzheimer's dementia, who are not able to form a rational decision, would be an incident of sexual abuse, even though the residents may be calm and agreeable. * Incidents that must be Reported: - Resident injuries of unknown (underlined) origin. These are injuries whose source was not observed by any person or the source of the injury could not be explained by the resident AND, the injury includes severe bruising on the head, neck, or trunk, fingerprint bruises anywhere on the body, lacerations, sprains, or fractured bones... * Specific Possible Neglect Situations that must by Reported: - Staff mistakes, that result in the resident's need for hospitalization , treatment in a hospital emergency room , fractured bones...or death... * FOR ALL OF THE ABOVE INCIDENTS: - ALL ALLEGATIONS must be immediately reported to the facility's Administrator and the Department's hotline...no later than 24 hours from the discovery of the incident...Fax the completed investigation to the survey agency within five (5) working days... * All investigations must be signed by the Administrator within five working days of the allegation/incident. This signature indicates the administrator has reviewed the investigation, approves it as complete, and has ensured that appropriate measures have been taken... *INVESTIGATION GUIDANCE:. Components of a thorough investigation include: - Date and time of the incident -A clear and legible description of exactly what occurred -All pertinent staff (or other witnesses) must be interviewed and the results of the interview documented in some form. Whenever possible, have witnesses sign a written statement - Interview the resident(s) involved - All visible injuries must be MEASURED and described in detail - In cases of injury of unknown source, all staff having possible contact with the resident over the 24 hours prior to injury discovery must be interviewed - In cases of unwitnessed incident, the facility needs to determine when the resident was last observed by staff and what the resident was doing at that time..." The survey team entered the facility on 4/21/11 at 8:30 am, and requested that the Administrator provide all the Incident/Accident investigation reports and all Abuse/Neglect investigation reports from January 2011 through the current date. At 9:00 am, the Administrator provided one Resident-to-Resident abuse investigation report and stated that was the only one for the requested time period. NOTE: The investigation report involved an incident between Resident #s 1 and 7. 1. This example involved an incident on 4/16/11, which involved Resident #2 and 3. Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #3's most recent quarterly MDS assessment, dated 2/28/11, coded: * Sometimes understood and sometimes understands others * Short-term and Long-term memory problems * Severely impaired cognitive skills for daily decision making * Inattention and disorganized thinking behavior which fluctuated * Feeling down, depressed, or hopeless * Wandering behavior occurred daily Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's most recent quarterly MDS assessment, dated 1/15/11, coded: * BIMS score of 8 indicating moderately impaired cognitive skills for daily decision making * Wanders daily On 4/21/11 at 3:40 pm, LN #7 was interviewed. She stated she witnessed Resident #2 put her hand down Resident #3's pants on the day shift on Saturday, 4/16/11. "(Resident #3) was in (Resident #2's) room. I walked in and (Resident #2) pulled her hand out of (Resident #3's) pants." The LN stated she re-directed the residents, then called the DON. "She (DON)notified everyone else. She asked me to write a statement. Nothing was put in the chart by me. I was instructed not to. The DON said, 'Write a statement and put it under my door.'" The LN stated, "I wrote it on a blank piece of paper, the IDT form, and slipped it under (name of DON's) door before I left for the night." The LN was asked if she notified the physician. She acknowledged she did not. She was also asked if she immediately assessed Resident #3 for physical injuries or for any emotional distress. "I did a head-to-toe assessment on Resident #3." She acknowledged she did not document the assessment. "I should have, but I didn't." She also stated, "I questioned it as abuse and called my DON and she said they would discuss it on Monday. She stated the DON would notify the ACU Director and the Administrator." The LN stated no one interviewed her. The LN stated, "I should have done an I/A even though they said they would do it." The LN was asked what immediate safety interventions were initiated. "We kept them separated and involved them in activities." She acknowledged no additional staff was provided for 1:1 staff supervision for Resident #2 and to ensure Resident #3's protection from Resident #2. The LN was asked how the staff ensured the residents' safety without additional staff. "They both (Residents #s 2 and 3) go to bed after supper, so they were separated." The LN also stated, "The next nurse that came on (duty) I told the details and to keep them apart and told the aides to keep them apart." The LN stated that to her knowledge the physician and family were not notified of the incident. The LN also stated she was not certain if the residents' care plans or behavior sheets were updated to reflect the incident. On 4/22/11 at 2:00 pm, the Administrator was interviewed. She was asked her role in the facility's investigative process as it pertained to allegations of abuse. The Administrator stated staff members were to immediately call the DON, who would in turn call her. "Then we investigate it. If it's a reportable event either (DON) or I would call it in." The Administrator was then asked her role in the incident which involved Resident #s 2 and 3. She stated, "I was called that afternoon, (DON) called me and told me the nurse walked in, (Resident #3) was sitting leaned forward, (Resident #2) was in front of her, and the nurse saw her (Resident #2) pull her hand up. I said we need to keep these ladies apart and investigate this." The Administrator also stated that at that time she was unaware that the allegation also included that Resident #2 had her hand down Resident #3's pants. "On Monday, I still did not see how the nurse could have seen the hand in the pants. Then the story changed. On Tuesday the nurse says, 'Oh, her hands were in her pants'...Then she (LN #7) said, 'no, her hands came out of the waist band of her pants.'..When you have somebody reenact what happened, visualize it in your mind, there is no way in my mind that her hands were in her pants." The Administrator was informed that during the teams' interview with LN #7, the LN told the same account of the incident as she had documented in her written statement. The Administrator acknowledged she had not read the written statement by the LN. The Administrator was informed that the facility had not provided any documentation that the incident was investigated, that the residents were protected, that the treating physicians and responsible family members were notified of the incident, or that physical and psychosocial assessments were performed. The Administrator was asked if it was the practice of the staff to not document incidents. "Oh no, all allegations should be documented." The Administrator acknowledged that she had not reviewed the residents' records for documentation. "I did not do a very good job of investigating. I did not call it in. The (DON) told me she had a note (from LN #7) but I did not read it. I should have read it. It should have been in the record. I do not know why the nurse did not chart it." 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's admission MDS assessment, dated 3/17/11, coded: * Severely impaired cognitive skills for daily decision making * Being short tempered, easily annoyed half or more of the prior 14 days * Verbal behavioral symptoms directed toward others, 1-3 of the prior 14 days * Significantly intruded on the privacy or activity of others, 1-3 of the prior 14 days * Wandering which significantly intruded on the privacy or activity of others, daily Resident #1's Care Plan included the following focus areas, goals, and interventions - initiated on the date indicated: * Resident wanders in to others rooms is easily redirected. 3/27/11 - 1:1 supervision to see (Resident #1) at all times. 3/28/11-4/4/11 * Exhibits inappropriate behaviors of... rummaging in others rooms related to: Dementia and inability to differentiate others belongings. There will be no resident to resident incidents when residents (sic) goes in others rooms. 3/27/11 - 1:1 staff supervision to redirect (Resident #1) from going in peers rooms. 3/28/11, discontinued 4/4/11 EMR documented: * 3/27/11 - "Resident accidentally presented himself in another resident room. The room is a female resident shared with 2 females. One female resident became very upset with his presence, was very loud and vocal stating to resident to get out, is not your room. Staff approaching to intervene, this resident was standing in the middle of the room. Female resident was lying on the floor next to doorway. Claiming to have been handled by resident. Resident (#1) stating, 'I am sorry.' No notable injuries on resident. Seemed upset (at) the time." * 4/1/11 - "On resident weekly skin assessments 2 bruises were found to resident's right arm. The 1st bruise to resident right wrist measures 3 cm (centimeter) x 3 cm and the 2nd is a bruise to resident right elbow that measures 6.5 cm x 4.5 cm." There were no staff interviews or indication of any other investigatory action, and the incident was not reported to the Bureau of Facility Standards as an Injury of Unknown Origin. A 3/28/11 IDT Cares Review note documented a description of the 3/27/11 altercation between Residents #1 and 7. It concluded, "Will follow in 1 week," but the resident's medical record did not include documentation of an IDT meeting about this resident or situation the following week. MDS assessment notes written by the ACU Director in various sections of the resident's medical record documented: * 3/28/11: A description of the 3/27/11 incident with Resident #7 * 4/20/11: "Had an incident on 4/18/11 in which he kissed a female peer on the forehead and cheek in the hallway. The two residents were separated without incident and redirected to separate areas of unit. Will continue to observe." NOTE: There was no documentation that the physician was notified of this event, or that an incident report was initiated. No investigation was done. CSR logs from the ACU documented the following entries related to Resident #1: * 3/27/11 - "(Resident to resident) altercation - no injuries." * 4/17/11 - "Wandering all (night), entering all rooms, (urinated) in (a female resident's) toilet, flirty with (same female resident), hand holding. (Same female resident) not appropriate (with) clothing tonight (with Resident #1) entering room, she came out half dressed to hallway (twice) - happy, flirty. Aggressive (with CNA), upset tonight because she was (constantly) redirecting him as is her job; (another male resident) upset - 4 letter words (and a different male resident) due to (Resident #1) in (their) room. No calls made because we were able to redirect but (Resident #1) was busy busy busy, (up and down) all (night and) refuses to (change) wet clothes this early (morning). Sleeping on couch sitting up (at) 4:30 AM." NOTE: There was no documentation that the physician was notified of this evening's events, or that an incident report was initiated. On 4/21/11 at 5:20 PM the administrator was interviewed about Resident #1's wandering in the ACU unit. She stated, "He only goes in and turns around and leaves. The only time he was rifling was the incident with (Resident #7). The Surveyor advised the Administrator that documentation showed that not be true. The Administrator responded, "Oh." 3. Resident #3 also sustained injuries that were not thoroughly investigated. The following three EMRs documented in part: * 3/28/11 at 10:00 am - "Event: Self inflicted injury - Resident is found with an eccymosed (sic) area on R(ight) outer thigh (2 cm diameter). Resident unable to verify occurrence. Staffing unable to note any occurrence. - Witnesses: (Two CNA staff listed) - Were there any contributing factors? Yes. Resident is up and about ad lib. Resident is able to amb(ulate) with no problems. Can have a lack of safety net when approaching tables or other stationary devices. - Summary of interview(s): (left blank.) - Resident's explanation of event: Resident unable to verify of any occurrence. - Was the resident's cognition/behavior a factor? No. - Nurse Manager/Supervisor Review: (left blank) - Status: Not completed - Last modified by: (Name of LN) 3/29/2011 at 8:33 PM." The facility failed to perform the above interventions (b, c, e). * 4/5/11 at 3:00 pm - "Event: Self inflicted injury - Resident is noticed with a large eccymosed (sic) area on right wrist (2.5 cm x 3 cm in length). Resident in (sic) unaware of occurrence stating has no pain sensation on the sight. Staffing does not recall any incidents that would have caused the incident. Resident is amb. ad lib. - Witnesses: (Name of LN who completed the form) - Is there alleged abuse? No - State Agency Notified? No - Resident's condition before event/accident: Confused - Status: Not complete - Last Modified: (Name of LN) 4/5/2011 at 3:03 PM." * 4/16/11 at 9:00 pm - Event: Fall - No one witnessed fall but resident stated she fell and scraped her back. Noted to have several superficial abrasions on R(ight) lower back....TV in the room noted to be on the floor. - Witnesses: (Two CNA staff listed) - Is there alleged abuse/neglect? No - Resident's condition before event/accident: Disoriented - Family/responsible party notified? 4/17/11 at 6:00 am, (nine hours after the incident.) - State agency notified? No - Last Modified "(Name of LN) 4/16/11 at 4/16/2011 at 11:46 PM." Resident #3's IPNs documented the following in part: * 4/5/11: "...Resident is usually amb ad lib. Does have another peer whom she follow closely, will cont(inue) with observation..." * 4/7/11: "..Continues to follow another resident closely. Resident is easily re-directed..." * 4/16/11: "Resident states she fell & hurt her back. She states she tried to grab TV & TV went down..." * 4/17/11: "...Resident is talkative, continues with confusion, cannot explain what happened last eve(ning) does express pain in R rib to chest area..." * 4/18/11: "Skin assessment today, check on buttock area. R buttock area eccymosed (sic)area (10 cm length x 4 cm wide) Abrasion to upper buttock are toward center of back, (0.5 cm diameter) R mid forearm and L mid forearm eccymosed (sic) area (3 cm diameter) each side. Reported to (Name of PAC), who was here for resident evaluation d/t (due to) fall..." The facility failed to perform the above interventions (a, b, c, d, e). 4. Resident #16 was admitted to the facility on [DATE] after being hosptalized on [DATE] with [DIAGNOSES REDACTED]. The hospital report documented in part: 8/21/10: "...She apparently suffered a mechanical fall in her home where she lives independently but has no idea why she fell or if she lost consciousness. On arrival at the emergency department, she reported that over the last 7 days she had been home alone. She had been unable to stand or weight bear. She had been crawling around on the floor and had nothing to eat. She reported to the emergency department personnel that she had been drinking water from the dog's bowl and finally was able to get to the phone and activate EMS. EMS reported...the patient was laying on the floor when they arrived at the house and that the house was unlivable...very malodorous and poorly kept with feces and trash all over the floors...The patient is alert, but somewhat confused..." Resident #16's [DIAGNOSES REDACTED]. Her Admission MDS assessment, dated 8/24/10, coded: * Moderately impaired cognitive skills for daily decision making * Easily distracted * Periods of altered perception or awareness of surroundings * Episodes of disorganized speech * Mental function varies over the course of the day * Usually understands (may miss some part/intent of message) physician progress notes [REDACTED]. * 8/23/10: "...Doesn't remember essentially any recent events accurately..." * 8/24/10: "...[DIAGNOSES REDACTED] profound confussion (sic)..." * 8/27/10: "...A & O to person...not to place...OMS (with) [MEDICAL CONDITION]" * 8/31/10: "...Generally reclusive but no major combativeness @ this time..." An EMR, dated 1/11/11, 8:00 am, documented in part: - "Event: Fall - Injuries: Bruises, Fracture, skin tear - Is there alleged abuse/neglect? No - Location of fall: Resident's room - Cause: Resident health/mental status - Resident's condition before event/accident: Normal - Transferred to hospital? Yes - Physician notified? Yes, 1/11/2011, 08:05 am -Family notified? Yes, 1/11/2011, at 10:00 am." NOTE: Family was not contacted until two hours after the fall and after the resident had already been transported to the emergency room . - State agency notified? No - Describe the circumstances of the event: A female resident residing on ACU went into room (#) of resident (#16. Female resident) came to this nurse to report resident on the floor who resides in room (#). Entering room (#) found resident occupant of room (#) lying on the floor on her left side alert coherent indicating had attempted to get up out of bed. Found self falling onto floor. Blood was observed on the floor...Unit Director (Name) came immediately asking resident if she had pain anywhere, answering (') my chest hurts (')..complaints of pain in her chest became more evident...Order to transfer to hospital for evaluation... - Witness(es): (Names of the RN and ACU director listed.) - Hotline Notified? No - Extenuating Circumstances: None FALL INVESTIGATION: - Position before event occurred: (left blank) - What was resident doing at the time of the fall? (left blank) - Fall related to seating/positioning? (left blank) - Fall related to recent change in ambulation status? (left blank) - Comments: (left blank) - [MEDICATION NAME] Factors: [MEDICAL CONDITIONS] - Mental Status Prior to Fall: (left blank) - Recent Change in Cognition/Behavior: (left blank) - Environmental Factors: (left blank) - Footwear/Equipment at time fall: (left blank) - Assistive devices used by resident: (left blank, including 'none') - Equipment working properly? (left blank) - Was call light functioning? (left blank) - Was call light in reach of resident? (left blank) - Was bed in low position? (left blank) - How long since last voiding? (left blank) - Additional comments: (left blank) - The Clinical Management Team determined that the fall was related to (check at least on of the below): (left blank) - Summary of interview with witness(es): (left blank) - Root Cause Conclusion: (left blank) FRACTURE: - Were medications a factor? No - Cause of Injury: (left blank) SKIN INVESTIGATION: - Skin tear: Yes - Evaluation: (left blank) - Was mobility a factor? Yes - Was a device a factor? Yes - Was the resident's cognition a factor? No - Was the resident's behavior a factor? No - Additional comments: (left blank) - Resident's explanation of event : Resident stated was getting up from bed found self falling - Narrative conclusion of root cause; (left blank) - Nurse Manager/Supervisor Review: Staff interviewed: (left blank) - Summary of staff interview: (left blank) - Evaluation of event-cause or contributing factors: (left blank) - Status: Not Complete..." - Last modified by: (Name of RN) on 1/11/2011, 7:56 pm." Resident #16's IPNs were reviewed. There were no entries after 12/13/10. A Change of Condition Documentation form, dated 1/10/11, (rather than 1/11/11,) documented in part: "Resident was found on floor lying on left side - sign of blood from unknown source. Resident alert, coherent stating pain in chest..." The physician progress notes [REDACTED]. C/O L (complaint of left ) chest wall pain, hurts too much to move. Pt says she doesn't know how she fell ..." Resident #16 was admitted to the hospital on [DATE], after she sustained multiple left rib fractures and left elbow fracture. She remained hospitalized until 1/15/11. On 4/22/11 at 12:00 pm, the DON was asked if the facility had any further documentation related to their investigation that was not included in the documents received by the survey team at the beginning of the complaint survey. The DON stated, "That's all I have for the I/As (EMRs.)" The DON acknowledged there were no documented staff witness statements. She also stated, "The individual resident's nurses notes might reference the incident." On 4/28/11 at 11:45 am, the survey team requested Resident #16's IPNs for the time period of 12/14/10 through 1/11/11. At the time of the exit on 4/29/11, no additional documentation was received. The acting Administrator was contacted by phone on 5/3/11 at 10:40 am, and the documentation was again requested. At 2:44 pm, the acting Administrator called the BFS and informed the surveyor that he could not locate any IPNs for the requested time period. The facility failed to thoroughly investigate the circumstance of Resident #16's unwitnessed fall to rule out the possibility of abuse, neglect or staff error. The staff relied solely on the statement of the cognitively impaired resident as to the possible circumstance of the incident. There was no evidence the Administrative team reviewed the investigation report to ensure the incident was thoroughly investigated or that the Administrator signed/dated the investigation report as complete. 5. Resident #14 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #14's most recent quarterly MDS assessment, dated 4/10/11, coded: * Usually understood and usually understands * Short-term and Long-term memory problems * Severely impaired cognitive skills for daily decision making * Inattention and disorganized thinking behavior which fluctuated * Being short-tempered, easily annoyed nearly every day * Wandering behavior occurred daily An EMR documented in part: *11/1/10 at 9:00 AM - "Event: Unobserved injury - "Resident is observed with a hematoma on forehead up to hairline approx(imately) (4 cm x 5 cm) Faded light blue no complaints of pain to scalp. Has been now noted resident had announced to staff on approximately [DATE], of the evening, resident stating had a 'terrible' fall in her bathroom. Was responded to per caregivers on that

Based on a complaint from the general public received by the Bureau of Facility Standards (BFS) on 4/19/11, staff interviews, review of Event Management Reports (EMRs), review of the facility's Abuse & Neglect Prohibition Program, and review of clinical records, it was determined the Administrator, DON and management team failed to manage the facility to ensure the safety and well being of each resident. They contributed to the ongoing abuse and neglect of residents when they made decisions not to record, report, investigate, or provide interventions/supervision for residents. This failure resulted in findings of immediate jeopardy at both F223 for Resident #s 1-3, 7, 9, & 11, and at F225 for Resident #s 1-3, 7-8, 13-16. Additionally, deficient practices resulted in harm or potential harm to all residents residing in the facility including sampled/random residents identified in the report. Findings included: The complainant alleged that incidents in the ACU involving identified residents were not being investigated or documented in residents' records. Residents were allowed to continue intrusive behaviors. Family members were not notified of the incidents. The complainant also alleged a documented weight on an identified resident was "scratched out" to conceal a significant weight loss. The Administrator, DON and management team failed to: 1. Ensure residents were safe from physical and/or sexual contact with other residents. This impacted Resident #s 1-3, 7, 9, & 11. Refer to findings of immediate jeopardy at F223 for additional details. 2. Ensure thorough investigations into resident to resident physical and/or sexual contact, injuries of unknown origin and accidents were conducted to rule out abuse or neglect by staff or other residents. This impacted Resident #s 1-3, 7-8, 13-16. Refer to the findings of immediate jeopardy at F225 for additional details. 3. Ensure residents' needs for social services were evaluated as the residents' psychosocial health changed. This impacted Resident #s 1-3, 5-9, 11, 15, 22-23, & 25. Refer to the findings of harm at F250 for additional details. 4. Prevent severe weight loss. This impacted Resident #s 5, 6, 8, 15. Refer to the findings of harm at F325. 6. Address a resident's pain with appropriate interventions to alleviate the pain, treat residents with constipation and coordinate care with the [MEDICAL TREATMENT] center. This impacted Resident #s 1, 6, 8, 15. Refer to the findings of harm at F309 for additional details. 7. Ensure documentation was complete and accurately reflected residents' condition. This impacted Resident #s 2, 3, & 5. Refer to the findings of harm at F281 for additional details. 8. To provide treatment and services to address the mental and psychosocial adjustment difficulties experienced by a resident when the resident was admitted to the facility after living independently in the community. This impacted Resident #1. Refer to the findings of harm at F319 for additional details. 9. Ensure adequate supervision of residents to prevent falls which resulted in a [MEDICAL CONDITION] and a fractured left elbow and multiple left rib fractures. This impacted Resident #s 3, 7, 8, 11, 15, & 16. Refer to the findings of harm at F323 for additional details. 10. Assess residents' initial and continued need for placement on the locked ACU unit affecting Residents #s 12, 14, 16 & 24. Refer to the findings at F151 for additional details. 11. Notify the physician and/or family of a change in condition affecting Resident #s 1-3, 5-6, 8 & 15. Refer to the findings at F157 for additional details. 10. Ensure sufficient staff was available in the ACU to prevent physical and/or sexual contact between residents. This impacted all residents residing in the ACU. Refer to the findings at F353 for additional details.

