Every finding on record at Caldwell Care of Cascadia

Based on observation, record and policy review, and resident and staff interview, it was determined the facility failed to ensure a grievance process was available for residents. This deficient practice created the potential for psychosocial harm if residents' concerns were not identified and addressed in a timely manner. Findings include:The facility's Grievance Process policy, revised 8/29/25, documented the Grievance program addresses the concerns of residents, family members, and visitors and the facility should make prompt efforts to resolve grievances.On 3/2/26 at 8:30 AM, the SA requested a copy of the facility's grievances from September 2025 through March 2026.The facility provided grievances from January 2026 through March 2026. No additional grievances were available.On 3/3/26 at 4:02 PM, the Administrator, with the CRN present, stated there were no grievances available prior to January 2026. The CRN confirmed the facility had identified their grievance process required a performance improvement plan.

Based on observation, review of FDA Food Code, and staff interview, it was determined the facility failed to ensure employees were not wearing jewelry during food preparation and service, and cutting boards were not cleaned properly. These deficiencies had the potential to affect the 59 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include:1. The FDA Food Code Section 2-303.11 documented items of jewelry such as rings, bracelets, and watches may collect soil, and the construction of the jewelry may hinder routine cleaning. As a result, jewelry may act as a reservoir of pathogenic (disease causing) organisms transmissible through food.On 3/4/26 from 6:30 AM to 7:35 AM, [NAME] #1 and [NAME] Trainee #1 were observed preparing and serving food while wearing rings on their fingers, [NAME] Trainee #1 had additional bracelets on her right and left wrist. Hand hygiene was performed with the jewelry on.On 3/4/26 at 7:40 AM, the Dietary Manager stated jewelry should not be worn while preparing or serving food, and if the jewelry was permanent gloves should be worn to cover.2. The FDA Food Code Section 4-501.12 Cutting Surfaces documented cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.On 3/5/26 at 2:35 PM, it was observed the cutting boards in the kitchen had dark colored stains within the grains of the plastic.On 3/5/26 at 2:37 PM, the Culinary Manager stated the cutting boards should be replaced when they are not able to get clean or have the stains removed.

Based on record review, policy review, and staff interviews it was determined the facility failed to provide quarterly care conferences for 8 of 8 residents (#5, #6, #7, #9, #13, #25, #38 and #47), and for 2 of 16 residents (#5 and #34) whose care plans were not revised. This deficient practice created the potential for harm when the care conferences were not conducted, and when their care plans were not revised. Findings include:The facility's Resident Care Plan Revisions policy, revised 9/3/25, documented care plans will be created, reviewed, and revised by an interdisciplinary team (IDT), with family related to the residents' status and care needs, with active involvement from the resident and their representative, when applicable, updates to the care plan will occur as needed based on the residents' response to interventions and changes in condition.1. The following residents records did not have documentation quarterly care conferences were conducted:a. Resident #25 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including dementia, depression, anxiety, muscle weakness, and difficulty walking.Resident #25's record documented a quarterly care conference occurred on 7/9/25, attended by the Social Services Manager, the Resident Care Manager, the Culinary Manager, and Resident #25's representative. There was no record of additional quarterly care conferences in or around October 2025 or January 2026.b. Resident #13 was readmitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a chronic mental condition combining schizophrenia symptoms with mania or depression), insomnia, anxiety, depression, and dementia.A review of Resident #13's care plan documented a care conference on 8/5/25, attended by the Social Services Manager, the Assistant Chief Nursing Officer, and Resident #13's representative. There were no quarterly care conferences found in Resident #13's record related to care conferences for November 2025 or March 2026.c. Resident #5 was admitted to the facility on [DATE]with multiple diagnoses including paranoid schizophrenia, depression, anxiety, and difficulty walking.A review of Resident #5's care plan documented a care conference on 6/11/25, attended by the Social Services Manager, the Chief Nursing Officer, and the Culinary Manager, and Resident #5's representative. There were no quarterly care conferences recorded for September and December 2025, or documentation of March 2026's care conference being scheduled for Resident #5. d. Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder, depression, and anxiety.Resident #9's record documented a quarterly/annual care conference was completed on 9/10/25, attended by the resident, the Social Services Manager, the DON, a Resident Support Services Assistant and the Culinary Manager.Resident #9's record did not include documentation her quarterly care conference was conducted as required in December 2025. e. Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, dysphagia (difficulty swallowing) and sleep apnea.Review of Resident #47's record documented a care conference was held on 9/3/25 attended by the Social Services Manager, the DON, the Culinary Manager and Resident #47's representative. There was no other care conference documented on Resident #47's record.f. Resident #38 was readmitted to the facility on [DATE] with multiple diagnoses including dementia, bipolar disorder, and anxiety disorderResident #38's record documented a quarterly care conference occurred on 10/8/25, attended by the Social Services Manager, the Resident Care Manager, the DON, and Resident #38's representative.Resident #38's record did not include documentation of a care conference being conducted after 10/8/25.g. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses including dementia, bipolar disorder, and anxiety.Resident #6's record documented a 48 hour/admission care conference occurred on 8/22/25, attended by the Social Services Manager, the DON, and Resident #6's representative. There was no record of any quarterly care conferences for November 2025 or February 2026.h. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including dementia, major depressive disorder, and muscle weakness.Resident #7's record documented a quarterly care conference occurred on 6/24/25, attended the Social Services Manager, the DON, the Culinary Manager, and Resident #7's representative.There was no record of any quarterly care conferences for September 2025 or December 2025.On 3/4/2026 at 10:31 AM, the Administrator and CRN stated if the care conference is not in the residents [electronic health record] the care conference was not completed.2. The following residents did not have their care plans revised:a. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including paranoid schizophrenia, depression, anxiety, and difficulty walking.Resident #5's care plan, dated 8/24/23, documented fall interventions directing staff to provide a variety of fall preventions including a low bed position at night, call light within reach, non-skid socks, and to re-evaluate quarterly and with change of condition or if a fall occurs.On 12/1/25, a fall investigation report documented Resident #5 fell while unattended in the dining room. The IDT directed staff to supervise Resident #5 always while in the dining room.There was no record of this fall intervention being added to Resident #5's care plan until 1/27/26.On 3/4/26 at 2:10 PM, the DON confirmed the care plan related to staff supervision for Resident #5 was not added to the care plan until 1/27/26 when it should have been added in December 2025.Cross reference F689.b. Resident #34 was admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder, anxiety disorder, and alcohol dependence.A review of Resident #34's care plan, revised 4/6/22, documented the resident was independent with toileting, and staff were directed to provide one person assistance for occasional nighttime incontinence.A review of the Quarterly Minimum Data Set (MDS) dated [DATE], documented Resident #34 was dependent on staff assistance for all toileting needs, which was inconsistent with the toileting status documented in the resident's care plan.On 3/5/26 at 8:40 AM, the DON confirmed Resident #34 was dependent in toileting and stated the care plan should have been revised to reflect the resident's current care needs.

Based on observation, interviews and American Health Care Association (AHCA)/National Center for Assisted Living (NCAL) and CDC guidance, the facility failed to ensure an infection control prevention and practices were implemented during medication administration and cleaning of a urine spill. These deficient practices created the potential for the spread of infectious diseases which could harm the residents in the facility. Findings include:1. The American Health Care Association website accessed on 3/10/26, stated to place a clean and dry paper towel under blood glucose meter before placing on resident's table or on top of medication cart. Resident #56 was admitted to the facility on [DATE] with multiple diagnoses including diabetes and asthma. On 3/4/26 at 6:59 AM, RN #1 entered Resident #56's room with the glucometer with the test strip inserted into it, two insulin pens, lancet and alcohol wipes. RN #1 placed the glucometer and insulin pens on the foot of Resident #56's bed, performed hand hygiene and donned gloves. RN #1 then took the glucometer and placed it above the pillow where Resident #56's arm was resting and checked her blood glucose. RN #1 was not observed to place a barrier when she placed the glucometer and insulin pens on two different surfaces on Resident #56's bed. On 3/4/26 at 10:06 AM, the DON stated insulin pens and glucometer should be placed on top of a paper towel before placing them on any surface in residents' room. 2. The CDC web page titled Environmental Cleaning Procedures accessed on 3/12/26, under This is the general processes for cleaning of spills of blood or body fluids: Wear appropriate PPE. Confine the spill and wipe it up immediately with absorbent (paper) towels, cloths, or absorbent granules (if available) that are spread over the spill to solidify the blood or body fluid (all should then be disposed as infectious waste). Clean thoroughly, using neutral detergent and warm water solution. Disinfect by using a facility-approved intermediate-level disinfectant. Immediately send all reusable supplies and equipment (e.g., cleaning cloths, mops) for reprocessing (i.e., cleaning and disinfection) after the spill is cleaned up. On 3/4/26 at 9:57 AM, CNA #2 was observed assisting CNA #3 with a urine spill from a leaking urinary catheter collection bag in the [NAME] Wing common area. CNA #2 was observed placing a dry white towel over top of a small puddle of urine. CNA #2 donned gloves and wiped the urine spill with the dry white towel and left the [NAME] Wing common area. On 3/4/26 at 2:25 PM, when asked what the process was for cleaning soiled areas, CNA #2 stated the process was to wear gloves, wipe up the soiled area, and to use alcohol wipes or disinfectant wipes on the soiled area. When asked if CNA #2 used any alcohol wipes or disinfectants on the urine spill she cleaned that morning, CNA #2 stated she did not use any disinfectant and stated she should have sanitized the area and notified housekeeping of the spill.

Based on record review and staff interview, it was determined the facility failed to ensure residents receiving anticonvulsant medications were monitored for potential side effects as required by their comprehensive person-centered care plans. This was true for 2 of 5 residents (#34 and #41) whose records were reviewed for unnecessary medications. This failure created the potential for harm if side effects were undetected. Findings include:1. Resident #34 was admitted on [DATE] with multiple diagnoses including major depressive disorder, anxiety disorder, and alcohol dependence.Resident #34's record included a physician order for Depakote (an anticonvulsant) sprinkles delayed release capsule 250 mg by mouth three times a day for alcohol dependence.Resident #34's care plan revised 8/6/25, directed staff to monitor, notify the provider and document side effects for anticonvulsants such as:Over-sedation or lethargyRestless agitationIncreased confusion or poor concentrationMental status changeVisual disturbanceChange in gaitBehavioral changesWeight changeResident #34's record did not include documentation the facility staff were monitoring for side effects of anticonvulsants.2. Resident #41 was admitted to the facility on [DATE] with multiple diagnosis including borderline personality disorder, Alzheimer's disease, and suicidal ideations.Resident #41's record included a physician order for Depakote sprinkles delayed release capsule 750 mg by mouth two times a day for borderline personality disorder.Resident #41's care plan revised 10/14/24, directed staff to monitor, notify the provider and document side effects for anticonvulsant such as:Over-sedation or lethargyRestless agitationIncreased confusion/poor concentrationMental status changeVisual disturbanceChange in gaitBehavioral changesWeight changeResident #41's record did not include documentation that facility staff were monitoring for side effects of anticonvulsants.On 3/5/26 at 8:32 AM, The DON confirmed Resident #34 and #41's record did not include monitors for anticonvulsants.

Based on record review, pharmacy review, and staff interview, it was determined the facility failed to ensure recommended monitoring for adverse effects of antipsychotic medication was completed for 1 of 5 residents (Resident #38) reviewed for psychoactive medication monitoring. This created the potential for side effects to go undetected when the facility did not complete a current AIMS (an abnormal involuntary movement scale) or DISCUS (dyskinesia identification system condensed user scale) assessment as recommended by the consulting pharmacist. Findings include:Resident #38 was readmitted to the facility on [DATE] with multiple diagnoses, including bipolar disorder, anxiety disorder, and traumatic brain injury.Resident #38's care plan directed staff to monitor and report side effects and adverse reactions related to psychoactive medications.A physician order dated 7/22/25 documented:Seroquel (an antipsychotic medication) 300 mg by mouth once daily for traumatic brain injury.A pharmacy review dated 1/26/26 documented antipsychotic medications have the capacity to cause tardive dyskinesia and other movement disorders, and recommended that a movement disorder assessment, such as an AIMS or DISCUS test, be completed at least every six months while the resident remained on antipsychotic therapy.A review of Resident #38's medical record showed the last AIMS assessment was completed on 8/18/25, more than six months prior to the pharmacy recommendation and outside the recommended monitoring interval.On 3/4/26 at 9:55 AM, the DON confirmed the pharmacy recommendation had not been acted upon and Resident #38's record did not contain a current AIMS assessment.

Based on record review, and staff interview, it was determined the facility failed to ensure Residents' Preadmission Screening and Resident Review (PASRR) accurately reflected the resident's primary diagnosis. This was true for 1 of 3 residents (Resident #34) reviewed for accuracy of PASRR's. This failure resulted in incorrect PASRR Level I determination. Findings include:Resident #34 was admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder, anxiety disorder, and alcohol dependence.A review of Resident #34's medical diagnoses showed his primary diagnosis was recurrent major depressive disorder.Resident #34's PASRR Level I, dated 9/9/25, documented, Yes in Box 12, indicating the individual had a primary diagnosis of dementia or Alzheimer's disease.On 3/5/26 at 4:45 PM, the Social Worker confirmed Resident #34's PASRR Level I was inaccurately completed.

Based on record review, resident and staff interview, it was determined the facility failed to respect the right of residents when they did not provide written notification prior to moving a resident to a new room. This was true for 1 of 1 resident (Resident #13) who was moved prior to receiving written notification. This deficient practice created the potential for psychosocial harm if Resident #13 was not provided an opportunity to see the new location, meet a new roommate, or have questions answered related to the move. Findings include:The facility's Resident Room Changes & Roommate Rights Policy, revised 8/31/25, documented when a resident is being moved at the request of facility staff, the resident, family, and/or representative must receive an explanation in writing of why the move is required. The resident must be provided with the opportunity to see the new location, meet the new roommate, and ask questions.Resident #13 was re-admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a chronic mental condition combining schizophrenia symptoms with mania or depression), insomnia, anxiety, depression, and dementia.A Quarterly MDS assessment dated [DATE], documented Resident #13 was cognitively intact.A notice of Room-to-Room Transfer form, signed 11/13/25, documented the rational for Resident #13's transfer from room [ROOM NUMBER] to 219 as POA Notified. No further explanation was written.On 3/5/26 at 3:41 PM, the Social Services Manager stated the notification of room change was not filled out correctly and should have identified in writing why Resident #13 was moving from room [ROOM NUMBER] to 219.

Based on record review and staff interviews, it was determined the facility failed to ensure required transfer and discharge documentation was included in the resident's medical record to support the communication of essential information to the receiving healthcare provider. This was true for 1 of 2 residents (Resident #1) reviewed for discharge processes. This failure created the potential to result in delayed or inappropriate treatment. Findings Include:Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure, pneumonia, and chronic obstructive pulmonary disease.Resident #1's care plan initiated 6/19/23, documented he had altered respiratory status and directed staff to monitor and report to physician if signs of compromised airway occurred.Resident #1's record included the following:A progress note dated 1/16/26, documented Resident #1 was not responding to an albuterol breathing treatment and continued to have declining oxygen saturation requiring a higher level of care.A Notice of Transfer or discharge date d 1/16/26, documented Resident #1 required immediate transfer due to urgent medical needs.A bed hold agreement signed 1/16/26.Resident #1's record did not include documentation the following required information was sent to the receiving healthcare provider at the time of transfer:Contact information of the practitioner responsible for the care of the resident.Resident representative information including contact information.Advance Directive information.All special instructions or precautions for ongoing care, as appropriate.Comprehensive care plan goals.On 3/5/26 at 9:14 AM, the DON and the CRN confirmed Resident #1's record did not include the required transfer and discharge documentation.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure services provided met accepted professional standards of clinical practice This was true for 2 of 6 residents (#47 and #56) who were observed during medication administration and for 1 of 1 resident (Resident #3) who received hemodialysis services. These failures placed Resident's #47 and #56 at risk for harm when their medications were not administered appropriately, and placed Resident #3 at risk for harm when staff took his blood pressure on the arm with his hemodialysis access. Findings include: 1. Lippincott's Nursing 2026 webpage titled, Protecting a Hemodialysis Fistula; Clinical Do's and Don'ts, accessed 3/4/26, documented, do not take blood pressure readings on the access arm as it could contribute to clotting in the fistula, and do not put any excessive pressure on the access arm. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including end stage renal (kidney) disease and dementia. Resident #3's record documented he was dependent on hemodialysis (a treatment using a machine to replicate kidney function, removing waste from the bloodstream), and his dialysis access site was an AV fistula in his left forearm (an arteriovenous fistula is a surgical connection made between an artery and vein used for hemodialysis). Resident #3's care plan, dated 11/3/22, documented no blood pressures should be taken on the left arm due to his AV fistula dialysis access site. On 3/4/26 at 9:16 AM, Resident #3's vital signs records documented he had 18 blood pressure readings taken on the left arm in the past 90 days. On 3/6/26 at 8:34 AM, the DON confirmed Resident #3's record documented blood pressure readings were taken on his left arm. She added, it was likely the person measuring his blood pressure documented incorrectly as there had not been any adverse outcomes and the resident was aware blood pressures should not be taken on his left arm to protect his dialysis access. 2. The insulin aspart's pen Instruction for Use documented before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose selector to select 2 units. Hold the insulin pen pointing upwards, press the push-button all the way in. The dose selector returns to 0). A drop of insulin should appear at the needle tip. The Toujeo's insulin pen Instructions for Use documented select 3 units by turning the dose selector until the dose pointer is between 2 and 4. Then press the injection button all the way in. When insulin comes out of the needle tip, your pen is working correctly. Resident #56 was admitted to the facility on [DATE] with multiple diagnoses including diabetes and asthma. A physician's order documented Resident #56 was to receive the following medications: Novolog Injection Solution 100 unit/ml (insulin aspart), inject 35 units subcutaneously three times a day related to diabetes, ordered 10/23/25. Toujeo SoloStar (insulin glargine) 100 unit/ml, inject 64 units subcutaneously two times a day related to diabetes, ordered 2/27/26. On 3/4/26 at 6:59 AM, RN #1 was observed sanitizing Resident #56's Novolog and Toujeo insulin pens and replaced their needles. RN #1 then dialed the Novolog insulin pen to 35 units and Toujeo insulin pen to 64 units. RN #1 was not observed to prime the insulin pens. RN #1 entered Resident #56's room and administered both insulin injections. On 3/4/26 at 7:30 AM, RN #1 stated she did not prime Resident #56's insulin pens. On 3/4/26 at 10:06 AM, the DON stated insulin pens should be primed before dialing the prescribed amount ordered by the physician. 3. The Drugs.com website accessed on 3/10/26, stated to take potassium chloride tablets with food or just after a meal to reduce the risk of stomach irritation. Follow with full glass of water. Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, dysphagia (difficulty swallowing) and sleep apnea. A physician's order dated 9/19/24, documented Resident #47 was to receive potassium chloride 20 meq by mouth two times a day for diuretic use. On 3/3/26 at 3:27 PM, LPN #1 administered Resident #47's 20 meq potassium chloride which was dissolved in small amount of water and mixed it with pudding. Resident #47 answered, no when LPN #1 asked him if he would like to drink water after taking the medication. LPN #1 was not observed educating Resident #47 regarding the importance of drinking water after taking potassium chloride. On 3/3/26 at 3:30 PM, LPN #1 stated he offered Resident #47 water for his hydration. On 3/3/26 at 3:36 PM, the DON with the CRN present stated she would advise Resident #47 to drink a full cup of water after taking the potassium chloride. The CRN stated LPN #1 should have educated Resident #47 regarding drinking water after taking the potassium chloride.

Based on record review and staff interview, it was determined resident rights were not honored. This was true for 1 of 16 residents (Resident #9) whose records were reviewed for physician notification. This failure placed Resident #9 at risk for harm when abnormal vital signs were not reported to her physician. Findings include: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a severe chronic mental health condition), depression, and anxiety. Resident #9's blood pressure record documented four elevated readings the past 90 days:3/1/26: 171/1042/1/26: 164/981/22/26: 171/991/20/26: 173/104Resident #9's record did not document the physician was notified of the elevated blood pressure readings. On 3/6/26 at 9:20 AM, the DON stated the nurses should have notified the physician of Resident #9's elevated blood pressures immediately. The DON was unable to provide documentation the physician was notified.

Based on observation, record review, policy review, and resident and staff interview it was determined the facility failed to provide a homelike environment when resident's walls were left unrepaired and/or with visible patch work. This was true for 2 of 16 residents (#13 and #53) whose rooms were observed. This created the potential for psychosocial harm and embarrassment if residents did not have a homelike environment if their walls were not repaired and did not have consistent wall paint covering the white patchwork. Findings include: The facility's Homelike Environment policy, revised 9/17/25, documented the facility supports a residents rights to a safe, clean, comfortable, and homelike environment to promote dignity, independence, and quality of life.1. Resident #13 was re-admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a chronic mental condition combining schizophrenia symptoms with mania or depression), insomnia, anxiety, depression, and dementia.On 3/2/26 at 9:52 AM it was observed in Resident #13's room there was a jagged vertical damaged line on the wall from floor to ceiling exposing broken drywall. Other areas of the room walls were covered with white patches on top of colored paint. Resident #13 stated the white patches, and damaged wall had been there since she relocated to the room in November 2025.2. Resident #53 was admitted to the facility on [DATE] with multiple diagnoses including schizophrenia (a chronic, severe mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and COPD.On 3/2/26 at 2:35 PM it was observed in Resident #53's room various white patches on painted walls which were both small and large throughout the room. Resident #53 stated the white patches had been on the walls since she could remember.On 3/5/26 at 11:43 AM, the Maintenance Director stated Resident #13 and #53's room walls were patched and primed, ready to be painted; however, they had not been able to paint them yet. He further stated he was unaware Resident #13's room had any damaged walls that needed to be fixed.

Based on record review, policy review, and staff interview, it was determined the facility failed to prevent a fall when a fall intervention was not updated in the resident's care plan. This was true for 1 of 5 residents (Resident #5) reviewed for accident prevention. This deficient practice created the potential for harm when Resident #5 fell from her wheelchair when she was left unsupervised in the dining room. Findings include:Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including paranoid schizophrenia, depression, anxiety, and difficulty walking.On 12/1/25, a fall investigation report documented Resident #5 fell from her wheelchair while unattended in the dining room. The IDT investigation documented, to avoid future falls, Resident #5 was always to be supervised while in the dining room.On 1/26/26, a fall investigation report documented Resident #5 fell from her wheelchair on 1/23/26 when a staff member left her in the dining room unsupervised.A review of Resident #5's care plan, revised 1/27/26, documented Resident #5 should have constant supervision while in the dining room.There was no record of Resident #5's care plan being updated on 12/1/25 when the intervention was first identified as a fall prevention measure by the IDT.On 3/4/26 at 2:10 PM, the DON confirmed the care plan related to staff supervision for Resident #5 was not added to the care plan until 1/27/26 when it should have been added in December 2025. When asked if the fall on 1/23/26 could have been prevented if Resident #5's care plan had been updated in December 2025, the DON declined to answer.

Based on observation, record review, and staff interview, it was determined the facility failed to accurately report which resident was the victim and aggressor in an abuse investigation submitted to the Idaho BFS LTC Reporting System. This was true for 1 of 3 residents (Resident #13) reviewed for abuse. This deficient practice created the potential for psychosocial harm as Resident #13 was identified as the victim on the report and this was reported to Resident #13 and her family member, and to the State of Idaho, contradicting witness statements which identified Resident #13 as the aggressor. Findings include:The facility's Abuse - Reporting & Response: No Crime Suspected policy, dated 8/25/25, documented the report must include sufficient detail to describe the nature of the alleged violation, and new or revised information supplementing the initial report should be included in the follow-up submission to ensure completeness and accuracy.Resident #13 was re-admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a chronic mental condition combining schizophrenia symptoms with mania or depression), insomnia, anxiety, depression, and dementia.An abuse report, dated 11/13/25, documented Resident #13 was the victim in a resident-to-resident interaction when Resident #17 was heard banging on the restroom door while Resident #13 was using it. Resident #13 exited the bathroom on Resident #17's side, began yelling at her, and Resident #17 reacted by grabbing Resident #13's shirt, without making physical contact. Resident #13 reported she had a hurt arm, which was assessed, and no injury was found. Resident #13 was moved to a new room the same day as the facility believed Resident #13 should not share a bathroom with Resident #17 for their safety.The witness statement, dated 11/13/25, documented Resident #13 was the aggressor as she entering Resident #17's room and yelling at her. Resident #17 reacted to Resident #13 by grabbing her shirt.On 3/5/26 at 10:21 AM, the Administrator stated he filled the report out incorrectly as Resident #13 was the aggressor, not the victim as was documented on the investigation report.

Based on observations, record review, and staff interviews, it was determined the facility failed to implement and follow resident centered comprehensive care plan interventions and physician ordered treatments for 3 of 16 residents (Residents #9, #47, and #64) reviewed for quality of care. The facility failed to apply physician ordered interventions for Resident #47, failed to implement fall prevention interventions for Resident #64, and failed to complete reassessment of blood pressures for Resident #9. These failures created the potential for harm when required care plan interventions, treatments, and reassessments were not carried out. Findings include:1. Resident #64 was readmitted to the facility on [DATE] with multiple diagnoses, including history of falling, adult failure to thrive, and a need for assistance with personal care. A review of Resident #64's care plan, revised 3/19/26, documented she required one person assistance for ambulation and transfers. The care plan also directed staff to monitor Resident #64's position in bed and in her wheelchair for safety. A progress note dated 3/19/26 at 1:16 PM documented that CNA #1 was assisting Resident #64 with dressing. After completing the task, CNA #1 walked to the wardrobe closet to put away clothing. CNA #1 looked back and observed Resident #64 fall forward from the bed and strike her face on the floor. Nursing staff were notified, assessed the resident, and assisted her to stand. The note documented no injuries. During an interview on 3/5/26 at 11:15 AM, CNA #1 stated Resident #64 had been sitting on the edge of the bed when she stepped away to put the resident's shoes in the closet. CNA #1 stated she saw Resident #64 stand up and fall forward and attempted to stop her but was unable to reach her in time. A progress note dated 3/21/25 at 12:17 PM documented the Interdisciplinary Team determined that, due to the fall, an appropriate intervention would be to monitor Resident #64 for orthostatic blood pressures. On 3/5/26 at 3:40 PM, a request was made for documentation of orthostatic blood pressures, and none was provided. On 3/5/26 at 4:12 PM, the Director of Nursing (DON) confirmed the facility did not have records of any orthostatic blood pressures being obtained for Resident #64. 2. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses, including muscle weakness, dementia, and protein calorie malnutrition. A review of Resident #2's care plan, revised 1/7/25, directed staff to apply pressure relieving boots bilaterally at all times. A physician order dated 5/2/25 documented: Pressure relief/reducing boots to bilateral feet when in bed and up in wheelchair. Resident #2 was observed in the common area watching television without his pressure relieving boots on the following dates and times: 3/2/26 at 1:58 PM 3/3/26 at 9:35 AM 3/3/26 at 11:20 AM 3/4/26 at 7:25 AM 3/6/26 at 9:16 AM During both observations, the boots were seen in his room on the bedside nightstand, not on the resident. During an interview on 3/6/26 at 9:17 AM, LPN #1 confirmed Resident #2 was not wearing his boots and stated he only wears them when he's in bed. During an interview on 3/6/26 at 9:32 AM, the DON confirmed Resident #2 should have the boots on at all times. 3. Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder, depression, and anxiety. Resident #9's vital signs records documented a blood pressure reading on 3/1/26 of 171/104. Resident #9's record did not include documentation her blood pressure was reassessed on 3/1/26, or she was assessed for other symptoms related to the elevated blood pressure. On 3/6/26 at 9:20 AM, the DON stated, the nurses should have notified the provider of the elevated blood pressure and re-assessed the resident. The DON was unable to provide documentation the nurses reassessed Resident #9's blood pressure. 4. Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, dysphagia (difficulty swallowing) and sleep apnea. Resident #47's Skin Evaluation dated 3/2/26, documented he had pressure areas to his palm but no open areas. A physician's order dated 2/2/26, directed staff to apply a carrot splint to Resident #47's right hand as tolerated and monitor him for skin alteration two times a day. Resident #47 was observed with both his hands closed in a fist on 3/2/26 at 10:26 AM, 3/3/26 at 10:05 AM and 10:29 AM, and 3/4/26 at 9:30 AM, with no carrot splint to his right hand. On 3/4/26 at 9:34 AM RNA #1 helped Resident #47 to open his right hand. Resident #47's right hand was noted to have pressure marks from his fingertips, with no open areas on his right palm. On 3/4/26 at 9:54 AM, the DON reviewed Resident #47's care plan and physician's order, and stated the carrot splint should be applied to his right hand. On 3/4/26 at 3:07 PM, the Director of Rehabilitation stated Resident #47 was on PT/OT/RNA program for his upper extremities and the carrot splint was ordered as skin intervention for his right hand.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure its Antibiotic Stewardship practices were followed by initiating antibiotic therapy without obtaining culture and sensitivity results to guide appropriate treatment. This was true for 1 of 1 residents (Resident #64) reviewed for antibiotic stewardship. This failure created the potential for inappropriate antibiotic use and development of antibiotic resistant organisms. Findings include:The facility's Antibiotic Stewardship Policy, revised 8/10/25, documented the facility focuses on improving antibiotic use through an Antibiotic Stewardship Program to ensure appropriate antibiotic usage, promote therapeutic and cost effective care, and reduce the likelihood of developing multi drug resistant organisms. The policy also documented the facility utilizes McGeer's Criteria to validate infections and routinely reviews culture and sensitivity reports as part of infection surveillance.The Revised McGeer's Criteria for urinary tract infection (UTI) without an indwelling catheter requires both of the following be present:1. At least one clinical sign or symptom, such as:Fever, rigors, or new onset hypotension (low blood pressure) with no alternate site of infectionAcute change in mental status or functional decline with leukocytosis (extremely high white blood cell counts)New onset suprapubic pain or costovertebral angle tenderness (pain at the angle formed by the 12th rib and spine)Purulent discharge or acute pain/swelling of the testes, epididymis (inflammation of the coiled tube at the back of the testicle that stores and carries sperm) or prostate.AND:2. At least one microbiologic criteria, such as: 10 cfu/mL of no more than two organisms in a voided urine sample 10^2 cfu/mL of any organism in a catheterized specimenResident #64 was readmitted to the facility on [DATE] with multiple diagnoses, including history of falling, adult failure to thrive, and a need for assistance with personal care.Resident #64's care plan revised 3/27/25, directed staff to encourage fluids and monitor for the following symptoms:[urinary] frequency malaisefoul smelling urinedysuria (pain when urinating)fevernauseavomitingflank painsupra-pubic painhematuriacloudy urinealtered mental statusloss of appetitebehavioral changesA progress note dated 3/27/25 at 4:43 PM, documented Resident #64 was observed to be increasingly lethargic with decreased muscle function. As a result, the provider was notified, and the following new orders were given:CBC (complete blood count lab test)CMP (comprehensive metabolic panel blood test)Urine analysis with culture and sensitivityCefdinir (an antibiotic) 300mg by mouth twice daily for 5 days for a diagnosis of urinary tract infection.A review of Resident #64's lab results documented the urine specimen was collected on 3/27/25 at 1:45 PM and the culture and sensitivity were completed on 3/29/25 at 7:54 AM, 3 days after antibiotics were started.On 3/5/26 at 4:12 PM, the DON confirmed Resident #64 did not meet McGeer's criteria for antibiotics for a urinary tract infection.

Based on observation and interview, it was determined the facility failed to ensure expired medications were removed from the medication storage room and not available for administration to residents. This was true for 1 of 1 medication room observed. This failed practice created the potential for adverse effects if residents received expired medications with decreased efficacy. Findings include:On 3/4/26 at 1:14 PM, during the inspection of the Medication Storage Room with the ADON, five acetaminophen suppositories which expired on 10/2025 were found inside the refrigerator. The ADON stated the acetaminophen suppositories were expired and should not be kept in the refrigerator.

Based on observation and staff interview, it was determined the facility failed to ensure resident rights were honored when past survey results were not posted in an area readily accessible to residents and their representatives. This failure created the potential for misinformation about the facility's prior 3 years of survey results and plans of correction. Findings include:On 3/2/26, 3/3/26, 3/4/26, and 3/5/26, a binder labeled State Survey Results was observed in a pocket folder on the wall of a corridor leading to the courtyard. The access to the binder was blocked by a stuffed chair with other large equipment stacked on top of it, two vitals signs towers, and an extra large padded specialized wheelchair. On 3/4/26 at 3:25 PM, during a Resident Council group discussion with surveyors, residents stated they were not aware of the facility's responsibility to make the past 3 years of survey results readily accessible or their right to review the results and plans of correction. The residents stated they did not know where the survey results were posted in the facility. On 3/5/26 at 2:23 PM, the Administrator confirmed the survey results were not accessible because they were blocked by stored equipment.

Based on review of facility staffing records and staff interview, it was determined the facility failed to ensure an RN was on duty at least 8 consecutive hours per day, 7 days a week. This was true for 1 of 38 days reviewed for RN staffing coverage. The failure created the potential for harm if routine and/or emergency nursing needs went unmet and had the potential to affect all residents living in the facility. Findings include: Licensed Nurse time punches for 9/1/24 to 10/8/24, documented the facility did not have an RN on duty for 8 consecutive hours on 9/1/24. On 10/10/24 at 5:15 PM, the CRN and DON stated on 9/1/24, the RN was covered by an LPN and confirmed there was not an RN for 8 consecutive hours that day.

Based on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to appropriately store, label, and serve foods. This deficient practice had the potential to affect the 59 residents who received meals in the dining room and eat snacks that had been stored in the snack refrigerators. This placed residents at risk for the potential for consuming contaminated and spoiled foods, and adverse health outcomes related to food-borne illnesses. Findings include: Review of the Idaho Food Code, revised February 2021, stated,. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and 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 when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Facility Food and Supply Storage policy dated 11/28/17, documented, For food products that are opened and not completely used or prepared at facility and stored, the product should be labeled as to it contents and use by dates. On 10/7/24 at 11:40 AM, 3 outdated yogurts (10/2/24) were observed in the walk-in refrigerator. On 10/7/24 at 11:42 AM, the CDM stated the outdated yogurts should have been removed from the walk-in refrigerator on 10/2/24. On 10/9/24 at 1:30 PM, an ice cream container with open date of 9/2/24 and used by date of 10/2/24, was observed in the resident snack freezer. On 10/9/24 at 1:35 PM, the CDM stated the ice cream container should have been removed on 10/2/24.

Based on policy review, record review, staff interview, and review of the State Survey Agency's Long-Term Care Reporting Portal, it was determined the facility failed to ensure a resident received CPR. This failure resulted in a serious adverse outcome for Resident #5 when CPR was not provided and placed the health and safety of 19 residents in the facility who had a Full Code status in immediate jeopardy of serious harm, impairment, or death. Findings include: The facility's policy, Cardiopulmonary Resuscitation, updated [DATE], stated residents who requested Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status were to receive basic life support, including initiation of CPR in the event they experienced cessation of respirations and/or pulse. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), epilepsy, and colostomy (surgical opening called a stoma. The opening creates a passage from the large intestine to the outside of the body). Resident #5's POST form, signed by Resident #5 and her physician on [DATE], documented she requested a Full Code in the event she did not have a pulse and/or was not breathing. Resident #5's care plan, initiated on [DATE], documented Resident #5 was a Full Code and she had a POST in place. A facility Reported Incident, dated [DATE], documented at 3:00 PM, Resident #5 complained to her CNA of leg pain. At 4:00 PM on [DATE], Resident #5 complained to her CNA of stomach and leg pain. CNAs were called to Resident #5's room two more times that afternoon to find her laying sideways on her bed, appearing pale, and complaining that she did not feel well. The incidents and complaints were reported to Resident #5's nurse, LPN #1. At approximately 5:20 PM, Resident #5 was found by 2 CNAs, laying sideways on her bed, with shallow breathing, cyanosis (bluish color in the skin, lips, and nail beds caused by a shortage of oxygen in the blood) of her fingers and lips, and her eyes half opened. The CNAs notified LPN #1 and the RCM. The RCM responded and assessed Resident #5 for a pulse and did not find one. LPN #1 performed a sternal rub (application of painful stimulus with the knuckles of a closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli) on Resident #5 resulting in no response from her. The RCM instructed LPN #1 not to perform CPR until she verified Resident #5's code status. After determining Resident #5 was a Full Code, the RCM returned to Resident #5's room and informed LPN #1. The RCM then left the room and proceeded to call the facility's CNO to report the event and received instructions to have an RN on staff pronounce Resident #5's death, notify Resident #5's physician and family, and obtain staff statements related to the event. The facility's CNO and CRN were interviewed together on [DATE] at 3:27 PM. They stated staff did not initiate CPR for Resident #5 or call 911. The RCM was interviewed by phone on [DATE] beginning at 5:35 PM. She stated she did not know why she told LPN #1 not to perform CPR until she checked Resident #5's code status, but she wanted to be sure CPR was appropriate for Resident #5. When asked if she had expected LPN #1 to initiate CPR after she notified him of the Full Code status, she stated, I don't know. I didn't know to do that. She stated, after she told LPN #1 Resident #5 was a Full Code, she left the room to call the CNO to tell her Resident #5 had passed. When asked how she determined Resident #5 had passed, she stated, Because I checked her pulse. The facility's failure to ensure a resident received cardiopulmonary resuscitation (CPR) who was a Full Code status placed the health and safety of 19 other residents in the facility who had a Full Code status in immediate jeopardy of serious harm, impairment, or death. On [DATE] at 11:50 AM, the Administrator, CNO, and CRN were informed verbally and in writing of an Immediate Jeopardy (IJ) determination at F678 related to the facility's failure to provide CPR on a resident. This failure resulted in a serious adverse outcome for Resident #5 when CPR was not provided and placed the health and safety of 19 residents in the facility who had a Full Code status in immediate jeopardy of serious harm, impairment, or death. On [DATE] at 12:00 PM, the facility provided a plan to remove the immediacy which was accepted. The facility's IJ removal plan included: - Review of all residents' code status. - Audit of all licensed nurses for Code Blue (a code indicating a medical emergency, usually cardiac or respiratory arrest) education. - Facility CNO and CRN educated all staff regarding the facility's Code Blue policy, Cardiopulmonary Resuscitation policy, and Code/Rapid Response Event form as they related to their roles. Each nursing staff member was required to complete a post-test prior to starting their next shift. On [DATE] at 5:00 PM, the CNO, CRN, and Administrator were verbally notified the immediacy was removed based on onsite verification the IJ removal plan was implemented. Following the removal of the immediacy, noncompliance remained at actual harm

Based on policy review, record review, staff interview, and review of the State Survey Agency's Long-Term Care Reporting Portal, it was determined the facility failed to protect Resident #5's right to be free from neglect when CPR was not provided. This was true for 1 of 5 residents (Resident #5) whose closed records were reviewed. This deficient practice resulted in a serious adverse outcome to Resident #5 when CPR was not provided per her wishes and physician order. Findings include: The facility's policy, Cardiopulmonary Resuscitation, updated [DATE], stated residents who requested Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status were to receive basic life support, including initiation of CPR in the event they experienced cessation of respirations and/or pulse. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), epilepsy, and colostomy (surgical opening in the abdomen that creates a passage from the large intestine to the outside of the body). Resident #5's POST form, signed by Resident #5 and her physician on [DATE], documented she requested to be a Full Code in the event she did not have a pulse and/or was not breathing. Resident #5's care plan, initiated on [DATE], documented Resident #5 was a Full Code and she had a POST in place. A facility Reported Incident, dated [DATE], documented at 3:00 PM, Resident #5 complained to her CNA of leg pain. At 4:00 PM on [DATE], Resident #5 complained to her CNA of stomach and leg pain. CNAs were called to Resident #5's room two more times that afternoon to find her laying sideways on her bed, appearing pale, and complaining that she did not feel well. The incidents and complaints were reported to Resident #5's nurse, LPN #1. At approximately 5:20 PM, Resident #5 was found by 2 CNAs, laying sideways on her bed, with shallow breathing, cyanosis (bluish color in the skin, lips, and nail beds caused by a shortage of oxygen in the blood) of her fingers and lips, and her eyes half opened. The CNAs notified LPN #1 and the RCM. The RCM responded and assessed Resident #5 for a pulse and did not find one. LPN #1 performed a sternal rub (application of painful stimulus with the knuckles of a closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli) on Resident #5 resulting in no response from her. The RCM instructed LPN #1 not to perform CPR until she verified Resident #5's code status. After determining Resident #5 was a Full Code, the RCM returned to Resident #5's room and informed LPN #1. The RCM then left the room and proceeded to call the facility's CNO to report the event and received instructions to have an RN on staff pronounce Resident #5's death, notify Resident #5's physician and family, and obtain staff statements related to the event. The RCM was interviewed by phone on [DATE] beginning at 5:35 PM. She stated she did not know why she told LPN #1 not to perform CPR until she checked Resident #5's code status, but she wanted to be sure CPR was appropriate for Resident #5. When asked if she expected LPN #1 to initiate CPR, she stated, I don't know. I didn't know to do that. She stated after she told LPN #1 that Resident #5 was a Full Code, she left the room to call the CNO to tell her Resident #5 had passed. When asked how she determined Resident #5 had passed, she stated, Because I checked her pulse. On [DATE] at 3:27 PM, the CNO, Administrator, and CRN were interviewed together. They stated staff did not initiate CPR for Resident #5 when she did not have a pulse and was a Full Code. The facility failed to protect Resident #5's right to be free from neglect when CPR was not provided per her wishes and physician order.

