Every finding on record at Cherry Ridge of Cascadia

Based on record review, review of the SOM, and staff interview, it was determined the facility failed to ensure the designated Culinary Manager met the required professional qualifications for overseeing food and nutrition services. This failure had the potential to impact all residents receiving meals and nutrition services. Findings include:The SOM, Appendix PP, revised 7/23/25, documented, if a qualified dietician or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services. The director of food and nutrition services must at a minimum meet one of the following qualifications:-A certified dietary manager.-A certified food service manager, or-has similar national certification for food service management and safety from a national certifying body; or-Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or-Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. The facility's Culinary Manager position description documented the following qualifications:License/Certification:-Food Handlers permit if required per state regulations-ServSafe Food Safety Certification required.-One or more of the following required:Certified Dietary Manager (CDM)Certified Food Protection Professional (CFPP) with the Dietary Manager's AssociationDietetic Technician, Registered, with the commission on Dietetic Registration of the American Dietetic Association; or,Certification with the American Culinary Federation On 7/7/26 at 8:42 AM, the Culinary Manager (CM) stated she had been working at the facility since August 2025 as the CM. The CM further stated she was overseen by the facility's Registered Dietician (RD) who worked at the facility one day per week.Documentation of the CM certification was requested and no certification for the CM was provided for the following dates and times:-7/7/26 at 9:00 AM-7/7/26 at 4:24 PM-7/9/26 at 3:48 PMOn 7/9/26 at 8:11 AM, when asked about her education and experience, the CM stated she had two years of experience as a cook and one year of experience as a kitchen manager at a boarding school. On 7/9/26 at 10:51 AM, the CEO confirmed the CM did not have qualifications and was in the process of getting certified.Cross Reference F804 and F812

Based on observation, review of the FDA Food Code, review of the SOM, and staff interviews, it was determined the facility failed to ensure 1) the kitchen cooking hood was kept clean, 2) food items were free from mold, 3) personal staff beverages were stored in a manner to prevent contamination, 4) kitchen staff performed proper hand hygiene, 5) required food and refrigerator temperatures were recorded to ensure safe hot-holding and cold-holding of Time/Temperature Control for Safety (TCS) foods. These failures placed all residents who consumed meals prepared by the facility at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include:1.The FDA Food Code Section 6-501.14 (A) documented cleaning ventilation systems intake and exhaust air ducts shall be cleaned so they are not a source of contamination by dust, dirt, and other materials.On 7/10/26 at 9:43 AM, the gray kitchen cooking hood vent was observed with a layer of brown particles on the outside of the hood vent.On 7/10/26 at 9:45 AM, when asked about the kitchen cleaning schedule, the CM stated kitchen staff were to clean vents once per week. When asked about the cleaning of the cooking hood vent, the CM stated she didn't think the kitchen staff realize that is also considered a vent. 2. The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.On 7/10/26 at 9:16 AM, a box labeled cantaloupe was observed to the lower wire rack shelf in the dry storage area. Three cantaloupes were observed in the box. One cantaloupe was observed to have a large oblong shape, white in color, fuzzy substance on the cantaloupe. The white fuzzy substance was observed to be in contact with the other two cantaloupes in the box.On 7/10/26 at 9:26 AM, the CM with the RD present was asked how often the facility receives fruit. The CM stated they receive fruit every two weeks. When asked how often fruit is inspected, the CM stated they inspect fruit anytime they go to use the fruit. When asked when the cantaloupe was last ordered, the CM spun the box around to see the front label on the box and stated the cantaloupe was last ordered on 6/25/26 and stated the cantaloupe was bad and removed the box from the dry storage area. When asked to describe the condition of the cantaloupe, the CM stated they were white and moldy. When asked how long fresh fruit is kept, the CM stated fruit is kept for three to five days and stated the cantaloupe should have been pulled on 6/30/26. 3. The FDA Food Code Section 2-401.11 Eating, Drinking, or Using Tobacco Products states an employee shall eat, drink, or use any form of tobacco products only in designated areas where contamination of exposed food or other items needing protection can not result.On 7/7/26 at 8:22 AM, the surveyor observed a McDonald's cup in the kitchen freezer with a dark liquid filling the cup. When asked who the cup belonged to, [NAME] #1 stated It's mine.On 7/7/26 at 8:43 AM, when asked about personal staff drinks, the CM stated personal drinks should not be kept in the freezer.4. The FDA Food Code Section 2-301.12 Cleaning Procedure states food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink.On 7/9/26, [NAME] #2 was observed during tray line preparation washing his hands for four seconds at the following times:-7:12AM-7:14 AM-7:17 [NAME] 7/9/26 at 7:44 AM, [NAME] #2 was observed to have a cream, off-white colored substance stuck to the back or his right arm. [NAME] #2 was not observed to wash the substance from his arm prior to serving food.On 7/10/26 at 9:51 AM, the CM stated employees should be vigorously washing their hands for 20 seconds.5a. The SOM, Appendix PP, revised 7/23/25 states, temperatures are critical in preventing foodborne illness. Cooking food to the temperature and for the time specified below will either kill dangerous organisms or inactivate them sufficiently so that there is little risk to the resident if the food is eaten promptly after cooking.Monitoring the food's internal temperature is important and will help ensure microorganisms can no longer survive and food is safe for consumption. Foods should reach the following internal temperatures in these situations:-Poultry and stuffed foods, i.e., turkeys, pork chops, chickens, etc. - 165 degrees F;-Ground meat (e.g., ground beef, ground pork), ground fish, and eggs held for service - at least 155 degrees F;-Fish and other non-ground meats - 145 degrees F.On 7/9/26 at 9:41 AM, the CM was asked about puree food temperatures as it was left blank on the 7/9/26 breakfast Food Temperature Log. The CM stated puree food temperatures were recorded under minced and moist as the puree was an extension of minced and moist. The facility's Food Temperature Logs for May 2026-July 2026 were requested and reviewed which documented no food temperatures for the following days:-5/17/26-dinner-5/22/26-lunch-5/23/26-breakfast, lunch, & dinner-5/26/26-dinner-6/15/26-dinnerOn 7/10/26 at 10:01 AM when asked about the missing food temperatures, the CM stated she didn't catch that they weren't doing them.b. The SOM, Appendix PP, revised 7/23/25 states, PHF/TCS [Potentially Hazardous Foods/Time/Temperature Control for Safety] foods must be maintained at or below 41 degrees F, unless otherwise specified by law. Frozen foods must be maintained at a temperature to keep the food frozen solid. Refrigeration prevents food from becoming a hazard by significantly slowing the growth of most microorganisms. Inadequate temperature control during refrigeration can promote bacterial growth. Adequate circulation of air around refrigerated products is essential to maintain appropriate food temperatures. Foods in a walk-in unit should be stored off the floor. Practices to maintain safe refrigerated storage include:-Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operationi) On 7/7/26 at 9:30 AM, the facility's Refrigerator Temp. Log was observed in a transparent plastic sheet fixed to the front of a black refrigerator near the activities area. The Refrigerator Temp. Log was dated June 2026 with the location documented as activities. The Refrigerator Temp. Log indicated an area to record both refrigerator temperatures and freezer temperatures. The temperature log was observed to have six large X's crossing out the section to record freezer temperatures. The Refrigerator Temp. Log was also observed to be missing refrigerator temperatures for the following days:-6/27/26-6/28/26-6/29/26-6/30/26On 7/9/26 at 9:19 AM, the facility's Refrigerator Temp. Log was observed fixed to the front of the activities refrigerator that was dated July 2026. The temperature log was observed to be complete and current with refrigerator temperatures. Two large X's were observed crossing out part of the section to record freezer temperatures.On 7/9/26 at 10:07 AM, when asked how often refrigerator temperatures are taken, the Activities Director (AD) stated he checks the refrigerator temperatures daily. When asked if he checks the freezer temperatures, the AD stated he only checks the refrigerator temperatures because the refrigerator was only being used. The AD accompanied the surveyors to the activities refrigerator. When asked if there was anything in the freezer, the AD opened the freezer and stated there were blue ribbon orange cycle ice cream bars in the freezer. When asked if there was a thermometer in the freezer to monitor the temperature of the ice cream bars, the AD stated no, and further stated there should be a thermometer in the freezer.On 7/9/26 at 10:13 AM, when asked if the activities refrigerator temperature logs were documented anywhere else, the AD stated he personally did not document temperature logs anywhere else other than the Refrigerator Temp. Log on the front of the refrigerator and further stated he had missed a few days of logging temperatures. When asked who takes the temperatures on the days the AD is not there, the AD stated he was the only staff member checking the temperatures on the weekdays and stated the temperatures are not checked on Saturdays and Sundays when he is out of the building. When asked how the temperature log is being completed for Saturday's and Sundays when he is out of the building, the AD stated he uses the temperature reading from Friday when he left and the temperature reading from Monday when he returns to fill in and complete the log.ii) On 7/9/26 at 9:16 AM, the facility's Activities refrigerator was observed to have condensation on the interior back wall of the refrigerator. The refrigerator was observed to have a large oblong shape and black in color build up noted to the lower shelf. The temperature was noted above the safe line on the thermometer and read 51 degrees. The refrigerator was observed to have 2 bottles of hot sauce in the door and a jug of blue juice on one of the shelves.On 7/9/26 at 9:30 AM, the activities Refrigerator Temp. Log was reviewed for June-July 2026 and the temperature log was observed to have notations in the left side margin as follows:-On 6/18/26 adjusted temp controller to get it lower-On 6/25/26 adjusted even lower, maintenance notified-On 7/8/26 changed thermometer to checkOn 7/9/26 at 10:09 AM, the AD was asked what the temperature of the refrigerator was. The AD took the thermometer out of the refrigerator and confirmed the thermometer was reading above the safe line and stated the refrigerator was at 42 degrees. When asked what temperature the refrigerator should be, the AD stated 36 to 40 degrees were safe temperatures. The AD further stated it would not be appropriate to use anything in the refrigerator. When asked who oversaw the cleaning of the refrigerator, the AD stated he was in charge of cleaning the refrigerator. When asked what the black build up in the refrigerator was, the AD stated I don't know.

Based on the facility's Quality Assurance and Performance Improvement (QAPI) Committee policy, the facility's Quality Assurance Performance Improvement Plan, and staff interview, it was determined the facility failed to ensure good faith efforts were made to implement and monitor performance improvement activities related to skin assessments and food sanitation. This failure created the potential to affect all residents who reside in the facility and receive nursing services or consume food provided by the facility. Findings include:The facility's Quality Assurance and Performance Improvement Committee Policy, revised 9/1/25, documented that the committee identifies performance improvement opportunities through tracking and trending of data.The facility's Quality Assurance Performance Improvement Plan, dated 4/1/26, documented the organization will continue to monitor progress toward goals by comparing results to benchmarks and historical performances.On 7/10/26 at 3:47 PM, the CEO stated he had three performance improvement plans (PIPs). When asked about PIP #1, he stated it addressed incomplete skin assessments. He stated PIP #1 was initiated on 3/30/26 and completed the following week on 4/6/26. When asked why the PIP remained active, he stated, we didn't want to fall off track. When questioned regarding benchmark measurements, he stated he used percentages but confirmed PIP #1 did not include documented benchmark measurements.On 7/10/26 at 3:55 PM, the CEO stated PIP #2 was initiated on 5/2/26 when the QAPI committee identified issues with food labeling in the snack room. When asked about benchmark measurements, he stated, we did not do percentages on this one, and reported the benchmark measurement was documented as improved.On 7/10/26 at 3:57 PM, the CEO stated PIP #3 was complete and no longer in place. The CEO did not provide additional information on what was included on PIP #3. On 7/10/26 at 3:58 PM, the CEO stated, maybe we need to re write our benchmark measurements. He confirmed the current method used to measure performance improvement plans did not adequately track whether improvement had occurred since the date of implementation.

Based on record review and staff interview, it was determined the facility failed to ensure residents were informed in advance of the care and treatment to be furnished, including the risks and benefits of treatment. This was true for 1 of 5 residents (Resident #23) whose records were reviewed for informed consent. This failure created the potential for miscommunication and adverse effects when Resident #23 was not informed in advance of the risks and benefits of his ordered medication. Findings include: Resident #23 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD) anxiety, and post-traumatic stress disorder (PTSD). Resident #23's record included the following physician orders:-Seroquel (antipsychotic) Extended-Release 200 mg by mouth at bedtime for schizoaffective disorder and bipolar disorder, initiated on 3/11/26.-Seroquel 100 mg by mouth once a day for bipolar disorder, initiated on 3/12/26.-Lorazepam (anti anxiety) 2 mg/mL give 0.5 mL by mouth every 4 hours as needed for palliative care related to chronic obstructive pulmonary disease, initiated on 6/29/26. A review of Resident #23's record showed no documentation that Resident #23 or his representative were informed of the risk and benefits or consents for the initiation of Seroquel and lorazepam. On 7/10/26 at 10:42 AM, the Clinical Resource Nurse (CRN) and Chief Nursing Officer (CNO) both confirmed Resident #23 did not have signed consents for Seroquel or lorazepam.

Based on observation, resident and staff interviews, it was determined the facility failed to ensure residents' call lights are within their reach. This was true for 1 of 1 resident (Resident #38) reviewed for residents' rights. This deficient practice created the potential for harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention. Findings include:Resident #38 was admitted to the facility on [DATE], with multiple diagnoses including acute cystitis (bladder infection) with hematuria (presence of red blood cells in the urine), diabetes, and cirrhosis (advance scarring of the liver caused by chronic diseases) of the liver.On 7/10/26 at 9:14 AM as three surveyors were passing by Resident #38's room, Resident #38 asked one of the surveyors to call a staff member. Resident #38 was sitting in the chair with the front wheel walker in front of her. When asked where her call light was, Resident #38 extended her arm toward her call light which was hanging on the wall and out of reach. Resident #38 stated she was assisted to her room by a staff member after her breakfast and had been sitting in the chair for a while.On 7/10/26 at 10:28 AM, RN #1 and CNA #1 entered Resident #38's room after being informed by the surveyor that Resident #38 needed assistance.On 7/10/26 at 10:40 AM, CNA #1 stated Resident #38 was unable to reach her call light which was on the other side of her bed. CNA #1 stated Resident #38's call light should be within her reach and it was not.

Based on the State Operations Manual (SOM), record review, and staff interview, it was determined the facility failed to ensure a copy of a resident's advance directive was maintained in the medical record. This was true for 1 of 12 residents (Resident #32) whose records were reviewed for advanced directives. The absence of the advance directive created the potential for an adverse outcome if Resident #32 became unable to communicate treatment preferences and those preferences were not available to guide care. Findings include: The SOM, Appendix PP, defines an advance directive as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law . relating to the provision of health care when the individual is incapacitated. The Manual further clarifies that a Physician Orders for Life Sustaining Treatment (POLST) form is a portable medical order communicating a patient's treatment preferences during a medical emergency, based on the patient's current medical condition, and is not an advance directive.Resident #32 was admitted to the facility on [DATE] with multiple diagnoses including dementia, muscle weakness, and protein calorie malnutrition.Resident #32's care plan, revised 5/12/22, documented: Provide Resident #32 and his appointed healthcare representative with education regarding advance directives as needed.Resident #32's care conference evaluation dated 6/26/26 documented, the resident had an advance directive in his record.On 7/8/26 at 10:13 AM, Resident #32's medical record was reviewed. A living will or a durable power of attorney for health care was not located.On 7/8/26 at 5:00 PM, the CNO confirmed Resident #32's record did not include an advance directive, and the facility did not have a living will on file.

Based on record review and staff interview, it was determined the facility failed to ensure medications were administered with an appropriate clinical indication. This was true for 1 of 5 residents (Resident #23) reviewed for unnecessary medications. The lack of an appropriate indication created the potential for chemical restraint use and improper medication administration. Findings include:Resident #23 was admitted to the facility on [DATE], with diagnoses including COPD, anxiety, and PTSD.Resident #23's care plan, revised 5/27/26, documented, give medications as ordered by physician.A review of Resident #23's physician orders documented, Lorazepam 2 mg/mL, 0.5 mL by mouth every 4 hours as needed, ordered for palliative care related to chronic obstructive pulmonary disease, initiated on 6/29/26.On 7/9/26 at 2:45 PM, the CNO reviewed the lorazepam order and stated the indication should be shortness of breath or anxiety.

Based on record review and staff interviews, it was determined the facility failed to ensure an allegation of misappropriation was reported to the State Agency as required. This was true for 1 of 1 resident (Resident #23) reviewed for misappropriation. This failure created the potential for poor communication and continued misappropriation of resident funds. Findings include:Resident #23 was admitted to the facility on [DATE], with diagnoses including COPD, anxiety, and PTSD.On 7/7/26 at 10:39 AM, Resident #23 stated that approximately two months prior, he reported $1,600.00 missing to the Social Services Director (SSD). He stated he told the SSD he believed another resident had taken the money. Resident #23 stated the SSD asked, How long ago did it happen? and when Resident #23 responded about one and a half months ago, the SSD told him it had been too long ago to investigate.On 7/9/26 at 1:42 PM, a call was made to the SSD for interview, with no response.On 7/10/26 at 10:40 AM, the CNO stated she recalled a resident's family member mentioning Resident #23's missing funds but she did not ask any further questions. When asked why she did not inquire further or report the allegation, the CNO stated the allegation was never made directly to her or facility staff.On 7/10/26 at 12:16 PM, the CEO stated the allegation should have been reported to the State Agency.

Based on record review and staff interviews, it was determined the facility failed to ensure an allegation of misappropriation was investigated as required. This was true for 1 of 1 resident (Resident #23) reviewed for misappropriation. This failure created the potential for continued misappropriation of resident funds. Findings include: Resident #23 was admitted to the facility on [DATE], with diagnoses including COPD, anxiety, and PTSD.On 7/7/26 at 10:39 AM, Resident #23 stated that approximately two months prior, he reported $1,600.00 missing to the SSD. He stated he told the SSD he believed another resident had taken the money. Resident #23 stated the SSD asked, How long ago did it happen? and when Resident #23 responded about one and a half months ago, the SSD told him it had been too long ago to investigate.On 7/8/26 at 2:31 PM, the facility's grievance records dated February 2026 through June 2026 were reviewed. No allegations of misappropriation involving Resident #23 were documented.On 7/8/26 at 2:46 PM, the Long Term Care Reporting Portal was reviewed. No reports of misappropriation involving Resident #23 were identified. On 7/9/26 at 1:42 PM, a call was made to the SSD for interview, with no response.On 7/10/26 at 10:40 AM, the CNO stated she recalled a resident's family member mentioning Resident #23's missing funds but she did not ask any further questions. When asked why she did not inquire further or report the allegation, the CNO stated the allegation was never made directly to her or facility staff.On 7/10/26 at 12:16 PM, the CEO stated the allegation should have been reported to him and investigated for potential misappropriation.

Based on record review, policy review, and staff interviews, it was determined the facility failed to ensure that a written notice of discharge was provided to 1 of 3 residents (Resident #37) whose records were reviewed for discharges and transfers. This failure created the potential for Resident #37 to be without access to discharge information or appeal advocacy resources. Findings include: Review of the facility's Discharge or Transfer policy, revised 8/30/25 documented: Notice of Transfer or Discharge1. The facility must provide the resident, the resident's representative (if any), and the Office of the State Long-Term Care Ombudsman with a written notice at least 30 days before the resident is transferred or discharged , except when:a.The resident's safety or the safety of others would be endangered by remaining in the facility;b.The resident's health has improved sufficiently to allow a more immediate discharge;c.The resident's urgent medical needs require an immediate transfer; ord.The facility ceases to operate.2. The written notice must include:a.The reason for transfer or discharge;b.The effective date of transfer or discharge;c.The location to which the resident is being transferred or discharged ;d.The name, address, and telephone number of the State Long-Term Care Ombudsman; ande.For residents with developmental disabilities or mental disorders, the contact information for the relevant protection and advocacy agency. 3. A copy of the notice shall be maintained in the resident's clinical record.The facility's Notice of Discharge or Transfer form documented that, the facility must notify the resident and, if known, a resident advocate or legal representative of the resident of the transfer or discharge and the reason(s) for the move in writing and in a language and manner they understand.Resident #37 was admitted to the facility on [DATE] and discharged on 5/19/26 with multiple diagnoses that included; other chronic osteomyelitis, multiple sites (an autoinflammatory condition which is characterized by recurring episodes of inflammation, pain, and bone lesions in multiple skeletal areas), paraplegia (an impairment or loss of motor and sensory function in the lower half of the body), and chronic pain syndrome.An admission MDS assessment dated [DATE], documented Resident #37 to be cognitively intact.The Notice of Discharge or Transfer form dated 5/21/26 in Resident #37's record documented no signature from him under the Verification of Receipt of Notice section. Instead, the signature line stated, Resident #37 left the facility against medical advice (AMA) and included the initials of the SSD and CNO.On 7/10/26 at 9:00 AM, an interview was conducted with the CEO. The CEO stated the SSD was responsible for discharges and transfers from the building. The CEO further stated the facility did get a current address for Resident #37 but did not know if he received a written notice.A review of Resident #37's admission Record sheet documented an address on file.On 7/10/26 at 12:03 PM, a telephonic interview was conducted with the SSD. The SSD stated that it would be important for a discharging resident to receive the notice, however, since Resident #37 left AMA, it was different. The SSD further stated that Resident #37 did not receive a copy of his notice because he left the facility and did not return and there was no address to mail it to him.

