Every finding on record at Clearwater Health & Rehabilitation of Cascadia

Based on observation, interview, and review of the U.S. Food and Drug Administration 2022 Food Code, it was determined the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This was true for 1 of 2 garbage cans observed in the kitchen. This deficient practice had the potential to affect all residents and staff in the facility. Findings include:U.S Food and Drug Administration 2022 Food Code, 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled.On 6/22/26 at 11:52 AM, a large gray garbage can on wheels was observed halfway under the dirty dish counter without a lid.On 6/22/26 at 3:01 PM, the Kitchen Manager stated she didn't know the garbage can needed to be covered and further stated she was under the impression it was okay to be stored under the counter without a lid.

Based on observation, review of the FDA Food Code, and staff interviews, it was determined the facility failed to ensure the kitchen equipment, ice machines, and cutting surfaces were maintained, clean, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 36 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1.The FDA Food Code Section 6-501.14 (A) documented cleaning ventilation systems intake and exhaust air ducts shall be cleaned so they are not a source of contamination by dust, dirt, and other materials.On 6/22/26 at 12:00 PM, the internal walk-in refrigerator fans were observed with a thick gray and fuzzy appearing build-up.On 6/22/26 at 3:05 PM, the Kitchen Manager stated maintenance cleans the fans in the refrigerator and confirmed the refrigerator fans were not clean. 2.The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.On 6/22/26 at 12:02 PM, a closed storage tub dated 6/10/26, with a use by date of 6/17/26, and was labeled ckn [chicken] soup was observed on the top right-hand shelf near the back of the walk-in refrigerator.On 6/22/26 at 3:03 PM, when asked about expired food, the Kitchen Manager confirmed the soup should have been discarded on 6/17/26 and should not have been in the refrigerator. 3. The FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils documented surfaces of utensils and equipment contacting food that is not time/temperature control for food shall be cleaned in equipment such as ice bins and enclosed components of equipment such as ice makers, at a frequency specified by the manufacturer, or absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.The SOM Appendix PP revised 7/23/25, documented equipment can become contaminated in various ways including improper sanitation.On 6/22/26 at 3:09 PM, the ice machine was observed to have orange colored, rust-like round spots on the interior hood of the ice machine.On 6/22/26 at 3:11 PM, the Kitchen Manager stated It's icky and there were spots of discoloration in the ice machine and further stated maintenance was responsible for cleaning the ice machines. 4. The FDA Food Code Section 4-501.12 Cutting Surfaces documented cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms (organisms that cause diseases like bacteria, viruses, and fungi) transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.On 6/24/26 at 1:35 PM, white cutting boards were observed to be stored under the steam table and were scratched and scored with residue and debris.On 6/24/26 at 1:38 PM, when asked about the cutting boards, the Dietary Manager confirmed the white cutting boards had debris on them but stated the kitchen staff just received new colored cutting boards and were no longer using the white cutting boards. When asked about the new cutting boards, the Kitchen Manager stated the new colored cutting boards were received about 30 days ago. When asked when the old cutting boards should have been discarded, the Kitchen Manager stated she should have discarded the old white cutting boards when the new cutting boards arrived.

Based on review of the State Operations Manual (SOM), record review, and staff interview, it was determined the facility failed to ensure residents exercised their right to formulate an Advanced Directive. This was true for 1 of 5 residents (Resident #5) whose records were reviewed. This failed practice created the potential for an adverse outcome if the residents' wishes were not followed. Findings include:The SOM, Appendix PP, revised 7/23/25, defined an Advance Directive is a written instruction such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Physician Orders for Life-sustaining Treatment (or POLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patient's treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST paradigm form is not an advanced directive.Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including dementia with agitation, stroke (occurs when a blood vessel in the brain becomes blocked or severely narrowed), and pulmonary embolism (PE- Occurs when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung).A Care Conference Review Comprehensive dated 4/3/26 documented, Resident #5 had an advanced directive.Resident #5's advanced directive was unable to be located in his medical record.On 6/26/26 at 9:48 AM, a request for a copy of Resident #5's advanced directive was made.On 6/26/26 at 11:19 AM, the CEO confirmed Resident #5 did not have an advanced directive on file.

Based on observation, policy review, and staff interview it was determined the facility failed to provide a homelike environment when resident's walls were left unrepaired and baseboard heater coils were left exposed. This was true for 1 of 12 residents (Resident #13) whose rooms were observed. This created the potential for psychosocial harm and embarrassment if residents did not have a homelike environment if their walls and baseboard heaters were not repaired and did not have consistent wall paint. Findings include: The facility's Homelike Environment policy, revised on 9/17/25, documented the facility supports a resident's right to a safe, clean, comfortable, and homelike environment to promote dignity, independence, and quality of life. Interior and exterior surfaces necessary for the health, safety, and comfort of the residents shall be kept at the highest practicable level, clean and in good repair.Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including dementia, post-traumatic stress disorder (PTSD- a psychiatric or mental health condition that can develop in individuals who have experienced or witnessed a life-threatening, shocking, or terrifying traumatic event), traumatic brain injury (TBI-brain damage caused by an external physical force), anxiety, and major depressive disorder.On 6/22/26 at 2:31 PM, it was observed throughout Resident #13's room, large chipped grayish-blue paint exposing jagged, round, and vertical white patches. Large horizontal white and black scratches were observed near the lower portion of the bathroom wall and three large oblong, jagged areas exposing both white and brown patches were noted to the left side of the sink wall. A black baseboard heater was noted below the window exposing gray/silver-colored coils.On 6/25/26 at 3:44 PM, the CEO was asked about the maintenance process. The CEO stated if a resident discharges from the facility and another resident is admitting, the maintenance department would be notified in their stand-up meetings to make sure any holes were patched, and walls were painted.On 6/25/26 at 3:52 PM, the CEO accompanied the Surveyor to Resident #13's room. The CEO described Resident #13's room as having a lot of chipped paint and the baseboard heater cover needed to be moved over. The CEO confirmed the heating coils for the baseboard heater were exposed and stated the condition of Resident #13's room was not a homelike environment.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure an allegation of resident abuse was reported to the State Survey Agency Portal within 2 - 24 hours. This was true for 1 of 3 residents (Resident #6) reviewed for abuse and neglect. This failure created the potential for harm if allegations were not acted upon in a timely manner and the resident abuse continued. Findings include:The State Operation Manual Appendix PP, issued 7/23/25, documented the reporting requirements of alleged abuse to the State Agency as follows:1.All alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property.2.The results of all investigations of the alleged violations.3. Immediately but not later than 2 hours - if the alleged violation involves abuse or results in serious bodily injury.4.Not later than 24 hours - if the alleged violations involve neglect, exploitation, mistreatment, or misappropriation of resident property, and does not result in serious bodily injury.Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including dementia with psychotic disturbance, difficulty walking and heart disease.A Comprehensive MDS assessment dated [DATE], documented Resident #6 was severely cognitively impaired.On 6/24/26 at 2:12 PM, when asked if he was informed of an abuse allegation of a resident, the Social Services stated he received an email from the Ombudsman regarding a resident [Resident #6] and a staff member. The Social Services stated he called the CEO and was told by the CEO she would take care of it.On 6/23/2026 at 3:22 PM, the Surveyor spoke to the Travel Nurse over the phone. The Travel Nurse stated he was on a night shift when he saw CNA #1 push Resident #6's both legs to her chest. Resident #6 was flailing her arms and stated to CNA #1 You are hurting me. The Travel Nurse stated CNA #1 slapped Resident #6's arms and reported it to the nurse on call.On 6/24/26 at 2:32 PM, the CEO with the Clinical Resource Nurse present, stated she was informed by the ACNO regarding Resident #6 was slapped by CNA #1 as reported by the Travel Nurse. The CEO stated she interviewed CNA #1. The CNA stated was trying to put Resident #6 to bed. Resident #6 was flailing her arms and CNA #1 put her arm up to avoid herself from being hit by Resident #6. The CEO stated there was another CNA in the room attending to another resident who reported the same thing. The CEO stated she interviewed the Travel Nurse and asked what he saw. The CEO stated the Travel Nurse reported he saw CNA #1 putting her arm to Resident #6, when asked to explain further what he saw. The CEO stated the Travel Nurse stated there was so much happening. The CEO stated the Travel Nurse was unable to provide specific information to clarify what he saw. When asked if the incident was reported to the State Portal, the CEO stated she did not report the incident to the State Portal. The Clinical Resource Nurse stated It was very vague. There was no true allegation of abuse. On 6/24/26 at 3:30 PM, the MDS Nurse with the ACNO present, stated she received a call from the Travel Nurse (MDS Nurse unable to recall the date of the call) that a CNA slapped Resident #6. The MDS Nurse stated she called the ACNO who then called the CEO. The ACNO stated she and the CEO went to the facility in the morning and interviewed the CNA.The facility's investigation report dated 4/13/26, documented the CEO spoke to the CRN about the situation. It was determined it was not potential abuse, However conducted abuse investigation and education with residents and staff. The Clinical Resource Nurse educated CEO that any time abuse is alleged it must be reported even if ruled out in the first 24 hours.

Based on record review, review of the SOM, and staff interview, it was determined the facility failed to ensure an allegation of abuse was investigated thoroughly for 1 of 3 residents (Resident #6) reviewed for abuse and neglect. This failure created the potential for residents to be subjected to ongoing abuse and risk of physical and psychosocial harm. Findings include:The SOM Appendix PP, issued 7/23/25, documented the facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment:1.Thoroughly investigate the alleged violation.2.Prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation was in progress.3.Take appropriate action, as a result of the investigation.Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including dementia with psychotic disturbance, difficulty walking and heart disease.A Comprehensive MDS assessment dated [DATE], documented Resident #6 was severely cognitively impaired.On 6/23/26 at 3:22 PM, the Surveyor spoke to the Travel Nurse over the phone. The Travel Nurse stated he was on a night shift when he saw CNA #1 push Resident 6's both legs to her chest. Resident #6 was flailing her arms and stated to CNA #1 You are hurting me. The Travel Nurse stated CNA #1 slapped Resident #6's arms and reported it to the nurse on call.On 6/24/26 at 2:12 PM, when asked if he was informed of an abuse allegation of a resident, the Social Services stated he received an email from the Ombudsman regarding a resident [Resident #6] and a staff member. The Social Services stated he called the CEO and was told by the CEO she would take care of it.On 6/24/26 at 2:32 PM, the CEO provided a copy of an investigation of Resident #6 alleged abuse by CNA #1. It documented the CNA #1; Travel Nurse and another CNA were interviewed regarding the alleged abuse to Resident #6. The investigation report documented that the Travel Nurse was standing in the doorway and watched CNA #1 putting her hand on the resident. When asked to clarify further the Travel Nurse was unable to provide more information. The report documented Resident #6 was having difficult time going to bed and was flailing her arms. CNA #1 was observed by another staff putting her hands up to block Resident #6 from hitting her. The report also documented that another CNA was called and confirmed Resident #6 was slightly agitated and was flailing her arms and legs.On 6/24/26 at 2:32 PM, the CEO stated when investigating an abuse allegation, she would typically get a written report from all the witnesses and make sure to assess the resident. The CEO stated she interviewed the CNA over the phone. The CEO stated the Travel Nurse was unable to provide specific information to clarify what he saw. When asked if the alleged abuse of Resident #6 was thoroughly investigated, the CEO stated Yes.The investigation report did not include interviews with another resident who were under the care of CNA #1, interviews of other staff who had worked with CNA #1, or an assessment of Resident #6 after the incident.

Based on record review, policy review, and staff interviews, it was determined that the facility failed to provide hospital transfer documents for 2 of 3 residents (#8 and #42) reviewed for hospitalization. This deficient practice created the potential for residents to experience harm if they were not treated in a timely manner due to lack of information. Findings include:The facility's Discharge or Transfer policy revised 8/30/25, documented that if a resident was being transferred and return was expected, the following information should be conveyed to the receiving provider:1. Contact information of the practitioner who was responsible for the care of the resident;2. Resident representative information, including contact information;3. Advance directive information;4. Special instructions and/or precautions for ongoing care, as appropriate such as:a. Treatments and devices (oxygen, implants, IVs, tubes/catheters).b. Transmission-based precautions such as contact, droplet, or airborne;c. Special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions; 5. The resident's comprehensive care plan goals;6. All other information necessary to meet the resident's needs, which includes, but may not be limited to:a. Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs;b. Diagnoses and allergies;c. Medications (including when it was last received);d. Most recent relevant labs, other diagnostic tests, and recent immunizations. The policy also documented, Facilities may choose their own method of communicating transfer or discharge information, such as a universal transfer form or an electronic health record summary, as long as the method contains the required elements. For residents being discharged (return not expected), the facility should convey all information listed above.The facility's Communication for Emergent Discharge/Transfer to Acute form, documented The marked boxes and clarifying information noted below is evidence that the information has been exchanged with the facility to which the resident is transferred, as well as to the individuals transporting the resident (if indicated). See progress notes for additional details. The form included the following items with check boxes next to each: Written Physician Order placed in PCC, Resident transfer form, face sheet, Order Summary Report, MARS, TARs, Care plan goals, Physician History and Progress Notes, Advanced Directive, POST.1.Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a progressive irreversible lung condition that restricts airflow, primarily caused by smoking or long-term exposure to lung irritants), dementia and repeated falls. A nursing progress note dated 3/4/26 at 12:45 PM documented that Resident #28 was transferred to the hospital via non-emergent transport for her hip. The face sheet, POST, and medications list were sent with the EMT. Family was aware of Resident #8's transfer to the hospital. On 6/24/26 at 9:40 AM, the CNO, with the CRN present, stated they were unable to find documentation indicating that the required documents were sent with Resident #8 when she was transferred to the hospital. When asked what should have been sent with Resident #8, the CNO stated that all documents listed on the Transfer form should have accompanied her during the transfer to the hospital. 2. Resident #42 was admitted to the facility on [DATE], with multiple diagnoses including iron deficiency anemia, hypertension, and duodenal (part of the small intestine) ulcer without hemorrhage or perforation.A nursing progress note dated 4/7/26 at 12:08 PM, documented around 6:10 AM staff went to Resident #42's room, while trying to help Resident #42, she stopped breathing for about 30 seconds. The nurse was called and notified the provider. The face sheet, discharge/transfer paperwork, and POST were sent with EMS.Resident #42's Communication for Emergent Discharge/Transfer to Acute form dated 4/7/26, did not have any boxes checked to indicate which documents were sent with her during transfer to the hospital.On 6/23/26 at 5:53 PM, the CNO, with the CRN present, reviewed Resident #28's Transfer form. The CNO stated there were no boxes checked on the Transfer form to identify which documents were sent when Resident #28 was transferred to the hospital.

Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct assessment information. This was true for 1 of 2 residents (Resident #13) whose MDS records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include:The RAI Manual, revised 10/1/2025, documented section A1500, Preadmission Screening and Resident Review (PASRR) was to be coded yes when a PASRR Level II screening determines a resident had a serious mental illness and/or intellectual ability, or related condition.Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including PTSD, TBI, anxiety, and major depressive disorder.Resident #13's admission MDS assessment dated [DATE], documented under A1500 in Section A, no for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? However, there was a PASRR Level II observed in his electronic medical record, dated 10/7/25.On 6/26/26 at 2:21 PM, the CEO with the MDS Nurse confirmed Resident #13's MDS assessment was coded that he did not receive a PASRR Level II, and it should have been coded yes.

Based on review of records, policy review, and staff interview, it was determined that the facility failed to ensure residents received further evaluation after being identified as having major mental illness. This was true for 1 of 2 residents (Resident #8) reviewed for PASRR Level II evaluations. This deficient practice created the potential for harm if residents specialized services for mental health needs were not evaluated by an appropriate state-designated authority. Findings include: The facility's Pre-admission Screening & Resident Review (PASRR) Process policy revised 8/29/25, documented a positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II. When a Level II PASARR screening is warranted, it should be obtained (as well as determination letter) prior to admission, unless otherwise authorized by such agency.Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including PTSD and major depressive disorder. A PASRR Level 1 assessment, dated 4/30/25, documented Resident #8 had personality disorder and PTSD which are both classified as major mental illness. Resident #8's record did not contain documentation indicating she was referred for PASRR Level II evaluation. On 6/25/26 at 5:02 PM, the CEO reviewed Resident #8's PASRR Level I assessment. The CEO stated, I could not determine if it was sent for Level II assessment. The CEO further stated it should have been sent for Level II evaluation.