Based on observation, staff interview, review of nationally recognized standards of practice, policy review, review of facility documents, review of employee screening logs, review of employee work schedules and timesheets, it was determined the facility failed to ensure infection control prevention practices were implemented and maintained to prevent and contain COVID-19. These failures placed all residents and staff at risk for exposure to COVID-19 with the likelihood of serious harm, impairment, or death. Findings include: On [DATE] at 12:00 PM, the DON confirmed the facility had experienced a total of 103 COVID-19 positive cases, including staff and residents, beginning on [DATE]. The DON confirmed 11 residents died , and she said another resident died the previous night related to COVID-19. 1. The facility's policy for Screening and Management of COVID-19, revised [DATE], documented the following: * Staff, vendors, and providers were screened for risk of COVID-19 exposure before entering resident care areas. The screening included checking the temperature and self-report of respiratory symptoms. If a risk factor was identified, a medical review was completed with that person, and a determination was made whether they could enter resident care areas. If the person had a fever, they were sent home immediately. Staff were instructed to leave the work area and notify their supervisor if they developed symptoms during their shift. * Staff who had or were suspected of having COVID-19, with mild to moderate illness and not severely immunocompromised, were allowed to return to work if they met the following conditions: 1. At least 24 hours passed since the last fever, without the use of fever-reducing medication; and 2. There was improvement in symptoms; and 3. at least 10 days passed since symptoms first started. * Asymptomatic staff who had unprotected exposure to COVID-19 may be excluded from work for 14 days after the last exposure. The CDC Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19, dated [DATE], stated, HCP should self-monitor when they are not at work and be actively screened upon entering the facility. The facility policy and CDC guidelines were not followed. The facility's employee screenings logs and timesheets, dated [DATE] through [DATE] and from [DATE] through [DATE], were reviewed for all employees of the facility. There were inconsistencies between the timesheets and the staff screening logs. a. The following staff were not screened prior to working their shift: * The screening logs and timesheets, dated [DATE], did not include screening for 6 CNAs, 1 LPN, 1 Dietary Staff, and the Maintenance Director. * The screening logs and timesheets, dated [DATE], did not include screening for 2 CNAs, 1 LPN, 1 RN and the Maintenance Director. * The screening logs and timesheets, dated [DATE], did not include screening for 8 CNAs, 2 LPNs, 1 RN, 1 Housekeeper, and 1 Social Worker. b. The employee screening log included a section to document a temperature, six yes/no questions related to symptoms associated with COVID-19, a section for the initials of the reviewer, and a section for action taken. The employee screening logs did not include documentation of an action taken when staff answered yes to potential symptoms of COVID-19. * The screening logs and timesheets, dated [DATE], documented 1 CNA and 1 Social Worker worked when they answered yes to the questions of symptoms associated with COVID-19. * The screening logs and timesheets, dated [DATE], documented 1 Social Worker worked when they answered yes to the questions of symptoms associated with COVID-19. * The screening logs and timesheets, dated [DATE], documented 1 CNA, 1 LPN, and 1 PTA worked when they answered yes to the questions of symptoms associated with COVID-19. * The screening logs and timesheets, dated [DATE], documented 3 CNAs, and 1 NA worked when they answered yes to the questions of symptoms associated with COVID-19. * The screening logs and timesheets, dated [DATE], documented 1 PTA and 1 Dietary Staff worked when they answered yes to the questions of symptoms associated with COVID-19. * The screening logs and timesheets, dated [DATE], documented 1 CNA and 1 PTA worked when they answered yes to the questions of symptoms associated with COVID-19. On [DATE] at 12:46 PM, Housekeeper #1 said when he entered the building, he came in the West Wing door, took his own temperature, wrote his own answers to questions on the screening log, and went to the laundry room to get his assignment. Housekeeper #1 said no one asked him the questions in the screening log. On [DATE] at 1:30 PM, CNA #14 said when she came to work she checked her temperature and answered the screening questions. CNA #14 said she filled out the information herself and left it for the nurse to look at it. On [DATE] at 1:45 PM, RN #4 said when she came to work she checked her temperature and answered the questions on the screening log, and she entered the information herself. RN #4 said if there was a question about whether a staff member had symptoms, that person should go to the charge nurse. RN #4 said she did not know who reviewed the staff screening logs or when they were reviewed. On [DATE] at 1:48 PM, CNA #4 said when he entered the building, he came in the West Wing door, performed hand hygiene, took his own temperature, wrote it in the screening log, put on a gown, a face mask, goggles or face shield, and proceeded to report to work. CNA #4 said he answered the questions on the screening log himself and no one observed him. On [DATE] at 3:15 PM, the DON said staff were expected to screen with a partner or ask someone to witness their temperatures. The DON said if the staff had symptoms they were expected to ask to see the RN, or they did not come in to work. On [DATE] at 3:16 PM, the IP said she reviewed the screening logs at certain times and she initialed the log. The DON said she and the IP reviewed the screening logs at least daily. When asked who was responsible for overseeing the employee screening process, the DON said, we tag team it. 2. The facility's policy for Screening and Management of COVID-19, revised [DATE], documented staff were to use the following guidelines for PPE: * Use of PPE in the COVID-19 unit (Red Zone): Continuously wear a gown, respirator face mask, eye protection, and gloves. The facility had red signs posted outside the doors of residents who were positive for COVID-19. The red sign was to inform staff Enhanced Droplet Precautions were in place, and full PPE was required. The sign documented a gown, a respirator face mask, eye protection (goggles or face shield), and gloves were required upon entry. Staff were observed not following the Enhanced Droplet Precautions and wearing all PPE indicated on the sign when entering resident rooms. Examples include: a. On [DATE] at 10:20 AM, CNA #1 entered room [ROOM NUMBER]. A red sign was posted on the door, which indicated a COVID-19 positive resident inside, CNA #1 was wearing a gown, a respirator face mask, and eye protection, but he was not wearing gloves. CNA #1 performed hand hygiene on exit from the room. On [DATE] at 1:30 PM, CNA #1 said he did not wear gloves in the room because he did not provide cares to the resident and was just checking on her. b. On [DATE] at 10:56 AM, Resident #12 had a red sign posted on their door. RN #4 entered Resident #12's room with medication in a clear plastic medication cup. RN #4 was wearing a gown, goggles, and a blue surgical mask over a white mask, and she was not wearing gloves. RN #4 then exited the room with the medication cup in her hand, and she obtained a washcloth from the linen closet outside Resident #12's room. RN #4 did not put on gloves, and she re-entered the room. RN #4 went to the sink and moistened the washcloth and went to Resident #4's bedside, which was behind a closed curtain. RN #4 emerged from behind the curtain and then washed her hands and exited the room. RN #4 said the red sign on the door meant staff were to wear a gown, goggles, and face mask because of COVID-19. RN #4 said If I was going to do something I would wear gloves-I tried to wake her (Resident #12) up, but she was not going to wake up. I saw chocolate pudding on her face, so I got a washcloth from the linen closet and wiped her face. RN #4 said she did not wear gloves when she went into Resident #12's room. c. On [DATE] at 10:39 AM, CNA #4 entered room [ROOM NUMBER] which had a red sign posted on the door. CNA #4 was wearing a gown, a face mask, and eye protection, but he was not wearing gloves. CNA #4 walked around the room as he looked around and touched various items in the room with his bare hands. CNA #4 touched a resident's bedside table, then he went to another resident's dresser and opened the drawer. CNA #4 looked in the drawer, picked up some clothing items with his bare hands, and placed the items back in the drawer. After he closed the dresser drawer, CNA #4 exited the room. When asked about the red sign on the door that directed staff to wear gloves in the room, CNA #4 said he wore them if he did anything with the resident. d. On [DATE] at 12:25 PM, CNA #2 was providing drinks to Resident #16 from a cart on the West Wing. CNA #2 was wearing a gown, a respirator face mask and goggles, and was not wearing gloves. A red sign was posted on the door. CNA #2 said she did not put on gloves to go into the room, she only put on gloves if she was going to touch the resident or their things, not when she was handing them something. e. On [DATE] at 1:56 PM, CNA #4 went into room [ROOM NUMBER] with a red sign posted on the door while distributing paper products. He had on a gown, face mask and goggles, and did not put on gloves. CNA #4 said he performed hand hygiene when he came out of the room. CNA #4 stated he was unsure whether he should have worn gloves. f. On [DATE] at 12:59 PM, the Social Worker entered Resident #15's room. A red sign was posted on the door, which indicated Enhanced Droplet Precautions were in place and full PPE was required. The sign documented a gown, a respirator face mask, eye protection (goggles or face shield), and gloves were required. The Social Worker was wearing a white lab coat, which was buttoned up the front, goggles, a face mask, and gloves. The Social Worker did not put on a gown prior to entering the room, and she talked to Resident #15 behind a closed curtain for several minutes. The Social Worker then exited the room, removed her gloves, and disposed of them. The Social Worker was still wearing the same lab coat, goggles, and face mask. She said the resident was on precautions because she was COVID-19 positive. The Social Worker said she did not perform cares for Resident #15. The Social Worker said she talked with Resident #15 about her menu. The Social Worker said the red sign on the door indicated staff were to wear PPE, including a gown, gloves, a face mask, and eye wear. The Social Worker said she considered the lab coat as her gown, and she put it in the laundry at the end of the day or she would change it if it became soiled. On [DATE] at 2:53 PM, the DON said when staff go into a room with a red precaution sign staff were to follow what was on the red precaution sign and perform hand hygiene when they go in and out of the room and use gloves. On [DATE] at 3:08 PM, the IP said a gown should have been worn over the Social Worker's white lab coat when entering Resident #15's room. The IP said staff should wear gloves when going into a room that was on precautions. 3. The facility's policy for PPE Donning and Doffing, revised [DATE], directed staff to Put on Mask or Respirator. If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/face mask should be extended under the chin. Both your mouth and nose should be protected. Do not wear respirator/face mask under your chin . The facility's policy also stated Protective glasses must wrap around the eyes. Vented glasses are not acceptable. This policy was not followed. a. On [DATE] at 10:26 AM, RN #1 was wearing regular eyeglasses with small clear pieces attached on each side behind the lenses. The attachments were approximately 2 inches in length and 1 inch or less in width, and there were several small openings in the plastic attachments. The top of RN #1's eyeglass lenses were just at or slightly below her eyebrows, and her glasses did not wrap around her eyes. RN #1 said she purchased the eyeglass attachments from Amazon, and the advertisement said they were acceptable. On [DATE] at 11:00 AM, the DON said she could not find information regarding the appropriate use of the eyeglass attachments as eye protection. b. On [DATE] from 11:20 AM to 11:40 AM, RN #1 was talking on a cell phone at the nurse's station. A white mask was hanging underneath her chin and neck, and it was not secured to her face. RN #1 said her mask should be over her mouth and nose with the straps in place, and it was not in place while she was talking on the phone because she pulled it down so the other person on the phone could hear her. On [DATE] at 3:08 PM, the IP said a face mask should be worn to cover the mouth and nose, and it was not acceptable for staff to wear it below their chin. 4. The facility's policy for Hand Hygiene, dated [DATE], stated hand hygiene was to be performed: * After touching blood, body fluids, secretions, excretions and contaminated items, whether gloves are worn. * After handling soiled equipment or utensils. * After removal of medical/surgical or utility gloves. * After gloves are removed between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. This policy was not followed. a. On [DATE] beginning at 10:27 AM, Housekeeper #2 was in room [ROOM NUMBER] mopping the floor with gloved hands. She then took off her gloves and put new gloves on without performing hand hygiene and continued mopping. Housekeeper #2 then grabbed a plastic yellow triangular wet floor sign and placed it outside of room [ROOM NUMBER] and closed the door to the room. She took off her gloves and put them in the trash and put new gloves on without performing hand hygiene. Housekeeper #2 then entered room [ROOM NUMBER]. She took a cloth from a bucket on her cart and wiped down the plastic glove box holder in the room, wiped the television screen, and the light fixtures at the end of the bed. She then wiped the top of the bedside table and the table legs. Housekeeper #2 touched her hair with her right hand with her contaminated glove, removed her gloves and put on new gloves without performing hand hygiene, and then wiped her forehead with the back of her right hand. She then grabbed a new cloth from her cart, went back into room [ROOM NUMBER] and opened the bathroom door and proceeded to clean surfaces in the bathroom. Housekeeper #2 exited the bathroom in room [ROOM NUMBER], removed her gloves, put them in the trash and put new gloves on without performing hand hygiene. She went to her cart outside of the room and took a toilet brush into the bathroom in room [ROOM NUMBER] and proceeded to clean. When she finished cleaning she placed the toilet brush back on her cart and grabbed a broom from the cart and swept the bathroom and then the floor by the bed. She moved the bedside table with her gloved hand and then swept under the bed. Housekeeper #2 finished sweeping the room, returned the broom to her cart, then reached into a bucket with mop pads in liquid solution. She wrung out one of the pads in the bucket and went back into the room and mopped the bathroom. Housekeeper #2 exited the bathroom and took the mop over by the bed and reached down to pick up the call light that was on the floor and placed it on the bedside table without cleaning it. Housekeeper #2 continued to mop the floor until she reached the doorway to room [ROOM NUMBER]. She took off the dirty mop pad and disposed of it and put the mop on the cart. She removed her gloves and took the broom from the cart and swept the rest of the debris in the doorway of room [ROOM NUMBER]. Housekeeper #2 did not perform hand hygiene after removing her gloves. Housekeeper #2 then replaced the broom on the cart and pushed her housekeeping cart down the hallway toward the next room. On [DATE] at 10:58 AM, Housekeeper #2 said she should have performed hand hygiene before and after putting on gloves and when exiting a resident's room. b. The facility's policy for PPE Donning and Doffing, dated [DATE], stated hands were to be washed prior to putting on a new gown. This policy was not followed. On [DATE] at 11:10 AM, CNA #6 entered the building through the west wing door where the screening log and staff PPE were located just inside the door. CNA #6 took her stored respirator face mask from a paper bag and secured it over her nose and mouth. CNA #6 then took a cloth gown from a rack across from the west wing door way and put it on over her scrubs and fastened the back of the gown. CNA #6 then put her name badge on and performed hand hygiene. CNA #6 did not perform hand hygiene before putting on her PPE. On [DATE] at 11:13 AM, CNA #6 said she should have performed hand hygiene before putting on her PPE. On [DATE] at 2:48 PM, the IP said staff should perform hand hygiene in and out of rooms, before putting on PPE, when putting on new gloves, and after taking off gloves. 5. The facility's policy for Handling, Transport, and Storage of Laundry, updated [DATE], stated the following: * After washing, cleaned and dried textiles, fabrics, and clothing are hung, folded, and prepared for transport, distribution and storage by methods that ensure their cleanliness until use (e.g., covered cart, closing closet doors, etc.). * Staff will handle and transport the laundry with appropriate measures to prevent cross-contamination. * Clean linens must be transported by methods that ensure cleanliness and protection from dust and soil during intra or inter-facility loading, transport, and unloading. * Clean linen must always be kept separate from contaminated linen through the use of separate rooms, closets, or other designated spaces with a closing door as the most secure methods for reducing the risk of accidental contamination. This policy was not followed. On [DATE] at 11:10 AM, next to the West entrance door was a metal clothing rack with gowns on hangers. CNA #6 was putting on PPE and took a gown from the metal clothing rack. The gowns hung loosely on hangers on the metal rack and did not have a protective covering. On [DATE] at 12:42 PM, 16 cloth gowns were observed on hangers on a metal clothing rack against the wall between the kitchen door and room [ROOM NUMBER]. The gowns hung loosely on hangers on the metal rack and did not have a protective covering. The Case Manager was walking by the gowns, toward the 100 hall, and brushed his left shoulder against some of the gowns. On [DATE] at 12:55 PM, Housekeeper #4 was pulling an empty clothing rack down the 200 hall toward the door that led to the laundry outside of the building. As she walked by the clothing rack on the wall between the kitchen door and room [ROOM NUMBER], her left shoulder lightly brushed against some of the gowns. On ,[DATE] at 12:58 PM, Housekeeper #4 said the gowns hanging on the rack were clean gowns she provided from the laundry for staff to use when entering residents' rooms. Housekeeper #4 said she did not realize she brushed against the gowns and agreed if she did they would be contaminated. She said the gowns were considered clean linen and should be covered when transported or stored in the hall. On [DATE] at 3:16 PM, the IP said the gowns should be covered when stored in the hall. 6. The facility's Transmission-Based Precautions Conventional Plan, updated [DATE], stated resident care equipment was to be cleaned and disinfected before use on another resident using an Environmental Protection Agency (EPA) registered disinfectant. This policy was not followed. On [DATE] at 10:52 AM, CNA #3 was in room [ROOM NUMBER] with a clip board, thermometer, and pulse oximeter. The clip board was on top of Resident #17's bedside table with the thermometer and pulse oximeter on top of it. CNA #3 picked up the clip board and equipment on top of it, crossed the hall to room [ROOM NUMBER] and placed the clip board onto Resident #18's dresser. CNA #3 did not sanitize the clipboard prior to leaving room [ROOM NUMBER] and before placing it on Resident #18's dresser. CNA #3 performed hand hygiene, put on new gloves and cleaned the thermometer and pulse oximeter, then took Resident #18's vital signs. After she took Resident #18's vital signs, CNA #3 sanitized the thermometer and set the thermometer on top of Resident #18's dresser, removed her gloves, and wrote on the clip board. CNA #3 then performed hand hygiene, put on new gloves, and took the thermometer from Resident #18's dresser and took Resident #19's temperature who was in the same room as Resident #18. CNA #3 did not sanitize the thermometer that was on Resident #18's dresser before taking Resident #19's temperature. On [DATE] at 10:55 AM, CNA #3 said she had placed the clip board on Resident #17's bedside table and then placed it on Resident #18's dresser. She said she put the thermometer down on Resident #18's dresser, then picked it up and took Resident #19's temperature. On [DATE] at 3:00 PM, the DON said the equipment used to take vital signs should have been sanitized between each resident use, and the equipment should have been placed on microorganism barriers, and not directly on resident furniture. 7. The facility's PPE Conservation Plan, dated [DATE], stated: * Extended use (of PPE) refers to the practice of wearing the same PPE for repeated encounters with several residents, without removing between the encounters. Extended use may be implemented when multiple residents are infected, and residents are placed together in dedicated area, room or unit(s). * Reuse refers to the practice of using the same piece of PPE for multiple encounters with residents under precautions but removing it ('doffing') between encounters of other residents. The PPE is stored between encounters and reused. This policy was not followed. The facility's policy for Screening and Management of COVID-19, revised [DATE], documented staff were to use the following guidelines for PPE: * In the Orange Zone (negative for COVID-19 but previously exposed of positive): Use the two-gown system, respirator face mask, eye protection, gloves, and one time use gown for care. On [DATE] at 11:49 AM, CNA #2 took a yellow gown hanging on a rack outside of room [ROOM NUMBER] and put it on over the gown she was wearing in COVID-19 positive rooms, she then put a surgical face mask over the top of her respirator face mask that she wore into COVID-19 positive rooms. CNA then took a cup of soy milk and a cup of cranberry juice into room [ROOM NUMBER] that had an orange sign on it indicating it was a negative COVID-19 room. The sign directed staff to use a two-gown system, respirator face mask, eye protection (goggles or face shield) and gloves. The sign did not instruct staff to put on a clean gown over a dirty gown and it did not instruct staff to put on a surgical face mask over their respirator face mask. On [DATE] at 12:21 PM, LPN #1 said the COVID-19 positive residents had a red precaution sign posted on their door, and it instructed staff to put on a gown, a respirator face mask, a face shield, and gloves. LPN #1 said the COVID-19 negative residents had an orange precaution sign posted on their door, and it instructed staff to put on an additional disposable/washable one-time use gown for care. On [DATE] at 1:30 PM, CNA #1 said the orange precaution signs meant the resident was COVID-19 negative and the staff was to put on an extra gown and face mask over the already donned gown and N95/respirator because the gown and N95/respirator were already contaminated. On [DATE] at 11:44 AM, the Administrator said he was unsure what guidance was used for the two-gown system. On [DATE] at 5:29 PM, the Administrator sent the guidelines regarding the use of a two-gown system, was from a slide presentation by RB Health Partners, Inc., titled Combating A Super-Spreader COVID-19 Guidance for Long-Term Care, [DATE]. Under the section on Zone System, the document stated for COVID-19 positive residents, staff should use: * Full PPE - filtering facepiece respirator and face shield preferred * Two-gown system - Base gown to protect clothing - Disposable gown for high contact care activities The guidelines did not recommend a two-gown system for residents who were negative for COVID-19. 8. The facility's Dining Standards policy, dated [DATE], stated when providing in-room dining, food being transported to resident rooms was covered. This policy was not followed. Examples include: On [DATE] at 12:30 PM, CNA #3 was distributing lunches to rooms 111 through 116 on the COVID-19 positive West Wing unit from an uncovered rack on casters. Paper plates set on trays in the rack were covered with tin foil, and the Styrofoam cups with salad and dessert were not covered. The rack was rolled down the hall as the lunches were distributed. On [DATE] at 3:04 PM, the DON said the lunch trays should be transported in covered carts. On [DATE] at 4:15 PM, the Administrator and DON were informed of an Immediate Jeopardy determination for 42 CFR §483.80 (F880) via phone, and the Immediate Jeopardy template was subsequently sent via fax.

Based on record review, policy review, and staff interviews, it was determined the facility did not ensure residents were free from chemical restraints. There was no documented evidence a systematic process of evaluation and care planning was developed for staff to first implement specific resident focused non-pharmacological interventions should residents demonstrate aggressive behaviors. This resulted in harm to 1 of 8 residents (Resident #166) reviewed for [MEDICAL CONDITION] drug use. Resident #166 was harmed when he experienced increased somnolence, sedation, weight loss, dehydration, developed two pressure ulcers, and a decline in ADL's as a result of multiple [MEDICAL CONDITION] medications. Findings include: The facility's Restraints policy and procedure, released 5/28/15, stated residents had the right to be free from physical and chemical restraints imposed for the purpose of discipline or convenience, and were not required to treat the resident's medical symptoms. Resident #166 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #166 was discharged from the facility and admitted to a local hospital on [DATE]. Resident #166's was admitted to a hospital on [DATE]. A physician progress notes [REDACTED]. While in the hospital Resident #166 had a 1:1 sitter to prevent elopement. An H&P, dated 8/14/18, stated Resident #166 was brought to the facility from a local hospital. He was living in an ALF prior to his hospital admission when his behaviors escalated. The H&P stated Resident #166 saw his neurologist and was started on [MEDICATION NAME], but he became more violent and it was discontinued. He was then started on [MEDICATION NAME]. The H&P stated while in the hospital Resident #166 hit a staff member and was sexually inappropriate. The H&P included the [DIAGNOSES REDACTED]. The initial MDS assessment, dated 8/24/18, documented Resident #166 had moderate cognitive impairment and he was physically aggressive 1 to 3 days a week. The MDS documented he was not a risk to others and disturbed the environment. The MDS documented he required limited to extensive assistance of 1 to 2 staff members with all cares except eating. The care plan area addressing Resident #166's intrusive wandering behavior and invading the personal space of others, initiated 8/20/18, documented Resident #166 required 1:1 supervision while awake and 15 minute checks while asleep for intrusive wandering and invading the space of others and aggressive behaviors. Resident #166's care plan did not include his dementia, all his behaviors, or his use of antipsychotic medications. Resident #166's admission orders [REDACTED]. Resident #166 also had an order for [REDACTED].#166's H&P date 8/14/18. identified that [MEDICATION NAME] had been discontinued due to violent behaviors. Resident #166's record did not include [DIAGNOSES REDACTED]. A Behavior Monitor Flowsheet for August 2018, included monitoring Resident #166 for physical aggression, wandering, elopement, being resistive to cares, and sexually inappropriate behaviors. The flowsheet included suggested interventions for each behavior. The interventions for each behavior were as follows: - Physical aggression, elopement, and/or resistive to cares: redirection, offer activity, offer snack, discuss the reason the resident was upset - Wandering and/or sexually inappropriate: redirection, communicate concerns with behavior, 1:1 conversation The flowsheet also included sections to document the number of times the behavior occurred, which interventions worked, which interventions did not work, and the initials of the staff member. Resident #166's Progress Notes and Behavior Monitor Flowsheets, from 8/13/18 to 9/3/18, documented the following behaviors: - On 8/14/18 at 3:13 AM, the nurse stated Resident #166 was easy to redirect and flirted with staff, almost kissing a CNA. - On 8/14/18 at 1:41 PM, Resident #166 attempted to exit the facility after lunch. - On 8/14/18 at 9:20 PM, the nurse documented Resident #166 had delusions and showed signs and symptoms of aggression when receiving instruction. He was given the as needed [MEDICATION NAME]. - On 8/15/18 at 9:24 PM, the nurse stated Resident #166 .does tend to make inappropriate statements with possible delusions . There were no behaviors or interventions documented on the Behavior Monitor Flowsheet from 8/13/18 to 8/15/18. - On 8/16/18 at 11:24 PM, the nurse stated Resident #166 was trying to touch other residents and staff, and he was combative with male CNAs. The nurse stated he was trying to kiss a nurse. The note also stated Resident #166's roommate was afraid of him because of how Resident #166 stared at him or patted his back and shook his hand. The note did not describe how or why Resident #166 was combative. The Behavioral Flowsheet documented he was resistive to cares but did not include documentation of interventions. - On 8/17/18 at 11:00 AM, the Social Service Specialist stated Resident #166 was found by the night nurse pleasuring himself in the hallway next to another resident's room. She stated behavior monitors for sexually inappropriate behavior were in place. The Behavior Monitor Flowsheet did not include documentation Resident #166 was sexually inappropriate or that interventions were attempted. - On 8/17/18 at 1:03 PM, the nurse stated Resident #166 attempted to exit the facility 3 times. He also was taking items from other residents such as food during a meal, markers and a book, and a walker. The note included documentation of staff intervening when Resident #166 was taking food, but not for the other items taken from other residents. - On 8/17/18 at 1:20 PM, the nurse stated Resident #166 exited the building but was easily redirected to go back inside. - On 8/17/18 at 11:21 PM, the nurse stated Resident #166 was exit seeking and easy to redirect. She documented he was combative with male CNAs and attempting to touch other residents. The note did not include documentation how or why Resident #166 was combative, or what was meant when it stated he attempted to touch other residents. The Behavior Monitor Flowsheet documented Resident #166 was physically aggressive 4 times during the evening shift, he was wandering 10+ times during the evening shift and no interventions worked and 4 times during the night shift and all interventions worked, he eloped 2 times on the evening shift and no interventions worked, and he was resistive to cares 5 times on the evening shift and no interventions worked. - On 8/18/18 at 8:54 PM, the nurse stated Resident #166 was combative with staff and was attempting to touch other residents. He also told the nurse he had to stay out of his room all day because his roommate tells him things all day. The note did not include documentation how or why Resident #166 was combative, or what was meant when it stated he attempted to touch other residents. - On 8/19/18 at 1:03 PM, the nurse stated Resident #166 was confused, delusional, and hallucinating at times. She stated he was combative and sexually inappropriate with female staff and female visitor. The nurse stated Resident #166 was non-directable and attempted to kick her and bite her arm. She stated he did hit a CNA in the stomach and placed a closed fist next to a female resident's head and stated, I'm not gonna hit you. - On 8/19/18 at 2:30 PM, the nurse stated Resident #166 was given an injection of [MEDICATION NAME] (an antipsychotic medication) 20 mg per order after he was verbally and physically aggressive with staff and other residents. She stated other oral PRN medications and verbal redirection were ineffective. - On 8/20/18 at 1:47 PM, the nurse stated Resident #166 was intrusive and going into other female resident's rooms. She stated he was not directable and physically aggressive by wringing CNAs hands when they attempted to redirect him. - On 8/20/18 at 2:02 PM, the nurse stated Resident #166 was placed on 15 minute checks for intrusive wandering and invading the space of other residents. - On 8/20/18 at 11:27 PM, the nurse stated Resident #166 was combative with staff and given a PRN medication at 8:00 PM. She stated he was kicking and attempting to punch staff, squeeze staff's hands and pull their fingers back when he was being redirected. - On 8/21/18 at 5:19 AM, the nurse stated Resident #166 was given a PRN [MEDICATION NAME] (an antianxiety medication) at 3:00 AM with no effect. She stated he was wandering into other resident's rooms and being intrusive. The nurse stated he had 1:1 staff all night for safety. - On 8/21/18 at 10:22 AM, the nurse stated Resident #166 was physically aggressive when she attempted to redirect him. He made sexually inappropriate comments, grabbed her breast and buttock. Resident #166 attempted to hit and kick staff, and he pushed 2 staff members. The nurse stated she received an order from the psychiatrist for [MEDICATION NAME] 20 mg injection and it was given with the assistance of 2 CNAs and another nurse. There was no documentation on the Behavior Monitor Flowsheet Resident #166 was sexually inappropriate. - On 8/21/18 at 12:12 PM, Resident #166's psychiatrist ordered [MEDICATION NAME] 200 mg and [MEDICATION NAME] 0.5 mg 3 times a day. The wife was called, and she was ok with the orders but was worried about an overdose. The note documented the last time he was on multiple medications Resident #166 became weak and was unable to move. - On 8/21/18 at 2:09 PM, the nurse stated Resident #166 was attempting to push another resident down a hall in their wheelchair and became agitated and physically aggressive with staff when asking him to let go of the wheelchair. The nurse stated Resident #166 grabbed and squeezed the arms and hands of staff and punched the resident in the wheelchair in the back. The nurse stated the psychiatrist was called and new orders were given. - On 8/21/18 at 8:55 PM, the nurse documented Resident #166 was given an antianxiety medication at 2:00 PM for increased aggression with anxiety. The nurse stated Resident #166 had no symptoms of anxiety or aggression and was resting quietly in his room. - On 8/22/18 at 2:22 AM, the nurse stated Resident #166 was sleeping with no behaviors and being monitored closely due to his aggressive behaviors on the previous shift and the PRN [MEDICATION NAME] (an antipsychotic medication) was given. - On 8/22/18 at 3:42 AM, the nurse documented (Resident #166) is now awake and is mildly displaying s/s (signs and symptoms) of restless behaviors x4. He was calling out several times and was not directable. Staff changed his linen, clothes, toileted him & provided pericare, and re-positions him comfortably in bed. He was also given a glass of water. At the beginning of the shift, he was sleeping with his head resting at the foot of the bed. He has not attempted to get out of bed this noc (night). (Resident #166) was given prn [MEDICATION NAME] IM (intramuscular) to maintain calmness and prevent aggression. There was no documentation on the Behavior Monitor Flowsheet Resident #166 was physically aggressive, was resistive to cares, or sexually inappropriate. - On 8/22/18 at 8:47 PM, the nurse stated Resident #166 remained confused and had aggression. The nurse stated he was given [MEDICATION NAME] for the aggression and intrusiveness. There was no description how Resident #166 was aggressive or intrusive. The Behavior Monitor Flowsheet did not include documentation Resident #166 had physical aggression, was resistive to cares, or sexually inappropriate. - On 8/30/18 at 2:31, the nurse stated Resident #166's spouse was upset he was sitting in a chair and not speaking to her. His spouse was upset about the medications, [MEDICATION NAME] (an antipsychotic) and Klonopin (a benzodiazepine), prescribed by the psychiatrist and that she read about the black box warnings related to patients with dementia. The nurse stated an appointment was made for Resident #166's spouse to meet with the psychiatrist on 9/10/18. According to the Food and Drug Administration (FDA), website accessed 9/26/18, a black box warning appears on a prescription drug's label and is designed to call attention to serious or life-threatening risks. - On 8/31/18 at 1:43 PM, the nurse stated Resident #166's spouse was called about a new dietary order. The spouse stated Well, the problem is that he's not eating. They gave him something over the weekend that almost killed him and turned him into a vegetable. - On 9/3/18 at 10:58 AM, the nurse stated Resident #166's spouse informed the nurse she was taking him to a hospital. The spouse stated You are killing him. I am taking him to the hospital to see if they can save his life. The nurse stated she could call the physician and arrange for him to go to the hospital, Resident #166's spouse refused. Resident #166's MARs for August 2018 and September 2018 documented the following medications: [REDACTED] - [MEDICATION NAME] 75 mg 2 times a day for [MEDICAL CONDITION], ordered 8/13/18 and discontinued on 8/20/18. - [MEDICATION NAME] 12.5 mg every 6 hours PRN for [MEDICAL CONDITION], ordered 8/13/18 and discontinued on 8/27/18. - [MEDICATION NAME] 30 mg daily for depression, ordered 8/13/18 and discontinued on 8/20/18. - [MEDICATION NAME] 20 mg IM 1 dose for physically combative with staff and residents, ordered 8/19/18. - [MEDICATION NAME] 1 mg every 6 hours PRN for anxiety, ordered 8/20/18. - [MEDICATION NAME] 20 mg IM 1 dose for agitation, ordered 8/21/18. - [MEDICATION NAME] (extended duration medication) 20 mg IM 1 dose for [MEDICAL CONDITION], ordered 8/21/18. - [MEDICATION NAME] (short acting duration) 5 mg IM every 6 hours PRN for [MEDICAL CONDITION], ordered 8/21/18. - [MEDICATION NAME] 5 mg at 7:30 AM and 3:00 PM for [MEDICAL CONDITION], ordered 8/21/18. - Depo-[MEDICATION NAME] 150 mg IM 1 time every 28 days for dementia lewy body with behaviors, ordered 8/21/18. - Klonopin 0.5 mg 3 times a day for anxiety, ordered 8/21/18. - [MEDICATION NAME] 10 mg daily for [MEDICAL CONDITION], ordered 8/21/18. - [MEDICATION NAME] 200 mg daily for [MEDICAL CONDITION], ordered 8/21/18 and discontinued on 8/27/18. - [MEDICATION NAME] 100 mg daily for [MEDICAL CONDITION] related to dementia with lewy bodies, ordered 8/27/18. On 8/21/18, Resident #166's psychiatrist ordered 6 new medications for anxiety, dementia with behaviors and/or [MEDICAL CONDITION], and agitation. Of those 6 medications 3 are classified as antipsychotics. According to Drugs.com a nationally recognized medication information website, accessed 9/26/18, [MEDICATION NAME], and [MEDICATION NAME] had a black box warning for increased mortality in geriatric patients. The MAR indicated [REDACTED]. On 8/21/18, Resident #166 also received, in addition to the medications listed above, 1 injection of Depo-[MEDICATION NAME], 1 injection of [MEDICATION NAME], 1 injection of [MEDICATION NAME] 20 mg, and 2 injections of [MEDICATION NAME] 5mg. There was no clinical justification documented for the addition of the [MEDICATION NAME], Klonopin, [MEDICATION NAME] at a higher dose, and the [MEDICATION NAME]. On 8/20/18 at 4:25 PM, a progress note documented the psychiatrist examined Resident #166 and changed his medications. Resident #166's spouse was called, and she told the nurse she would get the new orders when she came in to visit. On 8/21/18 at 12:12 PM, a progress note documented the psychiatrist changed Resident #166's medications again and his spouse was called. She told staff .ok, but to watch for an overdose. Stated last time he was on a lot of medications he became weak, and could not move. A subsequent note at 2:09 PM, documented the psychiatrist was called and new orders were given, and a message was sent to Resident #166's spouse. There was no documentation his spouse responded to the message regarding the order changes. Resident #166's record did not include written consents for the medications listed above. Resident #166's MAR, from 8/13/18 to 9/3/18, documented he experienced the medication side effect of drowsiness from antipsychotic on the night shifts of 8/21/18 and 8/24/18 - 8/27/18, evening shifts of 8/24/18 - 8/26/18 and 8/28/18, and day shifts of 8/22/18 and 8/24/18 - 8/28/18. On 8/29/18 at 10:07 AM, Resident #166 was documented as losing 9.5 pounds in 1 week with a current weight of 153.5 pounds. The note documented Resident #166 had poor intake and he refused 12 meals the past week. The note documented Resident #166 was spending more time in bed. The note documented staff were to provide assistance with meals and include [MEDICATION NAME] food with meals. On 8/31/18 at 1:43 PM, Resident #166 was resting in his chair and would take food and fluids when offered but he would not respond when spoken to. On 9/1/18 at 1:39 PM, Resident #166 was in bed and did not answer questions when asked. The note documented a 3 cm by 3 cm red, blanchable area on his coccyx. The note documented the nurse applied barrier cream and instructed the CNAs to rotate Resident #166 from side to side when repositioning. A Hospital Consultation Note, dated 9/5/18, documented when Resident #166 arrived at the hospital he had developed 2 pressure ulcers and was stiff. The note documented Resident #166 was somnolent, lying in bed, needed assistance with feeding, was incontinent, and difficult to wake. The note documented Resident #166 was non-responsive with most attempts to rouse the resident. A Hospital Progress Note, dated 9/7/18, documented Resident #166 was admitted to the facility for over-sedation and noted to have 2 pressure injuries upon admit, to the sacrum and the left heel. The note documented the sacrum pressure ulcer was unstageable and the left heel was an intact bullae (fluid filled blister). On 9/19/18 at 8:24 AM, CNA #6 stated Resident #166 was pleasant when he first arrived at the facility. She stated she was not sure why he started throwing things, hitting, and kicking staff. CNA #6 stated Resident #166 struck a pregnant CNA in the belly on 8/19/18. She stated he was mostly agitated during the evening shift at first, and then it did not matter. CNA #6 stated Resident #166 calmed down after the shots and remained in bed. CNA #6 stated she had no other issues with him after the shots. On 9/19/18 at 8:40 AM, UM #2 stated Resident #166 was pleasant when he first arrived at the facility, wandering around the building on his own. He stated Resident #166 attempted to kiss or grab staff members on occasion. UM #2 stated Resident #166's behaviors escalated, and he struck a pregnant CNA in the belly on 8/19/18. UM #2 stated when this occurred the physician ordered [MEDICATION NAME] and the medication did not work to decrease his behaviors and [MEDICATION NAME] was ordered. UM #2 stated after the [MEDICATION NAME] was ordered and the medications were changed Resident #166 did not get up as much. He stated Resident #166 ate with the assistance of staff members and he recalled Resident #166 lost weight. UM #2 stated Resident #166 responded with eye raises if spoken to. He stated Resident #166's spouse had concerns about Resident #166's [MEDICATION NAME] and [MEDICATION NAME], and he set up an appointment for her to discuss the medications with the psychiatrist. UM #2 stated the spouse placed signs in Resident #166's room to not give the [MEDICATION NAME] and the [MEDICATION NAME], and the facility complied with the request around 8/30/18. He stated Resident #166's psychiatrist was notified when there were changes in his behaviors and the psychiatrist decreased Resident #166's [MEDICATION NAME]. UM #2 stated on 8/27/18, a skin assessment was completed, and Resident #166 did not have areas of concern to his coccyx. On 9/19/18 at 8:50 AM, LPN #3 stated Resident #166 was pleasantly confused when he first arrived at the facility and wandered around the building on his own. LPN #3 stated he noticed Resident #166's verbal and physical aggression on 8/19/18, when Resident #166 punched a pregnant CNA in the abdomen. He stated on 8/21/18, Resident #166 was attempting to enter another resident's room and was punching and kicking the CNA. LPN #3 stated [MEDICATION NAME] was ordered when Resident #166 struck a resident. He stated Resident #166 was mostly independent with cares before the medication changes and afterwards, he was in bed more often. LPN #3 stated he noticed the skin alteration on 9/1/18, and completed a skin alteration report. LPN #3 stated he applied barrier cream and requested CNAs turn Resident #166 every 2 hours. LPN #3 did not notice if Resident #166 lost weight, and staff assisted Resident #3 with eating in the dining room after Resident #166 became more lethargic and could not assist himself. On 9/19/18 at 9:08 AM, CNA #7 stated Resident #166 was pleasantly confused when he first arrived at the facility and he was easily redirected. CNA #7 stated he was independent with cares. She stated on an evening shift Resident #166 grasped her arm and did not let go. She stated another staff member had to assist her. CNA #7 stated Resident #166 calmed down after the shots and remained in bed. CNA #7 stated she had no other issues with him after the shots. CNA #7 stated she did not recall if Resident #166 had any concerns with his roommate. On 9/19/18 at 9:13 AM, CNA #8 stated Resident #166 was pleasantly confused when he first arrived at the facility and he was easily redirected. CNA #8 stated during an incident Resident #166 attempted to enter another resident's room and it took 4 people to hold him down. She stated this occurred 2 days before the [MEDICATION NAME] was ordered. CNA #8 stated she tried to redirect him by telling him this isn't your room let's go this way. CNA #8 stated when she told him this she tried to hold his hand and lead him in a different direction. CNA #8 stated Resident #166 had a 1:1 for about a week. She stated when the 4 staff members held him down 1 CNA blocked the door to prevent Resident #166 from entering another resident's room and then another approached and tried to lead him away. CNA #8 stated another CNA assisted the other 2 and tried to lead him away, and finally a nurse came and provided medications. CNA #8 stated after Resident #166's medication changes he was sleepy and stayed in bed. CNA #8 stated she was aware of his skin breakdown on his coccyx, and his urine smelled foul and was dark in color. CNA #8 was provided instructions to offer water with meals and snacks. CNA #8 stated she did not recall if Resident #166 had any concerns with his roommate. On 9/19/18 9:24 AM, CNA #9 stated she was assigned to be Resident #166's 1:1 not even for 1/2 a day. CNA #9 stated she was told Resident #166 was sexually inappropriate with females and a male was assigned to watch him. CNA #9 stated when Resident #166 was exhibiting behaviors she held his hand and tried to walk with him when he could walk. She stated when Resident #166 attempted to enter another resident's room, and if the CNAs were unable to lead him away, and he continued to hit, kick, and pinch them, the nurse gave a medication. CNA #9 stated he was independent with cares when he first arrived at the facility and after the shots the CNAs had to provide fluids, assist with meals, transfers, and assist with all cares. She stated Resident #166 was a 2 person assist for all cares after the medication changes. CNA #9 stated Resident #166's aggressiveness did decrease, and he was sleepier. CNA #9 stated she was aware of his skin breakdown on his coccyx and that his urine smelled foul and was dark in color. CNA #9 was provided instructions to offer water with meals and snacks. CNA #9 stated she did not recall if Resident #166 had any concerns with his roommate. On 9/19/18 at 9:56 AM, UM #1 stated Resident #166 was an inconsistent eater and to her knowledge his skin was intact from admission. She stated Resident #1 would walk about the facility under his own power when he first arrived. UM #1 stated she examined Resident #166's coccyx on 9/3/18, and it appeared to be an unblancheable area about 1/2 the size of my palm with a long line that looked like a slit. UM #1 stated she was unable to complete her assessment because Resident #166's spouse removed him from the facility. UM #1 stated she thought Resident #166 was going to harm his roommate which was one of the reasons the [MEDICATION NAME] was requested from the psychiatrist. UM #1 stated the [MEDICATION NAME] was effective for decreasing his behaviors and it made Resident #166 sleepy. UM #1 was unaware if Resident #166 was able to walk after the medications changed. UM #1 stated the spouse did not want Resident #166 to have most antipsychotic medications and told her you are killing him. UM #1 stated she was on the phone ordering an air mattress for Resident #166 when his spouse arrived to remove the resident. On 9/19/18 at 2:03 PM, the Psychiatrist stated Resident #166 had behaviors from the moment he arrived at the facility. The Psychiatrist stated he ordered 1 dose of [MEDICATION NAME] long acting and PRN short acting [MEDICATION NAME] to be used sparingly. The Psychiatrist stated he recalled discontinuing the [MEDICATION NAME], and when Resident #166's behaviors increased he ordered a higher dose of [MEDICATION NAME] to be restarted to try and get the medication in his system. The Psychiatrist stated when the resident displayed signs of over-sedation he decreased the medication on 8/27/18. The Psychiatrist stated he would expect the facility to obtain consents for all [MEDICAL CONDITION] medications and monitor for their behaviors. On 9/19/18 at 12:58 PM, the IDON stated Resident #166 was on multiple medications in the hospital and the psychiatrist had to jump to stabilize the resident. The IDON stated Resident #166 had a history of [REDACTED]. The IDON stated the spouse placed signs in Resident #166's room to not provide certain medications and she and UM #1 were unaware they were posted. The IDON stated Resident #166 was independent with all cares when he arrived and by the time he left he was dependent of staff for all cares. The IDON stated the family left the facility too quickly for the medications to be adjusted. The IDON stated sometimes the psychiatrist started at a higher dose to get the level up in the system and then adjusted the medications down from there. The IDON stated sometimes the residents went into a state where they required more assistance like Resident #166 to get their medications controlled. The IDON stated there was no excuse for the pressure ulcer that developed on his coccyx or the weight loss. On 9/19/18 at 3:50 PM, CNA #2 stated Resident #166 should have had a 1:1 from the beginning of his stay at the facility. CNA #2 stated he was up walking around at first and after the medication changes he was in bed. CNA #2 stated Resident #166 never hurt his roommate or attempted to hurt his roommate. On 9/19/18 at 5:15 PM, the IDON stated the psychiatrist was aware of Resident #166's sedation from the medications and examined the HOS documentation on the ADL Flowsheet. The IDON stated she was not aware the ADL Flowsheet did not include all three shifts for the psychiatrist to examine Resident #166's HOS and sedation. The IDON stated she could not locate documentation of notification of when they called the spouse for all the [MEDICATION NAME] administrations. The IDON stated she could not locate consents for the medications Resident #166 was provided. The IDON stated the Social Worker received verbal consent for the medications and did not receive written consent for the medications. The IDON stated the Social Worker thought the verbal consent was good enough. The IDON stated Resident #166's injury to his coccyx was considered a pressure ulcer and she was unaware of a pressure ulcer to his heels.