Based on record review, resident observation, and staff interviews, it was determined the facility failed to implement a comprehensive, person centered care plan as written. This was true for 1 of 12 residents (Resident #32) whose record was reviewed for care plan implementation. This failure created the potential for Resident #32 to develop pressure injuries and adverse outcomes when his heels were not offloaded as directed by his care plan. Findings include: Resident #32 was admitted to the facility on [DATE] with multiple diagnoses including dementia, muscle weakness, and protein calorie malnutrition.A review of Resident #32's care plan, revised 6/18/21, directed staff to offload Resident #32's heels or use Prevalon boots when in bed, as he allowed.On 7/9/26 at 11:22 AM, Resident #32 was observed in bed without Prevalon boots in place.On 7/9/26 at 11:23 AM, LPN #2 stated Resident #32 should have his boots on. LPN #2 lifted the blanket and observed Resident #32's legs resting on a pillow. When asked if Resident #32's heels were offloaded, LPN #2 stated, no and confirmed they should have been offloaded.

Based on observation, policy review, record review, and staff interviews, it was determined the facility failed to ensure resident's medications were administered according to professional standards of practice. This was true for 1 of 1 resident (Resident #30) whose medication was reviewed and true for 1 of 3 residents (Resident #9) whose medication administration was observed. This failed practice created the potential for Resident #30 to receive improper treatment, skin irritation, allergic reaction, or other adverse outcomes and created the potential for Resident #9 to not receive the full dose of their prescribed eye drops. Findings include: 1. Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including dementia, anxiety, and adult failure to thrive. On 7/7/26 at 10:58 AM, CNA #2 was observed assisting Resident #30 with activities of daily living (ADLs). CNA #2 stated Resident #30 had redness to her lower abdomen and under her breasts. CNA #2 stated she assisted Resident #30 with keeping the areas clean twice per day. Resident #30 declined to let the Surveyor observe treatment to the abdomen and breasts. A review of Resident #30's Skin Evaluation dated 7/6/26 documented, Resident #30 had redness to the abdominal folds and under the breasts with treatment in place. A review of Resident #30's physician orders and MAR/TAR documented no orders for skin treatment to the abdomen or breasts. On 7/8/26 at 3:56 PM, CNA #2 was asked about the treatment provided to Resident #30. CNA #2 stated she cleansed the affected areas with warm soapy water and patted the areas dry. CNA #2 further stated the nurse on duty then applied a powder to the affected areas. On 7/9/26 at 3:16 PM, LPN #2 was asked about the skin treatment for Resident #30. LPN #2 stated a Gold Bond powder was being applied to the affected areas. When asked if there was an order for Gold Bond powder application, LPN #2 stated there was no active order and she would text the physician. 2. The facility's Administration of Eye Drops policy revised 9/17/25 documented during post-administration of eye drops: a. Instruct the resident to close the eye gently (not squeeze). b. Encourage gentle eye movement to distribute the medication. c. Blot excess medication with a clean tissue. The American Family Physician webpage article titled Using Glaucoma (abnormally high pressure inside the eye) Eyedrops documented after you squeeze the drop of medicine into your eye, close your eye. Then press a finger between your eye and the top of your nose. Press for several minutes. This way, more of the medicine stays in your eye. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including unspecified glaucoma, hypertension, and prostate cancer. A physician order dated 7/29/26 documented, Resident #9 was to receive the following: -Brimonidine Tartrate (an eye drops to lower the elevated pressure in the eye) Ophthalmic Solution 0.2%, instill one drop in both eyes three times a day related to unspecified glaucoma. -Dorzolamide (an eye drops to lower the elevated pressure in the eye) HCL Ophthalmic Solution, instill one drop in both eyes two times a day related to unspecified glaucoma. On 7/9/26 at 7:05 AM, LPN #1 handed a tissue paper to Resident #9. LPN #1 then administered one drop of Brimonidine to both of Resident #9 eyes. Resident #9 was observed to rub both of his eyes with the tissue paper. LPN #1 told Resident #9 not to rub his eyes, but Resident #9 continued to rub his eyes. LPN #1 was not heard to instruct Resident #9 to press his finger between his eyes and the top of his nose after the administration of the eye drop. LPN #1 administered Resident #9 oral medications. When Resident #9 finished taking his oral medications, LPN #1 then administered one drop of Dorzolamide to both of his eyes. Resident #9 was observed to rub his eyes with the tissue paper. LPN #1 was not heard to educate Resident #9 regarding the rubbing of his eyes after the administration of his eye drops. On 7/9/26 at 10:00 AM, LPN #1 stated she told Resident #9 to dab his eyes and not to rub his eyes when she first administered his first eye drops. LPN #1 stated she did not educate Resident #9 on the importance of not rubbing his eyes after the eye drops administration.

Based on record review, resident observation, and staff interviews, it was determined the facility failed to ensure podiatry treatment orders and care plan interventions were implemented as written. This was true for 1 of 1 resident (Resident #32) reviewed for podiatry services. This failure created the potential for untreated foot conditions, discomfort, and deterioration of skin integrity due to the lack of required podiatry services. Findings include:Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including dementia, muscle weakness, and protein calorie malnutrition.A review of Resident #32's care plan, initiated 4/11/24, directed staff to provide podiatry evaluation and treatment as needed.On 7/9/26 at 11:25 AM, LPN #2 removed Resident #32's socks and stated his toenails needed to be trimmed. When describing the toenails, LPN #2 stated they were chunky, yellow, and irregular.On 7/9/26 at 11:34 AM, LPN #2 stated Resident #32 was on the podiatry list to be seen every three months.A review of Resident #32's podiatry visit dated 5/19/26 documented a physician order for:- Ammonium lactate 12% cream, apply to bilateral feet and callused skin as needed for 180 days.A review of Resident #32's physician orders from 05/01/26 through 07/09/26 documented no order for ammonium lactate.On 7/10/26 at 3:34 PM, the CNO stated that when the ammonium lactate order was received, Resident #32 was asked if he wanted the treatment implemented and he said no. The CNO stated the provider's notification of the refusal and the resident's refusal was not documented in the medical record.

Based on record review, resident observation, and staff interview, it was determined the facility failed to ensure proper monitoring was conducted to identify potential catheter associated urinary tract infections. This was true for 1 of 3 residents (Resident #32) reviewed for catheter care. This failure created the potential for undetected signs of infection if Resident #32 was not monitored for appropriate symptoms. Findings include:Resident #32 was admitted to the facility on [DATE] and was readmitted on [DATE], with multiple diagnoses including dementia, muscle weakness, and protein calorie malnutrition.A review of Resident #32's physician order, dated 2/14/25, directed staff to monitor, record, and report to the provider signs and symptoms of catheter associated urinary tract infection, including: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, changes in behavior, or changes in eating patterns.Resident #32 was observed with white, milky urine in his catheter tubing flowing into the catheter bag on the following dates:-7/7/26-7/8/26-7/9/26A review of Resident #32's MAR dated July 1-10, 2026, documented No for completion of the physician order initiated on 2/14/25 directing staff to monitor, record, and report signs and symptoms of catheter associated urinary tract infection.On 7/10/26 at 10:29 AM, the CNO stated she would not document a change when Resident #32's urine appeared milky white because this was his baseline. The CNO stated the monitoring order was not appropriate for Resident #32 because cloudiness would be normal for him. The CNO confirmed Resident #32's record did not include documentation of physician notification regarding urine changes.

Based on observation, resident and staff interviews it was determined the facility failed to ensure an oxygen concentrator was removed from the resident's room after the physician discontinued the resident's oxygen order. This was true for 1 of 1 resident (Resident #12) whose oxygen concentrator was observed. This deficient practice created the potential for harm if the resident attempted to use the oxygen equipment without a valid physician order. Findings include:The facility's Oxygen Administration, Safety, Storage & Maintenance policy revised 10/10/25, documented the facility would administer, store, and maintain supplemental oxygen safely in accordance with current standards of practice and licensed practitioner orders. If oxygen therapy was discontinued, discard all disposable components, replace filters as specified by the manufacturer, and disinfect the exterior surfaces of the oxygen equipment in accordance with the Instructions for Use.Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including morbid (severe) obesity with alveolar hypoventilation (occurs when breathing is too slow or too shallow to meet the body's metabolic needs), and diabetes.On 7/7/26 at 12:23 PM, Resident #12 was observed in his room sitting in his power chair. An oxygen concentrator was observed at his bedside. When asked how often he used his oxygen, Resident #12 stated he only used oxygen when he needed it.Review of Resident #12's physician orders did not include an order for oxygen.On 7/8/26 at 3:03 PM, the CNO stated Resident #12's oxygen concentrator should not be in his room because he no longer used the oxygen, it was discontinued on 6/17/26.

Based on record review and staff interview, it was determined the facility failed to ensure medications were administered with an appropriate clinical indication. This was true for 1 of 5 residents (Resident #23) reviewed for unnecessary medications. The lack of an appropriate indication created the potential for improper medication administration and use of medication without a clearly defined clinical need. Findings include:Resident #23 was admitted to the facility on [DATE], with multiple diagnoses including COPD, anxiety, and PTSD.Resident #23's care plan, revised 3/2/26, documented: give medications as ordered by physician.A review of Resident #23's physician orders documented the following order:- Morphine Sulfate 20 mg/mL, give 0.25 mL by mouth every 6 hours as needed for severe pain related to chronic obstructive pulmonary disease, initiated on 7/7/26.On 7/9/26 at 2:45 PM, the CNO stated she did not know what the appropriate indication for the morphine order should be.

Based on resident interview, staff interview, and record review, it was determined the facility failed to ensure food was served at palatable temperatures as required. This was true for 1 of 1 resident (Resident #31) reviewed for food quality. This failure created the potential for reduced enjoyment of meals and decreased dietary intake when food was not served at acceptable temperatures. Findings include: Resident #31 was admitted to the facility on [DATE] with multiple diagnoses including diabetes, gastro esophageal reflux, and chronic kidney disease.On 7/7/26 at 3:16 PM, Resident #31 stated the hot food is always cold. She stated she generally eats in the dining room and that most of the time it is a problem. Resident #31 stated she normally does not ask for her food to be reheated because cold food is normal in the facility.On 7/9/26 at 7:46 AM, a request for a breakfast tray was made to the kitchen.On 7/9/26 at 8:12 AM, the tray was delivered by the CM. Food temperatures were taken and documented as follows:-French toast: 84 F- Eggs: 93 F- Sausage: 79 F-Apple juice: 51 [NAME] 7/9/26 at 8:15 AM, upon review of the temperatures, the CM stated she was not sure what an acceptable food temperature should be upon delivery.

Based on record review and staff interviews, it was determined the facility failed to ensure a physician order was clarified regarding its clinical indication and medication dosage. This was true for 2 of 2 residents (#1 and #12) whose records were reviewed. This deficient practice resulted in inaccurate documentation within the resident's medical record. Findings include: The facility's Documentation of Resident Health Status Needs & Services, revised 9/1/25, documented that the resident's medical record should be accurate, objective and clinically relevant. 1. Resident #12 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including morbid (severe) obesity with alveolar hypoventilation, and diabetes. A physician order dated 6/4/26 documented Resident #12 was to receive the following medications: -Toujeo SoloStar Subcutaneous Solution Pen-Injector 300 units/ml (insulin glargine), inject 120 units subcutaneously one time a day related to morbid obesity with alveolar hypoventilation. - Toujeo SoloStar Subcutaneous Solution Pen-Injector 300 units/ml (insulin glargine), inject 120 units subcutaneously at bedtime related to type 2 diabetes. On 7/9/26 at 4:20 PM, the CRN reviewed Resident #12's physician order and stated the evening dose of insulin glargine was indicated for diabetes and the morning dose was indicated for obesity. The CRN stated insulin glargine was for diabetes and I don't know why the indication was changed to obesity. On 7/10/26 at 10:16 AM, during a follow-up interview, the CRN stated Resident #12's insulin glargine order should have been for diabetes and not for obesity, and that it had been mistyped by the nurse. 2. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including quadriplegia (paralysis affecting all four limbs and the torso), depression, and anxiety disorder. Resident #1's MAR documented a medication order dated 6/22/26 for hydroxyzine HCl (antihistamine) Give 1 tablet by mouth every 8 hours as needed for anxiety. The order did not include a dose. On 7/10/26 at 12:47 PM, the CNO confirmed there was not a dose listed on the order and should have been. The CNO further stated Resident #1 was previously getting hydroxyzine 25mg tablets and whoever put in the order did not catch the 25mg.

Based on record review, policy review, and interviews it was determined the facility failed to consider caregiver/support person availability, capacity, and capability to perform required care as part of the identification of discharge needs. This was true for 1 of 3 residents (Resident #1) reviewed for the facility's transfer and discharge process. This deficient practice created the potential for harm when Resident #1 was transported to a homeless shelter that was unable to provide the required level of care. Findings include: The facility's Discharge or Transfer policy revised 8/30/25, documented upon transfer of a resident, information necessary to meet the resident's needs should be provided.Resident #1 was readmitted to the facility on [DATE] with chronic kidney disease, morbid obesity (BMI 70), muscle weakness, difficulty walking, and anxiety/adjustment disorders.A Discharge MDS assessment dated [DATE], documented Resident #1 was cognitively intact and required supervision/touching assistance for eating, hygiene, dressing, toileting, and footwear, and substantial/maximal assistance for bathing.Resident #1's TAR dated January 2026 through February 2026 documented the following active wound care orders:Left second toe wound care twice weeklyCalmoseptine to bilateral buttocks twice daily for MASDRight lower extremity wound dressing changes every shiftA wound care progress note dated 1/26/26, documented Resident #1 had a chronic ulcer on her left lower leg with exposed subcutaneous tissue. The assessment documented the patient was refusing cares and garments which led to unhealable wounds and could cause sepsis and death.Resident #1's Discharge - Anticipated/Planned evaluation dated 2/2/26, documented Resident #1 had a follow-up medical appointment scheduled for 2/10/26 with her [patient preferred clinic].Resident #1's record did not include a referral to a wound care clinic, documentation of the receiving setting's ability to meet ADL or wound care needs, and a signed discharge plan.On 2/3/26 at 2:18 PM, the [Homeless Shelter] Case Manager #1 stated their bed cots cannot support individuals over 400 lbs and they cannot provide wound care or mobility assistance. She also stated the facility did not contact them prior to dropping off Resident #1 and confirmed they could not meet her care needs. On 2/4/26 at 11:16 AM, the [Homeless Shelter] provided documentation of their medically fragile program documenting the following requirements:Individuals must be independent with ADLsThey require advance notification from LTC facilities to verify bed availability and care capability.An in person assessment prior to acceptance is required.On 2/3/26 at 12:53 PM, and on 2/4/26 at 11:47 AM, the [Transportation Company] stated on 2/2/26 at 1:20 PM the [Transport Company] departed the facility with Resident #1. They arrived at [Homeless Shelter] at 2:10 PM. Resident #1 was offloaded at the homeless shelter when the shelter staff informed the driver, they could not accept the resident. The [Transportation Company] attempted to call the facility at 2:34 PM but had to leave a message. At 2:59 PM, the facility returned the call and was informed the shelter could not accept the resident. However, the facility did not request the resident be returned. Resident #1 remained outside the shelter until she was transported to the ER at 3:10 PM.On 2/3/26 at 2:50 PM, the Social Services Director stated the facility did not notify the shelter because it is a homeless shelter and stated she did not refer Resident #1 to a wound clinic because she felt Resident #1 could perform her own care.On 2/4/26 at 1:21 PM, the DON stated Resident #1 could not apply cream to bilateral buttocks without assistance.On 2/4/26 at 11:31 AM, Administrator #2 stated [LTC Facility] was notified by [Transport Company] between 2:00 - 2:30 PM that Resident #1 had not been accepted into [Homeless Shelter]. Administrator #2 stated [Transport Company] informed him Resident #1 had already been taken to the ER.Cross-reference F656 and F657

Based on record review, CMS SOM Appendix PP, policy review, and staff interview, it was determined the facility failed to ensure resident centered care plans were comprehensively written. This was true for 1 of 3 residents (Resident #1) whose care plans were reviewed in the sample. This deficient practice created the risk of adverse outcomes if residents comprehensive care plans did not reflect the care necessary for each resident. Findings include:The CMS SOM, Appendix PP dated 7/23/25, documented each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences, goals, and address the resident's medical, physical, mental and psychosocial needs.A Resident Assessment (RAI) & Comprehensive Care Plans Policy and Procedure, revised 9/3/25, documented under section 4a: The Interdisciplinary team (IDT) will develop a comprehensive, person-centered care plan within 7 days of the completion of the comprehensive assessment.Resident #1 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic kidney disease, venous insufficiency peripheral (poor blood flow to the extremities), and morbid severe obesity.Resident #1's Quarterly MDS assessment dated [DATE], documented under M1040 in Section A, Yes for the question, Infection of the foot and under Section C, Yes for the question Other open lesion foot. However, there was documentation in Resident #1's electronic medical record to indicate she was being treated for wounds.Resident #1's care plan initiated on 3/1/24, revised on 9/29/25, did not include directions to care for the wound on her foot.On 2/4/25 at 12:37 PM, the MDS Nurse reviewed Resident #1's MDS record and care plan, and stated, Resident #1 did not have a care plan for the foot infection and there should have been one.