Based on records review, policy review, and staff interview, it was determined the facility failed to ensure comprehensive resident-centered care plans included the target behavior being monitored for residents. This was true for 2 of 5 residents (#4 and #8) whose care plans were reviewed. This deficient practice created the potential for harm should residents receive inappropriate or inadequate care. Findings include:The facility's Comprehensive Care Plans & Conferences policy revised 9/3/25, documented, The facility will ensure that each resident has a timely, person-centered comprehensive care plan developed and maintained in accordance with professional standards of practice. The care plan will reflect the residents' individual conditions, risks, needs, behaviors, cultural values, and preferences, and will include measurable goals, appropriate interventions, and realistic timeframes.1. Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including major depressive disorder and other anxiety disorder.Resident #4's Behavior Monitoring directed staff to document the number of episodes per shift of the following target behavior 1. crying/tearful 2. suicidal ideations 3. poor appetite. The Behavior Monitoring also documented to monitor her for delusions/hallucinations.A review of Resident #4's care plan showed it did not address the identified behaviors.On 6/25/26 at 9:41 AM, the Social Services reviewed Resident #4's care plan. The Social Services stated Resident #4's signs of depression, delusions and hallucinations were not in the care plan and it should be.2. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including PTSD and major depressive disorder. Resident #8's Behavior Monitoring documented she exhibits potential mood disturbances and staff were directed to monitor her for crying, withdrawn, anger, irritability, anxiety and related behaviors.A review of Resident #8's care plan showed it did not address the identified behaviors.On 6/25/26 at 9:28 AM, the Social Services reviewed Resident #8's care plan. When asked if her target behavior were included in the care plan, Social Services stated, I don't see it currently on the care plan. The Social Services further stated, the target behavior should be in the care plan.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with respiratory services consistent with professional standards of practice. This was true for 1 of 2 residents (Resident #15) whose respiratory device was not stored properly. This deficient practice created the potential to cause contamination of respiratory equipment and increase the risk of respiratory infection for residents who require oxygen therapy. Findings include: The facility's Oxygen Administration, Safety, Storage, & Maintenance policy, revised on 10/10/25 documented to, Store oxygen and respiratory supplies in a plastic bag when not in use. Resident #15 was admitted to the facility on [DATE] with multiple diagnoses including COPD, congestive heart failure (CHF- a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), and obstructive sleep apnea (OSA-a chronic disorder where the upper airway repeatedly collapses during sleep, cutting off airflow.On 6/23/26 at 5:35 PM, Resident #15's wheelchair was observed sitting in the hallway next to Resident #15's bedroom door. The oxygen tubing was observed to be coiled and hanging around the right wheelchair handle, exposed and not in a bag. On 6/23/26 at 5:38 PM, CMA #2 was asked about the oxygen storage policy. CMA #2 stated oxygen tubing should be stored in a bag. CMA #2 then accompanied the Surveyor to Resident #15's room and confirmed Resident #15's oxygen tubing was hanging on the wheelchair and not stored in a bag. CMA #2 stated Resident #15's oxygen tubing should have been stored in a Ziploc or plastic bag that should have been attached to the back of Resident #15's wheelchair. On 6/23/26 at 5:51 PM, when asked about the oxygen storage policy, the CNO with the CRN present confirmed oxygen tubing should be stored in a bag when not in use.

Based on record review and staff interview, it was determined the facility failed to ensure nursing assistants (NAs) had completed or had enrolled in a state approved training and competency evaluation program within four months of hire. This was true for 1 of 6 NAs (NA #1) whose personnel file was reviewed. This failure had the potential to compromise the quality and safety of care provided to all residents living in the facility. Findings include:NA #1 was hired on 12/15/26 and had not obtained their CNA certification and had not enrolled in a CNA program within four months of hire. On 6/26/26 at 12:16 PM, the HR Manager confirmed NA #1 had not completed state approved training and competency evaluation program. The HR Manager further stated NA #1 last worked on 4/30/26 and confirmed NA #1 should not have been working after 4/15/26.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 3 of 3 residents (#4, #28, and #35) whose medications were reviewed. This deficient practice created the potential for Resident #4 to develop hypoglycemia when she did not receive her insulin. Resident #28 was at risk of worsening infection when he did not receive two doses of his antibiotic. Resident #35 was at risk of treatment failure when his cholestyramine was administered at the same time as his other medications, Findings include:The facility's Medication Administration policy, revised 9/10/25, documented that staff responsible for medication administration should follow the ten rights of medication administration.a. Right Medicationb. Right Residentc. Right Dosed. Right Routee. Right Time and Frequencyf. Right Documentationg. Right Assessmenth. Right to Refusei. Right Evaluationj. Right Education 1.Resident #4 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including diabetes, chronic kidney disease, and major depressive disorder. A physician order dated 12/16/25 documented Resident #4 was to receive Insulin lispro subcutaneously before meals and at bedtime for diabetes. Give even if residents do not eat. Inject per sliding scale as follows:-if 150 - 180 = 4 units181 - 220 = 6 units221 - 260 = 8 units261 - 400 = 10 unitsResident #4's June 2026 MAR documented she did not receive sliding scale of insulin lispro on 6/5/26 and 6/20/26.On 6/25/26 at 2:30 PM, the CRN stated they were unable to find documentation explaining why the insulin lispro was not administered to Resident #4. 2. Resident #28 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including stroke with hemiplegia and hemiparesis (paralysis and weakness of one side of the body), and aphasia (a language disorder that impairs a person's ability to speak, understand, read, and write).A physician's order dated 6/10/26 documented Resident #28 was to receive Cephalexin (antibiotic) 500 mg four times a day for infection.Review of Resident #28's June [DATE], documented he did not receive the 5:00 PM dose of Cephalexin on 6/15/26 and 6/16/26.On 6/25/26 at 2:34 PM, the CNO stated she spoke to RN #1, who said she did not administer the Cephalexin to Resident #28. The CNO stated RN #1 left it for the next shift nurse to administer, but unfortunately RN #1 did not inform the next shift nurse. 3. Resident #35 was admitted to the facility on [DATE], with multiple diagnoses including heart disease, dementia and PTSD.A physician order, dated 4/11/25, documented Resident #35 was to receive cholestyramine (used to treat chronic diarrhea caused by bile acid malabsorption) oral packet 4 grams. Give one packet by mouth before meals and at bedtime for chronic diarrhea mix in 4-6 oz of liquid. Hold for constipation. Take at least one hour prior to other medications or give other medications 4-6 hours after administration of cholestyramine.On 6/24/26 at 7:35 AM, CMA #1 administered Resident #35's cholestyramine along with his other 11 oral medications.On 6/25/26 at 9:58 AM, when asked how she administered Resident #35's cholestyramine, CMA #1 stated she administered it along with his other oral medications. CMA #1 stated, Yes, I am giving his medications all at the same time.Review of Resident #35's June [DATE], documented his cholestyramine was administered by CMA #1 in 52 out of 96 opportunities along with his other oral medications.On 6/25/26 at 10:02 AM, the CNO reviewed Resident #35's physician order for cholestyramine and was informed that the cholestyramine had been administered to Resident #35 along with his other oral medications. The CNO stated the physician's order should have been reviewed prior to administering the medications.

Based on record review and staff interview, it was determined the facility failed to provide a minimum of 12 hours of in-service education per year for 1 of 5 CNAs (CNA #2) reviewed for sufficient and competent CNA staffing. This failure placed residents at risk of receiving care from staff who are not adequately trained in competencies to meet residents' needs. Findings Include: On 6/25/26, the prior year's in-service training was requested for CNA #2.On 6/25/26 at 4:12 PM, the ACNO stated she was unable to provide documentation of CNA #2's 12-hour annual training.

Based on observation, Food Drug Administration (FDA) Food Code, and staff interview, it was determined the facility failed to ensure kitchen equipment was maintained. This deficiency had the potential to affect the 35 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes due to contaminated food services equipment. Findings include: The FDA Code Section 4-602.12 Cooking and Baking Equipment documented: Food-contact surfaces of cooking equipment must be cleaned to prevent encrustation's that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. On 4/17/25 at 8:03 AM, an aluminum baking sheet was observed being removed from the oven. The baking sheet was observed to have a dark film coating the pan and brown and black encrustation's with the hashbrowns being prepared. On 4/17/25 9:13 AM, the CDM stated the pans should be clean and should not have stains on them.

Based on staff interview, record review, and review of the State Survey Agency's Long-Term Care Reporting Portal, it was determined the facility failed to ensure residents were free from misappropriation of a controlled pain medication. This was true for 1 of 1 resident (Resident #44) reviewed for misappropriation of resident property. This failed practice created the potential for all facility residents to experience uncontrolled pain if misappropriation of their controlled pain medications went undetected, or if their controlled pain medication was not administered. Findings include: The facility's Drug Diversion policy, revised on 9/22/22, documented facility management shall investigate and make every reasonable effort to reconcile reported controlled substance discrepancies. The policy documented investigations would include interviews, medical record review, observation of facility practices, identify negative outcomes with residents, and evaluate if the loss is associated with specific individuals. A facility reported incident, dated 10/26/24, included an investigation summary which documented LPN #1 had removed 3 tablets of Oxycodone (an opioid pain medication) 5 milligrams each and placed them in a medication cup. LPN #1 then replaced the 3 tablets of Oxycodone with unidentified tablets. She then proceeded to ask LPN #2 who was coming on shift to administer the medication to the resident when the resident returned to the facility. Upon the residents return, LPN #2 was going to administer the medications in the cup when she noticed the tablets did not match the description of the opioid in the pharmaceutical packaging. LPN #2 requested a second opinion from a fell ow licensed nurse who agreed the medication left in the cup did not match the medication in the packaging. LPN #2 contacted the supervisor who confirmed the 3 tablets left in the medication cup with the resident's initials did not match the medication that was in the pharmaceutical packaging and notified the DON. The investigation summary documented 2 staff interviews indicating the medication left in the medication cup by LPN #1 did not match the description of the medication in the residents pharmaceutical packaging. The investigation summary documented the narcotic log, and the MAR were compared, and no discrepancies were identified. The facility medication carts were inventoried and found 1 resident to be missing 3 tablets of Oxycodone 5 mg. LPN #1 was terminated on 11/1/24 based on the results of the investigation. The facility notified the Idaho State Board of Nursing and the [NAME] Sheriff's Office of the alleged medication diversion. The nursing staff were provided training regarding the immediate reporting of anomalies in the narcotic log and medication administration. On 4/16/25 at 3:22 PM, during an interview with the DON and Administrator, the DON stated the investigation was determined to confirm misappropriation of resident property. There was sufficient evidence the facility corrected the non-compliance as of 11/1/24 as there were no further misappropriation reported after this date. At the time of the survey, the facility was in substantial compliance and therefore does not require a plan of correction.

Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure a residents Minimum Data Set assessment included correct information. This was true for 1 of 12 residents (Resident #29) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not monitored due to inaccurate assessments. Findings include: The RAI Manual, revised 10/1/24, documented section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR Level II screening determined a resident had a serious mental illness and/or intellectual disability, or related condition. Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder-depressive type, and generalized anxiety disorder. Resident #29's medical record included documentation of a PASRR Level I screening, dated 9/25/24 that identified he had a diagnosis of major mental illnesses, schizophrenia spectrum disorder and depressive disorder. Resident #29's medical record included documentation of a PASRR Level II screening, dated 9/27/24 that identified his major mental illness diagnoses and indicated he may benefit from specialized mental health services. Resident #29's medical record included documentation a PASRR MI (Mental Illness) Evaluation was conducted on 9/30/24. Resident #29's Admission MDS Assessment, dated 10/6/24, documented question A1500, PASRR Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability, or a related condition? The answer for this question was documented as no. On 4/16/25 at 4:17 PM, the MDS Coordinator stated she misinterpreted the question and answered A1500 no when it should have said yes.

Based on record review, and staff interview, it was determined the facility failed to ensure residents were offered non-pharmacological interventions while receiving opioid pain medication. This was true for 1 of 5 residents (Resident #7) reviewed for unnecessary medication. This failure created the potential for residents to experience adverse outcomes such as increased pain due to lack of offering non-pharmacological interventions. Findings include: Resident #7 was readmitted to the facility on [DATE], following a hip fracture with multiple diagnosis including history of falls, and history of osteoporosis with pathological fractures. Resident #7's care plan, revised on 4/8/25, documented Resident #7 was to use non-pharmacological interventions such as repositioning, reduced stimuli, warm towel, distraction, music, and massage to help manage their pain. A physician order, dated 10/21/19, documented non-pharmacological interventions were to be attempted prior to PRN pain medication administration. The order also documented this order was discontinued on 4/7/25. A physician order, dated 4/7/25, documented Hydrocodone-Acetaminophen 7.5-325 milligrams. Give 1 tablet by mouth every 8 hours as needed for a pain scale of 8 to 10 or severe pain. Resident #7's MAR documented the following as needed pain medication administrations: - 4/8/25 at 6:09 AM - 4/8/25 at 3:19 PM - 4/9/25 at 7:11 AM - 4/11/25 at 12:15 AM - 4/12/25 at 5:43 PM - 4/13/25 at 2:54 PM - 4/14/25 at 11:20 AM Resident #7's record did not contain documentation of non-pharmacological interventions attempted prior to pain medication administration. On 4/16/25 at 9:03 AM, the DON stated the record did not include documentation of non-pharmacological interventions.

Based on observation and staff interview, it was determined the facility failed to ensure medications available to residents were dated after opened. This was true for 1 of 2 medication carts reviewed for storage and labeling. This failure created the potential for residents to receive expired medication with decreased efficacy. Findings include: On [DATE] at 9:15 AM, during inspection of a medication cart, one prescription eye drop labeled Latanoprost 0.005% (a medication used to reduce intraocular pressure) documented on the packaging discard after 42 days. However, the medication did not document the date the medication was opened. On [DATE] at 9:22 AM, CMA #1 stated, the eye drops did not have an open date, and she could not tell when it was opened.

Based on record review, resident interview, and staff interview, it was determined the facility failed to ensure residents received physical therapy services as ordered by their physician. This was true for 1 of 3 residents (Resident #12) whose records were reviewed for rehabilitative services. This failure created the potential for Resident #12, who required physical therapy services, to experience decline in their physical functioning and ability to perform activities of daily living (ADL's) when these services were not provided consistently. Findings include: Resident #12 was readmitted to the facility on [DATE], with multiple diagnoses including muscle weakness, and gait and mobility abnormalities. On 4/14/25 at 4:46 PM, Resident #12 stated she did not have therapy services any more. A physician order, dated 3/7/25, documented Resident #12 was to receive physical therapy evaluation and treatment. Resident #12's care plan, dated 2/17/25, documented physical therapy as ordered. A Physical Therapy Evaluation and Treatment Plan, dated 3/28/25, documented Resident #12 was to have physical therapy 5 times a week for 8 weeks. On review of Resident #12's record, 5 out of 10 physical therapy sessions were provided. On 4/16/25 at 6:13 PM, the Rehabilitation Director stated Resident #12 did not receive all therapy sessions as per her physical therapy evaluation. She also stated Resident #12 should have been evaluated for therapy for 3 times a week based on her insurance.