Based on record review, policy review, and staff interviews, it was determined the facility did not ensure residents were free from chemical restraints. There was no documented evidence a systematic process of evaluation and care planning was developed for staff to first implement specific resident focused non-pharmacological interventions should residents demonstrate aggressive behaviors. This resulted in harm to 1 of 8 residents (Resident #166) reviewed for [MEDICAL CONDITION] drug use. Resident #166 was harmed when he experienced increased somnolence, sedation, weight loss, dehydration, developed two pressure ulcers, and a decline in ADL's as a result of multiple [MEDICAL CONDITION] medications. Findings include: The facility's Restraints policy and procedure, released 5/28/15, stated residents had the right to be free from physical and chemical restraints imposed for the purpose of discipline or convenience, and were not required to treat the resident's medical symptoms. Resident #166 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #166 was discharged from the facility and admitted to a local hospital on [DATE]. Resident #166's was admitted to a hospital on [DATE]. A physician progress notes [REDACTED]. While in the hospital Resident #166 had a 1:1 sitter to prevent elopement. An H&P, dated 8/14/18, stated Resident #166 was brought to the facility from a local hospital. He was living in an ALF prior to his hospital admission when his behaviors escalated. The H&P stated Resident #166 saw his neurologist and was started on [MEDICATION NAME], but he became more violent and it was discontinued. He was then started on [MEDICATION NAME]. The H&P stated while in the hospital Resident #166 hit a staff member and was sexually inappropriate. The H&P included the [DIAGNOSES REDACTED]. The initial MDS assessment, dated 8/24/18, documented Resident #166 had moderate cognitive impairment and he was physically aggressive 1 to 3 days a week. The MDS documented he was not a risk to others and disturbed the environment. The MDS documented he required limited to extensive assistance of 1 to 2 staff members with all cares except eating. The care plan area addressing Resident #166's intrusive wandering behavior and invading the personal space of others, initiated 8/20/18, documented Resident #166 required 1:1 supervision while awake and 15 minute checks while asleep for intrusive wandering and invading the space of others and aggressive behaviors. Resident #166's care plan did not include his dementia, all his behaviors, or his use of antipsychotic medications. Resident #166's admission orders [REDACTED]. Resident #166 also had an order for [REDACTED].#166's H&P date 8/14/18. identified that [MEDICATION NAME] had been discontinued due to violent behaviors. Resident #166's record did not include [DIAGNOSES REDACTED]. A Behavior Monitor Flowsheet for (MONTH) (YEAR), included monitoring Resident #166 for physical aggression, wandering, elopement, being resistive to cares, and sexually inappropriate behaviors. The flowsheet included suggested interventions for each behavior. The interventions for each behavior were as follows: - Physical aggression, elopement, and/or resistive to cares: redirection, offer activity, offer snack, discuss the reason the resident was upset - Wandering and/or sexually inappropriate: redirection, communicate concerns with behavior, 1:1 conversation The flowsheet also included sections to document the number of times the behavior occurred, which interventions worked, which interventions did not work, and the initials of the staff member. Resident #166's Progress Notes and Behavior Monitor Flowsheets, from 8/13/18 to 9/3/18, documented the following behaviors: - On 8/14/18 at 3:13 AM, the nurse stated Resident #166 was easy to redirect and flirted with staff, almost kissing a CNA. - On 8/14/18 at 1:41 PM, Resident #166 attempted to exit the facility after lunch. - On 8/14/18 at 9:20 PM, the nurse documented Resident #166 had delusions and showed signs and symptoms of aggression when receiving instruction. He was given the as needed [MEDICATION NAME]. - On 8/15/18 at 9:24 PM, the nurse stated Resident #166 .does tend to make inappropriate statements with possible delusions . There were no behaviors or interventions documented on the Behavior Monitor Flowsheet from 8/13/18 to 8/15/18. - On 8/16/18 at 11:24 PM, the nurse stated Resident #166 was trying to touch other residents and staff, and he was combative with male CNAs. The nurse stated he was trying to kiss a nurse. The note also stated Resident #166's roommate was afraid of him because of how Resident #166 stared at him or patted his back and shook his hand. The note did not describe how or why Resident #166 was combative. The Behavioral Flowsheet documented he was resistive to cares but did not include documentation of interventions. - On 8/17/18 at 11:00 AM, the Social Service Specialist stated Resident #166 was found by the night nurse pleasuring himself in the hallway next to another resident's room. She stated behavior monitors for sexually inappropriate behavior were in place. The Behavior Monitor Flowsheet did not include documentation Resident #166 was sexually inappropriate or that interventions were attempted. - On 8/17/18 at 1:03 PM, the nurse stated Resident #166 attempted to exit the facility 3 times. He also was taking items from other residents such as food during a meal, markers and a book, and a walker. The note included documentation of staff intervening when Resident #166 was taking food, but not for the other items taken from other residents. - On 8/17/18 at 1:20 PM, the nurse stated Resident #166 exited the building but was easily redirected to go back inside. - On 8/17/18 at 11:21 PM, the nurse stated Resident #166 was exit seeking and easy to redirect. She documented he was combative with male CNAs and attempting to touch other residents. The note did not include documentation how or why Resident #166 was combative, or what was meant when it stated he attempted to touch other residents. The Behavior Monitor Flowsheet documented Resident #166 was physically aggressive 4 times during the evening shift, he was wandering 10+ times during the evening shift and no interventions worked and 4 times during the night shift and all interventions worked, he eloped 2 times on the evening shift and no interventions worked, and he was resistive to cares 5 times on the evening shift and no interventions worked. - On 8/18/18 at 8:54 PM, the nurse stated Resident #166 was combative with staff and was attempting to touch other residents. He also told the nurse he had to stay out of his room all day because his roommate tells him things all day. The note did not include documentation how or why Resident #166 was combative, or what was meant when it stated he attempted to touch other residents. - On 8/19/18 at 1:03 PM, the nurse stated Resident #166 was confused, delusional, and hallucinating at times. She stated he was combative and sexually inappropriate with female staff and female visitor. The nurse stated Resident #166 was non-directable and attempted to kick her and bite her arm. She stated he did hit a CNA in the stomach and placed a closed fist next to a female resident's head and stated, I'm not gonna hit you. - On 8/19/18 at 2:30 PM, the nurse stated Resident #166 was given an injection of [MEDICATION NAME] (an antipsychotic medication) 20 mg per order after he was verbally and physically aggressive with staff and other residents. She stated other oral PRN medications and verbal redirection were ineffective. - On 8/20/18 at 1:47 PM, the nurse stated Resident #166 was intrusive and going into other female resident's rooms. She stated he was not directable and physically aggressive by wringing CNAs hands when they attempted to redirect him. - On 8/20/18 at 2:02 PM, the nurse stated Resident #166 was placed on 15 minute checks for intrusive wandering and invading the space of other residents. - On 8/20/18 at 11:27 PM, the nurse stated Resident #166 was combative with staff and given a PRN medication at 8:00 PM. She stated he was kicking and attempting to punch staff, squeeze staff's hands and pull their fingers back when he was being redirected. - On 8/21/18 at 5:19 AM, the nurse stated Resident #166 was given a PRN [MEDICATION NAME] (an antianxiety medication) at 3:00 AM with no effect. She stated he was wandering into other resident's rooms and being intrusive. The nurse stated he had 1:1 staff all night for safety. - On 8/21/18 at 10:22 AM, the nurse stated Resident #166 was physically aggressive when she attempted to redirect him. He made sexually inappropriate comments, grabbed her breast and buttock. Resident #166 attempted to hit and kick staff, and he pushed 2 staff members. The nurse stated she received an order from the psychiatrist for [MEDICATION NAME] 20 mg injection and it was given with the assistance of 2 CNAs and another nurse. There was no documentation on the Behavior Monitor Flowsheet Resident #166 was sexually inappropriate. - On 8/21/18 at 12:12 PM, Resident #166's psychiatrist ordered [MEDICATION NAME] 200 mg and [MEDICATION NAME] 0.5 mg 3 times a day. The wife was called, and she was ok with the orders but was worried about an overdose. The note documented the last time he was on multiple medications Resident #166 became weak and was unable to move. - On 8/21/18 at 2:09 PM, the nurse stated Resident #166 was attempting to push another resident down a hall in their wheelchair and became agitated and physically aggressive with staff when asking him to let go of the wheelchair. The nurse stated Resident #166 grabbed and squeezed the arms and hands of staff and punched the resident in the wheelchair in the back. The nurse stated the psychiatrist was called and new orders were given. - On 8/21/18 at 8:55 PM, the nurse documented Resident #166 was given an antianxiety medication at 2:00 PM for increased aggression with anxiety. The nurse stated Resident #166 had no symptoms of anxiety or aggression and was resting quietly in his room. - On 8/22/18 at 2:22 AM, the nurse stated Resident #166 was sleeping with no behaviors and being monitored closely due to his aggressive behaviors on the previous shift and the PRN [MEDICATION NAME] (an antipsychotic medication) was given. - On 8/22/18 at 3:42 AM, the nurse documented (Resident #166) is now awake and is mildly displaying s/s (signs and symptoms) of restless behaviors x4. He was calling out several times and was not directable. Staff changed his linen, clothes, toileted him & provided pericare, and re-positions him comfortably in bed. He was also given a glass of water. At the beginning of the shift, he was sleeping with his head resting at the foot of the bed. He has not attempted to get out of bed this noc (night). (Resident #166) was given prn [MEDICATION NAME] IM (intramuscular) to maintain calmness and prevent aggression. There was no documentation on the Behavior Monitor Flowsheet Resident #166 was physically aggressive, was resistive to cares, or sexually inappropriate. - On 8/22/18 at 8:47 PM, the nurse stated Resident #166 remained confused and had aggression. The nurse stated he was given [MEDICATION NAME] for the aggression and intrusiveness. There was no description how Resident #166 was aggressive or intrusive. The Behavior Monitor Flowsheet did not include documentation Resident #166 had physical aggression, was resistive to cares, or sexually inappropriate. - On 8/30/18 at 2:31, the nurse stated Resident #166's spouse was upset he was sitting in a chair and not speaking to her. His spouse was upset about the medications, [MEDICATION NAME] (an antipsychotic) and Klonopin (a benzodiazepine), prescribed by the psychiatrist and that she read about the black box warnings related to patients with dementia. The nurse stated an appointment was made for Resident #166's spouse to meet with the psychiatrist on 9/10/18. According to the Food and Drug Administration (FDA), website accessed 9/26/18, a black box warning appears on a prescription drug's label and is designed to call attention to serious or life-threatening risks. - On 8/31/18 at 1:43 PM, the nurse stated Resident #166's spouse was called about a new dietary order. The spouse stated Well, the problem is that he's not eating. They gave him something over the weekend that almost killed him and turned him into a vegetable. - On 9/3/18 at 10:58 AM, the nurse stated Resident #166's spouse informed the nurse she was taking him to a hospital. The spouse stated You are killing him. I am taking him to the hospital to see if they can save his life. The nurse stated she could call the physician and arrange for him to go to the hospital, Resident #166's spouse refused. Resident #166's MARs for (MONTH) (YEAR) and (MONTH) (YEAR) documented the following medications: [REDACTED] - [MEDICATION NAME] 75 mg 2 times a day for [MEDICAL CONDITION], ordered 8/13/18 and discontinued on 8/20/18. - [MEDICATION NAME] 12.5 mg every 6 hours PRN for [MEDICAL CONDITION], ordered 8/13/18 and discontinued on 8/27/18. - [MEDICATION NAME] 30 mg daily for depression, ordered 8/13/18 and discontinued on 8/20/18. - [MEDICATION NAME] 20 mg IM 1 dose for physically combative with staff and residents, ordered 8/19/18. - [MEDICATION NAME] 1 mg every 6 hours PRN for anxiety, ordered 8/20/18. - [MEDICATION NAME] 20 mg IM 1 dose for agitation, ordered 8/21/18. - [MEDICATION NAME] (extended duration medication) 20 mg IM 1 dose for [MEDICAL CONDITION], ordered 8/21/18. - [MEDICATION NAME] (short acting duration) 5 mg IM every 6 hours PRN for [MEDICAL CONDITION], ordered 8/21/18. - [MEDICATION NAME] 5 mg at 7:30 AM and 3:00 PM for [MEDICAL CONDITION], ordered 8/21/18. - Depo-[MEDICATION NAME] 150 mg IM 1 time every 28 days for dementia lewy body with behaviors, ordered 8/21/18. - Klonopin 0.5 mg 3 times a day for anxiety, ordered 8/21/18. - [MEDICATION NAME] 10 mg daily for [MEDICAL CONDITION], ordered 8/21/18. - [MEDICATION NAME] 200 mg daily for [MEDICAL CONDITION], ordered 8/21/18 and discontinued on 8/27/18. - [MEDICATION NAME] 100 mg daily for [MEDICAL CONDITION] related to dementia with lewy bodies, ordered 8/27/18. On 8/21/18, Resident #166's psychiatrist ordered 6 new medications for anxiety, dementia with behaviors and/or [MEDICAL CONDITION], and agitation. Of those 6 medications 3 are classified as antipsychotics. According to Drugs.com a nationally recognized medication information website, accessed 9/26/18, [MEDICATION NAME], and [MEDICATION NAME] had a black box warning for increased mortality in geriatric patients. The MAR indicated [REDACTED]. On 8/21/18, Resident #166 also received, in addition to the medications listed above, 1 injection of Depo-[MEDICATION NAME], 1 injection of [MEDICATION NAME], 1 injection of [MEDICATION NAME] 20 mg, and 2 injections of [MEDICATION NAME] 5mg. There was no clinical justification documented for the addition of the [MEDICATION NAME], Klonopin, [MEDICATION NAME] at a higher dose, and the [MEDICATION NAME]. On 8/20/18 at 4:25 PM, a progress note documented the psychiatrist examined Resident #166 and changed his medications. Resident #166's spouse was called, and she told the nurse she would get the new orders when she came in to visit. On 8/21/18 at 12:12 PM, a progress note documented the psychiatrist changed Resident #166's medications again and his spouse was called. She told staff .ok, but to watch for an overdose. Stated last time he was on a lot of medications he became weak, and could not move. A subsequent note at 2:09 PM, documented the psychiatrist was called and new orders were given, and a message was sent to Resident #166's spouse. There was no documentation his spouse responded to the message regarding the order changes. Resident #166's record did not include written consents for the medications listed above. Resident #166's MAR, from 8/13/18 to 9/3/18, documented he experienced the medication side effect of drowsiness from antipsychotic on the night shifts of 8/21/18 and 8/24/18 - 8/27/18, evening shifts of 8/24/18 - 8/26/18 and 8/28/18, and day shifts of 8/22/18 and 8/24/18 - 8/28/18. On 8/29/18 at 10:07 AM, Resident #166 was documented as losing 9.5 pounds in 1 week with a current weight of 153.5 pounds. The note documented Resident #166 had poor intake and he refused 12 meals the past week. The note documented Resident #166 was spending more time in bed. The note documented staff were to provide assistance with meals and include [MEDICATION NAME] food with meals. On 8/31/18 at 1:43 PM, Resident #166 was resting in his chair and would take food and fluids when offered but he would not respond when spoken to. On 9/1/18 at 1:39 PM, Resident #166 was in bed and did not answer questions when asked. The note documented a 3 cm by 3 cm red, blanchable area on his coccyx. The note documented the nurse applied barrier cream and instructed the CNAs to rotate Resident #166 from side to side when repositioning. A Hospital Consultation Note, dated 9/5/18, documented when Resident #166 arrived at the hospital he had developed 2 pressure ulcers and was stiff. The note documented Resident #166 was somnolent, lying in bed, needed assistance with feeding, was incontinent, and difficult to wake. The note documented Resident #166 was non-responsive with most attempts to rouse the resident. A Hospital Progress Note, dated 9/7/18, documented Resident #166 was admitted to the facility for over-sedation and noted to have 2 pressure injuries upon admit, to the sacrum and the left heel. The note documented the sacrum pressure ulcer was unstageable and the left heel was an intact bullae (fluid filled blister). On 9/19/18 at 8:24 AM, CNA #6 stated Resident #166 was pleasant when he first arrived at the facility. She stated she was not sure why he started throwing things, hitting, and kicking staff. CNA #6 stated Resident #166 struck a pregnant CNA in the belly on 8/19/18. She stated he was mostly agitated during the evening shift at first, and then it did not matter. CNA #6 stated Resident #166 calmed down after the shots and remained in bed. CNA #6 stated she had no other issues with him after the shots. On 9/19/18 at 8:40 AM, UM #2 stated Resident #166 was pleasant when he first arrived at the facility, wandering around the building on his own. He stated Resident #166 attempted to kiss or grab staff members on occasion. UM #2 stated Resident #166's behaviors escalated, and he struck a pregnant CNA in the belly on 8/19/18. UM #2 stated when this occurred the physician ordered [MEDICATION NAME] and the medication did not work to decrease his behaviors and [MEDICATION NAME] was ordered. UM #2 stated after the [MEDICATION NAME] was ordered and the medications were changed Resident #166 did not get up as much. He stated Resident #166 ate with the assistance of staff members and he recalled Resident #166 lost weight. UM #2 stated Resident #166 responded with eye raises if spoken to. He stated Resident #166's spouse had concerns about Resident #166's [MEDICATION NAME] and [MEDICATION NAME], and he set up an appointment for her to discuss the medications with the psychiatrist. UM #2 stated the spouse placed signs in Resident #166's room to not give the [MEDICATION NAME] and the [MEDICATION NAME], and the facility complied with the request around 8/30/18. He stated Resident #166's psychiatrist was notified when there were changes in his behaviors and the psychiatrist decreased Resident #166's [MEDICATION NAME]. UM #2 stated on 8/27/18, a skin assessment was completed, and Resident #166 did not have areas of concern to his coccyx. On 9/19/18 at 8:50 AM, LPN #3 stated Resident #166 was pleasantly confused when he first arrived at the facility and wandered around the building on his own. LPN #3 stated he noticed Resident #166's verbal and physical aggression on 8/19/18, when Resident #166 punched a pregnant CNA in the abdomen. He stated on 8/21/18, Resident #166 was attempting to enter another resident's room and was punching and kicking the CNA. LPN #3 stated [MEDICATION NAME] was ordered when Resident #166 struck a resident. He stated Resident #166 was mostly independent with cares before the medication changes and afterwards, he was in bed more often. LPN #3 stated he noticed the skin alteration on 9/1/18, and completed a skin alteration report. LPN #3 stated he applied barrier cream and requested CNAs turn Resident #166 every 2 hours. LPN #3 did not notice if Resident #166 lost weight, and staff assisted Resident #3 with eating in the dining room after Resident #166 became more lethargic and could not assist himself. On 9/19/18 at 9:08 AM, CNA #7 stated Resident #166 was pleasantly confused when he first arrived at the facility and he was easily redirected. CNA #7 stated he was independent with cares. She stated on an evening shift Resident #166 grasped her arm and did not let go. She stated another staff member had to assist her. CNA #7 stated Resident #166 calmed down after the shots and remained in bed. CNA #7 stated she had no other issues with him after the shots. CNA #7 stated she did not recall if Resident #166 had any concerns with his roommate. On 9/19/18 at 9:13 AM, CNA #8 stated Resident #166 was pleasantly confused when he first arrived at the facility and he was easily redirected. CNA #8 stated during an incident Resident #166 attempted to enter another resident's room and it took 4 people to hold him down. She stated this occurred 2 days before the [MEDICATION NAME] was ordered. CNA #8 stated she tried to redirect him by telling him this isn't your room let's go this way. CNA #8 stated when she told him this she tried to hold his hand and lead him in a different direction. CNA #8 stated Resident #166 had a 1:1 for about a week. She stated when the 4 staff members held him down 1 CNA blocked the door to prevent Resident #166 from entering another resident's room and then another approached and tried to lead him away. CNA #8 stated another CNA assisted the other 2 and tried to lead him away, and finally a nurse came and provided medications. CNA #8 stated after Resident #166's medication changes he was sleepy and stayed in bed. CNA #8 stated she was aware of his skin breakdown on his coccyx, and his urine smelled foul and was dark in color. CNA #8 was provided instructions to offer water with meals and snacks. CNA #8 stated she did not recall if Resident #166 had any concerns with his roommate. On 9/19/18 9:24 AM, CNA #9 stated she was assigned to be Resident #166's 1:1 not even for 1/2 a day. CNA #9 stated she was told Resident #166 was sexually inappropriate with females and a male was assigned to watch him. CNA #9 stated when Resident #166 was exhibiting behaviors she held his hand and tried to walk with him when he could walk. She stated when Resident #166 attempted to enter another resident's room, and if the CNAs were unable to lead him away, and he continued to hit, kick, and pinch them, the nurse gave a medication. CNA #9 stated he was independent with cares when he first arrived at the facility and after the shots the CNAs had to provide fluids, assist with meals, transfers, and assist with all cares. She stated Resident #166 was a 2 person assist for all cares after the medication changes. CNA #9 stated Resident #166's aggressiveness did decrease, and he was sleepier. CNA #9 stated she was aware of his skin breakdown on his coccyx and that his urine smelled foul and was dark in color. CNA #9 was provided instructions to offer water with meals and snacks. CNA #9 stated she did not recall if Resident #166 had any concerns with his roommate. On 9/19/18 at 9:56 AM, UM #1 stated Resident #166 was an inconsistent eater and to her knowledge his skin was intact from admission. She stated Resident #1 would walk about the facility under his own power when he first arrived. UM #1 stated she examined Resident #166's coccyx on 9/3/18, and it appeared to be an unblancheable area about 1/2 the size of my palm with a long line that looked like a slit. UM #1 stated she was unable to complete her assessment because Resident #166's spouse removed him from the facility. UM #1 stated she thought Resident #166 was going to harm his roommate which was one of the reasons the [MEDICATION NAME] was requested from the psychiatrist. UM #1 stated the [MEDICATION NAME] was effective for decreasing his behaviors and it made Resident #166 sleepy. UM #1 was unaware if Resident #166 was able to walk after the medications changed. UM #1 stated the spouse did not want Resident #166 to have most antipsychotic medications and told her you are killing him. UM #1 stated she was on the phone ordering an air mattress for Resident #166 when his spouse arrived to remove the resident. On 9/19/18 at 2:03 PM, the Psychiatrist stated Resident #166 had behaviors from the moment he arrived at the facility. The Psychiatrist stated he ordered 1 dose of [MEDICATION NAME] long acting and PRN short acting [MEDICATION NAME] to be used sparingly. The Psychiatrist stated he recalled discontinuing the [MEDICATION NAME], and when Resident #166's behaviors increased he ordered a higher dose of [MEDICATION NAME] to be restarted to try and get the medication in his system. The Psychiatrist stated when the resident displayed signs of over-sedation he decreased the medication on 8/27/18. The Psychiatrist stated he would expect the facility to obtain consents for all [MEDICAL CONDITION] medications and monitor for their behaviors. On 9/19/18 at 12:58 PM, the IDON stated Resident #166 was on multiple medications in the hospital and the psychiatrist had to jump to stabilize the resident. The IDON stated Resident #166 had a history of [REDACTED]. The IDON stated the spouse placed signs in Resident #166's room to not provide certain medications and she and UM #1 were unaware they were posted. The IDON stated Resident #166 was independent with all cares when he arrived and by the time he left he was dependent of staff for all cares. The IDON stated the family left the facility too quickly for the medications to be adjusted. The IDON stated sometimes the psychiatrist started at a higher dose to get the level up in the system and then adjusted the medications down from there. The IDON stated sometimes the residents went into a state where they required more assistance like Resident #166 to get their medications controlled. The IDON stated there was no excuse for the pressure ulcer that developed on his coccyx or the weight loss. On 9/19/18 at 3:50 PM, CNA #2 stated Resident #166 should have had a 1:1 from the beginning of his stay at the facility. CNA #2 stated he was up walking around at first and after the medication changes he was in bed. CNA #2 stated Resident #166 never hurt his roommate or attempted to hurt his roommate. On 9/19/18 at 5:15 PM, the IDON stated the psychiatrist was aware of Resident #166's sedation from the medications and examined the HOS documentation on the ADL Flowsheet. The IDON stated she was not aware the ADL Flowsheet did not include all three shifts for the psychiatrist to examine Resident #166's HOS and sedation. The IDON stated she could not locate documentation of notification of when they called the spouse for all the [MEDICATION NAME] administrations. The IDON stated she could not locate consents for the medications Resident #166 was provided. The IDON stated the Social Worker received verbal consent for the medications and did not receive written consent for the medications. The IDON stated the Social Worker thought the verbal consent was good enough. The IDON stated Resident #166's injury to his coccyx was considered a pressure ulcer and she was unaware of a pressure ulcer to his heels.

