Every finding on record at Clearview

Based on interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible for 1 or 6 residents (R9) reviewed for falls. R9 had a fall from bed, sustaining fractures (fx.) of left clavicle (collar bone) and left ribs 3-6, when CNA J (Certified Nursing Assistant) rolled R9 away from CNA J while performing cares. The facility did not have contemporaneous evidence CNA J, an agency CNA, received education to prevent future incidents from occurring. Evidenced by: The facility's Fall Prevention and Management policy, dated 2/28/25, states, in part: .Definitions Fall: The Centers for Medicare and Medicaid Services (CMS) defines a fall as an unintentional change in position that results in someone landing on the ground or a lower surface. Procedure .6. Responding to a fall .o. The RN Unit Manager will review and discuss trends, follow-up action, and educate staff. R9 admitted to the facility on [DATE] and has diagnoses that include, in part: Multiple Sclerosis (a disease that causes breakdown of the protective covering of nerves, which can cause weakness and lack of coordination); dementia (decline in mental ability severe enough to interfere with daily life); muscle weakness; cognitive communication deficit (difficulty in communication caused by cognitive process rather than speech or language issues). R9's Minimum Data Set (MDS), dated [DATE], indicate a Brief Interview of Mental Status (BIMS) score of 4, indicating moderate cognitive impairment, and indicates a rolling left to right score of 01-dependent (needs full assistance). R9's Care Plan states, in part: Problem Potential for Injury Trauma-falls r/t (related to) unstable condition r/t disease process AEB (as evidenced by): weakness, impaired sense of balance, may have altered sense of safety awareness, may display restlessness, may be agitated, medication effects, potential for altered mental status, may be impulsive, non-ambulatory.Approach 2 assist for incontinence cares and LB (lower body) cares when in bed. Edited 12/3/24. R9's Progress Notes state, in part: *11/29/24 11:46 AM Writer was called to assess the resident at approximately 9:46 AM d/t (due to) a fall out of bed. *11/29/24 1:51 PM .A CT (Computed Tomography Scan / CAT scan; a medical imaging procedure that uses x-ray and computer technology to create detailed, cross-sectional images of the body) of the head and cervical spine were completed that showed a left clavicle fracture. x-ray showed left sided rib fx. (fractures) of 3, 4, 5, 6. R9's Resident Incident/Accident Worksheet, undated, states, in part: Date and Time of Incident 11/29/24 9:40 AM. Name of staff reporting incident: CNA J. Other staff involved/witnesses: n/a (not applicable); Incident type: rolled out of bed; .Behaviors that may have contributed to the injury: staff turned her away from them and she was too close to edge of bed when turned and fell out of bed . R9's Event Report, dated 12/2/24, states, in part: . Date/Time of Occurrence 11/29/24 9:40 AM. Type of Fall-rolled out of bed (fall) . Conclusion and Notifications-Cause: staff rolled resident away from them during cares instead of towards them and didn't take 2 staff in to do cares. Intervention to prevent reoccurrence: 2 staff to do cares when in bed at all times. Agency Employee Logs for CNA J indicate the following dates worked with start time 6:00 AM and end time 2:15 PM: 11/29/24, 12/2/24, 12/3/24, 12/4/24, 12/6/24, 12/7/24, 12/8/24, 12/11/24, 12/12/24, 12/13/24, 12/16/24 On 8/4/25 at 11:07 AM, Surveyor interviewed FM K (Family Member) during initial screening. FM K stated they sat R9 up in bed and left R9 at the edge of the bed and R9 fell and broke ribs. On 8/6/25 at 8:17 AM, Surveyor interviewed CNA E (Certified Nursing Assistant) and asked how many staff members are needed when assisting a resident with care in their bed. CNA E stated usually 2, but for some residents it can be done solo. Some residents have 2 assist listed on their care card. CNA E stated that when working solo, CNA E will try to roll residents toward her, but sometimes you need to roll them away to be able to wash the resident thoroughly if this is the case staff need to bring the resident closer to them to make a bit more room on the bed when rolling a resident away from you. On 8/6/25 at 8:38 AM, Surveyor interviewed RN/IC H (Registered Nurse / Inservice Coordinator) who indicated that if staff are turning a resident in bed for cares, the resident should be turned toward something to protect them, yourself or another staff member. On 8/6/25 at 10:15 AM, Surveyor interviewed RN/UM F (Registered Nurse /Unit Manager) about R9's fall. RN/UM F stated CNA J turned R9 toward the window (away from staff), not sure if she turned her back or left to get supplies. RN/UM F stated RN/UM F spoke with CNA J and got a statement on 12/3/24. Surveyor asked if education was completed and documented. RN/UM F provided a household in-service record dated 12/4/24. Important to note: the 12/4/24 in-service is not signed by CNA J. On 8/6/25 at 4:02 PM, Surveyor called CNA J. Surveyor was unable to reach CNA J and was unable to leave a message on CNA J's voicemail as the voicemail indicated it was full. Surveyor did not receive a return call from CNA J. On 8/6/25 at 4:02 PM, Surveyor interviewed DON B (Director of Nursing) and asked about follow-up for R9's fall. DON B stated that CNA J turned R9 away from CNA J and R9 was too close to the edge of the bed and fell. DON B stated RN/UM F followed up with CNA J and the incident was reported to CNA J's agency. Education was completed by Household in-service sheets and a house wide in-service that included safe moving of residents in bed. Surveyor asked if CNA J received education and had the necessary information prior to working with other residents. DON B stated she could not confirm CNA J received the education. DON B stated that DON B couldn't speak to what was said to CNA J, but the facility is not allowed to document education with agency staff due to rules of Human Resources (HR). Surveyor asked when CNA J's agency was notified. DON B stated she would need to look. On 8/7/25 at 7:58 AM, DON B stated there was no documentation of notification of CNA J's agency. On 8/7/25 at 8:41 AM, Surveyor interviewed HRS I (Human Resources Specialist) who indicated that the facility is not able to do education in writing, as the facility is not the agency staff's employer. If they are doing something wrong, we can tell them, but we are not able to put it in writing. If there is an investigation, the information is sent to HR, and HR will send the information to the agency. The agency educates the staff member and then sends information of the education back to the facility to be put in the agency file. HRS I stated this did not occur with CNA J and there was nothing in CNA J's file. R9 sustained a fall with multiple fractures after CNA J rolled R9 away from her when providing care. CNA J continued to work with other residents without evidence of contemporaneous education being completed with CNA J prior to working with other residents to prevent a reoccurrence.

Based on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 or 16 residents (R9) reviewed for change of condition.R9 went to the hospital for evaluation following a fall from bed. R9 sustained fractures (fx) of left clavicle (collar bone) and left ribs 3-6 and nursing assessments were not performed on return to the facility.Evidenced by:The facility's Fall Prevention and Management policy, dated 2/28/25, states, in part: .Definitions Fall: The Centers for Medicare and Medicaid Services (CMS) defines a fall as an unintentional change in position that results in someone landing on the ground or a lower surface. Procedure .6. Responding to a fall .l. Follow up assessments of the resident will be completed no less than the next 3 consecutive shifts. m. All assessments will be documented in the E.H.R. (electronic health record) with vital sign collection.R9 admitted to the facility on [DATE] and has diagnoses that include, in part: Multiple Sclerosis (a disease that causes breakdown of the protective covering of nerves, which can cause weakness and lack of coordination); dementia (decline in mental ability severe enough to interfere with daily life); muscle weakness; cognitive communication deficit (difficulty in communication caused by cognitive process rather than speech or language issues).R9's Minimum Data Set (MDS), dated [DATE], indicate a Brief Interview of Mental Status (BIMS) score of 4, indicating moderate cognitive impairment.R9's Progress Notes state, in part:*11/29/24 11:46 AM Writer was called to assess the resident at approximately 9:46 AM d/t (due to) a fall out of bed.*11/29/24 1:51 PM .A CT (Computed Tomography Scan / CAT scan; a medical imaging procedure that uses Xray and computer technology to create detailed, cross-sectional images of the body) of the head and cervical spine were completed that showed a left clavicle fracture. Xray showed left sided rib fx of 3, 4, 5, 6.*11/29/25 5:38 PM Resident returned to facility around 5:00 PM. Assisted into bed. Sling in place. Resident is to wear sling for comfort and immobilization. Biggest risk is for pneumonia as R9 has 3 broken ribs. Monitor for SOB (shortness of breath) and s/s (signs and symptoms) of pneumonia.*11/30/24 4:01 PM Resident lying in supine position in bed when TL (Team Lead) went into check on her. Resident had left arm in sling. When asked if she was in pain, resident responded yes PRN (as needed) Morphine given at 3:15 PM for comfort. Curing the time writer was in room, encouraged resident to deep breath. Continue to monitor for comfort and continue to reposition resident.R9's Neurological Assessment sheet with start date of 11/29/24 indicates that neurological checks were completed on 11/29/24 at 9:40 AM, 9:55 AM, 10:10 AM, and 10:25 AM. The following dates/times are listed with no assessment documented: 11/29/24 10:55 AM, 11/29/24 11:25 AM, 11/29/24 12:25 PM, 11/29/24 1:25 PM, 11/29/24, 5:25 PM, 11/29/24 9:25 PM, 11/30/24 1:25 AM, 11/30/25 5:25 AM, 11/30/24 9:25 AMR9's Physician's Order Sheet, dated 11/29/24, no time indicated, states D/C (discontinue) neuro checks due to CT scan completed.R9's Emergency Department/Urgent Care Documentation dated 11/29/24, states, in part: .Patient Instructions Patient has a fractured clavicle. Sling is given for this. She also has 3 broken ribs. Biggest risk is pneumonia. Incentive spirometry is recommended. Watch for signs of pneumonia such as cough and fever.On 8/6/25 at 10:15 AM, Surveyor interviewed RN/UM F and asked about nursing assessments following R9's return from hospital evaluation with noted fractures. RN/UM F stated that neurological assessments were discontinued per physician orders, but pain and respiratory assessments should have been completed at least once per shift following resident's return to facility. Surveyor asked if those assessments were completed. RN/UM F stated no, there were no assessments documented until 4:01 PM the following day.On 8/6/25 at 4:02 PM, Surveyor interviewed DON B and asked about assessments for R9 following her hospital evaluation with noted fractures. DON B indicated assessments were not completed and should have been done once per shift.

Based on interview and record review, the facility did not ensure that a resident maintains acceptable parameters of nutritional status and is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 1 of 16 residents (R2) reviewed for nutrition.R2 was not weighed weekly for four weeks from time of admission and did not have a reweight when there was a loss of 9.8 pounds one month after admission. A nutritional supplement was ordered for R2 and was not routinely documented.As evidenced by: The facility's Nutritional Assessment and Care Planning policy, dated 3/20/23, states, in part: Realizing the importance of good nutrition in promoting optimal health and to identify problems which impact nutritional status, facility conducts nutritional assessment of all residents within 5 to 14 days of admission and at least quarterly or more often as needed and develops an individualized plan of care for each resident. Procedure . Weight .a. Weight is to be measured within 24 hours of admission, weekly while on Medicare or for at least one month and until weights are stable for other admissions, or more frequently as determined to be necessary.b. If weight varies by more than 4# (pounds) from previous weight, a reweight must be obtained within 48 hours. c. Amount of weight loss or gain is noted and whether it is planned or not, along with an evaluation of the source of the weight change (diuresis, poor appetite, fluid overload, etc.) .5. Need for, appropriateness, acceptance, and tolerance of therapeutic and mechanically altered diets, with referral to other disciplines as necessary. Use of nutritional supplements and appropriateness of them. A therapeutic diet is defined as a diet ordered to manage problematic health conditions and refers to alteration in nutritional content of foods (including the provision of nutritional supplement during meals which alter the nutritional content of the diet). R2 admitted to the facility on [DATE] and has diagnoses including: dementia with mood disturbance (a decline in mental ability severe enough to interfere with daily life ); breakdown of internal fixation device of bone in right lower leg (a mechanical failure or malfunction of the hardware used to stabilize a bone fracture); depression; anxiety disorder; Type 2 Diabetes Mellitus (a condition where the body either doesn't produce enough insulin or cannot properly use the insulin it produces, leading to elevated blood sugar levels); Crohn's disease of both small and large intestine (a chronic inflammatory bowel disease that can lead to diarrhea, abdominal pain, weight loss, and fatigue).R2's MDS (Minimum Data Set) dated 7/22/25, indicates a BIMS (Brief Interview of Mental Status) score of 6, indicating severe cognitive impairment.R2's Physician Orders include: *Ensure or supplement of choice at breakfast and at supper. start date 7/17/25 end date 8/6/25*Ensure or supplement of choice at lunch.start date 7/18/25 end date 8/6/25*Give Glucerna at meals: document under intake supplement (lunch) start date 7/31/25 end date 8/6/25*Give Glucerna if eats less than 50% of meal: document under intake supplement (breakfast and supper) start date 6/17/25 end date 7/31/25R2's Progress Notes include:*4/22/25 Nutrition admission Assessment.Wt. (weight) 4/14/25 207.2# .Appetite: resident with regular diet and tolerating meals with fair to good intake (51-100%) at most meals x 10 since admit, poor intake (1-50%) x 6.Assessment: Resident at moderate nutrition risk due to age, diagnosis, past medical history, regular diet and fair to good intake at most meals. Will monitor intake and appetite, progress, labs, weight and follow up with recommendation as needed.*7/17/25 Nutrition Assessment.Wt: 7/13/25 190.3#, 6/15/25 192.8#, 5/18/25 197.4#, 4/14/25 207.2# .Assessment: Resident at moderate to high nutrition risk due to age, diagnoses, past medical history, Regular diet with varied intake at most meals, breakfast seems to be the best at 76-100%. Current weight loss of 16.9# since admit. Will send a referral to nursing to offer Ensure with lunch and supper.*7/18/25 Nutrition Follow up: New order for Ensure or nutrition supplement of choice with meals TID (three times a day) due to weight loss. Will continue to monitor weight.R2's Vitals report indicates the following weights:*4/14/25 207.2 lbs (pounds)*5/18/25 197.4 lbs*6/1/25 193.4 lbs*6/8/25 193.4 lbs*6/15/25 192.8 lbs*6/29/25 193.6 lbs*7/6/25 192.8 lbs*7/13/25 190.3 lbs*7/20/25 190.6 lbs*8/1/25 187.4 lbsImportant to note: there is no documentation of a reweight following the 5/18/25 weight. R2's Vitals report indicates the following documentation for Supplements:*5/1/25 12:26 PM Supplements 240 ml Amount 76-100%*7/1/25 9:49 PM Supplements Amount 76-100%*7/6/25 12:08 PM Supplements Amount 26-50%*8/5/25 12:58 PM Supplements Not Taken: Refused*8/6/25 8:38 AM Supplements Not Taken: RefusedImportant to note that supplement was ordered for three times daily (scheduled) from 7/18/25 through 8/6/25 for a total of 57 times. In that time frame supplements were documented as offered on two occasions. R2's Vitals report indicates that meal intakes were documented as 1-25% or less, as follows:Breakfast:4/27/25,5/15/25,6/6/25, 6/7/25, 6/8/25, 6/21/25,7/9/25, 7/17/25 (8 instances)Lunch: 4/18/25, 4/21/25, 4/26/25, 5/2/25, 5/4/25, 5/7/25, 5/10/25, 5/14/25, 5/15/25, 5/16/25, 5/17/25, 5/23/25, 5/25/25, 5/26/25, 5/30/25, 6/2/25, 6/7/25, 6/8/25 6/9/25, 6/17/25, 6/19/25, 6/22/25, 6/23/25, 6/25/25, 6/26/25, 6/29/25, 7/2/25, 7/22/25, 7/23/25, 7/27/25, 8/1/25, 8/4/25 (32 instances)Dinner: 4/14/25, 4/19/25, 4/20/25, 4/21/25, 4/24/25, 5/6/25, 5/8/25, 5/20/25, 5/21/25, 5/27/25, 5/29/25, 6/1/25, 6/2/25, 6/21/25, 6/26/25, 6/30/25, 7/1/25, 7/15/25, 7/26/25, 8/2/25 (20 0ccurrences)Important to note: a supplement was documented as offered for just one of the 60 instances of meal intake of 1-25% or less.On 8/4/25 at 2:53 PM, Surveyor interviewed R2 during initial screening. R2 indicated thinking that R2 had lost weight. R2 stated that a friend had come to visit and made a comment about the weight R2 had lost.On 8/5/25 at 2:46 PM, Surveyor interviewed CNA L (Certified Nursing Assistant) who indicated that nutritional supplements and intakes are documented in the computer. CNA L stated that weights are done monthly unless told by the nurse otherwise. CNA L indicated that if a weight is off by 5-10 pounds a reweight will be done.On 8/6/25 at 8:12 AM, Surveyor interviewed CNA E who stated that nutritional supplements are written on the care plan and the meal ticket and that anyone who doesn't eat at least 50% of their meal is offered an Ensure. CNA E indicated that supplements and intakes are documented with a percentage consumed or that the supplement was refused. If refused, the nurse is also updated.On 8/6/25 at 9:35 AM, Surveyor interviewed RN/UM F (Registered Nurse/Unit Manager) who indicated that residents are weighed weekly for 4 weeks from time of admission, then if stable, changed to monthly. RN/UM F stated that a reweight is done if the weight is off; 5 or 10 pounds, dependent on the situation. Surveyor asked if R2 had been weighed weekly at admission. RN/UM F stated no, unless it was on paper. Surveyor asked if a reweight had been done following the 5/18/25 weight which indicated a 9.8# loss. RN/UM F stated, no, it is not charted in the computer. RN/UM F stated that R2 had just moved from another unit the week prior and the RN/UM G may have additional information. Surveyor asked about documentation of nutritional supplements. RN/UM F stated that the documentation is not always completed; everyone knows that they need to document on the supplement/intakes for all three meals.On 8/6/25 at 10:47 AM, Surveyor interviewed RN/UM G who indicated that weekly weights are expected for the first four weeks. RN/UM G stated that most residents on RN/UM G's unit remain at least weekly weights. Surveyor asked RN/UM G about weekly weights from time of admission for R2. RN/UM G provided no further documentation and stated that the weights should have been completed. RN/UM G stated that a weight change of 4# would trigger a reweight and stated that no reweight was found for R2 following the 5/18/25 weight loss. Surveyor asked about documentation of nutritional supplements. RN/UM G stated that the supplements are documented in the computer by the CNAs.On 8/6/25 at 1:25 PM, Surveyor interviewed RD D (Registered Dietician) who stated that weight changes are discussed with a 5% change in 30 days and a 10% change at 180 days, or when concerns are verbalized. RD D indicated that dietary should have had a referral for R2 in May with the loss of 9.8 pounds; R2 didn't quite trigger for significant weight loss. On 8/6/25 at 3:38 PM, Surveyor interviewed DON B (Director of Nursing) who indicated that residents are to be weighed at least weekly times four from time of admission, then weight frequency is determined per resident. DON B indicated that a reweight is done if weight is off by 5 or more pounds. DON B reviewed weight documentation for R2. DON B indicated that the weekly weights should have been done and a reweight was indicated following the 5/28/25 weights. DON B reviewed supplement documentation and how most instances of mealtime supplements were not documented in the computer. DON B indicated that supplements are to be administered as ordered and documented in computer for each occurrence.