Based on a complaint from the general public, record review, resident interview, and staff interview, it was determined the facility failed to ensure residents did not sustain severe weight loss. This was true for 4 of 16 (#s 5, 6, 8 and 15) sampled residents. The facility failed to recognize, evaluate and address the needs of these residents in a timely manner and intervene to avoid harm. The facility failed to monitor these residents effectively after care plan implementation and make revisions to avoid continued weight loss and debilitation. * Resident #5 was harmed when he lost 25 pounds (163 pounds to 138 pounds) in a 13-day period (3/25/11 to 4/7/11), had ill-fitting dentures, and although reported to management, appropriate interventions were not implemented, followed, or evaluated for effectiveness. * Resident #6 was harmed when he lost 40 pounds (146 pounds to 106 pounds) in a 90-day period (1/14/11 to 4/14/11). The resident had difficulty with mastication and the facility did not prioritize the need for a dental appointment and/or implement other interventions to improve nutritional intake. * Resident #8 was harmed when she lost 11% of her body weight (10 pounds) in a 2 week period; laboratory data supported that the problem was nutritionally based and not due to her [MEDICAL CONDITION]. * Resident #15 was harmed when she lost 8.4% of her body weight (10%) in a 1 month period; 12% (14 pounds) in 3 months, and a total of 38 pounds since admission. Findings included: A complaint from the general public was received by the BFS on 4/19/11, alleging severe weight loss in a resident. 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The (local hospital) report, dated 3/19/11, documented the resident was admitted after presenting with a one week history of decreased appetite and strength. It also documented the resident had no [MEDICAL CONDITION]. The Medical Nutrition Therapy Assessment, dated 3/28/11, documented an admission weight of 163 pounds. In addition, a handwritten note under Resident Comments stated, "Pt. patient) reports sig. (significant) wt. (weight) loss last 3 weeks. 20-30 lbs (pounds)." Also documented was "edentulous, full/partial dentures, chewing ability," with a handwritten note above the latter that read, "ill fitting dentures." The Assessment portion of this form documented, "Nutrition needs are not met with current intake," with an additional handwritten note that read, "...Pt (patient) has ill-fitting dentures which he doesn't wear causing chewing difficulty...." The Assessment noted the resident was on a House Consistent Carbohydrate diet with as needed and bedtime snacks. A document received from the facility described the House Consistent Carbohydrate diet as a less restrictive diet when blood glucose and wieght are controlled. It does not restrict calories. The Plan area of this assessment documented, "Maintain current weight-no sig. changes. Enc. (encourage?) increase intakes greater than 50% all meals-monitor daily. Monitor labs as available." The resident's initial MDS assessment, dated 4/1/11, documented the following: * Moderately impaired cognitive status for daily decision making * Usually understood and able to understand others * Felt down, depressed, or hopeless and felt bad about himself 7-11 days in the last two weeks * Felt tired, having little energy and poor appetite 12-14 days in the last two weeks * Needs assistance requiring set up help only for eating The CAA for Nutritional Status, dated 4/4/11, documented a therapeutic diet and only indicated this was a care plan consideration to "avoid complications." The Physician Orders (recapitulation), dated April 2011, documented the following: "Dietary-Diet type: House Consistent Carbohydrate (HCC) Texture: Regular Special Instructions: Difficulty chewing as does not wear dentures..." and had an order start date of 3/25/11. Resident #5's Care Plan, dated 3/28/11, documented the focus, "Nutrition Care Plan: Alteration in Nutrition Status Diagnosis/disease/condition/treatment-...Dental/oral problems-ill fittinf (sic) dentures, weight loss, chewing difficulty." A handwritten goal, dated 4/18/11, documented, "Intakes less than 50 percent. Weight to stabilize. Temp. (temporary) ground diet while dentures repaired." These handwritten notations had no initials or signatures indicating who had made these entries. NOTE: There was no evidence of a physician order for [REDACTED]. The Hydration Care Plan for the resident, dated 3/28/11, documented, "Report food and fluid intake of less than 50% for three consecutive days to licensed nurse/dietitian." The Nutrition Care Plan, dated 3/28/11, documented, "Offer meal alternates for intake less than 50%," and a handwritten note referenced above for a temporary ground diet while the dentures were being repaired, dated 4/18/11. The Acting DON was asked for documentation for these Care Plan interventions on 4/28/11 at approximately 10:00 am. She stated the only documentation was in the IPN written by nursing and it only documented notations such as "poor appetite." NOTE: There was a focus area added to this Care Plan on 4/18/11, that read, "Weight loss admit-163 lbs...Refused (to be reweighed) until (4/18) 137 lbs." On 4/21/11 at 1:10 pm, CNA #10, who was responsible for weighing residents in the facility, was interviewed regarding Resident #5's weights. She stated she had weighed the resident on 4/7/11 and it showed a severe weight loss for the resident. CNA #10 stated she was told by the DON to completely black out the weight on the Weekly/Monthly Weight Record Worksheet for April because the recorded weight would show a weight loss. She stated the resident did refuse to be weighed again the following two days. She added she does not work on the weekends and so the next time she weighed the resident was on 4/18/11. She stated the resident weighed 134 pounds. She added that she had an accurate memory of what Resident #5 did weigh on 4/7/11 and it was 138 pounds. This was a 25 pound weight loss in 13 days. There was no documentation medical staff (physician/physician exterder) was aware of the resident's weight loss or his refusals to be reweighed before 4/18/11. Resident #5's IPN for 3/25/11 at 2:00 pm, documented "...Has dentures upper/lower and didn't fit well and took dremmel tool and attempted to refit. They do not stay in now..." On 4/18/11, 24 days after admission, was documented, "Has apt (appointment) with Denturist 9 am on 4/21 to re-line dentures after he (resident) 'fixed them with a drummel (sic) tool' prior to admission." On 4/2/11 at 9:00 am, the IPN documented, "Breakfast at bedside untouched." At 1:00 pm, it documented, "Ate poor at lunch..." On 4/3/11 at 10:10 am was documented, "...Ate poor breakfast..." and again on 4/5/11, "...Poor appetite..." These kinds of remarks continued throughout these notes. Meal monitors for Resident #5 documented the following: 3/26-4/26/11 Ate 50% or less of breakfast 25 out of 32 days Ate 50% or less of lunch 31 out of 32 days Ate 50% or less of supper 30 out of 31 days Ate bedtime snack 0 out of 31 days The ADON, RD and the Regional Director Nutrition Services (RDNS) were interviewed with regards to Resident #5 on 4/27/11 at 2:50 pm. The RD said that it was noted at a Care Conference on 3/31/11 that the resident needed to eat more. She stated they changed his table in the dining room and changed his room in the facility to be closer to the nurse's station. She also noted he was encouraged to eat. She stated the physician had written an order on 4/25/11 (one month after his admission and weight loss) for the resident to be allowed to have a glass of wine or a beer and to allow him to smoke if he wished. She stated these were to encourage the resident's appetite. She also stated his [MEDICATION NAME] (diuretic) was decreased on 4/26/11. The RD was asked how any of her orders or concerns was communicated to medical staff. She stated she attended the IDT meetings on Mondays and the facility was responsible for communicating this information to the medical staff. The RD stated the information should have been documented in writing. The ADON was asked where the Care Plan interventions of informing the LN and the dietitian of food and fluid intake of less than 50% should have been documented. She stated it should have been documented on the meal monitors but it "was not." On 4/28/11 at 11:00 am, the Acting DON was interviewed as to the delay in providing or arranging dental care for Resident #5. The Acting DON stated the van driver was responsible for making the appointments for residents. When asked if there was documentation of when the van driver would have received that request for a resident, she replied there was not. When asked if there was documentation to show when the van driver had made an attempt to make an appointment for Resident #5, she replied there was not. Resident #5 was hosptalized on [DATE], during the survey, for pneumonia with systemic [MEDICAL CONDITION] and dehydration. Resident #5 suffered a significant decline in his nutritional status, losing 30 pounds or 18% of his body weight in the first 24 days of his admission. It was documented from his admission he had ill-fitting dentures and could not wear them, causing him difficulty with mastication and nutritional intakes yet the facility failed to prioritize his need for an appointment with a denturist until 4/18/11. It was documented from admission the resident had a recent history of weight loss yet he was not aggressively care planned nor were his care-planned interventions followed or evaluated for effectiveness. The facility failed to document physician notification of the resident's severe weight loss. There was no documentation the facility attempted to communicate with this resident how to best meet his nutritional needs and assist him in refitting his dentures in an expeditious manner. The Acting DON and Acting Administrator were informed of this issue on 4/28/11 at 2:40 pm. No further information was received on this matter from the facility. 2. Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. An IPN for Resident #6, dated 1/17/11, documented, "(Resident) was admitted on [DATE] with [DIAGNOSES REDACTED]." On 1/24/11, documented, "...Pt. on ground diet for poor dentition." Resident #6's Admission Nursing Assessment, dated 1/14/11, documented in the section, Oral/Nutritional, that the resident had chewing problems and was missing upper and lower teeth. The initial Medical Nutrition Therapy Assessment for the resident, dated 1/18/11, documented in the section, Oral/Dental, "chewing ability," with a handwritten note above that read, "poor dentition." Laboratory data listed on this assessment listed protein results at 4.7, with an indication of "low," as well as [MEDICATION NAME] results at 2.1, with an indication of "low." Lab values for 3/4/11 documented protein total values of 5.1, a low value, and [MEDICATION NAME] at 2.5, also a low value. On 4/11/11, pre-[MEDICATION NAME] lab value was 11, also a low value. NOTE: Protein lab values, including [MEDICATION NAME] and pre-[MEDICATION NAME], were considered as they were indicators of malnourishment (Nutrition and Diet Therapy, 7th Edition,De Bruyne, Pinna, and Whitney). The resident's admission MDS assessment, date 1/21/11, documented the following: * Moderately impaired cognitive skills for daily decision making * Poor appetite or overeating 12-14 of the last 14 days * Independent requiring set up help only for eating * Mechanically altered diet * Obvious or likely cavity or broken natural teeth The Nutritional Status CAA, dated 1/24/11, documented the functional problem that affected the resident's ability to eat as, "Inability to perform ADLs without significant physical assistance," and did not identify any dental/oral problems as had been documented on the MDS assessment. The resident's Care Plan, dated 1/18/11, documented the Focus area, "Nutrition Care Plan: Involuntary weight loss related to: Difficulty chewing, hip fx (fracture), osteopenia,[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disorder), tobacco addiction." This was documented as initiated on 1/18/11 and the only intervention listed that pertained to poor dentition was for a House-ground diet with snacks as needed. Other interventions listed included: * "Offer alternate meal for intake less than 50%," * "Encourage family to bring in favorite foods," * "Meals in dining room," * "Weekly weights until stable," * "Monitor labs as available." A new focus area, "Intakes decreased, refuses weights," dated 1/24/11, was handwritten on the Care Plan, with a goal, "Intakes to 50%." Interventions for this additional focus area included, "Cont. (continue) to try to get weight," with a note that read, "DC 3/28/11," and the DON initialed the change on the Care Plan. An additional focus area added on 2/14/11, "Weight Loss," documented the goal, "Intakes to 50%, Weight to stabilize," with the interventions, "Honor pt. food/fluid requests, snacks-sup (supplemental) meals." On 4/4/11, a goal was added to the Care Plan, "Anticipate weight loss with decline and poor intakes," with an intervention, "All interventions above, health shakes QID (four times daily)." The Hydration Care Plan for the resident, dated 1/18/11, documented, "Report food and fluid intake of less than 50% for three consecutive days to licensed nurse/dietitian," and had a handwritten note, "DC (discontinue) 2/15/11," with no initials identifying who made the notation. A Dysphagia Evaluation for Resident #6, dated 3/7/11, documented his nutritional status as, "weight loss and nutritional risk," and dental status as, "own teeth," "functional-no," with a handwritten note that read, "missing molars." The quarterly Medical Nutrition Therapy Assessment for Resident #6, dated 4/4/11, documented, "...Pt. has had consistent weight loss since admit with poor intakes and multiple refusals. Pt. is on House-ground diet-sup meals-eats in room. Independent eater...Pt at high risk for [MEDICAL CONDITION] and dehydration-drinks very little. All staff is encouraging him to drink...Pt continues with sig. weight loss due to poor appetite and intakes. He is drinking healthshakes QID but little else. Obtained add. (additional) likes/dislikes-advised kitchen to send to try and increase intakes." Meal monitors for Resident #6 documented the following: * 1/15-1/31 Ate 50% or less of breakfast 13 out of 17 days Ate 50% or less of lunch 16 out of 17 days Ate 50% or less of supper 14 out of 16 days Ate bedtime snack 0 out of 16 days NOTE: Resident was in emergency department for constipation on 1/28/11 * 2/1-2/28 Ate 50% or less of breakfast 27 out of 28 days Ate 50% or less of lunch 23 out of 28 days Ate 50% or less of supper 25 out of 28 days Ate bedtime snack 4 out of 28 days * 3/1-3/31 Ate 50% or less of breakfast 31 out of 31 days Ate 50% or less of lunch 26 out of 31 days Ate 50% or less of supper 28 out of 31 days Ate bedtime snacks 0 out of 31 days * 4/1-4/26 thru lunch Ate 50% or less of breakfast 21 out of 26 days Ate 50% or less of lunch 22 out of 26 days Ate 50% or less of supper 22 out of 25 days Ate bedtime snacks 1 out of 25 days Resident #6's admission weight was 146 pounds. His weight declined as follows: 2/7/11 121 pounds - 25 pound weight loss in 23 days or 17% in less than one month 2/14 Documented as refused 2/21 Documented as refused 2/25 119 pounds - 27 pound weight loss in 41 days or 18% 3/7 Documented as refused 3/14 117 pounds - 29 pound weight loss in 58 days or 20% 3/21 115 pounds - 31 pound weight loss in 65 days or 21% 3/28 113 pounds - 33 pound weight loss in 72 days or 23% 4/4 & 4/11/11 106 pounds - 40 pound weight loss in 79 days or 27% The PPNs for the resident documented the following: * 2/26/11 "...has fair appetite..." documented as PAC visit. NOTE: By this visit, the resident had lost 27 pounds since admission and no orders for nutrition intervention were instigated. * 3/18 "...Staff noted decreased PO (oral) intake," with the following orders, "...GERD ([MEDICAL CONDITION] reflux disease) increase [MEDICATION NAME] 20 mg bid" and "Weight loss, offer ensure 2 oz. with med (medication) pass, check [MEDICATION NAME]." documented as PAC visit NOTE: By this visit, the resident had lost 29 pounds since admission and only healthshakes [MEDICAL CONDITION] was ordered * 3/19 "...poor appetite...may consider [MEDICATION NAME] (appetite stimulant)" documented as PAC visit. NOTE: The medical record did not provide evidence [MEDICATION NAME] was ordered/started. * 4/4 "...Staff notes he has been more lethargic lately...decreased appetite and refusing meals..." with the following order, "Decrease appetite, check weight this week..." documented as Physician Assistant visit. * 4/11 "...Appetite small improvement," with the following order, "Weight loss, will check [MEDICATION NAME] and pre-[MEDICATION NAME]." documented as PAC visit. The Physician Orders (recapitulation), dated April 2011, documented a House Ground diet for the resident, with an order date of 1/14/11. A Interdisciplinary Communication to Nutrition Services (ICNS), dated 4/11/11, signed by the Speech Language Therapist, documented a pureed diet with a comment, "72 hour trial." An ICNS, dated 4/14/11, documented a diet change order for pureed diet. On 4/27/11 at approximately 2:00 pm, an email dated 4/12/11, addressing food texture order changes from the RDNS, addressed to therapy training, was given to the surveyor and documented, "1. When upgrading or downgrading food texture orders please go through the Nurse so the order can be entered into Point Click Care from the MD." (The Point Click Care system is a computerized system for entering physician orders). The Physician Orders did not reflect this diet change. On 4/3/11 at 5:00 pm, the IPN documented, "...Spoke (with resident) about recovery and remains negative. 'I can't, you don't understand. They work me too hard, I don't like the food, I have bad teeth.'...(Resident) was tearful and kept repeating 'I just don't know what to do.'...." A COC form, dated 4/4/11, documented the bath aide noted the resident's weight to be 106 pounds, and had a note that read, "put in provider box per request 4/4/11," notifying the physician of the resident's weight. This was the only documented physician notification found in the medical record and it was after the resident had lost 40 pounds in three months. On 4/25/11 at 12:50 pm, Resident #6 was interviewed with regards to his poor dentition and inability to eat. He stated he thought he had lost close to 50 pounds since admission to the facility. He stated he lost a tooth when he was in the hospital for his [MEDICAL CONDITION] and thought he may have lost another after admission to the facility. He stated he was started on a regular diet but could not chew it due to dental pain. He stated he had now been placed on a pureed diet but could not eat it because it tasted so terrible. He stated he had reported these issues, both his dental pain and the unpalatability of the food, to staff, but nothing had changed. Federal guidance states, "Decisions to downgrade or alter the consistency of diets must include the resident (or the resident's representative), consider ethical issues (such as the right to decline treatment), & be based on a careful review of the resident's overall condition, correctable underlying causes of the risk or problem, the benefits & risks of a more liberalized diet, & the resident's preferences to accept risks in favor of a more liberalized food intake." On 4/27/11 at 3:00 pm, the Acting DON, RDNS, and the RD were interviewed regarding Resident #6's severe weight loss. The RD stated the resident had been started on enhanced meals since admission. She indicated the resident suffered chronic and severe pain and took pain medication. She stated the physician had ordered Ensure (facility use as a healthshake, according to RD) on 3/17/11 but it was actually a healthshake and not Ensure that was given to the resident. When asked about the diet change, the Acting DON stated the Speech Language Therapist could ask for a temporary diet change order but the RD was not aware of the change to a pureed diet. She stated when she was in the building, once a week for the IDT meeting, she would meet with residents who had incurred weight loss and visit with them. The RD stated she reviewed the resident's meal monitors and was aware he was not eating. She stated any orders, comments or concerns she had regarding a resident would be communicated to the physician by nursing and social services. She stated she did not communicate concerns directly to the physician. The ADON was asked if any written communication was available, documenting the facility's actions to inform the physician and she stated there was not, other than a COC form. When asked how the staff communicated the poor meal intakes to nursing or the medical team, she stated there was not written documentation of such communications. On 4/28/11 at 11:00 am, the ADON was interviewed as to the delay in providing or arranging dental care for Resident #6. The Acting DON stated the van driver was responsible for making the appointments for residents. When asked if there was documentation of when the van driver would have received a request for a resident, she replied there was not. When asked if there was documentation to show if the facility had made an attempt to make an appointment for Resident #6, she replied there was "not." Resident #6 suffered a significant decline in his nutritional status, losing 40 pounds or 27% of his body weight in the first three months of his admission. It was documented from his admission he had missing teeth, causing him difficulty with mastication and decreased nutritional intakes yet the facility failed to prioritize his need for an appointment with a dentist. The ADON and Acting Administrator were informed of this issue on 4/28/11 at 2:40 pm. No further information was received on this matter from the facility. 3. Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. NOTE: According to the 5/5/10 initial admission MDS, the resident weighed 139 pounds. The resident was noted to be on a mechanically altered diet with dietary supplement between meals and had broken, loose, or carious teeth. Weekly Weight Records documented a weight of 143 pounds on the date of admission. The 10/30/10 quarterly MDS assessment coded: * Disorganized thinking continually present, does not fluctuate * Limited physical assistance by 1 person for eating * Weight 114 pounds, with 5% or more weight loss in prior month or 10% or more in prior 6 months, not on physician-prescribed weight-loss regimen * Mechanically altered diet * No dental or oral problems A 1/25/11 Surgical History and Physical documented: "There was an unwitnessed fall where she injured her left hip today... X-rays were taken which showed a... left hip basilar neck fracture." Changes from the prior MDS assessment which were reflected on the resident's 2/5/11 5-day scheduled (readmission) MDS assessment coded: * Modified independence with cognitive skills for daily decision making * Feeling tired or having little energy, nearly every day * Trouble concentrating on things, nearly every day * Independent eating * A fall with fracture in the 6 months prior to (re)admission * Weight 119 pounds, without weight loss of 5% or more in the prior month or 10% or more in prior 6 months NOTE: This entry was incorrect - she weighed 111 pounds as documented elsewhere in the medical record. * Antidepressant medication Changes from the prior MDS assessment which were reflected on the resident's 3/25/11 60-day scheduled MDS assessment coded: * Severely impaired cognitive skills for daily living * Feeling down, depressed, or hopeless; feeling tired or having little energy; poor appetite or overeating - several days of the prior 2 weeks * Trouble concentrating on things, half or more days of the prior 2 weeks * No falls or history of falls with fracture in the 6 months prior to admission - NOTE: This entry was incorrect. The resident fell and fractured her hip 1/25/11. * Weight 105 pounds, with weight loss of 5% or more in the prior month, or 10% or more in the prior 6 months, not on a physician-prescribed weight-loss regimen NOTE: Worsening cognition; worsening psychosocial status; and her weight loss continued. Resident #15's Admission Evaluation and Interim Care Plan, dated 5/1/10, documented: Weight 143 pounds; no behaviors; dental caries; regular diet, regular consistency, thin liquids; and dependent for all ADLs. The resident's Nutritional Care Plan in effect 9/17/10 through 1/14/11 included the following interventions: * Monitor food/fluid intake; offer a substitute if less than 75% * Weights as ordered, review at least monthly; Diet/Texture as ordered * Registered Dietician to review PRN; Speech Therapy Evaluation PRN; Review in IDT for 4 weeks and PRN * Snacks TID; Continue to offer unit snacks and meals; Offer Ensure or equivalent as ordered * Do not prompt (at) meals (due to) resident will refuse to eat; Offer food in separate bowls; Try offering half and half in place of milk The resident's 10/1/11 Activities Care Plan interventions included: Likes food related activities; Snack and chat in mornings. The resident's 1/14/11 Nutrition Care Plan documented a focus of: Involuntary weight loss related to depression, difficulty chewing/swallowing, cognitive impairment - dementia, [MEDICAL CONDITION], hypertension, [MEDICAL CONDITIONS] dysphagia; as evidenced by weight loss trend: Interventions included: * 1/14 - Appetite stimulant as ordered; choice menu daily; encourage family to bring in favorite foods; fortified foods with meals; meals in dining room; offer alternate meal for intake less than 50%; provide house-ground diet... (with) snacks PRN; provide verbal cues; weekly weights until stable; monitor labs as available; adaptive equipment: foods in individual bowls * 1/24 - Speech therapy screen for possible diet upgrade - moist foods, ensure getting snacks, RNA dining * 3/21 - Weekly weights and [MEDICAL CONDITION] checks, follow up labs, [MEDICAL CONDITION] levels; all interventions above The resident's 1/14/11 Hydration Care Plan included the intervention, "Report food and fluid intake of less than 50% for 3 consecutive days to licensed nurse and dietician. " A 4/7/11 Care Plan Conference Summary documented that the resident's Care Plan was discussed with the resident's family and staff. Summary notes documented: "Has good days and bad days, but overall she is making progress... does enjoy sweets but she has always watched her weight... Discussed [MEDICATION NAME] 7.5 mg... (family) were in agreement that it (should be continued)." Resident #15's Weight Records and VS Flow Sheets for October 2010-April 2011 documented the following weights in pounds: * 10/13: 115, 10/22: 114 * 11/5: 116, 11/12: 116, 11/14: 117, 11/26: 117 * 12/2: 114, 12/9: 117, 12/16: 115, 12/23: 118, 12/31: 119 * 1/6: 116, 1/13: 113, 1/20: 111 NOTE: No entry for last week in January * 2/3: 117, 2/4: 119, 2/10: 115, 2/17: 113, 2/24: 111 * 3/3: 109, 3/10: 106, 3/11: 105, 3/15: 104 NOTE: No entry for last 2 weeks in March * 4/7: 107, 4/14: 105 PPN documented: * 10/8/10 - "Seen per request, have bilateral lower (extremity) [MEDICAL CONDITION] that's weeping... 