Based on observation, record review, staff interview, and review of facility policies, it was determined the facility failed to prevent the development and worsening of pressure ulcers. This was true for 3 of 4 residents (#10, #52, and #162) reviewed for pressure ulcers. This deficient practice caused harm to Resident #10, #52, and #162 when: * Resident #10 developed an unstageable pressure ulcer on his coccyx. * Resident #52 developed a bruise on his right lower leg that deteriorated and became an unstageable pressure ulcer, and he developed unstageable pressure ulcers on the left ankle and right ankle. * Resident #162 developed an unstageable pressure ulcer on her right heel. Findings include: The facility's policy and procedure for Prevention and treatment of [REDACTED]. * A risk assessment would be performed on admission and at designated times throughout the resident's stay. * The Braden Scale would be used to identify residents at risk for pressure ulcers. * Based upon the assessment and the resident's clinical condition, choices, and identified needs, basic or routine care could include, but is not limited to, interventions to: - Redistribute pressure (such as repositioning, protecting, and/or offloading heels, etc.) - Minimize exposure to moisture and keep skin clean, especially of fecal contamination. - Provide appropriate, pressure-redistributing, support surfaces. - Provide non-irritating surfaces. - Maintain or improve nutrition and hydration status, where feasible . * treatment of [REDACTED]. 1. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses, including unspecified dementia with behavioral disturbance, contracture of muscle, multiple sites, and [MEDICAL CONDITION] (swelling). Resident #10 was transferred to another facility on 5/8/18. Resident #10's annual MDS assessment, dated 2/7/18, documented the following: * Severe cognitive impairment * Not at risk for pressure ulcers. * No unhealed pressure ulcers. * Moisture associated skin damage. * Pressure reducing device for chair. * Pressure reducing device for bed. Resident #10's quarterly MDS assessment, dated 3/16/18, documented the following: * Short term and long term memory problems. * Severe cognitive impairment in daily decision making. * At risk for pressure ulcers. * No unhealed pressure ulcers. * A skin tear was present. * Moisture associated skin damage. * Pressure reducing device for chair. * Pressure reducing device for bed. * Application of nonsurgical dressings. Resident #10's care plan documented: Potential impairment to skin integrity related to incontinence was initiated on 2/10/17. A pressure relieving/reducing chair cushion, pressure relieving/reducing mattress, and weekly skin assessments by the licensed nurse were initiated on 2/10/17 and revised on 9/21/17. A Progress Note, dated 3/6/18 at 5:39 AM, documented blisters developed above Resident #10's coccyx that were fluid-filled and intact. A Weekly Skin Check, dated 3/12/18 at 1:02 AM, documented Resident #10 had no skin conditions or changes, ulcers, or injuries, and Skin is intact. Has slightly abraded area on buttock responding rapidly to treatment. A Progress Note, dated 3/16/18 at 8:23 PM, documented Resident #10 had a weight loss of 15.8 pounds over the past 30 days. Resident #10 was recently fitted for a new wheelchair. There was a skin tear on the coccyx and treatment was in place. A Progress Note, dated 3/17/18 at 11:35 PM, documented there was a large wound on Resident #10's coccyx that was draining and had white eschar (dead tissue) at the base. The wound was covered with a dressing and was unstageable. The assessing nurse would call the morning nurse the next day and measurements would be done in the morning. A Weekly Pressure Ulcer/BWAT Report, dated 3/18/18 at 1:46 PM, documented a new onset pressure ulcer on Resident #10's coccyx measuring 7.0 cm (length) by 4.0 cm (width) by 0.2 cm (depth) and was unstageable. The date of initial observation was 3/18/18. The wound was treated with [MEDICATION NAME] and a sacral dressing. A Progress Note, dated 3/18/18 at 1:57 PM, documented Resident #10 developed an open wound on the coccyx measuring 7 cm by 4 cm by 0.2 cm. The wound was cleansed and a temporary dressing was applied. Staff were to turn Resident #10 side to side, and he was to be the last person to get up and first person to bed at mealtimes. A Progress Note, dated 3/19/18 at 10:36 AM, documented a pressure ulcer on Resident #10's coccyx that measured 1 by 1 on 3/15/18, then 7 cm by 4 cm by 0.2 cm on 3/18/18. The wound care nurse was to assess the wound on that day and discuss it with the physician. Occupational therapy (OT) had recently changed the wheelchair to a cube chair, and it was to be evaluated to determine whether the wheelchair caused pressure to the coccyx. Staff members were educated to turn the resident side to side and not onto his back. A Progress Note, dated 3/19/18 at 11:00 AM, documented Resident #10's wound was evaluated by the Assistant Director of Nursing (ADON) and the floor nurse. The wound was between Stage 2 and Stage 3. Treatment orders were requested from the physician for Silver Triact (brand name Restore, a type of wound dressing) to the base of the wound covered by [MEDICATION NAME] basic and a [MEDICATION NAME] dressing. OT was consulted regarding placing a Roho (pressure relief) cushion in the resident's chair. A Weekly Skin Check, dated 3/19/18 at 12:40 PM, documented a linear or elongated pressure ulcer on Resident #10's coccyx (tailbone area) and new suspected ulcer/deep tissue injury. Wound care orders were as follows: Cleanse the wound with wound cleaner, apply silver with a soft pad and a sacral dressing. A Progress Note, dated 3/19/18 at 2:46 PM, documented Resident #10's weight loss was discussed with a family member. The facility was going to obtain an air bed, turn him side to side, try to encourage nutritional intake, and limit time out of bed. Resident #10's physician orders [REDACTED]. Resident #10's Weekly Pressure Ulcer/BWAT Reports documented the following: * On 3/25/18 at 1:46 AM: The pressure ulcer on the coccyx measured 6 cm by 6.5 cm by 0.1 cm and was Stage 2. There was significant improvement, there was no sign of infection, and the wound width increased due to irregular shape and spreading his buttocks for treatment. * On 4/1/18 at 1:46 AM: The pressure ulcer on the coccyx measured 6 cm by 4.5 cm by 0.1 cm and was Stage 2. The area was significantly improved. There was no sign of infection. The wound center remained red and surrounding tissue was a pink scar. * On 4/8/18 at 1:46 AM: The pressure ulcer on the coccyx measured 3.5 cm by 4 cm by 0.1 cm and was Stage 2. Treatment was to continue a few more days. The wound was essentially healed, skin is intact, pink scar is very fragile and fresh. * On 4/14/18 at 1:46 AM: The pressure ulcer on the coccyx measured 1.5 cm by 1 cm by 0.1 cm and was Stage 2. The wound was almost healed and had a small open area in the center of fresh pink scar tissue. The surrounding skin was very fragile. The resident was incontinent, on an air bed, had contractures, and required routine turning as he could not reposition himself. * On 4/21/18 at 10:10 AM: The pressure ulcer on the coccyx measured 1.4 cm by 1 cm by 0 cm and was Stage 2. The area was almost healed and had a fresh pink scar. The skin remained fragile. The resident was incontinent of bowel and bladder. Staff continued the air bed and every two hour turning, and contractures limited his mobility. * On 4/28/18 at 9:56 AM: The pressure ulcer on the coccyx measured 1.0 cm by 1 cm by 0 cm and was Stage 2. The area was almost healed. The resident continued to have fragile skin, incontinence, and contractures. Staff continued every two hour turning. On 6/29/18 at 9:23 AM, the Unit Manager said Resident #10 had a skin tear on his coccyx on 3/15/18 and she did not recall how it happened. The Unit Manager said the wound was 1 cm x 1 cm x 0.1 cm, and it progressed and was determined to be a pressure sore on on 3/18/18. The Unit Manager said the wound had improved on 3/22/18, and slough (layer of dead tissue separated from surrounding living tissue) made it impossible to measure the depth. The Unit Manager said the pressure ulcer showed significant improvement with visible depth on 3/25/18. On 6/29/18 at 9:35 AM, the Unit Manager said Resident #10 was on an air mattress, although she did not know when it was applied. 2. Resident #52 was readmitted to the facility on [DATE] with multiple diagnoses, including heart failure, acute and chronic [MEDICAL CONDITION], muscle weakness, and dementia. Resident #52's Braden Scale for Predicting Pressure Sore Risk, dated 2/5/18, 2/12/18, 2/19/18, 2/26/18, and 3/5/18, documented he was at risk for pressure sores. Resident #52's quarterly MDS assessment, dated 2/18/18, documented the following: * Moderate cognitive impairment. * Total dependence on the physical assistance of two people for bed mobility and transfers. * At risk for pressure ulcers. * No unhealed pressure ulcers. * Skin and ulcer treatments, including a pressure reducing device for the chair and bed. Resident #52's quarterly MDS assessment, dated 5/18/18, documented the following: * Severe cognitive impairment. * Total dependence on two person physical assistance with bed mobility and transfers. * At risk for pressure ulcers. * One unstageable pressure ulcer with suspected deep tissue injury. * Skin and ulcer treatments, including a pressure reducing device for the chair and bed, nutrition or hydration intervention, pressure ulcer care, application of non-surgical dressings. Resident #52's physician orders [REDACTED]. Resident #52's current care plan documented the following: * Initiated and last revised on 3/28/18: A wound on the left gluteal fold. The care plan directed staff to float heels at all times, check that the head of the bed was not higher than 30 degrees, administer wound care as ordered by the physician, and turn side to side every two hours when in bed. *Initiated and last revised on 3/28/18: Impaired circulation and [MEDICAL CONDITION] (swelling) related to [MEDICAL CONDITION], and directed staff to elevate legs when resting, ensure proper-fitting footwear, inspect feet frequently for areas of injury, and inspect foot/ankle/calf frequently for changes. Resident #52's Weekly Skin Checks, dated 4/3/18 and 4/10/18, documented there were no skin conditions, changes, ulcers, or injuries. A Progress Note, dated 4/19/18 at 12:35 PM, documented the physician examined an unusual spot on Resident #52's right calf and determined it was a bruise. Staff were directed to apply [MEDICATION NAME] (an antiseptic) and cover it with a foam dressing daily until resolved. A physician's note, dated 4/19/18, documented the physician saw Resident #52 at the request of nursing staff. A dark purple spot was noted on the left lateral leg two days prior. An oval area of purple discoloration with some mild [DIAGNOSES REDACTED] (redness) right around the edge. The area measured approximately 2.5 cm by 1.5 cm, and the central area was going to slough. The area was diagnosed as a superficial bruise on the right lateral leg. The physician ordered swabbing the wound with [MEDICATION NAME] and applying a foam dressing. The physician said the resident has advanced age, poor circulation, nutrition and is a risk for a wound . A physician's orders [REDACTED].#52's right calf with [MEDICATION NAME] and cover with a foam dressing once a day until resolved, and notify physician if worse or not improving. A Weekly Skin Check, dated 4/24/18 at 2:49 AM, documented there was a dressing to the bruise on Resident #52's right calf. A Progress Note, dated 5/8/18 at 9:42 PM documented the physician examined Resident #52 on that day, wanted to continue treatment to a sloughing bruise on the leg, and the resident was to wear Prevalon boots when in bed. A physician's note, dated 5/8/18, documented the physician examined Resident #52 and documented the area on the right lateral leg was a superficial bruise with thickening and slough. There were no signs of infection. The wound was slow to heal. There were no signs of infection, and the resident was to wear Prevalon boots. A Progress Note, dated 5/15/18 at 7:25 PM documented an antibiotic was ordered four times a day for 7 days for Resident #52's wound with dressing changes. A Progress Note, dated 5/15/18 at 10:37 PM documented the physician examined Resident #52, new wound care orders were received for the RLE, Prevalon boots were to be on at all times, and Keflex (antibiotic) four times a day for 7 days for mild RLE infection. Resident #52's physician's orders [REDACTED]. Change every other day, and [MEDICATION NAME] capsule (antibiotic) 500 mg four times a day for RLE wound infection. A Weekly Skin Check, dated 5/15/18 at 2:49 AM, documented there was a sloughing bruise and Resident #52 was on an antibiotic. A physician note, dated 5/15/18, documented the physician examined Resident #52 and said the bruise had some thickening of the eschar (dark, crusty dead tissue). The wound was not getting worse but was not improving. Staff had been applying [MEDICATION NAME] and an island dressing. There was also an abrasion to the ankle area at that time. The resident had multiple illnesses and was declining fairly rapidly since he came here. There was some tenderness to the wound on the right lateral leg and some swelling behind it. The assessment included a bruise to the right lateral lower extremity that was slow to resolve and had possible very early onset wound infection, and there was an abrasion to the right ankle area. The wounds were to be cleaned, dried thoroughly, [MEDICATION NAME] ointment applied, and covered with an island dressing every other day. [MEDICATION NAME] was discontinued. Prevalon boots were to be on at all times, and [MEDICATION NAME] was started four times a day for 7 days. Resident #52 was at high risk for skin breakdown related to his poor nutritional status, weight loss, and protein calorie malnutrition, and was at risk for poor wound healing due to his overall condition. A physician's note, dated 5/17/18, documented Resident #52's condition was poor and he continued to decline. A Progress Note, dated 5/18/18 at 2:36 PM, documented Keflex was continued for Resident #52's RLE wound. Resident #52's Progress Note, dated 5/19/18 at 9:21 AM documented RLE wound: dry thoroughly, apply (B)acitracin ointment and cover with island dressing/change every other day . A Progress Note, dated 5/20/18 at 10:06 PM, documented Keflex was continued for Resident #52's RLE wound. A Progress Note, dated 5/21/18 at 5:41 PM, documented Resident #52's wound started as a small bruise, and it had increased in size and severity. The ADON assessed the wound and it measured 1.5 cm by 0.5 cm by 0.1 cm. The wound was oblong-shaped and had a yellow wound bed. The skin at the outer perimeter of the wound was very red and the resident complained of soreness at the outer edges of the wound. There was minimal drainage which was serosanguinous (bloody) in color. A new dressing was placed, and the nurse would notify the physician at the next visit. A Progress Note, dated 5/22/18 at 3:43 PM, documented the physician examined Resident #52. The wound ointment was changed to Santyl and the dressing was to be changed daily. A physician note, dated 5/22/18, documented Resident #52's right lower leg had a linear wound measuring 1 cm wide by 2.5 cm long. The base had 100% yellow slough. The assessment was an ulceration of the right lateral lower extremity and the antibiotic ointment was discontinued. Santyl was ordered to the wound base and cover with an island dressing daily. A Progress Note, dated 5/23/18 at 10:00 PM, documented Resident #52 had completed the course of antibiotics, and the Wound changes between a white mealy wound bed and a dark brown pliable crust. There is no drainage. Now being treated with daily Santyl. A wound healing note, dated 5/25/18 documented pressure ulcers on Resident #52's right lateral calf, right ankle, right second toe, and left ankle. It was ordered to encourage repositioning every 2 to 3 hours, encourage offloading of heels and bony prominences, provide a supportive cushion in the wheelchair, and reposition the resident every 2 to 3 hours when up in wheelchair. A Progress Note, dated 5/31/18 at 4:30 AM, documented a new dressing was applied to Resident #52's wounds on the lower right leg. A Weekly Skin Check, dated 6/8/18 at 2:44 AM documented there were open wounds on Resident #52's right lower leg (rear), right ankle (outer) and left ankle (outer). A Progress Note, dated 6/8/18 at 12:28 PM, documented the Interdisciplinary Team met and discussed Resident #52's weight loss and wound status. A low air loss mattress was started on the previous day at the recommendation of the wound nurse practitioner for wounds to legs. A Progress Note, dated 6/10/18 at 2:28 PM, documented Resident #52's Pressure Ulcer BWAT report was completed. The right lower leg (rear) pressure wound measured 4.0 cm (length) by 2.1 cm (width), undetermined depth and unstageable. The wound was initially observed on 5/23/18. The right ankle (outer) pressure wound measured 1.8 cm by 1.0 cm and depth was undetermined and unstageable. The wound was initially observed on 5/23/18. A Progress Note, dated 6/10/18 at 9:37 PM, documented Resident #52's Pressure Ulcer BWAT report was completed. The left ankle (outer) pressure wound measured 0.5 cm by 0.5 cm, and depth was undetermined and unstageable. The wound was initially observed on 5/23/18. A Progress Note, dated 6/15/18 at 9:48 AM, documented Resident #52's Pressure Ulcer BWAT report was completed. The right lateral calf pressure wound measured 3.7 cm by 2.7 cm, depth was zero and unstageable. The wound was initially observed on 4/19/18. The eschar was separating from the wound edges leaving a narrow pink-red ring around it. This could account for the slightly larger size of the wound this week. Will consider cornstarch next Friday. A Progress Note, dated 6/15/18 at 10:11 AM, documented Resident #52's Pressure Ulcer BWAT report was completed. The left ankle (outer) pressure wound measured 0.6 cm by 0.4 cm, and depth was zero and unstageable. The wound was initially observed on 5/25/18. The wound was improved and slightly smaller with no signs of infection. A Progress Note, dated 6/15/18 at 9:37 PM, documented Resident #52's Pressure Ulcer BWAT report was completed. The right ankle (outer) pressure wound measured 1.8 cm by 1.7 cm, and depth was zero and unstageable. The wound was initially observed on 5/25/18. The wound was slightly smaller than the previous week, and still had slough on the wound bed. A Progress Note, dated 6/18/18 at 11:03 AM, documented the wounds to Resident #52's left ankle and right second toe were improved and had smaller measurements. The wound on the right lateral calf and right ankle were slightly larger. There were no signs of infection. A Progress Note, dated 6/19/18 at 10:57 AM documented the physician ordered Juven (a nutrition powder) twice a day for 14 days per the dietician's recommendations to promote wound healing for Resident #52. A Progress Note, dated 6/22/18 at 10:27 AM, documented Resident #52's Pressure Ulcer BWAT report was completed. The right ankle (outer) pressure wound measured 1.9 cm by 1.4, cm depth was 0 and suspected deep tissue injury. The wound was initially observed on 5/25/18. There was no change in treatment. A Progress Note, dated 6/22/18 at 1:55 PM, documented Resident #52's Pressure Ulcer BWAT report was completed. The right lateral calf pressure wound measured 4 cm by 2.5 cm, and depth was zero and unstageable. The wound was initially observed on 4/19/18. The eschar was separating from the wound edges and the base of the wound was covered with soft black eschar. The resident winced when the area was touched. A Progress Note, dated 6/22/18 at 2:03 PM, documented Resident #52's Pressure Ulcer BWAT report was completed. The left ankle (outer) pressure wound measured 0.6 cm by 0.4 cm, and depth was zero and unstageable. The wound was initially observed on 5/25/18. Current treatment was continued and make effort to offload. Resident #52's wound healing notes documented the following: On 6/1/18, 6/8/18, 6/15/18, and 6/22/18: Pressure ulcers on the right lateral calf, right ankle, right second toe, and left ankle. Wound orders included the following: *To the right calf: cleanse with normal saline or wound spray. * Protect around the wound with skin protectant. * Apply Iodosorb (a common wound treatment) * Cover the wound with bordered foam. * Change the dressing daily or as needed. * To the right ankle: cleanse with normal saline or wound spray. * Protect around the wound with skin protectant. * Cover the wound with bordered foam. * Change the dressing daily or as needed. * To the right second toe: cleanse with normal saline or wound spray. * Protect around the wound with skin protectant. * To the left ankle: cleanse with normal saline or wound spray. * Protect around the wound with skin protectant. * Cover the wound with bordered foam. * Change the dressing daily or as needed. Additional orders included painting the wound with [MEDICATION NAME], encourage repositioning every 2 to 3 hours, a total air loss mattress per the primary physician's orders [REDACTED]. Resident #52's TAR documented the following: Turn side to side every two hours when in the bed. It was not documented the every 2 hour turns were completed on the following dates/times: * Day shift on 4/4/18, 1/14/18, 4/19/18, 4/22/18, 4/23/18, 5/2/18, 5/23/18, 5/26/18, 5/31/18, 6/2/18, 6/4/18, 6/8/18, 6/9/18, 6/15/18, and 6/18/18. * Evening shift on 4/2/18, 4/6/18, 4/13/18, 4/17/18, 4/22/18, 5/8/18, 5/9/18, 5/19/18, 5/26/18, 6/2/18, 6/3/18, 6/11/18, and 6/14/18. * Night shift on 5/3/18, 5/10/18, 5/11/18, 5/18/18, 5/21/18, 5/25/18, 5/28/18, 5/30/18, 6/2/18, 6/13/18, 6/15/18, 6/18/18, 6/24/18, and 6/25/18. On 6/26/18 at 9:47 AM, LPN #1 was observed performing wound care to Resident #52's right ankle, left ankle, and right lateral leg. The wound on the right lateral leg appeared mildly reddened around the edges. The wound on the right ankle and left ankle appeared as ulcerations on the bony prominences of the outer ankles. At that time, LPN #1 stated the wounds were measured on Fridays, there was a physician's assistant following the resident for the wounds, the wounds were from pressure, and she believed the wounds developed in the facility. On 6/27/18 at 9:32 AM, CNA #3 said staff repositioned Resident #52 every 2 hours, he had boots, and staff were to keep his feet up. CNA #3 said she did not know where to document it but staff did turn him every 2 hours. On 6/27/18 at 9:35 AM, LPN #1 said there were no wounds on Resident #52's buttock area at that time. LPN #1 said the wound on his outer calf came first, it started as a small open area, he was treated with an antibiotic then it got hard eschar. LPN #1 said there was a different treatment on it at that time, and there was a red area on it. LPN #1 said the wound on Resident #52's calf was caused from him not getting up and from his disease process, then the right ankle wound came next from pressure. LPN #1 said she thought the left ankle wound was fairly recent and it was just from positioning. LPN #1 said pillows were placed underneath Resident #52's legs and a wedge was placed under his legs after the first ulcer developed. LPN #1 said Resident #52 had always been on an air mattress and turned every 2 hours. On 6/27/18 at 9:45 AM, the Unit Manager said the CNAs would report signs of a pressure ulcer and the resident would be put on alert charting. The Unit Manager said the physician saw an unusual bruise on Resident #52's leg on 4/19/18, and it was treated it with [MEDICATION NAME] and a foam dressing. The Unit Manager said the physician indicated on 5/8/18 that it was not from pressure and it was a sloughing bruise. The Unit Manager said Resident #52's leg was protected with Prevalon boots and he was put on Keflex. The Unit Manager said it was determined the Prevalon boot was causing pressure on Resident #52's leg. The Unit Manager said the wound care nurse practitioner started seeing Resident #52 and he did not wear the Prevalon boot anymore. The Unit Manager said the CNA noticed the area on Resident #52's leg and reported it to the nurse on approximately 5/20/18. The physician evaluated the wound 1 to 2 days later and ordered the wound to be covered and protected. The Unit Manager said the wound team evaluated Resident #52's wound and said the wound was pressure related on 5/23/18. The Unit Manager said Resident #52 was turned often, had an air mattress, had his heels floated, and staff did not elevate his head more than 30 degrees for comfort if he was sleeping. The Unit Manager said the right ankle wound came next, that it was on a bony prominence and had to be from pressure. The Unit Manager said floating the heels was done shortly after the Prevalon boot was removed and there was a protective dressing over it. The Unit Manager said the left ankle was the same thing, and staff were putting skin prep around it and applying a protective dressing. On 6/27/18 at 10:23 AM, the Unit Manager said Resident #52 received an air mattress on 6/7/18. On 6/27/18 at 10:30 AM, the DNS said Resident #52 was being followed by a wound care nurse practitioner for multiple wounds on his legs. The DNS said it started on 4/19/18 as an unusual bruise, it was observed by the physician and was treated with [MEDICATION NAME]. The DNS said the Prevalon boot might have contributed to the pressure ulcer, so the boot was removed and a wedge and air mattress were put in place. The DNS said Resident #52 did not like to be turned, and the wound nurse did not think the wounds would heal due his medical state. The DNS said when the first wound came up, the physician looked at it and prescribed an order, and the physician did not feel it was pressure related. The physician described it as a sloughing bruise. The DNS said staff added Prevalon boots and floating his heels to relieve pressure. The DNS said wound care started in May, and the wound care team thought it was from pressure from the Prevalon boot so an air mattress and a wedge were added. The DNS said the physician saw the right lower leg wound again on 5/15/18 and wrote an order for [REDACTED]. The DNS said the wound care nurse practitioner saw the wound for the first time on 5/18/18, and no orders were made until the first official wound team visit on 5/25/18. The DNS said the low loss air mattress was put in place on 6/7/18. The DNS said staff should check the skin integrity on the resident's leg whenever the Prevalon boot is removed and before placing it back on the leg. The DNS said the staff were monitoring the skin under Resident #52's Prevalon boot and the weekly skin checks would document status of his skin. The DNS said Resident #52 was at risk for pressure ulcers. On 6/29/18 at 9:45 AM, the DNS said repositioning was considered a standard of care and it was not necessarily documented. The DNS said Resident #52 was resistant to turning. 3. Resident #162 was readmitted to the facility on [DATE] with multiple diagnoses, including Type 2 diabetes mellitus and hereditary and idiopathic [MEDICAL CONDITION] (nerve damage). Resident #162 passed away in the facility on 4/5/18. Resident #162's quarterly MDS assessment, dated 1/8/18, documented severe cognitive impairment, not at risk for developing pressure ulcers, and no unhealed pressure ulcers. Resident #162's Significant change MDS assessment, dated 3/8/18, documented severe cognitive impairment, extensive assistance of two persons with bed mobility and transfers, at risk for pressure ulcers, one unhealed pressure ulcer that was unstageable, presence of and pressure reducing device for the chair and bed, pressure ulcer care, and application of dressings to feet. Resident #162's care plan documented the following: * A potential for skin integrity issues related to incontinence and decreased mobility was initiated on 12/23/14. Staff interventions included the following: A pressure reduction mattress was initiated on 12/23/14. Float heels with pillows while in bed and Prevalon boots in place when in wheelchair was initiated on 2/1/18. Encourage turning and repositioning every 2 hours or assist if she unable to reposition independently was initiated on 9/27/15. * Resident #162 had a deep tissue injury to her right heel was initiated on 1/30/18 and revised on 4/6/18. Staff interventions included the following: One to one staff supervision while awake due to the resident attempting to remove the boots was initiated on 2/27/18. Apply [MEDICATION NAME] and heel cup every shift was initiated on 1/30/18 and revised on 3/1/18. A Keene wedge to the bed for absolute pressure relief was initiated on 1/30/18 and revised on 3/1/18. Encourage a high protein diet and protein-rich snacks was initiated on 3/26/18. Prevalon boots on at all times was initiated on 1/30/18. Wound care as prescribed by the physician was initiated on 3/12/18. Resident #162's (MONTH) (YEAR) physician orders [REDACTED]. * Started on 1/30/18: Right heel deep tissue injury: Apply [MEDICATION NAME] and cover with a protective heel cup every shift, and Prevalon boot on at all times. * Started on 2/14/18: Complete the pressure ulcer report weekly, document findings in the nurse's notes and on the appropriate evaluation every Wednesday, A Weekly Pressure Ulcer BWAT Report, dated 1/30/18 at 5:25 PM, documented a pressure ulcer on Resident #162's right heel that measured 3.0 cm by 3.5 cm and was unstageable. Deep tissue injury was suspected. The wound was first observed on that date. [MEDICATION NAME] was to be applied every shift per physician's orders [REDACTED]. A Progress Note, dated 1/21/18 at 9:49 PM, documented a CNA reported to the nurse there was discoloration to Resident #162's feet. The nurse assessed the feet and noted bluish discoloration to the left second, third, and fourth toes and a red area on the right fifth toe. The skin was intact, and the resident was to be added to the podiatrist's schedule that week. A Progress Note, dated 1/30/18 at 5:25 PM, documented Resident #162's Pressure Ulcer BWAT Report was completed for a right heel wound measuring 3.0 cm by 3.5 cm and was unstageable. There was a suspected deep tissue injury initially observed on 1/30/18. Staff were to apply [MEDICATION NAME] every shift, Prevalon boots at all times, and a heel cup for protection. A Progress Note, dated 1/30/18 at 6:05 PM, documented a deep tissue injury was noted to Resident #162's inner right heel measuring 3.0 cm by 3.5 cm and(TRUNCATED)

Based on record review and staff interview, it was determined the facility failed to ensure there was behavior monitoring for a resident receiving an anti-anxiety medication. This was true for 1 of 6 residents (#18) reviewed for [MEDICAL CONDITION] medications. This failed practice created the potential for harm should residents experience adverse reactions and behaviors from [MEDICAL CONDITION] medications. Findings include: The facility's policy and procedure for Unnecessary Medications and [MEDICAL CONDITION] Drugs/Antipsychotic Medication, dated 11/28/17, documented the following: * A resident's medication regimen is free of any medication used in excessive dose (including duplicative therapy), excessive duration, without adequate monitoring, without adequate indications for its use . * Documentation of signs of distress, [MEDICAL CONDITION], or other changes in status. * Medications are monitored for to follow progress towards goals and to detect any adverse effects. Resident #18 was admitted to the facility on [DATE] with multiple diagnoses, including generalized anxiety disorder. Resident #18's quarterly MDS assessment, dated 4/10/18, documented the following: * Short term and long term memory problems. * Some difficulty in new situations with making decisions regarding daily tasks of life-modified independence. * Anxiety disorder. * Anti-anxiety medication received on 7 of the last 7 days. Resident #18's physician orders [REDACTED]. Resident #18's current care plan documented the following: * Resident #18 had anxiety. * Allow him to make decisions about treatment. * When he is anxious, offer a walk, visiting, calling his spouse, and reassurance. * Encourage participation and interaction as much as possible during cares. * Provide activities that focus on life history and present strengths. Resident #18's (MONTH) (YEAR) and (MONTH) (YEAR) MARs documented the [MEDICATION NAME] was administered each day except for 5/19/18. Documentation of the monitoring of resident specific behaviors related to Resident #18's anxiety, was not completed prior to 6/28/18, the day prior to the survey exit conference on 6/29/18. On 6/28/18 at 3:49 PM, the Unit Manager said the behavior monitoring was not completed for Resident #18's [MEDICATION NAME] and it should be. On 6/29/18 at 9:45 AM, the DNS said if a resident was on [MEDICATION NAME], the nurse should get an order and sign off on behavior monitoring and side effects.

Based on observation, resident and staff interview, and record review, it was determined the facility failed to ensure residents were provided with the level of supervision necessary for safety. This was true for 4 of 4 sample residents (#s 1-4) and 4 random residents (#s 5-8), and had the potential to impact the remaining 52 residents in the facility. Specifically: a) Resident #1 had the potential for being seriously injured from retaliation by other residents when he wandered unsupervised into other residents' rooms and negative outcomes occurred. b) Resident #2 reported she was abused when Resident #1 intrusively wandered into her room unsupervised while she was partially dressed and threatened her. c) Residents #s 3-8 were impacted by Resident #1's intrusive wandering. This deficient practice placed Residents #'s 1-8 in immediate jeopardy of serious harm, injury, or death and had the potential to impact the remaining 52 residents in the facility due to the facility's failure to provide supervision to a resident with known physical and verbal aggression, who was not easily redirected and who was allowed wander unsupervised. Findings include: The facility's 10/31/17 Accidents and Supervision to Prevent Accidents policy and procedures documented facility staff were directed to identify resident behaviors with potential risk to resident safety, resident to resident altercations, and unsafe wandering. Facility staff were directed to implement interventions on the care plan, supervise staff and residents, document the interventions, implement individualized, resident-based interventions such as adequate supervision to reduce risks of injury, and monitor the effectiveness of the interventions and modify the interventions as necessary. Facility staff were directed to provide adequate supervision to prevent accidents and to identify residents with a history of disruptive or intrusive interactions or other behaviors that would increase the likelihood of an altercation. When facility staff identified a resident with these risks, the policy and procedure directed staff to provide staffing levels that would ensure adequate supervision, ensure staff assignments were consistent for the resident, provide areas for the resident to remain safe and have unrestricted movement, eliminate or reduce the sources of distressing behavior, monitor the environment for sources such as temperature, lighting, and noise levels, and provide ongoing training, competency, and supervision of facility staff in regards to managing resident behaviors. 1. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's 9/27/17 Admission MDS (Minimum Data Set) assessment documented severe cognitive impairment, delusions, and physical behaviors. The MDS documented Resident #1 did not wander. Resident #1's care plan directed staff to intervene in the following ways to address his psychosocial and behavior problems: remove him to a calm, safe environment when a conflict occurs, approach him from the side carefully, facilitate the resident talking to his son-in-law on the phone, give a 5 minute time out when agitation is expressed and then re-approach, identify yourself and what you want the resident to do, re-direct him by talking about the saw mill when he becomes agitated, remove him from other residents in the area if his behavior is out of control, consider moving him to a room with two beds (instead of four beds) to decrease stimulation, and get him dressed and out of his room prior to his roommates getting up. Resident #1's care plan did not include the need for supervision to address wandering. Resident #1's 9/20/17-11/20/17 Order Summary Report documented behavior monitoring regarding the number of episodes per shift of the following behaviors: delusions, resistive to cares, frequent changes in mood as exhibited by physical aggression, verbal aggression, and frequent wandering into others' rooms or areas. On 10/17/17 at 1:04 pm, Resident #1's Behavior Note documented Resident #1 was walking in the hallway, peeking into bedrooms but rarely putting a foot inside the bedrooms. The facility did not provide increased supervision or otherwise update his care plan to reflect the resident's wandering. On 10/18/17 at 1:50 am, Resident #1's Behavior Note documented he was restless, aggressive towards staff, pacing and walking in the hallway for nearly 4 hours, and attempted to enter other residents' rooms multiple times. The facility did not update his care plan or provide increased supervision in response to the resident attempting to enter other rooms. On 11/2/17 at 2:47 pm, Resident #1's Behavior Note documented he was walking every waking moment and he opened a female resident's door multiple times without knocking. When a staff member attempted to re-direct Resident #1, he said I own this building and I'll go anywhere I damn well please. The facility did not update his care plan or provide increased supervision in response to the resident entering other resident rooms. On 11/2/17 at 9:20 pm, Resident #1's Health Status Note documented he continued to wander and exhibit aggressive behavior. The facility did not increase supervision for Resident #1. Resident #1's 11/2/17 Behavior Monitor Additional Behavior Details documented he was wandering into other residents' rooms, waking residents up, telling them to leave, yelling and screaming when he was asked to leave. The note documented Resident #1 was, Wanting to hit and threaten(ed) to kill residents on (the) other side! Resident #1's 11/3/17 Behavior Monitor Additional Behavior Details documented he was continuously entering other residents' rooms and started yelling when Certified Nursing Assistants (CNAs) redirected him. Resident #1's clinical record did not document or show evidence of increased supervision following any of the above events. On 11/7/17 at 1:40 pm, Resident #1 was observed walking up and down the hall at the opposite end of the building from his room, unsupervised. Resident #1 entered another resident's room for. No other residents were in the room at the time. After approximately one and one half minutes, a male staff member entered and redirected the resident back out into the hall. Resident #1 entered another resident's room approximately two minutes later and exited the room on his own accord. On 11/7/17 at 2:13 pm, Resident #1 entered another resident's room and the CNA directed him to exit the room. On 11/8/17 at 12:05 pm, the Executive Director (E.D.) said Resident #1 should be on every 15 minute checks to make sure he was not being intrusive to other residents. The E.D. said he was not sure if the resident was previously on 1:1 supervision but he was on 1:1 supervision as of this date. 2. Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Quarterly MDS assessment, dated 10/6/17, documented she was cognitively intact and had no signs and symptoms of psychosis or delirium. An 11/3/17 Health Status Note documented Resident #2 was awake most of the night and was upset about another resident. An 11/4/17 Behavior Note documented Resident #2 was upset about another resident coming into her room. The note documented Resident #2 informed social services and a nurse that she felt unsafe as a male resident (Resident #1) entered her room when she was naked. The note document Resident #2 looked at her side and repeated three times, I'm not safe. The note documented the nurse told Resident #2 that staff could not stop Resident #1 from walking the hallways; however, staff would be more diligent in attempting to keep him from entering other rooms. The note did not document a specific plan to increase supervision for Resident #1. On 11/7/17 at 9:29 am, Resident #2 stated she did not feel safe in the facility due to Resident #1 coming into her room and seeing her with her shirt off and threatening her. She stated she told a Registered Nurse (RN) about the situation but there had been no follow up. Resident #2 stated the RN told her staff could not stop Resident #1 from walking the halls; however they would try and make sure he did not enter other residents' rooms. Resident #2 stated the situation started a few weeks ago she noticed Resident #1 walking the halls, clicking his walker and knocking on walls, doors and hand rails. Resident #2 stated Resident #1 walked into her room and, Peered around my curtain and just stared at me. She stated it scared her that he just walked into her room. Resident #2 stated she told a CNA and nothing was done about it. Resident #2 stated on a second occasion, which was just the previous week, she was in her room and had removed her shirt to get ready for bed when she reached behind her to get her nightshirt and touched Resident #1's walker. Resident #2 stated she turned to find Resident #1 standing right next to her bed. Resident #2 stated she was startled by his presence and Resident #1 asked her if he could share a room with her. Resident #2 stated she asked him nicely to leave twice and he wouldn't leave, so she yelled at Resident #1 and told him to get out of her room. Resident #2 stated Resident #1 responded by yelling back, You f***ing [***] I'll take you to hell! Resident #2 stated she told a RN about the incident and no resolution was found yet. Resident #2 stated Resident #1 had entered her room one more time since the shirt incident and banged his walker against the end of her bed and stared at her again with a menacing look. Resident #2 stated she did not want to leave her room because she feared possible negative interactions with Resident #1 and she stated she did not feel safe in her room either because she was fearful of Resident #1 walking in. Resident #2 stated she had started keeping her door closed to try and prevent him from returning. Resident #2 stated Resident #1 had wandered into other residents' rooms on this hall and threatened them as well. Resident #1's clinical record did not document, and the facility had no evidence of, increased supervision following Resident #2's reports. 3. Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #4's 10/17/17 quarterly MDS assessment documented she was cognitively intact. Resident #4 stated one day the previous week, Resident #1 had been walking in the hall when she saw him lunge at a nurse. Resident #4 stated she was afraid for the nurse's safety, so she yelled at Resident #1 to stop. Resident #4 stated Resident #1 then turned his attention to her and yelled, I will knock your block off you f***ing [***] . Resident #4 stated the nurse had to physically intervene to keep her (Resident #4) safe, but placed her own safety at risk in doing so. On 11/7/17 at 8:50 am, Resident #4 stated that Resident #1 had wandered into her room on occasion, she was aware Resident #1 wandered into other residents' rooms as well. 4. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's Quarterly MDS assessment, dated 10/11/17, documented she was cognitively intact and had no signs and symptoms of psychosis, delirium or behaviors. On 11/7/17 at 1:43 pm, Resident #3 stated Resident #1 wandered down the hall often and he would click his walker and knock loudly on the walls and doors. Resident #3 stated a few weeks ago Resident #1 banged his walker into her door and came into her room. Resident #3 stated Resident #1 raised his voice to her, pointed his finger at her, and told her to stay in her room and, Do not come out. 5. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's Quarterly MDS assessment, dated 8/17/17, documented he was cognitively intact and had no signs and symptoms of psychosis, delirium or behaviors. On 11/7/17 at 2:05 pm, Resident #5 stated Resident #1 wandered down the hall often clicking his walker and knocking on doors and walls while he walks. Resident #5 stated Resident #1 recently entered his room. Resident #5 stated he yelled at him to get out. He stated he did not give Resident #1 the option to talk back to him and Resident #5 stated he currently was not threatened by him, however, Resident #5 stated Resident #1 could be dangerous. Resident #5 stated he had seen Resident #1 being defiant with staff and other residents, for example, when someone asked him to stop doing something Resident #1 told them no, he would do what he wanted to do. 6. Resident #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6's Quarterly MDS assessment, dated 8/18/17, documented he was cognitively intact and had no signs and symptoms of psychosis, delirium or behaviors. On 11/7/17 at 1:50 pm, Resident #6 stated Resident #1 wandered into his room on more than one occasion, and when Resident #6 told him to leave, Resident #1 would argue that the room was not Resident #6's room. 7. Resident #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7's Quarterly MDS assessment, dated 10/6/17, documented he was cognitively intact and had no signs and symptoms of psychosis, delirium or behaviors. On 11/7/17 at 1:59 pm, Resident #7 stated Resident #1 wandered down the hall clicking and knocking frequently. Resident #7 stated Resident #1 had wandering into his room twice while he was present in the room. Resident #7 stated on one of these occasions not too long ago, Resident #1 threatened to Kick my ass, and kick me in the balls. 8. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8's Quarterly MDS assessment, dated 10/20/17, documented he was cognitively intact and had no signs and symptoms of psychosis, delirium or behaviors. On 11/7/17 at 2:01 pm, Resident #8 stated Resident #1 had wandered into his room as well. Residents' #s 3-8 clinical records did not contain documentation of the incidences involving Resident #1's wandering. 9. Staff Interviews On 11/7/17 at 2:45 pm, CNA #1 stated she observed #1 walking the halls; however, she never saw him enter other residents' rooms. CNA #1 stated Resident #1 was usually easily redirected but sometimes he got agitated. CNA #1 stated a female resident told her Resident #1 attempted to enter the female resident's room. On 11/8/17 at 9:13 am, Licensed Social Worker (LSW) #2 said she was aware that Resident #1 had wandered into a female resident's room; however, she was not aware that a verbal altercation occurred between the two residents. On 11/8/17 at 9:40 AM, LSW #1 said the facility needs to protect others from Resident #1, and they were trying measures such as adjusting Resident #1's medications, attempting to get him to walk in a different direction, and stopping him before he entered another resident's room. LSW #1 said it was hearsay that Resident #1 wandered into others' rooms, and the facility could not stop a mobile person from wandering. LSW #1 said the residents who resided in the hall at the opposite end of the building from Resident #1 had been asked to gently re-direct him if he entered their room. The facility did not increase supervision for Resident #1 to protect other residents from Resident #1's unwanted entrance into their rooms, name calling and/or verbal threats. The facility failed to ensure Resident #1 was supervised to ensure his safety. On 11/8/17 at 10:10 am, the acting Director of Nursing (ADON) said they try to keep Resident #1 in his own hall. The ADON confirmed Resident #1 did not have a wandering care plan. The ADON stated she thought Resident #1 was on 1:1 supervision and care when he first entered the facility, but she could not remember when or why that intervention had been discontinued. The ADON stated the facility had no formal plan to increase supervision for Resident #1. On 11/8/17 at 12:05 pm, the Executive Director stated Resident #1's wandering had not been identified as an issue, and the facility had not increased supervision for Resident #1. Refer to F225 and F226 as it relates to the faculties failure to identify Resident #1's behaviors as verbal abuse, threatening and/or intimidating to other residents. The facility was notified in writing on 11/8/17 at 4:52 pm of the Immediate Jeopardy and the need to formulate and implement and plan of removal. 6. On 11/9/17 at 12:00 pm, the facility provided an acceptable plan to remove the Immediate Jeopardy. The plan included: * Reporting newly identified allegations of abuse to the State agency. * Providing 1:1 staff to a resident who was implicated in abuse allegations. * Interviewing all interviewable residents regarding abuse. * Operationalization of policies and procedures regarding abuse allegations. * Providing education to the leadership team and facility staff regarding abuse and neglect prevention, identification and reporting. Implementation of the above actions was verified on-site and the facility informed on 11/9/17 at 5:00 pm, that the immediate jeopardy was removed.

Based on observation, resident and staff interview, record review, and review of the facility's policies and procedures, it was determined the facility failed to ensure the Quality Assessment and Assurance Program (QAA) identified deficient practices, and developed and implemented effective plans of action to protect residents related to potential abuse and neglect, accidents, incidents, and quality of care issues that placed the health and safety of all 62 residents in the facility in Immediate Jeopardy of serious harm, impairment or death. The QAA program additionally failed to ensure prior deficient practice did not recur. The lack of a effective ongoing QAA processes placed all residents in the facility in immediate jeopardy of impairment, or death. Findings include: 1. The following deficiencies were identified as an Immediate Jeopardy during the survey: * Refer to F 225 as it related to the facility's failure to ensure verbal abuse was recognized, investigated, and reported to the facility's Abuse Coordinator as potential indicators of abuse or neglect. * Refer to F 226 as it related to the facility's failure to operationalize policies and procedures to prevent, identify, investigate, protect against, and report potential incidents of resident abuse, neglect, and/or misappropriation of property. * Refer to F 323 as it related to the facility's failure supervise residents who engaged in verbally abuse, entering other resident rooms uninvited and intimidation of other residents. The facility was previously cited at F 323 during the prior recertification surveys on 12/2/16. * Refer to F 490 as it related to the oversight of daily operations related to resident care. On 11/8/17 at 10:10 am, the Executive Director (ED) stated it was not facility protocol to complete a full investigation for all incidents of verbal abuse. The ED stated the facility was a behavior unit and the staff would be doing investigations all the time if they completed an investigation for each incident. The ED stated he was not aware of the verbally abusive incidents that occurred as identified in F 225. He stated the QAA had not recently reviewed abuse and neglect in their QAA committee meeting. The ED stated the facility cannot always keep residents on their designated sides, however, the facility tried to segregate them. The ED stated he was aware of a person who wandered and staff were instructed to try and keep that resident from going beyond the kitchen. The facility was notified in writing of the Immediate Jeopardy and the need to develop and implement a plan of removal on 11/8/17 at 4:52 pm. On 11/9/17 at 12:00 pm, the facility provided an acceptable plan to remove the immediacy. The plan included: * Administrative staff received education from the Director of Clinical Operations related to abuse and neglect, accidents and incidents to include supervision of residents, the QAA and responsibility of the Administration. The Director of Clinical Operations would also educate all staff prior to their next shift. * The ED and leadership team would provide oversight to staff regarding the management of wandering residents and increased supervision to prevent resident to resident altercations. Concerns regarding potential verbal abuse would be presented in the QAA committee meetings as needed. * The facility would review their abuse policy and procedure in the QAA committee. The QAA committee would ensure the facility investigated incidents of verbal abuse appropriately and ensure the facility's abuse policy was implemented. Implementation of the above actions was verified on-site and the facility informed on 11/9/17 at 5:00 pm, that the immediate jeopardy was removed. 2. The facility's QAA program did not provide sufficient monitoring to maintain ongoing compliance and had the potential for harm to all residents in the facility due to care and services not being provided in a safe and effective manner as follows: * Refer to F 329 as it related to the administration of medications with specific target behaviors identified for monitoring, specific indications for use and clinical rational and justification for the continued use of a medication. On 11/8/17 at 12:05 pm, the ED stated the QAA recently reviewed staffing issues, infection control, weight loss, workers compensation, and phase 2 regulation changes in their meeting. The ED stated the QAA committee had not previously identified the issues above or other concerns brought forth during the survey.

Based on observation, review of facility policies and procedures, resident grievances, and resident and staff interviews, it was determined the facility failed to follow their policies and standards of practice regarding identification, reporting, and investigation of abuse and neglect; train and verify staff competency in the provision of care and services; and ensure adequate supervision was provided to protect residents from harm. This failed practice placed the health and safety of 4 of 4 (#'s 1-4) residents and all other residents in the facility in immediate jeopardy of serious harm, impairment or death from abuse or neglect. Findings include: 1. Immediate Jeopardy was identified in the following areas: * Refer to F 225 as it relates to the facility's failure to ensure allegations of abuse were recognized, investigated, and reported to the facility's Abuse Coordinator as abuse or neglect. * Refer to F 226 as it relates to the facility's failure to operationalize policies and procedures to prevent, identify, investigate, protect against, and report potential incidents of resident abuse, neglect, and/or misappropriation of property. * Refer to F 323 as it relates to the facility's failure to ensure adequate supervision was provided to wandering residents whom then engaged in verbally abusive altercations with other residents. * Refer to F 520 as it relates to the facility's failure to ensure the Quality Assessment and Assurance program effectively monitored facility care processes to protect residents from potential harm. On 11/7/17 at 2:50 pm, CNA #1 stated she never witnessed Resident #1 going into another residents room. On 11/8/17 at 9:13 am, LSW #2 said she was aware that a male resident #1 had wandered into a female resident's room, however, she was not aware that the female resident had considered this event abusive. LSW #2 said if an altercation occurred between two residents, ideally social services would have followed up, and it would be documented in each residents' chart. LSW #2 stated she had not followed up on any such incidents recently. LSW #2 stated if she witnessed an abuse incident she would intervene right then and there and would not always document it. She stated if an abusive incident was reported to her she would investigate the incident and document it on an abuse investigation form. On 11/8/17 at 9:40 am, LSW #1 stated: * If a resident wandered into another resident's room, it should be investigated. * The ED told LSW #1 which verbal incidents needed to be investigated. During the same interview LSW #1 stated, regarding Resident #1 and #2 specifically: * She was aware of Resident #1 calling other residents names, but was not sure which residents. * She was aware of a verbal altercation involving Resident #1 and Resident #2 the previous week. * She was present when Resident #2 reported an allegation of verbal abuse and she felt unsafe. LSW #1 could not explain the lack of investigation for this allegation. * The altercation had not been investigated. * Reports of Resident #1's wandering were hearsay. * The facility needed to protect other residents from Resident #1, and had implemented measures including adjusting the resident's medications, attempting to get him to walk in another direction, and stopping him before he entered other resident's rooms. * The facility could not stop a mobile resident, such as Resident #1, from wandering. * Other residents in the facility had been educated to gently redirect Resident #1 if he wandered into their rooms. The facility was unable to provide evidence this education with other residents had occurred. * She did not know how many resident rooms Resident #1 had entered, how long he had remained in the rooms, whether other residents were in the rooms when he entered, or how frequently this behavior occurred. * Without an investigation into the allegations of verbal abuse regarding Resident #1, it was not possible to rule out physical, mental, or sexual abuse, given the nature of the allegations. On 11/8/17 at 10:10 am, the Executive Director (ED) stated it was not facility protocol to complete a full investigation for all incidents of verbal abuse. The ED stated the facility was a behavior unit and the staff would be doing investigations all the time if they completed an investigation for each incident. The ED stated he was not aware of the verbally abusive incidents that occurred as identified in F225. He stated the QAA had not recently reviewed abuse and neglect in their QAA committee meeting. The ED stated the facility cannot always keep residents on their designated sides, however, the facility tried to segregate them. The ED stated he was aware of a person who wandered and staff were instructed to try and keep that resident from going beyond the kitchen. The facility's failure to have knowledge of the impact of Resident #1's unspervised wandering, recognize and investigate all allegations of abuse, and protect residents from further abuse, placed all residents in the facility at immediate risk of serious harm or injury. The facility was notified in writing of the Immediate Jeopardy and the need to develop and implement a plan of removal on 11/8/17 at 4:52 pm. On 11/9/17 at 12:00 pm, the facility provided an acceptable plan to remove the immediacy. The plan included: * Administrative staff received education from the Director of Clinical Operations related to abuse and neglect, accidents and incidents to include supervision of residents, the QAA and responsibility of the Administration. The Director of Clinical Operations would also educate all staff prior to their next shift. * The ED would ensure the facility investigated verbal abuse incidents and implement the facility's abuse policy. * The leadership team would provide oversight to staff regarding the management of wandering residents and increased supervision to prevent resident to resident altercations and verbal abuse. Implementation of the above actions was verified on-site and the facility informed on 11/9/17 at 5:00 pm, that the immediate jeopardy was removed. 2. Non-Immediate Jeopardy deficiencies were identified in the following areas: * Refer to F 166 as it relates to residents' complaints not being recognized or investigated as allegations of abuse. * Refer to F 174 as it relates to inadequate private phone access for residents. * Refer to F 250 as it relates to the facility's failure to provide medically related social services to residents whose behaviors placed them at risk of being abused by other residents, or to residents who had been abused by other residents. * Refer to F 279 as it relates to the development of comprehensive care plans. * Refer to F 329 as it relates to the failure of identification of targeted behaviors, indications for the use of [MEDICAL CONDITION] medications, and monitoring of [MEDICAL CONDITION] medication usage. * Refer to F 497 as it relates to the failure of completion of staff in-service trainings and competency-based trainings. * Refer to F 501 as it relates to the facility's policies and procedures were not reviewed and signed off by the Medical Director.