Based on observation, interview, and record review, the facility did not ensure a resident's environment remained free of accident hazards and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 resident (R) reviewed for accidents (R14). Facility staff did not ensure R14's reclining chair remote was out of her reach per R14's care plan. R14 lifted the chair without staff present and fell resulting in a fracture. Evidenced by: The facility's Policy and Procedure entitled Fall Prevention and Management with a last reviewed date of 4/11/23 documents, in part: .Each resident be reviewed on admission, quarterly and with major change of condition for the potential fall risks, and preventative interventions taken when necessary. The purpose of the falls prevention and management program is to identify residents at risk for falls, initiate preventative approaches, and monitor and evaluate resident outcome. Should a resident fall, the licensed nurse will complete the documentation regarding the event in the electronic health record. The information will be reviewed to see if there were any contributing factors to the fall and interventions will be added to the plan of care as needed. (Which could include resident, family and/or staff education). R14 was admitted to the facility on [DATE] and has diagnoses that include in part: Hemiplegia and Hemiparesis following cerebral infraction affecting right dominant side (Disrupted blood flow to the brain causing muscle weakness and partial paralysis to the right side,) Unspecified fracture of shaft of right tibia, unspecified fracture of lower end of right femur, unspecified fracture of shaft of left tibia, closed fracture with routine healing, unspecified fracture of shaft of left fibula, Paroxysmal atrial fibrillation, Essential hypertension, Aphasia, Dysphagia, Osteopenia (lower than normal bone mass), and history of falls with fractures. R14's Significant Change Minimum Data Set (MDS) with a target date of 2/19/24 indicates R14 has a BIMS (Brief Interview for Mental Status) of 15 out of 15. R14 is dependent for toileting, personal hygiene, and upper and lower body cares. R14 requires extensive assistance in bed and transfers with the assistance of three staff members and the Golvo (full body lift). R14's Fall Risk tool, dated 1/13/24 at 2:46 PM, has a score of 16 which indicates R14 is at risk for falls. R14's Fall Event Report dated 1/20/24 at 7:45 AM, and a completion date of 1/22/24 at 04:06 (4:06 AM) AM states in part: .Description: noted on floor. Fall details: Date/time of occurrence: 01/20/2024 07:45 (7:45 AM). Type of fall, .noted on floor. Describe the event: Resident had been sitting in recliner. Resident then kept pushing button on recliner which then kept tilting the char [sic] forward causing resident to slide out of recliner and onto the floor.Where did the fall occur? Resident room . R14 yelling out intermittently. Range of motion assessment completed, range of motion per usual for resident. How was the environment when the fall occurred? Quiet .activity of resident at the time of the fall .sitting in chair .equipment being used: .recliner. Interventions already in place: keep call light in reach at all times. Monitor for mood, behavior or cognitive changes that may affect safety awareness patterns. Monitor for side effects of psych meds: low BP (blood pressure), gait disturbance, EPS (extrapyramidal side effects), vertigo lethargy etc. interventions to prevent reoccurrence. Staff to not place recliner remote by resident unless staff are there to observe how resident is using the remote . 24-hour follow-up documentation: AM follow-up: continues with complaints of lower back pain (chronic) PRN tramadol given. No injury noted. PM follow-up: Resident c/o (complains of) mild pain earlier in day, no further c/o throughout the evening. Neuro (neurological) checks WNL (within normal limits) with no c/o headache, nausea, or dizziness. No injury noted. NOC (night shift) follow-up: Neuro checks WNL with complaints of dizziness, headache, or nausea. Resident denies any pain or discomfort. Resting comfortably. No injury noted . (Of note: the facility falls investigation indicates that the new fall intervention put in place to prevent reoccurrence is, staff to not place recliner remote by resident unless staff are there to observe how the resident is using the remote. This intervention was added to the care plan on 1/20/24.) R14's care plan dated 1/20/24, states in part: Problem: Falls . interventions: staff to not place recliner remote by resident unless staff are there to observe how resident is using the remote. Place bed at height determined to be safe for resident's functional abilities with brakes locked. Provide resident an environment free of clutter and the floor is free of glare, liquids, and foreign objects . R14's Fall Event report with even date of 1/22/24 at 2:14 PM and completed date of 1/27/24 at 6:47 AM, states in part: Description slid out of recliner. Fall details. Date/time of occurrence: 01/22/2024 13:15 (1:15 PM). Type of fall .slid out of chair .Describe the event: Resident resting in recliner after lunch. Staff alerted by resident's crying, noting resident on the floor with her electric recliner in the up position, causing resident to slide out of chair. Resident (R14) noted to be laying on her right side on the floor between the recliner and the bathroom wall. Resident states that she did hit her head. Skin check completed with no injury noted. Resident (R14) assisted with the Golvo lift and 3 assist back into bed. Neuro checks initiated. Where did the fall occur? Resident room . How was the environment when the fall occurred? Quiet . Activity of resident at the time of the fall .sitting in recliner . interventions already in place: staff not to place recliner remote by resident unless staff are there to observe how resident is using the remote. Call light within reach. Keep personal items within reach of resident. Cause: Resident incorrectly using recliner remote. Interventions to prevent reoccurrence. Manual recliner .24-hour follow-up documentation: AM follow-up: Resident continues with immobilizer placed by ER. Unable to remove immobilizer d/t (due to) cotton wrapping around it. CMS (circulation motion sensation) WNL . Resident without pain at this time. Golvo lift used for transfers - resident (R14) non wt. (weight) bearing. Will continue to monitor . PM follow-up: Resident c/o increased pain to her left ankle, I sprained it. Slight bruising to the inner ankle, no increased swelling. X-ray ordered. X-ray results show a left tibia and left fibula fracture. The resident was sent to the ER. NOC Follow-up: resident (R14) back here at 2245 (10:45 PM). (R14) is wearing a cast to left leg and leg is wrapped. R14 able to wiggle toes, no redness to toes. (R14) is NWB (non-weight bearing) and uses the Golvo lift . Of note, there is no indication on the Fall event form to indicate R14's range of motion was assessed. R14's care plan was not followed as evidence by R14 having access to the recliner remote without staff present and having a second fall out of the recliner. On 1/22/24 at 7:35 PM, R14's progress note states in part: x-ray results received showing an acute fracture involving left distal tibia and distal fibula with no/mild to minimal displacement. MD Q (Medical Doctor) updated with orders to send to ER for eval . On 6/13/24 at 5:57 PM, Surveyor interviewed LPN P (Licensed Practical Nurse). Surveyor asked LPN P if R14 had an intervention to not have access to chair remote unless staff were present, should she have had the remote to the chair? LPN P stated, I am assuming not. On 6/13/24 at 2:49 PM, Surveyor interviewed RN E (Registered Nurse). Surveyor asked RN E what interventions were in place for R14 after the first fall on, 1/20/24. RN E stated we added to the care plan not to place the recliner remote by resident, unless staff are there to observe how resident is using the remote. Surveyor asked RN E if it was communicated to everyone? Yes, the hall CNA sheets were updated, and the care plan would have been updated. RN E stated the first intervention to not place the recliner remote near the resident did not work. The new intervention: get a manual chair, did work. R14 is now in a Broda chair. Surveyor asked RN E if there was a lift chair assessment done before R14 used the lift chair. RN E stated that therapy will do an assessment with lift chairs if they work with the resident. Typically, we don't do lift chair assessments. R14's Fall Risk tool dated 1/23/24 at 3:26 PM, has a score of 14 which indicates R14 is at risk for falls. On 6/10/24 at 9:47 AM, Surveyor interviewed resident R14 while the resident was sitting in a Broda chair in front of the TV in the resident's room. The bedside table was at the side of the Broda chair with several personal items on the table. Surveyor asked R14 when you push the call light do staff come and assist you? R14 said yes, they come quickly. On 6/13/22 at 5:50 PM, Surveyor interviewed CNA N and asked, how do you know what fall interventions to use? CNA N stated that we look at the resident care cards that are printed and updated. On 6/13/24 at 5:58 PM, Surveyor interviewed CNA O and asked, how do you know what fall interventions to use? CNA O stated that we have training on the computers, and the CNA Kardex. How are new interventions communicated to you? The nurse tells us when care plans are updated. On 6/13/24 at 5:18 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what would you expect the RN assessment to look like after a fall? DON B stated I would expect the RN to assess pain, the extremities for range of motion, have the resident move their limbs. I would expect them to ask the resident what they were doing at the time of the fall. I also expect them to take the resident's vital signs. Surveyor asked DON B who is responsible for assessing the resident at the time of a fall. DON B stated that the RN on the unit assesses the resident and completes the Fall Incident Report. Surveyor asked DON B once the team has determined an intervention, how is the new intervention communicated to the rest of the team? DON B stated that we have stand-up meetings 4 days a week, as RN teams. We disseminate information through the different license levels by providing updates from shift to shift. DON B stated that household meeting minutes are also posted on households for staff to read and review. Surveyor stated that resident R14 had a new intervention put in place recently. The intervention was that staff to not place recliner remote by resident unless staff are there to observe how the resident is using the remote. On 1/22/24, R14 had a second fall while sitting in the recliner and using the remote unsupervised. On 6/20/24 at 3:05 PM, Surveyor observed a stationary chair in R14's room, no electric recliner was observed in room. R14 was at risk for falls. R14 had a fall from the lift chair, the facility put an intervention in place to only allow R14 access to the remote with staff supervision. R14 had access to the remote without staff present, lifted the recliner chair, and fell resulting in a fracture.

Based on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 52 residents. The staff line lists contain signs/symptoms (s/sx) such as something I ate, sick, ill, cold sx. They are not specific. The staff line lists were missing some Date last Symptom occurred dates. The facility's COVID summary not complete or accurate. This is evidenced by: The facility policy entitled Nursing Services/Infection Control: Infections: Reporting, Interventions, and Surveillance, dated 2/10/24, states, in part: . Policy: An infection control report will be initiated for any resident with symptoms of an infection, in order to provide a systemic approach for monitoring, controlling the spread of and reducing infections. An infection may be identified by observation of clinical signs/symptoms, physician's diagnosis, and diagnostic tests . Staff calling in ill with infectious signs/symptoms will be given guidelines of when they can safely return to work. Staff may be encouraged to consult with their own physician prior to returning to work. Staff line lists will be maintained by the ADON (Assistant Director of Nursing) . Procedure: For Staff . 2. Staff calling in with gastrointestinal signs/symptoms (vomiting, diarrhea-may also have headache, fever/chills, and abdominal cramps) are required to stay home until they are symptom free for at least 48 hours. Symptomatic staff with Influenza like illness signs/symptoms (fever, chills, cough, sore throat, runny nose) are required to stay home at least 24 hours after they no longer have a fever (without fever reducing medicines) . 3. Staff should review all signs and symptoms with infection preventionist to determine return to work date . 5. The Infection Control Nurse/ADON will maintain staff line lists which include staff names, household/department, dates when calling in, signs/symptoms if determined to be infectious, dates signs/symptoms ended, and date staff returned to work. The facility policy entitled Gastroenteritis-Like Illness, dated 2/21/24, states, in part: . All facility staff should be monitoring for and reporting gastrointestinal illness among residents and staff year-round . Employees will report symptoms of gastrointestinal-like illness when calling in or when on duty so as to limit the spread . D. Management of Ill Staff . 5. A log should be maintained to record ill staff symptoms, date when they became ill, date they became well, and when they returned to work by the Infection Control Nurse or designee . Example 1 The May 2024 staff line list contains 9 call ins. 3 of 9 staff did not have specific symptoms on the line lists. Symptoms include: something I ate and sick. These symptoms are not specific to allow the infection preventionist or designee to track, trend, and surveil for illnesses and outbreaks. The Date of Last Symptom dates were left blank on the staff line list for 1 resident in May. Note: Without date of last symptom the return-to-work dates cannot be determined. The March 2024 staff line list contains 16 staff call ins. 7 of the 16 staff did not have specific symptoms on the line lists. Symptoms include: ill, sick, cold s/sx, GI (gastrointestinal,) and possible allergic reaction. These are not specific symptoms. The Date of Last Symptom dates were left blank on the staff line list for 1 resident in March. Note: Without date of last symptom the return-to-work dates cannot be determined. The February 2024 staff line list contains 27 staff call ins. 9 of 27 staff did not have specific symptoms on the line lists. Symptoms include: sick, not feeling well, upper respiratory, and ill. These are not specific symptoms. The Date of Last Symptom dates were left blank on the staff line list for 2 residents in February. Note: Without date of last symptom the return-to-work dates cannot be determined. The January 2024 staff line list contains 35 staff call ins. 6 of 35 staff did not have specific symptoms on the line lists. Symptoms include: upper respiratory s/sx, GI, In ER (emergency room ) all night-no specific, other, doesn't feel well, and sick. These are not specific symptoms. The Date of Last Symptom dates were left blank on the staff line list for 1 resident in January. Note: Without date of last symptom the return-to-work dates cannot be determined. Example 2 The facility COVID Outbreak Summary for December does not provide accurate information. The COVID end date is inaccurate. Facility identified outbreak being over 12/30/24 with isolation ending. A resident tested positive 12/19/24 and then a staff tested positive 13 days later. Staff continued to test positive from January through April with last staff testing positive on 4/26/24. May 10th would have ended outbreak with no positive tests from 4/26/24 until 5/10/24. Outbreak summary did not include what interventions went into place and when medical director was notified. The outbreak summary did not include when and how residents, staff, and families were notified of outbreak. On 6/13/24 at 9:03AM, Surveyor interviewed DON B (Director of Nursing) and IP G (Infection Preventionist.) Surveyor asked IP G if something I ate, ill, not feeling good, or cold sx are specific sx. IP G indicated no; they could be more specific. Surveyor asked if specific symptoms should be on the staff line lists and IP G indicated yes. Surveyor asked IP G if Date of last symptom dates should be on the line lists and IP G indicated yes, they should be on there to determine the return-to-work dates. Surveyor asked IP G looking at COVID line list and Outbreak Summary if the end date or isolation end date is accurate and IP G confirmed that the outbreak continued into April with last staff testing positive on 4/26/24 and outbreak would have ended May 10th. Surveyor mentioned to IP G Outbreak Summary should include details such as when medical director was notified, interventions put into place and when, and if public health was notified and when.

Based on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a significant change in condition. This occurred for 1 of 17 residents (R46) reviewed for change in condition. R46 had a change in condition on 5/5, 5/26, and 6/10/24 that was not reported to R46's provider timely. This is evidenced by: The facility policy, entitled Physician Notification/Change in Condition dated 1/22/2024, states, in part: Policy: .A change in condition is when there is: .2. A significant change in the resident's physical, mental or psychological status (that is a deterioration in health, mental or psychological status in either life-threatening conditions or clinical complications. 3. A need to alter treatment significantly (that is. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment.Please refer to the attached physician notification parameters tool for more information about falls and other conditions requiring physician notification. Alteration in mental status: Immediate notification-sudden change in mental status: lethargy, loss of consciousness, syncope, vertigo. According to the American Medical Directors Association Acute Change of Condition in Long-Term Care Setting standard of practice. A facility should notify the physician for bleeding the next office day when the bleeding is controlled with no further episodes .Alteration in mental status: sudden notify immediately. R46 was admitted to the facility on [DATE], and has diagnoses that include Non-ST elevation myocardial infarction (a type of heart attack), unspecified diastolic heart failure (heart condition which reduces the amount of blood [NAME] out to the body), venous insufficiency (a condition which decreases the leg veins ability to send blood back to the heart), chronic atrial fibrillation (an irregular and often rapid heart rhythm), and personal history of renal calculi (kidney stones / hard deposits of minerals and salts inside the kidneys). R46's Quarterly Minimum Data Set (MDS) assessment dated [DATE] shows R46 has a Brief Interview of Mental Status (BIMS) score of 6, indicating severe cognitive impairment. R46's progress notes include: 5/5/24 4:57AM- Writer called to room as resident was noted to have frank blood in his pull-up (incontinent brief). Upon further assessment, resident noted to have hematuria (blood in urine) with small amount of blood from penis. No open areas noted. Resident has had this before. Denies any pain/discomfort. Resident is afebrile. Will continue to monitor. No documentation indicating R46's provider was updated. 5/26/2024 4:36 PM- Writer called to resident's room. Resident was sitting on the toilet and CNA was attempting to arouse resident, which was difficult. Vitals were taken at this time and WNL (within normal limits). Staff then transferred resident into bed via golvo lift (mechanical transfer device). RN notified about event and came to unit No documentation indicating R46's provider was updated. 5/26/24 4:51PM- called to unit for resident's unresponsive episode. Resident is seen lying in bed, alert. He does not recall passing out. Resident most likely with vasovagal response (a sudden drop-in heart rate and blood pressure leading to fainting) as he is alert at time of assessment. Pulse is 40, not unusual for this resident .updated provided to dtr (daughter) via phone call. No documentation indicating R46's provider was updated. 6/10/24 9:48PM- writer summoned to resident's bathroom by staff who report bright red blood in resident's urine during his shower. Writer observed and confirmed bright red blood present. Resident denies any s/sx's (signs / symptoms) consistent with UTI (urinary tract infection). Resident is afebrile (free of fever). RN notified. No documentation indicating R46's provider was updated. On 6/13/23 at 9:54 AM, Surveyor interviewed RN E (Registered Nurse). Surveyor asked if a resident is experiencing hematuria (blood in urine) what would be the next steps. RN E stated it would depend on the resident's diagnosis and medications. If there is a large amount of blood or pain or if the bleeding is new the physician should be notified right away or within 24 hours. Surveyor asked if a resident is sitting on the toilet and becomes difficult to arouse, what would be the next steps. RN E stated, call the nurse, sternal rub, if arouses assist to bed or chair, if new condition update physician right away. On 6/13/24 at 10:20 AM, Surveyor interviewed RN H. Surveyor asked if a resident is experiencing hematuria what would be the next steps. RN H stated ensure it is urinary related, not an open area or other symptom, check diagnoses, if new issue update physician. Surveyor asked what is the timing of that update to the physician. RN H stated fairly quickly, if all else is stable (no other signs and symptoms) within 2 hours. Surveyor asked if a resident is difficult to arouse what are the next steps. RN H stated check vital signs, check that all else is normal, check to see if this is something that occurs for this resident, ensure safety, ensure that the resident comes around. If new for the resident, update the physician right away and ask about any additional orders. Surveyor read progress note from 5/25/24 and asked if physician should have been notified. RN H stated this is not a resident that she knows has had incidents in the past and if this is not normal for him the physician should have been notified. He does get diuretics (water pills) twice daily, there are things that we could do right away. RN H stated that she would like to review the resident's chart. At 10:43AM, RN H stated after looking at the chart, I would've updated the physician right away when it happened. He was changed to palliative care on 5/6/24, but there are notes about hematuria, low pulse, poor intake, doc (Physician) should have been updated at that time. There was a progressive change, and he may have needed a change in his orders at that time. On 6/13/24 at 2:40 PM, Surveyor interviewed RN I. Surveyor asked if a resident is experiencing hematuria what are the next steps. RN I stated it depends if it is chronic or acute, if new will contact physician. If chronic, then no need to call unless there is a large amount of blood. Surveyor asked is hematuria a concern for R46. RN I stated I don't recall. If it is new for him there should be a call to the doctor. Surveyor asked if a resident is difficult to arouse what are the next steps. RN I stated it depends on the situation, but an assessment should be done. Surveyor asked if a resident has a vaso-vagal incident should the physician be notified. RN I stated it depends; I wouldn't leave my shift knowing something was off with him. Surveyor asked when the physician might need to be updated in relation to a pulse. RN I stated immediate notification per the facility parameters. On 6/13/24 at 3:15 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked if a resident is having hematuria would you expect staff to notify the physician. DON B stated yes, especially if it is something new. Surveyor asked if a resident is difficult to arouse and staff assess a resident with a vaso-vagal incident would staff be expected to update the physician. DON B stated if it is new, yes.

Based on interview and record review the facility did not ensure prompt resolution of all grievances for 2 of 14 residents (R47 and R32) reviewed for grievances out of a total sample of 17 residents. R47 voiced a grievance/concern to staff and did not receive any follow up on her voiced grievance/concern. R32 voiced a grievance/concern to staff and did not receive any feedback or a resolution to her concern/grievance. Evidenced by: Facility policy, entitled Grievance Policy and Procedure, effective date of 12/11/23, includes, in part: . staff are to ensure the prompt resolution of all grievances regarding the resident's rights. Any person is able to freely voice having a concern or problem with any matter concerning their rights including those with respect to care and treatment . the behavior of staff and other residents, and other concerns regarding their long-term care facility stay. (Facility Name) promotes an environment with the objective that all residents feel comfortable . The party shall provide verbal or in written statement describing his or her grievance/concern to the household Social Services staff, Registered Nurse, or any other staff member with whom he/she feels comfortable . Any household staff member made aware of a grievance/concern will notify the Director of Social Services/Grievance Officer . An investigation will be conducted concerning the grievance and its cause. Within 5 business days, if possible, a resolution to the grievance shall be determined following a review of the investigation results. The party who filed the grievance will then receive a summary of the grievance, findings, conclusion, and any action taken. If the party is still not satisfied with the disposition of the grievance, the party may bring the grievance to the attention of the Administrator and Administrative Team . Example 1 R47 admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 3/14/24 indicates R47 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. On 6/11/24 at 10:59 AM R47 voiced a concern related to the quality of food being served in the facility. R47 indicated she told LPN D (Licensed Practical Nursing) about her concern and she saved some meat to show management. R47 indicated the facility did not follow up with her concern. R47 indicated she feels like it is no use bringing concerns forward if there will not be any follow up. On 6/11/24 at 4:06 PM during an interview LPN D (Licensed Practicing Nurse) indicated R47 reported to her a concern regarding the chicken in her pot pie on 6/1/24. LPN D indicated she did not fill out a grievance, did not start an investigation, and did not meet with R47 related to a resolution to her grievance. LPN D indicated she was not sure if this happened once or if R47 had concerns related to the quality of other foods. LPN D indicated any concern related to residents' stay or care is considered a grievance and she should have followed the facility grievance process. On 6/13/24 at 10:55 AM during an interview SW C (Social Worker) indicated residents can voice concerns to any staff member or can fill out a grievance form. SW C indicated when staff receive concerns, they are to fill out a grievance form and then the Grievance Official will oversee the grievance process and alert all who need to be involved in an investigation. SW C indicated there was not a grievance form with this concern on it and if there was an investigation it would have been completed and a resolution would have been discussed with R47. SW C indicated the facility can't track and trend if grievances are not recorded using the grievance process. On 6/13/24 at 11:17 AM DON B (Director of Nursing) indicated staff need to fill out grievance forms for all resident concerns so the facility can investigate, track, trend, and work out a resolution to the residents' concerns. DON B indicated there are only 3 grievances recorded since January 2024. Example 2 R32 admitted to the facility on [DATE]. Her most recent MDS with ARD of 3/21/24 indicated R32 is cognitively intact with a BIMS score of 15 out of 15. On 6/11/24 at 10:26 AM R32 voiced a concern about CNA F (Certified Nursing Assistant)being grumpy, unfriendly, rough, disrespectful, nasty and was taking it out on R32. R32 indicated CNA F would not assist her with rearranging things in her room because she did not have time. R32 indicated she verbally reported this grievance to RN E (Registered Nurse) and has not heard anything back about the follow up from her concern. R32 indicated this interaction was not nice and made R32 feel like a bother. R32 indicated she relies on staff to meet her daily needs and stated, I'm in a wheelchair so I can't bend over and do some things. On 6/12/24 at 10:44 AM RN E indicated R32 voiced a concern to her regarding CNA F dressing inappropriately and being in her room complaining about being the only staff on the unit, complaining about being underpaid, and complaining about being overworked. RN E indicated CNA F should not be talking like this in a resident room as it can cause a resident to have mental anguish. RN E indicated she was unsure if other residents had concerns related to CNA F. RN E indicated she did not follow the facility's grievance process/policy or the facility's abuse process/policy. RN E indicated she did not think this was an allegation of abuse and should have filled out a grievance form so the facility management team could have investigated this further. Surveyor reviewed CNA F's personnel file and had no concerns with education or with disciplinary actions. On 6/13/24 at 11:17 AM DON B indicated staff need to fill out grievance forms for all resident concerns so the facility can investigate, track, trend, and work out a resolution to the residents' concerns. DON B indicated there are only 3 grievances recorded since January 2024.