Based on observation, policy review, staff interview, and record review, it was determined the facility failed to prevent the development of avoidable pressure ulcers. This was true for 2 of 3 residents (#3 and #38) reviewed for pressure ulcers. Resident #38 was harmed when he developed a Stage II pressure ulcer to his right heel and Resident #3 was harmed when she developed a Stage II pressure ulcer that worsened to an unstageable pressure ulcer to her left heel. Findings include: The facility's Prevention and treatment of [REDACTED]. condition demonstrates they were unavoidable. An Avoidable pressure ulcer means the resident developed a pressure ulcer and the facility did not do not evaluate the resident's clinical condition, implement interventions or revise the interventions as appropriate. Interventions included, Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.). The National Pressure Ulcer Advisory Panel website (www.npuap.org), accessed on 3/6/19, stated a pressure injury is damage to an area of skin and underlying soft tissue, usually located over a bony prominence, and may be associated with a medical or other device. The pressure injury can appear as intact skin or an open ulcer. A pressure injury results from severe and/or prolonged pressure or pressure with shearing. The website stated a Stage 2 pressure injury is 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. The Lippincott Manual of Nursing Practice, tenth edition, stated measures to prevent pressure ulcer development included repositioning every two hours, using special devices to cushion the specific area, and use an alternating pressure mattress or air fluidized bed for patients who are at high risk. 1. Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #38's quarterly MDS assessment, dated 2/2/18, documented he was moderately cognitively impaired and required extensive assistance of one staff with bed mobility and transfers. The MDS documented Resident #38 was at risk for pressure ulcers and had a history of [REDACTED]. Resident #38's at risk for skin breakdown care plan, dated 3/11/18, included interventions for a pressure reducing mattress to the bed and a cushion to his wheelchair, a padded foot rest to the right wheelchair foot pedal, weekly skin checks by the licensed nurse, and use of a draw sheet for turning and repositioning while in bed. The care plan did not include how often Resident #38 should have been repositioned in bed or to float his heels with pillows while in bed. Resident #38's record included documentation of visits at a clinic on 4/5/18 and 4/10/18. The documentation from the 4/5/18 clinic visit, signed by a physician on 4/10/18, stated Resident #38 had a bruise to his right lower humerus (arm bone). There was no documentation of a blister or wound. The clinic visit dated 4/10/18, signed by a physician assistant on 4/12/18, stated Resident #38 had no [MEDICAL CONDITION] or wounds. An Incident and Accident Report, dated 4/13/18 at 2:00 AM, documented Resident #38 had a flat blister with discoloration beneath. The blister was 4.2 cm x 4.0 cm to the right inner part of his heel. A Nurse's Progress Note, dated 4/13/18 at 4:30 AM, documented Resident #38 had a discolored area to the bottom of his right heel. The area was a flat blister which measured 4.2 cm x 4.0 cm with discoloration beneath the blister. The note stated Area Stage 2 pressure area as determined by site and wound. Resident with recent decline in ADL status and subsequent [DIAGNOSES REDACTED]. The note documented a heel boot was placed to relieve pressure to Resident #38's right heel. Resident #38's TAR documented weekly skin assessments were to be completed on Wednesdays. A Skin Integrity Review form, dated 3/28/18, documented Resident #38's skin was intact. A subsequent Skin Integrity Review form, dated 4/22/18, documented Resident #38 had blisters and an old open area. The body diagram on the form did not illustrate where the blisters and or open area were located. Skin assessments were not documented as completed on 4/4/18 and 4/11/18. Resident #38's skin breakdown care plan, revised on 4/26/18, documented a Potus boot (heel lift boot) was to be worn to relieve pressure to his right foot. The ADL's for bathing for (MONTH) (YEAR) documented Resident #38 received a shower on 4/2/18, 4/4/18, 4/8/18, and 4/12/18. On 4/11/18 it was documented Resident #38 refused. On 2/11/19 at 11:50 AM, Resident #38 was observed with a wrap to his right foot and ankle, TED (stockings worn to prevent blood clots) hose over the wrapped dressing, and a heel lift boot. CNA #1 stated Resident #38 had an open area to his right heel for a long time and he was going to the wound clinic for the first time on 2/12/19. A Wound Clinic Consult Report, dated 2/12/19, documented Resident #38 had a Stage II pressure ulcer and this was his first visit to the clinic. The report stated debridement to the right heel was .performed to remove devitalized tissue: biofilm and slough. Post debridement measurements: 2.5 cm x 2.3.cm x 0.3 cm noted as Stage 2 Pressure Injury. The report stated dressing changes were to be completed every two days. On 2/14/19 at 3:28 PM, the Dietitian stated the facility completed weekly skin checks on the residents scheduled shower days. The Dietitian stated Resident #38 refused to have a shower on 4/11/18. On 2/14/19 at 3:30 PM, a request was made to observe the dressing change for Resident #38. The DON stated the dressing was not due to be changed until 2/15/19, on the night shift. The DON stated she was not employed at the facility when Resident #38 acquired the pressure ulcer on 4/13/18. The DON stated Resident #38 had a Stage II pressure ulcer to his inner right heel. She stated they should have floated his heels when he was in bed and when he had a change of condition on 4/10/18. The DON was unable to provide documentation Resident #38's heels were floated prior to 4/13/18. The DON stated Resident #38's right leg was contracted which may have caused difficulty when trying to float his heels while in bed. On 2/14/19 at 3:40 PM, the RNC was unable to provide documentation in Resident #38's record the staff floated his heels while he was in bed from 4/4/18 through 4/13/18. She stated after the heel boot was in place on 4/13/18, the boot reduced pressure to his right heel. The RNC stated it was later changed to the heel lift boot on 4/26/18, to prevent further breakdown to his right heel. 2. Resident #3 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 1/31/19, documented Resident #3 was severely cognitively impaired and required extensive assistance of two staff with bed mobility and total assistance with transfers. An admission Braden Scale (a tool used to assess a resident's risk for developing pressure ulcers) assessment, dated 10/24/18, documented Resident #3 was at moderate risk for developing a pressure ulcer. Resident #3's record included a care plan initiated on 10/25/18 and 10/26/18, which identified her code status, her risk for falls, risk for an ADL deficit, and nutritional risk. Her care plan was revised to include risk for impaired skin integrity on 11/6/18. The skin integrity care plan included interventions for a pressure reducing cushion to her wheelchair and staff were to remind Resident #3 and assist her with repositioning at least every 2 hours. Resident #3's record included documentation she was assisted by staff with bed mobility and required total assistance with 2 or more staff on 11/2/18, 11/3/18, 11/4/18, 11/5/18, 11/6/18, and 11/7/18. There was no documentation in the record Resident #3 was assisted with repositioning, turning, or floating her heels. A Weekly Skin Check Report, dated 11/6/18 at 4:20 PM, documented Resident #3 had no skin conditions or changes, pressure ulcers, or injuries. A Weekly Pressure Ulcer Report, dated 11/7/18 at 8:32 PM, documented Resident #3 developed a new Stage II pressure ulcer to her left heel which measured 5.0 cm x 4.0 cm, and was described as a fluid filled blister. The report documented the pressure ulcer had a scant amount of thin, watery, pale red/pink fluid. The report also stated Resident #3 had limited activity for the past few days. A pressure ulcer care plan, initiated 11/8/18, documented staff were to float Resident #3's heels while in bed as she allowed, follow facility's policies/protocols for the prevention and treatment of [REDACTED]. Resident #3's (MONTH) (YEAR) TAR, dated 11/8/18 at 3:30 PM, documented licensed nurses were to assess the heel lift boot to her left foot two times a day, until the blister was resolved. Resident #3's (MONTH) (YEAR) TAR, dated 11/12/18 at 3:30 PM, documented licensed nurses were to apply skin prep to her bilateral heels two times a day for skin protection. A Physical Restraint Consent, dated 11/13/18, documented Resident #3 and spouse consented to have an air mattress with perimeter sides for her impaired skin (pressure injury). On 2/11/19 at 11:23 AM, Resident #3 was observed laying on her back in bed wearing her heel lift boot. Her left heel was turned sideways with her left heel touching her bed. CNA #2 stated the heel lift boot was not positioned correctly and repositioned the heel lift boot to have Resident #3's left heel not touching the bed. CNA #2 stated the heel lift boot was to allow the heel to float and alleviate any type of pressure to her heel. CNA #1 and CNA #2 stated the heel lift boot was initiated after Resident #3 developed a pressure ulcer to her left heel in November. On 2/11/19 at 12:22 PM, the DON was observed providing a dressing change to Resident #3's left heel. The left heel wound was black in color (eschar) with the wound bed edges lifted. The DON measured the wound and it measured 3.3 cm x 2.0 cm and the depth was undetermined, because the wound bed was covered with eschar. The DON cleansed the left heel wound, applied Santyl ointment (debridement ointment to remove the eschar), and covered the wound with an adhesive dressing. The DON stated the Santyl ointment was initiated a week ago and the wound bed edges were now lifting with the current treatment. The DON stated the staff should be checking and repositioning Resident #3's heel lift boot every two hours to ensure her heel was not touching anything to cause pressure. A Pressure Ulcer Investigation, signed by the DON on 2/13/19, stated Resident #3 had a left heel pressure ulcer discovered on 11/7/18. The investigation documented the pressure ulcer was 5 cm by 4 cm. The DON documented the facility consistently implemented interventions which included preventive skin care, consistently turn and position, utilization of appropriate pressure reduction support surfaces, incontinence management program, a registered dietician consult, and prevention was addressed on care plan to manage identified risk factors. Resident #3's care plan did not identify skin integrity as a risk until 11/6/18, and the consent for a pressure relieving mattress was not signed until 11/13/18. There was no documentation in Resident #3's record she was turned and repositioned consistently. On 2/14/19 at 3:54 PM, the RNC, with the DON, stated due to Resident #3's co-morbidities and refusal of care the facility did not cause the wound to Resident #3's left heel. The DON and the RNC stated the staff should check and reposition the heel lift boot at least every two hours and should have been documented as an intervention on Resident #3's care plan. The RNC was unable to provide documentation in Resident #3's record her heels were floated by pillows prior to the development of the pressure ulcer to her left heel.

Based on observation, policy review, resident and staff interview, and record review, it was determined the facility failed to ensure residents received diet textures ordered by their physician. This was true for 1 of 3 residents (Resident #23) whose diets were reviewed. This failure resulted in harm when Resident #23 experienced a choking episode which required emergency measures and transport to the hospital. Findings include: The facility's Meal Distribution policy, dated 3/2014, documented, 1. The Food Service Director will ensure that all meals are assembled in accordance with the individualized diet order, plan of care and preferences .3. The nursing staff shall be responsible for verifying the accuracy and delivery of meals to the residents/patients .4.the dietary department staff, under the supervision of the licensed nurse, will assemble the meal in accordance with the indicated meal card and present it to the resident/patient or care staff for delivery to the resident/patient. Resident #23 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A physician's admission order, dated 9/25/18, included a mechanical soft texture diet. An admission MDS assessment, dated 10/2/18, documented Resident #23 was cognitively intact, had coughing or choking during meals, had difficulty or pain with swallowing, and required a mechanically altered diet. An ST evaluation documented dates of service were from 9/26/18 to 1/28/19. The short-term goal for Resident #23 was to safely consume mechanical soft/chopped textured foods. An Incident and Accident Report, dated 12/16/18 at 1:15 PM, documented Resident #23 was sitting straight up in bed and visibly choking. Resident #23 could not breathe or make a sound, her face was severely red, lips were blue, and she was flailing her right arm and leg. The licensed nurse performed the [MEDICATION NAME] maneuver countless times before the object finally expelled. The object was a large piece of meat. Resident #23 began gasping for air, sobbing, and was sent to the ER for evaluation. On 2/13/19 at 10:00 AM, the consulting Registered Dietician stated she was aware Resident #23 had a choking episode. She stated dietary staff were retrained on meal service and tray preparation. On 2/13/2019 at 4:45 PM, RN #2 stated she was the RN on duty on 12/16/18, when Resident #23 choked on the food she was eating. RN #2 stated Resident #23 was not served the correct meal tray she was served a regular diet when mechanical soft was ordered. She said Resident #23 was eating while in the bed, and not in a chair as recommended. RN #2 stated staff was not present in the room as Resident #23 initially started choking. RN #2 stated staff heard noises coming from the Resident #23's room and found her banging the call light on the overbed table to get staff's attention. RN #2 described the emergent care provided which included the [MEDICATION NAME] Maneuver (a life-saving technique to clear the airway when an object becomes lodged) was administered to dislodge the meat and clear Resident #23's airway to allow her to breathe. RN #2 stated Resident #23 was transferred to the hospital for examination following the incident and then returned to the facility the same night. RN #2 stated Resident #23 complained of being sore, due to the [MEDICATION NAME] Maneuver when she returned to the facility. On 2/13/19 at 5:00 PM, the Director of Rehabilitation stated Resident #23 was assessed for safe eating and it was determined Resident #23 required a mechanical soft/chopped diet, should be seated in a chair or wheelchair to eat, and required supervision with meals. On 2/13/19 at 7:15 PM, Resident #23 stated she remembered the choking episode, and stated the food she swallowed was a piece of meat about the size of a golf ball. Resident #23 stated the choking episode was terrifying.