Based on staff interview and record review, it was determined the facility failed to ensure: * Allegations of verbal abuse were investigated by the facility's leadership team and reported to the State Agency. * Facility Abuse policies and procedures on abuse training, prevention, recognition, protection, reporting, and investigation were operationalized. This deficient practice placed 4 of 4 sample residents (#s 1-4) and 4 of 4 random residents (#s 5-8) in Immediate Jeopardy of serious harm, injury, or death and had the potential to impact the remaining 52 residents in the facility due to the facility's failure to ensure all staff were trained on abuse and neglect; recognize a resident's history of past abuse as an indicator of future abusive behavior; identify the resident was abusing others and was at risk of being abused himself; recognize resident reports of abuse; protect residents from further abuse, report allegations of abuse; and investigate all allegations of abuse. Findings include: 1. The facility's Detecting Abuse, Neglect, Misappropriation, and Injuries of Unknown Origin Policy and Procedure, revised 10/31/17, directed facility staff to do the following: 1) Identify events and occurrences that may involve abuse and neglect 2) Investigate allegations of abuse including physical, sexual, verbal, neglect, involuntary seclusion, corporal punishment, unusual occurrences, misappropriation, exploitation, and injuries of unknown origin 3) Report mistreatment, neglect, or abuse 4) Respond to allegations of abuse, and 5) Document the allegations. Specifically: * Identification - The policy documented grievances; complaints; allegations of abuse, neglect, injuries of unknown origin, and misappropriation of resident property; or any other evidence of physical, verbal, sexual, or psychological abuse should be reviewed and immediately reported to the Executive Director (ED), Director of Nursing (DON) and/or Social Services. Any affected resident should be assessed for signs of negative psychosocial impact from the event. *Protection: The facility should immediately increase supervision for the victim and other residents as indicated, with staffing and room changes as necessary. The victim should be provided emotional support and counseling during and after the investigation. * Investigation - An investigation into any allegation of abuse included observations and interviews with the person/s involved to determine the specifics of the allegation. Interviews should include residents, staff, and any other potential witnesses. * Reporting - Staff should immediately report any alleged mistreatment, neglect, or abuse to a senior clinician or leader, and other officials are notified in accordance with state regulations and within designated timeframes. If the reportable event did not involve serious bodily injury, it was reported to the State Agency no later than 24 hours after the allegation. The affected resident's family should be contacted and given a report regarding care of the resident's distress or injury. * Responding - The facility should analyze the results of the investigation to determine why the abuse occurred and if changes are needed to prevent recurrence. Staff members should be trained and demonstrate competency regarding response to abuse allegations. All allegations of abuse should be reported immediately to the ED and to other officials, including the State agency and adult protective services, no later than 2 hours after the allegation has been made if serious bodily injury is involved, and no more than 24 hours if no abuse and no serious bodily injury is involved. * Documentation - Staff were to document the affected resident's physical and psychosocial status, action taken by clinical staff, notification of the physician and new orders received, and notification of the family in the resident's clinical record. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Health Status Notes, Behavior Notes, and Post Fall Assessment Notes between 9/20/17 and 11/7/17 documented Resident #1 displayed physical and verbal aggression in the facility towards staff and other residents, as well as intrusive wandering. Between 11/7/17 and 11/9/17, Resident #s 2-8 stated they had experienced and/or witnessed Resident #1's physical and verbal aggression, and had reported those events to staff. Resident #s 2-8 all stated the facility had not responded to their reports. The facility had no documentation of grievances or of abuse allegations for (MONTH) or (MONTH) (YEAR), or between 11/1/17 and 11/9/17. The facility had no documentation the State agency or other entities were notified of allegations of verbal abuse. On 11/7/17 at 10:48 am, the Administrator confirmed the facility had not documented any allegations of abuse since 6/28/17, grievances in (MONTH) or (MONTH) (YEAR), or between 11/1/17 and 11/9/17. On 11/7/17 at 2:20 pm, LN #1 stated if a resident struck another resident she would call the event an altercation and initiated an investigation into the matter. LN #1 stated if she intervened before physical contact she would not consider it an incident to investigate. LN #1 stated the process to investigating a resident to resident altercation consisted of separating residents and explaining to residents that their actions were not appropriate and brainstorming a better way to handle the situation. LN #1 stated she would report the event to the nurse manager and the social worker. LN #1 stated the social worker would chart the incident in the residents' medical record. On 11/7/17 at 2:50 pm, CNA #1 stated if an incident of resident to resident altercations occurred they were reported to the nurse manger and the social worker. On 11/8/17 at 9:13 am, LSW #2 stated calling someone a f***ing b*tch would be verbal abuse, but she was not aware of any residents doing that. LSW #2 said she was not aware of any incidents of verbal abuse being investigated involving Resident #1 and any of the identified residents above. LSW #2 said she was aware that Resident #1 had wandered into a female resident's room, however, she was not aware that an incident of verbal abuse occurred between the two residents. LSW #2 was not aware that Resident #1 called two other residents f***ing [***] es. LSW #2 said she was not sure if the facility was aware of Resident #1's history of aggressive behavior prior to his admission. LSW #2 said she was aware of the altercation involving Resident #1, and the CNA using the mechanical lift after Resident #1's admission, but she was not aware the resident hit the CNA in the face. LSW #2 said if an altercation occurred between two residents, ideally it would be documented in each residents' chart. LSW #2 said in order to determine if abuse occurred it would be discussed with the ED, acting Director of Nursing (ADON), the nurse, and LSW #1. LSW #2 she did not know what happened in the incidents above and why she was not notified. LSW #2 stated if she witnessed an abuse incident she would intervene right then and there and would not always document it. She stated if an abusive incident was reported to her she would investigate the incident and document it on an abuse investigation form. On 11/8/17 at 9:40 am, LSW #1 stated: * If a resident exhibited verbal aggression such as name calling or swearing, it was not always thought of as verbal abuse. * If a resident called another resident a f***ing b*tch it would be considered verbal aggression because, with dementia they don't always know what they're saying. * The facility monitored verbally aggressive behaviors through resident behavior monitors, and if the monitor showed an escalation in behaviors that would trigger an investigation. * If a resident wandered into another resident's room, it should be investigated. * The ED told LSW #1 which verbal incidents needed to be investigated. During the same interview LSW #1 stated, regarding Resident #1 and #2 specifically: * She was aware of Resident #1 calling other residents names, but was not sure which residents. * She was aware of a verbal altercation involving Resident #1 and Resident #2 the previous week. * She was present when Resident #2 reported the altercation, and that the altercation made her feel unsafe. * The altercation had not been investigated. * Reports of Resident #1's wandering were hearsay. * The facility needed to protect other residents from Resident #1, and had implemented measures including adjusting the resident's medications, attempting to get him to walk in another direction, and stopping him before he entered other resident's rooms. * The facility could not stop a mobile resident, such as Resident #1, from wandering. * Other residents in the facility had been educated to gently redirect Resident #1 if he wandered into their rooms. * She did not know how many resident rooms Resident #1 had entered, how long he had remained in the rooms, whether other residents were in the rooms when he entered, or how frequently this behavior occurred. * Without an investigation into the allegations of verbal abuse regarding Resident #1, it was not possible to rule out physical, mental, or sexual abuse, given the nature of the allegations. On 11/8/17 at 12:23 pm, the ADON (Acting Director Of Nursing) said perhaps incidents of verbal abuse were not reported because the policy does not say we need to. The ADON said it sounded like verbal abuse, Has been happening but it was not documented. On 11/8/17 at 12:39 pm, the Administrator said it was clear we need to be a little deeper in recognizing and reporting verbal abuse. The Administrator stated it was not facility protocol to investigate verbal abuse allegations. 3. Abuse Training The facility's abuse prevention policy, release date 10/31/17, documented in-service training would be provided to new and existing staff regarding prohibition and preventing all forms of abuse. CNA A's employee file documented she was hired on 8/8/17. There was no documentation she received any training regarding prohibition and preventing all forms of abuse. On 11/9/17 at 12:23 pm, the ADON said that staff members should know the categories of abuse and they just had training in October. When asked to provide evidence that CNA A received training regarding prohibition of abuse, the ADON said the facility was bought by another company and the previous company kept some documentation regarding previous training that employees received, and the facility has not been able to access this information. The ADON stated the presumption was CNA A's training records were among that information. The facility did not provide documentation that CNA A received training regarding prohibition of abuse. 4. Refer to F 225 as related to the facility's failure to ensure all staff recognized and reported abuse, including verbal abuse; preventive measures were implemented for residents at risk of abuse or of abusing others; allegations of abuse were identified and investigated; residents were protected from further abuse once an allegation was made; and allegations of abuse, including verbal abuse, were reported to the State Agency. 5. The facility was notified in writing on 11/8/17 at 4:52 pm of the Immediate Jeopardy and the need to formulate and implement and plan of removal. On 11/9/17 at 12:00 pm, the facility provided an acceptable plan to remove the Immediate Jeopardy. The plan included: * Reporting newly identified allegations of abuse to the State agency. * Providing 1:1 staff to a resident who was implicated in abuse allegations. * Interviewing residents regarding abuse. * Operationalization of policies and procedures regarding abuse allegations. * Providing education to the leadership team and facility staff. Implementation of the above actions was verified on-site and the facility informed on 11/9/17 at 5:00 pm, that the immediate jeopardy was removed.

Based on observation, resident and staff interview, and review of clinical records and Incident and Accident Reports, it was determined the facility failed to: * Ensure allegations of verbal abuse reported by residents and/or staff were thoroughly investigated. * Ensure staff recognized certain resident complaints as allegations of verbal, mental, or sexual abuse. * Ensure allegations of verbal abuse were reported to the facility's abuse coordinator and thoroughly investigated. * Ensure the facility's administrator/abuse coordinator was notified of potential verbal abuse incidents in a timely manner. * Ensure all residents were protected from verbal abuse and/or threats of physical abuse. * Consistently provide abuse and neglect training to staff. This was true for 4 of 4 sample residents (#s 1-4), 4 of 4 random residents (#s 5-8), and had the potential to affect all 60 residents in the facility. Specifically: a) Resident #1 was exposed to the potential for harm by other residents whose rooms he intrusively wandered into on numerous occasions. b) Resident #4 sustained psychosocial harm when Resident #1 verbally assaulted her and raised his hand in a physical threat to strike her. c) Resident #2 sustained psychosocial harm from multiple instances in which Resident #1 verbally abused her and wandered into her room while Resident #2 was in a state of partial undress. d) Residents #3 and Resident #s 5 - 8 experienced occasions of verbal abuse from Resident #1 or witnessed Resident #1 verbally abusing other residents. This deficient practice placed Residents #'s 1 - 8 in immediate jeopardy of serious harm, injury, or death and had the potential to adversely affect the remaining 52 residents in the facility due to the facility's failure to recognize, prevent, protect, and report potential incidents of abuse and/or neglect. Findings include: The facility's abuse prevention policy and procedure, release date 10/31/17, documented the facility was responsible for identifying residents most at risk of neglect and abuse, including those with dementia; psychosocial/interactive disorders; verbally and/or physically aggressive behavior; and those who wander into other residents personal rooms/space. The policy and procedure required the facility to assess, care plan, and monitor these residents whose needs and behaviors . might lead to conflict or neglect. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's 9/27/17 admission MDS (Minimum Data Set) assessment documented severe cognitive impairment, delusions, and physical behaviors. The Behavior Care Plan, initiated 9/22/17, documented Resident #1 would punch and hit unexpectedly and was verbally abusive to staff. The care plan directed staff to approach Resident #1 carefully and from the side, contact a specific family member, provide a 5 min(ute) time out and re-approach when the resident was agitated, explain themselves before attempting an interaction, and remove other residents from area if (he) is out of control. Other areas of the care plan directed staff to remove Resident #1 from the room before getting his roommates out of bed, administer [MEDICAL CONDITION] medications as ordered, talk about his former employment, decrease stimulation, consider relocating the resident from a room with 3 roommates to a room with only 1 roommate, and remove the resident to a calm safe environment where he could vent/share feelings when a conflict arose. Physician order [REDACTED]. areas. Resident #1's 9/20/17 Admission Note documented he arrived at the facility at 2:20 pm from a hospital after striking an employee and another resident at his previous assisted living facility (ALF) residence. The Note documented Resident #1 did not remember the incident. A 9/22/17 Post Fall Assessment documented at 6:20 am that Resident #1 was sitting on his bed as 2 CNAs were assisting his roommates from bed. Resident #1 suddenly stood up, grabbed the Hoyer lift, and punched one CNA in the face when she tried to get him to release his grip on the Hoyer lift. Resident #1 tried to ram the CNA with the Hoyer lift, lost his balance and fell on to the floor, striking his head. Resident #1, who was assessed with [REDACTED]. A 9/25/17 Investigation Interview regarding the 9/22/17 incident confirmed the Post Fall Assessment findings. A 9/25/17 Health Status Note documented Resident #1's order for physical therapy was discontinued due to the resident's violent behavior. A 10/4/17 Behavior Note documented at 3:00 am that Resident #1 was hitting and grabbing any item he can grab in his hands and swinging the item, slamming doors, disrupting other residents' sleep, and that he pushed a wheelchair into a staff member's knee. Resident #1's physician was contacted by phone and a medication order was requested to help the resident calm down so he won't be a danger to himself or others. A 10/17/17, Behavior Note documented at 1:04 pm that Resident #1 became angry at breakfast, where he shouted at a tablemate, calling the tablemate a fat f***, and threatened the tablemate by saying, I'll come over there and kill you, you fat pig. The Behavior Note also documented Resident #1 was peeking into (other residents') bedrooms but rarely putting a foot inside the bedrooms. A 10/18/17 Behavior Note documented at 1:50 am that Resident #1 was restless, aggressive towards staff, pacing and walking in the hallway for nearly 4 hours, and attempted to enter other residents' rooms multiple times. An 11/2/17 Behavior Note documented at 2:47 pm that Resident #1 was walking every waking moment and opened a female resident's door multiple times without knocking. When a staff member attempted to re-direct Resident #1, he stated, I own this building and I'll go anywhere I damn well please. At 3:56 pm, staff documented Resident #1 was very verbally aggressive towards residents and staff, yelling and threatening to harm other residents and staff, and calling others inappropriate names. At 9:20 pm, staff documented Resident #1 continued to wander and exhibit aggressive behavior. Behavior/Antidepressant Monitor Flowsheets for (MONTH) and (MONTH) (YEAR) documented the following: * Resident #1 exhibited delusions on multiple dates and times in (MONTH) and November. * Resident #1 exhibited physical aggression at night on multiple dates and shifts in October. * Resident #1 exhibited verbal aggression towards others on multiple dates during night shift in November. * Resident #1 wandered into others' rooms on multiple dates and times during November. Behavior Monitoring Flowsheets documented the following: * 10/23/17 - Resident #1 attempted to enter other residents' rooms, went to the other side of the building, called other residents names, and became angry when staff attempted to redirect him. * 10/24/17 and 10/25/17 - Resident #1 attempted to enter other residents' rooms and became aggressive when redirected by staff. * 11/2/17 - Resident #1 was verbally aggressive towards other residents and staff, wandered into other residents' rooms, woke residents by telling them to leave their own rooms, and screamed when he was asked to leave. Resident #1 was described as wanting to hit and threaten(ed) to kill residents on (the) other side! *On 11/3/17, Resident #1 was continuously entering other residents' rooms and started yelling when CNAs redirected him. On 11/7/17 at 1:40 pm, Resident #1 was observed walking up and down the hall at the opposite end of the building from his room. Resident #1 entered another resident's room for approximately one and one-half minutes. No other residents were in the room at the time. A male staff member entered the room and redirected the resident back into the hall. Resident #1 briefly entered another resident's room approximately two minutes later and exited the room on his own accord. On 11/7/17 at 2:13 pm, Resident #1 was observed entering another resident's room, where a CNA directed him to exit the room. 2. Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 10/6/17, documented Resident #2 was cognitively intact and exhibited no signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION]. A 10/9/17 Social Services Progress Note documented Resident #2 exhibited increased behaviors and was recently verbally aggressive and argumentative. A 10/10/17 Incident Note documented Resident #2 had a verbal altercation with another resident and accused the other resident of stealing her food. An 11/3/17 Health Status Note documented Resident #2 was awake most of that night and upset about another resident. An 11/4/17 Behavior Note documented Resident #2 was upset about another resident (Resident #1) coming into her room. The Note documented Resident #2 informed social services and a nurse that she felt unsafe as Resident #1 entered her room when she was naked. The Note document Resident #2 looked at her side and repeated three times, I'm not safe; the nurse told Resident #2 that staff could not stop Resident #1 from walking the hallways, but would be more diligent in attempting to keep him from entering others' rooms. The facility did not provide evidence of an investigation for the 11/4/17 incident. On 11/7/17 at 9:29 am, Resident #2 stated she did not feel safe in the facility because Resident #1 saw her with her shirt off and threatened her. Resident #2 stated she told Licensed Nurse (LN) #2 and Licensed Social Worker (LSW) #1 about the incident, but they did not believe her or follow up on her report. Resident #2 stated she had become increasingly frustrated in the previous few weeks and lashed out at others because staff did not take her concerns seriously. Resident #2 stated LN #2 told her staff could not stop Resident #1 from walking the halls, but would try and make sure he did not enter other residents' rooms. On 11/7/17 at 9:35 am, Resident #2 stated she began feeling unsafe at the facility a few weeks prior when Resident #1, while walking the halls, clicked his walker and knocked on walls, doors and hand rails. Resident #2 stated Resident #1 walked into her room one day, peered around her privacy curtain, and stared at her. Resident #2 stated she told a CNA about the incident and that she was fearful of Resident #1, but the facility failed to respond to her fear. On another occasion, Resident #2 stated she was changing her shirt with her back to the door when she reached for her night shirt and Resident #1 was standing next to her bed. Resident #2 stated she realized Resident #1 was in the room only when she reached for her shirt her hand brushed his walker. Resident #2 stated she was startled by his presence, and Resident #1 asked her if he could share a room with her. Resident #2 stated she asked him nicely to leave twice, but he would not leave. Resident #2 stated Resident #1 was staring at the top-half of her body in a manner that made her feel she was visually raped. Resident #2 stated after asking nicely twice, she yelled, You don't belong here! Get out! Get out, to which Resident #1 responded by yelling, You f***ing [***] ! I'll take you to hell! Resident #2 stated she told a nurse about the incident, but no resolution had yet been reached. Resident #2 stated Resident #1 entered her room on another occasion since then, hit his walker against the end of her bed, and stared at her with a menacing look. Resident #2 stated she did not want to leave her room because she feared possible negative interactions with Resident #1 and that she did not feel safe in her room either because she was fearful of him walking in. Resident #2 stated she now kept her door closed to prevent Resident #1 from returning. Resident #2 stated she was aware that Resident #1 wandered into other residents' rooms on the hall and threatened them as well. On 11/7/17 at 9:12 am, Resident #3 stated she was in her room the previous week when she heard Resident #2 arguing with Resident #1, in Resident #2's room. Resident #3 stated she heard Resident #1 calling Resident #2 a f***ing [***] . Resident #3 stated she left her room, went to Resident #2's room next door, and told Resident #1 to leave. 3. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 10/17/17 quarterly MDS assessment documented Resident #4 was cognitively intact. On 11/7/17 at 8:50 am, Resident #4 said that she was waiting for medications at the medication cart on or about the afternoon of 11/3/17 while Resident #1 walked up and down the hallway nearby. She stated Resident #1 suddenly lunged at the nurse. When Resident #4 yelled at Resident #1 to stop, she said, Resident #1 turned toward Resident #4 and said, I will knock your block off, you f***ing b*tch and raised his fist as if to hit her. The nurse placed herself between Resident #1 and Resident #4 to prevent a physical altercation. Resident #4 stated the nurse spoke to the Executive Director (ED) about the incident, however no staff member followed up with her regarding the incident. On 11/7/17 at 2:20 pm, LN #1 stated she recalled the 11/3/17 incident. LN #1 stated Resident #1 yelled and raised his fist as if to strike Resident #4 and she intervened by getting between them to prevent a physical altercation. LN #1 stated she would not call it an actual altercation because Resident #1 did not make physical contact with Resident #4. LN #1 stated if Resident #1 had struck Resident #4 she would have called the event an altercation and initiated an investigation into the matter. LN #1 stated the process to investigating a resident to resident altercation consisted of separating residents and explaining to residents that their actions were not appropriate and brainstorming a better way to handle the situation. LN #1 stated she would report the event to the nurse manager and the social worker. LN #1 stated the social worker would chart the incident in the residents' medical record. On 11/7/17 at 2:50 pm, CNA #1 said during the incident on 11/3/17, Resident #1 raised his arm to Resident #4, then the LN stepped in and got Resident #1 to move away from Resident #4. CNA #1 stated if an incident of resident to resident altercations occurred they were reported to the nurse manger and the social worker. 4. Additional Resident Reports: a) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/7/17 at 1:43 pm, Resident #3 stated Resident #1 wandered down the hall often and he would click his walker and knock loudly on the walls and doors. Resident #3 stated a few weeks ago Resident #1 banged his walker into her door and came into her room. Resident #3 stated Resident #1 raised his voice to her, pointed his finger at her, and told her to, stay in her room, and, do not come out. Resident #3 stated she did not stay in her room and as soon as he left she went and told a CNA. She could not remember the exact date this occurred or the name of the CNA she told. Resident #3's clinical record did not contain documentation of the incident. b) Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/7/17 at 2:05 pm, Resident #5 stated Resident #1 wandered down the hall often clicking his walker and knocking on doors and walls while he walks. Resident #5 stated Resident #1 recently entered his room. Resident #5 stated he yelled at him to get out. He stated he did not give Resident #1 the option to talk back to him and Resident #5 stated he currently was not threatened by him, however, Resident #5 stated Resident #1 could be dangerous. Resident #5 stated he had seen Resident #1 being defiant with staff and other residents, for example, when someone asked him to stop doing something Resident #1 told them no, he would do what he wanted to do. c) Resident #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/7/17 at 1:50 pm, Resident #6 stated there were two residents who wandered into his room. Resident #6 stated one of them was Resident #1. Resident #6 said Resident #1 would argue with him about Resident #6's room being Resident #1's room. In addition, Resident #6 stated he was watching television in his room the previous week with his door closed when he heard the loud voices of a man and woman yelling at each other. Resident #6 stated he did not remember what was said but stated he heard explicit language being used. d) Resident #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/7/17 at 1:59 pm, Resident #7 stated Resident #1 wandered down the hall clicking and knocking frequently. Resident #7 stated Resident #1 had wandered into his room twice while he was present in the room. Resident #7 stated on one of these occasions, Resident #1 threatened to kick my ass, and kick me in the balls. Resident #7 stated LN #3 was present in the hall when Resident #1 threatened him and Resident #7 asked LN #3 if s/he heard what Resident #1 had said to him. Resident #7 stated LN #3 stated s/he had heard the remarks Resident #1 made towards Resident #7. Resident #7's clinical record did not contain documentation of the incident. e) Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/7/17 at 2:01 pm, Resident #8 stated Resident #1 entered his room and took his walker a few weeks ago. Resident #8 stated he was without his walker for a period of time before being given his walker back later that day. Resident #8 stated Resident #1 had wandered into his room on other occasions as well. Resident #8's clinical record did not contain documentation of the incident. The facility did not provide evidence of an investigation regarding the allegations of verbal abuse involving Resident #1 and other residents. 5. Facility Leadership Interviews: On 11/8/17 at 9:13 am, LSW #2 stated calling someone a f***ing b*tch would be verbal abuse, but she was not aware of any residents doing that. LSW #2 said she was not aware of any incidents of verbal abuse being investigated involving Resident #1 and any of the identified residents above. LSW #2 said she was aware that Resident #1 had wandered into a female resident's room, however, she was not aware that an incident of verbal abuse occurred between the two residents. LSW #2 was not aware that Resident #1 called two other residents f***ing [***] es. LSW #2 said she was not sure if the facility was aware of Resident #1's history of aggressive behavior prior to his admission. LSW #2 said she was aware of the altercation involving Resident #1, and the CNA using the mechanical lift after Resident #1's admission, but she was not aware the resident hit the CNA in the face. LSW #2 said if an altercation occurred between two residents, ideally it would be documented in each residents' chart. LSW #2 said in order to determine if abuse occurred it would be discussed with the ED, acting Director of Nursing (ADON), the nurse, and LSW #1. LSW #2 she did not know what happened in the incidents above and why she was not notified. On 11/8/17 at 9:40 am, LSW #1 stated: * If a resident exhibited verbal aggression such as name calling or swearing, it was not always thought of as verbal abuse. * If a resident called another resident a f***ing b*tch it would be considered verbal aggression because, with dementia they don't always know what they're saying. * The facility monitored verbally aggressive behaviors through resident behavior monitors, and if the monitor showed an escalation in behaviors that would trigger an investigation. * If a resident wandered into another resident's room, it should be investigated. * The ED told LSW #1 which verbal incidents needed to be investigated. During the same interview LSW #1 stated, regarding Resident #1 and #2 specifically: * She was aware of Resident #1 calling other residents names, but was not sure which residents. * She was aware of a verbal altercation involving Resident #1 and Resident #2 the previous week. * She was present when Resident #2 reported the altercation, and that the altercation made her feel unsafe. * The altercation had not been investigated. * Reports of Resident #1's wandering were hearsay. * The facility needed to protect other residents from Resident #1, and had implemented measures including adjusting the resident's medications, attempting to get him to walk in another direction, and stopping him before he entered other resident's rooms. * The facility could not stop a mobile resident, such as Resident #1, from wandering. * Other residents in the facility had been educated to gently redirect Resident #1 if he wandered into their rooms. * She did not know how many resident rooms Resident #1 had entered, how long he had remained in the rooms, whether other residents were in the rooms when he entered, or how frequently this behavior occurred. * Without an investigation into the allegations of verbal abuse regarding Resident #1, it was not possible to rule out physical, mental, or sexual abuse, given the nature of the allegations. On 11/8/17 at 10:10 am, the ADON said they would consider a resident calling another resident a f***ing b*tch verbal abuse, but she was not aware of this happening in the facility. The ADON stated the facility did not investigate allegations of verbal abuse. The ADON stated if verbal abuse occurred it was facility practice to separate the residents and speak with them about the incident. On 11/8/17 at 10:19 am, the ED said he was aware of Resident #4 yelling at Resident #1 when she approached him aggressively and unsolicited on 11/3/17, and said Resident #4 did not like Resident #1. The ED stated he was not aware of the other incidents involving Resident #1, and would have to look to see if any investigations had been completed. The ED stated one resident calling another a f***ing b*itch would be verbal abuse, but the facility did not investigate all allegations of verbal abuse. On 11/9/17 at 12:40 pm, the Medical Director stated he doubted the facility called him on all verbal abuse incidents, but he hoped if the verbal abuse was really bad that the staff would notify him so medications could be adjusted or added, and closer observation could be ordered. 6. Notification and Removal of Immediate Jeopardy The facility was notified verbally and in writing on 11/8/17 at 4:52 pm of the Immediate Jeopardy. On 11/9/17 at 12:00 pm, the facility provided an acceptable plan to remove the Immediate Jeopardy. The plan included: * Newly identified allegations of abuse, including verbal abuse, were reported to the State agency. * Providing 1:1 staff to Resident #1 to ensure the safety of other residents, and to protect him from residents who may respond to his intrusiveness or aggression. * Speaking with all interviewable residents to rule out further unrecognized allegations of abuse. * Providing education to the facility's leadership team and facility staff regarding abuse and neglect prevention, identification and reporting. Implementation of the above actions was verified on-site and the facility informed on 11/9/17 at 5:00 pm, that the immediate jeopardy was removed.

Based on observation, interview, and record review, it was determined the facility failed to ensure medically related social services were provided for residents. This was true for 3 of 4 sample residents (#s 1, 2 and 4) when the residents did not receive social services interventions after Resident #1 repeatedly demonstrated verbally and physically aggressive behavior. Residents #2 and #4 experienced psychosocial harm due to Resident #1's behavior. Resident #1 was at risk for harm from other residents. Findings include: 1. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's 9/27/17 Admission MDS (Minimum Data Set) assessment documented severe cognitive impairment, delusions, and physical behaviors. Resident #1's care plan to address his psychosocial and behavior problems documented to remove him to a calm, safe environment when a conflict occurs; approach him from the side carefully, facilitate the resident talking to his son-in-law on the phone; give a 5 minute time out when agitation is expressed and then re-approach; identify yourself and what you want the resident to do; re-direct him by talking about his work history when he becomes agitated; remove him from other residents in the area if his behavior is out of control; consider moving him to a room with two beds (instead of four beds) to decrease stimulation; and get him dressed and out of his room prior to his roommates getting up. Resident #1's 9/20/17-11/20/17 Order Summary Report documented behavior monitoring regarding the number of episodes per shift of the following behaviors: delusions, resistive to cares, frequent changes in mood, verbal aggression, and frequent wandering into others' rooms or areas. On 9/20/17 at 2:20 pm, Resident #1's Admission Note documented he arrived at the facility from the hospital after he struck an employee at his previous residence in an ALF (Assisted Living Facility). On 10/4/17 at 3:00 am, Resident #1's Behavior Note documented he was being physically aggressive, hitting and grabbing any item he can grab in his hands and swinging the item . The resident slammed doors, disrupted other residents' sleep, and pushed a wheelchair into a staff member's knee without any injury to the staff member. Resident #1's physician was contacted by phone and a medication order was requested to help the resident calm down so he won't be a danger to himself or others. On 10/17/17 at 1:04 pm, Resident #1's Behavior Note documented he became angry during breakfast, shouting at a tablemate, calling his tablemate a fat f*** and threatened, I'll come over there and kill you, you fat pig. Resident #1 was also walking in the hallway, peeking into bedrooms but rarely putting a foot inside the bedrooms. On 10/18/17 at 1:50 am, Resident #1's Behavior Note documented he was restless, aggressive towards staff, pacing and walking in the hallway for nearly 4 hours, and attempted to enter other residents' rooms multiple times. On 11/2/17 at 2:47 pm, Resident #1's Behavior Note documented he was walking every waking moment and he opened an unidentified female resident's door multiple times without knocking. When a staff member attempted to re-direct Resident #1, he said, I own this building and I'll go anywhere I damn well please. On 11/2/17 at 3:56 pm, Resident #1's Behavior Note documented he was very verbally aggressive towards residents and staff, yelling and threatening to harm residents and staff members, calling others inappropriate names. On 11/2/17 at 9:20 pm, Resident #1's Health Status Note documented he continued to wander and exhibit aggressive behavior. Resident #1's 11/2/17 Behavior Monitor Additional Behavior Details documented he was wandering into other residents' rooms, waking residents up, telling them to leave, yelling and screaming when he was asked to leave. The note documented Resident #1 was, wanting to hit and threaten(ed) to kill residents on (the) other side! Resident #1's 11/3/17 Behavior Monitor Additional Behavior Details documented he was continuously entering other residents' rooms and started yelling when CNAs (Certified Nursing Assistants) redirected him. On 11/7/17 at 1:40 pm, Resident #1 was observed walking up and down the hall at the opposite end of the building from his room. Resident #1 entered another resident's room for approximately one and one-half minutes. No other residents were in the room at the time. A male staff member entered and redirected the resident back out into the hall. Resident #1 entered another resident's room approximately two minutes later and exited the room on his own accord. On 11/7/17 at 2:13 pm, Resident #1 entered another resident's room and staff directed him to exit the room. The facility did not have evidence of a social service evaluation of Resident #1's wandering and other behavioral symptoms and the potential risk to residents safety. 2. Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Quarterly MDS assessment, dated 10/6/17, documented she was cognitively intact and had no signs and symptoms of psychosis or delirium. Resident #2's Progress Notes, dated 10/1/17 through 11/7/17, documented 3 episodes of verbal aggression, increased behaviors, and verbally aggressive and argumentative on 10/9/17; verbal altercation on 10/10/17; and calling a staff member a 'horrible word' on 11/4/17. The 11/4/17 note documented Resident #2 had no memory of the incident and was waiting to be punished. Resident #2's Behavior Monitor Flowsheets contained an Additional Behavior Details section which documented upset with other res(ident) on 10/2/17; yelling on 10/8/17; ganging up on other residents on 10/10/17; manic most of the day on 10/11/17; upset because a Resident is walking in the hallway on 10/30/17; bullying on 11/1/17; (Resident #2) wanted to call the police because (Resident #1) was on this side of the building on 11/3/17; Very paranoid about (Resident #1) coming to her room on 11/4/17; and, Paranoid about res(ident) from another hall hiding in her bathroom in an undated entry. Resident #2's Progress Notes documented multiple episodes of the resident being upset, including: * An 11/3/17 Health Status Note documented Resident #2 was awake most of the night and was upset about another resident. * An 11/4/17 Behavior Note documented Resident #2 was upset about another resident coming into her room. The note documented Resident #2 started to tell Licensed Nurse (LN) #2 and Licensed Social Worker (LSW) #1 about a concern and Resident #2 asked LSW #1 to leave the room. The note documented LSW #1 did not leave the room as the staff members felt that Resident #2's agitation level was high. The note documented Resident #2 informed social services and the nurse that she felt unsafe as a male resident (Resident #1) entered her room when she was naked. The note document Resident #2 looked at her side and repeated three times, I'm not safe. The note documented the nurse told Resident #2 that staff could not stop the resident (Resident #1) from walking the hallways, however, staff would be more diligent in attempting to keep him from entering other rooms. On 11/6/17, Resident #2's Psychiatric Progress Note documented Resident #2's delusions and hallucinations had worsened the past couple weeks. The note documented Resident #2 was, seeing people in her room and frequently is yelling out and accusing staff and other patients of various things that are not occurring. On 11/7/17 at 9:29 am, Resident #2 stated she did not feel safe in the facility due to Resident #1 coming into her room, seeing her with her shirt off and threatening her. She stated she told LN #2 and LSW #1 about the situation and no one had followed up with her about it or believed her. Resident #2 stated when LN #2 and LSW #1 talked to her on 11/4/17, she twice asked the LSW #1 leave the room due to LSW #1 not believing her, but the LSW did not leave. Resident #1 stated she no longer felt safe in the presence of LSW #1 because LSW #1 never believed her and she felt LSW #1 tried to discredit her. Resident #2 stated she was not stupid and knew when she got upset it was hard for her to calm down. Resident #2 stated she was tired of telling staff about Resident #1 and them not believing her. She stated that both LSW #1 and LSW #2 told her that they did not believe that Resident #1 was ever in her room. Resident #2 stated when she got frustrated she lashed out at people, which had been happening more frequently in the past few weeks since Resident #1 started wandering into her room. Resident #2 stated sometimes all she needed was someone taking the time to sit and listen to her concerns. On 11/7/17 at 9:35 am, Resident #2 described the events over the last few weeks and that she did not feel safe. Resident #2 stated a few weeks ago Resident #1 was walking the halls and clicked his walker and knocked on walls, doors and hand rails. Resident #2 stated around that time, Resident #1 walked into her room and, peered around my curtain and just stared at me. She stated it scared her that he walked into her room unnoticed. Resident #2 stated she told a CNA and nothing was done about it. Another instance happened one night the previous week when she was changing her shirt with her back to the door. When she reached for her night shirt Resident #1 was standing next to her bed, which she discovered when she reached for her shirt her hand brushed his walker. Resident #2 stated Resident #1 asked her if he could share a room with her. Resident #2 stated she asked him nicely to leave twice and he wouldn't leave. Resident #2 stated Resident #1 was staring at her top-half and if she could be raped with eyes she felt she was being raped. Resident #2 stated after asking nicely twice, she, Yelled at him saying 'You don't belong here! Get out! Get out!' Resident #2 stated she continued to, Yell 'Get out!' Resident #2 stated Resident #1 responded by yelling back, You f***ing b*tch!! I'll take you to hell! Resident #2 stated she told an RN about the incident but the facility did not follow up with her. Resident #2 stated Resident #1 had entered her room one more time since the shirt incident and she stated he had banged his walker against the end of her bed and stared at her again with a menacing look. Resident #2 stated she did not want to leave her room because she feared possible negative interactions with Resident #1 and she stated she did not feel safe in her room either because she was fearful of Resident #1 entering. Resident #2 stated she had started keeping her door closed to try and prevent him from returning. Resident #2 stated Resident #1 had wandered into other residents' rooms on this hall and threatened them as well. On 11/7/17 at 9:12 am, Resident #3 stated she was in her room last week and she heard Resident #2 arguing with Resident #1. Resident #3 stated she heard Resident #1 calling Resident #2 a f***ing b*tch. Resident #3 stated she left her room and went next door to Resident #2's room and told Resident #1 to leave. On 11/8/17 at 9:13 am, LSW #2 said she was aware that Resident #1 had wandered into a female resident's room, however, she was not aware that the female resident had considered this event abusive. LSW #2 was not aware that Resident #1 called other residents f***ing [***] es. LSW #2 said she was not sure if the facility was aware of Resident #1's history of aggressive behavior prior to his admission. LSW #2 said if an altercation occurred between two residents, ideally social services would have followed up, and it would be documented in each residents' chart. LSW #2 stated she had not followed up on any such incidents recently. LSW #2 stated if she witnessed an abuse incident she would intervene right then and there and would not always document it. She stated if an abusive incident was reported to her she would investigate the incident and document it on an abuse investigation form. On 11/8/17 at 9:40 am, LSW #1 stated: * If a resident exhibited verbal aggression such as name calling or swearing, it was not always thought of as verbal abuse. * If a resident called another resident a f***ing b*tch it would be considered verbal aggression because, with dementia they don't always know what they're saying. * The facility monitored verbally aggressive behaviors through resident behavior monitors, and if the monitor showed an escalation in behaviors that would trigger an investigation. * If a resident wandered into another resident's room, it should be investigated. * The ED told LSW #1 which verbal incidents needed to be investigated. During the same interview LSW #1 stated, regarding Resident #1 and #2 specifically: * She was aware of Resident #1 calling other residents names, but was not sure which residents. * She was aware of a verbal altercation involving Resident #1 and Resident #2 the previous week. * She was present when Resident #2 reported an allegation of verbal abuse and she felt unsafe. LSW #1 could not explain the lack of investigation for this allegation. This altercation was previously described in the 11/4/17 behavior note above. * The altercation had not been investigated. * Reports of Resident #1's wandering were hearsay. * The facility needed to protect other residents from Resident #1, and had implemented measures including adjusting the resident's medications, attempting to get him to walk in another direction, and stopping him before he entered other resident's rooms. * The facility could not stop a mobile resident, such as Resident #1, from wandering. * Other residents in the facility had been educated to gently redirect Resident #1 if he wandered into their rooms. The facility was unable to provide evidence this education with other residents had occurred. * She did not know how many resident rooms Resident #1 had entered, how long he had remained in the rooms, whether other residents were in the rooms when he entered, or how frequently this behavior occurred. * Without an investigation into the allegations of verbal abuse regarding Resident #1, it was not possible to rule out physical, mental, or sexual abuse, given the nature of the allegations. 3. Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #4's 10/17/17 quarterly MDS assessment documented she was cognitively intact. On 11/7/17 at 8:50 am, Resident #4 said that on approximately (MONTH) 3, (YEAR) in the afternoon, she was waiting to receive medication at the nurse's cart and Resident #1 had been walking up and down the hall. Resident #1 lunged at the nurse, Resident #4 said she was afraid Resident #1 was going to hurt the nurse, and yelled at Resident #1 to stop. Resident #1 then turned on Resident #4 and said, I will knock your block off you f***ing [***] , while raising his fist as if to hit her. The nurse placed herself between Resident #1 and Resident #4 to prevent a physical altercation. Resident #4 stated the RN (Registered Nurse) spoke with the Administrator about the incident. Resident #4 stated no staff member followed up with her. Resident #4 stated she was aware of other incidents where Resident #1 had either intrusively wandered into resident rooms, or was physically or verbally abusive with other residents. Resident #4 stated the facility was not taking resident complaints of abuse seriously and not investigating them. Resident #4 stated she was concerned not only for her personal safety, but the safety of others. On On 11/8/17 at 9:13 am, LSW #2 said she had not followed up with either Resident #1 or Resident #4 following the incident. On On 11/8/17 at 9:40 am, LSW #1 said she had not followed up with either Resident #1 or Resident #4 following the incident. The facility failed to provide social services interventions to reduce risk of altercations or abuse. when Resident #1 engaged in intrusive wandering and aggression towards others. Resident #s 2 and 4 reported incidents which they identified as allegations of verbal, mental, and/or sexual abuse. The facility failed to provide social services to follow up to ensure Resident #s 2 and 4 had not experienced further instances of abusive behavior, and did not experience latent effects of past abuse allegations. Resident #2 was harmed when she began to feel unsafe, lash out at others, and self isolate after Resident #1 began wandering into her room, threatening and frightening her. Resident #4 was harmed when the facility's failure to respond to Resident #1's aggressiveness and intrusiveness led her to act out in defense towards Resident #1.