Based on observation, interview, and record review, the facility failed to ensure that lab values were monitored according to professional standards of practice for one resident (R8) out of 17 reviewed for professional standards of care. Specifically, the facility failed to properly identify and notify staff of one resident's lab value that differs from the accepted therapeutic range, which has the potential to cause R8 to experience adverse effects from not properly holding or administering the medication. R8 was recommended an INR (international normalized ratio, assesses how fast blood clots) therapeutic range from 1.5 to 2, which was not made readily available to nursing staff to review prior to holding or administering medication. Findings include: The National Library of Medicine's article titled International Normalized Ratio (INR) (2023), indicates: For normal patients who are not on anticoagulation (blood thinning medication), the INR is usually 1.0 regardless of the ISI (international sensitivity index) or the particular performing laboratory. For patients who are on anticoagulant therapy, the therapeutic INR ranges between 2.0 to 3.0. INR levels above 4.9 are considered critical values and increase the risk of bleeding . Complications: INR level below the target range is associated with increased risk of thrombosis (blood clot). Research showed that more than three-fold risk of recurrent venous thromboembolism (blood clot in veins) is associated with the subtherapeutic INR level. On the other hand, INR above the therapeutic range is associated with increased risk of bleeding among which the most concerning condition is an intracranial hemorrhage (brain bleed). Patients can also present with gastrointestinal bleeding (stomach or intestinal bleeding), hematuria (blood in urine) or bleeding from any other site. Review of the facility policy titled Warfarin (Coumadin)(anticoagulant) Therapy last reviewed on 11/23/23 states in part, Policy: All residents receiving Warfarin therapy will receive monitoring per resident observation and INR lab draws as ordered by the physician. Additionally, the policy states, Procedure: 5. Upon received of the results, the nurse will notify the physician/medical provider of INR results less than 2.0 or greater than 3.0 (unless other guidelines have been established by the physician/medical provider) .7. The nurse will notify the physician/medical provider of symptoms of active bleeding. Review of the facility policy titled Physician Orders, Obtaining and Processing last reviewed on 3/18/2024 states in part, Care Plan: 3. Use care to add information/medications/interventions to care plan in appropriate area/problem. Review of the facility policy titled Diagnostic Services last reviewed on 1/20/2023 states in part, Guideline: AMDA- Acute Change of Condition in[sic] the Long-Term Care Setting Clinical Practice Guideline. The policy also states, Procedure: 3. Lab results in the extreme low (XL), panic high (PH) range, or that are positive (See Appendix A-attached) will be reported to the physician promptly, on the same day they are drawn/results obtained. Other results to be reported promptly are . INR/PT (prothrombin time, assesses how fast blood clots) 3 IUs (international units, unit of measurement for INR test) or above (get order to hold warfarin) . 4. INR/PT INR below 3 IUs . Of note: Appendix A lists INR critical high above 6 and no critical low is listed. R8 was admitted to the facility on [DATE] with diagnosis that include in part . Hemiplegia (one-sided paralysis or weakness) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke) affecting left non-dominant side, unspecified fracture of T9-T10 (fracture of vertebra in the spine), paroxysmal atrial fibrillation (uncontrolled irregular heart rhythm), hypertension (high blood pressure), and long-term use of anticoagulants. Review of R8's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/14/2024 indicates R8 has a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicates R8 is cognitively intact. Primary medical condition is listed as stroke with additional diagnosis of hypertension. The High-Risk Drug Classes indicates R8 is receiving an anticoagulant. R8's care plan states, in part, Problem: Alteration in Cardio-respiratory Perfusion/Neurological Status r/t Disease Process- A-fib (atrial fibrillation), HTN (hypertension), Hx (history) of CVA (cerebrovascular accident-stroke) with L (left) hemiparesis/plegia AEB: SOB (shortness of breath) with exertion, edema (swelling), hx long term use anticoagulant . Approach: Monitor for any s/s (signs/symptoms) of active bleeding (blood in stools, epistaxis (bloody nose), bruising). Of note: There is no indication on the care plan specifying R8's INR range. Physician's order dated 3/11/2021, states in part, May HOLD any meds if condition warrants. Physician order dated 3/28/2024, states in part, LABS: INR weekly . warfarin tablet; 1 mg (milligram); amt: 1 tab; oral Special Instructions: give 1 tab PO (by mouth) daily at 1900 (7:00 PM) for anticoagulant. Of note: Physician orders do not indicate R8's INR range. In review of R8's EMAR (electronic medication administration record), the facility administered warfarin as ordered from 5/12/2024 through 6/9/2024. The medication was held (not administered) on 6/10/2024 and 6/11/2024 for an INR of 2.6. In review of R8's progress note dated 6/6/24 at 9:25 AM, [Physician] reviewed INR again from yesterday as [APNP] did review yesterday, with INR being 2.6, no hematuria noted at this time, with no new orders to be given. Progress note dated 6/8/24 at 9:29 PM states, Hematuria noted in urine this evening. Resident offers no c/o (complaint). RN updated, will continue to monitor. Progress notes dated 6/9/24 at 6:33 AM and 10:11 PM state, Moderate hematuria, no c/o pain or discomfort and Resident continues w/ frank blood (bright red blood) in urine. No c/o offered. Progress note dated 6/10/24 at 9:10AM states, MD SEE: [Physician] saw resident for routine see, reviewed physician orders, VS (vital signs), weights, and overall status, note to be dictated when she returns to her office. [Physician] updated on hematuria over the weekend, noting last INR was 2.6, with new order to hold coumadin tonight on 6/10 and to recheck INR on Wednesday. Physician progress note dated 6/10/2024 states R8 has an INR goal between 1.5 and 2. Of note: This note is the only indication, in the paper or electronic record, of R8's recommended INR range. Progress note dated 6/11/24 at 12:45 PM states, [APNP] in house and updated that hematuria continues w/ resident, noting that coumadin (warfarin) was held last night per [Physician] order. New order given today to hold coumadin tonight and wait for INR tomorrow. In review of the R8's paper chart on 6/12/2024 at 2:22 PM, Surveyor located a page titled Temporary Changes/New Problems Log, this sheet was blank upon review. A Physician Order Sheet includes the following orders: 6/10/24-hold coumadin x1 tonight, 6/11/24-hold warfarin today, 6/12/24-hold warfarin tonight 6/12/24, coagulation tomorrow 6/13/24. A sheet titled Anticoagulant/INR Tracking Form was also located with R8's name at the top and three entries, the last being on 8/9/2023. This sheet also contains a note stating, per [Physician]- no spreadsheet needed for INR. Of note: Nothing in the R8's paper chart indicated the resident's INR range. On 6/12/24 at 3:53 PM, Surveyor interviewed RN I (Registered Nurse). Surveyor asked RN I what the process is for notifying a physician after receiving lab results. RN I stated that if the lab value is outside parameters, they scan the results and email them to the nurse practitioner and physician. If RN I doesn't hear anything back within an hour, RN I will call the on-call physician. Surveyor asked RN I what the normal INR range is according to standards of practice. RN I was unsure but reported that R8 is supposed to be on the lower end of the therapeutic range. Surveyor asked RN I where the prescribed therapeutic range for R8 was located. RN I stated that it should be listed in the chart, and that residents will be at different therapeutic ranges depending on why they are taking warfarin. RN I stated that R8 is on brittle warfarin because when she has an INR of two, R8 starts having blood in her urine. Surveyor asked RN I to show them where the ordered therapeutic range can be found in the chart. RN I was unable to locate this information. On 6/12/24 at 3:58 PM, Surveyor interviewed RN J. Surveyor asked RN J what her expectation would be for receiving a lab result outside of expected parameters. RN J states that it depends on the patient. Surveyor asked RN J specifically regarding R8's lab parameters. RN J states that she does better on a low INR and that the physician is aware. RN J also states that R8 is better off when she is below 2 because she ends up with hematuria (blood in urine). RN J also reported that staff have held warfarin for several days due to an INR result of 2.6 and 2.3. Surveyor asked RN J at what level hematuria is likely to occur for R8. RN J states that R8 usually has hematuria with an INR over 2. Surveyor asked RN J how staff track R8's INR range. RN J states that staff keep an INR tracking sheet in the paper chart, but that they are not using that sheet per physician order because the resident doesn't need to be in the normal therapeutic range to avoid hematuria. On 6/12/24 at 4:33 PM, Surveyor interviewed RN I. Surveyor asked RN I if she would expect R8's therapeutic INR range to be recorded in the chart. RN I said yes. Surveyor asked RN I what the process is for holding medications. RN I said this isn't commonly done on their shift, however when the staff RN receives the lab result, if it is out of range, the nurse holds the medication on the EMAR (electronic medication administration record) and notifies the physician. Surveyor asked RN I how they know what to report to the physician if no INR range can be found in R8's chart. RN I reported that they report every INR result or look at the last result to compare. On 6/13/24 at 10:07 AM, Surveyor interviewed RN K. Surveyor asked RN K to show Surveyor where the ordered therapeutic INR range could be found for R8. RN K was unable to locate this information in the paper chart. RN K then looked through the electronic medical record. The only indication of an ordered therapeutic INR range for R8 was located in a physician progress note from 6/10/24, after Surveyors were already in the building and questioning R8's INR range. Previous physician progress note also read from April of 2024 and it did not indicate a therapeutic INR range for R8. RN K stated that there is a policy with a lot of different lab values that specifies when to update the physician. Surveyor referenced this policy previously, and only indicates reporting around the normal INR therapeutic range. On 6/13/24 at 10:55 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B where she would expect to find a resident's ordered INR reference range. DON B states that she would expect to find this information in the physician's orders. Surveyor asked DON B if physician recommendations are considered orders at this facility. DON B indicates that physician recommendations are considered orders. Surveyor asked DON B where she would expect to find a therapeutic INR value if she was unfamiliar with R8 or any other resident. DON B indicated that she would expect to find it on the Anticoagulant/INR Tracking Form and in the care plan. The facility did not ensure that physician's orders for R8's therapeutic lab values were easily accessible and documented for all staff to review as needed in accordance with professional standards of practice.

Based on observation, resident and staff interview, and record review, the facility did not ensure 2 Residents (R)(R209 and R30) of 2 residents reviewed for respiratory care received care consistent with professional standards of practice. R209 and R30's respiratory care equipment was not sanitized and stored in a manner to maintain infection control standards. Findings include: The facility's Oxygen Administration policy, dated 4/19/16, contained the following information: Replace oxygen cannula or mask, humidifier bottle if used, and tubing every 7 days. Obtain a physician's order prescribing a 7 day change, document in the resident's MAR (Medication Administration Record)/TAR (Treatment Administration Record) and date the supplies when changed. Supplies should be changed also when visibly soiled, or when known contamination occurs. The facility's Nursing Services: Nebulizer Care procedure, dated 4/19/16, states supplies should be changed also when known contamination occurs. The procedure instructs staff to clean the mask with soap and warm water for approximately 1 minute or until clean, shake out the mask completely, set the mask on a paper towel to air dry and keep the device in a clean area. 1. On 3/20/23, Surveyor reviewed R209's medical record. R209 was admitted to the facility on [DATE] with diagnoses including acute respiratory disease, viral pneumonia, acute on chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) and chronic obstructive pulmonary disease (COPD). R209 had no cognitive impairment, but required staff assistance for activities of daily living (ADLs). R209's medical record contained a physician order, dated 3/14/23, for Ipratropium-albuterol 0.5 mg (milligrams)-3 mg per nebulizer 4 times daily. On 3/20/23 at 10:38 AM, Surveyor interviewed R209. Surveyor noted a nebulizer (respiratory treatment) device and a mask (placed on the face for the respiratory treatment) on R209's bedside table. The mask was intact (not taken apart) and laying directly on the surface of the table. Surveyor noted a film on the inside of the mask and particles throughout the mask. Surveyor asked R209 if the mask was cleaned after treatments. R209 stated staff turned the machine off and set the mask on the table, but did not observe staff clean the mask. R209's soiled mask was observed numerous times on R209's bedside table in direct contact with the table surface on 3/20/23 and 3/21/23. On 3/21/23 at 11:11 AM, Surveyor interviewed Unit Manager (UM)-C who stated masks should be cleaned when soiled and changed out weekly. UM-C also stated masks should be rinsed after treatments and placed on the resident's vanity to dry. UM-C stated if a resident coughed in a mask, the mask should be cleaned as well. On 3/21/23 at 11:13 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who stated masks are rinsed with soap and water after use and placed on a paper towel to dry. LPN-D verified R209 had a nebulizer treatment that morning. LPN-D stated R209 was busy with therapy and LPN-D did not get to wash R209's mask; however, LPN-D would clean the mask before leaving. LPN-D stated R209 would receive another nebulizer treatment at 1:00 PM. On 3/21/23 at 11:16 AM, Surveyor interviewed UM-E who stated nebulizer masks are taken apart for cleaning, rinsed with water after use, and set on a barrier to dry. UM-E stated each resident should have an order to exchange/clean the mask. On 3/21/23 at 11:19 AM, Surveyor and UM-E entered R209's room. UM-E verified R209's mask was soiled and did not look like it was cleaned. LPN-D replaced R209's mask with a clean mask. On 3/21/23 at 12:51 PM, Surveyor interviewed UM-F who stated R209 did not have a previous order for cleaning/exchanging nebulizer equipment; however, an order was now entered. 2. On 3/20/23, Surveyor reviewed R30's medical record. R30 was last admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure, COPD and pneumonia. R30 had moderate cognitive impairment and required staff assistance for ADLs. On 3/20/23 at 11:20 AM, Surveyor interviewed R30. Surveyor noted a nebulizer machine and mask on R30's bedside table. R30's mask was in direct contact with the surface of the table. R30 stated R30 had a respiratory treatment earlier that day and used the nebulizer machine and mask on the bedside table. Surveyor noted the mask had a film with particles throughout the inside part of the mask that was connected to the nebulizer machine via tubing. Surveyor asked R30 if the mask was cleaned after treatments. R30 stated R30 thought staff probably cleaned the mask. R30's soiled mask was observed numerous times on R30's bedside table in direct contact with the table surface on 3/20/23 and 3/21/23. On 3/21/23 at 11:11 AM, Surveyor interviewed UM-C who stated masks should be cleaned when soiled and changed out weekly. UM-C also stated masks should be rinsed after treatments and placed on the resident's vanity to dry. UM-C stated if a resident coughed in a mask, the mask should be cleaned as well. On 3/21/23 at 11:13 AM, Surveyor interviewed LPN-D who stated masks are rinsed with soap and water after use and placed on a paper towel to dry. On 3/21/23 at 11:16 AM, Surveyor interviewed UM-E who stated nebulizer masks are taken apart for cleaning, rinsed with water after use, and set on a barrier to dry. UM-E stated each resident should have an order to exchange/clean the mask. On 3/21/23 at 11:19 AM, Surveyor and UM-E entered R30's room. UM-E verified R30's mask was soiled and did not look like it was cleaned. LPN-D replaced R30's mask with a clean mask. On 3/21/23 at 12:51 PM, Surveyor interviewed UM-F who stated R30 did not have a previous order for cleaning/exchanging nebulizer equipment; however, an order was now entered.

Based on observation, staff interviews, and record review, the facility did not ensure social distancing practices were followed to help prevent the spread of COVID-19 infection for 6 Residents (R) (R8, R23, R40, R61, R63, and R84) of 19 residents residing on Unit B2. The facility did not incorporate appropriate social distancing practices for R8, R23, R40, R61, R63, and R84 during communal dining or transit through dining areas during mealtime observed on 3/1/21, 3/2/21, and 3/3/21. Findings include: The Centers for Medicare & Medicaid Services (CMS) memo QSO-20-39-NH, dated 9/17/20, states, While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur. Residents may eat in the same room with social distancing (e.g., limited number of people at each table and with at least six feet between each person). The facility policy titled Pandemic COVID-19 Preparedness and Response, dated 3/2/21, documents under the Implementation section, Meals are to be served in small groups with tables distanced at least 6 feet apart when able. On 3/1/21 during initial tour beginning at 9:30 AM, Surveyor noted residents in common areas did not wear face masks. Resident record reviews between 3/1/21 and 3/3/21 verified residents on Unit B2 chose not to wear facemasks. On 3/3/21 at 11:49 AM, Registered Nursing Unit Manager (RUM)-G verified residents on Unit B2 chose not to wear facemasks, and staff should encourage social distancing. On 3/1/21 at 11:42 AM, Surveyor began continuous observation of lunchtime meal service in Unit B2. Unit B2 was divided into two resident room hallways, rooms 201 to 210 (referred to as 210 side) and 211 to 220 (referred to as 220 side). Each resident hallway was connected to a dining area, and the two dining areas were adjoined by an open doorway. Resident dining location was not dependent on room number. Surveyor noted no tables were six feet across, and residents seated in the dining rooms were not spaced at least six feet apart. Surveyors noted Certified Nursing Assistants (CNAs) overseeing the transport of residents into the dining room repeatedly asked or assisted residents to adjust their placement as residents in wheelchairs, utilizing walkers, or ambulating independently were unable to navigate to preferred seating without an obstructed path. Particularly noted on the 210 side: ~R40 was seated directly across from R61 at the kitchen counter ~R63 was seated at a table less than six feet away from R40 ~Three residents including R8, R84, and an unidentified resident were seated together at one table On 3/1/21 at 11:56 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D related to dining room spacing. LPN-D verified that residents should be spaced six feet apart from one another. LPN-D indicated the facility utilized a new dining set-up which went through the facility infection control and prevention process review. LPN-D indicated Unit B2 incorporated a new seating arrangement including placing residents at counters to eat, placing a maximum of two residents at each table, and seating residents across from one another. At this time, Surveyor pointed to 220 side distance between stationary kitchen counter where one unidentified resident was seated and a table where two unidentified residents were seated. LPN-D verified the distance was not appropriate, indicated the table was probably moved due to a bingo activity earlier in the day, and proceeded to relocate the table to allow for appropriate spacing. When R61's meal was completed, R61 attempted to navigate through dining room with R61's electric wheelchair. Surveyor noted R61 was not wearing a mask and was unable to maintain six feet of distance from other residents while attempting to pass through the dining room. R61's path was blocked by diners and dining furniture, and R61 was unable to proceed through the dining area. Staff directed R61 to turn around and use alternate route to exit dining area and return to R61's room. On 3/2/21 at 11:39 AM, Surveyor observed lunchtime meal service. Surveyor noted tables on 220 side were appropriately spaced from when LPN-D moved them on 3/1/21. On the 210 side, residents were seated as follows: ~R40 was seated directly across from R61, within six feet, at the kitchen counter ~R63 was seated at a table less than six feet away from R40 ~R40 shifted R40's chair toward R63's table after finished eating while waiting for staff assistance and remained within approximately three feet of R63 for three minutes. Neither resident wore a mask. On 3/2/21 at 12:47 PM, Surveyor interviewed CNA-I related to spacing of residents in the dining room. CNA-I confirmed with Surveyor that R40 and R61 as well as R40 and R63 were within six feet of one another while eating. CNA-I indicated that residents should be five to six feet apart. CNA-I explained that R40 had to wait for assistance due to both CNAs assisting other residents with dining. CNA-I verified R40 moved even closer to R63 than when they were eating. On 3/3/21 at 11:39 AM, Surveyor observed lunchtime meal service. Surveyor noted R23 and R63's shared table on the 210 side had been moved toward the medication preparation counter, away from the kitchen counter. A bedside table was added next to the kitchen counter. Surveyor observed R23 and R63 seated at the dining room table maskless when R84, also without a mask, walked up to the medication preparation counter to receive medications from LPN-D. Surveyor noted R84 was within six feet of R23 and R63 while LPN-D administered medications to R84. On 3/2/21 at 2:14 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-H. ADON-H indicated unit managers worked with dietary staff and CNAs to develop spacing plans in the dining rooms. ADON-H also indicated that unit managers should be monitoring and observing meals to ensure social distancing is maintained. On 3/3/21 at 11:49 AM, Surveyor interviewed Registered Nursing Unit Manager (RNM)-G. RNM-G explained that staff encourage residents to socially distance and wear masks but staff take into account resident choice, such as the choice not to wear a mask, as well. RNM-G indicated that all residents on Unit B2 were vaccinated but verified that residents still need to keep six feet apart when possible. RNM-G indicated that there is a plan for communal dining, and staff now use the kitchen island counter and bedside tables to accommodate adequate spacing. RNM-G explained that night shift has to move the tables in the dining room to mop underneath. RNM-G further explained that there was no formal process in place to ensure adequate distance between dining stations, but staff should be monitoring to make sure resident dining tables are spaced correctly. RNM-G revealed there were no visual markers utilized to assist staff with this process. RNM-G was not able to articulate preventative measures that were taken to ensure residents' social distanced navigation through the dining room at meal times.

Based on observation and interview, the facility did not date medications when opened in accordance with professional standards of practice to ensure medications were not used beyond the recommended use by dates in 3 of 6 medication carts reviewed. This practice had the potential to affect 5 Residents (R) (R29, R1, R67, R17, and R55). Artificial tears were not dated when opened for 4 residents (R29, R1, R67, R17). R55's [MEDICATION(S)] was not dated when opened. Findings include: 1.On 3/1/2021 at 11:15 AM, during the F2 Hall 1 medication cart review with Licensed Practical Nurse (LPN)-C, the Surveyor observed medications in multi-dose packaging with no dates to identify when the medications had been opened. LPN-C indicated awareness that it is the facility's standard of practice to document open dates on the multi-dose medications. 2.On 2/12/2020 at 4:35 PM, during the A2 Hall 1 medication cart review with LPN-D, the Surveyor observed medications in multi-dose packaging with no dates to identify when the medications had been opened. LPN-D indicated LPN-D was aware that it is the facility's standard of practice to document open dates on the multi-dose medications. 3.On 03/03/21at 8:59 AM, the Surveyor interviewed Director of Nursing (DON)-B. DON-B who indicated staff is aware they should label multiple dose vials on the date they are opened. DON-B provided the medication storage policy as outlined by the facility pharmacy Omnicare. 4. On 3/3/2021 at 7:48 AM, during Hall F2 medication station review with LPN-J, the Surveyor observed several medications in multi-dose packaging with no dates to identify when the medication had been opened. LPN-J indicated LPN-J was aware that it is the facility's standard of practice to document open dates on multi-dose medications. The above observations noted the following medications to be open and undated: Artificial tears for R29, R1, R67, and R17. In addition, [MEDICATION(S)] for R55 was not dated when opened.

Based on observation, staff interview, and record review the facility did not provide special assistive eating equipment for 1 Resident (R)(R63) of 1 sampled residents reviewed for assistive devices. The facility did not provide R63 with a plate guard (device to raise plate edges to prevent spills) as indicated per the functional maintenance plan of care. Findings include: On 3/1/21 to 3/3/21, Surveyor reviewed R63's medical record which documented R63 had a diagnosis of [CONDITION(S)] (a disorder of the central nervous system marked by weakness, numbness, and a loss of muscle coordination). Per Occupational Therapy Functional Maintenance/Restorative Plan for Self-Feeding, dated 3/26/20, Occupational Therapist/Therapy Director (OTD)-F assessed R63 and determined R63 required a plate guard. On 3/2/21 12:16 PM, Surveyor observed Certified Nursing Assistant (CNA)-I approach R63's table, begin to place R63's meal, and verbalize R63's plate guard was missing. CNA-I made a quick search of the kitchenette without success in locating a plate guard and returned to R63's table to serve R63's meal. R63 used utensils to scoop mixed vegetables and, while scooping, inadvertently pushed mixed vegetables off of the plate. Surveyor noted mixed vegetables spilled onto the table, into R63's lap, and onto the floor. On 3/3/21 at 12:03 PM, Surveyor interviewed OTD-F related to R63's plate guard. OTD-F indicated that R63 uses a plate guard to increase intake and that, without a plate guard, it would be harder for R63 to get food onto R63's utensils. OTD-F also indicated to Surveyor that dining may be [NAME] for R63 without a plate guard. OTD-F explained to Surveyor that the expectation would be for CNAs to notify the nurse if a plate guard was not available for a resident. OTD-F also indicated that if no plate guards were available on the unit, staff should contact the therapy department who has extra plate guards available.