Based on record review, review of the State Survey Agency's Long-Term Care Reporting Portal, hospital record review, and staff interview, it was determined the facility failed to ensure a resident's care plan was followed to prevent falls. This was true for 1 of 4 residents (Resident #10) whose records were reviewed for falls. This failure harmed Resident #10 when she suffered fractures to her right lower leg after a fall from her bed. Findings include: Resident #10 was admitted to the facility on [DATE] with multiple diagnoses including multiple sclerosis (an irreversible condition in which the body's immune system attacks the central nervous system), and Alzheimer's disease. On 8/8/22, Resident #10's care plan documented she required total assistance for transfers with two staff and a mechanical lift. On 8/14/22, Resident #10's care plan documented an intervention was initiated to use fall mats on the right side of the bed and to have her bed in the lowest position. On 10/1/22, Resident #10's care plan documented she used bolsters to the sides of her mattress to help her define the edges of the bed. On 11/1/23 at 11:20 AM, a fall report documented CNA #1 and #2 witnessed Resident #10 have ground level fall. The report documented after CNA #1 put a sling under Resident #10, they lowered the bed to the lowest position, and left the room to retrieve the mechanical lift and CNA #2 to assist with transferring her. Upon reentering the room, CNA #1 and #2 observed Resident #10 rolling over the bolster on right side of her bed onto the floor, landing on her right hip and, at that time, she was assessed and was not showing symptoms of injury. On 11/1/23 at 8:00 PM, Resident #10 was observed to have swelling and bruising of her right lower leg and the physician directed staff to transport her to the ED for an x-ray. On 11/1/23 at 8:47 PM, an x-ray report documented tibial and fibular fractures on her right lower leg. On 11/8/23, the facility submitted their investigation report for the fall to the State Survey Agency Long-Term Care Reporting Portal. The report documented the facility investigation found the bed was not at the lowest position and the fall mat was not in place when Resident #10 fell out of bed. On 8/22/24 at 3:30 PM, the DON stated during their investigation they recognized inconsistencies in the reports from CNA #1 and #2 and determined the reports provided by the CNA's involved were not honest or accurate. The DON stated CNA #1 and #2 did not follow Resident #10's care plan and were terminated on 11/3/23 due to their dishonesty related to Resident #10's fall. The facility took the following actions: -A licensed nurse assessed Resident #10 immediately after the fall for signs on injury. -Resident #10's family representative was informed of the incident. -Alert charting was initiated to monitor for signs of injury. -The facility's Medical Director, Administrator, and Director of Nursing were notified. -When symptoms of injury became apparent, the facility notified the physician. -The physician sent her to be assessed and the injury was treated appropriately. -The Bureau of Facility Standards was notified through the reporting portal. -On 11/2/23, all nursing staff were reeducated and assessed to be knowledgeable about following care plans and appropriately handling falls with injury. -On 11/3/23, all CNA's were assessed to be proficient in following care plans and safely transferring residents with mechanical lifts. -The incident and Resident #10's care plan were reviewed with the IDT and identified the two CNA's involved had been dishonest and her care plan remained appropriate, but the failure to follow the care plan was what made the injury occur. -CNA #1 and #2 were terminated. -The facility followed up with specialists to care for the fractures. These investigative findings represent past noncompliance with this regulatory requirement. There was sufficient evidence the facility investigated and corrected the noncompliance as of 11/3/23. At the time of this survey the facility was in substantial compliance for this regulatory requirement and therefore does not require a plan of correction for this citation.

Based on staff interview, policy review, review of facility incident reports, and record review, it was determined the facility failed to ensure residents were provided the level of supervision necessary to prevent falls. This was true for 1 of 3 residents (Resident #3) reviewed for supervision and accidents. Resident #3 was harmed when he sustained a [MEDICAL CONDITION] when the staff failed to develop and implement interventions to provide sufficient supervision. Findings include: The facility's Accidents and Supervision to Prevent Accidents policy, revised 4/4/19, documented an avoidable accident was an accident that occurred because the facility failed to: *Identify environmental hazards and/or assess individual resident's risk of an accident, including the need for supervision and/or assistive devices *Evaluate/analyze the hazards and risks and eliminate them, if possible, or if not possible, identify and implement measures to reduce the hazards/risks as much as possible *Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan, and current professional standards of practice to eliminate the risk, if possible and if not, reduce the risk of an accident *Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice The policy further stated if a resident was found on the floor, a fall was considered to have occurred. The above policy was not followed. Resident #3 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The Admission Assessment, dated 11/24/20 at 1:08 PM, documented Resident #3 had left sided [MEDICAL CONDITION] (weakness of one side of the body). The assessment documented Resident #3 did not experience pain with movement, exhibit evidence of pain, or have a [DIAGNOSES REDACTED]. The musculoskeletal section of the assessment documented Resident #3 had weakness to his left arm, left hand, and left leg. The assessment documented Resident #3 had fallen in the last 30 days and in the last 6 months. The summary section of the assessment documented Resident #3 was observed self-transferring and staff were unable to redirect him due to his cognitive deficit/dementia. Resident #3's record included a Fall Risk Assessment, dated 11/24/20 at 1:08 PM, which documented Resident #3 had a history of [REDACTED]. The assessment documented Resident #3 did not have pain that affected his level of function. The Fall Risk Assessment documented Resident #3 was scored a 9 out of 10, a score of 4 or more was considered at risk for falling. A Nurse's Progress Note, dated 11/24/20 at 1:53 PM, documented by the DNS, stated Resident #3 was possibly hallucinating by seeing people that were not there and was noted to be ataxic (impaired coordination) in stance and is obviously a high fall risk. The note documented 15-minute checks had been initiated. Resident #3's care plan documented Resident #3 had impaired mobility with risk for falls related to [MEDICAL CONDITION] (stroke) with left [MEDICAL CONDITION]. Resident #3's care plan did not include 15-minute checks or other level of supervision necessary to protect him from falls. A Nurse's Progress Note, dated 11/24/20 at 3:46 PM, documented by the DNS, stated she had spoken to Resident #3's niece and told her the facility had identified early on that Resident #3 was a high fall risk and expressed deep concern and asked if family members, after being tested for COVID-19, could come in and sit with Resident #3 and assist with his communication with staff some of the time. The DNS also expressed concerns regarding Resident #3's quarantine status as a new admission and his mental status. The nurse's note documented Resident #3's niece verbally stated, Resident #3 had fallen at home and had been seeing people that were not there prior to his hospitalization . A Nurse's Progress Note, dated 11/25/20 at 8:07 PM, documented Resident #3 was out of his room most of the day in the lobby, sitting in wheelchair. The note stated In evening, he became difficult to keep safe in his wheelchair. Continues to get out of wheelchair and does not understand English. He is refusing to sit in his chair, insisting on sitting and/or standing in hallway. A Nurse's Progress Note, dated 11/25/20 at 8:18 PM, documented, Resident is on the floor on his hands and knees in the hallway. He is very confused and does not respond to redirection. Continuing to monitor. A Nurse's Progress Note, dated 11/26/20 at 2:33 AM, documented Resident #3 was unable to be redirected with non-pharmacological interventions and was getting physically aggressive with staff at times when they were trying to intervene with safety measures. A Nurse's Progress Note, dated 11/26/20 at 1:51 PM, documented Resident #3 was having pain and swelling to his right hip. Resident #3 was unable to bend or abduct his right leg. The note documented physician orders [REDACTED]. The bedside x-ray results, dated 11/26/20 at 3:36 PM, documented history of pain in right hip and unspecified fall with the significant findings to the right hip with 2-3 unilateral views. The findings included: There is a right intertrochanteric fracture (top of the thighbone where the muscles of the thigh and hip attach) with no displacement. The joint shows no dislocation .There is modest [MEDICAL CONDITION]. A Nurse's Progress Note, dated 11/26/20 at 3:50 PM, documented Resident #3 was sent to the hospital for evaluation. A Nurse's Progress Note, dated 11/26/20 at 4:40 PM, documented Resident #3 was in bed that morning and complained of right leg pain, Tylenol was given, and Resident #3 rested for a while. The note stated the nurse was asked by a CNA to assess Resident #3's right leg. The nurse documented Resident #3's right leg in the hip region was swollen and tender. Resident #3 was unable to bend his knee or move his leg in any direction. A reportable incident report, dated 11/26/20, documented Resident #3 had an injury of unknown origin. The facility initiated an investigation with witness statements. The witness statements included: *A witness statement by day shift nurse, RN #2, on 11/25/20 documented, Resident #3 was in his wheelchair throughout the whole day and he did not appear to be in any pain - no grimacing or wincing. The statement documented by the end of her shift Resident #3 was more resistant to redirection and continually tried to stand up. RN #2 documented to keep Resident #3 safe, he was always near staff. The statement documented Before I left, I witnessed him stand up out of his wheelchair in the hallway, get down on his hands and knees, and slowly crawl a short distance. He was touching the walls with his hands and then just stationary in the hall, on his hands and knees. There was no documentation in the witness statement that staff attempted to assist Resident #3 from the floor or assess him for reasons he got down on the floor on his hands and knees. *A witness statement by evening shift nurse, LPN #1, on 11/25/20 at 8:15 PM, documented Resident #3 was restless and anxious sitting in his wheelchair in the lobby. Resident #3 was standing without staff assistance for safety. The statement documented Resident #3 continued to stand and staff were instructed to provide stand by assistance for safety with ambulation. Resident #3 became increasingly agitated when staff attempted to redirect or touch him when he became unstable with ambulation. Resident #3 became combative towards staff and lowered himself to the floor on his hands and knees with staff standing by for assistance. Resident #3 started scooting around on his bottom and crawling on his knees while pushing/pulling wheelchair around. LPN #1 instructed staff to keep Resident #3 in sight and approach him later when he calmed down. LPN #1 continued to check on Resident #3 every 5 minutes until she noted Resident #3 laying on the floor on his left side and he told her he was tired, and two staff members assisted Resident #3 to bed. Resident #3 stated he was having pain and LPN #1 attempted to administer Tylenol and Resident #3 refused. The witness statement did not include where Resident #3's pain was located and there was no documentation he was assessed to determine the source of the pain. There was not an incident report initiated or a nurse's progress note in Resident #3's record documenting LPN #1 found Resident #3 laying on the floor on his left side. *A witness statement by CNA #1 documented she worked the evening shift of 11/25/20. The statement documented Resident #3 was very restless and she was unable to get him to remain seated, so she laid him down in bed and she rested for about 30 minutes. CNA #1 documented Resident #3 rang his bell about 5:00 PM and when she entered the room she found him attempting to walk out of his room. The statement documented CNA #1 sat him down and gave him water. CNA #1 documented she left the room to get Resident #3 a snack and upon return found him sitting in his wheelchair in the hallway. The statement documented Resident #3 would walk a short distance and then get on his knees and slowing lay on the floor. CNA #1 documented that around 7:00 - 7:30 PM Resident 33 laid down and fell asleep on the hallway floor. He was assisted to bed by two staff. The statement documented after he was in bed Resident #3 stated he was in pain and touched his legs. CNA #1 documented she notified the nurse of Resident #3's pain and he remained in bed at the end of her shift. There was no documentation Resident #3 was assessed to determine the cause of his pain. *A witness statement by CNA #2, documented on 11/26/20 at 6:00 AM, documented she entered Resident #3's room and her co-worker CNA had Resident #3 sitting at the edge of the bed. CNA #2 observed Resident #3 was delayed in responses and while he was sitting on the edge of the bed his left arm grasped onto the wheelchair very tightly and no verbal response. The CNAs laid Resident #3 back down in bed because he did not look well and proceeded to provide cares when Resident #3 stated he was in excruciating pain on his right leg and she noticed his right leg seemed bigger/swollen than his left and reported her findings to the nurse. The facility's conclusion of the unknown origin to right [MEDICAL CONDITION] documented Resident #3 did not have a fall. Resident #3 was observed lowering himself to the floor and crawling around on his hands and knees and that was not considered a fall. There was no investigation into the reason Resident #3 lowered himself to the floor. The conclusion documented Resident #3 was known to have [MEDICAL CONDITION] which could result in a pathological fracture (related to a disease) occurring without known cause or trauma. Resident #3's medical record did not include [MEDICAL CONDITION] as a diagnosis. Resident #3's past medical history from the hospital did not include [MEDICAL CONDITION] as a diagnosis. On 12/15/20 at 3:30 PM, the DNS stated Resident #3 lowered himself down to the floor and crawled around the lobby area on his hands and knees reaching for things and touching the wall and then he got himself back up off the floor. The DNS demonstrated how Resident #3 lowered himself down to the floor and crawled around and how he grabbed onto the handrail or the wheelchair to get himself back up. The DNS stated Resident #3 lowered himself to the floor and that was not a fall and an incident or accident report was not initiated. The DNS stated 15-minute checks were provided by staff and he was out in the lobby where staff kept line of sight on Resident #3 at all times. The DNS was unable to answer why 15-minutes were not included in Resident #3's care plan when he was at high risk for falls. The DNS was unable to provide documentation staff provided 15-minute checks for Resident #3. On 12/15/20 at 3:48 PM, the Administrator stated Resident #3 was witnessed lowering himself to the floor and he did not expect an incident report to be initiated. The Administrator was unable to provide documentation staff provided 15 minute checks for Resident #3. The Administrator stated Resident #3 had a history of [REDACTED]. On 12/15/20 at 4:20 PM, RN #1 stated if a resident intentionally lowered him/herself to the floor, she would not initiate an incident report. RN #1 stated if a resident was found on the floor she would initiate neurological assessments and an incident report. RN #1 stated she was the nurse that assessed Resident #3's right leg and it was obvious he had a fracture. RN #1 stated he was in bed all day on 11/26/20 and had pain and received Tylenol without effectiveness. On 12/15/20 at 4:41 PM, the Director of Rehabilitation stated Resident #3 was evaluated for Physical and Occupational Therapy on 11/24/20 and had no pain. The Director of Rehabilitation stated on 11/26/20 Resident #3 was unable to participate with therapy related to increased pain. The facility failed to provide sufficient supervision to protect Resident #3 from a major injury resulting in hospitalization .

Based on record review, the facility's policies and procedures, the facility's allegation of neglect findings, and staff interview, it was determined the facility failed to ensure a resident was free from neglect. This affected 1 of 6 (#15) residents reviewed for mechanical lift transfers. Resident #15 was harmed when he sustained several fractures, a facial laceration and skin tears, during an improper mechanical lift transfer by one staff member. Findings included: The facility's Abuse Prohibition Policy and Procedure, revised on 5/1/16, documented: Neglect is defined as the failure to provide goods and services necessary to avoid physical harm .Examples include: Staff mistakes that result in the patient's need for hospitalization . The facility's Safe Resident Handling/Transfer Equipment Policy, revised on 11/30/15, documented: .Staff will be trained in the use of each type of equipment .The Total Lift will be used as the primary intervention to manual lifting, transferring, and repositioning and requires a minimum of two persons to perform the lift .The full body sling is only used when the divided sling is not appropriate . Resident #15 was admitted to the facility on [DATE] with multiple diagnoses, including dementia and a history of falling. Resident #15's 4/5/16 quarterly MDS documented he was totally dependent with two person assistance for transfers. Resident #15's ADL care plan documented a revised intervention on 4/5/16, Full body sling for all transfers . Resident #15's Progress Notes on 5/5/16 at 6:15 am, documented he had fallen in his room. The facility's Risk Management System dated 5/5/16, documented an incident which involved Resident #15 and CNA #1: CNA (#1) was transferring resident alone with hoyer (mechanical) lift. Resident slipped out of hoyer from a distance of three feet and hit the right side of his head/face on the metal base of the hoyer. CNA (#1) called for help. LN (#1) and another CNA (#2) arrived into room to assist. Resident was bleeding from head. CNA (#2) instructed to hold pressure to stop bleeding and to secure resident's cervical spine. Nurse assessed resident and called 911 . Resident #15's ER record from Hospital #1 documented Resident #15 sustained a stable burst [MEDICAL CONDITION] cervical vertebra, a traumatic displacement of the second cervical vertebra, a fracture around the right eye, a facial laceration which required sutures, and skin tears to his left arm and hand. Resident #15 was transferred to Hospital #2 due to a need for a higher level of care. Resident #15's ER record from Hospital #2 documented Resident #15's cervical injuries would require surgical intervention with an external immobilization halo device. Resident #15's family members declined the surgery and he was placed in a cervical neck collar and given pain medications for comfort care. The facility's Allegation of Neglect report, dated 5/11/16, documented Resident #15 fell from a mechanical lift when CNA #1 transferred him from his bed to his wheelchair without one of the four sling straps attached and without a second staff member (The sling rests under the resident and is gathered by the four corners via the straps which then pull the resident up). A statement written by CNA #1 documented she transferred Resident #15 by herself and one of the straps may not have been attached. A statement written by LN #1 documented CNA #1 called out and LN #1 went to Resident #15's room and found him on the floor and one of the sling straps was not attached to the mechanical lift. LN #1 documented she and CNA #2 were in the facility at the time of the incident and could have helped but CNA #1 did not ask for their help. On 5/18/16 at 1:40 pm, CNA #2 with the Administrator present, said she was in another resident's room at the time of the incident, but could have helped if CNA #1 had asked for help. On 5/18/16 at 2:30 pm, the CNE said the facility policy for all mechanical lift transfers was for two staff members to complete a transfer and CNA #1 did not follow that policy. The CNE asked CNA #1 why she chose to transfer Resident #15 by herself and CNA #1 did not have an answer but said that she knew she 'messed up.' The CNE said there were two other CNAs and a nurse in the facility at the time of the incident and CNA #1 should have asked for assistance. On 5/18/16 at 3:00 pm, the Administrator said the facility determined the allegation of neglect was substantiated.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure 2 of 12 sampled (#3 and #4) residents were provided the necessary care and services. This failure resulted in harm to Resident #3 when the facility failed to effectively coordinate with hospice and she was placed on a diuretic without potassium added to maintain accepted potassium levels. Resident #3's potassium levels were not monitored and her potassium dropped to a critical level. Resident #4 did not receive appropriate instruction during meals to prevent choking and coughing, which placed her at of aspiration. Additionally the facility failed to ensure Resident #3's swallowing ability was reassessed. Findings include: 1. Resident #3 was admitted to the facility on [DATE] after a fall at home and placed on hospice care. The resident s admitting [DIAGNOSES REDACTED]. On 11/16/15, hospital progress notes and orders documented Resident #3 had chronic diastolic [MEDICAL CONDITION] and had orders for the diuretic [MEDICATION NAME] ([MEDICATION NAME]), 20 mg tablet once a day. In addition to the diuretic, potassium chloride 20 mEq once a day was ordered. On 12/18/15, the [MEDICATION NAME] and potassium chloride were discontinued by hospice. On 1/12/16, hospice ordered the diuretic [MEDICATION NAME] ([MEDICATION NAME]) 2 mg every morning. The order noted hospice was to be contacted if the resident gained more than 3 pounds in one day or more than 5 pounds in a week. The order did not contain a corresponding order for potassium chloride or address potassium. [MEDICATION NAME] ([MEDICATION NAME]) is a Loop diuretic that has contraindications and cautions for elderly patients with decreased renal function. Black Box Warnings: monitor for [DIAGNOSES REDACTED]; intake and output; weight; and electrolyte, BUN , [MEDICATION NAME], and carbon [MEDICATION NAME] levels frequently. (Nursing 2016 Drug Handbook (2016). Philadelphia: Wolters Kluwer, 242-243). Nurses' Progress Notes and Nutrition Progress Notes for January, February, and March did not contain documentation regarding Resident #3's use of a loop diuretic or dietary supplements addressing potassium. Review of Resident #3's MAR for January 2016, February 2016 , and March 2016 documented the resident received [MEDICATION NAME] ([MEDICATION NAME]) 2 mg at 6 am for [MEDICAL CONDITION]. The record did not contain documentation Resident #3 received potassium chloride or was monitored for potassium levels or renal function. On 4/6/16, physician progress notes [REDACTED].#3 to assess her pressure sore and had ordered labs for baseline studies for the wound clinic. On 4/7/16, Laboratory Reports documented Resident #3's potassium level as critical at 2.2 mmol/L with the normal reference range of 3.4-5.0 mmol/L; and BUN 29 mg/dL, high with the normal reference range of 9.0-20.0 mg/dL. On 4/11/16, Laboratory Reports documented Resident #3's potassium level as critical at 1.9 mmol/L with the normal reference range of 3.4-5.0 mmol/L; and BUN 45 mg/dL, high with the normal reference range of 9.0-20.0 mg/dL [DIAGNOSES REDACTED] (low potassium) can lead to cardiac [MEDICAL CONDITION] and increased Blood Urea Nitrogen (BUN) value are used to evaluate renal function and hydration status (Leeuwen & Bladh (2015), Comprehensive Handbook of Laboratory & Diagnostic Tests with Nursing Implications, 6th ed. F. A. Davis Company: Philadelphia, 1278). On 4/11/16 at 9:50 am, Nurses' Progress Notes documented the physician was notified of the critical lab values. At 11:54 am, the physician ordered 20 mEq of potassium now, and suggested Resident #3 be sent to the hospital. Resident #3's family was notified of the critical labs. The family stated they wished to keep the resident at the facility on comfort measures. At 4:03 pm, the resident had refused 3 attempts to give the potassium chloride. On 4/11/16 at 11 am, Resident #3 was observed sitting in her wheelchair in the facility lobby. The resident was extremely thin and non-responsive to verbal stimulus. At 12:10 pm, Resident #3 was in the dining room slowly drinking from a cup. When the lunch tray arrived, Resident #3 moved her utensil through the food, but did not eat. At 12:34 pm, the DON sat with the resident to encourage the resident to eat. On 4/11/16 the [MEDICATION NAME] was discontinued. On 4/12/16 at 9:25 am, Resident #3 was observed in bed during a dressing change. The resident did not respond to verbal or tactile stimuli. On 4/13/16 at 4:10 pm, in an interview with the DON and MCO, the MCO stated the labs had been ordered because the NP had seen the resident for her wound and labs had not been done for a long time. They stated the order had come from hospice. They did not know the reason potassium chloride had not been ordered with the [MEDICATION NAME] or the reason Resident #3's potassium levels had not been monitored or addressed. 2. Resident #4's Admission Record stated Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4's most recent MDS, a quarterly assessment dated [DATE], included: mechanically altered/therapeutic diet, extensive assistance from staff was needed for feeding, and the resident had swallowing concerns, including holding food in mouth or residual food in mouth after meals and coughing or choking during meals or when swallowing medication. Resident #4's Speech Therapy Safe Swallow Guidelines, dated 5/29/14 and labeled Please Leave in Chart read, in part, Precautions: 1:1 Supervision; Alternate liquids with solids; cue to clear mouth between bites, upright 90 degrees for meals. Resident #4's recent care plan, dated 4/12/16 included: Focus: Patient demonstrates difficulty with swallowing secondary to stroke; Goal: Patient will consume meals safely without signs and symptoms of aspiration for 92 days; Interventions: Alternate bites of food with liquids. Use verbal cues to get patient through meal. Ensure patient is upright. Cue patient to chew thoroughly and swallow as indicated. Resident #4 was observed on 4/11/16 between 12:10 p.m. and 12:55 pm during the lunch meal service. Resident #4 was seated in her wheelchair and the back of the wheelchair was reclined back at an approximate 15 to 20 degree angle. Pureed food and three cups of fluid were served. CNA #7 was observed to give Resident #4 several bites of pureed food alternating with one drink of fluid throughout the meal. The resident was not encouraged or assisted to tuck her chin with bites of food or drinks of liquid. Resident #4 was observed to choke and gag eight times throughout the meal. Resident #4 was observed again on 4/12/16 between 12:15 pm and 12:45 pm while eating lunch. The resident was again seated in her wheelchair reclined approximately 15 to 20 degrees. Thickened fluids and pureed food was served. A staff member (CNA #7) was observed to give Resident #4 two to four bites of food alternating with one to two sips of fluid throughout the meal. Resident #4 was not assisted or encouraged to tuck her chin while swallowing food or fluid. The resident was observed to cough or choke six times during the meal. During an interview on 4/12/16 at approximately 4:00 pm, the MCO acknowledged staff should be following the protocols. She stated Speech Therapy would conduct an evaluation of Resident #4's ability to swallow as soon as possible to ensure Resident #4 was being assisted appropriately.