Based on observation, staff interview, record review, policies and recipes, it was determined the facility failed to ensure physician-ordered pureed diets and thickened liquids were the appropriate consistency when served to residents. This was true for 5 of 15 sampled residents (#1, #2, #4, #10, and #13) and 7 random residents (#16 - #22). The facility failed to ensure: a) Resident #4 received food and liquid consistencies as ordered to protect her from aspiration, was positioned appropriately during food and liquid intake, and pureed foods and honey-thick liquids were not combined to avoid a mixed consistency; and b) Residents #1, #2, #4, #10, #13 and #16 - #22 received pureed-consistency food per physician orders. c) Residents #1, #4, #10, #13, #17 and #22, who were on pureed diets and had orders for thickened liquids, received pureed food that was not of a thinner consistency than their liquids. These deficient practices placed the above residents in Immediate Jeopardy of serious harm, impairment, or death due to aspiration of food and/or fluids into their airways. Findings include: The Idaho Diet Manual for Health Care Facilities, 11th edition, 2015, documented the ideal puree consistency should resemble whipped topping or mashed potatoes and occasionally pureed foods may be a thinner consistency to meet an individual's needs. In addition, the idaho Diet Manual documented that foods with high water content must be drained or have additional fluid thickened to the correct consistency. The Idaho Diet Manual referenced the National Dysphagia Diet: Standardization for Optimal Care guidelines. The National Dysphagia Diet: Standardization for Optimal Care 2002, documented a pureed diet was for people who had moderate to severe dysphagia with poor oral phase abilities and reduced ability to protect their airways. A puree diet consists of pureed, homogenous, and cohesive foods and should be pudding-like. A 12/7/16 InterNet search of The American Speech-Language-Hearing Association at http://www.asha.org/public/speech/swallowing/Swallowing-Disorders-in-Adults, documented a 2004 study that identified signs and symptoms of swallowing disorders included coughing during that or right after eating or drinking, wet or gurgly sounding voice during or after eating or drinking, extra effort or time needed to chew or swallow, and food or liquid leaking from or getting stuck in the mouth. The study noted treatments for those with swallowing disorders included positioning and strategies to help the individual swallow more effectively. The facility's 5/28/16 NCD Thickened Fluid Consistency P&P documented nectar thick fluid falls slowly from spoon and can be sipped through a straw or cup, honey thick fluid drop from a spoon, but too thick to be sipped from a straw, and pudding thick fluid maintains shape, needs to be taken with a spoon, too thick to drink. It documented a physician's orders [REDACTED]. It also documented pre-thickened beverages would be purchased to ensure proper consistency and that beverages not available in a pre-thickened form would be thickened according to the directions for the commercial thickening agent used. The label on the instant food thickener used in the facility directed staff to stir the liquid for 10-20 seconds and allow it to sit for 1-4 minutes until the right consistency was reached. The above standards of practice and facility used products directions, were not followed. Examples include: 1. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual MDS assessment, dated 8/15/16, documented Residents #4 had difficulty swallowing liquids and solids leaking from her mouth. The 8/15/16 Nutritional Status and Dehydration/ fluid maintenance CAA worksheet documented Resident #4 had difficulty swallowing. The 11/15/16 quarterly MDS assessment documented Resident #4 had severe cognitive impairment, was unable to communicate her needs, and required a mechanically-altered diet. Resident #4's Physicians' orders included: * Regular pureed texture diet with honey thick liquids and Nosey cups with meals, initiated 11/25/13. * Boost Plus 1.5 cal/mL thickened to honey thick during medication passes and documentation of the mL accepted, initiated 11/17/16. * A full serving of regular pudding 4 times a day with medications, initiated 6/7/16. Resident #4's 3/13/15 Nutrition Care Plan documented a risk for nutritional decline related to [MEDICAL CONDITION]'s Chorea and the need for a pureed diet. Interventions included: * Staff to provide all liquids in a coffee cup with lids and straws, beginning 2/11/15. * Staff to offer between meal food items, revised 6/10/16. * Staff to provide meals per physician diet orders of pureed honey thick liquids, initiated 8/14/14, and revised 6/10/16. * Staff to provide Resident #4 with total assistance during meals, revised 6/10/16. * Staff to provide Nosey cups, revised 6/10/16. A Chewing Difficulty Care Plan goals, dated 1/30/15, documented Resident #4 would have no episodes of choking when eating. Interventions included: * Staff to monitor and evaluate food and beverage intake via observations and meal intake records, beginning 1/30/15. * Staff to refer for a speech therapy evaluation and follow-up as indicated, beginning 1/30/15. Resident #4's care plan did not include her history of swallowing difficulty and safe swallowing practices. A 4/23/15 ST note documented Resident #4 met the goal, .exhibiting less than 15% s/sx of swallow impairment given full assistance from trained staff or caregivers following safe swallow procedures. The note documented facility staff were trained on the safest, least restrictive diet of pureed foods and safe feeding practices to decrease signs and symptoms of aspiration. The note did not document the safe swallowing procedures staff were to follow or position for Resident #4 during food or beverage intake. On 11/29/16 at 10:36 am, the SDC was observed giving 2 sips of water to Resident #4, who was in bed. The bed was raised approximately 20-degrees and Resident #4 was turned slightly to the left with her head positioned down and near her left shoulder. On 11/29/16 at 11:18 am, RN #1 was observed administering several oral medications that had been crushed and mixed in a pudding-like substance to Resident #4. Resident #4 was observed double swallowing after each bite of the pudding-medication mixture, which was administered with a spoon. The head of the bed was raised approximately 40-degrees and her head was hyperextended back which may increase the risk for aspiration according to the ST on 11/30/16 at 2:25 pm. On 11/29/16 at 12:20 pm, CNA #2 was observed preparing Resident #4's lunch at the bedside. The meal consisted of pureed mashed potatoes, brussel sprouts and chicken; and to drink honey thickened milk, boost, and juice. CNA #2 placed a couple spoonfuls of mashed potatoes into a Nosey cup and poured a small amount of honey thickened milk into the cup. She stirred the mixture a couple times and proceeded to give the potato and milk mixture to Resident #4. Immediately after the first sip, Resident #4 started to cough. The cough had a wet vocal quality to it. The mixture came out of the corners of her mouth. CNA #2 added more honey thickened liquids to the mixture and stirred a couple times and gave it to the resident. The food and honey-thick liquids were not mixed together completely and came out of the cup at different consistencies. Resident #4 immediately coughed again. The cough had a wet vocal quality to it. Initially, the head of the bed was raised approximately 40 degrees. After the second coughing episode, CNA #2 stopped the feeding, raised the head of the bed to approximately 65 degrees, repositioned Resident #4 and placed a pillow behind her head. CNA #2 resumed the feeding. At 12:36 pm, Resident #4 slid down in the bed, began to double swallow after each bite and coughed intermittently. At 12:40 pm, Resident #4 clamped her mouth and would not accept food. At that time, CNA #2 lowered the head of the bed to approximately 40 degrees and stopped feeding the resident. On 11/29/16 at 5:28 pm, CNA #11 brought a dinner tray into Resident #4's room, where the resident was slouched down in her bed. CNA #11 donned gloves and repositioned Resident #4 higher on her bed to an angle of approximately 60-degrees. CNA #11 stated she was not sure Resident #4's care plan addressed how to best help Resident #4 eat her meals. She stated Resident #4 began choking when eating meals. CNA #11 began assisting Resident #4 with her meal without first washing her hands or removing her gloves after assisting the resident reposition and adjust her clothing. CNA #11 stated she forgot to wash her hands and then used the safety-coated spoon to feed Resident #4 the mashed potatoes. CNA #11 gave Resident #4 five spoonfuls of food before the resident began to cough. Resident #4 clamped her mouth shut and would not accept another bite of food. CNA #11 put a cup of juice up to Resident #4's mouth and tipped the thickened fluids into her mouth. Resident #4 then accepted more juice and additional bites of food, which caused Resident #4 to cough intermittently throughout the meal observation. After CNA #11 finished assisting Resident #4 with her meal, she lowered the bed to approximately a 30-degree angle. On 11/30/16 at 11:06 am, Resident #4 was observed in the dining room sitting in a Broda chair. Her head was hyperextended and the chair was tilted back approximately 20-degrees. RN #1 gave Resident #4 her medications. There was also a serving of pudding to be given to Resident #4 by a CNA. CNA #5 prepared a cup of water for Resident #4 using a pre-filled/ pre-measured coffee cup, which contained the facility's thickening powder measured in the kitchen. (The coffee cup was to be used for hot beverages such as hot cocoa per the DM.) CNA #5 filled a coffee cup mug with water, stirred it with a spoon to dissolve the thickener and gave it immediately to Resident #4, placing the cup to her mouth and tipping it up. The water sprayed out of Resident #4's mouth and she coughed a couple of times after continuing to drink the water. CNA #5 placed the water cup on the table and left the room. CNA #10 then began to feed pudding to Resident #4. Resident #4 clamped her mouth shut after 2 bites of pudding. On 11/30/16 at 11:49 am, CNA #5 stated the cup of water she prepared had pre-measured/filled thickening powder already in it from the kitchen and labeled with an N, that meant nectar thick, or an H, which meant honey thick. She stated the cup was then filled with 8 ounces of water, which CNA #5 speculated squirted from the resident's mouth because of the way the resident moves her tongue. According to the label on the thickening powder, the mixture must set for 1-4 minutes to reach the right consistency. (If not allowed to set the right amount of time the mixture may be too thin.) On 11/30/16 at 12:00 pm, the Dietary Manager stated pre-filled coffee cups with thickener were for hot beverages but not cold fluids; and the facility used pre-thickened honey-and-nectar-thick water, juice, and milk for residents. She stated staff was educated in orientation on thickened liquids, all of which were provided by the kitchen. The Dietary Manager stated the Thickened Fluid Consistency policy and procedure provided to staff during orientation did not specify how long the thickener needed to sit before being given to residents. On 11/30/16 at 12:40 pm, CNA #2 brought in Resident #4's lunch tray containing pureed mashed potatoes, corn, rice and enchiladas. The corn, rice and enchilada had not held their forms and were running together on the plate. In addition, the tray also contained honey thick water, Boost, milk and juice. CNA #2 repositioned Resident #4 up in bed to approximately a 60 degree angle. CNA #2 filled a Nosey cup with a couple scoops of corn and poured honey thick water into the cup. She stirred the mixed items briefly then gave it to Resident #4. At 12:46 pm, CNA #2 added more corn and more honey thick liquids to the cup, stirred it twice and immediately gave it to the resident. The corn and water mixture were not thoroughly mixed together and came out of the cup at different consistencies into Resident #4's mouth. Resident #4 immediately started to cough after a sip. The cough had a wet vocal quality to it. CNA #2 stirred the cup of corn again then put the cup down. At 12:49 pm, CNA #2 placed a couple spoonfuls of rice into a Nosey cup and added thickened milk to the cup, stirred it briefly and gave Resident #4 a sip of the mixture. The rice and milk were not thoroughly mixed together and they came out of the cup at different consistencies into Resident #4's mouth. Resident #4 immediately started coughing after the sip. The cough had a wet vocal quality to it. CNA #2 added more rice and milk to the cup, stirred it a couple more times and gave it to Resident #4. CNA #2 stated Resident #4 had started coughing last week and appeared to have an increased swallowing issue. The CNA said she asked an RN what to do about the residents increased difficulty in swallowing and the RN told her to try mixing the pureed food and liquids. On 11/30/16 at 2:25 pm, ST #1 stated pureed food consistency should be like pudding and not spread out on the plate. He stated he had not looked at the pureed food provided on the lunch plate closely for its consistency, but stated he would check the food to see if the consistency was correct. The ST stated pureed food and liquids should not be mixed together because it would produce two different consistencies in one food item if not mixed completely. ST #1 stated positioning of residents was important and he would evaluate Resident #4 that afternoon for increased swallowing difficulties. The ST stated that in general, 90 degrees was appropriate for intake, but positioning would vary depending on individual circumstances. He stated he would evaluate Resident #4 for proper positioning and recommend what was appropriate in her case. He stated residents at risk for aspiration should remain upright for 20-30 minutes after intake of food or drink. On 11/30/16 at 4:09 pm, ST #1 was observed testing the consistency of 2 pureed food items prepared for the evening meal service that night. The food items included a turkey sandwich on wheat bread, a pea green colored food item with a mashed potato like consistency, and a light brown food item (turkey sandwich on wheat) that poured easily when the ST tipped the cup. The pureed turkey sandwich spread out onto the plate and readily dripped off a spoon. ST #1 said the turkey sandwich was thin and poured easily, which it was not the correct consistency for pureed. He said he was not sure if it was even honey thick or nectar thick consistency and that he would talk to the dietary staff the next day about the incorrect consistency of the turkey sandwich. On 11/30/16 at 4:16 pm, ST #1 stated staff should not give mixed consistencies to residents at the same time. The pureed food he looked at was not the correct consistency, but noted Resident #4 was evaluated and deemed safe to consume a pureed diet with honey thick liquids. He stated his recommendations would consist of positioning and educating staff on safe feeding practices. On 11/30/16 at 4:36 pm, RD #1 said pureed foods should be like pudding in consistency and, for the sake of safety, consistencies should not be mixed together. On 12/2/16, the facility provided the ST evaluation, dated 11/30/16, which documented Resident #4 was referred for swallowing difficulties during meals during the previous week. The note documented skilled ST was necessary to educate the caregivers and without therapy Resident #4 was at risk for possible aspiration. The note documented Resident #4 should be at an angle of no less than 60-degrees during intake and for 20 minutes after oral intake. Resident #4 was not to receive thin liquids, but was to receive pureed foods with honey thick liquids. 2. On 11/30/16 at 4:09 pm, ST #1 was observed testing the consistency of two pureed food items prepared for the evening meal service that night. The food items included a turkey sandwich on wheat bread, a pea green colored food item with a mashed potato like consistency, and a light brown food item (turkey sandwich on wheat) that poured easily when the ST tipped the cup. The pureed turkey sandwich spread out onto the plate and readily dripped off a spoon. ST #1 said the turkey sandwich was thin and poured easily, which it was not the correct consistency for pureed. He said he was not sure if it was even honey thick or nectar thick consistency and that he would talk to the dietary staff the next day about the incorrect consistency of the turkey sandwich. On 11/30/16 at 4:36 pm, RD #1 said pureed foods should be like pudding in consistency. The RD was informed of the earlier observation with the ST regarding the incorrect consistency of pureed turkey sandwich on wheat bread. On 11/30/16 at 5:35 pm, RD #1 was observed in the kitchen informing the Dietary Manager that the turkey sandwich was not the correct consistency for pureed. The facility's turkey sandwich on wheat bread recipe instructions were to arrange 1 slice of bread on a sheet pan with 2 slices of turkey on the bread and another slice of bread on top. The pureed turkey sandwich instructions directed staff to prepare the sandwich per the regular recipe. The instructions directed further for staff to prepare a slurry of water/stock and thickener, and lastly add 3 oz of slurry per portion. The recipe notes documented the amount of thickener required may vary relative to the liquid content of the cooked product, alternate processing and thickener for best results and check consistency of the food item periodically. On 11/30/16 at 5:40 pm, a test tray containing pea-green food item was of mashed potato consistency and maintained its shape. A thin light brown item, which the Dietary Manager identified as pureed turkey sandwich on wheat bread, was spread out on the plate and readily dripped from a spoon. When asked if the pureed turkey sandwich was to be served to residents, the Dietary Manager stated yes. The Dietary Manager initially said the pureed turkey sandwich looks a little thin, then said It looks alright to me when asked again if she was intended to serve the pureed turkey sandwich to residents. When asked to describe the consistency a pureed food should be, the Dietary Manager said pureed foods should be mashed potato or pudding like consistency. When asked if the turkey sandwich was the consistency of mashed potato or pudding like, the Dietary Manager stated No. The Dietary Manager then said she would not serve the pureed turkey sandwich to residents and then instructed staff to remove all meal trays with the pureed turkey sandwich. On 11/30/16 at 5:52 pm, the Dietary Manager delivered new pureed foods for the residents of mashed potato like consistency turkey sandwiches. On 11/30/16 at 7:00 pm, the DNS stated the first turkey sandwich was not the correct consistency. There were 14 residents in the facility with orders for pureed diets, seven of whom also had orders for thickened liquids, and one resident who requested pureed foods. a. Residents with orders for a pureed diet and thickened liquids included: i. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's annual MDS, dated [DATE], documented his cognitive skills were severely impaired. Resident #1's Nutrition care plan, dated 2/24/16, documented he was at risk for nutritional decline related to a choking episode on 1/27/15. Resident #1's physician's orders [REDACTED]. ii. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4's Nutrition Care Plan, dated 3/13/15, documented the risk for nutritional decline related to [MEDICAL CONDITION]'s chorea and the need for a pureed diet. Interventions included meals per physician diet orders of pureed honey thick liquids, initiated 8/14/14, and revised 6/10/16. Resident #4's Physicians' orders included a pureed texture diet with honey thick liquids and Nosey cups with meals, started 11/25/2013. iii. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 8/7/14 Nutrition Care Plan documented Resident #10 was at risk for nutritional decline related to swallowing difficulty, no teeth or dentures and a mechanically altered diet. Interventions included meals per physician diet orders with regular pureed and nectar thick liquids, revised 6/10/16. Resident #10's December 2016 recapitulation of Physicians' orders included a regular pureed texture diet with nectar thick liquids, beginning 9/01/2015. iv. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 3/9/16 Nutrition Care Plan documented Resident #13 was at risk for nutritional decline related to altered texture for Alzheimer's. Interventions included meals per physician order [REDACTED]. * Resident #13 was on swallowing precautions and was to be out of bed in his wheelchair to eat/drink. Staff was to have him elevated 90 degrees using pillows, as needed, and for 30 minutes after eating. Resident #13's December 2016 Recapitulation of Physicians' orders included a regular pureed texture diet with nectar thick liquids, beginning 9/1/15. v. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #17's December 2016 Recapitulization Physicians' orders included a regular pureed texture diet with nectar thick liquids, beginning 11/03/15. vi. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #22's December 2016 Recapitulization Physicians' orders included a regular pureed texture diet with nectar thick liquids, beginning 9/01/15. b. Residents with orders for a pureed diet included: i. Resident #2 was admitted to the facility in 2012 and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. A 4/18/16 Nutritional Care plan documented Resident #2 was at risk for nutritional decline. Interventions included meals per the physician's orders [REDACTED]. Resident #2's recapitulation of Physicians' orders included a regular diet, pureed texture, starting on 4/19/16. ii. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #16's December 2016 Recapitulization Physicians' orders documented Resident #16 was on a regular pureed texture diet, beginning 11/03/15. iii. Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #18's December 2016 Recapitulization Physicians' orders documented Resident #18 was on a regular pureed texture diet, beginning 9/01/15. iv. Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #19's December 2016 Recapitulization Physicians' orders documented Resident #19 was on a regular pureed texture diet with 1:1 assistance for cueing Resident #19 to slow down while eating and alternate liquids and solids, beginning 9/01/15. v. Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #20's December 2016 Recapitulization Physicians' orders documented Resident #20 was on a regular pureed texture diet for difficulty chewing and swallowing, beginning 11/09/16. vi. Resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #21's December 2016 Recapitulization Physicians' orders documented Resident #21 was on a limited concentrated sweet pureed texture diet for dysphagia, beginning 10/25/16. The facility failed to ensure the health and safety of residents whose nourishment included pureed foods and/or thickened liquids, were not placed at imminent risk of serious risk of harm, impairment, or death. NOTIFICATION AND REMOVAL OF IMMEDIATE JEOPARDY: On 11/30/16 at 7:05 pm, the facility Administrator and DNS were notified verbally and in writing regarding the Immediate Jeopardy situations, and of the need to formulate and implement a plan of removal. On 12/1/16 at 11:55 am, the facility provided evidence that an acceptable plan to remove the immediacy had been developed and implemented. Resident #4 was evaluated by the ST. A seating evaluation was ordered for proper positioning during meals and other times of intake and modifications to Resident #4's Broda chair were in process. All residents with orders for a pureed diet and/or thickened liquids were assessed and evaluated for signs and symptoms of aspiration. The removal plan also included re-education of dietary staff on following recipes and ensuring pureed foods were of pudding like consistencies. The nursing staff were also educated to return incorrect consistency foods to the kitchen; use pre-packaged nectar, honey and pudding thickened fluids; follow outlined directions to thicken hot beverages (except coffee to be thickened by kitchen staff); residents to remain upright for 20 minutes after eating; and not to alter the consistency of food or fluids by combining them unless specifically ordered by the physician. The above actions were verified and the Immediate Jeopardy removed prior to the survey exit conference completed on December 2, 2016.

Based on staff interview and record review, it was determined the facility failed to ensure adequate indications for use, justification for duplicate therapy, and monitoring for [MEDICAL CONDITION] medications; justification for duplicate therapy for antihypertensive medications; coordination between prescribing physicians; and adequate monitoring for antihypertensive medications. This was true for 3 of 9 sampled residents (#s 1, 4, and 5). *Resident #4 was harmed when she experienced multiple falls in conjunction with the administration of multiple [MEDICAL CONDITION] medications, when other causes of behavioral changes had not been ruled out. Resident #4 also received an antihypertensive medication without her blood pressures being monitored as ordered. *Resident #1 was harmed when he received routine hypnotic medication after he had been identified to become so drowsy he would fall asleep standing up, and experienced multiple falls. *Resident #5 had potential for harm when he received multiple antihypertensives, antipsychotics, and benzodiazapines without clear clinical indication. Findings included: Federal Guidance at F-329, specifically regarding the use of anti-psychotic medications in elderly residents, documented, "Before initiating or increasing an antipsychotic medication for enduring conditions, the target behavior must be clearly and specifically identified and documented. Monitoring must ensure that the behavioral symptoms are...not due to a medical condition or problem...and not due to environmental stressors alone...and not due to psychological stressors alone...and persistent...when dosing an antipsychotic, the treatment should be at the lowest possible dose to improve the target symptoms being monitored...when monitoring antipsychotics, it is important to not only evaluate ongoing effectiveness and potential adverse consequences...after initiating or increasing the dose of an antipsychotic medication, the behavioral symptoms must be evaluated periodically...to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing the dose based on target symptoms..." Federal Guidance at F-329, specifically regarding duplicate therapy "refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication that the individual is taking." 1. Resident #4 was originally admitted to the facility on [DATE], and most recently admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Please see F 323 for Resident #4's most recent MDS data. According to the resident's 6/24/14 Admission physician's orders [REDACTED].#4's received Glimepiride 2 mg daily for diabetes, [MEDICATION NAME] 20 mg daily for hypertension, [MEDICATION NAME] XR 150 mg daily for recurrent depression with [MEDICAL CONDITION], [MEDICATION NAME] HCl 75 mg twice daily for depression, [MEDICATION NAME] 10/325 mg every 4 hours as needed, and [MEDICATION NAME] 50 mg every 6 hours as needed for generalized pain. According to the 2015 Nursing Drug Handbook (NDH), [MEDICATION NAME] had a Black Box Warning, "Drug isn't indicated for use in elderly patients with dementia-related [MEDICAL CONDITION] because of increased risk of death from CV (cardiovascular) disease or infection." Adverse effects were documented as dizziness and agitation. [MEDICATION NAME] had a Black Box Warning, "Drug may increase hostility, agitation, and depressed mood." Adverse effects were documented as [MEDICAL CONDITION], delusions, and [MEDICAL CONDITION]. The resident's MAR from 7/1/14 through 9/18/14 documented the resident's [MEDICATION NAME] was to be held if her systolic blood pressure was less than 110. The medication was administered daily, however there was no documentation her blood pressure was taken in conjunction with the administration of this medication. The resident had multiple Monthly Behavior Monitoring Flowsheets (MBMF) for each month. When asked on 11/4/14 at 9:15 AM, the DNS stated there was one of the flow sheets for the LN to fill out, and one for the CNAs. The forms documented a pre-printed list of generic interventions to be attempted if a target behavior occurred, which were not specific to the resident. The forms for the LN and CNA did not document the same behaviors, and the behaviors on each of these forms varied from month to month. Many of the flow sheets had holes in the documentation. It was not clear which of the behaviors being monitored had been identified by the physician as the target behavior for the use of antipsychotic medication. On 7/1/14, the resident's nurses's notes (NN) documented the resident was awakened when the staff were providing cares to the resident's roommate, began yelling, tried to unplug her roommate's television and turn off the lights in the room. The physician was notified, and ordered [MEDICATION NAME] 10 mg every 6 hours as needed for [MEDICAL CONDITION]. It was not clear from the documentation how the resident reacting to awakening to find other people interacting in her private living space was determined to be "[MEDICAL CONDITION]" which required the use of an antipsychotic medication. There was no documentation regarding the risks and benefits of using two antipsychotic medications for this resident. According to the 2015 NDH, [MEDICATION NAME] had a Black Box Warning, "Drug may increase risk for CV or infection-related death in elderly patients with dementia. [MEDICATION NAME] ([MEDICATION NAME]) isn't approved to treat patients with dementia-related [MEDICAL CONDITION]." Adverse reactions were documented as [MEDICAL CONDITION], abnormal gait, and orthostatic [MEDICAL CONDITION]. At this point, the resident had orders for 3 [MEDICAL CONDITION] medications with Black Box Warnings, all of which had adverse reactions of agitation and falls. For July 2014, the target behaviors for Resident #4 were documented as refusing medication, isolation, verbal aggression, exit seeking, and becoming argumentative. On 7/21/14, the resident's [MEDICATION NAME] was changed to 150 mg of an extended release form once per day (same overall dosage), and [MEDICATION NAME] 200 mg twice per day for a [DIAGNOSES REDACTED]. There was documentation on the resident's MBMFs of "verbal aggression" on evening shift 7/20/14 through 7/22/14. On one of those occasions, the only documented intervention was that the room temperature was changed, on the other two occasions the documented intervention was medication, though the form instructed medication should not be the first choice as a behavioral intervention. The NN documented on 7/19/14 the resident had been pleasant and cooperative with cares. On 7/21/14 the NN documented she was "impulsive" with "mood swings," hence the need for the addition of the [MEDICATION NAME] as a "mood stabilizer." It could not be determined from the documentation how persistent the resident's behaviors were, what individualized approaches had been made to alter them, nor how they presented a danger to the resident or others. Also not clear from the documentation regarding the addition of [MEDICATION NAME] was when the resident was diagnosed with [REDACTED]. According to the 2015 NDH, adverse reactions for [MEDICATION NAME] were documented as ataxia (impaired gait), dizziness, confusion, and [MEDICAL CONDITION]; and each dose of the medication could remain in the resident's system for 50 to 130 hours (approximately 5 1/2 days). The resident fell on [DATE], 7/29/14, and 7/30/14. There was no documentation the addition of [MEDICATION NAME] was ruled out as a causative factor in the resident's falls. After the resident's fall on 7/29/14 she began to, and continued to, complain of back pain. She was later diagnosed with [REDACTED]. The resident's MBMFs documented target behaviors for the month of August 2014 as "repetitive", delusions with paranoia, verbal aggression, physical aggression, argumentative, "very confused," refusing bathing, refusing ADL assistance, and anger towards others. It was not clear why the target behaviors had changed since the previous month, which behavior was the target behaviors for either of her antipsychotics, her antidepressant, or her mood stabilizer. There were many blanks on the MBMFs. On 8/25/14 at 5:45 AM, the resident's NN documented she was awake most of the night, with multiple trips to the bathroom. The NN documented the resident identified trouble sleeping at night due to a long history of working the night shift. The NN documented the facility would obtain a urine sample to rule out the presence of a urinary tract infection [MEDICAL CONDITION]. On that same date at 1:58 PM, there was an entry from a social worker which documented, "...appears to have some delusional thinking and manifests this by trying to help others as she did when she was a nurse..." On 8/26/14, the resident's care plan was updated to include an intervention, "...She would like to be retired. When she is helping others as if she were the staff, remind her that she is not working this shift and to let you do the work..." There was no documentation of coordination between nursing and social services to reconcile these two perspectives on the resident's current behaviors. The NN documented a urine sample was collected on 8/26/14, but was contaminated. On 8/27/14 a urine analysis showed positive results for a UTI. On 8/29/14, the resident was started on [MEDICATION NAME] for 10 days. The resident's MBMFs for September 2014 documented target behaviors of fluctuating confusion, refusing ADLs, anger towards others, refusing bathing, physically and verbally aggressive, argumentative with others, exit seeking. There were duplicates of some of the forms, and the values documented on those forms did not match. Additionally, many areas of the forms were blank. It could not be determined how the information documented on these forms could help determine the resident's behavioral patterns or the effectiveness of interventions attempted. On 9/5/14, while the resident was still being treated for [REDACTED]. The monitor documented the resident slept a total of ten hours on 9/1/14 and 9/2/14, nine hours on 9/3/14, five hours on 9/4/14, seven hours on 9/5/14 and 9/6/14, nine hours on 9/7/14 and 9/8/14. While there were some dates where few hours of sleep were documented on night shift, the facility had established the resident had worked as a night shift nurse for many years. There was no documentation of what her normal sleeping patterns were and what the facility had done to recognize and adapt her daily routines accordingly. There was no documentation that the resident's goal was to change her sleep/wake patterns. There was also no documentation of any sleep hygiene interventions to adjust those patterns before sleep medication was used. On 9/8/14 at 2:45 AM, a NN documented the resident had been awake off and on through the night, and was refusing to sit or lay down due to back pain. The note further documented, "Resident was given PRN (as needed) [MEDICATION NAME] and also PRN [MEDICATION NAME] for increased confusion, agitation and anxiety...although every hour (resident) feels she needs to use the bathroom...transferred with the wheelchair..." When asked on 11/4/14 at 9:15 AM, the DNS agreed pain and incrased confusion were not indications for use for [MEDICATION NAME]. On that date, which was the last day the resident was receiving the antibiotic for her UTI, her [MEDICATION NAME] dose was increased to 200 mg daily, [MEDICATION NAME] mg at bedtime as needed was started. The resident was documented to continue to use the wheelchair that day. The resident's MAR indicated [REDACTED]. On 9/9/14, the NN documented the resident had a room change. There was no documentation the psychosocial stressors of her room change were assessed and addressed prior to the hypnotic medication being administered. On 9/10/14, the NN documented the resident was attempting to climb out of bed, and was given Ambien. The MAR indicated [REDACTED]. There was no documentation that her room change or pain had been assessed and addressed before the hypnotic medication was given. The NN documented the resident was still not sleeping at 12:30 AM on 9/11/14, when the MAR indicated [REDACTED]. The resident's MAR indicated [REDACTED]. There was no additional documentation regarding [MEDICATION NAME] for 9/11/14. According to the 2015 NDH, adverse reactions [MEDICATION NAME] documented as amnesia, dizziness, and nervousness. On 9/12/14 at 1:06 AM, the NN documented the resident was awake and trying to wake her roommate by throwing toiletries at her. The physician was notified and issued a one-time dose of [MEDICATION NAME] 10 mg IM. At 5:00 AM, the NN documented the resident was scheduled to have a repeat UA following the treatment of [REDACTED]. At 10:11 AM, the resident was noted to be intrusively wandering, confused, and running into walls with her wheelchair. There was no documentation to rule out whether the resident's behavior may be related to the increase in her [MEDICATION NAME] dose, the use of Ambien, the dose of IM [MEDICATION NAME], or a continued UTI. The physician was notified, and issued an order for [REDACTED]. Within the 24 hour period of 9/12/14, the resident received two doses of [MEDICATION NAME], either one or two tabs (exact dose not documented), 10 mg [MEDICATION NAME], 10 mg [MEDICATION NAME], 50 mg [MEDICATION NAME], and 200 mg [MEDICATION NAME]. According to the 2015 NDH, [MEDICATION NAME] had a Black Box Warning, "Elderly patients with dementia-related [MEDICAL CONDITION] treated with atypical or conventional antipsychotics are at increased risk for death. Antipsychotics aren't approved for the treatment of [REDACTED]. Though no further behavioral concerns were documented over the next 3 days, on 9/15/14 [MEDICATION NAME] discontinued and her [MEDICATION NAME] dose was again increased to 400 mg daily, which was double the previous dose. On 9/19/14 at 3:40 AM, the physician ordered an increase in the resident's antihypertensive medication [MEDICATION NAME], even though her blood pressure values had not been monitored with the administration of the current dose as ordered; an increase in her diabetic medication Glimepiride; and a routine dose of the pain medication [MEDICATION NAME] in addition to her "as needed" dose. On 9/20/14 it was confirmed the resident had three compression fractures in her vertebrae at undetermined stages of healing. On 9/21/14 at 9:20 PM, the NN documented the resident was "quite manic," yelling, crying, and angry. She was given PRN [MEDICATION NAME] at 4:30 PM, which was documented as minimally effective. There was no documentation of pain from her fractures being considered and ruled out as a factor in this behavioral change, nor any of her recent medication changes. 9/21/14 was the first day for the month of September the resident did not receive [MEDICATION NAME] for back pain. On 9/22/14 at 11:49 AM, the resident's [MEDICATION NAME] was increased, with the continuing with a 200 mg dose daily and adding another 400 mg. At 3:12 PM, the resident was ambulating with her walker, lost her balance, and fell over her walker. Please see F 323 for details. Her recent medication changes were not documented as considered and ruled out as causative factors. There was no documentation of follow-up being completed regarding her UTI, in terms of a repeat urinalysis. The resident had 2 MBMF records for the month of October 2014. One of the records documented either blanks or zeroes for the number of behavioral occurrences. During an interview on 11/4/14 at 9:15 AM, the DNS identified this as the form the LN filled out. The target behaviors for October were documented as [MEDICAL CONDITION] mood swings, [MEDICAL CONDITION], and depression. The LN's MBMF documented one instance of "[MEDICAL CONDITION] mood swings" on night shift on 10/16/14, and one instance of depression on day shift 10/16/14 and 10/17/14. No interventions or outcome were documented on the LN's MBMF. On 10/18/14 at 9:53 AM, a NN documented the resident woke up screaming, continued to scream while being assisted to the bathroom, activated the bathroom call light repeatedly, and cursed at staff when they responded. The physician was notified, and at 10:00 AM, the resident received one-time dose of [MEDICATION NAME] 20 mg IM. At 2:14 PM, the NN documented the LN was unable to obtain an orthostatic blood pressure from the resident because she was too drowsy. The 2015 NDH documented a Black Box Warning for [MEDICATION NAME], "In elderly patients with dementia-related [MEDICAL CONDITION], drug isn't indicated for use because of increased risk of death from CV events or infection." Adverse reactions were documented as dizziness, anxiety, [MEDICAL CONDITION], and orthostatic [MEDICAL CONDITION]. On 10/19/14 at 2:50 PM, the resident fell . The NN documented the resident lost her balance and fell backwards, with a CNA at her side. The resident fell from bed on 10/20/14 at 4:55 PM. See F 323 for details. On 10/20/14, the resident's morning dose of [MEDICATION NAME] was discontinued, but the bedtime dose continued. [MEDICATION NAME] 10 mg was added in place of the morning dose of [MEDICATION NAME]. Additionally, the [MEDICATION NAME] dose was doubled to 300 mg daily, and the [MEDICATION NAME] dose was increased to 300 mg twice daily. An ongoing order for [MEDICATION NAME] 20 mg every 8 hours as needed for [MEDICAL CONDITION] was started. According to the 2015 NDH, [MEDICATION NAME] had a Black Box Warning, "Elderly patients with dementia-related [MEDICAL CONDITION] treated with atypical antipsychotics are at increased risk for death. [MEDICATION NAME] isn't approved for the treatment of [REDACTED]." Adverse reactions were documented as anxiety, [MEDICAL CONDITION], dizziness, nervousness, hostility, manic behavior, confusion, abnormal gait, and restlessness. Additionally, the NDH documented a drug-to-drug interaction with [MEDICATION NAME] and antihypertensives, as the use of [MEDICATION NAME] may enhance their effect, causing [MEDICAL CONDITION]. The NDH advised blood pressures be monitored with the use of the drug. The NDH also documented a dose of [MEDICATION NAME] could remain in a patient's system for over 6 days. The resident's medications now included four antipsychotics ([MEDICATION NAME], and [MEDICATION NAME]), a mood stabilizer ([MEDICATION NAME]), and an anti-depressant ([MEDICATION NAME]). Four of these medications were either added or increased in dosage on the same day. Five of the medications carried a Black Box Warning. There was no documentation as to why the resident required multiple antipsychotic medications, or why multiple medication doses were adjusted on the same day. The resident fell on [DATE] at 7:20 AM, 10/28/14 at 8:15 PM, 10/29/14 at 3:15 PM, and 11/1/14 at 12:20 PM. There was no documented evaluation of the effects of her multiple [MEDICAL CONDITION] medication changes as a factor in any of these falls. On 11/4/14 at 9:15 AM, when asked, the DNS stated: *No specific target behavior corresponding to the use of each of the resident's [MEDICAL CONDITION] medications was identified. The DNS stated the resident did become agitated, and was believed to have a behavior of, "putting herself on the floor to get attention." Please see F 323 for details. *Some of the resident's mediation changes were made by her primary care physician, some were made by the facility's medical director (a psychiatrist). The DNS stated she did not know of any formal dialogue between the two providers regarding this resident, and as a rule such an interaction would not happen for any resident. *The resident was diagnosed with [REDACTED]. The DNS did not know what diagnostic tool the physician had used to arrive at that diagnosis. The DNS could not provide research or documentation from the physician regarding a resident being diagnosed as [MEDICAL CONDITION] after already being diagnosed with [REDACTED]. *The DNS agreed it was not a "best practice" to make multiple [MEDICAL CONDITION] medication changes in a single day, as it was difficult to monitor both effectiveness, and adverse effects of these medications when this occurred. *The facility had discovered at some point that the resident had been a night shift RN for at least seventeen years. However, since the resident was felt not to be sleeping at night, the facility felt putting the resident [MEDICATION NAME] help her sleep at night was justified. The DNS could not explain how the facility had incorporated the resident's past history into her plan of care, other than the single additional intervention to her care plan on 8/26/14. *The DNS could not explain how root causes of the resident's behavioral changes, such as pain, UTIs, or room changes, had been ruled out before making [MEDICAL CONDITION] medication changes. Resident #4 was harmed when the facility initiated multiple [MEDICAL CONDITION] medications, including antipsychotics and mood stabilizers, without first investigating the root cause of her behavioral changes. Many of these medications carried Black Box Warnings and had documented adverse effects, which were not assessed as the resident began to have behavioral changes, falls, decline in her functional abilities, and confusion. The target symptoms for the use of these medications were not clearly identified or monitored, and individualized non-pharmacological interventions consistent with the resident's personal history and preferences were not developed or implemented. The resident experienced fourteen falls with injuries which included fractured vertebrae, increased pain which was at times treated with [MEDICAL CONDITION] medications, and a decline in her functional status as these medication changes evolved. The resident's polypharmacy was not identified as a possible root cause of these changes, nor investigated and ruled out. On 11/4/14 at 3:10 PM, the Administrator was informed of these findings. The Administrator indicated he had been led to believe some of these factors had been investigated, although there was no documentation to confirm that. The Administrator stated, "There is no defense for the indefensible." The facility offered no further information. 2. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Please see F 323 for Resident #1's MDS data. Resident #1's MARs from 7/1/14 through 9/5/14 documented an order for [REDACTED]. The MARs documented the resident received the medication on 4 occasions in July, but not at all in August or September. The resident's NN for from 7/1/14 through 9/5/14 did not document any concerns with the resident sleeping patterns. On 9/5/14 at 5:59 PM, Resident #1's NNs documented, "New order to discontinue Ambien, begin [MEDICATION NAME] 30 mg (by mouth at bedtime)." There was no documentation as to why the resident was started on a routine hypnotic medication, when he had not used the "as needed" hypnotic available to him for over a month. The 2015 NDH for [MEDICATION NAME] documented, "...Indications and dosages...Elderly or debilitated patients: 7.5 mg (by mouth) at bedtime until individual response is determined." Each dose of the medication was documented to take over 17 hours to clear from the resident's system. Adverse reactions included drowsiness, dizziness, lethargy, disturbed coordination, daytime sedation, confusion, nightmares, [MEDICAL CONDITION], weakness, nervousness, and blurred vision. On 9/5/14, the resident's care plan was updated with a focus area of, "Impaired Sleep Pattern (related to): Inability to fall asleep." Interventions included the use of medication, helping the resident to find a calm and quiet environment, offering music, limiting caffeine and fluids before bedtime, offering warm milk, and offering a banana or high carbohydrate snack. It could not be determined how the facility was to provide both a quiet environment and music, and both limit fluids and offer warm milk. Resident #1's NN on 9/7/14 at 6:13 AM documented the resident was awake at the beginning of night shift (10:00 PM), but was assisted to bed due to being on a new sleep medication. The NN for night shift on 9/8/14 and 9/9/14 documented the resident awakened occasionally throughout those nights, but had to be put back in bed due to his new sleeping medication. On 9/8/14, a progress note from the resident's psychiatrist documented, "...continues to be rather drowsy during the day. Nursing reports that he tends to fall asleep even standing up, at times he falls asleep at meals and at various other inconvenient times...Review of his medication shows significant doses of [MEDICATION NAME], which is likely the most prominent contributor of the sedation..." The progress note did not document the recent addition of [MEDICATION NAME] as a possible contributing factor to the resident's drowsiness, and the psychiatrist did not make changes in that medication. Additionally, even though the psychiatrist had identified the resident's [MEDICATION NAME] as a possible contributing factor, there was no documented change in the [MEDICATION NAME] dose, and no documentation the psychiatrist communicated this concern to the resident's primary care physician. On 9/11/14, a progress note from the resident's primary care physician documented, "The patient is an elderly male...quite debilitated. Today when I see him, he is sleeping soundly in his room. He does have episodes where he becomes extremely sleepy and sleeps quite soundly. Today, he did not awaken for the examination..." The progress note documented a [DIAGNOSES REDACTED]. The resident fell twice on 9/14/14, and again on 9/21/14. The resident was later diagnosed with [REDACTED]. Please see F 323 for details. The resident continued on the dose of [MEDICATION NAME] at the time the survey was conducted. On 11/4/14 at 12:35 PM, when asked, the DNS stated she had talked to the physician about using [MEDICATION NAME] for this resident, but the physician felt it was the best medication and wanted to continue it. When asked, the DNS stated the she was not sure why the psychiatrist had ordered the [MEDICATION NAME] for the resident. The DNS agreed if the resident had not been using the "as needed" sleep medication, and there were no changes in sleep patterns documented, it did not make sense to start a routine sleep medication. Resident #1 was harmed when he began to receive hypnotic medication without indication for its use. The resident was seen by two physicians, each of whom noted the resident's excessive drowsiness, but neither of whom considered the effects of the hypnotic use. The resident experienced three falls within 16 days of the initiation of this medication, and sustained injuries which required surgical intervention. On 11/4/14 at 3:50 PM, the Administrator was informed of these findings. The facility offered no further information. 3. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's Admission MDS, dated [DATE], documented the resident was cognitively intact and required 2 person extensive assistance for bed mobility, transfer and toileting. The resident did not have delusions, manifest behavioral symptoms, reject care by caregivers or exhibit wandering behaviors. According to the physician's orders [REDACTED]. notify the physician if the resident's B/P was greater than 170/95 or less than 90/50. According to the 2015 NDH: *[MEDICATION NAME] had adverse reactions of lightheadedness, dizziness and [MEDICAL CONDITION]. Additionally, there was a caution which documented, "Elderly patients may experience enhanced adverse reactions." *Klonopin had adverse reactions of confusion, glassy-eyed appearance, [MEDICAL CONDITIONS], agitation, anxiety, hostility, irritability, nervousness, abnormal coordination, dizziness, ataxia (lack of muscle control during voluntary movement), and sleep disturbances. *[MEDICATION NAME] had adverse reactions of dizziness, headache, and fatigue. *[MEDICATION NAME] had adverse reactions of dizziness, drowsiness, weakness and orthostatic [MEDICAL CONDITION]. The drug-drug interactions listed [MEDICATION NAME] which could increase the risk of orthostatic [MEDICAL CONDITION], and directed to help the patient stand slowly until effects are known. Additionally, the NDH directed to use [MEDICATION NAME] cautiously in patients receiving other antihypertensives, to monitor blood pressure, and pulse rate frequently and elderly patients could be more sensitive to the drug's hypotensive effects. *[MEDICATION NAME] and [MEDICATION NAME] had drug to drug interactions with antihypertensives which could increase effects of those medications, and cautioned to monitor blood pressure. Resident #5 was on three antihypertensive medications in addition to multiple [MEDICAL CONDITION] medications. It could not be determined from the physician's orders [REDACTED]. The resident's MAR indicated [REDACTED]. Therefore, it was impossible to determine whether the resident was experiencing adverse effects from the use of multiple antihypertensive medications. On 9/5/14 the resident fell , (see F-323). The facility requested the physician review the medications as a result. A NN on 9/7/14 and 9/8/14 documented the resident had been confused, agitated, irritable, nervous, dizzy and had abnormal coordination. A Physician Telephone Order on 9/8/14 documented an increase of Klonopin 0.5 mg BID and to decrease the [MEDICATION NAME] to 60 mg BID. It could not be determined why the physician increased the resident's Klonopin, considering the adverse effects of this medication were agitation, irritability and nervousness. A physician's orders [REDACTED]. The 2015 NDH for [MEDICATION NAME] included a nursing consideration to reduce doses in elderly patients as these patients may be more sensitive to the drug's adverse CNS effects. Additionally, the adverse reactions for [MEDICATION NAME] included dizziness, lethargy, disturbed coordination, confusion, weakness, headache, fatigue, and anxiety. No documentation was found which indicated the facility had used resident specific non-pharmaceutical approaches for resident behaviors. There was no documentation of how persistently the resident was experiencing hallucinations, delusions or [MEDICAL CONDITION]; or how they were harmful to the resident or others. It could not be determined what the therapeutic goals were or how the effectiveness of the medication changes would be monitored. The monitoring of the resident's total hours of sleep was already in place and documented the resident had experienced only one day where he slept less than 6 hours prior to the 9/11/14 order for [MEDICATION NAME]. A NN on 9/13/14 documented the resident was walking to his room with a CNA, became weak and his knees buckled. On 9/14/14 a NN documented th