2+ [MEDICAL CONDITION] (with) [DIAGNOSES REDACTED]." * 10/11 - "[MEDICAL CONDITION] has improved... 1+ [MEDICAL CONDITION]." * 10/19 - "[MEDICAL CONDITION] improved... trace [MEDICAL CONDITION] appears to be improving/resolving." * 10/21 - "[MEDICAL CONDITION] - monitor (without changes of treatment) for now." * 11/2 - "Daily weights for 1 week (and) then weekly for weight loss. [MEDICATION NAME] for (situational) depression secondary to dementia (and) anorexia (and) weight loss... (trace) [MEDICAL CONDITION] (weight) 143 (pounds) (decreased to) 116 (pounds)... protein ([MEDICAL CONDITION])... [MEDICAL CONDITION] (weight) loss - add [MEDICATION NAME]. [MEDICAL CONDITION]-controlled... (multiple) falls (and) fractures - healing... really doing remarkably well (and) seems content. Continue to focus on nutrition (and) comfort." NOTE: The physician did not order hospice services or "comfort care only" measures - he ordered a focus on nutrition and comfort for the resident. . * 12/20 - "(Resident) unable to participate in (review of symptoms). 'I think I'm hungry...' Non-[MEDICAL CONDITION] elevate (bilateral lower extremities)." * 1/3/11 - "Lower (extremities) 2+ [MEDICAL CONDITION]." * 1/5 - "Lower (extremities) 2+ [MEDICAL CONDITION]." * 1/30 - "(status [REDACTED]. Will need supportive cares... (and) dietary consult." * 1/31 - "Staff report fair appetite." * 2/2 - "(Resident) says she feels tired (at) times." * 2/8 - "(Complains of) lethargy-doesn't have energy to do anything. Somnolent." * 3/3 - "This AM staff with no real concerns. She did refuse meds which she does often... appetite fair... trace [MEDICAL CONDITION]." * 3/14 - "(Resident) stated she wasn't sure how she's doing... she denies... weight loss... (Resident) appears healthy, if slightly confused." * 3/22 - "She reports fair appetite." * 3/28 - "Nursing reports (no) concerns. She has been eating (and) resting well." * 4/5 - "Staff claims (increased) confusion (and increased) lethargy... [MEDICAL CONDITION] overtreated, (decrease) [MEDICATION NAME]." * 4/19 - "Reports fair appetite." * 4/25 - "Seen per request, staff noticed thick productive cough (and) 'feeling awful'... more confused than normal, she doesn't recognize me this morning which she usually does. Staff notes (increased) confusion... [MEDICAL CONDITION], (increased) confusion (secondary to) above... chronic dementia-she is not at baseline today." The resident's April 2011 Physician's Orders Recapitulation documented the following orders: * [MEDICATION NAME] 40 mg tablet by mouth daily every day for [MEDICAL CONDITION] * [MEDICATION NAME] Sodium 0.125 mg tablet by mouth BID for [MEDICAL CONDITION] * [MEDICATION NAME] 25 mg tablet by mouth daily every day for [MEDICAL CONDITION] * [MEDICATION NAME] 7.5 mg tablet by mouth at bedtime everyday for other persistent mental disorder * Standard House diet, Ground texture, May omit diet restrictions on special occasions * Nurse may change diet consistency x 24 hours and notify (physician) * Physician has reviewed and approved the resident's plan of care * Weigh weekly x 4 weeks post admission then monthly FPR for October 2010-March 2011 documented average meal intakes for Breakfast (B), Lunch (L), Supper (S), and HS Snack (H): - October: B 63.8%, L 34.3%, S 51.6%, H 18.3% - Overall 42% average - November: B 67.6%, L 39.1%, S 31.1%, No HS snacks - Overall 34.4% average - December: B 75.8%, L 61.9%, S 31.9%, H 3.8% - Overall 43.3% average - January: B 87.3%, L 60.4%, S 42.5%, No HS snacks - Overall 47.5% average - February: B 66.7%, L 34.8%, S 40.5%, H 7.1% - Overall 37.2% average - March: B 69.6%, L 44.8%, S 60.8%, No HS snacks - Overall 43.8% average Activity Notes documented: * 10/1/10 - "She is dependent on staff for all ADLs. During our visits she is very pleasant and (especially) enjoys news, socials, food related activities..." * 2/3/11 - "At this time she is up in geri chair for news and mealtimes... does enjoy attending (activities), being around peers, snacking...." MARs documented: * November 2010 - [MEDICATION NAME] refused or not administered 6 of 28 doses (21%). * December 2010 - [MEDICATION NAME] refused or not administered 2 of 30 doses (6.6%). Nutrition Progress Notes documented: * 11/3/10 - Regular ground diet, no supplements, no cha

Based on a complaint from the public, staff interviews, record review and review of the facility's Alzheimer's Program standards, it was determined the facility failed to provide medically related social service interventions to address residents' needs related to behavioral symptoms, insomnia, grief and depression. This was true for 10 of 14 sampled residents (#'s 1-3, 5-9, 11 & 15) and 3 random residents (#s 22, 23, 25). In addition, social services in the ACU were provided by the Alzheimer's Program Director (APD) who was a CNA and also the Activities Director for the ACU, which limited the APD's ability and availability to provide direction to staff regarding appropriate medically related social service interventions. This had the potential to affect all resident's residing in the ACU. Specifically: * Resident #1 was allowed to intrusively wander into other residents' rooms resulting in harm to Resident #7, who was pushed to the ground in a resident to resident altercation with Resident #1; Resident #11 who expressed anxiety and could not sleep after Resident #1 wandered all night in and out of rooms; Resident #9 who became "flirty" and left her room without her top on after Resident #1 wandered into the room; Resident #s 23 & 25 who became angry after Resident #1 wandered into their rooms; and Resident #s 22 & 23 who felt the need to "watch" the halls to prevent Resident #1 from entering rooms after Resident #1 wandered into 7 resident rooms several times the night before. In addition, Resident #1 suffered from insomnia. Resident #1's wandering and insomnia behaviors were not adequately assessed, monitored, or care planned until the altercation with Resident #7, and the care plan was not updated when Resident #1's intrusive wandering increased. No referral was made to evaluate Resident #1's behaviors. Resident #1's intrusive wandering was not viewed as a problem unless the behavior resulted in agitation or aggressive behavior toward other residents. The psychosocial impact of Resident #1's behavior on other residents was not assessed or evaluated. * Female Residents #s 2 & 3 were harmed when behaviors of a sexual nature were not documented, assessed, monitored or care planned immediately after the first occurrence to prevent the behavior from recurring, resulting in several more occurrences of the same and other behaviors of a sexual nature (See F223). These additional behaviors were not documented, assessed, monitored or care planned. There were no referrals initiated to evaluate the behaviors of either resident. * Resident #s 5 & 6 were harmed when both residents did not receive appropriate social service assessments, monitoring or referrals when they expressed thoughts of wanting to die and experienced severe weight loss. (See F325) *Resident #s 8 & 15 were harmed when neither resident received appropriate social service assessments, monitoring, or referrals for grief and/or depression and experienced severe weight loss. (See F325) Findings included: The BFS received a complaint from the public on 4/19/11, alleging resident privacy was violated by intrusive wandering on the ACU. The complainant stated all residents have a right to privacy and, "This should not go on." In addition, the complaint alleged behaviors of a sexual nature between 2 female residents were not documented, and family members were not notified of these behaviors. NOTE: The survey team interviewed 20 employees on 4/21 and 4/22/11. In order to keep the interview information anonymous, the employees were assigned random identification numbers (Employee #...) which did not correspond to the order each employee was interviewed. Each employee's title/role was excluded from this report. The date/time of each interview was also excluded from this report, to ensure anonymity. 1. NOTE: The Dementia Education & Training Program in Managing Behavioral Symptoms of Residents with Dementia in the Long-Term Care Setting, 2009, states on pp. 26-31, "Wandering is important because this behavior may produce elopements, injuries, or patient-on-patient aggression... The treatment team should carefully monitor the resident's behavior over a 7-10 day period... The team should note the type of wandering, frequency, duration, time of day as well as other behaviors associated with these episodes... the treatment team should record each type of information in the medical record to develop a composite picture of the resident's behavior... All wandering residents should be placed on a toileting, feeding and hydration schedule. These individuals may be seeking a bathroom, food or water... The treatment options for wandering behaviors are based on the causes and clinical features of this disruptive activity... One goal of therapy for all wandering residents is to prevent intrusion into other resident rooms... A very small group of residents persistently and aggressively wander. These individuals may become hostile during redirection and create chaos on the units. Such residents should be referred to a specialist with expertise in geriatric psychiatry or behavioral neurology for a more detailed assessment and recommendations for psychotropic medications." (http://www.alzbrain.org/pdf/handouts/2009.%20behavior%20book.pdf) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's admission MDS assessment, dated 3/17/11, coded: * Usually understood and usually understands others * Severely impaired cognitive skills for daily decision making * Inattention and disorganized thinking behavior which fluctuated * Trouble falling or staying asleep, or sleeping too much, nearly every day * Trouble concentrating on things, nearly every day * Being short tempered, easily annoyed half or more of the prior 14 days * Verbal behavioral symptoms directed toward others, 1-3 of the prior 14 days * Significantly intruded on the privacy or activity of others, 1-3 of the prior 14 days * Wandering which significantly intruded on the privacy or activity of others, daily CAAs triggered on the 3/17/11 admission MDS assessment included: * Cognitive Loss/Dementia * Behavioral Symptoms Additionally, the following areas were marked as addressed in the care plan: * Psychosocial well being * Behavioral symptoms MDS assessment notes documented on 3/17/11: "(Resident #1) was admitted to the unit direct from the community, he is (ambulatory) by self, wanders, intrusive to other rooms, lives in the (Alzheimer's) unit... we do have a (diagnosis) of advanced dementia." The resident's admission Nursing Assessment, dated 3/14/11, included the following documentation: * Resident appears anxious * Repetitive physical movements * Stays up late at night * No psychoactive medications * Mental state: confused Resident #1's Initial Care Plan included the following focus areas, goals, and interventions - initiated on 3/4/11 and unchanged until 3/27/11: * Altered cognitive status (and) communication deficit AEB short term memory problem, confusion/disorientation to person/place/time, potential for elopement. Client will be oriented to self, room, and facility; be able to follow simple directions; assist in making daily choices in cares. - When anxious/frustrated, gently attempt to calm and/or redirect focus. - Keep distractions at a minimum. - Staff to adjust the tone and/or volume as needed during verbal communication. * Exhibits inappropriate behavior, resists treatment/care AEB resident has refused to bathe for last 3 years related to: cognitive impairment. Resident will comply with care routine/medical regime will bathe 1 time weekly. - Allow for flexibility in ADL routine to accommodate residents mood. - Document care being resisted on behavior monitoring flow sheet. - If resident refuses care, leave resident and return in 5-10 minutes. - Provide non-care related conversation proactively before attempting bathing. No behaviors were documented as monitored from 3/4/11-3/27/11, even though refusals were to be monitored according to the care plan; the MDS assessment notes identified intrusive wandering as a behavioral issue; the MDS admission assessment identified intrusive wandering; and numerous entries concerning these and other problem behaviors such as urinating in other resident's rooms, insomnia and resisting re-direction were documented by the nurses on IPN, by the IDT, by the APD, by the physician (PPN), and by licensed staff on the Change in Status Report (CSR) (which was not a part of the permanent medical record) as follows: * CSR: 3/7/11 - "Sleeps 1 (hour from 10 PM to 5 AM). Wanders in (rooms), redirects easily, cooperative." * CSR: 3/11 - "Wandering, intrusive...." * IPN: 3/11 - "Resident has been adjusting well to the new environment, continues to wander into other rooms, easily redirected. Name plate is placed on resident's door for him to recognize own room." * APD: 3/11: "Wanders in and out of others' rooms, is easily redirected." * CSR: 3/15 - "Using trash cans for urine elimination, trash can in dining hall, looks suspicious...." * IPN: 3/15 - "Resident is resistant to some requests, has been noted to eliminate 'not' in his assigned room area." * IPN: 3/16 - "Resident continues to go in other people's room. Staff tries redirecting... resident is resistant to some requests... some residents get angry (and) some yelling back and forth had happening (sic) today after resident attempted to go in another resident room." * IPN: 3/17 - "Still confused as to where he is, which room is his. Resident is not always fully dressed when he comes out of room." * PPN: 3/18 - "Nursing staff report he grabbed one of the aides by the neck this morning... agitation - (new order for) Lorazepam... PRN." * IPN: 3/18 - "Resident was in hallway without pants on." * IPN: 3/19 - "Several episodes of resident walking in (and) out of rooms. Staff redirects resident to his own room." * IDT: 3/21 - "(Resident #1) is adjusting well to placement... exhibits behavior of... inappropriate urination. Staff redirect resident to use toilet... continues to wander in secure unit and others' rooms. Will follow next week." * APD: 3/22 - "Mood indicators include varied sleep pattern, short attention span, and is easily annoyed with redirection. Behaviors include daily wandering and verbal aggression towards caregivers when they redirect him out of others' rooms. (Resident #1) is on no psychoactive meds." * APD: 3/22 - "Is adjusting well to placement... No care plan interventions were documented regarding the resident's increasing intrusive wandering behavior present since admission, resistance to redirection, or verbal aggression until 3/27/11 when Resident #1 was involved in a resident to resident altercation with Resident #7, in which Resident #1 wandered into Resident #7's room. The resident's problems with insomnia and urinating in other resident's rooms were not addressed. After the altercation, the following focus areas, goals, and interventions -initiated on the date indicated - were implemented on Resident #1's care plan: * Resident wanders into others' rooms is easily redirected. There will be no (resident to resident) incidents related to wandering. 3/27/11 - Redirect resident to own room pointing to shadow box and pictures on his door. 3/27/11 - Use calm non threatening approach. 3/27/11 - 1:1 supervision to see (Resident #1) at all times. 3/28/11, DC 4/4/11 * Exhibits inappropriate behaviors of... rummaging in others' rooms related to: Dementia and inability to differentiate others belongings. There will be no resident to resident incidents when residents (sic) goes in others' rooms. 3/27/11 - Calmly redirect (Resident #1) from going in other residents' rooms using soft calm voice and simple directions. 3/27/11 - 1:1 staff supervision to redirect (Resident #1) from going in peers' rooms. 3/28/11, DC 4/4/11 - Shadow box in front of room. 3/27/11 - Pictures on door. 3/27/11 After those care plan interventions were implemented and after the altercation with Resident #7, an Inservice Record form, dated 3/31/11 and signed by the DON as the "In-Service Proctor", directed staff to: *"Staff delivering 1:1 care for (Resident #1): Beginning today we want to allow (Resident #1) to go into others rooms if he tries to. Then please document what he did (i.e. visited (with) peer; turned & left; riffled (sic) through items). If he approaches another Res(ident) in the room, allow conversation, but do not allow confrontation. DO NOT ALLOW (Resident #1) TO GO INTO (Resident #7's) ROOM." The form was signed by 7 staff members including CNAs and LNs below the statement, "By signing below, I indicate that I have attended or read the in-service and have had the opportunity to have my questions answered." Resident #1's Behavioral Drug Monthly Flow Records for March and April 2011 documented that the following behaviors were monitored after the altercation with Resident #7: * Trespassing in others' rooms (started to monitor on 3/28) - 119 times; 79 of those occurred between 4/17 and 4/21. * Attempting to enter others' rooms without appropriate purpose (started to monitor on 3/31) - 117 times; 74 of those occurred between 4/17 and 4/21. * Anger or agitation towards peers (started to monitor on 3/31) - 13 times; all after 4/17. Resident #1's behaviors escalated dramatically on 4/17/11 and continued to greatly increase until he was transferred out of the facility on 4/21/11. The resident's hours of sleep were not monitored. Resident #1's Care Plan was not changed after 3/27/11, despite the dramatic changes in the resident's behavior. The physician was not notified of the changes in behavior until 4/19/11. The resident was not placed back on 1:1 monitoring after it was discontinued on 4/4/11, despite the dramatic increase in behaviors - especially after 4/17/11. There were no social service referrals to evaluate these behaviors. The lack of assessment, monitoring, care planning interventions, inappropriate directions from the DON that allowed intrusive wandering, and lack of referrals to evaluate Resident #1's escalating behavior and insomnia resulted in harm as follows: a. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment, dated 3/23/11, coded: * Moderately impaired cognitive skills for daily decision making * No behavioral symptoms * Daily non-intrusive wandering Resident #7's Care Plan documented the focus area, dated 1/4/11, "Potential to exhibits (sic) behaviors of verbal/physical aggression...," Interventions, dated 1/4/11, included, "Be cognizant of not invading resident's personal space...." A EMR form documented on 3/27/11 at 7:15 am, "Loud vocals were heard from Room (# listed). Female resident (Resident #7) yelling, 'Get out of my romm (sic). What are you doing in here?' Staff responded to see female Res(ident) (#7) falling to floor and hitting head. Male Res (Resident #1) standing in middle of room. Female res laying by door with head toward door. Female Res stated, 'He pushed me down.' Male stated 'I didn't mean to push her, but she just scared me. I can't help it." Female Res was assessed... a very small protrusion on palpitation on occipital region of head and an abrasion to (right) elbow (approximately 0.5 centimeters) in diameter...." Resident #1 was placed on 1:1 monitoring on 3/28/11 which continued until 4/4/11 at 6:00 pm as documented: * IDT: 3/28/11: "(Resident #1) was the aggressor in (resident to resident) incident on 3/27/11 in which he entered female peer's room; female peer (then) entered her room, startled (Resident #1) by yelling, 'Get out of my room!' (Resident #1) then pushed her to the floor, stating, 'I'm sorry. I didn't mean to push her.' (Resident #1)... is currently on 1:1 observation... now has family pictures on his door as well as a shadow box to help identify his own room. Signs were placed on peers' doors stating, '(Resident #1) this is not your room' to help distract him from going into peers' rooms. Will follow in 1 week." * APD: 3/28: Was involved in (resident to resident) incident the morning of 3/27/11... stating, 'I did not mean to push you but you scared me. I'm sorry, I can't help it.' Normally is not physically aggressive but does wander daily." * CSR: 3/31: "Starting today with staff delivering 1:1 allow (Resident #1) to go into others' room, document what he did (visiting (with) peer, turned (and) left, riffled (sic) through items). If he approaches another resident allow the conversation but do not allow confrontation. Aides are to let the nurse know for ongoing daily charting. Document every shift." * APD: 4/4: "Has shown no aggression towards peers since incident on 3/27/11. Will discontinue 1:1 at this time and observe for s/s (signs and symptoms) of aggression." * IPN: 4/4: "Resident shows no aggression toward peers or staff. Has had x 2 episodes of wandering into another room that is located next to his, possibly checking for familiar items, then turning around, leaving. 1:1 staff person released (at 6 PM)." b. Resident #11 was admitted to the facility's ACU on 2/8/11 with [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 2/15/11, coded, severely impaired cognitive skills for daily decision making, wandered daily. The following information was documented in the IPN notes for Resident #1 and the Change of Status Report for Resident #1 and #11: * IPN: 4/7/11 (Resident #1) - "Resident had episodes of wandering into other residents' room removing items taking them to his room and urinating into other residents' restroom, garbage cans and corner in room. He will easily redirect without agitation or aggressiveness. Wandering in rooms were more active in the earlier hours of day in the afternoon..." * IPN: 4/8/11 (Resident #1) - "Resident continues to wander in and out of rooms. Will open dressers rummage through belongings. Will remove items taken (sic) them to his room. Items are returned to proper residents. He is easily redirected with (no) agitation or aggression towards others. He will also go into other rooms for toileting purposes." * CSR: 4/10/11 - (Resident #1) - "Going into (other residents') rooms, taking (other residents') belongings - will not redirect. Upset several others. Finally fell asleep in chair." * CSR: 4/11/11 - (Resident #11- a female) - "Evaluate for new roommate? Up all noc (night) not wanting to go to bed. Thinks roommates (sic) a 'man...' Appears fearful of (roommate)...." IPN notes for Resident #1 recorded the following: * 4/18/11 - "Late entry for 4/17/11 6 PM - 6 AM. Reported verbally to (DON) and Program Director that (at 6:15 AM) of 4/18/11 aides came (and) reported (Resident #1) being in hallway 'kissing another female resident on forehead (and) cheeks in ACU hallway.' No physical harm to either resident. Both are separated (and) redirected by aides." IPN note for Resident #11 recorded: * 4/18/11 at 4:30 pm - "...wanting to talk with her daughter... This nurse has been unable to reach her... OT (occupational therapy) aides reported resident crying tears. Stating, 'I just want to go home'..." IDT note for Resident #11 recorded: * 4/20/11 - This worker notified of an incident in which (Resident #11) was walking in the hallway, stop to talk to male resident, she grabbed his hand, male resident kissed (Resident #11) on the forehead and hand... In an interview with Employee #23, it was reported that the other night, Resident #11 was kissed on the cheek and forehead by Resident #1. Employee #23 stated that Resident #11 was strict (named religion) and was not the same after the kiss. Resident #11 was crying the next day. c. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 4/11/11, documented moderately impaired cognitive skills for daily decision making, wanders daily, limited assistance of one person for dressing, walks in corridor and room independently. Documentation on the CSR for 4/17/11 included: * (Resident #1) - "Wandering all (night), entering all rooms, (urinated) in (Resident #9's) toilet, flirty with (Resident #9), hand holding. (Resident #9) not appropriate (with) clothing tonight with (Resident #1) entering room, she came out half dressed to hallway (twice) - happy, flirty." IPN notes for Resident #1 recorded: * 4/18/11 - "Resident wandering all (night), in (and) out of room 20+ times. Staff constant redirect (sic). Upsets two gentlemen (with) entering rooms, one entry into female room includes both residents holding hands x 2 (with) redirection to exit room as to inappropriate nature. (Resident #1) gets agitated this evening (with) aide who is providing consistent redirecting due to wandering, as is her duties and no physical harm to resident or aide. He is finally quiet, calm, sleeping on couch in sitting position (at) this time. No calls made as resident did not harm or hurt himself or anyone else." d. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 1/16/11, coded a BIMs score of 5 indicating severely impaired cognitive skills for daily decision making. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Documentation on the CSR for 4/17/11 included: * (Resident #1) - "Wandering all (night), entering all rooms, (urinated) in (a female resident's) toilet, flirty with (same female resident), hand holding. (Same female resident) not appropriate (with) clothing tonight (with Resident #1) entering room, she came out half dressed to hallway (twice) - happy, flirty." * (Resident #1) - "Aggressive with (CNA's name), upset tonight because she was constant redirecting him as is her job. (Resident #25) upset - four letter words and (Resident #23) due to (Resident #1) in room. No calls made because we were able to redirect, but he (Resident #1) was busy, busy, busy (up and down) all noc and refuses to (change) wet clothes this early a.m. Sleeping on couch sitting up (at) 4:30 am." IPN notes for Resident #1 recorded the following: * 4/18/11 - "Resident wandering all (night), in (and) out of room 20+ times. Staff constant redirect (sic). Upsets two gentlemen (with) entering rooms, one entry into female room includes both residents holding hands x 2 (with) redirection to exit room as to inappropriate nature. (Resident #1) gets agitated this evening (with) aide who is providing consistent redirecting due to wandering, as is her duties and no physical harm to resident or aide. He is finally quiet, calm, sleeping on couch in sitting position (at) this time. No calls made as resident did not harm or hurt himself or anyone else." e. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 3/8/11, coded a BIMS score of 7 indicating severely impaired cognitive skills for daily decision making. On 4/18/11, the following note was recorded on the CSR, "(Resident #1) rm (room) enterys (sic): (Resident #9) x (times) 2, (Resident #25) x 3, (Resident #23) x1, (Resident #14) x 1, (Resident #11's) room x 1, (Resident #22) x 1, (Resident #10) x1. Awake still at 0230 (2:30 am) non agitated on couch TV on & quiet...." On 4/19/11, the following note was recorded on the CSR, "Reported to (Resident #23) that (Resident #1) had went into (Resident #27's) room. (Resident #23) upset/angry. Staff talked to (Resident #23). He (Resident #23) and (Resident #22) continued a 'watch' on the hall." On 4/21/11 at 5:20 PM, the Administrator was interviewed about Resident #1's wandering in the ACU unit. She stated, "He only goes in and turns around and leaves. The only time he was rifling was the incident with (Resident #7)." The Surveyor advised the Administrator that documentation showed that not to be true. The Administrator responded, "Oh." On 4/22/11 at 1:34 pm, the DON was asked about Resident #1's wandering behavior. She stated, "He wasn't aggressively wandering into other people's rooms." The DON was asked who was consulted when behaviors were identified. The DON stated, "I have no knowledge of a social worker since (name of the provider) took over (in July 2010). That would be a question you'd need to ask (the administrator)." On 4/22/11 at 3:10 pm, the Administrator was interviewed. She stated that a social worker was not employed at the facility. There was no contract with a social worker to provide medically related social services. And that there had not been any social worker visits since 7/1/10. 2. NOTE: The Dementia Education & Training Program in Managing Behavioral Symptoms of Residents with Dementia in the Long-Term Care Setting, 2009, stated on pp. 38-45, "Sexuality in the older resident with Alzheimer's disease is a complex issue that involves resident's rights and safety ... Persons with moderate to severe dementia rarely retain the ability to give informed consent for sexual activity ...The first step in assessing 'abnormal sexual behavior' is to specify the type of abnormal behavior, frequency of occurrence, duration of the symptoms, and settings that produce the symptoms. The treatment team must examine both 'the aggressor' and the person who is the target of the symptoms. The team must determine whether both parties were able to give consent based on cognitive and psychiatric status. The team must then determine the relative threat level of 'the aggressor...' The treatment team must gather specific details about the incident...The treatment team must determine whether the behavior is true, sexually driven activity or pseudo-sexual behavior masquerading as sexual aggression...examples of pseudo sexual behavior include...climbing into bed with other residents...Behavioral interventions should be employed to diminish aggression... Difficult...residents should be referred to a specialist for further assessment and management." *Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 1/15/11, coded a BIMS score of 8 indicating moderately impaired cognitive skills for daily decision making. * Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 2/28/11, coded severely impaired cognitive skills for daily decision making. Employees interviewed, (See F223), reported Resident #2 and #3 had engaged in behaviors of a sexual nature beginning around the end of December 2010 and continuing to the present time. The behaviors included: * Holding hands * Kissing on the lips * Sharing a bed: one resident clothed and the other naked * Sharing a bed: one resident clothed and the other resident with a tee shirt and attends * Hand down the front of the other resident's pants The medical record does not document any of these behaviors in either resident's chart. The Employees interviewed stated the APD, DON and Administrator were aware of these behaviors. Employee interviews reported the following: * Employee #13 stated, "We have a couple females in ACU. One believes the other is a male, calling her a 'he-she.'" The employee stated the two residents have been observed holding hands and, "kissing on the lips." The employee named Resident #s 2 and 3. "(Resident #2) believes (Resident #3) is the male." The employee stated staff separate the two residents when these incidents occur. "(Resident #2) used to be the aggressor. (Resident #2) took (Resident #3's) arm and directed (Resident #3) to (Resident #2's or Resident #3's) room. (Resident #2) says (Resident #3) is he-she because (Resident #3) wears her hair short." * Employee #13 also stated, "I have walked in and (Resident #3) was in bed with (Resident #2) in (Resident #2's) bed. (Resident #2) had her clothes off and (Resident #2) had her clothes on." The employee stated the incident occurred at bedtime, approximately near Christmas. "I believe I wrote a statement." The employee also stated, "I walked in...(Resident #2) was facing the wall and (Resident #3's) chest was to (Resident #2's) back." The employee placed a gown on Resident #3 and assisted her to Resident #3's room. The employee stated the incident was immediately reported to the nurse on the ACU. She again stated, "I believe I wrote a statement." The employee was asked by the survey team if management staff interviewed the employee. The employee stated there were no follow-up questions by administration. The employee indicated other staff have also witnessed and/or heard of incidents in the ACU. * Employee #13 stated the incidents were reported to the nurse working in the ACU, then to the Alzheimer's Program Director (APD), then the APD follows through with the DON. * Employee #26 stated, "Everyone knows (Resident #2) has this behavior." The employee stated the sexual conduct between the two residents has not been charted, so could not be addressed by staff. * Employee #15 received information during shift report, approximately 2-3 days a week, about Resident #s 2 and 3 kissing. At times the report was that the two residents, "Were kissing, a romantically engaged kiss." The employee also heard within the last week (April 10-16) about the two residents involved in a more sexual contact, described to her as "genital touching." The employee thought there may have been an in-service to keep the two residents separated and involved in activities. * Employee #13 also stated that on Saturday, 4/16/11, she heard that staff, "Caught (Resident #2) with her hands down (Resident #3's) pants." * Employee #26 stated, "(Resident #2) got caught with her hands down (Resident #3's) pants. This happened on the day shift last Saturday (4/16/11)...The person who witnessed it reported it to the DON. The person who saw it was told not to chart it and that it would be taken care of." The employee stated, "If I were the family I would think I would want to know...The whole ACU (staff) knows what's going on." The employee described this encounter between the residents as, "This was more extreme. This should be wrote up. This has been going on but staff was told not to write it up." * Employee #26 also stated there have been no incident reports written on any of the inappropriate occurrences in the ACU and no documentation in resident records. The employee stated the staff, "need to be able to chart exactly what behaviors are occurring and be able to write the accurate monitoring." * On 4/21/11 at 3:40 pm, LN #7 was interviewed. She stated she witnessed Resident #2 put her hand down Resident #3's pants on the day shift on Saturday, 4/16/11. "(Resident #3) was in (Resident #2's) room. I walked in and (Resident #2) pulled her hand out of (Resident #3's) pants." The LN stated she re-directed the residents and then called the DON. "She (DON) notified everyone else. She asked me to write a statement. Nothing was put in the chart by me. I was instructed not to. The DON said, 'write a statement and put it under my door.'" The LN stated, "I wrote it on a blank piece of paper, the IDT form, and slipped it under (name of DON's) door before I left for the night." The LN was asked by the survey team to describe more accurately what she witnessed. The LN stated, "I was doing cares with another resident. I knocked on (Resident #2's) door. (Resident #3) was sitting on (Resident #2's) bed. (Resident #2) was standing in front of (Resident #3) and (Resident #2's) hand was coming out of (Resident #3's) pants, the front of her pants...I don't know how far she had her hand down there. I know (Resident #3) is not supposed to be in (Resident #2's) room. (Resident #2) knew what she did was

Based on a complaint from the general public, staff interview and record review, it was determined the facility failed to adhere to nursing professional standards of practice: a) When the DON told a CNA to "black out" a resident's weight that was recorded by the CNA which would have documented a severe weight loss for 1 of 16 (#5) sampled residents. This deliberate action by the DON to hide weight loss considered severe, resulted in a delay in care and harm to the resident. b) By failing to document incidents in each resident's record that occurred between two cognitively impaired residents (#s 2 and 3), who resided in the locked ACU. c) By failing to rechecking a resident's blood sugar in 15 minutes after the initial blood sugar was 50. Findings included: A complaint from the general public was received by the Bureau of Facility Standards on 4/19/11, alleging the alteration of documentation on a resident's record, and lack of important incident documentation between two additional residents. Fundamentals of Nursing, 7th Edition, by Potter and Perry, describes data documentation as, "...the last part of a complete assessment. The timely, thorough, and accurate documentation of facts is necessary when recording client data. If you do not record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the client...Observation and recording of client status is a legal and professional responsibility. The nurse practice acts in all states and the American Nurses Association Nursing's Social Policy Statement (2003) mandate, or require, accurate data collection and recording as independent functions essential to the role of the professional nurse." (pg. 243) In addition, Potter and Perry describe quality documentation and reporting as having the five characteristics of factual, accurate, complete, current, and organized (pg. 389). 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's initial MDS assessment, dated 4/1/11, documented the following: * Moderately impaired cognitive status for daily decision making * Usually understood and able to understand others * Felt down, depressed, or hopeless and felt bad about himself 7-11 days in the last two weeks * Felt tired, having little energy and poor appetite 12-14 days in the last two weeks * Needs assistance requiring set up help only for eating * Always continent of bowel and bladder The Hydration Care Plan for the resident, dated 3/28/11, documented, "Report food and fluid intake of less than 50% for three consecutive days to licensed nurse/dietitian." The Nutrition Care Plan, dated 3/28/11, documented, "Offer meal alternates for intake less than 50%." There was a focus area added to this Care Plan on 4/18/11, that read, "Weight loss admit-163 lbs Hosp. (hospital) 155 lbs. Refused until (4/18) 137 lbs." On 4/21/11 at 1:10 pm, CNA #10, who was responsible for weighing residents in the facility, was interviewed regarding Resident #5's weights. She stated she had weighed the resident on 4/7/11 and it showed a severe weight loss for the resident. CNA #10 stated she was told by the DON to completely black out the weight on the Weekly/Monthly Weight Record Worksheet for April because the recorded weight would show a weight loss. She stated the resident did refuse to be weighed again the following two days. She added she does not work on the weekends and so the next time she weighed the resident was on 4/18/11. She stated the resident weighed 134 pounds. She added that she had an accurate memory of what Resident #5 did weigh on 4/7/11 and it was 138 pounds. This was a 25 pound weight loss in 13 days. There was no documentation the medical staff was aware of his weight loss or his refusals to be reweighed before 4/18/11. However, the statement that the resident had refused until 4/18/11 was not true as he had been weighed on 4/7/11. Resident #5 suffered a severe decline in his nutritional status, losing 30 pounds or 18% of his body weight in the first 24 days of his admission. (Please refer to F325 as it relates to the severe weight loss for this resident.) The unethical and unprofessional actions taken by the DON when she told CNA #10 to "black out" her documented weight caused a delay in the care of this resident. Her actions were not in keeping with legal and professional standards of nursing. 2. Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 2/28/11, coded: * Sometimes understood and sometimes understands others * Short-term and Long-term memory problems * Severely impaired cognitive skills for daily decision making * Inattention and disorganized thinking behavior which fluctuated * Feeling down, depressed, or hopeless * Wandering behavior occurred daily Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 1/15/11, coded: * BIMS score of 8 indicating moderately impaired cognitive skills for daily decision making * Wanders daily During staff interviews on 4/21-22/11, the following statements were received: - Employee (#24) stated cognitively impaired residents could be intrusive, and wander. Resident #2 put her arm around another resident, and recently, Resident #2 was holding hands with Resident #3, and trying to take the resident to Resident #2's room. The employee stated she did not witness this but it was told in report and the incident was written down on the 24 hour report. NOTE: There was no documented evidence that this behavior/incident was documented in either resident's record. - Employee (#13) stated, "We have a couple females in ACU. One believes the other is a male, calling her a 'he-she.'" The employee stated the two residents have been observed holding hands and, "kissing on the lips." The employee named Resident #s 2 and 3. "(Resident #2) believes (Resident #3) is the male." The employee stated staff separate the two residents when these incidents occur. "(Resident #2) used to be the aggressor. (Resident #2) took (Resident #3's) arm and directed (Resident #3) to (Resident #2's or Resident #3's) room. (Resident #2) says (Resident #3) is he-she because (Resident #3) wears her hair short." Employee (#13) stated, "I have walked in and (Resident #3) was in bed with (Resident #2) in (Resident #2's) bed. (Resident #2) had her clothes off and (Resident #2) had her clothes on." The employee stated the incident occurred at bedtime, approximately near Christmas. "I believe I wrote a statement." The employee also stated, "I walked in...(Resident #2) was facing the wall and (Resident #3's) chest was to (Resident #2's) back." The employee placed a gown on Resident #3 and assisted her to Resident #3's room. The employee stated the incident was immediately reported to the nurse on the ACU. She again stated, "I believe I wrote a statement." The employee was asked by the survey team if management staff interviewed the employee. The employee stated there were no follow-up questions by administration. The employee indicated other staff members have also witnessed and/or heard of incidents in the ACU. The employee stated the incidents do get reported to the nurse working in the ACU, then to the Alzheimer's Program Director (APD), then the APD follows through with the DON. Employee (#13) also stated that on Saturday, 4/16/11, she heard that staff, "Caught (Resident #2) with her hand down (Resident #3's) pants." NOTE: There was no documented evidence that these behaviors/incidents were documented in either resident's record. - Employee (#26) stated, "Everyone knows (Resident #2) has this behavior." The employee stated the sexual conduct between the two residents has not been charted, so could not be addressed by staff. "Something so bad happened between these two residents that has not been addressed." The employee stated, "Everyone knows, everyone's scared, everyone is intimidated they may lose their jobs." The employee stated the Administrator "is aware." Employee (#26) also stated there have been no incident reports written on any of the inappropriate occurrences in the ACU and again stated there had been no documentation in resident records. The employee stated the staff, "need to be able to chart exactly what behaviors are occurring and be able to write the accurate monitoring." Employee (#26) stated, "(Resident #2) got caught with her hands down (Resident #3's) pants. This happened on the day shift last Saturday (4/16/11)...The person who witnessed it reported it to the DON. The person who saw it was told not to chart it and that it would be taken care of." The employee stated, "If I were the family I would think I would want to know...The whole ACU (staff) knows what's going on." The employee described this encounter between the residents as, "This was more extreme. This should be wrote up. This has been going on but staff was told not to write it up." - Employee #23 stated she had not witnessed any female to female inappropriate physical contact but had been told about incidents between Resident #s 2 and 3, "They've been caught together kissing and touching, quite abit." The employee stated she was unaware if these incidents had been reported. - Employee #15 stated the staff try their best to keep the residents in the ACU "occupied and separated." The employee stated she has not witnessed any inappropriate physical contact between residents. She has received information during shift report, approximately 2-3 days a week, about Resident #s 2 and 3 kissing. At times the report was that the two residents, "Were kissing, a romantically engaged kiss." The employee also heard within the last week (April 10 - 15), about the two residents involved in a more sexual contact, described to her as "genital touching." The employee thought there may have been an in-service to keep the two residents separated and involved in activities. On 4/21/11 at 3:40 pm, LN #7 was interviewed. She stated she witnessed Resident #2 put her hand down Resident #3's pants on the day shift on Saturday, 4/16/11. "(Resident #3) was in (Resident #2's) room. I walked in and (Resident #2) pulled her hand out of (Resident #3's) pants." The LN stated she re-directed the residents, then called the DON. "She (DON)notified everyone else. She asked me to write a statement. Nothing was put in the chart by me. I was instructed not to. The DON said, 'write a statement and put it under my door.'" The LN stated, "I wrote it on a blank piece of paper, the IDT form, and slipped it under (name of DON's) door before I left for the night." The LN was asked if she immediately assessed Resident #3 for physical injuries or for any emotional distress. "I did a head-to-toe assessment on Resident #3." She acknowledged she did not document the assessment. "I should have, but I didn't." On 4/22/11 at 1:10 pm, the DON was interviewed by the survey team. She was informed of an allegation made by multiple staff and the complainant that a staff member witnessed Resident #2 with her hand down the pants of Resident #3 while they were in Resident #2's room. The DON was also informed that the survey team received no investigation report of this incident when such instances of alleged abuse investigations were requested upon entrance on 4/21/11. The DON was asked if there was an investigation after the incident. The DON stated, "To my knowledge there was no investigation." The DON was asked if LN #7 performed an assessment on Resident #3 after the incident to assess for possible injuries. The DON stated, (LN #7) did not do a head to toe assessment on (Resident #3.)" The DON acknowledged she did not document the phone calls with the LN, Administrator, or the ACU director, or any instructions received or given." She stated, "I asked (LN #7) to write a statement and stick it under my door." The DON stated she did not ask any other staff to write a statement. The DON also stated, "(LN#7) asked, 'What should I chart?' I said don't chart anything." The DON stated she showed the statement by LN #7 to the Administrator who talked to the ACU director about the incident. Resident #2 was placed on behavior monitoring and the treating physician came in and evaluated the resident. The DON was asked her knowledge of any other staff who allegedly witnessed an incident in December, 2010, where the two same residents were lying in bed together and Resident #2 was dressed, but Resident #3 was lying naked against Resident #2 with her front body facing Resident #2's back, as in the "spooning" position. The DON stated, "It was reported to me that they were laying on the bed, not that (Resident #3) was naked, but they were laying on the bed." The DON acknowledged there was no investigation into this incident. She was not certain if staff who reported the incident to her had documented the incident in the residents' records. "There should be something in the care plan for redirection of (Resident #2 out of Resident #3's) room." The DON was asked if there was any documentation of a sexual relationship between the two residents. "Not that I'm aware of." The DON was asked again about the 4/16/11 (Saturday) incident between the two residents. The DON was asked if there was any reason why the incident would not be documented in each resident's record. The DON stated, "I'm thinking she (LN #7) may have asked, 'How do you want me to document this?' I said, 'just don't, just put it under my door.' I don't want to tell her how to document this. (Administrator) and I will talk about it on Monday." At this time the survey team requested a copy of LN #7's written statement. The DON returned at approximately 2:00 pm, with the copy of LN #7's written statement, signed/dated "4/16/11, 1300 (1:00 pm.)" which documented: "(Name of DON.) At 1130 (AM) I had one aid finishing lunch...At 1145 (AM) I personally knocked on (Resident #2's door). Upon entering (Resident #3) was sitting on (Resident #2's) bed and (Resident #2) was pulling her hand out of the front of (Resident #3's) pants. (Resident #2) voiced, 'I know that I can't do that and that she is not supposed to be in my room.(') (Resident #2) got upset due to the separation and refused lunch. Up to the timeframe of doing cares (Resident #s 2 and 3) were in day room sitting apart from each other and visiting with one another. (Resident #3) has shown no distress over the situation." On 4/22/11 at 2:00 pm, the Administrator was interviewed. She was asked if it was the practice of the staff to not document incidents. "Oh no, all allegations should be documented." The Administrator acknowledged that she had not reviewed the residents' records for documentation. "I did not do a very good job of investigating. I did not call it in. The (DON) told me she had a note (from LN #7) but I did not read it. I should have read it. It should have been in the record. I do not know why the nurse did not chart it." 3. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's physician's orders [REDACTED]." The [MEDICATION NAME] was scheduled to be given at 8:00 am and 4:00 pm. The resident's recapitulated All Active Orders for April 2011 documented: * "[MEDICATION NAME] (insulin [MEDICATION NAME]) 12 units Solution Subcutaneous (SQ) - Before all meals. Everyday." This insulin was scheduled to be given at 7:00 am, 11:00 am and 4:30 pm. "[MEDICATION NAME] (insulin [MEDICATION NAME]) sliding scale Solution Subcutaneous (SQ) - Before all meals. Everyday: <60 = -2 units, 60-99= -1 units, 100-149 = 0 units..." This insulin was scheduled to be given at 7:00 am, 11:00 am, and 4:30 pm after blood sugar checks were done. On 4/25/11 at 8:00 pm, the IPN documented, "(At) 1800 (6:00 pm) Resident blood sugar check was recorded (at) 50. [MEDICATION NAME] 12 u(nits) held, [MEDICATION NAME] 36 u held. Gave resident an Ensure supplement 120 cc. Recheck blood sugar (at) 1930 (7:30 pm). Result (at) 87. Gave ensure supplement, resident drank a couple sips. Gave [MEDICATION NAME] 36 u. Call to (physician assistant) for (physician name) to update. Will continue to observe." The nursing note above, written by LN #4, indicated the blood sugar check was done 1.5 hours later (6:00 pm) than scheduled (4:30 pm) with no documented reason for the delay. In addition, the blood sugar recheck was done 1.5 hours after the initial reading of 50 instead of the rechecking the blood sugar in 15 minutes according to the facility's current policy and the recommendations of the American Diabetic Association (ADA). Also the resident's [MEDICATION NAME], scheduled to be given at 4:00 pm, was given at 7:30 pm. And, the resident's [MEDICATION NAME]12 u, scheduled to be given at 4:30 pm, was held without a physician order. The current order, referenced above, was to decrease the [MEDICATION NAME]by -1 if the blood sugar was between 66 and 99. The dose of [MEDICATION NAME]that should have been given was 11 units. The facility's Current Policy for Diabetic Management documented, "If blood sugar is <60 and resident is awake: ...Recheck blood sugar in 15 minutes. If blood sugar remains low and no other hypoglycemic reactions are noted, continue to give supplemental carbohydrates. Recheck blood sugar in 15 minutes and continue to monitor the resident until condition is stable..." The ADA's Standards of Medical Care in Diabetes, January 2010, defines [DIAGNOSES REDACTED] as a glucose level less than 70. The ADA recommends 15-20 G (grams) of glucose in the treatment of [REDACTED]. If the blood glucose level showed continued [DIAGNOSES REDACTED], the treatment and blood glucose rechecks should be repeated until the blood glucose level was normal. On 4/28/11 at 4:20 pm, the ADON was asked about the nurses note from 4/25/11. She stated the blood sugar should have been checked sooner and the recheck should not have been done 1.5 hours later but should have been checked "sooner than that."