Based on observation, staff interview, and review of clinical records and Incident and Accident Reports, it was determined the facility failed to ensure: * Injuries of unknown origin and residents' allegations of staff mistreatment were recognized as potential indicators of abuse or neglect. * Allegations of potential abuse and neglect, as well as injuries of unknown origin, were thoroughly investigated. * Staff received abuse and neglect training. * Allegations of potential abuse or neglect, and injuries of unknown origin, were reported to the State Agency and the facility's Abuse Coordinator. This was true for 9 of 17 residents (#'s 7 - 9 and #'s 11 - 16) reviewed for accidents and supervision and for 1 of 3 Certified Nursing Assistants (CNA) #4, who did not receive abuse/neglect training prior to working in the facility. Specifically: a) Resident #7 sustained a 7 centimeter (cm) by 7 cm purple bruise to her right breast that the facility failed to investigate as an injury of unknown origin or report to the State Agency. b) Resident #9 was assessed on 7/4/17 with bruises to her left inner wrist and right forearm that were depicted by the facility as possibly caused by finger tips. There was no evidence the facility investigated this statement as potential abuse or to determine the cause of the injury. The facility failed to report the injury of unknown origin to the State Agency. c) Resident #12 voiced a concern of an unsafe transfer on 6/11/17, which resulted in a fall and skin injuries to her back. The facility did not conduct an investigation into the resident's concerns and failed to report the incident to the State Agency. Resident #12 sustained other injuries of unknown origin on 7/25/17, which the facility failed to investigate or report to the State Agency. d) Residents #'s 8, 11, 13, 14, 15 and 16 sustained various injuries of unknown origin in which the facility failed to thoroughly investigate or report to the State Agency. e) CNA #4 was unable to identify various forms of abuse and neglect. This deficient practice placed Residents #'s 7 - 9 and #'s 11 - 16, as well as 19 other residents in the facility, in immediate jeopardy of serious harm, injury, or death from the facility's failure to recognize, prevent, protect, and report potential incidents of abuse and/or neglect. Findings include: 1. Resident #7's quarterly Minimum Data Set (MDS) assessment, dated 6/26/17, documented moderate cognitive impairment with no signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION]; did not exhibit behaviors; required the total assistance of at least two staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; was non-ambulatory; and required the total assistance of one staff for wheelchair mobility. a. A 6/20/17 Interdisciplinary Progress Note documented staff observed a purple bruise to Resident #7's right breast that measured 7 centimeters (cm) by 7 cm. The Note documented the resident did not know the cause of the bruise and noted, (Resident #7) does use (the) sit to stand (mechanical lift and transfer device) with sling, this may be the cause of the bruise. Family notified. A 6/20/17 Incident and Accident (I&A) Report documented staff discovered a 7 cm x 7 cm purple bruise on Resident #7's right breast; the resident was sleeping immediately prior to staff discovering the bruise; and Resident #7, whose skin was described as dry, fragile, transparent/thin, decreased sensation, impaired circulation, experienced both short- and long-term memory impairment. The I/A documented Resident #7 had a history of [REDACTED]. The I/A, which had been signed by a direct care nurse and the facility's Director of Nursing (DON), documented the bruise to Resident #7's right breast was probably d/t (due to) sit to stand sling - res (Resident #7) has lg (large) breast (sic) - sling won't cover (her) breasts so staff will put (the sling) under her breast (sic). On the reverse side of the I/A, the DON wrote, Staff inserviced for placement of sling straps. The I&A included no other documentation. On 8/24/17 at 2:40 pm, Resident #7 stated she did not remember anything about the June bruising to her right breast. b. Resident #7's August 2017 physician's orders [REDACTED]. Resident #7's Interdisciplinary Progress Notes from 7/1/17 through 8/24/17 did not include any documentation or investigation related to a bruise on the resident's right forearm. 2. Resident #8's annual MDS assessment, dated 8/9/17, documented severe cognitive impairment; no signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION], no behaviors; total assistance of at least two staff required for bed mobility, transfers, toileting, and bathing; unable to ambulate; extensive assistance of one staff required for wheelchair mobility and personal hygiene; and anticoagulant therapy. a. A 7/26/17 I&A Report documented, Upon arriving at (6:00 pm) .CNA notified this nurse of bruise on (Resident #8's) left hip. The I&A Report documented the bruise was purple; the resident experienced short- and long-term memory impairment; required extensive assistance with transfers; and was dependent on staff for bed mobility. The I&A Report's Summary documented, CNA reported finding bruise at start of shift (6:00 pm) and unknown (sic) how it happened. The report was not signed by the DON to indicate it had been reviewed, and did not contain any other documentation. A 7/28/17 Interdisciplinary Progress Note documented a late-entry note for 7/26/17 of a bruise of unknown origin to Resident #8's left hip. The Note documented staff attempted to to notify the resident's family, and the resident's physician was notified of the bruise. b. A 7/29/17 Interdisciplinary Progress Note documented a nurse contacted the facility's Medical Director regarding an abrasion to Resident #8's right knee and bruise to her right leg. A 7/29/17 I&A Report documented, CNA notified this nurse of (an) abrasion on (Resident #8's right) knee and fading bruise on left sided (sic) shin. The wounds were described as red, no cause had been identified for the bruise or abrasion, the resident was independent with bed mobility, but required extensive staff assistance with transfers, and had an elevated PT/INR (blood clotting) lab value which made her prone to bleeding and bruising. The Report's Summary documented, Educate CNAs about safety with transfers when using Hoyer (mechanical lift). The report was not signed by the DON and included no other documentation. 3. Resident #11's quarterly MDS assessment, dated 6/26/17, documented severe cognitive impairment; no signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION]; no behaviors; total assistance of at least two staff required for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; total assistance of one staff required for wheelchair mobility; and the resident was not receiving anticoagulant therapy. a. A 3/26/17 I&A Report documented Resident #11 was assessed with [REDACTED]. The I/A documented Resident #11 had been sleeping prior to the identification of the bruised lower lip and noted that her identified behaviors included, Lays head on surfaces when tired. The I/A documented Resident #11 had 1 bruise in the previous 30 days, had fragile skin, and there had been no changes in Resident #11's usual caregiver. The I/A Summary documented, Resident lays head on surfaces when tired and this might be how she got her bruise. When resident shows signs of being tired will be layed (sic) down in bed. The DON signed the report on 3/30/17 and added, C/P (Care plan) when sleepy/leaning forward, (Aassist) to bed . The I/A included no other documentation. b. A 7/24/17 I&A Report documented a bruise on Resident #11's right forearm was red and that the resident was dependent on staff for transfers and that she experienced both short- and long-term memory impairment. The Report's Summary documented, (Resident #11) has bruise on (right) forearm, notified MD (physician on) 7/25/17, will continue to monitor area. The Report documented the resident would be equipped with arm protectors, and had been signed as reviewed. No other documentation was included in the Report. A 7/25/17 Interdisciplinary Progress Note documented a physician's Telephone Order directed staff to monitor Resident #11's right forearm bruise daily until resolved. The facility failed to thoroughly assess the potential cause of injuries sustained by Resident #s 7, 8, and 11 to rule out abuse and protect each resident from further injury. 4. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's Annual MDS assessment, dated 7/28/17, documented severe cognitive impairment and extensive assistance or dependence on 1 staff member for activities of daily living (ADL). An Impaired Cognition Care plan, dated 3/16/17, documented Resident #9 was cognitively impaired related to dementia and [MEDICAL CONDITION]. An I&A Report, dated 7/4/17, documented Resident #9 sustained multiple bruises of unknown origin that were nickel sized and brownish on her left inner wrist and right forearm. No further measurements were included and the report did not include a body diagram to illustrate the bruises arrangement at either location. A 7/5/17 follow-up to the I&A documented Resident #9's bruises were small and circular, appeared to be caused by finger tips, and were 3-5 days old. The I/A concluded the bruising was likely due to staff assisting Resident #9 with transfers, but no specific occurrence was determined. The I/A did not include witness statements, staff interviews, or resident interviews to determine the origin of the bruises, or a complete investigation to rule out potential abuse or neglect. The injuries of unknown origin were not reported to the State Agency. Resident #9's clinical record did not contain progress notes identifying the discovery of the wounds, their progression, or investigations of their cause. 5. Resident #12 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Skin Risk Care Plan, dated 6/23/16, documented Resident #12 was at risk of skin breakdown related to incontinence and immobility. Resident #12's Quarterly MDS assessment, dated 7/25/17, documented moderate cognitive impairment and dependence on 2 staff for transfers, bed mobility, toileting, and showers. A Fall Care Plan, dated 7/28/17, documented Resident #12 was at risk for falls and directed transfers were to be performed by 2 staff using a Hoyer mechanical lift. a. An I&A Report, dated 6/11/17, documented Resident #12 sustained 2 abrasions on her back. The report did not document the size or appearance of the abrasions. The report, which noted Resident #12 required the assistance of 2 staff for transfers, documented the abrasions were caused by a fall on 6/10/17. A 6/11/17 Witness Statement documented CNA #5 first observed the back abrasions while showering Resident #12. CNA #5 stated Resident #12 became upset when asked about the abrasions and stated she had been dropped on the floor by a staff member. CNA #5 stated Resident #12 said 1 staff member was assisting with the transfer, but the resident could not remember the name of the CNA. A 6/11/17 Witness Statement documented CNA #6 was showering Resident #12 and noticed red marks on her back. CNA #6 asked Resident #12 what happened and Resident #12 said she fell the day before when a staff member, whose name she could not remember, dropped her to the floor while assisting the resident transfer. A 6/16/17 Follow up to the I&A documented the abrasions were probably related to a gait belt used during transfers. No other witness statements where included in the report and the injuries of unknown origin and the 6/10/17 fall were not reported to the State Agency. b. An I&A Report, dated 7/25/17, documented staff discovered an open area on Resident #12's right buttock and a scratch on her right hip. The report did not document the size or appearance of the wounds. The report documented Resident #12 required 2 staff and a Hoyer mechanical lift for transfers. A follow-up to the I&A, which did not identify the cause of the 2 wounds, was signed as reviewed on 7/27/17. The conclusion did not include witness statements, staff interviews, or resident interviews to determine the cause of the wounds or to determine whether the injuries were the result of potential abuse or neglect. Resident #12's injuries of unknown origin were not reported to the State Agency. 6. Similar findings were found for Residents #'s 13-16. On 8/24/17 at 9:15 am, the DON stated the I&A reports were completed to his knowledge and any witness statements would be attached to the applicable I&A report. The DON stated he did not always document witness statements, especially if the witness did not see anything. The DON stated he submitted investigations to the facility's Executive Director when there were signs of potential abuse or neglect. On 8/24/17 at 3:37 pm, the Executive Director stated an injury of unknown origin was an injury which could not be explained, that was unwitnessed, and the resident could not identify how it occurred. The Executive Director stated the facility was to obtain witness statements, interview staff and residents to try and determine the cause of an injury, and investigate the incident as a case of potential abuse or neglect. The Executive Director said providing State Agency notification of potential abuse and neglect was dependent of the circumstances of the investigation. He stated if the circumstances indicated abuse and/or neglect occurred, then the facility would intervene and report. The Executive Director stated all injuries of unknown origin should be reported to the State Agency. The Executive Director stated he did not complete the investigations for injuries of unknown origin involving Resident #s 7-9 and #s 11-16 as these were a clinical thing. The Executive Director stated investigation reports were to come to him for review. The Executive Director stated the DON completed the investigations and that there was not a system in place for supervising the investigations related to injuries of unknown origin. The Executive Director stated he had not reviewed some of the investigations outlined above and that he was not aware of those investigations' deficiencies until 8/24/17. The Executive Director stated if a resident fell while being transferred by 1 staff when he/she was care planned for transfers by 2 staff then the incident should be investigated for potential neglect or abuse. On 8/24/17 at 3:55 pm, the DON stated an injury of unknown origin was an injury that was unexplainable, unwitnessed, and the resident was unable to tell how it occurred. He stated he was not sure when injuries should be reported to the State Agency. 7. On 8/25/17 at 10:40 am, CNA #4 said she had been working in the facility since April 2017 and had not received training on abuse and neglect from the facility upon her hiring. CNA #4 stated she had not received a refresher training on abuse and neglect since she had been employed, and was able to identify only three types of abuse, physical verbal, and mental. CNA #4 could not identify sexual abuse, corporal punishment, involuntary seclusion, or misappropriation of residents' property as signs of possible abuse or neglect. CNA #4 stated she did not know what to do if she suspected the facility's Executive Director of resident abuse. CNA #4's employee file was did not include a training record for any topic related to abuse and neglect. An All Staff Education Attendance Sheet on Abuse and Neglect, dated 1/12/17 from 4:10 pm - 4:25 pm, identified 60 individuals who were required to attend. The attendance sheet contained 25 signatures from staff members. An All Staff Education Attendance Sheet on Resident Abuse, dated 1/12/17 from 4:25 pm - 4:35 pm, identified 60 individuals who were required to attend. The attendance sheet contained the same 25 signatures from the 4:10 pm to 4:25 pm meeting. An All Staff Education Attendance Sheet on Resident Abuse, dated 7/18/17 and scheduled for 15 minutes, identified 47 individuals who were required to attend. The attendance sheet contained 13 signatures from staff members. CNA #4's name was not identified on the list as an individual required to attend the training. On 8/25/17 at 11:15 am, the DON stated he could not provide evidence that CNA #4 received training on abuse and neglect prior to working in the facility. He stated there were other staff working in the facility, as well, who had not yet received abuse/neglect training. The DON stated the All Staff Education Training Records provided for review were all the abuse/neglect training records the facility had on file. The facility was notified in writing of the immediate jeopardy and the need to formulate and implement a plan of removal on 8/25/17 at 8:23 am. On 9/1/17 at 11:59 pm, the facility provided evidence that an acceptable plan to remove the immediacy had been developed and implemented. The plan included: * Updating the facility's Abuse Policy and Procedure to meet regulatory guidelines and include injuries of unknown origin. * Investigation of the injuries of unknown origin outlined above and implementation of the facility's abuse policy. * Educating staff on the new abuse policy and procedure to ensure injuries of unknown origin were reported and investigated to determine potential neglect and/or abuse.

Based on staff interview and record review, it was determined the facility failed to ensure: * Investigations into injuries of unknown origin and/or potential abuse and neglect allegations were completed. * Allegations of potential abuse were reported to the facility's Executive Director and State Agency responsible for regulatory oversight. * Neglect/Abuse policies and procedures were current and implemented with existing regulatory requirements. This deficient practice placed Residents #'s 7 - 9 and #'s 11 - 16, and all 19 other residents in the facility, in immediate jeopardy of serious harm, injury, or death from potentially unrecognized abuse or neglect. Findings include: The facility's Resident Abuse Policy and Procedure, revised 9/1/16, defined physical abuse, verbal abuse, sexual abuse, psychological/ emotional abuse, neglect, and misappropriation of residents' property, but did not define corporal punishment, involuntary seclusion and or injuries of unknown origin. Additionally, the Policy and Procedure documented: * Training - Staff would receive education and training during orientation and annually thereafter on resident rights, and resident abuse and neglect reporting. An addendum documented staff would receive training and competency testing upon hire, quarterly and following allegations of abuse, neglect or misappropriation of property. It was unclear whether training and education would be provided quarterly and/or annually. * Employee Obligation - The policy documented staff making a false or misleading report of abuse would be in violation of the facility's policy and did not provide protection from reprisal for staff who made allegations of potential abuse and/or neglect in good faith. * Prevention - The policy documented the facility was committed to preventing abuse, neglect, and misappropriation of property, but did not address corporal punishment and involuntary seclusion. * Identification - All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) were to be investigated by the Director of Clinical Services. Patterns or trends would be identified that might constitute abuse. This information was to be forwarded to the Executive Director, who serves as the facility's Abuse Coordinator, and an abuse investigation was to be conducted. The policy did not, however, include injuries of unknown origin requiring investigation for potential abuse or neglect. * Investigation - The policy documented the Abuse Coordinator or a designee would investigate all reports or allegations of abuse. The policy documented those suspected of potential abuse would be segregated from residents pending the investigation. The policy documented a nurse would perform and document a thorough nursing assessment of the resident and file an incident report with the Abuse Coordinator. The policy documented the Abuse Coordinator or the Director of Clinical Services would obtain statements from the victim, the suspect, and all possible witnesses including all other employees in the vicinity of the alleged abuse, and complete a report. The policy did not include an investigative procedure to follow for injuries of unknown origin. * Procedures for Reporting Abuse - The policy documented staff members suspecting abuse must immediately notify nursing supervision, who must immediately report to the Executive Director. The policy specified the Executive Director was responsible for reporting allegations to officials per federal guidelines. An addendum documented the facility must complete and submit an initial report to the State Agency within 24 hours and a completed full investigation within 5 days. The policy did not distinguish between allegations of serious bodily harm and harm for reporting purposes; specify that allegations involving serious bodily harm must be reported to the State Agency no later than 2 hours after an allegation was made; and did not inform staff when to report injuries of unknown origin as defined by regulatory requirement. On 8/24/17 at 9:15 am, the Director of Nursing (DON) stated the facility's Incident & Accident Report (I&A) file was complete. The DON stated witness statements would be attached to the applicable I&A Report. The DON stated he did not always document witness statements when the person did not personally witness a reported event. The DON stated he would submit investigations for review to the Executive Director if through the investigation process there were signs of potential abuse or neglect. On 8/24/17 at 3:37 pm, the Executive Director stated an injury of unknown origin was an unwitnessed injury which could not be explained and the resident could not identify how it occurred. He stated the policy did not define injuries of unknown origin because it was not necessary and that staff would investigate these type of injuries. When shown several of the facility's I&A reports, the Executive Director stated he was seeing some of the investigations outlined above for the first time and that he was not aware until 8/24/17 that full and thorough investigations were not completed as required. The Executive Director said the DON completed the investigations and stated that there was no system in place for supervising the investigations related to injuries of unknown origin. Refer to F225 as related to the facility's failure to identify injuries of unknown origin and potential abuse or neglect, report such injuries to the Executive Director and State Agency, and provide abuse/neglect training to staff prior to the provision of resident care. Refer to F494 as related to the facility's failure to provide abuse/neglect training to staff. Refer to F498 as related to the facility's failure to ensure CNA competencies were completed. The facility was notified in writing on 8/25/17 at 8:23 am of the immediate jeopardy and the need to formulate and implement a plan of removal. On 9/1/17 at 11:59 pm, the facility provided evidence that an acceptable plan to remove the immediate jeopardy had been developed and implemented. The plan included: * Updating the Abuse Policy and Procedure to meet regulatory guidelines and include injuries of unknown origin. * Investigation of injuries of unknown origin and implementation of the facility's abuse policy. * Educating staff on the new abuse policy and procedure to ensure injuries of unknown origin were reported and investigated as potential incidents of abuse and/or neglect.

Based on observation, review of facility policies and procedures, resident grievances, and resident and staff interviews, it was determined the facility failed to follow and update policies to reflect current regulatory guidelines and standards of practice regarding abuse and neglect; train and verify staff competency in the provision of care and services; and ensure infection control programs were implemented to protect residents from infection. This failed practice placed the health and safety of 9 of 17 (#'s 7 - 9 and #'s 11 - 16) residents and all other residents in the facility in immediate jeopardy of serious harm, impairment or death from staff abuse or neglect. Findings include: 1. Immediate Jeopardy was identified in the following areas: * Refer to F225 as it related to ensure injuries of unknown origin and resident allegations of possible neglect were recognized, investigated, and reported to the State Agency and facility Abuse Coordinator as potential indicators of abuse and/or neglect. The facility additionally failed to ensure staff received abuse/neglect training upon hire and annually. * Refer to F226 as it related to update and operationalize policies and procedures to prevent, identify, investigate, protect against, and report potential incidents of resident abuse, neglect, and/or misappropriation of property. * Refer to F520 as it related to ensuring the facility's Quality Assessment and Assurance program effectively monitored facility care processes to protect residents from potential harm and previously identified deficient practices did not recur. On 8/24/17 at 3:37 pm, the Executive Director stated injury of unknown origin investigations were a clinical thing for which the Executive Director had no responsibility other than to review the investigations to ensure they were complete. The Executive Director stated he now realized injuries of unknown origin should be reported to the State Agency. On 8/25/17 at 7:30 am, the Executive Director stated facility procedure required the Director of Nursing (DON) to notify the Executive Director of injuries of unknown origin only when neglect or abuse was suspected. The Executive Director said the facility's Assistant Director of Nursing (ADON) was not aware he/she was expected to investigate and report these type of incidents when the DON was absent from the facility. On 8/25/17 at 11:15 am, the DON stated he could not provide evidence that staff received abuse/neglect training prior to working in the facility and that the facility currently had staff working in the building who had not received abuse/neglect training. The DON stated the facility did not yet have a scheduled employee training developed for newly hired staff and there were no individual staff training records available for review. The facility was notified in writing of the Immediate Jeopardy and the need to formulate and implement a plan of removal on 8/25/17 at 9:48 am. On 9/1/17 at 11:59 pm, the facility provided evidence that an acceptable plan to remove the immediacy had been developed and implemented. The plan included: * Administrative staff received education related to abuse, neglect and injuries of unknown origin by the Director of Compliance, who would also educate all staff prior to their next shift. *The Executive Director would report all allegations of potential abuse and neglect to the State Agency. * The Executive Director would ensure the facility investigated injuries of unknown origin and implement the facility's abuse policy. 2. Non-Immediate Jeopardy deficiencies were identified in the following areas: * Refer to F279 as it related to the development of comprehensive care plans. * Refer to F280 as it related to the revision of care plans based on residents' needs. * Refer to F309 as it related to diabetic management. * Refer to F323 as it related to adequate supervision and safety assessments. * Refer to F329 as it related to targeted behaviors, indications for the use of [MEDICAL CONDITION] medications, and monitoring of [MEDICAL CONDITION] medication usage. * Refer to F441 as it related to infection control. * Refer to F463 as it related to resident call light system function and monitoring. * Refer to F494 as it related to staff abuse and neglect training. * Refer to F498 as it related to the completion of Certified Nursing Assistant (CNA) competencies.

Based on observation, resident and staff interview, record review, and review of the facility's policies and procedures, it was determined the facility failed to ensure the Quality Assessment and Assurance Program (QAA) identified deficient practices, and developed and implemented effective plans of action to protect residents related to potential abuse and neglect, identification of injuries of unknown origin, infection control, and quality of care issues that placed the health and safety of 9 of 17 (#'s 7 - 9 and #'s 11 - 16) residents in the facility in Immediate Jeopardy of serious harm, impairment or death. The QAA program additionally failed to ensure prior deficient practice did not recur. The lack of an effective ongoing QAA processes placed all residents in the facility at risk of serious harm, impairment, or death. Findings include: 1. The following deficiencies were identified at Immediate Jeopardy during the survey: * Refer to F225 as it related to injuries of unknown origin and resident allegations of possible neglect and/or abuse and staff training. The facility was previously cited at F225 during the prior recertification survey of 6/10/16. * Refer to F226 as it related to the operationalization of facility policies and procedures for the protection of residents and the prevention, identification, investigation, and reporting of potential abuse, neglect, and injuries of unknown origin. * Refer to F490 as it related to the oversight of daily operations related to resident care. The facility was notified in writing of the Immediate Jeopardy and the need to formulate and implement a plan of removal on 8/25/17 at 9:48 am. On 9/1/17 at 11:59 pm, the facility provided evidence that an acceptable plan to remove the immediacy had been developed and implemented. The plan included: * The Executive Director would ensure infection control logs were current and concerns were brought forward to the QAA committee meetings. * The facility would review the updated abuse policy and procedure through the QAA committee, and the QAA committee would ensure the facility investigated injuries of unknown origin appropriately and ensure the facility implemented the facility's abuse policy. 2. Additionally, the facility's QAA program did not provide sufficient monitoring to maintain ongoing compliance and had the potential to harm all residents in the facility if care and services were not provided in a safe and effective manner as follows: * Refer to F279 as it related to the development of comprehensive care plans. The facility was previously cited at F279 during the prior recertification survey of 6/10/16. * Refer to F280 as it related to the revision of care plans based on residents' needs. The facility was previously cited at F280 during the 8/26/16 revisit survey . * Refer to F309 as it related to diabetic management. The facility was previously cited at F309 during the April 2012, August 2013, October 2014, and June 2016 recertification surveys, as well as the August 2016 revisit survey. No surveys were completed at the facility during calendar year 2015. * Refer to F323 as it related to supervision and safety assessments. The facility was previously cited at F323 during the April 2012, October 2014, and June 2016 recertification surveys. No surveys were completed at the facility during calendar year 2015. * Refer to F329 as it related to the administration of medications with specific target behaviors identified for monitoring, specific indications for use, clinical rational and justification for the continued use of a medication, and effectiveness monitoring. The facility was previously cited at F329 during August 2013, October 2014, and June 2016 recertification surveys, as well as the August 2016 revisit survey. No surveys were completed at the facility during calendar year 2015. * Refer to F441 as it related to infection control. The facility was previously cited at F441 during the June 2016 recertification surveys. On 8/25/17 at 7:30 am, the Executive Director stated each department audited another department in the facility as part of the QAA process. The Executive Director could not explain how audits would incorporate return demonstration and ensure correct procedures were performed when, for example, the Maintenance Director audited a clinical area and vice versa. The Executive Director stated this audit system had not identified the issues above or other concerns brought forth through survey.