Based on observation, interview and record review, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers from developing for 1 of 4 residents (R48) reviewed for pressure injuries (PI). R48 developed PIs to coccyx, left buttocks and bilateral heels. Coccyx wound is currently a stage 3, left buttock wound is currently a stage 2, and bilateral heel wounds are currently unstageable. This is evidenced by: According to the www.npuap.org <http://www.npuap.org> the NPUAP (National Pressure Ulcer Advisory Panel): Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe Moisture Associated Skin Damage (MASD) including Incontinence Associated [MEDICAL CONDITION] (IAD), Intertriginous [MEDICAL CONDITION] (ITD), Medical Adhesive Related Skin Injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole, undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions . Risk factors for heel pressure injuries: Extrinsic factors: pressure, friction, shear. [MEDICATION NAME] Factors: age (decreased cushioning), decreased mobility and activity, malnutrition/dehydration, decreased sensation, decreased L[NAME] (level of consciousness), vascular disease, fragile skin/[MEDICAL CONDITION], underlying comorbidities, contractures and hammocking of mattress . Repositioning for Preventing Heel Pressure Ulcers 1. Ensure that the heels are free of the surface of the bed. Ideally, heels should be free of all pressure - a state sometimes called ' floating heels '. 1.1. Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon . The facilities policy entitled Prevention of Pressure Injuries, with an effective date of 2/9/18, states, in part: Guideline Standard: Facility uses the Pressure Injury Prevention and Treatment Guidelines developed by the European and National Pressure Ulcer Advisory Panel .The RN (Registered Nurse) will complete the risk assessment on re-admission, quarterly and following a major change of condition. The RN will conduct a skin assessment using the Braden Scale .Score of 15-18 is at risk, 13-14 is moderate risk .NOTE: if a resident has other major risk factors such as low [MEDICATION NAME], poor intake, fever, advanced age, diastolic B/P (blood pressure) under 60 mmHg (millimeters of mercury), or hemodynamic instability advance them one score higher than they scored. 3. Factors that contribute to the resident's risk of acquiring a pressure injury will be addressed on an individual basis in the care plan. These may be: Sensory loss, incontinence, degree of activity, physical health status (healthy versus dying state), mobility status, nutritional status, diagnosis, medications, compliance and any factors that may cause friction or shearing of the tissue. 4. In addition to managing the factor addressed in #3, the degree of risk is treated in the following manner: .a) Score or 15-18- interventions should include: frequent turning and positioning (approximately every 2 hours or more often depending on individual needs), facilitation of maximum mobilization, protection/floating of the heels, management of moisture/friction/shear, pressure-reduction support surface if bed or chair bound . The facility uses a REST-Q mattress as their standard mattress. The mattress is rated for PIs up to Stage 4. The facility provided a video (https://www.comfortexinc.com/rest-q-video/) from the manufacture Comfortex on the REST-Q for Surveyor to review which indicated, the bed doesn't treat wounds, you do, turning and repositioning is required even while on the mattress. According to (YEAR) National Pressure Ulcer Advisory Panel < www.npuap.org> A Kennedy Terminal Ulcer has the following characteristics: 1. Shaped like a pear, 2. Always on the coccyx or sacrum, 3. Red, yellow and black, 4. Sudden onset, 5. Death is imminent. R48 admitted to the facility in (YEAR). R48 has the following Diagnoses: [REDACTED]. R48's skin risk assessment with Braden Scale, dated 12/12/18, indicated R48 scored an 18, indicating R48 was at risk. This assessment documents, in part: .no pressure injuries .[MEDICAL CONDITION] .Resident has 1+ [MEDICAL CONDITION] to bilateral lower legs and feet . R48's Physician order [REDACTED].cushion with Dycem in w/c (wheelchair) or recliner when on pass, .reposition approximately every 2 hours when in bed for comfort, S/P (supra-pubic) catheter, . VasCura stocking thigh length . On 1/18/19, the facility obtained orders to start comfort care/palliative care with no further hospitalization s. R48 had a decline in health status at this time. There is no documentation that a skin assessment with Braden Scale was done at this time of decline, as it states in the facilities policy. The facility failed to implement an intervention at this time to prevent potential skin integrity impairment. On 1/20/19, the facility completed a Safety Event that documents, in part: .Description: Pressure injuries .Type of injury: other- blister to each heel, purple area to buttock, Describe the event: LPN (Licensed Practical Nurse) in room to change dressing to coccyx. Noted purple area to left buttock. Also noted, intact fluid filled blister to each heel. Resident had been sitting up in bed at about 60 degree angle with nothing under heels .Interventions already in place: pressure relieving mattress. Avoid shearing resident's skin during positioning, transferring, and turning .Cause: Likely related to pressure due to decreased mobility since recent acute illness . There is no documentation that a skin assessment with Braden Scale was done at this time of identifying R48 has developed multiple PIs as it states in the facilities policy. (It is important to note that R48 already had a skin concern to the coccyx at the time the PIs to left buttock and heels were discovered.) (Of note, the head of the bed (HOB) being greater than 30 degrees increases the risk for shearing/friction, which is a key component of PI development.) R48's skin risk assessment with Braden Scale, dated 1/25/19, indicated R48 scored a 14, indicating R48 was at moderate risk. This assessment documents, in part: .maceration to coccyx .maceration .maceration noted to buttocks with skin peeling/rubbing off measuring 3.6 cm (centimeters) x 1.2 cm linear in shape, no S/S (signs or symptoms) of infection, no depth, areas cleansed with foam dressing applied to cover . R48's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date), of 6/21/18, has a CAA (Care Area Assessment) that indicates R48 requires extensive assistance, has bed mobility problem and is at risk of developing pressure ulcers. Extrinsic risk factors: requires staff assistance to move sufficiently to relieve pressure over any one site, confined to a bed or chair all or most of the time, needs special mattress or seat cushion to reduce or relieve pressure, and requires regular schedule of turning. [MEDICATION NAME] risk factors: incontinence. Treatments and other factors that cause complications: functional limitation in range of motion and devices that can cause pressure, such as oxygen or indwelling catheter tubing, TED hose, casts, or splints. Care plan consideration: will proceed to care plan with any current treatments, preventative measures, close monitoring of skin. (It is important to note that R48 did not have a skin care plan in place prior to 1/20/19.) R48's Comprehensive Care Plan Skin, dated 1/20/19, states, in part: Resident has altered skin integrity r/t (related to) decreased mobility, due to disease process AEB (as evidenced by): stage two PI to (L) (left) heel, Stage III PI to (R) (right) heel, stage III PI to coccyx, mobility deficit, requires assist to reposition, chronic pain to back. Approaches, dated 1/20/19, as follows: use moisture barrier product to perineal area, use heel manager to relieve pressure on the heels, use cushion for pressure reduction when resident is in chair, skin treatment as ordered, monitor wound for healing progress and for S/S infectious process, monitor skin closely for any S/S irritation or breakdown, encourage head of bed to be less than 30 degrees, closely inspect resident skin with all cares, transfers, body pillow to assist with positioning, heel manger to keep heels free floating, reposition q (every) 1-2 hours, encourage to keep HOB (head of bed) less than 30 degrees, avoid friction and shearing forces during transfers or position changes, and assist with routine repositioning. Approaches, dated 2/2019, as follows: heel off-loading shoes for transfers and air mattress. Approach, dated 2/22/19, is as follows: Resident to be up only for meals. Nurse's Note, dated 02/14/2019 03:51,Blisters on heels now appear to have turned into blood blisters. The blisters have deflated and are noted to be dark red to dark purple in color. Heels elevated on heel lift pillow to avoid friction and feet are open to air. Nurse's Note, dated 02/16/2019 11:05, Writer called hospital for on-call MD (Medical Doctor) to review macerated areas to buttocks, Dr. called back and was updated on areas with new order for coccyx region using [MEDICATION NAME] moistened and cover with foam dressing daily and to left buttocks to apply DABT (double antibiotic) ointment and cover with foam dressing QOD (every other day). Writer did fax this information to Dr. Nurse's Note, dated 02/20/2019 12:44, It is noted that resident often refuses to lay from side to side in bed to alleviate pressure to coccyx maceration wound, resident educated on the benefits of laying side to side, stating that (R48) doesn't like to lay that way. Resident continues to use heel manager and is compliant with this. Resident educated on the benefits of using an air mattress to assist with coccyx wound, and in agreement with this plan. Dr. updated with new order for air mattress. It is also noted that resident continues to transfer with EZ stand and is now using heel offloading shoes with transfers to alleviate pressure from bilateral heels. Heels are closed with no s/s of infection. Continues to be re-positioned Q 1-2 hours while in bed and (R48) is up for meals only. New order received today from Dr. for Juven to increase protein for active wound healing, resident prefers not to eat a regular breakfast with the exception of an English muffin and Nutella. (R48) requests salads at mealtimes, as resident does not like to eat meats. Dietary Note, dated 02/22/2019 08:37, Nutrition MDS (Minimum Data Set) Change of Condition assessment. Resident is palliative care. Diet: General, high fiber with power pudding at breakfast, small portions at lunch and supper, offer HS (hour of sleep) snack. medications: [REDACTED]#, 10/7/18: 148.8#, 9/9/18: 154.4#. Weight down 29.6# over the last 6 months or 19% (percent) weight loss. Resident with overall health decline per Progress Notes. Noted to have antibiotics for UTI (urinary tract infection) in January. Please see Progress Notes. Resident with variable intake, generally refuses lunch, intakes better at breakfast. Labs: 1/18/19: Na (sodium): 141 wnl (within normal limits, K (potassium): 5.4 high, BUN (Blood Urea Nitrogen): 24 high, Creatinine: 1.3 wnl, Glucose: 110 high. Resident with continued preferences for no milk, no bread/pancakes, no cereal, no eggs. Likes lunch offered at supper. Daily Likes: a special chef salad with no cheese or eggs and (spouse) provides (R48) preferred salad dressing. Also enjoys soup and an English muffin at supper daily. Resident with coccyx maceration and wounds to bilateral heel. Sent referral to nursing to receive supplements: Juven BID (twice a day), MVI (multivitamins) with minerals, as well as nutrition supplement TID (three times a day). Will monitor for MD Order and update care plan as needed. Nurse's Note, dated 02/22/2019 13:17, Upon assessment to coccyx macerated area, it was noted today that this wound has slough within wound with dark brown discoloration within wound as well. This area has now been determined to be a stage 3 pressure ulcer. Resident using an air mattress which (R48) states (R48) is getting used to and in agreement with this at this time. Education given today on the importance of re-positioning from side-to-side using body pillow and regular pillows to assist with this positioning. Resident continues to use heel manager and prefers to use personal small pillow to place between bilateral lower legs to assist in positioning as lower legs tend to want to lean on each other. Offloading heel shoes are used with positioning, as (R48) uses the EZ stand for transfers. (R48) is up for meals only. Resident chooses to only eat an English muffin and Nutella for breakfast and often refuses to eat lunch. If (R48) does eat lunch it is usually 25-50%. Dinners are noted to have a slightly increased intake of 26-50 or 51-75%. Education given to resident for appropriate nutrition along with re-positioning benefits, and resident stated understanding, but is choosing to keep oral intake as it is. Staff to continue to re-positioning Q 1-2 hours and to offer education as well. R48's (MONTH) Physician order [REDACTED]. On 2/21/19 at 10:40 AM, Surveyor interviewed R48. Surveyor asked if R48 had any pain. R48 stated I always have pain in my back, I have rods and plates in there but now I have these sores on my butt and they are painful. Surveyor asked R48 how long the sores on the butt have been there, R48 said I'm not sure exactly but they are pretty new, there's some on my heels too. Surveyor asked R48 if the sores on the heels are painful too, R48 said no, not really. On 2/26/19 at 8:56 AM, Surveyor observed LPN C complete R48's wound treatment to coccyx and left buttock. Surveyor observed the wound to R48's coccyx, noting the left upper corner to have brown slough present, entire right side and underneath brown slough to have yellow slough, and outer perimeter of wound to have pink granulation tissue present, and wound bed is noted to be almost rectangular in shape (left to right). Surveyor observed wound to R48's left buttock to be circular in shape and pink granulation tissue present. LPN C commented that wound to left buttock this looks great. Surveyor interviewed LPN C and asked if R48 had a treatment to the heel wounds, LPN C said we are just monitoring heels. Surveyor then requested to see each heel. Surveyor observed right heel noting hard black and tan eschar to medial and posterior aspect of heel. Surveyor then observed left heel noting hard lighter black in color eschar to lateral aspect of heel. On 2/26/19 at 1:10 PM, Surveyor interviewed RN UM D (Registered Nurse Unit Manager). Surveyor asked RN UM D when R48 received the Tri-cell air mattress that is on the bed now. RN UM D said the air mattress was applied recently. Surveyor asked RN UM D to explain how the coccyx wound started. RN UM D explained the coccyx wound began as a macerated area. Surveyor asked RN UM D what preventative measure R48 had in place prior to developing the pressure injuries to coccyx and heels. RN UM stated R48 was on a turning program, had a cushion in w/c (wheelchair) and recliner, and the purple REST-Q mattress. Surveyor asked if RN UM D knew the specs of the REST-Q mattress. RN UM D thought that mattress was good for up to stage 4 wounds. On 2/26/19 at 1:50 PM, Surveyor interviewed CNA [NAME] (Certified Nursing Assistant). Surveyor asked what shift CNA [NAME] normally works, CNA [NAME] said AM shift. Surveyor asked CNA [NAME] what skin interventions R48 had in place prior to developing the PIs to coccyx and bilateral heels. CNA [NAME] explained that R48 was usually up for breakfast, then in recliner, alternating with time spent in the w/c, R48 was repositioned every 2 hours, R48 often declined lunch and was in bed at that time, R48 had therapy a couple times per week (was unsure to the type of therapy), and R48 used a cushion in the w/c and recliner. Surveyor asked CNA [NAME] what type of cushion it was. CNA [NAME] said it was possibly a ROHO. Surveyor asked CNA [NAME] if R48 was agreeable to these interventions, CNA [NAME] said R48 was compliant. On 2/26/19 at 1:55 PM, Surveyor interviewed CNA F. Surveyor asked what shift CNA F normally works, CNA F said AM shift. Surveyor asked CNA F what skin interventions R48 had in place prior to developing the PIs to coccyx and bilateral heels. CNA F explained R48 pivot transferred into the recliner, R48 was repositioned every 2 hours with weight shifting when toileted, R48 never ate lunch, R48's spouse and son took resident to the lobby in the w/c, and R48 used a black cushion in the w/c and the recliner, approximately.2 inches thick. Surveyor asked CNA F if R48 was agreeable to these interventions. CNA F stated R48 would occasionally refuse to use the cushion and, in the past, declined using pillows to prop side-to-side, but has become more compliant since acquiring the PIs. On 2/26/19 at 2:00 PM, Surveyor interviewed CNA G. Surveyor asked what shift CNA G normally works, CNA G said PM shift. Surveyor asked CNA G what skin interventions R48 had in place prior to developing the PIs to coccyx and bilateral heels. CNA G explained R48 was up in the recliner with a ROHO cushion, R48 stayed in room, and R48 was assisted to bed at 9 PM. Surveyor asked CNA G if R48 was agreeable to these interventions. CNA G said R48 would request that a pillow be placed between feet and sometimes R48 would allow staff to place the pillow under feet. On 2/26/19 at 2:05 PM, Surveyor interviewed CNA H. Surveyor asked what shift CNA H normally works, CNA H said PM shift. Surveyor asked CNA H what skin interventions R48 had in place prior to developing the PIs to coccyx and bilateral heels. CNA H floats Unit to Unit and did not care for R48 very often. Surveyor asked if CNA H knew anything about R48's care, CNA H said R48 sat in the recliner and ate in room. On 2/26/19 at 4:40 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B to see R48's Skin Care Plan prior to development of the PIs. DON B said R48 did not have a Skin Care Plan prior, R48 was up and stable then. Surveyor asked DON B if R48 was turned and repositioned prior to the development of the PIs. DON B said R48 was in bed, in wheelchair, in recliner, and able to assist in repositioning self. Surveyor asked DON B when R48 was in bed, was R48 repositioned; DON B said when R48 would let them. Surveyor asked DON B if a risk versus benefit conversation was had with R48 to explain what could happen if repositioning was not done. DON B said the staff talked to R48 about it on many occasions. (It is important to note that the documentation reviewed on many occasions encourages R48 to be repositioned, but does not explain to R48 what the consequences of not being repositioned are.) Surveyor asked DON B if anyone explained to R48 what the consequences could be from not being repositioned, DON B stated, well that's what they meant. On 2/26/19 at 5:23 PM, Surveyor interviewed DON B. Surveyor asked DON B what guideline they use for PIs, DON B stated NPUAP. Surveyor asked DON B what the NPUAP guideline recommends for heels. DON B stated she wasn't sure exactly, but could bring a copy of NPUAP to see. DON B gave Surveyor Heel Pressure Ulcers: 2014 International Pressure Ulcer Prevention and Treatment Guidelines. Surveyor asked DON B why she felt the REST-Q mattress did not work to prevent R48's PIs to bilateral heels, DON B stated, I have no clue how it happened. Surveyor asked DON B if the facility has a Wound Care Certified Nurse. DON B said their previous DON was, but right now they do not have a Wound Care Certified Nurse. On 2/27/19 at 10:15 AM, Surveyor interviewed RM I (Regional Manager of Comfortex (Comfortex is the company that makes the REST-Q mattress)). Surveyor asked RM I if the REST-Q mattress would prevent or treat PIs. RM I stated the REST-Q mattress is designed to be a tool, not the answer for prevention or treatment of [REDACTED]. Surveyor asked RM I what the recommendation would be for a resident that has had a Change of Condition. RM I stated frequent repositioning and a bath blanket or towel mid-calf, between bed frame and mattress, helps to offset pressure. Surveyor asked RM I what the recommendation would be for a resident that may sweat or be incontinent. RM I said the key is to be clean, have anything soiled removed, and diligence of linen being dry. Surveyor asked RM I if the REST-Q mattress has any wicking properties to it. RM I stated no, the cover protects the core of mattress. R48 developed avoidable PIs to the coccyx, left buttocks and bilateral heels. R48 was identified as at risk for PI development; however, did not have a care plan in place for this concern. R48 had a decline in condition. The facility failed to re-assess and implement interventions to prevent PI development.

Based on interview, medical record review, facility documentation review, and policy review, the facility did not provide assistive devices, supervision, and care according to resident care plans in a manner to prevent accidents and injury for 1 of 12 residents (R7) reviewed for falls and accidents, out of a total sample of 24. R7 had a fall from bed on 10/05/17, where R7's care plan was not followed. R7 was to have fall prevention measures of a mat on the floor next to the bed and the bed is to be in the lowest position. R7's 15 minute check sheet was filled out for over an hour without those interventions being in place. On 10/07/17, R7 fell from her wheelchair. The facility did not thoroughly investigate this fall to determine when R7 had last been toileted or checked and changed prior to the fall. The facility did not identify if R7's care plan had been followed. R7 was incontinent of feces at the time of this fall. On 10/09/17 at 7:30 PM, R7 was found to have a 10 cm (centimeter) by 14 cm bruise on her inner right thigh. When the nurse interviewed staff if they were aware of the cause of the bruise, it was learned a CNA (Certified Nursing Assistant) transferred R7 alone. R7's care plan directed R7 to be transferred with assistance of two staff. Also, R7 had not been toileted or checked and changed for four hours between the time the CNA transferred R7 to her wheelchair, at approximately 3:15-3:30 PM, and when R7 was laid down for bed at 7:30 PM. On 10/10/17 R7 was diagnosed with [REDACTED]. The facility was aware staff did not follow R7's care plan on three occasions within five days of the hip fracture being diagnosed . The facility did not educate all nursing staff on the importance of following R7's care plan and the care plans for all residents. This is evidenced by: R7 has [DIAGNOSES REDACTED]. R7's MDS (Minimum Data Set) assessment, dated 10/02/17, identified R7 requires extensive assistance of two staff for transfers. 10/05/17 Fall: During review of R7's medical record, Surveyor read Nursing Progress Notes, dated 10/05/17, which identified that R7 rolled out of bed, had a fall from bed on 10/05/17 at 2:45 PM. No apparent injury noted at the time of the fall. A 10/05/17 4:51 PM note read, in part: bed was not in lowest position and mat not on floor. These were two fall interventions on R7's care plan that were not followed at the time of this fall. The note included: Re-educated staff on following resident care plan. The documentation in R7's medical record, regarding R7's fall from bed on 10/05/17, does not identify how resident was positioned on the floor when R7 was found on the floor. During an interview with RN E (Registered Nurse) on 10/08/17, beginning at approximately 2:00 PM, RN E told Surveyor R7 was found lying on her left side on the floor. RN E verified R7's mat was not on the floor by her bed and her bed had not been in the lowest position. Surveyor asked RN E if she educated staff regarding R7's fall interventions not being in place. RN E stated she educated CNA I, who was the only aide on PM shift at the time, when R7 was found on the floor. RN E stated she wrote an educational form out for CNA H; the CNA who had laid R7 down on the day shift. Facility documentation identified CNA H, who laid R7 down on the day shift, was educated regarding following resident's plan of care. CNA H was also educated regarding documenting, on the 15 minute check sheets, that R7 had been checked on without the interventions in place. RN E explained the day CNAs and the evening shift CNAs are to do a walk through together and give report. RN E said that apparently didn't happen because PM shift CNA had not seen R7 yet before the fall. 10/07/17 Fall: A Nursing Progress Note, dated10/07/17 at 2:42 PM, identified R7 slid out of her wheelchair. A staff witnessed R7 on the edge of her wheelchair seat, sliding off, but could not get to R7 in time to prevent the fall. No apparent injury was noted. It was identified R7 was incontinent of feces at the time of this fall. The facility documentation does not identify the time R7 had last been toileted or checked and changed. R7's care plan at that time read R7 was on a Dignity changing schedule r/t (related to) inability to participate in toileting schedule. R7's care plan did not identify when the changing was to occur. The facility documentation does not identify what R7 was wearing on her feet at the time of the fall or what she was sitting on in her wheelchair. The facility did not thoroughly investigate to determine these factors as part of the root cause analysis of this fall to prevent future falls. During an interview with RN C on 11/08/17, Surveyor asked how staff is to know when R7 should be checked for incontinence and changed. Surveyor was told it was according to the Dignity Toileting policy. Surveyor reviewed the facility's policy and procedure titled Toilet Programs for Incontinence, with the effective date of 02/20/17, and identified the policy, read, in part: e. Dignity Maintenance: Residents who have neither the physical nor mental ability to maintain continence are placed on a routine pattern of care to maintain their personal dignity. This requires staff to provide the total care needed to maintain cleanliness and preserve the skin tissue. (This policy does not identify the frequency in which residents on this program are to be toileted or checked for incontinence and changed.) During an interview on 11/09/17, Surveyor asked the DON (Director of Nursing) for further clarification about when a resident, who is on the Dignity Toileting plan, should be checked and changed. The DON stated it is individualized. Surveyor asked should R7 have been checked and changed between 3:30 PM and 7:30 PM. The DON said, Yes. On 11/09/17, Surveyor was provided with a Nursing Progress Note for R7, dated 10/03/17. The note, read, in part: PROGRAMS: toileting maintenance program, upon rising, after meals, at HS (hour of sleep) and prn (as needed) upon request/need pads and briefs are used. (This information was not included on R7's care plan at the time of R7's 10/07/17 fall. R7's care plan updated 11/02/17, now identifies dignity changing program every 2 hours.) On 11/13/17, Surveyor received additional information from the DON and RN C. This document identifies RN C interviewed seven regular CNAs regarding what R7's routine for dignity check and change is (after the surveyors left the building). It reads, in part: After lunch, resident checked and changed PRN (if soiled) and lay down between 1300 (1:00 PM) and 1345 (1:45 PM). Again, if resident does not lie down, check and change still occurs along with repositioning in w/c (wheelchair) at this time. (This information does not identify the specific times when R7 was checked and changed on 10/07/17 prior to the fall.) 10/09/17 Bruise Found: On 10/09/17 at 7:30 PM, R7 was found to have a 10 cm by 14 cm bruise to her right inner thigh. Staff identified the bruise lined up with where R7 holds her hands with her splints on. Surveyor interviewed several staff and they related R7 is known to sit with her legs crossed and her hand with her splint on/by her inner thigh. (Surveyor reviewed R7's Nursing Progress Notes dating back to 07/01/17 and did not find any documentation of R7 having a bruise in this area previously. The bruising in this area was new for R7.) On 11/08/17, starting at 3:07 PM, Surveyor interviewed LPN G (Licensed Practical Nurse), the nurse on duty, on 10/09/17, when R7's right inner thigh bruise was found. LPN G stated the CNA reported the bruise to her at 7:30 PM on 10/09/17. LPN G stated she went right away and looked at the bruise. LPN G stated she was pretty surprised by the bruise. Surveyor asked why she was surprised. LPN G said the size and the fact that it was toward the end of the shift and that was the first time anyone had seen it. Surveyor asked LPN G if she had interviewed the CNAs on that evening regarding the possible cause of the bruise. LPN G said she spoke with the CNAs and in doing so, LPN G learned CNA J had transferred R7 alone and did not follow R7's care plan, which directed R7 to be transferred with the assistance of two staff. CNA J transferred R7 alone using the gait belt and a pivot transfer. LPN G told Surveyor CNA J had said everything went just fine with the transfer. LPN G was asked if she had asked CNA J if he had seen any bruising on R7's right inner thigh, when he did cares, and got her up before supper. LPN G said CNA J had said the bruising was definitely not there when he got her up. LPN G shared with Surveyor, through speaking with the CNAs on duty the evening shift of 10/09/17, it was learned that none of the CNAs had toileted or checked and changed R7 from the time CNA J had gotten her up, around 3:15-3:30 PM, until R7 was laid down at 7:30 PM. Approximately four hours had elapsed between R7 receiving cares. Surveyor asked LPN G if she had done range of motion to R7's right leg at the time the bruise was found on 10/09/17. LPN G said she did not, but when RN K checked her, RN K moved her leg and did abducting and bent her knees. LPN G said R7 didn't show signs or symptoms of pain then. On 11/08/17, beginning at 4:08 PM, Surveyor interviewed CNA J regarding R7's bruise on her right leg and the right hip fracture diagnosed on [DATE]. CNA J said R7 had been incontinent and he completed incontinence care for R7 before getting her up. CNA J said R7 was cooperative with cares. Surveyor asked CNA J if he saw any redness or bruising at that time on R7's inner right leg. CNA J said he didn't see anything then. CNA J stated he did see it later and that it would have been hard to miss. Surveyor asked CNA J to describe how he transferred R7 that afternoon. CNA J said he got R7 up on 10/09/17 around 3:15-3:30 PM. CNA J said he used a gait belt and did a pivot transfer with R7 from her bed to her wheelchair. CNA J verified he did transfer R7 by himself. Surveyor asked CNA J if R7 exhibited any signs of pain during cares and the transfer such as moaning, groaning or facial grimacing. CNA J said R7 made her normal sounds, not anything that would throw a flag. Surveyor asked CNA J how many staff were to assist R7 with transferring. CNA J said two. I didn't know at the time. I was recently trained for transfer with two but some girls tell him they do it with one. CNA J stated he was trained that night. Surveyor asked CNA J where he can find how a resident is to be transferred. CNA J said it is on their care sheet. CNA J was asked if he had a care sheet for R7 that day. CNA J said yes, for everyone in the household. Surveyor asked CNA J if he looked at R7's care sheet to see how she is to be transferred. CNA J said not that day. Surveyor asked CNA J if he had toileted/checked/changed R7 between the time he got her up and when the other CNAs assisted her to bed and found the bruise. CNA J said he did not. Surveyor shared with CNA J it was learned no one had done cares for R7 between the times he had gotten R7 up and when she was assisted to bed at 7:30 PM. CNA J said the fault lies with all of us. Surveyor identified there was no documentation in R7's medical record by RN K regarding an assessment by this RN. On 11/09/17, at approximately 1:00 PM, Surveyor interviewed RN K by phone and asked RN K if she had done an assessment for R7 on 10/09/17, after the bruise was found. RN K said she did. RN K was asked if she had done any further assessment of range of motion to R7's hips and knees. RN K said she did not as (R7) was in bed and appeared to be comfortable. Surveyor asked RN K if she documented her assessment anywhere. RN K said she did not remember; it was a long night. RN K was asked if she had notified a physician related to the bruise on R7's right inner thigh. RN K said I don't think I did. Surveyor asked RN K if she had known R7 to have bruising on her inner legs previously. RN K said no. RN K was asked if she had considered the area of bruising on R7's inner right thigh an injury of unknown origin or possible abuse. RN K said no, I did not think of that. RN K was asked if she had been made aware the evening of 10/09/17, that CNA J had transferred R7 not according to R7's care plan. RN K said she was not aware of that. RN K said she did not consider it possible abuse because she was aware R7 had the two previous falls. RN K stated after she learned R7 had the fracture that she probably had a hairline fracture from one of the falls that allowed her to be at baseline and then something happened that displaced the fracture. A Nursing Progress Note, on 10/10/17 at 2:46 AM, written by LPN L read: bruise remain (sic) to right inner thigh, no indication of discomfort, resting well in bed. (During review of R7's medical record documentation for 10/09/17, Surveyor identified RN F had not documented her assessment of R7's bruise or right leg on 10/09/17.) RN F documented, on 10/10/17 at 8:11 AM, No s/sx of infection noted to bruised area to right thigh. No swelling noted. Resident showing no s/sx of pain or discomfort. ROM (range of motion) is (sic) right leg is wnl (within normal limits) for this resident. (This note did not identify the time RN F had completed her assessment of R7's bruise and R7's right leg range of motion.) RN F worked the night shift of 10/09/17 to the morning of 10/10/17. During a phone interview with RN F, on 10/09/17 at approximately 3:15 PM, Surveyor asked RN F what time she had come on duty on 10/09/17. RN F said she came on at 6:00 PM and worked on the third floor initially. RN F stated LPN G and RN K told her about the bruise on R7's leg. RN F was asked if she went and assessed R7. RN F said she did after she finished up passing meds on third floor. Surveyor asked RN F if she knew what time she did that assessment. Surveyor explained the concern that her Nursing Note does not identify the time of the assessment being done, as her note was charted at 8:11 AM on 10/10/17. RN F said she understood the concern. RN F said she assessed R7's leg sometime between 8:00 PM and 12:00 midnight. RN F said she touched R7's thigh and hip area and lifted R7's leg up and down and to the left and right and she didn't wince. RN F stated R7 acted normal for her. CNAs didn't report pain with repositioning that night. On 10/10/17 at 12:37 AM, Nursing Progress Note by RN C read: AM FOLLOW UP: r/t recent roll out of bed and slide out of chair. Per staff, resident not participating in ambulation program today as resident is not bearing wt (weight) to R (right) leg. Per C.N.A. (initials) resident ambulated per her baseline 10/9/17. Resident was seen not wanting to bear wt. during ambulation attempt. However, resident is able to lift bilateral legs off the floor without assist. No lengthening or shortening noted to bilateral extremities, no rotation noted. Resident tolerated writer to manipulate bilateral lower extremities to abduction and adduction without grimace or s/s of pain, no yelling out. Transfers per baseline. No grimace with palpation to bilateral legs/thighs. No bruising noted to R hip, no swelling. Staff to continue to monitor as needed. At 12:52 PM, RN C added, Bruise remains to R inner thigh per I&A (incident and accident). At 1:45 PM on 10/10/17, RN C charted, Resident now seen laying in bed, bruise to R inner thigh a deep purple with lighter purple pink surrounding. Resident noted to move bilateral legs on her own, however, will not adduct R leg per her usual (resident with strong Hx (history) of crossing R leg over left). R leg noted shorter now that resident is laying flat on her back in bed with both legs fully extended. Resident shows no s/s of pain with manipulation, no grimace. Does appear timid with movement. Writer will call to update M.D. (medical doctor). RN C's next note, at 2:59 PM on 10/10/17, identified R7's physician was notified and an x-ray of R7's right hip, femur and pelvis was ordered. A Progress Note by RN E, on 10/10/17 at 8:10 PM, read in part: (Dr. Name) notified of x-ray results stating Acute femoral neck fracture. MD stating that it would be okay to have resident sent out for evaluation of fracture if husband would like . On 11/08/17 at 11:00 AM, Surveyor met with RN C and requested the facility's investigations and any documentation related to R7's falls on 10/05/17 and 10/07/17, the bruise found on 10/09/17, and the right hip fracture diagnosed on [DATE]. Surveyor also requested evidence of education completed with staff related to following resident care plans for fall prevention measures and transfers. On 11/09/17, Surveyor was provided with evidence that CNA H, I and J were re-educated. (Surveyor was initially told that all staff was educated through team meetings. When Surveyor asked for verification of this training, Surveyor was given a copy of the Household Meeting Minutes, dated 10/12/17, with an entry under Topic of Discussion that read: Be sure we are following the entire care plan. Be sure we carry our care sheets. Print them daily. (This document did not identify which household it was for or any specific information related to fall prevention measures or transferring. This document was signed by 11 staff. There were no titles of the staff identified or dates by the staff names to identify when they received this information.) Another Household Meeting Minutes sheet, dated 10/24/17, identified it was for area AB2 and this read: (R7's initials) repo frequent off of R hip, use caution when turning. And Now @ (Name of Hosp (hospital)). A second page of this document that was undated read: Read & carry hall sheets - If corrections are needed let (name) know. *Follow care plans*. (There were no staff signatures on the second page. This information did not identify staff were educated regarding following resident care plans specifically related to fall prevention interventions and transferring residents. This sheet was signed by 13 staff. There were no dates by the staff names. Surveyor identified, from the employee list, approximately 150 nursing staff that work in resident households. This is not counting agency staff that may work with the residents.) During an interview, on 11/09/17 at 4:10 PM, Surveyor asked how staff ,who were not on duty at the time the team meetings were held, were provided with education regarding following resident care plans. ADON D (Assistant Director of Nursing) said staff is expected to go back and read the minutes when they come to work next. Surveyor said, since there are no dates by the staff signatures, how do you know when the staff received the education. ADON D said she doesn't get the household meeting minutes till the end of the month. Surveyor asked how they ensure that every pertinent staff receives the education. ADON D said when they have all the signatures. Surveyor asked does someone track if staff received the education. ADON D said no one monitors the binders for that. Surveyor asked if all nursing staff, for all households, were trained/educated on following resident care plans after the incidents with R7 were identified. ADON D said no. The facilty failed to follow R7's care plan on 10/5/17 by not putting a matt on the floor next to her bed and put bed in owest position to prevent injuries and she fell out of bed, on 10/7/17 failed to thouroughlly investigate a fall out of the wheel chair to determine if the care plan was followed or to determine the root cause to prevent future falls. In addition, on 10/9/17 when a large bruise was found on R7's inner thigh area and an investigation ensued it was determined that prior to finding the bruise a CNA transfered R7 with one staff pivot transfer and not 2 staff as her care plan states. On 10/10/17 R7 was found with a fractured hip.