Based on observation, record review and staff interview, it was determined the facility failed to ensure a resident did not develop a pressure sore while at the facility. This was true for 1 of 4 residents reviewed for pressure sores (#3). The facility failed to accurately identify, monitor and timely implement interventions to prevent Resident #3 from developing a pressure sore. As a result, Resident #3 was harmed when she developed a pressure sore which increased in size from 3.2 cm x 1.8 cm on 2/26/16 to 6.5 cm x 5.75 cm on 4/14/16 (49 days), and became infected. Findings included: Resident #3 was admitted to the facility on [DATE] after a fall at home and placed on hospice care. The resident's admitting [DIAGNOSES REDACTED]. A POST document, dated 12/15/16, documented Resident #3 as do not resuscitate; comfort measures only; no feeding tubes or IV fluids; but yes to antibiotics and blood products. An Admission Assessment, dated 12/15/15, documented a skin tear, bruise, calluses on feet/toes, and staples to Resident #3's head. No other skin issues were documented. Resident #3's care plan, dated 12/16/15, identified the resident was at risk for skin breakdown related to limited mobility, dementia, hypertension and low body weight. The care plan initiated the following interventions related to Resident #3's risk for skin breakdown on 12/16/15: *Evaluate for any localized skin problems, i.e. dryness, redness, pustules, inflammation. *Evaluate for skin risk factors per protocol. *Float heels while in bed. *Monitor skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decreased sensation, and skin that does not blanch easily. *Observe skin condition with ADL care daily and report abnormalities. *Obtain dietitian consult as needed/ordered. *Offer/encourage fluids of choice. *Pressure redistribution surfaces to bed as per protocol. *Pressure redistribution surfaces to chair as per protocol. *Wound treatment as ordered. *Weekly skin assessments by licensed nurse. *Weekly wound assessment to include measurements and description of wound status. Resident #3's Admission MDS assessment, dated 12/22/15, documented the resident was moderately cognitive impaired; required extensive assistance of 1 to 2 persons for mobility; was wheelchair bound; occasionally incontinent of bladder; always continent of bowel; weighed 99 pounds; and was at risk for pressure sores. On 12/29/15 and 1/5/16, Nursing Progress Notes documented assessments for predicting pressure sore risk which identified Resident #3 as at mild risk for pressure sores. On 2/26/16, Nursing Progress Notes included, new onset/change in skin integrity as evidenced by abrasion. Left gluteal measuring 3.2 cm x 1.8 cm .physician notified. The intervention to trim the resident's nails every week was added to the TAR. On 2/26/16, the TAR stated, cleanse left gluteal area with NS and cover with non-adherent dressing for protection until healed q day and PRN. On 2/26/16, a Skin Integrity Report documented a 3.2 cm x 1.8 cm x <0.1 cm deep abrasion, intact, inflamed and indurate scabbed area. The area for staging the wound was blacked out. Resident #3's care plan identified the resident had an actual skin breakdown, but did not contain documentation of new, revised, or different interventions implemented on admission to prevent skin breakdown. On 3/3/16, a Skin Integrity Report documented a 1.8 cm x 1.0 cm <0.1 cm deep, staging documented as N/A (non-applicable), granulated, inflamed, and indurated area with healthy wound edges. The visualization of granulation tissue requires exposure of the wound bed. A stage II pressure ulcer is a partial-thickness loss of dermis presents as a shallow open ulcer with red-pink wound bed exposed without slough. (Treas & Wilkinson (2014), Basic Nursing; Concepts, Skills & Reasoning, Philadelphia: F A Davis Company, 1233-1239). On 3/8/16, a Skin Integrity Report documented a 1.5 cm x 1 cm, 50% granulated, 50% slough area. Staging was documented as N/A. Surrounding tissue was documented as healthy and pink with odor as N/A. The box noting care plan updating was left blank. On 3/15/16 and 3/22/16, Skin Integrity Reports documented a 1 cm x 1 cm, 50% granulated, 50% slough area. Staging was documented as N/A. Surrounding tissue was documented as healthy and pink with odor as N/A. The box noting care plan updating was left blank. On 3/21/16, Nursing Progress Notes documented an assessment for predicting pressure sore risk which identified Resident #3 as at mild risk for pressure sores. On 3/22/16, the TAR documented, Left Gluteal Fold: Clean with wound cleanser, apply Hydrogel (moisture regulating dressing) to site, and cover with [MEDICATION NAME] (dressing), every three days and PRN. On 3/22/16, Resident #3's Quarterly MDS documented Resident #3 was moderately cognitively impaired; required extensive assistance of 2 persons for mobility; was wheelchair bound; always incontinent of bladder and bowel; weighed 90 pounds; and was at risk for pressure sores. No pressure sores, staged or un-staged were documented. On 3/22/16 Resident #3's care plan documented the implementation of turning the resident every 2 hours, and then on 3/24/16, the turning schedule was changed to every hour and an air mattress was implemented. The care plan did not contain revisions, new or different interventions for skin at risk from the care plan's implementation on 12/16/15 to 3/22/16. On 3/24/16, Nursing Progress Notes documented, wound assessed by 2 RN(s). 25% slough, 50% eschar, peri-wound skin red, inflamed and blanching. No odor observed. Minimal drainage. Area started as abrasion. Resident has weight loss that is addressed by RD. Interventions in place to include high calorie snacks. Air mattress placed in bed with q 1 h (every hour) turning schedule. OT to assess resident for an off loading wheel chair cushion. MD and family made aware. The documentation did not include staging or measurement of the wound area. Resident #3's medical record did not contain documentation that an off-loading wheelchair cushion was implemented. On 3/29/16, a Skin Integrity Report documented a 1.5 cm x 1 cm, 50% eschar, 25% slough, and 25% granulation area. Staging was documented as N/A. Surrounding tissue was documented as healthy and pink with slight macerated wound edges and odor as N/A. The box noting care plan updating was left blank. On 3/30/16, the TAR documented, Santyl Ointment 250 Unit/GM. Apply to left gluteal fold topically every night shift Clean with wound cleanser; apply Santyl (an enzymatic [MEDICATION NAME] ointment) to left gluteal fold. Cover with border gauze daily and as needed. On 3/30/16, Nursing Progress Notes documented a wound dressing change due to saturation of dressing. The notes further stated, Wound with eschar in the wound base and non-blanching [DIAGNOSES REDACTED] surrounding the wound. Cleansed with wound cleanser. Santyl (medication cream) applied, covered with Borderguaze. Resident #3's medical record did not contain documentation the physician was notified or other measures were implemented. On 4/2/16, Nursing Progress Notes documented a skin check assessment of a pressure area: Left gluteal fold. On 4/3/16, Nursing Progress Notes documented a dressing change to the left gluteal fold. LN noted a moderate amount of drainage and odor to area. Turned q hour (every hour) per MD. Denies pain to the left gluteal fold during treatment. Resident #3's medical record did not contain documentation the physician was notified or other measures implemented. On 4/5/16, a Skin Integrity Report documented a 2 cm x 2 cm x <0.1 cm deep, 75% soft eschar, 25% slough area. Staging was documented as N/A. Surrounding tissue was documented as healthy, pink and blanching with healthy wound edges and odor as N/A. The box noting care plan updating was left blank. On 4/5/16, IDT Meeting Progress Notes documented, resident has unstageable wound of left hip that is being monitored by the wound care coordinator. On 4/5/16, Resident #3's care plan documented, position changes for offloading while up in wheelchair and with cares. On 4/6/16, physician progress notes [REDACTED].#3's wound and ordered labs. The NP documented the patient is noted to have a very large unstageable decubitus ulcer of the left ischial tuberosity. There is slough and eschar in the center of this wound. Due to this it is unstageable. The plan documented an order to take Resident #3 to the wound clinic for surgical debridement. I believe it would be in her (Resident #3) best interest that we (the facility) have an expert with wounds evaluate and treat this. The NP also documented Resident #3 was cachectic with very poor intake .is at extremely high risk for further skin break down . She (Resident #3) occasionally has behavioral issues but spends a majority of her time in her wheelchair. I believe that this is definitely contributing to her skin breakdown. On 4/7/16, Laboratory Reports documented Resident #3 had WBC of 21.1 K/ul with normal reference range of 4.0-10.0 K/ul. On 4/11/16, Laboratory Reports documented Resident #3 had WBC of 27.4 K/ul with the normal reference range of 4.0-10.0 K/ul. An increase in WBC is used as an indicator of infection (Leeuwen & Bladh (2015), Comprehensive Handbook of Laboratory & Diagnostic Tests with Nursing Implications, 6th ed. F. A. Davis Company: Philadelphia, 523). On 4/8/16, an order was received for an x-ray of Resident #3's left hip to rule out osteo[DIAGNOSES REDACTED] (bone infection). On 4/11/16 at 11 am, Resident #3 was observed sitting in her wheelchair in the facility lobby. The resident was extremely thin and non-responsive to verbal stimulus. At 12:10 pm, the resident was in the dining room slowly drinking from a cup. When the lunch tray arrived, Resident #3 moved her utensil through the food, but did not eat. At 12:34 pm, the DON sat with Resident #3 to encourage the resident to eat. On 4/12/16 at 9:25 am, an observation of Resident #3's wound assessment with the Skin Integrity Coordinator (wound nurse) and the corporate Manager of Clinical Operations, was completed. Resident #3 was observed awake but non responsive to verbal or tactile stimuli. Resident #3 was observed to have a closed pressure ulcer on her left ischial tuberosity. The pressure area measured 3.8 cm x 3.5 cm, 90% dark eschar, 10% slough with a 1.5 cm of undermining, soft, mushy and rebounding eschar in the center of the pressure sore. In the 8 o'clock position a 1 cm dark purple, non-blanching area extended down from the pressure area into the surrounding area. The surrounding tissue of 9 cm x 8 cm encompassing the pressure sore had [DIAGNOSES REDACTED], was red, and inflamed, with slight blanching. The area extended and bulged out approximately 4 cm beyond the surface of the unaffected tissue of Resident #3's left hip. An odor was noted. The wound nurse applied Santyl cream to the pressure area and covered the area with border gauze dressing. At the time of the wound assessments, the Skin Integrity Coordinator (wound nurse), stated that although she had attended the class for certification, she was not a certified wound nurse. She stated she was from an affiliated facility and came to this facility once a week to do wound care. The wound nurse measured the left gluteal wound and stated the area as 3.8 cm x 3.5 cm, black and yellow slough, necrotic tissue that was red with bleeding edges and no smell. She stated the wound had started as an abrasion and had not been open and therefore unstageable. At this time, the surveyor asked to observe Resident #3's right hip area. Observation revealed the right hip trochanter area to have approximately a 4 cm reddened circular area with slight blanching that remained reddened during cares. Resident #3's medical record was reviewed after the observation and did not include documentation of this. On 4/12/16 at 10:52 am, Nursing Progress Notes by the Skin Integrity Coordinator (wound nurse) documented the observed assessment and dressing change as, Resident's left gluteal measures 3.8 cm x 3.5 cm with minimum serous drainage, 90% soft eschar and 10% slough, edges are healthy, and surrounding tissues with pink blanching tissues and at about 8 o'clock deep purple non blanching tissue seen. Area is warm without odor. No signs or symptoms of infection locally at site and no signs or symptoms of pain. Continue with treatment as ordered and will continue to follow. On 4/13/16 at 4:10 pm, in an interview with the MCO and DON, they stated it was an abrasion and had not been identified as a pressure sore. When the MCO was asked about what she had observed during the dressing change, she had no comments, but did indicate there was an odor present. They stated Resident #3 was admitted on hospice, but were unsure of the [DIAGNOSES REDACTED]. The DON stated she had not seen the pressure sore since last week, but had been in contact with the family. The DON and MCO were asked the reason antibiotics were not used, given antibiotic use was consistent with Resident #3's advance directives or POST. The DON stated the family had discontinued hospice care, did not want the resident taken to the wound clinic, and was aware of Resident #3's infection and critical lab values, but wanted only comfort care measures. The MCO stated a new POST should be completed. On 4/13/16 at 4:30 pm, the DON presented an Incident and Accident Report, dated 4/1/16 at 2:40 pm, updating the initial 2/26/16 wound Incident and Accident Report. The report documented the wound now as unstageable .Resident has self-inflicted abrasion on left gluteal fold. Wound has since worsened. Under the box to summarize all findings to support 'Unavoidable' determination or provide additional comments as needed: the box had See letter from doctor. Attached to the Incident and Accident Report, was an undated, typed letter from the facility's medical director. Within the context of the letter, the 4/7/16 labs with the date were cited. The inclusion of the labs dated 4/7/16 conflicted with the 4/1/16 date of the Incident and Accident Report. The discrepancy could not be explained. Resident #3's medical records were reviewed. They did not contain documentation the medical director had seen Resident #3 or assessed her pressure sore. On 4/14/16, Nursing Progress Notes documented, Wound assessed by DON, measurements: 6.5 cm x 5.75 cm. Periwound skin 4 cm x 1 cm. Edges of wound slightly macerated. No odor after cleansing wound. Reddened area bright red, is blanchable. Wound bed covered by thin layer of eschar with center being soft. Continues to be unstageable related to eschar. Although the area is red, no temperature difference between peri-wound skin and surrounding skin. Vital signs remain at baseline. Resident is afebrile. Family does not wish to investigate any further causes of infection such as cultures .Call to MD to update him on the wound and request MD come out to facility to assess wound. Resident #3 had declined in the last 3 weeks and had stopped eating. Interventions of an air mattress and hourly turning were initiated approximately one month after the pressure sore was identified.