Based on a public complaint, record review, and staff interview it was determined the facility failed to provide appropriate treatment and services to address the mental and psychosocial adjustment difficulties experienced by a resident recently admitted to the facility after living independently in the community. This was true for 1 of 5 residents (#1) reviewed for social service concerns. Resident #1 displayed signs and symptoms of adjustment difficulties which included anxiety, intrusive wandering, aggression and violence, social isolation, sleep pattern disturbance, inappropriate urination, and an inability to control behaviors; he was psychosocially harmed when the facility did not provide timely or appropriate intervention for these indicators of adjustment difficulties. Findings include: INVESTIGATIVE GUIDELINES state that mental and psychosocial adjustment difficulties refer to problems residents have in adapting to changes in life's circumstances... "Mental and psychosocial adjustment difficulties are characterized primarily by an overwhelming sense of loss of one's capabilities; of family and friends; of the ability to continue to pursue activities and hobbies; and of one's possessions... A resident with a mental adjustment disorder will have a sad or anxious mood, or a behavioral symptom such as aggression. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM/IV), specifies that adjustment disorders develop within 3 months of a stressor (e.g., moving to another room) and are evidenced by significant functional impairment... social isolation (e.g., loss or failure to have relationships); sleep pattern disturbance (e.g., disruptive change in sleep/rest pattern as related to one's biological and emotional needs); (and) inability to control behavior and potential for violence (aggressive behavior directed at self or others)... Appropriate treatment and services... may include... systematic orientation programs; arrangements to keep residents in touch with their communities, cultural heritage, former lifestyle, and religious practices; and maintaining contact with friends and family... crisis intervention services... psychotherapy, drug therapy... monitoring of drug therapy and other rehabilitative services." APPENDIX P of the STATE OPERATIONS MANUAL - Survey Protocol for Long Term Care states that Severity Level 3 "can include but may not be limited to clinical compromise, decline, or the resident's inability to maintain and/or reach his/her highest practicable well-being." Examples of negative psychosocial outcomes as a result of the facility's noncompliance may include but are not limited to: significant decline in former social patterns; irritability; anxiety; psychomotor agitation, verbal agitation, markedly diminished ability to think or concentrate; resistance to care; moderate aggressive or agitated behaviors; sleeplessness; agitation indicative of understimulation as manifested by fidgeting, restlessness, and/or needing to find something; anger that has caused aggression that could lead to injuring self or others; verbal aggression; and physical aggression such as hitting or shoving others." The Bureau of Facility Standards received a complaint from the public on 4/19/11, which alleged that inservice notes in the ACU documented that Resident #1 "was to be allowed to wander in and out of rooms," which infringed upon the rights of other residents. Resident #1 was admitted to the facility's ACU (a locked unit) on 3/4/11 with [DIAGNOSES REDACTED]. He was discharged from the facility to a geriatric psychiatric hospital on [DATE]. Resident #1's 3/17/11 admission MDS assessment coded: * Severely impaired cognitive skills for daily decision making * Inattention and disorganized thinking behavior which fluctuated * Trouble falling or staying asleep, or sleeping too much, nearly every day * Trouble concentrating on things, nearly every day * Being short tempered, easily annoyed half or more of the prior 14 days * Verbal behavioral symptoms directed toward others, 1-3 of the prior 14 days * Significantly intruded on the privacy or activity of others, 1-3 of the prior 14 days * Rejection of care, 4-6 of the prior 14 days * Wandering which significantly intruded on the privacy or activity of others, daily NOTE: The resident lived alone, independently in the community, prior to admission to the facility. Resident #1's 3/4/11 Care Plan included the focus area, goal, and interventions: * Altered cognitive status (and) communication deficit AEB short term memory problem, confusion/disorientation to person/place/time, potential for elopement. Client will be oriented to self, room, and facility; be able to follow simple directions; assist in making daily choices in cares. - When anxious/frustrated, gently attempt to calm and/or redirect focus. - Keep distractions at a minimum. - Staff to adjust the tone and/or volume as needed during verbal communication. NOTE: The care plan was not updated prior to the resident's discharge from the facility. PPN documented: * 3/14/11: "(Advanced) dementia - (minimal agitation at) present." * 3/18: "Nursing staff report he grabbed one of the aides by the neck this morning.... Agitation - (new order for) [MEDICATION NAME] 1 mg po or IM (intramuscularly) q (every) 8 (hours) PRN." NOTE: No incident report or investigation was completed for this incident. The order was not included on the physician's orders [REDACTED]. * 3/22: "Agitation - controlled; follow." * (date illegible): "(Resident) denies... easy bruising... or sleep changes.... Dementia - stable." NOTE: This entry was noted by nursing staff on 4/4. * 4/19: "Called to evaluate (increased) 'sundowning' (and) wandering (and increased) difficulty redirecting him... Wandering, curious, frustrated, not combative (at) present. Dementia (with increased) agitation. Much worse during evening/night. See orders for trial continued (non-pharmaceutical treatment and) minimal pharmacologic (treatment)." * 4/21: "Resident is pocketing meds (and) refusing to take them. Sundowning/agitation continues... wandering. Dementia (with) agitation/sundowning." physician's orders [REDACTED]. * 4/19/11 - [MEDICATION NAME] 250 mg po BID at noon and evening meal time - mood stabilization * 4/21 - Trial (change prescription) to [MEDICATION NAME] sprinkles to see if resident will take in pudding The resident's 3/4/11 admission Nursing Assessment documented: * Resident appears anxious * Repetitive physical movements * Stays up late at night * No psychoactive medications * Ambulates and transfers independently * No skin or wound conditions * Mental state: confused A 3/11/11 Monthly Summary for Resident #1 documented, "Seems to have trouble sleeping (at night). Has had some urine elimination in inappropriate areas. Staffing has been attempting to redirect resident to his room especially when noted with the possibility of resident observed wandering, may be seeking his room." Resident #1's 3/11/11 Social Services History/Admission Assessment documented: * Behaviors of wandering and exit seeking * Normal daily routine: Stays up late at night; naps regularly during days; stays busy with hobbies, reading, or fixed daily routine; spends most of time alone or watching TV; and moves independently indoors Resident #1's 3/24/11 LTC Adjunct Assessment documented the resident's usual mood as content, with evenings more difficult for the resident. MDS assessment notes written by the APD in various sections of the resident's medical record documented: * 3/11/11: "Was admitted to this facility on 3/4/11 from his home... is on no psychoactive meds (medications)." * 3/11: "Enjoys looking at magazines, doing puzzles and watching television in his room and in common areas... wanders in and out of others' rooms, is easily redirected. Activities will invite, assist, and encourage activity participation." * 3/22: "Mood indicators include varied sleep pattern, short attention span, and is easily annoyed with redirection. Behaviors include daily wandering and verbal aggression towards caregivers when they redirect him out of others' rooms. (Resident #1) is on no psychoactive meds." * 3/22: "Is adjusting well to placement. He enjoys independent and leisure activities of choice, looking at magazines, doing jigsaw and crossword puzzles as well as watching television in his room and common area.... Activities will invite, assist and encourage (Resident #1) to participate in group activities of choice." * 3/28: "Was involved in (resident to resident) incident the morning of 3/27/11... stating, 'I did not mean to push you but you scared me. I'm sorry, I can't help it...' Normally is not physically aggressive but does wander daily." * 4/4: "Has shown no aggression towards peers since incident on 3/27/11. Will discontinue 1:1 at this time and observe for S/S of aggression." * 4/20: "Continues to wander in others' rooms, at times will just wander hallways looking at shadow boxes (and) reading names on the doors; is redirected without incident... Starts to sundown at (approximately) 3 PM daily and has not been sleeping well at night.... (New orders) to start [MEDICATION NAME] 250 mg PO BID at noon and (6 PM).... Also had an incident on 4/18/11 in which he kissed a female peer on the forehead and cheek in the hallway. The two residents were separated without incident and redirected to separate areas of unit. Will continue to observe." * 4/21: "Has not been taking his meds...." * 4/21: "Will be transferred to (geriatric psychiatric hospital) this PM related to wandering, intrusive behavior with no anticipated return." Resident #1's Behavioral Drug Monthly Flow Records for March and April 2011 documented that the following behaviors were monitored: * Trespassing in others' rooms (started to monitor on 3/28) - 119 times; 79 of those occurred between 4/17 and 4/21. * Attempting to enter others' rooms without appropriate purpose (started to monitor on 3/31) - 117 times; 74 of those occurred between 4/17 and 4/21. * Anger or agitation towards peers (started to monitor on 3/31) - 13 times; all after 4/17. NOTE: No behaviors were documented to be monitored from 3/4 - 3/27/11. Resident #1's behaviors escalated dramatically on 4/17 and continued to be greatly increased from his baseline until he was transferred out of the facility on 4/21/11. COC forms documented: * 3/27/11 - "Resident accidentally presented himself in another resident room. The room is a female resident shared with 2 females. One female resident became very upset with his presence, was very loud and vocal stating to resident to get out, is not your room. Staff approaching to intervene, this resident was standing in the middle of the room. Female resident was lying on the floor next to doorway. Claiming to have been handled by resident. Resident stating, 'I am sorry.' No notable injuries on resident. Seemed upset (at) the time." * 4/1 - "On resident weekly skin assessments 2 bruises were found to resident's right arm. The 1st bruise to resident right wrist measures 3 cm (centimeter) x 3 cm and the 2nd is a bruise to resident right elbow that measures 6.5 cm x 4.5 cm." * 4/20 - "Resident (without) cooperation (with) taking meds. Will 'cheek' them and spit out or just refuse them. After speaking (with another nurse) she also has noticed this behavior. Unable to explain to him the need of med due to (decrease) in comprehension/cognition. Could we try liquid [MEDICATION NAME]?" IPN documented: * 3/8/11 - "Resident is quiet, will come out to sitting room, attempt to mingle among other residents. Some residents whom (sic) have maintain (sic) residency here for longer time frame seem to have an uneasy attitude toward resident, as resident attempts to familiarize himself to the ACU wing.... Appears to be a little stressed in the event of needing guidance." * 3/11 - "Resident has been adjusting well to the new environment, continues to wander into other rooms, easily redirected. Name plate is placed on resident's door for him to recognize own room." * 3/15 - "Resident is resistant to some requests, has been noted to eliminate 'not' in his assigned room area." * 3/16 - "Resident continues to go in other people's room. Staff tries redirecting... resident is resistant to some requests... some resident(s) get angry (and) some yelling back and forth had happening (sic) today after resident attempted to go in another resident room." * 3/17 - "Still confused as to where he is which room is his. Resident is not always fully dressed when he comes out of room." * 3/18 - "Resident was in hallway without pants on." * 3/19 - "Several episodes of resident walking in (and) out of rooms. Staff redirects resident to his own room." * 3/28 - "Resident up ad lib needing staff guidance to keep resident safe from presenting self in other rooms without permission." NOTE: Resident #1 had 1:1 supervision 3/28 - 4/4, and his behaviors decreased significantly during this time. * 3/29 - "Staff continues with constant guidance to keep resident safe from presenting self in other rooms without permission. Resident has been calm today; episode of another resident accidentally tapped his hat while on head (and) continued with remaining quiet. Likes to read magazines (and) books. Has taken short naps today." * 3/29 - "Resident is (continued with) 1:1 this (night) shift. Has had no aggression, no trespassing." * 3/30 - "Resident did not attempt to enter in any of the resident rooms. (Continues) on 1:1 supervision." * 3/30 - "Resident (continues) as 1:1, is (up and down) all of early shift until 1:30 AM when he falls asleep. Peaceful (and) still... No aggression or trespassing." * 4/1 - "Had (no) episodes of wandering or aggression towards others." * 4/1 - "No behaviors noted this evening." * 4/2 - "Has had (no) episodes of wandering into other rooms or aggression towards others." * 4/3 - "Resident (continues) with constant observation for his safety... most of today has been content reading. No vocals no disruptions toward staff or peers." * 4/4 - "Resident continues (with) 1:1... no aggressive behaviors, quiet (and) pleasant. Wanders from day room to (dining room and bath room), but has not slept. No attempts to enter residents' rooms thus far." * 4/4 - "No aggressive behaviors, no trespassing into other residents rooms, pleasant, quiet, cooperative. No sleep, sits (with) aides all (night). (Continues) as 1:1. This nurse sat (with) resident (and) aides for (approximately) 20 (minutes). He was confused but stayed cooperative. Aides allowed (and) nurse (sic) resident to stay up as he could not sleep." * 4/4 - "Resident shows no aggression toward peers or staff. Has had x 2 episodes of wandering into another room that is located next to his, possibly checking for familiar items, then turning around, leaving. 1:1 staff person released (at 6 PM)." * 4/5 - "Has not been seen entering other rooms." * 4/6 - "Resident had a few episodes of wandering other resident's room. Was easily redirect (sic) without aggressive behavior. Ambulates around unit sometimes talking to other residents. Most conversations don't make (sense. No) aggressive behaviors toward staff or residents." NOTE: Behaviors began to increase again after the 1:1 supervision was removed on the evening of 4/4/11. * 4/7 - "Resident had episodes of wandering into other residents' room removing items taking them to his room and urinating into other residents' restroom, garbage cans and corner in room. He will easily redirect without agitation or aggressiveness. Wandering in rooms were more active in the earlier hours of day in the afternoon. Resident spends time in dayroom sitting and reading magazines or newspapers." * 4/8 - "Resident continues to wander in and out of rooms. Will open dressers rummage through belongings. Will remove items taken them to his room. Items are returned to proper residents. He is easily redirected with (no) agitation or aggression towards others. He will also go into other rooms for toileting purposes." * 4/9 - "Resident had 2 episodes of wandering into other residents rooms without reason. Incident was walking into rooms then immediately leaving room. Resident enjoys sitting in day room and reading magazines. (No) agitation or aggression to staff or other residents." * 4/10 - "Resident has had some wandering today. Staffing is redirecting when observed getting close to other resident room threshold. Has been most of his waking time in our sitting room, reading magazines, newspapers and other readable materials. Observed attempting conversations with other residents in view of staff. Very kind gestures. No extreme agitation when attempting to redirect resident." * 4/11 - "Resident unknowingly entered a female room, as though possibly seeking a bathroom, did not touch anything as staff intervened just stood motionless. Resident redirected to his assigned room reintroduced to his bathroom, did not use commode. Redirected to sitting area sitting by self. Had chatted short time with another resident - no agitation." * 4/11 - "Resident has a few remarks associated with redirection, has stated, 'take your clothes off, now.' This nurse told him that will not happen. Attempts to friendly (sic), no touching up to present." NOTE: Next entry 4/13. * 4/13 - "(Resident) had uneventful day mostly staying to himself, wandered into 2 other residents room, was able to redirect." NOTE: Next entry 4/18. * 4/18 - "Resident wandering all (night), in (and) out of room [ROOM NUMBER]+ times. Staff constant redirect (sic). Upsets two gentlemen (with) entering rooms, one entry into female room includes both residents holding hands x 2 (with) redirection to exit room as to inappropriate nature. (Resident #1) gets agitated this evening (with) aide who is providing consistent redirecting due to wandering, as is her duties and no physical harm to resident or aide. He is finally quiet, calm, sleeping on couch in sitting position (at) this time. No calls made as resident did not harm or hurt himself or anyone else." NOTE: Significant increase of behaviors began on 4/17 - see Behavioral Drug Monthly Flow Records above. * 4/18 - "Late entry for 4/17/11 6 PM - 6 AM. Reported verbally to (DON and) Program Director that (at 6:15 AM) of 4/18/11 aides came (and) reported (Resident #1) being in hallway 'kissing another female resident on forehead (and) cheeks in ACU hallway.' No physical harm to either resident. Both are separated (and) redirected by aides." * 4/19 - "Resident (continues) to wander, checking out door knobs (and) other devices, looks (at) shadow boxes, some other residents are territorial and needs extra guidance (and) redirection. (Physician) in for an evaluation, leaving new orders." * 4/20 - "(Resident) cheeked meds this AM and spit them out in hand when I wasn't looking although I had observed him swallow... water after putting meds in mouth he refused to take noon meds. (Unit Director) had sat down by him (and) was encouraging him to go ahead (and) take meds. He then got angry when I wouldn't leave and continued to sit by him. Will have (physician) evaluate meds and dose." * 4/22 - "Resident was discharged last evening at 8:20 PM to (geriatric psychiatric hospital)...." IDT cares review notes documented: * 3/7/11: "Had not been to (physician) or bathed in over 3 (years). Has been seen by (physician) on 3/4/11. Had bath on 3/5/11. Will follow next week." NOTE: No documentation for 3/14. * 3/21: "Adjusting well to placement.... Exhibits behavior of... inappropriate urination. Staff redirect resident to use toilet... continues to wander in secure unit and others' rooms. Will follow next week." * 3/28: "Was the aggressor in (resident to resident) incident on 3/27... is currently on 1:1 observation... now has family pictures on his door as well as a shadow box to help identify his own room. Signs were placed on peers' doors stating, '(Resident #1) this is not your room' to help distract him from going into peers' rooms. Will follow in 1 week." NOTE: No documentation for 4/4. * 4/12: "Continues to wander in and out of others' rooms, easily redirected." * 4/18: "Continues to wander in others' rooms, is easily redirected without aggression." NOTE: IDT notes and the resident's adjustment difficulties indicated that his behaviors and other concerns should have been evaluated at least weekly; there was no documentation in the medical record that the IDT had discussed his situation during the weeks of 3/14 and 4/4/11. CSR documented the following entries related to Resident #1: * 3/7/11 - "Sleeps 1 (hour from 10 PM to 5 AM). Wanders in (rooms), redirects easily, cooperative." * 3/11 - "Wandering, intrusive." * 3/13 - "Had shower, talked him into a different cap, helps his looks. Might tone down other residents' thinking he is not a 'nice' guy." * 3/15 - "Using trash cans for urine elimination, trash can in dining hall, looks suspicious." * 3/27 - "(Resident to resident) altercation - no injuries." * 3/29 - "(Up and down) most of (night), redirected by 1:1 back to bed. No trespassing. Sleep (at 1:30 AM, slept 4.5 hours)." * 3/31 - "Starting today with staff delivering 1:1 allow (Resident #1) to go into others' room, document what he did (visiting (with) peer, turned (and) left, ruffled through items). If he approaches another resident allow the conversation but do not allow confrontation. Aides are to let the nurse know for ongoing daily charting. Document every shift." NOTE: A directive to allow the resident to go into other residents' rooms was an infringement on the rights of all other residents who resided in the ACU. * 4/5 - "Pleasantly confused, quiet (and cooperative. No) concern, (no) agitation." * 4/7 - "Wanders into other rooms. Remove(s) items of other residents, taking them to his room. Goes into other rooms to void." * 4/10 - "Going into (other residents') rooms, taking (other residents') belongings - will not redirect. Upset several others. Finally fell asleep in chair." * 4/12 - "Wandering all (night), a couple entries to others' rooms, but quiet (and without) agitation." * 4/17 - "Wandering all (night), entering all rooms, (urinated) in (a female resident's) toilet, flirty with (same female resident), hand holding. (Same female resident) not appropriate (with) clothing tonight (with Resident #1) entering room, she came out half dressed to hallway (twice) - happy, flirty. Aggressive (with CNA), upset tonight because she was (constantly) redirecting him as is her job; (another male resident) upset - 4 letter words (and a different male resident) due to (Resident #1) in (their) room. No calls made because we were able to redirect but (Resident #1) was busy busy busy, (up and down) all (night and) refuses to (change) wet clothes this early (morning). Sleeping on couch sitting up (at) 4:30 AM." * 4/18 - List of residents whose rooms Resident #1 entered: Female residents 5 times, male residents 5 times. * 4/20 - "Resident cheeks (morning) meds taken in mouth, took drink and swallowed (and) when I stood up to walk away he spit them out in hand. At noon did same." Resident #1's Resident Recapitulation of Stay Discharge Plan and Instructions, dated 4/21/11, documented: * Reason for admission: Dementia * Progress (include any complications experienced): Stable * Reason for discharge/discharge diagnoses): (Increased) behaviors On 4/22/11 at 12:50 pm, the Administrator was interviewed about the facility's social services program, and asked if the facility had a Social Worker on contract. She stated, "(The corporation) took over 7/1/10. Prior to that we had a (Social Worker) consultant monthly. Since then we haven't had one." Resident #1 displayed behaviors and other symptoms of negative psychosocial outcome at the harm level, after he was admitted to the ACU (a locked unit) from living independently in the community. The facility failed to provide appropriate and timely assessments and interventions to reduce or alleviate negative outcomes for the resident. On 4/28/11 at 2:40 PM, the Acting Administrator, Acting DON, RVP, and RNC were advised of the findings. No further information was received from the facility.