Based on review of fall investigations, record review and staff interview, it was determined the facility failed to ensure the safety of residents from falls and accidents. This was true for 5 of 9 (#s 1,4,5,7 & 9) sampled residents. *Resident #1 was harmed when he fell and sustained a left lateral tibial plateau fracture and torn meniscus. *Resident #4 was harmed when she fell 14 times in a 4 month period, experienced increased pain and decreased function, and was later diagnosed with [REDACTED]. *Resident #5 was harmed when he fell five times and sustained a left hand fracture of the 5th metacarpal with unknown origin. *Resident #7 fell due to lack of 1:1 supervision. *Resident #9 fell two times with one witnessed fall and one unwitnessed fall. Findings included: 1. Resident #4 was originally admitted to the facility on [DATE], and most recently admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #4's Admission MDS, dated [DATE], coded: *BIMS of 8, indicating moderately impaired cognitive skills; *Delusions; *Verbal behavioral symptoms 1-3 days out of the past 7 days; *Behavioral symptoms did not impact the resident, others, or disrupt the social environment of the facility; *Supervision after set-up for ambulation; *Extensive assistance of 2 for toileting; *Limited assistance of 1 for dressing; *Frequent pain of 7 out of 10, which required medications but no non-pharmacological interventions; and *Falls in the past month, but no falls for 2-6 months prior to that. Resident #4's current fall care plan documented the resident had falls, and was at increased risk for further falls due to poor balance, impaired perception of her body position, confusion, visual deficits, gait, balance impairment, incontinence, and psychotropic medication use. Interventions in place beginning 6/3/14 included ensuring the call light was in reach and encouraging the resident to use her four-wheeled walker when ambulating, as well as PT to evaluate and treat as needed. On 6/24/14, an intervention to verbally instruct her when seating or transferring her, using one-step instructions was added. The 6/24/14 intervention was the only new fall intervention put in place for this resident when she returned to the facility following a surgical procedure to remove a large bowel obstruction. There was no documentation for additional supervision for the resident who was acutely ill and confused. The resident fell 14 times between 7/9/14 and 11/1/14. The following documents were reviewed for each of the resident's falls: Nursing Progress Notes (NN), Post Fall Investigations (PFI), Interdisciplinary Team Event Reviews (IDT) care plan updates (CP), Physician's progress notes (MDPN), Morse Fall Risk Scale (MFRS), Weights and Vitals Summary for Blood Pressure (BP), MARs, and the 2015 Nursing Drug Handbook (NDH). Fall #1. On 7/9/14 at 11:50 AM, a NN documented the resident slid out of bed trying to scratch her abdomen; the PFI documented the fall occurred when the resident was sitting at the edge of her bed; and witness statements documented she was attempting to dress herself and scratch her abdomen. The PI (Performance Improvement) Recommendations documented the resident would wear non-skid socks or shoes at all times. The resident's CP was updated to monitor for gait changes, but did not include an update for non-skid socks. On 7/16/14, seven days after the fall, an IDT review in the resident's NN documented the resident had agreed to wear non-skid socks. When asked on 11/4/14 at 9:15 AM, the DNS stated she had determined the root cause to be the lack of appropriate footwear, based on an interview with the resident the day following the fall. The DNS stated she had not documented the interview anywhere, and could not explain how other factors, such as as the amount of assistance offered for dressing, or the cause of the itching on the resident's abdomen had been ruled out. The DNS stated the facility did not incorporate increased assistance or supervision to the resident's CP following this fall. On 7/9/14, a Morse Fall Risk Scale was completed for Resident #4 with a score of 85, indicating the resident was at high risk for falls. The fall risk scale was repeated on 7/26/14, 7/29/14, 7/30/14, 9/4/14, and 9/22/14. The resident remained in the high risk for falls category for each of these assessments. The "Risk Variables" were documented as a history of falls, the need for a walker when ambulating, the resident's tendency to overestimate or forget limitations, the use of multiple medications, [DIAGNOSES REDACTED]. On 7/16/14, the resident was discharged from Physical Therapy (PT) and Occupational Therapy (OT). The PT and OT discharge summaries documented the resident was "modified independent" (resident completing more than 50 percent of the task, requiring adaptive equipment, or needing reminders for safety) with ambulation up to 400 feet, bed mobility if a "log roll" technique was used, transfers, dressing/undressing, and toileting. On 7/21/14 at 6:03 PM, the NN documented the resident was started on the medication Tegretol 200 mg twice per day for a new [DIAGNOSES REDACTED]. The NDH documented potential adverse reactions for both medications as dizziness, ataxia (impaired gait), and syncope. Fall #2. On 7/26/14 at 11:30 AM, a PFI for Resident #4 documented a second fall. The NN documented the resident abandoned her walker in the dining room, ambulated to a "side table" to pick dead leaves off of a plant, lost her balance, and fell . The PFI documented PI Recommendations of closed toe, closed heeled non-skid shoes, and to remind the resident to use her walker. On 7/29/14 at 10:04 AM, an IDT Event Review in Resident's #4's NN documented the resident was forgetful and required reminders to use her walker. (NOTE: This intervention was added to the resident's care plan on 6/3/14, therefore should have been implemented when the resident abandoned her walker to approach the plants on the side table.) The NN documented the resident's preference to wear Croc-type shoes, with a plan that social services would talk to the resident about using different shoes. The intervention of "solid grip tennis shoes" was added to the resident's care plan on 10/14/14, however the resident did not receive the tennis shoes until 10/27/14. The event review did not document whether the addition of Tegretol and increased Wellbutrin just 5 days prior had been evaluated as a contributing factor to the resident's fall. No interventions for increased supervision or assistance were added to the resident's care plan. When asked on 11/4/14 at 9:15 AM, the DNS and DDCO stated the facility provided the resident with non-skid socks, but not different shoes. The DDCO confirmed the documentation related to the fall did not address if adverse effects of the medication changes had been considered and ruled out as a causative factor. Fall #3. On 7/29/14 at 3:30 PM a NN documented the resident fell in the dining room while trying to get into a chair. The resident complained of new onset of back pain and was medicated with Ultram. At 8:19 PM the physician was notified of continued back pain. The NN documented the physician ordered ice to be placed to the resident's back three times daily, and a x-ray be obtained if the complaints of pain continued the next day. The FSI documented maintenance to examine/repair "leg sliders" on the bottom of the dining room chair legs, as the chair the resident was using had worn sliders. The resident's MAR documented complaints of back pain which continued throughout the remainder of July, August, and September 2014. See F 309 for details. When asked on 11/4/14 at 9:15 AM, the DNS stated the root cause of this fall was related to worn down small plastic attachments on the bottom of the dining room chair legs, which made it difficult to slide the chairs across the floor. The facility inspected and replaced the worn parts to correct the problem. Additionally,the DNS was asked why the x-ray had not been obtained for this resident when her complaints of back pain continued. The DNS stated she did not know. Fall #4. On 7/30/14 at 6:00 AM, a PFI documented the resident fell from her bed, stating the mattress was slick. The NN documented the resident continued to complain of back pain from her fall the previous day. The facility documented they changed her bed from a bariatric bed to a "regular" bed with bolsters, however it was not added to the resident's care plan until 8/17/14. An 8/1/14 IDT Event Review NN documented an unknown family member reported a history of the resident sliding to the floor to get attention. It was unclear how the family member had determined this to be a deliberate behavior, how often it occurred, what may trigger the behavior, or what interventions may be helpful if the behavior occurred. The care plan was not updated with this information until 10/20/14, after the resident had fallen 6 more times. On 11/4/14 at 9:15 AM, the DNS stated the resident had been on a bariatric air bed at the time of her re-admission to the facility, and was changed to a standard hospital bed with bolsters to define the edge of the bed after the 7/30/14 fall. The DNS could not explain why the root cause of the resident's back pain had not been identified and addressed. Fall #5. On 9/4/14 at 6:30 AM, a PFI documented the resident fell getting out of bed. A NN documented the resident was wearing poorly fitting non-skid socks. On 9/4/14 at 11:17 PM, and again on 9/5/14 at 9:49 AM, the NN documented the resident was now using a wheelchair for mobility, however the wheelchair was not added to the resident's care plan until 10/31/14. The PI recommendations documented non-skid strips on the floor at bedside, and staff was to ensure the resident was wearing "fitted" non-skid socks. The PI recommendations were added to the care plan on 9/4/14. This was the third of her 5 falls attributed in part to improper footwear. The resident continued to complain of back pain after this fall. On 11/4/14 at 9:15 AM, the DNS confirmed the resident was wearing poorly fitted non-skid socks at the time of the fall, and the IDT concluded staff was to ensure the resident had "fitted" non-skid socks. No explanation was offered as to how the facility had addressed the resident's ongoing complaints of back pain. From 9/4/14 to 9/19/14, Resident #4's NN documented multiple changes in her health and behavioral status, including continued complaints of back pain, at times at an intensity of 10 out of 10; a UTI; an increase in her Seroquel dose on 9/8/14 and 9/15/14; the addition of Ambien on 9/8/14; an increase in her Tegretol dose on 9/15/14; and new orders for "as needed" Haldol and Benadryl on 9/12/14. Please see F 329 for details. On 9/19/14, Resident #4's NNs documented new orders to increase her diabetic medication (causing the potential for low blood glucose levels), increase her anti-hypertensive medication Lisinopril (increasing her risk for hypotensive episodes), and initiate a routine dose for Ultram, in addition to her "as needed" dose. Additionally, there was an order for [REDACTED]. The resident's Final X-Ray Report dated 9/20/14 documented the resident had osteoporotic compression fractures of T12, L2, and L4 vertebrae, of undetermined age. It could not be determined from the documentation if the resident required further diagnostic work-up, or if there was a need for precautions and/or limitations related to the fractures. On 11/4/14 at 9:30 AM, the DNS stated she did not know why the resident's back had not been x-rayed between the onset of her complaints of back pain following her 7/29/14 fall, and the time the x-ray was completed on 9/19/14. The DNS was unable to provide evidence the resident had received increased supervision following any of her falls or medication changes, and was unaware whether there was to be any further diagnostic work-up or treatment needed for the fractures. The DNS stated she did not believe the fractures could be attributed to the 7/29/14 fall, as the resident had a history of [REDACTED]. for providing adequate assistance and supervision to prevent falls for this resident. On 9/22/14 at 11:49 AM, the NN documented the resident had been having back pain, and was scheduled for a CT urogram the following day due to continued UTIs. Fall #6. On 9/22/14 at 3:30 PM, the PFI documented the resident fell trying to ambulate from a chair in her room to look for a stuffed dog. The NN documented the resident had recently been moved to a new room and was trying to find her things. The PI Recommendations included moving the resident to a "high traffic" room (near the nurse's station); encouraging the resident to participate in activities; providing staff assistance when the resident was "looking for things;" and wear non-skid socks. No new interventions were documented on the resident's care plan. On 9/25/14 an IDT review documented the resident had been "more manic," noncompliant, and a history of putting herself on the floor. On 9/29/14, the results of the resident's CT urogram documented, "Multiple new compression fractures...the compression fractures are likely the etiology (cause) of the resident's back pain." On 11/4/14 at 9:15 AM, the DNS stated after the 9/22/14 fall, the facility determined the resident had a long history of putting herself on the floor to get attention, therefore it was unclear if this event was a fall. The DNS stated she had been sitting in her office at the time of the fall, and did not hear a "thud" therefore she determined the resident had placed herself on the floor, and had not "technically" fallen. When asked, the DNS stated the facility's process for acclimating a resident to a new room was to show the resident their new room, introduce them to their roommate, explain the reason for the room change, and monitor if they liked the room. The process did not involve increased supervision, or ongoing orientation for the resident to identify placement of his or her things. Additionally, the DNS was asked if the multiple medication changes were considered and ruled out during the investigative process, the DNS was unable to explain. Fall #7. On 10/11/14 at 3:00 AM, the PFI documented the resident had fallen in her room after taking herself to the restroom. The PI Recommendations documented the resident was to be offered assistance to the toilet "every round" at night, and this was added to the resident's care plan. The NN documented the resident was reminded to use her call light to ask for assistance. It could not be determined how the facility assessed the cognitively impaired resident was able to remember to ask for assistance at night. Fall #8. On 10/14/14 at 5:55 AM, the PFI documented, the resident fell in her room, wearing no pants, no incontinence brief, or shoes. Additionally, the resident was incontinent and was attempting to retrieve a new brief from the closet when she fell . The form documented the resident "self toilets," even though the new intervention from her fall on 10/11/14 documented the resident was to be offered assistance toileting at night. The PI Recommendations documented a physical therapy referral was requested for the resident, and the alarmed mat was to be removed; however this was the first documentation of an alarmed mat for the resident and it was not on the care plan. Additionally, the physician was to evaluate her blood pressures. On 10/16/14 at 8:40 AM, an IDT event review documented the resident did not consistently understand or agree with her limitations and would at times argue or laugh when reminded. The event review documented the resident fell on [DATE], and had been assisted by staff to use the bathroom at night since that time, and had not fallen since. However, the resident fell on [DATE] while taking herself to the toilet at night. On 11/4/14 at 9:15 AM, the DNS stated the resident was now working with PT, and the physician had evaluated her blood pressures on 10/28/14. The DNS could not explain the delay in these interventions being implemented. On 10/18/14 at 10:00 AM, the NN documented the resident received 30 mg of Geodon IM due to threatening staff, and at 2:14 PM the resident had been sleeping most of the time since the medication was given. Fall #9. On 10/19/14 at 2:50 PM, the PFI documented the resident objected to a staff member helping her to ambulate back to bed from the bathroom, and the resident fell backwards. The PI Recommendations documented the facility's medical director (a psychiatrist) was to review the resident. On 10/20/14 at 3:20 PM, an IDT event review documented the resident had some low blood pressures, however, no BP values were given. The facility documented the physician would review the resident's BPs at the "next visit." The IDT review referred to the fall on 10/14/14 and documented, "She has not been to therapy since July will refer back to PT to work on balance..." At 3:48 PM second IDT event review documented the resident had called out for help, a CNA approached her to steady her by reaching for the resident's belt loop, at which point the resident objected to the care provided and fell backwards. On 11/4/14 at 9:15 AM, the DNS was unable to explain why the resident's blood pressures had not been reviewed. Additionally, PT was recommended after the fall on 10/14/14, however had not started until after the fall on 10/19/14. The DNS confirmed the belt loop would not be the preferred method of preventing a fall. The DNS said she did not think a CNA grabbing the resident by the belt loop would cause resistive behavior. Fall #10. On 10/20/14 at 4:55 PM, the PFI documented a CNA observed the resident, "on the floor on her bottom pushing herself around the floor on her bottom with her hands." The PI Recommendations documented the primary physician was to review the resident, however the documentation did not identify what specifically the physician was to review. A NN documented the resident was encouraged to use a wheelchair, but refused. On 10/20/14 at 7:14 PM, the NN documented the new orders for Geodon 20 mg IM every 8 hours as needed, increase her dosages of Wellbutrin and Tegretol, add Abilify, and continue her Seroquel at a lower dose. On 10/21/14, the resident was evaluated by PT and the evaluation documented the resident had deteriorated in her abilities to move herself around in bed, walk, transfer, and had decreased balance after she was discharged from services on 7/16/14. On 11/4/14, when asked, the DNS stated the facility requested the physician evaluate the resident for her BP medications. The DNS offered no explanation as to why this evaluation had not occurred. The DNS was asked and was unable to explain if or how the facility had increased monitoring of the resident following the multiple psychotropic medication changes made on 10/20/14. Fall #11. On 10/22/14 at 7:20 AM, a PFI documented the resident was found in a seated position in the hallway with her walker behind her. A NN documented the resident was calm, changed her story twice, and complained of pain, however, pain medications were not administered related to concerns it would cause the resident to be even more unsteady. The PI Recommendation documented to have the primary physician evaluate the resident. No new interventions were implemented to ensure the resident's safety while waiting for the physician's evaluation. On 11/4/14 at 9:15 AM, the DNS stated the facility wanted the physician to review the resident's blood pressures. The DNS stated the facility had determined the resident had fallen deliberately, based on her demeanor at the time of the fall, inconsistencies in her story, and the resident's son stating this had been a previous history for her. The DNS was unable to explain why the resident had not been treated for [REDACTED]. On 10/28/14 the physician reviewed the resident's blood pressures, and increased her blood pressure medication. Fall # 12. On 10/28/14 at 8:15 PM, a PFI documented the resident was ambulating in the hallway, started to sway, and was lowered to the floor. The PI Recommendations for this fall were, "Family conference to discuss discharge and fall prevention to accomplish this," and, "...have asked Social Services to schedule a care conference...which includes safety compliance and more appropriate ways to get attention than being on the floor. She (the resident) needs to understand that with the meds she takes she is higher risk and we will explain the safety factors she needs to be aware of..." Fall #13. On 10/29/14 at 3:15 PM, a PFI documented the resident was standing near her bed holding onto her walker and fell to the floor, and the nurse had been in the room with the resident 2 minutes prior to the fall. The PI Recommendations documented the resident was to use a wheel chair instead of a walker for mobility, and if the resident was insistent on using her walker without staff, the walker was to be removed from the resident's reach. Additionally, the purchase of stable shoes was recommended. On 10/29/14 at 4:11 PM, a NN documented a care conference was held with the resident, two nurses, a social worker, and the Administrator. The plan was to remind the resident of her goal of transitioning to an assisted living; to use her call light; and to wear non-skid socks; and non-skid shoes were to be purchased for the resident. On 10/31/14, an IDT event review documented the facility purchased shoes for the resident. On 11/4/14 at 9:15 AM, when asked why the resident did not already have the non-skid shoes as an intervention for a fall on 7/29/14, the DNS stated the resident had refused to wear different shoes at the time the original intervention was identified. The refusals had not been documented. The DNS was unsure if the resident had other shoes available before the facility purchased them on 10/31/14. Fall #14. On 11/1/14 at 1:31 PM, a NN documented the resident fell attempting to take herself to the bathroom, less than an hour after she was reminded to call for help. The facility had not finished the investigation of this fall at the time of the survey. Resident #4 was harmed when she fell 14 times in a four month period, complained of new onset back pain, experienced a decline in her functional abilities, and suffered from 3 compression fractures in her back. The facility failed to determine the underlying causes for the resident's falls and did not implement interventions to include increased supervision. The facility did not monitor and evaluate the effectiveness of their interventions, or modify those interventions after the resident continued to fall. On 11/4/14 at 3:20 PM, the Administrator was informed of these findings. The Administrator stated, "I know the resident had a history of [REDACTED]. There is no defense against the indefensible." The facility offered no further information. 2. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. On 7/2/14, the resident's change of condition MDS assessment coded: *Cognitively intact; *Impaired range of motion in one arm and one leg; *No mood indicators, including insomnia; *No behaviors; *Supervision for transfers, ambulation, and eating; *Limited assistance of 1 person for dressing, bed mobility, and hygiene; *Continent of bladder; and *1 fall with minor injury since his previous MDS assessment on 3/30/14. No falls care plan was documented for the resident until 7/7/14. Fall #1. On 7/3/14 at 4:00 PM, a PFI documented the resident became dizzy and fell while ambulating from his room to the dining room. The PI Recommendations included new shoes for the resident. There was no documentation on the resident's care plan regarding footwear until 8/25/14. On 11/4/14 at 12:35 PM, when asked, the DNS stated the resident's shoes had not been fastened properly when he fell , and the facility determined the resident would need new, special order orthotic shoes to fit over a brace he wore on his left leg. The DNS stated the facility let the resident's wife know of this need, but did not know for sure when the resident was fitted for, or received, his new shoes. On 7/4/14, PT progress notes documented the resident was able to ambulate with a 2-wheeled walker and transfer with modified independence and supervision in crowded areas, but continued to be a fall risk. There were no concerns documented with range of motion in the resident's left knee or the resident's ability to bear weight through his lower extremities. On 7/7/14, the facility initiated a care plan for risk of falls due to diminished safety awareness and history of falls. Interventions included anticipate and meet the resident's needs; encourage use of the call light and prompt response to requests for assistance; encourage the use of a cane when ambulating; and monitor for gait changes. NOTE: Since the resident had left sided weakness from his stroke, he used his right hand to manage his cane. On 9/5/14, the resident was started on Restoril 30 mg at bedtime routinely for a [DIAGNOSES REDACTED]. Please see F 329 for details. On 9/8/14, a progress note from the resident's psychiatrist documented, "...continues to be rather drowsy during the day. Nursing report that he tends to fall asleep even standing up...Review of his medication shows significant doses of methadone, which is likely the most prominent contributor of the sedation..." The note did not address the addition of a hypnotic medication for insomnia just three days prior, or the resident's methadone. Fall #2. On 9/14/14 at 12:20 PM, a PFI documented the resident fell while attempting to stand and put his shoes on. The description of the event documented the resident had received new orthotic shoes, and was trying to remove them while standing in the hallway. A CNA assisted the resident to remove his shoes, without having him sit, and he lost his balance and fell . The PI Recommendations were to educate the CNA to have the resident sit when assisting him with his footwear. The resident's record documented his right wrist was tender, but did not document an assessment of his range of motion for any of his extremities following this fall. The facility did not document increased supervision for the resident after he fell , even though he was complaining of tenderness in the extremity he used to manage his cane. The PFI did not document the addition of a hypnotic medication 9 days prior. The PFI documented the incident took place at 12:20 PM, but the physician and family were both notified at noon, twenty minutes before the event occurred. On 11/4/14 at 12:35 PM, when asked, the DNS stated the resident reported after he fell that he had received his new orthotic shoes, and was instructed to wear them for only an hour and a half at a time until they were broken in. The DNS stated the facility was unaware the resident had received his new shoes, and had not received instructions as to when and how they were to be applied from the orthotic shoe provider. The DNS agreed this was information the facility should have had, and the facility should have been evaluating the resident after he received the shoes. The DNS stated the resident told the facility he had been wearing the new shoes for the allotted time, and was trying to remove them while standing in the hallway. The resident did request assistance from a CNA who was in the room across the hall. The DNS stated it was a new CNA who did not realize the resident should sit when being assisted with footwear. The DNS stated the fall was determined to be the facility's fault, and the CNA was educated. The DNS could not determine, from the documentation on the PFI or in the NN, if the resident's range of motion had been assessed after this fall. The DNS could not determine which physician had been notified, when they were notified, or what the physician's response had been. The DNS was unable to determine what, if any, increased supervision was provided for the resident after his fall. Fall #3. On 9/14/14 at 3:05 PM, less than 3 hours after the previous fall, a PFI documented the resident fell again. The description of the fall documented, "My knee was sore from earlier fall. (Left) knee buckled. Also with (increased) weakness in (right) hand which he holds cane with." The PI Recommendations from this fall documented the resident was to use a wheelchair until a PT evaluation could be obtained, and staff to assist with ambulation until "back to baseline." At 3:48 PM, the resident's NN documented, "...(complains of) pain left knee 4 (out of) 10...Also stated his right hand felt weaker. (Range of motion) good in all extremities but left..." The PFI documented the physician was notified of the fall at 4:00 PM, but did not document whether the notification included the resident's complaints that his knee buckled and was painful, or that his right wrist was weak and tender. The form did not document which physician was notified. The form did not document whether the physician was notified in person, by telephone, or via fax. There was no response from the physician documented on either the PFI or in the NN at the time of the fall. There was no documentation as to how the resident was being transferred by staff after his second fall on 9/14/14. On 9/14/14 at 7:47 PM, the NN documented the resident complained of right thumb pain, and was given pain medication. On 9/14/14, the resident's care plan was updated to include "actual falls" as a focus area. Interventions included, "All dressing including putting on jacket and shoes while sitting down due to left sided weakness and poor balance," and to monitor for pain, bruises and change in mental status for 72 hours due to new onset confusion, sleepiness, and agitation. On 9/15/14 at 7:21 AM, the NN documented that throughout the night, the resident had complained of 8 out of 10 pain in his left knee, and would not put weight on his leg. The NN documented pain medication was given, but did not document the physician was notified of these developments. On 9/15/14 at 10:48 AM, the NN documented the physician was updated on the resident's falls and complaints of pain. The NN documented the resident reported tenderness in the left medial knee and radiated to his posterior knee. An x-ray to the left knee was requested. On 9/15/14 at 11:15 AM the facility documented the medical director (a psychiatrist) ordered an x-ray to the left knee. At 12:12 PM, the facility requested, and an order was provided, for a x-ray of the left wrist and forearm. There was no documentation as to why the left forearm and wrist were being x-rayed in light of the resident's complaints of pain to his right wrist and thumb. On 9/15/14, a Final X-Ray Report for the resident's left forearm documented the results were normal. The Final X-Ray Report for the resident's left knee documented no fracture was seen, but mild osteoporosis and mild osteoarthritis were present. No new orders or other instructions were documented. It could not be determined whether the resident's primary care physician had been made aware of any of the resident's falls, or complaints of tenderness, weakness, or pain after the falls. On 9/16/14 a PT Plan of Care documented the resident had 9/10 pain in his left knee and 6/10 pain to his right wrist which had a severe effect on his function; impaired ROM and strength in his left leg; needed maximum (75%) assistance for transfers, and was unable to ambulate. On 9/

Based on facility incident report review, record review and staff interview, it was determined the facility failed to ensure timely diagnostic work-ups and treatments for injuries residents received from falls in the facility. This was true for 2 of 9 residents (#s 1 and 4) sampled for falls. Resident # 4 was harmed when she experienced new onset of back pain conjunction with a fall, but did not have x-rays determining she had fractures until more than a month later. Resident #1 was harmed when he experienced acute knee pain following a fall in September, but did not receive an orthopedic consult for almost a month. Additionally, the orthopedist ordered a procedure to address the injury discovered, but the procedure was not scheduled for yet another month. Findings included: 1. Resident #4 was admitted to the facility on [DATE], and re-admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #4's current falls care plan documented a history of chronic left hip and back pain related to a left hip replacement on 5/30/14. There was no documentation the resident had a history of [REDACTED]. Resident #4's Admission MDS, dated [DATE], coded: *Moderately impaired cognitive skills; *Supervision after set-up for ambulation; *Extensive assistance of 2 for toileting; *Limited assistance of 1 for dressing; *Frequent pain of 7 out of 10, which required medications but no non-pharmacological interventions. Resident #4 experienced 14 falls in the facility between 7/9/14 and 11/1/14, including falls on 7/9/14, 7/26/14, and 7/29/14. Please see F 323 for details. Resident #4's MAR for July 2014 documented she received [MEDICATION NAME] HCl/[MEDICATION NAME] 10/325 mg tablets 1-3 times per day. The resident had abdominal surgery on 6/20/14, thus the majority of her pain complaints were documented as abdominal pain. The MAR indicated [REDACTED]" on 7/20/14 at 1:15 AM, and pain in the lower back on 7/26/14. On 7/16/14, the resident was discharged from Physical Therapy (PT) and Occupational Therapy (OT). The PT and OT discharge summaries documented the resident was "modified independent" (resident completing more than 50 percent of the task, requiring adaptive equipment, or needing reminders for safety) with ambulation up to 400 feet, bed mobility if a "log roll" technique was used, transfers, dressing/undressing, and toileting. On 7/29/14 at 3:00 PM, a facility Post Fall Investigation (PFI) documented the resident fell while trying to sit in a chair in the dining room. A corresponding Nurse's Note (NN) documented the resident hit her head on a doorframe and complained of back pain. The resident was medicated with 50 mg [MEDICATION NAME]. On 7/29/14 at 8:19 PM, a NN documented the resident's physician was updated regarding continued complaints of back pain. The physician's response was documented as a new order for ice three times daily for the resident's back, and that an x-ray would be considered if the resident's pain continued the next day. This was also documented on a pain assessment completed at 10:48 PM. On 7/30/14 at 5:40 AM, Resident #4's NN documented, "Res(ident) was ambulating to the bathroom at the start of shift and was walking very slowly and complaining of lower back pain related to her fall in the dining room..." No updates to the resident's pain care plan were made on 7/29/14 or 7/30/14. Resident # 4's MAR indicated [REDACTED]. There was no documentation until 9/14/14 that the physician was notified of these continued complaints, or that an x-ray had been considered as documented in the 7/29/14 NN. Back pain was documented in the NN as well, including an entry on 9/4/14, when the resident experienced a fall and complained of 6/10 back pain (on a pain rating scale of 1-10). On 9/11/14, the NN documented 10/10 back pain. On 9/14/14, a NN documented the resident's physician was notified of continued complaints of flank pain. On 9/15/14, the NN documented a correlation between back pain and increased behaviors. Additionally, the NN documented decreased functional abilities for this resident. Beginning on 9/4/14, after a fall, the resident continued to complain of back pain, required the use of a wheelchair at times (9/4/14, 9/8/14, and 9/12/14), and when ambulating displayed an unsteady gait (9/5/14 and 9/10/14). On 9/18/14, a physician's progress note documented, "...Her main complaint today is her chronic low back pain, it is located in the lumbosacral region. She noted that she took a fall, but she cannot tell me when or where that happened...The patient will have a lumbosacral spine film. She has not had any x-rays recently. It is difficult with her history to know when and how she fell as she is quite confused today..." A CT urogram of her pelvic region was also ordered. There was a 53 day delay between the time the resident's 7/29/14 fall and onset of back pain, and the time an x-ray was ordered to ascertain whether there was an injury to that area. On 9/19/14, a Final X-Ray Report for Resident #4 documented osteoporotic compression of T12, L2, and L4 vertebrae of undetermined age. On 9/20/14, a NN documented the physician was aware of the new [DIAGNOSES REDACTED]. The NN also documented the physician wanted to be kept updated on the resident's pain. On 9/22/14 at 11:49 AM, the NN documented the resident continued to complain of back pain. At 3:12 that afternoon, the resident experienced another fall, this time complaining of "slight pain" to her right side and hip. On 9/29/14, the abdominal and pelvic CT results documented, "Multiple new compression fractures as compared to 6/20/14... the compression fractures are the likely etiology of the patient's back pain..." There was no documented response from the physician regarding these results. At the time the survey was conducted, there was no documentation the resident had been evaluated by a physician following the [DIAGNOSES REDACTED]. On 11/4/14, when asked, the DNS stated she did not know why the x-ray had not been completed after the 7/29/14 fall when the resident's complaints of back pain continued; how pain from the fractures had been ruled out as a cause of her behavioral and functional changes; or whether the resident would benefit from further evaluation of her fractures to determine whether any precautions or limitations would be warranted to promote healing of her injuries. It could not be determined when the resident's status would be evaluated again to ensure healing was proceeding as expected. The DNS agreed there was a delay between the onset of the resident's complaints of back pain and x-rays being obtained. Resident #4 was harmed when she fell on [DATE] and began to complain of back pain. Although the facility documented the physician planned to obtain an x-ray of the resident's back if her pain complaints continued, this was not done. The resident continued to complain of back pain, x-rays were obtained on 9/19/14, and compression fractures were discovered. The facility did not ascertain what limitations or precautions were needed to ensure the injury healed as planned, nor was there a plan documented to ascertain if the injury had healed. On 11/4/14 at 3:20 PM, the Administrator, DNS, and DDCO were informed of these findings. The facility offered no further information. 2. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Please see F 323 for the resident's MDS data. *On 7/3/14 a PFI documented the resident fell . The PI recommendations after the fall documented the resident needed new shoes. Please see F 323 for details. On 11/4/14 at 12:35 PM, when asked, the DNS stated the resident's shoes had not been fastened properly when he fell , and the facility determined the resident would need new, special order orthotic shoes to fit over a brace he wore on his left leg. The DNS stated the facility let the resident's wife know of this need, but did not know for sure when the resident was fitted for, or received, his new shoes. The DNS stated the resident's wife had taken care of the matter, and did not believe the facility was involved with ensuring the resident obtained the necessary footwear identified to prevent further falls. *On 9/14/14 at 12:20 PM, a PFI documented the resident fell while trying to take off his new orthotic shoes,which he had just received. A NN following this fall documented the resident complained his right wrist was tender. It was not documented the resident's range of motion was assessed. On 11/4/14 at 12:35 PM, when asked, the DNS could not explain why the resident had just received his shoes at the time of the 9/14/14 fall, when the facility identified after his fall over two months prior the need for new shoes. The DNS stated she would have expected to see documentation the resident's range of motion was assessed after his fall, and could not explain why that had not been done. *On 9/14/14 at 3:05 PM a PFI documented the resident had another fall, this time complaining of left knee pain and right wrist weakness as contributing factors. A NN documented resident's range of motion was "good" in all his extremities but the left. At 7:47 PM, a NN documented the resident complained of right thumb pain. On 9/15/14 at 7:21 AM, a NN documented the resident had complained of left knee pain throughout the night. At 10:48 AM, a request was sent to a physician for an order for [REDACTED]. The x-ray results were documented as received by the facility on 9/15/14 at 1:19 PM, 25 hours after the first fall. The x-ray results documented no some abnormalities to the left knee, but the left wrist and forearm were normal. The x-ray results did not document the resident's right hand, wrist, or thumb had been assessed. On 11/4/14 at 12:35 PM, when asked, the DNS could not explain why there had been a delay after the resident fell and complained of pain, and orders were requested for x-rays. It could not be determined why the left forearm and wrist had been x-rayed when the resident's complaints of pain were on the right. As of the 11/4/14 interview, no diagnostic work-up had been done on the resident's right wrist, thumb, or hand. *On 9/17/14 at 10:50 AM, an IDT Event Review note documented the resident was evaluated by PT and the physician on 9/16/14 due to his falls. The PT evaluation documented the resident complained of 9/10 pain (on a pain scale of 1-10) in the left knee, needed 75% assistance with transfers, and could not ambulate. A progress note documenting the physician's assessment of the resident's falls and continued complaints of pain and functional changes, was not found in the resident's record. On 11/4/14 at 12:35 PM, when asked, the DNS stated the facility's medical director, a psychiatrist, had signed that he had seen the x-ray results on 9/16/14. However, the DNS stated if there was not a progress note from a physician documenting a physical assessment of the resident, it could not be determined that the resident was actually seen and evaluated by a physician on that date. *On 9/21/14 at 6:00 AM, a PFI documented another fall for the resident. The PI recommendations documented the resident was to use a wheelchair with staff assistance until the resident's knee could be evaluated, and the facility would request the resident's primary care physician to order an orthopedic consult. On 9/23/14, a progress note from the resident's primary care physician documented the resident had a fall on 9/15/14. (NOTE: The resident actually fell twice, on 9/14/14). This was the first documented physician's assessment since the resident's two falls on 9/14/14 and the fall on 9/21/14. The physician documented the resident's left knee continued to feel weak, "gave out" when he was not expecting it, would "pop", and felt unstable. The physician's assessment was documented as, "Fall with some knee injury, now with buckling of the knee in a patient with [MEDICAL CONDITION]." The progress note documented the resident should have an orthopedic consult to see if an MRI needed to be done, and an order for [REDACTED]. On 11/4/14 at 12:35 PM, when asked the DNS stated the delay between the fall on 9/21/14 and the physician's visit on 9/23/14 was because the fall took place on a Sunday and the physician made her next visit to the facility on a Tuesday. The DNS stated the facility did not think to question this because the resident had already had a x-ray of the left knee, which did not show a fracture. The DNS agreed the resident's symptoms of "popping" and "buckling" were concerning. It could not be determined if the resident would have benefited from a second x-ray after falling and complaining again of knee pain on 9/21/14, six days after the x-ray was obtained. The facility documented they faxed a referral sheet to the orthopedic physician on 9/25/14. There was no documentation as to why the referral was not provided to the orthopedic physician for 2 days after the order for the referral was written. The documentation provided by the facility did not include any clinical information provided to the orthopedist, other than the resident had a fall with a knee injury, which needed to be diagnosed and treated. On 10/9/14, two weeks after the primary care physician ordered the consultation, and orthopedic progress note documented the resident presented in the office with left knee pain from an injury fall approximately three weeks prior. The injury was described as a "twisting" injury. The progress note documented the resident was given a Cortisone shot in the physician's office, but if the pain did not improve over the next 1-2 days the resident would require an MRI to rule out a torn meniscus. There were no entries in the resident's record at the facility that this appointment had taken place, nor that the resident would need to be monitored for the effectiveness of the injection or follow up with the orthopedic physician if relief was not noted within 1-2 days. There was no documentation as to whether the resident had an MRI. In fact, between 10/10/14 and 10/15/14 there were no entries in the resident's NN. On 10/15/14 at 9:08 PM, a NN documented the facility was contacted by the orthopedic physician, verbally informing the facility of MRI results and ordered the resident to be non-weight bearing through his left leg, and that he would need a follow-up appointment as soon as possible. On 10/16/14 at 9:14 AM, a NN documented the resident's wife had scheduled the follow up appointment for 10/21/14. The facility did not have a copy of the MRI results at the time of the survey on 11/4/14. After requested by the survey team, the facility contacted the orthopedist and obtained a copy of the MRI, which documented the resident had a nondisplaced [MEDICAL CONDITION] tibial plateau, possible small superficial medial meniscal tear and a mild lateral tilt of the patella. On 10/21/14 at 9:45 PM, a NN documented the resident had returned from an orthopedic appointment that day, and the orthopedist's office would be scheduling an arthroscopy. The NN documented if the facility had not received confirmation of an appointment being scheduled within a week, the facility should contact the orthopedist's office to schedule the procedure. No further documentation regarding this issue was noted. It could not be determined if the appointment had been scheduled within a week, as ordered by the orthopedist; and/or the facility had made contact if the appointment had not been scheduled. On 11/4/14 at 12:35 PM, the DNS stated she did not know if the appointment for the arthroscopy had yet been scheduled, but she would check on it. At 3:05 PM, the DNS provided a hand-written sticky note which documented the procedure was scheduled for 11/19/14 at 8:45 AM, almost a month after the physician ordered the procedure be scheduled. When asked when the appointment had been made, the DNS did not respond. The facility failed to facilitate a resident receiving orthotic shoes in a timely manner, or assisting the resident to adapt to the use of those shoes to prevent falls. The resident experienced further falls, and was harmed when the facility failed to ensure he was evaluated by a physician after falling multiple times. The resident experienced an increase in his discomfort and a decline in his function. Once the resident was evaluated, the facility failed to ensure follow-up diagnostic evaluations and treatment plans were implemented timely, and that the resident was protected from further injury while awaiting these evaluations. Further, it could not be determined an appointment for a treatment determined to be necessary to facilitate healing of the resident's injuries, alleviate his pain, and enable him to return to his prior level of functioning was scheduled timely by the facility. On 11/4/14 at 3:50 PM, the Administrator was informed of these findings. The facility offered no further information.