Based on observation, staff interview, and record review, it was determined the facility did not thoroughly assess a resident's changing status, notify the physician so a diagnostic work-up could be done and treatment started, or consistently follow residents' care plans. This deficient practice was true for 3 of 9 residents (#s 2, 3, and 4) sampled for quality of care. Resident #4 was harmed when her physician was not notified of her shortness of breath for a period of 6 days, resulting in a delay of treatment. When the physician was finally notified and diagnostic work-up done, Resident #4 was found to be profoundly anemic and in [MEDICAL CONDITION], requiring a blood transfusion and new medications. Resident #s 2, 3, and 4 had the potential for more than minimal harm when they did not receive assistance consistent with their plans of care. Findings included: 1. Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. *The Annual MDS assessment dated [DATE] documented: -Wants or needs a translator to talk with health care professionals. -Preferred language is Spanish. -Unable to complete the BIMS, assessed by staff with long term and short term memory deficits, rarely or never makes daily decisions. (NOTE: It was determined the facility did not engage a translator for Resident #4's assessments. Please refer to F 154.) -Extensive assist of 2 for transfers. -No shortness of breath. Resident #4's care plan documented: -Under the focus area of "Nutrition", the intervention of, "Observe and report [MEDICAL CONDITION]." Date Initiated 9/20/12. -Under the focus area of "Risk for Falls", the intervention, "Assist resident getting in and out of bed with 2 assistance using a FWW (front wheeled walked) or (wheelchair) and gait belt." Date initiated 9/19/12. -Under the focus area of "Hydration", the intervention of, "Obtain lab work as per orders. Notify MD of abnormal values." a. Resident #4's Physician's Progress Notes documented: -10/16/13. "(Right) upper forehead scrape from scratching - BGs better last (illegible) 89-241 - (weight) up 198 (to) 203 (pounds)." There was no assessment from the physician regarding the root cause of this weight gain. There was no documentation the physician had assessed for [MEDICAL CONDITION], listened to the resident's lungs, or obtained her oxygen saturations. There was no new lab work ordered after this visit. See F 325 related to significant weight gain. Resident #4's Nurse's Progress Notes documented: -10/17/13 at 7:00 PM, "Resident having increased restlessness (with) rapid breathing noted and jitteriness when verbally speaking..." -10/17/13 at 8:15 PM, "...labored breathing." There was no documentation of any further assessment regarding Resident #4's rapid or labored breathing, such as listening to her lungs, obtaining oxygen saturations, or assessing for possible [MEDICAL CONDITION]. There was no documentation the physician was notified. On 10/21/13 at 2:15 PM, Resident #4 was observed sitting in her room, in her wheelchair, which was located next to the left side of her bed, with the resident facing the head of the bed. She was approximately 10 feet from the doorway to the room. As the surveyors entered the room, Resident #4 could be heard with wheezing as she breathed. As the surveyors approached the resident, her ankles were visibly [MEDICAL CONDITION], to the point of her skin appearing taut. As she spoke, her voice sounded forced, as if she was having to exert herself to speak. NOTE: 86.25 hours had elapsed since the facility had first noted rapid breathing. On 10/22/13 at 11:00 AM, the surveyors entered Resident #4's room, along with LN #1, to observe a BG check. Resident #4 was again wheezing, with her ankles visibly swollen as they had been on the surveyor's previous observation above. Resident #4 was wearing blue cotton ankle socks and black shoes, with her skin so taut it was bulging slightly around the top of her socks. When Resident #4 spoke, her voice sounded forced and as if she were having to exert herself. LN #1 did not remark on or assess Resident #4's [MEDICAL CONDITION], or her breathing at that time. On 10/23/13 at 3:55 PM, the surveyors reviewed Resident #4's chart. They could find no documentation for follow-up of the rapid or labored breathing noted in the nurse's notes 10/17/13, nor any documentation noting the [MEDICAL CONDITION] and wheezing observed by the surveyors between 10/21/13 and 10/23/13. The surveyors immediately summoned the former IDON (FIDON) and requested she assess the resident. Along with the surveyors, the FIDON approached Resident #4 in her room. Per request of the surveyors, the FIDON assessed Resident #4's breathing and [MEDICAL CONDITION]. The FIDON stated the [MEDICAL CONDITION] in Resident #4's BLEs at that time was "Probably 2 plus [MEDICAL CONDITION]." The FIDON agreed Resident #4's breathing was "rattly." NOTE: 135 hours had elapsed since the facility first noted rapid breathing. On 10/23/13 at 4:30 PM, FIDON notified the surveyors Resident #4 was, "on her way out to get a chest x-ray. I had the nurse go in and assess her." The FI DNS stated Resident #4's physician did not want to give any further orders or treatment until the x-ray results were obtained. On 10/23/13 at 4:35 PM, a Change of Condition Documentation form in Resident #4's chart documented: -"Resident noted (with) (shortness of breath) respiratory wheezes and increased respirations. Res (with) facial swelling and 2 + [MEDICAL CONDITION] to BLE. Lower lung sounds clear bilaterally. Res afebrile. MD notified and chest x-ray obtained." NOTE: The resident was sent out of the facility shortly after this time so a chest x-ray could be obtained. On 10/24/13 at 9:30 AM, the facility reported back to the surveyors with the results of the chest x-ray for Resident #4. The report documented, "Mild cardiomegaly. Moderate [MEDICAL CONDITION] vascular congestion suspected. Diminished lung volumes." The report documented it had been dictated on 10/23/13 at 5:17 PM. On 10/24/13 at 1:50 PM, the surveyor approached LN #1 to inquire about follow-up from the physician regarding the chest x-ray results for Resident #4. LN #1 stated the results had been faxed to the physician, and the physician had requested her medication list. LN #1 stated she had faxed the medication list and was waiting to hear back from the physician. On 10/24/13 at 2:45 PM, the FI DNS provided a copy of a physician's orders [REDACTED]. On 10/24/13 at 3:00, the facilty's Regional Medical Director (RMD) met with the surveyors regarding Resident #4. The RMD stated he had called Resident #4's primary care physician regarding the chest x-ray results, and the [MEDICATION NAME] and potassium orders. On 10/24/13 at 3:57 PM, a Preliminary Laboratory Report in Resident #4's record documented: -Hemoglobin of 4.1, identified as critically low. Normal value, 12-16. -Hematocrit of 17, critically low. Normal value 37-47. -Red Blood Cells of 2.89, identified as low. Normal value 4.2-5.4. On 10/24/13 at 4:30 PM, the RMD met again with the surveyors regarding Resident #4. The RMD stated labs had been drawn for Resident #4, and, "We know the cause of the heart failure. She is profoundly anemic, which makes the heart work harder, which put her into heart failure." The RMD stated Resident #4 likely needed to be taken to the hospital for a blood transfusion. On 10/24/13 at 6:15 PM, the IFDON informed the surveyors Resident #4 was being sent to the hospital for a blood transfusion. The surveyors observed Resident #4 being assisted into the facility van at that time. On 10/25/13 at 6:10 AM, the Final Laboratory Report in Resident #4's record documented: -Brain natriuretic peptide (BNP) value of 155.4, high, with normal being 0-100. -Iron value of less than 10, low. Normal value 37-16. -Ferritin level 3.11, low. Normal 13-150. On 10/25/13 at 3:40 PM, the facility provided the surveyors with a copy of the 10/25/13 final laboratory report for Resident #4, with the physician's response written on it. The hand writing on the report documented, "A1C Excellent! 2 u (units) pRBC (packed red blood cells) given 10/24 pm." Resident #4 was harmed when she was noted with rapid or labored breathing, with a delay in treatment of [REDACTED]. It was only when the surveyors brought this to the attention of the facility, that the facility began to respond. Even so, there was an additional delay of 21 hours and 28 minutes between the time the facility notified the physician, and the time any treatment was ordered. Ultimately, Resident #4 was found to be "profoundly anemic", to the point of requiring a blood transfusion, as well as a new [DIAGNOSES REDACTED]. On 10/24/13 at 6:15 PM, the Administrator, FIDON, RMCO and IDON were notified of the surveyor's concerns. The facility provided additional information, in terms of the written physician's response on Resident #4's laboratory results, and a physician's progress note dated 10/28/13. However, this information did not resolve the concerns. b. On 10/23/13 at 4:00 PM, the surveyor and the FIDON entered Resident #4's room. CNA #7 was transferring Resident #4 from her bed to her wheelchair. CNA #7 was holding Resident #4 by the right elbow. There was no second person assisting, or gait belt in use, both of which were specified in Resident #4's care plan. The brakes on Resident #4's wheelchair were not locked, and the wheelchair rolled backwards slightly as the resident sat in it. On 10/24/13 at 12:50 PM, the FIDON was asked about the transfer the surveyor had observed. The FIDON stated, "Yep. I saw it too. I was hoping you didn't." On 10/24/13 at 6:15 PM, the Administrator, IDON, RCMO, and FIDON were informed of the surveyor's findings. The facility offered no further information. 2. Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #2's most recent MDS assessment, dated 8/20/13, coded: -Unable to complete the BIMS, with no staff assessment of his cognitive abilities. -Totally dependent of 2 for bed mobility, transfers, and dressing. -Totally dependent of 1 for eating. Resident #2's care plan documented, under the Focus area of "Nutrition", the Intervention of, "Adaptive equipment: Plastic tip spoon RNA dining: Cue to take bite, chew, and swallow with meals. (update 4/20/11)" On 10/22/13 at 12:30 PM, Resident #2 was served his meal, which was ground chicken, jello, and pureed peas. (NOTE: Please refer to F 365 as it pertains to appropriate diet texture.) CNA #6 sat down at the table and began to feed Resident #2. The IDON was also sitting at the table, feeding Resident #2's tablemate. CNA #6 was observed to place several bites of food in Resident #2 mouth, without explaining she was about to give him a bite of food, or cueing him to chew or to swallow. After each bite was placed in his mouth, Resident #2's mouth would begin a chewing motion, but he kept chewing for an extended period of time without swallowing. CNA #6 continued to place bites of food into Resident #2's mouth, even with remnants of the previous bite still present. After giving Resident # 2 three bites of chicken, a bite of jello, and a bite of peas, CNA #6 sighed and stated, "(Resident #2) let's have a drink," and offered Resident #6 a drink of water from a glass with a straw. (NOTE: Please see F 369 as it pertains to adaptive equipment with meals.) The mixture of peas, chicken, and jello was overflowing from Resident #2's mouth and onto his chin. CNA #6 wiped the excess food from his chin with a napkin, then without checking to see if his mouth was clear began to place more bites of chicken and peas in his mouth. CNA #6 did not cue Resident #2 about receiving bites of food, chewing, or swallowing. Again the food overflowed from Resident #2's mouth onto his chin. CNA #6 took Resident #2's spoon, wiped the excess food (a mixture of ground chicken and pureed peas) from his chin, and placed the mixture back into his mouth. CNA #6 then offered and assisted Resident #2 with another drink from a glass with a straw, without checking to see if his mouth was clear. Resident #2 sucked some water through the straw, then coughed. CNA #6 waited for Resident #2 to stop coughing, then resumed feeding him as before. This pattern continued throughout the meal. The IDON was also sitting at the table with this resident, but did not intervene with this process. On 10/23/15 at 5:15 PM, the Administrator, FIDON, RDCO, and IDON were informed of the surveyors's observations. On 10/24/13 at 6:15 PM, the Administrator stated, "Thank you for letting us know (Resident #2) was coughing. We didn't know he was doing that. We got a speech therapy evaluation for him." However, the facility offered no further information to resolve the surveyor's concerns. 3. Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 9/1/13 coded, in part: * Intact cognition with a BIMS score of 13; * Total assistance of 2 or more persons for bed mobility; and, * Functional limitation in range of motion in 1 upper and 1 lower extremity. Resident #3's care plan included the focus areas and their associated interventions: * Nutrition - "[MEDICAL CONDITION] checks per nursing r/t (related to) diuretics" - initiated 5/6/12, revised 10/18/12, and reviewed 7/24/13. * At risk for skin alterations - "Elevate heels when in bed..." - initiated 8/12/09 and reviewed 7/24/13. a) The resident's recapitulation of Active Orders from 10/1/13 to 10/31/13 included an order for [REDACTED]. Reveiw of Resident #3's clinical record revealed there were no [MEDICAL CONDITION] checks documented in the clinical record. On 10/23/13 at about 9:30 a.m., Resident #3 was observed in bed with LN #4 in attendance. At that time, no [MEDICAL CONDITION] was noted in the resident's lower extremities. b) On 10/23/13 at about 9:45 a.m., Resident #3 was observed supine on her bed with a tan leather, custom-made ankle foot orthosis on her left foot. LN #4, who was in attendance, placed a pillow under the resident's lower legs and stated the pillow was used, "to raise the heels." The LN was about to leave the room, when the surveyor pointed out that the resident's left heel orthosis was still in contact with the mattress. LN #4 stated, "Yes it is. That's always how it is." LN #4 then raised the knee of the bed about 5 degrees which raised the resident's left heel off the bed slightly. On 10/24/13 at 9:30 a.m., the RMCO and the IDON were interviewed. When asked about Resident #3's care plan for [MEDICAL CONDITION] checks and to elevate for the heels when in bed, they agreed the [MEDICAL CONDITION] checks were not documented and the care plan included to elevate the heels while in bed. At about 9:45 a.m., the former IDON joined the interview and said [MEDICAL CONDITION] checks were stopped in December 2012 and should have been removed from the resident's care plan. On 10/24/13 at 6:10 p.m., the Administrator, IDON, former IDON, and RMCO were informed of the failure to follow care planned interventions. No other information or documentation was received from the facility which resolved the issue.