Based on observation, interview, and record review, the facility did not ensure that all alleged violations involving mistreatment, neglect, or abuse are reported immediately to the administrator of the facility and to other officials in accordance with state law through established procedures including the State survey and certification agency. The facility did not have evidence that all alleged violations are thoroughly investigated and further abuse was prevented while the investigation was in progress. The results of the investigation were not reported to state officials within 5 working days of the incident and corrective action taken for 1 of 1 sampled (R1 (Residents)). This had the potential to effect 34 of 122 residents. R1 was upset because he felt CNA G (Certified Nursing Assistant) was scolding him and was rough with him. The allegation was not fully investigated, nor was it reported within 5 working days to the state agency. CNA G continued to work with residents. Evidenced by: R1's [DIAGNOSES REDACTED]. R1 has a guardian. R1's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 6/26/17, indicates R1 has moderate cognitive loss, is usually understood and usually understands, and has no behaviors. The MDS also indicates, R1 is frequently incontinent of bowel and bladder, needing extensive assistance of one person for toileting. R1's care plan problem: Alteration in Thought process, potential for mood concerns, dated 7/5/17, includes, in part, the following: Dated 7/5/17: Resident responds well to a slow calm approach. Explain each task gently and keep them simple. He responds well to light humor. Take your time completing a task with resident or resident may feel rushed, frustrated, or get tearful. Allow resident to do what he can for himself. Get down to his level when talking to him. Ensure you have his attention before speaking to him about important tasks or topics. Dated 8/2/17: For resident's peace of mind due to his perceptions of staff at times, 2 staff are to be with resident when doing cares. R1's medical record included the following, in part, nursing progress notes: 7/30/17, 10:42 PM, Date of Occurrence: 7/30/17, Time of Occurrence: 2:30 PM, Occurrence type: superficial scratch to right posterior upper thigh. Location: resident's room. Injury: no c/o (complaints of) pain. Actions/First Aid: cleansed with soap and water and left open to air. Witness/Staff involved: CNA G and CNA K. Evaluation: resident sitting in his recliner chair visiting with his brother, resident was upset but denies pain or discomfort at this time. Interviewed Resident: Resident states that he is upset because he feels like CNA G was scolding him and that she was too rough with him while she was assisting him to get cleaned up. When this writer asked resident if he was in any pain or hurt, resident stated no. Staff interviewed CNA G: states that she went into resident room at approximately 1:55 PM and could tell that resident had had a bowel movement. She stated that she told the resident that next time he should try and call to go to the bathroom before this happens because she doesn't want him to have skin breakdown. Then she proceeded to help him get cleaned up. Staff interviewed CNA K: stated that she came to the room while CNA G was getting resident cleaned up and took over after resident was assisted to the commode. CNA K states CNA G did not appear to be aggressive or rough with resident. Activity at the time: toileting. Equip (equipment) being used: EZ Stand. Cause: fragile skin. Conclusion: Based on my evaluation, this injury does not constitute actual or potential abuse. Notification: family, notified resident's wife (FM C (Family Member)). Physician review: notified on next rounds. Interventions to prevent reoccurrence: staff to slow down when doing cares on resident and observe skin while doing cares. 7/30/17, 11:11 PM, Late entry 7/30/17, 3:00 PM, Comments: this writer was called to resident's room by resident's brother, resident was crying and stated that he was angry at the AM shift CNA. He felt she scolded him and was too rough with him when she assisted him into the EZ stand because she was rushing. Resident stated he has no pain or was not hurt by the incident. This writer spoke with CNA G, the Day shift CNA, over the phone and the CNA stated that she went into the resident's room at approximately 1:55 PM and could tell that resident had had a bowel movement. She stated that she told the resident that next time he should try and call to go to the bathroom before this happens, because she doesn't want him to have skin breakdown. Then she proceeded to help him get cleaned up. This writer talked with CNA G about rephrasing what she says to residents, because sometimes they have a difficult time processing information and that maybe he wasn't processing that he should call to go to the bathroom, before it was too late, so her comment to him could have been perceived as scolding, when in fact she was trying to help. CNA G stated understanding. CNA K, the PM shift CNA, was also interviewed. She stated that she came to the room while CNA G was getting resident cleaned up and took over after resident was assisted to the commode. CNA K states CNA G did not appear to be aggressive or rough with resident. Resident's wife (FM C), DON and social services were informed of the incident. R1's medical record included the following, in part, social service progress notes: 7/31/17, 5:08 PM, Type of Note: other, writer did follow up with resident on this date following a situation that occurred yesterday. Resident was incontinent of stool and when the CNA did come in to do care with him. The CNA did state that it would be best for him to call her earlier, as she did not want him to have any skin breakdown. This comment wasn't received by the resident as the staff member intended it, as she was concerned that he would get an open area related to incontinence. Writer did talk with R1 and also stated, that for his comfort, we would use two staff to do cares and he was OK with this. Yesterday he did tell the nurse that the CNA's do rush when using the easy stand and he did perceive this as being rough. This writer did ask if the staff member harmed or hurt him and he said no. He did state that he did not want this CNA working with him. Writer and household social worker will meet with R1 and his guardian in the AM tomorrow. Writer did place a call to guardian this evening and left a message. 8/2/17, 5:03 PM, Type of Note: other, Follow up on concern with (R1) related to his interactions and his response to CNA interaction on 7/30/17. Writer did speak with resident on 7/31/17, to clarify his perception from Sunday afternoon when a CNA assisted him. Writer and SW L (Social Worker) did speak with his wife (guardian), on 8/1/17, to follow up on the meeting with (R1). Writer did inform her that when talking with R1, that it was upsetting to him, that the CNA asked him to let her know before he has an accident. His guardian was comfortable with the follow up and did state that R1 does not always process information as stated, that he does not often hear the second half of a message related to his cognitive deficits. We will be using two staff in cares for his comfort level, as he has a difficult time relaying information to staff. Others often assume he may be saying something and then it becomes difficult for him to relay his message. SW will continue to provide support. The facility's, Complaint made by R1, included, in part, the following: Date 8/3/17 - Writer was called, on 7/30/17, in regards to a complaint made by R1 to RN J (Registered Nurse/Nurse Supervisor). CNA G had told RN J, when she was leaving, that she heard R1 crying when she came to see him, as she was leaving. CNA G had told her, that R1 had put his call light on, at 1:55 PM, and that he had been incontinent of stool. CNA G had told R1 he should try and call soone,r to go to the bathroom, so he would not get skin breakdown. Writer did update the Administrator. We discussed the situation. Initially R1 was upset and difficult to interview, so she waited until he calmed. When R1 was alone and calmer, he was able to answer to the RN J that he was not harmed or hurt by CNA G. RN J stated that staff member CNA G said that R1 was upset after he had an incontinent episode of BM (bowel movement). CNA G stated that she made the statement that he should have called sooner, as she did not want him to have any skin break down. CNA G then said she proceeded to help clean him up with CNA K, who took over for CNA G, who did not notice anything that was out of the ordinary. Writer and SW L met with R1 and his brother FM D, who was present. R1 was becoming upset as there were three people in the room, as we were discussing. Writer did ask SW L and FM D to allow this writer to meet with R1 when he calmed. FM D did come to this writer's office, at the time SW L and DON B (Director of Nursing) were in the office. FM D wanted to clarify his interpretation the sequence of events. He stated he was not in the room at the time CNA K was in the room finishing cares. FM D had asked R1 if CNA K was the one involved and R1 indicated that no, she was not. FM D asked R1, did she hit you and he said no, then FM D asked, where did she hit you? And he pointed to his tummy and leg. (Which is where the e-z stand sling does touch with transfers.) FM D then said that he knows there is abuse in nursing homes and he expressed he may have jumped to a conclusion. We did reassure him, that we are here to look into the situation thoroughly. Writer did read what RN J had documented from the previous day to R1 and he did indicate by verbalizing that yes, that was accurate, and shaking his head yes. Writer asked him again to confirm that nobody had hurt him. R1 did agree with the documentation, indicating that he felt rushed when asked and he was not hit or hurt. On 8/3/17, at 11:50 AM, Surveyor interviewed R1. R1 stated CNA G was not patient, was rough, and fast during cares. R1 stated he was afraid of CNA G. Surveyor asked R1 if CNA G hurt him. R1 stated hit me. Surveyor asked R1 where. R1 indicated by pointing to his left thigh and left lower abdomen. Surveyor asked R1 if he wanted to work with CNA G again. R1 stated no. R1 was tearful, crying, and would become upset when CNA G's name was mentioned throughout the interview. On 8/3/17, at 12:00 PM, Surveyor interviewed FM D. FM D stated, on 7/30/17, at approximately 2:10 PM, he came to see R1. FM D stated R1 was very distraught, upset, looked scared, he was crying. FM D stated CNA K was in the room. FM D asked R1 what was wrong, asked if it was CNA K, R1 replied no. FM D stated CNA K stated CNA G was in the room before her. FM D stated if it was CNA G, R1 replied yes. FM D stated he asked R1 if CNA G yelled at him. R1 replied no. FM D stated he asked R1 if CNA G hit him. R1 replied yes. FM D stated he asked R1 where did CNA G hit him. R1 replied by touching his left thigh and left lower abdomen. FM D stated he called R1's daughter, FM E, and she suggested FM D inform RN J. FM D stated he informed RN J immediately, about 2:30 PM. FM D stated these behaviors were very different from R1's norm. On 8/3/17, at 12:10 PM, Surveyor interviewed FM C. FM C stated she came to see R1, 7/30/17, in the evening. R1 would not eat supper or work with Physical Therapy. FM C stated this was the first time she was aware he wouldn't eat or work with therapy. FM C stated she called the facility, on 7/31/17, to inquire how R1 was. CNA G answered the phone on the unit, informed FM C that CNA I was caring for R1. CNA G informed FM C that R1 started to cry when he saw her in the dining room at breakfast. CNA G told FM C I didn't do anything wrong, I am innocent. On 8/3/17, at 12:15 PM, Surveyor interviewed FM D. FM D stated he came in to see R1, on 7/31/17, and R1 was still upset and tearful regarding the situation. FM D stated he spoke with SW F and DON B regarding R1's allegation. SW F told FM D that RN J had returned to R1's room to speak with him later, on 7/30/17, and he did not indicate he had been hit. On 8/3/17, at 12:25 PM, Surveyor interviewed FM E. FM E stated she was visiting, on 7/30/17, in the early afternoon, leaving approximately 1:30 PM. FM E stated R1 ate his lunch, worked with Physical Therapy, played Connect 4 with FM E, seemed to be in a good mood. On 8/3/17, at 12:28 PM, Surveyor interviewed FM D. FM D stated that when SW F and SW L came into to speak with R1, on 7/31/17 regarding the allegation, R1 became frustrated and upset. R1 shouted out, I wish I was dead. FM D stated SW F and SW L left R1's room after that happened. On 8/3/17, at 12:30 PM, Surveyor interviewed FM C. FM C stated SW F and SW L had left her voicemails, on 7/31/17. FM C played the voicemails for Surveyor. SW L's voicemail, dated 7/31/17, 12:45 PM, included, in part: SW L had spoken with R1, continue to look into things of what happened yesterday. Having a difficult time of clearly understanding him. When there were a couple of staff in the room, R1 seemed to be overwhelmed. SW F would return later to R1's room to speak with him alone. We are continuing to look into this. We are available tomorrow, at 8:30 AM, to discuss and follow up. SW F's voicemail, dated 7/31/17, 5:01 PM, included, in part: follow up regarding R1's situation from yesterday. We will meet with you tomorrow. FM C stated she did meet with SW F and SW L, regarding the allegations, and was told that the facility did not need to notify state, because no abuse was suspected after the investigation. On 8/3/17, at 1:00 PM, Surveyor interviewed CNA G. RN H sat in on the interview. CNA G stated she had worked with R1 on the AM shift, on 7/30/17. CNA G stated R1 was very pleasant that day. CNA G stated, at 1:50 PM, R1 had his call light on. Upon entering the room, R1 had two fingers up and there was an odor of bowel movement. CNA G stated R1 was really a mess, he needed to be cleaned up, then she put R1 onto the toilet. CNA G stated she told R1, that next time you can try to tell me before, don't want to get a sore bottom. CNA G stated CNA K came into the room, so she left. CNA G stated she could hear R1 cry, so she informed RN J, that R1 was upset about something. CNA G stated R1 would be tearful at times. CNA G stated she did not know why she informed RN J about R1's crying this time. CNA G stated RN J did call her that evening to discuss concerns and a scratch on R1. CNA G stated DON B did meet with her before the AM shift, 7/31/17, and discuss how she could have rephrased what she said to him. CNA G stated this was a rehab unit and we are trying to keep people continent. CNA G stated what she said was not in anger. CNA G stated at breakfast, 7/31/17, she was wiping counters in the dining room when R1 came into the dining room. R1 cried out again, I do not understand why. I was working on the adjacent hallway, however, after breakfast, I was moved to the B unit so I wouldn't upset R1. CNA G stated she had worked with R1 before and had never had an issue. CNA G stated she had no idea what upset R1, other than next time let's call sooner. CNA G stated she was in-service annually regarding abuse and neglect. On 8/3/17, at 1:10 PM, Surveyor interviewed RN H. RN H stated that the family would like to give R1 a couple of days and then CNA G will reapproach R1 with the SW, before she is returned to the unit. On 8/3/17, at 1:30 PM, Surveyor interviewed CNA I. RN H sat in on the interview. CNA I stated she had assisted R1 with his morning cares, he was good, the nurse came in and asked how he slept and R1 started to cry. CNA I stated, on 7/31/17, approximately 7:30 PM, she assisted R1 into the dining room. R1 was acting as if he was scared of CNA G, backing away from the table, pointing at CNA G, R1 would not eat. CNA G went to the other hallway. CNA I stated she helped calm R1 down, turned on the TV, and assisted him back to the table and he ate some breakfast. CNA I stated R1 did have times when he was down in the dumps/weepy, but had never seen R1 have any behaviors like this before. CNA I stated she did report the behavior to RN H, at the end of her shift. CNA I stated she really did not read much into the behavior, until she realized something happened over the weekend. CNA G told CNA I that she was not able to come over to the hall anymore and the floor nurse kept us up on what happened. CNA I stated she had worked with CNA G before and CNA G could get frustrated, you could tell by the tone in her voice, she could get short and annoyed at times. CNA I stated she never informed anyone of this. CNA I stated she did not remember being educated about staff burnout. On 8/3/17, at 1:45 PM, Surveyor interviewed RN H. RN H stated she informed DON B and SW F regarding CNA I's concerns regarding R1's behaviors at breakfast. RN H stated SW F informed her CNA G had already informed someone about the behavior and was moved to another unit shortly afterwards. On 8/3/17, at 1:50 PM, Surveyor interviewed SW F. SW F stated a formalized report was not sent into the state agency because the allegation did not meet the definition of abuse because R1 said he had not been hurt. SW F stated RN J had called her regarding a situation between R1 and CNA G, approximately 3:00 PM ,on 7/30/17. CNA G informed RN J that R1 was crying. CNA G informed RN J that R1 had been incontinent of bowel and she told R1 he should call sooner so he wouldn't get any skin breakdown. SW F stated RN J stated R1 was too upset to be understood at first and when he was calmer he said he was not harmed or hit, he felt rushed. SW F stated RN J stated R1 said yes when asked if CNA G made him feel bad when she stated he should call sooner. SW F stated she did not feel it was a matter of abuse but a matter of performance, a non-therapeutic interaction. SW F stated she and SW L went into R1's room, on 7/31/17, to speak with him. R1's FM D was there. R1 was having a difficult time trying to express himself, he was overwhelmed with too many people. SW F stated she met with FM C, on 8/1/17, and FM C asked that CNA G not be assigned to care for R1 anymore. Surveyor asked SW F why the allegation was not fully investigated or reported to the state agency. SW F stated it did not meet the definition of abuse due to there was no physical abuse, no intent to cause psychological abuse. CNA G said this was not her intent, it was not her intent to humiliate R1. SW F stated R1 was not happy with CNA G, he was just upset with what she said. Surveyor asked SW F if she interviewed other residents or staff about working with CNA G? SW F stated only CNA K, only asking her questions about the interaction she had with R1 and CNA G on 7/30/17. SW F stated that the interaction could have been distressing to R1, depending on CNA G's tone. SW F stated she had no knowledge that CNA G could be frustrated, short, and annoyed at times while working with residents. SW F stated that she does not feel CNA G intended to cause harm, however, she did distress R1 and at that point we looked at it as not a good interaction by CNA G. We should have fully investigated and reported the allegation. It is important to know that, on 8/3/17, at 3:35 PM, Surveyor called CNA K and left a message with no return call.