Based on observation, staff interview and record review, it was determined the facility failed to provide the necessary care and treatment for [REDACTED]. This was true for 2 of 13 (#4 & #3) residents sampled for quality of care. Resident #4 was harmed when a venous ulcer increased in size due to improper Unna Boot application. Resident #3's care plan was not updated to include comfort measures. This placed the resident at risk for unmet needs related to comfort measures. Findings included: 1. Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The 7/3/13 Significant Change in Status MDS and the 10/2/13 Quarterly MDS Assessment, both, documented the resident: *had moderate cognitive impairment; and, *had functional limitation in range of motion with impairment to both sides of her lower extremities. Both assessments documented the use of a wheelchair, however, the 7/3/13 assessment included the use of a walker. The 7/5/13 Progress Notes documented a MDS nursing and social service note the resident was showing a cognitive decline and was more forgetful and confused. Additionally, the resident had an increase in urinary incontinence and decrease in physical functioning due to increased difficulty with ambulation and required a WC for mobility and staff to propel majority of the time. The resident's care plan, dated 3/29/13, for the problem of "Self Care Deficit: ADL's (activities of daily living) related to deteriorating physical condition" documented in part: Uses w/c (wheelchair) for mobility, encourage to propel self, and was a 2 person transfer. The resident's care plan, dated 3/29/13, for the problem of "Skin/Tissue Integrity Impaired: Potential related to history of vascular ulcer and fragile skin of past ulcer site" documented in part: *weekly skin checks by LN (licensed nurse); *assure footwear is protective and fits well during weekly LN skin check *float heels on pillows when in bed; and, *[MEDICATION NAME] size D (or indicate which leg). NOTE: The care plan did not contain documentation that the resident went to a wound clinic, wore an Unna Boot and a Prevalon boot on the right lower extremity or wore a [MEDICATION NAME] dressing on the left lower extremity. The resident's Patient Nursing Evaluation on admission, dated 3/29/13, documented, on page 2 under skin inspection, the resident was admitted to the facility with five non-pressure ulcers on the outer right ankle. There was documentation the skin was warm, dry and intact with frail, scaly skin on the outer right ankle from history of vascular ulcer with the following measurements measuring distal to proximal: *1 x 0.5 cm; *0.3 x 0.1 cm; *1 x 0.4 cm; *0.3 x 0.2 cm; and, *0.8 x 0.7 cm. The resident's Weekly Non-Pressure Skin Condition Report documented the right ankle wounds gradually decreased in size and were last measured on 4/25/13 from distal to proximal: *0.2 x 0.1 (cm); *0.2 x < 0.1 (cm); *0.2 x 0.2 (cm); and, *0.2 x 0.1 (cm). NOTE: The medical record did not contain measurements of the right ankle wounds after 4/25/13 or document the wounds had healed. On 3/13/14 at 9:50 AM, the SDC was interviewed regarding the timeline of events of the right ankle measurements. She stated the measurements of the venous ulcers should have been measured weekly but the last measurements she could find were taken on 4/25/13. The next measurement was taken on 6/2/13, for one wound on the right ankle, and was not included on a Weekly Non-Pressure Skin Condition Report. There were no other wound measurements except for one right ankle wound. Additionally, the SDC stated the resident became ill and missed two visits to the Wound Clinic in September. During this time, the SDC measured the right ankle wound which increased in size as a result of being ill. The resident's progress notes, dated 5/24/13, documented a condition change by LN #4, "Ulcer on right outer ankle is not improving with current treatment. It is now 0.5 (cm) x 0.5 (cm) x 0.1 (cm)...May we have an order for [REDACTED]. The medical record contained a physician's telephone order, dated 5/24/13: "(1) DC (discontinue) [MEDICATION NAME] (2) [MEDICATION NAME] Ointment to ulcer cover with island dressing, (change) everyday (3) Prevalon boot when in bed" A progress note, dated 6/2/13, documented by LN #2, the wound had increased in size, "R (right) lower lateral skin wound with partial thickness loss of skin involving epidermis, edges distinct with cream colored wound base. Size 0.7 (cm) x 0.5 (cm) x 0.1 cm with slight cratered base. Scant serosanguinous exudate, surrounding tissue dark red/purple consistent with [MEDICAL CONDITION] advise with consideration of wound consult." On 6/15/13, LN #1 received a telephone order, from the resident's physician, to make an appointment (with a local wound care center) for the wound to R (right) ankle." The resident's physician's Nursing Home Visit note, dated 6/25/13, documented, "dressing changes were not showing signs of improvement so expertise was needed as this has been a chronic wound and she has been seen by the (local wound clinic) in the past." NOTE: The order for the local wound clinic was received 13 days after the request, 6/2/13 to 6/15/13. A Wound Care Initial Evaluation, with a date of service of 6/27/13, documented the Chief Complaint was evaluation of a venous stasis ulcer of the right lateral malleolus. The evaluation documented the resident had not been seen for a couple of years but had developed a "new recurrent area of ulceration over the right lateral malleolus." The wound measured Length 1.4 cm x Width 0.9 cm x Depth 0.2 cm. The Plan included in part: *(1) PolyMem Silver dressing with a cover three times per week and, as needed; *(2) Physical Therapy to evaluate; and, *(3) Recheck the resident in two weeks or sooner for worsening, new symptoms or other concerns. On 7/11/13 a Wound Care Progress Report documented the resident was seen for follow-up evaluation for the right lateral malleolus. The skin wound examination documented the wound measured Length 0.7 cm x Width 0.9 cm x Depth 0.1 cm. The wound was debrided and Unna Boots were placed bilaterally. The Plan included in part: *(1) [MEDICATION NAME] and PolyMem Ag dressing with cover changed twice weekly. *(2) Bilateral lower extremity Unna Boot wraps per physical therapy. *(3) Unna Boot wraps should be changed twice weekly. *(4) Recheck in 2 weeks or sooner for worsening conditions, signs or symptoms of infection, complications, concerns or questions. The Treatment Record for July, 2013, documented the facility changed the Unna Boots bilaterally on 7/13/13, 7/17/13,7/21/13, and 7/22/13. NOTE: The Unna Boot order was to change the wraps twice weekly. However, the week of the 7/21/13 the wraps were changed on two consecutive days, 7/21 and 7/22. NOTE: The resident's care plan did not identify the use of the Unna boots and did not include the approach of a schedule for when to change the Unna boots. The resident's next visit to the Wound Center was on 7/25/13. The Wound Care Progress Note documented, "the compression wraps were improperly applied today. There is some concern that staff may not have the appropriate education to apply these dressings." Additionally, there was documentation, "a new and very small area of superficial ulceration appreciated at the left medial gaiter region. This may be associated with her improperly applied wraps." Measurements of the right lateral malleolus documented the Length 1.6 cm x Width 1.4 cm x Depth 0.1 cm. The left medial malleolar region examination documented the wound measured Length 0.6 cm x Width 0.8 cm x Depth less than 0.1 cm. The Plan included in part: *(1) Dressings of [MEDICATION NAME]-Ag and cover changed twice weekly or as needed for soilage or drainage. *(2) Compression wraps to the bilateral lower extremities for [MEDICAL CONDITION] management. *(3) Patient to return to clinic twice weekly for dressing changes with nursing and physical therapy. *(4) Bring staff to learn wrap method at these dressing changes. The medical record documented a telephone order for the resident "to return to clinic 2 X (times) week for drsg/unnaboot application until facility staff able to come to clinic to learn proper unna boot technique." A Progress Note, dated 7/25/13, by the SDC documented the resident was "out to wound clinic for follow up wound on Rt ankle is improving." NOTE: The wound actually increased in size from 7/11/13 to 7/25/13. On 7/29/13, the SDC returned to the Wound Center with the resident for education on proper technique for Unna Boot application. On 3/12/14 at 12:30 PM, the SDC was interviewed and said the resident returned with Unna Boots bilaterally on 7/11/13 from the Wound Clinic. She also said, she pulled the facility policy and procedure for [MEDICATION NAME] (Unna Boot) Application and gave it to LN #2 and LN #4, the nurses who would be applying the Unna Boots. At that point they told her they knew how to apply Unna Boots. The SDC stated she only became involved with the resident when the Wound Clinic determined the Unna Boots were improperly applied on 7/25/13. She stated she went to the Wound Clinic on 7/29/13 for education on how to apply Unna Boots and became the designated person to apply the Unna Boots. On 3/13/14 at 8:20 AM, the SDC was interviewed and stated she remembered a conversation where the nurses were talking about how to wrap the impregnated gauze (Unna Boot). She remembered the nurses discussed they had seen it wrapped both ways - meaning (1) the impregnated gauze was wrapped directly next to the skin followed by dry gauze/padding, and (2) dry gauze/padding was placed directly next to the skin followed by the impregnated gauze. On 3/13/14 at 11:10 AM, the surveyor and the SDC reviewed the policy and procedure for Unna Boot Application. The list of equipment did not include gauze, which was mentioned in Step 17 in the procedure column. It was unclear whether or not this was the Unna Boot dressing. Additionally, the procedure did not mention medicated gauze, dry gauze or cast padding, coban or ace bandage after Step 17 of the procedure column. The SDC agreed the terminology varied throughout the policy and was unclear. She stated she would bring it to the DDCO's attention. Additionally, she agreed the resident's care plan for skin integrity did not contain approaches for Unna Boots or a Prevalon Boot. The SDC stated those should have been updated and approaches should have been care planned. On 3/13/14 at 1:45 PM, the surveyor observed the SDC apply the Unna Boot to the resident's right lower extremity and noted the Unna Boot box documented directions for the correct application of Unna Boots. A progress note, dated 1/29/14, documented "resident to wound clinic and returned; res (resident) not to wear rt (right shoe), is to wear Prevalon boot at all times." However, the physician's orders [REDACTED]. On 3/13/14 at 3:15 PM, the DON stated he was aware the policy and procedure for Unna Boots needed to be updated. The DON was made aware the resident was to wear the Prevalon boot at all times, not only when in bed as ordered on the physician's orders [REDACTED]. On 3/14/14 at 10:20 AM, the DON was interviewed regarding the Unna Boot Application. He stated he had never applied Unna Boots. He stated when it was identified we were doing it wrong, the SDC was appointed to go to the Wound Clinic to learn how to apply them. When asked if the policy and procedure for Unna Boots was updated after it was discovered the staff had applied the Unna Boots incorrectly. The DON stated it did not occur to him to change the policy. The DON was made aware the directions for the Unna Boots application was listed on the box and the DON stated understanding. The resident was harmed when the facility failed to provide the necessary care and treatment for [REDACTED]. - when the facility did not educate staff on the proper application of Unna Boots bilaterally over a two week period. The right ankle wound increased in size and a new ulceration was found on the left ankle. As a result, the Wound Clinic requested the resident return to the Wound Clinic for the proper application of Unna Boots and requested staff come to the Wound Clinic to learn proper Unna Boot technique. - when the policy and procedure for Unna Boot Application was unclear and the terminology varied throughout the policy. As a result, the Unna Boot was not applied correctly. - when the care plan was not revised to include the resident went to a wound clinic, wore Unna Boots, needed to wear a Prevalon Boot, wore a [MEDICATION NAME] dressing on the left lower extremity, and did not include a schedule for when to change the Unna boots. -when the facility did not ensure the Physician order [REDACTED]. On 3/14/14 at 10:35 AM, the DON, Administrator and DDCO were informed of the quality of care concerns regarding the improper Unna Boot Application and the increased size of the right lateral malleolus when the Unna Boot was applied improperly. On 3/14/14 at 11:05 AM, the DDCO stated she agreed the Unna Boots were not applied correctly. On 3/17/14 at 2:15 PM, the facility faxed additional information, however, the information provided did not resolve the issue. 2. Resident #3 was admitted to the facility with multiple [DIAGNOSES REDACTED]. The resident's 3/3/14 annual MDS coded severe cognitive impairment, totally dependent on staff for ADLs, and always incontinent of bowel and bladder. The resident's 1/28/14 Idaho Physician order [REDACTED]. The resident's physician Nursing Home Visit reports documented, in part, the following: - 10/1/13, "...does not attempt to speak...advanced [MEDICAL CONDITION] to be much more mobile and verbal...outlook...exceedingly poor...." - 12/19/13, "...end-stage Parkinson disease and dementia...nonverbal most this time...requires total care...dementia is advancing...does not really awaken for the examination..." - 1/30/14, "...requires total care...completely immobile...not as verbal as...used to be and the aids and staff anticipate...needs...condition...declining...severely debilitated...DNR with comfort measures...ongoing decline...not going to improve...extremely stiff...very immobile..." - 2/11/14, "...decline in...status...in...last days...decreased movement, decreased ability to swallow, cough, eat...ongoing difficulties...do not think...imminently terminal, but...definitely in the last months...prognosis of 6 months or less..." The resident's 3/5/14 Care Plan (CP) was reviewed. The CP identified problems, goals, and problem approaches. For example: - Problem: Self-Care Deficit: Hygiene. Three of the six problem approaches were, "Allow ample time for tasks...May become resistive with accepting help with ADL's {sic} and require re-approach...Staff use a gentle approach and encourage to accept assistance." - Problem: Anxiety. Three of the eight problem approaches were, "...Acknowledge health care complaint and consult with appropriate professional...Encourage discussion of fear/anxiety. Allow to cry. Report tears/crying...Redirect focus from self by providing diversional act (activity)..." - Problem, Coping, Ineffective, Individual. Four of the five problem approaches were, "Encourage resident to reminisce and review life to identify past coping skills...Group activities to establish trust relationship. Allow to discuss feelings of fear and frustration. Encourage to discuss feelings about placement in LTC (long term care) facility, physical condition, loss of independence...Offer positive feedback when effective coping skills are used..." - Problem, Verbal Communication, Impaired. One of the three problem approaches was, "...Encourage to communicate slowly & to repeat requests. Do not rush..." - Problem, Resident at risk for falls. One of the nine problem approaches was, "Orient to surroundings & room number as frequently as needed." - Problem, Self-Care Deficit: Bathing/Showers. Three of the seven problem approaches were. "...Allow ample time for tasks...Praise efforts, successes & general appearance...Set up bathing supplies. Encourage to complete task and assist as needed." - Problem, Self-Care Deficit: Dressing/Grooming. The two problem approaches were, "Allow ample time for tasks. Allow to make choices RE: clothing selection." Note: The resident's CP was not individualized or updated to reflect the actual status of the resident for comfort measures. Federal guidance at F309 indicated, in part, "...Care Plan Revision...based upon the following...Change in resident condition, ability to make decisions, cognition, medications, behavioral symptoms or visual problems..." On 3/11/14 at 1:57 p.m., the resident's physician was interviewed. The physician said the resident was on comfort measures and no heroic measures were to be taken. The resident was not on comfort cares to the point of discontinuing medications, just comfort measures. On 3/12/14 at 2:55 p.m., the surveyor discussed with the DON and the District Director of Clinical Operations the resident's physician Nursing Home Visits documented the resident's on-going decline and imminently terminal status however the CP did not reflect the resident's comfort measures. The surveyor shared with the DON the above identified approaches that did not reflect the resident's current ability or status. The DON acknowledged the CP should have been updated to reflect what the facility does for the resident's "comfort measures." On 3/14/14 at 1:00 p.m., the Administrator was informed of the finding.

Based on observation, record review, review of Post-Event Assessments/Investigations (also known as Incident and Accident reports), in-service records, and staff interview, it was determined the facility failed to ensure 3 of 3 sample residents (#s 2, 5, and 9) reviewed for pressure ulcer prevention/treatment did not develop avoidable pressure ulcers. Specifically: * Resident #2 was harmed when six stage II pressure ulcers and two blood blister (unstageable PU by definition) developed. Three of the stage II PU, at the "gluteal cleft near the vaginal intraitus (opening)", the "outer" labia, and the left upper thigh, were documented as related to incontinence briefs. Documentation of the anatomical locations of the PU was inconsistent and the blood blisters, on the left first and third toes, and an outer labia stage 2 PU, were not thoroughly assessed, nor monitored. In addition, the resident's care plan was not updated to include any of the PU/blood blisters. * Resident #5 developed a stage II PU on the right inner thigh related to incontinence brief placement. * Resident #9 developed a fluid-filled blister on the right abdomen, also related to incontinence brief placement. The failed practice created an alteration in the residents' skin which placed them at risk for further skin breakdown and possibly infection. Findings included: Note: The National Pressure Ulcer Advisory Panel (NPUAP) redefined the stages of pressure ulcers (PU) in 2007 to include: "Stage II: Partial thickness...May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister..." and "Suspected Deep Tissue Injury - depth unknown(:) Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue...Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's annual MDS assessment, dated 10/23/12, coded, in part: intact cognition, with a BIMS score of 15; total physical assistance of 2 plus persons for bed mobility, transfers, and toilet use; frequent urinary incontinence; at risk for PU; no unhealed PU at stage I or higher; pressure reducing device for chair/ bed; and, ointments/medications-other than feet. A quarterly Patient Nursing Evaluation, dated 10/30/12, documented Resident #2's skin was "all intact." And, a 10/30/12 Braden Scale for Predicting Pressure Sore Risk documented the resident was at low risk with a total score of 16. The resident's CP identified the problem, "Skin/tissue integrity impaired: potential," on 11/17/09. The problem was related to diabetes, [MEDICAL CONDITION], overactive bladder, dry skin, long history of calluses to toes, history of stasis ulcers, and history of fragile skin. The approaches, their implementation date, and the staff assigned, included: * 12/17/09 - Report any red or open areas - Nursing Assistants (NA) and nursing; * 8/24/11 - Weekly skin checks - LN; * 12/8/09 - [MEDICATION NAME] cream to toes/feet twice a day, CNA may apply - NA; * 1/26/10 - Remind resident often to have staff assist with calluses - LN; * 1/26/10 - Monitor and "manicure" calluses to toes with baths - LN/NA; * 8/24/11 - Keep nails trimmed and filed - LN; and, * 9/8/11 - Barrier cream every incontinent episode - All/NA. NOTE: This CP did not document any actual skin impairment and a CP regarding actual skin impairment was not found in the resident's clinical record. I&A reports for Resident #2 included the following documentation: * 11/22/12 at 1:50 p.m. - "Two small open areas noted to gluteal cleft near vaginal intraitus (opening), and one noted on outer labia. No c/o (complaint of) pain associated (with) open areas. Location appears consistent (with) where attends (sic) could have caused irritation. Interdisciplinary Team Review on 11/26/12, "...appears that the resident was noted to have 2 small blisters, one to outer labia (and) one near vaginal intraitus...attend (sic) bunching (and) rubbing in area resulting in 2 blisters. Plan: Continue to monitor (and) tx (treat) until resolved, staff ed(ucation) r/t (related to) attend (sic) placement...bariatric size." NOTE: An Internet search was conducted 1/17/13. Wikipedia defined intergluteal cleft as, "The intergluteal cleft, also known as the natal cleft, the vertical gluteal crease, the gluteal cleft, and, colloquially, the 'butt crack' or 'arse crack', is the groove between the buttocks that runs from just below the sacrum to the perineum, so named because it forms the visible border between the external rounded protrusions of the gluteus maximus muscles. The intergluteal cleft is located superior to the anus." Therefore, from an anatomical perspective, the gluteal cleft is not near the vaginal intraitus. * 12/13/12 at 2:00 p.m. - "Res(ident) found to have stage II sores on (L) (upper) thigh, (R) buttock, (and) (L) inside gluteal fold. (T)egaderm applied. N/O (new order) for air mattress, dressing change Q (every) 3 days." Caregiver Questions: "Why do you think event occurred? Res(ident) is obese and up in w/c (wheelchair) for long periods of time." Immediate Corrective Action Taken: "Care Plan updated(,) Pain Assessment(,) Staff Education." Performance Improvement Recommendations: "Cont(inue) to monitor (and) tx until resolved, staff ed r/t toileting bariatric residents, air mattress to bed." Interdisciplinary Team Review on 12/14/12, "...appears that the resident was noted to have abrasion like area to gluteal folds, res is bariatric which is a contributor..." The resident's clinical record contained Resident Weekly Skin Check Sheets (RWSCS). The RWSCS directions instructed, "Indicate below skin injuries/ulcers such as pressure ulcers, venous insufficienchy/ischemia ulcers...diabetic neuropathic ulcers, bruises, abrasions, lacerations and abnormal skin discoloration by marking the body. Comment on color, moisture, temperature, integrity and/or turgor, as appropriate." The RWSCS contained 4 sections on the front and the back sides of the page with a front and back body diagram and comment area in each of the sections. Resident #2's RWSCS included the following documentation: * 10/5/12 - "Skin warm, dry. Redness in peri-area...Small blood blisters noted on 1st (and) 3rd toe on (L) (left) foot. Lotion applied. No other issues noted." * 10/12/12 - "Skin warm, dry, (decreased) redness in peri-area...Small blood blisters on 1st (and) 3rd toe of left foot unchanged. No other issues noted." * 10/19/12 - "Skin assessment unchanged - (no) new red areas noted - Tx (treatment) cont(inues) to groin areas. * 10/26/12 - "Area to (L) lateral foot and (L) heel blancheable red. Will educate on relieving foot area on w/c pedal when up, obtain off-load boot, float heels in bed otherwise skin clear." Note: The toe blisters were not mentioned. * 11/2/12 - "Chronic red (lower) legs. Otherwise skin intact." * 11/16/12 "...some redness in gluteal folds bilaterally and between buttocks..." * 11/23/12 - "Some red areas in perineum. Cleansed, barrier cream applied." * 11/30/12 - "(L) gluteal fold area cont to heal...(No) red areas in perineum otherwise..." * 12/7/12 - "...Some redness noted under (L) breast (and) peri-area. [MEDICATION NAME] applied per prn (as needed) order. Small healing sore on (L) buttock. No other issues noted." * 12/14/12 - "...Redness noted in peri area and under abdominal fold, barrier (sic) cream applied. Three stage II sores on (and) around buttocks covere (sic) (with) [MEDICATION NAME] dressing intact." * 12/21/12 - "...Multiple stage II pressure sores on bottom area (locations on pressure monitor sheet.)...(R)edness noted in peri-area, barier (sic) cream applied. (F)eet have scaly patches of skin bilaterally." * 12/28/12 - "Stage II pressure sores continue to buttocks/peri area but are resolving with current tx..." * 1/4/13 - "...(R)ednes (sic) noted...peri-area, tx in place. (S)ores on bottom healing well tx in place. (See ulcer report for details.) No other issues noted. Weekly Pressure Ulcer Reports (WPUR) were also found in the resident's clinical record. The WPUR included areas to document: PU location, shape, date of first observation, stage/depth, size, wound edges and surrounding skin condition, healing status, associated pain, and treatment/evaluation of effectiveness. Also, anterior, posterior, left, and right side body diagrams were included on which to note the location and shape of the PU. WPUR for Resident #2 included the following documentation: * Location: left posterior thigh, at the upper, inner aspect (per the posterior body diagram drawing), no date of first observation; Stage I: - 11/26/12; size: 1 centimeter (cm) by 1 cm; no pain; "(B)lister in line (with) attends line. (S)urface is intact (no) drainage surrounding area (without) compromise. Blister has resolved leaving dry new skin area. Will use barrier cream." NOTE: There was no other documentation regarding a PU at this location. * Location: left posterior thigh, midline at the upper aspect (per the posterior body diagram drawing); first observed on 12/13/12 as Stage II: - 12/13/12; size 1.8 cm by 1.9 cm; stage II; edges distinct, outline clearly visible, attached, even with wound base; scant serosanguinous exudate; periwound skin bright red and/or blanches to touch; pain with movement and during treatment; "Sore covered (with) [MEDICATION NAME], cleansed (with) NS (normal saline) and skin prep applied prior to bandage aplication (sic)...put on air mattress..." - 12/21/12; size 2 by 1.2; periwound skin, pink or normal; otherwise unchanged. - 12/28/12; size 1.7 by 1.4; edges indistinct, diffuse, none clearly visible; pain with movement; otherwise unchanged; "Improving..." - 1/4/13; size 0.3 by 0.3; no exudate; pain with movement and during treatment; unchanged otherwise; "Open to air (and) barrier cream being applied, N/O to apply antifungal barier (sic) cream and then apply [MEDICATION NAME] (sic). (H)ealing well." * Location: right buttock (per handwriting and the posterior body diagram drawing); first observed on 12/13/12 as Stage II: - 12/13/12; size 1 by 0.6 cm; stage II; distinct edges; scant serosanguinous exudate; periwound skin bright red and/or blancheable; pain with movement and during treatment. - 12/21/12; size 1.6 by 1.2; periwound skin pink or normal; unchanged otherwise. - 12/28/12; size 1.6 by 1.0; pain with movement, unchanged otherwise. - 1/4/13; size 1 by 1; no exudate; "Open to air (and) barrier cream being applied, N/O to apply antifungal barier (sic) cream and then apply [MEDICATION NAME] (sic). (H)ealing well." * Location: left gluteal fold, medial (inside) aspect (per handwriting and the posterior body diagram drawing); first observed on 12/13/12 as Stage II: - 12/13/12; size 0.3 by 0.3 cm; stage II; scant serosanguinous exudate; periwound skin bright red and/or blancheable; pain with movement and during treatment. - 12/21/12; size 1 by 0.6; periwound skin pink or normal; unchanged otherwise. - 12/28/12; size 0.5 by 0.5; stage I; no exudate; "...wound resolving." - 1/4/13; "Resolved." A 1/3/13 Physician Telephone Order for Resident #2 included, "Antifungal barrier cream to groin rash bid (twice a day) (and) cover (with) [MEDICATION NAME] powder bid until resolved then bid prn (as needed)." NOTE: No other physician orders [REDACTED]. Review of Resident #2's Treatment Records (TR) revealed the following documentation: * October 2012 through January 8, 2013 - Skin checks done weekly; * October 2012 - Air mattress to bed (noted as discontinued 8/1/12); * November - "Monitor area on (L) (lower) butt cheek Q (every) day until resolved. Barrier cream Q shift." Noted as started 11/25/12. * December - "Monitor areas in gluteal cleft and on labia every week until resolved." Noted as started 11/22/12. "Monitor area on (L) (lower) butt Q day until resolved. Barrier cream Q shift." Air mattress reinstituted 12/13/12. Cover sores on (L) upper thigh, (R) buttock, (and) (L) inside gluteal fold (with) (T)egaderm, (change) Q 3 days and PRN (as needed)..." Started 12/13/12. And, "Monitor sores on (L) upper thigh, (R) buttock, and (L) inside gluteal fold Q shift (times) 72 (hours) then Q day until healed." Started 12/13/112. * January - Same as December with, "Antifungal barrier cream to groin rash BID (twice a day) (and) cover (with) [MEDICATION NAME] power BID until resolved then BID PRN" added 1/3/13. CNA Flow Sheet Records (FSR) for October 2012 - January 7, 2012 documented: * [MEDICATION NAME] cream was applied to the resident's feet/toes twice daily; and * Barrier cream was applied to "open areas on gluteal cleft near vagina and on labia" twice daily from 11/23 - 11/3012. On 1/9/13 at 8:45 a.m., LN #2 was observed as he applied 2% [MEDICATION NAME] cream, then [MEDICATION NAME] powder to Resident #2's groin and peri-area. One small red area was noted just below the resident's left gluteal fold at midline and another small red area was noted on the right buttock close to the gluteal cleft. Both areas were intact. On 1/9/13 at 3:00 p.m., the DON was interviewed regarding the multiple stage 2 PU and toe blood blisters documented for Resident #2. The DON stated he would review the documentation and get back with the surveyor. When asked if the facility had designated wound care staff, the DON stated the facility's wound nurse left a few months ago and now he, the SDC, and the LN supervisors shared the job. On 1/9/13 at 3:30 p.m., LN #3 was observed as she removed Resident #2's non-slip socks. A pencil lead size black dot was noted on the tip of the resident's left third toe. Otherwise, the resident's feet/toes were intact. On 1/10/13 at 10:45 a.m., the DON, in the Administrator's presence, stated that Resident #2's left upper thigh sore "was a result of the Attends and the others were excoriation." When asked about documentation of anatomical locations, such as gluteal fold versus gluteal cleft, the DON indicated the documentation was what it was. Regarding the toe blood blisters, the DON stated he needed to do more research. At 4:45 p.m. that day, the DON, in the Nurse Consultant's presence, stated he had talked to the LN who documented the blood blisters on Resident #2's toes. The DON stated that the LN said he used the "wrong word" because they were bruises, not blisters, that were caused during nail care. The DON and Nurse Consultant both agreed that "blood blister" was documented on the resident's RWSCS for 2 weeks in a row and no change was documented a week later. Also, when asked for an I&A report of the nail care incident, the DON indicated there wasn't one. On 1/10/13 at about 5:00 p.m., the SDC provided documentation of Continence Management in-services on 11/15/12 and 11/20/1 . While the in-service material included Adult Brief or Underpads, there was nothing specify about how to appropriately apply an adult brief to avoid skin breakdown. On 1/11/13 at 1:30 p.m., the SDC provided additional documentation that numerous CNA staff were monitored on 11/13/12 through 11/29/12 regarding female pericare in general. And, specifically on 11/26/12, several CNA staff were monitored regarding female pericare, Attends placement, and barrier cream for Resident #2. On 1/14/13 at 4:06 p.m., a 5 page facsimile (fax) from the facility was received at the BFS. The fax was regarding Resident #2's weekly skin check sheet dated October 5th of "small blood blisters noted on her 1st and 3rd toes on her left foot." Immediate Interventions were "weekly skin checks performed until the areas resolved." The Investigation and Conclusion documented, "...Upon interview of the LN, he stated that the use of blister was a poor choice of words. When asked to describe the areas he stated that they were black, non raised areas below a callous just below the nail line. Upon interview with (resident's name) she states the areas were not new and that it was something she had for a long time. The blood blisters were located at the nail line of the 1st and 3rd toes...diabetic shoes and socks on, which have plenty of space for her toes and provide protection...denies any pain. The areas in question are not determined to be pressure, but are located in the nail line and which would indicate trauma from nail care. The healing process from the blood blisters appears to be consistent with the description and compromised status of...lower extremity circulation. The black area under the skin would take a lengthy amount of time to completely absorb related to her DM, [MEDICAL CONDITION], and poor circulation...It was determined that the blood blisters are a result of trauma from nail care and not from pressure or shearing which would not classify the blood blisters and pressure ulcers. Plan to Prevent Recurrence: * Continue diabetic shoes and socks...* Increase foot care with lotion and observation to daily. * Re-educate LN staff on nail care and proper documentation for skin concerns that are identified... Resident #2 was harmed when she developed multiple stage 2 PU on her buttock, thigh, and perineal areas, and blood blisters on her toes. There was no evidence the facility thoroughly assessed or monitored the "outer labia" sore and the blood blisters on the resident's toes. In addition, the resident's care plan was not updated to reflect any of the PU or blood blisters. And lastly, the facility's terminology regarding anatomical locations was confusing and inconsistent which made it more difficult to ensure the PU were accurately assessed and monitored. 2. Resident #9 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #9's most recent significant change in condition MDS assessment, dated 12/13/12, coded: -Extensive assistance of 2 persons for bed mobility, transfers, and toileting. -Extensive assistance of 1 person for personal hygiene. -Frequently incontinent of urine, occasionally incontinent of bowel. Resident #9's Care Plan documented the following: -Problem: "Skin/Tissue Integrity Impaired: Potential", dated 1/19/12. *Goal: "Will be free of skin breakdown", dated 1/19/12. * Approaches included, "Apply protective barrier cream after each incontinent episode and/or with AM and PM cares", dated 6/18/12. On 11/1/12, Resident #9's PNs documented on a "Condition Change Form", "During skin assessment resident was found to have a small fluid-filled blister on (right) side of lower abdomen below pannus. Attends rubbing on area (and)resident sweating in that area..." On 11//2/12, a facility I/A form documented: -"Resident needs to be refitted for Attends. Attends are rubbing (and) when sitting up they are tight fitting in that area." -"Nursing to check for appropriate size and placement." NOTE: There were no updates to the approaches on Resident #9's care plan for her potential for skin breakdown after 6/18/12. Cleaning or monitoring the area below her pannus was not identified in her care plan. On 1/10/13 at 9:10 AM, the DON was interviewed about Resident #9's fluid-filled blister. The DON reported the facility did frequent training on proper attends size and placement. Regarding issues with sores from incontinence briefs, the DON stated, "Certainly two residents had it. We do frequent inservices." On 1/10/13 at 6:30 PM, the Administrator, DON, Staff Development Coordinator, Social Worker, and Corporate Nurse Consultant were informed of the surveyor's findings. On 1/11/13 at 1:30 PM the DON provided copies two inservices. The first was dated 11/15/12, which included the facility procedure for changing an incontinence brief. (NOTE: The inservice did not address placement of incontinence briefs, how placement related to skin breakdown, or information specific to caring for Resident #9). The second inservice contained a list of general interventions to prevent skin breakdown, but there were no interventions regarding the placement of incontinence briefs as a preventive measure. 3. Resident #5 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #5's most recent MDS assessment, dated 12/2/12, coded: -Extensive assistance of 1-2 persons for bed mobility, transfers, and toileting. -Extensive assistance of 1 person for personal hygiene. -Always incontinent of urine, frequently incontinent of bowel. Resident #5's Urinary Incontinence CAA, dated 12/4/12, documented in the "Analysis of Findings" area, "...(Resident #5) is at risk for impaired skin (and) UTI from inc. (incontinence)" Resident #5's Pressure Ulcer CAA, dated 12/4/12, documented in the "Analysis of Findings" area, "...she has a hx (history) of impaired skin. (Resident #5) is at risk for impaired skin without staff interventions." Resident #5's Incontinence Care Plan, dated 11/6/2007, documented: -Goal as, "Will be clean, dry (and) free of skin breakdown", dated 5/4/11 -Approaches included, "Provide incontinence protection: adult briefs/diapers", dated 5/4/11. Resident #5's Skin/Tissue Integrity Impaired Potential Care Plan, dated 2/5/08, documented: -Goal as, "Will have skin intact for the next 90 days", dated 3/21/12. -Approaches included: *"Use positioning (and) pressure relieving device to bed/WC air mattress to bed", dated 3/14/12. *"Barrier cream after each shift and after each incontinent episode. Keep clean and dry. Toilet frequently", dated 8/6/11. On 12/17/12, a facility I/A report documented, "During cares aides found red open area along attends line." The cause was documented as "Improper attends placement." NOTE: The care plan approach update on 3/14/12 on Resident #5's skin integrity care plan was the most recent update to her skin care plan. The approach added to her incontinence care plan regarding incontinence briefs was the most recent update to her incontinence care plan. On 12/17/12, a Physician Telephone Order form documented, "monitor (right) inner thigh red open area (every) day until resolved." On 1/10/13 at 9:10 AM, the DON was interviewed about Resident #5's red open area. The DON reported the facility did frequent training on proper attends size and placement. Regarding issues with sores from incontinence briefs, the DON stated, "Certainly two residents had it. We do frequent inservices." On 1/10/13 at 6:30 PM, the Administrator, DON, Staff Development Coordinator, Social Worker, and Corporate Nurse Consultant were informed of the surveyor's findings. On 1/11/13 at 1:30 PM the DON provided copies two inservices. The first was dated 11/15/12, which included the facility procedure for changing an incontinence brief. (NOTE: The inservice did not address placement of incontinence briefs, how placement related to skin breakdown, or anything specific to caring for Resident #5) The second inservice contained a list of general interventions to prevent skin breakdown, but there were no interventions regarding the placement of incontinence briefs as a preventive measure.