Based on observation, staff interview, and record review, it was determined the facility did not ensure residents maintained acceptable parameters of nutritional status. This was true for 1 of 3 residents (#4) sampled for nutritional issues. Resident #4 was harmed when she experienced a severe weight gain of 53 pounds from 9/20/12 and 10/6/13, but was not assessed by the physician for weight gain based on multiple diagnoses and medications administered. Additionally, the facility did not discuss their concerns regarding weight gain and interventions with Resident #4 in a language she could understand. Findings included: The New England Diet Manual for Extended Care, Revised in 2008, identified by the facility as the diet manual in use, documented under, "Modification in Calories and Carbohydrate, Calorie and Carbohydrate Controlled Diets for Weight Management and Diabetes Mellitus Glycemic Control": -"Description...providing adequate nutrition is the primary concern for the resident in long term care facilities if [MEDICAL CONDITION] is to be prevented or corrected...The Registered Dietician (RD) should be consulted to make appropriate recommendations for each resident. The diet is individualized according to the resident's age, gender, body mass index (BMI), activity level, hypoglycemic regimen, blood glucose levels, and quarterly HgbA1C (glycated hemoglobin) levels." -"Generally, for overweight residents a weight loss diet is not recommended unless obesity impairs activities of daily living and the resident is in agreement with the weight loss plan." -"The diet should be individualized and realistic for the resident." Resident #4 was admitted to the facility on [DATE] with multiple diagnoses including recurrent persistent [DIAGNOSES REDACTED], brittle diabetes mellitus, failure to thrive, [MEDICAL CONDITION], severe dementia, chronic [MEDICAL CONDITION], mild [MEDICAL CONDITION], and chronic protein calorie [MEDICAL CONDITION] (PCM). Resident #4's admission H&P, dated 9/18/12, documented, "Given the patient's increased risk for metabolic complications including severe [DIAGNOSES REDACTED] and severe mental status due to it, the patient is being admitted to the telemetry unit." CMS's RAI Version 3.0 Manual, Chapter 3, Section (K), Swallowing/Nutritional Status, item K0310: Weight Gain coding instructions, documented, "Code 2, yes, not on physician-prescribed weight-gain regimen: if the resident has experienced a weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight gain was not planned and prescribed by a physician." Resident #4's MDS assessments coded: *Admission, 9/26/12: -Wants or needs a translator to talk with health care professionals. -Preferred language is Spanish. -Weight 150 pounds. -Diagnoses of [MEDICAL CONDITION], diabetes, and [MEDICAL CONDITION]. -No [DIAGNOSES REDACTED]. *Quarterly, 12/21/12. -Weight 162 pounds, a 12 pound weight gain. -No significant weight gain. (NOTE: This weight change represented an 8% increase since the previous MDS assessment.) -[DIAGNOSES REDACTED]. *Quarterly MDS, 3/22/13 -Weight of 171 pounds, a 21 pound weight gain since admission. - "2" for significant weight gain, not prescribed by the physician. -[DIAGNOSES REDACTED].#4's nutritional status or removing the [DIAGNOSES REDACTED]. *No further MDS data available until 9/27/13. *Annual MDS, 9/27/13: -Wants or needs a translator to talk with health care professionals. -Preferred language is Spanish. -Weight 197 pounds, a 47 pound weight gain since admission. -No significant weight gain. (NOTE: This weight change represented an increase of 15.2% since the MDS 3/22/13.) -No [DIAGNOSES REDACTED].) Resident #4's Care Plan documented: -Focus area of, "Nutrition Care Plan: Potential alteration in Nutrition Status Diagnosis/disease condition/treatment - DM, severe dementia, anxiety-depression, FTT, PCM, HTN, [MEDICAL CONDITION], Inability to verbalize food/fluid needs/desires." Date Initiated 9/20/12. -Goal of, "Will tolerate HCC-small portions. Intakes (greater than) 75%." Date Initiated 9/20/12. (NOTE: The facility did not document Resident #4 was started on small portions until 3/14/13.) -Goal of, "Will not have significant change in weight of 5% in 30 days or 10% in 180 days." Date Initiated 9/20/12. -Intervention of, "Small portions at meals. add snacks tid (three times dily) enc(ourage) dietary compliance. (sic)." Date initiated 11/1/12. (NOTE: The first documentation from the facility that small portions were in fact provided was on 3/14/13.) -Intervention of, "Start small portions-enc(ourage) dietary compliance." Date Initiated 3/14/13. -Intervention of, "Observe for abnormal laboratory data." Date Initiated 9/20/12. -Intervention of, "Observe and report [MEDICAL CONDITION]." Date Initiated 9/20/12. Resident #4's admission medication orders, dated 9/19/12, documented: [MEDICATION NAME] 2.5 mg daily at 5:00 PM. This dose was increased to [MEDICATION NAME] 2.5 mg twice daily on 7/10/13. (NOTE: Please see F 329 as it pertains to [MEDICATION NAME] use.) -Routine [MEDICATION NAME] and sliding scale [MEDICATION NAME]for diabetes management. -No concentrated sweets diet. No further dietary restrictions noted. Resident #4's Nursing Assessment forms documented: -9/19/12 *Primary Language, "Spanish." *Weight 150 pounds. *Oxygen saturations (O2 sats) blank. *[MEDICAL CONDITION], "No." *Pedal pulses present on both right and left. -12/27/12 *Primary Language, "Spanish." *Weight 162 pounds (gain of 12 pounds, or 7.4% of initial body weight). *O2 sats, "N/A." *[MEDICAL CONDITION], "Pitting 2 plus." Location as, "BLE" (bilateral lower extremities.) *Pedal pulses present on left and right, "Faint." -3/23/13 *Weight 183 pounds (gain of 33 pounds, or 22% of initial body weight). *O2 sats, "N/A." *[MEDICAL CONDITION], "Pitting 1 - 2 plus." Location as, "BLE." *Pedal pulses present on both right and left. -7/21/13 *Weight 195 pounds (gain of 45 pounds, or 30% of initial body weight). *O2 sats 97% on room air. (NOTE: This is the first and only documentation of Resident #4's O2 sats.) *[MEDICAL CONDITION], "Pitting plus 1." Location as, "BLE." *Pedal pulses present on both right and left. -9/25/13 *Weight 197 pounds (gain of 47 pounds, or 31.3% of initial body weight). *O2 sats blank. *[MEDICAL CONDITION], "Pitting 1 plus." Location as, "BLE." Resident #4's Physician's Progress Notes, dated 11/14/12 - 10/16/13, documented, in their entirety: (NOTE: Please see F 386 as it pertains to the content of the physician's visits.) -11/14/12. "Dementia-short term memory loss - DM II - BG's (increased) (with) UTI? Txed (treated) this wk (week) (with) [MEDICATION NAME]." (NOTE: There was no documentation as to how the physician assessed the degree of her dementia, given the language barrier.) -12/12/12. "DM II (and) BGs somewhat improved - Expect 'loose' controll (sic) (with) her mental deficits." (NOTE: There was no documentation as to how Resident #4's mental deficits were assessed.) -1/9/13. "DM II BGs have improved - PO 100% (with weight increase) 15 (pounds) in 4 months." (NOTE: The physician did not indicate an assessment as to the cause of the weight increase, whether or not the weight increase was a concern, nor whether or not Resident #4's diet should be further restricted, or converse with the resident regarding her weight gain. The physician did not document any awareness of whether or not Resident #4 was experiencing [MEDICAL CONDITION] at the time of this assessment. The physician did not address adverse reactions to medication as a consideration in Resident #4's weight gain.) (Please see F 329 regarding unnecessary medications.) -2/20/13. "Marked dementia. Short term memory loss. DM II sl (slightly) stabilized." -3/20/13. "BGs vary 180 - 280 - improved stability (and) adequate improvement." -4/17/13. "BGs adequate controll (sic) for her condition. Marked dementia." -5/15/13. "DM II (with) loose but improved BG controll (sic). Severe Dementia." -6/12/13. "BG controll (sic) adequate. Severe Dementia." -7/10/13. "75 (year old) type II DM (Hispanic) (with) dementia. Reviewing fall rate of falls - 12 documented falls since January. Pt (patient) continues to fall even with 1 on 1 attendent (sic) - will be transferring to (name of town)." (NOTE: On this date, Resident #4's anti-psychotic medication was doubled in dose. Please see F 329.) -8/7/13. "(Decrease) falls - No longer 1 on 1 - BGs remain unstable 70 to 400 - will continue conservative DM II care." -9/18/13. "BGs remain very erratic - range 100-300 (and) making stabalization difficult - but pt doing well (with) no recent falls - smiling (and) content this AM." -10/16/13. "(Right) upper forehead scrape from scratching - BGs better last (illegible) 89-241 - (weight) up 198 (to) 203 (pounds)." (NOTE: Again, the physician noted Resident #4's weight gain, but no further assessment or recommendations were documented.) Resident #4's Medical Nutrition Therapy (MNT) Assessment forms documented: -9/20/12: *Resident Comments, "Spanish speaking." (NOTE: There was no documentation as to how this factor would be addressed as the assessment proceeded. There were no further comments from the resident documented.) *Clinical Conditions, "Severe dementia...DM, [MEDICAL CONDITION] PCM...FTT, [MEDICAL CONDITION], acute [MEDICAL CONDITION]." *For "Cognitive Status", the boxes for, "Alert", "Oriented", and "Confused" were all marked. *No [MEDICAL CONDITION] noted. *Medications included [MEDICATION NAME], and both [MEDICATION NAME] and [MEDICATION NAME] (NOTE: [MEDICATION NAME] is the generic name for [MEDICATION NAME]). *Diet, "HCC regular" with no MD prescribed weight reduction. *Meal intake 100%. *Admission weight, usual weight, and current weight were all documented as, "150 lbs." *The space for BMI documented, "--". *DBW (Desired body weight) goal was documented as, "140 +/- 12 pounds." (NOTE: There was no documentation stating how this goal was arrived at, or that Resident #4's body weight had ever been as low as 140 pounds. There was no documentation the physician had determined the goal to be ideal for this resident. There was no documentation Resident #4, or her family, had been involved in setting this goal.) *Total calories consumed by the resident were documented as 1750 k cals (kilo calories), protein as 68 grams, and fluids as 1750 milliliters. *The Laboratory Data area of the form was blank. *Nutrition and fluid needs were documented as met. *No new labs. *Plan, "maintain current weight - (no significant) changes. Maintain intakes (greater than) 75% - monitor daily. Monitor labs and b.g.s (sic) control regularly as available." (NOTE: There was no plan as to how the facility would monitor Resident #4's status in terms of her PCM or FTT diagnosis, or to resolve her [MEDICAL CONDITION]. There was no documentation as to the potential for weight gain related to the use of [MEDICATION NAME].) -12/20/12: *Resident comments, "DNR." (NOTE: This was the area of the form for resident participation in the dietary assessment process.) *Diagnoses included severe dementia, DM, PCM, FTT, [MEDICAL CONDITION], and [MEDICAL CONDITION]. *For "Cognitive Status", the boxes for, "Alert", "Oriented", and "Confused" were all marked. *[MEDICAL CONDITION], "none noted." *Medications included [MEDICATION NAME] and [MEDICATION NAME]. *Diet: HCC regular, with no MD prescribed weight reduction. *Meal intake 100%. *DBW goal, "140 +/- 12 pounds." *The space for BMI documented, "--". *Weight was 162 pounds. 90 days ago had been 150 lbs. The space to document the percentage of this change was blank. (NOTE: Resident #4's weight represented an 8% increase at the time of this assessment.) *No changes in total calories, protein, or fluids consumed by the resident. *The Laboratory Results area of the form was blank. *Nutrition and fluid needs met. *Assessment, "Pt's weight - 162 lbs. - (up) 12 lbs 90 (days). (Greater than ideal body weight)...(no) new labs..." *Plan as, "Maintain current weight - (no significant) changes. Maintain intakes (greater than) 75% - monitor daily. Monitor labs as available." (NOTE: The assessment did not address Resident #4's 8% weight gain, or the potential for weight gain related to [MEDICATION NAME] use. There were no laboratory results to address PCM, BG control, or [MEDICAL CONDITION]. There was no indication as part of the assessment for this resident that labs would be requested.) -3/14/13: *Resident comments, "DNR." *The diagnoses of PCM, [MEDICAL CONDITION], and FTT are no longer listed. (NOTE: There was no physician's documentation, physician's orders [REDACTED].) *For "Cognitive Status", the boxes for, "Alert", "Oriented", and "Confused" were all marked. *[MEDICAL CONDITION] as, "none noted." *Diet was, "HCC - Regular small portions", with an MD prescribed weight reduction. (NOTE: There was no physician's documentation or order for a weight reduction plan, or assessment as to how weight reduction would safely be accomplished in light of the resident's history of PCM, FTT, and [MEDICAL CONDITION]. There was no documentation the resident had been consulted, informed, or involved with this plan, nor that such information had been translated for her into her primary language.) *Usual weight was now listed as, "160's". (NOTE: On the previous assessments, Resident #4's usual weight was documented as 150 lbs. There was no documentation as to how this "new usual weight" or why, if this new figure were considered as her usual body weight, she would need to be on a physician prescribed weight loss plan.) *Weight was 171 lbs., up from 168 lbs. 30 days prior, 162 lbs. 90 days prior, and 150 lbs. 180 days prior. (NOTE: The areas to calculate the percentage of change in her body weight were blank.) *The space for BMI documented, "--". *DBW goal, "140 +/- 12 pounds." *No changes identified in total calories, protein, or fluids consumed by the resident. *The laboratory data area of the form was blank. *Nutrition and fluid needs documented as met. *Assessment, "Pt's weight - 183 lbs. (NOTE: Resident #4's weight was documented as 171 lbs. on the same form.) (Up) 12 lbs. this week- (up) 20 lbs. 90 (days)...Enc(ourage) dietary and snack compliance (NOTE: There was no documentation Resident #4 had not been compliant with dietary and snack restrictions prior. Other than HCC diet, there were no dietary or snack restrictions identified, prior to this time, for Resident #4. There was no assessment from the RD, MD, or nursing staff as to why there had been a 12 pound weight gain in one week's time. There was no documentation of the resolution of the 2 plus [MEDICAL CONDITION] noted in the nursing assessment from 12/27/12, or if [MEDICAL CONDITION] had been identified as a potential factor for this sudden weight gain.) Plan was, "Gradual weight loss desired due to weight gain/ (greater than) IBW. Maintain intakes (greater than) 75% - monitor daily. Monitor labs as available. Enc(ourage) dietary compliance." (NOTE: There was no indication from this assessment that laboratory studies should be requested, even though the diagnoses of FTT, PCM, and [MEDICAL CONDITION] had been removed.) -6/13/13: *Resident Comments, "DNR." *PCM, FTT, and [MEDICAL CONDITION] were not listed as diagnoses. *Cognitive status, "Alert," "Oriented," and "Confused." *[MEDICAL CONDITION] was, "1-2 (plus) BLE." (NOTE: Even though [MEDICAL CONDITION] had been documented on the previous 2 quarterly nursing assessments, this was the first notation from the RD indicating an awareness of Resident #4's [MEDICAL CONDITION].) *Diet HCC regular with small portions. No physician prescribed weight reduction plan. (NOTE: The 3/14/13 MNT assessment documented a HCC diet with a physician prescribed weight reduction plan. There was no documentation as to when or why that was changed before the 6/13/13 assessment.) *Meal intakes 100%. *Usual weight now 180 lbs. (NOTE: This figure had increased from 150 lbs. on her admission just 9 months prior, and 160 lbs. since the last nutritional assessment 3 months prior.) *The space for BMI was blank. *DBW was documented as, "140 lbs. +/- 12 lbs." *Weight was documented as 193 lbs., up from 189 lbs. 30 days prior, 171 lbs. 90 days prior, and 162 lbs. 180 days prior. *The weight percentage of weight change areas of the form were blank. *The Laboratory Data area of the form was blank. *Nutrition and fluid needs were met. *Assessment as, "Pt weight - 193 lbs. - (up) 22 lbs (in 90 days) - (greater than) IBW...(no) new labs...enc(courage) dietary compliance - monitor for trying to eat off others plates." (NOTE: The behavior of eating from other's plates was not documented prior to this note. It was not addressed in this assessment if this had developed as a new behavior after the facility placed Resident #4 on small portions.) *Plan as, "Maintain current weight - (no) continued weight gain. Maintain intakes (greater than) 75% - monitor daily. Enc(ourage) dietary compliance. Monitor labs as available." (NOTE: Even though monitoring labs was identified yet again as part of the nutritional plan for Resident #4, there was not a request for labs to be drawn. There was no evidence Resident #4 had been consulted or involved with the facility's concerns regarding her continued weight gain, or the plan to address the weight gain. [MEDICAL CONDITION] in Resident #4's lower extremities could have been a factor, but was not addressed in the nutritional assessment or plan.) -9/10/13. *Resident comments, "DNR. POST. (No tube feeding, no IV)." *Diagnoses did not include PCM, FTT, or [MEDICAL CONDITION]. *Cognitive Status, "Alert," "Oriented X 2," and "Confused." *[MEDICAL CONDITION] was identified to BLEs. *Medications included [MEDICATION NAME] and [MEDICATION NAME]. (NOTE: There was no indication on this assessment the doses of either medication had been increased.) *Diet, HCC ground (texture) small portions. "MD Prescribed Weight Reduction" was marked as, "Yes." (NOTE: There was no indication as to when or why the physician had again ordered a new weight reduction program since the previous nutritional assessment 6/13/13, or what new interventions were implemented as a part of this plan. There was no evidence the facility had involved Resident #4, in a language she understood, regarding her input on her continued weight gain, or her willingness to participate in a weight reduction plan.) *Usual weight was documented as, "190 lbs." (NOTE: This the third documented change in Resident #4's usual body weight, with no rationale as to why this change was made.) *BMI was blank. *DBW was, "140 lbs. +/- 12 lbs." *Weight was, 197 lbs. *The percentage in weight change areas of the form were blank. *The Laboratory Data area of the form was blank. *Nutritional and Fluid needs were documented as met. *Assessment as, "Pt.'s weight 197 lbs. (Down) 1 lb. this mo., (up) 4 lbs. in 90 (days)...Was started on smaller portions as previously to prevent further weight gain..." *Plan as, "Gradual weight loss is desired due to obesity. (NOTE: Obesity was not listed by the physician as a diagnosis. Previously, FTT, [MEDICAL CONDITION], and PCM were listed as diagnoses by the physician, with no rationale as to when, how, or why those diagnoses were considered resolved.) Maintain intakes (greater than) 75%. Monitor daily. Enc(ourage) dietary compliance. Monitor labs as available." The RD Interdisciplinary Progress Notes (PNs) documented: 11/1/12, "Pts weight (9/19) 150 lbs. on admit, (10/2) 154 lbs. (10/14) 156 lbs., (10/21) 158 lbs., (10/28) 159 lbs...Pt has been running high b.g.s (sic)(with) (increased) insulin...Pt. complains of being hungry (and) seeking food (between) meals. Will change to small portions (at) meals (and) add snacks tid (with) fiber/protein to prevent further weight loss and) promote DM management. Labs (10/19) (glucose) 563 (elevated). BUN/CR 20 (elevated). All else WNL incl. protein levels. Will follow for needed interventions." (NOTE: Resident #4 had been identified with a weight gain, not a weight loss. There was no documentation the resident was consulted as to her feelings of hunger, participated in developing interventions to alter that feeling, or guidance to the staff as to how they should proceed when the resident complained of hunger.) -5/7/13. "...Weight (up) 6 lbs. additional this month. Pt. is on HCC-Regular diet and was changed to small portions...will (change) PB & J @ hs (Peanut butter and jelly at bedtime) to 1/2 sand(wich.) Discourage (between) meal snacks, or make healthier options...All staff aware of diet plan." (NOTE: There was no documentation of a communication to Nutrition Services regarding changing the sandwich to a half portion. There was no documentation the resident was aware of and agreement with the diet plan, in addition to the staff.) -10/10/13. "...Weight (up) 6 lbs. additional this month. Was stable last couple months. Pt is on HCC ground diet - small portions...small portions were started previously due to weight gain which was successful. She was receiving snacks tid which were changed to HS only. She is busy and sitting in LSDR (low stimulus dining room) most of the time asking for cocoa. Suggest give only 1 glass cocoa (and) then diet beverages to prevent further weight gain..." Resident #4's Interdisciplinary Communication to Nutrition Services forms documented: -9/19/12. New Admission. HCC Regular -11/17/12. "Needs Full PB & J sandwich (at) HS plus extra sandwich avail(able) in fridge for (low) blood sugar." (NOTE: There was no communication to provide small portions as indicated in the RD PN from 11/1/12. The RD PN identified a concern of high blood glucose levels, whereas this communication identified a concern with low blood glucose levels.) -1/9/13. 1500 calorie ADA diet. -3/14/13. HCC Regular texture small portions. 6/18/13. Ground texture, "put food in separate dishes (at) all meals for portioning." (NOTE: There is no indication on this communication as to whether or not Resident #4 should continue on the HCC diet, or the small portions.) Resident #4's Nurse's PNs documented ongoing episodes of restlessness and calling out at night, specifically: -8/29/13 at 4:10 AM, "Res awake most of the NOC (night) shift, yelling, pulling call light cord out of wall...(increased ) behaviors, Res denies pain when asked. Res stated, "I'm hungry" several times (and) was given some snacks..." -9/23/13 at 4:10 AM, "Res having issues (with) [MEDICAL CONDITION], shouting "I'm hungry" during beginning of NOC, waking up roommate who was upset by noise. Res given a sandwich..." Resident #4's PNs also documented: -10/17/13 at 7:00 PM, "Resident having increased restlessness (with) rapid breathing noted and jitteriness when verbally speaking..." -10/17/13 at 8:15 PM, "...labored breathing." On 10/21/13 at 2:15 PM, Resident #4 was observed sitting in her room, in her wheelchair. Her chair was located to the left side of her bed, next to the bed, with the resident facing the head of the bed. She was approximately 10 feet from the doorway to the room. As the surveyors entered the room, Resident #4 could be heard with wheezing as she breathed. As the surveyors approached the resident, her ankles were visibly [MEDICAL CONDITION], to the point of her skin appearing taut. As she spoke, her voice sounded forced, as if she was having to exert herself to speak. On 10/22/13 at 11:00 AM, the surveyors entered Resident #4's room, along with LN #1, to observe a BG check. Resident #4 was again wheezing, with her ankles visibly swollen as they had been on the surveyor's previous observation above. Resident #4 was wearing blue cotton ankle socks and black shoes, with her skin so taut it was bulging slightly around the top of her socks. LN #1 did not remark on or assess Resident #4's [MEDICAL CONDITION], or her breathing at that time. (NOTE: The 2014 Nursing Drug Handbook identified, in part, potential adverse reactions to [MEDICATION NAME] to be [MEDICAL CONDITION], [MEDICAL CONDITION], dry mouth, increased appetite, thirst, weight gain, [MEDICAL CONDITION], and abnormal gait. The handbook also lists [MEDICATION NAME] ([MEDICATION NAME]) as having a Black Box Warning, "Drug may increase the risk of cardiovascular or infection-related death in elderly patients with dementia. [MEDICATION NAME] isn't approved to treat patients with dementia-related [MEDICAL CONDITION]." Please see F 329 related to medication management.) On 10/23/13 at 3:15 PM, the surveyors asked the pharmacist about possible medicines contributing to Resident #4's weight gain. The pharmacist identified [MEDICATION NAME] as a medication known to cause weight gain, particularly if the dosage had been increased. The pharmacist also stated increased [MEDICAL CONDITION] and fluctuating BG levels could also be side effects of [MEDICATION NAME]. The pharmacist stated he did not recall being informed that Resident #4 had weight gain, difficulty with BG management, or [MEDICAL CONDITION]. On 10/23/13 at 3:55 PM, the surveyors, along with the FIDON, approached Resident #4 in her room. Per request of the surveyors, the FIDON assessed Resident #4's breathing and [MEDICAL CONDITION]. The FIDON stated the [MEDICAL CONDITION] in Resident #4's BLEs at that time was "Probably 2 plus [MEDICAL CONDITION]." The FIDON agreed Resident #4's breathing was "rattly." On 10/23/13 at 4:30 PM, the surveyors were notified Resident #4 was going to be sent out for a chest x-ray. (NOTE: Please see F 309 as it pertains to timely assessment of changing medical status.) On 10/24/13 at 10:30 AM, the RD was asked about the weight gain for Resident #4, as follows: *The RD stated Resident #4 had gained 53 pounds from the time of her admission in September 2012 to the present. The RD stated Resident #4's weight had stabilized between June and August of 2013, after the facility implemented healthy low calorie snacks and talked to the activities department about limiting Resident #4's cocoa. *The RD stated Resident #4's weight had shown an increase again in October 2013, but she was not sure why. *When asked about Resident #4's [MEDICAL CONDITION], the RD stated Resident #4 had chronic [MEDICAL CONDITION], which was, "pretty well controlled." The RD stated she would be informed of changes in Resident #4's [MEDICAL CONDITION] via the nursing staff. *The RD stated if Resident #4's care plan called for [MEDICAL CONDITION] checks, she would expect to see them on the MAR. She was unable to state whether or not there were [MEDICAL CONDITION] checks on the MAR for Resident #4. *When asked how Resident #4's PCM would be monitored, the RD stated she would look at the labs. After reviewing Resident #4's chart, the RD stated, "There are no labs in here. I will check on that." *When asked at what point labs would typically be requested for a resident with a PCM diagnosis, the RD stated, "I would ask. But she eats very well. She consistently eats a well-balanced diet we provide for her." The RD also stated it was likely she had requested labs for Resident #4, but the resident had refused to allow labs to be drawn. The RD was asked to show the surveyors where such requests and refusals would be documented. After reviewing Resident #4's record, the RD stated, "It's not. But her BG's have been stable, not erratic or brittle." *The RD was asked where in Resident #4's nutritional assessments an evaluation of the resident's BGs would be documented. The RD reviewed her assessments for Resident #4, then stated, "If they're not out of the ordinary I don't mention them." The RD stated she would obtain her information regarding the stability of a resident's BGs from the physician's progress notes, then stated, "What does the physician say about it?" The RD then reviewed the MD progress notes for Resident #4, and stated, "He talks a lot about her BGs and dementia." (NOTE: Resident #4's MD documented either poorly controlled or erratic BGs on 11/24/12, 12/12/12, 8/7/13, and 9/18/13.) *The RD stated the MD would have documented on Resident #4's weight gain. After reviewing Resident #4's record, the RD stated, "He does not talk about nutrition." *The RD was asked how the MD was made aware of her concerns with Resident #4's weight gain. The RD stated, "We would use a condition change form." The RD was asked for this form on Resident #4. The RD initially stated the nursing staff would have filled out the form for Resident #4. She then stated, "I didn't fill one out because the weight gain was never significant." *The RD was asked if Resident #4 was receiving enough calories and nutrients to maintain her weight and good nutritional status on her current diet. The RD stated, "Yes." *The RD was asked how much protein Resident #4 would require on a daily basis, given her [DIAGNOSES REDACTED]." The RD was asked if Resident #4's current diet of HCC small portions provided adequate protein for Resident #4. The RD stated, "I don't know, but I'm sure it does. I'll have to check." The RD was asked if the amount of protein available on a certain diet would a factor for consideration when deciding on the diet, the RD stated, "Yes." The RD then stated it was of primary concern for Resident #4 to lose weight. When asked which would be more important for Resident #4, weight loss or adequate protein, the RD stated, "Weight, because of mobility and diabetic control." When asked how those conclusions were formulated without laboratory studies, the RD stated she did not know. The RD stated, "I would love for there to be some labs." *The RD stated Resident #4 most recently had labs on 10/19/12. The RD was asked when those labs should be repeated, given Resident #4's diagnoses of PCM, DM, FTT, and [MEDICAL CONDITION], as well as her weight gain. The RD stated, "Every 6 months. Which means 6 months ago." *The RD was asked how factors such as [MEDICAL CONDITION], medication side effects, other underlying medical issues had been ruled out as potential causes of her weight gain. The RD said the physician and the pharmacist would make those decisions, but her assessment of Resident #4's weight gain was from the number of calories she had consumed. (NOTE: Please see F 329 as it pertains to unnecessary drugs.) *The RD was asked about documentation that Resident #4 was hungry at times. The RD stated, "She's always hungry. That's why she gained weight." *The RD was asked how many extra calories Resident #4 would have had to consume in order to gain 53 pounds in a year, and if that amount of calories was available to Resident #4 given her current diet in the facility. The RD stated, "Everybody's different. We made some changes, and the weight gain stabilized. Plus she's on some psych meds, which can prevent some people from losing weight. But the pharmacist usually says it is more important to manage behaviors than stabilize weight." The RD stated she could not recall when she had this conversation with the pharmacist regarding Resident #4, and she did not document it. *The RD was asked if Resident #4 had ever been notified, in her primary language, of the facility's concerns with her weight gain, or had been if she wanted interventions to alter it. The RD stated, "No. She has dementia." The RD was asked how she knew if it was dementia or a language barrier which was the most challenging for Resident #4's participation in her own plan of care. The RD stated, "I don't." The RD was asked if she had ever requested a translator to interpret a conversation for Resident #4. The RD stated, "No. She has dementia." On 10/24/13, at 4:35 PM, the surveyors interviewed the facility's RMD regarding Resident #4. The RMD was asked about possible causes for Resident #4's weight gain, including [MEDICAL CONDITION], side effects her [MEDICATION NAME], or other underlying medical issues. The RMD stated, "Those are good questions. I would ask the same thing." When asked about monitoring her PCM, FTT, and [MEDICAL CONDITION], the RMD stated, "Those are all very good questions. I wish I had the answers." On 10/24/13 at 6:00 PM, the Administrator and the IDON were informed of the surveyor's concerns. The facility offered additional information, in terms of laboratory studies, RD assessments, and MD assessments completed after the surveyor's had called the facility's attention to Resident #4's condition. The information provided did not resolve the surveyor's concerns about the deficient practice.