Based on interview and record review, the facility did not implement its policies and procedures that prohibit mistreatment, abuse and neglect of residents. Facility staff did not immediately report the allegation, the facility did not immediately investigate the allegation and the facility did not take steps to prevent further potential abuse as the accused Certified Nursing Assistant (CNA) was allowed to continue working with residents (R) and without increased supervision. This had the potential to affect all 34 of 122 residents. The facility did not implement its policy and procedure to protect, do a complete investigation and report to the State Agency when R 1 was upset, because he felt CNA G was scolding him and was rough with him. Evidenced by: The facility's policy, Policy and Procedure Regarding Allegations of Misconduct, dated 5/2/17, includes, in part, the following: A. Procedure to follow when alleged misconduct has occurred. Step one: Protect/Assess the effects on the resident. 3. To prevent further potential mistreatment during investigation, the accused must be removed from the resident care area, he/she may be reassigned to non-resident care duties or sent home as a suspension with pay. Step two: Report the Incident. 5. The Department of Quality Assurance (DQA) will be notified by the lead investigator if misconduct is suspected via the initial reporting form immediately. Staff to refer to Attachment B and C to determine if the incident should be reported. 6. The Administrator or designee must be involved in the decision of the submission of the report. 7. The facility then has up to five (5) days to complete the investigation in full. Step three: Investigate the Allegation. 8. Interview other residents to determine if they have been mistreated. Step Four: Additional elements may be required for different types of misconduct. Abuse is . the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Also, verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through use of technology. Willful means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. Attachment A: ABUSE c. Causes or could be reasonably expected to cause mental or emotional damage to a resident, including harm to the resident's psychological or intellectual functioning that is exhibited by anxiety, depression, withdrawal, regression, outward aggressive behavior, agitation, or fear of harm or death or a combination of these behaviors. Example 1 R1's [DIAGNOSES REDACTED]. R1 has a guardian. R1's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 6/26/17, indicates R1 has moderate cognitive loss, is usually understood and usually understands, and has no behaviors. The MDS also indicates R1 is frequently incontinent of bowel and bladder, needing extensive assistance of one person for toileting. R1's medical record included the following, in part, nursing progress notes: 7/30/17, 10:42 PM, Date of Occurrence: 7/30/17. Time of Occurrence: 2:30 PM. Occurrence type: superficial scratch to right posterior upper thigh. Location: resident's room. Injury: no c/o (complaints of) pain. Actions/First Aid: cleansed with soap and water and left open to air. Witness/Staff involved: CNA G and CNA K. Evaluation: resident sitting in his recliner chair visiting with his brother, resident was upset but denies pain or discomfort at this time. Interviewed Resident: Resident states that he is upset because he feels like CNA G was scolding him and that she was too rough with him while she was assisting him to get cleaned up. When this writer asked resident if he was in any pain or hurt, resident stated no. Staff interviewed: CNA G states that she went into resident room at approximately 1:55 PM and could tell that resident had had a bowel movement. She stated that she told the resident that next time he should try and call, to go the bathroom, before this happens because she doesn't want him to have skin breakdown. Then she proceeded to help him get cleaned up. Staff interviewed: CNA K stated that she came to the room while CNA G was getting resident cleaned up and took over after resident was assisted to the commode. CNA K states CNA G did not appear to be aggressive or rough with resident. Activity at the time: toileting. Equip (equipment) being used: EZ Stand. Cause: fragile skin. Conclusion: Based on my evaluation, this injury does not constitute actual or potential abuse. Notification: family, notified resident's wife (FM C). Physician review: notified on next rounds. Interventions to prevent reoccurrence: staff to slow down when doing cares on resident and observe skin while doing cares. 7/30/17, 11:11 PM, Late entry 7/30/17, 3:00 PM, Comments: this writer was called to resident's room by resident's brother, resident was crying and stated that he was angry at the AM shift CNA because he felt she scolded him and was too rough with him when she assisted him into the EZ stand, because she was rushing. Resident stated he has no pain or was not hurt by the incident. This writer spoke with CNA G, the Day shift CNA, over the phone and the CNA stated that she went into the resident room, at approximately 1:55 PM, and could tell that resident had had a bowel movement. She stated that she told the resident, that next time he should try and call, to go the bathroom, before this happens, because she doesn't want him to have skin breakdown. Then she proceeded to help him get cleaned up. This writer talked with CNA G about rephrasing what she says to residents, because sometimes they have a difficult time processing information and that maybe he wasn't processing, that he should call to go to the bathroom before it was too late, so her comment to him could have been perceived as scolding, when in fact she was trying to help. CNA G stated understanding. CNA K, the PM shift CNA, was also interviewed. She stated that she came to the room, while CNA G was getting resident cleaned up, and took over after resident was assisted to the commode. CNA K states CNA G did not appear to be aggressive or rough with resident. Resident's wife (FM C), DON and social services were informed of the incident. The facility's, Complaint made by R1, included, in part, the following: Date 8/3/17 Writer was called, on 7/30/17, in regards to a complaint made by R1, to RNJ (Registered Nurse / Nurse Supervisor). CNA G had told RN J, when she was leaving, that she heard R1 crying, when she came to see him, as she was leaving. CNA G had told her that R1 had put his call light on, at 1:55 PM, and that he had been incontinent of stool. CNA G had told R1 he should try and call sooner to go to the bathroom ,so he would not get skin breakdown. Writer did update the Administrator. We discussed the situation initially. R1 was upset and difficult to interview, so she waited until he calmed. When R1 was alone and calmer, he was able to answer to the RN J that he was not harmed or hurt by CNA G. RN J stated that staff member CNA G said that R1 was upset after he had an incontinent episode of BM (bowel movement). CNA G stated that she made the statement, that he should have called sooner, as she did not want him to have any skin break down. CNA G then said she proceeded to help clean him up with CNA K, who took over for CNA G, who did not notice anything that was out of the ordinary. Writer and SW L met with R1 and his brother (FM D) who was present. R1 was becoming upset, as there were three people in the room, as we were discussing. Writer did ask SW L and FM D to allow this writer to meet with R1 when he calmed. FM D did come to this writer's office, at the time SW L and DON B were in the office. FM D wanted to clarify his interpretation the sequence of events. He stated he was not in the room at the time CNA K was in the room finishing cares. FM D had asked R1 if CNA K was the one involved and R1 indicated that no she was not. FM D asked R1 did she hit you and he said no. FM D asked where did she hit you? R1 pointed to his tummy and leg. (Which is where the e-z stand sling does touch with transfers.) FM D then said that he knows there is abuse in nursing homes and he expressed he may have jumped to a conclusion. We did reassure him, that we are here to look into the situation thoroughly. Writer did read what RN J had documented from the previous day to R1. He did indicate by verbalizing that yes, that was accurate, and shaking his head yes. Writer asked him again to confirm that nobody had hurt him. R1 did agree with the documentation, indicating that he felt rushed when asked and he was not hit or hurt. On 8/3/17, at 1:30 PM, Surveyor interviewed CNA I. RN H sat in on the interview. CNA I stated she had assisted R1 with his morning cares, he was good, the nurse came in and asked how he slept and R1 started to cry. CNA I stated, on 7/31/17, approximately 7:30 PM, she assisted R1 into the dining room. R1 was acting as if he was scared of CNA G, backing away from the table, pointing at CNA G, R1 would not eat. CNA G went to the other hallway. CNA I stated she helped calm R1 down, turned on the TV, and assisted him back to the table and he ate some breakfast. CNA I stated R1 did have times when he was down in the dumps/weepy, but had never seen R1 have any behaviors like this before. CNA I stated she did report the behavior to RN H, at the end of her shift. CNA I stated she really did not read much into the behavior until she realized something happened over the weekend. CNA G told CNA I that she was not able to come over to the hall anymore and the floor nurse kept us up on what happened. CNA I stated she had worked with CNA G before and CNA G could get frustrated, you could tell by the tone in her voice, she could get short and annoyed at times. CNA I stated she never informed anyone of this. CNA I stated she did not remember being educated about staff burnout. On 8/3/17, at 1:45 PM, Surveyor interviewed RN H. RN H stated she informed DON B and SW F regarding CNA I's concerns regarding R1's behaviors at breakfast. RN H stated SW F informed her CNA G had already informed someone about the behavior and was moved to another unit shortly afterwards. It is important to know this allegation was not fully investigated or reported to the State Agency and CNA G continued to work with residents in the facility.

Based on interviews and personnel credential review, it was determined 1 of 1 Nurse Technician (NT) working was not licensed, certified, or registered in accordance with applicable State law. While reviewing verification of employment eligibility status it was noted 1 of 1 employee working in the capacity of NT in the facility had not completed the Certified Nursing Assistant (CNA) registry examination in the State of Wisconsin approved by the department. Evidenced by: The State of Wisconsin Department of Health Services DQA Memo 11-006, dated 2/10/11, includes, in part, the following: A person described by the Board as a nurse technician is a nurse aide under both Wisconsin and federal law (Wis. Stat. §§ 50.01(2) and 146.40(1)(d), and 42 CFR 483.75(e).). Accordingly, a nurse technician who is employed to perform direct care duties in a health care facility must comply with the training and testing requirements that apply to nurse aides. Example 1 On 10/18/16 Surveyor randomly chose 8 staff who have worked at the facility. NT C was chosen and her background information and licensure information was requested and reviewed. NT C's information reviewed did not include a copy of CNA registry information. On 10/18/16 at 4:15 PM Surveyor interviewed Human Resource Director (HRD) D. HDR D looked NT C's information up on the CNA registry website. HRD D stated NT C was not on the CNA registry. On 10/18/16 at 4:45 PM Surveyor interviewed Director of Nursing (DON) B. DON B stated she did not know NT C was not on the registry and would not allow NT C to work as a Nurse Technician or CNA until she either was on the registry or has completed her nurse examination. On 10/19/16 at 7:15 AM Surveyor interviewed DON B. DON B stated she spoke with NT C and she has not taken the CNA Registry examination. DON B stated the facility did not check the CNA Registry when NT C was hired. DON B stated she would expect the facility to have checked to assure NT C was on the CNA Registry prior to allowing her to work as a Nurse Technician.

Based on interview and record review, the facility did not ensure that 1 (Resident 1) of 1 residents with dementia, received care and treatment that promoted optimal mental and psychosocial well-being. Resident 1 has a [DIAGNOSES REDACTED]. The facility identified Resident 1 as being physically and verbally aggressive, would hit, kick, yell, and bite staff during cares, and showers. Resident 1 was intrusive wandering into other resident's rooms and required constant 1:1 due to her behaviors. Resident 1 would become very distressed during showers the facility implemented a seatbelt restraint for showering and the use of towels around Resident 1's limbs for safety. The facility did not attempt other measures or seek additional resources to aid in reducing Resident 1's distress with cares especially with bathing. This is evidenced by: Resident 1's Minimum Data Set (MDS) with an Assessment Reference Date of 1/11/16 indicates a Brief Interview of Mental Status (BIMS) was completed by staff and staff indicated Resident 1 is moderately impaired. Section E0100 [MEDICAL CONDITION]: b. delusions is check marked, Section E 0200 Behavior Symptoms: A. Physical behavior is marked 4-6 days, B. Verbal behavior is marked 4-6 days, C. Other symptoms directed toward others is marked daily. E 0800 Refection of care is marked 1-3 days and 0900 wandering is marked as daily. Section G Activities of Daily Living indicated Resident 1 required extensive assistance with bathing and personal hygiene. Section H: 0300 Urinary Continence and 0400 Bowel Continence indicated Resident 1 was continent of both bowel and bladder. Resident 1's comprehensive care plan Alteration in thought processes, with behavioral symptoms dated 12/14/15 states in part; Manifested by: can display verbal and physical outburst towards staff , mood fluctuates rapidly uses vulgar language Approach: staff typically walk behind resident since it agitates resident if resident gets closer to peer staff to intervene and stand between resident and peer. Divert attention, speak slowly/clearly, explain procedures, take to quieter setting if agitated, may need to go back and try cares later if agitated. Will pace the household looking for home and at times will try the exit doors. Offer walks on shared space on the 2nd floor as walking is calming for her. Carry pillow to provide resident with something soft and safe while exhibiting physical outburst. Exhibits anger/frustration when confuse or disoriented when sundowning if not able to redirect offer to walk with her offer validation and reassurance. Switch out staff frequently with increase agitation. 1:1 at all times when switching out staff to stay within visual to ensure resident has calmed; if not calm 2:1 to continue. 12/18/16 May use blanket as a barrier and /or shield if needed for safety. 2/2/16 If resident is agitated when you approach her to have cares/shower completed ensure safety and re-approach at a later times. If cares are vital to be completed at that time (ie: incontinence, shower day) stay with resident and attempt to redirect to room for cares. May need to have 3-6 staff members to complete cares/shower; may use towels on extremities to allow for movement and prevent self-injurious behaviors. Resident 1's comprehensive care plan Self Care deficit dated 5/5/15 an approach to this comprehensive care plan dated 7/21/15 states in part; may walk off unit with staff in hallway and on to other household. An approach dated 1/29/16 states in part; when showering resident 5-6 staff to assist as needed as resident is combative with cares. Staff to bring reclining shower chair behind resident and assist her to sit; using towels around wrist, ankle and over hands allowing movement, but preventing self-injurious behaviors, place seatbelt around resident in shower chair, recline chair and extend footrest. Assist resident with undressing one staff member to continue to give attention to each extremity. Once in shower stall, staff to assist with cares 1-2 staff as needed washing and drying while remaining staff continue attention to each extremity. When providing activities of daily living (ADL) cares 1-3 staff to assist. Staff to complete cares for resident with assisting to change clothes and undergarments. Staff may utilize towels to extremities allowing for movement and (sic) preventing self-injurious behavior. Of note, Resident 1 is on a bed hold and was not present at the facility during this survey. Of note, Resident 1 received a shower two times a week. On 1/29/16 Resident 1's showers increased to 3 times per week and orders were obtained for a physical restraint to complete the shower. It should be noted that a reasonable person would find it harmful to have multiple staff attempt to give them a shower and use physical restraints to do so. Additionally, there is no clear reasoning indicated for increasing from 2 times a week to 3 times a week such a distressing event for this resident. December 2015 CNA Charting indicates Resident 1 received a shower on Mondays and Wednesday. Per CNA records Resident 1 did not receive a shower 2 times in December. January 2016 CNA Charting indicates Resident 1 received a shower on Mondays and Wednesdays. Per CNA records Resident 1 did not receive a shower 2 times in January. On January 29, 2016 CNA Charting indicates Resident 1's showers increased to Monday/Wednesday/Fridays. Resident 1 received a shower on 1/29/16. February 2016 CNA Charting indicates Resident 1 received a shower on 2/1, 2/3, 2/5, 2/7 and 2/9. Resident 1 was transferred to an outside facility on 2/12/16. Resident 1 has a telephone order dated 2/1/16 which states in part; May use seatbelt in shower for safety. Resident 1 has a telephone order dated 2/3/16 which states in part; May use towels around extremities to prevent self-injury during shower. Towels will allow for movement of extremities. Nursing notes dated 2/5/16 at 7:30 AM state in part; shower give per plan of care. Resident 1 was very combative striking out and hitting walls of spa at times. Staff used towels as interventions to try to divert self-injurious behavior with upper and lower extremities as able. Resident 1 would slide down in chair causing seatbelt to rub from umbilical region to under breast and then boost herself (sic) back upright to seated position. Nursing notes dated 2/9/16 at 12:28 PM state in part; staff assisted with lab draw and urinalysis per MD order. Resident combative at times during procedure hitting, kicking out, attempting to bite staff, staff utilized interventions per plan of care. On 2/16/16 at 2:00PM Surveyor interviewed Certified Nursing Assistant (CNA) D regarding Resident 1's shower. CNA D stated that it would take 5 - 8 staff to shower Resident 1. One person for each extremity staff would put a towel around limb to hold Resident 1 and help from hitting another person or hurting herself. Surveyor asked CNA D if the towels prevented Resident 1 from moving her extremities. CNA D stated she could move her arms but we could direct her arms away from hitting us by pulling the towel and her arm the other way. It should be noted that a reasonable person would find it harmful and distressing to have 5 - 8 staff attempt to give them a shower. On 2/16/16 at 1:50 PM Surveyor interviewed CNA F regarding showers for Resident 1. CNA F stated the staff would put towels around Resident 1's wrists and ankles one staff per extremity. Resident 1 would still have motion of the extremities but the towel would prohibit her from striking others or hurting herself. CNA F stated Resident 1 would scream then at times go limp and then start screaming again. Surveyor asked CNA F Resident 1 is placed in the shower chair. CNA F stated the shower chair is placed behind Resident 1 staff put their hands on Resident 1's shoulders and assist Resident 1 to sit in the shower chair the seatbelt is attached and staff place the towels around each extremity. CNA F stated it takes about 5 people to shower Resident 1 and 2-3 to toilet Resident 1 or change her clothes we would use towels if needed for toileting. Surveyor asked CNA F if she has received training that was specific to dementia care or ever watched bathing without a battle CNA F stated No. Surveyor asked CNA F if the staff were ever given other approaches to aid in making shower time less stressful for Resident 1 CNA F stated not that I recall just using the pillow and now the seatbelt and towels. Surveyor asked CNA F if Resident 1 could refuse a shower CNA F stated yes we would just re-approach until we could get her in the shower. Surveyor asked CNA F how Resident 1 was showered prior to the restraint use. CNA F stated we would shower her in her room on the toilet and use towels to deflect her hits or pillows. Surveyor asked CNA F how frequently Resident 1 receives showers CNA F stated 3 times a week. On 2/16/16 at 4:10 PM, Surveyor interviewed CNA O regarding Resident 1's shower. CNA O stated it would usually take 5 people to shower Resident 1. CNA O stated 4 people would hold the towels around her arms and legs and the 5th person would wash Resident. CNA O stated the staff was instructed to wrap towels around Resident 1's arms and legs and hold the towel so Resident 1 could not hit or kick during her shower. CNA O stated Resident 1 would scream and holler during the shower and would attempt to hit and kick the staff. Surveyor asked CNA O did Resident 1 make contact with anyone while trying to hit or kick. CNA O stated no we held her with the towels so she could not swing or kick anyone. When Resident 1 would try to hit out we pulled her arm back and held it so she could not reach the person. Surveyor asked CNA O did Resident 1 ever hit any other residents during her stay. CNA O stated Yes Resident 1 would get in a violent rage and she would go after any Resident in her way. CNA O stated Resident 1 hit Resident 3 very hard and pulled Resident 8's hair. Resident 1 hit Resident 13 several times; she seemed to target Resident 13 a lot. CNA O sated she has also seen Resident 1 hit Resident 10. CNA O continued to state residents have also stated they are afraid of Resident 1. CNA O stated Resident 3, Resident 8, Resident 5 and Resident 10 have also stated they are very afraid of Resident 1. On 2/17/16 at 7:50 AM Surveyor interviewed Significant Other (SO) K regarding Resident 1's bathing routine. SO K stated Resident 1 would bath/shower daily or almost daily prior to admission to the facility. Surveyor asked SO K if the facility discussed with him and provided him with risks/benefits, alternatives to using the restraints including the use of the towels around Resident 1's extremities. SO K stated he signed a form for a seatbelt in the shower but he does not recall the facility discussing the use of towels around Resident 1's extremities. On 2/17/16 at 9:00 AM Surveyor interviewed CNA L regarding Resident 1's shower. CNA L stated Resident 1 was originally showered in her room and staff would wait until she was in her room to tell her she was going to receive a shower. CNA L stated she was very physical during the shower sometimes she would not start with behaviors until water was on her body and then she was battling us the entire time during the shower. We would try to keep her and ourselves as safe as we could but get her clean. CNA L stated the staff used a towel or pillow originally to deflect her hits. When we moved to the spa we started using the shower chair with a seatbelt and towels within the last month or so. It would take at least 5-6 staff to bath her one for each extremity and one to two to wash her. She still fought us the entire time she was very verbally abusive and combative sometimes she would go limp like she had fainted and then start hitting at us again. Surveyor asked CNA L if the towels help prevent Resident 1 from hitting CNA L stated we could direct her hands the other way and prevent hitting it kept her from swing at us. CNA L stated Resident 1 would scream, yell, and try to hit, kick and bite throughout the entire shower. Surveyor asked CNA L if she has received training that was specific to dementia care or ever watched bathing without a battle CNA L stated No. Surveyor asked CNA L if the staff were ever given other approaches to aid in making shower time less stressful for Resident 1 CNA L stated not that I recall just using the pillow and now the seatbelt and towels. Surveyor interviewed CNA J regarding Resident 1 CNA J stated Resident 1 had unpredictable behaviors would be happy one minute than hitting the next. CNA J stated it took up to 4 people to toilet Resident 1. We would have to use pillows to protect ourselves and others. Surveyor asked CNA J if she received training on dementia care. CNA J stated there was a little discussion on the type of dementia but not how to care for someone like Resident 1. Nursing notes dated 10/11/15 at 11:05 AM updated Social Worker (SW) C regarding Resident 1 behaviors in regards to interventions to try. Interventions include putting laundry out for Resident 1 as likes to fold laundry, offer to go to therapy bike and burn off some energy. If becomes agitated can go to 2:1 monitoring if she escalates. Nursing notes dated 11/4/16 at 11:43 AM state in part; combative with shower, physically aggressive toward staff. Ripped staff's top at seam by pulling on material. Staff tried interventions per plan of care without change in behavior. Nursing notes dated 11/10/15 at 3:42 PM state in part; shower given resident agreeable and started shower became agitated during shower hit at staff but was redirected with 2 staff. Nursing notes dated 11/13/15 at 11:54 AM state in part; informed not enough blood was obtained this am to run labs ordered. Resident 1 was combative and required 4 staff to obtain lab. Lab called and stated will not return to draw labs in the future concerned for their safety. Lab has attempted to obtain lab weekly for the past 4 weeks. Nursing notes dated 11/23/15 at 11:46 AM state in part; resident hitting head against window and window shattered. Updated MD possibility of glass in resident's head as it is seen in hair and scalp. Nursing notes dated 12/7/15 at 11:30 AM state in part; mood swings rapidly up and down had staff change out multiple times beginning or shift was hard to calm. Nursing notes dated 12/13/15 at 3:41 AM state in part; frequent staff changes during periods of agitation will remain 2:1 during agitation. Nursing notes dated 12/15/15 at 7:00 AM state in part; remained 1:1 all night and 2:1 when agitated. Nursing notes dated 1/5/16 at 4:13 AM state in part; remains 1:1, 2:1. Nursing notes dated 1/6/16 at 7:39 AM state in part; redirected with 2 staff remains 1:1. Nursing notes dated 1/12/16 at 1:50 AM state in part; staff changed as needed was 1:1, 3:1 with agitation. Nursing notes dated 1/21/16 at 8:41 AM state in part; resident was 1:1 at all times, 2:1, 3:1 when agitated. Nursing notes dated 1/24/16 at 7:54 AM state in part; staff changed frequently during night shift, resident was 1:1, 3:1 at times. Nursing notes dated 1/25/16 at 11:38 AM state in part; Certified Nursing Assistant (CNA) staff punched in stomach, CNA had hair pulled, hit, and pushed during shower 5 staff to assist. Resident 1 settled after done with shower. Nursing notes dated 1/29/16 at 3:44 PM state in part; agitated, kicking throwing objects, hitting, slapping, rapidly pacing, running after staff to hit them after early AM shower did settle after approximately 2 hours of pacing with outburst of aggression. Nursing notes dated 2/3/16 at 12:31 AM state in part; unable to redirect behavior staff changed out 2:1 during extreme agitation. Nursing notes dated 2/5/16 at 7:30 AM state in part; shower given per plan of care resident very combative, striking out and hitting walls of spa at times. Staff used towels as interventions to try to divert self-injurious behavior with upper and lower extremities as able. Resident would slide herself down in chair causing seatbelt to rub from umbilical region to under breast and then boost herself (sic) back upright to seated position. Nursing notes dated 2/5/16 at 11:13 PM state in part; staff continues to come between resident and others 2:1. Nursing notes dated 2/6/16 at 7:00 AM state in part; swearing at staff, resident 1:1, 2:1 all night did increase staff to 5:1 during severe agitation unable to redirect behavior. Nursing notes dated 2/7/16 at 4:07 PM state in part; assisted with 5 staff to wash change pants Resident 1 hitting, screaming, kicking and scratching. Nursing notes dated 2/9/16 at 7:47 AM state in part; remained 5:1 during night shift staff changed frequently. Nursing notes dated 2/9/16 at 10:31 AM state in part; cares provided by staff times 5 as resident very combative hitting, kicking, swings hands/fists, attempts to bite staff, digs nails into arms and hand of staff, yells for attention, will let body go limp and need to be lowered to the floor. Nursing notes dated 2/9/16 at 11:28 AM state in part; came out of bathroom with hand full of feces took 4 staff to wash hands. On 2/17/16 Surveyor spoke to RN M regarding Resident 1 RN M stated Resident 1's current [DIAGNOSES REDACTED]. Resident 1 continues to be impulsive, intrusive and aggressive but medication changes have been completed and staff are monitoring for the effectiveness of the changes. On 2/17/16 at 9:15 AM Surveyor interviewed Registered Nurse (RN) I and Social Worker (SW) H regarding the bathing process for Resident 1 and the use of the seatbelt and extremity restraints for Resident 1. RN I stated Resident 1 was becoming more incontinent and due to Resident 1's constant wandering she was sweating more and had greasy hair and needed to be bathed more frequently. Surveyor asked RN I and SW H if they were aware of Resident 1's behaviors during bathing RN I stated she had observed the bathing process and the use of the towels were not a restraint but used to assist Resident 1 from self-injurious behavior during the shower. Surveyor asked RN I and SW H if they provided education to staff regarding catastrophic reactions with bathing such as bathing without a battle or reached out to outside agencies such as the Alzheimer's Alliance for ideas on how to reduce Resident 1's catastrophic reactions during the bathing process. SW H stated she had not. On 2/17/16 at 4:15 PM Surveyor asked Director of Nursing (DON) B if she had spoken to any of the Certified Nursing Assistants (CNAs) on the A or B household related to Resident 1 and other Residents being fearful of Resident 1. DON B stated no she did not talk to or ask the CNAs regarding Resident 1 behaviors or the effect on other residents. DON B stated she spoke with RN I regarding Resident 1 when Resident 1 was at the facility. Despite knowledge that Resident 1's catastrophic reactions during the bathing process and resistance to taking a shower the facility did not develop alternative approaches to showering Resident 1 but implemented restraints for the bathing process and increased the number of showers from 2 to 3 times per week. The facility also increased the number of staff during the bathing process and with day to day cares at times taking up to 5 staff to care for Resident 1 who has a dementia [DIAGNOSES REDACTED]. Consequently, Resident 1 experienced psychological distress, as evidenced by screaming, yelling kicking, screaming attempting to bite staff and would go limp when staff attempted to give her a shower. In addition, as Resident 1's behaviors increased the facility would add additional staff to care for Resident 1 increasing Resident 1's psychosocial distress.