Based on observation, interview, and record review, it was determined the facility failed to minimize the risk of injury for 2 of 21 residents (#6 and #17) reviewed for supervision and assistive devices. This deficient practice created the potential for harm if residents did not receive adequate supervision or safe assistive devices to avoid injury. Findings include: 1. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #17's Impaired Cognition Care Plan, dated 3/4/16, documented, Impaired cognition related to dementia. (The) resident will maintain (his) highest level of cognitive functioning as evidence (sic) by being able to make his wants and needs known, able to understand verbal cues and direction from staff, and remain alert and orientated (sic) to self, place, and others through the next review. Staff were to monitor Resident #17 for changes in cognition and provide reorientation/validation as needed. A 5/30/16 Physician's Telephone Order, countersigned by the physical therapist and a nurse, documented Resident #17 was assessed as safe to walk outside the facility without an assistive device or supervision. A Physical Therapy Discharge Summary, dated 5/31/16, documented Resident #17 met all long-term goals for treatment and could enter and exit the facility without an assistive device or supervision. The Summary documented Resident #17 could independently inform staff he was leaving the facility, sign the log book before leaving, and walk more than 500 feet on varied surfaces before requiring a rest. A Fall Prevention Care Plan, dated 12/6/16, documented Resident #17 was at risk for falls due to impaired cognition, and that staff were to complete quarterly fall risk assessments as well as observe the resident for changes in cognition/functional status. Resident #17's quarterly Minimum Data Set assessment, dated 7/21/17, documented moderate cognitive impairment, antianxiety medication therapy, and supervision and set-up assistance required for all activities of daily living (ADLs), including transfers and ambulation. On 8/22/17 at 10:26 am, Resident #17 was observed walking out the front door of the facility alone. The resident did not tell staff he was leaving the facility nor did he sign the facility's sign-out book. Resident #17 crossed the facility's parking lot and walked down the driveway, which had an approximately 15- degree slope and led to a street in front of the facility. The resident lit a cigarette and then walked down the street to an intersection that led to a two-lane highway. Resident #17 walked to the intersection at the highway, turned, and walked along the left side of the highway for approximately 40 feet, the last 15 feet of which had no shoulder. The resident then approached an overturned orange street construction cone lying in the road, which he picked up and repositioned on the side of the road. At that time, Resident #17 stood at the end of the road and continued to smoke the cigarette. At 10:28 a.m., Certified Nursing Assistant (CNA) #1 drove by in her car and waved at Resident #17. Shortly after, Resident #17 returned to the facility. On 8/22/17 at 11:15 am, Resident #17 stated he had a cigarette lighter in his pocket that he used to light his cigarette. He stated he liked to smoke by the highway. The resident stated he liked to go out and walk, and that he usually walked to a log pile one mile up the road and then back. The resident stated he was supposed to sign out or tell staff whenever he left the building, but that he forgot to tell staff when he left the building at 10:26 am. On 8/22/17 at 11:38 am, Licensed Practical Nurse (LPN) #1 stated Resident #17 was the only resident in the facility who was allowed to leave the facility's ground and and walk by himself. She stated residents were required to be independent with ADLs, cognitively intact, not be at risk for falls, and assessed as safe by a physical therapist to walk outside the facility without supervision. LPN #1 stated she did not believe Resident #17 was allowed to walk along the highway, and said she thought Resident #17 was to remain on the facility's property. On 8/22/17 at 11:45 am, CNA #1 stated she saw Resident #17 by the highway and thought it was suspicious because he usually stayed on the facility grounds or walked in the surrounding area. CNA #1 stated she would need to ask the Director of Nursing (DON) to determine whether it was safe for Resident #17 to be near the highway. On 8/22/17 at 12:00 pm, the DON stated Resident #17 was encouraged to walk outside, but that he would not want Resident #17 to walk along the highway as he had at 10:26 am. The DON stated residents who walk outside the facility were supposed to sign out or tell the front office staff they were leaving the facility. The DON said Resident #17 did not always sign out when he left the facility. An 8/22/17 letter from the facility's Medical Director documented he had been asked to review Resident #17's status of having both outside and off-grounds privileges, both without assistive devices and unaccompanied. The Medical Director stated the request was in response to concerns the resident's [DIAGNOSES REDACTED]. The Medical Director stated Resident #17 had a physician's orders [REDACTED]. The Medical Director noted the order had been issued with the support of physical therapists and wrote in the letter that the order is appropriate. On 8/22/17 at 4:00 pm, the facility's Therapy Department Director stated Resident #17 had not been recently evaluated for safety awareness or walking outside near cars and that therapists did not evaluate residents for safety in crossing roads where traffic was present. 2. Resident #6 was readmitted to the facility on [DATE] with multiple diagnoses, including contractures of the right forearm, cerebrovascular accident (CVA - stroke), aphasia, dementia, muscle weakness, abnormal posture, [DIAGNOSES REDACTED] and hemiparesis affecting the right side, and dependence on a wheelchair for locomotion. The Quarterly MDS assessment, dated 7/19/17, documented Resident #6 experienced moderate cognitive impairment and required the extensive assistance of 1 staff member for transfers and bed mobility. The MDS documented the resident required supervision with wheelchair locomotion and experienced unilateral range-of-motion (ROM) impairment affecting both the upper and lower extremities. Resident #6's ADL Care Plan, dated 7/25/17, documented staff assistance was required with ADLs due to impaired mobility related to [DIAGNOSES REDACTED] and that the resident used his foot to self-propel his wheelchair. A Skin Prevention Care Plan, dated 4/26/17, documented Resident #6 was at risk for skin breakdown related to wheelchair dependence and impaired mobility and that he was to wear antiembolic hose to his right leg when he was out of bed. An Incident /Accident (I&A) Report, dated 4/26/17, documented, Resident #6 sustained a recent injury of unknown origin (skin tear), which was described as dry, the size of a nickel, and with edges (that) do not approximate easily. The I&A documented the wheelchair pedal's rough edges may have contributed to Resident #6's skin tear, which was discovered during a shower on the bottom of his foot, and measured 2 centimeters (cm) x 1.2 cm x 0.1 cm. The I&A documented Physical Therapy would evaluate the foot pedal to ensure the resident's safety. On 8/22/17 at 8:47 am, Resident #6 was observed self-propelling a wheelchair down the hallway with his right foot dragging on the ground slightly under the foot pedal. Resident #6 stopped his wheelchair in front of his room and attempted to raise his foot onto the foot pedal, but could not extend his leg high enough to place his foot on the foot pedal. Resident #6 attempted to raise his foot another 3 times before once again self-propelling the wheelchair down the hall with his foot dragging on the floor slightly under the foot pedal. On 8/23/17 at 2:52 pm, the DON stated he thought Resident #6's skin tear was caused by the wheelchair pedal or from dragging his foot on the ground. The DON stated Physical Therapy evaluated the wheelchair foot pedal to ensure Resident #6's safety. The clinical record did not contain documentation that a physical therapist evaluated Resident #6's wheelchair foot pedal. On 8/24/17 at 2:00 pm, the facility's Rehabilitation Director stated she was not aware Physical Therapy received a referral to evaluate Resident #6's wheelchair foot pedal in April 2017.

Based on observation, resident and staff interview, and review of medical records, the facility failed to ensure residents were provided an environment free from abuse, intimidation, and free of harm. This was true for 1 of 3 residents (#4) reviewed for abuse. This resulted in Resident #4 being forced to urinate in her pants while a nurse performed a wound debridement procedure against her will. Findings include: An observation and interview was completed with Resident #4 on 6/6/16 at 11:20 am. Resident #4 was observed to be alert and oriented and sitting in a wheelchair in her room reading the newspaper. During the interview, Resident #4 was questioned as how the facility encourages her to do as much as she can for herself. Resident #4 made the statement, Yes (staff) take me to the bathroom and I call for them to come help (her out of bathroom). Resident #4 continued to state, I can take care of things (toileting) except the night that the nurse had them hold my leg. I kept telling them I had to go to the bathroom. She (nurse) told me to shut up and I had no choice but wet the bed. Resident #4's Quarterly MDS assessments, dated 1/5/16 and 2/9/16, documented she was cognitively intact. The assessments documented there were no behaviors demonstrated by Resident #4 and she was continent of bladder. A Witness Statement, dated 2/29/16, documented an incident that occurred on 2/26/16 with Resident #4. The statement documented that Resident #4 was held down against her will, while a nurse performed debridement of a wound on Resident #4's right leg. E #9, who indicated she was present during the incident, documented the following statement, I participated in the wrapping of resident (Resident #4's) leg with Agency Nurse (LN #5) and another (E #8). This procedure took a lot of time and (E #9 and E #8) had to take turns holding (Resident #4's) leg so the nurse could have access to the wound. The procedure took so long and it was making (Resident #4's) angry and she needed to use the bathroom the whole time, but didn't say anything and consequently wet her pants. She (Resident #4) could not understand why the nurse was doing the procedure and it made her upset. During a meeting with the Administrator, the IDCS, and the DCS, on 6/9/16 at 5:30 pm, the IDCS verified Resident #4 was continent of bladder and was not allowed to go to the bathroom while the nurse performed a new wound care procedure that took over 1 hour to complete.

Based on observation, record review, and staff, family member, and resident interviews, it was determined the facility failed to ensure residents had access to, and the ability to use, a call light. This was true for 1 of 9 sampled residents (#3) residing in the facility. The deficient practice resulted in Resident #3 being unable to alert staff of pain or other needs. Findings include: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3's history and physical, dated 12/08/14, documented Resident #3 had a history of [REDACTED]. Resident #3's Quarterly MDS assessment, dated 5/19/16, documented Resident #3 was severely cognitively impaired and totally dependent for mobility, eating and all cares. Resident #3's Care Plan, revised 8/20/15, identified her as requiring assistance with all ADL's. Interventions included placing the call light within reach and answering the call light promptly. On 6/6/16 at 7:00 am, Resident #3 was observed in bed moaning and crying out. At that time, her husband stated his wife was, in a lot of pain. Resident #3's push button call light was observed to be over the corner of the upper left side of the bed mattress, above Resident #3's affected left side, and out of the reach of her right hand and arm. At 11:30 am, Resident #3 continued to moan and cry out. Resident #3's call light remained on her left side out of reach. At 2:35 pm, Resident #3's call light was observed hanging over the upper left corner of the mattress, out of her reach. On 6/7/16 at 8:15 am, Resident #3 was observed crying out. Her call light was observed placed to the upper left side of the bed by her head and out of reach of Resident #3's right hand. At 12:15 pm, Resident #3's call light was observed in the same position as the previous observation at 8:15 am. On 6/7/16 at 4:30 pm, Resident #3 was asked if she could reach her call light or knew where it was. Resident #3 stated, I don't know .I don't know. On 6/8/16 at 2:30 pm, Resident #3's husband was asked if his wife could use her call light. He stated he was unsure if she could reach or use the call light. He said he did not recall the last time she had called for help. He stated he often pushed his call light to get help for his wife. On 6/9/16 at 7:45 am, Resident #3's call light was observed flipped back over her pillow and hanging off the front end of the bed out of her reach. At 2:15 pm, Resident #3's call light was observed on the top of her pillow to the right of her head. Resident #3 stated she I don't know, when asked where her call light was. On 6/9/16 at 5:30 pm, the IDCS and DCS stated Resident #3 could use her right hand and Resident #3's husband often called for help for his wife.