Based on a complaint from the general public received by the Bureau of Facility Standards (BFS) on 4/19/11, staff interviews, record review, and review of the Event Management Reports (EMRs), it was determined the facility failed to provide the required supervision to prevent injury. This failed practice impacted 6 of 16 sampled residents (#s 3, 7, 8, 11, 15, 16). This failed practice resulted in harm to Residents #s 15, and 16. Resident #16 was harmed when she apparently stood up from bed, lost her balance and fell . She suffered a fractured left elbow and multiple left rib fractures. The EMR investigation report failed to determine if the resident fell due to abuse/neglect or staff error, and solely relied on the statement of the cognitively impaired resident. Resident #15 was harmed when her dependence on staff assistance for mobility increased, her care plan was not modified, she did not have a care planned bed alarm in place, and she fell and fractured her hip, which required surgical intervention. This failed practice had the potential of harm to Resident #s 3, 7, 8, and 11, and to impact all residents of the facility, especially residents with cognitive impairments who could not be interviewed by staff to explain the events or the cause of suspicious bruising/injuries. Findings include: The complainant alleged that on 4/18/11, an identified staff member was overheard telling a second identified staff member that on 4/16/11, on the day shift, Resident #2 was found in Resident #3's room and in bed with Resident #3. Resident #2 had her hand down Resident #3's pants. According to the complainant, the first staff member said she was told not to complete an Incident/Accident report and not to document the incident in the residents' records. Family members were not notified of the incident. The complainant also alleged that during the approximate week of 4/3/11, Resident #1 was wandering in and out of other residents' rooms on the ACU, and getting into other residents' belongings. Resident #1 went into Resident #7's room, and Resident #7 hit Resident #1. The complainant alleged that the staff inservice book documented staff were to allow Resident #1 to wander in other residents' rooms. The survey team entered the facility on 4/21/11 at 8:30 am, and requested that the Administrator provide all the Incident/Accident investigation reports and all Abuse/Neglect investigation reports from January 2011 through the current date. At 9:00 am, the Administrator provided one Resident-to-Resident abuse investigation report and stated that was the only one for the requested time period. NOTE: The investigation report involved an incident between Resident #s 1 and 7. 1. Resident #16 was admitted to the facility on [DATE] after being hosptalized on [DATE] with [DIAGNOSES REDACTED]. The hospital report documented in part: 8/21/10: "...She apparently suffered a mechanical fall in her home where she lives independently but has no idea why she fell or if she lost consciousness. On arrival at the emergency department, she reported that over the last 7 days she had been home alone. She had been unable to stand or weight bear. She had been crawling around on the floor and had nothing to eat. She reported to the emergency department personnel that she had been drinking water from the dog's bowl and finally was able to get to the phone and activate EMS. EMS reported...the patient was laying on the floor when they arrived at the house and that the house was unlivable...very malodorous and poorly kept with feces and trash all over the floors...The patient is alert, but somewhat confused..." Resident #16's [DIAGNOSES REDACTED]. Her admission MDS assessment, dated 8/24/10, coded: * Moderately impaired cognitive skills for daily decision making * Easily distracted * Periods of altered perception or awareness of surroundings * Episodes of disorganized speech * Mental function varies over the course of the day * Usually understands (may miss some part/intent of message) * Resistive to cares * Two person assist with bed mobility * Total dependence for transfers * Unable to attempt balance while standing without physical help * Other person wheeled for mode of locomotion Resident #16's care plan documented in part: *8/21/10 -Problem: "Fall risk, as evidenced by: history of falls; unable to ambulate without assistance; Unable to transfer without assistance..." -Interventions: "Remind resident to call when needing assistance; Keep call light and most frequently used personal items within reach..." -Problem: "Total assist for transfers, mobility, ambulation...related to weakness...unsteady gait, balance problem..." -Interventions: "...Assist with ADL's (bed mobility, transfer, locomotion...toileting)..." *9/13/10 -Problem: "Incontinence, Functional Urinary, related to cognitive deficit..." -Interventions: Check resident every two hours and assist with toileting as needed; Provide bedside commode; Keep call light within reach, and remind resident to call for assistance..." *9/18/10 -Problem: "Poor safety awareness related to acute brainstem CVA." -Interventions: "Hi-Low bed with fall mat to promote safety. 1/11/10 (sic) (2011) (No) commode @ bedside." The IPNs were reviewed. There was no documented evidence of any IPNs in the resident's record after 12/13/10, except for a COC Documentation's form, dated 1/10/11, which documented, "Resident was found on floor lying on left side - sign of blood from unknown source. Resident alert, coherent, stating pain in chest L(eft) side...(increased complaint of) pain to L side chest wall when attempted to move...Call to (family) for update...Send to ER for evaluation . ER here for pickup at 0830 (8:30 am)...0845 (8:45 am) out of facility with ER personal (sic)" NOTE: The form was misdated as "1/10/11" instead of "1/11/11." An EMR, dated 1/11/11, 8:00 am, documented in part: - "Event: Fall - A female resident residing on ACU went into room (#) of resident (#16.) Female resident came to this nurse to report resident on the floor who resides in room (#). Entering room (#) found resident occupant of room (#) lying on the floor on her left side alert coherent indicating had attempted to get up out of bed. Found self falling onto floor. Blood was observed on the floor...Unit Director (Name) came immediately asking resident if she had pain anywhere, answering (') my chest hurts (')..complaints of pain in her chest became more evident...Order to transfer to hospital for evaluation... - Mental Status Prior to Fall: (This was left blank) - Recent Change in Cognition/Behavior: (left blank) - Environmental Factors: (left blank) - Footwear/Equipment at time fall: (left blank) - Assistive devices used by resident: (left blank, including 'none') - Equipment working properly? (left blank) - Was call light functioning? (left blank) - Was call light in reach of resident? (left blank) - Was bed in low position? (left blank) - How long since last voiding? (left blank) - Additional comments: (left blank) - Summary of interview with witness(es): (left blank) - Resident's explanation of event : Resident stated was getting up from bed found self falling - Contributing factors: Was resident's cognition/behavior a factor? No - Narrative conclusion of root cause; (left blank) - Nurse Manager/Supervisor Review: Staff interviewed: (left blank) - Summary of staff interview: (left blank) - Status: 'Not Complete...' - Last modified by: (Name of RN) on 1/11/2011, 7:56 pm." The PPN, signed/dated 1/11/11, by the PAC, documented in part: "Nsg (Nursing) staff report pt fell this AM, was found on the floor. C/O L (complaint of left) chest wall pain, hurts too much to move. Pt says she doesn't know how she fell ..." Resident #16 was admitted to the hospital on [DATE], after she sustained multiple left rib fractures and left elbow fracture. She remained hospitalized until 1/15/11. On 4/22/1 at 12:00 pm, the DON was asked if the facility had any further documentation related to their investigations that was not included in the documents received by the survey team at the beginning the the complaint survey on 4/21/11. She stated there was no further documentation. On 4/28/11 at 10:05 am, during an interview with the RSC and the acting Administrator, the RSC was asked the criteria for admitting Resident #16 to the ACU. The RSC stated Resident #16 was, "confused when she came in...She needed a secure environment to make her feel safe." The RSC stated that on 9/1/10, the SLP performed a Mini Mental evaluation. "She scored a '10', on the scale of '1 - 19' which equals dementia." On 4/28/11 at 11:45 am, the survey team requested Resident #16's IPNs for the time period of 12/14/10 through 1/11/11. At the time of the exit on 4/29/11, no additional documentation was received. The interim Administrator was contacted by phone on 5/3/11 at 10:40 am, and the documentation was again requested. At 2:44 pm, the interim Administrator called the BFS and informed the surveyor that he could not locate any IPNs for the requested time period for Resident #16. The facility failed to thoroughly investigate the circumstance of Resident #16's unwitnessed fall to rule out the possibility of abuse, neglect or staff error, for example, was the resident's call light within each, and if so, did the resident activate it. The staff relied solely on the statement of the cognitively impaired resident as to the possible circumstance of the incident. Staff members were not interviewed to determine if they were busy assisting other residents, and therefore unavailable to ensure adequate supervision of the resident to prevent the fall. It could not be determined that the resident's care plan to prevent falls was implemented. 2. Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #15's 5/5/10 admission MDS assessment coded: * Moderately impaired cognitive skills for daily decision making * Total dependence on physical assistance by 1 person for bed mobility, locomotion, and personal hygiene * Total dependence on physical assistance by 2 ore more persons for transfers, dressing, and toilet use * Not able to attempt balance test while sitting or standing without physical help * No limited range of motion * Wheelchair used for locomotion * Deteriorated ADL self performance as compared to 90 days prior * fell in prior 30 days * Physical therapy RAPS notes written by the RSC on 5/13/11 documented: "Was living in a ALF (an assisted living facility) where she became weaker r/t (related to) Parkinson's (disease). Frequent falls with fracture r/t osteoporosis... Resident is afraid if she moves she will fall. She has been anxious and fearful. Will proceed to Care Plan... had increasing falls while living at the ALF. High risk prevention. Low bed, floor mat at bedside. Pressure alarm to alert staff of self rising." Changes from the prior MDS assessment which were reflected on the resident's 7/30/10 quarterly MDS assessment included: * Severely impaired cognitive skills for daily living * Extensive physical assistance by 1 person for bed mobility, locomotion off unit, dressing, and personal hygiene * Extensive physical assistance by 2 or more persons for transfers and toilet use * Limited physical assistance by 1 person for locomotion on unit * fell in prior 30 days * Occupational and physical therapy Changes from the prior MDS assessment which were reflected on the resident's 10/30/10 quarterly MDS assessment coded: * Disorganized thinking continually present, does not fluctuate * Extensive physical assistance by 1 person for transfers, toilet use, and personal hygiene * No falls in prior 6 months * No physical, occupational, restorative, or speech therapy services Changes from the prior MDS assessment which were reflected on the resident's 2/5/11 5-day scheduled (readmission) MDS assessment coded: * Extensive physical assistance by 1 person for bed mobility, transfers, dressing, and personal hygiene * Not steady, only able to stabilize with human assistance for moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer * Lower extremity limitation in range of motion on 1 lower extremity * A fall with fracture in the 6 months prior to (re)admission * Antidepressant medication * Physical and occupational therapy services Changes from the prior MDS assessment which were reflected on the resident's 3/25/11 60-day scheduled MDS assessment coded: * Extensive physical assistance by 1 person for bathing * No falls or history of falls with fracture in the 6 months prior to admission - NOTE: The resident fell and fractured her hip on 1/25/11. Resident #15's Admission Evaluation and Interim Care Plan, dated 5/1/10, documented a history of vertigo, and dependent for all ADLs. Care Plan interventions in effect from 10/1/11 through 1/25/11 included a high/low bed for safety with floor mat, alarm, and bed against wall to help prevent falls The resident's April 2011 physician's orders [REDACTED]. * Lasix 40 mg tablet by mouth daily every day for CHF * Levothyroxine Sodium 0.125 mg tablet by mouth BID (twice daily) for [DIAGNOSES REDACTED] * Spironolactone 25 mg tablet by mouth daily every day for CHF * Remeron 7.5 mg tablet by mouth at bedtime everyday for other persistent mental disorder * Physician has reviewed and approved the resident's plan of care PPN documented: * 11/2/10 - "(Multiple) falls (and) fractures - healing... really doing remarkably well." * 1/30/11 - "(status [REDACTED]. Will need supportive cares." Fall Risk Evaluations documented: * 5/1/10 - Score of 26, where scores of 10 or higher indicated high risk * 10/22/10 and 1/3/11 - unscored fall risk assessments were completed * No other fall risk assessments were found in the resident's medical record Restrictive Device Evaluations documented that the resident had a high-low bed with rubber mat on the floor next to the bed, in place from 7/17/10 through 1/25/11. EMR documented: * 1/25/11 Fall - "Resident was yelling help from room. Upon witness entering room, Resident was found lying on the floor on her left side. She was bleeding from a 3 inch laceration to the left side of her forehead and complaining of hip pain on the left side. Resident stated she had tried to get up when she lost her balance and fell . Resident was sent to hospital per emergency transport... Resident's bed was in lowest position and floor mat was in place when Resident attempted transfer/ambulation... Resident has history of confusion and dementia. Resident stated she wanted to go find someone and could not figure out what made her think she could walk... She has used her call light in the past and it was within reach... She stood from low bed onto mat, apparently attempted to walk and fell . She fell on left side, lower extremities on the mat and majority of body on the floor. She fell on hip and hit adjacent bed (with) her head." The area to mark "was an alarm being used for resident?" was marked, No. The area to indicate "Care Plan Updated" was marked, No. The form was marked, "completed" by the DON on 1/27/11. The resident sustained [REDACTED]. Resident #15 had a history of [REDACTED]. She was care planned for a high/low bed, fall mat, and bed alarms. Her dependence on staff assistance for mobility increased, but her care plan was not modified after admission. When she fell on [DATE] the care planned alarm was not in place. She sustained a hip fracture which required surgical intervention. On 4/28/11 at 2:40 PM, the Acting Administrator, ADON, RVP, and RNC were advised of the findings. No further information was received from the facility. 3. Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #3's most recent quarterly MDS assessment, dated 2/28/11, coded: * Sometimes understood and sometimes understands others * Short-term and long-term memory problems * Severely impaired cognitive skills for daily decision making * Inattention and disorganized thinking behavior which fluctuated * Feeling down, depressed, or hopeless * Wandering behavior occurred daily Resident #3's IPNs and EMR documented the following in part: IPNs: * 1/5/11 on the Monthly Summary, "...likes to follow another female peer who seems to have befriended her..." * 3/4: "Quarterly Review...(Resident #3) has come close with another female resident and they participate in activities together as well as they enjoy sitting together just visiting." NOTE: This entry was signed by the ACU's APD. * 4/5: "...Resident is usually amb ad lib. Does have another peer whom she follows closely, will cont(inue) with observation..." * 4/7: "...Continues to follow another resident closely. Resident is easily re-directed..." * 4/16: "Resident states she fell & hurt her back. She states she tried to grab TV & TV went down..." EMR: * 4/16/11 at 9:00 pm, - Event: Fall - No one witnessed fall but resident stated she fell and scraped her back. Noted to have several superficial abrasions on R(ight) lower back....TV in the room noted to be on the floor. - Witnesses: (Two CNA staff listed) - Is there alleged abuse/neglect? No - Resident's condition before event/accident: Disoriented - Family/responsible party notified? 4/17/11 at 6:00 am, (nine hours after the incident.) - State agency notified? No - Last Modified: "(Name of LN) 4/16/11 at 4/16/2011 at 11:46 PM." NOTE: Refer to F 223 as it addressed a separate incident earlier in the day on 4/16/11, when the resident was found in Resident #2's room. IPN: * 4/17: "...Resident is talkative, continues with confusion, cannot explain what happened last eve(ning) does express pain in R rib to chest area..." * 4/18: "Skin assessment today, check on buttock area. R buttock area eccymosed (sic) area (10 cm length x 4 cm wide) Abrasion to upper buttock are toward center of back, (0.5 cm diameter) R mid forearm and L mid forearm eccymosed (sic) area (3 cm diameter) each side. Reported to (Name of PAC), who was here for resident evaluation d/t (due to) fall..." During an interview with LN #7 on 4/21/11 at 3:40 pm, the LN was asked what immediate safety interventions were initiated after the 4/16/11 incident between Resident #s 2 and 3. "We kept them separated and involved them in activities." She acknowledged no additional staff was provided for 1:1 staff supervision for Resident #2 and to ensure Resident #3's protection from Resident #2. The LN was asked how the staff ensured the residents' safety without additional staff. "They both (Residents #s 2 and 3) go to bed after supper, so they were separated." The LN also stated, "The next nurse that came on (duty) I told the details and to keep them apart and told the aides to keep them apart." The LN was asked if she immediately assessed Resident #3 for physical injuries or for any emotional distress after the incident with Resident #2. She stated, "I did a head-to-toe assessment on Resident #3." She acknowledged she did not document the assessment. Resident #3's care plan was not revised to arrange for increased supervision after the incident between Resident #2 and #3 to ensure Resident #3 was protected from further contact with Resident #2. Then, later that day the resident reported to the staff that she fell in her room. The staff relied solely on the statement of the cognitively impaired resident as to the possible circumstances of the fall. There was no investigation to rule out the possibility of abuse. The lack of the thorough investigation of both incidents made it unclear if the suspicious injuries described in the IPN, dated 4/18/11, were sustained only from the fall. 4. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 2/15/11, coded: * Severely impaired cognitive skills for daily decision making * Short and long term memory problems * Requires extensive assistance of two persons for transfer and bed mobility Resident #11's Resident Fall Evaluation, dated 2/8/11, included the following fall risk factors: * A change in mobility, gait and transfer ability * Confusion with a change in mental status * Receiving medications that could cause orthostatic blood pressure changes Resident #11's recapitulated All Active Orders for April 2011 documented, "May use high/low bed, bed alarm and floor mat for safety...Everyday." The start date was 2/8/11. The resident's April 2011 TAR included the above order. Initials were present in each space for days and evenings up to 4/25/11, indicating the bed was in low position, bed alarm was on and floor mat was in place. The resident's 4/8/2011 Care Plan identified the problem, dated 4/26/11, "Fall-OOB (out of bed)." Interventions for the problem included, "...Continue with low bed at noc (night) or when in bed (with) floor mat next to low bed." This intervention was not included under any problem areas on the current care plan prior to 4/26/11, even though the intervention was ordered on [DATE] and was included on the current April 2011 TAR. On 4/24/11 at 6:15 am, an EMR form recorded Resident #11 was "found on the floor, sitting with back to bed stating she slid down to floor. States buttock sore, denies any other problems..." Witnesses reported, "...that resident was in bed. Bed in low position. Did not hear any noise. Found resident on floor when walking by room." There was no mention in the report if the mat was beside the bed or if the bed alarm was on the bed. Interventions initiated after the fall included, "Continue with hi-low bed and floor mat...will ask PT (physical therapy) screen for ability to transfer self..." There was no mention of the bed alarm. On 4/26/11 at 8:45 am, 9:00 am and 9:15 am, Resident #11 was observed in bed lying close to the edge of the bed. The bed was in the low position but there was no mat by the bedside. At 9:15 am, LN #4 was asked about the lack of a mat at the bedside. LN #4 immediately placed the mat beside the bed and said, "We need to have the mat by her bed. She sneaks in (her bed) after breakfast and we don't know (she is in bed)." No bed alarm was observed on the bed. On 4/26/11 at 1:05 pm, Resident #11 was observed lying in bed with her left foot dangling off the left side of the bed. The bed was in the low position but there was no mat at the bedside. CNA #s 8 & 9 were notified of the observation. The CNAs went into the resident's room, repositioned the resident on the bed and placed the mat beside the bed. No bed alarm was observed on the bed. On 4/28/11 at 2:40 pm, the Acting Administrator, ADON, RNC and the RVP were informed of the issue. The facility provided no other information or documentation that resolved the concern. 5. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 4/4/11. The resident's 9/22/10 quarterly MDS assessments coded: * Moderately impaired cognitive skills for daily living * Independent ambulation * No falls in prior 180 days The resident's 4/4/11 discharge MDS assessment coded: * One fall with minor injury since prior assessment * Antipsychotic and antidepressant medications received Resident #7's Care Plan included the following focus areas, goals, and interventions - initiated on the date indicated: * Poor safety awareness... 1/13/11 - Provide verbal cues.... (No date; hand written entry) * Risk for falls... remain free from falls (11/6/10); Decreasing number of falls by next review (1/4/11). - Encourage resident to communicate needs/ask for assistance. 11/6/10 - Ensure environment is free of clutter. 11/6/10 - Resident to wear nonslip footwear. 1/4/11 - Encourage resident to use handrails or assistive devices properly. 1/4/11 - ....Provide verbal cues for safety while allowing (and) encouraging (resident's independence). (No date; hand written entry) The resident's April 2011 physician's orders [REDACTED]. * Norvasc 5 mg tablet by mouth daily for unspecified essential hypertension * Paxil 20 mg tablet by mouth daily for unspecified adjustment reaction * Seroquel 50 mg tablet by mouth daily for dementia with behavioral disturbances * Seroquel 100 mg tablet by mouth daily for dementia with behavioral disturbances Resident Fall Evaluations for Resident #7 were completed on 12/3/10, 1/19/11, and 3/20/11. EMR documented: * 11/6/10 - Fall - "Resident left dining room after supper, staff in dining room with other residents. Staff heard this resident scream, sounded like a startle scream; when staff got to resident she was found laying comfortably on the floor on her left side with elbow folded and head resting on arm." The area to indicate, "Care Plan updated?" was marked, Yes. * 1/19/11 at 9:45 AM - Injuries of Unknown Source - "Bathing aide reported a skin wound, 1 outer aspect knee laceration. 0.5 cm (centimeter) diameter. Resident stating had tripped and fell in the facility, making statement that 'Maybe I need to slow down and not go so fast.' Cannot verify (where) or when... No reports from staff as witness to any occurrences." The area to indicate, "Care Plan updated?" was marked, Yes. NOTE: This was the resident's second documented fall/reported fall since 11/6/10. There was no evidence that the resident's Care Plan was updated in relation to this incident. * 1/19/11 at 10:10 AM- Fall - "Resident just getting prepared to sit in a chair in south sitting room; the chair she was attempting to sit in slid from behind her toward a corner, causing resident to loose (sic) balance striking self against a wall, sliding down onto buttocks. Stating hit head. ROM (range of motion) to all extremities reveals no structural injuries. Unable to detect any protrusion on skull at present." The area to indicate, "Care Plan updated?" was not completed. The facility's additional comments on the investigation report were, "isolated, environmental situation." NOTE: This was the resident's third documented fall since 11/6/10. The resident's care plan was not updated. * 2/7/11 - Fall - "During an activity in dining room resident became slightly entangled in a walker belonging to another resident. Could not keep her balance, fell to her (both) knees. Resident denies pain, ROM to extremities no notable structural injuries." The area to indicate, "Care plan updated" was marked, No. The facility's additional comments on the investigation report were, "This is an isolated incident." NOTE: This was the resident's fourth documented fall/stated fall since11/6/10. The resident's care plan was not updated. A 3/20/11 Nursing Assessment documented: * Mood and Behavior - Anger, regarding placement; Exit Seeking/Wandering * Psychoactive Mediations: Antidepressant, Antipsychotic * Balance during transitions and walking: Steady at all times NOTE: The resident had fallen/stated she fell 4 times since 11/6/10. A 3/27/11 IDT Cares note documented: "Independent in ambulation... wanders about secure unit and courtyard daily." The Resident's Recapitulation of Stay Discharge Plan and Instructions, dated 4/4/11, documented: * Physical functioning status: Ambulatory NOTE: The resident's history of falls and list of medications were not included on the form. There was no indication that any other information had been attached or reported to the receiving facility in any form. Resident #7 fell 4 times in the facility from 11/6/10-3/20/11. The resident's care plan was not updated after 3 of the falls, interventions were not modified, and documentation by multiple staff did not include the fall history. On 4/28/11 at 12:45 PM, the ADON was informed of the findings. She stated, "We just started educating the nurses on how to do care plan changes with incident reports. It wasn't being done appropriately, and there was no follow up to include that the report was finished." On 4/28/11 at 2:40 PM, the Acting Administrator, ADON, RVP, and RNC were advised of the findings. No further information was received from the facility. 6. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 3/31/11 Admission Nursing Assessment documented: * Anxious * Psychoactive medications * Locomotion via other person wheeled wheelchair, or walker, with 1 person assist for ambulation and transfers * Functional range of motion impairments on both sides, upper and lower extremities * Not steady, only able to stabilize with human assistance for moving from seated to standing position, walking, and turning around; not steady but able to stabilize without human assistance for moving on and off toilet, and surface-to-surface transfers. A 3/31/11 Device Evaluation documented: "Resident (alert and oriented), able to make needs known, is aware of own limitations and able to ask for help. Doesn't need any safety device at this time." NOTE: No other Device Evaluations were present in the resident's medical record. The resident's 4/7/11 admission MDS assessment coded: * Cognitively intact * Independent bed mobility, transfers, and walking in room * Supervision required for walking in corridor and locomotion on unit * Supervision with 1 person physical assistance required for locomotion off unit, dressing, and toilet use * Not steady, but able to stabilize without human assistance for moving from seated to standing position; walking; turning around, and surface-to-surface transfer * Not steady, only able to stabilize with human assistance for moving on and off toilet * Functional limitation in range of motion on one upper extremity * Walker and wheelchair used for mobility * 1 fall without injury since admission * Antianxiety, antidepressant, and antibiotic medications in the prior 7 days * Dialysis treatments The 4/13/11 5 Day Admission MDS Assessment note documented: "Needs assist (with) dressing (and) toilet use... (history) of fall (out of bed)." Resident #8's 4/14/11 Care Plan documented the following focus areas and interventions, which were initiated on 4/14/11 unless otherwise noted. * Use of drugs having an altering effect on the mind ... - Ensure appropriate mobility aides and safety devices used for transfer and ambulation - Observe resident's gait for steadiness, balance, muscle coordination, ability to position and turn. * Risk for falls... - Have commonly used articles within easy reach. - Encourage resident to transfer and change positions slowly. - Reinforce need to call for assistance. - Resident to wear non slip footwear. - Place call light within easy reach of resident. - Evaluate effectiveness and monitor for side effects of psychotropic drugs i.e. Xanax. - Encourage resident to communicate needs/ask for assistance. - Assist resident with ambulation providing staff assistance. - Assist resident getting in and out of bed with staff assistance. - Maintain adjustable bed to proper height to allow resident to sit on edge (with) feet firmly on floor. NOTE: This intervention was initiated on 4/23/11. physician's orders [REDACTED]. * 3/31/11 - Xanax 0.25 mg by mouth up to 2 times daily, PRN; Remeron 15 mg (1-2 t

Based on a complaint from the general public, record review and staff interview, it was determined the facility did not ensure the highest level of functioning and well being for 4 of 9 residents (#s 1, 6, 8, and 15) sampled for bowel, pain and [MEDICAL TREATMENT] care. Specifically: 1) Resident #6 suffered intractable pain without sufficient interventions. His physical, mental, and psychosocial health severely declined, resulting in harm. 2) Residents # 1, 6, 8, and 15 experienced constipation but did not receive ordered bowel care interventions. 3) Resident #8 received [MEDICAL TREATMENT] treatments at a [MEDICAL TREATMENT] center 3 times a week, but the facility did not have an agreement with the [MEDICAL TREATMENT] provider, which outlined how her care was to be managed. Findings included: The BFS received a complaint from the general public on 2/10/11, alleging failure to effectively treat pain in residents. 1. Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident admission MDS assessment, date 1/21/11, documented the following: * Moderately impaired cognitive skills for daily decision making * Poor appetite or overeating 12-14 of the last 14 days * Independent requiring set up help only for eating * Continent of bowel and bladder * Mechanically altered diet * Obvious or likely cavity or broken natural teeth * On a scheduled pain medication regimen * Received prn pain medications * Received non-medication interventions for pain * Pain in the last 5 days * Pain present almost constantly * Pain made it hard to sleep at night * Pain has limited day-to-day activities * Pain rated as a 9/10 in last 5 days NOTE: The facility was asked for copies of all care plans for the resident on 4/26/11 at approximately 2:00 pm. A second request was made on 5/16/11 at 10:00 am via telephone. A copy of an initial care plan was received on 5/16/11 at 5:00 pm. It contained no specific care plan to address constipation or chronic pain. a. Resident #6 suffered chronic pain throughout his stay at the facility from 1/14 to 4/28/11, as documented by IPN and the use of prn pain medications on a regular basis since admission. His physical and psychosocial health suffered a severe decline, resulting in harm to the resident. The resident's Care Plan, dated 4/8/11, documented the focus area, "Pain related to: immobility, [MEDICAL CONDITIONS] joint disease," and documented the interventions: * Monitor pain on scale of 1-10 * Observe for potential side effects of medication such as: constipation, decline in function, sedation, or appetite suppression. * Administer pain medication as per MD orders and note the effectiveness. Notify MD if pain not reduced. * Give PRN meds for breakthrough (pain) as per MD orders and note the effectiveness. Notify MD if pain not reduced. * Encourage resident to communicate presence of pain. * Document report complaints and non-verbal signs of pain. * Assist to reposition for comfort. * Implement relaxation and/or distraction techniques to assist with pain control. IPN forms documented ongoing pain: 1/14/11 4:45 pm "...Has hx (history) of chronic back pain with recent surg. (surgery)...c/o (complains of) discomfort to hip and back upon admit..." 11:00 pm "Asking for pain meds (medications) early. States he is used to much more pain (medication possibly)..." 1/15 3:15 am "Call placed to (physician) as resident is insisting he needs more pain meds more frequently. Received order increasing to Oxy (2 tablets) Q 2 hours (every 2 hours) prn pain for 8 hours and then must be re-evaluated by provider." 11:00 pm "Continues to be uncomfortable in spite of increase pain coverage..." 1/16 2:50 pm "medicated x 1 with 1 oxy 5 mg for breakthrough pain with relief noted..."11:00 pm "...requesting more pain meds than able to give him..." 1/17 2:45 am "Resident...c/o not having enough 'pain meds' to bring relief at HS (bedtime)..." 2:50 am "...chart indicates... needs re-eval (reevaluated) for pain meds; however, admit orders auth (authorize) Tyl (Tylenol) 650 (mg) Q (every) 4 hours prn... gives Tyl 650 as resident is indeed with c/o breakthrough pain with facial grimacing..." 6:10 am "Requesting pain med for 'uncontrollable pain.' Med with Tylenol 650 mg..." 10:30 am "New orders...increase in pain med dose and frequency, appears more comfortable with 2 doses (8:30 am, 10:30 am)..." 1/17 12:30 am (appears to be dated in error, out of chronological order, should be 1/18/11) "Resident...cooperative with better pain control today with increase in Oxy 5 mg to 2 tabs allowable Q 2 hours. 1/19 2:30 am ",,,A and O ..pleasant, cooperative...Regular c/o 'terrible pain' medicated thus far with scheduled and Oxy 5 mg 2 tabs at (6:30 pm, 9:45 pm,12:30 am, and 2:30 am. Pain scale never below 5 (5/10)... Resident breaks down with this nurse at (7:00 pm), eyes teary and very emotional d/t (due to) pain and how he is 'supposed to deal with this pain.' Note that last noc (night) when he attempted his transfer to toilet...he c/o 'worst pain ever,'... would like 'better pain control, this is wrong, give me something, I can't hurt like this,' followed by 'I will say my goodbye's if I have to but I can't live like this.' Note-spoke with RSC (staff name) earlier this evening. States care conference was today and this nurse request she f/u (follow up) with resident tomorrow. This nurse does not feel that resident is 'med seeking,' he has had several major accident (sic) in his life, recently d/c (discharged ) from this facility for his back issues and his pain is and cont. to be followed closely so as to provide this resident 'comfort' and relief..." COC -1/19/11 at 4:50 am, "... wants to speak with Dr. this am (morning). He states 'if I can't get more relief then I want to go back to the hospital.' He remains pleasant and cooperative but adament (sic) that pain control must bring 'more relief - longer.' Oxy 5 mg 2 tablets has been given this shift..." (Next IPN -no time) "N.O. (new order) increase [MEDICATION NAME] to 60 mg BID. 1/20 1:10 am "...Thus far he has taken [MEDICATION NAME] ER (extended release) 5 mg 2 (tablets) po Q 2 hours all the shift. Even with increase in scheduled pain medication res c/o uncontrollable pain and asks 'what will I do?'..." COC - 1/20/11 at 1:30 am, documented, "Res cont to c/o uncontrollable pain. Has been med Q 2 hours and scheduled pain meds. FYI (for your information)...Asking for meds...cont to ask 'What am I going to do?'" 1/20 9:15 am "N.O. increase [MEDICATION NAME] ER to 80 mg BID." 11:00 pm "...Given increased dose of [MEDICATION NAME]. Also medicated Q 2 hours with Oxy IR (immediate release). Resident - 'It is not enough!' Continues to c/o pain in between doses...States pain never lets up." 1/21 11:00 pm "...Resident is unmotivated. Feels he is in too much pain. Medicated q 2 hours for pain. Feels pain control is inadequate..." 1/22 11:00 pm "...Asking for more pan med after 1 hour..." 1/23 10:00 am "Cont to c/o inadequate pain control..." 11:30 am "...request pain med. regularly." 12:00 pm "...c/o discomfort of hip."11:15 pm "...motivation-poor r/t (related to) pain,..." 11:30 pm "...frequent c/o breakthrough pain to R (right) hip and back. Note Oxy increase to 80 mg BID this week and Oxy 5 as written..." 1/24 12:25 pm "Cont to c/o severe discomfort from R hip...Affect flat, eye contact poor...'Put me out of my misery.' Meds given q 2 hours as requested by pt...Refusing therapies secondary to pain." 2:15 am "N.O. for increase in HS [MEDICATION NAME]. Physician reportedly expected to come see resident in am and further eval pain. C/O pain this hs are 98% R hip with 1 c/o back pain. Resident takes [MEDICATION NAME] 120 mg at (8:30 pm), then requests prn at (12:15 am). Had previously rec'd (received) Oxy 5 2 tablets at (7:30 pm) 1/25 9:10 am "N.O. Oxy IR 5 mg 3 tablets PO 30 minutes (by mouth every 30 minutes) before OT/PT (occupational therapy/physical therapy) and continue to 1 to 2 Q 2 hours prn dx (diagnosis) pain...Increase [MEDICATION NAME] to 75 mg PO Q HS for pain/[MEDICAL CONDITION] and sit (situational) depression ..." 1/26 5:10 am "...c/o 'terrible pain' 90% of shift..." 3:30 pm "...stating that the pain meds are not helping at all but res continues to request pain meds Q 2 hours..." 1/27 10:30 pm "...Still c/o a lot of hip pain." 1/28 10:00 am "Med with Oxy IR 5 mg as per orders for therapy. Pt refused to participate in therapy (secondary) to discomfort..." 1/28 12:00 am (actually 1/29) "... states he is in continuous terrible pain." 1/29 11:00 pm "...Has been refusing therapies due to pain issue..." 2/2 3:50 am "Resident states he hasn't slept well and 'held out to (sic) long on pain pill.'...tone is indicitive (sic) of discomfort...Primary location of pain is to R hip..." 2/2 11:00 pm "...C/O pain in R hip. Medicated prn...Stands without weight bearing of R leg. Cries out during entire transfer..." Monthly Summary, dated 2/3, documented in additional notes, "Continues to require very frequent prn pain meds. Often asks for more moments after getting them...Feels he is through..." 2/4 11:00 pm "...Very demanding this evening...Medicated every few hours for breakthrough pain..." COC - 2/7/11 at 8:30 am, "Pt c/o rt (right) leg and ft (foot) burning, tingling and tearful. Frequently c/o 'I feel like giving up.' Could we try [MEDICATION NAME] 30 mg PO x 7 days (by mouth for 7 days) then increase to 50 mg PO QD (by mouth every day) if good results seen? Can the order for [MEDICATION NAME] 75 mg PO Q HS dx (diagnosis) be changed to [MEDICAL CONDITION]?" 2/8 3:05 pm "Res cont to request pain meds Q 2-3 hours..." 2/9 no time "N.O. (new order) [MEDICATION NAME] 30 mg PO QD,..." 2/11 12:50 pm "...Has been sleeping most of morning..."..." 2/17 11:00 pm "...Antidepressant appears to be helping resident deal with his hip and back pain..." 2/20 3:10 pm "...Requires much encouragement to participate in own ADLs..." 2/25 11:00 pm "...Isolating self in his room..." Monthly Summary, dated 3/9/11, documented the resident as withdrawn, quiet, expresses according to situation and additional notes stated, "...Pt reluctant to participate in own cares and therapies..." COC - 3/3/11 at 2:15 pm, "C/O Rt 'knee' pain. Upon assessment the rt calf is tender upon palpation with positive Homans (sign)..." 3/9 11:00 pm "...Res with flat affect..." 3/14 11:30 pm "...Resident states the pain never totally goes away..." 3/21 3:00 am "...Scheduled Q2 hour positioning ineffective as resident positions to R and L side and will roll to supine positioning after staff leaves room. States, 'just can't handle it.'" 3/22 9:20 pm "...encourage positioning, met with refusals thus far d/t 'uncomfortable'..." 3/24 5:50 am "Res has requested pain med nearly q 2 hours or before c/o R leg and hip pain, has slept very little tonight." 