Based on observation, staff interview, and record review it was determined the facility did not ensure residents were free from unnecessary antipsychotic medications. This was true for 3 of 6 (#s 4, 6, and 8) residents reviewed for antipsychotic medication use. Resident #4 was harmed when she experienced a weight gain of 53 pounds, [MEDICAL CONDITION], recurrent infections, and increased appetite, without those symptoms being ruled out as adverse reactions to [MEDICATION NAME] use. Additionally, for Residents #s 4, 6, and 8, the physician did not identify specific target behaviors for anti-psychotic use, nor identify why the potential benefits of the medications outweighed the potential risks per the FDA black box warning. The facility also did not consistently identify and implement non-pharmalogical interventions for behaviors, or monitor for adverse reactions. This deficient practice had the potential for harm for Resident #s 6 and 8 should they experience adverse reactions. Findings included: The State Operations Manual, Appendix PP, Guidance to Long Term Care Surveyors, documented under F 329, in part: -"Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug used...Without adequate monitoring...without adequate indications for use..." -"Antipsychotic drugs. Based on a comprehensive assessment of a resident, the facility must ensure...behavioral interventions..." -Indications for Use of Medication (including Initiation or Continued Use of Antipsychotic Medication)...An evaluation of the resident helps to identify his/her needs...the evaluation also clarifies...whether other causes for the symptoms (including behavioral distress that could mimic a psychiatric disorder) have been ruled out...Whether non-pharmacological interventions are considered...Whether a particular medication is clinically indicated to manage the symptom or conidition...A history of prior and current medications and non-pharmacological interventions." -"Monitoring for Efficacy and Adverse Consequences...Incorporate into a comprehensive care plan that reflects appropriate medication related goals...including the likely medication effects and potential for adverse consequences. Examples of this information may include the FDA boxed warnings or adverse consequences that may be rare, but have sudden onset or that may be irreversible...establish parameters for evaluating the ongoing need for the medication; and verify...the underlying [DIAGNOSES REDACTED]. 1. Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #4's medication list from the acute care hospital, dated 9/18/12, documented [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg each evening at 5:00 PM, and 5 mg twice daily as needed for agitation. The form documented, "This is a new (medication)." (NOTE: The form did not specify a specific behavior related to Resident #4's "agitation.") The form also documented [MEDICATION NAME] 10 mg daily for depression, and [MEDICATION NAME] 0.5 mg twice daily for anxiety. NOTE: [MEDICATION NAME] is the generic name for the brand name antipsychotic. medication [MEDICATION NAME]. At various times facility documentation refers to the medication using both of these names. The 2014 Nursing Drug Handbook, pages 1018 and 1019 identified, in part, potential adverse reactions to [MEDICATION NAME] to be [MEDICAL CONDITION], [MEDICAL CONDITION], dry mouth, increased appetite, thirst, weight gain, [MEDICAL CONDITION], and abnormal gait. The handbook also listed [MEDICATION NAME] as having a Black Box Warning, "Drug may increase the risk of cardiovascular or infection-related death in elderly patients with dementia. [MEDICATION NAME] isn't approved to treat patients with dementia-related [MEDICAL CONDITION]." *Resident #4's Annual MDS assessment, dated 9/27/13, coded: -Wants or needs a translator to talk with health care professionals. -Preferred language is Spanish. -Unable to complete the BIMS, assessed by staff with long term and short term memory deficits, rarely or never makes daily decisions. (NOTE: It was determined the facility did not engage a translator for Resident #4's assessments. Please refer to F 154.) -Unable to participate in the mood interview. Staff assessed no depressive symptoms. -Has [MEDICAL CONDITION]. (NOTE: There was no indication how [MEDICAL CONDITION] were assessed, given the language barrier.) -No behavioral symptoms, with an improvement since the last assessment. (NOTE: Resident #4's MDS prior to this assessment, dated 3/22/13, also coded no behavioral or depressive symptoms.) Resident #4's Active Orders (Physician's Recapitulation Orders) for October 2013 documented: -[MEDICATION NAME] 20 mg daily for depression, order date 4/29/13. -[MEDICATION NAME] 2.5 mg twice a day for [MEDICAL CONDITION], order date 7/10/13. Resident #4's Physician's Progress Notes documented: -11/14/12. "Dementia-short term memory loss - DM II - BG's (increased) (with) UTI? Txed (treated) this wk (week) (with) [MEDICATION NAME]." (NOTE: There was no documentation as to how the physician assessed the degree of her dementia, given the language barrier.) -12/12/12. "DM II (and) BGs somewhat improved - Expect 'loose' controll (sic) (with) her mental deficits." -1/9/13. "DM II BGs have improved - PO 100% (with weight increase) 15 (pounds) in 4 months." -2/20/13. "Marked dementia. Short term memory loss. DM II sl (slightly) stabilized." -3/20/13. "BGs vary 180 - 280 - improved stability (and) adequate improvement." -4/17/13. "BGs adequate controll (sic) for her condition. Marked dementia." -5/15/13. "DM II (with) loose but improved BG controll (sic). Severe Dementia." -6/12/13. "BG controll (sic) adequate. Severe Dementia." -7/10/13. "75 (year old) type II DM (Hispanic) (with) dementia. Reviewing fall rate of falls - 12 documented falls since January. Pt (patient) continues to fall even with 1 on 1 attendant (sic) - will be transferring to (name of town)." (NOTE: On this date, Resident #4's anti-psychotic medication was doubled in dose.) -8/7/13. "(Decrease) falls - No longer 1 on 1 - BGs remain unstable 70 to 400 - will continue conservative DM II care." -9/18/13. "BGs remain very erratic - range 100-300 (and) making stabalization difficult - but pt doing well (with) no recent falls - smiling (and) content this AM." -10/16/13. "(Right) upper forehead scrape from scratching - BGs better last (illegible) 89-241 - (weight) up 198 (to) 203 (pounds)." None of the physician's progress noted identified that the resident was on [MEDICAL CONDITION] medications, or what the target behaviors were. The physician did not document that the benefits of the medications outweighed the risks. The physician did not assess Resident #4's weight gain, erratic blood glucose levels, or falls as a potential adverse reaction of her [MEDICAL CONDITION] medications. The physician did not document a rationale for doubling the routinely scheduled anti-psychotic dose from 2.5 mg per day to 5 mg per day on 7/10/13. Resident #4's care plan documented: -Focus of, "Exhibits behaviors of agitation AEB (as evidenced by): scratching or striking out at staff with cares related to: Anxiety with paranoid thought, Cognitive impairment Dx [MEDICAL CONDITION]." Date initiated 9/20/12, revision on 9/25/12. *Goal of, "Reduced incidents of agitated behavior." Date initiated 9/20/12. *Interventions included: ~"Becomes delusional and hallucinates with very high blood sugars. Has [MEDICAL CONDITION] that caregiver has been 'mean' to her. Reassure her that you are here to help her." Date initiated 10/29/12. (NOTE: The intervention did not direct staff to check and address elevated blood sugars, what would be considered a "very high" blood sugar, or when the physician should be contacted. There was no documentation as to how it was determined her thoughts of caregivers being mean to her were [MEDICAL CONDITION]. There was no direction as to what to say to the resident to reassure her, since she was primarily Spanish speaking.) ~"Elicit family input for best approaches to resident." Date initiated 9/20/12. (NOTE: It had been over a year since this intervention had been added to Resident #4's care plan. However, there was no documentation this had been carried out, or which approaches family had identified.) ~"Give resident item or task in an attempt to distract." Date initiated 9/20/12. (NOTE: There were no suggestions as to which items or tasks were effective for Resident #4, or where those items or tasks could be found.) ~"Monitor for (side effects) of anti-psychotic med: somnolence, dizziness, constipation, dry mouth, weight gain, etc." Date initiated 9/20/12. (NOTE: It was not clear where these items were to be documented. The list of side effects to be monitored did not include [MEDICAL CONDITION], increased appetite, [MEDICAL CONDITIONS], thirst, or abnormal gait, as identified by the 2014 Drug Handbook.) ~"Res. gets very hungry, offer low cal. snacks." Date initiated 10/11/12. (NOTE: Even though this was identified as a new symptom for Resident #4 22 days after her admission, shortly after [MEDICATION NAME] was started, there was no documentation the hunger was assessed as a possible adverse drug reaction.) Resident #4's care plan did not document her language barrier, or how it was to be addressed. Resident #4's Behavior Monthly Flow Sheets documented, for [MEDICATION NAME] and [MEDICATION NAME]: -August 2013. Target behavior, "Throwing Things." No behaviors noted. -September 2013. Target behaviors, "Depressed withdrawn" and "Paranoia [MEDICAL CONDITION]." No behaviors noted. -October 2013. Target Behaviors, "Depressed withdrawn" and "Hallucinations/paranoia/ delusion". No behaviors noted. There was no documentation from Resident #4's physician as to what the specific target behavior for [MEDICATION NAME] was, or why the target behavior changed from August to September. There was no documentation as to what Resident #4 was throwing or why, or whether or not items were thrown in such a way as to cause harm to the resident or others. There was no documentation as to how staff were to assess the presence of hallucinations, [MEDICAL CONDITION], or paranoia, given the language barrier. The interventions on the Behavior Monthly Flow Sheets did not include checking the resident's blood glucose level, which had been identified in the care plan as an antecedent to her [MEDICAL CONDITION]. On 9/27/13, Resident #4's [MEDICAL CONDITION] Medication Evaluation Form for [MEDICATION NAME] documented [DIAGNOSES REDACTED]." "Behavior warranting use of a medication" was documented as, "Yelling, picking, anger." Adverse reactions, "None apparent." The form identified the evaluation should be done quarterly, although the form was not dated until 9/27/13, more than 12 months after the resident was admitted . The target behavior on the form did not coincide with the behaviors being tracked for September 2013. At the time this form was completed, Resident #4 had gained 47 pounds since admission, was documented by the physician as having "erratic" blood glucose levels, and was noted to complain of feelings of hunger. The form did not assess any of these symptoms as potential adverse reactions to the anti-psychotic use. Resident #4's Initial Psychiatric Evaluation, dated 10/10/12, documented,"...history of poorly controlled diabetes...(facility name) stated she just appeared very frightened. She is Spanish speaking. One staff member stated she just seemed like she wanted to hide in a corner. The patient and I were able to communicate minimally with my minimal Spanish. The patient told me she was always nervous. When asked, she stated she slept okay. When asked if she wanted to die, she said, 'Yes, would you do something about it? No.' When asked if she felt scared she said, 'Yes.'...In the future, we might consider more focus on the antipsychotic as she appears to be suffering from symptoms of [MEDICAL CONDITION]." There was no documentation as to exploration of underlying causes of Resident #4's fear and nervousness. It is unclear how much of this interaction Resident #4 understood, given the minimal communication with the practitioner's minimal Spanish. Resident #4's Psychiatric Medication Follow Up Evaluations documented: -11/14/12. "(Facility name) staff say (Resident #4) does appear better, much less terrified looking. (Resident #4) reports feeling some better, although she reports still feeling depressed. Still endorsed suicidal ideation, albeit passive. Reported sleeping well at night. (Resident #4) does have a urinary tract infection that she is being treated for [REDACTED].'...We speak some in my broken Spanish and some in English. She does tell me she is less 'nerbiosa' but stated, 'I am too depressed.'...Will also change [MEDICATION NAME] 20 mg to [MEDICATION NAME] 20 mg which would be a dose increase. [MEDICATION NAME] 20 mg is equivalent to [MEDICATION NAME] 40 mg..." (NOTE: There was no documentation as to how Resident #4's "terrified" appearance was monitored, how her current infection may be impacting her mood state, or whether or not the presence of the infection or her sleeping patterns may be adverse reactions to her [MEDICAL CONDITION] medication use.) -1/9/13. "(Facility Name) staff say ever since tapering and discontinuing (Resident #4's) [MEDICATION NAME] she has showed episodes where she becomes so anxious she yells. (Resident #4) does endorse feeling, 'nerbious.' Otherwise, she is doing fairly well...(Resident #4) is lying in bed sleeping, She is a bit mystified as to who I am. She is gracious about my Spanglish and seems to understand what I say to her...Restart [MEDICATION NAME] .125 mg twice a day. This was a gradual dose reduction failure...Greater than 50 percent of my time was spent in coordination of care." -2/20/13. "(Facility Name) staff say (Resident #4) has been doing well..." -3/13/13. "(Facility Name) staff say (Resident #4) has been doing quite well..." -4/10/13. "...more isolative (sic) and anxious appearing. She has been doing some picking on her forehead...When I ask how she is replies 'malo' or bad...Will get a UA (urinalysis) and at least temporarily increase [MEDICATION NAME]" (NOTE: There was no indication as to the timeframe the "temporary" medication increase was to continue. There was no rationale as to why a [MEDICAL CONDITION] medication increase was warranted instead of the suspected underlying medical cause being ruled out and treated if indicated.) -5/8/13. "...There has been mention that (Resident #4) has gained weight. I am not sure how much. We will monitor that next appointment." (NOTE: The facility documented Resident #4's admission weight in 9/20/12 had been 150 lbs. Resident #4's monthly weight on 5/5/13 was documented as 189 lbs, a gain of 39 lbs. over a period of approximately 8 months. Please see F 325 as it pertains to weight gain. There was no documentation Resident #4's weight gain was assessed as a potential adverse reaction to her [MEDICATION NAME].) -6/12/13, "...staff say the patient has been diagnosed with [REDACTED].#4's weight gain. There was no evaluation of another infection being a possible adverse reaction to Resident #4's [MEDICATION NAME] use.) -7/10/13. "...staff say (Resident #4) probably has a chronic urinary tract infection. They say that she has been extremely restless, very difficult to redirect. They say she has had 12 falls, I believe, in the last two months. They say that she is now on one-to-one staffing...The patient was sleeping soundly...We will just try increasing the [MEDICATION NAME] to 2.5 mg twice a day. I am not sure if that will help, but we will just see if it is some sort of phychosia (sic). I believe this patient may be transferred to another facility. If not, I will be happy to follow her in a month." (NOTE: There was no documentation the chronic infection or falls had been assessed as potential adverse medication reactions to the [MEDICATION NAME]. There was no clear indication of the presence of [MEDICAL CONDITION], or rationale, besides falls, to increase the [MEDICATION NAME] dose. There was no further evaluation of Resident #4's weight gain.) -9/11/13. "I reviewed the patient's chart and discussed the patient with caregivers and did a brief mental status exam. Caregivers say (Resident #4) is doing better overall behaviorally. They say they had to do some adjustment of toileting her during the night, which has resulted in things going much more smoothly for everyone..." (NOTE: This was the first mental health visit since the [MEDICATION NAME] was increased. More than 2 months had passed. There was no documentation as to how, given the language barrier, the mental status exam was conducted, nor of the results. There was no documentation as to how it was determined the resident had improved behaviorally. There was no mention of why a toileting program had not been previously identified or implemented.) -10/9/13. "...The patient's blood sugars have been quite erratic which may contribute at times to her feelings of anxiety. Staff say she has been pretty stable behaviorally. Not as fearful or anxious appearing. Not as attention seeking...I asked her in Spanish how she was feeling and she replied, 'malo.' When I asked why or how she replied, 'I don't know.' She smiled and had good eye contact. Insight and judgement poor. Intelligence less than average. Intelligence is very hard to ascertain, but I am guessing less than average by virtue of dementia..." (NOTE: There was no documentation of Resident #4's erratic blood sugars being ruled out as a potential adverse reaction to her [MEDICATION NAME] increase. This was the first mention of behavior characterized as, "attention seeking." There was no documentation Resident #4's feelings of, "malo" were further explored by the practitioner who conducted this evaluation, or facility staff notified so they could follow up on those complaints. It is unclear how the practitioner assessed Resident #4's intelligence, or how that data was pertinent to the [MEDICAL CONDITION] medication evaluation.) Resident #4's Interdisciplinary Progress Notes (PNs), prior to the increase in [MEDICATION NAME] on 7/10/13 documented: -7/2/13 at 1:00 PM. Cares for 2 falls - both on 6/30/13 - Resident is getting OOB (out of bed) both times. Bed alarms working. Observation has increased Q (every) 15 minutes. Plan to review afternoon activity to provide activity for her. Will review psy ([MEDICAL CONDITION]) med (due to) (signs and symptoms) of (increased) restlessness in the afternoon" -7/2/13 at 10:10 PM. "...(No) attempts to self-transfer this shift..." -7/3/13 at 4:15 AM. "...Res has been sleeping quietly so far this shift, (without) (negative) behaviors." (NOTE: There was no documentation as to what specific behavior would constitute a "negative" behavior.) -7/7/13 at 3:55 PM. "Resident alarm sounded. When CNA responded found resident sitting on floor in hallway, just outside of resident's room. Resident unable to state what she was trying to do. Res denied need for toileting. Res had been noted sleeping in bed (at 3:45 PM)..." (NOTE: There was no documentation as to whether or not Resident #4 had been offered an afternoon activity, as identified in the note from 7/2/13. There was no documentation of Resident #4's needs being assessed in a language she understood.) -7/8/13 at 7:00 AM. "...(No) neg (negative) behaviors noted this shift. (No) attempts to self-transfer noted..." -7/8/13 at 2:00 PM. "...(No) attempts to self-transfer this shift..." -7/8/13 at 8:15 PM. "...(increased) neg behaviors this shift. Yelling (at)( staff (and) hitting. Res removed from environment (and) calmed. (No) attempts to self-transfer." (NOTE: There was no documentation assessing potential antecedents to Resident #4's behaviors, what environment she was in when they occurred, or to which environment she was taken to calm her.) -7/9/13 at 3:05 PM. "Discharge when bed available." -7/10/13 at 3:45 PM. "Received (and) processed order to (increase) [MEDICATION NAME]." Resident #4's PNs after the increase in her [MEDICATION NAME] documented: -7/12/13. "Late entry for 7/11/13 (night) shift. Res was up (at) start of the shift (and) constantly keep (sic) ringing her call light (and) when asked what she needed she stated she had to use the restroom (and) Res was toileted (4 times) in a 2 hour period only one of the times did Res urinate...Res attempted to get out of bed (more than 7 times)..." -7/18/13 at 9:00 AM. "Resident had 1 episode of yelling in the hallways after breakfast because resident could not get right into bed..." -7/28/13 at 5:00 AM. "Res attempting to self transfer (two times). Res alarm sounded (and) res found sitting on commode. Res didn't use call light either time." -8/13/13 at 2:00 AM. "(Increased) [MEDICAL CONDITION], pulling call light cord out of wall constantly, refusing to state what is needed when staff inquires..." -8/29/13 at 4:00 AM. "Res awake most of (night) shift, yelling, pulling call light cord out of the wall...(increased) behaviors, res denies pain when asked. Res stated "I'm hungry" several times (and) was given some snacks, then cont(inued) to yell "I sleepy" but would not be calmed or redirected when trying to get out of bed..." -9/19/13 at 5:00 PM. "Res has had high BGs this shift ranging 426-478. BG on 9/18/13 (at 4:30 PM) was 478, BG on 9/19/13 (at 7:00 AM) /426, (11:00 AM) /458. Urine dip obtain results as follows. Polyuria noted (and) frequently more incontinent..." -9/23/13 at 4:10 AM. "...Res having issues (with) [MEDICAL CONDITION], shouting "I'm hungry" during beginning of (night)...given sandwich, cont. to yell for some time afterwards...Res also cont. to pull call light cord out of wall (and) wrap it around her neck like a scarf. Res advised not to place cord around neck because of safety issues..." -9/25/13 at 12:40 PM. "Cares - Fall 9/20 (no) injury, attempting to self-transfer - plan to toilet right after each meal..." -10/15/13 at 5:30 AM. "Res const pulling call light cord out of wall (and) pulling on it...got agitated...then took off her attends (and) threw them across the room. Res was yelling loudly each time someone passed the room, would not answer when staff inquired what was needed...Res also pulling pillow case off pillows, removing bedding..." -10/17/13 at 7:00 PM. "Resident having increased restlessness (with) rapid breathing and jitteriness when verbally speaking. Continues to touch forehead (with) bilateral fingertips on her hands. Res is unable to remember that she went to the toilet (every) 5 minutes (four times) (with) no results as far as voiding or bowel movement..." -10/17/13 at 8:15 PM. "LN assisted resident to the restroom (at) this time. LN noted resident ripping the toilet paper off the roll and throwing it onto the floor (three times) during this time. LN noted teeth grinding (with) labored breathing." (NOTE: Each of these entries identified either a symptom which might have indicated Resident #4 was experiencing adverse reactions to her [MEDICATION NAME], a physical need which may need to be addressed as a nonpharmalogical intervention, or a potential issue the resident was having difficulty communicating due to her language barrier) On 10/21/13 at 2:15 PM, Resident #4 was observed sitting in her room, in her wheelchair, which was located next to the left side of her bed, with the resident facing the head of the bed. She was approximately 10 feet from the doorway to the room. As the surveyors entered the room, Resident #4 could be heard with wheezing as she breathed. As the surveyors approached the resident, her ankles were visibly [MEDICAL CONDITION], to the point of her skin appearing taut. As she spoke, her voice sounded forced, as if she was having to exert herself to speak. On 10/23/13 at 3:40 PM, the Pharmacist was interviewed regarding Resident #4's [MEDICATION NAME] use and potential adverse reactions. The Pharmacist stated one of the adverse reactions to [MEDICATION NAME] was weight gain, and if the medication was increased in dose, the rate of weight gain could increase as well. The Pharmacist stated, "Oh, yes. People on [MEDICATION NAME] usually gain at least 10 pounds, sometimes more, depending on the person." The Pharmacist was asked if [MEDICATION NAME] could cause elevated blood glucose levels. The Pharmacist stated, "Oh, yes. Probably [MEDICATION NAME] is the worst for that. I would recommend frequent A1-C's (Hemoglobin A1-C), every 6 months on a resident with stable BGs, every 3 months if the BGs were less stable." The pharmacist was asked if it would be important for him to know if a resident on [MEDICATION NAME] had [MEDICAL CONDITION]. The Pharmacist stated, "Of course. The patient's clinical condition is always important." The Pharmacist was asked if the facility had ever informed him Resident #4 had weight gain, unstable BG's, or [MEDICAL CONDITION]. The Pharmacist stated, "No. I didn't know that." On 10/24/13 at 12:52 PM, the FIDON was interviewed regarding Resident #4's [MEDICATION NAME] use. The FIDON stated she was unsure what the specific target behavior was for Resident #4, but she would investigate. The FIDON stated Resident #4 was followed by a mental health nurse practitioner, which should cover those issues for Resident #4. The FIDON was asked how the facility monitored potential adverse reactions or side effects for Resident #4's [MEDICATION NAME]. The FIDON stated side effects were onitored on the resident's MAR. The surveyors stated they had not seen which side effects, specifically, were to be monitored for [MEDICATION NAME]. The FIDON stated, "If I was the nurse, and they weren't listed, I would go look them up. That's what I would expect." On 10/24/13 at 3:00 PM, the facility's Regional Medical Director (RMD) was interviewed regarding Resident #4's [MEDICATION NAME] use. The RMD stated the facility had contacted him in July of 2013 to review Resident #4's chart. The RMD stated he was able to make some recommendations of medication changes to reduce the risk of adverse reactions such as falls and BG levels. The RMD stated he felt Resident #4 was on a very small dose of [MEDICATION NAME]. The RMD was asked what the target behavior for Resident #4's [MEDICATION NAME] was. The RMD stated, "That's a good question. I'll have to look into that." The RMD was asked if he was aware of the increase in Resident #4's [MEDICATION NAME] dose on 7/10/13. The RMD stated, "Right. I just saw that. That was not done from my recommendation, I don't know why." The RMD was asked about unstable BG's, falls, [MEDICAL CONDITION], hunger, and weight gain as possible adverse reactions to [MEDICATION NAME] use. The RMD stated, "Those are all good questions. She's got some heart failure, and I've listened to her lungs and talked to her attending physician. We got some [MEDICATION NAME] ordered, and we'll see about getting some labs." On 10/25/13 at 10:50 AM, the Resident Services Supervisor (RSS) was asked about target behaviors identified by the physician for anti-psychotic use. The RSS stated typically the target behavior was not identified by the physician, but by the facility. As far as indications for use, the RSS stated, "It is my understanding they have to have some kind of [MEDICAL CONDITION] or [MEDICAL CONDITION]. I sit on the IDT, and I'm responsible to fill out the target behaviors on the behavior monitors, but that's about it." On 10/25/13 at 6:15 PM, the Administrator, IDON, FIDON, and RDCO were informed of the surveyor's findings. The facility offered no further information. Note: Please see F 154 as it pertains to providing information in an understandable fashion, F 309 as it pertains to delay in treatment, and F 325 as it pertains to nutritional status for Resident #4. 2. Resident #6 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #6's most recent Quarterly MDS, dated [DATE], coded: -No speech, rarely understood, rarely understands others. -Unable to participate in the BIMS, assessed by staff with long term and short term memory. -Unable to participate in the mood interview, assessed by staff with daily loss of interest in activities, and feeling tired or having little energy daily. -No hallucinations, [MEDICAL CONDITION], or other behaviors. -Resident #6's Active Orders (Physician's Recapitulation Orders) for October 2012 documented [MEDICATION NAME] 75 mg twice daily, starting 9/3/13. Resident #6's record contained no physician's progress notes since her admission. (NOTE: Please see F 387 as it pertains to the frequency of physician's visits.) Resident #6's care plan documented: -Focus area of, "(Diagnosis) of [MEDICAL CONDITION] disorder with occasional loud vocalizations, (history) of slapping at staff, restlessness." Date Initiated: 6/28/13. *Goals of, "No loug (sic) vocalizations or slapping staff," and, "Will be able to sit thru meals and activities." Date initiated 6/26/13. *Interventions included, "Avoid overly stimulating environment," and, "Monitor s/e (side effects) of anti-psychotic medication..." (NOTE: There were no additional non-pharmalogical interventions listed. While there was an intervention to monitor the effects of medication, there was not an intervention to administer the medication.) -Focus area of, "Exhibits inappropriate behavior, resists treatment/care AEB pushing staff away related to: Fear or pain." Date Initiated 6/26/13. -Interventions included, "Administer medication as ordered." "Allow flexibility in ADL routine to accommodate residents mood." "If resident refuses care, leave resident and return in 5-10 minutes." "Praise/Reward resident for demonstrating consistent desired/acceptable behavior." Date initiated for all the interventions was 6/26/13. On 10/23/13 at 7:45 AM, the Administrator, FIDON, and IDON were interviewed regarding the anti-psychotic use for Resident #6. The FIDON stated the target behavior for the anti-psychotic medication for this resident was jitteriness or nervousness. When asked if these behaviors would warrant the use of an anti-psychotic medication, the FIDON stated, "It doesn't." The Administrator, IDON, and FIDON were asked about Resident #6's [DIAGNOSES REDACTED]. The Administrator stated he did not know the answer to that, as he had never seen anyone with that disorder before. The IDON stated she would expect the facility would have found out what causes the syndrome, what can be done about it, and in-serviced the staff. The Administrator, IDON, and FIDON stated to the best of their knowledge, this had not been done, even though Resident #6 had been in the facility for 4 months. The Administrator, IDON, and FIDON were asked how it was determined in Resident #6's care plan her behaviors were "inappropriate", rather than normal and expected due to her disease process. The Administrator stated he did not know, but would check. The Administrator, IDON, and FIDON were asked when and by whom Resident #6 had been diagnosed with [REDACTED]. The Administrator stated he would check. On 10/23/13 at 9:15 AM, the Administrator provided a document to the surveyor entitled, "[DIAGNOSES REDACTED]." The document identified it had been obtained from a genetics website on 4/24/13. It documented, in part, "The name of the syndrome is French for 'cry of the cat', referring to the distinctive cry of children with this disorder. The cry is caused by abnormal larynx development...Cri-du-chat is caused by a deletion...on the short arm of chromosome 5...often, the larynx doesn't develop correctly, which causes the signature cat-like cry...people with cri-du-chat usually have difficulty walking and talking correctly..." The Administrator also provided a H&P dated 4/22/13, almost 2 months prior to Resident #6's admission to the facility, which documented "[MEDICAL CONDITION] disease" under "Past Medical History." However, there were no further details as to when or how this disorder was diagnosed . On 10/24/13 at 3:00 PM, the RMD was asked about the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The RMD stated he had not been involved in the care for Resident #6, but in his experience it would be very difficult to make that [DIAGNOSES REDACTED]. On 10/24/13 at 6:15 PM, the Administrator, IDON,