Based on observation, record review and staff, resident, and family interviews, it was determined the facility failed to ensure residents received necessary care and services. This was true for 4 of 9 sampled residents (#1, #3, #7, and #10) residing in the facility. This resulted in a) harm to Resident #1 and Resident #10 when treatment was delayed following accidents, 2) Resident #3 when she experienced ongoing pain due to lack of pain management by the facility; and 3) psychosocial harm to Resident #7 due to the manner in which a loved one's body was removed from the facility, and subsequent lack of therapeutic services to assist Resident #7 through the grief and trauma of his loved one's death. Findings include: 1. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3's history and physical, dated [DATE], documented Resident #3 had a history of [REDACTED]. Resident #3's Quarterly MDS assessment, dated [DATE], documented Resident #3 was severely cognitively impaired, totally dependent on others for mobility, eating and all cares. The MDS assessment documented Resident #3 did not have a condition or disease that may result in a life expectancy of less than 6 months. The assessment documented Resident #3 had received prn pain medication or had been offered pain medication and refused, and had denied pain when asked in the last 5 days. Resident #3's Care Plan did not identify pain as an issue or contain documentation related to: pain; pain related diagnoses; pain assessment; pain monitoring; pain interventions, or pain medications. On [DATE], Physician Notes documented Resident #3 was having pain, but only taking pain medication intermittently and may need a [MEDICATION NAME]. The note documented the [DIAGNOSES REDACTED]. The note included recommendations that long acting narcotics ([MEDICATION NAME]) were not indicted for a patient not already on high doses of narcotics and to continue with [MEDICATION NAME] as needed. Long acting medications would be considered if taking the [MEDICATION NAME] more than 3 times a day. On [DATE], Physician Notes documented that pain had been an issue with Resident #3, but Resident #3 had declined narcotics because of the way they made her feel and therefore, the physician was uncomfortable in ordering a [MEDICATION NAME] against Resident #3's will. The note documented Resident #3 did have a terminal [DIAGNOSES REDACTED].#3 desired it. On [DATE], Physician Notes documented [MEDICAL CONDITION] appears to advancing .fungating lesion on chest wall, and an ulcerated mass filling much of left axilla (armpit) with hyperpigmentation and puckering from axilla to nipple .active bleeding from the axilla. A fungating wound is [MEDICAL CONDITION] that is growing under the skin breaks through the skin to create a wound. Physician order [REDACTED]. * [MEDICATION NAME] ,[DATE] mg tablets, 1 tablet every 4 hours as needed for pain; and * Tylenol 325 mg tablets, ,[DATE] tablets every 4 hours as needed for pain. Resident #3's Pain Flow Sheet assessments and Medication Administration Record [REDACTED] * [DATE]: [MEDICATION NAME] was administered 15 times for a mean pain rating of 8 out of 10. * [DATE]: No pain flow sheet were available. * [DATE]: From ,[DATE]-,[DATE], [MEDICATION NAME] was administered 4 times for a mean pain of 6 out of 10. On [DATE] at 7:00 am, Resident #3 was observed in bed moaning and crying out. She had arm and leg contractures and appeared very thin. At that time, her husband stated his wife was, in a lot of pain, On [DATE] at 9:15 am, LN #3 stated Resident #3 had fungating [MEDICAL CONDITION] and would often cry out in pain. From 11:30 am to 12:50 pm, Resident #3 continued to moan in pain. During this time, two CNA's entered the room to assist Resident #3's husband to the bathroom. The CNAs and husband then left the room. At 12:15 pm, a CNA delivered a lunch tray and told Resident #3 she would ask the nurse if there was something they could give Resident #3(for pain). Resident #3's husband returned to the room at 12:50 pm. On [DATE] at 1:15 pm, LN #3 stated even though Resident #3 was crying out in pain and saying she was hurting, if directly asked she would often deny pain and refuse pain medication. LN #3 stated pain was assessed on the MAR indicated [REDACTED]. On [DATE] at 2:35 pm, Resident #3 was observed during pressure sore dressing changes. Resident #3's legs were contracted upwards at her hips and knees preventing her from straightening her legs. Resident #3's left arm was [MEDICAL CONDITION] and immobile with dark tumorous tissue protruding out from her deltoid (the muscle forming the rounded contour of the shoulder). Resident #3's left axillary had raw, dark purple and red tumorous tissue extending out and through the extent of her armpit. Resident #3 had pressure ulcers and open areas on her coccyx, back and left foot. Resident #3 cried out with pain and leave me alone, with each movement during the dressing change. On [DATE] at 4:30 pm, Resident #3 was observed moaning and crying out. When asked if she was in pain, Resident #3 stated, I don't know. When asked if she could reach her call light or knew where it was, Resident #3 stated, I don't know. On [DATE] at 4:50 pm, LN #3 stated she had asked Resident #3 about taking a pain pill before a dressing change and Resident #3 had refused. When asked about other forms of pain medication, LN #3 stated a patch had been discussed, but the physician was worried about overdosing Resident #3. LN #3 stated liquid pain medication such as [MEDICATION NAME] (liquid opioid pain medication) had not been discussed. On [DATE] at 12:00 pm, Resident #3 was moaning, ow, ow, hurts, hurts .oh god, ow, please, please, ow, ow, ow! At 12:17 pm, CNA #6 was observed taking a lunch tray into Resident #3. CNA #6 asked Resident #3 if she wanted strawberry shortcake. Resident #3 yelled, No, hurts! Oh god! CNA #6 told Resident #3, We'll get you a pill, and continued to prepare the tray. CNA #6 told Resident #3 to drink some juice and she would get a pain pill. Resident #3 yelled, Hurts, hurts! At 12:19 pm, CNA #6 left the room. Medication records documented Resident #3 received a [MEDICATION NAME] at 11:30 am for pain rated a ,[DATE]. The pain flow sheet documented reduced pain intensity (untimed). No one other than CNA #6 was observed to enter Resident #3's room from 12:00 pm to 12:45 pm. Resident #3's Medication Administration Record [REDACTED]. On [DATE] from 5:30 to 6:30 pm, Resident #3 continued moaning and crying out. During this time, the Administrator, IDCS and DCS were in the room across from Resident #3's room meeting with the survey team. Neither the Administrator, IDCS nor the DCS responded to Resident #3 before or during the meeting. On [DATE] at 7:45 am, 8:20 am, 9:00 am, and 1:40 pm, Resident #3 was observed crying out ow, ow, and moaning. At 5:00 pm, the Administrator and RD stated Resident #3 directed her own care, and did not want to be bothered, or badgered. The Administrator stated it was her (Resident #3) right to refuse, leave her alone and choose to die. 2. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On [DATE] an SBAR communication form documented Resident #10 complained of left lower leg and mid-shin pain. An investigation report documented that on [DATE] at 9:30 am, a CNA had bumped Resident #10's foot on the edge of a bookshelf. The CNA and Resident #10 both heard a pop. Resident #10 was medicated for pain on [DATE]. On [DATE], Resident #10 continued to complain of pain. On [DATE], Resident #10 complained of pain to the touch and when lifting her leg. On [DATE] at 11:20 am Resident #10 was sent to the emergency room for an X-ray and evaluation. X-rays of Resident #10's left leg identified a distal tibia fracture. On [DATE] at 5:30 pm, the Administrator, IDCS, and DCS, could not explain the reason medical evaluation of Resident #10's injury was delayed 2 days. The DCS stated Resident #10 should have been sent right away to be evaluated. 3. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On [DATE] at 3:55 pm, an Incident and Accident report documented Resident #1 had fallen while coming out of the bathroom. Nursing Progress Notes documented on [DATE], stated Resident #1 was complaining of left knee intermittent sharp pain that increased with bending her knee. The next note, documented on [DATE], stated Resident #1 complained of pain. Resident #1's left knee was swollen, painful to the touch and with movement. At 2:00 pm, Resident #1 was sent to the emergency room for an evaluation. X-rays of Resident #1's left leg showed Resident #1 had a fractured tibia. On [DATE] at 5:30 pm, the Administrator, IDCS, and DCS, could not explain the reason medical evaluation of Resident #1's injury was delayed 2 days. The DCS stated Resident #1 should have been sent right away to be evaluated. 4. During an initial observation and interview with Resident #7 on [DATE] at 9:30 am, he was teary eyed when speaking about his husband (with whom he had been life partner for over [AGE] years). Resident #7's voice was cracking as he pointed to numerous pictures on the wall of his loved one and described how his husband was also a resident of the facility when he died in December of 2015 (6 months prior). Resident #7's medical record documented [DIAGNOSES REDACTED]. Resident #7 was admitted to the facility on [DATE] with his husband. The Admission/Readmission Data Collection, documented Depends on life partner for emotional stability. After the death of his husband on [DATE], Resident #7 continued to live in the facility. On [DATE], social services met with Resident #7 and discussed moving to an assisted living facility. According to the Consent to Room Transfer form, dated [DATE], Resident #7 was moved to another room as Resident #7 stated he could not sleep in the room with the new roommate. Resident #7's medical record did not contain documentation regarding the death of Resident's #7's husband. Review of Resident #7's History and Physical, dated [DATE], documented Staff does report that he has been eating and drinking less and there has been some concern with him grieving for the loss of his long-term partner who recently died of [MEDICAL CONDITION] related issues. On [DATE] at 6:30 pm, Resident #7, pointing to pictures on the wall, stated he had shared his room with his husband before his death around Christmas. Resident #7 began to cry and became distraught and stated they had been together for [AGE] years. He stated they (facility) had put his husband in the body bag right in front of him .didn't close the curtains or anything. Resident #7 stated he could not get the image out of his head of his husband being put in the bag, sealed up and taken off. Resident #7 stated he did not have a chance to say his goodbyes and tell him how much he loved him. On [DATE] at 7:15 pm, CNA #5 stated Resident #7 and his partner were married at the facility. CNA #5 stated Resident #7 was having difficulty dealing with the death and often talked about seeing his husband placed in the body bag. On [DATE] at 5:00 pm, the Administrator, DCS, and interim DCS, stated the facility followed the standard protocol for after death care. The Administer stated Resident #7 was in therapy, but had been in therapy prior to his husband's death and not specifically for this issue. They stated they were not aware of a policy that specifically addressed this issue, and a resident should not have to experience what Resident #7 did. On [DATE] at 10:10 am, Resident #7 began crying and stated that no one should have to experience what he did when his husband died . Resident #7 again stated he could not get the image out of his head. Resident #7 stated he was told by a nurse, who no longer worked at the facility, that his husband had passed and he would be able to be with him after they cleaned and prepared his husband. Resident #7 stated he was able to hold his husband's hand for about 10 minutes and then the mortician came in the room and he was told by the nurse that they had to take his husband. Resident #7 stated he and his husband had met with the mortuary to make arrangements prior to his husband's death, so he recognized the mortician. Resident #7 stated he did not remember being asked to leave, or a suggestion that he leave, while the mortician took the body. Resident #7 stated he did not remember all the details, but he remembers them placing his husband's body in the bag and sealing it up. Resident #7 stated the facility usually dealt with single people and he did not believe they (facility) knew what to do with couples. He stated the facility needed to know what to do, so no one else would have to go through what he went through.

Based on observation, record review and staff interviews, it was determined the facility failed to ensure residents did not develop multiple pressure ulcers. This was true for 1 of 5 residents sampled for pressure ulcers (#3) and resulted in harm to Resident #3, who developed multiple pressure sores, including one Stage III ulcer. Findings include: 1. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A 5/19/16 quarterly MDS assessment documented Resident #3 was severely cognitively impaired; totally dependent on at least two staff for mobility, transfers, and toileting; always incontinent of bowel and bladder; equipped with pressure reducing devices to her chair and bed; on a turning/repositioning program; had nutritional and hydration interventions in place; and had one unstageable pressure ulcer. a. A Braden Pressure Sore Risk Assessment, dated 12/6/15, documented Resident #3 was at severe risk of developing pressure ulcers. A 12/9/15 Braden Pressure Sore Risk Assessment documented she was at high risk for developing pressure sores. Pressure Ulcer Records, dated 12/29/15 and 1/5/16, documented Resident #3 developed a Stage I ulcer to the left foot/great toe and included a diagram with the ball of the left foot marked with an x. A 12/30/15, a Nurse's Note documented the IDT conducted a wound care meeting for Resident #3's left foot and noted, Will continue current POC (Plan of Care). Will monitor for care. Pressure Ulcer Records, dated 1/6/16, 1/25/16, 2/2/16, 2/9/16, and 2/16/16, documented Resident #3's Stage I ulcer was now unstageable, but that classification had a hand-drawn line through it and a handwritten DTI (deep tissue injury) had been substituted on each assessment date. A Nurse's Note, dated 1/6/16, documented the IDT met to discuss the pressure wound to Resident #3's left lateral ball of foot and decided to continue with current POC will monitor weekly for improvement. Nurse's Notes documented additional IDT wound care meetings for Resident #3's various wounds were conducted regularly. A 1/27/16 Nurse's Note, documented Resident #3's left foot/toe pressure ulcer now met (the) criteria for (an) unavoidable wound and recommended placing Resident #3 on pallative care. Neither the facility's classification of the wound as unavoidable nor the rationale for placing the resident on pallative care were explained. The wound was classified as a DTI on the Pressure Ulcer Records weekly from 2/24/16 through 3/22/16, and for 4/3/16. Pressure Ulcer Records dated 4/8/16, 4/12/16, 4/17/16, 5/2/16, 5/10/16, and 5/17/16 each documented the wound was UTS (unable to stage). Each Pressure Ulcer Record from 12/29/15 through 5/17/16 documented Resident #3's left foot/toe pressure ulcer was not present upon admission to the facility, and recorded the wound first measured 0.3 cm by 0.3 cm, but grew to 3 cm X 3 cm by 0.1 cm, when it was at its largest. b. A Pressure Ulcer Record, dated 3/23/16, documented Resident #3 developed a Stage II pressure ulcer to her coccyx that measured 0.2 cm by 0.2 cm by 0.1 cm. A 3/22/16 Nurse's Note documented, Late Entry: (Physician) in to see resident today for new coccyx wound. c. Pressure Ulcer Records, dated 2/22/16, 3/1/16, and 3/15/16, documented Resident #3 developed a Stage II pressure ulcer to her left hip that measured 2 cm by 2 cm by 0.1 cm at its largest, and 0.3 cm by 0.3 cm by 0.1 cm at its smallest. A 2/23/16 Nurse's Note documented, New wound on (left) hip. Stage II. Interventions turn (every two hours) and [MEDICATION NAME] to site. MD (physician) notified and unavoidable worksheet completed . No explanation was provided for classifying the left hip pressure ulcer at unavoidable. A 3/8/16 Nurse's Note documented, IDT met today in regards to her wounds. (Left) hip (and left) foot pressure related ulcers. (No) improvements noted at this time. Continue (with) current interventions. Monitoring, remains on comfort measures, MD states unavoidable wounds. d. A Pressure Ulcer Record, dated 6/2/16, documented Resident #3 developed a an unstageable pressure sore to her right hip that measured 1.5 cm by 1.8 cm with black eschar covering the wound bed. e. A Non-Pressure Skin Condition Record, dated 6/5/16, documented a 1.2 x 2.5 x 0.1 reddened area on the right side of Resident #3's back and two areas on her right hip measuring 0.5 x 0.3 x 0.1 and 1.3 x 1.5 x 0.1. Resident #3's Care Plan, dated 8/20/15, and in effect at the time of survey, documented the following: * Problem: (Resident #3) is at risk for pressure related ulcers d/t self care deficit, fragile skin, muscle weakness, w/c (wheelchair) dependant, incontinent of B&B (bowel and bladder), dx (diagnosis) [MEDICAL CONDITION], prefers to spend most of time in bed sleeping. * Goal: (Resident #3) will exhibit no s/s (signs and symptoms) of skin breakdown by next review, X (for) 90 days. * Interventions/Approaches: Pressure reducing mattress to bed; weekly skin sweep; Braden assessment quarterly; monitor labs; skilled therapies as ordered; cushion for w/c; offer and encourage fluids throughout the day; check positioning frequently during rounds; reposition . (every) 2 hours and as needed; treatments as ordered; off-loading boot on left foot; turn onto side, prop (with) pillows, treat per orders until healed as patient allows; 'she is on comfort care;' treat as ordered for pressure ulcer to (left) great toe. On 6/6/16 at 2:35 pm, Resident #3 was observed with a Stage II pressure ulcer on the middle of her back over a rib adjacent to the backbone. The open area of the wound measured approximately 2 cm x 2 cm in size, and a Stage II ulcer on her coccyx measured approximately 1 cm x 1 cm. An elongated open area extending upward from the coccyx measured approximately 1 cm x 3 cm. Resident #3's left large toe was observed with a large black eschar area; her left hip had reddened areas over the hip bone and ilium crest. LN #3 stated the area on Resident #3's back was not a pressure sore, but rather was a self-inflicted scratch. LN #3 stated at this time that the area on the back of Resident #3 was not a pressure sore, but a scratch. LN #3 stated it did not matter whether the area was identified as a scratch or pressure sore, the treatment was the same per Resident #3's physician. Resident #3 did not attempt to scratch at the open area on her back rib during the observation. On 6/7/16 at 4:30 pm, LN #3 measured the open area on Resident #3's mid-right back at 1.9 cm x 2.5 cm x 0.3 cm. When assessing the coccyx wound, LN #3 stated the areas were merging together, and measured 4 cm x 1.75 cm. Resident #3's right hip bone area measured 3 cm x 1.5 cm, and the ilium crest area measured 5 cm x 2 cm. Resident #3's right hip areas remained reddened consistent with the 6/6/16 observation. On 6/8/16 at 11:15 am, the IDCS stated the facility does not distinguish between pressure sores and non-pressure sores. The IDCS stated the treatment would be the same for either per the physician and, therefore, the facility did not want to cause Resident #3 more discomfort by measuring the wounds weekly. The IDCS stated that even a non-pressure area would receive weekly monitoring and treatment.

Based on observation, record review and staff interview, it was determined the facility failed to ensure residents did not develop contractures. This was true for 2 of 9 residents (#3 and #5) sampled for range-of-motion concerns. The deficient practice resulted in harm when residents experienced pain and a decrease in mobility. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 12/18/14, documented Resident #3 did not have range-of-motion impairments in her upper or lower extremities, was receiving PT, and was not in a restorative program. A Physical Therapy Discharge Summary, dated 12/19/14, documented Resident #3 refused treatment and seldom rose from bed. The summary documented a referral to RNP to maintain strength and reduce the risk for contractures. A quarterly MDS assessment, dated 5/19/16, documented Resident #3 had impaired ROM in her upper and lower extremities and was totally dependent on staff for mobility. On 6/6/16 at 7:00 am, Resident #3 was observed lying in bed. Resident #3's left arm was immobile and her left leg contracted at the hip and knee in a fixed position with limited movement. Resident #3's right leg was also contracted at the hip and knee. At 2:35 pm, during a dressing change to a pressure ulcer on the left foot, Resident #3 cried in pain during movement. LN #3 stated Resident #3 did not like to be moved and could not straighten her legs due to contractures. On 6/9/16 at 5:30 pm, the IDCS stated the facility did not have a restorative program because the facility did not have anyone to oversee the program. The IDCS and DCS confirmed there were no restorative records for Resident #3 and she had not received ROM. 2. Resident #5's medical record documented she fractured her right hip on 3/17/15, and underwent surgery on 3/18/15. Resident #5 was admitted to the facility on [DATE] for OT and PT evaluation and treatment. After the completion of PT, RNP was to continue working on exercises and strengthening with Resident #5. Resident #5's MDS assessment, dated 3/16/16, documented range-of-motion impairment to the lower extremity on one side. The MDS assessment documented Resident #5 required extensive assistance with transfers and did not ambulate. Resident #5 was observed on 6/6/16 at 8:00 am seated in a wheelchair with her feet dangling. There were no foot supports available. On 6/8/16 at 8:55 am, Resident #5 was observed seated in the wheelchair with her feet dangling and the toes of her right foot touching the floor. The wheelchair was not equipped with foot rests. A CNA pushed the wheelchair forward to Resident #5's room with her feet hanging and occasionally touching the floor. On 6/8/16 at 3:50 pm, the IDCS stated the facility did not have a restorative nursing program and that there was no restorative documentation for Resident #5.