Based on interview and record review the facility did not ensure that all alleged violations involving mistreatment, neglect or abuse were reported immediately to other officials in accordance with State law through established procedures including to the State survey and certification agency and the facility did not have evidence that all alleged violations were thoroughly investigated for 5 of 5 incidents reviewed (Residents 1, 13, 14, 8, 3 and 2). Resident 1 has moderate cognitive impairment and disruptive behaviors that affect other residents. Resident 1 is noted to be combative, verbally abusive, agitated, aggressive, wanders, hits, shoves, swings hands/fists. Resident 1 was noted to be involved in 4 residents-to resident incidents and the facility failed to complete a thorough investigation into these incidents. Resident 13 was struck by Resident 1 on two separate occasions. Facility staff was aware of the incidents but did not complete a thorough investigation and ensure other residents safety due to the lack of investigation into the incidents. Resident 14 was struck by Resident 1. Facility staff was aware of the incident but did not complete a thorough investigation and ensure other residents safety due to the lack of investigation into the incidents. Resident 8 had her hair pulled by Resident 1. The Facility staff were aware of the incident but did not complete a thorough investigation and ensure other residents safety due to the lack of investigation into the incidents. Resident 3 was struck in the shoulder by Resident 1. Facility staff was aware of the incident but did not complete a thorough investigation and ensure other residents safety due to the lack of investigation into the incidents. Resident 1 attempted to remove the necklace from Resident 2's neck without his permission. This is evidenced by the following: The facility's policy entitled Allegations of Misconduct dated 2/4/16 states in part; Step One Protect/Assess the Effects on the Resident: 3. if the accused is the resident, increase monitoring to provide safety for all residents. 4. Nursing supervisor immediately completes a body assessment and documents findings. 6. Lead investigator must assess for psychological treatment and support to the resident. 8. An initial evaluation can be completed for resident -to-resident but should be reported to the administrator and administrative team. Step Three Investigate the Allegation: 3. Interviews will be conducted with all staff, residents or others who may have witnessed or have knowledge of the incident. Written statements from those aware of the situation should be obtained at this time, including identification of staff, time and date. 5. Who was present at the time of the incident (victim, accused, and witnesses). 7. Each person should be interviewed separately. 8. Interview other residents to determine if they have been mistreated. 9. Specifically where did the incident occur and when. 10. How did it happen and reenact the situation. 13. Obtain written, signed statements from all witnesses or persons with information. Example 1 Resident 13's Minimum Data Set (MDS) with an Assessment reference Date of 12/28/15 indicates a Brief Interview for Mental Status (BIMS) was completed by staff; staff indicated Resident 13 has severe cognitive impairment. A Resident to Resident Altercation Flowchart dated 10/22/15 states in part; no altercation grabbed residents arm as resident was swinging arm. There was no injury or force that was applied staff assessed Resident 1 could not understand Resident 13's arms moving. Of note, there is no documentation of this incident in Resident 13's medical record. Nursing notes in Resident 1's medical record dated 10/22/15 at 1:24 AM state in part; late entry for 6:30 PM staff reported Resident 1 was walking past Resident 13 in dayroom and Resident 1 had been pacing and 1:1 throughout PM shift when she walked past and quickly grabbed onto Resident 13's left arm before staff could intervene. Asked Resident 1 why she did it and Resident 1 replied she was waving her hands all over. Resident 13 had no noted injury at time of assessment. Staff redirected Resident 1 and no further interaction between the two residents. The facility has no evidence that a thorough investigation into this incident was completed. The facility did not complete witness statements of staff or other residents who observed this incident. Resident 13 has severe cognitive impairment and is not interviewable the facility has no evidence that staff assessed Resident 13 for potential psychological distress related to this incident. Of note, the reasonable person would be frightened of someone who grabs them especially if this person is combative, agitated, swings and hits others. On 2/17/16 at 4:00 PM Surveyor interviewed Director of Nursing (DON) B and Social Worker (SW) C regarding investigations. SW C stated that they have the staff reenact the incident and they decide if it is a resident-to-resident, casual contact or communication. SW C stated that residents with dementia often communicate with touch and it is not intentional. SW C stated Resident 1 is not doing this with intent. The incident was not aggressive. Surveyor asked if this incident should have been documented in Resident 13's record. DON B stated she would expect the incident to be documented in Resident 13's record. SW C stated when an actual incident occurs we do more of an investigation. Surveyor asked SW C and DON B if they obtain witness statements and document the conclusion of their determination. DON B stated the investigation is in the medical record. SW C stated they do look at the psychosocial aspect. Surveyor asked SW C and DON B where the facility documents there investigation including witness statements, conclusions. DON B stated our documentation of the incident is in the residents medical record. Occurrence B A Resident to Resident Altercation Flowchart dated 12/20/15 states in part; determined communication as resident walked by and reached over staff and tapped her head no intensity with tap. Nursing notes dated 12/20/15 at 10:28 PM state in part; late entry for 4:10 PM No ill effects from communication between resident and peer. Resident 13 continued with her normal behavior. No further episodes with peer. Nursing notes for Resident 1 dated 12/20/15 at 8:22 PM state in part; late entry for 4:10 PM communicates with different means, will tap or touch staff and peer in a non-threatening way. Resident 1 was pacing with 1:1 staff, non-agitated state when Resident 13 was clapping hands. Staff noted that Resident 1 was going towards Resident 13 and placed themselves between the Resident 13 and peer. Resident 1 reached over the staff's shoulder and tapped Resident 13 on top of the head. Resident 13 showed no indication that it had happened she continued with her clapping and peer was redirected away. Resident 13 was immediately checked for injury or reaction to episode; no injury noted and no change in behavior. The facility has no evidence that a thorough investigation into this incident was completed. The facility did not complete witness statements of staff or other residents who observed this incident. Resident 13 has severe cognitive impairment and is not interviewable the facility has no evidence that staff assessed Resident 13 for potential psychological distress related to this incident. Of note, the reasonable person would be frightened of someone who taps them especially if this person is combative, agitated, swings and hits others. On 2/17/16 at 9:15 AM Surveyor interviewed Registered Nurse (RN) I and Social Worker (SW) H regarding the incident involving Resident 13 and resident -to-resident investigations. SW H stated we have staff demonstrate the incident and we decide based on the reenactment if the incident is a resident-to resident, casual contact or communication. RN I stated the staff should make sure resident is safe and then we interview resident we discuss with head of social services. We do our investigation and then contact management. Surveyor discussed the incidents with Resident 13 RN I stated based on the information obtained these did not rise to the level of resident-to-resident requiring reporting. Surveyor asked if the information regarding the investigation is documented RN I stated it is charted in the medical record. Example 2 Resident 14's Minimum Data Set (MDS) with an Assessment reference Date of 1/4/16 indicates a Brief Interview for Mental Status (BIMS) was completed by staff; staff indicated Resident 14 has severe cognitive impairment. A Resident to Resident Altercation Flowchart dated 2/2/16 states in part; Resident 1 walked by she tapped Resident 14's helmet there was no malice movement. Resident 14 did not appear to notice. Nursing notes dated 2/2/16 at 4:56 PM state in part; Resident 14 had no acknowledgement from interaction with peer. Nursing notes in Resident 1's record dated 2/2/16 at 4:55 PM state in part; resident walked past Resident 14 and tapped his helmet and continued to walk past. Resident 14 had no acknowledgement Resident 1 has been weepy and continued to pace. The facility has no evidence that a thorough investigation into this incident was completed. The facility did not complete witness statements of staff or other residents who observed this incident. Resident 14 has severe cognitive impairment and is not interviewable the facility has no evidence that staff assessed Resident 14 for potential psychological distress related to this incident. Of note, the reasonable person would be frightened of someone who taps them especially if this person is combative, agitated, swings and hits others. On 2/17/16 at 9:15 AM Surveyor interviewed Registered Nurse (RN) I and Social Worker (SW) H regarding the incident involving Resident 14 and resident -to-resident investigations. SW H stated we have staff demonstrate the incident and we decide based on the reenactment if the incident is a resident-to resident, casual contact or communication. RN I stated the staff should make sure resident is safe and then we interview resident we discuss with head of social services. We do our investigation and then contact management. Surveyor discussed the incidents with Resident 14 RN I stated based on the information obtained these did not rise to the level of resident-to-resident requiring reporting. Surveyor asked if the information regarding the investigation is documented RN I stated it is charted in the medical record. On 2/17/16 at 4:00 PM Surveyor asked DON B and SW C if any of the above incidents would have met the criteria of resident to resident incident SW C stated these incidents were not intentional as Resident 1 was incapable of intent. SW C stated these incidents were considered casual contact or communication and were not considered resident-to-resident incidents. The facility failed to have evidence that all alleged violations were thoroughly investigated. The facility has no evidence that interviews were conducted with all staff, residents or others who may have witnessed or have knowledge of the incident. There is no evidence of written statements from those aware of the situation. There is no evidence other residents were interviewed to ensure other residents were not negatively impacted by the incident. The facility's failed to immediately ensure residents safety due to the lack of investigation into the incidents. Example 3 Resident 8's Minimum Data Set (MDS) with a completion date of 2/1/16 indicates Resident 8's Brief Interview for Mental Status (BIMS) score was 15. Resident 8 is cognitively intact and is her own decision maker. A Resident to Resident Altercation Flowchart dated 10/23/15 states in part; Resident 1 has Dementia. Does not recall incident or respond to questions - pacing. Do not feel there was intent. Resident 8, no complaint of (c/o) pain or redness to scalp, not upset by peer and says she if fine. (Note: The one page form is not signed to identify the person completing the resident to resident form.) Resident 8's Incident report, nursing note, dated 10/23/16 at 5:35 PM, Peer (Resident 1) was ambulating on household with staff and was agitated. Staff tried redirecting her away from residents but did end up making contact with this resident (Resident 8) and pulled hair on the back of her head and did toss a pillow onto her lap. Staff member, Certified Nursing Assistant, (CNA) was able to redirect resident away and notified team leader and Registered Nurse (RN). Witness/Staff involved: 2 CNAs identified. Interviewed: Household specialist and writer talked with Resident 8 after incident and resident denied pain and is not upset by peer. Resident states, I am fine. Sitting in day room. Conclusion: Based on my evaluation, this injury does not constitute actual or potential abuse. On 2/17/16 at 9:30 AM, Surveyor spoke with Resident 8. Resident 8 stated Resident 1 came up and pulled her hair on her head. Resident 8 stated the staff had to make her let go of my hair. Resident 8 stated she was nit sure who Resident 1 would target next or hit. Resident 8 stated she is terrified of Resident 1. On 2/17/16 at 4:00 PM Surveyor interviewed Director of Nursing (DON) B and Social Worker (SW) C regarding investigations. SW C stated that they have the staff reenact the incident and they decide if it is a resident-to-resident, casual contact or communication. SW C stated that residents with dementia often communicate with touch and it is not intentional. SW C stated Resident 1 is not doing this with intent. The incident was not aggressive. SW C stated when an actual incident occurs we do more of an investigation. Surveyor asked SW C and DON B if they obtain witness statements and document the conclusion of their determination. DON B stated the investigation is in the medical record. Surveyor asked SW C and DON B where the facility documents there investigation including witness statements, conclusions. DON B stated our documentation of the incident is in the resident's medical record. SW C stated she does keep a copy of the actual witness statements in her office in a file when an actual incident occurs. Surveyor requested the witness statements for Resident 8's incident from SW C. SW C stated she would look in her files and see if there were any actual statements obtained for this incident. No further information was provided to Surveyor . The facility does not have evidence that a thorough investigation into this incident was completed. The facility did not complete witness statements of staff or other residents who observed this incident. The conclusion was made at the same time the incident occurred without a thorough investigation being completed. Example 4 Resident 3's Minimum Data Set (MDS) with a completion date of 1/11/16 indicates Resident 3's Brief Interview for Mental Status (BIMS) score was 14. Resident 3 is cognitively intact. A Resident to Resident Altercation Flowchart dated 11/28/15 states in part; the front of the form lists Resident 3 and Resident 1 - Casual contact. The back of the form states: Resident 1 went down the hall and as she was walking she did have a brief but not intentional to harm peer Resident 3. Registered Nurse (RN) demonstrate contact and was not with and intent to have an altercation with peer. (Note: The one page form is not signed to identify the person completing the resident to resident form.) Resident 3's nursing note dated 11/28/16 at 8:17 PM, Communication: Resident 3 was walking in the dining room area for supper and as peer Resident 1 was walking past him. Peer made contact with Resident's shoulder with closed fist, as Resident was trying to move away from path of peer. As Resident was moving away contact was made. Resident denies pain and no bruising or marks of any kind resulted from contact. Resident unaffected emotionally from incident as well. (Of Note: A facility incident report was not found in Resident 3's medical record.) On 2/17/16 at 9:14 AM, Surveyor spoke with Resident 3. Resident 3 stated Resident 1 punched him in the shoulder while he was in the dining room. Resident 3 stated it was a hard punch. Resident 3 also stated the staff now have to carry pillows to protect us from Resident 1. On 2/17/16 at 4:00 PM Surveyor interviewed Director of Nursing (DON) B and Social Worker (SW) C regarding investigations. SW C stated that they have the staff reenact the incident and they decide if it is a resident-to-resident, casual contact or communication. SW C stated that residents with dementia often communicate with touch and it is not intentional. SW C stated Resident 1 is not doing this with intent. The incident was not aggressive. SW C stated when an actual incident occurs we do more of an investigation. Surveyor asked SW C and DON B if they obtain witness statements and document the conclusion of their determination. DON B stated the investigation is in the medical record. Surveyor asked SW C and DON B where the facility documents there investigation including witness statements, conclusions. DON B stated our documentation of the incident is in the resident's medical record. SW C stated she does keep a copy of the actual witness statements in her office in a file when an actual incident occurs. Surveyor requested the witness statements for Resident 8's incident from SW C. SW C stated she would look in her files and see if there were any actual statements obtained for this incident. Surveyor asked SW C when the determination was made that the occurrence was considered abuse or reportable. SW C stated the staff decides after they investigate and reenact if the allegation or incident is an actual reportable occurrence. SW C stated if it is during the week SW C would look at the incident. SW C stated the incident is investigated and then the decision is made to report the allegation or not. No further information was provided to Surveyor . The facility failed to have evidence that all alleged violations were thoroughly investigated. The facility has no evidence that interviews were conducted with all staff, residents or others who may have witnessed or have knowledge of the incident. There is no evidence of written statements from those aware of the situation. There is no evidence other residents were interviewed to ensure other residents were not negatively impacted by the incident. The facility's failed to immediately ensure residents safety due to the lack of investigation into the incidents. There is also no evidence the administrator was notified of the Resident to Resident altercation. Example 5 Resident 2's Minimum Data Set (MDS) with a completion date of 1/18/16 indicates Resident 2's Brief Interview for Mental Status (BIMS) score was 14. Resident 2 is cognitively intact. A Resident to Resident Altercation Flowchart dated 11/28/15 states in part; the front if the form lists Resident 2 and Resident 1 - Necklace thought was hers (Resident 1). (It is important to note Resident 2's Resident to Resident altercation is documented on the same form as Resident 3's altercation with Resident 1. Facility staff did not use a separate investigation form process for each Resident to identify if abuse occurred.) The back of the form states: Writer spoke with Register Nurse (RN) Supervisor reported that Resident 1 was walking down hallway and grabbed the necklace and said it was hers. Staff and Resident 2 said it was not and she let go no contact of attempt to harm or take necklace (Note: The one page form is not signed to identify the person completing the resident to resident form.) Resident 2's nursing note, dated 11/28/15 at 8:03 PM, Communication: Peer, Resident 1 was walking with staff (just after as needed (PRN) medications were taken) throughout both households. Peer had walked up to Resident 2 and grabbed his green beaded necklace stating that this was hers and she wanted it back. Staff then placed her hand on peers hand telling her to let go of the necklace. Resident 2 also stating to let go of necklace. Peer then let go of the necklace and took off quickly down the hall. Resident was no injured - no pain or bruising noted. On 2/17/16 at 9:14 AM, Surveyor spoke with Resident 2. Resident 2 stated Resident 1 is not a nice lady she tried to take my beads. Resident 2 pointed to the beads around Resident 2's neck. On 2/17/16 at 4:00 PM Surveyor interviewed Director of Nursing (DON) B and Social Worker (SW) C regarding investigations. SW C stated that they have the staff reenact the incident and they decide if it is a resident-to-resident, casual contact or communication. SW C stated that residents with dementia often communicate with touch and it is not intentional. SW C stated Resident 1 is not doing this with intent. The incident was not aggressive. SW C stated when an actual incident occurs we do more of an investigation. Surveyor asked SW C and DON B if they obtain witness statements and document the conclusion of their determination. DON B stated the investigation is in the medical record. SW C stated Resident 1 did not take Resident 2's necklace the staff intervened with her. SW C stated there are not interviews related to this incident. SW C stated there are no interviews from the staff documented, if there are any interviews they would be documented in the medical record.