Based on interview and record review, it was determined the facility did not provide care and services to meet a resident's psychosocial needs, dignity, or cleanliness at the end of life. This was true for 1 of 4 residents (Resident #1) sampled for end of life care. Resident #1 was harmed when the facility failed to incorporate their knowledge of his increased confusion and declining function into the care provided at the end of life. As a result, Resident #1's family found him partially disrobed and soiled with feces on his hands, legs, and groin after not having care from facility staff for a period of 5 hours, the day before his death. Further, when Resident #1's family addressed their concerns the facility responded in such a way as to negatively impact what would become the last visit between Resident #1 and his family. Findings included: Federal guidance at F 309 documented, "Studies have identified various factors that are considered important for a 'good death,' including...being kept clean; being comfortable with the staff providing care...strengthening relationships with loved ones; having someone to listen and be present; and maintaining one's dignity." Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 5/11/13, Resident #1 enrolled in hospice services. Resident #1's medical record from the facility included a report from Adult Protective Services (APS), dated 1/13/13. The report documented, in part, "(Resident #1) lives alone and there is no plumbing...(Resident #1) understands he needs to go to SNF...was receptive to this...his toilet is not working and (Resident #1) pees into garbage can by the chair and defecates into towels and throws them away...(Resident #1) reported...that he has not been eating very much, he eats one orange per day because he cannot get up to cook for himself...having weakness...received home health...reported that the nursing assistance was OK, but that he needs more assistance with bathing, cooking, and cleaning...(Resident #1's) son is his only support; son's wife lives in (name of town) and...has [MEDICAL CONDITION]" Resident #1's most recent Quarterly MDS assessment, dated 4/24/13, coded moderately impaired cognitive skills, and no rejection of care. At that time, Resident #1's MDS coded independence with toileting. Resident #1's care plan documented: Focus area of, "Feelings of sadness, emptiness, anxiety, uneasiness, depression characterized by: ineffective coping, low self-esteem," the approaches, "Encourage loved ones to keep in contact/ visit. Son works out of town and visits on weekends" and "Provide emotional support to resident/family as needed." Dated 1/29/13, updated 3/1/13. Focus area of, "Self Care Deficit," the goal of , "Will be odor free, appropriately groomed, and needs will be met daily," and an approach of, "Adjust level of care according to individual needs and report persistent changes to physician and family." Dated 1/30/13. Resident #1's nurse's Progress Notes (PNs) documented: *5/2/13, unknown time. "Cares - 2 falls. 4/29 had increased confusion and unable to say how he fell . Root cause - increased confusion (with decreased) safety awareness. 5/1/13 - continues confused - Root cause - decreased safety R/T (related to) confusion. Resident has a new dx (diagnosis) of liver CA (cancer) - has recently gone to see oncologist. Condition declining. Will continue to monitor." *5/2/13 at 9:30 PM. "...cont to be confused (and) requiring assist (with) all ADL's..." *5/12/13 at 5:45 PM. "Res daughter-in-law standing at the nurses station asked, 'If I was the supervisor on duty.' LN stated 'yes'. The daughter-in-law asked LN to follow her to her father-in-law's room. Daughter-in-law was noted by LN and (sic) appeared irate, anxious, and angry towards LN about the appearance (and) condition her dad was in. LN noted Res to be laying with his legs half off the bed, his adult brief (at) the bottom of the bed, and stool on his fingers and groin. LN stated 'I will get someone in her(sic) to take care of the matter immediately,' Daughter-in-law insisted to continue to degrade the nurse with comment (sic) such as 'How would you like your dad to lay here like this'? (sic) Res's daughter-in-law was unable to listen or be directed towards any resolution to the problem. LN stated to Res's daughter-in-law not to make a scene in the hallways by yelling (and) being loud with her voice. LN stated 'Let's go into the nurses office (and) discuss this.' Res daughter-in-law was noted to be apprehensive when speaking to her." (NOTE: Resident #1 had been diagnosed with [REDACTED].) *5/12/13 at 6:30 PM: "Res son notified Res's hospice providers after leaving the facility. Hospice stated he wasn't being bathed (and) that they would provide this service along with his adult briefs (and) wipes. Hospice also discussed pain management for the Res until comfortable." *5/13/13 at 4:20 AM: "Res refused vitals except temp - 97.2. Res c/o (complained of) pain (and) was given PRN (as needed) meds which appeared to be effective. Res asleep at this time. Will cont. to monitor." *5/13/13 at 8:45 AM: "Res passed away (at 8:00 AM)..." (NOTE: There was no documentation of Resident #1 being assessed between 4:20 AM and 8:00 AM, when Resident #1 was discovered to have passed away. At the time it was discovered Resident #1 had passed away, only 14 hours and 15 minutes had elapsed since his daughter-in-law had brought to the attention of the staff Resident #1 was soiled with feces and partially disrobed, and had been reprimanded when this condition was brought to the attention of the charge nurse.) A facility Risk Management System form (I&A), dated 5/12/13 at 5:00 PM, documented: *Event of "alleged neglect": on 5/12/13 at 5:00 PM *Summary of investigator's findings": "(Resident #1's) daughter-in-law came in for a visit and walked up to the nurses' station reporting to the Licensed Nurse that the resident was found in bed with feces on his hands, legs, and buttocks. His brief was off and at the bottom of his bed. Upon notification and assessment the nurse informed the CNA's who immediately cleaned the resident. The CNA's continued to make frequent rounds. Incontinence care was provided twice more on that shift." On 5/29/13 at 8:40 AM, the Assistant Administrator (AA) was asked for a copy of facility abuse investigations. At 10:20 AM, the AA provided investigations which included a file on the above incident for Resident #1. The file included: *A "Summary of Investigation" form regarding this incident with Resident #1, faxed to BFS on 5/20/13 at 5:06 PM, which documented: -Date and time of event: 5/12/13 at 5:45 PM. -Pertinent Resident History: "...admitted to the facility on [DATE] after a hospital admission...at the time of hospitalization , a call was made to adult protective services as he was residing in poor living conditions such as defecating in a towel and urinating in a garbage can... (Resident #1 had poor short and long term memory and required extensive assistance with activities of daily living including toileting needs..." *Investigation: "(Resident #1) had been given a shower before the lunch meal...around 1:30 a CNA walked passed (sic) (Resident #1's) room...at approximately 3:00 PM, his nurse saw him as she passed his room and his brief was on at that time and no feces was noted to be on him (NOTE: The nurse did not actually enter the room to physically check on Resident #1. It is unknown if he had been incontinent of bowel at that time, only that the nurse who walked by the room did not see feces on the resident from her vantage point in the hallway.) (Resident #1's) son was noticed in the facility around 5:15 PM...at approximately 5:45 PM (Resident #1's) daughter-in-law approached the licensed nurse on duty and asked the nurse to come to (Resident #1's) room with her. (Resident #1) was in his bed, with his feet hanging out, his brief off and feces was on his hands, legs, and buttocks. His brief was at the bottom of his bed...at about 5:45 PM, (Resident #1's) hospice agency called the facility and informed the licensed nurse that they had received a complaint from his son about the cares (Resident #1) was receiving..." -Conclusion: "From the CNA shift change at 1:00 PM until 5:45 PM, no CNA had been in (Resident #1's) room to provide incontinence care...Though no willful intent or single staff responsibility was identified, the allegation is being substantiated related to the resident being found incontinent of bowel at the time the grievance was made..." -Actions taken: "Resident was immediately cleaned up, given clean sheets, and a clean brief." "Specific assignments will be given to CNA's." "Customer service training given to staff." "Staff re-educated on abuse." "Staff educated on frequent in room rounding, assessment and observation of incontinent residents." This form was signed by the AA and the DON. *Staff statements obtained on 5/14/13 and 5/17/13 documented a CNA "checked on" Resident #1 at 12:40 PM. There was no documentation as to what "checked on" entailed. (NOTE: No staff were in Resident #1's room until Resident #1's daughter-in-law informed facility staff Resident #1 had feces on him at 5:45 PM, over 5 hours later.) *A "Mandatory In-Service and Training Record", dated 5/13/13, which included "Content and Objectives", in its entirety, "Staff to provide care to all residents routinely throughout the shift." On 5/29/13 at 8:40 AM, the Assistant Administrator (AA) was asked to provide the surveyors with the facility grievance file for the past 3 months. The AA stated the facility had not received any grievances "this year. (2013)." On 5/30/13 at 8:45 AM, the AA and the Manager of Clinical Operations (MCO) were interviewed regarding the events of 5/12/13 and 5/13/13, the date of Resident #1's death. The AA and MCO reported the following: *On 5/12/13, the date of the incident, the lead CNA for the day shift had been caring for Resident #1 in the morning. At some point in the morning Resident #1 was bathed. Between 12:15 and 12:40 PM, the lead CNA sat with Resident #1 to assist him with his lunch. At 12:40 when the CNA left Resident #1, he was clean and dry, and had water available. The lead CNA "peeked in" Resident #1's room, but did not enter the room again. The lead CNA ended her shift at 1:30 PM. *Another CNA "peeked in" Resident #1's room, but did not enter the room, at approximately 12:45 PM. *The charge nurse "walked by" Resident #1's room at approximately 3:00 PM. The charge nurse reported to the MCO that as far as she could tell, Resident #1's brief was still on. *The charge nurse saw Resident #1's son in the hallway of the facility at approximately 5:15 PM. Resident #1's son did not speak to the nurse. *At approximately 5:45 PM, Resident #1's daughter in law entered the facility and asked the nurse to accompany her to Resident #1's room to observe his condition. *The AA and the MCO concluded there was no one person responsible for what happened to Resident #1, so no staff-specific action was taken. The AA and MCO were asked if there was a charge nurse assigned to oversee Resident #1's care that day. After some hesitation, the AA and MCO stated there was a nurse assigned to Resident #1. They identified the nurse who made the progress note when the incident was discovered by family, as the charge nurse for Resident #1 that day. *The AA and MCO were asked about the nurse's note from 5/12/13 regarding the interaction between the charge nurse and Resident #1's daughter-in-law. The MCO stated, "She did not mean it to sound that way. Yes, she could have done a better job, and we have educated her, along with everyone else in the building. We have taken that step to ensure this won't happen to another resident again." The MCO was asked if she was referring to the 5/13/13 in-service. The MCO stated, "Yes." The MCO was asked if she felt this had been adequate to address the situation. The MCO stated, "We have also taken steps to update our assignment sheets." *The AA and MCO were asked about the inclusion of the contents of the 1/13/13 APS report in the "Pertinent Resident History" section of the incident investigation, especially the inclusion of only the information regarding Resident #1's toileting habits, and not the statements from Resident #1 that he felt he needed more help. The AA and the MCO stated this information was, "Strictly listed as a reason leading up to his residing in long-term care" and did not have anything to do with what happened on 5/12/13. *The MCO and AA were asked if there had been a social work referral for Resident #1, given the complexity of his psychosocial status, i.e., his terminal illness, his identified coping difficulties, his son's ability to visit only on weekends due to his work schedule, and his daughter-in-law's terminal illness so similar to his own. The MCO stated, "I don't know. We'll have to ask the SSD," and, "I don't really even know if he was that close to his family." On 5/30/13 at 9:20 AM, the SSD was interviewed regarding Resident #1. The SSD described Resident #1's family as, "difficult, and having a difficult time coping with his situation." The SSD was asked if there had been a social work consult requested for Resident #1. The SSD replied, "Well, we encourage hospice." The SSD was asked if, aside from hospice, the facility provided a social work consult for Resident #1, since he did not enroll in hospice until 5/11/13. The SSD stated, "I've never made a social work referral for anyone here." Resident #1 was without care from facility staff for a period of 5 hours and 5 minutes, the day before his death, even though Resident #1 had been noted with increased confusion and declining function. Between 12:40 PM and 5:45 PM on 5/12/13, the resident became partially disrobed, and had a bowel movment which left feces on his legs, hands, and groin. The facility did not become aware of the situation until the resident's daughter in law informed staff. The facility's response to the daughter in law's concerns resulted in the family leaving the facility upset, without resolution to their grievance. Resident #1 was terminally ill, and enrolled in hospice services. His last visit with his family was when they found him partialed disrobed and covered with feces, as he passed away the next morning. The facility caused harm to Resident #1 when they did not provide care to ensure he had a "good death." The facility failed to keep Resident #1 clean, maintain his dignity, and create an environment conducive to strengthening family relationships and having someone to listen and be present.