Based on observation, record review, and interviews, it was determined the facility failed to ensure residents were free adequately supervised to prevent accidents. This was true for 2 of 12 residents reviewed for accidents and supervision (#10 and #12). The deficient practice resulted in harm when a) Resident #10 sustained 4 fractures during care and transfers by facility staff, and b) Resident #12, with a [DIAGNOSES REDACTED]. Findings include: 1. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #10's quarterly MDS assessment, dated 4/15/16, documented severe cognitive impairment and total dependance on staff for mobility and cares. Resident #10 sustained 5 injuries, 4 with fractures, as the result of cares or transfers provided by facility staff: * On 5/15/15, an SBAR communication form documented Resident #10 complained of left lower leg and mid-shin pain. An investigation report documented that on 5/15/15 at 9:30 am, a CNA had bumped Resident #10's foot on the edge of a bookshelf. The CNA and Resident #10 both heard a pop. Resident #10 was medicated for pain that day, but on 5/16/15 the resident continued to complain of pain. On 5/17/15, Resident #10 complained of pain to the touch and when lifting her leg. At 11:20 am, Resident #10 was sent to the emergency room for an X-ray and evaluation. X-rays of Resident #10's left leg identified a distal tibia fracture. * An I&A and SBAR noted that on 7/20/15 at 9:10 pm, Resident #10 was being transferred from her wheelchair to bed via Hoyer mechanical lift when the sling pad became entangled with Resident #10's arm. The CNA used the Hoyer lift without assistance and against facility policy. Resident #10 sustained a left humerus fracture. Resident #10's care plan was updated to to include a 2-person assist with all ADLS and transfers with Hoyer lift. * On 12/6/15, an SBAR documented a possible left leg fracture while two CNA's were transferring Resident #10 into her wheelchair via the Hoyer lift. Resident #10 slid out of her chair and onto the floor and her left leg was bent back. On 12/7/15, a left distal femur fracture was documented. On 12/8/15, facility staff were trained on proper use of the Hoyer lift. Resident #10's care plan was updated to include a non-slip pad in her wheelchair. *On 1/23/16 at 7:30 am, Resident #10 was found with a bruise to her left eye during morning cares. The Hoyer lift bar lines matched the placement of the bruise and CNAs were trained on how to transfer with the Hoyer to avoid future injuries. The I&A noted misuse of equipment. *I&A and SBAR reports, noted that on 4/13/16, Resident #10 was found with bruising to her left hand. X-ray reports documented a left wrist fracture of unknown origin. Resident #10's care plan identified her as at risk for falls due to wheelchair dependency, medications, [DIAGNOSES REDACTED]. Interventions included: * Complete quarterly fall risk assessments * Observe for changed in cognition/function * Environment free of clutter * Observe medications for side effects * Call light within reach and remind to use call light for assistance * Assure adequate lighting and clear pathways * Hoyer lift for all transfers * Skilled therapies as ordered * Personal items within reach * Dycem pad to chair Resident #10's care plan identified specific problems related to a left humerus fracture, vertical fracture of humeral head, left knee fracture, and a left wrist fracture. Interventions included: 2-staff assistance with all ADLS; transfers with Hoyer lift; use of draw sheets; positioning; braces; splints; and immobilizer. Resident #10 was diagnosed with [REDACTED]. Resident #10's care plan and interventions did not provide staff guidance or interventions addressing prevention of further injuries. On 6/9/16 at 5:30 pm, the IDCS and DCS stated staff had received in-services on using the Hoyer lift. 2. Resident #12 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An Elopement Risk Evaluation, dated 3/18/16, documented Resident #12 was determined to be at risk for elopement. Resident #12's Admission Care Plan, dated 3/18/16, included: * Falls/Safety/Elopement Risks - Goal: Remain free of injuries and falls. A handwritten entry documented, Elopement initiated. A Behavior Symptom Monitoring Flow Record, dated March, 2016, documented the behavior of Wandering-Elopement, and included pharmacological interventions (an anti-psychotic medication), as well as non-pharmacological interventions, including re-orienting; redirecting with an activity such as knitting; offering coffee; reassurance that she and her children were safe; and 15 minute checks (line of sight). A Resident Safety Check form, dated 5/18/16, documented that 15-minute checks were performed from 2:00 pm until 10:00 pm. Fifteen minute checks were not documented between 5/18/16 at 10:01 pm and 6/5/16 at 9:59 am. Documentation of 15-minute check resumed on 6/5/16 at 10:00 am. An I&A Report, dated 6/5/16, documented that Resident #12 left the facility unsupervised at 10:35 am. On 06/9/16 at 2:18 pm, the Administrator, DCS, and surveyor followed CNA #4 to the site where CNA #4 found Resident #12 on 6/5/16. The road where the resident was found was a main road leading into and out of the town; the speed limit was 45 mph. The site was approximately 0.2 miles from the facility parking lot. On 6/9/16 at 9:07 am, the Social Services Manager stated Resident #4 was found on the road alone and that she wanted to go home, especially when her husband left, at which time Resident #4 would pack up. The Social Services Manager stated the facility's wander guards were ineffective and the system was not working. On 6/9/16 at 9:25 am, CNA #4 stated that on 6/5/16 at about 9:45 am, a former employee walked through the staff breakroom and stated Resident #12 had her bag and was walking alongside the road. CNA #4 stated she, LN #2, and the activities staff member retrieved Resident #4 by car. CNA #4 was unsure if any type of alarm system was functioning at the time of Resident #12's elopement. The facility failed to ensure Resident #4 received the supervision necessary to keep her safe.

Based on observation, record review, and staff and resident/family member interviews, it was determined the facility failed to ensure a resident on palliative care received monitoring and care planning necessary to support the resident's nutritional needs. This was true for 1 of 9 sampled residents (#3) residing in the facility. This deficient practice resulted in Resident #3 experiencing an undeterminable weight loss and severely compromised nutritional status. Findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's History and Physical, dated 12/8/14, documented a history of dementia, anxiety,[MEDICAL CONDITION] left-side [MEDICAL CONDITION], history of [MEDICAL CONDITION]. An Admission Nutritional Evaluation, dated 12/11/14, documented Resident #3 weighed 137 lbs with assessed caloric needs of 1868 Kcal, 49-75 g of protein, and 1800 cc of fluids per day. Resident #3's Admission Lab values did not include [MEDICATION NAME] or pre-[MEDICATION NAME] protein levels. The evaluation identified inadequate intake due to percentage of oral intake. The evaluation stated Resident #3 had dentures, ate in her room, and required assistance and cueing to eat. The evaluation documented her nutritional status would be difficult to assess using weights due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Recommendations included a regular diet with fortified meals, whole milk, weights per policy, and the RD was to monitor her anticipated decline. Resident #3's admission MDS assessment, dated 12/18/14, documented moderate cognitive impairment and total dependence on staff for eating. Resident #3's admission weight was 135 lbs. The MDS assessment, and subsequent MDS assessments, dated 6/8/15 and 2/28/16, noted Resident #3 did not have a condition or disease that would result in a life expectancy of less than 6 months, was not on hospice care, did not have a [DIAGNOSES REDACTED]. A 4/21/15 physician progress notes [REDACTED]. Palliative care is when a resident has reached a stage in their illness in which cure is no longer possible or when they refuse further treatment. Palliative care does not mean nothing more will be done .Palliative care is actually aggressively planned comfort care. Treas, L. S. & Wilkinson, J. M. (2014). Basic Nursing: Concepts, Skills & Reasoning. F.A. Davis Company: Philadelphia. Resident #3's Care Plan did not contain documentation related to palliative care, comfort care, or end-of-life care. Resident #3's Care Plan, revised 8/20/15, identified Resident #3 was at risk for altered nutrition related to a [DIAGNOSES REDACTED]. * Diet as ordered; * Allow time to complete meal; * Monitor intake; * Monitor weight for significant changes monthly/prn (crossed out); * Set up assist for meals (crossed out), dependent on staff at meals (added); * Food preferences as provided/available; * Staff assist as needed; * Skilled therapies as ordered; * Adjust food portions as needed; * Supplements as needed per order; * Notify physician if weight decreases by more than 5 pounds; * Offer alternative if refuses meal; * Labs as ordered; * Assess for malnutrition-cachexia, eyes dull/sunken, gums swollen, muscle wasting, skin turgor tent, pale skin color, dry oral/nasal mucosa. Resident #3's Care Plan did not address what staff were to do when she refused fluids or food. The Nurse Tech Information Kardex, undated, documented the following regarding Resident #3: * Ambulation - under the category of other comfort care * Personal Hygiene - dentures (documentation did not indicate if Resident #3 wore them) * Eating - regular diet/no salt and dependant on staff * Fluids - no documentation (blank) The Kardex did not provide nursing staff guidance or direction in caring for Resident #3 regarding palliative/comfort care, food intake, fluids intake, supplements, preferences, frequency of offering food and fluids, intake assistance, or oral care. Quarterly Nutritional Reviews were not documented between Resident #3's 12/11/14 Initial Nutritional Assessment and 9/15/15, when the next Quarterly Nutritional Review was documented. The 9/15/15 Quarterly Nutritional Review documented that on 6/2/15 Resident #3 weighed 105.8 lbs. Resident #3's quarterly MDS assessment, dated 6/8/15, documented her most recent weight in the previous 30 days as 135 lbs. The response to the assessment question of whether Resident #3 had weight loss of 5% or more in the last month or 10% or more in last 6 months was documented as, No or unknown. The assessment did not reflect Resident #3's weight on 6/2/15 of 105.8 lbs, a loss of 31.2 lbs (22.7%) since admission, or loss of 29.2 lbs (21.6%) since the admission MDS assessment on 12/18/15. A 6/17/15 physician's orders [REDACTED]. Resident #3's Quarterly Nutritional Review, dated 9/15/15, documented Resident #3 consumed 60% of her regular meal and 180-240 cc of fluids per meal. The review documented Resident #3 was independent in eating and ate in her room. The review documented the continuation of the plan of care, regular diet per physician's orders [REDACTED]. Dentures were not noted or assessed. Additional dietary interventions were not implemented. A 9/15/15 Quarterly Nutritional Review and subsequent Quarterly Nutritional Reviews and dietary notes did not address Resident #3's 6/2/15 weight of 105.8 lbs, or include further weights, assessments of her nutritional status, or new interventions. Resident #3's medical record did not include further documentation related to her 6/2/15 weight of 105.8 lbs. An IDT Progress Note, dated 10/10/15, documented Resident #3's weight loss was expected with terminal illness and that on 6/17/15 weights were discontinued. The note documented Resident #3 ate in her room, and averaged 25-30% intake with meals with 5 refusals in 7 days. A regular diet for Resident #3 was continued with the addition of Med Pass 2 oz three times a day. An IDT Progress Note, dated 11/11/15, documented Resident #3 had refused the health shakes. On 12/29/15, a Nutritional Evaluation documented Resident #3 consumed 45% of meals, providing 1000 kcal a day and that based on her last weight she needed to consume 55%. The evaluation noted Resident #3 remained on a regular diet and ate independently in her room. Recommendations were to continue the plan of care. On 12/29/15, malnutrition was identified on the care plan, and the intervention of providing clear Ensure three times a day on (Resident #3's) room tray per resident request was added. On 3/4/16, a quarterly Nutritional Review documented Resident #3 remained on a regular diet and Ensure three times a day, providing 540 Kcal and 27 g of protein. Resident #3 consumed 25% of meals, required assistance for eating in her room, and had pressure sores to her left toe and left hip. Recommendation were Med Pass 2 oz. three times a day to add extra Kcal and protein for wounds. An IDT Progress Note, dated 4/28/16, documented a decrease in Resident #3's intake in the previous 7 days of 15% with poor fluid intake. The note stated Resident #3 was in pain, but refused medication as well as supplements and assistance. A 5/4/16 physician progress notes [REDACTED]. On 5/16/16, a quarterly Nutritional Review documented Resident #3 had no dietary changes. The review documented Resident #3 consumed 10% of meals and verbalized No to staff attempts to assist with meals, and to continued attempt to assist with meals. The review documented pressure sore treatments continued and the wounds were considered unavoidable. Quarterly Nutritional Reviews since admission documented progressive declines in intake with the implementation of: *12/19/14- fortified meals and whole milk; *10/10/15 and 3/4/16- Med pass 2 oz. three times a day; and *3/4/16-clear Ensure three times a day. Resident #3's quarterly MDS assessment, dated 5/19/16, documented severe cognitive impairment, and total dependence for mobility, eating and all cares. The assessment documented Resident #3's most recent weight in the previous 30 days was 135 lbs. The assessment documented Resident #3 did not have a condition or disease that resulte in a life expectancy of less than 6 months, was not on hospice care, and did not have a [DIAGNOSES REDACTED]. The MDS assessment did not document additional [DIAGNOSES REDACTED]. On 6/6/16 at 7:00 am, Ensure, 75% full (180 cc); 2 glasses of juice, one full and one half full, were observed on the resident's nightstand. At 11:20 am, no change in the level of fluids was noted. At 12:00 pm, a CNA brought Resident #3's lunch tray. At 12:15 pm, the CNA left the room with the lunch tray. The half full glass of juice was no longer in the room. ADL sheets for 6/6/16 documented Resident #3 refused lunch. On 6/6/16 at 2:35 pm, Resident #3 was observed lying in bed. She appeared extremely thin and had contractures of one arm and both legs. Resident #3's dentures were observed to remain in a cup at the sink during the survey from 6/6/16 - 6/10/16. On 6/7/16 at 8:15 am, Resident #3 had an unopened container of Ensure and a full glass of juice on her night stand. Her family member stated he was not sure whether the resident had breakfast yet. He stated he usually waited until the resident's breakfast arrived before he left for the dining room. At 12:15 pm, a full Ensure, full glass of thickened water, and juice were on the night stand. At 4:50 pm, a full Ensure, full glass of thickened water, and juice were observed on the night stand. On 6/8/16 at 12:20 pm, CNA #6 was observed taking a lunch tray into Resident #3's room. CNA #6 left the room with the tray after a few minutes. The lunch tray had pieces of chicken, mashed potatoes, and a green vegetable. CNA #6 stated Resident #3 took a few small bites of potatoes and drank her juice,160 cc glass. CNA #6 stated Resident #3 had not been eating and she did not return to offer Resident #3 more food or alternatives. CNA #6 stated Resident #3 usually drank the red juice. On 6/9/16 at 8:00 am, CNA #4 was observed delivering a breakfast tray of French toast, bacon, creamed cereal, and juice to Resident #3. CNA #4 stated Resident #3 did not wear her dentures because they did not fit, needed to be re-evaluated, and because she rarely ate. CNA #4 stated she was unsure why the cereal and bacon was on the tray because Resident #3 could not eat the bacon and did not like cereal. When asked the reason Resident #3's trays were not left in the room and whether staff came back and periodically offered Resident #3 more food, CNA #4 stated meal trays were not to be left in the rooms. CNA #4 stated Resident #3 usually drank an Ensure at each meal. When asked how CNA #4 knew about offering food and fluids or comfort care, she stated she did not know if something was written, other than on the Kardex. CNA #4 said she usually tried to get Resident #3 to drink the Ensure and her juice. On 6/8/16 at 9:30 am, the RD stated she had reviewed all of Resident #3's nutritional information and did not know what more the facility could have done to meet the resident's nutritional needs. The RD stated Resident #3 was in control of her care. On 6/9/16 at 5:00 pm, the RD stated Resident #3 directed her care although she was severely cognitively impaired. The RD stated Resident #3 refused to eat, spit out food at staff, and would tell staff to get out of her room. The RD stated the facility was following Resident #3's direction and that the only weight available to complete a nutritional assessment was Resident #3's admission weight. The RD stated a telephone order was obtained on 6/7/15 to discontinue weighing Resident #3. The RD stated Resident #3 did not wear her dentures because she did not want to wear them and that her diet had not changed from a regular diet because she did not want to take away that option from her. The RD stated she believed it was possible Resident #3 could eat a regular meal without her dentures. The RD stated Resident #3 was in pain and pain could affect her eating. The RD stated Resident #3's only real caloric intake was clear Ensure, which she received three times a day. She stated she had not calculated Resident #3's actual caloric intake, but a regular meal provided approximately 1800 Kcal and Resident #3 was consuming approximately 10%, therefore her intake would be approximately 180 Kcal. The RD stated Med Pass was tried, but Resident #3 did not like it. When asked about returning and offering food or more fluids throughout the day, the RD stated Resident #3 did not want it and she spits out her food at you. The RD stated she was unsure what else could be done as Resident #3 refused care and wanted to be left alone, noting, (Resident #3) directs her care. On 6/9/16 at 5:30 pm, the OT stated Resident #3 probably did not wear her dentures because they fell out due to weight loss. The OT stated she had just attempted a speech evaluation, but Resident #3 refused. The OT stated a speech evaluation had not been done or attempted previously. On 6/9/16 at 5:30 pm, the Administrator and RD stated Resident #3 had lost a significant amount of weight, but Resident #3 directed her own care, and did not want to be bothered or badgered. The Administrator stated it was her (Resident #3) right to refuse, to leave her alone and choose to die. On 6/10/16 at 9:30 am, Resident #3 was observed lying in bed with her dentures in her mouth. When asked a question, Resident #3 attempted to reply, but her dentures kept dropping down. On 6/10/16 at 9:30 am, the IDCS and DCS stated residents were usually weighed on shower days on a wheelchair scale, which did not require extra manipulation of the resident. The IDCS and DCS could not provide an explanation why weights had not been obtained when Resident #3 was showered in the previous months.