Based on observation, interview and record review the facility did not ensure medically related social services were provided to 8 (Residents 1, 13, 14, 8, 5, 4, 3, and 2) of 14 residents reviewed to help them maintain their highest practicable physical, mental and psychosocial wellbeing. Resident 1 has episodes of behaviors that affect others including wandering into others rooms, intrusiveness and threatening others, would use vulgar language and was physically and verbally aggressive. Resident 1 had several incidents of resident-to-resident altercations on the 2nd floor and almost daily displayed incident of verbal and physical aggression which was witnessed by other residents. Assessments of Resident 1's behavior and monitoring by the social worker were not adequately documented in the medical record. Resident 8 had her hair pulled by Resident 1. Resident 8 also witnessed Resident 1 in a violent rage and staff could not keep Resident 1 from hitting others. Resident 4 verbalized she feared Resident 1 and would cower whenever she would see her coming. Resident 4 stated she witnessed Resident 1 hit other Residents. Resident 5 had her personal items taken by Resident 1. Resident 5 voiced to the facility staff she was afraid of Resident 1. Resident 13 was struck by Resident 1 on two separate occasions. Resident 14 was struck by Resident 1. Resident 3 was struck by Resident 1. Resident 3 stated he was afraid of Resident 1 Resident 2 had a resident to resident altercation with Resident 1. This is evidence by: Resident 1 has moderate cognitive impairment and disruptive behaviors that affect other residents. At times Resident 1 threatens others and tends to target residents and staff. The facility/social service department failed to assess the impact Resident 1's behaviors have on other resident's psychosocial well-being. Resident 1's verbal and physical outbursts negatively impacted others and had the potential to impact others. On 2/16/16 at 4:10 PM, Surveyor interviewed Certified Nursing Assistant. (CNA) O regarding the impact that Resident 1 had on other resident on the A and B household. Surveyor asked CNA O did witness Resident 1 hit any other residents during her stay at the facility. CNA O stated Yes Resident 1 would get in a violent rage and she would go after any Resident in her way. CNA O stated Resident 1 hit Resident 3 very hard and pulled Resident 8's hair. Resident 1 hit Resident 13. CNA O stated she has also seen Resident 1 hit Resident 10. CNA O continued to state residents have also stated they are afraid of Resident 1. CNA O stated Resident 3, Resident 4, Resident 8, Resident 5 and Resident 10 have also stated they are very afraid of Resident 1. Example 1 Resident 1's [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS) with an Assessment reference Date of 1/11/16 indicates a Brief Interview for Mental Status (BIMS) was completed by staff. Staff indicated Resident 1 has moderate cognitive impairment. Resident 1's comprehensive care plan Alteration in thought processes, with behavioral symptoms dated 12/14/15 states in part; Manifested by: can display verbal and physical outburst towards staff , mood fluctuates rapidly uses vulgar language Approach: staff typically walk behind resident since it agitates resident if resident gets closer to peer staff to intervene and stand between resident and peer. Divert attention, speak slowly/clearly, explain procedures, take to quieter setting if agitated, may need to go back and try cares later if agitated. Will pace the household looking for home and at times will try the exit doors. Offer walks on shared space on the 2nd floor as walking is calming for her. Carry pillow to provide resident with something soft and safe while exhibiting physical outburst. Exhibits anger/frustration when confuse or disoriented when sundowning if not able to redirect offer to walk with her offer validation and reassurance. Switch out staff frequently with increase agitation. 1:1 at all times when switching out staff to stay within visual to ensure resident has calmed; if not calm 2:1 to continue. May use blanket as a barrier and /or shield if needed for safety. If resident is agitated when you approach her to have cares/shower completed ensure safety and re-approach at a later times. If cares are vital to be completed at that time (ie: incontinence, shower day) stay with resident and attempt to redirect to room for cares. May need to have 3-6 staff members to complete cares/shower; may use towels on extremities to allow for movement and prevent self-injurious behaviors. Social Service note dated 6/23/15 at 8:49 PM state in part; staff provides 1:1 and support as needed to Resident 1. Social Service notes dated 6/23/15 at 9:47 PM state in part; staff continues to monitor Resident 1's behaviors and update team leader, registered nurse (RN) and social services for further interventions needed. Social Services note dated 6/24/15 at 3:38 PM state in part; during assessment period Resident 1 exhibited verbal, physical outburst toward staff along with wandering and persistent anger of being easily annoyed with placement. Social Service note dated 8/12/16 at 8:25 AM state in part; during assessment period she displayed wandering and exit seeking and walking the halls, persistent anger of being easily annoyed with others and repetitive physical movements of being anxious/restless. Nursing notes dated 9/13/15 at 10:40 PM state in part; resident has been increasingly more verbal with peers, tries to start arguments difficult to redirect most of the time. Nursing notes dated 10/3/15 at 3:41 PM state in part; noted to be with staff and wanting to sit in recliner in shared area. Resident 1 went to sit in recliner next to peer whom was in wheelchair close to recliner Resident 1 made casual contact with back of peers head with her hand. Staff asked Resident 1 why she did this and Resident 1 stated did what? Had no recollection of action to peer and then became combative with staff. Nursing notes dated 10/5/15 at 3:21 AM states in part; is uncooperative, agitated, wanders throughout nursing home, attempts to wander into other resident's rooms. Nursing notes dated 10/5/15 at 9:41 AM states in part; swearing, calling staff foul names and becoming combative. Nursing notes dated 10/6/15 at 5:01 AM states in part; shouts, swings hands/fists, swears, wanders throughout nursing home, wanders into other resident rooms, threatens, screams, curses, yells shouts, hits, shoves and makes disruptive noises. Nursing notes dated 10/10/15 at 8:23 PM states in part; is combative, agitated hit staff in the face with a shoe. Nursing notes dated 10/11/15 at 10:43 AM states in part; at 7:30 AM grabbed garbage can and threw it at writer, almost hitting peers sitting at table for breakfast. Resident 1 continued to come at writer and grabbed right arm pulled on writers arm and punched in stomach. Resident 1 swearing and using obscene language very upsetting to peers as on stated My God I have never heard such language. Another peer stated she needs soap in her mouth. Resident 1 continued to swear and scream obscenities. At 8:30 AM noted to have clip board and using then to threaten I will kill you all. At 10:00 AM grabbed pillow from under peers head as passing by and then attempted to hit another resident but writer blocked it; unable to redirect continues 1:1. Nursing notes dated 10/11/15 at 11:05 AM updated Social Worker (SW) C regarding Resident 1 behaviors in regards to interventions to try. Interventions include putting laundry out for Resident 1 as likes to fold laundry, offer to go to therapy bike and burn off some energy. If becomes agitated can go to 2:1 monitoring if she escalates. Nursing notes dated 10/11/15 at 1:29 PM state in part; approached peer's family and told them to shut the F up and get the hell out of here. Took 3 staff to remove from dayroom; Resident 1 was yelling at peer's grandson and calling him profanities. Nursing notes dated 10/16/15 at 1:10 PM state in part; resident went into B side family room and took visiting family's plate of pizza and when writer told her that wasn't hers, she spit on it and handed it back and stated profanities. Nursing notes dated 10/17/15 7:21 PM states in part; yelling and pounding on doors, walls, hitting counter flung glass vase on counter across room. Nursing notes dated 10/20/15 at 7:57 AM state in part; pacing attempting to go into other resident's room, difficult to redirect behavior. Social Service note dated 10/20/15 at 12:05 PM state in part; staff noted that Resident 1 has little interest in doing things, trouble concentrating on things, and being short tempered/easily annoyed nearly every day. During assessment period Resident 1 displayed verbal aggression, socially inappropriate, wandering, physical aggression, resistive behaviors, persistent anger, repetitive physical movements, repetitive verbalizations, unrealistic fears/delusions, repetitive anxious complaints, change in sleep pattern, and crying/weeping 3 or more times. Recently reviewed with RN I and psychiatrist regarding change in severity of behaviors recent medication changes completed. Nursing notes dated 10/24/15 at 6:43 PM states in part; is verbally abusive swears, derogatory language toward staff and peers. Staff constantly in protective stance unsure if she will kick or hit continue to put themselves between her and other residents to prevent unpredictable abusive attacks to other residents. Nursing notes dated 10/31/15 at 10:24 PM state in part; walked up to peer in dayroom and brushed her hand against peers hair then pointed her finger at his nose and speaking in word salad (jumbled words). Nursing notes dated 11/7/15 at 6:47 PM state in part; Resident 1 was carrying food tray in day room two other residents in day room. Resident 1 began shaking a butter knife at staff; staff able to get butter knife away from Resident 1. Resident 1 became angry stood up and started swinging food tray and getting close to other resident while she was swinging food tray. Resident 1 was on the floor kicking and swinging her arms and the other resident was backed up against an end table in his wheel chair, staff came to assist and attempted to block any kicks or punches; no other residents were injured. Nursing notes dated 11/15/16 at 3:48 PM state in part; Resident 1 ambulating past peer and without warning lunged toward him. Staff present between Resident 1 and peer and prevented resident contact. Nursing notes dated 11/13/15 at 4:21 PM state in part; any attempt to direct from peers room or away from peers caused outburst of hitting staff. Nursing notes dated 11/22/15 at 9:51 PM state in part; staff are unable to trust Resident 1 by other residents; peers continue to be cautious of her. Nursing notes dated 11/29/15 at 6:56 AM wanders throughout nursing home wanders into other resident rooms. Nursing notes dated 11/29/15 at 4:32 PM at 3:30 PM was attempting to hit staff as they were preventing her from getting close to other resident walking in hall. Nursing notes dated 11/30/15 at 12:36 AM state in part; Resident 1 wandering from A2 to B2 and around units attempting to go into other resident's rooms, swearing and hitting staff. Nursing notes dated 12/01/15 at 7:15 AM state in part; Resident 1 went into another resident's room and tried to get in bed with resident, staff stood between resident's bed and Resident 1 started hitting staff and then left room. Resident 1 blocked staff in peer's room by holding door shut, another staff intervened. Attempted to enter another peers room staff stood in front of peers door and resident started hitting staff and pulling staff's hair, chased staff around table to hit staff remained 1:1 to 3:1 during times of agitation. Nursing notes dated 12/8/15 at 7:27 AM states in part; attempts to go into other resident's rooms, hits staff. Pinches, pulls hair, would walk by staff and grab at hair. Nursing notes dated 12/9/15 at 11:46 PM states in part; late entry for 12/7/15 Resident 1 approached another resident and attempted to give a hug the other resident grabbed hand and put other hand on Resident 1's head; no injury. Nursing notes dated 12/10/15 at 7:03 AM state in part; attempted to hit other resident staff intervened and resident never got close enough to make contact, hit staff, attempted to enter other resident's room staff stood between resident and door so resident could not get into room, resident would start hitting and kicking staff to get to room very difficult to redirect. Nursing notes dated 12/18/15 at 3:49 AM state in part; pounding on doors, agitated. Nursing notes dated 1/12/16 at 1:50 AM state in part; attempting to go into other resident's rooms, yelling in hallway. Nursing notes dated 1/13/16 12:00 AM states in part; uncooperative with staff, wears, yells, shouts swings hands/fists, disruptive with other residents and is agitated with other residents. Social Service note dated 1/21/16 at 6:16 AM state in part; continues with 1:1 monitoring for her safety on and off the household. Nursing notes dated 1/23/16 at 3:58 PM state in part; Resident 1 is agitated, aggressive hitting, kicking, slapping, pounding on doors, throwing objects, swearing and yelling. Nursing notes dated 1/24/16 at 7:54 AM state in part; pacing from unit to unit shutting doors so staff could not follow, throwing items she picked up , tipping chairs, attempted to tip recliners, banging with fists on doors, yelling and swearing at staff, holding fist and shaking it asking staff do you want some of this? Nursing notes dated 1/25/16 at 7:42 AM states wandered form unit to unit hit, kicked, pinched, scratched, spit and shoved staff, ripped up papers from nursing station, cursed at staff, shut doors and would not allow staff through. Nursing notes dated 1/30/16 at 6:47 PM state in part; is uncooperative combative pushing staff wanders swings hands/fists yells and shouts Get out of here! Nursing notes dated 1/31/16 at 11:22 PM states in part; Resident 1 is uncooperative, combative is verbally abusive, agitated swings hands/fists yells and shouts, pushes, wanders to each household. Nursing notes dated 2/3/16 at 12:31 AM state in part; wandering from unit to unit attempting to go into other resident's room, slapped staff, pushed staff swearing unable to redirect. Nursing notes dated 2/4/16 at 2:51 AM states in part; slamming doors, hitting attempting to enter other residents rooms, charging at staff to hit and kick them, pushing furniture, throwing items unable to redirect. Nursing notes dated 2/4/16 at 11:56 PM state in part; did attempt to strike out at another resident and her family, staff able to come between Resident 1 and peer and prevent harm. Nursing notes dated 2/5/16 at 6:33 PM state in part; Resident 1 grabbed at other resident's food and would take it away, staff would be sure to keep Resident 1 from harming peers. Nursing notes dated 2/5/16 at 11:13 PM state in part; staff continue to come in between resident and others; physically abusive and is not easily redirected. Nursing notes dated 2/6/16 at 7:00 AM state in part; tipping furniture, hitting, kicking, pushing staff, shutting door on staff, charging at staff. Nursing notes dated 2/6/16 at 4:18 PM state in part; rapidly changing from pleasant to violent within seconds. Staff stands between Resident 1 and peers to prevent interactions. Nursing notes dated 2/8/16 at 7:32 AM state in part; Resident 1's behavior is very unpredictable throws pepper shaker, garbage can, tips furniture, wanders from unit to unit. Nursing notes dated 2/9/16 at 7:35 AM state in part; resident wandering unit to unit throwing plant, radio, and other items. Kicked, hit and pulled staff's hair shut doors on staff, chased staff unable to redirect behavior. Nursing notes dated 2/9/16 at 2:35 PM state in part; throwing chairs, threw lunch all over dining room. Social Service note dated 2/9/16 at 8:02 AM state in part; contact activated health care power of attorney (AHCPOA) to discuss recent changes in behaviors as they are becoming increasingly aggressive and difficult to redirect. Discussed possible referral to (Behavior facility name); AHCPOA gave permission to make referral. Social Service notes dated 2/12/16 at 4:20 PM Resident 1 was admitted to (Behavioral facility name). Nursing notes dated 2/11/16 at 6:36 PM state in part; as more activity started for dinner time Resident 1 got more excited and uncooperative, combative and disruptive, wanders, resistive, swings hands/fists kick at staff. Other residents separated to prevent confrontation. On 2/16/16 at 5:45 PM Surveyor interviewed confidential employee (CE) N regarding Resident 1. CE N stated that Resident 1 has significant behaviors; in December Resident 1 hit a Certified Nursing Assistant (CNA) so hard against the wall that it knocked the CNA unconscious and then Resident 1 punched the CNA and fractured the CNA's ribs. CE N stated other residents are affected by Resident 1's behaviors other residents are watching staff being hit, kicked, knocked down and swore at. CE N stated I do not understand why management allowed Resident 1 to walk over to the other unit that unit is not Resident 1's home. Would you allow a person in your home that was cursing and hitting others in your home? The residents were afraid of her. CE N stated that the week Resident 1 was discharged the staff had to shut the doors between the 2 dining rooms on Resident 1's household and place all the residents that lived on the household on one side and Resident 1 on the other side of the doors because Resident 1's behaviors were so unpredictable and out of control it was the only way to keep everyone safe. CE N stated that once the residents were done eating their dinner meal the staff had to file the other residents one by one back to their room just to keep them safe. On 2/16/16 at 10:10 AM Surveyor interviewed Certified Nursing Assistant (CNA) D regarding Resident 1's behaviors. CNA D stated Resident 1 was very aggressive she would wander off of her household and go over to the other household. Resident 1 was very difficult to redirect and was 1:1 at all times. CNA D stated Resident 1 would target residents on the other household. Surveyor asked CNA D if Resident 1 ever had Resident-to Resident incidents CNA D sated I know she did on the other household but I do not know who the resident was. On 2/16/16 at 10:20 AM Surveyor interviewed CNA E regarding Resident 1's behaviors. CNA E stated Resident 1 would hit, kick and was aggressive staff carried a pillow to place between Resident 1 and staff or Resident 1 and other Residents for safety. CNA E stated she was not aware of any contact made between Resident 1 and peers because staff always was there to intervene but there were attempts and you could tell residents were afraid of Resident 1. On 2/16/16 at 10:30 AM Surveyor interviewed CNA F regarding Resident 1's behaviors. CNA F stated Resident 1 would hit, kick, strike staff and scream she has thrown laundry baskets and put her head through a window. CNA F stated she was aware Resident 1 would attempt to strike Resident 13 and another peer but she did not think contact was made as staff would carry a pillow to protect staff and residents from Resident 1's hitting. Surveyor asked CNA F if management such as Social Workers were aware of Resident 1's behavior. CNA F stated management was aware they saw it first-hand. On 2/16/16 at 10:55 AM Surveyor interviewed CNA G regarding Resident 1's behaviors. CNA G stated Resident 1 would wander from neighborhood to neighborhood all day long. Resident 1 would hit, kick and was aggressive. CNA G stated residents on the other household would say they were scared of her. On 2/16/16 at 4:10 PM Surveyor interviewed Certified Nursing Assistant (CNA) O regarding Resident 1. Surveyor asked CNA O has she ever witnessed Resident 1 hit another Resident. CNA O stated yes, Resident 1 hit Resident 13 while Resident 13 was sitting in the dining room. CNA O stated Resident 1 always targeted Resident 13. Resident 1 hit Resident 13 in the back and head area. CNA O also stated she witnessed Resident 1 hit Resident 10 when she was in a violent rage and would go into the B house hold. CNA O continued to state Resident 1 would get into the faces of any resident on the A and B household and just scream in their face CNA O stated Resident 8 and Resident 5 have told us multiple times they feared Resident 1. CNA O stated they did tell us to carry a pillow to get in between Resident 1 and the other residents so when she struck out they would not get hurt. CNA O stated Resident 1 would just take the pillow and throw it she was very strong and when she got into a violent rage we could not control her. On 2/17/16 at 7:15 AM Surveyor interviewed Social Worker (SW) C regarding Resident 1's behaviors. SW C stated that in October/November Resident 1's behaviors increased. Resident 1 was being seen by the psychiatrist and Resident 1 had many medication changes. SW C stated that management worked with the staff regarding different ways they could approach and work with Resident 1. On 2/17/16 at 9:15 AM Surveyor interviewed Registered Nurse (RN) I and Social Worker (SW) H regarding Resident 1's behaviors and what the facility was doing to ensure Resident 1's behaviors were not negatively impacted others. SW H stated Resident 1 was assessed by the facility psychiatrist within the first several weeks of admission and received multiple medication changes. On 6/8/15 we spoke to staff on household about dementia. We initiated a cue card in December for staff to use this cue card to help give staff ideas for redirection. Management tried to model for staff we were out on the household trying to assist with Resident 1. Surveyor asked RN I and SW H why Resident 1 who wore a wandering bracelet was allowed to leave her household and go to other household RN I stated it was calming for Resident 1 and the two units are one household. Surveyor asked RN I and SW H if they were aware of resident's on the other household being afraid of Resident 1. RN I and SW H stated they were not aware of residents being fearful of Resident 1. On 2/17/16 at 2:26 PM Surveyor interviewed CNA P regarding Resident 1 and her stay at the facility. CNA P stated she witnessed Resident 1 hit Resident 13 in the back shoulder head area. CNA P stated it was a hard smack, i would have said owe. CNA P stated Resident 13 screamed and tried to hit Resident 1 back, but the staff moved her so she could not reach. CNA P stated Resident 1 reached over me and smacked her. CNA P stated I tried to stop her but she grabs the pillow and shoves you out of her way. Resident 1 is very strong and when she is and when she is in a rage it is hard. Surveyor asked CNA P how the other resident felt about Resident 1. CNA P stated Resident 5 was very afraid of Resident 1. CNA P stated I informed the nurse managers and the social workers when any resident stated they were afraid of Resident 1. On 2/17/16 at 4:00 PM Surveyor interviewed Social Worker (SW) C, and Director of Nursing (DON) B regarding Resident 1's behaviors. Surveyor asked SW C what the facility did to protect other resident from Resident 1's wandering, intrusive verbal and physically threatening behaviors. SW C stated that Resident 1 was always a 1:1 with staff. Surveyor asked SW C and DON B if they were aware of resident's being fearful of Resident 1. DON B and SW C stated they were not aware. Surveyor asked SW C if management ever spoke to the other resident's about Resident 1's behaviors and if Resident 1's behaviors negatively impacted them. SW C and DON B stated they had not received reports of resident's being afraid and had not spoken to residents about the negative impact Resident 1's behavior had on other residents. Resident 1 has moderate cognitive impairment and disruptive behaviors that affect other residents. At times Resident 1 threatens others and tends to target residents and staff. The facility/social service department failed to assess the impact Resident 1's behaviors have on other resident's psychosocial well-being. Resident 1's verbal and physical outbursts negatively impacted others and had the potential to impact others. Example 2 Resident 8 has the following Diagnoses: [REDACTED]. Resident 8's Minimum Data Set (MDS) with a completion date of 2/1/16 indicates Resident 8's Brief Interview for Mental Status (BIMS) score was 15. Resident 8 is cognitively intact and is her own decision maker. Resident 8 needs limited assist to transfer, does not walk. Resident 8 uses a wheel chair to move around in the facility. A Resident to Resident Altercation Flowchart dated 10/23/15 states in part; Resident 1 has Dementia. Does not recall incident or respond to questions - pacing. Do not feel there was intent. Resident 8, no complaint of (c/o) pain or redness to scalp, not upset by peer and says she if fine. (Note: The one page form is not signed to identify the person completing the resident to resident form.) Resident 8's Incident report, nursing note, dated 10/23/16 at 5:35 PM, Peer (Resident 1) was ambulating on household with staff and was agitated. Staff tried redirecting her away from residents but did end up making contact with this resident (Resident 8) and pulled hair on the back of her head and did toss a pillow onto her lap. Staff member, Certified Nursing Assistant, (CNA) was able to redirect resident away and notified team leader and Registered Nurse (RN). Witness/Staff involved: 2 CNAs identified. Interviewed: Household specialist and writer talked with Resident 8 after incident and resident denied pain and is not upset by peer. Resident states, I am fine. Sitting in day room. Conclusion: Based on my evaluation, this injury does not constitute actual or potential abuse. Resident 8's nursing note dated 10/24/15, I'm all right but that woman makes me nervous. Why is she always coming over here? On 2/16/16 at 4:10 PM Surveyor interviewed Certified Nursing Assistant (CNA) O regarding Resident 1. CNA O stated Resident 1 would get into the faces of any resident on the A and B household and just scream in their face CNA O stated Resident 8 and Resident 5 has told us multiple times she feared Resident 1. CNA O stated they did tell us to carry a pillow to get in between Resident 1 and the other residents so when she struck out they would not get hurt. CNA O stated Resident 1 would just take the pillow and throw it she was very strong and when she got into a violent rage we could not control her. CNA O stated yes Resident 8 stated she was afraid every time Resident 1 entered the house hold. On 2/17/16 at 9:30 AM, Surveyor spoke with Resident 8. Resident 8 stated Resident 1 came up and pulled her hair on her head. Resident 8 stated the staff had to make her let go of my hair. Resident 8 stated she was not sure who Resident 1 would target next or hit. Resident 8 stated she is terrified of Resident 1. Resident 8 stated it was terrifying to watch her hit and knock done the Certified Nursing Assistants (CNA). We were not sure what she was going to do next or if she was going to come after us (other residents) while the CNA was trying to get off the floor or get her pillow that Resident 1 threw across the room. Resident 8 stated the swearing was awful. It was terrifying to be here with her, wouldn't you be terrified of someone so violent and she just kept coming back over here and they just let her keep coming. Resident 8 stated her husband also lives in this household and he cannot defend himself or move on his own. Resident 8 stated it terrified me to think of what she may do next. On 2/17/16 at 4:00 PM Surveyor interviewed Director of Nursing (DON) B and Social Worker (SW) C regarding Resident 8's verbalization of being afraid of Resident 1. SW C and DON B stated they were not aware of Resident 8's reaction to Resident 1. DON B stated she would expect the staff to inform the nurse managers, social services and DON B of any Resident who expressed fear of another Resident. The facility/social service department failed to assess the impact Resident 1's behaviors have on Resident 8's psychosocial well-being Example 3 Resident 4 has the following Diagnoses: [REDACTED]. Resident 4's Minimum Data Set (MDS) with a completion date of 1/4/16 indicates Resident 4's Brief Interview for Mental Status (BIMS) score was 15. Resident 4 is cognitively intact. Resident 4 is dependent for transfer and supervision with locomotion moving on the unit. Resident 4 uses a motorized wheel chair for mobility. Resident 4's Nursing note, dated 2/12/16 at 11:30 AM, Emotional state: Resident appears frightened with other residents. Resident 4's nursing note, dated 2/12/16, at 11:34 PM, Mood patterns: Resident did express unrealistic fear regarding her environment several times (days) per week but not daily. (Note: On 1/15/16: Last documentation related to fears: Resident 4 did not express fears about environment, and is emotionally adjusted.) On 2/16/16 Surveyor reviewed Resident 4's Social Services notes from 9/1/15 through 2/17/16. Resident 4's Social services notes did not show evidence Resident 4 was reviewed for any psychosocial impact related to Resident 1 outburst and fear toward Resident 1. *12/23/15, Mood/Behavior: Resident 4 is agreeable to answering questions. She scored a 15/15 on the BIMS and voiced no mood concerns. *1/21/16, Quarterly staffing: Guardian was invited and did not attend. Social Services goals reviewed and remain appropriate. Will remain available to resident. On 2/16/16 at 4:10 PM, Surveyor interviewed Certified Nursing Assistant. (CNA) O regarding the impact that Resident 1 had on other resident on the A and B household. CNA O stated Resident 1 could become in a violent rage and then we (the staff) could not control her. Resident 1 would go into the B household and would scream and yell at the residents. CNA O stated Resident 4 has verbalized to the staff she was afraid of Resident 1. CNA O stated she reported every time a resident stated they were afraid to the nurses. On 2/17/16 at 10:45 AM, Surveyor spoke with Resident 4 regarding Resident 1. Surveyor asked Resident 4 if she remembered Resident 1. Resident 4 stated yes, she was the lady who kept coming over her and the staff would chase her carrying pillows because she kept hitting them. Surveyor asked Resident 4 how Resident 1 made her feel; Resident 4 stated whenever she seen Resident 1 she would cower in her wheel chair whenever she would come near her. Surveyor asked Resident 4 what she meant by cower? Resident 1 demonstrated she would lean way forward in her chair and cover her head or lean to the right side of her wheel chair as far as she could and cover her head. Resident 4 stated I did not want her to hurt me like she was hurting everyone else. Surveyor asked Resident 4 if she ever seen Resident 1 hit other residents. Resident 4 stated yes she has hit several other resident especially when we are at meals or in the main areas, she comes running threw and hits who ever she can reach. Resident 4 went on to stay she disrupted every meal in the dining room and Resident 1 would scream, yell and she swore. Resident 4 stated she would hit the staff really hard and take away the pillow they were to carry to protect us from Resident 1. Resident 4 stated we all watched it happened several times day. Resident 4 stated Resident 1 opened her door and tried to come in her and she screamed and screamed for s