3/29 5:20 pm "Res medicated x 2 for breakthrough pain and x 1 (one time) for therapy....Res requesting pain meds within 30 minutes of receiving pain meds, requesting to call the MD because he isn't getting his pain meds..." 3/29 11:30 pm "...New order increasing [MEDICATION NAME] to 120 mg at HS..." 3/31 3:20 pm "N.O. decreasing [MEDICATION NAME] to 60 mg PO QD..." 4/1 11:00 pm "...is mostly sleeping...Appears lethargic. Lacks motivation." 4/3 8:00 am "Resident withdrawn and quiet. Told staff 'Don't touch me' when time to turn. ..'Just leave me be.' To cont (continue) to encourage activity...." 1:00 pm "...Very negative...Resident making neg (negative) statements 'It's not worth it, I can't do this, I can't live like this.' Encouragement and support given with resident unreceptive to any suggestions." 5:00 pm "... tearful and kept repeating 'I just don't know what to do.' When asked if he was depressed pt became irate, stating, 'Of course not, I just hurt and need to be left alone to heal.'..." 4/5 8:00 am "...Resident expresses 'suicidal tendency' by stating at 1930 (7:30 pm) 'just get someone to shoot me or get me a gun, I can't do this, I don't and can't do it.'..."" Monthly Summary, dated 4/7/11, documented the resident as withdrawn, quiet, expresses according to situation and additional notes stated, "...Poorly motivated and appears to have given up..." 4/11 1:00 pm "...C/O hurting 'all the time'..." 4/13 4:50 am "...Overall resident demeanor reflects that of dx (diagnosis) of Dpn (depression) with 'lost hope,' hopelessness to his situation..." The resident's January MAR indicated [REDACTED] * [MEDICATION NAME] Hcl 5mg Q 2 hours prn * [MEDICATION NAME] Hcl 5 mg Q 4 hours prn * [MEDICATION NAME] Hcl 5 mg 2 tablets Q 2 hours for 8 hours prn * Tylenol 650 mg Q 4 hours prn * [MEDICATION NAME] 100 mcg (micrograms)/hr change Q 3 days * [MEDICATION NAME] 40 mg BID * [MEDICATION NAME] 5 mg give 3 tablets 30 minutes before PT/OT * [MEDICATION NAME] 60 mg twice daily (changed to order below) * [MEDICATION NAME] ER 80 mg twice daily * [MEDICATION NAME] ER 60 mg two tablets at bedtime * [MEDICATION NAME] ER 80 mg every morning PRN pain medications were given 117 times in 18 days of admission in January, an average of once every 3.7 hours. Changes made to pain medications in February were as follows: * [MEDICATION NAME] 30 mg every day, although ordered for situational depression, not pain Dosage changed to 60 mg on 2/18/11 * [MEDICATION NAME] 120 mg daily PRN pain medications were given 135 times in 28 days in February, an average of once every 5.0 hours. Changes made to pain medications in March were as follows: * [MEDICATION NAME] 60 mg every day, Dosage changed to 120 mg every day on 3/29/11 PRN pain medications were given 107 times in 31 days in March, an average of once every 7 hours. Changes made to pain medications in April were as follows: * [MEDICATION NAME] 60 mg every day, changed on 3/31/11 PRN pain medications were given 81 times in 20 days in April, an average of once every 6 hours. The resident continued to report intractable pain that affected his mood and ability to successfully reposition himself throughout his stay. He continued to rely upon prn medications on a regular basis which is not the intent of an "as needed" medication for breakthrough pain, as he suffered breakthrough pain on an almost continual basis. Although there was a reduction in frequency of use, it continued to be utilized on a regular basis and not on an "as needed" basis. The facility failed to utilize pain medications judiciously to alleviate the resident's pain level and he suffered chronic pain that affected his mental and psychosocial health, as evidenced by his suicidal statements, and a physical decline, as he was unable to tolerate position changes or participate fully in therapies necessary for him to meet his rehabilitation potential. There was no documentation to support that nursing notified the physician of all of the ongoing reports by the resident that his pain never went away and he had become depressed and felt hopeless. The Acting Administrator and the Acting DON were informed of this issue on 4/28/11 at 2:40 pm. A copy of the January MAR indicated [REDACTED]. No further information regarding this issue was received from the facility. b. Resident #6's Admission Nursing Assessment, dated 1/14/11, documented in the section, Genito-Urinary/Gastro-Intestinal, under Bowel Elimination History that the resident had a history of [REDACTED]. It also documented his last bowel movement was on 1/13/11. Resident #6 received the following medications that listed constipation as a side effect: [MEDICATION NAME], and [MEDICATION NAME]. The resident's Hydration Care Plan, dated 1/18/11, documented, "Risk for dehydration characterized by fluid volume deficit, dry skin and mucous membranes, poor skin turgor and integrity related to: pain, laxative use, hip fx (fracture), osteopenia," with a handwritten additional note that read, "chronic pain." The only interventions listed specifically for constipation were, "Observe effectiveness and side effects of laxatives, observe resident for signs of dehydration..., and offer water throughout the day." NOTE: There was no specific care plan for constipation for the resident. A review of the Resident Functional Performance Records (RFPR) for 1/14 to 4/21/11 documented no bowel movements (BM) for the following dates: 1/22-1/29 8 days without a BM 2/13-2/18 6 days without a BM 4/1-4/13 13 days without a BM 4/17-21 5 days without a BM IPN documented: 1/28/11 8:00 am "...Abd with positive bowel tones tho (sic) hypoactive..." 2:00 pm "...Smeared BM when transferred to w/c (wheelchair)..." 4:00 pm "To transfer to ER (emergency room ) for eval per MD order...." 11:00 pm "Received back from (ER) via gurney by EMS...Returning [DIAGNOSES REDACTED]. 1/29 11:00 pm "...Has had multiple BMs today." 1/30 3:35 pm "...Res encouraged to use commode for BM and res did so with large results." 2/2 11:00 pm "...C/O constipation and suppository given. Had x lg (extra large) BM following..." Monthly Summary, dated 2/3/11, documented bowels were subject to impaction, selected frequent laxatives, and suppositories, as well. Additional notes documented, "...Constipated a lot. Resolves with suppository on 2/2..." 2/18 10:00 am "[MEDICATION NAME] 30 cc PO TID until res has BM then resume current dose, [MEDICATION NAME] suppository PR (per rectum) until res has BM, 1/2 bottle Mag (magnesium) [MEDICATION NAME] now and in 8 hours if no BM d/t day 6 no BM." 2/19 4:00 pm "...Abd soft with hyperactive bowel sounds x 4 quads (quadrants). Refused [MEDICATION NAME]" Monthly Summary, dated 3/9/11, documented bowels as subject to impaction, incontinent at times, frequent laxatives and suppositories. Additional notes documented, "Incontinent lg (large) soft stool last noc (night)...Having mod (moderate) amt (amount) [MEDICATION NAME]. Cont. to require [MEDICATION NAME], senna, [MEDICATION NAME], suppositories 2 to constipation..." Monthly Summary, dated 4/7/11, documented bowels as subject to impaction, incontinent, selected frequent laxatives, and suppositories, as well. 4/12 2:55 pm "...Res continues to refuse suppository. Day 4 bowel protocol followed. Abdomen remains soft and nontender. Res denies feeling of constipation. BT x 4..." NOTE: This would not have been Day 4 bowel protocol as the resident had not had a bowel movement since 3/31/11. 4/13 4:50 am "...reportedly on 11 day BM list and has been previously medicated with PO liquids and pills but continues to refuse a suppository. BT x 4 normal, no distention, soft, palpable..." COC - 4/12/11 at 4:00 pm "... has had no BM x 11 days. ... refusing a suppository. Res given Milk of Mag (magnesia), Encelose, and [MEDICATION NAME] along with [MEDICATION NAME] and Senna. Res denies feeling consipated (sic). Abdomen nondistended and nontender. BT x 4...." Noted on the form for 4/14/11 were orders from the physician extender that documented, "give suppository as (illegible), 1/2 bottle mag [MEDICATION NAME] now and again in 4 hours if no BM, and notify Provider if continues with no BM." 4/14 11:00 pm "...Had multiple very large BM's following laxative regimen earlier in the day..." The Physician order [REDACTED]. * [MEDICATION NAME] 8.6 mg tablet by mouth as needed, give 1 twice daily for no BM x 2 days, start date 1/14/11 * [MEDICATION NAME] 17gm by mouth as needed, give 1 twice daily for no BX x 3 days, start date 1/14/11 * [MEDICATION NAME] 20 gm/30 cc solution as needed, give twice daily for no BM x 4 days, start date 1/14/11 * [MEDICATION NAME] 10 mg suppository as needed, give prior to 5:00 am on the 5th day of no BM, call MD by noon if no BM, start date of 1/14/11 Additional orders written by a physician extender after an emergency room visit, on 1/28/11, documented: * [MEDICATION NAME] 100 mg twice daily * [MEDICATION NAME] 20 gm/30 ml twice daily, ordered 2/4/11 * Fleets enema as needed * [MEDICATION NAME] suppository as need physician's orders [REDACTED]. * Increase [MEDICATION NAME] 30 cc three times daily until BM * [MEDICATION NAME] suppository twice daily until BM * Magnesium [MEDICATION NAME] 1/2 bottle now and again in 8 hrs if no BM MARs for Resident #6 documented the following prescribed bowel medications were not given: * January 2011 - Fleet Enema 7-19 gm/118 ml and Fleet Liquid [MEDICATION NAME] suppository - Not given NOTE: Even though the resident went 8 days without a BM, none of the prn bowel medications were given. * February 2011 - [MEDICATION NAME] 20 gm/30 cc - Given as ordered, except documented as refused on the afternoon of 2/11 and 2/19, held on afternoon 2/18. - [MEDICATION NAME] 30 cc prn for no BM for 4 days - Given on 2/17 - NOTE: Should have been given on 2/16 as it was the 4th day without a BM. - [MEDICATION NAME] suppository 10 mg to be given prior to 5:00 am on the 5th day of no BM - Given on 2/19 at 5:30 am - NOTE: Should have been given on 2/17 as it was the 5th day of no BM. - Fleets enema 7-19 gm/118 ml as needed for constipation - Not given in February - [MEDICATION NAME] suppository to be given BID until resident has BM then DC, ordered 2/18 - Not given in February. The resident had no bowel concerns for March 2011. * April 2011 - [MEDICATION NAME] 200 mg y - Given as ordered, except documented as refused on morning and afternoon of 4/17. - [MEDICATION NAME] 20 gm/30 ml - Given as ordered, except documented as refused on afternoons of 4/16-4/18 and mornings of 4/17-4/20. - Sennosides 8.6 mg - Given as ordered, except documented as refused on the afternoon of 4/17. - Fleets Liquid [MEDICATION NAME] suppository prn - not given - [MEDICATION NAME] 17 gm to be given for no BM for 3 days - not given. NOTE: Should have been given on 4/3 and 4/19. - [MEDICATION NAME] 30 cc prn for no BM for 4 days - Given on 4/6 and documented as given on 4/10 and 4/12 because the resident had refused the suppository below- NOTE: Should have been given on 4/4 and 4/20 as these were the 4th days without a BM. - [MEDICATION NAME] suppository 10 mg to be given prior to 5:00 am on the 5th day of no BM and notify MD if no BM by noon for further orders.- documented as refused on 4/12 and 4/13 - NOTE: Should have been given on 4/5 and 4/13 as these were the 5th days of no BM. MD not notified on those dates. - Fleets enema 7-19 gm/118 ml as needed for constipation - Not given in April - Magnesium [MEDICATION NAME] 1/2 bottle now and again in 8 hours if no BM, ordered 2/18 - Order changed on 4/14 to give 1/2 bottle every for constipation. In addition, ordered to give remaining 1/2 bottle if no BM. and notify the provider if no BM continues. Documented as given on 4/14 at 11:00 am and 3:00 pm. Resident had no BM from 4/17-4/21 and did not receive this bowel medication. The resident had four extended periods without a bowel movement and the facility bowel medication and physician notification protocols were not followed. The only documentation the physician was notified of any refusals of bowel medications by the resident was on 4/12. In addition, the facility never addressed the need for a care plan for constipation for the resident. The Acting Administrator and the Acting DON were notified of this issue on 4/28 at 2:40 pm. On 5/16 at 1:46 pm, a copy of the January MAR indicated [REDACTED]. 2. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 4/7/11 admission MDS assessment coded: * Cognitively intact * Supervision required for personal hygiene * Supervision with 1 person physical assistance required for toilet use * Not steady, only able to stablilize with human assistance for moving on and off toilet * [MEDICAL TREATMENT] treatments Resident #8's 4/14/11 Care Plan documented the following interventions: - Evaluate resident's bowel elimination pattern and follow bowel regime for establishing elimination routine. - Observe for s/s dehydration. - Administer PRN medications as ordered and note effects. NOTE: The care plan did not address [MEDICAL TREATMENT]-related nursing concerns, potential complications, or coordination of care with the [MEDICAL TREATMENT] treatment center. The Encyclopedia of Nursing and Allied Health documents nursing considerations for [MEDICAL TREATMENT] shunts which include: * The primary complications of vascular access are clotting and infection. * Avoid injections, intravenous needles or fluids, or taking blood samples in the access site arm. * Do not take blood pressure or put pressure on the access arm. * Check the temperature and color of the fingers and the pulse of the access arm for adequate circulation. * Check for signs of infection at the access site. <http://www.enotes.com/nursing-encyclopedia/[MEDICAL TREATMENT]-shunt-graft-fistula-care> Medscape Reference documents [MEDICAL TREATMENT] Complications of [MEDICAL CONDITION] which include [MEDICAL CONDITION], hemorrhage, and [MEDICAL CONDITION] due to [MEDICAL CONDITION]. <http://emedicine.medscape.com/article/ 79-overview> A February 2000 American Journal of Medicine research article documented an association between orthostatic [MEDICAL CONDITION] and recurrent falls in nursing home residents, concluding that: "Orthostatic [MEDICAL CONDITION] is an independent risk factor for recurrent falls among elderly nursing home residents. Although the benefit of treating orthostatic [MEDICAL CONDITION] will require further study, it may be prudent to identify high-risk residents and institute precautionary measures." <http://www.ncbi.nlm.nih.gov/pubmed/ 303> Resident #8's 3/25/11 History and Physical documented: * Past Medical History: End stage [MEDICAL CONDITION] on [MEDICAL TREATMENT], [MEDICAL CONDITIONS], history of shunt placement * Assessment: [MEDICAL CONDITION], dehydration, hypokalemia, severe [MEDICAL CONDITION] and [MEDICAL CONDITION], and poorly controlled type 2 diabetes April 2011 Resident Functional Performance Records (RFPR) for Resident #8 documented no BM x 5 days, 4/19-4/23. PPN documented: * 4/1/11 - (Complains of) constipation this morning... Constipation - enema if needed, later today - (recheck) frequently." * 4/4 - "Seen per request... irregular diarrhea/constipation... diarrhea." * 4/11 - "Constipation - improved." * 4/13 - "[MEDICAL CONDITION] (increase) PO fluids - (Resident #8) will need help (with) free fluid offering and someone to hold glass." NOTE: "Assistance with free fluid offering and someone to hold glass" were not added to the resident's care plan or TAR. COC forms documented: * 4/4/11 - "Reporting loose stools x 3 days, requesting... antidiarrheal... please evaluate." * (Undated) - "(Resident) woke this morning and was shaky or 'jumpy' as (resident) stated... states, 'I have not been feeling good the past couple days.' (Resident) weak, occasional nausea, (no) emesis, (no fever). Addressed (at emergency room ) 4/12/11. (Resident) taken there directly after [MEDICAL TREATMENT] (by family)." * 4/20 - "(Resident) came back from (afternoon) out (with) assistant (and) fell while bending over bed looking through mail. (Resident) landed on left side. No apparent injuries noted." An EMR documented that Resident #8 fell on [DATE] at 7:40 PM - "Resident sitting up at edge of bed, leaned over to get 'something' and 'slowly slide (sic) to buttocks on floor.' States, 'I didn't fall, I just slowly slid.'" The are to indicate Care Plan Updated was marked, No. IPN documented: * 4/1/11 - Dressing changed to left [MEDICAL TREATMENT] shunt. "Area around is very bruised (and) swollen. (Left) hand swollen ... (Resident) given suppositories x2 this AM (secondary to) constipation. Evacuated (medium/large) stool (after second) suppository given. Stool soft (and) dry.... Asking for something for diarrhea. Explained (history) of constipation (and) need to get cleared out before anything for diarrhea." * 4/2 - "Has had 3 (incontinent) diarrhea stools." * 4/5 - "(Resident) returned from [MEDICAL TREATMENT], states she doesn't feel well." * 4/5 - "Slipped from edge of bed to floor." * 4/9 - "Swelling to face, arms, (lower) legs... (bilateral) arms are swollen, (left) arm very purple (and [MEDICAL CONDITION])." * 4/13 - "Taken by companion to (emergency room ) from [MEDICAL TREATMENT]... the shaking/jerking that alarmed them (at [MEDICAL TREATMENT]) is a rare side effect found in some ([MEDICAL TREATMENT] patients)... (left) arm is significantly less swollen (and) bruising is notably less as well." * 4/13 - "(Resident continues) to have jerking movements." * 4/14 - "(No) jerky movements this shift." * 4/16 - "Legs have given out x2 this AM. (First) while being weighed, (second) while getting in car. (No) fall occurred secondary to having staff there spotting. Resident able to regain balance (with) staff assist. Monitoring." * 4/20 - "While bending over spare bed lost balance (and) fell to floor." * 4/20 - "Received call from ([MEDICAL TREATMENT] center)... (discontinue) [MEDICATION NAME] felt (resident) was (too) sleepy. If jerking arms start again notify (physician)." physician's orders [REDACTED]. * 4/4 - [MEDICATION NAME] 2 mg po 4 times daily PRN diarrhea, notify physician if diarrhea persists longer than 48 hours * 4/7 - Please send a sack lunch (with) resident on [MEDICAL TREATMENT] days * 4/12 - [MEDICATION NAME] 100 mg 1 PO daily * 4/20 - Discontinue [MEDICATION NAME] A 4/4/11 Care Plan Conference Summary documented: "(Resident) stated she has had problems with her (bowels), either loose or constipated." Resident #8's MAR for April 2011 documented [MEDICATION NAME] administered on 4/5 and 4/7; no other PRN bowel medications were administered. Resident #8 experienced complications related to her [MEDICAL TREATMENT] treatments, including tremors, [MEDICAL CONDITION], and falls. She was not appropriately care planned or monitored for potential complications of [MEDICAL TREATMENT] treatments. In addition, she went 5 days without a BM or any treatments for constipation. On 4/26/11 at 10:15 AM, the Acting Administrator was asked to provide the facility's [MEDICAL TREATMENT] agreements. On 4/26/11 at 12:30 PM, he stated, "We don't have a [MEDICAL TREATMENT] agreement." On 4/28/11 at 2:40 PM, the Acting Administrator, Acting DON, RVP, and RNC were advised of the findings. No further information was received from the facility. 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was discharged to another facility on 4/21/11. Resident #1's admission MDS assessment, dated 3/17/11, coded: * Severely impaired cognitive skills for daily decision making * Limited assistance of 1 staff for transfers and personal hygiene * Independent with set up assistance for toilet use Resident #1's Care Plan did not address constipation. RFPR for March and April 2011 documented: * No BM x 4 days, 3/9-3/12 * No BM x 4 days, 3/15-3/18 * No BM x 4 days, 3/27-3/30 * No BM x 4 days, 4/3-4/6 * No BM x 4 days, 4/9-4/12 * No BM x 5 days, 4/15-4/19 Resident #1's April 2011 physician's orders [REDACTED]. no BM by noon on 5th day, call physician for further orders. physician's orders [REDACTED]. * 3/16/11 - [MEDICATION NAME] 100 mg 1 po q day * 3/18 - [MEDICATION NAME] 30 ml (milliliters) (with) 8-12 oz of (water) po bid x 2 days * 3/18 - [MEDICATION NAME] 10 mg suppository 1 rectally bid today NOTE: The resident had not had a BM in 4 days on 3/18/11. The facility's bowel care protocol had not been followed. COC forms documented: * 3/16/11 - "Resident has not had BM in 2 days. On 3/14/11 resident had formed normal stool. Can we get order for [MEDICATION NAME] 100 mg po qd for constipation?" * 3/18 - "Resident needs something for constipation x 4 days." Resident #1's March and April 2011 MAR indicated [REDACTED]. On 4/28/11 at 2:40 PM, the Acting Administrator, ADON, RVP, and RNC were advised of