Based on record review and staff interview, it was determined the facility failed to prevent avoidable pressure ulcers. This was true for 1 of 1 residents (#7) sampled for skin ulcers and resulted in harm when Resident #7 developed a Stage IV pressure ulcer following an improper staff-assisted repositioning in bed. The wound ultimately became infected and the resident was subsequently diagnosed with [REDACTED]. Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 2/9/12, documented the following: * Intact cognitive skills for daily decision making * Extensive assistance of one staff member required for bed mobility and transfers * Extensive assistance of at least two staff members required for toileting * Always continent of bowel * At risk for pressure ulcers A Skin Integrity Care Plan, dated 12/20/10, documented the following: * "Problem/Need: Potential for skin breakdown r/t (related to) immobility, incontience (sic) of bowel and bladder." Problem onset: 12/20/10. * "Approaches: Braden scale upon admission and quarterly; pressure relieving mattress/chair/cushion; skin assessment per weekly skin sweeps; peri care after each incont(inent) episode." A handwritten note documented the Skin Integrity Care Plan was reviewed on 5/2/11. An undated Admission/Re-admission Data Collection & Initial Plan of Care Braden Scale pressure ulcer risk assessment form documented the resident scored an "11." Residents with scores of 10-12 were considered to be at "high risk" for the development of pressure ulcers. An Incident and Accident Report, dated 4/24/11, documented Resident #7 sustained a "skin tear" when staff were changing the resident's adult brief in bed. The report documented, "(No) draw sheet used to turn resident while being changed. When CNA helped roll her she took heel of her hand and pushed up on buttocks resulting in tear on skin around coccyx area. CNA educated immediately on use of draw sheet (with) rolling." The form documented that the resident was continent of both bowel and bladder. A single sheet Care Plan, dated 4/24/11, documented the following: * "Problems/Issues: Skin tear coccyx area." * "Goals: Heal in 30 days." * "Approaches: Tx (Treatment) as ordered. Turn resident side to side. Use lift blanket to turn resident. Air mattress." Skin Grid - Pressure sheets documented a Stage II pressure ulcer was initially identified on the resident's coccyx on 4/24/11; measured 4.3 centimeters (cm) by 1.2cm by 0.1cm; and had slough. On 4/25/11, the facility received a Physician's Telephone Order that documented, "Treatment order: Gently cleanse coccyx with soap (and) water qod (every other day). Cover with [MEDICATION NAME] sticky side out and place [MEDICATION NAME] over top until healed." Care Management Summary forms, dated 5/4/11 and 5/11/11, documented, respectively, that the resident had a "skin tear on coccyx," and a "skin tear buttocks (crease) (illegible) (with) [MEDICAL CONDITIONS] - frequent diarrhea ..." A Physician's Progress Note, dated 5/10/11, documented, "(Resident #7) continues to have wound care for her pressure ulcer. status [REDACTED]. We will take off contact precautions." The Skin Grid - Pressure sheets documented that the wound's measurements remained consistent on assessments dated 5/1/11, 5/6/11, 5/9/11, 5/14/11, 5/20/11, and 5/23/11. However, on 5/27/11, the wound was documented as a Stage III pressure ulcer which measured 4.3cm by 1.5cm by 0.1cm. A Nurses Note, dated 5/23/11, documented, "Also notified (physician) of (Resident #7's) loose mucous stool (with) foul odor. Received order from (physician) for stool specimen for [MEDICAL CONDITION]." A Nurses Note, dated 5/29/11, documented the resident was "incont(inent) of (bowel and bladder)." A Physician's Telephone Order, dated 5/31/11, documented, "Wound errors: Clean BID (twice daily) (with) soap and (water), put [MEDICATION NAME] BID, cover (with) [MEDICATION NAME] cushion, hold (with) [MEDICATION NAME]." On 6/6/11, the Skin Grid - Pressure form documented the Stage III wound measured 4.4cm by 2.2cm by 1.5cm. A Nurses Note, dated 6/9/11, documented, "(Physician) in to assess wound to coccyx area. Culture pending. Referral to (physician's name) (at) wound clinic. admitted to (nearby hospital at 3:00 p.m.)." An Admission History and Physical (H&P) from the nearby hospital, dated 6/9/11, documented, "... (Resident #7 was) evaluated today at (the facility) as part of routine rounds. During the evaluation, her sacral decubitis ulcer was noted. It was last evaluated ... on 5/10/11 and was roughly coin-sized and did not extend past the dermis. Nursing staff states that is has had a foul odor and has gotten progressively worse over the last couple of weeks. Assessment of the sacrum shows a teardrop decubitis ulcer that is 4cm in length, 3cm in width and probed at least 3-4cm deep, down to bone. There is mucal purulent drainage noted. A Hospital History and Physical (H&P), dated 6/13/11, documented, "(Resident #7) has (a) Stage IV pressure ulcer over the sacrococcyx area. This ulcer show some slough but good granulation below. The measurement of the open ulcer is 2.5 X 1.5(cm) with a straight-in depth of 1.3(cm). There is undermining in the 12 o'clock position of 2.2cm, 2 o'clock position of 2cm, 3 o'clock position of 2.3cm, and 4 o'clock position of 2.4cm. There is generalized [DIAGNOSES REDACTED] indicative of the undermining and more [MEDICAL CONDITION] reaction toward the right side and the left side. There is a large area of superficial ulceration, [DIAGNOSES REDACTED] of the periwound and superficial breakdown of skin measuring 11cm of length and 9cm of width ... the radiology report suggests bone marrow [MEDICAL CONDITION] and enhancement within the coccyx and lower sacral segment consistent with changes of osteo[DIAGNOSES REDACTED]. There is no overt destruction of bony structure noted, and there is no visible bone in the ulcer today. The patient has infection associated with this state (sic) IV pressure ulcer. The tissue culture ... showed a heavy growth of Escherichia coli. The patient has been admitted to the hospital after discovery of a pressure ulcer that dramatically worsened from (physician's) visit at the (facility) last month to this month. At this point, I think it would be a consideration for surgical intervention of this ulcer ..." A Nurses Note, dated 6/18/11, documented, "Resident (re)admitted to (facility) ... wound vac in place ... resident turned (every two hours) and continues on bedrest ..." The Skin Grid - Pressure form's next documented measurement of the wound was on 6/22/11, at which time the ulcer was described as a "Stage IV" wound measuring 2.5cm by 0.5cm, by 1.5cm with serosanguinous drainage and macerated edges. The Skin Grid - Pressure forms documented wound measurements and appearance every three-to-four days until 9/28/11, at which time the wound was described as "healed." On 4/25/12, at 1:45 p.m., the DON was interviewed. When asked about Resident #7's pressure ulcer, the DON stated, "That started as a skin tear, then she got the [MEDICAL CONDITION] and it just went from there." The DON acknowledged that the resident's skin was initially compromised by a staff member improperly positioning the resident during an adult brief change and stated, "The nurse who looked at this reported to me so I looked at it and it was definitely a skin tear. I spoke to the CNA and she told me what happened." Resident #7 was harmed when she developed a Stage IV pressure ulcer from improper repositioning technique by facility staff. The wound eventually became infected and led to a [DIAGNOSES REDACTED].

Based on observation, resident and staff interview and record review, it was determined the facility failed to: 1) develop care plan interventions that were individualized to residents specific fall risk behaviors and address supervision needed to prevent falls. Residents #4 and #5 were harmed when both residents had a fall which resulted in fractured hips and required surgery. 2) secure chemicals so cognitively impaired residents did not have access to them. The falls affected 2 of 11 sample residents ( #4 and #5) and the unsecured chemicals had the potential to affect 11 of 11 sampled residents (#1 - 11). Findings include: 1. Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment, dated 7/1/11, documented the resident: * was severely cognitively impaired (BIMS = 7), * required limited assistance with bed mobility, transfers, dressing and personal hygiene, * was occasionally incontinent of bowel and bladder, * was unsteady and required assistance for moving from a sitting to standing position, moving on and off the toilet and transferring between even surfaces, * used a wheelchair for mobility, and * had a fall within the 30 days prior to admission. The resident's care plan, dated 6/26/11, documented a problem of, "Fall risk (related to) poor safety awareness, poor balance." The interventions were: * "fall mats, * pressure alarms to bed and wheelchair, * tab alarms on recliner, * remind resident frequently to call for help, * concave mattress." The resident had multiple episodes of exhibiting at risk behaviors. After the resident exhibited the behaviors the facility failed to adjust the care plan and implement more supervision before she fell and fractured her hip. The "Care Track" narrative notes documented: 6/25/11 at 6:05 p.m. "....Self transfer (out of bed) to (bathroom) x 2. Alarm in place (patient) turning to off position (before) transfer...." 6/26/11 at 5:00 am to 5:00 p.m. "Helped (resident) get up in AM. Left her in wheelchair with alarm on. Next time I saw her she was in the bathroom. Not sure if someone helped her in between or if she shut her alarm off. Managed to smash her left pinky finger in the door. Reported it to me when I went in. Said she felt something but didn't realize she was the one shutting the door on her own finger. Was only slightly purple under the nail in AM. By afternoon half the finger was purple and bruised...." 6/27/11 at 5:00 p.m. to 5:00 a.m. "...Resident made several attempts to self transfer. CNA explained call light and how it works...." 6/28/11 at 5:00 p.m. to 5:00 a.m. "...Continues to attempt self transfer. Frequently reminded to ask staff for assist." 7/3/11 at 5:00 a.m. to 5:00 p.m. "...Does not follow safety precautions, gets up and starts wandering around room for no reason...." 7/3/11 at 5:00 p.m. to 5:00 a.m. "...Several attempts made to ambulate (independently). Staff able to intervene and assist resident in the task at hand...." 7/4/11 at 5:00 a.m. to 5:00 p.m. "....Doesn't remember to follow safety precautions. Alarms are on...." 7/5/11 at 5:00 a.m. to 5:00 p.m. "...Does not remember to follow safety precautions..." 7/5/11 at 5:00 p.m. to 5:00 a.m. "...During the night ambulate via wheelchair. Gait is unsteady and she forgets and tries to get up to walk.... frequent redirection to comply (with) safety issues." 7/6/11 at 11:00 p.m. "...Resident continent up to bathroom x 1 independently. Assisted back to bed (after) noted poor safety awareness, (decreased) balance..." 7/7/11 at 5:00 a.m. to 5:00 p.m. "...Continues to self transfer, pressure alarm in place, reminded resident to use call light for assistance throughout the day...." 7/8/11 at 3:50 a.m. "...Alarms utilized (secondary to) fall risk, poor safety awareness, (assisted ambulation, gait unstable at times." 7/10/11 at 5:00 p.m. to 5:00 a.m. "....Needs extensive assistance to prevent elopement...reluctant to use wheelchair. Attempts to walk away." 7/11/11 at 5:00 a.m. to 5:00 p.m. "...Needs extensive assistance as she will not use alarms, turns them off. Try's (sic) to ambulate out of wheelchair..." 7/11/11 at 5:00 p.m. to 5:00 a.m. "...Frequently attempts to ambulate independently, appears to have little concept of safety... Resident is unable to remember the direction given... Will continue to encourage resident to request assistance for transfers and ambulation...." 7/12/11 at 5:00 p.m. to 5:00 a.m. "....Attempted to ambulate (without) assist back to room. Staff able to intercept and assist her to her room. Resident reminded each time to use call light to request assistance. Gait unsteady at this time..." 7/14/11 at 2:00 p.m. "...Needs reminding to call for assistance to transfer or ambulate. Her gait is unsteady...." 7/15/11 at 2:10 a.m. "Heard crash. Found patient in room sitting on floor in front of chair facing bed. Walker laying beside resident on floor, wheelchair at bedside. Was up at 1:30 (a.m.) ready for 'breakfast' reoriented to time wanted to sit in chair and watch TV, alarm box on, not sounding when resident noted on floor. Resident (complains) of pain with attempts to move left lower extremity..." The clinical record documented that the resident was transferred to the hospital and eventually had surgery to repair a fractured left hip. The DON was interviewed on 4/26/12 at 11:15 a.m. She indicated that the resident had supervision because: her room was next to the nurses station, and staff would have her sit near the nurses station when she was trying to ambulate without assistance. There was no documentation of these interventions. The DON was asked about the care plan and the lack of interventions to deal with the resident turning off the alarms and then ambulating. There was no further documentation or information provided to show increased supervision of the resident. The facility failed to: * provide increased supervision when the resident made multiple attempts to walk and had a gait problem. * develop a care plan to address the resident's turning off the alarms then attempting to ambulate. 2. Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 3/15/12, documented the following: * Severely impaired cognitive skills for daily decision making * Extensive assistance of one staff member required for mobility, transfers, and toileting * Supervision only required for locomotion within the facility * One injury fall after admission to the facility Clinical Review forms, dated 1/24/11, 5/15/11, 7/18/11, and 8/30/11, each documented that Resident #5 was not oriented to person, place, or time; had short-term memory impairment; was incontinent of bladder, was not on a toileting program, was able to ambulate without an assistive device, and had a history of [REDACTED]. NOTE: A Care Management Summary, dated 4/20/11, documented the following: - "Safety/Fall & Injury Prevention/History of Falls/Fall Risk: No falls. Remains (at) risk." - "Prior Level of Function: Falls. Syncopal episodes. Maintains in room more." - "Barriers to Achieving Goals: Syncopal episodes. Dementia. Self-isolation." A self-reported Incident Investigation report to the Idaho Department of Health and Welfare, Bureau of Facility Standards (BFS), dated 9/12/11, documented that Resident #5 was found by staff "laying on (her) bathroom floor" on 9/4/11 at 8:40 a.m. The report documented that the resident "complained of pain in her left hip, and her left foot was externally rotated." The resident was transported to a nearby emergency room , where she was diagnosed with [REDACTED]. The report noted that Resident #5 "does have a history of falls," but "it has been the wishes of her family to allow (the resident) the independence of ambulating independently, knowing there are risks of falls with injuries." A hospital History and Physical, dated 9/4/11, documented the resident sustained [REDACTED]. She is alert, but not oriented to place and things. The left leg is shortened, very painful to any motion." A letter to the facility from six members of the resident's family, dated 9/8/11 and provided to surveyors, documented, "We know there is a risk vs. (versus) independence in the area of falling. As we have communicated previously we accept that risk, as she would want, and have encouraged you to promote her independence. She has fallen. Several years ago she fractured a hip and a few years later she fell outside which resulted in stitches. Her joy and well-being outweigh the thought of impinging her independence. We understand that (Resident #5) fell in the restroom. She has been good about using her walker leaving the room and returning to her room but inside her room she usually moves between the bed, chair and restroom door and once inside the restroom uses the bars on the wall. We cannot see a way this fall could have been predicted or prevented." Resident #5's Falls Prevention Care Plan in effect prior to the September 2011 fall - dated 9/23/10 with updates on 12/23/10, 3/7/11, 6/7/11, and 7/11/11 - documented the following: * "Problem/Need: Potential for fall related to fall past 31-180 days. Problem onset: 9/23/10." * "Goal & Target Date: Remain free of injuires (sic) as evidence (sic) by no contusions, bruises, skin tears or laceration by next review. Will have no serious injury from falls by next review ..." NOTE: Two handwritten notes on the Care Plan documented, "Will have (no) injuries from fall" (dated 5/11/11), and "Encourage use of 4 wheel walker when out of room" (dated 5/23/11). * "Approaches: Monitor/anticipate/intervene for factors causing prior falls; encourage use of walkers, cane, etc as clinically indicated; fall risk assessment quarterly and PRN (as needed); analyze previous falls by resident to determine whether pattern/trend can be addressed; routine rounding to assist (with) toileting (dated 1/1/11); pressure alarm on bed while resident is in bed (handwritten, no date documented)." NOTE: The 9/23/10 Falls Prevention Care Plan maintained the pre-fall intervention of routine rounding on the resident rather than provide for increased supervision following the 9/4/11 fall in which Resident #5 fractured her hip. The resident's Falls Prevention Care Plan in effect at the time of the facility's annual re-certification and licensure survey and dated 12/9/11, included two interventions not in effect at the time of the September 2011 fall. Those interventions documented, "Place call light (at) end of bed, hanging over foot board when sitting in chair," (undated), and "Hand rails on sides of toilet," dated 1/23/12. A review of the facility's Incident and Accident Reports documented the following two non-injury falls: * 1/21/12, 7:40 p.m.: "Resident found sitting on buttocks between wall (and) toilet by female resident who shares BR (bathroom). (No change) in orders." * 1/25/12, 1:00 p.m.: "Resident fell backwards onto her back, was standing (at) nurses station. Hematoma (left) chin caused by 4WW (four-wheeled walker) landing on top of her." A Nurse's Note, dated 1/21/12, documented, "(Resident #5) found on the floor in the BR (after) adjoining room res(ident) sought out RN to notify her. Res(ident) lying semi supine between (right) wall (and) toilet). She states she does not know what happened." A Nurse's Note, dated 1/25/12, documented, "Sitting (at) nurses station heard a loud noise, immediately got up to find resident laying on her back (with) 4ww laying on top of her. Another female resident was standing there (and) saw her fall backwards. Resident was found (with) eyes open but (not) responding verbally for approx(imately) 45 sec(onds). When asked if she could hear me, she stated 'yes,' was able to state that she hurt (and) pointed to her chin." On 4/25/12, at 1:35 p.m., the DON was interviewed. When asked about Resident #5's September 2011 fall that resulted in a fractured hip and the two subsequent non-injury falls in January 2012, the DON stated the resident's family was in agreement and wanted the facility to place a higher priority on the resident's independence than safety in terms of accidents. When asked to elaborate, the DON stated the family did not want restrictions placed on Resident #5's independence. Federal Guidance at 42 CFR 483.25(H) (1) and (2) documented, "The intent of this requirement is to ensure the facility ... provides supervision and assistive devices to each resident to prevent avoidable accidents. Supervision is an intervention and a means of mitigating accident risk. Facilities are obligated to provide adequate supervision to prevent accidents." No further information was provided by the facility. Resident #5 was admitted to the facility with a history of- and known risk for falls. The facility failed to implement interventions, including increased supervision, to prevent the resident from sustaining a fall-related fractured hip in an accident that very closely resembled a subsequent fall by the resident approximately four months later. 3. On 4/23/12 at 10:35 am, in the unlocked storage closet located next to Room 10, two-96 ounce bottles of bleach were found on the floor of this closet. This posed a danger to any resident with cognitive impairment. The Administrator was immediately notified of this danger. The Administrator removed the bottles of bleach from the closet at that time and notifed the Maintenance Director of the need to put an automatic locking device on the door to prevent it from accidentally being left unlocked. The Administrator and DON were informed of this issue on 4/26/12 at 4:00 pm. No further information regarding this matter was received from the facility.